Alimentary Track: Crohn’s Disease (CD)

DESCRIPTION

Idiopathic and chronic intestinal inflammation. This is a transmural inflammatory condition affecting mainly the distal ileum or colon, but may affect the entire gastro-intestinal tract. Common complications are intestinal obstruction and abscess formation.

GENERAL MEASURES

Smoking cessation, as smoking is a strong predictor of relapse. Refer to dietician for dietary advice.

MEDICINE TREATMENT

Antidiarrhoeal medication should not be used in acute flares of inflammatory CD. Diarrhoea will subside with appropriate care. After terminal ileal resections, to reduce diarrhoea due to bile salt malabsorption:

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• Cholestyramine, oral, 2–8 g daily. Ileal disease All patients:

• Vitamin B12, IM, 1 mg, 3 monthly. Monitor for iron and folate deficiency. Colonic disease

• Sulfasalazine, oral, 500 mg 12 hourly, up to 1.5 g 8 hourly. o Acute attacks: 1–2 g, 4–6 hourly. o Maximum dose: 3–4 g daily. AND

• Prednisone, oral, 1.5 mg/kg daily. Taper dose to lowest possible maintenance dose over 3–4 weeks. Severe disease Maintenance of remission: Sulfasalazine may be useful for maintaining remission in patients with Crohn’s colitis but is of no real use in purely ileal CD. For patients with recurrent attacks of CD or those with extensive disease, i.e. ileum and colon:

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• Azathioprine, oral, 2 mg/kg daily. Specialist initiated. OR

• Methotrexate, oral, 15–25 mg weekly. Specialist initiated.

PLUS

• Folic acid, oral, 5 mg weekly with methotrexate. Emergency management at specialist facility will include:

» resuscitation with parenteral fluids;

» blood transfusions;

» corticosteroids;

» antibiotics; and

» nasogastric suction as indicated. Peri-anal disease There is evidence of recurrence on withdrawal of therapy and prolonged treatment may be indicated.

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• Metronidazole, oral, 400–800 mg 8 hourly. OR

• Ciprofloxacin, oral, 500 mg 12 hourly.

REFERRAL

» For further therapy.

» Peri-anal abscesses/fistula if surgery is required after appropriate assessment.

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