rapidly absorbed, pure 5-ASA (mesalamine) must be specially packaged in coated capsules or pills or taken as a suppository to be effective in the colon. Other aminosalicylates (sulfasalazine, olsalazine, and balsalazide) use 5-ASA covalently linked to a carrier molecule. Sulfasalazine is the least expensive, but side effects resulting from its sulfapyridine component are common. When aminosalicylates alone cannot control the disease, steroid therapy may be required to induce remission. Whenever possible, steroids should not be used for long-term therapy. An immunosuppressive drug, such as 6-mercaptopurine or azathioprine, is useful to spare excessive steroid use in difficult cases. More potent immunosuppressives, such as cyclosporine or anti–tumor necrosis factor (TNF) agents such as infliximab may be used as rescue therapy when other treatments fail. Surgical colectomy with ileoanal anastomosis is an option for unresponsive severe disease or electively to end chronic symptoms and to reduce the risk of colon cancer, which is increased in patients with UC.
Inflammation in CD typically responds less well to aminosalicylates; oral or IV steroids are more important in inducing remission. To avoid the need for repetitive steroid therapy, immunosuppressive drugs, usually either azathioprine or 6-mercaptopurine, are often started soon after diagnosis. CD that is difficult to control also may be treated with subcutaneous methotrexate or with agents that block the action of TNF-α. Infliximab is the most effective such drug and is given intravenously. Other antibodies that inhibit white blood cell (WBC) migration or action, such as natalizumab, also show promise. As with UC, surgery is sometimes necessary, usually because of obstructive symptoms, abscess, or severe, unremitting symptoms. Because surgery is not curative in CD, its use must be limited, and the length of bowel resection must be minimized.
Celiac disease is an injury to the mucosa of the small intestine caused by the ingestion of gluten (a protein component)from wheat, rye, barley, and related grains. Rice does notcontain gluten and can be eaten freely, as can special purepreparations of oats not contaminated by other grains. In itssevere form, celiac disease causes malabsorption and malnutrition. Diagnosis was based on the presence of typicalsymptoms, followed by small bowel biopsy. The availabilityof more sensitive and specific serologic testing has revealedmany patients with few or no gastrointestinal symptoms whohave early, attenuated, or latent disease. Approximately 1 in110 persons in the United States have celiac disease, but onlya small proportion have been diagnosed. The disease is seenin association with type 1 diabetes, thyroiditis, Turner syndrome, and trisomy 21.
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Diarrhea Pubertal Delay Failure to Thrive
Symptoms can begin at any age when gluten-containingfoods are given. Diarrhea, abdominal bloating, failure to thrive,irritability, decreased appetite, and ascites caused by hypoproteinemia are classic. Children may be minimally symptomaticor may be severely malnourished. Constipation is found in a fewpatients, probably because of reduced intake. A careful inspection of the child’s growth curve and evaluation for reducedsubcutaneous fat and abdominal distention are crucial. Celiac disease should be considered in any child with chronic abdominal complaints. Extraintestinal manifestations include osteoporosis, pulmonary hemorrhage, seizures/encephalopathy,dermatitis herpetiformis, and erythema nodosum.