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    Inflammatory Bowel Disease

    KidsHealth>Teens>Diseases & Conditions> Digestive System> Inflammatory Bowel Disease

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    What Is IBD? Who Gets IBD? What 6uuhyhigrs Do? How Is IBD Treated?

    Listen

    Digestive problems are among the most common conditions affecting Americans today. Thereare many different types of digestive problems, from gastrointestinal infections that make a

    person miserable but pass quickly to long-term illnesses like inflammatory bowel disease (IBD).IBD is a general term that refers to illnesses that cause chronic inflammation in the intestines.

    If you're having diarrhea, stomach cramps, and other symptoms that make you question yourdigestion, you might want to learn more about the digestive system and IBD, as well as other

    digestive conditions.

    What Is IBD?

    Thedigestive systemis the set of organs that digest food and absorb the important nutrients yourbody needs to stay healthy and grow. Two of the major parts of the digestive system are the

    small and large intestines. Just like other organs in your body, the intestines can develop

    problems or diseases.

    IBD (which is not the same thing as irritable bowel syndrome, or IBS), can cause more serious

    problems than just diarrhea and pain. IBD may also cause adelay in pubertyor growth problemsfor some teens with the condition, because it can interfere with a person getting nutrients from

    the foods he or she eats.

    The two major types of IBD are Crohn's disease and ulcerative colitis.

    Crohn's disease occurs when the lining and wall of the intestines become inflamed and ulcersdevelop. Although Crohn's disease can occur in any part of the digestive system, it often occurs

    in the lower part of the small intestine where it joins the colon.

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    The intestine becomes inflamed, meaning the lining of the intestinal wall reddens and swells. It

    can become irritated, causing it to bleed and preventing it from properly absorbing the nutrients

    from digested food.

    People with Crohn's disease usually have these symptoms:

    abdominal cramps or pain diarrhea, sometimes with blood in the stool (bowel movements) fever weight loss

    These symptoms often cause people with Crohn's disease to feel tired and lose their appetites.

    Some people with Crohn's disease have minor symptoms and hardly any discomfort or pain.

    Their symptoms may only flare a few times. But others may experience frequent diarrhea,

    intestinal ulcers, and problems in other parts of their bodies, such as inflammation of the joints,skin rashes, and eye problems.

    Crohn's disease can cause the intestines to become blocked by swelling and scar tissue. Peoplewith the condition may also be more susceptible to infections and developing abscesses in and

    around their intestines.

    In ulcerative colitis, the large intestine becomes inflamed and ulcers may develop. Ulcerative

    colitis affects only the large intestine. The inflammation begins in the rectum (the last few inches

    of the large intestine where feces are stored before they leave the body) and can affect only therectum or the part of the large intestine that joins it. However, most kids and teens who have

    ulcerative colitis have the condition throughout their large intestines.

    The most common symptoms of ulcerative colitis are abdominal pain and bloody diarrhea. But

    some people also experience these symptoms:

    tiredness weight loss loss of appetite nausea

    Some people with ulcerative colitis may have periods of time when they are free of symptoms

    (this is called remission) and other times when they feel sick (called relapse).

    Like Crohn's disease, ulcerative colitis can be associated with problems in other parts of the

    body. These problems may include inflammation of the joints, eye problems, andanemiadue toblood loss.

    Continue

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    endoscopecolonoscopyupper endoscopybiopsybarium

    studybariumcorticosteroidsimmunosuppressantsimmunomodulators 123

    For Teens

    Inflammatory Bowel DiseaseWhat is inflammatory bowel disease?

    Inflammatory bowel disease is the name of a group of disorders that cause the intestines to become

    inflamed (red and swollen). The inflammation lasts a long time and usually comes back over and over

    again. More than 600,000 Americans have some kind of inflammatory bowel disease every year.

    If you have inflammatory bowel disease, you may have abdominal cramps and pain, diarrhea, weight

    loss and bleeding from your intestines. Two kinds of inflammatory bowel disease are Crohn's disease

    and ulcerative colitis. Crohn's disease usually causes ulcers (open sores) along the length of the small

    and large intestines. Crohn's disease either spares the rectum, or causes inflammation or infection with

    drainage around the rectum. Ulcerative colitis usually causes ulcers in the lower part of the large

    intestine, often starting at the rectum.

    Return to top

    What causes inflammatory bowel disease?

    The exact causes are unknown. The disease may be caused by a germ or by an immune system problem.

    You don't have to worry about your family members catching the disease from you, because it isn't

    contagious. However, inflammatory bowel disease does seem to be hereditary (runs in your family).

    Return to top

    How is inflammatory bowel disease diagnosed?

    Based on your symptoms, your doctor may suspect that you have Crohn's disease or ulcerative colitis.

    Your bowel movements may be tested for germs and the presence of blood. Your doctor will probably

    look inside your intestines with a sigmoidoscope or a colonoscope. In these procedures, the doctor uses

    a narrow flexible tube to look directly inside your intestines. Special x-rays may be helpful in diagnosing

    this illness.

    Return to top

    How is inflammatory bowel disease treated?

    The best thing you can do is take good care of yourself. It's important to eat a healthy diet. Depending

    on your symptoms, your doctor may ask you to cut down on the amount of fiber or dairy products in

    your diet. In addition to eating well, you need to get enough rest. It's also important that you learn to

    manage the stress in your life. When you become overly upset by things that happen at home or at

    work, your intestinal problems can get worse.

    http://void%280%29/http://void%280%29/http://void%280%29/http://void%280%29/http://void%280%29/http://void%280%29/http://void%280%29/http://void%280%29/http://familydoctor.org/online/famdocen/home/common/digestive/disorders/252.html#tophttp://familydoctor.org/online/famdocen/home/common/digestive/disorders/252.html#tophttp://familydoctor.org/online/famdocen/home/common/digestive/disorders/252.html#tophttp://familydoctor.org/online/famdocen/home/common/digestive/disorders/252.html#tophttp://familydoctor.org/online/famdocen/home/common/digestive/disorders/252.html#tophttp://familydoctor.org/online/famdocen/home/common/digestive/disorders/252.html#tophttp://familydoctor.org/online/famdocen/home/common/digestive/disorders/252.html#tophttp://familydoctor.org/online/famdocen/home/common/digestive/disorders/252.html#tophttp://familydoctor.org/online/famdocen/home/common/digestive/disorders/252.html#tophttp://void%280%29/http://void%280%29/http://void%280%29/
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    You will most likely be treated by a team of doctors. This team may include your family physician, a

    gastroenterologist (a specialist in stomach and intestinal disorders) and, possibly, a surgeon.

    The goal of treatment is to get rid of the inflammation. Many types of medicine can reduce

    inflammation, including anti-inflammatory drugs such as sulfasalazine, corticosteroids such as

    prednisone, and immune system suppressors such as azathioprine and mercaptopurine. An antibiotic,

    such as metronidazole, may also be helpful for killing germs in the intestines, especially if you have

    Crohn's disease.

    To help treat your symptoms, your doctor may recommend anti-diarrheals, laxatives, pain relievers or

    other over-the-counter (OTC) drugs. It is important to talk to your doctor before taking any OTC

    medicine on your own. Your body may not be able to handle the effects of medicine. If you have severe

    symptoms, such as diarrhea, fever or vomiting, you may need to go to the hospital to be treated with

    special fluids and medicines that must be given intravenously (in your veins).

