Crohn's disease
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
Diagnosis
GI Symptoms
- Abdominal pain
- Diarrhea
- Wt loss
- Perianal fissures or fistulas
Extraintestinal Symptoms (50%)
- Arthritis
- Peripheral arthritis
- Migratory monarticular or polyarticular
- Ankylosing spondylitis
- Pain/stiffness of spine, hips, neck, rib cage
- Sacroiliitis
- Low back pain w/ morning stiffness
- Peripheral arthritis
- Ocular
- Uveitis
- Acute blurring of vision, photophobia, pain, perilimbic scleral injection
- Episcleritis
- Eye burning or itching w/o visual changes or pain; scleral and conj hyperemia
- Uveitis
- Dermatologic
- Erythema nodosum
- Painful, red, raised nodules on extensor surfaces of arms/legs
- Pyoderma gangrenosum
- Violacious, ulcerative lesions w/ necrotic center found in pretibial region or trunk
- Erythema nodosum
- Hepatobiliary
- Cholelithiasis (33%)
- Fatty liver
- Autoimmune hepatitis
- Primary sclerosing cholangitis
- Cholangiocarcinoma
- Vascular
- Thromboembolic disease
Work-Up
- Labs
- CBC
- Chemistry
- ESR/CRP
- C.diff toxin
- Type and Cross/Screen if any bleeding suspicion
- Imaging:
- Plain abdominal films - r/o obstruction, perforation and toxic megacolon
- CT A/P
- Most useful diagnostic test in pts w/ acute symptoms who have known or suspected Crohn
- Findings: bowel wall thickening, mesenteric edema, local abscess, fistulas
DDx
- Ulcerative colitis
- Ischemic bowel disease
- Pseudomembranous enterocolitis
- Lymphoma
- Ileocecal amebiasis
- Sarcoidosis
- Yersinia
- Campylobacter
Management
Initial ED Management: IVF, bowel rest, analgesia, electrolyte correction, and NGT (if obstruction/ileus/toxic megacolon)
- Rule-out 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)
- Can be intraperitoneal, retroperitoneal, interloop, or intramesenteric
- Fistula
- Occurs due to extension of intestinal fissure into adjacent structures
- Suspect if changes in pt'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 w/ massive GI bleeding
- Obstruction
- Rule-out therapy complications:
- Leukopenia /thrombocytopenia
- Fever / infection
- Pancreatitis
- Renal / liver failure
- Medications: Alterations should be discussed with GI
- Aminosalicylates (5-ASA) - Mild-to-moderate Crohn's dz. 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 pts
- 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 pts 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 pts w/ surgical contraindication. Slower onset.
- 6-Mercaptopurine 1-1.5 mg/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 dz
- Infliximab (Remicade) 5mg/kg IV
- Adalimumab (Humira), Natalizumab or certolizumab pegol can also be used
- Aminosalicylates (5-ASA) - Mild-to-moderate Crohn's dz. Give with probiotics.
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