Crohn's disease resident survival guide: Difference between revisions
No edit summary |
Kiran Singh (talk | contribs) |
||
(11 intermediate revisions by 2 users not shown) | |||
Line 2: | Line 2: | ||
{{CMG}}; {{AE}} {{M.P}} | {{CMG}}; {{AE}} {{M.P}} | ||
== | ==Overview== | ||
[[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. | [[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. | ||
==Causes== | ==Causes== | ||
===Life Threatening Causes=== | ===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 | ===Common Triggers=== | ||
Common factors recognized to exacerbate CD are | Common factors recognized to exacerbate CD are | ||
* [[Campylobacter]] | * [[Campylobacter]] | ||
Line 24: | Line 24: | ||
{{Family tree/start}} | {{Family tree/start}} | ||
{{familytree | {{familytree | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | A01=<div style="float: left; text-align: left; height: 50em; width: 15em; padding:1em;"> '''Characterize the symptoms:'''<br> | ||
---- | ---- | ||
❑ [[Abdominal pain]] <br> | ❑ [[Abdominal pain]] <br> | ||
Line 46: | Line 46: | ||
❑ Burning micturition <br> | ❑ Burning micturition <br> | ||
❑ [[Cough]], [[breathlessness]] <br> | ❑ [[Cough]], [[breathlessness]] <br> | ||
❑ [[Eye pain]], [[blurring of vision]] <br> </div>}} | ❑ [[Eye pain]], [[blurring of vision]] <br> | ||
{{familytree | ---- | ||
{{familytree | '''Obtain detailed history:'''<br> | ||
---- | |||
❑ Recent travel H/O <br> | |||
❑ Recent drug H/O <br> | |||
❑ Abdominal or pelvic radiation H/O <br> | |||
❑ Family H/O <br> | |||
❑ Systemic illness H/O <br> </div>}} | |||
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | B01=<div style="float: left; text-align: left; height: 28em; width: 25em; padding:1em;">'''Assess volume status:''' | |||
---- | ---- | ||
❑ General condition <br> | ❑ General condition <br> | ||
Line 59: | Line 67: | ||
'''Examine the patient:'''<br> | '''Examine the patient:'''<br> | ||
---- | ---- | ||
❑ Skin (swelling, pain | ❑ Skin (swelling, pain, erythema or ulceration) <br> ❑ Oral cavity (ulcers) <br> ❑ Respiratory system (wheezing or crackles) <br> ❑ Cardiovascular system <br> ❑ Abdomen (mass, distension or tenderness) <br> ❑ Anorectal (perianal skin tags, sinus tracts or bleeding) <br> ❑ Eye (swelling, pain, edema or vision loss) <br> ❑ Musculoskeletal (Axial, large and small joints) <br> </div>}} | ||
{{familytree | {{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | }} | ||
{{familytree | {{familytree | | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | | | | | | C01= <div style="float: left; text-align: left; height: 21em; width: 25em; padding:1em;">'''Order tests:'''<br> | ||
❑ [[Complete blood count|Complete blood count (CBC)]] <br> | ❑ [[Complete blood count|Complete blood count (CBC)]] <br> | ||
❑ [[Erythrocyte sedimentation rate|Erythrocyte sedimentation rate (ESR)]]<br> | ❑ [[Erythrocyte sedimentation rate|Erythrocyte sedimentation rate (ESR)]]<br> | ||
Line 67: | Line 75: | ||
❑ [[Serum electrolytes]] <br> | ❑ [[Serum electrolytes]] <br> | ||
❑ Serum [[iron]] and [[vitamin B12]] levels<br> | ❑ Serum [[iron]] and [[vitamin B12]] levels<br> | ||
❑ [[Diarrhea laboratory findings|Stool analysis (occult blood, WBC's, culture, ova and parasites)]]<br> | ❑ [[Diarrhea laboratory findings|Stool analysis (occult blood, WBC's, calprotectin, lactoferrin, culture, ova and parasites)]]<br> | ||
❑ [[Clostridium difficile laboratory findings|Stool for Clostridium difficile toxin]] <br> | ❑ [[Clostridium difficile laboratory findings|Stool for Clostridium difficile toxin]] <br> | ||
❑ [[Urinalysis]] <br> | ❑ [[Urinalysis]] <br> | ||
Line 74: | Line 82: | ||
❑ [[Serum glucose]]<br> | ❑ [[Serum glucose]]<br> | ||
❑ [[Liver function tests]] <br> </div>}} | ❑ [[Liver function tests]] <br> </div>}} | ||
{{familytree | {{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree | {{familytree | | | | | | | | | | | | | | D10 | | | | | | | | | | | | | | | | | | | | | | D10= <div style="float: left; text-align: left"> '''Confirmatory diagnostic tests:'''<br> ❑ [[Colonoscopy|Colonoscopy and biopsy]] <br> ❑ Upper GI scopy and biopsy<br> ❑ [[Computed tomography|Computed tomography (CT)]] <br> ❑ [[Barium enema]] (length and location of strictures) <br> ❑ Upper gastrointestinal series with small bowel follow through (SBFT) <br> ❑ [[Magnetic resonance imaging]] (enterography)<br> ❑ [[Wireless capsule endoscopy]]<br> | ||
