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Crohn’s Disease

Title               

Ñ    Crohn’s Disease

Definition

Ñ    Chronic inflammatory condition

Ñ    Unknown aetiology

Ñ    May affect any part of the bowel from mouth to anus

Pathogenesis

Causes

Ñ    Unknown

Contributory factors

Ñ    Family history

Ñ    Smoking

Pathological Process

Histology

Ñ    The characteristic feature is a non-caseating granuloma

Ñ    This consists of epithelioid cells and Langerhans’ giant cells

Macroscopic appearance

Ñ    Aphthous ulcers

Ñ    Snail track ulcers

Ñ    Fissures

Ñ    Cobblestone appearance

Ñ    Transmural inflammation

Ñ    Strictures

Ñ    Fistulae

Ñ    Abscesses

Ñ    Skip lesions:

Areas of involved mucosa with intervening area of normal mucosa:

·          Characteristic

Clinical Features

Age

Ñ    Commonly affects young adults

History

E&M

Ñ    Loss of weight

Ñ    Fever

Ñ    Sweats

GIT

Ñ    Anorexia

Ñ    Mouth ulcers

Ñ    Vomiting

Ñ    Abdominal pain

Ñ    Diarrhoea

Ñ    Bleeding and mucous per rectum

Ñ    Perianal discharge

KUB

Ñ    Dysuria and frequency:

Ureteric involvement

Ñ    Hydronephrosis:

Ureteric involvement

Ñ    Rectovesical fistulae

LMS

Ñ    Osteomalacia

Examination

E&M

Ñ    Fever

Ñ    Loss of weight

IS

Ñ    Clubbing

Ñ    Erythema nodosum

Ñ    Pyoderma gangrenosum

CVS

Ñ    Tachycardia

GIT

Ñ    Angular cheilitis

Ñ    Mouth ulcers

Ñ    Glossitis

Ñ    Tenderness over affected bowel

Ñ    Abdominal mass

Ñ    Anal skin tags

Ñ    Anal fissures

Ñ    Perianal Fistulae

RAG

Ñ    Colovaginal, rectovaginal fistulae

HS

Ñ    Anaemia

LMS

Ñ    Enteropathic arthritis

Ñ    Psoas abscess

CNS

Ñ    Uveitis

Complications

GIT

Ñ    Gall stones:

Bile acid malabsorption

Ñ    Autoimmune hepatitis

Ñ    Primary sclerosing cholangitis

Ñ    Cholangiocarcinoma

KUS

Ñ    Oxalate stones

Ñ    Amyloidosis

LMS

Ñ    Osteoporosis

Investigations

Fluids

Haematology

Ñ    Anaemia:

Iron deficiency

B₁₂ deficiency

Folate deficiency

Biochemistry

Ñ    Hypokalaemia:

Diarrhoea

Ñ    Albumin:

Decreased

Ñ    ALT, alkaline phosphatase:

Increased

Ñ    Mg, Zn, Se:

Deficiency

Urine

Ñ    Sterile pyuria:

Ureteric involvement

Imaging

Plain X-ray abdomen

Ñ    Intestinal obstruction

Ñ    Suggestion of mass

Ñ    Mucosal oedema and ulceration in colitis

CT scan

Ñ    Image masses

Ñ    Inflammation of the bowel

MRI

Ñ    Image fistulae

Ñ    Small bowel imaging

Barium Studies

Small bowel studies (barium follow through or small bowel enema):

Ñ    Alteration in mucosal pattern

Ñ    Ulcers:

Deep

Ñ    Strictures

Barium enema

Ñ    Large bowel involvement

Nuclear Medicine

Ñ    Labelled white cell scan:

Localises inflammatory lesions

Endoscopy

Upper and lower GI endoscopy (shows lesions and allows biopsies for histological confirmation):

Ñ    Ulceration

Ñ    Fissuring

Ñ    Cobblestoning of mucosa

Ñ    Strictures

Ñ    Fistulae

Surgery

Ñ    Diagnostic laparoscopy or laparotomy

Management

Control

Drugs

Induction of remission:

Ñ    Steroids

Ñ    Antibiotics:

Ciprofloxacin, metronidazole

Ñ    5 Amonosalicylic acid preparations:

Not very effective

Maintenance of remission:

Ñ    5 Amonosalicylic acid preparations

Ñ    Azathioprine

Ñ    6-mercaptopurine

Ñ    Methotrexate

Ñ    Thalidomide

Surgery

Ñ    Induction of remission in localised disease

Ñ    Management of complications

Biological Agents

Anti-TNF antibodies:

Ñ    Infliximab, Adalimumab:

Induction of remission and maintenance of remission

Lifestyle Adjustments

Ñ    Smoking:

Cessation

Ñ    Diet:

Supplementation

Induction of remission and maintenance of remission with elemental diet

Staffing

Ñ    Dietician regarding nutritional supplementation, elemental feeding

Equipment

Ñ    Specialised equipment (pumps, delivery systems) for nutritional therapy

Prognosis

Ñ    Small increase in mortality

Ñ    25% have long periods of remission, 25% have chronically active symptoms and 50% relapse and remit

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