Clinical Features of Crohns Disease

Crohn's disease is a disease of flares and remissions, although 10-20% of patients have refractory, chronically active, or steroid-dependent disease (Rutgeerts 2002) (Fig. 12.1). It is characterized by chronic transmural inflammation that may affect any part of the gastrointestinal tract. In approximately one-third of patients, CD is confined to the small intestine, whereas 40-50% of patients will have involvement of both the small intestine and the colon. Twenty % to 30% of patients have only colonic involvement. When disease is restricted to the colon, it can be difficult to differentiate between CD and UC. This type of disease is referred to as indeterminate colitis and is seen in approximately 5% of patients with CD. Symptoms include abdominal pain and tenderness, chronic and nocturnal diarrhea, rectal bleeding, weight loss, and fever (Hanauer and Present 2003). CD evolves over time from a primarily inflammatory disease into one of two clinical patterns -stricturing (obstructive) or penetrating (fistulizing) (Hanauer and Present 2003). Current treatment strategies for CD use a "step-up" approach. Oral 5-aminosa-

licylate agents, sulfasalazine, antibiotics, or budesonide are used as first-line therapies for mild to moderate disease. Moderate to severe disease is treated with systemic steroids, azathioprine, 6-mercaptopurine, metho-trexate, or infliximab, the first biologic indicated for treatment of CD. Severe, fulminant CD requires intravenous steroids, infliximab, conventional immunosup-pressant drugs (e.g., cyclosporine), or surgery (Fig. 12.2). The current treatment paradigm does not modify the natural course of CD. New treatment approaches are needed that will alter the natural history of CD and prevent the need for surgery. The advent of biologics is changing the goal of CD therapy. These agents have the ability to change the course of the disease and induce and maintain complete remission, thereby preventing complications (obstruction, fistuli-zation), and reducing the need for surgery.

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