Crohn's disease resident survival guide

Jump to navigation Jump to search

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mugilan Poongkunran M.B.B.S [2]


Crohn’s disease (CD) is an inflammatory condition of unknown etiology primarily affecting the gastrointestinal (GI) tract from mouth to perianal region, with specific clinical and pathological features characterized by focal, asymmetric, transmural, and occasionally, granulomatous inflammation and with a potential to cause systemic and extraintestinal complications.


Life Threatening Causes

Crohn’s disease (CD) can be a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Triggers

Common factors recognized to exacerbate CD are


The algorithm is based on the American Journal of Gastroenterology guidelines for management of Crohn's disease in adults.[1]

Characterize the symptoms:

Abdominal pain
Chronic diarrhea or nocturnal diarrhea (onset, duration, pattern, bloody, mucous or watery)
Abdominal distention
Loss of appetite
Loss of weight
❑ Mental status change
❑ Rectal bleeding
❑ Painful defecation

Extraintestinal symptoms:

Skin lesions
❑ Oral pain
Odynophagia and dysphagia
Joint pains
❑ Burning micturition
Cough, breathlessness
Eye pain, blurring of vision

Obtain detailed history:

❑ Recent travel H/O
❑ Recent drug H/O
❑ Abdominal or pelvic radiation H/O
❑ Family H/O

❑ Systemic illness H/O
Assess volume status:

❑ General condition
❑ Thirst
Blood pressure
❑ Eyes
❑ Mucosa

Examine the patient:

❑ Skin (swelling, pain, erythema or ulceration)
❑ Oral cavity (ulcers)
❑ Respiratory system (wheezing or crackles)
❑ Cardiovascular system
❑ Abdomen (mass, distension or tenderness)
❑ Anorectal (perianal skin tags, sinus tracts or bleeding)
❑ Eye (swelling, pain, edema or vision loss)
❑ Musculoskeletal (Axial, large and small joints)
Confirmatory diagnostic tests:
Colonoscopy and biopsy
❑ Upper GI scopy and biopsy
Computed tomography (CT)
Barium enema (length and location of strictures)
❑ Upper gastrointestinal series with small bowel follow through (SBFT)
Magnetic resonance imaging (enterography)
Wireless capsule endoscopy
Findings suggestive of Crohn's disease:
❑ Discontinuous lesions
❑ Biopsy (Transmural inflammation, noncaseating granuloma)
❑ Cobblestoning (Serpiginous and linear ulcer)
❑ Normal rectum
❑ Isolated terminal ileum involvenent
❑ Aphthous ulcers
❑ Negative stool examination for infectious causes
Assessment of severity
Mild to moderate

❑ Ambulatory patients
❑ Tolerating oral diet
❑ No dehydration
❑ No toxicity
❑ No abdominal tenderness or mass
❑ No obstruction
Weight loss <10 percent

Moderate to severe

❑ Intermittent nausea or vomiting
❑ Mild to moderate dehydration
❑ Abdominal pain and tenderness
❑ No obstruction
❑ Weight loss > 10 percent

Severe to fulminant

❑ High fever
❑ Persistent vomiting
❑ Severe dehydration
❑ Significant peritoneal signs
❑ Evidence of abscess
Intestinal obstruction


Management of Mild to Moderate Crohn's Disease

❑ Outpatient therapy
❑ Start altered diet
❑ Start oral rehydration therapy
Ileitis and colitis
Oral lesion
Gastroduodenal disease
❑ Illeitis and Rt side colitis: Oral budesonide (9 mg/day)
❑ Distal colitis : Topical mesalamine or topical steroids (enemas or suppositories)
❑Other site : Oral mesalamine (4 g/day) or oral sulfasalazine (3-6 g/day)
triamcinolone acetonide
PPI or H2 antagonist, or sucralfate
❑ Oral mesalamine (Pentasa: 2 g/day)
Response to treatment in 3-4 wks
Oral metronidazole (10-20 mg/kg/day)
Significant response
No response
Maintenance therapy

Proctitis: Mesalamine suppositories
Distal colitis : Mesalamine enemas

❑ Others: Oral sulfasalazine or olsalazine or mesalamine(3-3.6 g/day) or balsalazide
Treat as moderate to severe disease
Azathioprine or 6-mercaptopurine for inadequate response

