Sandbox/v23

Management

The algorithm is based on the American Journal of Gastroenterology guidelines for management of Crohn's disease in adults.

Characterize the symptoms: ❑ Abdominal pain ❑ Chronic diarrhea or nocturnal diarrhea (onset, duration, pattern, bloody, mucous or watery) ❑ Nausea ❑ Vomiting ❑ Abdominal distention ❑ Fever ❑ Loss of appetite ❑ Loss of weight ❑ Mental status change ❑ Rectal bleeding ❑ Painful defecation Extraintestinal symptoms: ❑ Skin lesions ❑ Oral pain ❑ Odynophagia and dysphagia ❑ Joint pains ❑ Burning micturition ❑ Cough, breathlessness ❑ Eye pain, blurring of vision Obtain detailed history: ❑ Recent travel H/O ❑ Recent drug H/O ❑ Abdominal/pelvic radiation H/O ❑ Family H/O ❑ Systemic illness H/O

Assess volume status: ❑ General condition ❑ Thirst ❑ Pulse ❑ Blood pressure ❑ Eyes ❑ Mucosa Examine the patient: ❑ Skin (swelling, pain, erythema or ulceration) ❑ Oral cavity (ulcers) ❑ Respiratory system (wheezing or crackles) ❑ Cardiovascular system ❑ Abdomen (mass, distension or tenderness) ❑ Anorectal (perianal skin tags, sinus tracts or bleeding) ❑ Eye (swelling, pain, edema or vision loss) ❑ Musculoskeletal (Axial, large and small joints)

Order tests: ❑ Complete blood count (CBC) ❑ Erythrocyte sedimentation rate (ESR) ❑ C-reactive protein (CRP) ❑ Serum electrolytes ❑ Serum iron and vitamin B12 levels ❑ Stool analysis (occult blood, WBC's, calprotectin, lactoferrin, culture, ova and parasites) ❑ Stool for Clostridium difficile toxin ❑ Urinalysis ❑ BUN ❑ Creatinine ❑ Serum glucose ❑ Liver function tests

Confirmatory diagnostic tests: ❑ Colonoscopy and biopsy ❑ Upper GI scopy and biopsy ❑ Computed tomography (CT) ❑ Barium enema(length and location of strictures) ❑ Upper gastrointestinal series with small bowel follow through (SBFT) ❑ Magnetic resonance imaging (enterography) ❑Wireless capsule endoscopy

Findings suggestive of Crohn's disease: ❑ Discontinuous lesions ❑ Biopsy (Transmural inflammation, noncaseating granuloma) ❑ Cobblestoning (Serpiginous and linear ulcer) ❑ Normal rectum ❑ Isolated terminal ileum involvenent ❑ Aphthous ulcers ❑ Negative stool examination for infectious causes

Assessment of severity

Mild to moderate ❑ Ambulatory patients ❑ Tolerating oral diet ❑ No dehydration ❑ No toxicity ❑ No abdominal tenderness or mass ❑ No obstruction ❑ Weight loss <10 percent

Moderate to severe ❑ Fever ❑ Intermittent nausea or vomiting ❑ Mild to moderate dehydration ❑ Anemia ❑ Abdominal pain and tenderness ❑ No obstruction ❑ Weight loss > 10 percent

Severe to fulminant ❑ High fever ❑ Persistent vomiting ❑ Severe dehydration ❑ Significant peritoneal signs ❑ Evidence of abscess ❑ Intestinal obstruction ❑ Cachexia

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Mild to moderate ❑ Ambulatory patients ❑ Tolerating oral diet ❑ No dehydration ❑ No toxicity ❑ No abdominal tenderness or mass ❑ No obstruction ❑ Weight loss <10 percent

Moderate to severe ❑ Fever ❑ Intermittent nausea or vomiting ❑ Mild to moderate dehydration ❑ Anemia ❑ Abdominal pain and tenderness ❑ No obstruction ❑ Weight loss > 10 percent

Severe to fulminant ❑ High fever ❑ Persistent vomiting ❑ Severe dehydration ❑ Significant peritoneal signs ❑ Evidence of abscess ❑ Intestinal obstruction ❑ Cachexia

