INFLAMMATORY BOWEL DISEASE IN THE ELDERLY

Gastroenterology Clinics - Volume 30, Issue 2 (June 2001) - Copyright 2001 W. B. !un"ers Comp!ny - #$out %his Journ!l #"" Journ!ls Issue #lert
&'I( 10.101)* 0++,-+--3.2+0-.2,/01++-)

GASTROINTESTINAL DISORDERS IN THE ELDERLY

I012#33#%'45 B'W62 &I 6# 6 I0 %76 62&6425

Do glas !" Ro#ertson MD$ M%H Ian S" Gri&& MD

1 2

&ep!rtment o8 3e"i9ine, &!rtmouth 3e"i9!l 9hool: the e9tion o8 ;!stroenterology, White 4i<er Jun9tion Veter!ns #88!irs 3e"i9!l Center, White 4i<er Jun9tion, Vermont (&J4) &i<ision o8 &igesti<e &ise!se, =ni<ersity o8 0orth C!rolin! !t Ch!pel 7ill: !n" the ;!strointestin!l 6n"os9opy >ro9e"ures =nit, =ni<ersity o8 0orth C!rolin! 7ospit!ls,Ch!pel 7ill, 0orth C!rolin! (I ;)
1 2

Address reprint requests to &ougl!s J. 4o$ertson, 3&, 3>7 e9tion o8 ;!stroenterology (1116) 21- 0orth 3!in treet White 4i<er Jun9tion V#3C White 4i<er Jun9tion, V% 0-00,

T'e nat ral 'istory an( )rognosis o* in*la&&atory #o+el (isease ,IBD- in ol(er )atients 'as #een a &atter o* contro.ersy *or se.eral (eca(es" Researc' )er*or&e( #e*ore /012 s ggeste( t'at in t'e el(erly$ IBD o*ten *ollo+s a &ore aggressi.e an( * l&inant co rse +it' 'ig' rates o* &or#i(ity an( &ortality" More recent st (ies 'a.e s ggeste( t'at t'e )rognosis is & c' &ore *a.ora#le in t'e el(erly t'an )re.io sly ass &e(" As t'e n &#er o* el(erly )ersons in t'e )o) lation contin es to increase$ t'e (iagnosis an( treat&ent o* )atients +it' late;onset IBD +ill #eco&e increasingly i&)ortant" Since t'is to)ic +as last re.ie+e( in Gastroenterology Clinics of North America, &any i&)ortant st (ies regar(ing .ario s as)ects o* IBD in t'e el(erly 'a.e #een ) #lis'e(" Alt'o g' conce)ts *ro& )rior re.ie+s #ase( on ol(er literat re are incor)orate( in t'is article$ )artic lar e&)'asis is )lace( on ne+er in*or&ation ) #lis'e( ( ring t'e /002s"
3/45 3/65 3745 3085 3/7/5 3975 3615 3/2:5 3445

6>I&63I'2';IC # >6C%
Incidence

&etermining the in9i"en9e o8 IB& in the el"erly, !n" ?hether it h!s 9h!nge" in re9ent "e9!"es, h!s $een 9h!llenging. 1irst, ! l!rge num$er o8 popul!tion-$!se" stu"ies h!<e $een reporte" 8rom !roun" the ?orl". in9e 1,,0, !t le!st eight !rti9les h!<e !""resse" the epi"emiology o8 Crohn@s "ise!se (C&) in <!rious regions, !n" ! simil!r num$er h!<e !""resse" the epi"emiology o8 ul9er!ti<e 9olitis (=C). %ren"s in the in9i"en9e o8 IB& <!ry su$st!nti!lly $y lo9!tion. Whether these "i88eren9es represent true region!l <!ri!tion or "i88eren9es in 9!se "e8inition !n" !s9ert!inment is unDno?n. 3ost liDely, ! 9om$in!tion o8 these 8!9tors !99ounts 8or the o$ser<e" <!ri!tion. e9on", there is no st!n"!r" "e8inition o8 !n !ge th!t 9onstitutes elderly. #ny st!tements reg!r"ing 9h!nges in the 8reEuen9y o8 IB& in this popul!tion must $e Eu!li8ie". 1in!lly, it o8ten is "i88i9ult to "etermine the pre9ise !ge o8 onset 9!ses o8 IB& reporte" in the liter!ture.
A2,B A3-B AC3B A-/B A-+B A)2B A/)B A111B A113B A)3B

A)3B A),B A/CB A10CB A10/B A11CB

With the !8orementione" 9!<e!ts in min", the 8ollo?ing 9on9lusions 9!n $e "r!?n reg!r"ing the in9i"en9e o8 IB&. 1irst, the in9i"en9e o8 IB& in the el"erly is mu9h gre!ter th!n initi!lly suggeste" $y ?orD per8orme" in the 1,-0s. 6!rly stu"ies o8 the epi"emiology o8 C& $y V!n >!tter et !l !n" Crohn !n" 5!rnis reporte" th!t 8e?er th!n -. o8 p!tients "e<elope" l!te-onset C&. In 9ontr!st, ! re<ie? o8 the m!For epi"emiologi9 sur<eys per8orme" up until 1,,0 reporte" th!t on !<er!ge, the onset o8 C& is !8ter !ge )0 in 1). o8 !88e9te" p!tients. 2iDe?ise, !$out 12. o8 the p!tients ?ith ne?-onset =C !re 9onsi"ere" el"erly (%!$le 1) .
A11)B A22B ACCB

TABLE / -- >4'>'4%I'0 '1 >#%I60% WI%7 I012#33#%'45 B'W62 &I 6# 6 W7' #46 62&6425 #% %76 %I36 '1 '0 6% Disease =l9er!ti<e 9olitis Crohn@s "ise!se Mean ,<12 1) Range ,<+-20 /-2)

Data from Grimm IS, Friedman LS: Inflammatory bowel disease in the elderly. Gastroenterol Clin orth Am !":#$!%#&", !""'.

e9on", in the =nite" t!tes, the proportion o8 ne? 9!ses o8 IB& in p!tients ol"er th!n !ge -0 !ppe!rs to $e rel!ti<ely st!$le. In seri!l popul!tion-$!se" sur<eys 8rom 'lmste" County, 3innesot!, $et?een 1,C0 !n" 1,,3, the proportion o8 p!tients "e<eloping C& !8ter !ge -0 h!s !<er!ge" 1/.3.. &uring the most re9ent perio" stu"ie" (1,+C through 1,,3), the 9orrespon"ing proportion ?!s 13.+.. imil!rly, 21.2. o8 ne? 9!ses o8 =C

$et?een 1,C0 !n" 1,,3 o99urre" !8ter !ge -0, ?here!s "uring the most re9ent perio" stu"ie" (1,+C through 1,,3), the proportion ?!s 1,.. &uring the - "e9!"es stu"ie", the me"i!n !ge !t "i!gnosis h!s "e9re!se" mo"estly 8or C& (C3./ y to 2,.+ y) !n" =C (3/ y to 3C.- y). %his "e9re!se in the !ge o8 onset o8 IB& 9ontr!sts ?ith th!t seen in 6urope, ?here se<er!l stu"ies h!<e reporte" ! gr!"u!l in9re!se in the me"i!n !ge o8 "i!gnosis.
A)0B A/)B

A2,B A-+B

Bimodality

It gener!lly h!s $een hel" th!t there is ! $imo"!l "istri$ution in the !ge o8 onset 8or =C !n" C&. %he 8irst mo"e o99urs reli!$ly in the 20s. %he se9on" pe!D o99urs more <!ri!$ly $et?een the !ges o8 -0 !n" +0 !n" h!s not $een o$ser<e" in !ll popul!tions stu"ie".
A1)B A23B A32B A-,B A/3B A101B A3CB A3/B A3,B A//B A100B

A,B

%he eGisten9e o8 ! $imo"!l "istri$ution h!s $een Euestione". ome !uthors h!<e suggeste" th!t the se9on" pe!D o8 9olitis in the el"erly is eGpl!ine" $y is9hemi9 9olitis r!ther th!n IB&. Br!n"t et !l re<ie?e" the re9or"s o8 +1 p!tients ?ith 9olitis ?hose symptoms $eg!n !8ter !ge -0. #8ter !n!lyHing !ll !<!il!$le 9lini9!l in8orm!tion (in9lu"ing en"os9opi9 !n" p!thologi9 reports), they m!"e ! retrospe9ti<e "i!gnosis o8 is9hemi9 9olitis in /-. o8 the 9!ses, -0. o8 ?hi9h ?ere thought pre<iously to represent =C.
A13B

In more re9ent !ttempts to "e8ine the !ge "istri$ution o8 =C !n" C&, in<estig!tors h!<e !ttempte" "iligently to !<oi" in9lusion o8 p!tients ?ith is9hemi9 9olitis. 6urope!n epi"emiologi9 stu"ies h!<e 9ontinue" to suggest ! se9on" pe!D in the in9i"en9e o8 IB& in the el"erly. %he presen9e o8 ! se9on" pe!D o8 =C !n" C& in the !ge" is less !pp!rent in the most re9ent epi"emiologi9 sur<ey 8rom 'lmste" County, 3innesot!.
A2,B A-/B A-+B A,1B A)2B A)3B

>#%7'>75 I'2';IC C'0 I&64#%I'0

&espite rem!rD!$le !"<!n9es in 9ellul!r !n" mole9ul!r $iology, the pre9ise 9!use o8 IB& is elusi<e. e<er!l 8!9tors liDely inter!9t to promote the "e<elopment o8 9hroni9 nonspe9i8i9 gut in8l!mm!tion, in9lu"ing geneti9 pre"isposition, en<ironment!l eGposures, !n" immune responsi<eness. In<estig!tion h!s 8o9use" spe9i8i9!lly on "ysregul!tion o8 the helper % 9ell response, ?ith ! 9onseEuent in9re!se in 9ytoDine pro"u9tion !n" in8l!mm!tion. #s re<ie?e" pre<iously, IB& o99urs "e no<o in the el"erly popul!tion. %he el"erly !re p!rti9ul!rly sus9epti$le to g!strointestin!l in8e9tion, suggesting ! possi$le 9ompromise o8 the mu9os!l immune system ?ith !ge. %he Euestion !rises !s to ?hether the !ging o8 the gut in some ?!y pre"isposes to the "e<elopment o8 9olitis. #lthough it is gener!lly hel" th!t !ging is !sso9i!te" ?ith systemi9 immuno"e8i9ien9y, "!t! in<ol<ing the g!strointestin!l mu9os!l immune system !re less 9onsistent. In !nim!l mo"els, some in<estig!tors h!<e sho?n losses in spe9i8i9 B or % lympho9yte popul!tions (or $oth) ?ith

!ging. # "e9line in % suppressor*9ytotoGi9 9ell su$popul!tion in >eyer@s p!t9hes o8 ol" mi9e h!s $een "es9ri$e" in some, $ut not !ll, stu"ies.
A-CB A--B A2+B

