Crohn's disease: Difference between revisions
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*[[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 monoarticular or polyarticular | ***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 | ||
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**[[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%) | ||
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**Cholangiocarcinoma | **Cholangiocarcinoma | ||
*Renal | *Renal | ||
**Increased risk for calcium oxalate stones due to | **Increased risk for calcium oxalate [[nephrolithiasis|stones]] due to hyperoxaluria | ||
*Vascular | *Vascular | ||
**[[Thromboembolism]] | **[[Thromboembolism]] | ||
==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]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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==Evaluation== | ==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 | **ESR/CRP | ||
**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 | **[[Clostridium difficile|C.diff]] toxin | ||
**Type and screen if any bleeding suspicion | **Type and screen if any bleeding suspicion | ||
* | *Consider imaging: | ||
**Plain abdominal films - rule out [[small bowel obstruction]], perforation and toxic megacolon | **Plain abdominal films - rule out [[small bowel obstruction]], perforation and toxic megacolon | ||
**CT A/P | **CT A/P | ||
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==Management== | ==Management== | ||
===Acute Flare Management=== | ===Acute Flare Management=== | ||
*IVF | *[[IVF]] | ||
*Bowel rest | *Bowel rest | ||
*Analgesia | *[[Analgesia]] | ||
*Electrolyte correction | *[[Electrolyte repletion|Electrolyte correction]] | ||
*Consider steroid burst | *Consider [[steroid]] burst | ||
===Chronic Treatment=== | ===Chronic Treatment=== | ||
''Alterations should be discussed with GI'' | ''Alterations should be discussed with GI'' | ||
*Aminosalicylates (5-ASA) - Mild-to-moderate Crohn's disease. Give with probiotics. | *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]] patients | ***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 patients with active inflammation as can precipitate toxic megacolon | *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 | ||
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===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=== | ||
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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 | ||
==See Also== | ==See Also== |
Revision as of 19:10, 29 September 2019
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
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
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
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:
- 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
Acute Flare Management
- IVF
- Bowel rest
- Analgesia
- Electrolyte correction
- Consider steroid burst
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
- 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
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.