Management of Inflammatory Bowel Disease

In spite of immunosuppressive medication, a significant number of patients undergoing Ltx due to PSC will experience an exacerbation of IBD following transplantation, in some cases necessitating colectomy. Patients without IBD prior to Ltx have also been diagnosed with de novo IBD in the posttransplantation period [31]. Dvorchik et al. described a high incidence of progression of IBD following Ltx [31]. Haagsma et al. found that tacrolimus is more frequently associated with posttransplantation exacerbation of IBD and that patients on triple immunosuppression (cyclosporine, azathioprine, prednisolone) have less active bowel disease in follow-up [32]. Discontinuation of steroids has also been reported to increase the risk of IBD exacerbation [33]. Colorectal cancer in patients with IBD and PSC undergoing Ltx has been reported in several series [28].

Conclusive evidence that immunosuppression administered following Ltx may further increase the risk of colorectal cancer compared with the risk in the nontransplanted PSC patient with IBD is still lacking [34, 35]. PSC patients with a diagnosis of IBD and in whom a colectomy has not been performed should undergo colonoscopy on a yearly basis. If dysplasia is detected, colectomy should be considered.

If severe colitis or dysplasia is found during the waiting period, colectomy can also be performed during laparotomy for the transplantation provided the patient's general condition permits. Indeed, the ideal time to perform colectomy is not yet known. So far, it is a matter of local preference and the condition of the individual patient.

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