Stop Crohns Disease Naturally

Cured My Crohns

If you've ever gotten the fateful diagnosis you've got Crohns, you will know the massive upset that it can have on your way of life and how you feel about yourself and your relationship to other people. If you talk to your doctor about natural diets or some other method of curing your Crohns disease they will tell you that there is no way to fix it. However, there is often more to the story than modern medicine will tell you. New Age medicine is not a bunch of nonsense that hokey people subscribe to; New Age medicine fills in the gaps of knowledge that we have with modern medicine and helps us understand what is going on with our bodies. You will learn how to cure Crohns from someone who has cured it himself and has lived for over 10 years completely free of disease!

Cured My Crohns Overview

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Mild Moderate Acute Crohns Colitis

Although debate continues regarding the role of aminosalicylates for the treatment of mild-moderate CD, there is good evidence that sulfasalazine is efficacious for the treatment of colonic CD. There is less substantial evidence for alternative mesalamine agents. Nevertheless, the aminosalicylates are advocated as a first line therapy for mild-moderately active CD. The use of sulfasalazine in divided doses of 3 to 6 g d, supported by the National Cooperative Crohn's Disease Study (NCCDS), is compromised, in up to 25 of patients, by side effects attributable to the sulfapyridine carrier molecule, such as headache, nausea, GI upset, and, in males, a transient reduction in number and motility of sperm. Rare but more serious hypersensitivity reactions include hemolytic anemia, neutropenia, rash, and hepatitis. In contrast to UC, where alternative azo bond delivery systems such as olsalazine and balsalazide are effective alternatives, in Crohn's colitis these agents have not been shown to...

Surgical Management of Crohns Colitis

Surgery for colonic CD is indicated when medical treatment fails or complications of the disease develop. Rarely, toxic megacolon or fulminant colitis requires a colectomy. The most common indications for surgery include refractory steroid-dependent disease, obstructing strictures, hemorrhage, internal fistulas, or abscesses. Compared to small bowel disease, operations for abscesses and fistulas are less common for colonic disease. Similar to UC, dysplasia and cancer of the colon are related to disease extent, duration and the presence of primary sclerosing cholangitis. Thus, patients with longstanding Crohn's colitis should be entered into a surveillance colonoscopy program even though stricturing disease may preclude complete examination of the colon in all patients. Whether segmental resection is adequate for colonic dysplasia, or whether colectomy is required, remains controversial. The choice of operation and preoperative patient examination is of paramount importance with...

Moderate Severe Acute Crohns Colitis

Moderate-severe Crohn's colitis includes a spectrum of patients that have not responded to treatment for mildmoderate disease or individuals who are acutely ill with fever, dehydration, malnutrition, anemia, diarrhea, abdominal tenderness, or an inflammatory mass. Patients FIGURE 80-1. Treatment algorithm for induction and maintenance medical therapy for Crohn's colitis. ASA aminosalicylic acid IV intravenous 6-MP 6-mercaptopurine. FIGURE 80-1. Treatment algorithm for induction and maintenance medical therapy for Crohn's colitis. ASA aminosalicylic acid IV intravenous 6-MP 6-mercaptopurine.

Phase 2b Study of ISIS 2302 in Crohns Disease ISIS 2302CS9

Patients ages 14 to 80 were enrolled with moderately active (CDAI of 200350), steroid-dependent Crohn's disease (active disease for > 3 previous months despite 10-40 mg of prednisone or equivalent, with at least one unsuccessful taper attempt) (12). Corticosteroids were stable for at least the 2 wk prior to study entry. Patients were allowed stable doses of aminosalicylates, but immunosuppressives were excluded within the prior 4 wk.

Phase 12 Trial Experience of Alicaforsen ISIS 2302 Antisense to ICAM1 in Crohns Disease

We have reported a small, placebo-controlled, double-blind, dose-escalating study of ISIS 2302 for Crohn's disease (11). This phase I-II study was conducted in 20 patients between the ages of 18 and 80 with moderately active Crohn's disease (Crohn's Disease Activity Index CDAI of 200-350) despite stable background doses of steroids (maximum prednisone 40 mg d) with or without 5-ASA drugs. There were no differences in the baseline characteristics between ISIS 2302-treated and placebo groups. Corticosteroid dosages remained stable for the 26-d infusion period and then were adjusted by the investigator according to blinded clinical judgment. Patients received a total of 13 doses of ISIS 2302 or placebo by 2-h iv infusion. Four patients each were assigned to the 0.5- and 1.0-mg kg dose cohorts, and the remaining 12 patients were assigned to the 2.0-mg kg cohort. All patients were followed for a total of 6 mo. At the end of treatment on d 33, 7 of 15 (47 ) ISIS 2302-treated patients and 1...

Supplemental Reading

J Am Dent Assoc 1989 118 349-51. Benvenius J. Caries risk in patients with Crohn's disease a pilot study. Oral Surg Oral Med Oral Pathol 1988 65 304-7. Calobrisi SD, Mutasim DF, McDonald JS. Pyostomatitis vegetans associated with ulcerative colitis temporary clearance with fluocinonide gel and complete remission after colectomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995 79 452-4. Chan SWY, Scully C, Prime SS, et al. Pyostomatitis vegetans oral manifestation of ulcerative colitis. Oral Surg Oral Med Oral Pathol 1991 72 689-92. Chen TS, Chen PS. Rise and fall of the Plummer-Vinson syndrome. J Gastroenterol Hepatol 1994 9 654-8. Curran FT, Youngs DJ, Allan RN. Candidacidal activity of Crohn's disease neutrophils. Gut 1991 32 55-60. Dhote R, Bergmann JF, Leglise P, et al. Orocecal transit time in humans assessed by sulfapyridine appearance in saliva after sulfasalazine intake. Clin Pharmacol Ther 1995 57 461-70. Douglas LR, Douglass JB, Sieck JO, Smith PJ....

Alternatives And Costs

A review of the list of indications for small bowel resection (ischemia, tumor, Crohn's disease, Meckel's diverticulum) reveals a situation where nonsurgical options are few. At first glance, one would point out Crohn's disease as a disorder with multiple treatment options. In reality, however, Crohn's disease is a medical, not a surgical, problem. Patients require surgery because of complications associated with Crohn's disease (obstruction, abscess, bleeding, and so on) not on Crohn's disease per se. So, in fact, there are not any critical cost issues concerning surgery for disorders of small intestine.

Contraindications

Contraindications include fissures located off the midline, which may indicate a systemic illness (Crohn's disease, ulcerative colitis, tuberculosis, leukemia, syphilis, LGV) and fissures with atypical appearance (broad-based, deep, large, and or edema-tous tags), which can be associated with anal carcinoma or HIV AIDS. The presence of any degree of fecal incontinence in the patient is an absolute contraindication (we prefer to perform a lateral internal sphincterotomy with the patient placed in the prone jackknife position).

Mary Lawrence HarrisMD

Ulcerative colitis (UC) and Crohn's disease (CD), collectively referred to as inflammatory bowel disease (IBD), are diagnosed most commonly in patients in their childbearing years. The incidence of CD in young adults is increasing, whereas the incidence of UC affecting patients in their reproductive years has remained stable. The etiology of IBDs is unknown, but clearly genetic factors and tobacco use have been implicated. Women routinely express concern about sexual intimacy, self-esteem, marriage, fertility, offspring inheritance of IBD, role of disease activity during pregnancy, safety of medications, and, finally, outcome or general health of the fetus. The most important issues for the patient are education and optimal timing of the pregnancy.

