Faculty Bibliography

The management and understanding of Crohn's disease (CD) continues to evolve quickly. Intestinal strictures were previously thought to be an inevitable result of irreversible fibrosis caused by chronic inflammation. However, increased understanding of the dynamic nature of strictures and of the pathophysiology of this condition has highlighted emerging targets for potential treatment. In the diagnosis of strictures, a distinction must be made between inflammatory and fibrotic types, as the former may respond to medical therapy. Emerging technologies, such as dual-energy computed tomography enterography and iodine density, have allowed more accurate characterization of strictures. Surgical and endoscopic treatment remains the mainstay for fibrotic strictures, but developments in systemic and intralesional biologic therapy have shown efficacy. This article reviews the pathophysiology of this debilitating complication of CD as well as current and emerging diagnostics and treatments.

The incidence and prevalence of inflammatory bowel disease (IBD) is rising in the elderly population. Compared with patients with onset during their younger years, patients with elderly onset IBD have a distinct clinical presentation, disease phenotype, and natural history. Genetics contribute less to pathogenesis of disease, whereas biological changes associated with aging including immunosenescence, dysbiosis, and frailty have a greater impact on disease outcomes. With the advent of an increasingly wider array of biologic and small-molecule therapeutic options, data regarding efficacy and safety of these agents in elderly IBD patients specifically are paramount, given the unique characteristics of this population.

Inflammatory bowel disease (IBD) is often treated with biologics and immunomodulators, which can place elderly IBD patients at risk for serious and opportunistic infections. This article provides an updated account of research on therapies in IBD that are associated with an increased infection risk. Relevant serious and opportunistic infections in the elderly population are discussed along with methods for prevention and treatment. The incidence of infection increases with age and the degree of immunosuppression. Emphasis should be placed on performing vaccinations at the time of IBD diagnosis. Additionally, patients receiving immunosuppressive therapy should avoid live vaccines. Physicians should have a greater awareness of the increased risk of infection in elderly adults and the need for screening for infection prior to initiation of immunosuppressive IBD therapies.

The role of vitamin D has long been discussed in many chronic diseases, and its significance in inflammatory bowel disease has recently gained attention. This article reviews vitamin D homeostasis, the involvement of vitamin D in the pathophysiology of inflammatory bowel disease, and vitamin D deficiency as a result of inflammatory bowel disease. In addition, this article explores the possibility of age, specifically in the elderly population, as a risk factor for developing vitamin D deficiency in patients with inflammatory bowel disease.

Small bowel adenocarcinoma is a rare but well-known complication of Crohn's disease. The diagnosis of small bowel adenocarcinoma remains difficult since its presentation is highly variable and mimics active or obstructive Crohn's disease. The diagnosis is often delayed and typically detected only at surgery in an advanced stage with a poor prognosis. We report a case of metastatic ileal adenocarcinoma in a patient with Crohn's disease with prolonged survival. Our case describes serial promising treatment options of these advanced malignancies and raises a possible role for checkpoint immunotherapy.

PURPOSE OF REVIEW/OBJECTIVE:Early- and late-onset of inflammatory bowel disease (IBD) may perhaps be etiologically distinct and potentially attributed to genetics, environmental or microbial factors. We review disease factors and clinical characteristics, as well as unique management and treatment strategies to consider when caring for the "baby" or "baby boomer" with IBD. RECENT FINDINGS/RESULTS:Around 25% of cases of initial diagnosis of IBD is made before the age of 18 years old, and another 15-20% made after the age of 60. Crohn's disease (CD) typically presents as ileocolonic and stricturing or penetrating phenotype among early-onset, whereas among late-onset, it is mainly colonic and inflammatory. Pediatric ulcerative colitis (UC) is mostly pan-colonic versus primarily left-sided among the elderly. Treatment goal for both age groups is primarily symptom control, with growth and development also considered among pediatric patients. Due to alterations in pharmacokinetics, careful monitoring and reduced dose should be considered. A multidisciplinary care team is necessary to ensure better clinical outcomes. Onset of disease at either spectrum of age requires careful management and treatment, with both unique disease- and age-appropriate factors carefully considered.