Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.
Methotrexate (Rheumatrex,
Trexall) is both an immuno-modulator and
anti-inflammatory medication.
Methotrexate has been used for many years in the treatment of severe rheumatoid
arthritis and psoriasis. It has been helpful in treating patients with moderate
to severe Crohn's disease who are either not responding to azathioprine and 6-
MP or are intolerant of them. Methotrexate also may be effective in patients
with moderate to severe ulcerative colitis who are not responding to
corticosteroids, azathioprine, or 6-MP. It can be given orally or by weekly
injections under the skin or into the muscles, but it is more reliably absorbed
with the injections.
One major complication of methotrexate is the development of liver cirrhosis
when the medication is given over a prolonged period of time (years). The risk
of liver damage is higher in patients who also
abuse alcohol or are
severely
obese. Although it has been recommended that a liver biopsy should be obtained
in patients who have received a cumulative (total) methotrexate dose of 1.5
grams or higher, the need for such biopsies is controversial.
Other side effects of methotrexate include low white blood cell counts and
inflammation of the lungs.
Methotrexate should not be used in pregnant women because of toxic effects on
the fetus.
Surgery in Crohn's disease
There is no surgical cure for Crohn's disease. Even when all of the diseased
parts of the intestines are removed, inflammation frequently recurs in
previously healthy intestines months to years after the surgery. Therefore,
surgery in Crohn's disease is used primarily for:
Removal of a diseased segment of the small intestine
that is causing obstruction.
Drainage of pus from abdominal and peri-rectal
abscesses.
Treatment of severe anal fistulae that do not respond
to drugs.
Resection of internal fistulae (such as a fistula between the colon and
bladder) that are causing infections.
Usually, after the diseased portions of the intestines are removed
surgically, patients can be free of disease and symptoms for some time, often
years. Surgery, when successfully performed, can lead to a marked improvement in
a patient's quality of life. In many patients, however, Crohn's disease
eventually returns, affecting previously healthy intestines. The recurrent
disease usually is located at or near the previous site of surgery. In fact, 50%
of patients can expect to have a recurrence of symptoms within four years of
surgery. Drugs such as Pentasa or 6-MP have been useful in some patients to
reduce the chances of relapse of Crohn's disease after surgery.
There is accumulating evidence in favor of post-operative therapy to delay
recurrence in Crohn's disease. There appears to be some benefit of mesalamine in
reducing the risk of post-op recurrence for up to 3 years. A recent study has
also shown infliximab to be effective in preventing postoperative recurrence
after ileocecal resection, though relapse may occur when therapy is stopped5.
Treatment strategies by severity and location of disease (Based on the Second
European Evidence-Based Consensus on the Diagnosis and Management of Crohn's
Disease.)8
Mild to Moderate Active Disease
Commonly treated with oral mesalamine 3.2-4 g daily or sulfasalazine for
ileocolonic or colonic disease as 3-6 g daily in divided doses (this approach
has more recently been reported to be not very effective).
Budesonide (9 mg/day) is effective for disease confined to ileum and/or right
colon.
Proton pump inhibitors might help with symptomatic improvement in patients
with upper gastrointestinal Crohn's disease.
Moderate to Severe Disease
Prednisone 40-60 mg/day until resolution of symptoms.
Appropriate antibiotic therapy for infection or abscess.
Azathioprine and 6-MP are effective for maintaining a steroid-induced
remission.
Methotrexate 25 mg/wk is effective for steroid-dependent and
steroid-refractory Crohn's disease.
Infliximab, adalimumab, and certolizumab pegol are effective in the treatment
of moderate to severely active disease in patients who have not responded to
adequate therapy with a steroid or immunosuppressive agent.
Natalizumab is effective in the treatment of patients with moderate to
severely active CD who have had an inadequate response or are unable to tolerate
conventional Crohn's disease therapy and anti-TNF antibody therapy.
Perianal or Fistulizing Disease
Surgical drainage for abscess
Otherwise, treated medically with antibiotics (metronidazole),
immunosuppressives, or infliximab.
Are there any recommendations for diet,
supplementation, or vaccinations for Crohn's disease?
Dietary
changes and supplementation that may help control Crohn's
disease.
Since fiber is poorly digestible, it can worsen the
symptoms of intestinal obstruction. Hence, a low
fiber diet may be recommended,
especially in those patients with small intestinal disease.
A liquid diet may be
of benefit when symptoms are more severe.
Intravenous nutrition or TPN (total
parenteral nutrition) may be utilized when it is felt that the intestine needs
to "rest."
Supplementation of calcium,
folate and
vitamin B12 is helpful
when malabsorption of these nutrients is apparent.
