Crohn's disease: Difference between revisions

(Created page with "==Background== *Can involve any part of the GI tract from the mouth to the anus *Bimodal distribution: 15-22yr, 55-60yr *Pathology **All layers of the bowel are involved ***Reaso...")
 
 
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**"Skip lesions" are common
**"Skip lesions" are common


==Diagnosis==
{{Crohn's vs UC}}
GI Symptoms
 
*Abdominal pain
==Clinical Features==
*Diarrhea
[[File:Aphthous stomatitis.jpg|thumb|An aphthous mouth ulcer ([[aphthous stomatitis]]) on seen with Crohn's disease.]]
*Wt loss
[[File:A single EN.jpg|thumb|A single lesion of erythema nodosum.]]
*Perianal fissures or fistulas
===GI Symptoms===
Extraintestinal Symptoms (50%)
*[[Abdominal pain]]
*Arthritis
*[[Diarrhea]]
**Peripheral arthritis
*Weight loss
***Migratory monarticular or polyarticular
*[[Anal fissure|Perianal fissures]] or [[anal fistula|fistulas]]
**Ankylosing spondylitis
 
===Extraintestinal Symptoms (50%)===
*[[Arthritis]]
**Peripheral [[arthritis]]
***Migratory monoarticular or polyarticular
**[[Ankylosing spondylitis]]
***Pain/stiffness of spine, hips, neck, rib cage
***Pain/stiffness of spine, hips, neck, rib cage
**Sacroiliitis
**Sacroiliitis
**Low back pain w/ morning stiffness
**Low [[back pain]] with morning stiffness
*Ocular
*Ocular
**Uveitis
**[[Uveitis]]
***Acute blurring of vision, photophobia, pain, perilimbic scleral injection
***Acute blurring of vision, photophobia, pain, perilimbic scleral injection
**Episcleritis
**[[Episcleritis]]
***Eye burning or itching w/o visual changes or pain; scleral and conj hyperemia
***Eye burning or itching with out visual changes or pain; scleral and conj hyperemia
*Dermatologic
*Dermatologic
**Erythema nodosum
**[[Erythema nodosum]]
***Painful, red, raised nodules on extensor surfaces of arms/legs
***Painful, red, raised nodules on extensor surfaces of arms/legs
**Pyoderma gangrenosum
**[[Pyoderma gangrenosum]]
***Violacious, ulcerative lesions w/ necrotic center found in pretibial region or trunk
***Violaceous, ulcerative lesions with necrotic center found in pretibial region or trunk
*Hepatobiliary
*Hepatobiliary
**Cholelithiasis (33%)
**[[Cholelithiasis]] (33%)
**Fatty liver
**Fatty liver
**Autoimmune hepatitis
**[[Autoimmune hepatitis]]
**Primary sclerosing cholangitis
**[[Primary sclerosing cholangitis]]
**Cholangiocarcinoma
**Cholangiocarcinoma
*Renal
**Increased risk for calcium oxalate [[nephrolithiasis|stones]] due to hyperoxaluria
*Vascular
*Vascular
**Thromboembolic disease
**[[Thromboembolism]]


==Work-Up==
==Differential Diagnosis==
{{Colitis DDX}}
===Other===
*[[Appendicitis]]
 
==Evaluation==
===Work-Up===
*Rule out alternate etiologies for symptoms
*Evaluate for complications (e.g. fistulae, abscess, obstruction)
*Labs
*Labs
**CBC
**CBC
**Chemistry
**Chemistry
*CT A/P
**LFTs/lipase
**Most useful diagnostic test in pts w/ acute symptoms who have known or suspected Crohn
**May additionally consider:
**Findings: bowel wall thickening, mesenteric edema, local abscess, fistulas
***ESR/CRP
***Type and screen (if concern for significant bleeding)
***Fecal calprotectin (sensitive indicator of intestinal inflammation, unreliable in select Crohn's patients)<ref>van Rheenen PF, Van de Vijver E, Fidler V. Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis. BMJ. 2010;15(341):c3369.</ref>
***[[Clostridium difficile|C.diff]] toxin


==DDx==
*Consider imaging:
#Ulcerative colitis
**CT A/P if concern for [[small bowel obstruction]], perforation, or toxic megacolon
#Ischemic bowel disease
***Most useful diagnostic test in patients with acute symptoms who have known or suspected Crohn
#Pseudomembranous enterocolitis
***Findings: bowel wall thickening, mesenteric edema, local abscess, fistulas
#Lymphoma
 
