Crohn's Disease

Question 1

What is inflammatory bowel disease?

Answer 1

An umbrella term which covers Crohn’s disease and Ulcerative colitis. Characterised by chronic inflammation of the GI tract

Question 2

Difference between Crohn’s and Ulcerative Colitis

Answer 2

Crohn’s: Affects the whole GI tract (from mouth to intestine)

Ulcerative colitis: Can affect the region from the rectum to the whole colon

Question 3

Symptoms of Crohn’s disease

Answer 3

Depend on the site of disease

May include abdominal pain, diarrhoea, fever, weight loss and rectal bleeding.

Question 4

Complications of Crohn’s disease

Answer 4

Intestinal strictures or fistulae
Anaemia and malnutrition
Colorectal and small bowel cancers
Growth failure and delayed puberty in children
Extra-intestinal manifestation: arthritis or joints, eyes, liver and skin abnormalities
Secondary osteoporosis and osteopenia

Question 5

How is Crohn’s characterised?

Answer 5

Thickened walls of GI tract which extends through all layers, with deep ulceration and fissuring of the mucosa, and the presence of granulomas

Question 6

Non-drug treatment

Answer 6

Smoking cessation

Question 7

Acute treatment of Crohn’s disease if the flare up is the first in a 12 month period

Answer 7

1st: Prednisolone OR methylprednisolone, OR IV hydrocortisone

2nd: Budesonide: if patient has distal ileal, ileocecal or right sided disease

3rd: Aminosalicylates (sulfasalazine or mesalazine) - Fewer s/e but less effective

Question 8

Acute treatment of Crohn’s disease if the flare up is the second in a 12 month period

Answer 8

All in addition to the treatment used if first flare up in 12 months period

1st: Azathioprine or mercaptopurine (unlicensed indications)

2nd: Methotrexate if azo/merc is contraindicated or thiopurine methyltransferase (TPMT) activity is deficient

Severe: monoclonal antibodies

Question 9

Symptoms which suggest relapse

Answer 9

Unintended weight loss, abdominal pain, diarrhoea and general ill-health

Question 10

When would methotrexate be used to treat a Crohn’s flare up?

Answer 10

If it is the second flare-up in a 12 month period
If azo/merc is contraindicated
If thiopurine methyltransferase (TPMT) activity is deficient

Question 11

Maintenance therapy of Crohn’s disease

Answer 11

1st: Azathioprine or mercaptopurine

2nd: Methotrexate can be used if used in induction or can not tolerate aza/merc

Never use steroids for maintenance

Question 12

Maintenance therapy of Crohn’s disease after surgery

Answer 12

Azathioprine + metronidazole for 3 months post-op

Azathioprine alone if metronidazole is not tolerated

Question 13

When shouldn’t biologic therapies or budesonide be used in maintenance therapy of Crohn’s disease?

Answer 13

After complete macroscopic resection of ileocolonic Crohn’s disease

Question 14

Treatment of diarrhoea associated with Crohn’s disease

Answer 14

Loperamide
Codeine (only in Crohns not in ulcerative colitis)
Colestyramine

Question 15

What is Fistulating Crohn’s disease?

Answer 15

Complication that involves the formation of a fistula between the intestine and adjacent structure, e.g., perianal skin, bladder and vagina

Question 16

Treatment of Fistulating Crohn’s disease?

Answer 16

Can be left alone if asymptomatic

To improve symptoms (not fully heal) - Metronidazole +/- ciprofloxacin

Question 17

Duration of metronidazole treatment of Fistulating Crohn’s disease?

Answer 17

Usually only given for 1 month (no longer than 3 months due to peripheral neuropathy)

Question 18

Maintenance of Fistulating Crohn’s disease? + duration

Answer 18

1st: Azathioprine or mercaptopurine
2nd: infliximab if not responding

Treatment must last at least one year