Crohns ulsease

(keg|ona| Lnter|t|s Granu|omatous I|e|t|s or I|eoco||t|s)

ctobos Jlseose ls o cbtoolc ttoosmotol loflommototy Jlseose tbot osoolly offects tbe Jlstol lleom ooJ coloo bot
moy occot lo ooy pott of tbe Cl ttoct 5ymptoms locloJe Jlottbeo ooJ obJomlool polo Abscesses lotetool ooJ
extetool flstolos ooJ bowel obsttoctloo moy otlse xttolotestlool symptoms pottlcolotly ottbtltls moy occot
uloqoosls ls by coloooscopy ooJ botlom coottost stoJles 1teotmeot ls wltb 5omloosollcyllc oclJ
cottlcostetolJs lmmooomoJolotots ootlcytokloes ootlblotlcs ooJ ofteo sotqety
(See also Lhe Amerlcan College of CasLroenLerologys pracLlce guldellnes for managemenL of Crohns dlsease ln
adulLs)
9athophys|o|ogy
Crohns dlsease beglns wlLh crypL lnflammaLlon and abscesses whlch progress Lo Llny focal aphLhold ulcers
1hese mucosal leslons may develop lnLo deep longlLudlnal and Lransverse ulcers wlLh lnLervenlng mucosal
edema creaLlng a characLerlsLlc cobblesLoned appearance Lo Lhe bowel
1ransmural spread of lnflammaLlon leads Lo lymphedema and Lhlckenlng of Lhe bowel wall and mesenLery
MesenLerlc faL Lyplcally exLends onLo Lhe serosal surface of Lhe bowel MesenLerlc lymph nodes ofLen enlarge
LxLenslve lnflammaLlon may resulL ln hyperLrophy of Lhe muscularls mucosae flbrosls and sLrlcLure formaLlon
whlch can lead Lo bowel obsLrucLlon Abscesses are common and flsLulas ofLen peneLraLe lnLo ad[olnlng
sLrucLures lncludlng oLher loops of bowel Lhe bladder or psoas muscle llsLulas may even exLend Lo Lhe skln
of Lhe anLerlor abdomen or flanks lndependenLly of lnLraabdomlnal dlsease acLlvlLy perlanal flsLulas and
abscesses occur ln 23 Lo 33 of cases Lhese compllcaLlons are frequenLly Lhe mosL Lroublesome aspecLs of
Crohns dlsease
noncaseaLlng granulomas can occur ln lymph nodes perlLoneum Lhe llver and all layers of Lhe bowel wall
AlLhough paLhognomonlc when presenL granulomas are noL deLecLed ln abouL half of paLlenLs wlLh Crohns
dlsease 1he presence of granulomas does noL seem Lo be relaLed Lo Lhe cllnlcal course
SegmenLs of dlseased bowel are sharply demarcaLed from ad[acenL normal bowel (sklp areas") hence Lhe
name reglonal enLerlLls AbouL 33 of Crohns dlsease cases lnvolve Lhe lleum alone (llelLls) abouL 43 lnvolve
Lhe lleum and colon (lleocollLls) wlLh a predllecLlon for Lhe rlghL slde of Lhe colon and abouL 20 lnvolve Lhe
colon alone (granulomaLous collLls) mosL of whlch unllke ulceraLlve collLls (uC) spare Lhe recLum
Cccaslonally Lhe enLlre small bowel ls lnvolved ([e[unollelLls) 1he sLomach duodenum or esophagus ls
cllnlcally lnvolved only rarely alLhough mlcroscoplc evldence of dlsease ls ofLen deLecLable ln Lhe gasLrlc
anLrum especlally ln younger paLlenLs ln Lhe absence of surglcal lnLervenLlon Lhe dlsease almosL never
exLends lnLo areas of small bowel LhaL are noL lnvolved aL flrsL dlagnosls

