Symptom management in inflammatory bowel disease

Abstract

Patients with inflammatory bowel disease can present with a wide variety of symptoms. Most are related to disease activity and should be managed with appropriate medical therapy for inflammatory bowel disease. However, some patients may develop symptoms due to the side effects of the medications, or due to immunosuppression. In these cases, the offending medications should be discontinued until resolution of the symptoms and a few may be able to restart therapy. Symptoms can also occur as an extraintestinal manifestation of the disease or due to concomitant autoimmune-mediated disorders. Regardless of the etiology, symptoms should be addressed promptly with immediate evaluation and appropriate therapy, as a delay may lead to permanent sequela.

Keywords:

• abdominal pain
• alopecia
• anxiety and depression
• diarrhea
• dyspnea
• fatigue
• inflammatory bowel disease
• joint pain
• nausea and vomiting
• neurologic symptoms

Financial & competing interests disclosure

BP Abraham is a speaker for Abbvie, Janssen, Takeda, Salix, UCB and Prometheus. BP Abraham is on the Advisory Board for Abbvie, Janssen, Takeda, Shire, UCB and Genetech. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Key issues

• IBD patients can present with a wide variety of symptoms. It is the responsibility of the treating gastroenterologist to be able to determine the etiology of these symptoms and provide early evaluation for an accurate diagnosis and prompt treatment. Some symptoms may be ongoing, and mild, but others may require immediate evaluation due to high risk of morbidity and in some cases mortality.

• Diarrhea most often occurs due to disease activity, however infectious etiologies such as Clostridium difficile infection should be tested for and treated. IBS and functional aspects can contribute. Drug-related reactions can also cause diarrhea and the offending agent should be discontinued.

• Abdominal pain is one of the most debilitating symptoms of IBD. Treatment of underlying inflammation is the ultimate goal to reduce further complications from the disease; however intra-abdominal infections, functional pain, and other etiologies need to be ruled out. Narcotic use should be limited in IBD patients due to increased morbidity with its use.

• Joint pain can be due to IBD-related arthropathy where advancing IBD treatment can help resolve symptoms. However, patients will need to be evaluated for additional rheumatological disease, such as RA, AS, sacroilitis, or even drug-related arthropathy.

• Nausea and vomiting can occur due to disease activity but obstruction needs to be ruled out. Medications causing this as a side effect may need to be discontinued.

• Anxiety/depression is highly prevalent in IBD patients and can contribute to worsening disease symptoms. Treatment of this can improve patients’ health-related quality of life.

• Fatigue is a common symptom reported in IBD patients and is typically multifactorial involving disease activity, nutritional deficiencies, underlying additional medical comorbidities, as well as anxiety and depression. Often, treatment requires evaluation of these potential etiologies and addressing the pertinent ones that are contributing to their symptom.

• Dyspnea, although uncommon should be evaluated promptly due to potential for serious morbidity, especially thromboembolic phenomenon like DVT and PE. Drug-related toxicities can occur and the offending drug may need to be discontinued.

• Neurologic symptoms are quite important to evaluate when patients initially present, especially if they are on immunosuppressive therapy. Symptoms may be subtle, such as a headache, but can progress to significant weakness, or paresthesias. Often MRI brain can diagnose, but prompt evaluation to neurology may be required.

• Alopecia is often blamed on IBD medications, but limited studies suggest that it may be more often related to nutritional dificiencies and/or disease activity.

Notes

IBD: Inflammatory bowel disease; SLE: Systemic lupus erythematosis.

IBD: Inflammatory bowel disease.