</div>}} | </div>}} | ||
{{familytree | {{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree | {{familytree | | | | | | | | | | | | | | D10 | | | | | | | | | | | | | | | | | | | | | | D10= <div style="float: left; text-align: left"> '''Findings suggestive of Crohn's disease:'''<br> ❑ Discontinuous lesions <br> ❑ Biopsy (Transmural inflammation, noncaseating granuloma) <br> ❑ Cobblestoning (Serpiginous and linear ulcer) <br> ❑ Normal rectum <br> ❑ Isolated terminal ileum involvenent <br> ❑ Aphthous ulcers<br> ❑ Negative stool examination for infectious causes <br> | ||
</div>}} | </div>}} | ||
{{familytree | {{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree | {{familytree | | | | | | | | | | | | | | B01 | | | B01=Assessment of severity}} | ||
{{familytree | | | | | | | |, | {{familytree | | | | | | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| | | | | | | | | | | |}} | ||
{{familytree | | | | | | | C01 | {{familytree | | | | | | | C01 | | | | | C02 | | | | | C03 | | | | | | | | | | | | C01=<div style="float: left; text-align: left; height: 15em; width: 15em; padding:1em;">'''Mild to moderate''' | ||
---- | ---- | ||
❑ Ambulatory patients <br> | ❑ Ambulatory patients <br> | ||
Line 93: | Line 101: | ||
❑ [[Weight loss]] <10 percent <br> | ❑ [[Weight loss]] <10 percent <br> | ||
</div> | </div> | ||
| C02= <div style="float: left; text-align: left">'''Moderate to severe''' | | C02= <div style="float: left; text-align: left; height: 15em; width: 15em; padding:1em;">'''Moderate to severe''' | ||
---- | ---- | ||
❑ [[Fever]] <br> | ❑ [[Fever]] <br> | ||
Line 103: | Line 111: | ||
❑ Weight loss > 10 percent <br> | ❑ Weight loss > 10 percent <br> | ||
</div> | </div> | ||
| C03=<div style="float: left; text-align: left">'''Severe to fulminant''' | | C03=<div style="float: left; text-align: left; height: 15em; width: 15em; padding:1em;">'''Severe to fulminant''' | ||
---- | ---- | ||
❑ High fever <br> | ❑ High fever <br> | ||
Line 113: | Line 121: | ||
❑ [[Cachexia]] <br> | ❑ [[Cachexia]] <br> | ||
</div> }} | </div> }} | ||
{{familytree | | | | | | | | | {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{Family tree/end}} | |||
===Management of Mild to Moderate Crohn's Disease=== | |||
{{familytree | | | | | {{Family tree/start}} | ||
{{familytree | | | | {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |A01 =<div style="float: left; text-align: left; height: 6em; width: 12em; padding:1em;"> ❑ Outpatient therapy <br> ❑ Start altered diet <br> ❑ Start [[oral rehydration therapy]]</div>}} | |||
{{familytree | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | E02 | | E01 | | E03 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | E01=Oral lesion | E02= [[Ileitis]] and [[colitis]] | E03= Gastroduodenal disease}} | |||
{{familytree | | | | | | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | F02 | | F01 | | F03 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | F01=[[triamcinolone acetonide]] | F02=<div style="float: left; text-align: left; height: 17em; width: 12em; padding:1em;"> ❑ Illeitis and Rt side colitis: Oral [[budesonide]] (9 mg/day) <br> ❑ Distal colitis : Topical mesalamine or topical steroids (enemas or suppositories) <br> ❑Other site : Oral [[mesalamine]] (4 g/day) or oral [[sulfasalazine]] (3-6 g/day) </div>| F03=<div style="float: left; text-align: left; height: 15em; width: 12em; padding:1em;"> ❑ [[proton pump inhibitor|PPI]] or [[H2 antagonist]], or [[sucralfate]] <br>❑ Oral [[mesalamine]] (Pentasa: 2 g/day)</div>}} | |||
{{familytree | | | | | | | | | | |`|-|-|-|+|-|-|-|'| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | G01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |G01= Response to treatment in 3-4 wks}} | |||
