Sandbox/v23: Difference between revisions

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==Management==
<div style="text-align:center;">
The algorithm is based on the American Journal of Gastroenterology guidelines for management of Crohn's disease in adults.<ref name="LichtensteinHanauer2009">{{cite journal|last1=Lichtenstein|first1=Gary R|last2=Hanauer|first2=Stephen B|last3=Sandborn|first3=William J|title=Management of Crohn's Disease in Adults|journal=The American Journal of Gastroenterology|volume=104|issue=2|year=2009|pages=465–483|issn=0002-9270|doi=10.1038/ajg.2008.168}}</ref>
<div style="float:left; padding: .5ex 0; font-weight:bold; background-color:#cedff2; border:2px solid #a3b0bf; border-bottom:0; font-size:90%">&nbsp;&nbsp;1. [[Sandbox/v22|Introduction]]&nbsp;&nbsp;</div>
 
<div style="float:left; padding: .5ex 0; font-weight:bold; background-color:#dfe0e1; border:2px solid #999; border-bottom:0; font-size:90%">&nbsp;&nbsp;2. [[Sandbox/v23|Create a username]]&nbsp;&nbsp;</div>
{{Family tree/start}}
<div style="float:left; padding: .5ex 0; font-weight:bold; background-color:#dfe0e1; border:2px solid #999; border-bottom:0; font-size:90%">&nbsp;&nbsp;3. [[Sandbox/v24|Introduce yourself]]&nbsp;&nbsp;</div>
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | A01=<div style="float: left; text-align: left; height: 50em; width: 15em; padding:1em;"> '''Characterize the symptoms:'''<br>
<div style="float:left; padding: .5ex 0; font-weight:bold; background-color:#dfe0e1; border:2px solid #999; border-bottom:0; font-size:90%">&nbsp;&nbsp;4. [[Sandbox/v25|Join in!]]&nbsp;&nbsp;</div>
----
❑ [[Abdominal pain]] <br>
❑ [[Diarrhea|Chronic diarrhea or nocturnal diarrhea]] (onset, duration, pattern, bloody, mucous or watery) <br>
❑ [[Nausea]] <br>
❑ [[Vomiting]] <br>
❑ [[Abdominal distention]] <br>
❑ [[Fever]] <br>
❑ [[Loss of appetite]] <br>
❑ [[Loss of weight]] <br>
❑  Mental status change <br>
❑  Rectal  bleeding <br>
❑  Painful defecation <br>
----
'''Extraintestinal symptoms:'''<br>
----
❑ [[Skin lesions]] <br>
❑ Oral pain <br>
❑ [[Odynophagia]] and [[dysphagia]] <br>
❑ [[Joint pains]] <br>
❑ Burning micturition <br>
❑ [[Cough]], [[breathlessness]] <br>
❑ [[Eye pain]], [[blurring of vision]] <br>
----
'''Obtain detailed history:'''<br>
----
❑ Recent travel H/O <br>
❑ Recent drug H/O <br>
❑ Abdominal/pelvic radiation H/O <br>
❑ Family H/O <br>
❑ Systemic illness H/O <br> </div>}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | B01=<div style="float: left; text-align: left; height: 28em; width: 25em; padding:1em;">'''Assess volume status:'''
----
❑ General condition <br>
❑ Thirst <br>
❑ [[Pulse]] <br>
❑ [[Blood pressure]] <br>
❑ Eyes <br>
❑ Mucosa
----
'''Examine the patient:'''<br>
----
❑ Skin (swelling, pain, erythema or ulceration) <br> ❑ Oral cavity (ulcers) <br> ❑ Respiratory system (wheezing or crackles) <br> ❑  Cardiovascular system <br> ❑ Abdomen (mass, distension or tenderness) <br> ❑ Anorectal (perianal skin tags, sinus tracts or bleeding) <br> ❑ Eye (swelling, pain, edema or vision loss) <br> ❑ Musculoskeletal (Axial, large and small joints) <br>  </div>}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | | | | | | C01=  <div style="float: left; text-align: left; height: 21em; width: 25em; padding:1em;">'''Order tests:'''<br>
❑ [[Complete blood count|Complete blood count (CBC)]]  <br>
❑ [[Erythrocyte sedimentation rate|Erythrocyte sedimentation rate (ESR)]]<br>
❑ [[C-reactive protein|C-reactive protein (CRP)]]<br>