Complications and Management

Aside from the complications inherent to abdominal procedures in general, several complications are relatively specific to this operation including sexual dysfunction, nonhealing of the perineal wound, and complications related to the ileostomy stoma itself. Sexual dysfunction (erectile dysfunction or retrograde ejaculation in men and dyspareunia in women) has been reported in up to 11 of men undergoing proctectomy for inflammatory bowel disease (9) and up to 50 of women (10). Even with the use of intersphincteric proctectomy, nonhealing of the perineal wound remains a significant problem, occurring in 11 of patients operated on for ulcerative colitis and 33 of those operated on for Crohn's disease (11). Complications related to the ileostomy are reviewed earlier.

Patients complaining of rectal bleeding consider

Blood separate from faeces is most commonly due to haemorrhoids, but may also be due to a variety of other causes, including rectal carcinoma and proctitis, which can be associated with a mucous discharge. Is the blood fresh - bright red, or old - darkish brown this can help indicate where the bleeding is from. When does the patient notice it A proctoscopy should be carried out, but it may be that further investigation may be needed outside of our realm of care, in which case refer appropriately. Blood mixed with faeces may be due to Crohn's disease, or inflammatory bowel disease, carcinoma or vascular abnormalities, and the patient should be referred for careful investigation via a gastroenterologist (Rhodes & Hsin, 1995).

Jimmy KoMD and Lloyd MayerMD

The practicing gastroenterologist is frequently confronted with immune-related diseases, such as Crohn's disease (CD), ulcerative colitis (UC), celiac sprue, and pernicious anemia (PA). However, the role of the gastrointestinal (GI) tract as the body's largest lymphoid organ is often overlooked. In fact, the surface area of the GI tract could cover two tennis courts, and within that surface is a rich supply of B- and T-lymphocytes, macrophages, and dendritic cells. The number of lymphocytes in the GI tract exceeds that in the spleen, but unlike other lymphoid organs, immune-associated cells in the GI tract are constantly confronted with antigen (mainly in the form of bacteria and food). Gut-associated lymphoid tissue, generally known as mucosa-associated lymphoid tissue (MALT), regulates immune responses in the gut to maintain homeostasis. Without this tight regulation, inflammation would predominate in the GI tract. Therefore, it is not difficult to imagine how disease can result in...

Nutritional Therapies

Table 67-2.Therapy for Crohn's Disease Methotrexate for 6-MP AZA resistance or intolerance (less commonly used) Anti-TNF-a antibody in corticosteroid resistant patients, in fistulizing disease, in place of corticosteroids after and with immunomodulators Severe Crohn's disease Corticosteroids Anti-TNF-a antibody 6-MP AZA 5-ASA aminosalicylic acid AZA azathioprine CD Crohn's disease MP mercaptopurine MTX methotrexate TNF tumor necrosis factor TPN total parenteral nutrition.

Anthony P OliveMD and George D FerryMD

The child with Crohn's disease (CD) poses special challenges for all involved, including parents, extended family, school personnel, and medical caretakers. The unique psychosocial and physical changes encountered during childhood and adolescence make this period of time quite vulnerable to the many complications associated with this disease. The resulting physical and emotional scars can be permanent, with lasting repercussions into one's adult life. As such, the therapeutic goals in pediatric CD can be broken down into the following three basic principles (1) promote physical growth and development, (2) promote psychosocial growth, and (3) promote and improve quality of life. The strategies employed to achieve these goals are diverse and tailored to the individual, and include traditional medical and surgical approaches, nutritional therapies, psychological counseling, peer interaction opportunities, and aggressive involvement of the child's family and caretakers. Surgical...

Maintenance of Remission

The role of the aminosalicylates in maintenance of remission for Crohn's colitis is controversial, although they are frequently used for this means given their relatively good safety profile. They are usually continued at the same dose after inductive therapy for as long as they are effective. None of the aminosalicylates have been found to be effective for patients who have required steroids to induce remission.

Miles SparrowMD and Stephen B HanauerMD

Crohn's disease (CD) is a chronic, often granulomatous, inflammatory disease with the potential to affect any part of the gastrointestinal (GI) tract, from mouth to anus. It was not until the 1960s that CD, isolated to the colon, was described and distinguished from ulcerative colitis (UC). In a series by Farmer and colleagues (1975), of 615 CD cases from the Cleveland Clinic the anatomical location of disease was described and found to involve the small intestine in 29 of cases, the ileum and colon in 41 of cases, and the large intestine alone in 27 of cases. These figures have been replicated in subsequent series, such that roughly one-fourth of patients have disease isolated to the colon. Subtle but important differences exist in the presentation and management of CD of the small and large bowel.

David W LarsonMD and John H PembertonMD

The proper surgical management of perianal Crohn's disease (CD) is controversial. Ever since fistulas were first recognized as a manifestation of CD by Penner and Crohn, the specter of incontinence from aggressive perianal surgery has haunted its operative management. Given the often extensive presentation of CD, the decision of when to operate must be a collaborative effort among the patient, gastroenterologist, and surgeon.

Medical Management General

In looking at the control trials using corticosteroids in the treatment of CD, neither the National Cooperative Crohn's Disease Study, nor the European Cooperative Crohn's Disease Study randomized patients for fistula, and there is, therefore, no data available for this subgroup of patients. In these two steroid placebo controlled trials the only deaths occurred in patients who were receiving steroids and who had internal fistula with the subsequent development of an abscess and overwhelming sepsis. Multiple controlled trials have been performed evaluating a newer steroid, budesonide, in the treatment of CD. Efficacy has been demonstrated. However, all patients with a fistula were excluded from these placebo controlled trials. There is, therefore, no control data suggesting that steroids should be instituted in patients who developed perianal complications and fistula. I have experienced multiple patients with longstanding disease going on to develop fistulas and abscesses for the...

Risk Stratification for Colorectal Cancer

Most people are at average risk for colorectal cancer simply because they have reached the age when the prevalence of cancer is sufficient to justify screening. Based on age-incidence curves for this disease, guidelines recommend that screening of the average-risk population (both men and women) begin at the age of 50 years. Reported direct screening colonoscopy experiences in people age 40 to 49 years confirm the very low prevalence of advanced neo-plasia in average-risk people under age 50 years of age. Patients with a personal or family history of colorectal cancer or adenomas, or those with long standing ulcerative colitis (UC) or Crohn's colitis may have a higher risk of colorectal cancer that often begins at an earlier age, and these patients may benefit from special, more intensive examination or screening. Screening recommendations for these high risk groups are clearly outlined in the GI Consortium Guideline (Winawer et al, 2003) and will not be discussed further here. There...

Induction Therapy Mild Disease

Mesalamine agents have traditionally been the first line therapy for patients with mildly active SB CD. Formulations that deliver 5-aminosalicylates (5-ASA) to the SB include Asacol and Pentasa. Asacol is a Eudragit-S-coated mesalamine tablet that releases the active ingredients at pH > 7 in the distal ileum and the colon. Pentasa consists of ethylcellulose-coated mesalamine microgranules that release the active ingredients in a time-dependent fashion, starting from the duodenum throughout the remainder of the bowel. High doses of mesalamines are necessary to achieve efficacy. Pentasa at 4 g d, but not lower doses, is effective in inducing remission in patients with active CD, and may have the greatest efficacy in patients with SB CD. Asacol at 4 g d has also been shown to have comparable efficacy as methylprednisolone at 40 mg d for patients with Crohn's ileitis of mild to moderate severity. At doses higher than 4 g daily these agents may offer even greater benefit. This is...