Management of Moderate to Severe Crohn's Disease

❑ Inpatient therapy
❑ Start oral rehydration therapy or intravenous fluids based upon hydration status
No steroid contraindication
Steroid contraindicated
Oral prednisone (40-60 mg/day) with or without mesalamine
Consider methotrexate therapy

❑ A baseline CBC, CXR and LFT
Methotrexate (25 mg/wk i.m and once improvement 15 mg/wk i.m or oral or s.c)


Consider anti-TNF monoclonal antibody therapy

❑ A baseline PPD and CXR (Rule out TB)
Infliximab (5 mg/kg i.v at 0, 2 and 6 wks)
Adalimumab (160 mg s.c at 0 wk and 80 mg/2 wks)
Certolizumab pegol (400 mg/4wk s.c)

Consider Azthioprine or 6 MP therapy

❑ A baseline CBC and LFT
Azathioprine (2-3 mg/kg/day)
6-mercaptopurine (1-1.5 mg/kg/day)

Response to treatment
Response to treatment
Treat as severe to fulminant disease or consider managing as steroid contraindicated CD treatment
❑Taper steroids by 5-10 mg/wk until 20 mg and then by 2.5-5 mg/wk until discontinuation of therapy
❑ Baseline DEXA scan
❑ Oral calcium, vitamin D or bisphosphonates based on DEXA scan
Maintenance therapy

Infliximab montherapy
❑ Combined infliximab and azathioprine therapy
Methotrexate therapy (15 mg/wk i.m): For methotrexate induced remissions
Adalimumab therapy (40 mg/wk s.c): For adalimumab induced remissions
Certolizumab pegol therapy (400 mg/ 4wk s.c): For certolizumab pegol induced remissions
Natalizumab therapy (300 mg/ 4wk s.c): For natalizumab induced remissions

❑ Monitor CBC every 3 months
❑ Monitor periodically for side effects
Surgical consultation (ileocolonic resections / perioperative antibiotics)
Steroid dependent (Flare up of symptoms on tapering steroids)
Steroid independent (No flare up of symptoms on tapering steroids)
Manage as steroid contraindicated CD treatment

❑ Consider methotrexate therapy
❑ Consider anti-TNF monoclonal antibody therapy
❑ Consider Azthioprine or 6 MP therapy
❑ Maintenance therapy or surgical consultation according to Rx response

Maintenance therapy

Azathioprine (2-2.5 mg/kg)
6-mercaptopurine (1.5 mg/kg)

❑ Monitor CBC every 3 months ❑ Monitor periodically for side effects
Maintenance therapy

Natalizumab therapy (300 mg/ 4wk s.c)
Infliximab montherapy (1.5 mg/kg)

❑ Monitor CBC every 3 months
❑ Monitor periodically for side effects

Management of Severe to Fulminant Crohn's Disease

❑ Inpatient therapy
❑ Start intravenous fluids
❑ Consider total parental nutrition
Abscess or peritonitis or severe intestinal obstruction or refractory/severe painful fistulas
No abscess or partial intestinal obstruction
Surgical consultation (ileocolonic resections / abscess drainage / perioperative antibiotics)
Intravenous prednisone (40-60 mg/day)
Maintenance therapy

Natalizumab therapy (300 mg/ 4wk s.c)
Infliximab montherapy (1.5 mg/kg)

❑ Monitor CBC every 3 months
❑ Monitor periodically for side effects
No response to Rx
Significant response to Rx
Intravenous cyclosporine or tacrolimus
❑ Gradually switch to oral steroids and monitor the response
❑ Taper the dose of steroids as mentioned above

❑ Monitor for any relapses and treat accordingly

❑ Start the patient on maintenance therapy as above
No response to Rx
Significant response to Rx
Surgical consultation (ileocolonic resections / abscess drainage / perioperative antibiotics)
Bridging therapy

❑ Switch to oral cyclosporine
❑ Taper off the glucocorticoids over the first 4-6 weeks
❑ Taper off cyclosporine microemulsion over the next 6-8 weeks
❑ Start then 6-mercaptopurine (6-MP) or azathioprine

Maintenance therapy

Natalizumab therapy (300 mg/ 4wk s.c)
Infliximab montherapy (1.5 mg/kg)

