UlcerativeColitisPAT I E I\IT I I{ F O R MAT I O ]{

CanadianSociety ofIntestinalResearch

Lllcerative ColitisPublished by the Canadian Society of Intestinal Research rn aI

about (Jlcerative Colitis. For further information please contact u

What is ulcerative colitis?Ulcerative colitis is an inflammatory disease of the

large intestine (colon) or large bowel. A fine ulcerationofthe colon's inner surface occurs and special types ofinflammatory white blood cells infiltrate the involvedarea. Inflammation usually only involves the innermucosal lining and does not extend into the muscle wall.Characteristically, inflammation starts at the lower end ofthe colon, just above the anus and may extend upwards a

variable distance. In some patients only a short segment is

affected and in others it may involve the whole colon.Ulcerative colitis is not related to ulcers found

elsewhere in the gastrointestinal tract such as stomach orduodenal ulcers, but it has many similarities to another

chronic inflammatory disease of the bowel, Crohn'sdisease. Collectively, ulcerative colitis and Crohn'sdisease are called inflammatory bowel disease (lBD). The

main differences between Crohn's disease and ulcerativecolitis are that in Crohn's the inflammation extends intothe muscle and can affect any part of the digestive tract.

Ulcerative colitis is limited to the colon.

What causes ulcerative colitis?The cause of ulcerative colitis is unknown, in spite

of a fair degree of research. An infectious cause forulcerative colitis has been searched for but not found.

Other causes such as stress, allergies, and toxins have

also never been demonstrated. It's possible that ulcerative

colitis is an autoimmune disease whereby, after some

initial insult, the patient develops a reaction against his

or her own bowel. Ulcerative colitis is not a hereditarydisease although, like other conditions such as high bloodpressure, there may be an increased occurrence in certainfamily groups.

What are the symptoms of ulcerative colitis?The most common symptom is blood in the bowel

movement. This occurs in over 90% of patients. The

amount of blood varies. Sometimes moderate amounts,

including clots, may be passed. The second characteristicsymptom is diarrhea, this occurring in 80% of patients.Crampy abdominal pain may occur with the diarrheaand the severity can range from mild to severe. If thedianhea andblood loss are severe, weight loss may occur.

Sometimes a fever is experienced.Some patients have what are referred to as extra

intestinal manifestat ions of ulcerative colitis, includinginflammation of the eyes or joints, ulcers of the mouth,or tendeq inflamed modules on the shins. The causes ofthese conditions are also unknown.

Area Affected by Ulcerative Colitis

Colon

Ity'lamntation starls at the anus andextends up lo into the colon. It may

involve only a shorl segmenl or asntuch as the entire colon.

Rectum

How is ulcerative colitis diagnosed?Ulcerative colitis is primarily diagnosed by looking

into the lower bowel with a sigmoid scope. In thisprocedure, the intestinal tract is viewed with an instrumentthat enters the body via the anus. The scope is made of a

hollow, flexible tube with a tiny light and video camera.The specific nature of the inflammation is usuallyconfirmed by taking a small biopsy for examination undera microscope. The extent of the disease may be determinedby a barium enema X-ray or by colonoscopy, which travelsfurther up the colon than the sigmoid scope. Blood tests donot make a definitive diagnosis but are helpful in assessing

the amount of bleeding, activity of the inflammation, and

the nutritional state ofthe patient.

lswer to some of your questionsrs (details on back panel).

How is ulcerative colitis treated?The treatment of ulcerative colitis falls into two

broad categories: the management of symptoms and themanagement of the inflammation.

The management of symptoms includes treatingsuch things as diarrhea, cramps, pain, anemia, etc. Thistreatment does not affect the basic disease but is importantin making the patient feel and function better.

Management of the inflammation includes a numberof basic principles. The first principle is that of rest, sinceinflammation resolves quicker if the area is rested. Thebowel is rested by means of a diet that is easy to digestand devoid of irritants and bowel stimulants.

