Crohn's disease management

Crohn's disease management

Crohn's disease is an idiopathic, chronic, transmural inflammatory process of the bowel that often leads to fibrosis and obstructive symptoms. It can affect any part of the gastrointestinal tract from the mouth to the anus.

Clinical presentation

• Abdominal pain.

• Diarrhoea.

• Weight loss.

• Anorexia.

• Fever.

• Gross rectal bleeding or acute haemorrhage (uncommon).

• Anaemia due to ileal disease involvement.

• Small bowel obstruction due to stricturing.

• Perianal disease associated with fistulization.

• Gastroduodenal ulceration.

Investigations

Endoscopy

• Endoscopic evidence of rectal sparing.

• Skip lesions.

• Cobblestoning with linear ulceration appearance.

Histopathology

• Histological evidence of transmural disease.

• Aphthous ulcers.

• Non-caseating granulomas.

Pharmacological treatment

Maintenance of remission

• Methotrexate (PO) 7.5–15 mg weekly

OR

• Azathioprine (PO) 50 mg every 24 hours

Induction of remission

Add:

• Prednisolone (PO) 1–2 mg/kg for induction of remission only

Taper over 8 weeks.

Management of perianal disease or septic complications

• Metronidazole (PO) 400 mg every 8 hours for 7–10 days

OR

• Ciprofloxacin (PO) 500 mg every 12 hours for 7–10 days

These agents may be added in the presence of perianal disease or evident septic complications.

Severe disease flare or acute complications

For patients with severe disease flare, acute complications, inadequate response to conventional therapy, fistulizing Crohn's disease, enterocutaneous fistulas, or rectovaginal fistulas:

• Infliximab (IV) 5 mg/kg at weeks 0, 2, and 6

THEN

• Infliximab (IV) 5 mg/kg every 8 weeks thereafter

AND

• Azathioprine (PO) 1.5–2.5 mg/kg every 24 hours

Supportive management

• Resuscitative and supportive management should be instituted as described under the ulcerative colitis section.