Aggressive Treatments for Colitis and Crohn’s disease
The incidence of idiopathic inflammatory diseases is higher in North America and Northern Europe, and is low in Asia and South America. In North America, new cases per year is estimated at 2.2 to 19.2 per 100,000 population for ulcerative colitis and from 3.1 to 20.2 per 100,000 population for disease Crohn’s. From the few data available for Greece, the values appear to be the lower limit of the aforementioned (eg incidence of Crohn Crete 3.3 / 100,000 for the years 1990-1994).
The etiology of IBD is unknown. Genetic and environmental factors involved in their pathogenesis. There seems to be a pathological immune response in ‘stimuli’ which normally is not harmful. The result is a persistent inflammation of the digestive tract, which ultimately results in anatomical (e.g., stenosis) and functional (e.g. malabsorption) lesions.
Inflammatory diseases usually occur between the ages of 15 and 40 years, and there is a second attack peak age after 50 years. These chronic diseases posed by remissions and exacerbations, affecting the digestive tract, but is often accompanied by extraintestinal manifestations commonly affecting the joints, eyes, skin and liver.
Poor quality of life
The mortality of patients suffering from IBD is not increased compared with the general population. Nevertheless, chronicity, the variation in the events, the nature of symptoms and more responsible for the avowed poor quality of life. Feature is that rates of depression, problematic social and professional life is higher than 50% in these patients.
Specifically, ulcerative colitis is a chronic inflammation of the mucosa of the colon manifested by bloody diarrhea. In the majority of cases are affected last part of the large intestine (rectum), but the extent of infestation varies.
Generally, the longer attack the colon is associated with more severe disease. Most patients with ulcerative colitis do not require hospitalization. The need hospitalization occurs in the few patients who develop a large number of hemorrhagic diarrhea despite antifungal therapy.
Crohn’s disease may affect any part of the digestive tract, from the mouth to the anus. The most common identification are the last portion of the small intestine called the ileum. The most common manifestations of the disease are abdominal pain, diarrhea and weight loss.
Generally the attack of the small intestine involves the risk of disorders associated with poor absorption of necessary nutrients. The inflammation in Crohn relates extended bowel wall (transmural inflammation) and for this reason can lead to complications such as the narrowing of the lumen, the abscess and fistulas.
These complications cause structural defects and precisely for this reason the need for surgery is more likely in this disease compared with ulcerative colitis.
The suspected inflammatory disease of the intestine arises in any case of persistent (for longer than four weeks) diarrhea with or without accompanying blood loss to a new patient. For diagnosis carried colonoscopy, during which tissue samples were taken for microscopic examination (biopsy).
Especially for the diagnosis of Crohn’s disease is usually necessary and further tests to investigate the extent of the infection, since inflammation may involve any part of the digestive.
The control of the upper digestive made by gastroscopy and small intestine with wireless endoscopic capsule or magnetically enterografia. Additionally, for the diagnosis of possible complications of the disease may be necessary abdominal ultrasound and / or computed tomography. However, the diagnosis is based on consideration of all the data that will result from the patient history, blood tests, endoscopy and perhaps imaging evaluation.
There are few cases where diagnosis of idiopathic inflammatory bowel disease are not clear, and patients are placed under medical supervision.
Where targeted therapies
Tackling these diseases is not explanatory and therefore not ideal. The goal of therapy is to cure, since in the case of Crohn this is not feasible, and for ulcerative colitis only the total removal of the large intestine (colon) will lead to a cure.
The goal of the treatment of inflammatory diseases is firstly to ensure the recession of symptoms and secondly the maintenance of remission. The importance of complete healing of lesions evidenced by endoscopy (mucosal healing) emerged in recent years.
It appears that the healing-related quality of life, fewer surgeries, fewer hospitalizations and reduced risk of cancer in patients with inflammatory diseases.
The treatment in IBD is divided into medical and surgical. Drugs aimed at the suppression of inflammation. Most drugs have anti-inflammatory and immunosuppressive activity. In this category the aminosalicylates, cortisone, the thiopurines, methotrexate and cyclosporine. Besides efficacy, safety is an important parameter in the selection of treatment, since, on the one hand, given basically in young patients and, on the other hand, the administration is chronic and continuous.
In recent years they use biological agents with targeted action in the inflammatory process. These antibodies molecules with a central role in the pathogenesis of these diseases. Because it is targeted therapy is also very effective, while remaining safe and secure even classic options such as cortisone. The introduction of these therapies, for which the gastroenterology largely mimicked the rheumatology, revealed important new therapeutic targets, such as the aforementioned mucosal healing.
With the emergence of biological agents raised the issue of the treatment strategy selection (basically for Crohn’s disease): start treatment with less potent drug and gradual upgrade depending on the response or selection of the fittest agent as first-line treatment in order to change the natural course of the disease.
There are data indicating that the biological agents, if administered early in the course of the disease in patients who meet conditions worse evolution can alter its evolution. In other words, the more aggressive therapy may first prevents serious complications in the future, such as strictures and fistulas.
The surgical solution
The surgery concerns cases of ulcerative colitis who do not respond to drug therapy and the selected disease Crohn’s. Approximately half of the patients will undergo surgery in their lifetime. The combination of drugs and surgery is common practice in Crohn’s disease. For this reason, it required close cooperation of Gastroenterology and surgeons who have experience and expertise in idiopathic inflammatory bowel disease.
As part of the overall response includes the endoscopic surveillance of these patients in order to prevent bowel cancer. It appears that the risk of developing cancer of the colon is a little higher than in the general population.
Securing sustained remission of inflammation is the main method of preventing cancer in combination with a course of endoscopy of the colon (colonoscopy), during which biopsies are taken to emerge promptly dysplastic lesions.