The use of anti-diarrheal
agents (diphenoxylate and atropine [Lomotil],
loperamide [Imodium]) and antispasmotics also can help relieve symptoms of
cramps and diarrhea.
Vaccination recommendations for individuals with Crohn's disease
It is recommended that adults with inflammatory bowel disease generally
follow the same vaccination schedules as the general population.
They should
receive a single dose of Tdap, then Td booster every 10 years.
Women between the
ages of 9 and 26 should receive 3 doses of
HPV vaccine (and consideration should
be given to older patients who are HPV negative on
Pap smear). Men in the same
age range should also consider being vaccinated given the increased risk of HPV
with immunosuppression.
The influenza (flu) vaccine should be given annually to all patients
(though the live intranasal vaccine is contraindicated in patients on
immunosuppressive therapy).
One dose of pneumococcal vaccine should be given
between age 19-26 and then revaccination after 5 years.
Meningococcal vaccine is only recommended for patients with
anatomic or functional asplenia, terminal complement deficiencies, or others at
higher risk (college students, military recruits, etc).
A recent study found that active smoking is a risk factor for Crohn's
disease, and passive smoking can also contribute to a worse prognosis.
Therefore, smoking cessation should be advised among patients with Crohn's
disease.11
Osteoporosis with markedly reduced bone mineral densities has also
increasingly been recognized as a significant health problem in patients with
inflammatory bowel disease. Screening with a bone density study is recommended
in postmenopausal woman, men > age 50, patients with prolonged corticosteroid
use (> 3 consecutive months or recurrent courses), patients with personal
history of traumatic fractures with minimal trauma, and patients with
hypogonadism11. Most patients with inflammatory bowel disease should be taking
calcium and vitamin D supplements.
Crohn's Disease - Symptoms at Onset of DiseaseQuestion: The symptoms of crohn's disease can vary greatly from patient to patient. What were your symptoms at the onset of your disease?
Abdominal pain is pain in the belly and can be acute or chronic. Causes include inflammation, distention of an organ, and loss of the blood supply to an organ. Abdominal pain can reflect a major problem with one of the organs in the abdomen such as the appendix, gallbladder, large and small intestine, pancreas, liver, colon, duodenum, and spleen.
Diarrhea is a change is the frequency and looseness of bowel movements. Cramping, abdominal pain, and the sensation of rectal urgency are all symptoms of diarrhea. Absorbents and anti-motility medications are used to treat diarrhea.
Gallstones are stones that form when substances in the bile harden. Gallstones (formed in the gallbladder) can be as small as a grain of sand or as large as a golf ball. There can be just one large stone, hundreds of tiny stones, or any combination. The majority of gallstones do not cause symptoms.
Pink eye, also called conjunctivitis, is redness or irritation of the conjunctivae, the membranes on the inner part of the eyelids and the membranes covering the whites of the eyes. These membranes react to a wide range of bacteria, viruses, allergy-provoking agents, irritants, and toxic agents.
Anemia is the condition of having less than the normal number of red blood cells or less than the normal quantity of hemoglobin in the blood. The oxygen-carrying capacity of the blood is, therefore, decreased.
Colon cancer is a malignancy that arises from the inner lining of the colon. Most, if not all, of these cancers develop from colonic polyps. Removal of these precancerous polyps can prevent colon cancer.
Anal itching is the irritation of the skin at the exit of the rectum, known as the anus, accompanied by the desire to scratch. Causes include everything from irritating foods we eat, to certain disease and infections. Treatment options include local anesthetics, vasoconstrictors, protectants, astringents, antiseptics, keratolytics, analgesics, and corticosteroids. If condition persists, a doctor examination may be needed to identify an underlying cause.
Clostridium difficile (C. difficile) is a bacterium, and is one of the most common causes of infection of the colon. C. difficile spores are found frequently in hospitals, nursing homes, extended care facilities, and nurseries for newborn infants. They can be found on bedpans, furniture, toilet seats, linens, telephones, stethoscopes, fingernails, rings, floors, infants' rooms, and diaper pails. They even can be carried by pets. Antibiotic-associated (C. difficile) colitis is an infection of the colon caused by C. difficile that occurs primarily among individuals who have been using antibiotics. Treatment for C. difficile colitis hydration, replenishment of electrolyte deficiencies, discontinuing the antibiotic that caused the colitis, and using antibiotics to eradicate the C. difficile bacterium.
Ulcerative colitis is a chronic inflammation of the colon. Symptoms include abdominal pain, diarrhea, and rectal bleeding. Ulcerative colitis is closely related to Crohn's disease, and together they are referred to as inflammatory bowel disease. Treatment depends upon the type of ulcerative colitis diagnosed.