2ittle rese!r9h h!s eG!mine" spe9i8i9!lly 9h!nges in the hum!n mu9os!l immune system ?ith !ge. #rr!nH et !l stu"ie" !nti$o"y pro"u9tion in the !ge" (I /0 y ol") !n" younger !"ult 9ontrols (2- to -0 y ol") !8ter ! 9h!llenge ?ith <!rious "iet!ry !ntigens !n" 8oun" no "i88eren9e in immunoglo$ulin or !nti$o"y pro"u9tion in ?hole-gut l!<!ge 8lui" $et?een the t?o groups. JeFun!l $iopsy spe9imens sho?e" ! signi8i9!ntly lo?er intr!epitheli!l lympho9yte 9ount in the el"erly group, ho?e<er. %he signi8i9!n9e o8 this o$ser<!tion is unDno?n.
A3B

C2I0IC#2 3#0I16 %#%I'0 #0& C'=4 6

Ulcerative Colitis

In l!rge p!rt, the present!tion !n" 9ourse o8 =C in ol"er p!tients !re simil!r to those o$ser<e" in younger ones. &i!rrhe! !n" $lee"ing !re the 9lini9!l h!llm!rDs o8 the "ise!se in $oth popul!tions. %he 8ull r!nge o8 eGtr!intestin!l m!ni8est!tions !sso9i!te" ?ith =C m!y $e seen in ol"er in"i<i"u!ls. It h!s $een suggeste" th!t !rthritis !n" li<er test !$norm!lities m!y o99ur ?ith in9re!se" 8reEuen9y in ol"er in"i<i"u!ls, ?here!s sDin lesions !n" or!l ul9er!tion m!y o99ur less 9ommonly.
A1-B

6l"erly p!tients ?ith =C !re more liDely th!n younger p!tients to present ?ith le8t-si"e" "ise!se or pro9titis. %he ten"en9y 8or el"erly p!tients ?ith =C to h!<e ! more limite" eGtent o8 "ise!se h!s $een note" ?i"ely in 9ross-se9tion!l !n" prospe9ti<ely 9olle9te" 9ohorts. Jimmerm!n et !l "ire9tly 9omp!re" p!tients ?ith e!rly-(!ge 21 to 30 y) !n" l!te-onset (!ge I-1 y) =C !n" o$ser<e" th!t /).,. o8 the l!te-onset group presente" ?ith pro9to9olitis 9omp!re" ?ith only -3.2. o8 the e!rly-onset group. %he It!li!n Colon 4e9tum tu"y group reporte" on the presenting 8e!tures o8 =C !mong ! group o8 109onse9uti<ely o$ser<e" outp!tients in 1/ g!stroenterology 9enters. In this l!rge 9ohort, the el"est Eu!rtile o8 su$Fe9ts h!" signi8i9!ntly less eGtensi<e "ise!se th!n the younger su$Fe9ts. %hese results 9orro$or!te epi"emiologi9 stu"ies th!t sho? ! lo?er me!n !ge !t "i!gnosis 8or p!tients ?ith eGtensi<e =C 9omp!re" ?ith p!tients ?ith less eGtensi<e "ise!se.
A123B A+,B A2,B

%he 9ourse o8 l!te-onset =C gener!lly h!s $een reg!r"e" !s more se<ere th!n th!t o8 e!rly-onset "ise!se. #lthough more re9ent stu"ies h!<e not supporte" this 8in"ing 9onsistently, it !ppe!rs th!t the initi!l !tt!9D o8 =C in the el"erly "oes ten" to $e more se<ere. In the stu"y $y Jimmerm!n et !l, the 8irst episo"e o8 9olitis l!ste" roughly t?i9e !s long in the l!te-onset !s in the e!rly-onset group. %he !mount o8 time spent in remission !8ter the 8irst episo"e ?!s signi8i9!ntly shorter in the el"erly p!tients 9omp!re" ?ith the p!tients ?ith e!rly-onset "ise!se. In !nother stu"y, ol"er p!tients (I)- ye!rs) ?ere t?i9e !s liDely !s younger p!tients (K-- ye!rs) to $e !"mitte" 8or their 8irst !tt!9D o8 =C. Both stu"ies 8oun" th!t or!l glu9o9orti9oi" use ?!s reEuire" more 8reEuently in the el"erly th!n in the younger p!tients.
A+,B A123B A123B A-2B A-2B A123B

Crohn's Disease

#s 8or =C, the present!tion o8 C& in the el"erly is gener!lly simil!r to th!t o8 younger p!tients. # stu"y 9omp!re" ,+ p!tients ?ho presente" ?ith C& !8ter !ge C0 !n" 3C/ p!tients ?ho presente" $et?een the !ges o8 1+ !n" C0 !n" 8oun" no signi8i9!nt "i88eren9es in the 8reEuen9y or se<erity o8 presenting symptoms su9h !s "i!rrhe!, ?eight loss, !n" re9t!l $lee"ing $et?een the 2 groups. 6Gtr!intestin!l m!ni8est!tions h!<e $een 8oun" to o99ur ?ith eEu!l 8reEuen9y in ol"er !n" younger p!tients ?ith C&.
A11,B AC/B A10-B A11,B

e<er!l "i88eren9es in the present!tion o8 el"erly p!tients ?ith C& h!<e $een o$ser<e" repe!te"ly. 1irst, se<er!l !uthors note" th!t !$"omin!l p!in !n" 9r!mps m!y o99ur less 8reEuently in the el"erly th!n in younger p!tients. %his "i88eren9e h!s $een !s9ri$e" to !ltere" sensory per9eption, perh!ps rel!te" to the use o8 ! <!riety o8 me"i9!tions !n" the presen9e o8 9oeGisting systemi9 "ise!ses. e9on", p!tients ?ho present ?ith C& !t !n ol"er !ge !re less liDely to h!<e 8irst-"egree or se9on"-"egree rel!ti<es ?ith IB& th!n ?oul" $e eGpe9te" in ! younger popul!tion presenting ?ith "ise!se.
AC/B A11,B AC+B AC/B A+CB A11,B

In terms o8 !n!tomi9 eGtent, in the !ge", C& o8ten is limite" to the 9olon. ome !uthors h!<e suggeste" th!t the 8reEuen9y o8 ile!l "ise!se is signi8i9!ntly lo?er or r!re in ol"er su$Fe9ts. 3ore re9ent stu"ies "o9ument, ho?e<er, th!t isol!te" ileitis "oes o99ur in the el"erly. In ! re<ie? o8 33 p!tients in ?hom C& "e<elope" !8ter !ge )0, h!piro et !l reporte" th!t -0. h!" isol!te" ileitis. 'ther !uthors h!<e 8oun" no signi8i9!nt "i88eren9e in "ise!se lo9!liH!tion $et?een the ol"er !n" younger p!tients. #lthough the 8reEuen9y o8 h!<ing either ile!l or 9oloni9 in<ol<ement is simil!r in ol"er !n" younger p!tients, it !ppe!rs th!t younger p!tients more 8reEuently "e<elop 9om$ine" (ileo9oloni9) "ise!se, !s o$ser<e" in retrospe9ti<e !n" popul!tion-$!se" stu"ies.
A1/B A33B A-)B A)1B A,,B A10-B A11,B A11,B A3-B A-+B

%he e88e9t o8 C& on o<er!ll mort!lity gener!lly h!s $een 9onsi"ere" to $e mo"est. In ! popul!tion-$!se" stu"y o8 resi"ents o8 'lmste" County, the 20-ye!r sur<i<!l r!te 8or p!tients ?ith C& ?!s /,. 9omp!re" ?ith +). in the 9ontrol group. In this stu"y, ol"er !ge !t "i!gnosis ?!s !sso9i!te" ?ith ! rel!ti<e "e9re!se in sur<i<!l. 3ost stu"ies suggest th!t the in9re!se in mort!lity in el"erly p!tients ?ith C& is not !ttri$ut!$le to !n in9re!se in the 8reEuen9y o8 "e!ths resulting 8rom 9olore9t!l 9!n9er.
A30B A)2B A/-B A+1B A+3B A)2B A30B A/-B A+3B

&I#;0' I #0& &I116460%I#2 &I#;0' I

Overview

%he "i!gnosis o8 IB& 9!n $e "i88i9ult in !ny !ge group, $ut it is p!rti9ul!rly 9h!llenging in the el"erly. 'l"er p!tients !re more liDely to h!<e 9omor$i" 9on"itions, su9h !s !"<!n9e" <!s9ul!r "ise!se or "i<erti9ulosis. #s note" e!rlier, el"erly p!tients m!y present ?ith 8e?er !$"omin!l symptoms th!n their younger 9ounterp!rts. Be9!use o8 these 8!9tors !s ?ell !s ! lo?er in"eG o8 suspi9ion on the p!rt o8 the physi9i!n, C& is mis"i!gnose" initi!lly more 8reEuently in ol"er th!n in younger p!tients. Con"itions th!t m!y mimi9 IB& in ol"er p!tients !re !s 8ollo?s(
A3+B A10-B A11,B

In8e9tion Salmonella, Shi(ella, Campyloba)ter, *ersinia Clostridium diffi)ile +s)heri)hia )oli '1-/(7/ Is9hemi9 9olitis &i<erti9ul!r "ise!se &i<erti9ulosis, "i<erti9ulitis egment!l 9olitis !sso9i!te" ?ith "i<erti9ul! 3i9ros9opi9 9olitis Coll!genous 9olitis 2ympho9yti9 9olitis 3e"i9!tions (see l!ter) 'ther 2ymphom! 4!"i!tion entero9olitis V!s9ulitis #myloi"osis
Infection

;!strointestin!l in8e9tions !re !n import!nt "i!gnosti9 9onsi"er!tion in !ll p!tients presenting ?ith "i!rrhe!. It h!s $een estim!te" th!t !9ute "i!rrhe!l illnesses 9!n $e !ttri$ute" to !n in8e9tious 9!use in 3+. o8 9!ses. 9hum!9her et !l prospe9ti<ely stu"ie" 10- p!tients ?ith !n initi!l !tt!9D o8 9olitis to seeD 9lini9!l !n" histologi9 9lues th!t might "istinguish IB& 8rom in8e9tious "i!rrhe!. >!tients ?ith in8e9tious 9olitis gener!lly presente" ?ithin the 8irst ?eeD o8 illness !n" h!" e!rly 8e<er $ut typi9!lly "i" not h!<e histologi9 8e!tures 9h!r!9teristi9 o8 IB& on 9oloni9 mu9os!l $iopsy spe9imens.
A110B A,+B

4outine 9ultures to eG9lu"e 9ommon p!thogens, su9h !s Salmonella, Shi(ella, !n" Campyloba)ter, shoul" $e per8orme" in !ll p!tients in ?hom the "i!gnosis o8 IB& is $eing 9onsi"ere". #me$i9 9olitis shoul" $e eG9lu"e" $y !n eG!min!tion o8 the stools 8or trophoHoites. *ersinia entero)oliti)a is ! ?ell-Dno?n 9!use o8 !9ute ileitis !n" m!y mimi9 IB&. %he org!nism gro?s slo?ly !t st!n"!r" in9u$!tion temper!tures !n" 8orms
A11/B

pinpoint 9olonies on routine gr!m-neg!ti<e 9ulture me"i!. When in8e9tion ?ith *ersinia is suspe9te", the l!$or!tory shoul" $e !lerte" so th!t !ppropri!te me!sures to isol!te the $!9terium 9!n $e t!Den.
A++B

