Crohn's disease: Difference between revisions
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***Reason why fistulas and abscesses are common complications | ***Reason why fistulas and abscesses are common complications | ||
**"Skip lesions" are common | **"Skip lesions" are common | ||
{{Crohn's vs UC}} | |||
==Clinical Features== | ==Clinical Features== | ||
[[File:Aphthous stomatitis.jpg|thumb|An aphthous mouth ulcer ([[aphthous stomatitis]]) on seen with Crohn's disease.]] | |||
[[File:A single EN.jpg|thumb|A single lesion of erythema nodosum.]] | |||
===GI Symptoms=== | ===GI Symptoms=== | ||
*[[Abdominal pain]] | *[[Abdominal pain]] | ||
*[[Diarrhea]] | *[[Diarrhea]] | ||
*Weight loss | *Weight loss | ||
*Perianal fissures or fistulas | *[[Anal fissure|Perianal fissures]] or [[anal fistula|fistulas]] | ||
===Extraintestinal Symptoms (50%)=== | ===Extraintestinal Symptoms (50%)=== | ||
*Arthritis | *[[Arthritis]] | ||
**Peripheral arthritis | **Peripheral [[arthritis]] | ||
***Migratory | ***Migratory monoarticular or polyarticular | ||
**Ankylosing spondylitis | **[[Ankylosing spondylitis]] | ||
***Pain/stiffness of spine, hips, neck, rib cage | ***Pain/stiffness of spine, hips, neck, rib cage | ||
**Sacroiliitis | **Sacroiliitis | ||
**Low back pain | **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 | ***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]] | ||
*** | ***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 | ||
** | **[[Thromboembolism]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Colitis DDX}} | |||
===Other=== | |||
*[[Appendicitis]] | |||
* | |||
== | ==Evaluation== | ||
===Work-Up=== | ===Work-Up=== | ||
*Rule out alternate etiologies for symptoms | |||
*Evaluate for complications (e.g. fistulae, abscess, obstruction) | |||
*Labs | *Labs | ||
**CBC | **CBC | ||
**Chemistry | **Chemistry | ||
**ESR/CRP | **LFTs/lipase | ||
* | **May additionally consider: | ||
**Type and | ***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> | ||
**CT A/P | ***[[Clostridium difficile|C.diff]] toxin | ||
***Most useful diagnostic test in | |||
*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 | ***Findings: bowel wall thickening, mesenteric edema, local abscess, fistulas | ||
===Diagnosis=== | |||
==Management== | ==Management== | ||
===Acute | [[File:CT scan gastric CD.jpg|thumb|CT scan showing Crohn's disease in the fundus of the stomach.]] | ||
*IVF | ===Acute Flare Management=== | ||
* | *[[IVF]] | ||
*Analgesia | *Bowel rest | ||
*Electrolyte correction | *[[Analgesia]] | ||
*Consider steroid burst | *[[Electrolyte repletion|Electrolyte correction]] | ||
*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=== | ||
''Alterations should be discussed with GI'' | ''Alterations should be discussed with GI'' | ||
*Aminosalicylates (5-ASA) - Mild-to-moderate Crohn's | *Aminosalicylates (5-ASA) - Mild-to-moderate Crohn's disease. Give with probiotics. | ||
**Sulfasalazine 3-5gm/day PO (sulfa drug) | **[[Sulfasalazine]] 3-5gm/day PO (sulfa drug) | ||
***Caution: Can cause folate deficiency so give with folic acid, and can cause hemolytic anemia in G6PD | ***Caution: Can cause [[folate deficiency]] so give with [[folic acid]], and can cause [[hemolytic anemia]] in [[G6PD]] patients | ||
**Mesalamine 4gm/day PO | **[[Mesalamine]] 4gm/day PO | ||
***Active moiety of sulfasalazine, and formed from prodrug balsalazide | ***Active moiety of sulfasalazine, and formed from prodrug balsalazide | ||
**Balsalazide or Olsalazine - Bypasses small intestine to deliver drug into large intestine (better for UC) | **Balsalazide or Olsalazine - Bypasses small intestine to deliver drug into large intestine (better for UC) | ||
*Anti-diarrheal - Use caution in | *Anti-diarrheal - Use caution in patients with active inflammation as can precipitate toxic megacolon | ||
