Inflammatory bowel disease: Keys to diagnosis and treatment

Most patients with ulcerative colitis present with mild or moderate disease characterized by bloody diarrhea; one third or fewer present with severe disease. About 10% of patients have extraintestinal manifestations, including arthralgias, back pain, and skin or eye disorders at initial diagnosis. In Crohn's disease, abdominal pain, diarrhea, and weight loss are common. Postprandial pain with distention, nausea, and vomiting may indicate small-bowel obstruction. Abdominal films are indicated if bowel obstruction, toxic megacolon, or perforation is suspected. Mesalamine or hydrocortisone enemas may be sufficient to control mild ulcerative colitis, while oral aminosalicylates or corticosteroids may be required for more severe disease. Metronidazole may be effective in patients with mild Crohn's disease who do not respond to sulfasalazine or mesalamine; moderate to severe disease is best treated with prednisone, with the addition of sulfasalazine or mesalamine - or an immune modifier, such as azathioprine, 6-mercaptopurine, or methotrexate - to maintain remission.