The second principle is that of nutrition, sincethe body heals better when it is nutritionally replete.Improving nutrition may require dietary supplements,occasionally special elemental (pre-digested) diets, andoccasionally intravenous nutrition.

The third principle of treatment is medicationtherapy. There are several drugs that have a beneficialeffect by reducing inflammation of the bowel. Theoriginal drug used for ulcerative colitis was sulfasalazine(Salazopyrin@, SAS 500@). It combines a sulfa antibioticand 5-ASA with the latter being the active ingredient.Subsequently other combinations of 5-ASA have beenreleased, such as mesalamine (Asacol@, Mesasal@,Pentasa@, Salofalk@) and olsalazine (Dipentum@).These drugs act directly inside the bowel and onlysmall amounts are absorbed. They are very safe and

well tolerated for long-term use. They work by topicalaction and not by being absorbed into the body. The oraltablets are formulated to release the active medication inthe colon and allow the drug to come into contact withthe inflamed mucosa. 5-ASA not only helps to settle theacute inflammation, but taken on a long term basis tends

to keep the inflammation inactive.Oral corticosteroids such as prednisone have a

significant role to play but are usually reserved for moreserious exacerbations of ulcerative colitis. Prednisoneis a potent inhibitor of inflammation but does have side

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effects that need to be weighed against its benefit.A rectal suspension steroid, budesonide (Entocort@),

is similar to other rectal suspension steroids but withlow systemic activity. This means its side effects aresubstantially less than prednisone.

In some resistant cases, azathioprine (Imuran@),an immunosuppressive drug, is often effective incombination with low dose prednisone. Again, there arealso side effects that must be assessed.

Some antibiotics can be effective in treatingulcerative colitis. The drugs used are metronidazole(Flagyl@, Florazole ER@) and ciproflaxacin (Cipro@).Their mechanism of action is unknown.

For colitis just inside the anus (called ulcerativeproctitis), topical rectal treatment is best. 5-ASA canbe administered rectally by a liquid suspension enema(Pentasa@, Salofalk@) or by suppositories (Pentasa@,

Salofalk@). Enemas are also prescribed for colitis thatextends further up the large intestine (can be calledleft-sided colitis). Alternatively, steroids in a foam(Cortifoam@) or rectal suspension (Cortenema@,Entocort@) can be prescribed.

In patients with ongoing active disease that fails torespond to all forms of management, surgery may beindicated. If surgery is necessary the whole colon usuallymust be removed. In most of these patients, the anus canbe spared and a pouch can be created from the smallbowel. In these cases, bowel movements can pass throughthe anus rather than necessitating an ileostomy.

What is the course of ulcerative colitis?Ulcerative colitis can follow one of a number of

courses. The patient may have an initial episode and thengo into remission for a long period of time. Otherpatientsmay have occasional flare-ups, and still others may haveongoing continuous disease. Because of the tendencyfor relapses (recurrence) patients are maintained ontreatment (5-ASA) for long periods of time, usually twoyears or longer, since this will significantly decreasethe recurrence rate. Ulcerative colitis patients should bemonitored by their physician on a regular basis, even ifthey are in remission.

The Canadian Society of Intestinal Research (CSIR)fulfills an important mandate to increase public awarenessof gastrointestinal diseases and disorders.

We provide free educational materials to patients andhealth professionals, present public lectures and seminars,and raise funds for medical research.

Please consider joining the Society and/or offeringyour support to this impoftant cause by making a tax-deductible donation. You can do so by contacting us at:

Canadian Society of Intestinal Research855 West 12th Avenue

Vancouver, British Columbia, Canada, V52 lM9Phone: 604-87 5-4875 FAX: 604-87 5-4429Toll-free phone in Canada: 1-866-600-4875

Email: info@badgut.com Website: www.badgut.comRegistered Charity# 10809 0374 RR0001

This publication is made possible by an unrestrictededucational grant from:

FERRINGP'IARMACELJTII'ALS

Support our Society Today! Become a member of CSIRto support its educational and research mandate regardinggastrointestinal diseases and disorders.

