Archive for September, 2008
Posted by Alex
Although there is no evidence to support the concept that psychologic factors are etiologic in Crohn’s disease, there is no question that psychosocial pressures can influence the course of the patient’s illness and have to be addressed. The caring physician who is willing to answer questions and be available at all times is often all that is needed. At other times, mild psychotropic agents in conjunction with behavior modification and support groups are of enormous benefit. In this regard, the Crohn’s and Colitis Foundation of America can be extremely helpful in providing patients with emotional support and educational materials.
Posted by Alex
General Dietary Instructions and Nutritional Supplements
Food is the best source of nutrition, and the emphasis for most patients should be on normalization of the diet and adequate caloric intake. Patients with intestinal strictures and partial obstruction may benefit from a low-residue diet. Those patients with calcium oxalate stones associated with steatorrhea and hyperoxaluria should be instructed in a low-oxalate diet. In patients with extensive ileal resection and steatorrhea, a low-fat diet with medium chain triglyceride supplementation should be considered. These patients need replacement of calcium, vitamin D, and vitamin K as well. Lactose intolerance can mimic the symptoms of Crohn’s disease and should be documented or excluded if there is any question of its existence. A lactose-free diet with calcium supplementation can be offered if appropriate. In addition, patients with evidence of malabsorption, those with a low-calcium intake, and those receiving long-term steroid therapy are at risk for osteoporosis and osteomalacia. Bone density studies and referral for possible therapy with agents to prevent bone disease should be considered. Finally, vitamin B12 replacement may be necessary for patients with moderate or extensive ileal resections or those with chronic extensive ileal disease. A Schilling test should be performed several months postoperatively to document the need in those patients undergoing resection, and routine vitamin B12 levels should be obtained in those with long-standing active ileal disease.
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Posted by Alex
Aminosalicylates
Sulfasalazine
Introduced into clinical medicine in the early 1940s, sulfasalazine (Azulfidine)* has since become a mainstay in the therapy for inflammatory bowel disease. Controlled trials have shown its efficacy for active Crohn’s disease involving the colon, and although the studies have not uniformly demonstrated the drug’s benefit in isolated ileitis, there appears to be a subset of patients with Crohn’s ileitis who benefit from its use. It has not been shown to be useful in maintaining remission in Crohn’s disease and in preventing recurrence after operation. In any patient with mild to moderately active Crohn’s disease, the drug should be considered and given initially at a dose of 500 mg orally twice daily with advancement if tolerated to 3 to 4 grams per day. Folic acid, 1 mg per day, should be added because sulfasalazine may interfere with dietary folate absorption. Responses are usually seen within 4 weeks, and the drug should be continued at the level that achieved the clinical response for 4 to 6 months. If relapse occurs quickly on stopping of the agent, then reinstitution and long-term maintenance at a dose of 3 to 4 grams per day should be considered.
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