Inflammatory Bowel Disease

Ulcerative Colitis: Rectum and colonic mucosa involvement, no small intestine involvement, no skip lesions Blood diarrhea, spasm of anal sphincter (Tenesmus), weight loss, fever Staging: Mild < 4 stools a day, no symptoms Mod > 4 stools a day, minimal symptoms Severe > 6 stools a day, temp > 99.5 F, HR > 90, ESR > 30, Hb < 75% of normal, abdominal tenderness, bowel edema Fulminant > 10 stools a day, sever and transfusions required. Severe abdominal pain and dilated colon.	Crohn’s: Skip lesions, fistulas, the entire GI tract may be involved (terminal ileum and colon mostly). Non-bloody diarrhea, RCQ pain, weight loss, macrocytic anemia Staging Mild: tolerates oral, bo symptoms, less <10 weight loss Moderate: failed mild treatment, anemia, nausea and vomiting, considerable weight loss Severe/fulminant: No response to steroids, high temp, ab pain, vomiting, cachexia, rebound tenderness
Treatment:
5-ASA or budesonide or steroids or infliximab +/- azathioprine Severe: add TNF alpha, IV steroids, IV cyclosporins Maintenance: no steroids, oral mesalamine or 5-ASA or azathioprine	Budesonide +/- metronidazole +/- 5-ASA Severe: +/- steroids, MTX, TNF alpha, antibiotics or azathioprine. Fulminant: drain, hospitalize, IV cyclosporin Maintenance: 5-ASA, azathioprine or TNF alpha, no steroids.  Flagyl and cipro are drugs of choice.

• Aminosalicylates are drugs of choice for induction and maintenance (mesalamine and sulfasalazine)
• Corticosteroids are quick in acute flares. Not for maintenance.  Budesonide is 15 more potent than prednisone.
• Mercaptopurine, azathioprine, methotrexate all have a steroid-sparing effect. Long onset of action, so maintenance only. All-cause hepatotoxicity and bone marrow suppression, nausea, diarrhea, and rash.  Azathioprine and mercaptopurine cause pancreatitis, hepatosplenic t-cell lymphoma.
• Biologics: TNF alpha – infliximab, adalimumab, certolizumab, golimumab, natalizumab, vedolizumab.  Screen for hepatitis and TB.  Infusion-related reactions, delayed hypersensitivity (3-10 days after), contraindicated in HF, bone marrow suppression.  Natalizumab TOUCH program due to progressive multifocal leukoencephalopathy risks.  DO NOT USE in class III and V CHF.

Treatment of Ulcerative Colitis:

• Mild
  • Topical aminosalicylate or oral budesonide.  Patients who do not respond to oral may respond to topical alone or topical in combo with oral.  If refractory to all, add TNF alpha or prednisone.
  • Maintainence: Mesalamine supposorties or enemas (depending on locatoin of disease) or oral sulfasalazine, mesalamine or balasalzide.
• Moderate
  • Oral sulfasalazine, mesalamine or budesonide.  If refractory, prednisone.  If unresponsive, azathioprine or mercaptopurine.  TNF alpha if not responsive.
  • Maintenance as above, but may need azathioprine, mercaptopurine or a TNF alpha.
• Severe
  • 7-10 course of IV steroids.  If non-responsive, TNF alpha, cyclosporin and azathioprine or mercaptopurine.  Can consider colectomy.  Flagyl or cipro may be needed.

Medical Management of Crohn’s

• Mild: Oral mesalamine or sulfasalazine usually doesn’t work.  Budesonide is preferred.  Flagyl may be used in patients not responding to aminosalicylates (more effective if peritoneal or colonic). Cipro is as effective as mesalamine and usually used in combination with metronidazole.
• Moderate: Prednisone or budesonide or anti-TNF (not in NYHA III or IV heart failure) and thiopurines.  If unresponsive may try natalizumab or vedolizumab.  Use methotrexate for maintenance.
• Severe: Surgical intervention, steroids, may try IV cyclosporin.  Maintenance: Budesonide may be used up to 3 months.  Azathioprine/mercaptopurine or infliximab or mesalamine can be used. Methotrexate is good for people with chronic active disease.

Toxic Megacolon:

Reduction in motility can lead to toxic megacolon, so use loperamide, antispasmodics (dicyclomine, propantheline, hyoscyamine and cholestyramine) with caution.

• Symptoms:
  • Colon dilation > 6 cm
  • Fever >  101.5 F
  • Tachycardia
  • Abdominal pain
  • An absence of bowel sounds
  • A decrease in stool frequency
• Treatment:
  • Stop all opiates (they decrease peristalsis)
  • Replace fluids and electrolytes
  • High dose steroids (2 mg/kg of prednisone equivalence)
  • Empiric antibiotic coverage for aerobes and anaerobes