Colitis requires aggressive treatment, often with side effects

October 6, 2007

Colitis, an umbrella term encompassing ulcerative colitis (UC), Crohn's disease (CD) and inflammatory bowel disease (IBD), can be one of the more difficult conditions for family physicians to treat. More aggressive treatment tends to be more effective, said Thomas Kintanar, MD, family physician (FP) in Fort Wayne, Indiana.

Colitis, an umbrella term encompassing ulcerative colitis (UC), Crohn's disease (CD) andinflammatory bowel disease (IBD), can be one of the more difficult conditions for family physiciansto treat. More aggressive treatment tends to be more effective, said Thomas Kintanar, MD, familyphysician (FP) in Fort Wayne, Indiana.

"FPs who use an endoscope are probably a little more aggressive and a little more successfulwith their patients," Dr Kintanar said during a Saturday lecture at the American Academy of FamilyPhysicians 2007 Scientific Assembly in Chicago. "The reality is that these are chronic conditionsthat require long-term management and compromises."

Oral corticosteroids are frequently necessary to control moderate to severe colitis, DrKintanar noted. He cited an example of a CD patient who had been reasonably well controlled withsteroids for 20 years, but the patient was and remained very unsatisfied with the weight gain thataccompanied her treatment.

"She has accepted that she will be overweight as long as we continue to use steroids to keepher Crohn's under control," Dr Kintanar said. "But that does not mean that she is happy about thechange."

The basic effects of UC, CD, and IBD are similar, he continued, including diarrhea, pain, andweight loss. Specific details differ among the diseases, however. Smoking may cause CD, for example,while evidence suggests that tobacco use may prevent UC. The incidence of CD is about 7 cases per100,000 persons versus 11 cases per 100,000 persons for UC. Family history is important in bothconditions, but CD tends to occur in higher socioeconomic groups.

The lifetime risk of IBD is between 3% and 9% for those who have a first-degree relative withthe disease.

There is no specific antigenic trigger for any of the three forms of colitis, but all stemfrom activated T cells, which trigger a cytokine cascade. Just what activates the T cells to beginthe cytokine cascade is a matter for significant debate. The leading hypothesis calls for a triggerevent, such as a microbial infection or some dietary product, that provokes an initial immuneresponse. Another theory traces T cell activation to increased antibody secretion for some unknownreason.

Dominant symptoms for CD include a cobblestone appearance in the GI tract, perianal and smallintestine involvement, rectal sparing, discontinuous involvement, and aphthous ulcers. The dominantsymptom of UC is diarrhea, often with pinkish blood from rectal bleeding. Patients may also presentwith fever, pain in the lower quadrant or rectum, and weight loss. Patients with any form of colitisand severe diarrhea may also have electrolyte disorders.

"The treatment approach to any colitis is the same because we are dealing with aninflammatory process," Dr Kintanar said.

Treatment includes 5-ASAs (5-aminosalicylates), either orally, by enema, or suppository,antimicrobials, such as metronidazole and/or ciprofloxacin if bacterial involvement is suspected, andoral steroids. Patients with severe disease may also benefit from infliximab or another similaragent, he said.