❑ Outpatient therapy ❑ Start altered diet ❑ Start oral rehydration therapy

❑ Inpatient therapy ❑ Start oral rehydration therapy or intravenous fluids based upon hydration status

❑ Inpatient therapy ❑ NPO ❑ Startintravenous fluids ❑ Consider total parental nutrition

Oral lesion

Ileitis and colitis

Gastroduodenal disease

No steroid contraindication

Steroid contraindicated

Abscess or peritonitis or severe intestinal obstruction or refractory/severe painful fistulas

No abscess or partial intestinal obstruction

Topical triamcinolone acetonide

❑ Illeitis and Rt side colitis: Oral budesonide (9 mg/day) ❑ Distal colitis : Topical mesalamine or topical steroids (enemas or suppositories) ❑Other site : Oral mesalamine (4 g/day) or oral sulfasalazine (3-6 g/day)

❑ PPI or H2 antagonist, or sucralfate ❑ Oral mesalamine (Pentasa: 2 g/day)

Oral prednisone (40-60 mg/day) with or without mesalamine

Intravenous prednisone (40-60 mg/day)

Response to treatment in 3-4 wks

Response to treatment

No response to Rx

Significant response to Rx

Yes

No

Yes

No

Intravenouscyclosporine or tacrolimus

Oral metronidazole (10-20 mg/kg/day)

❑Taper steroids by 5-10 mg/wk until 20 mg and then by 2.5-5 mg/wk until discontinuation of therapy ❑ Baseline DEXA scan ❑ Oralcalcium, vitamin D or bisphosphonates based on DEXA scan

Treat as severe to fulminant disease or consider the following

No response to Rx

Significant response to Rx

Significant response

No response

Steroid independent (No flare up of symptoms on tapering steroids)

Steroid dependent (Flare up of symptoms on tapering steroids)

Gradual transition to oral medications

Treat as moderate to severe disease

Consider methotrexate therapy ❑ A baseline CBC, CXR and LFT ❑ Methotrexate (25 mg/wk i.m and once improvement 15 mg/wk i.m or oral or s.c) OR Consider anti-TNF monoclonal antibody therapy ❑ A baseline PPD and CXR (Rule out TB) ❑ Infliximab (5 mg/kg i.v at 0, 2 and 6 wks) OR ❑ Adalimumab (160 mg s.c at 0 wk and 80 mg/2 wks) OR ❑ Certolizumab pegol (400 mg/4wk s.c) OR Consider Azthioprine or 6 MP therapy ❑ A baseline CBC and LFT ❑ Azathioprine (2-3 mg/kg/day) OR ❑ 6-mercaptopurine (1-1.5 mg/kg/day)

Significant response

No response

Maintenance therapy ❑ Proctitis: Mesalamine suppositories OR ❑ Distal colitis : Mesalamine enemas OR ❑ Others: Oral sulfasalazine or olsalazine or mesalamine(3-3.6 g/day) or balsalazide

Maintenance therapy ❑ Azathioprine (2-2.5 mg/kg) OR ❑ 6-mercaptopurine (1.5 mg/kg) ❑ Monitor CBC every 3 months ❑ Monitor periodically for side effects

Maintenance therapy ❑ Infliximab montherapy OR ❑ Combined infliximab and azathioprine therapy OR ❑ Methotrexate therapy (15 mg/wk i.m): For methotrexate induced remissions OR ❑ Adalimumab therapy (40 mg/wk s.c): For adalimumab induced remissions OR ❑ Certolizumab pegol therapy (400 mg/ 4wk s.c): For certolizumab pegol induced remissions OR ❑ Natalizumab therapy (300 mg/ 4wk s.c): For natalizumab induced remissions ❑ Monitor CBC every 3 months ❑ Monitor periodically for side effects

Surgical consultation (ileocolonic resections / abscess drainage / perioperative antibiotics)

Azathioprine or 6-mercaptopurine for inadequate response

Maintenance therapy ❑ Natalizumab therapy (300 mg/ 4wk s.c) OR ❑ Infliximab montherapy (1.5 mg/kg) ❑ Monitor CBC every 3 months ❑ Monitor periodically for side effects