Inflammatory Bowel Disease

Inflammatory bowel disease
From Wikipedia, the free encyclopedia Jump to: navigation, search This article is about bowel inflammation. For functional disorder, see Irritable bowel syndrome.

Classification and external resources
Micrograph showing inflammation of the large bowel in a case of inflammatory bowel disease. Colonic biopsy. H&E stain. DiseasesDB eMedicine MeSH 31127 med/1169 emerg/106 oph/520 D015212
In medicine, inflammatory bowel disease (IBD) is a group of inflammatory conditions of the colon and small intestine. The major types of IBD are Crohn's disease and ulcerative colitis.[1][2][3]
Contents
[hide]
1 Forms 2 Symptoms and diagnosis 3 Treatment 4 Prognosis 5 Recent findings 6 References 7 External links
[edit] Forms
The main forms of IBD are Crohn's disease and ulcerative colitis (UC). Accounting for far fewer cases are other forms of IBD:

Collagenous colitis Lymphocytic colitis Ischaemic colitis Diversion colitis Behet's syndrome Indeterminate colitis
The main difference between Crohn's disease and UC is the location and nature of the inflammatory changes. Crohn's can affect any part of the gastrointestinal tract, from mouth to anus (skip lesions), although a majority of the cases start in the terminal ileum. Ulcerative colitis, in contrast, is restricted to the colon and the rectum.[4] Microscopically, ulcerative colitis is restricted to the mucosa (epithelial lining of the gut), while Crohn's disease affects the whole bowel wall. Finally, Crohn's disease and ulcerative colitis present with extra-intestinal manifestations (such as liver problems, arthritis, skin manifestations and eye problems) in different proportions. Rarely, a definitive diagnosis of neither Crohn's disease nor ulcerative colitis can be made because of idiosyncrasies in the presentation. In this case, a diagnosis of indeterminate colitis may be made. Although a recognised definition, not all centres refer to this.
[edit] Symptoms and diagnosis
High magnification micrograph of intestinal crypt branching, an indicator of chronic inflammation and a histopathologic finding associated with inflammatory bowel disease. Colonic biopsy of the mucosa in an individual with Crohn's disease. H&E stain. Although very different diseases, both may present with any of the following symptoms: abdominal pain, vomiting, diarrhea, rectal bleeding, weight loss and various associated complaints or diseases like arthritis, pyoderma gangrenosum, and primary sclerosing cholangitis. Diagnosis is generally by colonoscopy with biopsy of pathological lesions.
[edit] Treatment
Depending on the level of severity, IBD may require immunosuppression to control the symptom, such as prednisone, TNF inhibition, azathioprine (Imuran), methotrexate, or 6mercaptopurine. More commonly, treatment of IBD requires a form of mesalamine. Often, steroids are used to control disease flares and were once acceptable as a maintenance drug. In use for several years in Crohn's disease patients and recently in patients with ulcerative colitis, biologicals have been used such as TNF inhibitors. Severe cases may require surgery, such as bowel resection, strictureplasty or a temporary or permanent colostomy or ileostomy. Alternative medicine treatments for bowel disease exist in various forms, however such methods concentrate on controlling underlying pathology in order to avoid prolonged steroidal exposure or surgical excisement.[5] Usually the treatment is started by administering drugs with high anti-inflammatory effects, such as prednisone. Once the inflammation is successfully controlled, the patient is usually switched to a lighter drug to keep the disease in remission, such as Asacol, a mesalamine. If unsuccessful, a combination of the aforementioned immunosuppression drugs with a mesalamine (which may
also have an anti-inflammatory effect) may or may not be administered, depending on the patient. Histoplasma produces toxins that cause intestinal disease called histoplasmosis that is a serious consideration in an immunocompromised patient with signs and symptoms of IBD. Antifungal drugs such as nystatin (a broad spectrum gut antifungal) and either itraconazole (Sporanox) or fluconazole (Diflucan) have been suggested as a treatment for IBD disorders such as Crohns disease and ulcerative colitis that all share the same symptoms such as diarrhea, weight loss, fever, and abdominal pain.[6]
[edit] Prognosis
While IBD can limit quality of life because of pain, vomiting, diarrhea, and other socially unacceptable symptoms, it is rarely fatal on its own. Fatalities due to complications such as toxic megacolon, bowel perforation and surgical complications are also rare. While patients of IBD do have an increased risk of colorectal cancer, this is usually caught much earlier than the general population in routine surveillance of the colon by colonoscopy, and therefore patients are much more likely to survive. New evidence suggests that patients with IBD may have an elevated risk of endothelial dysfunction and coronary artery disease[7] The goal of treatment is toward achieving remission, after which the patient is usually switched to a lighter drug with fewer potential side effects. Every so often, an acute resurgence of the original symptoms may appear; this is known as a "flare-up". Depending on the circumstances, it may go away on its own or require medication. The time between flare-ups may be anywhere from weeks to years, and varies wildly between patients - a few have never experienced a flareup.
[edit] Recent findings

A recent hypothesis posits that some IBD cases are caused by an overactive immune system attacking various tissues of the digestive tract because of the lack of traditional targets such as parasites and worms. The number of people being diagnosed with IBD has increased as the number of infections by parasites, such as roundworm, hookworm and human whipworms, has fallen, and the condition is still rare in countries where parasitic infections are common. This is similar to the hygiene hypothesis applied to allergies.[citation needed] Initial reports[8] suggest that "helminthic therapy" may not only prevent but even cure (or control) IBD: a drink with roughly 2,500 ova of the Trichuris suis helminth taken twice monthly decreased symptoms markedly in many patients. It is even speculated that an effective "immunization" procedure could be developedby ingesting the cocktail at an early age.
Prebiotics and probiotics are showing increasing promise as treatments for IBD[9] and in some studies have proven to be as effective as prescription drugs.[10] More recently[when?], research[11] has shown that IL-23 is overexpressed in tissues taken from mouse models of IBD. The group showed that knocking out IL-23 (heterodimer of IL-12p40 and IL-23p19) sharply reduced inflammation of the bowel, both in terms of cells and proinflammatory cytokine production. Also, they found that a novel group of CD4+ T lymphocytes, Th17 T cells, are highly unregulated in bowels of diseased mice. Taken together, the group shows that IL-23 but not IL-12 (a heterodimer of IL-12p40 and IL-12p35) drives innate and T cell mediated intestinal inflammation. In 2005 New Scientist published a joint study by Bristol University and Bath University on the apparent healing power of cannabis on IBD. Reports that cannabis eased IBD symptoms indicated the possible existence of cannabinoid receptors in the intestinal lining, which respond to molecules in the plant-derived chemicals. CB1 cannabinoid receptors which are known to be present in the brain exist in the endothelial cells which line the gut, it is thought that they are involved in repairing the lining of the gut when damaged. The team deliberately damaged the cells to cause inflammation of the gut lining and then added synthetically produced cannabinoids; the result was that gut started to heal: the broken cells were repaired and brought back closer together to mend the tears. It is believed that in a healthy gut, natural endogenous cannabinoids are released from endothelial cells when they are injured, which then bind to the CB1 receptors. The process appears to set off a wound-healing reaction, and when people use cannabis, the cannabinoids bind to these receptors in the same way. Previous studies have shown that CB1 receptors located on the nerve cells in the gut respond to cannabinoids by slowing gut motility, therefore reducing the painful muscle contractions associated with diarrhoea. The team also discovered another cannabinoid receptor, CB2, in the guts of IBD sufferers, which was not present in healthy guts. These receptors, which also respond to chemicals in cannabis, appear to be associated with apoptosis programmed cell death and may have a role in suppressing the overactive immune system and reducing inflammation by mopping up excess cells.[12] Genetics play a crucial role in Crohn's disease but environmental factors are also involved; smoking appears to increase the risk.[citation needed]
Crohn's disease, also called regional enteritis, is a chronic inflammation of the intestines which is usually confined to the terminal portion of the small intestine, the ileum. Ulcerative colitis is a similar inflammation of the colon, or large intestine. These and other IBDs (inflammatory bowel disease) have been linked with an increased risk of colorectal cancer.
Crohn's diseaseaffected areas

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The inflammation of Crohn's disease is nearly always found in the ileocecal region. The ileocecal region consists of the last few inches of the small intestine (the ileum), which moves digesting food to the beginning portion of the large intestine (the cecum). However, Crohn's disease can occur anywhere along the digestive tract.
Normal anatomy
The gastrointestinal tract starts at the mouth, which leads to the esophagus, stomach, small intestine, colon, and finally, the rectum and anus. The GI tract is basically a long, hollow, muscular tube through which food passes and nutrients are absorbed.
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Inflammatory Bowel Disease

KidsHealth> Teens> Diseases & Conditions> Digestive System> Inflammatory Bowel Disease

