Crohn’s Disease – PSYCHOSOCIAL CONSIDERATIONS

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.

Crohn’s Disease – NUTRITIONAL SUPPORT

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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Crohn’s Disease – DRUG THERAPY

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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Crohn’s Disease – DIFFERENTIAL DIAGNOSIS

Patients with irritable bowel syndrome rarely present with “inflammatory” features. Persistent symptoms despite therapy for presumed irritable bowel syndrome (especially in the presence of weight loss), bleeding attributed to “hemorrhoids,” or a family history of IBD deserve a more comprehensive evaluation to exclude IBD. Most enteric infections are self-limited. Viral gastroenteritis typically lasts 1 to 4 days without rectal bleeding or fecal leukocytes. Most bacterial pathogens produce self-limited disease lasting less than 7 to 14 days, despite intermittent rectal bleeding, fevers, fecal leukocytes, and a mucosal appearance that may be indistinguishable from that of UC or CD. Occasionally, Campylobacter jejuni produces protracted symptoms and Clostridium C. difficile toxin-induced colitis can mimic the symptoms, signs, and endoscopic appearance of UC or CD. When a patient with IBD presents with new or exacerbated symptoms, stool cultures for enteric pathogens and studies for C. difficile toxin should be obtained, especially if the patient has been recently treated with antibiotics. In Northern Europe and Canada, Yersinia enterocolitica infection can mimic terminal ileitis. If the clinical suspicion warrants, cultures and serologic studies for Yersinia should be obtained. Similarly, tuberculosis of the gastrointestinal tract may mimic CD in geographic areas where intestinal tuberculosis is edemic, and, rarely, Actinomycosis simulates fistulizing CD.

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Crohn’s Disease – RADIOGRAPHY

Radiographic examination should begin with a supine and upright view of the abdomen. Associated findings of nephrolithiasis, cholelithiasis, or arthritis of the spine or sacroiliac joints may be identified. Intestinal dilatation or air-fluid levels suggesting obstruction preclude aggressive barium studies until the patient’s clinical condition is stabilized. In colitis, a plain view of the abdomen often demonstrates a tubular, ahaustral segment of colon in the presence of distal UC with fecal matter proximal to diseased mucosa. Intestinal edema, ulceration, or thumb-printing may give a gross estimate of disease activity. Air-contrast barium studies of the colon reveal diffuse, contiguous granularity, superficial ulceration, and absent haustration in active UC. Pseudopolyps or a tubular-appearing “lead pipe” colon may be found in chronic UC. Focal, asymmetric ulceration with linear or fissuring ulcers, the presence of fistulas, rectal sparing, or a diseased terminal ileum with reflux of the barium define the radiographic extent and severity of colonic CD. A small bowel follow-through or enteroclysis (small bowel enema) demonstrates the extent of small intestinal involvement in CD and is normal in the absence of backwash ileitis in UC.

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Crohn’s Disease – ENDOSCOPY

Patients presenting with colitic symptoms of rectal bleeding, cramping, tenesmus, mucopus, or watery diarrhea in conjunction with fecal leukocytes warrant a colonic examination. A proctoscopic examination or flexible sigmoidoscopy reveals the presence and pattern of distal colonic inflammation. In the absence of perianal disease, diffuse, continuous mucosal changes with a distinct upper boundary to adjacent normal-appearing mucosa are typical of ulcerative proctitis or proctosigmoiditis. Focal inflammation with aphthoid ulcers, linear or stellate ulcers with normal intervening mucosa, or inflammatory changes beginning above the rectum (rectal sparing) in previously untreated patients suggest CD. If the patient is not acutely ill, colonoscopy demonstrates more proximal colonic changes and allows examination and intubation of the ileocecal valve to evaluate terminal ileal findings. Patients with upper abdominal symptoms can be diagnosed with upper gastrointestinal endoscopy when typical mucosal changes of CD involve this area. Findings can be correlated with mucosal biopsy studies and radiographic evaluation of the small and large intestine.

Crohn’s Disease – DIAGNOSIS

There are no pathognomonic clinical, endoscopic, or histologic features of the idiopathic IBD’s. The physician must therefore consider the entire clinical picture and the evolution of the illness. It is particularly important to exclude other disorders that may mimic the broad range of IBD symptoms and findings. First it is important to establish the presence of intestinal inflammation. A cardinal feature is the exudation of inflammatory cells into the lumen, manifested by fecal leukocytes or red blood cells on stool examination. Symptoms of rectal bleeding, tenesmus associated with the passage of pus, nocturnal pain and diarrhea, fever, night sweats, weight loss, or extraintestinal symptoms or signs generally exclude an uncomplicated “irritable bowel syndrome.” The presence of anemia, electrolyte disorders, hypoalbuminemia, or an elevated erythrocyte sedimentation rate of C-reactive protein is sufficient, but not necessary, to suggest IBD. On physical examination, evidence of significant weight loss or extraintestinal signs, a palpable abdominal mass or tenderness, or significant perianal disease suggests IBD. When suspicion of the diagnosis warrants, endoscopic and radiographic studies, in conjunction with histologic interpretation of biopsy specimens, confirm the diagnosis; the degree of illness at presentation should determine the aggressiveness of the diagnostic workup. Acutely ill patients should be stabilized before invasive studies are pursued.