%he el"erly h!<e !n in9re!se" sus9epti$ility to pseu"omem$r!nous 9olitis. #lthough this 9on"ition o8ten is suspe9te" ?hen "i!rrhe! "e<elops in !sso9i!tion ?ith !nti$ioti9 use, it !lso m!y o99ur in the !$sen9e o8 re9ent !nti$ioti9 use. '99!sion!lly the onset o8 symptoms m!y $e "el!ye" $y ) ?eeDs !8ter !nti$ioti9s h!<e $een "is9ontinue". %he "i!gnosis usu!lly "epen"s on en"os9opi9 <isu!liH!tion o8 pseu"omem$r!nes or ! positi<e !ss!y 8or C. diffi)ile 9ytotoGin. #n in8e9tious !gent reEuiring p!rti9ul!r !ttention in the el"erly is +. )oli '1-/(7/, 8irst i"enti8ie" !s ! hum!n p!thogen in 1,+2. in9e then, numerous reports h!<e impli9!te" this !gent !s the 9!use o8 out$re!Ds o8 $loo"y "i!rrhe!. 6<i"en9e suggests th!t +. )oli '1-/(7/ is the most 9ommonly isol!te" $!9terium in p!tients ?ith 8r!nDly $loo"y stools in the =nite" t!tes. 3ost 9!ses o8 hum!n illness rel!te" to +. )oli '1-/(7/ 9!n $e tr!9e" to the ingestion o8 un"er9ooDe" $ee8 : ho?e<er, person-to-person tr!nsmission !lso h!s $een "es9ri$e". In the l!te 1,+0s, ! l!rge !n" "e!"ly out$re!D o8 "ise!se 9!use" $y +. )oli '1-/(7/ o99urre" in ! nursing home: the prim!ry out$re!D ?!s 9!use" $y ! 9ont!min!te" s!n"?i9h me!l !n" ?!s 8ollo?e" $y ! se9on"!ry out$re!D !ttri$ute" to person-to-person tr!nsmission.
A,0B A2)B A103B A2B A+B A1,B A2-B A120B A1+B

ome l!$or!tories "o not !ttempt routinely to i"enti8y +. )oli '1-/(7/ 8rom stool 9ultures. # sur<ey o8 t!te !n" %erritori!l >u$li9 7e!lth 2!$or!tory &ire9tors in the =nite" t!tes re<e!le" th!t o8 12, l!$or!tories th!t per8orme" stool 9ultures, only h!l8 reporte" s9reening either !ll stools or !ll $loo"y stools su$mitte" 8or 9ulture 8or +. )oli '1-/(7/. Clini9i!ns spe9i8i9!lly shoul" reEuest stool testing 8or this org!nism in p!tients presenting ?ith possi$le in8e9tious 9olitis.
A12B

Ischemic Colitis

Coloni9 is9hemi! is ! prin9ip!l 9onsi"er!tion in !ny el"erly person presenting ?ith !9ute !$"omin!l p!in !n" $loo"y "i!rrhe!. Clini9!l suspi9ion o8 is9hemi9 9olitis shoul" $e gre!test in p!tients ?ith pre"isposing 9on"itions, su9h !s 9ongesti<e he!rt 8!ilure, 9!r"i!9 !rrhythmi!s, !theros9leroti9 "ise!se, em$oli9 "ise!se, <!s9ulitis, !n" "i!$etes: ho?e<er, 9oloni9 is9hemi! o8ten o99urs in the !$sen9e o8 !ny i"enti8i!$le pre"isposing e<ent. %he 9ourse o8 is9hemi9 9olitis is 9h!r!9teriHe" $y the !9ute onset o8 !$"omin!l p!in, 8ollo?e" $y the p!ss!ge o8 grossly $loo"y stools. In 9!ses th!t "o not progress to in8!r9tion or per8or!tion, en"os9opi9 !n" r!"iogr!phi9 8in"ings resol<e r!pi"ly. =su!lly, re9o<ery is 9omplete, $ut l!te stri9tures m!y "e<elop in !re!s pre<iously !88e9te" $y is9hemi!. Br!n"t et !l propose" ! set o8 9lini9!l !n" r!"iogr!phi9 9riteri! to "istinguish is9hemi9 9olitis 8rom =C !n" Crohn@s 9olitis. 1e!tures spe9i8i9 8or 9oloni9 is9hemi! in9lu"e en"os9opi9 <isu!liH!tion o8 su$mu9os!l hemorrh!ges !n" e<i"en9e o8 9on9urrent is9hemi! in other !rteri!l $e"s.
A13B

Diverticular Disease

In the Western ?orl", "i<erti9ulosis is 9ommon in the el"erly. 6stim!tes suggest th!t 3-. to -0. o8 the popul!tion ol"er th!n !ge )0 m!y $e !88e9te". 3ost !88e9te" persons rem!in !symptom!ti9, $ut ! 8e? eGperien9e 9ompli9!tions, in9lu"ing "i<erti9ulitis, hemorrh!ge, 8istul! 8orm!tion, !$s9esses, or 9oloni9 o$stru9tion. Be9!use !$"omin!l p!in !n" $lee"ing !re 9h!r!9teristi9 o8 IB& !n" "i<erti9ulitis, "istinguishing the t?o "ise!ses 9!n $e 9h!llenging.
AC,B A)/B

It no? is re9ogniHe" th!t ! segment!l 9olitis 9!n o99ur in !sso9i!tion ?ith "i<erti9ulitis. Initi!lly "es9ri$e" in the 1,+0s, this syn"rome ?!s not "e8ine" more 8ully until the 1,,0s. %he h!llm!rD o8 segment!l, or "i<erti9ul!r, 9olitis is th!t mu9os!l in8l!mm!tion o99urs only in !re!s !88e9te" ?ith "i<erti9ulosis. %he rem!in"er o8 the 9olon, in9lu"ing the re9tum, is en"os9opi9!lly !n" histologi9!lly norm!l. >epper9orn "es9ri$e" eight su9h p!tients in ?hom isol!te" segment!l 9hroni9 !9ti<e 9olitis "e<elope" in !sso9i!tion ?ith sigmoi" "i<erti9ulosis. 6n"os9opi9!lly, there ?ere p!t9hy non9on8luent !re!s o8 hemorrh!ge !n" eGu"!te ?ithout ul9er!tion. >epper9orn@s report !n" t?o others "o9ument 9le!rly th!t the histop!thology o8 9olitis !sso9i!te" ?ith "i<erti9ul!r "ise!se is rem!rD!$ly simil!r to th!t o8 i"iop!thi9 IB& !n" m!y in9lu"e the presen9e o8 gr!nulom!s. # prospe9ti<e multi9enter tri!l 8rom It!ly 8oun" th!t 1.1-. o8 p!tients ?ith "i<erti9ulosis met the "i!gnosti9 9riteri! 8or segment!l 9olitis.
AC2B A-1B A))B A+2B A102B A102B A+2B AC2B A))B A-1B

%he 9lini9!l 9ourse o8 segment!l 9olitis !sso9i!te" ?ith "i<erti9ul!r "ise!se is <!ri!$le. %re!tment ?ith sul8!s!l!Hine, topi9!l steroi"s, or topi9!l mes!l!mine h!s $een e88e9ti<e, $ut re9urren9es !re possi$le. In the l!rgest prospe9ti<ely !9Euire" series 9onsisting o8 23 p!tients, - ultim!tely reEuire" sigmoi" rese9tion. %he !uthors suggeste" th!t this r!te o8 surgery 8or "i<erti9ul!r "ise!se is higher th!n ?oul" $e eGpe9te" i8 mu9os!l in8l!mm!tion h!" not $een present.
A))B

icrosco!ic Colitis

%he "i88erenti!l "i!gnosis o8 9hroni9 ?!tery "i!rrhe!, espe9i!lly in ol"er in"i<i"u!ls, in9lu"es mi9ros9opi9 9olitis. 7istop!thologi9!lly, mi9ros9opi9 9olitis is "i<i"e" 8urther into either 9oll!genous 9olitis or lympho9yti9 9olitis. Coll!genous 9olitis is "istinguishe" 8rom lympho9yti9 9olitis $y the presen9e o8 ! su$epitheli!l 9oll!gen $!n".
AC0B

Coll!genous 9olitis !n" lympho9yti9 9olitis pre"omin!ntly !88e9t ol"er ?omen. # popul!tion-$!se" stu"y 8rom p!in reporte" th!t the me!n !ge !t the onset o8 symptoms ?!s -3 8or 9oll!genous 9olitis !n" )C 8or lympho9yti9 9olitis. #""ition!lly, these in<estig!tors 8oun" 8em!le-to-m!le r!tios o8 C./-(1 !n" 2./(1 8or 9oll!genous 9olitis !n" lympho9yti9 9olitis. Coll!genous 9olitis !n" lympho9yti9 9olitis 9!n $e "istinguishe" 8rom IB& 8!irly e!sily $e9!use they !re 9h!r!9teriHe" $y norm!l-!ppe!ring mu9os! !t 9olonos9opy. %r!"ition!lly, tre!tment o8 mi9ros9opi9 9olitis h!s $een simil!r to th!t employe" 8or i"iop!thi9 IB&. Bismuth su$s!li9yl!te h!s $een propose" !s !n e88e9ti<e !ltern!ti<e tre!tment 8or mi9ros9opi9 9olitis. 1ine !n" 2ee tre!te" 13 p!tients (/ ?ith 9oll!genous
A3)B A31B

9olitis !n" ) ?ith lympho9yti9 9olitis) ?ith $ismuth su$s!li9yl!te (+ 9he?!$le 2)2-mg t!$lets "!ily 8or + ?eeDs) !n" o$ser<e" resolution o8 "i!rrhe! in 11 p!tients ?hile on ther!py: , rem!ine" ?ell "uring 8ollo?-up. #lthough this ?!s !n open-l!$el tri!l, ! $lin"e" !ssessment o8 9oloni9 histop!thology s9ores sho?e" m!rDe", st!tisti9!lly signi8i9!nt impro<ement.
Other Disorders "hat ay imic Inflammatory Bowel Disease

