Answers:

What additional tests will pt’s physician need to support this provisional diagnosis and to differentiate b/w Crohn’s Disease (CD) and Ulcerative Colitis (UC)?

The two primary procedures used to confirm the diagnosis of IBD are colonoscopy/sigmoidoscopy (C/S) and  barium contrast radiography. C/S, rather than contrast radiography, is better to define the severity and extent of mucosal inflammation. In addition, endoscopic biopsy can be done with C/S to permit a histologic diagnosis. C/S findings correlate better with disease activity and thus can be used to monitor response to therapy.  Multiple biopsies may be necessary to differentiate UC and CD.

What clinical and diagnostic features can help to differentiate b/w UC and CD?

What are the common complications of  IBD? 

Some of the complications associated with CD include abscesses, fistulas, strictures, obstruction, perianal disease. These complications are usually not present  in pts with UC. Extra-intestinal manifestations of IBD include arthritis, hepatic and biliary complications, urinary tract complications, dermatologic complications, ocular complications, amyloidosis, and hypercoagulability.  Additional complications may result from malabsorption; they include anemia, cholelithiasis, nephrolithiasis, and metabolic bone disease.  Extra-intestinal complications are usually less frequent with UC.  The development of toxic megacolon, however, is more common in pts with UC than in pts with CD and may require emergency colectomy.

What are the goals of therapy for pt with IBD?

The goals of therapy are to induce remission of symptoms and mucosal inflammation and to maintain remission. Management depends on the clinical severity of the acute episode and on the anatomic extent of disease. It is also important to maintain an adequate nutritional status, minimize side effects of medical treatments, and improve pt’s quality of life.

If this patient had UC, what are possible treatment options?

For acute management of mild-to-moderate colitis, initial treatment options include oral aminosalicylates, topical aminosalicylates, or topical corticosteroids, depending on disease location. Remember that topical (rectally administered) agents only go as far as the splenic flexure.  They do not affect the ascending or transverse colon. Treatment generally is efficacious within 2 to 4 weeks. The advantages of topical therapy are a more rapid response and less frequent dosing.  5-ASA therapy is effective in inducing and maintaining remission. Oral therapy with sulfasalazine is effective in inducing and maintaining remission; however, treatment with sulfasalazine may be limited by intolerance to side effects caused by the sulfapyridine component. Oral and rectal preparations containing 5-ASA (mesalamine) alone (e.g., Asacol, Colazal, Dipentum, Pentasa) may be useful in patients who are unable to tolerate sulfasalazine. Topical corticosteroid therapy is effective in inducing remission, but has not been shown to be effective in maintaining remission. Some patients, unresponsive to therapy given by one route,  may respond to combination therapy with topical and oral therapies. In patients who are unresponsive to these therapies, oral corticosteroids are recommended.

Immunomodulators, such as 6-mercaptopurine (6-MP) and azathioprine, are used in UC for their steroid-sparing effect in patients dependent on corticosteroids. These agents should not be considered until a trial of 5-ASA maintenance therapy is tried first.

UC is cured by surgery!  Surgery today doses not involve long-term presence of an ostomy.

If the patient had CD, what are possible treatment options?

For mild-to-moderate acute CD, treatment with oral budesonide or systemic (oral) corticosteroids is considered first-line therapy. For mild disease involving the colon alone, 5ASP may be useful. Antimicrobials can be added for (ileo) colonic or perianal disease (metronidazole or ciprofloxacin). For moderate-to-severe acute CD, oral corticosteroids are considered first-line therapy. Remember: you need to start your maintenance medication when you start corticosteroids. The addition of azathioprine or 6-MP to corticosteroids may also allow use of lower corticosteroid doses or even allow them to be tapered off completely.  Methotrexate has also been used for this purpose.

Patients treated acutely with corticosteroids often relapse within one year without some maintenance therapy. Corticosteroids are ineffective for maintaining remissions in Crohn's disease. Azathioprine and 6-MP are the drugs-of-choice for maintenance therapy in CD to prevent relapse after steroid-inductive therapy. Use methotrexate only if AZA/6-MP intolerant or pt. fails them. Infliximab (TNF antagonist) may be useful if oral maintenance therapies do not work optimally.

What else dose this patient need to know?

You need to tell him to avoid NSAIDs (i.e. ibuprofen).  Even though NSAIDs are anti-inflammatory agents, they make IBD symptoms worse.  Even COX-2 selective NSAIDs do this.  He’ll need something else for his headaches (eg, acetaminophen).