Crohn's disease resident survival guide
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 factors recognized to exacerbate CD are
- Clostridium difficile infection
- Lactose intolerance
- Upper respiratory tract infection
The algorithm is based on the American Journal of Gastroenterology guidelines for management of Crohn's disease in adults.
Characterize the symptoms:
❑ Abdominal pain
Obtain detailed history:
❑ Recent travel H/O
Assess volume status:
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)
❑ Complete blood count (CBC)
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
Management of Mild to Moderate Crohn's Disease
❑ Outpatient therapy
❑ Start altered diet
❑ Start oral rehydration therapy
|Ileitis and colitis||Oral lesion||Gastroduodenal disease|
|Response to treatment in 3-4 wks|
|Oral metronidazole (10-20 mg/kg/day)|
|Significant response||No response|
|Treat as moderate to severe disease|
|Azathioprine or 6-mercaptopurine for inadequate response|
Management of Moderate to Severe Crohn's Disease
|No steroid contraindication||Steroid contraindicated|
|Oral prednisone (40-60 mg/day) with or without mesalamine|
Consider methotrexate therapy
Consider anti-TNF monoclonal antibody therapy
Consider Azthioprine or 6 MP therapy
|Response to treatment||Response to treatment|
|Treat as severe to fulminant disease or consider managing as steroid contraindicated CD treatment|
❑ Infliximab montherapy
❑ 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
Management of Severe to Fulminant Crohn's Disease
❑ Inpatient therapy
❑ Start intravenous fluids
❑ Consider total parental nutrition
No abscess or partial intestinal obstruction
|Surgical consultation (ileocolonic resections / abscess drainage / perioperative antibiotics)||Intravenous prednisone (40-60 mg/day)|
|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
|No response to Rx||Significant response to Rx|
|Surgical consultation (ileocolonic resections / abscess drainage / perioperative antibiotics)|
- 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. 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.
- 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.
- 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.
- 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.
- 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.
- Always determine thiopurine methyltransferase (TPMT), the primary enzyme-metabolizing azathioprine/6-mercaptopurine, activity or genotype prior to initiating treatment with azathioprine or 6-mercaptopurine.
- 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. 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.
- Do vaccinate patients on immunosuppresants routinely for influenza, pneumococcal, meningococcus infection, and for tetanus in the appropriate settings.
- 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.
- 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.
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