Intestin!l lymphom!, ileo9e9!l 9!r9inom!, r!"i!tion entero9olitis, 9!r9inoi" tumors, <!s9ulitis, !n" !myloi"osis !ll m!y mimi9 IB&. 3!ny me"i9!tions h!<e $een !sso9i!te" ?ith the "e<elopment o8 9olitis, in9lu"ing the 8ollo?ing( 0onsteroi"!l !nti-in8l!mm!tory "rugs (0 #I&s) ;ol" >eni9ill!mine ul8!s!l!Hine --1lu9ytosine 3ethyl"op! %i9lopi"ine 0 #I&s !re !mong the most 8reEuently re9ogniHe" 9!uses o8 "rug-in"u9e" 9olitis. ;i$son re<ie?e" C0 9!ses o8 0 #I&-in"u9e" 9olitis "es9ri$e" in the liter!ture !n" 8oun" th!t the !<er!ge !ge o8 !88e9te" persons ?!s )3. With"r!?!l o8 the o88en"ing 0 #I& is e88e9ti<e tre!tment. %here is gro?ing e<i"en9e th!t ti9lopi"ine m!y 9!use 9olitis: C "i88erent in<estig!tors h!<e reporte" this !sso9i!tion. Coloni9 mu9os!l p!thology in these 9!ses h!s $een suggesti<e o8 lympho9yti9 9olitis. %he 9on"ition !ppe!rs to respon" to ?ith"r!?!l o8 the "rug.
ACB A/B A)+B A,/B

%46#%360%
General Overview

%he gener!l prin9iples o8 tre!ting IB& !re the s!me reg!r"less o8 the p!tient@s !ge. pe9i8i9 "et!ils reg!r"ing "rug ther!py o8 IB& h!<e $een re<ie?e" else?here. 3il" 8l!res o8 IB& !re m!n!ge" $est $y !minos!li9yl!tes "eli<ere" topi9!lly (e.g., $y enem! in le8t-si"e" =C) or or!lly. #minos!li9yl!tes !re the "rugs o8 9hoi9e 8or m!int!ining remission.
AC-B AC)B A/2B

3ore se<ere 8l!res o8 "ise!se (i.e., unresponsi<e to !minos!li9yl!tes) typi9!lly !re m!n!ge" ?ith or!l glu9o9orti9oi"s. #lthough glu9o9orti9oi" ther!py h!s ! host o8 short-

term !n" long-term si"e e88e9ts in !ll !ge groups, the el"erly !re p!rti9ul!rly prone to the 9ompli9!tions o8 these !gents. ;lu9o9orti9oi"s m!y !ggr!<!te or pre9ipit!te "i!$etes, hypertension, 9ongesti<e he!rt 8!ilure, osteoporosis, gl!u9om!, !n" 9!t!r!9ts. %hom!s et !l retrospe9ti<ely eG!mine" the long-term 9ompli9!tions o8 steroi"s in 100 p!tients !ge" ), !n" ol"er ?ho re9ei<e" them 8or ! host o8 9hroni9 9on"itions, in9lu"ing =C. %he most 9ommonly reporte" si"e e88e9ts ?ere 9ompression 8r!9tures (1). o8 su$Fe9ts) !n" hypertension (12. o8 su$Fe9ts). In this stu"y m!ny o8 the p!tients ?ere m!int!ine" on glu9o9orti9oi"s long-term, !n" in IB& glu9o9orti9oi"s gener!lly !re not re9ommen"e" 8or the m!inten!n9e o8 remission.
A111B

tu"ies to e<!lu!te the s!8ety o8 )-mer9!ptoprine ()-3>) !n" !H!thioprine h!<e not $een per8orme" spe9i8i9!lly in the !ge". 4etrospe9ti<e 9!se series "esigne" to !ssess the toGi9ity o8 these !gents h!<e in9lu"e" el"erly su$Fe9ts. >resent et !l reporte" their eGperien9e in 3,) p!tients ?ith IB& tre!te" ?ith )-3>. In th!t stu"y, )-3> ?!s initi!te" in su$Fe9ts up to !ge /0. imil!rly, ! group o8 in<estig!tors 8rom Johns 7opDins reporte" their eGperien9e in tre!ting /+ p!tients ?ith C& ?ith )-3>, in9lu"ing su$Fe9ts up to !ge )+. 0either stu"y reporte" !ny p!rti9ul!r pro$lem ?ith the use o8 )-3> in ol"er p!tients.
A+)B A/,B

4eg!r"less o8 !ge, it h!s $een estim!te" th!t immunosuppressi<e ther!py ?ith !H!thioprine or )-3> h!s to $e "is9ontinue" in roughly 10. o8 p!tients $e9!use o8 si"e e88e9ts. >!n9re!titis is one o8 the 9ommonest si"e e88e9ts !n" o99urs in !$out 3. o8 p!tients, typi9!lly in the 8irst month o8 ther!py. e<ere $one m!rro? "epression !n" leuDopeni! o99urs in !pproGim!tely 2. o8 p!tients. 1reEuent monitoring o8 the leuDo9yte 9ount is ne9ess!ry, p!rti9ul!rly !t in"u9tion o8 ther!py or !8ter in9re!ses in the "ose. # 9onser<!ti<e !ppro!9h 9!lls 8or "etermining the leuDo9yte 9ount ?eeDly "uring the 8irst month, then e<ery 2 ?eeDs 8or 1 month !n" monthly there!8ter. In el"erly p!tients ?ith gout, )-3> or !H!thioprine must $e use" ?ith 9!ution $e9!use !llopurinol inhi$its the met!$olism o8 these "rugs !n" m!y le!" to high "rug le<els !n" leuDopeni!.
A/,B A+)B A+-B

3e!surement o8 )-3> met!$olite le<els 9!n $e help8ul in optimiHing the ther!peuti9 response to ther!py ?ith either )-3> or !H!thioprine !n" in "ete9ting persons !t in9re!se" risD 8or "rug toGi9ity. #lthough !ging is not Dno?n to h!<e ! signi8i9!nt e88e9t on the met!$olism o8 these "rugs, there is 9onsi"er!$le geneti9 <!ri!tion in the !9ti<ity o8 thiopurine methyltr!ns8er!se, ?hi9h is ! m!For "etermin!nt o8 the 9ytotoGi9 !9ti<ity o8 )3>. 2o? le<els o8 thiopurine methyltr!ns8er!se le!" to eG9essi<e !99umul!tion o8 )thiogu!nine, ?hi9h m!y result in myelosuppression. %he 9lini9!l response to )-3> is highly 9orrel!te" ?ith )-thiogu!nine le<els. Veri8i9!tion th!t )-thiogu!nine le<els !re in ! ther!peuti9 r!nge shoul" $e 9onsi"ere" $e8ore 9on9lu"ing th!t )-3> is ine88e9ti<e.
A2/B

In8liGim!$, ! 9himeri9 mono9lon!l !nti$o"y "ire9te" !g!inst tumor ne9rosis 8!9tor-!lph!, is one o8 the ne?est "rugs in the !rm!ment!rium !g!inst IB&. # single in8usion o8 in8liGim!$ !t ! "ose o8 - mg*Dg h!s $een 8oun" to $e e88e9ti<e in in"u9ing remission in t?o thir"s o8 p!tients ?ith mo"er!te to se<ere C&. 3ore re9ent e<i"en9e suggests th!t repe!te" "osing o8 in8liGim!$ m!y $e use8ul 8or the m!inten!n9e o8 remission !mong p!tients ?ho respon" initi!lly, !s ?ell !s 8or the tre!tment o8 8istul!s !sso9i!te" ?ith
A10,B A,CB

C&. #lthough there !re insu88i9ient "!t! to !ssess the s!8ety o8 in8liGim!$ in p!tients !ge" )- !n" ol"er, this !gent h!s $een use" s!8ely 8or other in"i9!tions in the el"erly. In the #%%4#C% (#nti-%01 %ri!l in 4heum!toi" #rthritis ?ith Con9omit!nt %her!py) tri!l, /2 p!tients ol"er th!n !ge )- ?ere tre!te" ?ith the "rug, !n" there ?!s no "i88eren9e in the o$ser<e" e88e9ti<eness or s!8ety o8 in8liGim!$ $et?een ol"er !n" younger p!tients.
A+/B A)-B

Osteo!orosis

>ersons ?ith IB& !re !t 9onsi"er!$le risD 8or the "e<elopment o8 osteopeni!, osteoporosis, !n" resulting 8r!9tures. In !""ition to the gener!l risD 8!9tors 8or osteoporosis (%!$le 2) , p!tients ?ith IB& o8ten !re eGpose" to glu9o9orti9oi"s, ?hi9h h!sten $one resorption. %he in8l!mm!tory "ise!se pro9ess itsel8 !ppe!rs to 9ontri$ute to $one loss. In one stu"y, siG o8 eight ne?ly "i!gnose" p!tients ?ith C& h!" osteopeni!. 4eg!r"less o8 !ge, glu9o9orti9oi" use is !sso9i!te" ?ith !99eler!te" $one loss in IB&. B!seline me!surement o8 $one "ensity shoul" $e 9onsi"ere" in !ll p!tients !t the time o8 "i!gnosis or on initi!tion o8 glu9o9orti9oi" ther!py. %he stu"y o8 9hoi9e is "u!l energy Gr!y !$sorptiometry o8 the hip !n" spine.
A11-B A11+B A10B

TABLE 7 -- 4I L 1#C%'4 1'4 ' %6'>'4' I General 1em!le seG 'l"er !ge White or #si!n r!9e >hysi9!l in!9ti<ity %o$!99o*!l9ohol use IBD S)eci*ic &rugs ;lu9o9orti9oi"s 3ethotreG!te 3!l!$sorption Vit!min & C!l9ium In8l!mm!tion IB& M In8l!mm!tory $o?el "ise!se.

#lthough !ll p!tients ?ith IB& !re !t in9re!se" risD 8or osteoporosis, postmenop!us!l ?omen ?ith IB& su88er the gre!test r!tes o8 9orti9!l $one loss. Women shoul" $e !"<ise" to m!int!in ! 9!l9ium int!De o8 !t le!st 1200 to 1-00 mg*". 7ormone repl!9ement ther!py shoul" $e 9onsi"ere" 8or !ll postmenop!us!l ?omen ?ith IB&, in the !$sen9e o8 9ontr!in"i9!tions. %he e88i9!9y o8 hormone repl!9ement ther!py h!s $een sho?n in ! stu"y o8 C/ postmenop!us!l ?omen ?ith IB&. %his 9ohort o8 ?omen (2?ith =C !n" 22 ?ith C&) ?!s 8ollo?e" "uring 2 ye!rs !8ter the intro"u9tion o8 hormone repl!9ement ther!py, !n" st!tisti9!lly signi8i9!nt impro<ement in r!"i!l !n" spin!l $one "ensity ?!s note", e<en in ?omen ?ho ?ere re9ei<ing glu9o9orti9oi"s "uring the stu"y.
A21B A11-B A20B

>rophyl!Gis !g!inst osteoporosis shoul" $e initi!te" ?ith the intro"u9tion o8 glu9o9orti9oi"s. 4e9ommen"e" tre!tment 9onsists o8 9!l9ium 9!r$on!te, )-0 mg or!lly 3 times per "!y, !n" <it!min & supplement!tion, C00 I= or!lly t?i9e ! "!y. I8 the "ur!tion o8 ther!py ?ith glu9o9orti9oi"s eG9ee"s 3 months, more !ggressi<e ph!rm!9ologi9 prophyl!Gis (e.g., ?ith $isphosphon!tes) shoul" $e 9onsi"ere". #len"ron!te, 10 mg on9e "!ily, h!s $een sho?n to pre<ent glu9o9orti9oi"-in"u9e" osteoporosis e88e9ti<ely.
A1B A,-B