❑ Monitor CBC every 3 months
❑ Monitor periodically for side effects


  • Always assess first the volume status and adequate intravascular volume in CD patients presenting with diarrhea. Correcting fluid and electrolyte disturbances take priority over identifying the causative agent.
  • Always consider a diagnosis of underlying Crohn disease in patients with perianal disease that does not resolve with routine management and with unusual presentations such as complex anal fistulas, large indurated hemorrhoids and anal fissures that are not located in the midline.
  • Always consider alternative inflammatory bowel diseases (infectious, ischemic, radiation-induced, medication-induced, particularly related to the use of non-steroidal anti-inflammatory drugs), or idiopathic intestinal disorders (ulcerative colitis, celiac disease, or microscopic colitis), and irritable bowel syndrome as differential diagnosis to CD before initiating the treatment.
  • Colonoscopy with multiple biopsies (at least two biopsies from five sites including the distal ileum and rectum) is the first line procedure for diagnosing inflammatory bowel disease. Full colonoscopy is not advised in acute severe colitis, however phosphate enema prior to sigmoidoscopy is preferred and considered safe, except in those with colonic dilatation.
  • Always decide therapeutic recommendations based upon the disease location, disease severity, and disease-associated complications and always consider maintenance therapy for patients achieving remission.
  • Mid to moderate disease can be managed relatively early in the course of the disease with more potent therapies, such as biologic therapy or immunomodulator therapy, even before they receive glucocorticoids and become glucocorticoid dependent.
  • Consider symptomatic treatment with loperamide in patients not responding completely to first-line therapy in the absence of warning signs.[2] Cholestyramine can be given for patients with ileal resections who have bile salt diarrhea and non-stenosing ileitis who have chronic watery diarrhea.
  • Do a lactose avoidance trial for CD patients with symptoms suggestive of lactase insufficiency and a lactose breath hydrogen test is done in any case of doubt.[3]
  • Do C. difficile testing for all patients with IBD who develop diarrhea following recent hospitalization or antibiotic use or in the setting of previously quiescent disease or with a disease flare. Consider the simultaneous treatment for IBD flare and empiric therapy against C. difficile infection among IBD patients who have severe colitis.[4]
  • Serological studies evaluating antibodies against S. cerevisiae, antineutrophil cytoplasmic antibodies, antibodies directed against CBir1, OmpC are not sufficiently sensitive or specific to be used as screening tools, but are evolving to provide adjunctive support for the diagnosis of CD.[5]
  • Do complete blood cell count and liver function tests at the initiation of 5-ASA therapy with subsequent monitoring every two weeks during the first three months, then monthly for the second three months, and every three months thereafter.
  • Do serum blood urea nitrogen and creatinine and urinalysis testing at 6 weeks, 6 months, and 12 months after initiation of 5-ASA therapy and then annually.[6]
  • Do hepatitis B screening before initiating infliximab therapy.
  • Do complete blood counts, initially every 1-2 weeks and at least every 3 months for patients on azathioprine, 6 mercaptopurine and other immunomodulator therapy to avoid the risk of acute or delayed bone marrow suppression.[7]
  • Always determine thiopurine methyltransferase (TPMT), the primary enzyme-metabolizing azathioprine/6-mercaptopurine, activity or genotype prior to initiating treatment with azathioprine or 6-mercaptopurine.[7]
  • Do switch patients to an alternative anti-TNF agent who fail to respond to, lose their response to, or are intolerant of one biologic therapy.
  • Use metronidazole alone or in combination with ciprofloxacin for CD patients with non-suppurative perianal complications. Monitor patients for any evidence of peripheral neuropathy with long term metronidazole treatment and for tendonitis and tendon rupture with ciprofloxacin therapy.
  • Immunomodulator therapy should be considered in patients with symptomatic perianal fistulas who do not respond to antibiotics and local therapy.[8][9] Do treat patients with fistulae, especially those with actively draining fistulae or high output enteroenteric fistulae, with infliximab 5 mg/kg administered at weeks 0, 2, and 6 alone or in combination with azathioprine.
  • Surgical intervention is required in some CD patients to treat intractable hemorrhage, perforation, persisting or recurrent obstruction, abscess (not amenable to percutaneous drainage), dysplasia or cancer, or unresponsive fulminant disease.
  • Surgery should also be considered in patients who have active luminal CD and fail to improve within 7-10 days of intensive in-patient medical management.
  • Do recommend prophylaxis for venous thromboembolism for all hospitalized patients with IBD.[10]
  • Do vaccinate patients on immunosuppresants routinely for influenza, pneumococcal, meningococcus infection, and for tetanus in the appropriate settings.