Membership in CSIR includes our bi-ntonthly gastrointestinaldisease and disorder newsletter, The Inside Tract"'.

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CeliacDiseasePATIENT INFORMATION

CanadianSociety ofIntestinalResearch

Celiac DiseasePublished by the Canadian Society of Intestinal Research in i

about Celiac Disease. For further information please contact us

What is celiac disease?

Celiac disease is an autoimmune medical condition inwhich darnage to the epithelia (inner lining) of the smallintestine occurs following ingestion of a substance calledgluten. Gluten is a grain protein used in food processingbecause it binds, stabilizes, and prevents crumbling. Thegluten protein in wheat has a portion called gliadin, whichis toxic to people with celiac disease. Barley, rye, andtriticale also contain proteins toxic to celiac patients.

It is important to note that some people may havegluten intolerance or allergy without having celiac disease.This rneans that they are sensitive to gluten, and mayhave some allergy-like symptoms. without measurabledamage to the intestine, even though in some intolerant orallergic people, the rnucosal lining ofthe intestine becomesinflarned.

How does gluten cause damage?Gluten triggers an abnormal immune response that

flattens and alters the small intestinal villi. This decreasesthe lining's surface area and alters its absorptive abilities.Malabsorption of some or all nutrients occurs and thebody cannot get the essential proteins, fats, carbohydrates,vitamins, and minerals necessary for good health. lt isimportant to be aware that a tiny crumb of bread causesthe same damaging response as a whole slice, because ittakes only one molecule to trigger the destructive mucosalresponse.

Who gets celiac disease?There are variations in the figures for the incidence

and prevalence of celiac disease around the world. It ismore common in Caucasians. Some medical sourcesestimate that I in 200 Canadians have celiac disease.However, newer research in North America shows thatthe prevalence of celiac disease may be many times higherthan previously thought, and that people with no obvioussymptoms may have the condition. Researchers in a multi-centre coast-to-coast study examined blood from thousands

of subjects, looking for the telltale abnormal antibodies

typical in the blood of people with celiac disease. Mostwho tested positive also had an intestinal biopsy to confinnthe diagnosis. Here are the results:

Prevalence Description of group

1in56 People who have gastrointestinalsymptoms yet undiagnosed as celiac

I in22 People who have a first-degree relative(sibling, child, or parent) with celiac

1in39 People who have a second-degreerelative (grandparent. aunt" uncle, orcousin) with celiac

I in 133 Not at risk individuals

While celiac disease is more cornmonly first diagnosedduring childhood when growth is affected, people in the40-50-year-old age range rnay also be newly diagnosed.More than 90o/o of people diagnosed with celiac diseasehave a gene known as HLA-DQ2, which facilitates theinitiation of an immune response to gliadin. Researcherssuspect that environrnental factors also play a role in theexpression of this disease.

What are the symptoms?Common symptoms include anemia, chronic diarrhea,

weight loss, fatigue, cramps, bloating, irritability, and skinproblems. These symptoms may initially be confused withother gastrointestir.ral conditions such as irritable bowelsyndrome or inflammatory bowel disease. Some peoplewith celiac disease may not notice any syrnptoms.

Diagnosis may be difficult and/or delayed since theonset of syrnptoms can occur anytime frorn childhoodthrough adulthood, and symptorns are extremely variableand often vague from person to person.

People with celiac disease have a higher incidencethan the general population ofthese other conditions: typeI diabetes, Down syndrome, anernia, arthritis, osteoporosis,liver disease, infertility, thyroid problen.rs, depression,fatigue, neurological diseases, and short stature.

www.badgut.com

rnswer to some of your questions(details on back panel).

The symptoms of celiac disease may ormay not appear

in dermatitis herpetiformis, a related condition caused bya gluten allergy, which results in intense burning and itchyskin. The incidence of dermatitis herpetiformis is around I

in 100,000. An individual can have either or both of these

conditions.

