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.
Rowasa is 5-ASA in enema form. 5-ASA by enema is most useful for treating
ulcerative colitis involving only the distal colon since the enema easily can
reach the inflamed tissues of the distal colon. Rowasa also is used in treating
Crohn's disease in which there is inflammation in and near the rectum. Each
Rowasa enema contains 4 grams of 5-ASA. The enema usually is administered at
bedtime, and patients are encouraged to retain the enema through the night. The
enema contains sulfite and should not be used by patients with sulfite allergy.
Otherwise, Rowasa enemas are safe and well-tolerated.
Canasa is 5-ASA in suppository form. It is used for treating ulcerative
proctitis. Each suppository contains 500 mg of 5-ASA and usually is administered
twice daily.
Both enemas and suppositories have been shown to be effective in maintaining
remission in patients with ulcerative colitis limited to the distal colon and
rectum.
Corticosteroids
Corticosteroids (for example, prednisone, prednisolone, hydrocortisone, etc.) have
been used for many years to treat patients with moderate to severe Crohn's
disease and ulcerative colitis and to treat patients who fail to respond to
5-ASA. Unlike 5-ASA, corticosteroids do not require direct contact with the
inflamed intestinal tissues to be effective.
Oral corticosteroids are potent anti-inflammatory medications. After
absorption, corticosteroids exert prompt anti-inflammatory actions throughout
the body, including the intestines. Consequently, they are used in treating
Crohn's disease anywhere in the small intestine, as well as ulcerative and
Crohn's colitis. In critically ill patients, intravenous corticosteroids (such
as hydrocortisone) can be given in the hospital. For patients with proctitis,
hydrocortisone enemas (Cortenema) can be used to deliver the corticosteroid
directly to the inflamed tissue. By using the corticosteroid topically, less of
it is absorbed into the body and the frequency and severity of side effects are
lessened (but not eliminated) as compared with systemic corticosteroids.
Corticosteroids are faster-acting than 5-ASA, and patients frequently
experience improvement in their symptoms within days of beginning them.
Corticosteroids, however, do not appear to be useful in maintaining remission in
Crohn's disease and ulcerative colitis or in preventing the return of Crohn's
disease after surgery.
Side effects of corticosteroids
The frequency and severity of side effects of corticosteroids depend on the
dose and duration of their use. Short courses of corticosteroids, for example,
usually are well-tolerated with few and mild side effects. Long-term use of high
doses of corticosteroids usually produces predictable and potentially serious
side effects. Common side effects include:
thinning of the bones (osteoporosis) with fractures of the spine.
Children
receiving corticosteroids experience stunted growth.
The most serious complication from long term corticosteroid use is aseptic
necrosis of the hip joints. Aseptic necrosis is a condition in which there is
death and degeneration of the hip bone. It is a painful condition that can
ultimately lead to the need for surgical replacement of the hip. Aseptic
necrosis also has been reported in the knee joints. It is not known how
corticosteroids cause aseptic necrosis. The estimated incidence of aseptic
necrosis among corticosteroid users is 3% to 4%. Patients on corticosteroids who
develop pain in the hips or knees should report the pain to their doctors
promptly. Early diagnosis of aseptic necrosis with cessation of corticosteroids
might decrease the severity of the aseptic necrosis and the need for
hip
replacement surgery.
Prolonged use of corticosteroids can depress the ability of the body's
adrenal glands to produce cortisol (a natural corticosteroid necessary for
proper functioning of the body). Therefore, abruptly discontinuing
corticosteroids can cause symptoms due to a lack of natural cortisol (a
condition called adrenal insufficiency). Symptoms of adrenal insufficiency
include nausea, vomiting, and even shock. Withdrawing corticosteroids too
quickly also can produce symptoms of
joint pain, fever, and malaise. Therefore,
when corticosteroids are discontinued, the dose usually is tapered gradually
rather than stopped abruptly.
Even after corticosteroids are discontinued, the adrenal glands' ability to
produce cortisol can remain depressed from months up to two years. The depressed
adrenal glands may not be able to produce increased amounts of cortisol to help
the body handle the stress of accidents, surgery, and infections. Therefore, patients
need additional corticosteroids during stressful situations to avoid developing
adrenal insufficiency. Because corticosteroids are not useful in maintaining
remission in ulcerative colitis and Crohn's disease, and because they have
predictable and potentially serious side effects, they should be used for the
shortest possible length of time.
Proper use of corticosteroids
Once the decision is made to use systemic corticosteroids, treatment usually
is initiated with prednisone, 40-60 mg daily. The majority of patients with
Crohn's disease respond with an improvement in symptoms within a few weeks. Once
symptoms have improved, prednisone is reduced by 5-10 mg per week until a dose
of 20 mg per day is reached. The dose then is reduced at a slower rate until the
corticosteroid is discontinued. Gradually reducing corticosteroids not only
minimizes the symptoms of adrenal insufficiency, it also reduces the chances of
an abrupt recurrence of inflammation.
Many doctors use 5-ASA compounds and corticosteroids together. In patients
who achieve remission with corticosteroids, 5-ASA compounds often are continued alone to
maintain remission.
In patients whose symptoms return while corticosteroids are slowly being reduced, the dose of corticosteroids is increased slightly to control the symptoms.
Once the symptoms are under control, the reduction of corticosteroids can resume at a slower pace.
Unfortunately, many patients who require corticosteroids to induce remissions
become corticosteroid dependent, (especially individuals who smoke and have
disease of the colon). These patients consistently develop symptoms
whenever the corticosteroid dose falls below a certain level. In such patients
who are corticosteroid dependent as well as in patients who are unresponsive to
corticosteroids and other anti-inflammatory medications, immuno-modulator
medications, or surgery must be considered. The management of patients who are
corticosteroid dependent or patients with severe disease that responds poorly to
medications is complex. Doctors who are experienced in treating ulcerative
colitis and Crohn's disease and in using immuno-modulators should evaluate
these patients.
Prevention of osteoporosis
Long-term use of corticosteroids can cause osteoporosis. Calcium is very
important in the formation and maintenance of healthy bones. Corticosteroids
decrease the absorption of calcium from the intestine and increase the loss of
calcium from the kidneys. Increasing dietary calcium intake is important but
alone cannot halt corticosteroid-induced osteoporosis. To prevent or minimize
osteoporosis, management of patients on long-term corticosteroids should
include:
Adequate intake of calcium (1000 mg daily in
premenopausal women, 1,500 mg daily in postmenopausal women) and vitamin D (800
units daily).
Periodic review with the doctor of the need for
continued corticosteroid treatment and use of the lowest effective dose if
continued treatment is necessary.
For patients taking corticosteroids for more than three
months, a bone density study may be helpful in determining the extent of bone
loss and the need for more aggressive treatment.
Discussion with the doctor regarding the use of alendronate (Fosamax),
risedronate (Actonel), or
etidronate (Didronel) to prevent or treat
corticosteroid-induced osteoporosis.
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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