#Ileocecal amebiasis
===Diagnosis===
#Sarcoidosis
#Yersinia
Campylobacter#


==Management==
==Management==
#Rule-out complications:
[[File:CT scan gastric CD.jpg|thumb|CT scan showing Crohn's disease in the fundus of the stomach.]]
##Obstruction
===Acute Flare Management===
###Due to stricture or bowel wall edema
*[[IVF]]
##Abscess
*Bowel rest
###Can be intraperitoneal, retroperitoneal, interloop, or intramesenteric
*[[Analgesia]]
####More severe abdominal pain than usual
*[[Electrolyte repletion|Electrolyte correction]]
####Fever
*Consider [[steroid]] burst
####Hip or back pain and difficulty walking (retroperitoneal abscess)
**[[Methylprednisolone]] (e.g., 30mg IV bid) or [[prednisone]] (e.g., 60 mg day 1, then 40 mg daily x 4 days), OR
##Fistula
**[[Budesonide]] for mild to moderate disease due to fewer systemic side effects
###Occurs due to extension of intestinal fissure into adjacent structures
*Antidiarrheals are contraindicated
###Suspect if changes in pt's symptoms (e.g. BM frequency, amt of pain, wt loss)
 
##Perianal disease
===Chronic Treatment===
###Abscess, fissures, fistulas, rectal prolapse
''Alterations should be discussed with GI''
##Hemorrhage
*Aminosalicylates (5-ASA) - Mild-to-moderate Crohn's disease. Give with probiotics.
###Erosion into a bowel wall vesel
**[[Sulfasalazine]] 3-5gm/day PO (sulfa drug)
##Toxic megacolon
***Caution: Can cause [[folate deficiency]] so give with [[folic acid]], and can cause [[hemolytic anemia]] in [[G6PD]] patients
###Can be associated w/ massive GI bleeding
**[[Mesalamine]] 4gm/day PO
#Rule-out therapy complications:
***Active moiety of sulfasalazine, and formed from prodrug balsalazide
##Leukopenia /thrombocytopenia
**Balsalazide or Olsalazine - Bypasses small intestine to deliver drug into large intestine (better for UC)  
##Fever / infection
*Anti-diarrheal - Use caution in patients with active inflammation as can precipitate toxic megacolon
##Pancreatitis
**[[Loperamide]] 4-16mg/day
##Renal / liver failure
**[[Diphenoxylate]] 5-20mg/day
**Cholestyramine 4g once to six times daily
*[[Glucocorticoids]] - Symptomatic relief (course not altered)
**[[Prednisone]] - 40-60mg/day with taper once remission induced
**[[Methylprednisolone]] 20mg IV q6hr
**[[Hydrocortisone]] 100mg q8hr
***Do not start if any suspicion of infection (ie [[C. diff]] colitis)
***Double edge sword: Reduction of bone density in addition to underlying disease process(decreased Ca absorption)
*Antibiotics - Induce remission
**[[Ciprofloxacin]] 500mg q8-12hr '''OR'''
**[[Metronidazole]] 500mg q6hr '''OR'''
**[[Rifaximin]] 800mg BID
*Immunomodulators - Steroid-sparing agents used in fistulas and patients with surgical contraindication. Slower onset.
**6-Mercaptopurine 1-1.5mg/kg/day → Start at 50mg daily
**[[Azathioprine]] 2-2.5mg/kg/day → Start at 50mg daily
**[[Methotrexate]] IM
*Anti-TNF - Medically resistant moderate-to-severe Crohn's disease
**Infliximab (Remicade) 5mg/kg IV
**Adalimumab (Humira), Natalizumab or certolizumab pegol can also be used


==Disposition==
==Disposition==
===Inpatient Admission===
*Significant metabolic derangements (i.e. [[electrolyte imbalance]] or severe [[dehydration]])
*Fulminate [[colitis]]
*[[SBO|Obstruction]]
*[[Peritonitis]]
*Significant [[GI bleed|hemorrhage]]
===Surgical Intervention===
''Consult EARLY if any of the following suspicions''
*Perforation
*Abscess/fistula formation
*[[Toxic megacolon]]
*Significant [[GI bleed|hemorrhage]]
*Perianal disease
*Failed medical management
==Complications==
*[[Bowel obstruction]]
**Due to stricture or bowel wall edema
*Abscess
**Can be intraperitoneal, retroperitoneal, interloop, or intramesenteric
***More severe abdominal pain than usual
***[[Fever]]
***[[hip pain|Hip]] or [[back pain]] and difficulty walking (retroperitoneal abscess)
*Fistula
**Occurs due to extension of intestinal fissure into adjacent structures
**Suspect if changes in patient's symptoms (e.g. BM frequency, amt of pain, wt loss)
*Perianal disease
**[[perianal Abscess|Abscess]], [[anal fissure|fissures]], [[anal fistula|fistulas]], [[rectal prolapse]]
*[[GI bleed|Hemorrhage]]
**Erosion into a bowel wall vesel
*[[Toxic megacolon]]
**Can be associated with massive GI bleeding
===Therapy complications===
*[[Leukopenia]]/[[thrombocytopenia]]
*[[Fever]]/infection
*[[Pancreatitis]]
*[[Renal failure|Renal]]/[[liver failure]]


==See Also==
==See Also==
*[[Ulcerative Colitis]]
*[[Ulcerative Colitis]]
*[[Colitis]]


==Source==
==References==
Tintinalli
<references/>
 
[[Category:GI]]
[[Category:GI]]
1. Thomas N, Wu AW. Large intestine. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 10th ed. Elsevier; 2023.