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What Is IBD? Who Gets IBD? What Do Doctors Do? How Is IBD Treated?
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Digestive problems are among the most common conditions affecting Americans today. There are many different types of digestive problems, from gastrointestinal infections that make a
person miserable but pass quickly to long-term illnesses like inflammatory bowel disease (IBD). IBD is a general term that refers to illnesses that cause chronic inflammation in the intestines. If you're having diarrhea, stomach cramps, and other symptoms that make you question your digestion, you might want to learn more about the digestive system and IBD, as well as other digestive conditions.
What Is IBD?
The digestive system is the set of organs that digest food and absorb the important nutrients your body needs to stay healthy and grow. Two of the major parts of the digestive system are the small and large intestines. Just like other organs in your body, the intestines can develop problems or diseases. IBD (which is not the same thing as irritable bowel syndrome, or IBS), can cause more serious problems than just diarrhea and pain. IBD may also cause a delay in puberty or growth problems for some teens with the condition, because it can interfere with a person getting nutrients from the foods he or she eats. The two major types of IBD are Crohn's disease and ulcerative colitis. Crohn's disease occurs when the lining and wall of the intestines become inflamed and ulcers develop. Although Crohn's disease can occur in any part of the digestive system, it often occurs in the lower part of the small intestine where it joins the colon. The intestine becomes inflamed, meaning the lining of the intestinal wall reddens and swells. It can become irritated, causing it to bleed and preventing it from properly absorbing the nutrients from digested food. People with Crohn's disease usually have these symptoms:

abdominal cramps or pain diarrhea, sometimes with blood in the stool (bowel movements) fever weight loss
These symptoms often cause people with Crohn's disease to feel tired and lose their appetites. Some people with Crohn's disease have minor symptoms and hardly any discomfort or pain. Their symptoms may only flare a few times. But others may experience frequent diarrhea, intestinal ulcers, and problems in other parts of their bodies, such as inflammation of the joints, skin rashes, and eye problems. Crohn's disease can cause the intestines to become blocked by swelling and scar tissue. People with the condition may also be more susceptible to infections and developing abscesses in and around their intestines.
In ulcerative colitis, the large intestine becomes inflamed and ulcers may develop. Ulcerative colitis affects only the large intestine. The inflammation begins in the rectum (the last few inches of the large intestine where feces are stored before they leave the body) and can affect only the rectum or the part of the large intestine that joins it. However, most kids and teens who have ulcerative colitis have the condition throughout their large intestines. The most common symptoms of ulcerative colitis are abdominal pain and bloody diarrhea. But some people also experience these symptoms:

tiredness weight loss loss of appetite nausea
Some people with ulcerative colitis may have periods of time when they are free of symptoms (this is called remission) and other times when they feel sick (called relapse). Like Crohn's disease, ulcerative colitis can be associated with problems in other parts of the body. These problems may include inflammation of the joints, eye problems, and anemia due to blood loss.
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For Teens

What is inflammatory bowel disease? Inflammatory bowel disease is the name of a group of disorders that cause the intestines to become inflamed (red and swollen). The inflammation lasts a long time and usually comes back over and over again. More than 600,000 Americans have some kind of inflammatory bowel disease every year. If you have inflammatory bowel disease, you may have abdominal cramps and pain, diarrhea, weight loss and bleeding from your intestines. Two kinds of inflammatory bowel disease are Crohn's disease and ulcerative colitis. Crohn's disease usually causes ulcers (open sores) along the length of the small and large intestines. Crohn's disease either spares the rectum, or causes inflammation or infection with drainage around the rectum. Ulcerative colitis usually causes ulcers in the lower part of the large intestine, often starting at the rectum.
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What causes inflammatory bowel disease? The exact causes are unknown. The disease may be caused by a germ or by an immune system problem. You don't have to worry about your family members catching the disease from you, because it isn't contagious. However, inflammatory bowel disease does seem to be hereditary (runs in your family).
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How is inflammatory bowel disease diagnosed? Based on your symptoms, your doctor may suspect that you have Crohn's disease or ulcerative colitis. Your bowel movements may be tested for germs and the presence of blood. Your doctor will probably look inside your intestines with a sigmoidoscope or a colonoscope. In these procedures, the doctor uses a narrow flexible tube to look directly inside your intestines. Special x-rays may be helpful in diagnosing this illness.
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How is inflammatory bowel disease treated? The best thing you can do is take good care of yourself. It's important to eat a healthy diet. Depending on your symptoms, your doctor may ask you to cut down on the amount of fiber or dairy products in your diet. In addition to eating well, you need to get enough rest. It's also important that you learn to manage the stress in your life. When you become overly upset by things that happen at home or at work, your intestinal problems can get worse. You will most likely be treated by a team of doctors. This team may include your family physician, a gastroenterologist (a specialist in stomach and intestinal disorders) and, possibly, a surgeon. The goal of treatment is to get rid of the inflammation. Many types of medicine can reduce inflammation, including anti-inflammatory drugs such as sulfasalazine, corticosteroids such as prednisone, and immune system suppressors such as azathioprine and mercaptopurine. An antibiotic, such as metronidazole, may also be helpful for killing germs in the intestines, especially if you have Crohn's disease. To help treat your symptoms, your doctor may recommend anti-diarrheals, laxatives, pain relievers or other over-the-counter (OTC) drugs. It is important to talk to your doctor before taking any OTC medicine on your own. Your body may not be able to handle the effects of medicine. If you have severe symptoms, such as diarrhea, fever or vomiting, you may need to go to the hospital to be treated with special fluids and medicines that must be given intravenously (in your veins). If your ulcerative colitis becomes so severe that it can't be helped by medicines, it may be necessary to remove part or all of your colon surgically. Crohn's disease usually isn't helped with surgery. Because Crohn's disease and ulcerative colitis keep coming back and their symptoms cannot be
predicted ahead of time, patients with these illnesses can become depressed. If you feel depressed, talk with your family doctor. An antidepressant medicine could help you feel better.
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How can I get more information? By asking questions, reading informational materials and discussing your treatments with your doctor, you'll be able to understand your illness and manage it better. Patient support groups are helpful, especially if you have severe disease.
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Author: Sarvotham Kini, MD, Associate Professor of Emergency Medicine, Medical University of South Carolina, Charleston. Contributor Information and Disclosures Updated: Nov 20, 2009

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Introduction
Background
The term inflammatory bowel disease (IBD) refers to primarily ulcerative colitis (UC) and Crohn's disease (CD). These are chronic conditions of uncertain etiology, characterized by
recurrent episodes of abdominal pain, often with diarrhea. Although both ulcerative colitis and Crohn's disease have distinct pathologic findings, a significant percentage of patients with inflammatory bowel disease (IBD) have indeterminate findings. Crohn's disease is also referred to a regional enteritis, terminal ileitis, or granulomatous ileocolitis.
Pathophysiology
Multiple etiologies have been proposed for inflammatory bowel disease (IBD), but the precise cause is unknown. However, considerable evidence suggests that inflammatory mediators play an important role in the pathologic and clinical characteristic of these disorders. Cytokines, released by macrophages in response to various antigenic stimuli, bind to different receptors and produce autocrine, paracrine, and endocrine effects. Cytokines differentiate lymphocytes into different types of T cells. Helper T cells, type 1 (Th-1), are associated principally with Crohn's disease, whereas Th-2 cells are associated principally with ulcerative colitis. The immune response disrupts the intestinal mucosa and leads to a chronic inflammatory process.1 In ulcerative colitis (UC), inflammation begins in the rectum and extends proximally in an uninterrupted fashion to the proximal colon, eventually involving the entire length of the large intestine. The rectum is always involved in ulcerative colitis, and no "skip areas" (ie, normal areas of the bowel interspersed with diseased areas) are present. Ulcerative colitis primarily involves the mucosa and the submucosa, with formation of crypt abscesses and mucosal ulceration. The mucosa typically appears granular and friable. In more severe cases, pseudopolyps form, consisting of areas of hyperplastic growth with swollen mucosa surrounded by inflamed mucosa with shallow ulcers. In severe ulcerative colitis, inflammation and necrosis can extend below the lamina propria to involve the submucosa and the circular and longitudinal muscles, although this is very unusual. Ulcerative colitis remains confined to the rectum in approximately 25% of cases. In the remainder of cases, ulcerative colitis spreads proximally and contiguously. Pancolitis occurs in 10% of patients. The small intestine is never involved, except when the distal terminal ileum is inflamed in a superficial manner, referred to as backwash ileitis. Even with less than total colonic involvement, the disease is strikingly and uniformly continuous. As the disease becomes chronic, the colon becomes a rigid foreshortened tube that lacks its usual haustral markings, leading to the lead pipe appearance observed on barium enema. The skip areas observed in the colon in Crohn's disease do not occur in ulcerative colitis. Crohn's disease, on the other hand, consists of segmental involvement by a nonspecific granulomatous inflammatory process. The most important pathologic feature is that Crohn's disease is transmural, involving all layers of the bowel, not just the mucosa and the submucosa, which is characteristic of ulcerative colitis. Crohn's disease can affect any portion of the gastrointestinal tract from the mouth to the anus. Furthermore, Crohn's disease is discontinuous, with skip areas interspersed between one or more involved areas. Late in the disease, the mucosa develops a cobblestone appearance, which results from deep longitudinal ulcerations interlaced with intervening normal mucosa. The 3 major patterns of involvement in Crohn's disease are (1) disease in the ileum and cecum (occurring in 40% of
patients), (2) disease confined to the small intestine (occurring in 30% of patients), and (3) disease confined to the colon (occurring in 25% of patients). Rectal sparing is a typical but not constant feature of Crohn's disease. However, anorectal complications (eg, fistulas, abscesses) are common. Much less commonly, Crohn's disease involves the more proximal parts of the gastrointestinal (GI) tract, including the mouth, tongue, esophagus, stomach, and duodenum. Crohn's disease causes 3 patterns of involvement: inflammatory disease, strictures, and fistulas. Ulcerative colitis and Crohn's disease are generally diagnosed using clinical, endoscopic, and histologic criteria. Histologically, transmural non-necrotizing lymphoid granulomas are characteristic of Crohn's disease. However, they may not be found in a given case of Crohn's disease, and no single finding is absolutely diagnostic for one disease or the other. Furthermore, approximately 20% of patients have a clinical picture that falls between Crohn's disease and ulcerative colitis; they are said to have indeterminate colitis. The incidence of gallstones and kidney stones is increased in Crohn's disease because of malabsorption of fat and bile salts. Gallstones are formed because of increased cholesterol concentration in the bile, caused by a reduced bile salt pool. Patients who have Crohn's disease with ileal disease or resection also are likely to form calcium oxalate kidney stones. With the fat malabsorption, unabsorbed long-chain fatty acids bind calcium in the lumen. Oxalate in the lumen normally is bound to calcium. Calcium oxalate is poorly soluble and poorly absorbed; however, if calcium is bound to malabsorbed fatty acids, oxalate combines with sodium to form sodium oxalate, which is soluble and is absorbed in the colon (enteric hyperoxaluria). The development of calcium oxalate stones in Crohn's disease requires an intact colon to absorb oxalate. Patients with ileostomies do not develop calcium oxalate stones. Extraintestinal manifestations of inflammatory bowel disease (IBD) include iritis, episcleritis, arthritis, and skin involvement, as well as pericholangitis and sclerosing cholangitis. These extraintestinal manifestations (EIM) are observed in up to 20-40% of patients with IBD.2
Frequency United States
The incidence is 70-150 cases per 100,000 individuals. The incidence of inflammatory bowel disease (IBD) varies within different geographic areas. Crohn's disease (CD) and ulcerative colitis (UC) both occur at the highest incidence in Europe, the United Kingdom, and North America.
International
The incidence of inflammatory bowel disease (IBD) ranges from 2.2-14.3 cases per 100,000 person-years for ulcerative colitis and from 3.1-14.6 cases per 100,000 person-years for Crohn's disease. Overall, the combined incidence for inflammatory bowel disease is 10 cases per 100,000 annually.3,4
Mortality/Morbidity
The quality of life generally is lower in those with Crohn's disease than in those with ulcerative colitis, in part because of recurrences after surgery performed for Crohn's disease.