    If your ulcerative colitis becomes so severe that it can't be helped by medicines, it may be necessary to

    remove part or all of your colon surgically. Crohn's disease usually isn't helped with surgery.

    Because Crohn's disease and ulcerative colitis keep coming back and their symptoms cannot be

    predicted ahead of time, patients with these illnesses can become depressed. If you feel depressed, talk

    with your family doctor. An antidepressant medicine could help you feel better.

    Return to top

    How can I get more information?By asking questions, reading informational materials and discussing your treatments with your doctor,

    you'll be able to understand your illness and manage it better. Patient support groups are helpful,

    especially if you have severe disease.

    Return to top

    Inflammatory Bowel Disease

    Author: Sarvotham Kini, MD, Associate Professor of Emergency Medicine, MedicalUniversity of South Carolina, Charleston.

    Contributor Information and Disclosures

    Updated: Nov 20, 2009

    Print This

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    Email This

    Overview Differential Diagnoses & Workup

    Treatment & Medication Follow-up Multimedia References Keywords

    Information from Industry

    Bacterial RTIs: View S pneumoniae resistance mapClick on your state Consider the growing problem

    of antibacterial resistance. What is the S pneumoniae resistance rate in your state? Read more

    Introduction

    Background

    The term inflammatory bowel disease (IBD) refers to primarilyulcerative colitis(UC) andCrohn's disease(CD). These are chronic conditions of uncertain etiology, characterized by

    recurrent episodes of abdominal pain, often with diarrhea. Although both ulcerative colitis and

    Crohn's disease have distinct pathologic findings, a significant percentage of patients with

    inflammatory bowel disease (IBD) have indeterminate findings. Crohn's disease is also referredto a regional enteritis, terminal ileitis, or granulomatous ileocolitis.

    Pathophysiology

    Multiple etiologies have been proposed for inflammatory bowel disease (IBD), but the precisecause is unknown. However, considerable evidence suggests that inflammatory mediators play

    an important role in the pathologic and clinical characteristic of these disorders. Cytokines,

    released by macrophages in response to various antigenic stimuli, bind to different receptors andproduce autocrine, paracrine, and endocrine effects. Cytokines differentiate lymphocytes into

    different types of T cells. Helper T cells, type 1 (Th-1), are associated principally with Crohn's

    disease, whereas Th-2 cells are associated principally with ulcerative colitis. The immune

    response disrupts the intestinal mucosa and leads to a chronic inflammatory process.1

    In ulcerative colitis (UC), inflammation begins in the rectum and extends proximally in an

    uninterrupted fashion to the proximal colon, eventually involving the entire length of the largeintestine. The rectum is always involved in ulcerative colitis, and no "skip areas" (ie, normal

    areas of the bowel interspersed with diseased areas) are present. Ulcerative colitis primarily

    involves the mucosa and the submucosa, with formation of crypt abscesses and mucosalulceration. The mucosa typically appears granular and friable. In more severe cases,

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    pseudopolyps form, consisting of areas of hyperplastic growth with swollen mucosa surrounded

    by inflamed mucosa with shallow ulcers. In severe ulcerative colitis, inflammation and necrosis

    can extend below the lamina propria to involve the submucosa and the circular and longitudinalmuscles, although this is very unusual.

    Ulcerative colitis remains confined to the rectum in approximately 25% of cases. In theremainder of cases, ulcerative colitis spreads proximally and contiguously. Pancolitis occurs in10% of patients. The small intestine is never involved, except when the distal terminal ileum is

    inflamed in a superficial manner, referred to as backwash ileitis. Even with less than total colonic

    involvement, the disease is strikingly and uniformly continuous. As the disease becomes chronic,the colon becomes a rigid foreshortened tube that lacks its usual haustral markings, leading to the

    lead pipe appearance observed on barium enema. The skip areas observed in the colon in Crohn's

    disease do not occur in ulcerative colitis.

    Crohn's disease, on the other hand, consists of segmental involvement by a nonspecific

    granulomatous inflammatory process. The most important pathologic feature is that Crohn's

    disease is transmural, involving all layers of the bowel, not just the mucosa and the submucosa,which is characteristic of ulcerative colitis. Crohn's disease can affect any portion of the

    gastrointestinal tract from the mouth to the anus. Furthermore, Crohn's disease is discontinuous,with skip areas interspersed between one or more involved areas.

    Late in the disease, the mucosa develops a cobblestone appearance, which results from deep

    longitudinal ulcerations interlaced with intervening normal mucosa. The 3 major patterns ofinvolvement in Crohn's disease are (1) disease in the ileum and cecum (occurring in 40% of

    patients), (2) disease confined to the small intestine (occurring in 30% of patients), and (3)

    disease confined to the colon (occurring in 25% of patients). Rectal sparing is a typical but not

    constant feature of Crohn's disease. However, anorectal complications (eg, fistulas, abscesses)are common. Much less commonly, Crohn's disease involves the more proximal parts of the

    gastrointestinal (GI) tract, including the mouth, tongue, esophagus, stomach, and duodenum.

    Crohn's disease causes 3 patterns of involvement: inflammatory disease, strictures, and fistulas.

    Ulcerative colitis and Crohn's disease are generally diagnosed using clinical, endoscopic, and

    histologic criteria. Histologically, transmural non-necrotizing lymphoid granulomas arecharacteristic of Crohn's disease. However, they may not be found in a given case of Crohn's

    disease, and no single finding is absolutely diagnostic for one disease or the other. Furthermore,

    approximately 20% of patients have a clinical picture that falls between Crohn's disease andulcerative colitis; they are said to have indeterminate colitis.

    The incidence of gallstones andkidney stonesis increased in Crohn's disease because of

    malabsorption of fat and bile salts.Gallstonesare formed because of increased cholesterolconcentration in the bile, caused by a reduced bile salt pool. Patients who have Crohn's disease

    with ileal disease or resection also are likely to form calcium oxalate kidney stones. With the fat

    malabsorption, unabsorbed long-chain fatty acids bind calcium in the lumen. Oxalate in thelumen normally is bound to calcium. Calcium oxalate is poorly soluble and poorly absorbed;

    however, if calcium is bound to malabsorbed fatty acids, oxalate combines with sodium to form

    sodium oxalate, which is soluble and is absorbed in the colon (enteric hyperoxaluria). The

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    development of calcium oxalate stones in Crohn's disease requires an intact colon to absorb

    oxalate. Patients with ileostomies do not develop calcium oxalate stones.

    Extraintestinal manifestations of inflammatory bowel disease (IBD) includeiritis, episcleritis,

    arthritis, and skin involvement, as well aspericholangitisand sclerosing cholangitis. These

    extraintestinal manifestations (EIM) are observed in up to 20-40% of patients with IBD.

    2

    Frequency

    United States

    The incidence is 70-150 cases per 100,000 individuals.

    The incidence of inflammatory bowel disease (IBD) varies within different geographic areas.

    Crohn's disease (CD) and ulcerative colitis (UC) both occur at the highest incidence in Europe,the United Kingdom, and North America.

    International

    The incidence of inflammatory bowel disease (IBD) ranges from 2.2-14.3 cases per 100,000person-years for ulcerative colitis and from 3.1-14.6 cases per 100,000 person-years for Crohn's

    disease. Overall, the combined incidence for inflammatory bowel disease is 10 cases per 100,000

    annually.3,4

    Mortality/Morbidity

    The quality of life generally is lower in those with Crohn's disease than in those with ulcerative

    colitis, in part because of recurrences after surgery performed for Crohn's disease.

