Crohn's Disease

Key Terms

• IBD
• Inflammatory Bowel Diease
• IBD Flare
• previoulsy sx free but now w/ sx
• Primary Nonresponse
• no response to pharmacotherpy
• Secondary Nonresponse
• d/t either low lvl of therapy or antibody generation against pharm agent

Epidem

• Risk Factors

Etiology

• Initial Insult
• Disease Flare
• Antibody generation against pharmacotherapy
• Infection
• Medication non compliance
• Obesity, sleep disturbance, stress
• Cigarette Smoking

Patho

• Explain the functional changes associated with the condition here.

HPI

• Include details about the patient's symptoms and history here.

Physical Exam

• Describe key findings from the physical examination here.

Diagnostics

• General Monitoring
• If sx free, monitor in 3-6 months
• If sx, immediately assess for active inflammation/infection
• Low drug levels
• development of antibodies to therapy
• Screenings
• Bone mineral density -> DEXA
• Melanoma -> Dermatology
• Cervical Cancer -> PAP Smear (annually w/ immunosuppressives)
• Anxiety / Depression -> PHQ-9
• Colorectal Cancer -> Colonoscopy
• Anemia -> CBC, Iron, ferritin, folate, B12,
• Nutrition -> albumin
• IBD Flare
• imaging is indicated because labs do not differentiate b/w infection and inflammation
• gold standard is colonoscopy
• colonoscopy > MRE > abdominal CT
• C. diff testing
• if recent travel to endemic areas, parasitic testing
• Fecal Calprotectin
• correlation b/w small and large intestinal inflammation and endoscopic disease activity
• more sensitive than ESR/CRP
• does not differentiate b/w small and large intestinal inflammation
• does not differentiate b/w inflammation and infection processes
• Asymtomatic pt w/ elevated lvl means sx recurrence w/in 3 months
• Nrml lvl means remission of sx for about 3 months
• CRP - C-reactive Protein
• non specific
• ESR
• non specific
• Ileocolonsocopy
• Gold Standar in assessing disease activity

Tx

• Lifestyle Modification
• Smoking Cessation
• Weight loss if overweight
• Preventative
• Vaccines - recommendations are different for this pt population
• Pneumococcal Vaccine
• COVID-19 Vaccine
• High Dose Influenza Vaccine(not live vaccine d/t immunosuppressives)
• Herpes Zoster
• Hep A, Hep B
• Tdap
• HPV
• Meningococal
• MMR / Varicella (not while on immunosuppressives
• Immunosuppressive Therapy
• TNF Agents
• Infliximab
• If antidrug antibodies, switch to different agent rather than increase dose
• Adalimumab
• Vedolizumab
• Ustekinumab
• if primary non-response to anti-TNF
• Recent FDA approvals: Risankizumab and Upadacitinib
• Surgical
• involve surgery early in the care of Crohn's Disease

Referrals

• Dermatology
• risk of developing melanoma w/ anti-TNF agents
• risk of developing non-melanoma squamous cell cancer
• thus need individualized plan for ongoing skin cancer surveilance
• Surgery
• ???

References