Gastroenterology

Question 1

Management of Crohn’s Disease

Answer 1

Nutrition
Diarrhoea: stool specimen; consider bile acid sequestion if terminal ileum disease and start cholestyramine; use loperamide.
Cramps: antispasmodic (buscopan)
Psychological
Medications:
5ASA: as maintainence. sulfasalazine for large bowel, mesalazine for small bowel.
Steroids: for flare. (Monitor for aseptic necrosis of hip, osteoporosis, cataracts, diabetes, hypertension, mood disturbance).
If unable to wean steroids, start 6-mercaptopurine. Check thiopurine methyltransferase and 6 thioguanine nucleotide. Takes 3-6/12 to work. Watch for leukopenia.
Alternatives include methotrexate and mycophenylate.
If they are ineffective or fistulising disease, add anti TNF eg infliximab.
Check Mycobacterium tuberculosis and hepatitis B status prior.
Monitor for lupus, MS, psoriaform rash, opportunistic infections.
Fistulas: antibiotics, top down immunotherapy, drainage, resection.
Surgery indications: cancer, perforation, bleeding, toxic megacolon, symptomatic fibrotic stricture, intractable fistulae, therapy related complications, non responsive disease.