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<languages/>

==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 vs UC}}

==Clinical Features==

[[File:Aphthous stomatitis.jpg|thumb|An aphthous mouth ulcer ([[Special:MyLanguage/aphthous stomatitis|aphthous stomatitis]]) on seen with Crohn's disease.]]
[[File:A single EN.jpg|thumb|A single lesion of erythema nodosum.]]

===GI Symptoms===

*[[Special:MyLanguage/Abdominal pain|Abdominal pain]]
*[[Special:MyLanguage/Diarrhea|Diarrhea]]
*Weight loss
*[[Special:MyLanguage/Anal fissure|Perianal fissures]] or [[Special:MyLanguage/anal fistula|fistulas]]

===Extraintestinal Symptoms (50%)===

*[[Special:MyLanguage/Arthritis|Arthritis]]
**Peripheral [[Special:MyLanguage/arthritis|arthritis]]
***Migratory monoarticular or polyarticular
**[[Special:MyLanguage/Ankylosing spondylitis|Ankylosing spondylitis]]
***Pain/stiffness of spine, hips, neck, rib cage
**Sacroiliitis
**Low [[Special:MyLanguage/back pain|back pain]] with morning stiffness
*Ocular
**[[Special:MyLanguage/Uveitis|Uveitis]]
***Acute blurring of vision, photophobia, pain, perilimbic scleral injection
**[[Special:MyLanguage/Episcleritis|Episcleritis]]
***Eye burning or itching with out visual changes or pain; scleral and conj hyperemia
*Dermatologic
**[[Special:MyLanguage/Erythema nodosum|Erythema nodosum]]
***Painful, red, raised nodules on extensor surfaces of arms/legs
**[[Special:MyLanguage/Pyoderma gangrenosum|Pyoderma gangrenosum]]
***Violaceous, ulcerative lesions with necrotic center found in pretibial region or trunk
*Hepatobiliary
**[[Special:MyLanguage/Cholelithiasis|Cholelithiasis]] (33%)
**Fatty liver
**[[Special:MyLanguage/Autoimmune hepatitis|Autoimmune hepatitis]]
**[[Special:MyLanguage/Primary sclerosing cholangitis|Primary sclerosing cholangitis]]
**Cholangiocarcinoma
*Renal
**Increased risk for calcium oxalate [[Special:MyLanguage/nephrolithiasis|stones]] due to hyperoxaluria
*Vascular
**[[Special:MyLanguage/Thromboembolism|Thromboembolism]]

==Differential Diagnosis==

{{Colitis DDX}}

===Other===

*[[Special:MyLanguage/Appendicitis|Appendicitis]]

==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)<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>
***[[Special:MyLanguage/Clostridium difficile|C.diff]] toxin

*Consider imaging:
**CT A/P if concern for [[Special:MyLanguage/small bowel obstruction|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==

[[File:CT scan gastric CD.jpg|thumb|CT scan showing Crohn's disease in the fundus of the stomach.]]

