351.4 📋 章末速蚘 Summary

351.4.1 🔑 䞀句話瞜結

IBD includes Crohn’s disease (CD) + ulcerative colitis (UC) — autoimmune chronic relapsing-remitting GI inflammation; 0.5% prevalence Western, increasing globallyCDtransmural inflammation + skip lesions + any GI tract (ileum + colon most) + fistula/stricture/abscess complications + granulomas + smoking worsensUCmucosal inflammation + continuous from rectum proximally + colorectum only + bloody diarrhea hallmark + no granulomas + smoking protective + colectomy curativepresentationbloody diarrhea + cramping + weight loss + extraintestinal manifestations (joints #1 — type 1/type 2/AS; skin EN/PG/Sweet; eye uveitis; PSC strongly UC-associated; renal oxalate stones CD; hematologic anemia/hypercoagulable)diagnosiscolonoscopy + ileal intubation + biopsy (gold standard) + fecal calprotectin + MR enterography (MRE) for CD; pANCA (UC), ASCA (CD)treatment 2024 paradigm(1) 5-ASA (mesalamine) UC mild-moderate mainstay; (2) corticosteroids for induction (not maintenance); (3) immunomodulators (thiopurines AZA/6-MP, methotrexate) for maintenance; (4) biologics era — anti-TNF (infliximab/adalimumab/certolizumab/golimumab), anti-integrin (vedolizumab gut-selective), anti-IL-12/23 (ustekinumab), anti-IL-23 selective (risankizumab FDA 2022 CD/2024 UC, mirikizumab FDA 2023 UC, guselkumab emerging), JAK inhibitors (tofacitinib UC, upadacitinib UC+CD), S1P modulators (ozanimod FDA 2021, etrasimod FDA 2023); top-down approach for moderate-severe; treat-to-target mucosal healing; toxic megacolon (severe UC) → IV steroids + abx + cyclosporine/infliximab rescue + colectomy; perianal fistulizing CD → infliximab + drainage/setons; UC colectomy curative; CRC surveillance every 1-2 yr after 8-10 yr disease; pregnancy continue biologics, stop methotrexate; pouchitis post-IPAA → metronidazole + cipro。

351.4.2 💊 治療粟芁

  • mild-moderate UC5-ASA (mesalamine, sulfasalazine) oral + topical (suppositories, enemas) for distal disease + topical corticosteroids (budesonide) for active disease
  • moderate-severe IBDsystemic corticosteroids (prednisone, IV methylpred) for induction (not maintenance) + immunomodulators (thiopurines AZA/6-MP with TPMT testing, methotrexate for CD) for maintenance + biologics
  • biologics & small molecules (2024)
    • anti-TNFinfliximab, adalimumab, certolizumab, golimumab (UC); pre-treatment TB + HBV screen
    • vedolizumab (Entyvio) anti-integrin gut-selective
    • ustekinumab (Stelara) anti-IL-12/23
    • risankizumab (Skyrizi) anti-IL-23p19 — CD FDA 2022 + UC FDA 2024
    • mirikizumab (Omvoh) anti-IL-23 — UC FDA 2023
    • tofacitinib (Xeljanz) + upadacitinib (Rinvoq) JAK inhibitors — UC + CD; black box CV/thrombotic events
    • ozanimod (Zeposia) + etrasimod (Velsipity) S1P modulators — UC oral options
  • toxic megacolonIV steroids + broad antibiotics + cyclosporine or infliximab rescue + colectomy if refractory 24-72 h
  • perianal fistulizing CDinfliximab (best evidence) + surgical drainage + setons + combination immunomodulator + selected surgery
  • UC colectomy with IPAA (J-pouch) curative for UC; pouchitis treated with metronidazole + ciprofloxacin
  • CD surgery not curative: limited resection for complications + strictureplasty + endoscopic balloon dilation
  • pregnancy + IBD: continue TNF inhibitors through pregnancy + stop methotrexate (teratogenic) + plan with specialist
  • CRC surveillance: colonoscopy q 1-2 yr starting 8-10 yr after disease onset (earlier with PSC)

351.4.3 🎯 盧醫垫的考前提醒

  1. CD vs UC 鑑別必背CD transmural + skip lesions + any GI (ileocolic most) + fistula/stricture + granulomas + smoking worsens; UC mucosal + continuous from rectum + colorectum only + bloody diarrhea + no granulomas + smoking protective + colectomy curative
  2. PSC strongly UC-associated (especially pancolitis with positive ANCA); increases CRC + cholangiocarcinoma risk; monitor CA 19-9
  3. fecal calprotectin > 250 suggests IBD activity (vs IBS); useful for monitoring + screening; CRP also helpful but less specific
  4. MR enterography (MRE) preferred for CD evaluation (small bowel, fistula characterization); CT enterography alternative; US emerging
  5. biologic era 2010s-2024 revolutionanti-TNF first generation → vedolizumab (gut-selective) → ustekinumab (IL-12/23) → anti-IL-23 selective (risankizumab, mirikizumab) + JAK inhibitors (tofacitinib, upadacitinib) + S1P modulators (ozanimod, etrasimod) 2021-2024
  6. anti-IL-23 selective newer agentsrisankizumab (Skyrizi) CD FDA 2022 + UC FDA 2024; mirikizumab (Omvoh) UC FDA 2023; potentially better safety than broader anti-IL-12/23 (ustekinumab)
  7. JAK inhibitor black box warningCV events + thrombotic + malignancy + mortality (especially ≥ 50, RA history, smokers, tofacitinib > upadacitinib); careful patient selection + monitoring (lipids, CBC, infection)
  8. S1P modulators (ozanimod, etrasimod) for UC oral optionssphingosine-1-phosphate receptor modulator → lymphocyte sequestration in lymph nodes; first-dose bradycardia + macular edema + lymphopenia monitoring
  9. top-down approach for moderate-severe IBDearly biologic + immunomodulator combo (vs traditional step-up); SONIC trial in CD showed infliximab + AZA superior; reduces complications + surgery
  10. CRC surveillance in IBDcolonoscopy every 1-2 years starting 8-10 years after disease onset (UC and CD-colitis); earlier and more frequent with PSC; random + targeted (chromoendoscopy) biopsies; confirmed dysplasia → colectomy consideration