{{familytree | | | | | {{familytree | | | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree | | | | | {{familytree | | | | | | | | | | H01 | | | | | | H02 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |H01=Yes | H02= No}} | ||
{{familytree | | | | | | | | | | |!| | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | |!| | | | | | | I02 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |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>}} | |||
{{familytree | | | | | | | | | | |!| | | | | |,|-|^|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | |!| | | | | J01 | | | J02 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |J01= Significant response | J02 = No response}} | |||
{{familytree | | | | | | | | | | |`|-|-|-|v|-|-|'| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | |!| | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | M04 | | | | | K02 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |K02= Treat as '''moderate to severe disease''' | M04= <div style="float: left; text-align: left">'''Maintenance therapy''' | |||
---- | |||
❑ [[Proctitis]]: Mesalamine suppositories <br> | |||
'''OR''' <br> | |||
❑ [[colitis|Distal colitis]] : Mesalamine enemas<br> | |||
'''OR''' <br> | |||
❑ Others: Oral [[sulfasalazine]] or [[olsalazine]] or [[mesalamine]](3-3.6 g/day) or [[balsalazide]] </div>}} | |||
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | N01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | N01=Azathioprine or 6-mercaptopurine for inadequate response }} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{Family tree/end}} | |||
===Management of Moderate to Severe Crohn's Disease=== | |||
{{Family tree/start}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | | D02 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |D02 =<div style="float: left; text-align: left; height: 8em; width: 12em; padding:1em;"> ❑ Inpatient therapy <br> ❑ Start [[oral rehydration therapy]] or [[intravenous fluids]] based upon hydration status </div> }} | |||
{{familytree | | | | | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | E04 | | | | | | | | E05 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |E04 = No steroid contraindication | E05= [[Steroid]] contraindicated }} | |||
{{familytree | | | | | | | | | | |!| | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | F04 | | | | | | | | F05 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F04 = Oral [[prednisone]] (40-60 mg/day) with or without mesalamine|F05= <div style="float: left; text-align: left; height: 35em; width: 25em; padding:1em;"> Consider '''methotrexate''' therapy | |||
---- | ---- | ||
❑ A baseline [[CBC]], [[CXR]] and [[LFT]]<br> | ❑ A baseline [[CBC]], [[CXR]] and [[LFT]]<br> | ||
Line 152: | Line 185: | ||
❑ [[6-mercaptopurine]] (1-1.5 mg/kg/day) | ❑ [[6-mercaptopurine]] (1-1.5 mg/kg/day) | ||
</div> }} | </div> }} | ||
{{familytree | | | | | | |!| | | | | | | | | | |!| | | |,|-|^|-|.| | | | | | | | {{familytree | | | | | | | | | | |!| | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree | | | | | | | | {{familytree | | | | | | | | | | G02 | | | | | | | | G03 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |G02=Response to treatment| G03=Response to treatment}} | ||
{{familytree | | | | | | |!| | | | | | | | | | |!| | | |!| | | | | {{familytree | | | | | | | | | | |!| | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree | | | | | | | {{familytree | | | | | | | |,|-|-|^|-|-|.| | | | | | |,|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree | | | | | | | H03 | | | | H04 | | | | | H05 | | H06 | | | | | | | | | | | | | | | | | | | | | | | | | | | | |H04=Yes | H03= No| H05=Yes | H06=No}} | |||
{{familytree | | | | | | | |!| | | | | |!| | | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | I01 | | | | I03 | | | | | I04 | | I05 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |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 managing as steroid contraindicated CD treatment| I04= <div style="float: left; text-align: left">'''Maintenance therapy''' | |||
---- | ---- | ||
❑ [[ | ❑ [[Infliximab]] montherapy <br> | ||
'''OR''' <br> | |||
❑ Combined infliximab and [[azathioprine]] therapy<br> | |||