Latest revision as of 15:27, 13 September 2023

Background

  • Can involve any part of the GI tract from the mouth to the anus
  • Bimodal distribution: 15-22yr, 55-60yr
  • Pathology
    • All layers of the bowel are involved
      • Reason why fistulas and abscesses are common complications
    • "Skip lesions" are common

Crohn's disease vs. ulcerative colitis

Crohn's disease vs. ulcerative colitis
Finding Crohn's disease Ulcerative colitis
Depth of inflammation May be transmural, deep into tissues Shallow, mucosal
Distribution of disease Patchy areas of inflammation (skip lesions) Continuous area of inflammation
Terminal ileum involvement Commonly Seldom
Colon involvement Usually Always
Rectum involvement Seldom Usually (95%)
Involvement around anus Common Seldom
Stenosis Common Seldom

Clinical Features

An aphthous mouth ulcer (aphthous stomatitis) on seen with Crohn's disease.
A single lesion of erythema nodosum.

GI Symptoms

Extraintestinal Symptoms (50%)

Differential Diagnosis

Colitis

Other

Evaluation

Work-Up

  • Rule out alternate etiologies for symptoms
  • Evaluate for complications (e.g. fistulae, abscess, obstruction)
  • Labs
    • CBC
    • Chemistry
    • LFTs/lipase
    • May additionally consider:
      • ESR/CRP
      • Type and screen (if concern for significant bleeding)
      • Fecal calprotectin (sensitive indicator of intestinal inflammation, unreliable in select Crohn's patients)[1]
      • C.diff toxin
  • Consider imaging:
    • CT A/P if concern for small bowel obstruction, perforation, or toxic megacolon
      • Most useful diagnostic test in patients with acute symptoms who have known or suspected Crohn
      • Findings: bowel wall thickening, mesenteric edema, local abscess, fistulas

Diagnosis

Management

CT scan showing Crohn's disease in the fundus of the stomach.

Acute Flare Management

Chronic Treatment

Alterations should be discussed with GI

  • Aminosalicylates (5-ASA) - Mild-to-moderate Crohn's disease. Give with probiotics.
  • Anti-diarrheal - Use caution in patients with active inflammation as can precipitate toxic megacolon
  • Glucocorticoids - Symptomatic relief (course not altered)
    • Prednisone - 40-60mg/day with taper once remission induced
    • Methylprednisolone 20mg IV q6hr
    • Hydrocortisone 100mg q8hr
      • Do not start if any suspicion of infection (ie C. diff colitis)
      • Double edge sword: Reduction of bone density in addition to underlying disease process(decreased Ca absorption)
  • Antibiotics - Induce remission
  • Immunomodulators - Steroid-sparing agents used in fistulas and patients with surgical contraindication. Slower onset.
    • 6-Mercaptopurine 1-1.5mg/kg/day → Start at 50mg daily
    • Azathioprine 2-2.5mg/kg/day → Start at 50mg daily
    • Methotrexate IM
  • Anti-TNF - Medically resistant moderate-to-severe Crohn's disease
    • Infliximab (Remicade) 5mg/kg IV
    • Adalimumab (Humira), Natalizumab or certolizumab pegol can also be used

Disposition

Inpatient Admission

Surgical Intervention

Consult EARLY if any of the following suspicions


Complications

  • Bowel obstruction
    • Due to stricture or bowel wall edema
  • Abscess
    • Can be intraperitoneal, retroperitoneal, interloop, or intramesenteric
      • More severe abdominal pain than usual
      • Fever
      • Hip or back pain and difficulty walking (retroperitoneal abscess)
  • Fistula
    • Occurs due to extension of intestinal fissure into adjacent structures
    • Suspect if changes in patient's symptoms (e.g. BM frequency, amt of pain, wt loss)
  • Perianal disease
  • Hemorrhage
    • Erosion into a bowel wall vesel
  • Toxic megacolon
    • Can be associated with massive GI bleeding

Therapy complications

See Also

References

  1. ↑ van Rheenen PF, Van de Vijver E, Fidler V. Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis. BMJ. 2010;15(341):c3369.

1. Thomas N, Wu AW. Large intestine. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 10th ed. Elsevier; 2023.

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