Chinyu SuMD and Gary R LichtensteinMD

Approximately 40 to 50 of patients with Crohn's disease (CD) have disease in the terminal ileum and the colon at presentation, and another 20 of patients have disease limited to the small bowel (SB). Thus, the majority of CD patients have SB involvement. There are a number of important issues to consider in managing patients with SB CD. First, some medications are most effective for distal ileitis but not jeju-nitis, whereas other medications are not effective for SB disease. Thus, clinicians should have the knowledge of the site of active disease to appropriately select effective medications. Second, heterogeneity in clinical presentations is particularly important in SB CD, because both stricturing and penetrating clinical phenotypes are more common in SB than in colonic CD. In general, the clinical disease behavior for CD can be categorized into the following three patterns (1) stricturing (fibrostenotic), (2) penetrating (perforating or fis-tulizing), and (3) nonstricturing,...

Surveillance Intervals

*Editor's Note Oh, that all colonoscopists and pathologists were as compulsive and experienced as the Seattle groups. Incomplete preps, rushed endoscopy schedules, variable patient compliance, and increasing risk with time would seen to justify more frequent surveillance after 20 years of colitis, especially with childhood onset or with advanced chronologic age. It is also difficult to set the date of onset for patients with Crohn's colitis diagnosed after age 40 or, as below, patients with coexistent primary sclerosing cholangitis.

Comparison of Multiplexed Assays

The majority of the clinically useful autoantibody tests have been cleared by the FDA for in vitro use to help diagnose autoimmune diseases. These include those to help diagnose connective tissue diseases such as RA, SLE, SS, SSc, and PM DM gastrointestinal diseases such as celiac disease, Crohn's disease, and ulcerative colitis autoimmune liver diseases such as PBC and autoimmune hepatitis types I and II autoimmune vasculitides such as Wegener's granuloma-tosis and Goodpasture's syndrome autoimmune endocrine diseases such as Hashimoto's thyroiditis and Graves' disease and autoimmune coagulation disorders such as antiphospholipid syndrome. Examples of clinically useful autoantibody tests that have not been cleared by the FDA include antibodies to help diagnose pernicious anemia, autoimmune skin-blistering diseases such as pemphigus and pemphigoid, and some autoimmune neurological diseases. Auto-

Conditions Leading to Calcium and Vitamin D Deficiency

Given this background, it is clear that GI diseases resulting in inflammation or pathology of the upper small bowel are particularly susceptible to osteoporosis. Examples of these include celiac sprue, Crohn's disease (CD), pancreatic insufficiency (PI) (Moran et al, 1997) and postgastrectomy (Vestergaard, 2003). CD patients are especially at risk if they have had extensive surgical resections or have diffuse intestinal disease. With improved medical and surgical therapy for CD, extensive surgical resections are thankfully the exception. Patients with jejuno-ileal bypass are also at risk for osteoporosis. It remains to be seen whether less drastic weight loss surgeries, such as gastric banding, will contribute to decreased BMD over time. In chronic cholesta-tic liver disease, vitamin D and calcium are malabsorbed and should be supplemented. Inflammatory bowel diseases Crohn's disease

Interactions of PSGL1 with other molecules

In vitro, the N terminus of PSGL-1 binds to some chemokines. Binding was shown to require tyrosine sulfation but not specific glycosylation of PSGL-1 125 . It remains possible that glycosylation could positively or negatively modulate che-mokine binding under some conditions. The ability of PSGL-1 to bind chemokines suggests new possibilities for how it could regulate leukocyte trafficking in vivo. For example, chemokines might transiently bind to PSGL-1 and then transfer to G protein-coupled chemokine receptors that activate leukocyte integrins. Binding of chemokines to PSGL-1 might explain why mAbs to the N terminus of PSGL-1 are more protective than a combination of mAbs to all three selectins in a murine model of Crohn's disease 17 .

Steroid Sparing Therapy

Year after an initial course of steroid therapy, specific strategies focusing on steroid sparing need to be considered early in the management of these patients. Corticosteroid therapy should be tapered off once a good response is achieved. We typically taper steroids at a rate of 5 mg equivalent of prednisone every 1 to 2 weeks. Other standard medical therapies should be initiated before taking steroids or if disease flares up upon steroid withdrawal. Mesalamine (Pentasa) at 4 g d may allow steroid-withdrawal and decrease steroid dependency following steroid-induced remission. Agents that have been shown to have steroid-sparing benefit include AZA, 6-MP, MTX, and infliximab. In pediatric population where growth retardation from corticosteroids is of particular concern, initiation of 6-MP concurrent with steroid therapy at the initial diagnosis has been recommended by some. There is a separate chapter on inflammatory bowel disease therapy in children and adolescents (see Chapter 67,...

Medical Management General Concepts

However, the following concepts to guide therapy can be gleaned from examination of the literature and the personal experience of the authors. First, collage-nous lymphocytic colitis is an IBD that clinicopathologically responds to anti-inflammatory medications as used in idiopathic IBD (Crohn's disease and ulcerative colitis). Prompt improvement in diarrhea is noted in most patients, and histopathologic resolution of collagen banding is noted in some. Second, literature reports note a dramatic clinico-pathologic response with remission to antibacterial agents such as bismuth subsalicylate (Pepto-Bismol) in some patients. For these reasons, it may be prudent to attempt an initial trial of antibacterial treatment before using anti-inflammatory treatment. There are no studies of probiotics. Third, unless the patient has only mild diarrhea easily controlled by dietary restrictions, cholestyramine, and bulk or antimotility agents, a course of anti-inflammatory therapy...

Intraoperative Decision Making

Crohn's disease (CD) causing fistula between the terminal ileum, appendix, and transverse colon. FIGURE 68-1. Crohn's disease (CD) causing fistula between the terminal ileum, appendix, and transverse colon. FIGURE 68-2. Enterocutaneous fistula from Crohn's disease (CD).

Genital Ulcer Diseases

Most sexually transmitted genital ulcers in the UK are caused by Herpes simplex virus (HPA, 2005). Treponema pallidum is another common cause. Dark-ground microscopy, serological testing for syphilis and Herpes simplex culture can be performed to aid diagnosis. Nucleic acid amplification tests are also available for both organisms. Other sexually transmitted infective causes such as lymphogranuloma venereum, Haemophilus ducreyi and donovanosis should be considered, and a good travel history of both the patient and their partners is helpful. Other non-infective causes of genital ulcer disease include Behcet's disease and Crohn's disease.

Indications for the Procedure

Short gut syndrome (loss of approximately 70 of the native small bowel length) is the most frequently encountered cause of irreversible intestinal failure. Causes of short gut syndrome in children include necrotizing enterocolitis, atresia, and volvulus. In adults, etiologies are trauma, surgical damage, repeated resections for Crohn's disease, mesen-teric vascular injuries, extensive adhesions, and desmoid tumors. Defective motility of the gastrointestinal (GI) tract causing pseudo-obstruction is associated with total agan-glionosis, neuropathy, and myopathy. Impaired absorptive function is found secondary to radiation injury, autoimmune processes, extensive polyposis, and microvillus inclusion disease (Sturm et al, 1997 Thompson, 1994 Granata and Puri, 1997 Herzog et al, 1996).

