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Crohn’s disease

Jul 25, 2019

Crohn’s disease is a chronic inflammatory bowel disease that may affect any part of the gastro-intestinal system. This leads to pain in abdomen, diarrhea, vomiting, nausea, weight loss and fever. Patients may have occult blood in stools, anal skin tag, anal fissure or fistula. Extraintestinal manifestations include uveitis, episcleritis, gallstones, arthritis, sacroiliitis, erythema nodosum, deep venous thrombosis, osteopenia, osteoporosis, anemia and peripheral neuropathy.

Medications:

Before starting any Anti-TNF medications, rule out tuberculosis in all patients.

For mild to moderate disease (stepwise treatments)

Step 1 – Tab. Mesacol (Mesalazine 400 mg) for 6 weeks – adjust dose as below:

  • 17 to 32 kgs – 36 to 71 mg/kg/day, divided into 2 doses a day (maximum dose – 1.2 grams/day)
  • 33 to 53 kgs – 37 to 61 mg/kg/day, divided into 2 doses a day (maximum dose – 2 grams/day)
  • 54 to 90 kgs – 27 to 44 mg/kg/day, divided into 2 doses a day (maximum dose – 2.4 grams/day)

Step 2 – Tab. Cifran 500 (Ciprofloxacin 500 mg) 1 tablet twice a day for 6 weeks.

Step 3 – After 6 weeks – tab. Mesacol OD (Mesalazine 1200 mg) 2 tablets once a day, with food, as maintenance.

For moderate to severe disease (stepwise treatments)

Step 1 – Give oral steroid therapy – Tab. Medrol (Methylprednisolone) 8mg and 4mg tablets –

  • Day 1: 24 mg orally (8 mg before breakfast; 4 mg after lunch; 4 mg after dinner; 8 mg at bedtime).
  • Day 2: 20 mg orally (4 mg before breakfast; 4 mg after lunch; 4 mg after dinner; 8 mg at bedtime).
  • Day 3: 16 mg orally (4 mg before breakfast; 4 mg after lunch; 4 mg after dinner; 4 mg at bedtime).
  • Day 4: 12 mg orally (4 mg before breakfast; 4 mg after lunch; 4 mg at bedtime).
  • Day 5: 8 mg orally (4 mg before breakfast; 4 mg at bedtime).
  • Day 6: 4 mg orally (4 mg before breakfast).

Adjust initial dose until a significant response is obtained. Later decrease the dose gradually (usually weekly) to the lowest dose that maintains an adequate clinical response.

If patient doesn’t tolerate oral steroids – Inj. Solu-Medrol (Methylprednisolone 125 mg) intravenously over at least 30 minutes every 4 to 6 hours for 2 to 3 days. Paediatric dose: 0.11 to 1.6 mg/kg/day i.v. over at least 30 minutes every 4 to 6 hours for 2 to 3 days.

Step 2 – Disease modifying agent – Tab. Azimune (Azathioprine 50 mg) 1 – 4 mg/kg orally per day till symptoms improve. Consider withdrawing treatment once symptoms settle.

Supplementary treatments:

  • Cap. R B Tone (Elemental iron 30 mg, Folic acid, Vit B12, Zinc) 1 capsule once a day, two hours after meal.
  • Tab. Cyclopam (Dicyclomine 20 mg, Paracetamol 500 mg) 1 tablet orally 4 times a day as needed for abdominal pain.
  • Cap. Prowel (Probiotic and prebiotic) 1 capsule twice a day.
  • Tab. Supracal (Calcium citrate 1 gm, magnesium, zinc and vitamin D3) 1 tablet once a day.
  • Enteral nutrition – Ensure Original during flare ups – 6 scoops in water as one meal replacement.
  • Syrup Al5zyme (Alpha-galactosidase and Lactase enzyme supplementation) – 5 ml thrice a day after meals, if patient is not able to tolerate gluten and lactose containing foods.

General advice:

  • Recommend low fiber, low fat, lactose free, high caloric diet
  • Maintain a healthy weight and promote weight gain till optimum body mass index
  • Eat refined grains and five or six small meals in a day
  • Use lean or low-fat cuts of meat and poultry
  • Adequate fluid intake (> 2 L/day, provided there is no restriction on fluid intake in case of any kidney disorder)
  • Avoid nonsteroidal anti-inflammatory drugs (NSAIDS)
  • Stop smoking and consuming tobacco
  • Reduce physical and emotional stress factors
  • Promote regular exercise
  • Update vaccinations – Influenza vaccine, Pneumococcal vaccine, Hepatitis B vaccine
  • Foods to avoid – spices, milk, milk products, eggs, peanuts, tree nuts (e.g., walnuts, almonds, cashews, pistachios and pecans), corn, popcorn, wheat, soy and shellfish, broccoli, cauliflower, cabbage (gas forming foods) and insoluble fibre (i.e. raw vegetables, seeds, nuts, beans, green leafy vegetables, fruits and wheat bran), high fat foods like fried foods, butter, margarine, cream, gluten containing foods (wheat, rye and barley products), non-absorbable sugars (gums, candies, ice cream, apples, pears, peaches and prunes), ice cold liquids, coffee and tea and alcoholic beverages.

Investigations:

  • Complete blood count – to rule out nutritional deficiency.
  • Erythrocyte sedimentation rate – to assess inflammatory activity.
  • Stool routine – to rule out infection.
  • Liver function test – to rule out liver impairment.
  • Random blood sugar – to rule out diabetes.
  • Chest x ray – to rule out pulmonary tuberculosis if anti-TNF is indicated.
  • Saccharomyces cerevisiae antibodies – to diagnose Crohn’s disease.
  • Antineutrophil cytoplasmic antibodies – detected in 10–20% of patients with Crohn’s disease (CD) and 50–85% of patients with ulcerative colitis (UC).
  • Colonoscopy with ileoscopy – to diagnose Crohn’s disease.
  • Fecal calprotectin – Nearly 99% of patients who have active inflammatory bowel disease like Crohn’s have elevated levels.

Referral:

Consider referring the patient to gastroenterologist if there is inadequate response to above therapies or if patient presents with additional complications.