Treatment and Prognosis



The treatment of UC and Crohn’s disease is sim­ilar in that both disorders require chronic, non­specific therapeutic programs employing many of the same agents. In addition, the general treatment of the patient’s nutrition, psychological problems, anemia, and other systemic disabilities may be similar. Therapy and prognosis differ enough, however, to warrant separate brief discussions.

Ulcerative Colitis. Mild to moderate acute co­litis may respond to supportive measures supple­mented by sulfasalazine (4 to 6 grams dailyj alone. Sulfasalazine is split by bacterial action in the colon to yield sulfapyridine and 5-aminosalicy-late, the latter considered to be the active agent through its local inhibition of prostaglandin and leukotriene synthesis. If this regimen is insuffi­cient, it can be supplemented by corticosteroid therapy, given either as oral prednisone 10 to 20 mg daily or, especially for left-sided colonic in­volvement, as hydrocortisone (100 mg) adminis­tered as a bedtime enema. When the acute exac­erbation is over, the use of sulfasalazine alone is usually sufficient to control disease and prevent recurrence.

Acute, severe UC merges into the entity of toxic megacolon, described below. This represents a medical emergency requiring immediate hospi­talization, close attention to replacement of blood and electrolytes, systemic corticosteroids in large doses, coverage by broad-spectrum antibiotics, and surgical consultation. Emergency colectomy may be required for failure of toxic megacolon to improve clinically and radiographically in 36 to 48 hours, excessive hemorrhage, or perforation. The medical regimens for the individual patient must be determined within this spectrum for in­tensity and for duration.

Surgical treatment for UC is usually that of total colectomy with a permanent ileostomy and is ul­timately required in approximately 20 to 25 per cent of patients. The operation is “curative” in that UC as a disease is confined to the colon. The indications for elective as opposed to emergency colectomy described above are generally the fol­lowing: (a) Failure of medical management. This can be either during the first acute episode or after some years of treatment during which therapy is insufficiently effective in suppressing the disease or suppression requires unacceptably large amounts of corticosteroids, (b) Concern about the presence or future development of carcinoma. This may arise because of the detection of dys-plastic, presumably premalignant changes in the epithelium or of gross changes on radiographic or endoscopic examination that are suspicious for carcinoma. Of course colectomy may also be in­dicated for demonstrated carcinoma complicating UC.

Few patients (<5 per cent) die during an acute attack of UC. Most patients (>90 per cent) respond to therapy or have spontaneous remissions, but unfortunately most have recurrence of the disease months or even years later. Most patients with UC have a reasonably normal life span. Death from UC usually results either from an acute compli­cation (perforation, hemorrhage, sepsis, shock) or from the late development of carcinoma of the colon.

Crohn’s Disease. The medical treatment of Crohn’s disease is similar to that for UC, with sul­fasalazine and corticosteroids being the main agents used beyond general supportive and die­tary measures. Crohn’s disease is seldom acute, in contrast to UC, although it may present acutely as intestinal obstruction, for example. The response to treatment tends to be less striking than that of UC, and remissions are not as complete, i Sulfa­salazine is not effective in preventing exacerba­tions of Crohn’s disease, as documented in long-term trials. Some success has been noted with ileal disease in putting the bowel to rest by use of parenteral hyperalimentation.

Surgical treatment of Crohn’s disease is not cu­rative and is always undertaken with reluctance,since the disease tends to recur proximal to the site of excision and the patients are especially prone to forming postoperative adhesions. Sur­gery is most frequently required for obstruction, fistula formation, or abscesses (especially peri­rectal disease).

The prognosis for Crohn’s disease is generally less favorable than for UC, since it responds less well to medical management and cannot generally be cured by surgery. As is the case with UC, most patients with Crohn’s disease live a normal life span. Death from Crohn’s disease is usually from sepsis rather than from hemorrhage or carcinoma of the colon.