Incidence and Pathogenesis

There has been great variation in the reported incidence of fistula in patients with Crohn's disease (CD) ranging from a low of 17 up to almost 50 (Allan and Keighley, 1988). There have been several population-based studies reporting that the overall incidence of fistulas was 35 in patients with CD with perianal fistulas occurring in 20 (Schwartz et al, 2002). A cumulative incidence of fistulizing CD appeared in 33 of patients after 10 years and 50 of patients after 20 years (Hellers et al, 1980). Perianal fistulas were much more common in patients with colonic disease (41 ) versus those with ileal disease (12 ). The highest incidence occurred in those patients with CD involving the colon and rectum. It is interesting to note in this population-based study that recurrent fistulas occurred less frequently in patients who were placed on maintenance therapy with an immunosuppressive agent.

Specific Treatment of Inflammation Aminosalicylates

Who are sensitive to the 5-ASA and develop a chemical colitis manifest by edematous and often ulcerated mucosal which appears similar to Crohn's colitis. In a careful examination of patients with indisputable mesalamine sensitivity, we were unable to identify a serologic marker or histologic findings unique to mesalamine toxicity. If mesalamine sensitivity is suspected, discontinue the mesalamine drug for 72 hours. If symptomatic improvement occurs, this withdrawal trial supports mesalamine sensitivity. The different efficacies of the various 5-ASA products are discussed in the chapter on UC (see Chapter 78, Ulcerative Colitis).

Contraindications To Urinary Diversion

The patient with a history of inflammatory bowel disease poses a challenge to the surgeon in the selection of an appropriate bowel segment for diversion. Clearly, the use of the large bowel is to be avoided in the patient with ulcerative colitis. Likewise, the terminal ileum should not be used in patients with a history of Crohn's disease. This is particularly problematic because Crohn's disease may involve the entire gastrointestinal tract. In this situation, the use ofjejunum or stomach is preferable to the terminal ileum in the construction of the diversion. Ileal conduits are relatively contraindicated in children because of the risk of associated long-term chronic pyelonephritis and renal deterioration. Contraindications for orthotopic neobladder include tumor in the prostatic urethra, or in females, tumor at or near the bladder neck.

Normal Terminal Ileum

Peyersche Plaques Der Endoskopie

There is no consensus on whether inspecting the terminal ileum is a necessary part of every total colonos-copy. Intubation is often difficult and requires an experienced examiner. However, there are some patients in which pathologies are present only in the terminal ileum (e.g., Crohn disease). And, for certain indications (diarrhea, suspected chronic inflammatory bowel disease, unexplained gastrointestinal bleeding), examination of the terminal ileum is essential. At our center we therefore aim to perform an intubation of the Bauhin valve on every patient, in part given the benefit of practical experience gained by the examiner in performing this technique.

Colitis Inflammatory Bowel Diseases and Other Forms of Colitis

Sigmoid Colon

CD Crohn disease Ulcerative colitis and Crohn disease occur all over the world, but they appear more frequently in western industrialized countries. In North America, an estimated 1.3 million people are affected in Europe, 1.9 million and in Germany, 300000. Pathophysiological , chronic IBD manifests as a deregulated immune response of the intestinal mucosa to microbes or other environmental irritants in individuals who are genetically predisposed to increased susceptibility. In Europe there is a typical north-south gradient in incidence and prevalence. The rate of Crohn disease in Germany is near the European average, at 5.2 patients per 100000. The first manifestation usually occurs in earlier decades, though there is a second peak later in life (especially for ulcerative colitis less so for Crohn disease). The two diseases can be clearly distinguished in terms of immunopatho-genesis and clinical appearance. Only 1 of 5-10 of attacks remains unclear and is classified as...

Definition and Causes

Sigmoid Colon Stenosis

Benign stenoses can be caused either by inflammatory healing processes involving scarring (mainly associated with Crohn disease, but also ischemic colitis and NSAID nonsteroidal anti-inflammatory drug colitis) or they may occur as postoperative stricturing. Colitis. Stenosis is particularly common in fibrostenotic Crohn disease. Depending on the pattern of colon involvement, strictures can involve the terminal ileum, the Bauhin valve, or other colon segments. Strictures may appear with scarring and a smooth mucosa or they may also have variously deep ulcers if a-c Crohn disease. Inflammation and stenosis at ileoascendostomy (a). Advancement of a TTS balloon through the stenosis (b). Inflation of the balloon in the stenosis (c). a-c Crohn disease. Inflammation and stenosis at ileoascendostomy (a). Advancement of a TTS balloon through the stenosis (b). Inflation of the balloon in the stenosis (c). h, i Stenosis and inflammation of ileocolonic anastomosis in Crohn disease. Laying out the...

What Is Sigmoid Pale Mucosa

Ischemic Proctitis

Ulcerative colitis and Crohn disease. Heavy bleeding is responsible for 6-10 of emergency surgical procedures in patients with ulcerative colitis ulcerative colitis is the cause of lower gastrointestinal bleeding in 2-8 of patients (overview in 64). Nevertheless, massive lower gastrointestinal bleeding is not a frequent occurrence in chronic inflammatory bowel diseases. Massive hemorrhaging leads to hospitalization in 0.1 of patients with ulcerative colitis and 1.2 of patients with Crohn disease (37) (Figs. 13.22,13.23). Among Crohn patients, bleeding localization has been said to be evenly distributed among the small bowel, ileocolonic junction, and colon (37). Two studies have contradicted this, however. One cited the colon (6) and the other the ileocolonic junction (17) (Figs. 13.22,13.23) as the sites of predilection for gastrointestinal bleeding in Crohn disease. Fig. 13.22 a Bleeding in Crohn disease. Bleeding from the mucosa on the Bauhin valve in Crohn disease. b Cessation of...

Fistulas and Postoperative Leakages

Tiny Vagina

The formation of fistulas or anastomotic leakages can be associated with inflammatory diseases (especially Crohn disease) or therapeutic interventions, which lead to disruption in the continuity of the walls of hollow organs (Tab. 22.1). Colovesical fistulas. Colovesical fistulas occur in up to 2 of patients with diverticulitis (references in 2). Other causes include Crohn disease, malignancy, radiation therapy, and trauma. The rate of spontaneous healing is very low (2 ). Thus, surgical intervention is usually the therapy of choice, though endoscopic therapy can also be attempted. Fistulas can also occur involving the urethra (Fig. 22.2). Enteroenteric and enterocutaneous fistulas. There is normally no endoscopic therapy approach for enteroenteric and enterocu-taneous fistulas that appear, for example, in Crohn disease (Figs. 22.6,22.7). Therapy mainly consists of medication and, if necessary, surgical intervention. Perianal fistula opening in Crohn Perianal fistula opening in Crohn...

Postoperative Strictures and Suture Granulomas

Postoperative strictures are commonly observed in the anastomosed region of the lower rectum after rectal resection. They are occasionally the result of dehiscence after resection of very low rectal carcinomas. Therapy with balloon dilation can help dilate the stricture. Dilation should be performed step-by-step in intervals of three to four days (balloon diameter 15-25 mm). Intestinal resection in Crohn disease can also lead to inflammatory stenosis or scarring (Fig. 17.2), the latter of which is endoscopically treatable with balloon dilation, if a shorter bowel segment is affected.