The most common causes of death in inflammatory bowel disease (IBD) are peritonitis with sepsis, malignancy, thromboembolic disease, and complications of surgery. Toxic megacolon, one of the most dreaded complications of ulcerative colitis, can lead to perforation, sepsis, and death. Malnutrition and chronic anemia are observed in long-standing Crohn's disease. Children with Crohn's disease or ulcerative colitis can exhibit growth retardation.
Race

Incidence among whites is approximately 4 times that of other races. IBD is observed most commonly in Northern Europe and North America. It is a disease of industrialized nations. Incidence is higher in Ashkenazi Jews (ie, those who have immigrated from Northern Europe) than in other groups.
Sex
Incidence is slightly greater in females than in males.
Age

Incidence peaks in the second and third decades of life. A second smaller peak occurs in patients aged 55-65 years. Crohn's disease and ulcerative colitis can occur in childhood, although the incidence is much lower in children younger than 15 years.
Clinical
History
Patients with ulcerative colitis (UC) most commonly present with bloody diarrhea, whereas patients with Crohn's disease (CD) usually present with nonbloody diarrhea. o Abdominal pain and cramping, fever, and weight loss occur in more severe cases. o The greater the extent of colon involvement, the more likely the patient is to have diarrhea. o Rectal urgency or tenesmus reflects reduced compliance of the inflamed rectum. o Patients might have formed stools if their disease is confined to the rectum. o As the degree of inflammation increases, systemic symptoms develop, including lowgrade fever, malaise, nausea, vomiting, sweats, and arthralgias. o Fever, dehydration, and abdominal tenderness develop in severe ulcerative colitis, reflecting progressive inflammation into deeper layers of the colon.
The presentation of Crohn's disease is generally more insidious than that of ulcerative colitis, with ongoing abdominal pain, anorexia, diarrhea, weight loss, and fatigue. o Grossly bloody stools, while typical of ulcerative colitis, are less common in Crohn's disease. o Stools may be formed, but loose stools predominate if the colon or the terminal ileum is involved extensively. o One half of patients with Crohn's disease present with perianal disease (eg, fistulas, abscesses). o Occasionally, acute right lower quadrant pain and fever, mimicking appendicitis, may be noted. o Commonly, the diagnosis is established only after several years of recurrent abdominal pain, fever, and diarrhea. Crohn's disease with gastroduodenal involvement may mimic peptic ulcer disease and can progress to gastric outlet obstruction. Many patients with inflammatory bowel disease (IBD) have irritable bowel syndrome, which can produce occasional cramping, irregular bowel habits, and passage of mucus without blood or pus. Weight loss is observed more commonly in Crohn's disease than in ulcerative colitis because of the malabsorption associated with small bowel disease. Patients may reduce their food intake in an effort to control their symptoms. Systemic symptoms are common and include fever, sweats, malaise, and arthralgias. A lowgrade fever may be the first warning sign of a flare. Recurrences may occur with emotional stress, infections or other acute illnesses, pregnancy, dietary indiscretions, use of cathartics or antibiotics, or withdrawal of anti-inflammatory or steroid medications. Children may present with growth retardation and delayed or failed sexual maturation. In 10-20% of cases, patients present with extraintestinal manifestations, including arthritis, uveitis, or liver disease.
Physical

Fever, tachycardia, dehydration, and toxicity may occur. Pallor may be noted, reflecting anemia. The magnitude of these factors is related directly to the severity of the attack. Evaluate for signs of localized peritonitis, although abdominal tenderness is common. Patients with toxic megacolon appear septic. They have high fever; lethargy; chills; tachycardia; and increasing abdominal pain, tenderness, and distention. Patients with Crohn's disease may develop a mass in the right lower quadrant. The rectal examination often reveals bloody stool on gross or Hemoccult examination. Complications (eg, perianal fissures or fistulas, abscesses, rectal prolapse) may be observed in up to 90% of patients with Crohn's disease. The physical examination should include a search for extraintestinal manifestations, such as iritis, episcleritis, arthritis, and dermatologic involvement.
Distinguishing Features of Crohn's Disease Versus Ulcerative Colitis Open table in new window
[ CLOSE WINDOW ] Table Features Skip areas Cobblestone mucosa Crohns Disease Ulcerative Colitis Common Common Never Rare Occasional Never Never Never Occasional Occasional
Transmural involvement Common Rectal sparing Perianal involvement Fistulas Strictures Granulomas Features Skip areas Cobblestone mucosa Common Common Common Common Common
Crohns Disease Ulcerative Colitis Common Common Never Rare Occasional Never Never Never Occasional Occasional
Transmural involvement Common Rectal sparing Perianal involvement Fistulas Strictures Granulomas Causes
Common Common Common Common Common
The etiology of inflammatory bowel disease (IBD) is unknown. Environmental, infectious, genetic, autoimmune, and host factors have been suspected. Interactions among these factors may be more important. o Inflammatory mediators
Interleukin-1 Tumor necrosis factoralpha (TNF-alpha) o Aggravation by bacterial infection and inflammatory cascade o Positive family history: The most important risk factor for developing IBD is a positive family history. The risk of developing ulcerative colitis is higher in nonsmokers and former smokers than in current smokers. The onset of ulcerative colitis occasionally appears to coincide with smoking cessation. This does not imply that smoking would improve the symptoms of ulcerative colitis. Interestingly, some success in the use of nicotine patches has been reported. On the contrary, patients with Crohn's disease have a higher incidence of smoking than the general population, and those patients with Crohn's disease who continue to smoke appear to be less likely to respond to medical therapy.
More on Inflammatory Bowel Disease Overview: Inflammatory Bowel Disease Differential Diagnoses & Workup: Inflammatory Bowel Disease Treatment & Medication: Inflammatory Bowel Disease Follow-up: Inflammatory Bowel Disease Multimedia: Inflammatory Bowel Disease References
Inflammatory Bowel Disease: Differential Diagnoses & Workup