How is celiac disease diagnosed?While some symptoms may alert a doctor to suspect

celiac disease, he or she cannot diagnose this conditionbased on symptoms alone. Researchers encourage doctors

to be vigilant in remaining aware of the risk factors forthis relatively common genetic disorder and to test anyone

who could be at risk. A blood test can determine with veryhigh accuracy whether someone has celiac disease, but

many doctors still prefer to biopsy the small intestine as a

definitive diagnosis. Test results are most accurate if done

while the person is consuming gluten. The bowel's positive

response to a gluten-free diet can later help to verify the

diagnosis.

What is the treatment?At present, the only approved treatment for celiac

disease is lifelong avoidance of gluten in the diet. Thiscan be difficult and costly for sufferers, who may also be

at risk ofcross contamination during food processing, and

this can particularly be a problem when eating away fromhome.

Celiac patients must completely avoid all types ofobvious gluten (e.g. breads, pasta) and must watch forhidden sources in all packaged, processed foods (e.g.

soups, ice creams, and sauces), by reading all the labels

all the time, as manufacturers sometimes change and

include gluten in a previously gluten-free product. Some

mouthwashes and toothpastes even contain gluten!

There is clinical evidence that the consumption of50-70 grams per day of pure, uncontaminated oats may be

safe for adults with celiac disease. However, exceptions

can occur so it is best to discuss your ability to tolerate

oats with your doctor. Also, be cautioned that there is no

guarantee that oats available in Canada are uncontaminatedwith other grains.

The gluten protein in corn and rice is not toxic to celiacpatients and so you rnay substitute these products in the

diet with great success.

Eating out may pose certain problerns. Well-meaningwaiters, chefs, or even friends, who do not fully understandthe irnplications of consuming even a molecule of gluten,

may serve foods that contain it. Speaking personally u,iththe cook and requesting gluten-free foods that are preparedwith only known ingredients rnay help avoid problerns.Many people with celiac disease find it easier to frequentrestaurants where they know the chef and other stafTr.rnderstand this condition, and can guarantee appropriatecornpliance to the no-gluten lule. Others keep gluten-freesnacks with thern in case they cannot find sale fbod when

dining out. While adapting to lif-e with celiac disease may

seern overwhehning, eventually screening for gluten,whether shopping for horne supplies or approving rnenu

selections, becomes second nature.Following a gluten-free diet will stop syrrptonrs in

most people. The existing intestinal damage will beginto heal and, as long as no further exposure occurs, youwill avoid further damage. Improvernents usually begin

within days of starting the diet, and the small intestine willheal in as little as three months, although fbr some olderadults it rnay take up to two years for the villi to be fullyfunctional.

Although strict diet adherence alone will affecthealing in most patients, solne rnay require a course of an

immunosuppressive medication such as prednisone.

How does the disease progress?Feeling 'normal' or symptorn-free does not mean

tl.rat darnage to the intestinal sulface is not occurring dr,re

to known or unknown ingestion of gluten. If you don'tadhere to a strict gluten-free diet, then severe symptomsmay appear over time.

Only an absolutely gluten-free diet ensures no furtherdamage to the bowel and, therefore, no progression of the

disease.

Note: Some tax concessions are available to people withceliac disease due to the increased costs of'purcltasinggluten-fi'ee products. Contact our ffice .for up-to-datein/brntation on this.

The Canadian Society of Intestinal Research (CSIR)fulfills an irnportant mandate to increase public awareness

of gastrointestinal diseases and disorders.We provide free educational rnaterials to patients and

health professionals, presellt public lectr,rres and seminars,and raise f'unds for rnedical research.

Please consider joining the Society and/or offeringyour sllpport to this important cause by rnaking a tax-deductible donation. Yon can do so by contacting r.rs at:

Canadian Society of Intestinal Research855 l2'h Avenue West

Vancouver, British Columbia, Canada, V5Z 1M9Phone: 604-87 5-4875 FAX: 604-87 5-4429Toll-free phone in Canada: I-866-600-4875

Email: info@badgut.com Website: www.badgut.comRegistered charity# I 0809 03 74 RR000 I

This publication is made possible by tlte financialassistance of tlte Provittce oJ'Britislt Columbiu.

