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Inflammatory Bowel Disease

The initial diagnostic evaluation of chronic diarrhea includes stool cultures for enteric pathogens, tests for ova and parasites, Clostridium difficile toxin, and fecal leukocytes.

Ulcerative colitis

Ulcerative colitis (UC) is the most common cause of chronic colitis. The pathogenesis remain unknown. Inflammation is localized primarily in the mucosa. The most common symptoms are abdominal pain, rectal bleeding, diarrhea, fever, and malaise.

The incidence ranges from 4 to 15 cases per 100,000. Disease may present at any time but does so most often.

Extraintestinal manifestations

Musculoskeletal. Arthritis is the most common extraintestinal manifestation of ulcerative colitis. It is migratory, often involving the hip, ankle, wrist, or elbow. It is usually monoarticular and asymmetric.

Ocular. Episcleritis, uveitis, and iritis.

Dermatologic. Abnormalities may include erythema nodosum, pyoderma gangrenosum, lichen planus, and aphthous ulcers.

Hepatobiliary. Manifestations may include hepatic steatosis, primary sclerosing cholangitis (4%).

Miscellaneous. Other complications include nephrolithiasis and a hypercoagulable state.

Treatment of Crohn disease

Crohn disease (CD) is a chronic inflammatory process, which may involve any portion of the gastrointestinal tract from the mouth to the anus. Inflammation is characterized by transmural extension and irregular involvement.

Fever, abdominal pain, diarrhea, weight loss, and fatigue are common. Rectal bleeding is not as prominent a feature in Crohn disease as it is in ulcerative colitis. About 20% of patients have evidence of perianal disease, such as perirectal fistulas, anal skin tags, anal ulcerations or fissures, or perirectal abscesses. Crohn disease causes extra-intestinal manifestations like those of ulcerative colitis.

Management of ulcerative colitis

Mild-to-moderate cases of ulcerative colitis

The oral 5-ASA compound, mesalamine ( Asacol) is used for active ulcerative colitis, and olsalazine sodium ( Dipentum) is used for maintenance therapy. The target dosage for the tablet Asacol (in divided doses).

Moderately severe cases of ulcerative colitis

These patients may require rehydration or blood transfusion. Corticosteroids, a low-residue diet, and local therapy should be initiated.

Prednisone usually is started at a dose of 1 to 2 mg/kg per day for 1 to 2 weeks.

Antibiotics (metronidazole and ciprofloxacin) are useful in mild-to-moderate CD and perianal disease.

Immunosuppressive agents. Mercaptopurine and azathioprine are reserved for patients with continuous disease activity despite corticosteroid therapy. Cyclosporine may be beneficial in refractory patients.

Surgery for Crohn disease is not curative. Indications include obstruction or intractable symptoms. Disease almost always recurs.