Overview Differential Diagnoses & Workup Treatment & Medication Follow-up Multimedia
References Keywords Information from Industry
Bacterial RTIs: Consider the importance of broad-spectrum coverage See coverage in communityacquired pneumonia (CAP) Read more
Differential Diagnoses
Appendicitis, Acute Diverticular Disease Endometriosis Pelvic Inflammatory Disease
Other Problems to Be Considered
AIDS (The chronic diarrhea and diffuse colonic involvement of Kaposi sarcoma may mimic chronic UC.) Antibiotic-associated colitis Arteriovenous malformations Collagenous colitis Colon cancer Fever of unknown origin Infectious colitis (if confined to the rectum, rule out "gay bowel syndrome") Intestinal lymphoma Irritable bowel syndrome (can be present along with IBD): In IBS, diarrhea often alternates with constipation. In contrast to IBD, IBS is not associated with blood in the stool, nocturnal diarrhea, weight loss, or other inflammatory sequelae (eg, fever, arthritis, skin or eye lesions, perianal disease). Fecal WBCs are not observed in IBS. Ischemic colitis Pseudomembranous colitis Radiation-induced colitis
Workup
Laboratory Studies
CBC with differential o Anemia may result from acute or chronic blood loss or malabsorption (iron, folate, vitamin B-12) or may reflect the chronic disease state. o Leukocytosis, anemia, and thrombocytosis are common. A modestly elevated WBC is observed in active disease, but a marked elevation suggests the presence of an abscess or other suppurative complication.
Erythrocyte sedimentation rate: The sedimentation rate is typically elevated and has been used to monitor disease activity. Serum chemistry o Hypokalemia reflects the severity of the diarrhea. o Abnormal liver function test results may represent pericholangitis or sclerosing cholangitis, which are complications of inflammatory bowel disease . o Hypoalbuminemia, resulting from protein-losing enteropathy, suggests extensive colitis. o Decreased serum calcium level may reflect reduced serum albumin level. Type and crossmatch: Consider obtaining a type and crossmatch, especially in patients presenting with bloody diarrhea . Stool examination: Send stool for fecal leukocytes, ova and parasite studies, bacterial pathogens culture, and Clostridium difficile titer. o Amebiasis can be difficult to identify from the stool. Consider serologic testing in this regard. o As many as 50-80% of cases of acute terminal ileitis are due to Yersinia enterocolitis infections. This produces a picture of pseudoappendicitis. Yersiniosis also has a high frequency of secondary manifestations, such as erythema nodosum and monarticular arthritis, similar to IBD. Blood culture: Cultures may be positive if peritonitis or fulminant colitis is present. Serologic tests: Serologic tests have become available to aid in the diagnosis of inflammatory bowel disease (IBD) and differentiate between Crohn's disease and ulcerative colitis. Perinuclear antineutrophil cytoplasmic antibodies (pANCA) have been identified in some patients with ulcerative colitis, and anti-Saccharomyces cerevisiae antibodies (ASCA) have been found in patients with Crohn's disease. Furthermore, those patients with inflammatory bowel disease who are seronegative appear to have a lower incidence of resistant disease. Currently, these markers are not sensitive enough to be used as screening tests for inflammatory bowel disease.5
Imaging Studies
Upright chest radiography and abdominal series o Evaluate for an edematous irregular colon with "thumb printing." Occasionally, pneumatosis coli (air in the colonic wall) may be present. o Look for free air and especially for evidence of toxic megacolon, depicted in the image below, which appears as a long continuous segment of air-filled colon greater than 6 cm in diameter.
o
Inflammatory bowel disease. Toxic megacolon. Courtesy of Dr Pauline Chu. [ CLOSE WINDOW ]
Inflammatory bowel disease. Toxic megacolon. Courtesy of Dr Pauline Chu. In the supine position, dilatation is predominantly noted in the transverse colon secondary to air collection. o Repeat radiographs at 12- to 24-hour intervals to monitor the course of dilatation and to assess the need for emergency colectomy. o Associated findings include nephrolithiasis, cholelithiasis, or arthritis of the spine or the sacroiliac joints. Barium enema o In ulcerative colitis, a barium enema (BE) may reveal a shortened colon, with loss of haustrations and destruction of the mucosal pattern (ie, lead pipe colon). o Skip areas and rectal sparing are noted in Crohn's disease. o Barium enema is contraindicated in patients with moderate-to-severe colitis because it risks perforation or precipitation of a toxic megacolon. Upper GI with small bowel follow-through o In Crohn's disease, areas of segmental narrowing with loss of normal mucosa, fistula formation, and the string sign (a narrow band of barium flowing through an inflamed or scarred area) in the terminal ileum are typically observed. o Some patients with ulcerative colitis also demonstrate inflammatory changes in the terminal ileum (ileitis), but they lack the skip pattern characteristic of Crohn's disease. CT scanning and ultrasonography: CT scanning and ultrasonography are best for demonstrating intra-abdominal abscesses, mesenteric inflammation, and fistulas. MRI may be of help in detecting fistulas and abscesses. More recently, wireless capsule endoscopy, used most often to investigate the source of GI bleeding, has been found useful in diagnosing mucosal lesions in Crohn's disease. The detection rate of abnormalities was 70.5% for patients with suspected small bowel disease, and the diagnostic yield for patients with obscure gastrointestinal bleeding was higher than that for patients with abdominal pain or diarrhea (85.7% vs 53.3%, P<0.005).6
o
Procedures

Findings on sigmoidoscopy may be diagnostic in ulcerative colitis because the rectum is always involved. The mucosal surface becomes irregular and friable, bleeds easily when touched, and may have pseudopolyps. Because of the degree of sensitivity, a colonoscopy is recommended for making the diagnosis and for evaluating the extent and severity of disease. Procedures should be avoided in acutely ill patients. Guidelines on the use of endoscopy in the diagnosis and management of inflammatory bowel disease are available from the American Society for Gastrointestinal Endoscopy.7
Inflammatory Bowel Disease: Treatment & Medication

Treatment
Emergency Department Care

Initiate supportive care with bowel rest, nasogastric suction, and intravenous (IV) fluids containing electrolytes. Admit for toxicity, obstruction, hemorrhage, or localized peritonitis. Monitor severe cases for fat malabsorption. Treat perirectal disease. o Sitz baths o Soap and water after stooling o Surgical drainage of perirectal abscesses o Surgical treatment of recurrent fistulas if medical management fails Administer folate supplementation as needed.
Consultations

Consult a surgeon for complicating obstruction, hemorrhage, perforation, abscess or fistula formation, toxic megacolon, or perianal disease. Consider surgical intervention for patients in whom medical therapy fails. The 2 most common choices today (for ulcerative colitis) are proctocolectomy with ileostomy and total colectomy with ileoanal anastomosis. Elective surgery can sometimes be performed laparoscopically. For
fulminant colitis, the surgical procedure of choice consists of a subtotal colectomy with end ileostomy and creation of a Hartman pouch. In Crohn's disease, surgically resect only as much bowel as necessary to correct the problem because the recurrence rate after surgery approaches 100%. Patients with toxic megacolon initially require nasogastric suction and IV steroids. Failure to improve within 48 hours is an indication for total colectomy. Extracolonic manifestations (ie, uveitis, arthritis, dermatitis, sclerosing cholangitis) are best managed with the aid of specialty consultation.
Medication
Therapy for Crohn's disease generally is less effective than that for ulcerative colitis. In addition to the therapies outlined herein, intravenous cyclosporine is helpful in refractory ulcerative colitis. Zileuton, a 5-lipoxygenase inhibitor, has shown some efficacy in treating Crohn's disease. Hyperbaric oxygen therapy may be helpful in the treatment of inflammatory bowel disease (IBD) that is unresponsive to other therapies. Its therapeutic efficacy appears to result from decreased generation of prostaglandin E2. Previous work has linked mucosal prostaglandin E2 to the intestinal damage associated with IBD.8 Agents for symptomatic treatment include loperamide and the combination of diphenoxylate and atropine, which are useful in mild disease to reduce the number of bowel movements and to relieve rectal urgency. Cholestyramine, a resin that binds bile salts, is useful for reducing diarrhea in patients with Crohn's disease who have had ileal resections. The anticholinergic agent dicyclomine may help relieve intestinal spasms. Antidiarrheal and anticholinergic medications must be avoided in acute severe disease because they may precipitate toxic megacolon. Avoid the long-term use of narcotics for pain. An iron supplement should be added when significant rectal bleeding is present.
Antidiarrheal agents
These agents inhibit peristalsis in the GI tract.
Loperamide (Imodium)
Acts in intestinal muscles to inhibit peristalsis and to slow intestinal motility. Prolongs movement of electrolytes and fluid through bowel; increases viscosity and loss of fluids and electrolytes.

Dosing Interactions Contraindications Precautions
Adult
Initial dose: 4 mg PO Maintenance: 2 mg PO after each loose stool; not to exceed 16 mg/d
Pediatric
<2 years: Not established 2-6 years: 1 mg PO tid initially; followed by 0.1 mg/kg PO after each loose stool; not to exceed 1 mg tid 6-8 years: 2 mg PO bid initially; followed by 0.1 mg/kg PO after each loose stool; not to exceed 2 mg bid 8-12 years: 2 mg PO tid initially; followed by 0.1 mg/kg PO after each loose stool; not to exceed 2 mg tid >12 years: Administer as in adults Chronic diarrhea: 0.08-0.24 mg/kg/d PO divided bid/tid; not to exceed 2 mg/dose

Phenothiazines, tricyclic antidepressants, and CNS depressants may increase toxicity

Documented hypersensitivity; diarrhea resulting from infection; pseudomembranous colitis

Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Discontinue use if no clinical improvement is noted in 48 h; because metabolized primarily in liver, monitor for CNS toxicity in patients with hepatic insufficiency; do not use if high fever or blood in stool coincides with diarrhea
Diphenoxylate and Atropine (Lomotil)
Drug combination that consists of diphenoxylate, a constipating meperidine congener, and subtherapeutic amount of atropine to discourage abuse. Inhibits excessive GI propulsion and motility.

Adult
15-20 mg/d PO tid/qid; followed by 5-15 mg/d

Pediatric
<2 years: Not recommended >2 years: 0.3-0.4 mg/kg/d PO divided qid 2-5 years: 2 mg PO tid 5-8 years: 2 mg PO qid 8-12 years: 2 mg PO 5 times/d >12 years: Administer as in adults

May delay metabolism of drugs by liver; CNS depressants, MAOIs, and antimuscarinic agents may increase toxicity

Documented hypersensitivity; narrow-angle glaucoma; hepatic insufficiency

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Dehydration may influence variability of response in young children, predisposing them to delayed diphenoxylate intoxication; caution in patients with UC; decrease in intestinal motility may be detrimental to patients with diarrhea resulting from Shigella and Salmonella species and toxigenic strains of Escherichia coli
Cholestyramine (Questran)
Useful in treating diarrhea associated with pseudomembranous colitis. Inhibits enterohepatic reuptake of intestinal bile salts by forming nonabsorbable complex with bile acids in intestine.

