Small bowel disease

Sulfasalazine treatment results in an 85% remission rate in mild to moderate ulcerative colitis. Termination of therapy leads to an 80% relapse within the next year. In Crohn s disease, sulfasalazine acts primarily on involved colonic mucosa, although remission of ileal disease also has been reported. The National Cooperative Crohn s Disease Study found sulfasalazine to be better in the treatment of colonic disease, while corticosteroids were judged better in the treatment of small bowel disease. Since sulfasalazine does not prevent relapse of Crohn s disease once remission is achieved, maintenance therapy is not characteristically used. 

In contrast to ulcerative colitis, about 50% of patients with Crohn s colitis will respond to metronidazole given for up to 3 months, although adverse effects including alcohol intolerance, and peripheral neuropathy from such prolonged therapy often limit its use. The drug is also helpful in controlling perianal and small bowel disease and it decreases the incidence of anastamotic recurrence after surgery. Other antimicrobials, particularly ciprofloxacin may also be effective. 

In an 18-month, double-blind, randomized, placebo-controlled trial in 318 patients, mesalazine 4 g/day did not significantly affect the postoperative course of Crohn s disease compared with placebo (11). There was some relapse-preventing effect in patients with isolated small bowel disease. The overall incidence of adverse effects was similar with mesalazine and placebo. Of the serious adverse effects reported, only one case of alopecia... 

Prolonged-release mesalazine also reduced disease activity in patients with mild to moderately active Crohn s disease. In Crohn s disease, mesalazine was more effective in preventing relapse in patients with isolated small bowel disease than in those with colonic involvement. Prolonged-release mesalazine appears to be as well tolerated as placebo, and the incidence of adverse effects does not appear to be dose related. Nausea/vomit-ing, diarrhea, abdominal pain, and dyspepsia are the most commonly reported. Reports of nephrotoxicity with this formulation are rare. 

Small bowel disease Mucosal lesion e.g. Celiac disease Tropical sprue Bacterial overgrowth deconjugation of bile salts) Parasites e.g. Giardia Intestinal resection Ileal disease - Crohn s Abetalipoproteinemia Drugs... 

Sucrase-isomaltase deficiency usually presents clinically in infancy when sucrose and fruit are introduced in the diet, " but sometimes first presents in adulthood. The deficiency is rare in Caucasians, but more common in Eskimo groups. Deficiencies of both lactase and sucrase-isomaltase may occur secondary to other small bowel diseases (e.g., cehac disease, Crohn s disease,or acute gastroenteritis). Trehalase deficiency is a rare disorder,except in Greenland, where it occurs in 8% of the population. It is manifested by diarrhea following the ingestion of mushrooms. 

Vitamin D and its metabolites play an important role in the maintenance of extracellular calcium concentrations and in normal skeletal structure and mineralization. Vitamin D is necessary for the optimal absorption of calcium and phosphorus. On a worldwide basis, the most common cause of hypocalcemia is nutritional vitamin D deficiency. In malnourished populations, manifestations include rickets and osteomalacia. Nutritional vitamin D deficiency is uncommon in Western societies because of the fortification of miUc with ergocalciferol. " The most common cause of vitamin D deficiency in Western societies is gastrointestinal disease. Gastric surgery, chronic pancreatitis, small-bowel disease, intestinal resection, and bypass surgery are associated with decreased concentrations of vitamin D and its metabolites. Vitamin D replacement therapy may need to be administered by the intravenous route if poor oral bioavailability is noted. Decreased production of 1,25-dihydroxyvitamin D3 may occur as a result of a hereditary defect resulting in vitamin D-dependent rickets. It also can occur secondary to chronic renal insufficiency if there is insufficient production of the 1 -a -hydroxylase enzyme for the... 

Hypomagnesemia is usually associated with disorders of the intestinal tract or kidney. Drugs or conditions that interfere with intestinal absorption or increase renal excretion of magnesium can result in hypomagnesemia (Table 50-6). Decreased intestinal absorption as a result of small bowel disease is the most common cause of hypomagnesemia worldwide. These disorders include regional enteritis radiation enteritis ulcerative colitis acute and chronic diarrhea pancreatic insufficiency and other malabsorptive syndromes small-bowel bypass surgery and chronic laxative abuse. ... 