    The most common causes of death in inflammatory bowel disease (IBD) areperitonitis withsepsis, malignancy, thromboembolic disease, and complications of surgery.

    Toxic megacolon, one of the most dreaded complications of ulcerative colitis, can lead toperforation, sepsis, and death.

    Malnutrition and chronic anemia are observed in long-standing Crohn's disease. Children with Crohn's disease or ulcerative colitis can exhibit growth retardation.

    Race

    Incidence among whites is approximately 4 times that of other races. IBD is observed most commonly in Northern Europe and North America. It is a disease of

    industrialized nations.

    Incidence is higher in Ashkenazi Jews (ie, those who have immigrated from Northern Europe)than in other groups.

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    Sex

    Incidence is slightly greater in females than in males.Age

    Incidence peaks in the second and third decades of life. A second smaller peak occurs in patients aged 55-65 years. Crohn's disease and ulcerative colitis can occur in childhood, although the incidence is much

    lower in children younger than 15 years.

    Clinical

    History

    Patients with ulcerative colitis (UC) most commonly present with bloody diarrhea, whereaspatients with Crohn's disease (CD) usually present with nonbloody diarrhea.

    o Abdominal pain and cramping, fever, and weight loss occur in more severe cases.o The greater the extent of colon involvement, the more likely the patient is to have

    diarrhea.

    o Rectal urgency or tenesmus reflects reduced compliance of the inflamed rectum.o Patients might have formed stools if their disease is confined to the rectum.o As the degree of inflammation increases, systemic symptoms develop, including low-

    grade fever, malaise, nausea, vomiting, sweats, and arthralgias.

    o Fever, dehydration, and abdominal tenderness develop in severe ulcerative colitis,reflecting progressive inflammation into deeper layers of the colon.

    The presentation of Crohn's disease is generally more insidious than that of ulcerative colitis,with ongoing abdominal pain, anorexia, diarrhea, weight loss, and fatigue.

    o Grossly bloody stools, while typical of ulcerative colitis, are less common in Crohn'sdisease.

    o Stools may be formed, but loose stools predominate if the colon or the terminal ileum isinvolved extensively.

    o One half of patients with Crohn's disease present with perianal disease (eg, fistulas,abscesses).

    o Occasionally, acute right lower quadrant pain and fever, mimicking appendicitis, may benoted.

    o Commonly, the diagnosis is established only after several years of recurrent abdominalpain, fever, and diarrhea.

    Crohn's disease with gastroduodenal involvement may mimic peptic ulcer disease and canprogress to gastric outlet obstruction.

    Many patients with inflammatory bowel disease (IBD) haveirritable bowel syndrome, which canproduce occasional cramping, irregular bowel habits, and passage of mucus without blood or

    pus.

    Weight loss is observed more commonly in Crohn's disease than in ulcerative colitis because ofthe malabsorption associated with small bowel disease. Patients may reduce their food intake in

    an effort to control their symptoms.

    http://emedicine.medscape.com/article/180389-overviewhttp://emedicine.medscape.com/article/180389-overviewhttp://emedicine.medscape.com/article/180389-overviewhttp://emedicine.medscape.com/article/180389-overview
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    Systemic symptoms are common and include fever, sweats, malaise, and arthralgias. A low-grade fever may be the first warning sign of a flare.

    Recurrences may occur with emotional stress, infections or other acute illnesses, pregnancy,dietary indiscretions, use of cathartics or antibiotics, or withdrawal of anti-inflammatory or

    steroid medications.

    Children may present with growth retardation and delayed or failed sexual maturation. In 10-20% of cases, patients present with extraintestinal manifestations, including arthritis,

    uveitis, or liver disease.

    Physical

    Fever, tachycardia, dehydration, and toxicity may occur. Pallor may be noted, reflecting anemia.The magnitude of these factors is related directly to the severity of the attack.

    Evaluate for signs of localized peritonitis, although abdominal tenderness is common. Patientswith toxic megacolon appear septic. They have high fever; lethargy; chills; tachycardia; and

    increasing abdominal pain, tenderness, and distention.

    Patients with Crohn's disease may develop a mass in the right lower quadrant. The rectal examination often reveals bloody stool on gross or Hemoccult examination. Complications (eg, perianal fissures or fistulas, abscesses,rectal prolapse) may be observed in

    up to 90% of patients with Crohn's disease.

    The physical examination should include a search for extraintestinal manifestations, such asiritis, episcleritis, arthritis, and dermatologic involvement.

    Distinguishing Features of Crohn's Disease Versus Ulcerative Colitis

    Opentable in new window

    [CLOSE WINDOW]

    Table

    Features Crohns DiseaseUlcerative Colitis

    Skip areas Common Never

    Cobblestone mucosa Common Rare

    Transmural involvementCommon Occasional

    Rectal sparing Common Never

    Perianal involvement Common Never

    Fistulas Common Never

    Strictures Common Occasional

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    Granulomas Common Occasional

    Features Crohns DiseaseUlcerative Colitis

    Skip areas Common Never

    Cobblestone mucosa Common Rare

    Transmural involvementCommon Occasional

    Rectal sparing Common Never

    Perianal involvement Common Never

    Fistulas Common Never

    Strictures Common Occasional

    Granulomas Common Occasional

    Causes

    The etiology of inflammatory bowel disease (IBD) is unknown. Environmental, infectious,genetic, autoimmune, and host factors have been suspected. Interactions among these factors

    may be more important.

    o Inflammatory mediators Interleukin-1 Tumor necrosis factoralpha (TNF-alpha)

    o Aggravation by bacterial infection and inflammatory cascadeo Positive family history: The most important risk factor for developing IBD is a positive

    family history.

    The risk of developing ulcerative colitis is higher in nonsmokers and former smokers than incurrent smokers. The onset of ulcerative colitis occasionally appears to coincide with smoking

    cessation. This does not imply that smoking would improve the symptoms of ulcerative colitis.

    Interestingly, some success in the use of nicotine patches has been reported. On the contrary,

    patients with Crohn's disease have a higher incidence of smoking than the general population,

    and those patients with Crohn's disease who continue to smoke appear to be less likely to

    respond to medical therapy.

    More on Inflammatory Bowel Disease

    Overview: Inflammatory Bowel Disease

    Differential Diagnoses & Workup: Inflammatory Bowel Disease

    http://emedicine.medscape.com/article/774566-diagnosishttp://emedicine.medscape.com/article/774566-diagnosishttp://emedicine.medscape.com/article/774566-diagnosis
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    Treatment & Medication: Inflammatory Bowel Disease

    Follow-up: Inflammatory Bowel Disease

    Multimedia: Inflammatory Bowel Disease

    References

    Inflammatory Bowel Disease: Differential

    Diagnoses & Workup

    Author: Sarvotham Kini, MD, Associate Professor of Emergency Medicine, Medical

    University of South Carolina, Charleston.

