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MEDICAL MANAGEMENT OF CROHN'S DISEASE

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					                                                                                               MEDICAL MANAGEMENT OF CROHN’S DISEASE
                                    1. Diagnosis of IBD                                                                                                                                                                             Crohn’s Disease (CD)
•   history & examination                                                                                                                                                                                  Characterised by patchy, transmural inflammation which may affect any
•   exclude infection                                                                                                                                                                  EP
                                                                                                                                                                                         A TR I A T I O    part of the gastrointestinal tract




                                                                                                                                                                                                     N
                                                                                                                                                                                   R
•   abdominal x-ray
                                                                                                                                                                                 GENERAL        HOSPITAL

                                                                                                                                                                                                           Symptoms include:
•   FBC, ELU, LFT, ESR, CRP                                                                                                                                                            DAW PARK
                                                                                                                                                                                                           • abdominal pain
                                                                                                                             Southern Adelaide
•   sigmoidoscopy where disease is severe                                                                                      Health Service                                                              • diarrhoea
•   colonoscopy for mild to moderate disease                                                                                                                                                               • weight loss
•   histopathology.                                                                                                                                                                                        • +/-systemic symptoms of malaise, anorexia or fever.

                                                            Management depends on 1) the Affected site: Ileal/ileocolonic/colonic/other and 2) the Disease pattern: inflammatory/stricturing/fistulising
                                                                                                  Active Disease                                                                                                                 Maintenance of Remission
                                                                                                                                                                                                           •   Cease smoking
1. ILEOCOLONIC                                                                                                          2. FISTULISING
                                                                                                                                                                                                           •   Fish Oil 2 capsules daily
• Dietitian referral                                                                                                    • MRI and EUA recommended
                                                                                                                                                                                                           •   Corticosteroids, including Budesonide, are not effective
  MILD                                                                                                                  • Antibiotics first line therapy:
                                                                                                                                                                                                           •   Mesalazine is of limited benefit, and is ineffective at doses <2mg daily
• Mesalazine 4gm daily, although data limited                                                                             Metronidazole 400mg tds or ciprofloxacin 500mg BD
                                                                                                                                                                                                           •   Mainstay of therapy is immunomodulation with Azathioprine
  MILD - MODERATE                                                                                                       • Azathioprine/6-Mercaptopurine once abscess excluded
                                                                                                                                                                                                               (2-2.5mg/kg/day or 6-Mercaptopurine (1-1.5mg/kg/day).
• Prednisolone 40-60mg daily (up to 1mg/kg), reducing to zero over                                                      • Infliximab reserved for refractory fistulae (3 infusions of 5mg/kg given
                                                                                                                                                                                                           •   Need regular CBE and LFTs if on immunomodulators as follows:
  8-12 weeks once clinical response achieved.                                                                             at weeks 0, 2 & 6)
                                                                                                                                                                                                               - weekly for 4 weeks, then monthly for the next 2 months then
      OR                                                                                                                • Surgery (including seton drainage) appropriate for persistent or
                                                                                                                                                                                                                   3 monthly
                                                                                                                          complex fistulae
    Budesonide 9 mg daily reducing to zero over 6 weeks if Prednisolone                                                                                                                                    •   If Azathioprine/6-MP therapy fails or intolerance consider Methotrexate
    not tolerated                                                                                                       • Dietitian referral.
                                                                                                                                                                                                               as follows:
•   Addition of Metronidazole 20mg/kg in bd divided dose may give benefit                                                                                                                                      - Commence at 25mg IM weekly for 12 weeks, then consider weekly
    SEVERE                                                                                                                                                                                                         oral dosing. When on methotrexate, also should have folic acid
•   IV Hydrocortisone 100mg QID                                                                                                                                                                                    5-10mg a week
•   Consider addition of IV Metronidazole 500mg bd                                                                                                                                                         •   If Immunomodulator therapy fails consider Infliximab (5mg/kg) infusions
•   If poor response after 5-7 days consider Infliximab infusion 5mg/kg as                                                                                                                                     at 8 weekly intervals or upon evidence of flare
    a bridge to Azathioprine/6-Mercaptopurine therapy                                                                                                                                                      •   Dietitian referral
•   Avoid Infliximab in stricturing disease & be aware of its reduced efficacy                                                                                                                             •   Consider DEXA, as osteoporosis common in Crohn’s Disease.
    in smokers.


                 Preventon of Post-Operative Recurrence                                                                                                                                                                  General Management of IBD Principals
• Cessation of smoking reduces relapses                                                                                                                                                                    • Refer all patients to:
• Mesalazine at doses >2gm daily is effective in small bowel disease,                                                                                                                                        - IBD Nurse Coordinator at FMC, contact 8204 3942
  but not following colonic resection                                                                                                                                                                             OR
• Mainstay of therapy in the prevention of post-op relapse is
                                                                                                                                                                                                               - IBD Specialist Nurse at RGH, contact 8275 1745
  Azathioprine/6-Mercaptopurine
                                                                                                                                                                                                           •   Discuss and make treatment decisions with the patient
• Metronidazole (20mg/kg/day for 3 months) is effective in recurrence
  after ileo-colonic resection for up to 18 months. Not well tolerated-                                                                                                                                    •   Ensure rapid access to clinic appointments
  peripheral neuropathy a major side effect.                                                                                                                                                               •   Provide clear management plans
                                                                                                                                                                                                           •   As non-specific pain is a common feature of IBD, where possible deter
BSG Guidelines for the Management of Crohn’s Disease. Reference:GUT 2004 • Created by the Southern Adelaide IBD Service June 2006, enquiries 8204 3942                                                         mine cause & treat. Avoid analgesics; tramadol if necessary.

				
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