Crohn_Disease_Presentationwowwe (1).pptx

It's a very informative ppt

1. Crohn's Disease — Overview & Treatment Definition • Classification (modern) • Presentation • Diagnosis • Treatment with drug details

2. Outline Definition & Epidemiology Montreal (modern) Classification Clinical features & complications Diagnosis & investigations Treatment strategy by form & severity Drugs: indications, contraindications, side effects, doses References / further reading

3. Definition Chronic, transmural, relapsing inflammatory bowel disease that can affect any part of GI tract from mouth to anus. Characterized by skip lesions, transmural inflammation, fistulae, strictures, and granulomas in some cases. Etiology: multifactorial — genetic predisposition, dysregulated immune response, environmental triggers, microbiome.

4. Epidemiology & Risk Factors Peak onset: 15–35 years (can occur at any age). Incidence increasing globally; higher in Western countries but rising in Asia. Risk factors: family history, smoking (worse for Crohn's), NSAID use can precipitate flares. Protective: Appendectomy (uncertain), breastfeeding (possible), certain diets. Genetics: NOD2, ATG16L1 and other susceptibility loci. Extraintestinal manifestations common: arthropathy, skin, ocular, hepatobiliary.

5. Montreal Classification (modern) A — Age at diagnosis: A1 ≤16, A2 17–40, A3 >40 L — Location: L1 ileal, L2 colonic, L3 ileocolonic, L4 isolated upper GI (can be added to L1-3) B — Behavior: B1 non-stricturing non-penetrating (inflammatory), B2 stricturing, B3 penetrating (fistulae); ±p perianal disease modifier Useful for prognosis and therapeutic decisions.

6. Clinical Signs & Symptoms Common: chronic/relapsing abdominal pain (RLQ/ileal), diarrhea (may be bloody or non-bloody), weight loss, fever, fatigue. Perianal disease: fissures, fistulae, abscesses, tags. Complications: strictures → obstruction, fistulae, intra-abdominal abscess, malabsorption, nutritional deficiencies (B12, iron, vit D). Extraintestinal: peripheral/axial arthropathy, erythema nodosum, pyoderma gangrenosum, uveitis, PSC (less frequent vs UC).

7. Diagnosis & Investigations Clinical assessment + labs: CBC (anemia), CRP/ESR (inflammation), electrolytes, LFTs, albumin. Stool tests: rule out infection (culture, C. difficile), fecal calprotectin (sensitive for intestinal inflammation). Endoscopy: ileocolonoscopy with biopsies — gold standard for diagnosis and assessment. Cross-sectional imaging: CT enterography / MR enterography for extent, strictures, fistulae, abscess. Small bowel evaluation: capsule endoscopy (if no high-grade stricture) or enterography. Histology: discontinuous transmural inflammation, fissuring ulcers, granulomas (in some).

8. Severity & Indices Clinical indices (example): Crohn's Disease Activity Index (CDAI) — used in trials. Practical severity stratification: Mild — moderate — severe/fulminant based on systemic signs, labs, weight loss, obstruction, peritonitis, high fever, severe pain. Also consider disease behaviour (inflammatory vs stricturing vs penetrating) and location for treatment choice.

9. Treatment Principles Goals: induce and maintain remission, heal mucosa, prevent complications and surgery, treat complications (abscess, obstruction, fistula). Step-up vs top-down approaches: high-risk patients (severe disease, early complicated disease) may benefit from earlier biologic therapy (top-down). Multidisciplinary care: gastroenterology, surgery, nutrition, radiology, stoma care, IBD nurse. Address smoking cessation, vaccination status, bone health, fertility/pregnancy counselling.

10. Medical Treatment by Form & Severity (Summary) Mild ileocecal disease: budesonide 9 mg/day (for up to 8 weeks) preferred over systemic steroids. Moderate–severe luminal disease: systemic corticosteroids (prednisone 40–60 mg/day) for induction; steroid-sparing with thiopurines or methotrexate; biologics if steroid‑dependent or refractory. Perianal/fistulizing disease: antibiotics (metronidazole, ciprofloxacin) + anti-TNF (infliximab) for fistula closure; seton and surgery as needed. Stricturing disease with obstructive features: consider endoscopic balloon dilation for short fibrotic strictures; surgery if refractory. Abscess: drain (radiologic/surgical) + antibiotics; defer immunosuppression until controlled.

11. Selected Drugs — Part 1 Prednisone Budesonide (Entocort) 5-ASA (mesalazine) Metronidazole Systemic induction; many adverse effects long‑term (osteoporosis, hyperglycemia). Lower systemic exposure; good for terminal ileum/ascending colon. Usual 9 mg once daily for induction. Limited evidence in Crohn's; more effective in UC; sometimes used for colonic Crohn's. Useful for perianal disease and abscess adjunct; side effects: metallic taste, neuropathy with long use.

