What is the treatment for non-specific ileal ulcers and ileitis?

Treatment of Non-Specific Ileal Ulcers and Ileitis

For non-specific ileal ulcers and ileitis, treatment should be tailored based on disease severity, with high-dose mesalazine (4 g/daily) as first-line therapy for mild disease, and oral corticosteroids such as prednisolone 40 mg daily for moderate to severe disease. 1, 2

Treatment Algorithm Based on Disease Severity

Mild Disease

• High-dose mesalazine (4 g/daily) is appropriate as initial therapy for mild ileal/ileocolonic disease 1, 2
• Metronidazole (10-20 mg/kg/day) may be considered for certain infective causes, though it's not typically first-line due to potential side effects 2
• Exclude infectious causes before attributing symptoms to inflammatory disease 3

Moderate to Severe Disease

• Oral corticosteroids (prednisolone 40 mg daily) are appropriate for patients with moderate to severe disease or those who failed to respond to mesalazine 1
• Prednisolone should be reduced gradually over 8 weeks, as more rapid reduction is associated with early relapse 1
• Budesonide 9 mg daily is appropriate for patients with isolated ileo-caecal disease with moderate activity, though slightly less effective than prednisolone 1

Severe Disease

• Intravenous steroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) are appropriate for patients with severe disease 1
• Concomitant intravenous metronidazole is often advisable to help distinguish between active disease and septic complications 1
• Total parenteral nutrition is appropriate adjunctive therapy in complex, fistulating disease 1

Adjunctive Treatments

• Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) may be used as adjunctive therapy and steroid-sparing agents, though their slow onset of action precludes use as sole therapy 1, 2
• Elemental or polymeric diets are less effective than corticosteroids but may be used to induce remission in patients with contraindications to corticosteroid therapy 1
• Elemental or polymeric diets are appropriate adjunctive therapy 1

Special Considerations for Specific Etiologies

Crohn's Disease

• When non-specific ileitis progresses to confirmed Crohn's disease, treatment follows standard Crohn's disease protocols 2
• Infliximab 5 mg/kg is effective but should be avoided in patients with obstructive symptoms 1

Infectious Ileitis

• Metronidazole and/or ciprofloxacin are appropriate first-line treatments if infectious etiology is suspected 1
• Always exclude infectious causes before escalating therapy 3

Surgical Management

• Surgery should be considered for those who have failed medical therapy 1
• Surgery may be appropriate as primary therapy in patients with limited ileal or ileo-caecal disease 1

Important Clinical Considerations

• Recent research shows that the majority of patients with ileo-cecal ulcers have specific etiologies (55%), while non-specific ileitis/colitis accounts for approximately 45% of cases 4
• In patients with superficial ulcers and non-specific inflammation, the absence of fever, diarrhea, GI bleeding, or weight loss has a negative predictive value of 92% in excluding more serious conditions like intestinal tuberculosis or Crohn's disease 5
• Close follow-up is necessary for patients diagnosed with non-specific ileitis, as some cases may later develop into specific diseases requiring targeted treatment 4