❑ [[Serum electrolytes]]  <br>
❑ Serum [[iron]] and [[vitamin B12]] levels<br>
❑ [[Diarrhea laboratory findings|Stool analysis (occult blood, WBC's, calprotectin, lactoferrin, culture, ova and parasites)]]<br>
❑ [[Clostridium difficile laboratory findings|Stool for Clostridium difficile toxin]] <br>
❑ [[Urinalysis]] <br>
❑ [[BUN]] <br>
❑ [[Creatinine]]<br>
❑ [[Serum glucose]]<br>
❑ [[Liver function tests]] <br> </div>}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | D10 | | | | | | | | | | | | | | | | | | | | | | D10= <div style="float: left; text-align: left"> '''Confirmatory diagnostic tests:'''<br> ❑ [[Colonoscopy|Colonoscopy and biopsy]] <br> ❑  Upper GI scopy and biopsy<br> ❑ [[Computed tomography|Computed tomography (CT)]] <br> ❑ [[Barium enema]](length and location of strictures) <br> ❑ Upper gastrointestinal series with small bowel follow through (SBFT) <br> ❑ [[Magnetic resonance imaging]] (enterography)<br> ❑[[Wireless capsule endoscopy]]<br>
</div>}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | D10 | | | | | | | | | | | | | | | | | | | | | | D10= <div style="float: left; text-align: left"> '''Findings suggestive of Crohn's disease:'''<br> ❑ Discontinuous lesions <br> ❑ Biopsy (Transmural inflammation, noncaseating granuloma) <br> ❑ Cobblestoning (Serpiginous and linear ulcer)<br> ❑ Normal rectum <br> ❑ Isolated terminal ileum involvenent <br> ❑ Aphthous ulcers<br> ❑ Negative stool examination for infectious causes <br>
</div>}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | B01 | | | B01=Assessment of severity}}
{{familytree | | | | | | | |,|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|-|.| | | | | | | | | | | |}}
{{familytree | | | | | | | C01 | | | | | | | | | | | | | | | | C02 | | | | | | | | | C03 | | | | | | | | | | | | C01=<div style="float: left; text-align: left">'''Mild to moderate'''
----
❑ Ambulatory patients <br>
❑ Tolerating oral diet <br>
❑ No dehydration <br>
❑ No toxicity <br>
❑ No abdominal tenderness or mass <br>
❑ No obstruction <br>
❑ [[Weight loss]] <10 percent <br>
</div>
</div>
| C02= <div style="float: left; text-align: left">'''Moderate to severe'''
----
❑ [[Fever]] <br>
❑ Intermittent nausea or vomiting <br>
❑ Mild to moderate dehydration <br>
❑ [[Anemia]] <br>
❑ Abdominal pain and tenderness <br>
❑ No obstruction <br>
❑ Weight loss > 10 percent <br>
</div>
| C03=<div style="float: left; text-align: left">'''Severe to fulminant'''
----
❑ High fever <br>
❑ Persistent vomiting <br>
❑ Severe [[dehydration]] <br>
❑ Significant [[peritoneal signs]] <br>
❑ Evidence of [[abscess]] <br>
❑ [[Intestinal obstruction]] <br>
❑ [[Cachexia]] <br>
</div> }}


{{Family tree/end}}
<div style="clear:both; width:100%; border:3px solid #fc0;">
  <div style="padding:1ex; ">


    <div style="float: left; width: 90%; margin-left: 4.5%; margin-bottom: 2%;">
      <div style="float: left; padding-right: 8%;">
<h3 style="font-size: 100%; margin: 0;">What is a username...</h3>
* A username identifies you on WikiDoc.
* It's '''very easy''' to set up, and all we will need is you to create a username and a password.
* Once you create a username, you'll be able to contribute content and get credit for your contributions (your username will appear in the page history), view all of your contributions, and you will be able to create a user page to tell others about you. Other users will be able to contact you on your user talk page.
      </div>
    </div>