Support our Society Today! Become a mernber of CSIRto suppoft its educational and research mandate regardinggastrointestinal diseases and disorders.

Benefits of nrentltership in CSIR incltrde The Insicle Troc't". obi -rnon lh l.t' gcrslro i rt le.st ina I cl iseuse oncl d is ordet' nev's I ettet'.

fl I enclose a $20 ar.rnual rr.ren.rbership t'ee.

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The Canadian Society of Intestinal Research (CSIR)provides free educational material regarding gastrointestinaldiseases and disorders.

Funds are also raised to support intestinal research at the

University of British Columbia and its teaching hospitals.To join the Society and/or to offer support b1 making

a tax-deductible donation, contact us at:

Canadian Society of Intestinal Research855 West l2'r'Avenue

Vancouver, British Columbia, Canada. V5Z 1\19Phone: 604-87 5-4875 FAX: 604-81 5 -4429Toll-free phone in Canada I -866-600-487,5

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This publication is made possible by the financialussistance of the Province of British Columbiu.

YES! I would like support CSIR's educational and research

mandate regarding intestinal diseases and disorders bybecoming a member and/or giving a donation. (Membershipincludes six issues of The Inside Tract"' - Canada's dieestir e

disease and disorder newsletter.)

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Crohn'sDiseasePATIEIVT INFORMATIOIV

CanadianSociety ofIntestinalResearch

What is Crohn's disease?

Crohn's disease is a chronic inflammatory diseaseof the digestive system that may affect any area ofthe gastrointestinal tract from the mouth to the anus.Various parts ofthe bowel may be affected by Crohn'sdisease either in continuity or as separate areas. Itfrequently affects the terminal ileum (the end of thesmall intestine), especially the section that joins withthe large intestine or colon, which may also often beaffected.

The inflammation involves the full thickness ofthe bowel wal1 and consists of swelling, dilated bloodvessels, and loss of fluid into the tissues.

Onset of Crohn's disease may occur at any age;however, it most frequently first occurs in youngpeople, and about 10% ofnewly diagnosed cases arein children under age 10. Once a diagnosis of Crohn'sdisease is made, various treatments are employed thathelp relieve symptoms; as yet there is no cure. TheCrohn's experience can differ widely. Some peoplenever develop complications, some only strictures,some abdominal abscesses, and others only peri-analand intestinal fi stulas.

Incidence of this disease varies throughout theworld but has been increasing significantly in recentyears.

What causes Crohn's disease?The cause of Crohn's disease is not known.

Bacterial and viral causes have been searched for butnever confirmed. Dietary and possible allergenic factorshave also been excluded. Although emotional factorsare not a cause of Crohn's, they may have an impacton the course of the disease. Environmental, genetic,and immunological factors have been researched atlength. Conclusions drawn at this time indicate thatmany of these factors could play a role in Crohn'sdisease. Further research is essential to find the truecause of this chronic disease.

What are the symptoms of Crohn's disease?The most common symptom of Crohn's disease

is diarrhea. Crohn's disease lnay prevent the properabsorption of food, resulting in diarrhea and theprecipitous elirnination of fat and other foodstuffs,leading to weight loss. The intestine may becomenarrowed and obstructed. When Crohn's is located inthe colon, the normal function of water re-absorption isimpaired, resulting in fiequent, liquid stools. Since thelining of the colon can also be ulcerated, the diarrheaoften contains blood. In the later stages of the diseasethe colon can become narrowed and shortened, withdecreased absorption ofwater, fecal urgency, and poorcontrol of bowel function.

