What is the best approach to manage a patient with ileitis?

Management of Ileitis

For mild ileocolonic Crohn's disease, initiate high-dose mesalazine 4g daily as first-line therapy, escalating to oral corticosteroids (prednisolone 40mg daily) for moderate-to-severe disease or mesalazine failure. 1

Initial Assessment and Differential Diagnosis

Before initiating treatment, determine the underlying cause of ileitis, as management differs substantially based on etiology:

• Infectious ileitis (most common cause at 33.3% of acute cases, particularly Yersinia species) typically presents with acute onset right lower quadrant pain, diarrhea, and fever 2
• Crohn's disease accounts for approximately 12% of ileitis cases and follows a chronic, relapsing course 2
• Other causes include spondyloarthropathies, vasculitides, medication-induced (NSAIDs), ischemia, and neoplasms 3
• Confirm ileal inflammation with imaging (CT or ultrasound showing terminal ileum pathology) before proceeding with treatment 2

Critical pitfall: Always consider alternative explanations beyond active inflammatory disease, including bacterial overgrowth, bile salt malabsorption, and fibrotic strictures, as these require different management approaches 1

Treatment Algorithm for Crohn's Ileitis

Mild Disease

• Start with mesalazine 4g daily as sufficient initial therapy for mild ileocolonic Crohn's disease 4, 1
• Mesalazine microgranular formulations (coated with Eudragit S) deliver medication specifically to the terminal ileum and show remission rates of 79% in mild-to-moderate ileitis 5
• Continue treatment for up to 40 days before determining therapeutic failure 6

Moderate-to-Severe Disease or Mesalazine Failure

• Initiate prednisolone 40mg daily for patients with moderate-to-severe disease or those who fail mesalazine therapy 1
• Taper prednisolone gradually over 8 weeks to prevent early relapse—rapid tapering is a common pitfall associated with disease recurrence 1, 7
• Corticosteroids are potent and fast-acting but should not be used for long-term maintenance due to serious side effects with prolonged use 8

Alternative Therapies

• Nutritional therapy (elemental or polymeric diets) is less effective than corticosteroids but may be considered for patients with contraindications to steroids or those preferring to avoid them 1
• Metronidazole (10-20mg/kg/day) can be effective but is not recommended as first-line therapy due to potential side effects 1

Refractory Disease Management

For patients failing conventional therapy:

• Immunomodulators (azathioprine, 6-mercaptopurine, methotrexate, or cyclosporine) should be considered for corticosteroid-dependent or corticosteroid-unresponsive disease 8
• Infliximab (5mg/kg at weeks 0,2, and 6, then every 8 weeks) is indicated for moderately-to-severely active Crohn's disease with inadequate response to conventional therapy 9
• Surgical intervention should be considered for patients who have failed medical therapy and may be appropriate as primary therapy in limited ileal or ileo-caecal disease 1

Special Considerations

Infectious Ileitis

• Most cases of bacterial ileitis are acute and self-limited, requiring supportive care rather than immunosuppression 3
• Do not delay corticosteroid treatment in presumed Crohn's disease while awaiting stool microbiology results, as acute onset can be difficult to distinguish from infectious colitis 4

Monitoring Requirements

• Assess disease severity by considering site (ileal, ileocolic, colonic), pattern (inflammatory, stricturing, fistulating), and activity before making treatment decisions 4
• Monitor for complications including obstruction, hemorrhage, and extraintestinal manifestations, particularly in chronic cases 3
• In long-standing Crohn's ileitis, symptom recrudescence may represent neoplasm development requiring investigation 3

Safety Warnings with Biologics

• Screen for latent tuberculosis before initiating infliximab and monitor all patients for active TB during treatment 9
• Discontinue infliximab if serious infection develops 9
• Be aware of increased malignancy risk, particularly hepatosplenic T-cell lymphoma in young males receiving concomitant azathioprine or 6-mercaptopurine 9