    Contributor Information and Disclosures

    Updated: Nov 20, 2009

    Print This Email This

    Overview Differential Diagnoses & Workup Treatment & Medication Follow-up Multimedia References Keywords

    Information from Industry

    Bacterial RTIs: Consider the importance of broad-spectrum coverage See coverage in community-

    acquired pneumonia (CAP) Read more

    Differential DiagnosesAppendicitis, AcuteDiverticular Disease

    Endometriosis

    Pelvic Inflammatory Disease

    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icine.medscape.com/article/774566-mediahttp://emedicine.medscape.com/article/774566-followuphttp://emedicine.medscape.com/article/774566-treatmenthttp://emedicine.medscape.com/article/774566-overviewmailto:enter%20email%20address%20here?Subject=eMedicine%20Article%20-%20Inflammatory%20Bowel%20Disease&Body=I%20thought%20you%20might%20be%20interested%20in%20this%20article%20from%20eMedicine.%20You%20may%20either%20click%20on%20the%20following%20link%20or%20copy%20and%20paste%20it%20into%20your%20browser.%0Dhttp://emedicine.medscape.com/article/774566-overview%0D%0A%0D%0AeMedicine%20is%20the%20leading%20provider%20of%20clinical%20medical%20information%20for%20medical%20professionals%20and%20consumers.%20To%20explore%20eMedicine%20today,%20visit%20http://emedicine.medscape.comhttp://emedicine.medscape.com/article/774566-printhttp://emedicine.medscape.com/article/774566-mediahttp://emedicine.medscape.com/article/774566-followuphttp://emedicine.medscape.com/article/774566-treatment
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    Other Problems to Be Considered

    AIDS (The chronic diarrhea and diffuse colonic involvement of Kaposi sarcoma may mimicchronic UC.)

    Antibiotic-associated colitis

    Arteriovenous malformationsCollagenous colitis

    Colon cancer

    Fever of unknown originInfectious colitis (if confined to the rectum, rule out "gay bowel syndrome")

    Intestinal lymphoma

    Irritable bowel syndrome (can be present along with IBD): In IBS, diarrhea often alternates with

    constipation. In contrast to IBD, IBS is not associated with blood in the stool, nocturnal diarrhea,weight loss, or other inflammatory sequelae (eg, fever, arthritis, skin or eye lesions, perianal

    disease). Fecal WBCs are not observed in IBS.

    Ischemic colitis

    Pseudomembranous colitisRadiation-induced colitis

    Workup

    Laboratory Studies

    CBC with differentialo Anemia may result from acute or chronic blood loss or malabsorption (iron, folate,

    vitamin B-12) or may reflect the chronic disease state.

    o Leukocytosis, anemia, and thrombocytosis are common. A modestly elevated WBC isobserved in active disease, but a marked elevation suggests the presence of an abscessor other suppurative complication.

    Erythrocyte sedimentation rate: The sedimentation rate is typically elevated and has been usedto monitor disease activity.

    Serum chemistryo Hypokalemiareflects the severity of the diarrhea.o Abnormal liver function test results may represent pericholangitis or sclerosing

    cholangitis, which are complications of inflammatory bowel disease .

    o Hypoalbuminemia, resulting fromprotein-losing enteropathy, suggests extensive colitis.o Decreased serum calcium level may reflect reduced serum albumin level.

    Type and crossmatch: Consider obtaining a type and crossmatch, especially in patientspresenting with bloody diarrhea .

    Stool examination: Send stool for fecal leukocytes, ova and parasite studies, bacterial pathogensculture, and Clostridium difficile titer.

    o Amebiasis can be difficult to identify from the stool. Consider serologic testing in thisregard.

    o As many as 50-80% of cases of acute terminal ileitis are due to Yersinia enterocolitisinfections. This produces a picture of pseudoappendicitis. Yersiniosis also has a high

    http://emedicine.medscape.com/article/767448-overviewhttp://emedicine.medscape.com/article/767448-overviewhttp://emedicine.medscape.com/article/182565-overviewhttp://emedicine.medscape.com/article/182565-overviewhttp://emedicine.medscape.com/article/182565-overviewhttp://emedicine.medscape.com/article/182565-overviewhttp://emedicine.medscape.com/article/767448-overview
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    frequency of secondary manifestations, such as erythema nodosum and monarticular

    arthritis, similar to IBD.

    Blood culture: Cultures may be positive if peritonitis or fulminant colitis is present. Serologic tests: Serologic tests have become available to aid in the diagnosis of inflammatory

    bowel disease (IBD) and differentiate between Crohn's disease and ulcerative colitis. Perinuclear

    antineutrophil cytoplasmic antibodies (pANCA) have been identified in some patients with

    ulcerative colitis, and anti-Saccharomyces cerevisiae antibodies (ASCA) have been found in

    patients with Crohn's disease. Furthermore, those patients with inflammatory bowel disease

    who are seronegative appear to have a lower incidence of resistant disease. Currently, these

    markers are not sensitive enough to be used as screening tests for inflammatory bowel disease.5

    Imaging Studies

    Upright chest radiography and abdominal serieso Evaluate for an edematous irregular colon with "thumb printing." Occasionally,

    pneumatosis coli (air in the colonic wall) may be present.

    o Look for free air and especially for evidence of toxic megacolon, depicted in the imagebelow, which appears as a long continuous segment of air-filled colon greater than 6 cm

    in diameter.

    o

    Inflammatory bowel disease. Toxic megacolon. Courtesy of Dr Pauline Chu.

    [CLOSE WINDOW]

    Inflammatory bowel disease. Toxic megacolon. Courtesy of Dr Pauline Chu.

    o In the supine position, dilatation is predominantly noted in the transverse colonsecondary to air collection.

    o Repeat radiographs at 12- to 24-hour intervals to monitor the course of dilatation and toassess the need for emergency colectomy.

    o Associated findings includenephrolithiasis,cholelithiasis, or arthritis of the spine or thesacroiliac joints.

    Barium enema

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    o In ulcerative colitis, a barium enema (BE) may reveal a shortened colon, with loss ofhaustrations and destruction of the mucosal pattern (ie, lead pipe colon).

    o Skip areas and rectal sparing are noted in Crohn's disease.o Barium enema is contraindicated in patients with moderate-to-severe colitis because it

    risks perforation or precipitation of a toxic megacolon.

    Upper GI with small bowel follow-througho In Crohn's disease, areas of segmental narrowing with loss of normal mucosa, fistula

    formation, and the string sign (a narrow band of barium flowing through an inflamed or

    scarred area) in the terminal ileum are typically observed.

    o Some patients with ulcerative colitis also demonstrate inflammatory changes in theterminal ileum (ileitis), but they lack the skip pattern characteristic of Crohn's disease.

    CT scanning and ultrasonography: CT scanning and ultrasonography are best for demonstratingintra-abdominal abscesses, mesenteric inflammation, and fistulas.

    MRI may be of help in detecting fistulas and abscesses. More recently, wireless capsule endoscopy, used most often to investigate the source of GI

    bleeding, has been found useful in diagnosing mucosal lesions in Crohn's disease. The detection

    rate of abnormalities was 70.5% for patients with suspected small bowel disease, and the

    diagnostic yield for patients with obscure gastrointestinal bleeding was higher than that forpatients with abdominal pain or diarrhea (85.7% vs 53.3%, P

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    Overview Differential Diagnoses & Workup Treatment & Medication Follow-up Multimedia References Keywords

    Information from Industry

    Bacterial RTIs: View S pneumoniae resistance mapClick on your state Consider the growing problem

    of antibacterial resistance. What is the S pneumoniae resistance rate in your state? Read more

    Treatment

    Emergency Department Care

    Initiate supportive care with bowel rest, nasogastric suction, and intravenous (IV) fluidscontaining electrolytes.

