Tx of Crohn's disease:
5-ASA agents:
Sulfasalazine, 1.5 - 2 g bid. Released in colon and not active in small bowel. Used for induction and maintenance
Mesalamine (Pentasa, Asacol): 4 g qid. Released in small bowel. 40% remission in mild to moderate ileocecal Crohn's dz.
ABX: useful even if there is no inf.
Metronidazole, 10 mg/kg/day or Ciprofloxacin, 500 mg po bid
Corticosteroids: suppress acute dz.
Prednisone, 40 - 60 mg po daily during acute flares with tapering dose after response.
Significant long term side effects
Budesonide is an oral steroid with less systemic absorption, used for maintenance only.
Immunomodulatory drugs: used for maintenance only, not for induction. Used to minimize steroid exposure.
Azathioprine (Imuran), 2 - 2.5 mg/kg. Therapeutic effects are delayed 6-8 wks; significant bone marrow suppression needs monitoring.
6-MP, 1 - 1.5 mg/kg
Methotrexate: used as 2nd or 3rd line maintenance drug.
Infliximab (Remicade): Recombinant anti-TNF. 5 mg/kg IV infusion. For mod to severe fistulizing dz. C/I for dz with strictures. Rpt IV infusion q2-4 wks x 3 doses; then consider maintenance dose q8 wks. TB ;must be ruled out prior to use (PPD, CXR). Long term Tx assoc with waning efficacy and increased allergic reactions. May reactivate latent TB.
Surgery: 50% of Pts will require surgery for obst or abscess if refractory to medical therapy.
Complications: Strictures, obstruction, fistulas, abscess, colorectal cancer, malabsorption, nephrolithiasis, cholelithiasis.
Ulcerative Colitis: Chronic, recurrent disease with diffuse mucosal inflammation of the colon. >50% are isolated to the rectum and sigmoid colon, and <20% involves the rest of the colon.
Age of onset: 20 - 40 y, but can occur <10 y and elderly.
Ashkenazi Jews, nonsmokers, and family history
smoking attenuates the dz
Course - repeated flares and remissions.
DDx: infectious colitis (salmonella, shigella, campylobacter, enteroinvasive E. coli, C. difficle, amebiasis), ischemic colitis, Crohn's colitis.
Dx: anemia of chronic dz, iron def, leukocytosis, hypoalbuminemia, elev CRP and ESR.
there is good relation between labs (Hb, Hct, albumin, ESR) and disease severity.
Stool studies; mic, c&s, O&P, C. difficile toxin.
Imaging: AXR shows loss of haustrations in colon leading to appearnace of "lead-pipe" appearance and colonic dilatation.
C-scopy: Avoid in a flare. Check colon and terminal ileum. Rectal involvement 95 - 100%, continuous circumferential ulcerations, and pseudopolyps. Terminal ileum is sometimes occasionally inflamed from "back-wash ileitis." Bx show acute/chronic inflammation, crypt abscesses, and absence of granulomas.
Tx: Location and severity of dz.
Distal disease: Mesalamine or hydrocortisone by suppository or enema.
Distal and proximal disease: Oral or IV agents.
Mild to moderate activity:
Sulfasalazine, 1.5 - 3 g po bid
Mesalamine, 2.5 - 4 g po qd
Prednisone, 40 - 60 mg po qd, if no response after 2-4 wks.
Severe activity:
Methylprednisone, 48-60 mg IV qd or hydrocortisone, 300 mg IV qd
~50-75% go into remission within 7 days.
If no response is seen in 7-10 days, colectomy is usually indicated.
Consider cyclosporine prior to colectomy.
Maintenance therapy:
Sulfasalazine, 1 - 1.5 g po bid
Mesalamine, 800 - 1200 mg po tid
Surgery can be curative and can eliminate the risk of cancer. Proctocolectomy with ileostomy is curative. Proctocolectomy with ileoanal anastomosis is often curative, but 25% have "pouchitis," or inflammation of the neorectum.
Complications; toxic megacolon, primary sclerosing cholangitis, colorectal cancer, extraintestinal manifestations: arthritis, eythema nodosum, oral apthous ulcers, episcleritis, pyoderma gangrenosum, uveitis.
If pt with toxic megacolon does not respond to medical tx within 72 hrs or those with si and sx of bowel perf, refer for emergent surgical tx (colectomy)
NSAID use can induce a flare of UC or Crohn's dz
The risk of CRC in Pts with UC >10 yrs is 0.5 - 1% per year; colonoscopy is recommended q1-2 yrs beginning 8 yrs after dx.