Diagnostic Modalities

Surgical therapy will be covered in another chapter (see Chapter 68 Surgical Management of Crohn's Disease) and the reader can refer to a recent American Gastroenterological Association technical review of the subject (American Gastroenterological Association, 2003). I would, however, point out that a frequent error in surgical management is the performance of diverting ostomy in the hope that the perianal fistula will heal. In my experience, this will provide only short term relief and the majority of patients will subsequently require a proctectomy. Likewise many anal strictures do not require any therapy. Physicians are often surprised to find that they cannot perform a digital rectal exam and yet the patient is having relatively normal bowel movements. Retrograde passage of a finger or a scope does not always correlate with antegrade progression of stool. The same concept can be applied when colonoscopy is ineffective in entering the terminal ileum. This does not mean obstruction.

Specific Etiologies and Treatments

Other less common sources include drug-induced ulcerations, Crohn's disease (CD), Dieulafoy's malformation, and metastatic tumors to the small bowel. The likely bleeding source varies depending on the age of the affected individual (Table 59-4). Small bowel tumors Crohn's disease Meckel's diverticulum Small bowel tumors Polyposis syndromes AVM Tuberculosis Syphilis Yersinia Campylobacter Inflammatory Diseases Crohn's disease Celiac disease Behget's syndrome Ulcerative jejunoileitis Vasculitis Radiation enteritis

Mayo Patients With Complex Aphthosis

Treatment of patients with complex aphthosis was successful in many patients with replacement of hematinic deficiencies, treating primary diseases such as Crohn's disease and GSE, modifying provocative factors such as drug reactions and trauma, and utilizing drugs such as systemic

Diets and Specific Nutrient Requirements

Deficiencies of water-soluble vitamins are relatively rare in short bowel patients. However, they may occur and it is therefore important that patients ingest 1 or 2 B-complex vitamin supplements and 200 to 500 mg of vitamin C daily. Vitamin B12 should be administered at a dose of 1,000 g intramuscularly every 3 months in patients who have had significant gastric or ileal resections, or in those who have active Crohn's disease in their remaining terminal ileum. The adequacy of vitamin B12 supplementation is best measured by following the serum methylmalonic acid (MMA) concentration. In the absence of sufficient B12, the MMA concentration will remain elevated because it will not be metabolized to succinyl coenzyme A. Similarly, folate is required for the metabolism of homocysteine to methionine. The Schillings test is not a test to determine vitamin B12 status, but to determine why a particular patient is vitamin B12 deficient. Once neuropathy (B12) or megaloblastic anemia (either) are...

Inflammatory Bowel Disease

Perhaps the most well established yet enigmatic relationship is between smoking and inflammatory bowel disease (IBD). IBD typically is divided into UC and Crohn's disease (CD). The onset of these disorders is influenced by both genetic and environmental factors. Surprisingly, smoking has opposite effects on CD and UC. In UC, smoking may protect against or delay onset of disease and ameliorate its course, whereas in CD smoking may lead to earlier onset and worse prognosis. These opposite effects have been the subject of intense clinical and laboratory study in hopes of better insights into the pathogenesis and treatment of these disorders. Crohn's Disease

Management of Complications of Sb Cd Fistulas and Abscesses

Fistulas arising from underlying CD rarely close spontaneously. Symptomatic fistulas can be managed medically or surgically. Mesalamine derivatives and corticosteroids are not effective for closing fistulas. Medications that can be used for managing CD fistulas, include immunomodulators such as AZA, 6-MP, cyclosporine, and tacrolimus, infliximab, and antibiotics. It should be noted that the data on the use of these agents for fistulizing disease are primarily for perianal fistulas, complications typically seen in patients with Crohn's colitis. The best available data for enteroenteric fistulas among these agents come from an uncontrolled report using 6-MP (Korelitz and Present, 1985). A course of bowel rest and TPN is often employed, although its benefit in closing fistula has not been consistently demonstrated. However, bowel rest temporarily decreases the output through the fistulas and improved nutritional status with PN may decrease postoperative complications. Octreotide, a...

Simple And Complex Aphthosis

The lesions of RAS may be associated with inflammatory bowel disease (IBD), such as ulcerative colitis and Crohn's disease. Simple or complex aphthosis may antedate, coexist, or serve as a marker for increasing intestinal disease activity. Patients with IBD not only have lesions of RAS but may also have erythema nodosum, papulopustular lesions or lesions of pustular vasculitis, and inflammatory ocular disease such as iritis and uveitis. Thus the distinction between multisystem IBD and BD may be difficult18-21.

Clinical Box 21 Graft Versus Host Disease

A main reason for the shortage of transplant organs is the fact that the tissues of the donor and the recipient need to match for successful transplantation. Tissues are matched when they have a similar pattern of cell surface proteins. Cell surface proteins are in fact glycoproteins due to the carbohydrates (sugars) attached to their surface. The carbohydrate acts as a flag designating the cell as belonging to the individual. The cellular gly-coprotein pattern may specify an individual within a species or specify a species. If a particular sugar is missing from the surface of a cell, the immune system may recognize this cell as foreign and try to kill it. An attack on self tissue may lead to autoimmune diseases, where the autoimmune reaction can be directed against a specific tissue such as the brain in multiple sclerosis or the digestive tube in Crohn disease. In other cases, the overly active immune system may attack many cells and tissues so that various organs are affected such...

Colonic Complications of NSAIDs

One common and clinically relevant side effect of NSAIDs is to cause relapse of classic IBD. About 20 of patients with Crohn's disease or ulcerative colitis have a clinical relapse of their disease within 1 week of receiving conventional NSAIDs. This relapse is shown to be associated with escalating inflammatory activity (vastly increased fecal calpro-tectin). In these cases we discontinue the particular NSAID and give the patient a crash course of prednisolone (30 mg d for 5 days, reducing the dose by 5 mg every 5 days). Within 4 to 5 days it is safe to give the patient the COX-2 selective agent nimesulide (Aulin),* because this drug is not associated with relapse of the disease (the safety of other COX-2 selective agents has not been formally tested). However, if the relapse occurs after 10 to 14 days of conventional NSAID treatment, it is most likely not due to the drug. In these cases we treat the relapse by conventional means and

Endoscopic Interventions

Based on experience, some fistula types offer little chance of successful endoscopic closure. These are malignant fistulas, stomalike fistulas, fistulas in a florid inflammatory stage of Crohn disease, and narrow fistulas with a distant cavity without sufficient drainage (pooling discharge, abscess formation). We do not advise endoscopic closure in such situations. The healing process can be supported with regularly occurring targeted irrigation (Fig. 22.10). For larger leakages following low anterior rectal resection, a stoma must often be attached prior to endo-scopic therapy (if a protective stoma has not already been attached).

Data Interpretation

The pathogenesis of a number of diseases is still not very well understood. The exact mechanisms of containment of either transformed or virally infected cells have not been determined. In general, effective adaptive T-cell responses are desirable in these diseases. The flip side of the coin - in the context of cellular immune responses - is a strong T-cell response which mediates auto-immune disorders. Many parameters exist to measure disease activity in autoimmune diseases, but the magnitude of a cellular immune response is hard to assess, particularly if no molecular targets have been identified. Since TCR CDR3 analysis visualizes objectively every alteration in the TCR composition, it may be helpful to define new markers of disease activity in autoimmune diseases it may also present a potential matrix to gauge immuno-suppressive effects of novel drugs. For instance, TCR diversity has been suggested as a readout in PBL from patient suffering from SLE (39), or in the synovial fluid...