'''OR''' <br> | |||
❑ [[Methotrexate]] therapy (15 mg/wk i.m): For methotrexate induced remissions <br> | |||
'''OR''' <br> | |||
❑ [[Adalimumab]] therapy (40 mg/wk s.c): For adalimumab induced remissions <br> | |||
'''OR''' <br> | '''OR''' <br> | ||
❑ [[ | ❑ [[Certolizumab pegol]] therapy (400 mg/ 4wk s.c): For certolizumab pegol induced remissions <br> | ||
'''OR''' <br> | '''OR''' <br> | ||
❑ | ❑ [[Natalizumab]] therapy (300 mg/ 4wk s.c): For natalizumab induced remissions <br> | ||
---- | |||
❑ Monitor [[CBC]] every 3 months<br>❑ Monitor periodically for side effects</div>| I05=Surgical consultation (ileocolonic resections / perioperative antibiotics)}} | |||
{{familytree | | | | | | | | | | | |,|-|^|-|.| | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | J04 | | J03 | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |J03= Steroid independent (No flare up of symptoms on tapering steroids)| J04=Steroid dependent (Flare up of symptoms on tapering steroids) }} | |||
{{familytree | | | | | | | | | | | |!| | | |!| | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | K02 | | K01 | | | | | | | K03 | | | | | | | | | | | | | | | | | | | | | | | | | | | | K01=<div style="float: left; text-align: left">'''Maintenance therapy''' | |||
---- | ---- | ||
❑ [[Azathioprine]] (2-2.5 mg/kg) <br> | ❑ [[Azathioprine]] (2-2.5 mg/kg) <br> | ||
Line 167: | Line 215: | ||
❑ [[6-mercaptopurine]] (1.5 mg/kg) | ❑ [[6-mercaptopurine]] (1.5 mg/kg) | ||
---- | ---- | ||
❑ Monitor [[CBC]] every 3 months ❑ Monitor periodically for side effects</div> | | ❑ Monitor [[CBC]] every 3 months ❑ Monitor periodically for side effects</div>|K02=<div style="float: left; text-align: left; height: 25em; width: 15em; padding:1em;"> '''Manage as steroid contraindicated CD treatment''' | ||
---- | ---- | ||
❑ | ❑ Consider '''methotrexate''' therapy<br> | ||
'''OR''' <br> | '''OR''' <br> | ||
❑ | ❑ Consider '''anti-TNF monoclonal antibody''' therapy<br> | ||
'''OR''' <br> | '''OR''' <br> | ||
❑ [[ | ❑ Consider '''Azthioprine or 6 MP''' therapy<br> | ||
'''PLUS''' <br> | |||
❑ Maintenance therapy or surgical consultation according to Rx response | |||
</div> |K03= <div style="float: left; text-align: left; height: 12 em; width: 10em; padding:1em;">'''Maintenance therapy''' | |||
---- | |||
❑ [[Natalizumab]] therapy (300 mg/ 4wk s.c) <br> | |||
'''OR''' <br> | '''OR''' <br> | ||
❑ [[ | ❑ [[Infliximab]] montherapy (1.5 mg/kg) | ||
---- | |||
❑ Monitor [[CBC]] every 3 months<br>❑ Monitor periodically for side effects </div>}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{Family tree/end}} | |||
===Management of Severe to Fulminant Crohn's Disease=== | |||
{{Family tree/start}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | | D03 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |D03=<div style="float: left; text-align: left; height: 8em; width: 12em; padding:1em;"> ❑ Inpatient therapy <br> ❑ NPO <br> ❑ Start [[intravenous fluids]] <br> ❑ Consider total parental nutrition</div>}} | |||
{{familytree | | | | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | E06 | | | | | | E07 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |E06 =<div style="float: left; text-align: left; height: 6 em; width: 12em; padding:1em;"> [[Abscess]] or [[peritonitis]] or [[intestinal obstruction|severe intestinal obstruction]] or refractory/severe painful fistulas</div> | E07=<div style="float: left; text-align: left; height: 6 em; width: 12em; padding:1em;"> No abscess or partial intestinal obstruction</div>}} | |||
{{familytree | | | | | | | | | | | |!| | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | F04 | | | | | | F05 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F04=Surgical consultation (ileocolonic resections / abscess drainage / perioperative antibiotics) | F05 = Intravenous prednisone (40-60 mg/day)}} | |||
{{familytree | | | | | | | | | | | |!| | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | G02 | | G03 | | | | | | G04 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |G02=<div style="float: left; text-align: left; height: 12 em; width: 10em; padding:1em;">'''Maintenance therapy''' | |||
