Prognosis

11 Prognosis

Patients with IBD must cope with considerable uncertainty and waiting in relation to the outcome of tests and treatments. However, in recent years their experience of illness has greatly improved because of advances in diagnostics, particularly imaging, and greater attention to the detail of medical and surgical therapy. No longer should one expect to encounter short-bowel syndrome, Cushingoid deformities, malnutrition or stunted growth, nor iatrogenic opiate addiction. The majority of patients can expect to lead a full and productive life, most of which should be free of disabling illness.

An important and emerging comorbidity is the risk of obesity and obesity-related metabolic disease. Whether this reflects the lifestyle of the general population or is, in part, influenced by anti-inflammatory and immunomodulatory treatment in people with IBD is unclear.

Ulcerative colitis

Mortality The risk of death in ulcerative colitis is highest in the first year of diagnosis and relates mainly to first attacks of acute severe ulcerative colitis. In this setting, fewer than 1% of patients now die, the principal causes of death being pulmonary embolism, perforation and sepsis. The overall mortality associated with ulcerative colitis is no different from that of the normal population, the risks of ulcerative colitis and associated colorectal cancer and sclerosing cholangitis possibly being counterbalanced by the non-smoking status of most patients with the disease (see Chapter 1).

Morbidity. Most patients experience a relapsing and remitting course of disease; 70% of untreated patients have flare-ups annually. In patients with distal disease at presentation, extension to involve the proximal colon occurs in about 20% after 10 years. The cumulative colectomy rate in patients with total colitis is 10–25% at 15 years.

Cancer risk. The risk of colorectal cancer is increased in those who have had subtotal or total ulcerative colitis for more than 10 years, the cumulative risk having fallen in recent decades from around 20% to 5–10% at 30 years, perhaps due to better control of inflammatory disease activity. Comorbidity with sclerosing cholangitis is an added risk factor. The prognosis of colonic cancer complicating ulcerative colitis resembles that of patients without colitis. Colonoscopic surveillance programs are widely used, but have not been proven to reduce mortality from colonic cancer in ulcerative colitis.

Crohn’s disease

Mortality The cumulative mortality of Crohn’s disease is approximately twice that in the general population. Death is predominantly from sepsis, pulmonary embolism, and complications of surgery and immunosuppressive therapy in those with severe chronic disease.

Morbidity. A higher proportion of patients with Crohn’s disease than with ulcerative colitis show a chronic active rather than a relapsing remitting course of disease. Surgery is required in about 50% of patients in the first 10 years after diagnosis. Of those having an operation, 50% will need further surgery in the next 10 years, the risks being higher in those with ileal and ileocolonic disease than in those with purely colonic disease. Complications of obesity and obesity-related metabolic disorders are, like Crohn’s itself, aggravated by smoking.

Key points – prognosis

• Mortality in ulcerative colitis resembles that in the general population, but in Crohn’s disease it is increased twofold.

• Causes of death in patients with severe IBD include sepsis, pulmonary embolism, colorectal cancer, sclerosing cholangitis and complications of surgical and immunosuppressive therapy.

• An increasing proportion of patients are now either overweight or obese and require treatment or preventive measures against metabolic syndrome and insulin resistance.

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