Abdominal pain is anothercommon symptorn. Theintestine has a muscular coat that is subject to musclespasm, as are muscles elsewhere in the body. However,the inflamed bowel sends more signals to the bowel'srichly supplied nerve elements, making it even moreirritable and subject to spasm. Often, the pain due tointestinal spasm is cramping in nature. Additionally,pressure can build up behind the narrowed intestineand produce cramps. Occasionally, the narrowing is so

severe that a blockage ofthe intestine occurs, requiringimmediate medical - and less frequently surgical

- attention. A sudden, short, severe type ofpain at theopening of the rectum is called tenesmus and resultsfrom inflammation and spasm in the rectum.

Fever frequently accompanies inflammation of anytype and is common in Crohn's. Weight loss is commondue to the bowel's inability to absorb sufficient nutrition.In children, a failure or delay in growth and rnaturitymay result.

The rectum and its opening (the anus) may becomea focal point for inflammation, with the formationof painful inflamed slits in the skin and superficialtissues, called anal fissures. Large pus pockets orabscesses may accumulate, producing severe pain andfever. An abnormal connection between the intestineand the skin may occur. When this communication isnear the opening of the rectum, it is referred to as an

anal fistula. Fistulae may also occur - only in Crohn'sdisease - between the intestine and the abdominal wall,particularly after surgery, or between loops of intestinewithin the abdomen.

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Anemia, or lorv red blood cell count, frequentlyoccllrs fiorn blood loss due to ulcerations in the liningof the intestine. Occasionally, blood loss may be so

severe as to require blood transf'usions. Blood proteinsmay be depleted due to loss of blood serum into thebowel and also due to a general state olrnalnutritionsecondary to the debilitating efl'ects olthe disease.

Arthritis, skin problems, liver disease, kidneystones, and eye inflaurnratiolt are antong the otherrnanif-estatior-rs of Crohn's disease outside of thedigestive tract.

How is the disease diagnosed?Unfbrtunately, the diagnosis ol Crol-rn's disease

is sometinres delayed. Malfr,rnction of the intestinaltract may occur fiom a wide variety of causes, andthe syrnptorns - diarrhea, cramps, and unintentionalwei-eht loss - may be very similar to other conditions.The accurate diagnosis of Crohn's disease is essential,as other diseases must be excluded.

A caretul evaluation of the history of the illness is

the first step to a correct diagnosis. How the diseasebegan and subsequent problents are fitted into a

rnear-ringful record. The nature of tlre diarrhea, typeof abdominal pain. as well as the characteristics and

3

quantity of rectal bleeding are all useful details inarriving at a proper initial diagnosis.

Scopes may be perfonned to determine the natureand extent of the disease. In these procedures, theintestinal tract is viewed with an instrument that entersthe body via the anus (colonoscopy/sigmoidoscopy) ormouth (endoscopy). The scope is made of a hollow,flexible tube with a tiny light and video camera.Sornetimes the terminal ileum can be visualized withthe colonoscope. These procedures require someadvance bowel preparation and may be uncomfortable.The advantage of these procedures is that any timeduring the examination a biopsy may be taken, andthe tissue sent for analysis.

An indirect procedure, less commonly performed,involves a barium enema. It is administered priorto an X-ray to help view the contours of the bowelmore readily. The last portion of the small intestine isimportant in Crohn's disease and can be seen eitherby working the bariurn back into the terminal ileumduring a barium enema, or by drinking barium andfollowing it through the small intestine (small bowelfollow through) with a series of x-rays.

In addition, examination of the blood for its variousconstituents is necessary. The stool is examined forinf-ectious agents and for hidden blood. Blood tests arevaluable in determining the extent of the disease (e.g.degree of anemia or protein loss). On rare occasions,the diagnosis is made at surgery.

Ultrasound and CT scan are helpful in looking forcomplications of Crohn's disease but are not useful inmaking the prirnary diagnosis.

How is the disease treated?Unfortunately, when the cause of a disease is

unknown, curative treatment is unavailable. In thecase of Crohn's disease, however, treatment may bedeveloped to control the disease or induce what ismedically referred to as remission, meaning that thedisease becomes inactive. The treatment of Crohn'sdisease is comprehensive and all of the followingmethods together, or in various combinations, may benecessary to obtain a satisfactory response.