In ol"er p!tients ?ith IB& or those Dno?n to h!<e !"<!n9e" $one "ise!se, e88orts shoul" $e m!"e to limit eGposure to glu9o9orti9oi"s. I8 glu9o9orti9oi" ther!py is reEuire", these p!tients shoul" $e 9onsi"ere" 9!n"i"!tes 8or e!rly tr!nsition to )-3>, !H!thioprine, or in8liGim!$. #nother option 8or these p!tients might $e $u"esoni"e. %his topi9!lly !9ti<e, or!lly !"ministere" 9orti9osteroi" h!s poor systemi9 !$sorption !n" ! lo?er si"e-e88e9t pro8ile th!n tr!"ition!l glu9o9orti9oi"s. #lthough not 9urrently !<!il!$le in the =nite" t!tes, $u"esoni"e is un"er re<ie? $y the 1oo" !n" &rug #"ministr!tion 8or the tre!tment o8 C&.
A112B

Colorectal Cancer #creening

#lthough p!tients ?ith long-st!n"ing =C !re !t in9re!se" risD o8 9olore9t!l 9!r9inom!, the !ge o8 onset o8 =C "oes not !ppe!r to $e !n in"epen"ent risD 8!9tor 8or the "e<elopment o8 9olore9t!l 9!n9er. %he t?o most import!nt risD 8!9tors 8or 9!r9inom! !re the eGtent !n" "ur!tion o8 9olitis. Current gui"elines !re to $egin sur<eill!n9e 9olonos9opy !8ter + ye!rs in p!tients ?ith p!n9olitis !n" !8ter 12 ye!rs in p!tients ?ith le8t-si"e" =C.
AC1B A-3B A10+B

#"<!n9ing !ge is !sso9i!te" ?ith !n in9re!se" risD o8 !"enom!tous polyps. %he optim!l m!n!gement o8 p!tients ?ith =C ?ho !re 8oun" to h!<e polyps on 9olonos9opy is 9ontro<ersi!l. I8 !n !"enom! "e<elops proGim!l to the !re! !88e9te" $y 9olitis, simple polype9tomy ?ith st!n"!r" 8ollo?-up 9olonos9opy seems re!son!$le. upport 8or this !ppro!9h 9omes 8rom 2 stu"ies in ?hi9h 20 su9h p!tients ?ere 8ollo?e": none "e<elope" 8l!t "yspl!si! or 9!n9er "uring su$seEuent 8ollo?-up. >olyps 8oun" in !re!s o8 !9ti<e or Euies9ent in8l!mm!tion nee" 9loser !ttention. 'ne re!son!$le str!tegy is to remo<e pe"un9ul!te" !"enom!s in the st!n"!r" 8!shion !n" s!mple the mu9os! !roun" the polyp. I8 no "yspl!si! is 8oun" !t the $!se, st!n"!r" sur<eill!n9e 9olonos9opy 9!n $e re9ommen"e". I8 "yspl!si! is 8oun" !t the $!se o8 the polyp, 9ole9tomy is in"i9!te".
A31B A,2B

%he m!n!gement o8 p!tients ?ith sessile polypoi" lesions in 9oliti9 mu9os! is more 9ontro<ersi!l $e9!use the 8in"ing o8 "yspl!si! in ! m!ss lesion is !sso9i!te" ?ith ! high risD o8 9oloni9 m!lign!n9y. &is9erning ?hi9h sessile lesion is ! "yspl!si!-!sso9i!te" lesion or m!ss (&#23) !n" ?hi9h is ! simple !"enom! 9!n $e "i88i9ult. Cole9tomy h!" $een re9ommen"e" ?hen !ny sessile lesion is 8oun", in p!rt $e9!use o8 ! stu"y $y Bl!9Dstone et !l, in ?hi9h -0. o8 p!tients ?ith ! &#23 su$seEuently ?ere 8oun" to h!<e 9oloni9 9!n9er. # report 8rom 3ount in!i 3e"i9!l Center suggests, ho?e<er, th!t !n !"enom!tous polyp 9!n $e "istinguishe" 8rom ! &#23 $!se" on the o$ser<!tion th!t only the l!tter is surroun"e" $y mu9os!l "yspl!si!. In this retrospe9ti<e !n!lysis, ! tot!l o8 /0 polyps ()0 in 9oliti9 mu9os!) ?ere remo<e" 8rom C+ p!tients ?ith 9hroni9 =C. In
A11B A,2B

e!9h 9!se, there ?!s no e<i"en9e o8 mu9os!l "yspl!si! in $iopsy spe9imens o$t!ine" !"F!9ent to the polyp. %hese p!tients 9ontinue" to un"ergo !ggressi<e 9olonos9opi9 sur<eill!n9e (e<ery 2 to ) months). #8ter !n !<er!ge 8ollo?-up o8 C.1 ye!rs, no 8urther e<i"en9e o8 "yspl!si! or 9!n9er ?!s 8oun" !t surgery or 8ollo?-up 9olonos9opy. #lthough 8urther stu"y seems ?!rr!nte" $e8ore this !ppro!9h 9!n $e re9ommen"e" gener!lly, this str!tegy m!y $e o8 p!rti9ul!r $ene8it to el"erly p!tients 9onsi"ere" to $e !t high risD 8or 9ole9tomy. 1igure 1 outlines the 9urrent m!n!gement options 8or p!tients ?ith IB& !n" !n !"enom!tous polyp.
Fig re /" 1lo? "i!gr!m o8 m!n!gement options in p!tients ?ith ul9er!ti<e 9olitis 8oun" to h!<e polyps on sur<eill!n9e en"os9opy.

#urgical Considerations

#ge !lone "oes not !ppe!r to $e !sso9i!te" ?ith in9re!se" mort!lity 8rom surgery in el"erly p!tients ?ith IB&. %he most import!nt pre"i9tors o8 !n !"<erse postoper!ti<e out9ome !re the p!tient@s preeGisting he!lth, 9oeGisting me"i9!l 9on"itions, se<erity o8 their !9ute !tt!9D, !n" nee" 8or emergent surgery. 0orris et !l re<ie?e" their surgi9!l eGperien9e in p!tients ?ith C& 8rom 1,/, through 1,,-. When 9omp!ring the ol"er 9ohort (me!n !ge, )3 y) ?ith younger su$Fe9ts (me!n !ge, 32.- y), the ol"er group h!" more 9!r"i!9 !n" respir!tory 9ompli9!tions !n" ! longer me!n postoper!ti<e hospit!l st!y: ho?e<er, there ?ere no "i88eren9es $et?een the t?o groups in r!tes o8 mort!lity or postsurgi9!l !n!stomoti9 le!Ds. In gener!l, !$"omin!l surgery in el"erly p!tients ?ith IB& 9!n $e 9omplete" s!8ely, $ut 9!re8ul preoper!ti<e !n" postoper!ti<e m!n!gement is essenti!l in p!tients ?ith signi8i9!nt 9omor$i" illness.
A3,B A/0B A/+B

#$"omin!l 9ole9tomy ?ith ile!l pou9h-!n!l !n!stomosis h!s $e9ome the st!n"!r" 8or m!ny p!tients reEuiring "e8initi<e surgi9!l tre!tment 8or ul9er!ti<e 9olitis. In this pro9e"ure, ! ne!rly tot!l proto9ole9tomy is per8orme". # pou9h is 9onstru9te" 8rom the termin!l portion o8 the sm!ll intestine !n" !n!stomose" to the !n!l 9!n!l. %o "!te, no stu"ies h!<e !""resse" spe9i8i9!lly "i88eren9es in out9omes !n" 9ompli9!tion r!tes $et?een younger !n" ol"er 9ohorts. 3!ny 9enters h!<e reporte" their eGperien9e ?ith ile!l pou9h-!n!l !n!stomosis in !ll p!tients (reg!r"less o8 !ge), !n" m!ny o8 these stu"ies in9lu"e" su$Fe9ts in their -0s !n" )0s. In terms o8 8un9tion!l out9ome, 'resl!n" et !l note" th!t p!tients ol"er th!n !ge -0 ?ere more liDely to eGperien9e ere9tile "ys8un9tion. 0onspe9i8i9 in8l!mm!tion o8 the pou9h (pou)hitis) is 9onsi"ere" the 9ommonest 9ompli9!tion !8ter ile!l pou9h-!n!l !n!stomosis, $ut the liDelihoo" o8 "e<eloping pou9hitis "oes not seem to $e rel!te" to the !ge !t ?hi9h the surgery ?!s per8orme". &e9re!se" !n!l sphin9ter tone in the el"erly m!y m!De them more prone to 8e9!l in9ontinen9e !8ter !n I>##.
A-0B A,)B A122B A)B A/1B A+0B A+0B A,)B A)CB A/1B

=33#45

#pproGim!tely 1-. o8 !ll p!tients ?ith IB& 8irst "e<elop symptoms !8ter !ge )-. #s the num$er o8 el"erly in the popul!tion 9ontinues to gro?, 9lini9i!ns shoul" eGpe9t to see ! gre!ter num$er o8 el"erly IB& p!tients. In gener!l, the presenting 8e!tures o8 IB& !re simil!r to those en9ountere" in younger p!tients, $ut the $ro!" "i88erenti!l "i!gnosis o8 9olitis in the el"erly 9!n m!De "e8initi<e "i!gnosis more 9h!llenging. #lthough most ther!pies 8or IB& h!<e not $een stu"ie" spe9i8i9!lly in the el"erly, !s ! gener!l rule, me"i9!l !n" surgi9!l tre!tment options !re the s!me reg!r"less o8 !ge. 'steoporosis, ! 9on"ition gener!lly !sso9i!te" ?ith !ging, shoul" $e m!n!ge" !ggressi<ely in p!tients ?ith IB& $e9!use m!ny ol"er persons !lre!"y h!<e ! su$st!nti!l $!seline risD 8or !99eler!te" $one loss.
Re*erences

1. #meri9!n

College o8 4heum!tology %!sD 1or9e( 4e9ommen"!tions 8or the pre<ention !n" tre!tment o8 glu9o9orti9oi"-in"u9e" osteoporosis. #meri9!n College o8 4heum!tology %!sD 1or9e on 'steoporosis ;ui"elines. #rthritis 4heum 3,(1/,1-1+01, 1,,) Cit!tion
2. #nonymous(

1rom the Centers 8or &ise!se Control !n" >re<ention( +s)heri)hia )oli '1-/(7/ in8e9tions !sso9i!te" ?ith e!ting ! n!tion!lly "istri$ute" 9ommer9i!l $r!n" o8 8roHen groun" $ee8 p!tties !n" $urgers--Color!"o, 1,,/. J#3# 2/+(+,1, 1,,/
3. #rr!nH

6, '@3!hony , B!rton J4, et !l( Immunosenes9en9e !n" mu9os!l immunity( igni8i9!nt e88e9ts o8 ol" !ge on se9retory Ig# 9on9entr!tions !n" intr!epitheli!l lympho9yte 9ounts. ;ut 33(++2-++), 1,,2 #$str!9t
C. B!ert

1, Wouters L, &@7!ens ;, et !l( 2ympho9yti9 9olitis( # "istin9t 9lini9!l entityN # 9lini9op!thologi9!l 9on8ront!tion o8 lympho9yti9 !n" 9oll!genous 9olitis. ;ut C-(3/--3+1, 1,,, #$str!9t
-. B!rry

>>( #n o<er<ie? o8 spe9i!l 9onsi"er!tions in the e<!lu!tion !n" m!n!gement o8 the geri!tri9 p!tient. #m J ;!stroenterol ,-(+-10, 2000 #$str!9t
). Be9Der

J3, 4!ymon" J2( Ile!l pou9h-!n!l !n!stomosis( # single surgeon@s eGperien9e ?ith 100 9onse9uti<e 9!ses. #nn urg 20C(3/--3+3, 1,+) #$str!9t
/. Berre$i

&, !utet #, 1leFou J1, et !l( %i9lopi"ine in"u9e" 9olitis( # histop!thologi9!l stu"y in9lu"ing !poptosis. J Clin >!thol -1(2+0-2+3, 1,,+ #$str!9t
+. Biel!sHe?sD!

