Crohn Disease: A rational approach to management

Crohn disease can involve any part of the digestive tract; it can manifest as inflammatory (diarrhea, abdominal pain, and fever), penetrating (abscess or fistula), or stricturing (recurrent bowel obstruction) disease. Treatment is based on the location and activity of the disease. Mesalamine is recommended to induce and maintain remission in patients with mild to moderate nonpenetrating, nonstricturing disease. Antibiotics may be used as an alternative or adjunct to mesalamine; ciprofloxacin and metronidazole are helpful in fistulizing Crohn disease. For patients with moderate to severe disease, corticosteroids are recommended to induce remission; infliximab is an alternative for those with severe or refractory disease. Remission is then maintained with immunosuppressive therapy, not with corticosteroids. Fistulas are difficult to treat but may respond to antibiotics or azathioprine; however, closure rates are low. Infliximab produces higher closure rates; azathioprine or 6-mercaptopurine should be used to maintain remission in this setting.