Physiological and pathological functions of PSGL1selectin interactions

The contributions of PSGL-1 to leukocyte adhesion in vivo have been documented in numerous studies, mostly in murine models. Studies with blocking mAbs to the N-terminal region of PSGL-1 initially demonstrated that PSGL-1 is the dominant ligand for mediating leukocyte rolling on P-selectin on inflamed endothelial cells in vivo 108, 109 (Fig. 2). Targeted disruption of the gene encoding murine PSGL-1 confirmed these observations very few PSGL-1-deficient leukocytes roll on P-selectin on activated venules, and those that do, roll very rapidly and irregularly 110, 111 . PSGL-1-deficient leukocytes exhibit reduced tethering to E-selectin in cytokine-activated venules however, those leukocytes that do tether to E-selectin roll with velocities equivalent to those of wild-type leukocytes 111 . Thus, PSGL-1 contributes to tethering to but not rolling on E-selectin, demonstrating that other E-selectin ligands are required for rolling (Fig. 2). One of the latter may be CD44 112 . Studies with...

Decision Models

For instance, they concern different management options in reflux disease, peptic ulcer, dyspepsia, hepatitis C infection, colorectal cancer, and Crohn's disease, to name just a few. The underlying intentions of such decision analyses are to advocate particular health policies that would be then taken up by the majority of gastroenterologists, be endorsed by professional societies, or even become mandated by governmental agencies. Because of their intended general audience and far-reaching purpose, the analyses try to paint a rather detailed and all-inclusive picture of the disease in question, which considers all potential disease scenarios, even if they are only associated with a low probability of occurrence. For these reasons, many such decision models have become rather complex and somewhat difficult to understand. Besides its general application as an instrument to promote a particular health policy, medical decision analysis also plays an important role as a clinical bedside...

Clinical Features

The symptoms of large bowel CD are similar to those of UC, usually presenting with diarrhea and rectal bleeding. In contrast, however, because of the transmural nature of CD, there is a greater likelihood that the symptoms will be associated with abdominal pain, fever, and weight loss. The distinction between UC and Crohn's colitis, although not possible in up to 10 to 15 of cases, is important with regard to potential medical interventions (eg, antitumor necrosis factor TNF therapy) and surgical management (the potential for creation of an ileal pouch anal anastomoses is less with CD due to disease recurrence in the ileal pouch). Perianal disease, present in 30 to 40 of patients with Crohn's colitis, is another differentiating feature from UC and is present in up to 80 of cases of Crohn's proctitis. Crohn's colitis is also more common in older patients (> 80 of Crohn's patients older than 40 years have colonic involvement) and in this population it must be differentiated from...

Ileitis

The ileum can be affected by Crohn disease or by a number of other cancerous and infectious diseases (Tab. 17.1). Differential diagnosis from acute appendicitis can also be difficult. Alongside sonography and CT, colonoscopy can often successfully confirm appendicitis (Fig. 17.11 ). Colonoscopic aspect includes redness and swelling of the appendix opening the normally smooth excavation is lost. Fistulizing cecal carcinomas are easily mistaken macro-scopically for Crohn disease and can spread to the terminal ileum. All ileocecal conglomerate tumors must be histologically evaluated and classified. Resection is desirable in the absence of certain histology and signs of stenosis.

High Risk Patients

Patients with UC and Crohn's colitis have an increased risk of colorectal cancer. The following two chief factors determine which patients are at increased risk (1) disease duration of more than 8 years and (2) disease extent proximal to the sigmoid colon. Primary sclerosing cholangitis (PSC) has been identified as a third factor the risk of neoplasia approaches 50 after 25 years duration of UC in these patients (Brentnall et al, 1996 Broom et al, 1992 D'Haens et al, 1993 Gurbuz et al, 1995). Patients with PSC have an 80 to 90 probability of having UC, but are often asymptomatic, and the duration of UC may be difficult to determine. Therefore, PSC patients who have not been diagnosed with UC should have periodic flexible sigmoidoscopy with 5 to 10 biopsies performed to determine whether UC has developed. PSC patients found to have UC should then undergo surveillance colonoscopy as soon as they are diagnosed, rather than waiting for the usual 8-year duration before initiating...

Antibiotics

The use of antibiotics in pediatric CD has been guided primarily by evidence from adult studies, but this evidence is not strong and there are no pediatric studies. We have used antibiotics (generally metronidazole or ciprofloxacin) primarily for mild to moderate acute Crohn's colitis or ileocolitis, as well as for perianal disease. The use of antibiotics for maintenance of remission in CD in children has not been studied, but we often use these agents for 6 to 12 months.

Anastomotic Leakage

Fortunately, leakage at the pouch-anus anastomosis is rare, especially when the anastomosis is protected by a diverting ileostomy. Most surgical series report this as less than 10 , though some higher rates are reported. Anastomotic leakage typically causes pelvic pain and abscess. Pouch dysfunction is exemplified by painful, incomplete evacuation, and excessive frequency. Demonstration of a leak with a retrograde barium contrast study (pouchogram) is usually diagnostic. Occasionally, a pouch-vaginal or pouch-perineal fistula may develop in association with anastomotic leakage this should always raise the question of unrecognized Crohn's

Mark A TalaminiMD

Crohn's disease (CD) is an inflammatory condition of the bowel that can affect the gut tube anywhere from the lips to the anus. The commonest site of pathology, however, is the small bowel (SB), and this is indeed the focus of most surgical therapy. Other sites, such as the colon and the duodenum, present unique challenges.

Philip B Miner JrMD

Dramatic changes have occurred in the understanding and management of inflammatory bowel disease (IBD) over the past decade. The interaction of luminal contents with the gastrointestinal (GI) immune system has enhanced our understanding of mucosal inflammation and has improved the focus of general management. Biologic therapy is coming of age and dozens of new silver bullet compounds are being developed to treat both Crohn's disease (CD) and ulcerative colitis (UC). In the midst of the excitement about what the future holds, it is important to focus on maximizing the treatment options that are currently available. I will review the current understanding of left-sided UC and issues regarding management of mucosal inflammation and symptoms of this disease.

Lisa TurnboughRN

Inflammatory bowel disease (IBD) patients must deal with socially embarrassing, painful, and, sometimes, body image altering diseases. They experience better outcomes when they are adequately educated about their disease process and treatment and have confidence that there is a reliable contact when problems or questions arise. These patients need to feel comfortable discussing their symptoms and fears in a relaxed atmosphere of empathy, compassion, and professionalism. They deserve accurate information given in a timely manner. Unfortunately, many patients report dissatisfaction in accessing the health care system. In large institutions it is easy for the patient to feel he she gets lost in the shuffle in the interim between regularly scheduled visits. Blaine Franklin Newman became frustrated with the inconsistent contacts and information he dealt with during his battle with Crohn's disease and vowed to help other patients avoid that distress. His generosity and foresight provided...

Refractory Disease

Patients who fail to respond to treatment should be re-evaluated in order to determine whether the initial diagnosis is correct or whether there has been extension of the disease to include a larger proportion of the colon. Unrecognized problems may include infection, SRUS (see separate chapter), ischemic colitis, Crohn's colitis, concurrent irritable bowel syndrome, drug-induced colitis, or mesalamine sensitivity. Mesalamine sensitivity may occur at any time in the course of treatment. Our published cases were documented to be sensitive to mesalamine by withdrawing the drug and observing symptomatic improvement. This was followed by a mesalamine enema challenge and repeat assessment of symptoms and endoscopic appearance. The response to withdrawal is dramatic and usually occurs within 72 hours. Reassessment should include physical examination, laboratory tests including stool cultures with an assessment for C. difficile, visualizing the mucosa by flexible sigmoidoscopy, or...