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Bowel rest is an important part of healing and can beachieved through the use of specialized diets, elementaldiets, and occasionally by fasting. Nutrition is one ofthe most important components for digestive health andwhen compromised by Crohn's disease, extra attentionmust be directed to special diets and supplements.On occasion, when the body cannot tolerate oral orenteral feeding, Total Parenteral Nutrition (TpN) maybe required. TPN is intravenous feeding that allowsthe digestive system complete rest while solutionsconsisting of fluids, carbohydrates, protein, lipids,electrolytes, vitamins, and trace elements are tailoredto the patient's clinical status, energy expenditure, andgrowth patterns, to ensure that appropriate nutrients aresupplied.

The pharmacological treatment of Crohn's diseasecan be classified into two areas: anti-inflammatory andsymptomatic. Dietary and surgical treatments are alsoimportant.

Anti-infl ammatory therapyTo reduce inflammation in Crohn's disease,5-ASA

(5-Aminosalicylic Acid) medication is used. Orallyin the form of tablets and capsules, these medicationsinclude mesalamine (Asacol@, Mesasal@, pentasa@,

Salofalk@) and olsalazine sodium (Dipentum@). Thesediverse preparations are designed to target differentareas in the digestive tract. Rectally, mesalamine(Pentasa@, Salofalk@) liquid suspension enemas andsuppositories are available. Your doctor will decidewhich form to prescribe for you, depending on thedisease location.

The original drug used to reduce inflammationin Crohn's disease was sulfasalazine (Salazopyrin@,S.A.S.@). This combination of 5-ASA and sulfaantibiotic is available both orally and rectally.

5-ASA medication - both alone and in combination

- is very safe and well tolerated for long-terrn use.To reduce inflammation in more serious cases

of Crohn's disease, corticosteroids are given orally,intravenously (lV), or rectally. These include:

. ORAL: budesonide (Entocort@) andprednisone;

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. IV: hydrocortisone sodium succinate (Solu-Cortef@) and methylprednisolone sodiumsuccinate ( Solu-Medrol@);

. RECTAL (enemas, foam, suppositories):budesonide ( Entocort@), hydrocortisone(Cortenema@), hydrocorti sone acetate(CortifoarnrM), hydrocorti sone acetate- pramoxine HCI (Proctofoarn@-HC), andbetamethane sodium phosphate (Betnesol@).

Budesonide is sirnilar to prednisone but has lowsystemic activity. This means its side effects aresubstantially less than those of prednisone. It cornes inboth oral form (capsule) fbr individuals with Crohn'slocated at the tenninal ileum, and rectal suspension(enerna) ideal for people who have inflamrnation inthe large bowel.

Studies indicate antibiotics can help iniriateremission in some patients. They are often cornbinedwith other antibiotics as well as other fonns of treatmentand are generally well tolerated. Specific antibioticsrnost widely prescribed include metronidazole(Flagyl@, Florazole ER@) and ciprofloxacin (Cipro@),used separately or in combination. Antibiotics are alsoimportant in treating secondary rnanifestations of thedisease such as peri-anal abscess and fistulae.

Immunosuppressive agents are frequently usedfor steroid-dependent or steroid-resistant patients andit may take up to six months or more of therapy tosee results. Relapse rate is high once medication isstopped. Immunosuppressive agents are often effectivein combination with low dose prednisone. They areused for both ileal and colonic Crohn's and also toreduce dependence on steroids. These agents includeazathioprine (hnuran@), cyclosporine, mercaptopurine

[6-MP] (Purinethol@), and methotrexate sodiurr.A newer medication, inflixirnab (Remicade@),

a biological response regulator, is used to induceremission in Crohn's disease or to facilitate steroidwithdrawal. It is especially effective in patients withfistulae. Long-term studies are still being conducted.

