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]]
***Violacious, ulcerative lesions with necrotic center found in pretibial region or trunk
***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 hyperoxaliuria
**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
*Imaging:
*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
==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 patient'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 with massive GI bleeding
===Therapy complications===
*Leukopenia /thrombocytopenia
*Fever / infection
*[[Pancreatitis]]
*Renal / liver failure


==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

Clinical Features

GI Symptoms

Extraintestinal Symptoms (50%)


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

Differential Diagnosis

Colitis

Other

Evaluation

Work-Up

  • Rule out alternate etiologies for symptoms
  • Evaluate for complications (e.g. fistulae, abscess, obstruction)
  • Labs
    • CBC
    • Chemistry
    • ESR/CRP
    • Fecal calprotectin (sensitive indicator of intestinal inflammation, unreliable in select Crohn's patients)[1]
    • C.diff toxin
    • Type and screen if any bleeding suspicion
  • 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

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

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.
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