Crohns Flashcards
Crohns definition & characterised by ..
= chronic, inflammatory bowel disease that mainly affects GIT.
➡ characterised by thickened areas of GI wall with inflammation extending through all layers, deep ulceration + fissuring of mucosa, & presence of granulomas
Symptoms of crohns
depend on site of disease but abdominal pain, diarrhoea, fever, weight loss + rectal bleeding.
Fistulating Crohn’s
= complication that involves formation of fistula between intestine & adjacent structures i.e perianal skin, bladder, and vagina
~ occurs in ~1/4 of patients, mostly when disease involves ileocolonic area.
Non-drug tx of Crohns
Smoking cessation + attention to nutrition
Acute crohns ~ what is used to induce remission if 1st presentation / single inflammatory exacerbation of Crohn’s disease in a 12-month period
corticosteroid (either prednisolone / methylprednisolone / intravenous hydrocortisone)
Acute crohns ~ In patients with distal ileal, ileocaecal or right-sided colonic disease, in whom conventional corticosteroid unsuitable or contra-indicated … give ?
Budesonide … less effective but fewer side-effects than other corticosteroids, as systemic exposure limited.
➡ Aminosalicylates = alternative option in these patients ~ less effective than corticosteroid or budesonide, but preferred as fewer side-effects. Aminosalicylates & budesonide not appropriate for severe presentations or exacerbations.
Add on treatment prescribed in acute crohns IF…
2 or more inflammatory exacerbations in 12-month period, or corticosteroid dose cannot be reduced.
Add-on tx to induce remission in acute Crohns …
Azathioprine / mercaptopurine [unlicensed indications]
if cannot tolerate azathioprine / mercaptopurine / in whom thiopurine methyltransferase (TPMT) activity deficient, methotrexate can be added to a corticosteroid.
Maintenance of remission
Crohns .. if choose not get maintenance tx
IF choose NOT to receive maintenance treatment during remission = made aware of symptoms that may suggest relapse (most frequently unintended weight loss, abdominal pain, diarrhoea & general ill-health).
Maintenance of remission
Crohns
Azathioprine / mercaptopurine [unlicensed] as monotherapy to maintain remission when previously used with corticosteroid to induce remission ~ also used in if not previously received these drugs (particularly those with adverse prognostic factors early age of onset, perianal disease, corticosteroid use at presentation, & severe presentations).
Methotrexate used to maintain remission ONLY in who required methotrexate to induce remission, or who are intolerant of or not suitable for azathioprine or mercaptopurine for maintenance. Corticosteroids / budesonide NOT used.
Maintaining remission following surgery (Crohns)
Azathioprine in COMBO with up to 3 months’ postoperative metronidazole [unlicensed indication] = maintain remission in ileocolonic Crohn’s disease who have had complete macroscopic resection within previous 3 months. Azathioprine alone if cannot tolerate metronidazole. Aminosalicylates NOT recommended as lack of clinical efficacy. NICE do not consider mercaptopurine as cost-effective
Biologic therapies NOT used to maintain remission after complete macroscopic resection of ileocolonic Crohn’s disease as limited evidence.
Budesonide NOT used either.
Diarrhoea in Crohns
Loperamide hydrochloride / codeine phosphate can if no colitis !!!!!
Colestyramine = licensed for relief of diarrhoea associated with Crohn’s
Fistulating Crohn’s disease is
➡ Perianal fistulae = most common occurrence in fistulating Crohn’s.
TX not necessary if simple, asymptomatic perianal fistulae.
When fistulae symptomatic, local drainage & surgery required with medical therapy.
Fistulating Crohn’s disease
Metronidazole or ciprofloxacin [unlicensed], alone or in combo = improve symptoms of fistulating Crohn’s disease but complete healing occurs rarely. Metronidazole usually 1/52, but no longer than 3 months as concerns about peripheral neuropathy.
Either azathioprine or mercaptopurine [unlicensed] to control inflammation & continued for maintenance.
Infliximab = if active fistulating Crohn’s not responded to conventional therapy (antibacterials, drainage & immunosuppressive treatments), or intolerant of or contra-indications to conventional therapy. Infliximab used after ensuring all sepsis actively draining.
Azathioprine, mercaptopurine, or infliximab continued as maintenance tx for at least 1 year.
For management of non-perianal fistulating Crohn’s disease (including entero-gynaecological and enterovesical fistulae)
Surgery = only option
