Treatment of Ileal Ulcers
Treatment for ileal ulcers should be tailored based on disease severity, with high-dose mesalazine for mild disease, corticosteroids for moderate to severe disease, and surgery for refractory cases. 1
Treatment Algorithm Based on Disease Severity
Mild Disease
- High-dose mesalazine (4g daily) is recommended as initial therapy for patients with mild ileocolonic Crohn's disease 1
- Pentasa (a mesalazine formulation) is particularly effective for ileal ulcers as it releases more 5-ASA into the small intestine compared to other formulations 2
- Patient preferences should be considered when selecting therapy to improve adherence and outcomes 1
Moderate to Severe Disease
- Oral corticosteroids such as prednisolone 40 mg daily are recommended for:
- Patients with moderate to severe disease
- Patients with mild to moderate disease who have failed to respond to mesalazine 1
- Prednisolone should be tapered gradually over approximately 8 weeks to prevent early relapse 1
- Systemic corticosteroids are potent and fast-acting but are not effective for maintaining remission 2
Alternative and Adjunctive Therapies
- Elemental or polymeric diets can be used to induce remission in patients with:
- Contraindications to corticosteroid therapy
- Preference to avoid steroids 1
- Metronidazole (10-20 mg/kg/day) can be effective but is not typically recommended as first-line therapy due to potential side effects 1
- For corticosteroid-dependent or unresponsive cases, immunomodulators should be considered, including:
- Azathioprine/6-mercaptopurine
- Methotrexate
- Cyclosporine 2
- Biologics such as anti-TNF agents (infliximab, adalimumab) may be necessary for refractory cases 3
Surgical Management
- Surgery should be considered for patients who have failed medical therapy 1
- Primary surgical intervention may be appropriate for patients with limited ileal or ileo-caecal disease 1
- Despite advances in medical therapy, a significant proportion of patients may eventually require surgical intervention 4
Common Pitfalls and Caveats
- Avoid rapid reduction of corticosteroids as this is associated with early relapse 1
- It is crucial to distinguish between Crohn's disease and ulcerative colitis, as treatment approaches differ significantly 1, 5
- Always consider alternative explanations for symptoms beyond active disease, such as:
- Bacterial overgrowth
- Bile salt malabsorption
- Fibrotic strictures 1
- Prolonged corticosteroid treatment can lead to serious side effects; they should be gradually reduced once remission is achieved 2
- For some patients with complex refractory disease, elective surgery may be a better alternative than prolonged conservative therapy after failure of first-line treatment 4