Small intestinal bacterial overgrowth (SIBO) refers to a condition in which abnormally large numbers of bacteria (at least 100,000 bacteria per ml of fluid) are present in the small intestine and the types of bacteria in the small intestine resemble more the bacteria of the colon than the small intestine. There are many conditions associated with small intestinal bacterial overgrowth, to include: diabetes, scleroderma, Crohn's disease, and others. There is a striking similarity between the symptoms of irritable bowel syndrome and SIBO. It has been theorized that SIBO may be responsible for the symptoms of at least some patients with irritable bowel syndrome. Symptoms of SIBO include: excess gas, abdominal bloating, diarrhea, and abdominal pain.
Ankylosing spondylitis is a type of arthritis that causes chronic inflammation of the spine. The tendency to develop ankylosing spondylitis is genetically inherited.
Psoriatic arthritis is a disease that causes skin and joint inflammation. Symptoms include painful, stiff, and swollen joints, tendinitis, and organ inflammation. Treatment involves antiinflammatory medications and exercise.
Inflammation of the inner lining of the colon is referred to as colitis. Symptoms of the inflammation of the colon lining include diarrhea, pain, and blood in the stool. There are several causes of colitis including infection, ischemia of the colon, inflammatory bowel disease (Crohn's disease, Ulcerative colitis, or microscopic colitis). Treatment depends on the cause of the colitis.
Canker sore is a small ulcer crater in the lining of the mouth. Canker sores are one of the most
common problems that occur in the mouth. Canker sores typically last for
10-14 days and they heal without leaving a scar.
The inflammatory bowel diseases (IBD) are Crohn's disease (CD) and ulcerative colitis (UC). The intestinal complications of Crohn's disease and ulcerative colitis differ because of the characteristically dissimilar behaviors of the intestinal inflammation in these two diseases.
Gastritis is an inflammation of the stomach lining. Causes of gastritis include drinking too much alcohol, medications such as NSAIDs, ibuprofen, aspirin, H. pylori infection, severe infections, burns, anemia, and autoimmune disorders. Gastritis is diagnosed with endoscopy, blood tests, or stool tests. Treatment depends upon the cause of gastritis.
Erythema nodosum is a skin inflammation that results in reddish, painful, tender lumps most commonly located in the front of the legs below the knees. Erythema nodosum can resolve on its own in 3 to 6 weeks, leaving a bruised area. Treatments include anti-inflammatory medications and cortisone by mouth or injection.
Corticosteroid drugs such as prednisone and prednisolone are commonly used to treat asthma, allergic reactions, RA, and IBD. Steroids such as these do have serious drawbacks such as steroid withdrawal symptoms such as: fatigue, weakness, decreased appetite, weight loss, nausea, vomiting, abdominal pain, and diarrhea. Speak with your healthcare provider prior to tapering off steroid medications.
Chronic pain is pain (an unpleasant sense of discomfort) that persists or progresses over a long period of time. In contrast to acute pain that arises suddenly in response to a specific injury and is usually treatable, chronic pain persists over time and is often resistant to medical treatments.
Bronchiectasis is a condition in which the bronchial tubes of the lung become damaged. Inflammation from infection or other causes destroys the smooth muscles of the bronchial tubes. Bronchiectasis is a form of COPD (which includes emphysema and chronic bronchitis). There are three primary types of bronchiectasis: 1) cylindrical bronchiectasis; 2) saccular bronchiectasis; and 3) cystic bronchiectasis. Bronchiectasis may also be acquired or congenital. The most common symptoms of bronchiectasis are recurrent cough and sputum production. There is no cure for bronchiectasis. Treatment is often geared toward controlling the symptoms of bronchiectasis.
Primary sclerosing cholangitis (PSC) is a chronic, progressive disease of the bile ducts that channel bile from the liver into the intestines. There is an association between primary sclerosing cholangitis and ulcerative colitis and Crohn's disease. Symptoms of primary sclerosing cholangitis include abnormal liver blood tests, itching, fatigue, and jaundice. Primary sclerosing cholangitis is treated with medications and in some cases, liver transplant.
Digestion is the complex process of turning food you eat into the energy you need to survive. The digestive process also involves creating waste to be eliminated, and is made of a series of muscles that coordinate the movement of food.
Vitamin D deficiency has been linked with rickets, cancer, cardiovascular disease, severe asthma in children and cognitive impairment in older adults. Causes include not ingesting enough of the vitamin over time, having limited exposure to sunlight, having dark skin, and obesity. Symptoms include bone pain and muscle weakness. Treatment for vitamin D deficiency involves obtaining more vitamin D through supplements, diet, or exposure to sunlight.
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