Treatment of Crohn's disease - medication and surgery

Therapeutic tactics for Crohn's disease depend on the degree of activity of the pathological process.

You can read about the causes and symptoms of the disease in the article “ Crohn's disease ”.

Treatment Goals

• Improving and maintaining the patient's quality of life.
• Treatment of the acute stage: reduction of acute symptoms, reduction of inflammation of the intestinal mucosa.
• Maintaining remission (quiet phase of the disease), ideally without steroids, preventing complications.

Treatment of CD during exacerbation

During this period it is recommended:

• limit fiber intake and, if tolerated, consume sufficient amounts of dairy products;
• use a slag-free (highly digestible) diet to reduce stool frequency;

• during the period of exacerbation, complete physical and mental rest must be ensured.

For emotional calm, you can drink moderate amounts of sedatives.

In the presence of intestinal ulcerations, it is recommended:

• liquid or parenteral nutrition , which reduces acute symptoms and promotes the disappearance of inflammation;
• to give up smoking;
• if necessary, prescribing hormones.

To objectively assess the activity of the inflammatory process and the effectiveness of the treatment, the Best index is used.

Best Crohn's Disease Activity Index

The Best Activity Index allows you to assess the degree of disease activity based on symptoms. Normally it should be equal to 0.

If more than 150, then the activity is high, if less than 150, then the disease activity is low.

The calculation method is in points 1-3. The patient records daily data for a week. These data are summed up and multiplied by the appropriate coefficient.

In paragraph 4, body weight deficit is calculated using the formula:

You can determine normal body weight here .

Diet

Following a diet for Crohn's disease is of utmost importance. All types of food that are poorly tolerated by a given patient are excluded from food.

Patients with activity less than 150 points are prescribed diet No. 4b .

If the degree of activity is above 150 points, patients are also recommended to diet 4b, but with the introduction of partial enteral or parenteral nutrition (elemental diet). The dosage of drugs depends on calorie needs. You should start with small doses, as non-slag preparations can cause diarrhea. Due to poor taste, the formula may be administered through a nasogastric tube. More details https://ogivote.ru/dieta/enteralnoe-parenteralnoe-pitanie.html .

The elemental diet is especially indicated for patients with intestinal fistulas or obstructions, as well as for children with growth retardation. It is also used in preoperative preparation.

In especially severe cases, the patient is completely transferred to parenteral nutrition.

After the body temperature decreases and the abdominal pain and diarrhea cease, you should gradually begin to switch to a normal diet (diet No. 4c).

Failure to follow dietary recommendations leads to significant weight loss, may increase the risk of secondary infection and worsen the results of surgical treatment.

If there is damage to the small intestine and symptoms of impaired absorption, fat-soluble vitamins, folic acid and vitamin B₁₂ are prescribed. It is necessary to add calcium, magnesium and zinc supplements.

In patients after extensive resection (100 cm) of the small intestine, steatorrhea develops due to impaired absorption of bile acids. In this case, it is necessary to use a diet low in fat. Additionally, medium-chain triglycerides are prescribed, since they do not require bile acids for absorption.

Anti-inflammatory drugs

Drugs with anti-inflammatory properties are used to treat Crohn's disease.

The main drugs are sulfasalazine, mesalazine (Salofalk) and corticosteroids.

With low activity of the inflammatory process (less than 150 points), and localized in the colon and ileocecal region, sulfasalazine is used.

The mesalazine tablet (salofalk, mesacol, salosinal) has a water-soluble coating, due to which the active substance begins to dissolve in the ileum (15-30%). The main part (60-75%) is released from the tablet in the colon.

Salosinal is effective for mild to moderate Crohn's disease of the colon and ileum.

Salofalk, as a maintenance therapy, can significantly reduce the number of exacerbations of Crohn's disease of the colon and distal small intestine.

Pentaxa gives an effect when the process is localized in the jejunum.

Prednisone

With pronounced activity (over 150 points), as well as in the absence of effect from treatment with the above drugs, prednisolone is used.

Prednisolone is effective primarily for Crohn's disease of the small intestine. It is recommended to take it immediately for patients with moderate to severe disease.

The dose should be adjusted daily according to the severity of the disease (no more than 1.0 mg per 1 kg of body weight). Corticosteroids may be given intravenously if the disease is severe.

For Crohn's disease of the rectum, enemas with corticosteroids are given daily, 2 times a day.

Corticosteroids cannot be used for a long time due to the development of side effects - diabetes, osteoporosis, increased blood pressure, bleeding.

After 3-4 weeks, the dose is reduced by 5 mg per week.

Treatment with anti-inflammatory drugs should be long-term. The minimum daily doses that can be used for several months are:

• mesalazine - 0.5-1 mg;
• sulfasalazine - 1-1.5 mg;
• prednisolone – 5-10 mg.

Combining these drugs is not advisable, as it does not give a positive effect.

Budenofalk

The indication for the use of budenofalk in the treatment of Crohn's disease is the acute stage of mild to moderate severity with localization in the ileum and the spread of the process to part of the ascending colon.

This drug is not recommended for use in cases of damage to the stomach and upper parts of the small intestine, as well as for extraintestinal lesions (skin, eyes, joints), since it has a local effect.

