Crohn's disease

The presentation of Crohn’s disease is far more variable than that of ulcerative colitis and depends on the site of the inflammation as well as presence of fistulizing or stricturing disease. Small bowel disease may present with abdominal pain, weight loss, anaemia, and obstructive symptoms. Colonic disease may present in a similar fashion to ulcerative colitis. Perianal disease typically presents with abscesses or discharging fistulas. Crohn’s disease is characterized by relapses between spontaneous or treatment-induced remissions; however, about 15 per cent of patients have non-remitting disease and 10 per cent prolonged remission. The prognosis appears to be affected by: the age at diagnosis, disease location, and disease behaviour (Box 14.1); the latter may be genetically determined.

Treatment

Smoking cessation is vital in patients with Crohn’s disease. The initial medical treatment of Crohn’s disease is usually prednisolone, followed by immunomodulating drugs such as azathio- prine, mercaptopurine, or methotrexate. In patients with severe active disease despite the use of standard therapy the anti-TNF therapies infliximab and adalimumab can be used usually in conjunction with azathioprine. Infliximab is given as an infusion with three induction treatments at 0, 2, and 6 weeks followed by maintenance infusions at 6-8-week intervals requiring hospital

Box 14.1 Factors associated with a worse prognosis in Crohn's disease

  • ? Extremes of age
  • ? Extensive small bowel disease
  • ? Fistulating disease
  • ? Stricturing
  • ? Multiple operations
  • ? Smoking.

attendance. Adalimumab is given as a self-administered subcutaneous injection at 1-2 week intervals. Both treatments are usually continued for 12 months with the need for ongoing treatment dependent on evidence of disease activity.

Surgery for Crohn’s disease is frequently necessary. Seventy per cent of patients will have an operation within 15 years of diagnosis and 36 per cent will have required two or more operations. The symptoms recur in 30 per cent within 5 years and in 50 per cent by 10 years.

 
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