Crohn's disease

Question 1

Characteristics and classic appearance

Answer 1

• thickened areas of the GI wall with inflammation extending though all layers
• deep ulceration and fissuring of mucosa
• classic cobblestone appearance
• presence of granulomas
• can affect any part of the GIT, from mouth to anus

Question 2

Symptoms include

Answer 2

• abdominal pain
• diarrhoea
• rectal bleeding
• fever
• weight loss

Question 3

complications

Answer 3

• malnutrition
• colorectal and small bowel cancers
• growth failure and delayed puberty in children
• intestinal strictures (narrowing)
• anaemia
• abscesses in walls of intestine or adjacent structures
• fistulae

Question 4

Extra intestinal manifestation

Answer 4

most commonly arthritis and abnormalities of the joints, eyes, liver, skin

Question 5

Link with osteoporosis

Answer 5

• cause of secondary osteoporosis
• inflammation in the gut, taking steroids, low levels of calcium and vitamin D or removal of parts of the small bowel all increase risk of weaker bones
• pt at greater risk should be monitored for osteopenia and assessed for fracture risk

Question 6

what is fistulating Crohn’s disease

Answer 6

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

Question 7

how common is fistulating crohns disease

Answer 7

• Occurs in ~ 1/4 of pt, mostly when disease involves the ileocolonic area

Question 8

treatment aims in fistulating Crohn’s

Answer 8

surgery and medical treatment aims to close and maintain closure of fistula

Question 9

Treatment of acute disease - mono therapy

Answer 9

• CCs (prednisolone, methylpred, HC IV) to induce remission in pt with first presentation or single inflammatory exacerbation in 12 month period
• consider budesonide in pt with distal ilea, ileocecal or right sided colonic disease in whom conventional CC unsuitable or contraindicated
• budesonide is less effective but may cause fewer SE than other CCs because systemic exposure limited
• aminosalicylates (e.g. sulfasalazine, mesalazine) are alternative in these pt - less effective than CCs and budesonide but may be preferred due to fewer SE

Question 10

Aminosalicylates and budesonide for severe presentations or exacerbations

Answer 10

not appropriate

Question 11

treatment of acute disease - when is add on therapy prescribed

Answer 11

if 2 or more inflammatory exacerbations in 12 month period, or if CC dose cannot be reduced

Question 12

treatment of acute disease - add on therapy to CC or budesonide to prescribe if there has been 2 or more inflammatory exacerbations in 12 months, or if CC dose cannot be reduced

Answer 12

• azathioprine or metacaptopurine (unlicensed indications) can be added to CC or budesonide to induce remission
• if not tolerated or if thiopurine methyltransferase (TMPM) activity is deficient, add MTX to a CC instead

Question 13

When can TNF-A inhibitors be given for Crohn’s, and name some examples

Answer 13

• under specialist supervision for severe, active Crohn’s
• only if inadequate response to conventional therapies or intolerant of/contraindications to conventional therapy
• e.g. adalimumab, infliximab
• adalimumab and infliximab can be used as mono therapy or combined with immunosuppressive

Question 14

When can vedolizumab or ustekinumab be offered

Answer 14

• vedo: moderate to severely active Crohn’s when therapy with adalimumab or infliximab unsuccessful , contraindicated or not tolerated
• ustekinumab: moderate to severely active Crohn’s when conventional therapy or therapy with adalimumab or infliximab unsuccessful , contraindicated or not tolerated

Question 15

advice for patients who chose not to receive maintenance treatment during remission to maintain remission

Answer 15

• be aware of symptoms that may suggest relapse e.g. unintended weight loss, abdominal pain, diarrhoea, general ill health
• create a suitable follow up plan to be agreed upon, and provide info on how to access healthcare if relapse occurs

Question 16

main 2 drugs that can be used to maintain remission

Answer 16

• azathioprine or mercaptopurine (unlicensed indications) as mono therapy can be used to maintain remission the previously used with CC to induce remission
• may also be used in pt who have not previously used this drugs, esp those with with adverse prognostic factors e.g. early onset age, perianal disease, CC use at presentation, severe presentation)

Question 17

when can MTX be used to maintain remission

Answer 17

only in pt who required it to induce remission, or who are intolerant of/not suitable for azathioprine or mercaptopurine maintenance treatment

Question 18

maintaining remission following surgery in pt with ileocolonic Crohn’s how have had complete microscopy resection within previous 3 months

Answer 18

• azathioprine + up to 3 months post metronidazole (unlicensed) should be used to maintain remission in these pt
• consider azathioprine alone in pt two cannot tolerate metro

Question 19

drugs NOT to use for maintaining remission following surgery in pt with ileocolonic Crohn’s how have had complete microscopy resection within previous 3 months

Answer 19

• aminosalicylates not recommended - lack of clinical efficacy
• mercaptopurine not cost-effective so not recommended
• do not use biologic therapies to maintain remission after complete macroscopic resection due to limited evidence
• also do not use budesonide

Question 20

3 drugs that can be used to manage diarrhoea associated with Crohn’s disease

Answer 20

• loperamide or codeine (as long as pt does not have colitis!!)
• cholestyramine

Question 21

What is the most common occurrence in pt with fistulating Crohn’s

Answer 21

perianal fistulae

Question 22

when is treatment for fistulating Crohn’s disease indicated

Answer 22

• treatment may not nee necessary for simple, asymptomatic perianal fistulae
• when they are symptomatic, local drainage and surgery may be required in conjunction with medical therapy

Question 23

abx for fistulating Crohn’s disease

Answer 23

metro or cipro (unlicensed indications), alone or in combo, can improve symptoms but complete healing occurs rarely
- metro usually given for 1 month, but max 3 months due to concerns about peripheral neuropathy
- give other abx if specially indicated e.g. in sepsis, and for managing bacterial overgrowth in small bowel

Question 24

treatment of inflammation and maintenance in fistulating Crohn’s

Answer 24

• azathioprine or mercaptopurine
• infliximab recommended for pt with active fistulating Crohn’s who have not responded to conventional therapy
• only use infliximab after ensuring all sepsis is actively draining
• abscess drainage fistulotomy and seton insertion may be appropriate, esp before infliximab treatment

Question 25

how long to continue azath/mercap/infliximab as maintenance for fistulating Crohn’s

Answer 25

at least 1 year

Question 26

management of non-perianal fistulating Crohn’s disease (including entero-gynaecological and enterovesical fistulae)

Answer 26

surgery is the only recommended approach