Difference between revisions of "Crohn's disease"

(Disposition)
Line 7: Line 7:
 
**"Skip lesions" are common
 
**"Skip lesions" are common
  
==Diagnosis==
+
==Clinical Features==
GI Symptoms
+
===GI Symptoms===
*Abdominal pain
+
*[[Abdominal pain]]
*Diarrhea
+
*[[Diarrhea]]
*Wt loss
+
*Weight loss
 
*Perianal fissures or fistulas
 
*Perianal fissures or fistulas
Extraintestinal Symptoms (50%)
+
===Extraintestinal Symptoms (50%)===
 
*Arthritis
 
*Arthritis
 
**Peripheral arthritis
 
**Peripheral arthritis
Line 40: Line 40:
 
**Thromboembolic disease
 
**Thromboembolic disease
  
==Work-Up==
+
==Differential Diagnosis==
 +
*Ulcerative colitis
 +
*Ischemic bowel disease
 +
*Pseudomembranous enterocolitis
 +
*Lymphoma
 +
*Ileocecal amebiasis
 +
*Sarcoidosis
 +
*Yersinia
 +
*Campylobacter
 +
 
 +
==Diagnosis==
 +
===Work-Up===
 
*Labs
 
*Labs
 
**CBC
 
**CBC
Line 52: Line 63:
 
***Most useful diagnostic test in pts w/ acute symptoms who have known or suspected Crohn
 
***Most useful diagnostic test in pts w/ 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==
 
*Ulcerative colitis
 
*Ischemic bowel disease
 
*Pseudomembranous enterocolitis
 
*Lymphoma
 
*Ileocecal amebiasis
 
*Sarcoidosis
 
*Yersinia
 
*Campylobacter
 
  
 
==Management==
 
==Management==
 
Initial ED Management: IVF, bowel rest, analgesia, electrolyte correction, and NGT (if obstruction/ileus/toxic megacolon)
 
Initial ED Management: IVF, bowel rest, analgesia, electrolyte correction, and NGT (if obstruction/ileus/toxic megacolon)
*Rule-out complications:
 
**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 pt's symptoms (e.g. BM frequency, amt of pain, wt loss)
 
**Perianal disease
 
***Abscess, fissures, fistulas, rectal prolapse
 
**Hemorrhage
 
***Erosion into a bowel wall vesel
 
**Toxic megacolon
 
***Can be associated w/ massive GI bleeding
 
*Rule-out therapy complications:
 
**Leukopenia /thrombocytopenia
 
**Fever / infection
 
**Pancreatitis
 
**Renal / liver failure
 
 
*Medications: Alterations should be discussed with GI
 
*Medications: Alterations should be discussed with GI
 
**Aminosalicylates (5-ASA) - Mild-to-moderate Crohn's dz. Give with probiotics.
 
**Aminosalicylates (5-ASA) - Mild-to-moderate Crohn's dz. Give with probiotics.
Line 132: Line 111:
 
*Perianal disease
 
*Perianal disease
 
*Failed medical management
 
*Failed medical management
 +
 +
==Complications==
 +
*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 pt's symptoms (e.g. BM frequency, amt of pain, wt loss)
 +
*Perianal disease
 +
**Abscess, fissures, fistulas, rectal prolapse
 +
*Hemorrhage
 +
**Erosion into a bowel wall vesel
 +
*Toxic megacolon
 +
**Can be associated w/ massive GI bleeding
 +
 +
===Therapy complications===
 +
*Leukopenia /thrombocytopenia
 +
*Fever / infection
 +
*Pancreatitis
 +
*Renal / liver failure
  
 
==See Also==
 
==See Also==

Revision as of 13:27, 4 August 2015

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

Clinical Features

GI Symptoms

Extraintestinal Symptoms (50%)

  • Arthritis
    • Peripheral arthritis
      • Migratory monarticular or polyarticular
    • Ankylosing spondylitis
      • Pain/stiffness of spine, hips, neck, rib cage
    • Sacroiliitis
    • Low back pain w/ morning stiffness
  • Ocular
    • Uveitis
      • Acute blurring of vision, photophobia, pain, perilimbic scleral injection
    • Episcleritis
      • Eye burning or itching w/o visual changes or pain; scleral and conj hyperemia
  • Dermatologic
    • Erythema nodosum
      • Painful, red, raised nodules on extensor surfaces of arms/legs
    • Pyoderma gangrenosum
      • Violacious, ulcerative lesions w/ necrotic center found in pretibial region or trunk
  • Hepatobiliary
    • Cholelithiasis (33%)
    • Fatty liver
    • Autoimmune hepatitis
    • Primary sclerosing cholangitis
    • Cholangiocarcinoma
  • Vascular
    • Thromboembolic disease

Differential Diagnosis

  • Ulcerative colitis
  • Ischemic bowel disease
  • Pseudomembranous enterocolitis
  • Lymphoma
  • Ileocecal amebiasis
  • Sarcoidosis
  • Yersinia
  • Campylobacter

Diagnosis

Work-Up

  • Labs
    • CBC
    • Chemistry
    • ESR/CRP
    • C.diff toxin
    • Type and Cross/Screen if any bleeding suspicion
  • Imaging:
    • Plain abdominal films - r/o obstruction, perforation and toxic megacolon
    • CT A/P
      • Most useful diagnostic test in pts w/ acute symptoms who have known or suspected Crohn
      • Findings: bowel wall thickening, mesenteric edema, local abscess, fistulas

Management

Initial ED Management: IVF, bowel rest, analgesia, electrolyte correction, and NGT (if obstruction/ileus/toxic megacolon)

  • Medications: Alterations should be discussed with GI
    • Aminosalicylates (5-ASA) - Mild-to-moderate Crohn's dz. Give with probiotics.
      • Sulfasalazine 3-5gm/day PO (sulfa drug)
        • Caution: Can cause folate deficiency so give with folic acid, and can cause hemolytic anemia in G6PD pts
      • Mesalamine 4gm/day PO
        • 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

Inpatient Admission

  • Metabolic derangements (ie electrolyte imbalance or severe dehydration)
  • Fulminate colitis
  • Obstruction
  • Peritonitis
  • Significant hemorrhage

Surgical Intervention

Consult EARLY if any of the following suspicions

  • Perforation
  • Abscess/fistula formation
  • Toxic megacolon
  • Significant hemorrhage
  • Perianal disease
  • Failed medical management

Complications

  • 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 pt's symptoms (e.g. BM frequency, amt of pain, wt loss)
  • Perianal disease
    • Abscess, fissures, fistulas, rectal prolapse
  • Hemorrhage
    • Erosion into a bowel wall vesel
  • Toxic megacolon
    • Can be associated w/ massive GI bleeding

Therapy complications

  • Leukopenia /thrombocytopenia
  • Fever / infection
  • Pancreatitis
  • Renal / liver failure

See Also

References