Comments

Editor's Note There are separate chapters on anorectal disease (see Chapter 91, Anorectal Diseases) and medical treatment of perianal disease (see Chapter 81,Perianal Complications in Crohn's Disease Patient Management). A complete 80-item reference bibliography for this detailed chapter can be obtained at Pemberton, John mayo.edu.

Benign Disease

Most anastomotic strictures, short (< 5 cm) Crohn's strictures, and some ischemic strictures, particularly those that are the consequence of abdominal aneurysm resection, have proven amenable to balloon endotherapy, whereas long, ischemic and diverticular strictures of the intraperitoneal colon are best left to surgical or conservative management. FIGURE 85-4. Arrows delineate short, annular stricture in a patient with obstructive Crohn's (A), treated with 12 to 15 mm CRE balloon (B). CRE continuous radial expansion. Editor's Note The results with anastomotic strictures in Crohn's disease have been best if it was over 7 years since surgery (TMB). Editor's Note The results with anastomotic strictures in Crohn's disease have been best if it was over 7 years since surgery (TMB).

Colonic Strictures

Resection a cure for patients with malignant ascites or liver metastasis or even in patients with Crohn's stenosis in whom recurrence, usually proximal to the anastomosis, is invariable (Kozarek, 2001). Finally, surgery has been associated with further stenosis with anastomotic leak, pelvic abscess, and local anastomotic ischemia (Porcellini et al, 1996). All of the above have helped push endoscopic therapy to the forefront in many cases of colonic stricture.

Abdominal

This is a chronic, localized, inflammatory process that often occurs weeks, months, or years after the integrity of the gastrointestinal mucosa is broken by surgery for acute appendicitis with perforation, or for perforated colonic diverticulitis, or by emergency surgery on the lower intestinal tract after trauma. Occasionally, abdominal actinomycosis may manifest without identifiable predisposing factors. The ileocecal region is involved most frequently (usually following appendicitis with perforation), with the formation of a mass lesion. The infection extends slowly to contiguous organs, especially the liver, and may involve retroperitoneal tissues, the spine, or the abdominal wall. Hepatic, renal, and splenic disseminations are uncommon complications (5). Persistent draining sinuses may form, and those involving the perianal region can simulate Crohn's disease or tuberculosis. The extensive fibrosis of actinomycotic lesions, presenting to the examiner as a mass, often suggests...

Figure 1028

Aminosalicylic acid and chronic tubulointerstitial nephritis. A, A 36-year-old man suffering from Crohn's disease exhibited severe renal failure after 23 months of treatment with 5-aminosalicylic acid (5-ASA, or Pentasa, Hoechst Marion Roussel, Kansas City, MO). B, The first renal biopsy showing widening and massive cellular infiltration of the interstitium, tubular atrophy, and relative spacing of glomeruli. C, The second renal biopsy 8 months, after discontinuation of the drug and moderate improvement of the renal function, again showing important cellular infiltration

Psychosocial Issues

Coexisting or newly emerging emotional issues or mental illness will affect the way in which an individual deals with IBD. If coping with the stress of IBD is overwhelming, the patient should be further examined and treated. Appropriate referrals are facilitated for psychiatry or social work. Most patients do not require such referrals. However, the health care team needs to be aware that IBD impacts upon the entire family. Support through the clergy and organizations, such as the Crohn's and Colitis Foundation (CCFA).

Anorectal Disease

Hemorrhoidal disease also is seen frequently. Factors predisposing to hemorrhoids may have predated the HIV infection. Severe diarrhea or proctitis may promote local thrombosis, ulceration, and secondary infection. Fleshy skin tags, resembling those seen in Crohn's disease, are also seen. Thrombosed hemorrhoids occur frequently, but it is unclear if the incidence is higher in AIDS patients than in a comparable population.

General Sources

Apies used in complementary medicine, and (3) diagnostic techniques used in complementary medicine. Within the symptoms and disorders section, therapies used for a variety of medical conditions are discussed. There is a section on GI conditions, although neither ulcerative colitis nor Crohn's disease is specifically included. Each therapy is given a rating as to the likelihood of achieving a therapeutic benefit and potential risks are listed. The level of evidence supporting any benefits (ie, case reports, clinical trials) is given, but unfortunately no references are provided.

Odds and Ends

When in doubt about management or pathology, get a second opinion. Biopsies with dysplasia should be assessed by a pathologist with expertise in IBD. Barium enema should not be substituted for colonoscopy in IBD patients because dysplasia may not cause a visible defect. Patients with ulcerative proctitis do not require surveillance because there appears to be no increased risk of colorectal cancer (Ekbom et al, 1990 Farmer and Brown, 1966). Patients with Crohn's colitis have the same elevated neoplastic risk as those with UC and, thus, should be under similar surveillance protocols (Ekbom et al, 1990).

Background

Ulcerations in the esophagus and stomach have been reported . These patients commonly present with symptoms of hematemesis, melena, and epigastric pain. However, the terminal ileum, cecum, and ascending colon are the sites more frequently affected, resulting in abdominal pain, diarrhea, and hematemesis. Kim et al. have described the colonscopic findings of 94 Korean patients with BD who presented with lower gastrointestinal complaints13. All of the patients had ulcerative lesions, with ileo-cecal involvement in all but three. The average ulcer size was 2.9 cm, and approximately two-thirds of the patients had single ulcerations. Complications of GI ulceration in BD may include perforation and enterocutaneous fistula. Surgical treatment is often necessary, but postoperative recurrence is as high as 68 14. In many cases it is difficult to distinguish intestinal BD from Crohn's disease. Lee et al. report that intestinal ulcerations due to BD tend to be more focally distributed and are...

Intestinal Failure

Intestinal failure or short bowel syndrome results from loss and or disease of the intestine to an extent that precludes adequate digestion and absorption. There is a separate chapter on short bowel syndrome (see Chapter 64, Short Bowel Syndrome). Crohn's disease, intestinal trauma and intestinal infarction are the most common causes. The patient often presents with weight loss, diarrhea, and weakness. Following an extensive resection of the small intestine, intestinal rehabilitation is more likely if the colon has been preserved and the ileocecal valve is maintained (Dudrick and Latifi, 1992). The nutritional management of short bowel syndrome depends on the amount and location of small bowel removed. Initially, gastric acid suppressing agents are employed to reduce gastric hypersecretions and anticholinergic agents are used to slow transit. PN is prescribed to meet nutritional needs and to reduce gastric and intestinal secretions associated with food ingestion. Oral feedings are...

Liver Abscess

Anaerobes may be involved in at least half of cases of pyogenic liver abscess (5). The most prevalent anaerobes in liver abscess are anaerobic and microaerophilic streptococci (not true anaerobes), Fusobacterium spp., B. fragilis group, and pigmented Prevotella and Porphyromonas spp. A colonic source is usually the initial source of infection. Staphylococcus aureus abscesses usually result from hematogenous spread of organisms involved with distant infections, such as endocarditis. Streptococcus milleri has been associated with both monomicrobial and polymicrobial abscesses in patients with Crohn's disease. S. aureus and beta-hemolytic streptococci are also associated with trauma Enterococcus spp., K. pneumoniae, and Clostridium spp. with biliary disease and Bacteroides and Clostridium spp. with colonic disease (Table 1).