Adult
4 g PO qd/bid; not to exceed 24 g/d or 6 doses/d

Pediatric
240 mg/kg/d PO divided tid

Inhibits absorption of numerous drugs, including warfarin, thyroid hormone, amiodarone, NSAIDs, methotrexate, digitalis glycosides, glipizide, phenytoin, imipramine, niacin, methyldopa, tetracyclines, clofibrate, hydrocortisone, and penicillin G

Documented hypersensitivity

Pregnancy
Precautions
Caution in constipation and phenylketonuria

Antispasmodic agents
These agents are used to treat functional disturbances of GI motility.
Dicyclomine (Bentyl)
Useful in treating GI motility disturbances; blocks action of acetylcholine at parasympathetic sites in secretory glands, smooth muscle, and CNS.

Adult
80 mg/d PO divided qid initially, then increase to 160 mg/d

Pediatric
10 mg/dose PO tid/qid

Effects are weakened when administered with anti-Parkinson drugs, haloperidol, and phenothiazines; toxicity increases when administered concurrently with amantadine, antihistamines, type I antiarrhythmics, phenothiazines, TCAs, or narcotic analgesics

Documented hypersensitivity; myasthenia gravis; narrow-angle glaucoma

Pregnancy
Precautions
Caution when administering to patients with hepatic or renal insufficiency, cardiovascular disease, urinary tract obstruction, UC, GI obstruction, hyperthyroidism, or hypertension
Aminosalicylates
These agents are effective for treating acute ulcerative colitis (UC) and for maintaining its remission; they are also beneficial in mildly to moderately active Crohn's disease (CD) when the colon is involved. Sulfasalazine has not been clearly shown to maintain remission in CD. Furthermore, there is some question as to its effectiveness versus small bowel disease. Newer aminosalicylate preparations without sulfapyridine (eg, 5-aminosalicylic acid [5-ASA]) were developed because tolerance of sulfasalazine has been limited by the sulfa-containing moiety. Because free 5-ASA is absorbed rapidly from the proximal GI tract, it has been modified in the newer formulations. Olsalazine consists of two 5-ASA molecules linked together by an azo bond. Intestinal bacteria cleave the bond, which enables olsalazine to work, primarily in the colon. Additional formulations of 5-ASA (mesalamine) are Asacol, Pentasa, Rowasa, and Balsalazide. Asacol is composed of 5-ASA coated in a pH-dependent acrylic resin, which allows delayed release of 5-ASA in the distal ileum and the right colon. Pentasa consists of 5-ASA encapsulated into microgranules of ethylcellulose and released continuously throughout the GI tract. Therefore, it is useful in patients with CD involvement of the small bowel and the colon. Rowasa contains 5-ASA in suppository or enema formulations, which are useful for treating and maintaining remissions in ulcerative proctitis and proctosigmoiditis. Balsalazide is mesalamine
linked to an inert carrier molecule. In the colon, bacteria cleave the bond and release free mesalamine. Because oral aminosalicylates interfere with folate absorption, folic acid supplementation (1 mg/d) should be given.
Sulfasalazine (Azulfidine)
Combination of 5-ASA or mesalamine and sulfapyridine. Taken PO, remains intact until it reaches terminal ileum and colon, where it is split by bacteria into its 2 moieties. Active portion appears to be 5-ASA, which inhibits prostaglandin synthesis; sulfa portion is absorbed and causes most adverse reactions. Abdominal discomfort common. Folate deficiency may result from competition between folate and sulfasalazine for absorption.

Adult
3-4 g PO qd in divided doses

Pediatric
<2 years: Not established >2 years: 30 mg/kg PO divided qid

Decreases effects of iron, digoxin, and folic acid; increases effects of PO anticoagulants, PO hypoglycemic agents, and methotrexate

Documented hypersensitivity; GI or GU obstruction

Dosing Interactions
Contraindications Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with renal or hepatic impairment, blood dyscrasias, or urinary obstruction
Olsalazine (Dipentum)
Alternate treatment for patients who do not tolerate sulfasalazine. Useful in maintaining remission in UC; exerts anti-inflammatory activity in UC.

Adult
500 mg PO bid
Pediatric
Not established

None reported

Pregnancy
Precautions
Relatively high incidence of diarrhea may be dose related (unclear whether other underlying causes may contribute)
Mesalamine (Asacol, Pentasa, Rowasa, Canasa)
Treats mildly to moderately active UC. Usual course of therapy in adults is 3-6 wk. Some patients may need concurrent PR and PO therapy.

Adult
Cap: 1 g PO qid Tab: 800 mg PO tid Rectal supp: Insert 1 PR bid

Pediatric
Not established

Decreases effects of iron, digoxin, and folic acid; mesalamine increases effect of PO anticoagulants, methotrexate, and PO hypoglycemic agents

Pregnancy
Precautions
Elderly patients may have difficulty administering and retaining rectal suppositories; caution in renal or hepatic impairment
Corticosteroids
These agents are the treatments of choice for an acute inflammatory bowel disease (IBD) attack; administer IV in severe disease. Give increased or stress doses to patients already on steroids. Do not use steroids for maintaining remission because of their lack of efficacy9 and potential complications, including avascular necrosis, osteoporosis, cataracts, emotional lability, hypertension, diabetes mellitus, cushingoid features, acne, and facial hair. Cortenema, Cortifoam, and Anusol-HC suppositories are useful in treating distal disease (proctitis and proctosigmoiditis). Budesonide (Entocort EC), a synthetic corticosteroid, is available for Crohn's disease (CD) with ileal or ileocecal involvement.10 It is indicated for PO treatment to induce remissions of attacks of mild-to-moderate severity involving the ileum and/or ascending colon.9 The drug contains budesonide granules in an ethylcellulose matrix coated with a methacrylic acid polymer. The coating, which requires a pH more than 5.5 to dissolve, prevents release of the drug in the stomach. The ethylcellulose matrix delays release further until the drug reaches the ileum and ascending colon. A potential advantage is that fewer adverse effects occur than with the use of systemic corticosteroids. However, some absorption occurs and may slow growth in adolescents.
Prednisone (Sterapred)
Used as immunosuppressant in treatment of autoimmune disorders; may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Adult
5-60 mg/d PO qd or divided bid/qid

Pediatric
4-5 mg/m2/d PO; alternatively, 1-2 mg/kg PO qd; not to exceed 60 mg/d; taper over 2 wk as symptoms resolve

Estrogens may decrease clearance; concurrent digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; viral, fungal, or tubercular skin infections

Pregnancy
Precautions
Abrupt discontinuation may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur
Methylprednisolone (Adlone, Medrol, Solu-Medrol)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and increasing permeability or capillaries.

Adult
125-250 mg IV loading dose, followed by maintenance dose of 0.5-1 mg/kg/dose IV q6h for up to 5 d
Pediatric
2 mg/kg IV loading dose, followed by maintenance dose of 0.5-1 mg/kg/dose IV q6h for up to 5 d

Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels; phenobarbital, phenytoin, and rifampin may decrease levels (adjust dose); monitor patients for hypokalemia when taking concurrently with diuretics


Pregnancy
Precautions
Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications
Hydrocortisone (Anusol-HC, Anuprep HC)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Adult
10-100 mg PR qd/bid for 2-3 wk

Pediatric
Not established

Clearance may decrease with estrogens; may increase digitalis toxicity secondary to hypokalemia


Pregnancy
Precautions
Caution in hyperthyroidism, osteoporosis, peptic ulcer, cirrhosis, nonspecific UC, diabetes mellitus, and myasthenia gravis
Immunosuppressants
These agents are useful as steroid-sparing agents, in healing fistulas, or when the patient has serious contraindications to surgery.9 They are used in patients refractory to or unable to tolerate steroids. Some agents, including azathioprine and its metabolite, 6-mercaptopurine, have been useful in Crohn's disease (CD) complicated by recurrent rectal fistulas or perianal disease; response can take up to 6 months. Methotrexate has also been tried.
Azathioprine (Imuran)
Inhibits mitosis and cellular metabolism by antagonizing purine metabolism and inhibiting synthesis of DNA, RNA, and proteins; these effects may decrease proliferation of immune cells and result in lower autoimmune activity.

Adult
1 mg/kg/d PO for 6-8 wk; increase by 0.5 mg/kg PO q4wk until response noted; not to exceed 2.5 mg/kg/d
Pediatric
Initial dose: 2-5 mg/kg/d PO/IV Maintenance dose: 1-2 mg/kg/d PO

Allopurinol increases toxicity; ACE inhibitors may induce severe leukopenia; may increase levels of methotrexate metabolites and decrease effects of anticoagulants, neuromuscular blockers, and cyclosporine


Pregnancy
Precautions
Increases risk of neoplasia; caution with liver disease and renal impairment; hematologic toxic effects may occur; check TPMT level before therapy and monitor liver, renal, and hematologic functions; pancreatitis is rarely associated
Antibiotics
Institute parenteral antibiotics active against coliforms and anaerobes for fulminant disease, including toxic megacolon. Agents may include metronidazole or ampicillin or a cephalosporin and an aminoglycoside.
Metronidazole (Flagyl)
Useful in treating fulminant disease; used successfully in CD complicated by perianal ulcers and perirectal abscesses and fistulas; unclear whether drug is active because of its antibacterial properties or through some other mechanism.