    Admit for toxicity, obstruction, hemorrhage, or localized peritonitis. Monitor severe cases for fat malabsorption. Treat perirectal disease.

    o Sitz bathso Soap and water after stoolingo Surgical drainage of perirectal abscesseso Surgical treatment of recurrent fistulas if medical management fails

    Administer folate supplementation as needed.Consultations

    Consult a surgeon for complicating obstruction, hemorrhage, perforation, abscess or fistulaformation, toxic megacolon, or perianal disease.

    Consider surgical intervention for patients in whom medical therapy fails. The 2 most commonchoices today (for ulcerative colitis) are proctocolectomy with ileostomy and total colectomy

    with ileoanal anastomosis. Elective surgery can sometimes be performed laparoscopically. For

    fulminant colitis, the surgical procedure of choice consists of a subtotal colectomy with end

    ileostomy and creation of a Hartman pouch.

    In Crohn's disease, surgically resect only as much bowel as necessary to correct the problembecause the recurrence rate after surgery approaches 100%.

    Patients with toxic megacolon initially require nasogastric suction and IV steroids. Failure toimprove within 48 hours is an indication for total colectomy.

    Extracolonic manifestations (ie, uveitis, arthritis, dermatitis, sclerosing cholangitis) are bestmanaged with the aid of specialty consultation.

    Medication

    http://emedicine.medscape.com/article/774566-overviewhttp://emedicine.medscape.com/article/774566-overviewhttp://emedicine.medscape.com/article/774566-diagnosishttp://emedicine.medscape.com/article/774566-diagnosishttp://emedicine.medscape.com/article/774566-followuphttp://emedicine.medscape.com/article/774566-followuphttp://emedicine.medscape.com/article/774566-mediahttp://emedicine.medscape.com/article/774566-mediahttp://as.webmd.com/event.ng/Type=click&FlightID=168337&AdID=271559&TargetID=32830&Values=205&Redirect=http:/www.medscape.com/infosite/levaquin?src=0_0_ad_newshttp://as.webmd.com/event.ng/Type=click&FlightID=168337&AdID=271559&TargetID=32830&Values=205&Redirect=http:/www.medscape.com/infosite/levaquin?src=0_0_ad_newshttp://as.webmd.com/event.ng/Type=click&FlightID=168337&AdID=271559&TargetID=32830&Values=205&Redirect=http:/www.medscape.com/infosite/levaquin?src=0_0_ad_newshttp://as.webmd.com/event.ng/Type=click&FlightID=168337&AdID=271559&TargetID=32830&Values=205&Redirect=http:/www.medscape.com/infosite/levaquin?src=0_0_ad_newshttp://as.webmd.com/event.ng/Type=click&FlightID=168337&AdID=271559&TargetID=32830&Values=205&Redirect=http:/www.medscape.com/infosite/levaquin?src=0_0_ad_newshttp://as.webmd.com/event.ng/Type=click&FlightID=168337&AdID=271559&TargetID=32830&Values=205&Redirect=http:/www.medscape.com/infosite/levaquin?src=0_0_ad_newshttp://as.webmd.com/event.ng/Type=click&FlightID=168337&AdID=271559&TargetID=32830&Values=205&Redirect=http:/www.medscape.com/infosite/levaquin?src=0_0_ad_newshttp://as.webmd.com/event.ng/Type=click&FlightID=168337&AdID=271559&TargetID=32830&Values=205&Redirect=http:/www.medscape.com/infosite/levaquin?src=0_0_ad_newshttp://emedicine.medscape.com/article/774566-mediahttp://emedicine.medscape.com/article/774566-followuphttp://emedicine.medscape.com/article/774566-diagnosishttp://emedicine.medscape.com/article/774566-overview
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    Therapy for Crohn's disease generally is less effective than that for ulcerative colitis. In addition

    to the therapies outlined herein, intravenous cyclosporine is helpful in refractory ulcerative

    colitis. Zileuton, a 5-lipoxygenase inhibitor, has shown some efficacy in treating Crohn's disease.

    Hyperbaric oxygen therapy may be helpful in the treatment of inflammatory bowel disease (IBD)

    that is unresponsive to other therapies. Its therapeutic efficacy appears to result from decreasedgeneration of prostaglandin E2. Previous work has linked mucosal prostaglandin E2 to the

    intestinal damage associated with IBD.8

    Agents for symptomatic treatment include loperamide and the combination of diphenoxylate and

    atropine, which are useful in mild disease to reduce the number of bowel movements and to

    relieve rectal urgency. Cholestyramine, a resin that binds bile salts, is useful for reducingdiarrhea in patients with Crohn's disease who have had ileal resections. The anticholinergic agent

    dicyclomine may help relieve intestinal spasms. Antidiarrheal and anticholinergic medications

    must be avoided in acute severe disease because they may precipitate toxic megacolon. Avoid

    the long-term use of narcotics for pain. An iron supplement should be added when significant

    rectal bleeding is present.

    Antidiarrheal agents

    These agents inhibit peristalsis in the GI tract.

    Loperamide (Imodium)

    Acts in intestinal muscles to inhibit peristalsis and to slow intestinal motility. Prolongs

    movement of electrolytes and fluid through bowel; increases viscosity and loss of fluids andelectrolytes.

    Dosing Interactions Contraindications Precautions

    Adult

    Initial dose: 4 mg POMaintenance: 2 mg PO after each loose stool; not to exceed 16 mg/d

    Pediatric

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    2 mg bid

    8-12 years: 2 mg PO tid initially; followed by 0.1 mg/kg PO after each loose stool; not to exceed

    2 mg tid>12 years: Administer as in adults

    Chronic diarrhea: 0.08-0.24 mg/kg/d PO divided bid/tid; not to exceed 2 mg/dose

    Dosing Interactions Contraindications Precautions

    Phenothiazines, tricyclic antidepressants, and CNS depressants may increase toxicity

    Dosing Interactions Contraindications Precautions

    Documented hypersensitivity; diarrhea resulting from infection; pseudomembranous colitis

    Dosing Interactions Contraindications Precautions

    Pregnancy

    B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

    Precautions

    Discontinue use if no clinical improvement is noted in 48 h; because metabolized primarily in

    liver, monitor for CNS toxicity in patients with hepatic insufficiency; do not use if high fever orblood in stool coincides with diarrhea

    Diphenoxylate and Atropine (Lomotil)

    Drug combination that consists of diphenoxylate, a constipating meperidine congener, and

    subtherapeutic amount of atropine to discourage abuse. Inhibits excessive GI propulsion and

    motility.

    Dosing Interactions Contraindications Precautions

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    Adult

    15-20 mg/d PO tid/qid; followed by 5-15 mg/d

    Pediatric

    2 years: 0.3-0.4 mg/kg/d PO divided qid2-5 years: 2 mg PO tid

    5-8 years: 2 mg PO qid

    8-12 years: 2 mg PO 5 times/d>12 years: Administer as in adults

    Dosing Interactions Contraindications

    Precautions

    May delay metabolism of drugs by liver; CNS depressants, MAOIs, and antimuscarinic agentsmay increase toxicity

    Dosing Interactions Contraindications Precautions

    Documented hypersensitivity; narrow-angle glaucoma; hepatic insufficiency

    Dosing Interactions Contraindications Precautions

    Pregnancy

    C - Fetal risk revealed in studies in animals but not established or not studied in humans; mayuse if benefits outweigh risk to fetus

    Precautions

    Dehydration may influence variability of response in young children, predisposing them to

    delayed diphenoxylate intoxication; caution in patients with UC; decrease in intestinal motilitymay be detrimental to patients with diarrhea resulting from Shigella and Salmonella species and

    toxigenic strains ofEscherichia coli

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    Cholestyramine (Questran)

    Useful in treating diarrhea associated with pseudomembranous colitis. Inhibits enterohepaticreuptake of intestinal bile salts by forming nonabsorbable complex with bile acids in intestine.