Perianal Region

Serpiginous Ulcer

0 12.6 Aphthous erosions in early phase of Crohn disease 0 12.6 Aphthous erosions in early phase of Crohn disease T 12.7 Ulcers in Crohn disease T 12.7 Ulcers in Crohn disease Solitary mini-ulcers in Crohn disease in ascending colon. Fig. 12.23 Pancolitis Crohn with varied appearance aphthous erythema, pseudopo-lyps, and small ulcers at the same time in ascending colon.

Backwash Ileitis

Normal Sigmoid Colon

A Crohn disease terminal ileitis. b Crohn disease terminal ileitis. a Crohn disease terminal ileitis. b Crohn disease terminal ileitis. Endoscopic appearances are varied. The proximal right side of the colon is usually affected, but disseminated disease also can occur. In the acute phase, there are often patchy erythemas, sometimes partly brown-red in color, intramucosal bleeding, and mucosal edema (Fig. 12.34). Vascular pattern usually remains intact or at least partially visible and erosions (including aphthous erosions) may be present. Ulcers are usually small and deep ulcers are rare. Thus, the mucosal architecture may seem to appear intact. Difficulties arise in that some longer term infectious colitis types can mimic IBD morphologically (Crohn disease, in particular). This is particularly true of Campylobacter jejuni colitis and amebiasis. Suspicious cases must therefore be serologically investigated. Diagnosis can also be difficult when there is a bacterial superinfection...

TPMT Activity

IBD, Black and colleagues (1998) showed that patients with Crohn's disease (CD) and a mutant TPMT allele incurred significant drug-induced leukopenia on AZA therapy and were compelled to discontinue treatment, whereas patients with the wild-type allele achieved a good clinical response while on AZA therapy with no side effects. Conversely, in a study by Colombel and colleagues (2000), TPMT enzyme deficiency was present in just 27 of patients with AZA-induced myelosuppression. The authors concluded that TPMT genotype testing may not circumvent the need for complete blood cell count monitoring. Although a very low dosing strategy (0.25 mg kg d) has been reported to be acceptable in patients with IBD and the homozygous recessive TPMT genotype, it remains most authors' opinion that patients with absent TPMT enzyme activity levels should not receive antimetabolite therapy. However, a moderate dosing strategy (1 mg kg d) can still be applied in patients with the heterozygous TPMT genotype...

Setons

Seton Placement

In a comparative study by Regueiro and Mardini (2003), perianal fistulas were treated with infliximab alone versus combination therapy with Seton placement. The findings showed that initial response was improved with Seton placement (100 versus 82.6 ), lower recurrence rates (44 versus 79 ), and longer time to recurrence (13.5 months versus 3.6 months). The preceding chapter (see Chapter 81, Perianal Complications in Crohn's Disease Patient Management) is on medical aspects of perianal disease treatment.

Anal Fissure

Anal fissure can be acute or chronic and is usually located in the midline of the anal canal, most commonly posteriorly. When a fissure is situated off the midline, other conditions, such as Crohn's disease (CD), mucosal ulcerative colitis, syphilis, tuberculosis, or leukemia, should be investigated.

Short Bowel Syndrome

Thirty-five to forty percent of patients with SBS have been found to develop gallstones (10). Risk factors for the development of cholelithiasis in patients with SBS include small intestinal length less than 120 cm, absent ileocecal junction, long-term total parenteral nutrition (TPN), and Crohn's disease (10). Cholestasis secondary to the use of TPN contributes to the formation of gallstones, although the administration of cholecystokinin may help to prevent biliary stasis. In stool, oxalate usually binds to intraluminal calcium to form an insoluble complex and is excreted. With fat malabsorption, calcium binds to free fatty acids resulting in large amounts of unbound oxalate. The free oxalate is absorbed in the colon and is eventually concentrated in the kidney leading to stone formation. Patients with hyperoxaluria should be placed on a low-oxalate low-fat diet to decrease urinary oxalate (1). In addition, cholestyramine can be added to bind free intraluminal oxalate and...

Eosinophilic Colitis

Infiltration of the GI tract with eosinophils may involve the entire GI tract but usually entails the stomach and small intestine. Isolated colonic involvement (eosinophilic colitis) is limited to sporadic case reports. Eosinophilic colitis can occur as a component of the inflammatory response in Crohn's disease, ulcerative colitis, parasitic diseases, milk protein-induced colitis, and eosinophilic gastroenteritis. Eosinophilic GI disease is estimated to have an incidence of 1 100,000, whereas isolated colonic involvement appears to be very sporadic.

Rectal pain

Fissured, macular and ulcerating lesions should be biopsied. Paget's and Bowen's diseases can only be diagnosed via histology, and are malignant diseases. Fistulas and perianal abscesses are easy to diagnose on examination. A main problem with this manifestation is not to recognise the possibility of underlying Crohn's disease, especially with the presence of thickened purplish skin tags, and another failing can be to assess the full extent of the fistula inaccurately. Further investigation by a specialist is commonly needed (Rhodes & Hsin, 1995). Anal tags are normal skin variation, and though they do not cause any symptoms or require treatment, sometimes they may be a clue to an underlying condition. As has earlier been stated, tags can be associated with Crohn's disease these tags are usually thick with a purplish appearance. Anal tags can occur as the result of a thrombosed external pile or may form the marked end to a chronic anal fissure.

Pouchitis

Most cases respond to metronidazole with or without ciprofloxacin given over a 5 to 10 day period. A chronic variety of pouchitis is much less common. We usually will treat such patients with initial long term (6 months plus) antibiotic therapy. Probiotics have been used to replace long term antibiotics in some patients. If there is little or no response, we will use, 5-ASA orally and or by enema. The next chapter (Chapter 80,Crohn's Colitis) details treatment of pouchitis, including a discussion of CD in IPAA. Occasionally ileostomy with pouch excision is necessary. Editor's Note Sometimes a predict-first strategy is helpful because some of the IBS patients give a very clear history of irritable bowel type symptoms for many years before they developed recognized UC. Because the small bowel is also irritable, an IPAA may not be the best option for such patients (Bayless), one can expect more than 10 evacuations per day in some because the irritable or spastic pouch can only hold 90 to...

Lactose Intolerance

And adult life, although rare congenital deficiencies can occur. Symptoms of lactase insufficiency are usually dose related and include bloating, flatulence, and diarrhea. Secondary lactase deficiency can result from viral gastroenteritis, radiation enteritis, Crohn's disease (CD), and celiac sprue. It is important from a management standpoint to understand that individuals with constitutive lactose intolerance (1) do not suffer severe and potentially life-threatening complications of ingesting lactose and (2) are able to consume naturally lactose free diary products including most cheeses and yogurts. This contrasts with cow's milk allergic individuals who may suffer anaphylactic or asthmatic reactions to dairy products and must avoid all foods containing the culprit cow's milk protein allergen, usually casein or p-lactoglobulin. There is a chapter on carbohydrate intolerance (see Chapter 62, Lactose Intolerance).

Daniel H Present MD

Since the classic paper published by Crohn and colleagues in 1932 describing the chronic inflammatory process of the bowel there have been multiple articles published on the complications of this illness. The description of perianal fistula was followed 6 years later with the incorrect concept that the inflammatory process extended from the bowel down to the perianal area. There are multiple problems that can affect the perianal area, including simple skin tags, fissures, hemorrhoids, high and low fistulas, strictures, rectovaginal fistulas, and, finally, neoplasia. Severe perianal skin excoriation can result in significant discomfort and impaired quality of life. The main purpose of this article is to review the perianal complications with a focus on management of fistulas.