Symptomatic controlThe symptoms of Crohn's disease are the most

distressing components of the disease. While treatingsymptoms does not address the underlying diseasecause, it does improve quality of life. A major featureof Crohn's disease is pain. For painful symptoms notcontrolled by other drugs, analgesics can be helpful,with acetaminophen being the preferred choice.

Another major symptom is diarrhea and this canbe improved in a number of ways. Dietary adjustmentmay be beneficial and anti-diarrheal medications alsohave a major role to play. It is easier to understand anti-diarrheal medications, directed at preventing crampsand controlling defecation, by splitting them into 2groups.

Group I alters muscle activity of the intestine,slowing down the movement of bowel contents(intestinal transit time). These medications can be takenfrom time to time as needed. They include:

. non-narcotic loperamide HCI (lmodium@);

. narcotic agents diphenoxylate HCI - atropinesulfate (Lomotil@), codeine, tincture ofopium and paregoric; and

. anti-spasmodic agents that block thetransmission of nerve impulses suchas hyoscyamine sulfate (Levsin@),dicyclomine HCI (Bentylol@), and hyoscinebutylbromide (Buscopan@).

Group 2 includes fibre (heterogeneous bulk-formers) that adjust stool looseness and frequency bybinding (soaking up) water and increasing the watercontent in the bowel. These bulk-forming agents comein the form of bran, psyllium seed, and ispaghula huskderivatives (e.g. Metamucil@, Prodiem'@). Dependingon the degree of disease activity you're experiencing,your physician can determine whether these productsare appropriate for you. Go slowly when adding fibreto your diet. Bile salt binders, such as cholestyramineresin (Questran@), are used against diarrhea andare especially useful when transit time in the smallintestine is very fast.

People with Crohn's disease may be anemic (have

a low red blood cell count) due to a combination of'7

factors such as chronic blood loss, malabsorptionof certain vitamins, and other factors. Anemia maybe improved by taking prescribed vitamin and ironsupplements, and occasionally a blood transfusion maybe necessary. If the extra-intestinal signs of Crohn'sdisease such as arthritis or inflammation of the eyesoccur, these conditions can be treated with targetedmedications.

If anxiety and stress are major factors, a programof stress management may be valuable. The gut hasits own independent nervous system, separate fromthe brain, which regulates the processes of digestingfoods and eliminating solid waste. When the centralnervous system experiences stress, the gut's nervoussystem may be affected and this could lead toincreased symptoms. (Ask for our pamphlet on S/essManagement.)

Dietary managementIt is important for a Crohn's patient to strive

for overall good health, and this includes notsmoking. Some foods may prove to be irritating,and may increase symptoms. A registered dietitiancan provide personalized dietary advice to ensurethat cornpensations are made for any rnalabsorptionand to address avoidance of irritants without loss ofnutrition.

What place does surgery have?An unfortunate feature of Crohn's disease is the

fact that there is a high recurrence rate, even though allvisible and microscopic disease has been removed. Forthis reason, surgery is best limited to two situations:complications and failure of medical management.Complications requiring surgery may be obstruction,fistulae, or abscess formation. It is more difficult todetermine when medical management is not adequate.Such factors as the patient's ability to work, look afterfamily, nutritional status, and other factors have tobe considered in relation to the possible benefits ofsurgery. A decision to proceed with surgery is madeafter careful consultation between doctor and patient.

Is Crohn's disease hereditary?Crohn's disease is not a hereditary disease in that

it is not passed from parent to child like some diseasesare. There is, however, a familial incidence so that inthe extended family there may be more than one personwith the disease. Some genetic markers have beenidentified but these are not entirely conclusive. Thereare also certain ethnic groups u,ith a high incidence ofCrohn's disease and some with a verv lou' incidence.

Is there anything new?With better diagnosis, irnproved nutrition, and

improved surgical techniques, the management ofCrohn's disease is getting better. The cause remainsa mystery and a great deal of research is stillnecessary.

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