Management of Inflammatory Bowel Disease: a long-term perspective

Abstract

Crohn’s disease and ulcerative colitis are inflammatory bowel diseases (IBD), characterized by relapsing-remitting inflammation of the gastrointestinal tract. IBD patients may experience abdominal pain, diarrhea, rectal bleeding, weight loss and severe fatigue. In the long term, inflammation irreversibly damages the gut and increases the risk of colorectal cancer (CRC). Since approximately 2000, new drugs including anti-tumor necrosis factor-alpha (anti-TNF) agents have improved the management of IBD. Simultaneously, advances have been made in endoscopic techniques for visualization of the intestinal mucosa and resection of (pre)malignant lesions. This thesis focuses on the long-term management of IBD. In section 1, we discuss whether patients with longstanding disease remission during anti-TNF treatment could safely withdraw treatment. Our studies indicate that withdrawal of co-medication (thiopurines, methotrexate) is relatively safe, but withdrawal of anti-TNF agents is associated with a high relapse risk. Endoscopically confirmed remission of disease and measurement of serum drug levels may help to predict the relapse risk. Section 2 discusses prevention of colitis-associated CRC. Screening for CRC is performed with colonoscopies to identify and resect pre-malignant lesions (dysplasia). We assessed potential risk factors for CRC in patients with IBD, including post-inflammatory polyps. Knowledge of risk factors for CRC in patients with IBD may aid to determine the optimal surveillance interval. This would allow prevention and/or early identification of CRC in high-risk patients, and reduce the burden and health care costs for patients at low risk of CRC.