---- | |||
❑ [[Natalizumab]] therapy (300 mg/ 4wk s.c) <br> | |||
'''OR''' <br> | '''OR''' <br> | ||
❑ [[ | ❑ [[Infliximab]] montherapy (1.5 mg/kg) | ||
---- | |||
❑ | ❑ Monitor [[CBC]] every 3 months<br>❑ Monitor periodically for side effects </div>|G03= No response to Rx| G04 = Significant response to Rx}} | ||
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | | H06 | | | | | | H07 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | H06= Intravenous [[cyclosporine]] or [[tacrolimus]]| H07=<div style="float: left; text-align: left; height: 17 em; width: 15em; padding:1em;"> ❑ Gradually switch to oral steroids and monitor the response <br> ❑ Taper the dose of steroids as mentioned above <br> | |||
❑ Monitor for any relapses and treat accordingly <br> | |||
❑ Start the patient on maintenance therapy as above</div>}} | |||
{{familytree | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | I04 | | I05 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |I04= No response to Rx | I05= Significant response to Rx}} | |||
{{familytree | | | | | | | | | | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | F04 | | F05 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F04=Surgical consultation (ileocolonic resections / abscess drainage / perioperative antibiotics)| F05=<div style="float: left; text-align: left; height: 17 em; width: 15em; padding:1em;">'''Bridging therapy''' | |||
---- | ---- | ||
❑ | ❑ Switch to oral cyclosporine <br> | ||
{{familytree | | | | | | | | ❑ Taper off the glucocorticoids over the first 4-6 weeks <br> | ||
{{familytree | | | | | | | ❑ Taper off cyclosporine microemulsion over the next 6-8 weeks <br> | ||
❑ Start then [[6-mercaptopurine]] (6-MP) or [[azathioprine]] | |||
</div> }} | |||
{{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | F04 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |F04=<div style="float: left; text-align: left; height: 12 em; width: 10em; padding:1em;">'''Maintenance therapy''' | |||
---- | ---- | ||
❑ [[Natalizumab]] therapy (300 mg/ 4wk s.c) <br> | ❑ [[Natalizumab]] therapy (300 mg/ 4wk s.c) <br> | ||
Line 190: | Line 273: | ||
---- | ---- | ||
❑ Monitor [[CBC]] every 3 months<br>❑ Monitor periodically for side effects </div>}} | ❑ Monitor [[CBC]] every 3 months<br>❑ Monitor periodically for side effects </div>}} | ||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{Family tree/end}} | {{Family tree/end}} | ||
Line 196: | Line 279: | ||
* 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 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 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. | * 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 decide therapeutic recommendations based upon the disease location, disease severity, and disease-associated complications and always consider maintenance therapy for patients achieving. | * [[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. | * 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. | ||
* 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.<ref name="pmid9219788">{{cite journal| author=Mishkin B, Yalovsky M, Mishkin S| title=Increased prevalence of lactose malabsorption in Crohn's disease patients at low risk for lactose malabsorption based on ethnic origin. | journal=Am J Gastroenterol | year= 1997 | volume= 92 | issue= 7 | pages= 1148-53 | pmid=9219788 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9219788 }} </ref> | * 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.<ref name="pmid9219788">{{cite journal| author=Mishkin B, Yalovsky M, Mishkin S| title=Increased prevalence of lactose malabsorption in Crohn's disease patients at low risk for lactose malabsorption based on ethnic origin. | journal=Am J Gastroenterol | year= 1997 | volume= 92 | issue= 7 | pages= 1148-53 | pmid=9219788 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9219788 }} </ref> | ||
* 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 | * 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.<ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 | pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232 }} </ref> | ||