<div style="width: 80%; margin: 0 auto; clear: both; white-space: nowrap; text-align: left; border-bottom: 1px solid #c0c0c0; margin-bottom: 1%;"> </div>


{|
|
{{divbox|navy|Step 1|Click on the '''create an account or log in''' link at the top of any WikiDoc page.}}




{{divbox|navy|Step 2|Pick a username and password and fill out the form.}}
|[[Image:Sign_up.PNG|300px|frame||'''Step 1''' - Select this link]]
|[[Image:Username.PNG|100px|frame|right|'''Step 2''' - Fill out the simple form]]
|}


==1==
</div>
 
<div style="width: 17em; margin: 0 auto; clear: both; white-space: nowrap; text-align: left;"> </div>
 


<!--
<div style="border-top:1px solid #fc0;padding:.3em 0;text-align:center;background-color:#ff9;margin-top:.5em;font-size:90%">[[Insert Link|'''Insert Text&gt;&gt;''']]
</div>
-->


{{Family tree/start}}
{{familytree | | | | | | | C01 | | | | | | | | | | | | | | | | C02 | | | | | | | | | C03 | | | | | | | | | | | | C01=<div style="float: left; text-align: left">'''Mild to moderate'''
----
❑ Ambulatory patients <br>
❑ Tolerating oral diet <br>
❑ No dehydration <br>
❑ No toxicity <br>
❑ No abdominal tenderness or mass <br>
❑ No obstruction <br>
❑ [[Weight loss]] <10 percent <br>
</div>
</div>
| C02= <div style="float: left; text-align: left">'''Moderate to severe'''
__NOEDITSECTION__
----
❑ [[Fever]] <br>
❑ Intermittent nausea or vomiting <br>
❑ Mild to moderate dehydration <br>
❑ [[Anemia]] <br>
❑ Abdominal pain and tenderness <br>
❑ No obstruction <br>
❑ Weight loss > 10 percent <br>
</div>
| C03=<div style="float: left; text-align: left">'''Severe to fulminant'''
----
❑ High fever <br>
❑ Persistent vomiting <br>
❑ Severe [[dehydration]] <br>
❑ Significant [[peritoneal signs]] <br>
❑ Evidence of [[abscess]] <br>
❑ [[Intestinal obstruction]] <br>
❑ [[Cachexia]] <br>
</div> }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | | |!| | | | | | | | | | | | |}}
{{familytree | | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | | | D03 | | | | | | | | | | | | D01 =<div style="float: left; text-align: left"> ❑ Outpatient therapy <br> ❑ Start altered diet <br> ❑ Start [[oral rehydration therapy]]</div> | D02 =<div style="float: left; text-align: left"> ❑ Inpatient therapy <br> ❑ Start [[oral rehydration therapy]] or [[intravenous fluids]] based upon hydration status </div> | D03=<div style="float: left; text-align: left"> ❑ Inpatient therapy <br>  ❑ NPO <br> ❑ Start[[intravenous fluids]] <br> ❑ Consider total parental nutrition</div>}}
{{familytree | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | |,|-|-|^|-|-|.| | | |,|-|-|-|^|-|-|.| | | | | | | | | | | |}}
{{familytree | | | E01 | | E02 | | E03 | | | | | | | | | E04 | | | | E05 | | E06 | | | | | E07 | | E01=Oral lesion | E02= [[Ileitis]] and [[colitis]] | E03=Gastroduodenal disease |E04 = No steroid contraindication | E05= [[Steroid]] contraindicated | E06 = [[Abscess]] or [[peritonitis]] or [[intestinal obstruction|severe intestinal obstruction]] or refractory/severe painful fistulas | E07= No abscess or partial intestinal obstruction}}
{{familytree | | | |!| | | |!| | | |!| | | | | | | | | | |!| | | | | |!| | | |!| | | | | | |!| | | | | | | | | | | | | | |}}
