What is the treatment for ileal ulcers?

Treatment of Ileal Ulcers

For ileal ulcers, treatment should be tailored to the severity of disease, with options including high-dose mesalazine for mild disease, corticosteroids for moderate to severe disease, or surgery for refractory cases. 1

Treatment Algorithm Based on Disease Severity

Mild Ileal Disease

• High-dose mesalazine (4g daily) may be sufficient as initial therapy for mild ileocolonic Crohn's disease 1
• Consider patient preferences when selecting therapy, as this impacts adherence and outcomes 1

Moderate to Severe Ileal Disease

• Oral corticosteroids such as prednisolone 40 mg daily are appropriate for patients with moderate to severe disease, or those with mild to moderate disease that has failed to respond to mesalazine 1
• Prednisolone should be reduced gradually according to severity and patient response, generally over 8 weeks to prevent early relapse 1
• Budesonide 9 mg daily is appropriate for patients with isolated ileo-caecal disease with moderate activity, though it is marginally less effective than prednisolone 1

Severe Ileal Disease

• Intravenous steroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) are appropriate for patients with severe disease 1
• Concomitant intravenous metronidazole is often advisable, as it may be difficult to distinguish between active disease and septic complications 1

Alternative and Adjunctive Therapies

Nutritional Therapy

• Elemental or polymeric diets are less effective than corticosteroids but may be used to induce remission in patients with contraindications to corticosteroid therapy or those who prefer to avoid steroids 1
• These diets can also serve as appropriate adjunctive therapy 1
• Total parenteral nutrition is appropriate adjunctive therapy in complex, fistulating disease 1

Antibiotics

• Metronidazole (10-20 mg/kg/day) can be effective but is not usually recommended as first-line therapy due to potential side effects 1
• It may be appropriate for selected patients with colonic or treatment-resistant disease, or those wishing to avoid steroids 1

Immunomodulators

• Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg/day) may be used as adjunctive therapy and as steroid-sparing agents 1
• Their slow onset of action precludes use as sole therapy for active disease 1

Biological Therapy

• Infliximab 5 mg/kg is effective but should be avoided in patients with obstructive symptoms 1
• It should be reserved for refractory cases as part of a comprehensive treatment strategy 1, 2

Surgical Considerations

• Surgery should be considered for patients who have failed medical therapy 1
• It may be appropriate as primary therapy in patients with limited ileal or ileo-caecal disease 1
• The decision for surgery should be made in conjunction with the patient, considering quality of life outcomes 1, 3

Common Pitfalls and Caveats

• Avoid rapid reduction of corticosteroids as this is associated with early relapse 1
• Distinguish between ulcerative colitis and Crohn's disease, as treatment approaches differ significantly 4, 2
• Always consider alternative explanations for symptoms other than active disease (bacterial overgrowth, bile salt malabsorption, fibrotic strictures) 1
• Monitor for complications and side effects of medications, particularly with long-term corticosteroid use 1, 2
• Regular assessment of disease activity is essential to guide treatment decisions and prevent complications 1