Crohn's and Colitis. Dr. Hillary Steinhart

be effective for both.

       Enlarging Lesions

      •Patients often say that erythema nodosum and pyoderma gangrenosum lesions seem to start with what they thought was a bruise or an insect bite but quickly enlarge and worsen. When this happens, a doctor should be notified promptly.

      •The drug infliximab has been shown to be particularly effective at healing pyoderma gangrenosum lesions.

       Erythema nodosum

      The lesions of erythema nodosum are red or purplish, raised, and painful. They occur most often on the shins. They typically appear when the bowel symptoms are more active and go away as the bowel disease responds to treatment, sometimes leaving a small area of discoloration.

       Pyoderma gangrenosum

      Pyoderma gangrenosum is an area of ulcerated skin that usually occurs on the legs, but can occur on other areas of the body, particularly near the site of an ileostomy or colostomy. The lesion is sometimes painful, but it often looks much worse than it feels. The ulcerated area can grow to be quite large — sometimes 2 inches (5 cm) or even more across — and fluid can often ooze from its surface. Although it may improve when the bowel disease is treated, it does not always. When the lesions heal, they may leave areas of scarring or changed pigmentation.

      Infliximab (Remicade) and adalimumab (Humira), two of the antitumor necrosis factor (anti-TNF) based treatments that are used to treat IBD, can be effective at healing pyoderma gangrenosum lesions.

       Skin Rashes

      Although treatments based on the antitumor necrosis factor (infliximab, adalimumab, and golimumab) may be effective at treating the skin lesions associated with IBD, their use may also result in unusual skin rashes. These are generally not serious and can usually be managed with creams or ointments applied to the site of the rash. In rare cases, these drugs can be associated with new onset of a skin condition called psoriasis or, in some cases, a worsening of psoriasis that was present prior to the start of therapy. This is an unusual reaction to therapy because these drugs are usually quite effective at treating psoriasis.

      Although it isn’t known for certain whether earlier treatment of the skin lesions of IBD results in better outcomes with treatment, it is important to be aware of any skin lesion that is particularly painful, ulcerated, or enlarging for no apparent reason. Patients often say that erythema nodosum and pyoderma gangrenosum lesions seem to start off as what they thought was a bruise or an insect bite but quickly enlarge and worsen. When this happens, see your doctor promptly.

       Liver

      The most serious liver condition related to IBD is called primary sclerosing cholangitis (PSC). PSC appears to be somewhat more common in ulcerative colitis than in Crohn’s disease, and when it occurs in Crohn’s disease, there is often involvement of the large intestine (colon) with inflammation. PSC is thought to begin as an inflammation that specifically involves the small channels (ducts) carrying bile from the liver to the small intestine. It can lead to scarring and narrowing of these bile ducts, and, when severe or advanced, can result in damage to the liver. If the condition continues to progress, it can lead to liver cirrhosis and liver failure. PSC also predisposes the patient to episodes of bacterial infection of the bile ducts.

       PSC Incidence

      No more than 5% of people with IBD are affected by the serious liver complication called primary sclerosing cholangitis (PSC). If the condition continues to progress, it can lead to liver cirrhosis and liver failure.

      PSC is usually first suspected because of abnormal blood tests. This usually requires further tests or scans to see if the strictures characteristic of PSC are present. Occasionally, a liver biopsy may be necessary to sort out the possible causes. Most doctors will include blood tests of liver function and inflammation as a part of the routine checkup, even for individuals whose IBD is quite stable and not flaring. This may allow for earlier detection of PSC, but there is not an effective therapy that will prevent the progression of PSC to liver cirrhosis.

       Fever and Jaundice

      In someone who has PSC, any episode of fever, particularly if it occurs with jaundice (yellow color) of the skin or eyes, needs to be assessed and treated immediately.

      Mildly abnormal blood tests indicating liver inflammation or irritation are usually temporary and do not indicate any serious damage or long-term consequence to the liver. The abnormal blood tests are probably due to small areas of inflammation within the liver tissue that are a reaction to the associated bowel inflammation. It is not known how or why this occurs, but it tends to go away on its own and can recur repeatedly over time.

      PSC is also associated with an increased risk of colorectal cancer. This increased risk requires specialized and intensive monitoring or surveillance with regular colonoscopies. PSC is also associated with an increased risk of bile duct cancer. Unfortunately, there is no good way to monitor for this complication.

       Bone Disease

      Although bone disease is not, strictly speaking, considered to be an extra-intestinal manifestation of IBD, individuals with IBD are at higher risk of developing certain types of bone disease. In the past, osteomalacia and rickets — serious problems with bone formation — were seen as a result of severe vitamin D deficiency in patients with Crohn’s disease. These conditions are seldom seen now, probably as a result of better medical and nutritional treatments for patients with IBD.

       Osteoporosis

      Osteoporosis has been recognized as a prevalent condition. Osteoporosis involves a decrease in the density of the bone that occurs as a result of a reduction in the amount of minerals, such as calcium, in the bones. The bones are not strong and, therefore, susceptible to fracture with only minor trauma or sometimes without any apparent reason. Osteoporosis does not produce any symptoms until a fracture occurs.

       Minerals and Vitamins

      For patients with IBD, maintaining an adequate intake of minerals and vitamins is an important means of preventing osteoporosis — not only good calcium and vitamin D intake but also good overall nutritional intake in terms of total calories and protein in the diet.

      While osteoporosis commonly occurs in older individuals without IBD, particularly in women, it seems to occur at an earlier age in patients with IBD. There are several reasons why IBD patients are more susceptible to developing osteoporosis at a younger age. The disease itself, particularly in Crohn’s disease, and the associated inflammation appear to lead to reduced bone density, probably as a result of factors released into the bloodstream from the inflamed tissues. These factors, in turn, interfere with bone formation. Poor intake or absorption of certain key nutrients, such as calcium and vitamin D, may also play an important role in some patients. In addition, a person’s overall nutritional state, as reflected by body weight, is also an important factor in determining bone density. In general, individuals who are underweight or malnourished tend to be more at risk of developing osteoporosis.

       Osteoporosis Risk

      People with IBD are at increased risk of developing osteoporosis, particularly if they have Crohn’s disease or if they have received steroid medications. Some studies have indicated rates of osteoporosis of 30% in IBD patients. Osteoporosis appears to be more common in Crohn’s disease than ulcerative colitis.

       Medications

      Medications are a major factor in the development of osteoporosis in IBD patients. In particular, steroid medications, such as prednisone, have been associated with an increased risk. Most doctors try to limit the duration of steroid treatment in their patients with IBD, and when starting someone on steroids, they will often recommend calcium and vitamin D supplements or start the patient on bisphosphonate medications (for example, etidronate, alendronate, zoledronate, and risedronate) that can help prevent further bone density loss. Most other medications