* 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.<ref name="pmid21816700">{{cite journal| author=Eugene C| title=The second European evidence-based consensus on the diagnosis and management of Crohn's disease (part 3). | journal=Clin Res Hepatol Gastroenterol | year= 2011 | volume= 35 | issue= 8-9 | pages= 516-7 | pmid=21816700 | doi=10.1016/j.clinre.2011.06.009 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21816700 }} </ref> | * 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.<ref name="pmid21816700">{{cite journal| author=Eugene C| title=The second European evidence-based consensus on the diagnosis and management of Crohn's disease (part 3). | journal=Clin Res Hepatol Gastroenterol | year= 2011 | volume= 35 | issue= 8-9 | pages= 516-7 | pmid=21816700 | doi=10.1016/j.clinre.2011.06.009 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21816700 }} </ref> | ||
* | * 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.<ref name="pmid17243140">{{cite journal| author=Gisbert JP, González-Lama Y, Maté J| title=5-Aminosalicylates and renal function in inflammatory bowel disease: a systematic review. | journal=Inflamm Bowel Dis | year= 2007 | volume= 13 | issue= 5 | pages= 629-38 | pmid=17243140 | doi=10.1002/ibd.20099 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17243140 }} </ref> | |||
* 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.<ref name="pmid16530532">{{cite journal| author=Lichtenstein GR, Abreu MT, Cohen R, Tremaine W, American Gastroenterological Association| title=American Gastroenterological Association Institute technical review on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease. | journal=Gastroenterology | year= 2006 | volume= 130 | issue= 3 | pages= 940-87 | pmid=16530532 | doi=10.1053/j.gastro.2006.01.048 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16530532 }} </ref> | |||
* Always determine thiopurine methyltransferase (TPMT), the primary enzyme-metabolizing azathioprine/6-mercaptopurine, activity or genotype prior to initiating treatment with azathioprine or 6-mercaptopurine.<ref name="pmid16530532">{{cite journal| author=Lichtenstein GR, Abreu MT, Cohen R, Tremaine W, American Gastroenterological Association| title=American Gastroenterological Association Institute technical review on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease. | journal=Gastroenterology | year= 2006 | volume= 130 | issue= 3 | pages= 940-87 | pmid=16530532 | doi=10.1053/j.gastro.2006.01.048 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16530532 }} </ref> | |||
* 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 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.<ref name="pmid10730928">{{cite journal| author=Ierardi E, Principi M, Rendina M, Francavilla R, Ingrosso M, Pisani A et al.| title=Oral tacrolimus (FK 506) in Crohn's disease complicated by fistulae of the perineum. | journal=J Clin Gastroenterol | year= 2000 | volume= 30 | issue= 2 | pages= 200-2 | pmid=10730928 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10730928 }} </ref><ref name="pmid10228190">{{cite journal| author=Present DH, Rutgeerts P, Targan S, Hanauer SB, Mayer L, van Hogezand RA et al.| title=Infliximab for the treatment of fistulas in patients with Crohn's disease. | journal=N Engl J Med | year= 1999 | volume= 340 | issue= 18 | pages= 1398-405 | pmid=10228190 | doi=10.1056/NEJM199905063401804 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10228190 }} </ref> 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.<ref name="pmid18574271">{{cite journal| author=Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR et al.| title=Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). | journal=Chest | year= 2008 | volume= 133 | issue= 6 Suppl | pages= 381S-453S | pmid=18574271 | doi=10.1378/chest.08-0656 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18574271 }} </ref> | * Do recommend prophylaxis for [[venous thromboembolism]] for all hospitalized patients with IBD.<ref name="pmid18574271">{{cite journal| author=Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR et al.| title=Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). | journal=Chest | year= 2008 | volume= 133 | issue= 6 Suppl | pages= 381S-453S | pmid=18574271 | doi=10.1378/chest.08-0656 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18574271 }} </ref> | ||