Don't s

  • Don't treat patients with severe diarrheal dehydration using 5% dextrose with 1/4 normal saline, as using solutions with lower amounts of sodium (such as 38.5 mmol/L in 1/4 saline with 5% dextrose ) would lead to sudden and severe hyponatremia with a high risk of death.[11]
  • Oral rehydration therapy is contraindicated in the initial management of severe dehydration, in patients with frequent and persistent vomiting (more than four episodes per hour), and painful oral conditions such as moderate to severe thrush.
  • Dont continue immunomodulator therapy in the occurrence of any hypersentivity reactions or toxic side effects.
  • Dont use narcotic analgesia except for the perioperative setting because of the potential for tolerance and abuse in the setting of chronic disease.
  • Dont use live vaccines in patients on immunosuppressants, so if these are required they should be administered at the time of inflammatory bowel disease diagnosis.
  • Dont use infliximab in patients with active infection, untreated latent tuberculosis (TB), preexisting demyelinating disorder or optic neuritis, moderate to severe congestive heart failure, or current or recent malignancies.
  • Dont treat patients with decompensated heart failure with infliximab because of the risk of further decline in cardiac function.
  • Dont use medications with anticholinergic or narcotic properties in patients with either toxic signs (fever, leukocytosis, or worsening symptoms) or megacolon, due to possibility of worsening colonic atony or dilatation, as increased colonic and small intestinal gas is a predictor of a poor outcome to medical therapy.


  1. Lichtenstein, Gary R; Hanauer, Stephen B; Sandborn, William J (2009). "Management of Crohn's Disease in Adults". The American Journal of Gastroenterology. 104 (2): 465–483. doi:10.1038/ajg.2008.168. ISSN 0002-9270.
  2. Barrett KE, Dharmsathaphorn K (1988). "Pharmacological aspects of therapy in inflammatory bowel diseases: antidiarrheal agents". J Clin Gastroenterol. 10 (1): 57–63. PMID 3282003.
  3. Mishkin B, Yalovsky M, Mishkin S (1997). "Increased prevalence of lactose malabsorption in Crohn's disease patients at low risk for lactose malabsorption based on ethnic origin". Am J Gastroenterol. 92 (7): 1148–53. PMID 9219788.
  4. Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH; et al. (2013). "Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections". Am J Gastroenterol. 108 (4): 478–98, quiz 499. doi:10.1038/ajg.2013.4. PMID 23439232.
  5. Eugene C (2011). "The second European evidence-based consensus on the diagnosis and management of Crohn's disease (part 3)". Clin Res Hepatol Gastroenterol. 35 (8–9): 516–7. doi:10.1016/j.clinre.2011.06.009. PMID 21816700.
  6. Gisbert JP, González-Lama Y, Maté J (2007). "5-Aminosalicylates and renal function in inflammatory bowel disease: a systematic review". Inflamm Bowel Dis. 13 (5): 629–38. doi:10.1002/ibd.20099. PMID 17243140.
  7. 7.0 7.1 Lichtenstein GR, Abreu MT, Cohen R, Tremaine W, American Gastroenterological Association (2006). "American Gastroenterological Association Institute technical review on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease". Gastroenterology. 130 (3): 940–87. doi:10.1053/j.gastro.2006.01.048. PMID 16530532.
  8. Ierardi E, Principi M, Rendina M, Francavilla R, Ingrosso M, Pisani A; et al. (2000). "Oral tacrolimus (FK 506) in Crohn's disease complicated by fistulae of the perineum". J Clin Gastroenterol. 30 (2): 200–2. PMID 10730928.
  9. Present DH, Rutgeerts P, Targan S, Hanauer SB, Mayer L, van Hogezand RA; et al. (1999). "Infliximab for the treatment of fistulas in patients with Crohn's disease". N Engl J Med. 340 (18): 1398–405. doi:10.1056/NEJM199905063401804. PMID 10228190.
  10. Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR; et al. (2008). "Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)". Chest. 133 (6 Suppl): 381S–453S. doi:10.1378/chest.08-0656. PMID 18574271.
  11. "" (PDF). Retrieved 2 January 2014. External link in |title= (help)

Template:WikiDoc Sources