    Dosing

    Interactions Contraindications Precautions

    Adult

    4 g PO qd/bid; not to exceed 24 g/d or 6 doses/d

    Pediatric

    240 mg/kg/d PO divided tid

    Dosing Interactions Contraindications Precautions

    Inhibits absorption of numerous drugs, including warfarin, thyroid hormone, amiodarone,

    NSAIDs, methotrexate, digitalis glycosides, glipizide, phenytoin, imipramine, niacin,

    methyldopa, tetracyclines, clofibrate, hydrocortisone, and penicillin G

    Dosing

    Interactions Contraindications Precautions

    Documented hypersensitivity

    Dosing Interactions Contraindications Precautions

    Pregnancy

    C - Fetal risk revealed in studies in animals but not established or not studied in humans; mayuse if benefits outweigh risk to fetus

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    Precautions

    Caution in constipation and phenylketonuria

    Antispasmodic agents

    These agents are used to treat functional disturbances of GI motility.

    Dicyclomine (Bentyl)

    Useful in treating GI motility disturbances; blocks action of acetylcholine at parasympathetic

    sites in secretory glands, smooth muscle, and CNS.

    Dosing

    Interactions Contraindications Precautions

    Adult

    80 mg/d PO divided qid initially, then increase to 160 mg/d

    Pediatric

    10 mg/dose PO tid/qid

    Dosing Interactions Contraindications Precautions

    Effects are weakened when administered with anti-Parkinson drugs, haloperidol, and

    phenothiazines; toxicity increases when administered concurrently with amantadine,

    antihistamines, type I antiarrhythmics, phenothiazines, TCAs, or narcotic analgesics

    Dosing Interactions Contraindications Precautions

    Documented hypersensitivity; myasthenia gravis; narrow-angle glaucoma

    Dosing Interactions

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    Contraindications Precautions

    Pregnancy

    B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

    Precautions

    Caution when administering to patients with hepatic or renal insufficiency, cardiovasculardisease, urinary tract obstruction, UC, GI obstruction, hyperthyroidism, or hypertension

    Aminosalicylates

    These agents are effective for treating acute ulcerative colitis (UC) and for maintaining its

    remission; they are also beneficial in mildly to moderately active Crohn's disease (CD) when the

    colon is involved. Sulfasalazine has not been clearly shown to maintain remission in CD.Furthermore, there is some question as to its effectiveness versus small bowel disease.

    Newer aminosalicylate preparations without sulfapyridine (eg, 5-aminosalicylic acid [5-ASA])

    were developed because tolerance of sulfasalazine has been limited by the sulfa-containing

    moiety. Because free 5-ASA is absorbed rapidly from the proximal GI tract, it has been modifiedin the newer formulations. Olsalazine consists of two 5-ASA molecules linked together by an

    azo bond. Intestinal bacteria cleave the bond, which enables olsalazine to work, primarily in the

    colon.

    Additional formulations of 5-ASA (mesalamine) are Asacol, Pentasa, Rowasa, and Balsalazide.

    Asacol is composed of 5-ASA coated in a pH-dependent acrylic resin, which allows delayedrelease of 5-ASA in the distal ileum and the right colon. Pentasa consists of 5-ASA encapsulated

    into microgranules of ethylcellulose and released continuously throughout the GI tract.

    Therefore, it is useful in patients with CD involvement of the small bowel and the colon. Rowasa

    contains 5-ASA in suppository or enema formulations, which are useful for treating andmaintaining remissions in ulcerative proctitis and proctosigmoiditis. Balsalazide is mesalamine

    linked to an inert carrier molecule. In the colon, bacteria cleave the bond and release free

    mesalamine.

    Because oral aminosalicylates interfere with folate absorption, folic acid supplementation (1

    mg/d) should be given.

    Sulfasalazine (Azulfidine)

    Combination of 5-ASA or mesalamine and sulfapyridine. Taken PO, remains intact until itreaches terminal ileum and colon, where it is split by bacteria into its 2 moieties. Active portion

    appears to be 5-ASA, which inhibits prostaglandin synthesis; sulfa portion is absorbed and

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    causes most adverse reactions. Abdominal discomfort common. Folate deficiency may result

    from competition between folate and sulfasalazine for absorption.

    Dosing Interactions Contraindications Precautions

    Adult

    3-4 g PO qd in divided doses

    Pediatric

    2 years: 30 mg/kg PO divided qid

    Dosing Interactions Contraindications Precautions

    Decreases effects of iron, digoxin, and folic acid; increases effects of PO anticoagulants, PO

    hypoglycemic agents, and methotrexate

    Dosing Interactions Contraindications Precautions

    Documented hypersensitivity; GI or GU obstruction

    Dosing Interactions Contraindications Precautions

    Pregnancy

    B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

    D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

    Precautions

    Caution in patients with renal or hepatic impairment, blood dyscrasias, or urinary obstruction

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    Olsalazine (Dipentum)

    Alternate treatment for patients who do not tolerate sulfasalazine. Useful in maintaining

    remission in UC; exerts anti-inflammatory activity in UC.

    Dosing Interactions Contraindications Precautions

    Adult

    500 mg PO bid

    Pediatric

    Not established

    Dosing Interactions Contraindications Precautions

    None reported

    Dosing Interactions Contraindications Precautions

    Documented hypersensitivity

    Dosing Interactions Contraindications Precautions

    Pregnancy

    C - Fetal risk revealed in studies in animals but not established or not studied in humans; mayuse if benefits outweigh risk to fetus

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    Precautions

    Relatively high incidence of diarrhea may be dose related (unclear whether other underlyingcauses may contribute)

    Mesalamine (Asacol, Pentasa, Rowasa, Canasa)

    Treats mildly to moderately active UC.Usual course of therapy in adults is 3-6 wk. Some patients may need concurrent PR and PO

    therapy.

    Dosing Interactions Contraindications Precautions

    Adult

    Cap: 1 g PO qidTab: 800 mg PO tidRectal supp: Insert 1 PR bid

    Pediatric

    Not established

    Dosing Interactions Contraindications Precautions

    Decreases effects of iron, digoxin, and folic acid; mesalamine increases effect of POanticoagulants, methotrexate, and PO hypoglycemic agents

    Dosing Interactions Contraindications Precautions

    Documented hypersensitivity

    Dosing Interactions Contraindications Precautions

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    Pregnancy

    B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

    Precautions

    Elderly patients may have difficulty administering and retaining rectal suppositories; caution in

    renal or hepatic impairment

    Corticosteroids

    These agents are the treatments of choice for an acute inflammatory bowel disease (IBD) attack;

    administer IV in severe disease. Give increased or stress doses to patients already on steroids. Do

    not use steroids for maintaining remission because of their lack of efficacy9

    and potentialcomplications, including avascular necrosis, osteoporosis, cataracts, emotional lability,

    hypertension, diabetes mellitus, cushingoid features, acne, and facial hair. Cortenema,

    Cortifoam, and Anusol-HC suppositories are useful in treating distal disease (proctitis andproctosigmoiditis).

    Budesonide (Entocort EC), a synthetic corticosteroid, is available for Crohn's disease (CD) withileal or ileocecal involvement.