Another common problem in the elderly is vitamin B12 deficiency, with the most common causes of clinically overt deficiency due to pernicious anemia, small bowel disease, and food-cobalamin malabsorption. A preclinical deficiency in vitamin B12 is seen in 5% to 30% of all seemingly healthy elderly patients and is predominantly metabolic in expression, although subtle neurologic and cognitive defects may be present. " ... 

Vitamin deficiency occurs when there is malabsorption because of a lack of intrinsic factor (pernicious anttemia). following gastrectomy (no intrinsic factor), or in various small bowel diseases, where absorption is impaired. Because the disease is nearly always cau.sed by malabsorption. oral vitamin administration is of little value, and replacement Iherapy, usually for life, involves injections of vitamin (left). Hydroxocobulamin is the form of choice for ilierapy because it is retained in Ihe body longer than cyanocobalamin (cyanocobalamin is bound less to plasma proteins and Ls more rapidly excreted in urine). 

These authors previously found (S12) that in all of 16 women who initially had subnormal serum folate concentrations, serum folate concentrations rose within 3 months after OCAs were stopped. Subsequently they reported (SIO) 3 women with low serum folate levels while taking OCAs and low folate polyglutamate absorption that persisted after medication was discontinued. It was of interest that one of these subjects developed gluten-sensitive enteropathy a year later and a second had a family history of that disease. Other case reports of folate deficiency and mild intestinal malabsorption in users of OCAs have appeared (J3, T2, W12). It should be emphasized, therefore, that evidence of impaired folate absorption in women taking these agents may suggest the presence of inapparent small bowel disease. 

Wiarda BM, Kuipers EJ, Houdijk LP et al (2005) MR enterocl-ysis imaging technique of choice in diagnosis of small bowel diseases. Dig Dis Sci 50 1036-1040 Williams NM, Jackson D, Everson NW et al (1998) Is the incidence of acute appendicitis really falling Ann R Coll Surg 80 122-124... 

Pallotta N, Tomei E, Viscido A et al (2005) Small intestine contrast ultrasonography an alternative to radiology in the assessment of small bowel disease. Inflamm Bowel Dis 11 146-153... 

Bodily KD, Fletcher JG, Solem CA et al (2006) Crohn disease mural attenuation and thickness at contrast-enhanced CT enterography-correlation with endoscopic and histologic findings of inflammation. Radiology 238 505-516 Boudiaf M, Jaff A, Soyer P et al (2004) Small-bowel diseases prospective evaluation of multidetector helical CT enteroclysis in 107 consecutive patients. Radiology 233 338-344... 

Hainaux B, Agneessens E, Bertinotti R et al (2006) Accuracy of MDCT in predicting site of gastrointestinal tract perforation. AJR Am J Roentgenol 187 1179-1183 Kara AK, Leighton JA, Virender K et al (2005) Imaging of small bowel disease comparison of capsule endoscopy,... 

Both CT and MRI have proven to be valuable adjuncts to barium studies and endoscopy in the evaluation of gastric, esophageal and small bowel diseases because of their ability to delineate the primary pathologic condition and demonstrate how far the disease has extended to adjacent or distant organs. 

The availability of high performance gradient systems has allowed the acquisition of three-dimensional MR data sets in a single breath-hold. MRI offers several chances for the non-invasive diagnosis of upper GI tract and for small bowel disease. 

Bender GN, Maglinte DD, KlOppel R et al (1999) CT-enterocl-ysis a superflous diagnostic procedure or valuable when investigating small bowel disease AJR Am J Roentgenol 172 373-378... 

Zhang LH, Zhang S, Hu HJ (2005) Multi-detector CT enter-ography with iso-osmotic mannitol as oral contrast for detecting small bowel disease. World J Gastroenterol ll(15) 2324-2329... 

In inflammatory bowel disease (IBD) high fiber diets have no special part to play in the management of Crohn s disease where enteral feeding (with formula low-residue, low-fiber preparations) is especially beneficial where there is acute extensive small bowel disease. In ulcerative colitis specific dietary advice is usually unnecessary though fiber supplements may be of benefit in patients whose disease is limited to proctitis (inflammation of the rectum). 

Chalmers, R.A., Valman, H.B. and Liberman, M.M. (1979), Measurement of 4-hydroxyphenylacetic aciduria as a screening test for small bowel disease. Clin. Chem., 25,1791. 

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