3, J!n"! J, Bl!ho<! L, et !l( 7um!n +s)heri)hia )oli '1-/(7/ in8e9tion !sso9i!te" ?ith the 9onsumption o8 unp!steuriHe" go!t@s milD. 6pi"emiol In8e9t 11,(2,,-30-, 1,,/ #$str!9t
,. Bin"er

V, Both 7, 7!nsen >L, et !l( In9i"en9e !n" pre<!len9e o8 ul9er!ti<e 9olitis !n" Crohn@s "ise!se in the County o8 Copenh!gen, 1,)2 to 1,/+. ;!stroenterology +3(-)3--)+, 1,+2 #$str!9t
10. BF!rn!son

I, 3!9pherson #, 3!9Dintosh C, et !l( 4e"u9e" $one "ensity in p!tients ?ith in8l!mm!tory $o?el "ise!se. ;ut C0(22+-233, 1,,/ #$str!9t
11. Bl!9Dstone

3', 4i""ell 47, 4ogers B7, et !l( &yspl!si!-!sso9i!te" lesion or m!ss (&#23) "ete9te" $y 9olonos9opy in long-st!n"ing ul9er!ti<e 9olitis( #n in"i9!tion 8or 9ole9tomy. ;!stroenterology +0(3))-

3/C, 1,+1 #$str!9t

12. Boy9e

%;, >em$erton #;, Wells J;, et !l( 9reening 8or +s)heri)hia )oli '1-/(7/--! n!tion?i"e sur<ey o8 9lini9!l l!$or!tories. J Clin 3i9ro$iol 33(32/--32//, 1,,- #$str!9t
13. Br!n"t

2, Boley , ;ol"$erg 2, et !l( Colitis in the el"erly( # re!ppr!is!l. #m J ;!stroenterol /)(23,2C-, 1,+1 #$str!9t
1C. Br!n"t

2J, Boley J, 3itsu"o ( Clini9!l 9h!r!9teristi9s !n" n!tur!l history o8 9olitis in the el"erly. #m J ;!stroenterol //(3+2-3+), 1,+2 #$str!9t
1-. Br!n"t

2J, &i9Dstein ;( In8l!mm!tory $o?el "ise!se( pe9i8i9 9on9erns in the el"erly. ;eri!tri9s CC(10/111, 1,+, #$str!9t
1). Bur9h

>4, "e &om$!l 1%, W!tDinson ;( #etiology o8 ul9er!ti<e 9olitis( II. # ne? hypothesis. ;ut 10(2//-2+C, 1,), Cit!tion
1/. C!rr

0, 9ho8iel" >1( In8l!mm!tory $o?el "ise!se in the ol"er p!tient. Br J urg ),(223-22-, 1,+2 #$str!9t
1+. C!rter

#', Bor9HyD ##, C!rlson J#, et !l( # se<ere out$re!D o8 +s)heri)hia )oli '1-/(7/--!sso9i!te" hemorrh!gi9 9olitis in ! nursing home. 0 6ngl J 3e" 31/(1C,)-1-00, 1,+/ #$str!9t
1,. Ciesl!D

>4, 0o$le J, 3!Gson &J, et !l( 7!m$urger-!sso9i!te" +s)heri)hia )oli '1-/(7/ in8e9tion in 2!s Veg!s( # hi""en epi"emi9. #m J >u$li9 7e!lth +/(1/)-1+0, 1,,/ #$str!9t
20. Clements

&, Compston J6, 6<!ns W&, et !l( 7ormone repl!9ement ther!py pre<ents $one loss in p!tients ?ith in8l!mm!tory $o?el "ise!se. ;ut 3C(1-C3-1-C), 1,,3 #$str!9t
21. Clements

&, 3otley 4J, 6<!ns W&, et !l( 2ongitu"in!l stu"y o8 9orti9!l $one loss in p!tients ?ith in8l!mm!tory $o?el "ise!se. 9!n" J ;!stroenterol 2/(10---10)0, 1,,2 #$str!9t
22. Crohn 23. &e<lin

BB, 5!rnis 7( 4egion!l Ileitis. >hil!"elphi!, ;rune O tr!tton, 1,-+

7B, &!tt! &, &ellipi!ni #W( %he in9i"en9e !n" pre<!len9e o8 in8l!mm!tory $o?el "ise!se in 0orth %ees 7e!lth &istri9t. Worl" J urg C(1+3-1,3, 1,+0 #$str!9t
2C. &iethelm

#;, 0i9Del W1J, W!ntH ;6( =l9er!ti<e 9olitis in the el"erly p!tient. urg ;yne9ol '$stet 12)(1223-122,, 1,)+ Cit!tion
2-. &orn

C4( +s)heri)hia )oli '1-/(7/. J #m Vet 3e" #sso9 20)(1-+3-1-+-, 1,,- Cit!tion 3>( +s)heri)hia )oli '1-/(7/ !n" its signi8i9!n9e in 8oo"s. Intern J 1oo" 3i9ro$iol 12(2+,-301,

2). &oyle

1,,1
2/. &u$insDy

3C, 2!mothe , 5!ng 75, et !l( >h!rm!9ogenomi9s !n" met!$olite me!surement 8or )mer9!ptopurine ther!py in in8l!mm!tory $o?el "ise!se. ;!stroenterology 11+(/0--/13, 2000
2+. 6$ersole

J2, te88en 3J, >!ppo J( e9retory immune responses in !geing r!ts( II. >henotype "istri$ution

o8 lympho9ytes in se9retory !n" lymphoi" tissues. Immunology )C(2+,-2,C, 1,++ #$str!9t

2,. 6D$om

#, 7elmi9D C, J!9D 3, et !l( %he epi"emiology o8 in8l!mm!tory $o?el "ise!se( # l!rge, popul!tion-$!se" stu"y in ?e"en. ;!stroenterology 100(3-0-3-+, 1,,1 #$str!9t
30. 6D$om

#, 7elmi9D C;, J!9D 3, et !l( ur<i<!l !n" 9!uses o8 "e!th in p!tients ?ith in8l!mm!tory $o?el "ise!se( # popul!tion-$!se" stu"y. ;!stroenterology 103(,-C-,)0, 1,,2 #$str!9t
31. 6ngelsgFer"

3, 1!rr!ye 1#, '"He 4&( >olype9tomy m!y $e !"eEu!te tre!tment 8or !"enom!-liDe "yspl!sti9 lesions in 9hroni9 ul9er!ti<e 9olitis. ;!stroenterology 11/(12++-12,C, 1,,, #$str!9t
32. 6<!ns

J;, #9heson 6&( #n epi"emiologi9!l stu"y o8 ul9er!ti<e 9olitis !n" region!l enteritis in the 'G8or" !re!. ;ut )(311-32C, 1,)33. 1!$ri9ius

>J, ;y"e 0, houler >, et !l( Crohn@s "ise!se in the el"erly. ;ut 2)(C)1-C)-, 1,+- #$str!9t

3C. 1!hrl!n"er

7, B!erlo9her C( Clini9!l 8e!tures !n" epi"emiologi9!l "!t! on Crohn@s "ise!se in the B!sle !re!. 9!n" J ;!stroenterol )()-/-))2, 1,/1 Cit!tion
3-. 1ello?s

IW, 1reem!n J;, 7olmes ;L( Crohn@s "ise!se in the 9ity o8 &er$y, 1,-1-+-. ;ut 31(12)212)-, 1,,0 #$str!9t
3). 1ine

L&, 2ee 62( 688i9!9y o8 open-l!$el $ismuth su$s!li9yl!te 8or the tre!tment o8 mi9ros9opi9 9olitis. ;!stroenterology 11C(2,-3), 1,,+ #$str!9t
3/. 1irem!n

J, ;rossm!n #, 2ilos >, et !l( 6pi"emiology o8 Crohn@s "ise!se in the Je?ish popul!tion o8 9entr!l Isr!el, 1,/0-1,+0. #m J ;!stroenterol +C(2---2-+, 1,+, #$str!9t
3+. 1oG?orthy

&3, Wilson J#( Crohn@s "ise!se in the el"erly( >rolonge" "el!y in "i!gnosis. J #m ;eri!tr o9i 33(C,2-C,-, 1,+-

3,. ;!rl!n"

C1, 2ilien8el" #3, 3en"elo88 #I, et !l( In9i"en9e r!tes o8 ul9er!ti<e 9olitis !n" Crohn@s "ise!se in 8i8teen !re!s o8 the =nite" t!tes. ;!stroenterology +1(111--112C, 1,+1 #$str!9t
C0. ;i!r"iello

13, 2!Hen$y #J( %he !typi9!l 9oliti"es. ;!stroenterol Clin 0orth #m 2+(C/,-C,0, 1,,,

1ull %eGt
C1. ;il!t

%, 1irem!n J, ;rossm!n #, et !l( Colore9t!l 9!n9er in p!tients ?ith ul9er!ti<e 9olitis( # popul!tion stu"y in 9entr!l Isr!el. ;!stroenterology ,C(+/0-+//, 1,++ #$str!9t
C2. ;le"hill

#, &iGon 31( Crohn@s-liDe re!9tion in "i<erti9ul!r "ise!se. ;ut C2(3,2-3,-, 1,,+ #$str!9t

C3. ;o?er-4ousse!u

C, !lomeH J2, &up!s J2, et !l( In9i"en9e o8 in8l!mm!tory $o?el "ise!se in northern 1r!n9e (1,++-1,,0). ;ut 3-(1C33-1C3+, 1,,C #$str!9t
CC. ;rimm

I , 1rie"m!n 2 ( In8l!mm!tory $o?el "ise!se in the el"erly. ;!stroenterol Clin 0orth #m 1,(3)1-3+,, 1,,0 #$str!9t
C-. 7!n!uer

B( In8l!mm!tory $o?el "ise!se Apu$lishe" err!tum !ppe!rs in 0 6ngl J 3e" 1,,) Jul

