Crohn Disease

Clinical Presentation of Crohn Disease

• Crohn disease is a transmural inflammatory process. The terminal ileum is the most common site of the disorder, but it may occur in any part of the GI tract. Most patients have some colonic involvement. Patients often have normal bowel separating segments of diseased bowel; that is, the disease is often discontinuous.
• Complications of Crohn disease may involve the intestinal tract or organs unrelated to it. Small bowel stricture with subsequent obstruction is a complication that may require surgery. Fistula formation is common (20%–40% lifetime risk) and occurs much more frequently than with UC.
• Systemic complications of Crohn disease are common and similar to those found with UC. Arthritis, iritis, skin lesions, and liver disease often accompany Crohn disease.
• Nutritional deficiencies are common with Crohn disease (weight loss, iron deficiency anemia, vitamin B12 deficiency, folate deficiency, hypoalbuminemia, hypokalemia, and osteomalacia).

Clinical Presentation of Crohn Disease

Signs and symptoms: Malaise and fever, Abdominal pain, Frequent bowel movements, Hematochezia, Fistula, Weight loss and malnutrition, Arthritis

Physical examination: Abdominal mass and tenderness, Perianal fissure or fistula

Laboratory tests: Increased white blood cell count and erythrocyte sedimentation rate, Anti–Saccharomyces cerevisiae antibodies.

TREATMENT

Goals of Treatment: Resolution of acute inflammatory processes, resolution of attendant complications (e.g., fistulas or abscesses), alleviation of systemic manifestations (e.g., arthritis), maintenance of remission from acute inflammation, or surgical palliation or cure.

PHARMACOLOGIC THERAPY

• The major types of drug therapy used in IBD are aminosalicylates, glucocorticoids, immunosuppressive agents (azathioprine, mercaptopurine, cyclosporine, and methotrexate), antimicrobials (metronidazole and ciprofloxacin), agents to inhibit tumor necrosis factor-α (TNF-α) (anti–TNF-α antibodies), and leukocyte adhesion and migration (natalizumab).
• Sulfasalazine combines a sulfonamide (sulfapyridine) antibiotic and mesalamine (5-aminosalicylic acid) in the same molecule.

Sulfasalazine (Azulfidine), Initial dose 500 mg to 1 g, Usual dose: 4–6 g/day.

Mesalamine enema (Canasa), Initial dose: 4 g, Usual dose is 4g daily to three times weekly.

Olsalazine (Dipentum), initial dose: 1.5 g/day, Usual dose 1.5–3 g/day.

Mercaptopurine (Purinethol), Initial dose 50–100 mg, Usual dose 1–2.5 mg/kg/day

Methotrexate (Trexall), initial dose 15–25 mg IM weekly, Usual dose 15–25 mg IM weekly.

Adalimumab (Humira), Initial dose 160 mg SC day 1, Usual dose 80 mg SC 2 (day 15), and then 40 mg every 2 weeks.