    10It is indicated for PO treatment to induce remissions of attacks

    of mild-to-moderate severity involving the ileum and/or ascending colon.9

    The drug contains

    budesonide granules in an ethylcellulose matrix coated with a methacrylic acid polymer. Thecoating, which requires a pH more than 5.5 to dissolve, prevents release of the drug in the

    stomach. The ethylcellulose matrix delays release further until the drug reaches the ileum and

    ascending colon. A potential advantage is that fewer adverse effects occur than with the use of

    systemic corticosteroids. However, some absorption occurs and may slow growth in adolescents.

    Prednisone (Sterapred)

    Used as immunosuppressant in treatment of autoimmune disorders; may decrease inflammationby reversing increased capillary permeability and suppressing PMN activity.

    Dosing Interactions Contraindications

    Precautions

    Adult

    5-60 mg/d PO qd or divided bid/qid

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    Pediatric

    4-5 mg/m2/d PO; alternatively, 1-2 mg/kg PO qd; not to exceed 60 mg/d; taper over 2 wk as

    symptoms resolve

    Dosing

    Interactions Contraindications Precautions

    Estrogens may decrease clearance; concurrent digoxin may cause digitalis toxicity secondary to

    hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism (consider

    increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

    Dosing Interactions Contraindications Precautions

    Documented hypersensitivity; viral, fungal, or tubercular skin infections

    Dosing Interactions Contraindications Precautions

    Pregnancy

    B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

    Precautions

    Abrupt discontinuation may cause adrenal crisis; hyperglycemia, edema, osteonecrosis,

    myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia

    gravis, growth suppression, and infections may occur

    Methylprednisolone (Adlone, Medrol, Solu-Medrol)

    Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and

    increasing permeability or capillaries.

    Dosing Interactions Contraindications Precautions

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    Adult

    125-250 mg IV loading dose, followed by maintenance dose of 0.5-1 mg/kg/dose IV q6h for upto 5 d

    Pediatric

    2 mg/kg IV loading dose, followed by maintenance dose of 0.5-1 mg/kg/dose IV q6h for up to 5d

    Dosing Interactions Contraindications Precautions

    Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia;

    estrogens may increase levels; phenobarbital, phenytoin, and rifampin may decrease levels(adjust dose); monitor patients for hypokalemia when taking concurrently with diuretics

    Dosing Interactions Contraindications Precautions

    Documented hypersensitivity; viral, fungal, or tubercular skin infections

    Dosing Interactions Contraindications Precautions

    Pregnancy

    C - Fetal risk revealed in studies in animals but not established or not studied in humans; may

    use if benefits outweigh risk to fetus

    Precautions

    Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria,psychosis, growth suppression, myopathy, and infections are possible complications

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    Hydrocortisone (Anusol-HC, Anuprep HC)

    Decreases inflammation by suppressing migration of polymorphonuclear leukocytes andreversing increased capillary permeability.

    Dosing

    Interactions Contraindications Precautions

    Adult

    10-100 mg PR qd/bid for 2-3 wk

    Pediatric

    Not established

    Dosing Interactions Contraindications Precautions

    Clearance may decrease with estrogens; may increase digitalis toxicity secondary to

    hypokalemia

    Dosing

    Interactions Contraindications Precautions

    Documented hypersensitivity; viral, fungal, or tubercular skin infections

    Dosing Interactions Contraindications Precautions

    Pregnancy

    C - Fetal risk revealed in studies in animals but not established or not studied in humans; mayuse if benefits outweigh risk to fetus

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    Precautions

    Caution in hyperthyroidism, osteoporosis, peptic ulcer, cirrhosis, nonspecific UC, diabetesmellitus, and myasthenia gravis

    Immunosuppressants

    These agents are useful as steroid-sparing agents, in healing fistulas, or when the patient hasserious contraindications to surgery.

    9They are used in patients refractory to or unable to tolerate

    steroids. Some agents, including azathioprine and its metabolite, 6-mercaptopurine, have been

    useful in Crohn's disease (CD) complicated by recurrent rectal fistulas or perianal disease;response can take up to 6 months. Methotrexate has also been tried.

    Azathioprine (Imuran)

    Inhibits mitosis and cellular metabolism by antagonizing purine metabolism and inhibitingsynthesis of DNA, RNA, and proteins; these effects may decrease proliferation of immune cells

    and result in lower autoimmune activity.

    Dosing Interactions Contraindications Precautions

    Adult

    1 mg/kg/d PO for 6-8 wk; increase by 0.5 mg/kg PO q4wk until response noted; not to exceed2.5 mg/kg/d

    Pediatric

    Initial dose: 2-5 mg/kg/d PO/IV

    Maintenance dose: 1-2 mg/kg/d PO

    Dosing Interactions

    Contraindications Precautions

    Allopurinol increases toxicity; ACE inhibitors may induce severe leukopenia; may increase

    levels of methotrexate metabolites and decrease effects of anticoagulants, neuromuscular

    blockers, and cyclosporine

    Dosing

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    Interactions Contraindications Precautions

    Documented hypersensitivity

    Dosing Interactions Contraindications Precautions

    Pregnancy

    C - Fetal risk revealed in studies in animals but not established or not studied in humans; may

    use if benefits outweigh risk to fetus

    Precautions

    Increases risk of neoplasia; caution with liver disease and renal impairment; hematologic toxiceffects may occur; check TPMT level before therapy and monitor liver, renal, and hematologic

    functions; pancreatitis is rarely associated

    Antibiotics

    Institute parenteral antibiotics active against coliforms and anaerobes for fulminant disease,including toxic megacolon. Agents may include metronidazole or ampicillin or a cephalosporin

    and an aminoglycoside.

    Metronidazole (Flagyl)

    Useful in treating fulminant disease; used successfully in CD complicated by perianal ulcers andperirectal abscesses and fistulas; unclear whether drug is active because of its antibacterial

    properties or through some other mechanism.

    Dosing Interactions Contraindications Precautions

    Adult

    20 mg/kg/d PO in divided doses

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    Pediatric

    Not established

    Dosing

    Interactions Contraindications Precautions

    May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increasetoxicity; disulfiram reaction may occur with orally ingested ethanol

    Dosing Interactions Contraindications Precautions

    Documented hypersensitivity

    Dosing Interactions Contraindications Precautions

    Pregnancy

    B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

    Precautions

    Adverse reactions include peripheral neuropathy, possible carcinogenesis, and mutagenesis;

    adjust dose in patients with severe hepatic disease (may metabolize metronidazole slowly);monitor patients for seizures and development of peripheral neuropathy

    Tumor necrosis inhibitors

    Infliximab (Remicade), given intravenously, consists of monoclonal antibodies to TNF-alpha.

    Infliximab is approved by the FDA for use in IBD.11

    Infliximab is somewhat more effective

    against CD than UC. The drug appears to promote mucosal healing, which not even prednisonedoes. Furthermore, it heals perianal and enterocutaneous fistulae and has been shown to reduce

    signs and symptoms, achieve clinical remission and mucosal healing, and eliminate

    corticosteroid use.12

    Infliximab is indicated for patients who have experienced inadequateresponse to conventional therapy.

    9

    Etanercept (Enbrel) is a TNF receptor fusion protein that binds to TNF-alpha and TNF-beta,

    blocking their interaction with TNF receptors. Although it is approved for the treatment of

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    moderate-to-severe rheumatoid arthritis, it has also been used investigationally for CD, although

    such use is not yet approved. Etanercept can cause an increased risk of infections, which can be

    serious and life threatening.

