The Medical clinics of North America
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Over the last decade, the medical treatment of inflammatory bowel disease (IBD) has been revolutionized, with increasing use of both immunomodulatory and biologic medications. Corticosteroids have increasingly been shown to increase the risk of serious and opportunistic infections, both independently and in combination with immunomodulator and biologic agents. ⋯ It is unclear if anti-tumor necrosis factor-alpha agents increase overall infectious risk in patients with IBD, but the available literature has demonstrated an increased risk of opportunistic infections, particularly in terms of tuberculosis and histoplasmosis. Combination therapy likely increases the risk of opportunistic infections in patients with IBD but this has not yet been conclusively proved.
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Fistulas manifest frequently in Crohn disease and can result in significant morbidity and often lead to the need for surgical intervention. Historically, it has been more difficult to obtain complete fistula closure in patients with perianal Crohn disease. Anti-tumor necrosis factor-alpha agents and the use of more accurate imaging modalities such as magnetic resonance imaging and rectal endoscopic ultrasound have enhanced the ability to manage fistulizing Crohn disease. A combined medical and surgical approach usually presents the best option for most patients.