Crohn's disease: Difference between revisions
 
(12 intermediate revisions by 4 users not shown)
Line 7: Line 7:
**"Skip lesions" are common
**"Skip lesions" are common


===[[Crohn's disease]] vs. [[ulcerative colitis]]===
{{Crohn's vs UC}}
[[File:Crohn's Disease vs Colitis ulcerosa.png|thumb|[[Crohn's disease]] vs. [[ulcerative colitis]]]]
{| {{table}}
| align="center" style="background:#f0f0f0;"|''''''
| align="center" style="background:#f0f0f0;"|'''Crohn's disease'''
| align="center" style="background:#f0f0f0;"|'''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==
==Clinical Features==
Line 79: Line 59:
**CBC
**CBC
**Chemistry
**Chemistry
**ESR/CRP
**LFTs/lipase
**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>
**May additionally consider:
**[[Clostridium difficile|C.diff]] toxin
***ESR/CRP
**Type and screen if any bleeding suspicion
***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
 
*Consider imaging:
*Consider imaging:
**Plain abdominal films - rule out [[small bowel obstruction]], perforation and toxic megacolon
**CT A/P if concern for [[small bowel obstruction]], perforation, or toxic megacolon
**CT A/P
***Most useful diagnostic test in patients with 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
===Diagnosis===


==Management==
==Management==
Line 97: Line 81:
*[[Electrolyte repletion|Electrolyte correction]]
*[[Electrolyte repletion|Electrolyte correction]]
*Consider [[steroid]] burst
*Consider [[steroid]] burst
**[[Methylprednisolone]] (e.g., 30mg IV bid) or [[prednisone]] (e.g., 60 mg day 1, then 40 mg daily x 4 days), OR
**[[Budesonide]] for mild to moderate disease due to fewer systemic side effects
*Antidiarrheals are contraindicated


===Chronic Treatment===
===Chronic Treatment===
Line 130: Line 117:
==Disposition==
==Disposition==
===Inpatient Admission===
===Inpatient Admission===
*Metabolic derangements (ie [[electrolyte imbalance]] or severe [[dehydration]])
*Significant metabolic derangements (i.e. [[electrolyte imbalance]] or severe [[dehydration]])
*Fulminate [[colitis]]
*Fulminate [[colitis]]
*[[SBO|Obstruction]]
*[[SBO|Obstruction]]
Line 177: Line 164:
<references/>
<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.

Retrieved from "https://www.wikem.org/w/index.php?title=Crohn%27s_disease&oldid=371465"