Adult
20 mg/kg/d PO in divided doses

Pediatric
Not established

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol


Pregnancy
Precautions
Adverse reactions include peripheral neuropathy, possible carcinogenesis, and mutagenesis; adjust dose in patients with severe hepatic disease (may metabolize metronidazole slowly); monitor patients for seizures and development of peripheral neuropathy
Tumor necrosis inhibitors
Infliximab (Remicade), given intravenously, consists of monoclonal antibodies to TNF-alpha. Infliximab is approved by the FDA for use in IBD.11 Infliximab is somewhat more effective against CD than UC. The drug appears to promote mucosal healing, which not even prednisone does. Furthermore, it heals perianal and enterocutaneous fistulae and has been shown to reduce signs and symptoms, achieve clinical remission and mucosal healing, and eliminate
corticosteroid use.12 Infliximab is indicated for patients who have experienced inadequate response to conventional therapy.9 Etanercept (Enbrel) is a TNF receptor fusion protein that binds to TNF-alpha and TNF-beta, blocking their interaction with TNF receptors. Although it is approved for the treatment of moderate-to-severe rheumatoid arthritis, it has also been used investigationally for CD, although such use is not yet approved. Etanercept can cause an increased risk of infections, which can be serious and life threatening.
Certolizumab pegol (Cimzia)
Pegylated anti-TNFalpha blocker, which results in disruption of the inflammatory process. Indicated for moderate-to-severe Crohn disease in individuals who have not responded to conventional therapies.

Adult
400 mg SC initially; repeat at weeks 2 and 4; if favorable response occurs, initiate maintenance dose of 400 mg SC q4wk Administer as 2 separate 200-mg SC injections at 2 separate sites in abdomen or thigh
Pediatric
Not established

May interfere with immune response to live-virus vaccines (eg, MMR) and may reduce efficacy; coadministration with anakinra (an interleukin-1 antagonist that also blocks TNF) may cause additive adverse effects, particularly development of serious infections; may interfere with activated partial thromboplastin time tests


Pregnancy
Precautions
Common adverse effects include headache, upper respiratory tract infections, abdominal pain, injection site reactions, and nausea; increases risk of serious infections, including infections that may result in hospitalization or death; may increase risk of opportunistic infections (eg, tuberculosis, invasive fungal), so test for latent tuberculosis, and, if positive, initiate tuberculosis treatment prior to starting certolizumab; if infection occurs, patients should contact their physician immediately; may cause reactivation of hepatitis B virus; may increase risk of lymphoma and other malignancies because of immune suppression; anaphylaxis or serious allergic reactions, demyelinating disease, cytopenias, pancytopenia, heart failure, and lupuslike syndrome have been reported with TNF blockers
Infliximab (Remicade)
Neutralizes cytokine TNF-alpha and inhibits binding to TNF-alpha receptor.

Adult
5 mg/kg IV as single infusion When long-term administration is needed, an induction dose of 5 mg/kg IV infusion at 0, 2, and 6 wk is administered, then 5 mg/kg q8wk for maintenance IV infusion must be administered over at least 2 h; must use infusion set with in-line, sterile, nonpyrogenic, low-protein-binding filter (pore size <1.2 m)
Pediatric
Induction: 5 mg/kg IV infusion; repeat for a total of 3 doses at 2, and 6 wk
Inflammatory Bowel Disease: Follow-up


Follow-up
Further Outpatient Care

Nutritional support in Crohn's disease includes supplementation with trace metals, fat-soluble vitamins, and medium-chain triglycerides. A low-oxalate diet with citrate supplementation helps reduce the risk of nephrolithiasis. Oral calcium or cholestyramine may serve as an intestinal oxalate binder. Encourage the patient to join an IBD support group, such as the Crohn's and Colitis Foundation of America (386 Park Avenue South, 17th Floor; New York, NY 10016; 1-800-932-2423).
Complications
Perforation and toxic megacolon are the most dreaded complications of ulcerative colitis (UC). Perforation can occur in the presence of fulminating disease, even in the absence of toxic megacolon. o The mortality rate is 50% if perforation occurs. o Suspect toxic megacolon in a patient with fulminant ulcerative colitis, especially if the number of daily stools has declined sharply without a corresponding improvement in
symptoms. The abdomen is typically distended, tender, and tympanitic. Toxic megacolon can be precipitated by antidiarrheal agents, hypokalemia, narcotics, cathartics, and enemas, including barium enemas. The best method of diagnosing toxic megacolon is through the use of plain radiography. Toxic megacolon occurs predominantly in the transverse colon, probably because air collects there in the supine position. The transverse colon is dilated, usually more than 8 cm. Dilation more than 6 cm is considered to be abnormal. A colectomy is required if no improvement occurs within 24-48 hours. Strictures usually are benign but can lead to obstruction. Fistulas and abscesses are much more common in Crohn's disease, but they are observed in about 20% of patients with ulcerative colitis. o Fistula types include enterovesical (leading to recurrent urinary tract infections and pneumaturia), enteroenteric, enteromesenteric, enterocutaneous, rectovaginal, and perianal. o Additional problems include stenosis and obstruction. o Perianal complications occur in 90% of patients with Crohn's disease. o In Crohn's disease, obstructive hydronephrosis may result from a right lower quadrant inflammatory mass, leading to external compression of the right ureter. Massive hemorrhage occurs in fewer than 1% of patients. Cancer concerns are as follows: o Ulcerative colitis carries a 10- to 30-fold increase in development of carcinoma of the colon. o Risk increases with extent and duration of the disease. o Cumulative risks of cancer after 15, 20, and 25 years are 8%, 12%, and 25%, respectively. o Perform periodic colonoscopies with biopsies, especially in patients with pancolitis. Most authors recommend beginning surveillance approximately 10 years after onset of disease and repeating surveillance at 1- to 2-year intervals. Evidence currently does not support the need for cancer surveillance in Crohn's disease. o The risk of cancer in Crohn's disease may be equal to that of ulcerative colitis if the entire colon is involved. Hence, screening may be beneficial for patients with Crohn's disease who have pancolitis. The risk of small intestinal malignancy in Crohn's disease is increased. However, the malignancy is as likely to arise in a normal as in an inflamed area, and no screening protocol has ever been demonstrated to be effective against small bowel Crohn's disease. Extraintestinal complications occur in approximately 20% of patients with inflammatory bowel disease (IBD). In some cases, they may be more problematic than the bowel disease itself. o Arthritic Peripheral arthritis, usually migratory and monoarticular, tends to parallel disease activity but may antedate it. Ankylosing spondylitis is associated with human leukocyte antigen-B27 (HLAB27). o Ocular Episcleritis, shown in the image below, manifests with burning eyes and scleral injection and is observed in 3-4% of IBD cases. Episcleritis parallels the course of the disease and resolves with treatment of the IBD. Topical steroids may be administered.
Inflammatory bowel disease. Episcleritis. Courtesy of Dr David Sevel. [ CLOSE WINDOW ]
Inflammatory bowel disease. Episcleritis. Courtesy of Dr David Sevel. Iritis, which manifests as an acute painful red eye with photophobia and conjunctival injection, often runs a course independent of intestinal disease. It can progress to blindness. Treatment is with topical or systemic steroids. Cataracts are associated with long-term steroid use. Patients taking long-term steroids should have an annual slit-lamp examination. Dermatologic Erythema nodosum is characterized by painful, tender, raised red or violaceous subcutaneous nodules, usually found over the extensor aspects of the arms and the legs, especially the anterior tibia. Activity usually follows that of the intestinal disease and often heralds onset of increased bowel activity. Pyoderma gangrenosum, shown in the image below, is characterized by ulcerating relatively painless lesions that correlate with bowel activity in about 50% of patients. Although ulcers may exhibit purulent drainage, culture to the present time, the treatment of pyoderma gangrenosum has involved the use of corticosteroids and cyclosporine. Reports have indicated that not only does the condition respond to infliximab13 but this drug should probably be considered the drug of choice against pyoderma gangrenosum.

Inflammatory bowel disease. Pyoderma gangrenosum. Courtesy of Dr Gene Izuno. [ CLOSE WINDOW ]
Inflammatory bowel disease. Pyoderma gangrenosum. Courtesy of Dr Gene Izuno.

o
Aphthous ulcers are more common in patients with IBD than in the general population. Additional extraintestinal manifestations include pericholangitis, chronic active hepatitis, cirrhosis, primary sclerosing cholangitis, and bile duct carcinoma. Pericholangitis is the most common hepatic complication of IBD and is usually
Other
asymptomatic. Look for elevations of the alkaline phosphatase, less often bilirubin. Primary sclerosing cholangitis can progress to cirrhosis, in which case liver transplantation is the treatment of choice. However, it can recur in the transplanted liver. Gallstones occur in about one third of patients with Crohn's disease, resulting from increased lithogenicity of the bile due to impaired ileal absorption of bile acids. A hypercoagulable state can occur, leading to deep venous thromboses, pulmonary embolism, and arterial thromboses. Additionally, portal or hepatic vein thrombosis, stokes, retinal venous thrombosis, gonadal vein thrombosis, and mesenteric venous thrombosis have been reported. The incidence of thrombotic complications may be as high as 39%. The hypercoagulable state correlates with the activity of the disease. Its cause is unclear, but it may be related to increased levels of plasminogen activator inhibitor, factors V and VIII and fibrinogen or to decreased levels of factor V Leiden, antithrombin III, and proteins C and S.
Prognosis
Ulcerative colitis o A small percentage of patients have a single attack and no recurrence. Typically, however, remissions and exacerbations are characteristic of ulcerative colitis (UC), with acute attacks lasting weeks to months. o Twenty percent of patients require colectomy, which is curative. o Long-term morbidity primarily results from complications of medical therapy, especially long-term steroids. Crohn's disease o Prognosis depends on the site and extent of disease. o Periodic remissions and exacerbations are the rule. o Approximately 50% of patients require surgical intervention; 50% of patients undergoing surgery require a second operation; of these patients, 50% have a third operation. o Rate of recurrence is 25-50% within 1 year for patients who have responded to medical management. This rate is higher for patients who require surgery. o Overall, the quality of life with Crohn's disease generally is lower than with ulcerative colitis. Death usually occurs as a consequence of surgery, pulmonary embolus, or sepsis. o Intestinal cancer may become a more important long-term complication in patients with Crohn's disease because of longer survival.
Patient Education
For excellent patient education resources, visit eMedicine's Crohn Disease Center and Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles, Inflammatory Bowel Disease, Crohn Disease, Crohn Disease FAQs, and Irritable Bowel Syndrome.
Miscellaneous
Medicolegal Pitfalls