{{familytree | | | F01 | | F02 | | F03 | | | | | | | | | F04 | | | | |!| | | |!| | | | | | F05 | | | | | F01=Topical [[triamcinolone acetonide]] | F02=<div style="float: left; text-align: left"> ❑ Illeitis and Rt side colitis: Oral [[budesonide]] (9 mg/day) <br>  ❑ Distal colitis : Topical mesalamine or topical steroids (enemas or suppositories) <br> ❑Other site : Oral [[mesalamine]] (4 g/day) or oral  [[sulfasalazine]] (3-6 g/day) </div>| F03=<div style="float: left; text-align: left"> ❑ [[proton pump inhibitor|PPI]] or [[H2 antagonist]], or [[sucralfate]]  <br>❑ Oral [[mesalamine]] (Pentasa: 2 g/day)</div>| F04 = Oral [[prednisone]] (40-60 mg/day) with or without mesalamine| F05 = Intravenous prednisone (40-60 mg/day)  }}
{{familytree | | | |`|-|-|-|+|-|-|-|'| | | | | | | | | | |!| | | | | |!| | | |!| | | | |,|-|^|-|-|-|.| | | | | | | | | | |}}
{{familytree | | | | | | | G01 | | | | | | | | | | | | | G02 | | | | |!| | | |!| | | | G03 | | | | G04 |G01= Response to treatment in 3-4 wks | G02 =Response to treatment | G03= No response to Rx| G04 = Significant response to Rx}}
{{familytree | | | |,|-|-|-|^|-|-|-|.| | | | | | | |,|-|-|^|-|.| | | |!| | | |!| | | | |!| | | | | |!| | | | | | |}}
{{familytree | | | H01 | | | | | | H02 | | | | | | H03 | | | H04 | | |!| | | |!| | | | H06 | | | | |!| | | | | | |H01=Yes | H02= No | H03=Yes | H04= No| H06= Intravenous[[cyclosporine]] or [[tacrolimus]]}}
{{familytree | | | |!| | | | | | | |!| | | | | | | |!| | | | |!| | | |!| | | |!| | |,|-|^|-|.| | | |!| | | | | | |}}
{{familytree | | | |!| | | | | | | I02 | | | | | | I03 | | | I01 | | |!| | | |!| | I04 | | I05 | | |!| | | | | | |I02= Oral [[metronidazole]] (10-20 mg/kg/day) | I03=<div style="float: left; text-align: left"> ❑Taper steroids by 5-10 mg/wk until 20 mg and then by 2.5-5 mg/wk until discontinuation of therapy <br> ❑ Baseline [[DEXA scan]]<br> ❑ Oral[[calcium]], [[vitamin D]] or [[bisphosphonates]] based on DEXA scan</div> | I01= Treat as '''severe to fulminant''' disease or consider the following | I04= No response to Rx |I05= Significant response to Rx}}
{{familytree | | | |!| | | | | |,|-|^|-|.| | | |,|-|^|-|.| | |!| | | |!| | | |!| | |!| | | |!| | | |!| | |}}
{{familytree | | | |!| | | | | J01 | | J02 | | J03 | | J04 | |!| | | |!| | | |!| | |!| | | |`|-|v|-|'| | |J01= Significant response | J02 = No response | J03= Steroid independent (No flare up of symptoms on tapering steroids)| J04=Steroid dependent (Flare up of symptoms on tapering steroids) }}
{{familytree | | | |`|-|-|v|-|-|'| | | |!| | | |!| | | |`|-|-|+|-|-|-|'| | | |!| | |!| | | | | X01 | | | | X01=Gradual transition to oral medications}}
{{familytree | | | | | | |!| | | | | | K02 | | |!| | | | | | K05 | | | | | | |!| | |!| | | | | | | | | | | | K02= Treat as '''moderate to severe disease''' | K05= <div style="float: left; text-align: left"> Consider '''methotrexate''' therapy
----
❑ A baseline [[CBC]], [[CXR]] and [[LFT]]<br>
❑ [[Methotrexate]] (25 mg/wk i.m and once improvement 15 mg/wk i.m or oral or s.c)
----
'''OR''' <br>
----
Consider '''anti-TNF monoclonal antibody''' therapy
----
❑ A baseline [[PPD]] and [[CXR]] (Rule out [[TB]]) <br>
❑  [[Infliximab]] (5 mg/kg i.v at 0, 2 and 6 wks)  <br>
'''OR''' <br>
❑ [[Adalimumab]] (160 mg s.c at 0 wk and 80 mg/2 wks)  <br>
'''OR''' <br>
❑ [[Certolizumab pegol]] (400 mg/4wk s.c)<br>
'''OR''' <br>
----
Consider '''Azthioprine or 6 MP''' therapy
----
❑ A baseline [[CBC]] and [[LFT]]<br>
