Small Crohn 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. 

Paralytic ileus, due to intrinsic abnormalities of the bowel wall, can be caused for example by drugs, after laparotomy, sepsis or peritonitis. Obstructive ileus is most often due to extrinsic causes, for example adhesions (in 70% of cases), incarcerated hernia, small bowel wall hematoma posttraumatic, neoplasms, Crohn disease and intussusception (Parker 2003 Devos and Meradji 2003). Clinically the child has a distended and tender abdomen with failure to pass stools or no defecation and possibly (bilious) vomiting. 

Fig. 5.23. a Enteroclysis in a boy with Crohn disease. The terminal ileum is affected and narrowed with prestenotic dilatation. There is an effacement of the mucosal pattern and septation of loops. Infiltration of the mesenteric fat causes isolation of the terminal ileum, b Crohn disease. CT demonstrates thickened small bowel up to distended cecum, c-e Child with Crohn disease. The US images show an irregular bowel wall thickening and a hyperechoic thickened mesentery... 

Di Mizio R, Macon i G, Romano S et al (2004) Small bowel Crohn disease sonographic features. Abdom Imaging 29 23-35... 

Yekeler E, Danalioglu A, Movasseghi B et al (2005) Crohn disease activity evaluated by Doppler ultrasonography of the superior mesenteric artery and the affected small-bowel segments. J Ultrasound Med 24 59-65... 

Crohn disease is a chronic granulomatous inflammatory intestinal disease with a mean age of presentation in the third and fourth decades. It can affect any part of the gastrointestinal tract from the mouth to the anus, often involving multiple discontinuous sites. The small intestine is involved in 80% of cases,... 

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... 

Wold PB, Fletcher JG, Johnson CS, Sandborn WJ (2003) Assessment of small bowel Crohn disease noninvasive peroral CT enterography compared with other imaging methods and endoscopy-feasibility study. Radiology 229 275-281... 

Neutral contrast agents have been shown to be valuable in the diagnosis of small-bowel disorders, including ischemia, neoplasms, and Crohn disease. 

That CT enterography helps detect both active Crohn disease and small howel strictures is particularly important now that early reports have shown that endoscopic patency capsules may themselves precipitate small bowel obstruction (Gay et al. 2005 Boivin et al. 2004). In many institutions, capsule endoscopic assessment is reserved for patients with negative CT examinations in whom clinical suspicion remains. 

MDCT-E is not used for the diagnosis or staging of ulcerative colitis. Even when radiologic findings are present, they are often non-specific (Horton et al. 2000). Because of the sensitivity of CT enterography for Crohn disease, the principal role of this modality in patients with suspected ulcerative colitis is to help exclude findings of Crohn disease such as small bowel inflammation. 

Doerfler OC, Ruppert-Kohlmayr AJ, Reittner P et al (2003) Helical CT of the small bowel with an alternative oral contrast material in patients with Crohn disease. Abdom Imaging 28 313-318... 

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). 

Sanderson, I.R., Udeen, S., Davies, P.S.W., Savage, M.O. and Walker-Smith, J.A. (1987). Remission induced by an elemental diet in small bowel Crohn s disease. Arch. Dis. Child. 61, 123-127. 

Ahrenstedt, O., Knutson, L., Nilsson, B., Nilsson-Ekdahl, K., Odlind, B. et al., Enhanced local production of complement components in the small intestines of patients with Crohn s disease, N. Engl. J. Med. 1990, 322, 1345-1349. 

Fallingborg, J., Pedersen, F., Jacobsen, B. A., Small intestinal transit time and intraluminal pH in ileocecal resected patients with Crohn s disease, Dig. Dis. Sci. 1998, 43, 702-705. 

Although hereditary neuropathies and myopathies affecting small intestinal motility are rare, the entire spectrum of diseases that can interfere with motility is wide, including for example diabetes mellitus, Crohn s disease, scleroderma, and postoperative and radiation sequelae [21,71, 116, 123, 131]. 

Inflammation. Chronic inflammatory bowel disease affecting the small bowel can lead to disturbances of intestinal motility [146], Potential mechanisms are previous surgery, development of fibrosis and strictures, malabsorption, and cross-talk between inflammatory and enteric nerves [156, 157], Patients with Crohn s disease are often included in aggregate studies of bacterial overgrowth [23, 75, 158], reflecting this link. 

Castiglione F, Rispo A, Di Girolamo E, Cozzo-lino A, Manguso F, Grassia R, et al Antibiotic treatment of small bowel bacterial overgrowth in patients with Crohn s disease. Aliment Pharmacol Ther 2003,18 1107-1112. 

Ulcerative colitis and Crohn s disease differ in two general respects anatomic sites and depth of involvement within the bowel wall. There is, however, overlap between the two conditions, with a small fraction of patients showing features of both diseases (Table 26-2). 

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