Failure to obtain early surgical consultation for suspected obstruction, peritonitis, or fulminant disease Failure to consider diagnosis of inflammatory bowel disease (IBD), especially Crohn's disease (CD), in patients presenting with perianal disease: Look for fistulous openings, induration, redness, or tenderness near the anus. Failure to recognize unusual presentations, such as sciatica resulting from a terminal ileal abscess with right iliopsoas extension Failure to recognize that steroids may mask the clinical severity of illness: The febrile patient on steroids may be harboring a serious bacterial infection or abscess. Failure to consider concomitant enteric infection (eg, C difficile) as the cause of an exacerbation Use of antidiarrheals, anticholinergics, and narcotics in fulminant disease, which should be avoided Overzealous use of steroids in the presence of an undrained abscess or when symptoms are due to a stricture or fibrotic process, rather than active inflammation Failure to perform endoscopic examination: Remember that all patients with new-onset rectal bleeding should undergo an endoscopic evaluation of the colon, unless an infectious etiology seems likely. For a young patient with apparent distal rectal bleeding (red blood on toilet paper and coating the stool), a flexible sigmoidoscopy may suffice. Prescribing NSAIDs: Beware of prescribing NSAIDs because they can lead to disruption of GI mucosal integrity and cause a flare of IBD. Failure to consider the diagnosis of Crohn disease in a patient with seemingly refractory gastric or duodenal ulcer disease.
Special Concerns
Children o Approximately 15-30% of patients with inflammatory bowel disease (IBD) are younger than 20 years. o Presentation can include growth failure from malnutrition and delayed sexual maturation. Many of these children also have depression. o Sulfasalazine may be used as in adults, but administer steroids on an alternate day regimen, if possible, to diminish adverse effects. o Although immunosuppressives have been used in children, concern for adverse reactions is high; the possibility of malignancy exists in view of potential for longer exposure. Pregnancy o Outlook generally is favorable; however, inflammatory bowel disease (IBD) is associated with an increased frequency of adverse pregnancy outcomes, especially if the disease is active at the time of conception. o Fertility in women with IBD is normal or only minimally impaired. The incidence of prematurity, stillbirth, and developmental defects in IBD are similar to those of the general population. o If the IBD is inactive at time of conception, it is likely to remain inactive during pregnancy. If IBD is active at the time of conception, ulcerative colitis tends to worsen. In two thirds of patients who have active Crohn's disease at the time of conception, the
degree of activity remains the same; in the other third, some have improvement and others have deterioration. Sulfasalazine and steroids may be administered during pregnancy. Sulfasalazine can be taken throughout pregnancy; however, it interferes with folate absorption, and pregnant women have an increased requirement for folic acid. Hence, women taking sulfasalazine should also take 1 mg of folate twice a day. The use of steroids during pregnancy has not been associated with an increased rate of activity; thus, the risks of treatment with sulfasalazine or corticosteroids in pregnant women with IBD are less significant than the risks of allowing disease activity to go untreated.
Acknowledgments
The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, William Shapiro, MD, to the development and writing of this article.
Inflammatory Bowel Disease: Multimedia


Bacterial RTIs: Consider the importance of broad-spectrum coverage See coverage in communityacquired pneumonia (CAP) Read more
Multimedia
Media file 1: Inflammatory bowel disease. Distinguishing features of Crohn disease (CD) and ulcerative colitis (UC).
(Enlarge Image) [ CLOSE WINDOW ]
Inflammatory bowel disease. Distinguishing features of Crohn disease (CD) and ulcerative colitis (UC). Media file 2: Inflammatory bowel disease. Toxic megacolon. Courtesy of Dr Pauline Chu.
Inflammatory bowel disease. Toxic megacolon. Courtesy of Dr Pauline Chu. Media file 3: Inflammatory bowel disease. Episcleritis. Courtesy of Dr David Sevel.
Inflammatory bowel disease. Episcleritis. Courtesy of Dr David Sevel. Media file 4: Inflammatory bowel disease. Pyoderma gangrenosum. Courtesy of Dr Gene Izuno.
(Enlarge Image)
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Great Collection of Funny Demotivators

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The Funniest T-Shirt Designs of the Decade

September 19th, 2010 Arthur Robbins Leave a comment Go to comments
30 Funny Print Ads thatll Make You Laugh
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In the world of print advertising, theres a small window to grab the audiences attention. Being restricted to a still image means the message must be very strong and catchy. Ad agencies often rely on humor to achieve this. A humorous print ad campaign starts with a funny idea, but must be brought to life with clever art direction and great visuals. For this post, weve rounded up 30 funny print ads thatll make you laugh.
8in1 Dental Snacks: Bad dog breath
Rowenta: 2100 Watt Vacuum Cleaner
Fast-working laxatives
Beautiful taps
Grannys fries without the Granny
Folgers: For mornings less complicated
Duende Azul Costumes: You, but funnier than you
Hyundai Coupe. 0 to 100 km/h in 8.4 sec
No insects left
Energizer: Never let their toys die
Suplicy
Pattex Superglue: Instant hold
Bad food, bad dog
Kerozen
Purina Bark in the Park
Face Detect
Tires that grip to the road
Kagatani knife: Dont Drop It
Juicy Fruit: Theres a much juicier chew
FinePix F70 with smile capture
Cafe Rico, an intense wake up call
Steady shot
Olympus Optical zoom
If you dont move, you get fat
Wide-angle lenses
Dog Toast: You eat what you touch
Dont let them get comfortable
Yoga classes now on
Cures car smells
Spring Cleaning
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An amazing inspirational post which features over 100 print based creative advertisement designs for you to enjoy, which will get your creativity flowing. In todays modern life advertisement plays a key role in order for any company or product to succeed the advertisement must deliver our powerful message which attracts the consumers attention. These are a collection of creative and also very funny advertisements which are granted to catch your attention and make you giggle. I believe that in order to have a good marketing campaigned of any product or service humour is the route to take, people always remember something which brought a smile to their face. Like always feel free to share your favourite funny and clever advertisement designs featured within the post in a comment below it would be very much appreciated, also share any creative design advertisements which you feel we may have missed from the post.
1. Aware Helpline: Verbal abuse, 2
2. Volkswagen Touareg: Goat
3. Tabaconomia : Calculates Tobacco Costs, Car
4. Decathlon: Better gear
5. Senior Self Defence Academy: Deadly seniors, Biker
6. You Eat What You Touch
6. Water
7. Stop Hiding Problems
8. Stockholms Hundforum (Daytime dog care)
9. One Life
10. Deadly Foot Odor
11. Espn Couch
12. WWF: Fireman
13. Tolnaftate cream: Fish
14. Soft Ian Rugby
15. Fiat: Fish
16. Baby Ronald
17. Timotei Styling Mousse: Lion
18. Arena Swimwear: Predator
19. General Tire: Wrapped by adventure
20. Kayaking Jumbo Peanut: Choking
21. Nikol baking dish: Jacuzzi
22. Breath Train
23. Reality Sucks 24. Coke
25. Kit Kat
26. Money
27. God Save Pig
28. Cremica Twin Cream Biscuits
29. Cremica Twin Cream Biscuits
30. Ripolin paint: Old man
31. Anti-smoking: Gun
32. Nicabate Pre-Quit:
33. Parmalat Panna Chef: Lifeguard
34. La Gazzetta Dello Sport: Rugby Italy vs New Zealand, 1
35. T3 lAW
36. Brastemp: Hippo
37. River North Dance Company
38. China Town: Day 39. Nokia
40. International Vegetarian Union: Anatomy Model Man
41. Cadbury Lunch Bar Man Size: Jaws
42. Koleston: Brush brown
43. Master Program In Advertising At New Bulgarian University: Horse
44. Kerozen: Mice
45. Kennedy & Coe Accounting Firm: Tick
46. Metro Shoes: Shoe Slide (Kids Shoes)
47. Canon Pixma Printers: Lighthouse
48. Eyes Of A Child
49. Cafe Rico: Wrecking ball
50. Take your vitamins
51. WMF knives: Fly
52. Metro Shoes: Shoe Lounge (Urban Shoes)
53. Kapiti: Designer ice cream, 3
54. Bear Wet Suits
55. Maglite: Museum
56. Restaurant Mirador del Alto: Clown
57. Canadian Marketing Association: Who Pulls The Strings?
58. Golds Gym Costa Rica: Tie
60. Killer Jeans: Wood carriage
61. ETA vacuum cleaner: Cat
62. Spid Advertising Photographer: Baby, 2
63. The Wyndham Championship: Street
64. Positive Options: Manipulation
65. Samantha Cracked Heel Lotion: Sexy Heels
66. Leroy Merlin: Humidity
67. Roy Awards: Eyes
68. Tame Ecuador Airlines: Fly Macas
69. Intersport: Free your sport, 4
70. Komatsu wheel loader: Titanic
71. Don de Vie (Give life): Organs
72. Restaurant Mirador del Alto: Piano
73. Xango: Lightning
74. BCAA Life Insurance: Leo
75. Ztrackz Sound Design: Dentist
76. SA Rugby: Pole Vault
77. Child Health Foundation: The Scream
78. Movistar: Acid
79. Globo News: Keyboard
80. Global Call to Action Against Poverty: Obama
81. Sedex Express Courier Service: Egg
82. Mebucaine: Little Hoarse
83. Sour Marbles: Tourist
84. Olympus: Bike
85. Mebucaine: Tight-Throat Tammy
86. Intersport: Free your sport, 2
87. Wienerschnitzel Chili Cheese Fries Eating Competition: Poster, 2
88. Mister Potato V Multi-crisp: Tomato
89. Furious Flood
90. Be Stupid
91. We Make Big Fast
92. Chicken 93. Alarm
94. Eagle Fighting
95. Space Attack
96. Olympus
97. Indian Elephant
98. Play-Seesaw
99. Card Building
100. Pincho No related posts.
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40 Creative and Funny Ads