12. Selected Drugs — Part 2 (Immunomodulators & Biologics) Azathioprine / 6‑MP Methotrexate Infliximab Adalimumab Vedolizumab Ustekinumab Thiopurines — maintenance, steroid‑sparing. Azathioprine ~2–2.5 mg/kg/day; monitor TPMT, CBC, LFTs. IM/SC weekly for steroid‑sparing (e.g., 25 mg/week); teratogenic — contraindicated in pregnancy. Anti‑TNF IV monoclonal antibody — induction & maintenance. Typical dosing 5 mg/kg IV at 0,2,6 weeks then q8w. Anti‑TNF SC option — induction often 160 mg then 80 mg at 2 weeks then 40 mg q2w; may escalate. Anti‑α4β7 integrin — 300 mg IV at 0,2,6 weeks then q8w; gut selective (slower onset). Anti‑IL12/23 — weight‑based IV induction then 90 mg SC maintenance (product dependent).

13. Azathioprine / 6‑Mercaptopurine — Key Points Indication: maintenance therapy, steroid‑sparing; often used with biologics for combination therapy. Dose: Azathioprine 2–2.5 mg/kg/day (start lower and titrate); check TPMT before start if available. Contraindications: prior thiopurine‑induced pancreatitis, active severe infection, severe hepatic impairment. Side effects: bone marrow suppression, hepatotoxicity, pancreatitis, increased infection and lymphoma risk. Monitoring: CBC, LFTs every 1–2 weeks initially, then every 1–3 months.

14. Methotrexate — Key Points Indication: steroid‑sparing maintenance in Crohn's (particularly when thiopurines not tolerated). Dose: typical 25 mg IM/SC weekly (or 15–25 mg/week PO in some settings); give folic acid to reduce toxicity. Contraindications: pregnancy (teratogenic), severe liver disease, significant renal impairment, alcohol abuse. Side effects: nausea, stomatitis, hepatotoxicity, cytopenias, pulmonary fibrosis (rare). Monitoring: CBC, LFTs, renal function regularly; counsel on contraception.

15. Anti‑TNF Agents — Key Points Indications: moderate–severe active Crohn's, steroid‑dependent disease, fistulizing disease (infliximab effective for fistula closure). Infliximab dosing: 5 mg/kg IV at 0,2,6 weeks then q8w (dose escalation possible for loss of response). Adalimumab: induction often 160 mg day 0, 80 mg at week 2, then 40 mg q2w (may increase to weekly). Contraindications: active serious infection (latent TB), caution in congestive heart failure (NYHA III/IV). Side effects: infusion/injection reactions, infections, rare demyelination, antibody formation; monitor drug levels if loss of response.

16. Vedolizumab & Ustekinumab — Key Points Vedolizumab: gut‑selective anti‑integrin; dosing 300 mg IV at 0,2,6 weeks then q8w. Slower onset; favorable safety profile. Ustekinumab: anti‑IL12/23; IV weight‑based induction then 90 mg SC maintenance q8–12 weeks depending on response. Indications: moderate–severe Crohn's, especially after anti‑TNF failure or when safety concerns exist. Side effects/monitoring: screen for infections; monitor clinical response; overall acceptable safety profile.

17. Fistulizing & Perianal Disease Management Examination and imaging; drainage of abscesses; seton placement as needed. Short course antibiotics (metronidazole ± ciprofloxacin) as adjunct. Anti‑TNF therapy (infliximab) has best evidence for fistula closure; combine with surgery for best outcomes. Consider ustekinumab/vedolizumab in refractory cases; surgical options if medical therapy fails.

18. Abscess & Infection Considerations Drain abscesses (radiologic or surgical) and give antibiotics prior to starting or escalating immunosuppression. Active severe infection is a contraindication to biologics until controlled. Vaccination: update inactivated vaccines before immunosuppression; avoid live vaccines while on biologics/immunosuppressants.

19. Special Situations: Pregnancy & Surgery Methotrexate is contraindicated in pregnancy (teratogenic). Thiopurines and many biologics are often continued in pregnancy if needed—discuss risks and benefits with obstetric team. Surgery indicated for complications (obstruction, perforation, refractory disease); goal is minimal bowel resection.

20. Practical Quick Reference Mild localized ileocecal: budesonide 9 mg/day (induction). Moderate–severe luminal: systemic steroids for induction → steroid-sparing agent (thiopurine/methotrexate) or biologic for maintenance. Fistulizing: seton + antibiotics + infliximab (consider combination with thiopurine). Abscess: drain + antibiotics before immunosuppression; reassess before biologic start.

21. References (selected) ECCO Guidelines on Therapeutics in Crohn's Disease (2020; 2023 updates available). Infliximab / Remicade HCP dosing & product info; Adalimumab / Humira dosing pages. Drug monographs for budesonide, azathioprine, methotrexate; Montreal classification paper (Satsangi et al.).