Immunosuppressants

There is no consensus among experts regarding the use of immunosuppressants (azathioprine, imuran). In some cases, they contribute to the healing of fistulas and severe manifestations of the disease in the intestines. However, severe side effects are also possible (for example, leukopenia, pancreatitis) and an increased risk of malignant diseases with long-term use.

Antibiotics

Antibiotics in the treatment of Crohn's disease are used in the event of a secondary infection, the presence of purulent complications, or infiltrates in the abdominal cavity.

Semi-synthetic penicillins (ampicillin, pentrexil) are recommended. The course of treatment should usually not exceed 2 weeks due to the risk of developing severe dysbiosis. At the same time, metronidazole can be used.

Metronidazole can be used as an alternative to mesalazine when Crohn's disease is localized in the ileocecal region, colon and perianal area.

Symptomatic remedies

Symptomatic medications should be taken with caution. So it must be taken into account that drugs such as imodium, diphenoxylate, codeine phosphate, used for cramping pain and diarrhea, increase intraintestinal pressure. In patients with ulcerative-destructive changes in the intestine, they can lead to intestinal perforation. They can be used only at the final stage of treatment and in a hospital setting, under the supervision of a doctor.

If there are no signs of intestinal obstruction, then you can take Smecta or Almagel to reduce diarrhea.

Patients with extensive lesions of the ileum or after its resection are prescribed cholestyramine, which binds bile acids.

If a patient with CD has diarrhea syndrome, it is necessary to exclude the development of clostridia (Clostridium difficile).

Maintenance treatment

After remission of Crohn's disease occurs, all medications are gradually discontinued. The drug must be withdrawn very slowly and maintained on maintenance therapy (low doses of medication) for months or years.

Surgical treatment of complications of Crohn's disease

Surgery should not be the primary treatment option. Surgery is indicated only if there is no effect from drug treatment or in case of complications. The rate of reoperation is high, especially for small bowel lesions. But postponing this treatment when it is necessary is dangerous.

Indications for surgery

There are absolute indications for surgery (when it must be done unambiguously) and relative ones (they do not require immediate surgical intervention, but strict monitoring is needed and, if urgent indications arise, surgery is required).

Absolute readings:

• intestinal perforation;
• peritonitis;
• toxic intestinal dilatation;
• heavy bleeding;
• acute intestinal obstruction.

Relative readings:

• lack of effect from drug therapy;
• chronic partial intestinal obstruction;
• lesions of the skin, eyes, joints that are not amenable to conservative treatment.

Surgical Treatment Options

• Drainage of abscesses.
• Segmental resection of the intestine.
• Gentle strictureplasty.
• Application of ileorectal or ileo-colon anastomosis.
• Temporary diverting ileostomy/colostomy in the presence of severe perianal fistulas.

Intestinal obstruction (obstruction)

Intestinal obstruction is one of the most common complications of Crohn's disease. It often develops when the ileum and ileocecal region are affected. Surgical treatment involves removing the minimum required portion of the small or large intestine.

Interintestinal abscess

Antibiotics are rarely effective for this complication, so treatment is usually surgical. The operation involves removing part of the intestine and draining the abscess. To avoid short bowel syndrome when part of it is removed, the operation is often performed in two stages.

At the first stage, the abscess is drained through a separate incision. After the inflammation subsides and the inflamed area decreases, the second stage is carried out - removal of the affected part of the intestine.

Intestinal fistula

A fistula is formed when the patency of the intestine is impaired due to thickening of its wall or as a result of its compression. Fistulas can be external or internal. In most cases, they require surgical treatment, especially in cases of large blind loop formation.

In addition to drainage and resection (removal) of abscesses in CD, stricturoplasty (opening of the stricture without removing the intestine) and excision of perirenal fistulas with plastic surgery of normal mucosa from other areas are used.

The most common variant of stricturoplasty is longitudinal dissection of the narrowed area with suturing with perpendicular sutures. Before plastic surgery, a frozen section of tissue from the area of ​​the stricture is sent for histological examination to exclude colorectal cancer.

Perianal abscesses

This type of complication occurs in 50% of patients, especially with localization in the rectum. Surgery is usually limited to incision and drainage of the abscess, although a temporary colostomy or ileostomy is sometimes necessary.

In conclusion, it should be noted that from 3 to 40% of patients with localization of the process in the small intestine undergo repeated resection. The results of surgical treatment of Crohn's disease of the colon are somewhat better than those with localization in the small intestine.

Relapse Prevention

All patients must be under strict constant supervision of a gastroenterologist, as they require constant therapy.

Practice shows that when all medications are discontinued, exacerbations appear within 6-12 months. In this regard, continuous maintenance treatment is recommended.

Metronidazole has good results with maintenance therapy. Its use may be limited by side effects such as taste disturbance and neuropathy.

A very important factor is quitting smoking, which significantly reduces the frequency of exacerbations of CD.

A necessary condition is compliance with the diet.

We have tried to outline all aspects of the disease and modern methods of treating it. However, self-medication is unacceptable; the course of treatment must be prescribed by a doctor.