❑ [[Azathioprine]] (2-3 mg/kg/day)<br>
'''OR''' <br>
❑ [[6-mercaptopurine]] (1-1.5 mg/kg/day)
</div> }}
{{familytree | | | | | | |!| | | | | | | | | | |!| | | |,|-|^|-|.| | | | | | |!| | |!| | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | |!| | | | | | | | | | |!| | | L01 | | L02 | | | | | |!| | |!| | | | | | | | | | | L01= Significant response | L02= No response }}
{{familytree | | | | | | |!| | | | | | | | | | |!| | | |!| | | |`|-|-|-|v|-|-|^|-|-|'| | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | M04 | | | | | | | | | M03 | | M01 | | | | | | M02 | | | | | | | | | | | | | | | | M04= <div style="float: left; text-align: left">'''Maintenance therapy'''
----
❑  [[Proctitis]]: Mesalamine suppositories <br>
'''OR''' <br>
❑ [[colitis|Distal colitis]] : Mesalamine enemas<br>
'''OR''' <br>
❑ Others: Oral [[sulfasalazine]] or [[olsalazine]] or [[mesalamine]](3-3.6 g/day) or [[balsalazide]] </div> |M03= <div style="float: left; text-align: left">'''Maintenance therapy'''
----
❑  [[Azathioprine]] (2-2.5 mg/kg) <br>
'''OR''' <br>
❑ [[6-mercaptopurine]] (1.5 mg/kg)
----
❑ Monitor [[CBC]] every 3 months ❑ Monitor periodically for side effects</div> | M01= <div style="float: left; text-align: left">'''Maintenance therapy'''
----
❑  [[Infliximab]] montherapy <br>
'''OR''' <br>
❑ Combined infliximab and [[azathioprine]] therapy<br>
'''OR''' <br>
❑ [[Methotrexate]] therapy (15 mg/wk i.m): For methotrexate induced remissions <br>
'''OR''' <br>
❑  [[Adalimumab]] therapy (40 mg/wk s.c): For adalimumab induced remissions <br>
'''OR''' <br>
❑ [[Certolizumab pegol]]  therapy (400 mg/ 4wk s.c): For certolizumab pegol  induced remissions <br>
'''OR''' <br>
❑ [[Natalizumab]] therapy (300 mg/ 4wk s.c): For natalizumab induced remissions <br>
----
❑ Monitor [[CBC]] every 3 months<br>❑ Monitor periodically for side effects</div> | M02= Surgical consultation (ileocolonic resections / abscess drainage / perioperative antibiotics)}}
{{familytree | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | N01 | | | | | | | | | | | | | | | | | | | | | N03 | | | | | | | | | | | | | | | | | | | | | | | | | N01= Azathioprine or 6-mercaptopurine for inadequate response | N03= <div style="float: left; text-align: left">'''Maintenance therapy'''
----
❑  [[Natalizumab]] therapy (300 mg/ 4wk s.c) <br>
'''OR''' <br>
❑ [[Infliximab]] montherapy (1.5 mg/kg)
----
❑ Monitor [[CBC]] every 3 months<br>❑ Monitor periodically for side effects </div>}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}
 
 
 
 
 
 
 
 
 
==References==
{{Reflist|2}}

Latest revision as of 23:23, 19 January 2014

  1. Introduction  
  4. Join in!  

What is a username...

  • A username identifies you on WikiDoc.
  • It's very easy to set up, and all we will need is you to create a username and a password.
  • Once you create a username, you'll be able to contribute content and get credit for your contributions (your username will appear in the page history), view all of your contributions, and you will be able to create a user page to tell others about you. Other users will be able to contact you on your user talk page.

Template:Divbox


Template:Divbox

frame Step 1 - Select this link
File:Username.PNG
Step 2 - Fill out the simple form


Retrieved from "https://www.wikidoc.org/index.php?title=Sandbox/v23&oldid=933688"