Crohn's disease resident survival guide: Difference between revisions
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{{familytree | | | |!| | | | | | | I02 | | | | | | I03 | | | I01 | | |!| | | |!| | I04 | | I05 | | |!| | | | | | |I02= Oral [[metronidazole]] (10-20 mg/kg/day) | I03=<div style="float: left; text-align: left"> ❑Taper steroids by 5-10 mg/wk until 20 mg and then by 2.5-5 mg/wk until discontinuation of therapy <br> ❑ Baseline [[DEXA scan]]<br> ❑ Oral [[calcium]], [[vitamin D]] or [[bisphosphonates]] based on DEXA scan</div> | I01= Treat as '''severe to fulminant''' disease or consider the following | I04= No response to Rx | I05= Significant response to Rx}} | {{familytree | | | |!| | | | | | | I02 | | | | | | I03 | | | I01 | | |!| | | |!| | I04 | | I05 | | |!| | | | | | |I02= Oral [[metronidazole]] (10-20 mg/kg/day) | I03=<div style="float: left; text-align: left"> ❑Taper steroids by 5-10 mg/wk until 20 mg and then by 2.5-5 mg/wk until discontinuation of therapy <br> ❑ Baseline [[DEXA scan]]<br> ❑ Oral [[calcium]], [[vitamin D]] or [[bisphosphonates]] based on DEXA scan</div> | I01= Treat as '''severe to fulminant''' disease or consider the following | I04= No response to Rx | I05= Significant response to Rx}} | ||
{{familytree | | | |!| | | | | |,|-|^|-|.| | | |,|-|^|-|.| | |!| | | |!| | | |!| | |!| | | |!| | | |!| | |}} | {{familytree | | | |!| | | | | |,|-|^|-|.| | | |,|-|^|-|.| | |!| | | |!| | | |!| | |!| | | |!| | | |!| | |}} | ||
{{familytree | | | |!| | | | | J01 | | J02 | | J03 | | J04 | |!| | | |!| | | |!| | |!| | | |`|-|v|-|'| | |J01= Significant response | J02 = No response | J03= Steroid independent | J04=Steroid dependent }} | {{familytree | | | |!| | | | | J01 | | J02 | | J03 | | J04 | |!| | | |!| | | |!| | |!| | | |`|-|v|-|'| | |J01= Significant response | J02 = No response | J03= Steroid independent (No flare up of symptoms on tapering steroids)| J04=Steroid dependent (Flare up of symptoms on tapering steroids) }} | ||
{{familytree | | | |`|-|-|v|-|-|'| | | |!| | | |!| | | |`|-|-|+|-|-|-|'| | | |!| | |!| | | | | X01 | | | | X01=Gradual transition to oral medications}} | {{familytree | | | |`|-|-|v|-|-|'| | | |!| | | |!| | | |`|-|-|+|-|-|-|'| | | |!| | |!| | | | | X01 | | | | X01=Gradual transition to oral medications}} | ||
{{familytree | | | | | | |!| | | | | | K02 | | |!| | | | | | K05 | | | | | | |!| | |!| | | | | | | | | | | | K02= Treat as '''moderate to severe disease''' | K05= <div style="float: left; text-align: left"> Consider '''methotrexate''' therapy | {{familytree | | | | | | |!| | | | | | K02 | | |!| | | | | | K05 | | | | | | |!| | |!| | | | | | | | | | | | K02= Treat as '''moderate to severe disease''' | K05= <div style="float: left; text-align: left"> Consider '''methotrexate''' therapy | ||
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* 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. | * 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. However full colonoscopy is not advised in acute severe colitis and phosphate enema prior to sigmoidoscopy is preferred and considered safe, except in those with colonic dilatation. | * 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. However full colonoscopy is not advised in acute severe colitis and 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. | * 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. | * 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.<ref name="pmid3282003">{{cite journal| author=Barrett KE, Dharmsathaphorn K| title=Pharmacological aspects of therapy in inflammatory bowel diseases: antidiarrheal agents. | journal=J Clin Gastroenterol | year= 1988 | volume= 10 | issue= 1 | pages= 57-63 | pmid=3282003 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3282003 }} </ref> [[Cholestyramine]] can be given for patients with ileal resections who have bile salt diarrhea and non-stenosing ileitis who have chronic watery diarrhea. | * Consider symptomatic treatment with [[loperamide]] in patients not responding completely to first-line therapy in the absence of warning signs.<ref name="pmid3282003">{{cite journal| author=Barrett KE, Dharmsathaphorn K| title=Pharmacological aspects of therapy in inflammatory bowel diseases: antidiarrheal agents. | journal=J Clin Gastroenterol | year= 1988 | volume= 10 | issue= 1 | pages= 57-63 | pmid=3282003 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3282003 }} </ref> [[Cholestyramine]] can be given for patients with ileal resections who have bile salt diarrhea and non-stenosing ileitis who have chronic watery diarrhea. |
Revision as of 15:02, 16 January 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mugilan Poongkunran M.B.B.S [2]
Definition
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 potential to cause systemic and extraintestinal complications.