===Acute Flare Management===

*[[Special:MyLanguage/IVF|IVF]]
*Bowel rest
*[[Special:MyLanguage/Analgesia|Analgesia]]
*[[Special:MyLanguage/Electrolyte repletion|Electrolyte correction]]
*Consider [[Special:MyLanguage/steroid|steroid]] burst
**[[Special:MyLanguage/Methylprednisolone|Methylprednisolone]] (e.g., 30mg IV bid) or [[Special:MyLanguage/prednisone|prednisone]] (e.g., 60 mg day 1, then 40 mg daily x 4 days), OR
**[[Special:MyLanguage/Budesonide|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.
**[[Special:MyLanguage/Sulfasalazine|Sulfasalazine]] 3-5gm/day PO (sulfa drug)
***Caution: Can cause [[Special:MyLanguage/folate deficiency|folate deficiency]] so give with [[Special:MyLanguage/folic acid|folic acid]], and can cause [[Special:MyLanguage/hemolytic anemia|hemolytic anemia]] in [[Special:MyLanguage/G6PD|G6PD]] patients
**[[Special:MyLanguage/Mesalamine|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 patients with active inflammation as can precipitate toxic megacolon
**[[Special:MyLanguage/Loperamide|Loperamide]] 4-16mg/day
**[[Special:MyLanguage/Diphenoxylate|Diphenoxylate]] 5-20mg/day
**Cholestyramine 4g once to six times daily
*[[Special:MyLanguage/Glucocorticoids|Glucocorticoids]] - Symptomatic relief (course not altered)
**[[Special:MyLanguage/Prednisone|Prednisone]] - 40-60mg/day with taper once remission induced
**[[Special:MyLanguage/Methylprednisolone|Methylprednisolone]] 20mg IV q6hr
**[[Special:MyLanguage/Hydrocortisone|Hydrocortisone]] 100mg q8hr
***Do not start if any suspicion of infection (ie [[Special:MyLanguage/C. diff|C. diff]] colitis)
***Double edge sword: Reduction of bone density in addition to underlying disease process(decreased Ca absorption)
*Antibiotics - Induce remission
**[[Special:MyLanguage/Ciprofloxacin|Ciprofloxacin]] 500mg q8-12hr '''OR'''
**[[Special:MyLanguage/Metronidazole|Metronidazole]] 500mg q6hr '''OR'''
**[[Special:MyLanguage/Rifaximin|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
**[[Special:MyLanguage/Azathioprine|Azathioprine]] 2-2.5mg/kg/day → Start at 50mg daily
**[[Special:MyLanguage/Methotrexate|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. [[Special:MyLanguage/electrolyte imbalance|electrolyte imbalance]] or severe [[Special:MyLanguage/dehydration|dehydration]])
*Fulminate [[Special:MyLanguage/colitis|colitis]]
*[[Special:MyLanguage/SBO|Obstruction]]
*[[Special:MyLanguage/Peritonitis|Peritonitis]]
*Significant [[Special:MyLanguage/GI bleed|hemorrhage]]

===Surgical Intervention===

''Consult EARLY if any of the following suspicions''
*Perforation
*Abscess/fistula formation
*[[Special:MyLanguage/Toxic megacolon|Toxic megacolon]]
*Significant [[Special:MyLanguage/GI bleed|hemorrhage]]
*Perianal disease
*Failed medical management

==Complications==

*[[Special:MyLanguage/Bowel obstruction|Bowel obstruction]]
**Due to stricture or bowel wall edema
*Abscess
**Can be intraperitoneal, retroperitoneal, interloop, or intramesenteric
***More severe abdominal pain than usual
***[[Special:MyLanguage/Fever|Fever]]
***[[Special:MyLanguage/hip pain|Hip]] or [[Special:MyLanguage/back pain|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
**[[Special:MyLanguage/perianal Abscess|Abscess]], [[Special:MyLanguage/anal fissure|fissures]], [[Special:MyLanguage/anal fistula|fistulas]], [[Special:MyLanguage/rectal prolapse|rectal prolapse]]
*[[Special:MyLanguage/GI bleed|Hemorrhage]]
**Erosion into a bowel wall vesel
*[[Special:MyLanguage/Toxic megacolon|Toxic megacolon]]
**Can be associated with massive GI bleeding

===Therapy complications===

*[[Special:MyLanguage/Leukopenia|Leukopenia]]/[[Special:MyLanguage/thrombocytopenia|thrombocytopenia]]
*[[Special:MyLanguage/Fever|Fever]]/infection
*[[Special:MyLanguage/Pancreatitis|Pancreatitis]]
*[[Special:MyLanguage/Renal failure|Renal]]/[[Special:MyLanguage/liver failure|liver failure]]

==See Also==

*[[Special:MyLanguage/Ulcerative Colitis|Ulcerative Colitis]]
*[[Special:MyLanguage/Colitis|Colitis]]

==References==

<references/>
[[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.

Crohn's disease/en - Revision history

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