    Certolizumab pegol (Cimzia)

    Pegylated anti-TNFalpha blocker, which results in disruption of the inflammatory process.Indicated for moderate-to-severe Crohn disease in individuals who have not responded to

    conventional therapies.

    Dosing Interactions Contraindications Precautions

    Adult

    400 mg SC initially; repeat at weeks 2 and 4; if favorable response occurs, initiate maintenance

    dose of 400 mg SC q4wk

    Administer as 2 separate 200-mg SC injections at 2 separate sites in abdomen or thigh

    Pediatric

    Not established

    Dosing Interactions Contraindications Precautions

    May interfere with immune response to live-virus vaccines (eg, MMR) and may reduce efficacy;

    coadministration with anakinra (an interleukin-1 antagonist that also blocks TNF) may cause

    additive adverse effects, particularly development of serious infections; may interfere withactivated partial thromboplastin time tests

    Dosing Interactions Contraindications Precautions

    Documented hypersensitivity

    Dosing Interactions Contraindications

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    PrecautionsPregnancy

    B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

    Precautions

    Common adverse effects include headache, upper respiratory tract infections, abdominal pain,injection site reactions, and nausea; increases risk of serious infections, including infections that

    may result in hospitalization or death; may increase risk of opportunistic infections (eg,

    tuberculosis, invasive fungal), so test for latent tuberculosis, and, if positive, initiate tuberculosistreatment prior to starting certolizumab; if infection occurs, patients should contact their

    physician immediately; may cause reactivation of hepatitis B virus; may increase risk of

    lymphoma and other malignancies because of immune suppression; anaphylaxis or serious

    allergic reactions, demyelinating disease, cytopenias, pancytopenia, heart failure, and lupuslike

    syndrome have been reported with TNF blockers

    Infliximab (Remicade)

    Neutralizes cytokine TNF-alpha and inhibits binding to TNF-alpha receptor.

    Dosing Interactions Contraindications Precautions

    Adult

    5 mg/kg IV as single infusion

    When long-term administration is needed, an induction dose of 5 mg/kg IV infusion at 0, 2, and

    6 wk is administered, then 5 mg/kg q8wk for maintenance

    IV infusion must be administered over at least 2 h; must use infusion set with in-line, sterile,nonpyrogenic, low-protein-binding filter (pore size

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    Author: Sarvotham Kini, MD, Associate Professor of Emergency Medicine, Medical

    University of South Carolina, Charleston.

    Contributor Information and Disclosures

    Updated: Nov 20, 2009

    Print This Email This

    Overview Differential Diagnoses & Workup Treatment & Medication Follow-up Multimedia References Keywords

    Information from Industry

    Bacterial RTIs: View S pneumoniae resistance mapClick on your state Consider the growing problem

    of antibacterial resistance. What is the S pneumoniae resistance rate in your state? Read more

    Follow-up

    Further Outpatient Care

    Nutritional support in Crohn's disease includes supplementation with trace metals, fat-solublevitamins, and medium-chain triglycerides.

    A low-oxalate diet with citrate supplementation helps reduce the risk of nephrolithiasis. Oral calcium or cholestyramine may serve as an intestinal oxalate binder. Encourage the patient to join an IBD support group, such as theCrohn's and Colitis Foundation

    of America(386 Park Avenue South, 17th Floor; New York, NY 10016; 1-800-932-2423).

    Complications

    Perforation and toxic megacolon are the most dreaded complications of ulcerative colitis (UC).Perforation can occur in the presence of fulminating disease, even in the absence of toxic

    megacolon.

    o The mortality rate is 50% if perforation occurs.o Suspect toxic megacolon in a patient with fulminant ulcerative colitis, especially if the

    number of daily stools has declined sharply without a corresponding improvement in

    symptoms. The abdomen is typically distended, tender, and tympanitic. Toxic

    megacolon can be precipitated by antidiarrheal agents, hypokalemia, narcotics,

    cathartics, and enemas, including barium enemas. The best method of diagnosingtoxic

    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ical%20professionals%20and%20consumers.%20To%20explore%20eMedicine%20today,%20visit%20http://emedicine.medscape.comhttp://emedicine.medscape.com/article/774566-print
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    megacolonis through the use of plain radiography. Toxic megacolon occurs

    predominantly in the transverse colon, probably because air collects there in the supine

    position. The transverse colon is dilated, usually more than 8 cm. Dilation more than 6

    cm is considered to be abnormal. A colectomy is required if no improvement occurs

    within 24-48 hours.

    Strictures usually are benign but can lead to obstruction. Fistulas and abscesses are much more common in Crohn's disease, but they are observed in

    about 20% of patients with ulcerative colitis.

    o Fistula types include enterovesical (leading to recurrent urinary tract infections andpneumaturia), enteroenteric, enteromesenteric, enterocutaneous, rectovaginal, and

    perianal.

    o Additional problems include stenosis and obstruction.o Perianal complications occur in 90% of patients with Crohn's disease.o In Crohn's disease, obstructive hydronephrosis may result from a right lower quadrant

    inflammatory mass, leading to external compression of the right ureter.

    Massive hemorrhage occurs in fewer than 1% of patients. Cancer concerns are as follows:

    o Ulcerative colitis carries a 10- to 30-fold increase in development of carcinoma of thecolon.

    o Risk increases with extent and duration of the disease.o Cumulative risks of cancer after 15, 20, and 25 years are 8%, 12%, and 25%, respectively.o Perform periodic colonoscopies with biopsies, especially in patients with pancolitis.

    Most authors recommend beginning surveillance approximately 10 years after onset of

    disease and repeating surveillance at 1- to 2-year intervals. Evidence currently does not

    support the need for cancer surveillance in Crohn's disease.

    o The risk of cancer in Crohn's disease may be equal to that of ulcerative colitis if theentire colon is involved. Hence, screening may be beneficial for patients with Crohn's

    disease who have pancolitis. The risk of small intestinal malignancy in Crohn's disease is

    increased. However, the malignancy is as likely to arise in a normal as in an inflamedarea, and no screening protocol has ever been demonstrated to be effective against

    small bowel Crohn's disease.

    Extraintestinal complications occur in approximately 20% of patients with inflammatory boweldisease (IBD). In some cases, they may be more problematic than the bowel disease itself.

    o Arthritic Peripheral arthritis, usually migratory and monoarticular, tends to parallel

    disease activity but may antedate it.

    Ankylosing spondylitisis associated with human leukocyte antigen-B27 (HLA-B27).

    o Ocular Episcleritis, shown in the image below, manifests with burning eyes and scleral

    injection and is observed in 3-4% of IBD cases. Episcleritis parallels the course of

    the disease and resolves with treatment of the IBD. Topical steroids may be

    administered.

    http://emedicine.medscape.com/article/374048-overviewhttp://emedicine.medscape.com/article/374048-overviewhttp://emedicine.medscape.com/article/1263287-overviewhttp://emedicine.medscape.com/article/1263287-overviewhttp://emedicine.medscape.com/article/1263287-overviewhttp://emedicine.medscape.com/article/374048-overview
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    Inflammatory bowel disease. Episcleritis. Courtesy of Dr David Sevel.

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    Inflammatory bowel disease. Episcleritis. Courtesy of Dr David Sevel.

    Iritis, which manifests as an acute painful red ey