Crohn's disease Flashcards
Characteristics and classic appearance
- 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
Symptoms include
- abdominal pain
- diarrhoea
- rectal bleeding
- fever
- weight loss
complications
- 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
Extra intestinal manifestation
most commonly arthritis and abnormalities of the joints, eyes, liver, skin
Link with osteoporosis
- 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
what is fistulating Crohn’s disease
Complication that involves the formation of a fistula between the intestine and adjacent structures e.g. perianal skin, bladder, vagina
how common is fistulating crohns disease
- Occurs in ~ 1/4 of pt, mostly when disease involves the ileocolonic area
treatment aims in fistulating Crohn’s
surgery and medical treatment aims to close and maintain closure of fistula
Treatment of acute disease - mono therapy
- 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
Aminosalicylates and budesonide for severe presentations or exacerbations
not appropriate
treatment of acute disease - when is add on therapy prescribed
if 2 or more inflammatory exacerbations in 12 month period, or if CC dose cannot be reduced
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
- 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
When can TNF-A inhibitors be given for Crohn’s, and name some examples
- 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
When can vedolizumab or ustekinumab be offered
- 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
advice for patients who chose not to receive maintenance treatment during remission to maintain remission
- 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