11:33-(2)(1C3B. 0 6ngl J 3e" 33C(+C1-+C+, 1,,) Cit!tion

C). 7!n!uer C/. 7!rper

B( In8l!mm!tory $o?el "ise!se. 0 6ngl J 3e" 33C(+C1-+C+, 1,,) Cit!tion

>C, 39#uli88e %2, BeeDen W2( Crohn@s "ise!se in the el"erly( # st!tisti9!l 9omp!rison ?ith younger p!tients m!t9he" 8or seG !n" "ur!tion o8 "ise!se. #r9h Intern 3e" 1C)(/-3-/--, 1,+) #$str!9t
C+. 7olt

>4( ;ener!l perspe9ti<es on the !ge" gut. Clin ;eri!tr 3e" /(1+--1+,, 1,,1 #$str!9t

C,. 7ughes

26( >ostmortem sur<ey o8 "i<erti9ul!r "ise!se o8 the 9olon( I. &i<erti9ulosis !n" "i<erti9ulitis. ;ut 10(33)-3CC, 1,), Cit!tion
-0. 7ulten

2( >ro9to9ole9tomy !n" ileostomy to pou9h surgery 8or ul9er!ti<e 9olitis. Worl" J urg 22(33-3C1, 1,,+ #$str!9t
-1. Imperi!li

;, 3eu99i ;, #l<isi C, et !l( egment!l 9olitis !sso9i!te" ?ith "i<erti9ul!( # prospe9ti<e stu"y. ;ruppo "i tu"io per le 3!l!ttie In8i!mm!torie Intestin!li (; 3II). #m J ;!stroenterol ,-(101C101), 2000 #$str!9t
-2. Jones

7W, 7o!re #3( &oes ul9er!ti<e 9olitis $eh!<e "i88erently in the el"erlyN #ge #geing 1/(C10C1C, 1,++ #$str!9t
-3. L!tHD!

I, Bro"y 4 , 3orris 6, et !l( #ssessment o8 9olore9t!l 9!n9er risD in p!tients ?ith ul9er!ti<e 9olitis( 6Gperien9e 8rom ! pri<!te pr!9ti9e. ;!stroenterology +-(22-2,, 1,+3 #$str!9t
-C. L!?!nishi

7, Liely J( Immunoregul!tory "e8e9ts in murine !ge" >eyer@s p!t9hes. 6ur J Immunol 1/(1223-122+, 1,+/ #$str!9t
--. L!?!nishi

7, Liely J( Immune-rel!te" !lter!tions in !ge" gut-!sso9i!te" lymphoi" tissues in mi9e. &ig &is 9i 3C(1/--1+C, 1,+, #$str!9t
-). Lyle

J( #n epi"emiologi9!l stu"y o8 Crohn@s "ise!se in 0orthe!st 9otl!n". ;!stroenterology )1(+2)+33, 1,/1 Cit!tion
-/. Lyle

J( Crohn@s "ise!se in the northe!stern !n" northern Isles o8 9otl!n"( #n epi"emiologi9!l re<ie?. ;!stroenterology 103(3,2-3,,, 1,,2 #$str!9t
-+. 2!pi"us

#, Bernell ', 7ellers ;, et !l( In9i"en9e o8 Crohn@s "ise!se in to9Dholm County 1,---1,+,. ;ut C1(C+0-C+), 1,,/ #$str!9t
-,. 2ee

1I, Costello 1%( Crohn@s "ise!se in Bl!9Dpool--in9i"en9e !n" pre<!len9e 1,)+-+0. ;ut 2)(2/C-2/+, 1,+- #$str!9t
)0. 2in"$erg

6, Jornerot ;( %he in9i"en9e o8 Crohn@s "ise!se is not "e9re!sing in ?e"en. 9!n" J ;!stroenterol 2)(C,---00, 1,,1 #$str!9t
)1. 2o9Dh!rt-3ummery )2. 2o8tus

76( Crohn@s "ise!se o8 the l!rge $o?el. Br J urg -,(+23-+2), 1,/2 Cit!tion

6V Jr, il<erstein 3&, !n"$orn WJ, et !l( Crohn@s "ise!se in 'lmste" County, 3innesot!, 1,C0-

1,,3( In9i"en9e, pre<!len9e, !n" sur<i<!l. ;!stroenterology 11C( 11)1-11)+, 1,,+ #$str!9t
)3. 2o8tus

6V Jr, il<erstein 3&, !n"$orn WJ, et !l( =l9er!ti<e 9olitis in 'lmste" County, 3innesot!, 1,C0-1,,3( In9i"en9e, pre<!len9e, !n" sur<i<!l. ;ut C)(33)-3C3, 2000 #$str!9t
)C. 2ohmuller

J2, >em$erton J7, &oHois 44, et !l( >ou9hitis !n" eGtr!intestin!l m!ni8est!tions o8 in8l!mm!tory $o?el "ise!se !8ter ile!l pou9h-!n!l !n!stomosis. #nn urg 211()22-)2/, 1,,0 #$str!9t
)-. 3!ini

4, t Cl!ir 6W, Bree"<el" 1, et !l( In8liGim!$ (9himeri9 !nti-tumour ne9rosis 8!9tor !lph! mono9lon!l !nti$o"y) <ersus pl!9e$o in rheum!toi" !rthritis p!tients re9ei<ing 9on9omit!nt methotreG!te( # r!n"omise" ph!se III tri!l. #%%4#C% tu"y ;roup. 2!n9et 3-C(1,32-1,3,, 1,,, #$str!9t
)). 3!D!pug!y

23, &e!n >J( &i<erti9ul!r "ise!se-!sso9i!te" 9hroni9 9olitis. #m J urg >!thol 20(,C-102, 1,,) #$str!9t
)/. 3!nousos

'0, %ruelo<e C, 2ums"en L( >re<!len9e o8 9oloni9 "i<erti9ulosis in gener!l popul!tion o8 'G8or" !re!. B3J 3(/)2-/)3, 1,)/
)+. 3!rtineH

#>, ;is$ert 3C, Ber$eg!l J, et !l( %i9lopi"ine-in"u9e" lympho9yti9 9olitis AletterB. 3e" Clin (B!r9) 10)(31/, 1,,)
),. 3!te-JimeneH

J, 3unoH , Vi9ent &, et !l( In9i"en9e !n" pre<!len9e o8 ul9er!ti<e 9olitis !n" Crohn@s "ise!se in ur$!n !n" rur!l !re!s o8 p!in 8rom 1,+1 to 1,++. J Clin ;!stroenterol 1+(2/-31, 1,,C #$str!9t

/0. 3!y$erry /1. 3e!gher

J1, 0e?9om$e 4;, 4ho"es J( 3ort!lity in Crohn@s "ise!se. PJ3 C,()3-)+, 1,+0

#>, 1!rouD 4, &oHois 44, et !l( J ile!l pou9h-!n!l !n!stomosis 8or 9hroni9 ul9er!ti<e 9olitis( Compli9!tions !n" long-term out9ome in 1310 p!tients. Br J urg +-(+00-+03, 1,,+ #$str!9t
/2. 3i9hetti

>, >epper9orn 3#( 3e"i9!l ther!py o8 spe9i8i9 9lini9!l present!tions. ;!stroenterol Clin 0orth #m 2+(3-3-3/0, 1,,, 1ull %eGt
/3. 3oller

C, 2in"en ;( =l9er!ti<e 9olitis in 1inl!n"( I. C!ses tre!te" !t 9entr!l hospit!ls, 1,-)-1,)/. &is Colon 4e9tum 1C(2-,-2)3, 1,/1 Cit!tion
/C. 3oum

B, V!tn 37, 6D$om #, et !l( In9i"en9e o8 ul9er!ti<e 9olitis !n" in"etermin!te 9olitis in 8our 9ounties o8 southe!stern 0or?!y, 1,,0-,3( # prospe9ti<e popul!tion-$!se" stu"y. %he In8l!mm!tory Bo?el outh-6!stern 0or?!y (IB 60) tu"y ;roup o8 ;!stroenterologists. 9!n" J ;!stroenterol 31(3)23)), 1,,) #$str!9t
/-. 3unDholm

>, 2!ngholH 6, &!<i"sen 3, et !l( Intestin!l 9!n9er risD !n" mort!lity in p!tients ?ith Crohn@s "ise!se. ;!stroenterology 10-(1/1)-1/23, 1,,3 #$str!9t
/). 3unDholm

>, 2!ngholH 6, 0ielsen '7, et !l( In9i"en9e !n" pre<!len9e o8 Crohn@s "ise!se in the 9ounty o8 Copenh!gen, 1,)2-+/( # siG8ol" in9re!se in in9i"en9e. 9!n" J ;!stroenterol 2/()0,-)1C, 1,,2 #$str!9t
//. 3yren

J, ;Fone 6, 7ertH$erg J0, et !l( 6pi"emiology o8 ul9er!ti<e 9olitis !n" region!l entero9olitis

(Crohn@s "ise!se) in 0or?!y. 9!n" J ;!stroenterol )(-11--1C, 1,/1 Cit!tion

/+. 0orris

B, olomon 3J, 6yers ##, et !l( #$"omin!l surgery in the ol"er Crohn@s popul!tion. #ust 0 J J urg ),(1,,-20C, 1,,, #$str!9t

/,. '@Brien

JJ, B!yless %3, B!yless J#( =se o8 !H!thioprine or )-mer9!ptopurine in the tre!tment o8 Crohn@s "ise!se. ;!stroenterology 101(3,-C), 1,,1 #$str!9t
+0. 'resl!n"

%, 1!sth , 0or"gren , et !l( %he 9lini9!l !n" 8un9tion!l out9ome !8ter restor!ti<e pro9to9ole9tomy( # prospe9ti<e stu"y in 100 p!tients. Int J Colore9t!l &is C(-0--), 1,+, #$str!9t
+1. >!lli

&, %r!llori ;, !ie<! C, et !l( ;ener!l !n" 9!n9er spe9i8i9 mort!lity o8 ! popul!tion $!se" 9ohort o8 p!tients ?ith in8l!mm!tory $o?el "ise!se( %he 1loren9e tu"y. ;ut C2(1/--1/,, 1,,+ #$str!9t
+2. >epper9orn

3#( &rug-responsi<e 9hroni9 segment!l 9olitis !sso9i!te" ?ith "i<erti9ul!( # 9lini9!l syn"rome in the el"erly. #m J ;!stroenterol +/()0,-)12, 1,,2 #$str!9t
+3. >ersson

>;, Bernell ', 2eiFonm!r9D C6, et !l( ur<i<!l !n" 9!use-spe9i8i9 mort!lity in in8l!mm!tory $o?el "ise!se( # popul!tion-$!se" 9ohort stu"y. ;!stroenterology 110(133,-13C-, 1,,) #$str!9t
+C. >olito

J3, Chil"s B, 3ellits 6&, et !l( Crohn@s "ise!se( In8luen9e o8 !ge !t "i!gnosis on site !n" 9lini9!l type o8 "ise!se. ;!stroenterology 111(-+0--+), 1,,) #$str!9t
+-. >resent