* Do | * Do vaccinate patients on immunosuppresants routinely for [[influenza]], [[pneumococcal]], [[meningococcus]] infection, and for [[tetanus]] in the appropriate settings. | ||
==Don't s== | ==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.<ref>{{Cite web | |||
| last = | |||
| first = | |||
| title = http://www.worldgastroenterology.org/assets/export/userfiles/Acute%20Diarrhea_long_FINAL_120604.pdf | |||
| url = http://www.worldgastroenterology.org/assets/export/userfiles/Acute%20Diarrhea_long_FINAL_120604.pdf | |||
| publisher = | |||
| date = | |||
| accessdate = 2 January 2014 | |||
}}</ref> | |||
* [[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 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 narcotic analgesia except for the perioperative setting because of the potential for tolerance and abuse in the setting of chronic disease. | ||
Line 227: | Line 325: | ||
[[Category:Medicine]] | [[Category:Medicine]] | ||
[[Category:Resident survival guide]] | [[Category:Resident survival guide]] | ||
{{WikiDoc Help Menu}} | {{WikiDoc Help Menu}} | ||
{{WikiDoc Sources}} | {{WikiDoc Sources}} |
Latest revision as of 13:00, 3 June 2015
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mugilan Poongkunran M.B.B.S [2]
Overview
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.
Causes
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
- 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 Obtain detailed history: ❑ Recent travel H/O | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Assess volume status:
❑ General condition 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) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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, 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 | Severe to fulminant
❑ High fever | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Management of Mild to Moderate Crohn's Disease
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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Response to treatment in 3-4 wks | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Oral metronidazole (10-20 mg/kg/day) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Significant response | No response | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Maintenance therapy
❑ Proctitis: Mesalamine suppositories | 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 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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Response to treatment | Response to treatment | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No | Yes | Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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 ❑ 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 | Maintenance therapy
❑ Azathioprine (2-2.5 mg/kg) ❑ Monitor CBC every 3 months ❑ Monitor periodically for side effects | Maintenance therapy
❑ Natalizumab therapy (300 mg/ 4wk s.c) ❑ Monitor CBC every 3 months ❑ Monitor periodically for side effects | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Management of Severe to Fulminant Crohn's Disease
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) ❑ 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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No response to Rx | Significant response to Rx | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Surgical consultation (ileocolonic resections / abscess drainage / perioperative antibiotics) | Bridging therapy
❑ Switch to oral cyclosporine | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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. 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.
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
|title=
(help)