What is the management approach for ileitis?

Management of Ileitis

The management of ileitis should be tailored to the underlying cause and disease severity, with high-dose mesalazine (4g daily) as first-line therapy for mild disease, corticosteroids for moderate to severe disease, and consideration of surgery for refractory cases. 1

Diagnostic Considerations

• Ileitis may be caused by various conditions beyond Crohn's disease, including infectious diseases, spondyloarthropathies, medication-induced inflammation, vasculitides, ischemia, and neoplasms 2
• Additional imaging of the small bowel should be considered in cases of suspected ileitis to differentiate between ulcerative colitis with backwash ileitis and Crohn's disease 3
• Faecal calprotectin can be a useful non-invasive marker to assess inflammation and monitor treatment response 3

Treatment Algorithm Based on Disease Severity

Mild Ileitis

• High-dose mesalazine (4g daily) is recommended as first-line therapy for mild ileocolonic disease 3, 1
• Mesalazine in microgranular formulation has shown similar efficacy to standard dosage of steroids in mild to moderate Crohn's ileitis 4

Moderate to Severe Ileitis

• Oral corticosteroids such as prednisolone 40mg daily are appropriate for moderate to severe disease or for mild to moderate disease that has failed to respond to mesalazine 3, 1
• Prednisolone should be reduced gradually over approximately 8 weeks to prevent early relapse 3, 5
• Budesonide 9mg daily is appropriate for patients with isolated ileo-cecal disease with moderate activity, though it is marginally less effective than prednisolone 3
• Intravenous steroids (hydrocortisone 400mg/day or methylprednisolone 60mg/day) are appropriate for patients with severe disease 3

Adjunctive Therapies

• Azathioprine (1.5-2.5mg/kg/day) or mercaptopurine (0.75-1.5mg/kg/day) may be used as adjunctive therapy and as steroid-sparing agents, though their slow onset of action precludes use as sole therapy 3, 5
• Elemental or polymeric diets can be used to induce remission in patients with contraindications to corticosteroid therapy or in those who prefer to avoid such therapy 3, 1
• Metronidazole (10-20mg/kg/day) can be effective but is not usually recommended as first-line therapy due to potential side effects 3, 5

Biological Therapy

• Infliximab 5mg/kg is effective for Crohn's ileitis but should be avoided in patients with obstructive symptoms 3, 6
• When initiating infliximab, perform testing for latent tuberculosis; if positive, start treatment for TB prior to starting infliximab 6
• Monitor all patients for active TB during treatment, even if initial latent TB test is negative 6

Surgical Management

• Surgery should be considered for patients who have failed medical therapy 3, 1
• Surgery may be appropriate as primary therapy in patients with limited ileal or ileo-cecal disease 3, 5
• In acute severe cases requiring surgery, a staged procedure is recommended, especially in patients taking ≥20mg prednisolone daily for more than 6 weeks or in those treated with anti-TNF agents 3

Special Considerations

Backwash Ileitis in Ulcerative Colitis

• Continuous extension of inflammation from the cecum into terminal ileum (backwash ileitis) is observed in up to 20% of patients with extensive colitis 3
• Patients with backwash ileitis tend to have a more refractory course of disease 3
• Additional small bowel imaging should be considered in cases of macroscopic backwash ileitis to differentiate UC from Crohn's disease 3

Common Pitfalls and Caveats

• Avoid rapid reduction of corticosteroids as this is associated with early relapse 3, 1
• Always consider alternative explanations for symptoms other than active disease (bacterial overgrowth, bile salt malabsorption, fibrotic strictures) 3, 5
• Misdiagnosis of Crohn's disease may be harmful to patients because of inadequate response to therapy and occasionally unnecessary operations 7
• Terminal ileitis is not always Crohn's disease - careful diagnostic evaluation is essential to determine the specific etiology 8, 7