&7, 3eltHer J, LrumholH 3>, et !l( )-3er9!ptopurine in the m!n!gement o8 in8l!mm!tory $o?el "ise!se( hort- !n" long-term toGi9ity. #nn Intern 3e" 111()C1-)C,, 1,+, #$str!9t
+). >resent

&7, 3eltHer J, LrumholH 3>, et !l( )-3er9!ptopurine in the m!n!gement o8 in8l!mm!tory $o?el "ise!se( hort- !n" long-term toGi9ity. #nn Intern 3e" 111()C1-)C,, 1,+, #$str!9t
+/. >resent

&7, 4utgeerts >, %!rg!n , et !l( In8liGim!$ 8or the tre!tment o8 8istul!s in p!tients ?ith Crohn@s "ise!se. 0 6ngl J 3e" 3C0(13,+-1C0-, 1,,, #$str!9t
++. 4!<el

4( Clini9!l 2!$or!tory 3e"i9ine( Clini9!l #ppli9!tion o8 2!$or!tory &!t!. t. 2ouis, 3os$y,

1,,+,. 4iegler

;, %!rt!glione 3%, C!rr!tu 4, et !l( #ge-rel!te" 9lini9!l se<erity !t "i!gnosis in 1/0- p!tients ?ith ul9er!ti<e 9olitis( # stu"y $y ;I C (It!li!n Colon-4e9tum tu"y ;roup) &ig &is 9i C-(C)2-C)-, 2000 #$str!9t
,0. 4iley

2W, 4emis 4 , 7elgerson &, et !l( 7emorrh!gi9 9olitis !sso9i!te" ?ith ! r!re +s)heri)hia )oli serotype. 0 6ngl J 3e" 30+()+1-)+-, 1,+3 #$str!9t
,1. 4ose

J&, 4o$erts ;3, Willi!ms ;, et !l( C!r"i88 Crohn@s "ise!se Fu$ilee( %he in9i"en9e o<er -0 ye!rs. ;ut 2,(3C)-3-1, 1,++ #$str!9t
,2. 4u$in

>7, 1rie"m!n , 7!rp!H 0, et !l( Colonos9opi9 polype9tomy in 9hroni9 9olitis( Conser<!ti<e m!n!gement !8ter en"os9opi9 rese9tion o8 "yspl!sti9 polyps. ;!stroenterology 11/(12,--1300, 1,,, #$str!9t

,3. 4us9h

V, imono?itH &#( Crohn@s "ise!se in the ol"er p!tient. urg ;yne9ol '$stet 1-0(1+C-1+), 1,+0 #$str!9t

,C. 4utgeerts

>, &@7!ens ;, %!rg!n , et !l( 688i9!9y !n" s!8ety o8 retre!tment ?ith !nti-tumor ne9rosis 8!9tor !nti$o"y (in8liGim!$) to m!int!in remission in Crohn@s "ise!se. ;!stroenterology 11/(/)1-/),, 1,,, #$str!9t !!g L;, 6mDey 4, 9hnitHer %J, et !l( #len"ron!te 8or the pre<ention !n" tre!tment o8 glu9o9orti9oi"in"u9e" osteoporosis. ;lu9o9orti9oi"-In"u9e" 'steoporosis Inter<ention tu"y ;roup. 0 6ngl J 3e" 33,(2,2-2,,, 1,,+ #$str!9t
,-.

!n"$orn WJ( >ou9hitis 8ollo?ing ile!l pou9h-!n!l !n!stomosis( &e8inition, p!thogenesis, !n" tre!tment. ;!stroenterology 10/(1+-)-1+)0, 1,,C Cit!tion
,).

9hme9D-2in"en!u 7J, LurtH W, 7eine 3( 2ympho9yti9 9olitis "uring ti9lopi"ine ther!py AletterB. &ts9h 3e" Wo9hens9hr 123(C/,, 1,,+ Cit!tion
,/.

9hum!9her ;, !n"ste"t B, Loll$erg B( # prospe9ti<e stu"y o8 8irst !tt!9Ds o8 in8l!mm!tory $o?el "ise!se !n" in8e9tious 9olitis( Clini9!l 8in"ings !n" e!rly "i!gnosis. 9!n" J ;!stroenterol 2,(2)--2/C, 1,,C #$str!9t
,+.

h!piro >#, >epper9orn 3#, #ntoniolo &#, et !l( Crohn@s "ise!se in the el"erly. #m J ;!stroenterol /)(132-13/, 1,+1 #$str!9t
,,.

hi<!n!n"! , >en! # , 0!p 3, et !l( 6pi"emiology o8 Crohn@s "ise!se in 4egio 2ei"en, %he 0etherl!n"s( # popul!tion stu"y 8rom 1,/, to 1,+3. ;!stroenterology ,3(,))-,/C, 1,+/ #$str!9t
100.

in9l!ir % , Brunt >W, 3o?!t 0#( 0onspe9i8i9 pro9to9olitis in northe!stern 9otl!n"( # 9ommunity stu"y. ;!stroenterology +-(1-11, 1,+3 #$str!9t
101.

l!"en ;6, 1ilipe 3I( Is segment!l 9olitis ! 9ompli9!tion o8 "i<erti9ul!r "ise!seN &is Colon 4e9tum 2/(-13--1C, 1,+C #$str!9t
102.

lutsDer 2, 4ies ##, ;reene L&, et !l( +s)heri)hia )oli '1-/(7/ "i!rrhe! in the =nite" t!tes( Clini9!l !n" epi"emiologi9 8e!tures. #nn Intern 3e" 12)(-0---13, 1,,/ #$str!9t
103.

ri<!st!<! 6&, 3!y$erry J1, 3orris %J, et !l( In9i"en9e o8 ul9er!ti<e 9olitis in C!r"i88 o<er 20 ye!rs( 1,)+-+/. ;ut 33(2-)-2-+, 1,,2 #$str!9t
10C.

t!lniDo?i9H 4, 6li!Dim 4, &i!$ 4, et !l( Crohn@s "ise!se in the el"erly. J Clin ;!stroenterol 11(C11C1-, 1,+, #$str!9t
10-.

t!lniDo?i9H 4, 6li!Dim 4, &i!$ 4, et !l( Crohn@s "ise!se in the el"erly. J Clin ;!stroenterol 11(C11C1-, 1,+, #$str!9t
10).

te?enius J, #"nerhill I, 6Delun" ;, et !l( =l9er!ti<e 9olitis !n" in"etermine 9olitis in the 9ity o8 3!lmo, ?e"en( # 2--ye!r in9i"en9e stu"y. 9!n" J ;!stroenterol 30(3+-C3, 1,,- #$str!9t
10/.

ugit! #, !9h!r &B, Bo"i!n C, et !l( Colore9t!l 9!n9er in ul9er!ti<e 9olitis( In8luen9e o8 !n!tomi9!l eGtent !n" !ge !t onset on 9olitis-9!n9er inter<!l. ;ut 32(1)/-1),, 1,,1 #$str!9t
10+.

10,. %!rg!n

4, 7!n!uer B, <!n &e<enter J, et !l( # short-term stu"y o8 9himeri9 mono9lon!l !nti$o"y 9#2 to tumor ne9rosis 8!9tor !lph! 8or Crohn@s "ise!se. Crohn@s &ise!se 9#2 tu"y ;roup. 0 6ngl J 3e" 33/(102,-103-, 1,,/ #$str!9t
110. %e"es9o

1J, 7!r"in 4&, 7!rper 40, et !l( In8e9tious 9olitis en"os9opi9!lly simul!ting in8l!mm!tory $o?el "ise!se( # prospe9ti<e e<!lu!tion. ;!strointest 6n"os9 2,(1,--1,/, 1,+3 #$str!9t
111. %hom!s

;#, 3ill!r-Jones &, 4ho"es J, et !l( In9i"en9e o8 Crohn@s "ise!se in C!r"i88 o<er )0 ye!rs( 1,+)-1,,0 !n up"!te. 6ur J ;!stroenterol 7ep!tol /(C01-C0-, 1,,- #$str!9t
112. %homsen

'', Cortot #, Je?ell &, et !l( # 9omp!rison o8 $u"esoni"e !n" mes!l!mine 8or !9ti<e Crohn@s "ise!se. Intern!tion!l Bu"esoni"e-3es!l!mine tu"y ;roup. 0 6ngl J 3e" 33,(3/0-3/C, 1,,+ #$str!9t
113. %r!llori

;, >!lli &, !ie<! C, et !l( # popul!tion-$!se" stu"y o8 in8l!mm!tory $o?el "ise!se in 1loren9e o<er 1- ye!rs (1,/+-,2). 9!n" J ;!stroenterol 31(+,2-+,,, 1,,) #$str!9t
11C. %ysD

C, J!rnerot ;( =l9er!ti<e pro9to9olitis in 're$ro, ?e"en( # retrospe9ti<e epi"emiologi9 stu"y, 1,)3-1,+/. 9!n" J ;!stroenterol 2/(,C--,-0, 1,,2 #$str!9t
11-. V!lentine

J1, ninsDy C#( >re<ention !n" tre!tment o8 osteoporosis in p!tients ?ith in8l!mm!tory $o?el "ise!se. #m J ;!stroenterol ,C(+/+-++3, 1,,, #$str!9t
11). V!n

>!tter W0, B!rgen J#, &oDerty 3B( 4egion!l enteritis. ;!stroenterology 2)(3C/, 1,-C ;, ;e$oes L, >onette 6( *ersinia enteritis. 3e" Clin 0orth #m ))()3,-)-3, 1,+2

11/. V!ntr!ppen

#$str!9t
11+. Vesterg!!r"

>, Lrogh L, 4eFnm!rD 2, et !l( 1r!9ture risD is in9re!se" in Crohn@s "ise!se, $ut not in ul9er!ti<e 9olitis. ;ut C)(1/)-1+1, 2000 #$str!9t
11,. W!gtm!ns

3J, Versp!get 7W, 2!mers CB, et !l( Crohn@s "ise!se in the el"erly( # 9omp!rison ?ith young !"ults. J Clin ;!stroenterol 2/(12,-133, 1,,+ #$str!9t
120. W!ll

>;, 39&onnell 4J, #"!D ;L, et !l( ;ener!l out$re!Ds o8 <ero 9ytotoGin pro"u9ing +s)heri)hia )oli '1-/ in 6ngl!n" !n" W!les 8rom 1,,2 to 1,,C. Commun &is 4ep C&4 4e< )(42)-433, 1,,) #$str!9t
121. W!tts

J3, "e &om$!l 1%, ;oligher JC( 6!rly results o8 surgery 8or ul9er!ti<e 9olitis. Br J urg -3(100--101C, 1,)) Cit!tion
122. Weiss

6;, WeGner &( urgi9!l ther!py 8or ul9er!ti<e 9olitis. ;!stroenterol Clin 0orth #m 2C(--,-/-, 1,,- #$str!9t
123. Jimmerm!n

J, ;!<ish &, 4!9hmile?itH &( 6!rly !n" l!te onset ul9er!ti<e 9olitis( &istin9t 9lini9!l 8e!tures. J Clin ;!stroenterol /(C,2-C,+, 1,+- #$str!9t