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Crohn’s disease itself may present or complicate as a life-threatening condition and must be treated as such irrespective of the causes.
Common Causes
Common factors recognized to exacerbate CD are
- Campylobacter
- Clostridium difficile infection
- Lactose intolerance
- NSAIDS
- Salmonella
- Shigella
- Smoking
- Upper respiratory tract infection
Management
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 Extraintestinal symptoms: ❑ Skin lesions | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Assess volume status:
❑ General condition Examine the patient: ❑ Skin (swelling, pain, edema, 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) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Order tests: ❑ 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) ❑ Cobblestoning (Serpiginous and linear ulcer) ❑ Normal rectum ❑ Isolated terminal ileum involvenent ❑ Aphthous ulcers | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Assessment of severity | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Mild to moderate
❑ Ambulatory patients | Severe to fulminant
❑ High fever | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Inpatient therapy ❑ Start oral rehydration therapy or intravenous fluids based upon hydration status | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Oral lesion | Ileitis and colitis | Gastroduodenal disease | No steroid contraindication | Steroid contraindicated | Abscess or peritonitis or severe intestinal obstruction or refractory/severe painful fistulas | No abscess or partial intestinal obstruction | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Topical triamcinolone acetonide | ❑ 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) | Oral prednisone (40-60 mg/day) with or without mesalamine | Intravenous prednisone (40-60 mg/day) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Response to treatment in 3-4 wks | Response to treatment | No response to Rx | Significant response to Rx | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | Yes | No | Intravenous cyclosporine or tacrolimus | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Oral metronidazole (10-20 mg/kg/day) | ❑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 | Treat as severe to fulminant disease or consider the following | No response to Rx | Significant response to Rx | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Significant response | No response | Steroid independent (No flare up of symptoms on tapering steroids) | Steroid dependent (Flare up of symptoms on tapering steroids) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Gradual transition to oral medications | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Treat as moderate to severe disease | Consider methotrexate therapy
❑ A baseline CBC, CXR and LFT OR Consider anti-TNF monoclonal antibody therapy ❑ A baseline PPD and CXR (Rule out TB) Consider Azthioprine or 6 MP therapy ❑ A baseline CBC and LFT | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Significant response | No response | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Maintenance therapy
❑ Proctitis: Mesalamine suppositories | Maintenance therapy
❑ Azathioprine (2-2.5 mg/kg) ❑ Monitor CBC every 3 months ❑ Monitor periodically for side effects | Maintenance therapy
❑ Infliximab montherapy ❑ Monitor CBC every 3 months ❑ Monitor periodically for side effects | Surgical consultation (ileocolonic resections / abscess drainage / perioperative antibiotics) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Azathioprine or 6-mercaptopurine for inadequate response | Maintenance therapy
❑ Natalizumab therapy (300 mg/ 4wk s.c) ❑ Monitor CBC every 3 months ❑ Monitor periodically for side effects | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Do's
- 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. However full colonoscopy is not advised in acute severe colitis and 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 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 CDI 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 sulfasalaine therapy.
- Do serum blood urea nitrogen and creatinine and urinalysis be measured at 6 weeks, 6 months, and 12 months after initiation of 5-ASA therapy and then annually.[6]
- 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.
- Do complete blood counts, initially every 1-2 weeks and at least every 3 months for patients on azthioprine, 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]
- Use metronidazole alone or in combination with ciprofloxacin for CD patients with non-suppurative perianal complications. Monitor patients with long term antibiotic metronidazole treatment for evidence of peripheral neuropathy and ciprofloxacin therapy for tendonitis and tendon rupture. 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 hospitalized patients with IBD.[10]
- Do colonoscopy screening for colon cancer in all Crohn's disease patient starting 10 year from the diagnosis.
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.
References
- ↑ 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.
- ↑ Barrett KE, Dharmsathaphorn K (1988). "Pharmacological aspects of therapy in inflammatory bowel diseases: antidiarrheal agents". J Clin Gastroenterol. 10 (1): 57–63. PMID 3282003.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 7.0 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ "http://www.worldgastroenterology.org/assets/export/userfiles/Acute%20Diarrhea_long_FINAL_120604.pdf" (PDF). Retrieved 2 January 2014. External link in
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