Difference between revisions of "Crohn's disease"

(Disposition)
(Background)
 
(40 intermediate revisions by 10 users not shown)
Line 7: Line 7:
 
**"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
 
**ESR/CRP
 
**ESR/CRP
**C.diff toxin
+
**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>
**Type and Cross/Screen if any bleeding suspicion
+
**[[Clostridium difficile|C.diff]] toxin
*Imaging:
+
**Type and screen if any bleeding suspicion
**Plain abdominal films - r/o obstruction, perforation and toxic megacolon
+
*Consider imaging:
 +
**Plain abdominal films - rule out [[small bowel obstruction]], perforation and toxic megacolon
 
**CT A/P
 
**CT A/P
***Most useful diagnostic test in pts w/ acute symptoms who have known or suspected Crohn
+
***Most useful diagnostic test in patients with acute symptoms who have known or suspected Crohn
 
***Findings: bowel wall thickening, mesenteric edema, local abscess, fistulas
 
***Findings: bowel wall thickening, mesenteric edema, local abscess, fistulas
  
==DDx==
+
==Management==
*Ulcerative colitis
+
[[File:CT scan gastric CD.jpg|thumb|CT scan showing Crohn's disease in the fundus of the stomach.]]
*Ischemic bowel disease
+
===Acute Flare Management===
*Pseudomembranous enterocolitis
+
*[[IVF]]
*Lymphoma
+
*Bowel rest
*Ileocecal amebiasis
+
*[[Analgesia]]
*Sarcoidosis
+
*[[Electrolyte repletion|Electrolyte correction]]
*Yersinia
+
*Consider [[steroid]] burst
*Campylobacter
 
  
==Management==
+
===Chronic Treatment===
Initial ED Management: IVF, bowel rest, analgesia, electrolyte correction, and NGT (if obstruction/ileus/toxic megacolon)
+
''Alterations should be discussed with GI''
*Rule-out complications:
+
*Aminosalicylates (5-ASA) - Mild-to-moderate Crohn's disease. Give with probiotics.
**Obstruction
+
**[[Sulfasalazine]] 3-5gm/day PO (sulfa drug)
***Due to stricture or bowel wall edema
+
***Caution: Can cause [[folate deficiency]] so give with [[folic acid]], and can cause [[hemolytic anemia]] in [[G6PD]] patients
**Abscess
+
**[[Mesalamine]] 4gm/day PO
***Can be intraperitoneal, retroperitoneal, interloop, or intramesenteric
+
***Active moiety of sulfasalazine, and formed from prodrug balsalazide
****More severe abdominal pain than usual
+
**Balsalazide or Olsalazine - Bypasses small intestine to deliver drug into large intestine (better for UC)  
****Fever
+
*Anti-diarrheal - Use caution in patients with active inflammation as can precipitate toxic megacolon
****Hip or back pain and difficulty walking (retroperitoneal abscess)
+
**[[Loperamide]] 4-16mg/day
**Fistula
+
**[[Diphenoxylate]] 5-20mg/day
***Occurs due to extension of intestinal fissure into adjacent structures
+
**Cholestyramine 4g once to six times daily
***Suspect if changes in pt's symptoms (e.g. BM frequency, amt of pain, wt loss)
+
*[[Glucocorticoids]] - Symptomatic relief (course not altered)
**Perianal disease
+
**[[Prednisone]] - 40-60mg/day with taper once remission induced
***Abscess, fissures, fistulas, rectal prolapse
+
**[[Methylprednisolone]] 20mg IV q6hr
**Hemorrhage
+
**[[Hydrocortisone]] 100mg q8hr
***Erosion into a bowel wall vesel
+
***Do not start if any suspicion of infection (ie [[C. diff]] colitis)
**Toxic megacolon
+
***Double edge sword: Reduction of bone density in addition to underlying disease process(decreased Ca absorption)
***Can be associated w/ massive GI bleeding
+
*Antibiotics - Induce remission
*Rule-out therapy complications:
+
**[[Ciprofloxacin]] 500mg q8-12hr '''OR'''
**Leukopenia /thrombocytopenia
+
**[[Metronidazole]] 500mg q6hr '''OR'''
**Fever / infection
+
**[[Rifaximin]] 800mg BID
**Pancreatitis
+
*Immunomodulators - Steroid-sparing agents used in fistulas and patients with surgical contraindication. Slower onset.
**Renal / liver failure
+
**6-Mercaptopurine 1-1.5mg/kg/day → Start at 50mg daily
*Medications: Alterations should be discussed with GI
+
**[[Azathioprine]] 2-2.5mg/kg/day → Start at 50mg daily
**Aminosalicylates (5-ASA) - Mild-to-moderate Crohn's dz. Give with probiotics.
+
**[[Methotrexate]] IM
***Sulfasalazine 3-5gm/day PO (sulfa drug)
+
*Anti-TNF - Medically resistant moderate-to-severe Crohn's disease
****Caution: Can cause folate deficiency so give with folic acid, and can cause hemolytic anemia in G6PD pts
+
**Infliximab (Remicade) 5mg/kg IV
***Mesalamine 4gm/day PO
+
**Adalimumab (Humira), Natalizumab or certolizumab pegol can also be used
****Active moiety of sulfasalazine, and formed from prodrug balsalazide
 
***Balsalazide or Olsalazine - Bypasses small intestine to deliver drug into large intestine (better for UC)  
 
**Anti-diarrheal - Use caution in pts with active inflammation as can precipitate toxic megacolon
 
***Loperamide 4-16mg/day
 
***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 pts w/ surgical contraindication. Slower onset.
 
***6-Mercaptopurine 1-1.5 mg/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 dz
 
***Infliximab (Remicade) 5mg/kg IV
 
***Adalimumab (Humira), Natalizumab or certolizumab pegol can also be used
 
  
 
==Disposition==
 
==Disposition==
 
===Inpatient Admission===
 
===Inpatient Admission===
*Metabolic derangements (ie electrolyte imbalance or severe dehydration)
+
*Metabolic derangements (ie [[electrolyte imbalance]] or severe [[dehydration]])
*Fulminate colitis
+
*Fulminate [[colitis]]
*Obstruction
+
*[[SBO|Obstruction]]
*Peritonitis
+
*[[Peritonitis]]
*Significant hemorrhage
+
*Significant [[GI bleed|hemorrhage]]
  
 
===Surgical Intervention===
 
===Surgical Intervention===
Line 128: Line 120:
 
*Perforation
 
*Perforation
 
*Abscess/fistula formation
 
*Abscess/fistula formation
*Toxic megacolon
+
*[[Toxic megacolon]]
*Significant hemorrhage
+
*Significant [[GI bleed|hemorrhage]]
 
*Perianal disease
 
*Perianal disease
 
*Failed medical management
 
*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==
Line 138: Line 155:
  
 
==References==
 
==References==
 
+
<references/>
 
[[Category:GI]]
 
[[Category:GI]]

Latest revision as of 21:17, 7 July 2021

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

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
    • ESR/CRP
    • Fecal calprotectin (sensitive indicator of intestinal inflammation, unreliable in select Crohn's patients)[1]
    • C.diff toxin
    • Type and screen if any bleeding suspicion
  • Consider imaging:
    • Plain abdominal films - rule out small bowel obstruction, perforation and toxic megacolon
    • CT A/P
      • Most useful diagnostic test in patients with acute symptoms who have known or suspected Crohn
      • Findings: bowel wall thickening, mesenteric edema, local abscess, fistulas

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.