Apr 26, 2010 Featured, Inspiration
Humor is one of the most frequently used elements in effective advertising. Whether its direct, blatant humor, or something a bit more subtle, a large majority of product advertisements use humor to grab our attention and keep us interested while they advertise their product. In this post, well look at 40 creative and funny product ads from various companies, who have decided to use humor as a way of marketing their products. From cars, mobile phones, fast food and job searching, youll see product ads from a variety of fields here. Let us know what you think of the post!
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Tags: Cars, Creative, Effective Advertising, Elements, Fast Food,
25 Funny Advertisements With Great Recall

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Funny advertisements always sell! Plain and simple. If you want people to remember your advertising campaign, your corporate identity or product branding, humor is the way to go. It does not only get the attention of consumers, it also make your product or service easier to recall or remember. We love to remember things that make us smile or laugh, dont we? People love to be entertained that is why laughter has an enormous power when it comes to advertisements. Do you have any advertisement that you seem to remember up to this day? I bet it is one of those advertisements that made you smile or laugh. So if you are a brand manager or a marketer, always remember that as long as people smile, they will surely buy.
Here are 25 great examples of such advertisements. To view the advertisements from source, just click on the link found below each image.
We also recommend that you check out these cool billboard ads that you will surely find hard to forget.
Funny Advertisement 01 Tooheys Beer
View funny advertisement Funny Advertisement 02 Perrier
View funny advertisement Funny Advertisement 03 Vintage Coffee Ad
View funny advertisement Funny Advertisement 04 Coca-Cola
funny advertisement Funny Advertisement 05- Subway
funny advertisement Funny Advertisement 06 Coke Light
Funny Advertisement Funny Advertisement 07- Jobs In Town
Funny Advertisement Funny Advertisement 08 Nivea Hair Care
Funny Advertisement Funny Advertisement 09 Have a BreakSit on a Kitkat
Funny Advertisement Funny Advertisement 10 Tree
Funny Advertisement Cant get enough of these funny advertisements? Heres more 11) Schizophrenia can be treated. Seek help.
Funny Advertisement 12) Mouse pad for tired hands
Funny Advertisement
13) Yoga Center
Funny Advertisement 14) Big Pilot Watch
Funny Advertisement 15) Pepsi Twist
Funny Advertisement
16) The New Mini John Cooper Works
Funny Advertisement 17) Carlsberg Beer
Funny Advertisement 18) FHM Ad
Funny Advertisement 19) Anti-Smoking Campaign
Funny Advertisement
20) New Audi makes everything else go pale
Funny Advertisement 21) Highway Ad
Funny Advertisement 22) True Blood Posters
Funny Advertisement 23) Olympus Binoculars
Funny Advertisement 24) Change Your Head
Funny Advertisement 25) FedEx ad
Funny Advertisement
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This entry was posted on Monday, July 6th, 2009 at 9:28 pm and is filed under Inspiration. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.
9 Responses to 25 Funny Advertisements With Great Recall
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40 Creative and Funny Advertisements Using Animals

By: Aidan in Inspiration | 61 Comments |

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Animal lovers, youre in for a treat! Todays collection of advertisements uses animals or creatures to attract the attention of viewers. Animals are all creatures belonging to the kingdom of Animalia, like birds, reptiles, fish, and other larger mammals. Many animals are often perceived as cute, cuddly and friendly.
Image from: DHL - Chicken or Egg Their innocence and helplessness reach out to our inner child and our empathy. But even if you arent an animal lover, you are still able to objectively look at the advertisement and appreciate its humour and the creativity that went into its concept. If you like creative and humorous advertisements, why not take a look at our previous post: 60 Humorous Print Advertisements to Tickle Your Bones.
40 Creative and Funny Ads Using Animals

Here are 40 creative and humorous advertisements using animals as a theme or in its concept.
Working Cow
Work for Food
Witte Molen
Without Clothes Cat
Wannabe Owl
Sad Leopard
Toyo Octopus
Time to Neuter Your Dog
Volkswagon: The Hyena
The Goats
Tennis Ground
Attack Crab
Temptation from Pig
Yo Sushi Prawn
Spring Cleaning
Snake Bus
Sleeping Hippo
Reservoir Dog
Above the Influence Rats
Rats City
Polar Bear
Podium of Dogs
Peugeot Rabbit
Pedigree Police Dog
Octopus Relaxing
Nearsightedness Dog
Hyundai: Long Tongue
WWF: Homeless Seal
Hard Working Car
Gorilla Show
Fight Sleep Man
Whale Fighting
Fiero Animals
Fiat 500: Panda
Whale and Dolphin Conservation Society Drift nets
Dog Dealer
Crocodile Spot
Costume Bear
Big Fast
Mad-Croc Whale
Which is Your Favorite Animals Ads?

The animal kingdom is such an amazing source of inspiration, but which of these animal advertisements are your favourite? Which animal helps you to be creative or reaches out to you in a special way? Do you think the use of animals as an advertising concept is a successful way of reaching out to your audience? If youve come across other high concept animal advertisements, feel free to share them with us as well and let us know your thoughts regarding this increase of such advertisements today? Posted on: February 2nd, 2010 Advertise Here
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Funny Ads That Make Us Want To Forget Our Past!

05/20/2010 - 1:00 pm By Richard Darell 3
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We are an interesting breed of individuals. We constantly try to be better while we also try to forget. Its a paradox that you dont think about much, isnt it? Well, it so happens that in order to get better at something, we need to know what we have done wrong in the past. This in turn means that we need to remember exactly what our mindset was when we previously failed so we can correct it to be better at whatever it was. There is a rather interesting and creative series of ads about vitamins that are good for your memory or something. What the creator managed to do is capture an interesting angle that we dont usually think about until we see the images used. Its of course not bringing up some very nice memories, but at least we all know were passed it and have bettered ourselves. I mean, who doesnt remember the era of disco or even the style of the neon clothes that we all wore to look cool during the 80s? We wore them every day even on the slopes trying to look all cool and edgy. Looking at pictures from that time isnt exactly flattering, is it? Well, all we can do is smile at it and hope our kids or loved ones never get a hold of them. What a horror that would be. If I had been in some of these, I
certainly wouldnt have given them away for some kind of ad I wouldnt have sold them. Do you have any embarrassing photos you might want to share? Please go ahead, I am sure everyone would love to see them.
Creative and funny advertising

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If you're looking for a creative ways to reach more customers, consider some of these interesting promotional items as give-aways.
You are here: Home Showcases 42 Really Funny And Creative Print Ads
42 Really Funny And Creative Print Ads

Posted on 10. Dec, 2009 by Ferman in Showcases 25 Comments and 14 Reactions
Designing a print ad is very difficult, you have to convey your message using few words and single image. If your ad can make others smile they will not forget their smile and so the ad. Adding humor in your ad is not easy too, you have to know fully about the product you are designing ad for and about consumers too. In this post i have gathered 42 really funny and amazing ads for your amusement. Do tell us which ad amused your more.
1. Arena Swimwear: Predator
2. Loteria de la Provincia de Buenos Aires: Money
3. Electro Recycling: Robot
4. Fiat: Boxes
5. Tobacco Free Florida: Pressure
6. Stockholms Hundforum (Daytime dog care): Wanking dog
7. Volkswagen Touareg: Goat
8. Al Nahda Resort & Spa: Bed
9. RSPCA: Vacuum
10. Ephone v900: Bear Trap
11. 21st Century Healthcare Repella Insect Repeller: Frog
12. Samantha Cracked Heel Lotion: Sexy Heels
13. Baygon: Jason
14. Tabaconomia : Calculates Tobacco Costs, Car
15. Pepsi: Mini can
16. Pepsi: Straws
17. WMF knives: Fly
18. Heinz Hot Ketchup: Fries
19. Burger King: Real big burgers
20. Sheetz fry
21. Coca-Cola Light
22. Anti-smoking: Gun
23. McDonalds: Baby Ronald
24. Minery: Foot care
25. KISS FM 97.7: Father
26. queer-travel.de: The other side of America
27. Sedex Express Courier Service: Egg
28. Union Bank of India: Currency, Lincoln
29. Lifebuoy: Dog
30. Softlan Ultra: Wrestling
31. French Kiss: Pepsi
32. Talcid: Chair
33. New Job Career Builder
34. Buenos Aires Zoo: Ape
35. Bajaj Room Heater: Fish
36. Timotei Styling Mousse: Lion
37. EPCOR: Cobra
38. Fibermesh Concrete Reinforcement: Karate
39. Ripolin paint: Old man
40. TNT Express: Pregnant lady
41. Kayaking Jumbo Peanut: Choking
42. Tesa: Bush
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