**Loperamide 4-16mg/day | **[[Loperamide]] 4-16mg/day | ||
**Diphenoxylate 5-20mg/day | **[[Diphenoxylate]] 5-20mg/day | ||
**Cholestyramine 4g once to six times daily | **Cholestyramine 4g once to six times daily | ||
*Glucocorticoids - Symptomatic relief (course not altered) | *[[Glucocorticoids]] - Symptomatic relief (course not altered) | ||
**Prednisone - 40-60mg/day with taper once remission induced | **[[Prednisone]] - 40-60mg/day with taper once remission induced | ||
**Methylprednisolone 20mg IV q6hr | **[[Methylprednisolone]] 20mg IV q6hr | ||
**Hydrocortisone 100mg q8hr | **[[Hydrocortisone]] 100mg q8hr | ||
***Do not start if any suspicion of infection (ie C.diff colitis) | ***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) | ***Double edge sword: Reduction of bone density in addition to underlying disease process(decreased Ca absorption) | ||
*Antibiotics - Induce remission | *Antibiotics - Induce remission | ||
**Ciprofloxacin 500mg q8-12hr OR | **[[Ciprofloxacin]] 500mg q8-12hr '''OR''' | ||
**Metronidazole 500mg q6hr OR | **[[Metronidazole]] 500mg q6hr '''OR''' | ||
**Rifaximin 800mg BID | **[[Rifaximin]] 800mg BID | ||
*Immunomodulators - Steroid-sparing agents used in fistulas and | *Immunomodulators - Steroid-sparing agents used in fistulas and patients with surgical contraindication. Slower onset. | ||
**6-Mercaptopurine 1-1. | **6-Mercaptopurine 1-1.5mg/kg/day → Start at 50mg daily | ||
**Azathioprine 2-2.5mg/kg/day → Start at 50mg daily | **[[Azathioprine]] 2-2.5mg/kg/day → Start at 50mg daily | ||
**Methotrexate IM | **[[Methotrexate]] IM | ||
*Anti-TNF - Medically resistant moderate-to-severe Crohn's | *Anti-TNF - Medically resistant moderate-to-severe Crohn's disease | ||
**Infliximab (Remicade) 5mg/kg IV | **Infliximab (Remicade) 5mg/kg IV | ||
**Adalimumab (Humira), Natalizumab or certolizumab pegol can also be used | **Adalimumab (Humira), Natalizumab or certolizumab pegol can also be used | ||
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==Disposition== | ==Disposition== | ||
===Inpatient Admission=== | ===Inpatient Admission=== | ||
* | *Significant metabolic derangements (i.e. [[electrolyte imbalance]] or severe [[dehydration]]) | ||
*Fulminate colitis | *Fulminate [[colitis]] | ||
*Obstruction | *[[SBO|Obstruction]] | ||
*Peritonitis | *[[Peritonitis]] | ||
*Significant hemorrhage | *Significant [[GI bleed|hemorrhage]] | ||
===Surgical Intervention=== | ===Surgical Intervention=== | ||
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*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== | ==Complications== | ||
* | *[[Bowel obstruction]] | ||
**Due to stricture or bowel wall edema | **Due to stricture or bowel wall edema | ||
*Abscess | *Abscess | ||
**Can be intraperitoneal, retroperitoneal, interloop, or intramesenteric | **Can be intraperitoneal, retroperitoneal, interloop, or intramesenteric | ||
***More severe abdominal pain than usual | ***More severe abdominal pain than usual | ||
***Fever | ***[[Fever]] | ||
***Hip or back pain and difficulty walking (retroperitoneal abscess) | ***[[hip pain|Hip]] or [[back pain]] and difficulty walking (retroperitoneal abscess) | ||
*Fistula | *Fistula | ||
**Occurs due to extension of intestinal fissure into adjacent structures | **Occurs due to extension of intestinal fissure into adjacent structures | ||
**Suspect if changes in | **Suspect if changes in patient's symptoms (e.g. BM frequency, amt of pain, wt loss) | ||
*Perianal disease | *Perianal disease | ||
