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Crohn's Disease

Crohn's disease is a chronic recurrent inflammatory disease of the intestinal tract. Crohn's disease and ulcerative colitis are together known as inflammatory bowel disease. Crohn's disease can involve any part of the gastrointestinal tract, including the mouth, esophagus, stomach, and the small and large intestine. The most common sites Crohn's disease occurs in are the last portion of the small intestine (the ileum) and the large intestine (the colon). Persistent inflammation in the intestinal lining leads to ulceration and bleeding. Some ulcers become deep enough to either perforate or to tunnel into adjacent organs or the skin. The inflammatory tracts created in this way are known as fistulas. Alternatively, the inflammation may cause enough thickening or scarring of the bowel wall to create an obstruction.

TREATMENTS: Because Crohn's disease can involve so many parts of the gastrointestinal tract and in multiple ways, a complete discussion of treatment options would be extremely long. Treatment in general falls into a few categories:

Mesalamine: The medications that contain mesalamine are commonly used in milder forms of Crohn's disease. They are distinguished from each other by their costs, their side effect profile, and where they are released in the gastrointestinal tract. Sulfasalazine (Azulfidine), Colazal, and Dipentum are released only in the colon. Asacol is released in the terminal ileum and colon. Pentasa is released throughout the small intestine and colon.

Antibiotics: Antibiotics appear to reduce the bacterial contribution to Crohn's disease and are commonly used sometimes for a prolonged period. Among the most frequently used antibiotics are used ciprofloxacin and metronidazole (Flagyl).

Steroids: Steroids such as prednisone are effective at inducing remission in moderate to severely active Crohn's disease. However, they have many side effects and should be tapered and discontinued if possible as soon as remission is achieved. Budesonide (Entocort) is a steroid which is rapidly broken down by the liver so that 90% of it never circulates throughout the rest of the body. However, if used long enough it too can result in similar steroid side effects.

Immunomodulators: For those with more refractory disease, especially those who cannot taper off steroids without a recurrence of their disease, immunomodulators are generally used: most commonly Imuran (azathioprine), 6-mercaptopurine (Purinethol) or methotrexate. Although effective at maintaining remission, these drugs take a long time to produce their full effect (about 3 months) and require periodic blood tests such as liver enzymes and white blood cell counts. As with all medications, a thorough discussion of side effects should be held with your physician before beginning them.

Biologic Agents: Infliximab (Remicade) is an antibody that neutralizes an inflammatory substance in your body called TNF. TNF appears important in perpetuating the chronic debilitating inflammation that characterizes Crohn's disease. Infliximab can be quite effective in controlling the disease in patients who have failed to respond to other treatments. It is given as an intravenous infusion every 8 weeks and usually in conjunction with an immunomodulatory agent such as those listed above. Many other biologic agents are either under investigation or are anticipated to be released soon.

Surgery: It is important to remember that surgery does not cure Crohn's disease and that the disease may recur after surgery in portions of the intestine that were previously uninvolved. Therefore, surgery is generally a last resort after medical therapy has failed. Nevertheless, 80% of Crohn's disease patients will undergo surgery at some time to close fistulas, bypass obstructions, or remove refractory effective areas of intestine.

B. Jeffrey Wallis, M.D., P.A. - Colonoscopy, EGD, Liver, ERCP

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