**Abscess, fissures, fistulas, rectal prolapse | **[[perianal Abscess|Abscess]], [[anal fissure|fissures]], [[anal fistula|fistulas]], [[rectal prolapse]] | ||
*Hemorrhage | *[[GI bleed|Hemorrhage]] | ||
**Erosion into a bowel wall vesel | **Erosion into a bowel wall vesel | ||
*Toxic megacolon | *[[Toxic megacolon]] | ||
**Can be associated | **Can be associated with massive GI bleeding | ||
===Therapy complications=== | ===Therapy complications=== | ||
*Leukopenia /thrombocytopenia | *[[Leukopenia]]/[[thrombocytopenia]] | ||
*Fever / infection | *[[Fever]]/infection | ||
*Pancreatitis | *[[Pancreatitis]] | ||
*Renal / liver failure | *[[Renal failure|Renal]]/[[liver failure]] | ||
==See Also== | ==See Also== | ||
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==References== | ==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
- All layers of the bowel are involved
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
GI Symptoms
- Abdominal pain
- Diarrhea
- Weight loss
- Perianal fissures or fistulas
Extraintestinal Symptoms (50%)
- Arthritis
- Peripheral arthritis
- Migratory monoarticular or polyarticular
- Ankylosing spondylitis
- Pain/stiffness of spine, hips, neck, rib cage
- Sacroiliitis
- Low back pain with morning stiffness
- Peripheral arthritis
- Ocular
- Uveitis
- Acute blurring of vision, photophobia, pain, perilimbic scleral injection
- Episcleritis
- Eye burning or itching with out visual changes or pain; scleral and conj hyperemia
- Uveitis
- Dermatologic
- Erythema nodosum
- Painful, red, raised nodules on extensor surfaces of arms/legs
- Pyoderma gangrenosum
- Violaceous, ulcerative lesions with necrotic center found in pretibial region or trunk
- Erythema nodosum
- Hepatobiliary
- Cholelithiasis (33%)
- Fatty liver
- Autoimmune hepatitis
- Primary sclerosing cholangitis
- Cholangiocarcinoma
- Renal
- Increased risk for calcium oxalate stones due to hyperoxaluria
- Vascular
Differential Diagnosis
Colitis
- Viral gastroenteritis
- Bacterial gastroenteritis
- Campylobacter infections
- Clostridium difficile colitis
- Colon cancer
- Crohn disease
- Cryptosporidiosis
- Mycobacterium Avium-Intracellulare
- Toxic megacolon
- Ulcerative colitis
- Ischemic bowel disease (e.g. mesenteric ischemia, strangulated hernia)
- Pseudomembranous enterocolitis
- Lymphoma
- Ileocecal amebiasis
- Sarcoidosis
- Yersinia
- Campylobacter
Other
Evaluation
Work-Up
- Rule out alternate etiologies for symptoms
- Evaluate for complications (e.g. fistulae, abscess, obstruction)
- Labs
- 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
- CT A/P if concern for small bowel obstruction, perforation, or toxic megacolon
Diagnosis
Management
Acute Flare Management
- IVF
- Bowel rest
- Analgesia
- Electrolyte correction
- 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
Alterations should be discussed with GI
- Aminosalicylates (5-ASA) - Mild-to-moderate Crohn's disease. 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 patients
- 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)
- Sulfasalazine 3-5gm/day PO (sulfa drug)
- Anti-diarrheal - Use caution in patients 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 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
- Significant metabolic derangements (i.e. 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
- Bowel obstruction
- Due to stricture or bowel wall edema
- 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
- ↑ 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.