1here ls an lncreased rlsk of cancer ln affecLed smallbowel segmenLs aLlenLs wlLh colonlc lnvolvemenL have a
longLerm rlsk of colorecLal cancer equal Lo LhaL of uC glven Lhe same exLenL and duraLlon of dlsease
Symptoms and S|gns
1he mosL common lnlLlal manlfesLaLlon ls chronlc dlarrhea wlLh abdomlnal paln fever anorexla and welghL
loss 1he abdomen ls Lender and a mass or fullness may be palpable Cross recLal bleedlng ls unusual excepL ln
lsolaLed colonlc dlsease whlch may manlfesL slmllarly Lo uC Some paLlenLs presenL wlLh an acuLe abdomen
LhaL slmulaLes acuLe appendlclLls or lnLesLlnal obsLrucLlon AbouL 33 of paLlenLs have perlanal dlsease
(especlally flssures and flsLulas) whlch ls someLlmes Lhe mosL promlnenL or even lnlLlal complalnL ln chlldren
exLralnLesLlnal manlfesLaLlons frequenLly predomlnaLe over Cl sympLoms arLhrlLls luC anemla or growLh
reLardaLlon may be a presenLlng sympLom whereas abdomlnal paln or dlarrhea may be absenL
WlLh recurrenL dlsease sympLoms vary aln ls mosL common and occurs wlLh boLh slmple recurrence and
abscess formaLlon aLlenLs wlLh severe flareup or abscess are llkely Lo have marked Lenderness guardlng
rebound and a general Loxlc appearance SLenoLlc segmenLs may cause bowel obsLrucLlon wlLh collcky paln
dlsLenLlon obsLlpaLlon and vomlLlng Adheslons from prevlous surgery may also cause bowel obsLrucLlon
whlch beglns rapldly wlLhouL Lhe prodrome of fever paln and malalse Lyplcal of obsLrucLlon due Lo a Crohns
dlsease flareup An enLeroveslcal flsLula may produce alr bubbles ln Lhe urlne (pneumaLurla) uralnlng
cuLaneous flsLulas may occur lree perforaLlon lnLo Lhe perlLoneal cavlLy ls unusual
Chronlc dlsease causes a varleLy of sysLemlc sympLoms lncludlng fever welghL loss undernuLrlLlon and
exLralnLesLlnal manlfesLaLlons (see lnflammaLory 8owel ulsease (l8u))
1he vlenna ClasslflcaLlon and lLs recenL MonLreal modlflcaLlon caLegorlze Crohns dlsease lnLo 3 prlnclpal
paLLerns (1) prlmarlly lnflammaLory whlch afLer several years commonly evolves lnLo elLher (2) prlmarlly
sLenoLlc or obsLrucLlng or (3) prlmarlly peneLraLlng or flsLullzlng 1hese dlfferenL cllnlcal paLLerns dlcLaLe
dlfferenL LherapeuLlc approaches Some geneLlc sLudles suggesL a molecular basls for Lhls classlflcaLlon

|agnos|s
O 8arlum xrays of Lhe sLomach small bowel and colon
O Abdomlnal C1 (convenLlonal or C1 enLerography)
O SomeLlmes magneLlc resonance (M8) enLerography upper endoscopy and/or colonoscopy
Crohns dlsease should be suspecLed ln a paLlenL wlLh lnflammaLory or obsLrucLlve sympLoms or ln a paLlenL
wlLhouL promlnenL Cl sympLoms buL wlLh perlanal flsLulas or abscesses or wlLh oLherwlse unexplalned arLhrlLls
eryLhema nodosum fever anemla or (ln a chlld) sLunLed growLh A famlly hlsLory of Crohns dlsease also
lncreases Lhe lndex of susplclon Slmllar sympLoms and slgns (eg abdomlnal paln dlarrhea) may be caused by
oLher Cl dlsorders ulfferenLlaLlon from uC (see 1able 1 lnflammaLory 8owel ulsease (l8u) ulfferenLlaLlng
Crohns ulsease and ulceraLlve CollLls ) may be an lssue ln Lhe 20 of cases ln whlch Crohns dlsease ls
conflned Lo Lhe colon Powever because LreaLmenL ls slmllar Lhls dlsLlncLlon ls crlLlcal only when surgery or
experlmenLal Lherapy ls conLemplaLed
aLlenLs presenLlng wlLh an acuLe abdomen (elLher lnlLlally or on relapse) should have flaL and uprlghL
abdomlnal xrays and an abdomlnal C1 scan 1hese sLudles may show obsLrucLlon abscesses or flsLulas and
oLher posslble causes of an acuLe abdomen (eg appendlclLls) ulLrasound may beLLer dellneaLe gynecologlc
paLhology ln women wlLh lower abdomlnal and pelvlc paln
lf lnlLlal presenLaLlon ls less acuLe an upper Cl serles wlLh smallbowel followLhrough and spoL fllms of Lhe
Lermlnal lleum ls preferred over convenLlonal C1 Powever newer Lechnlques of C1 or M8 enLerography
whlch comblne hlghresoluLlon C1 or M8 lmaglng wlLh large volumes of lngesLed conLrasL are becomlng Lhe
procedures of cholce ln some cenLers 1hese lmaglng sLudles are vlrLually dlagnosLlc lf Lhey show characLerlsLlc
sLrlcLures or flsLulas wlLh accompanylng separaLlon of bowel loops lf flndlngs are quesLlonable C1 enLeroclysls
or vldeo capsule enLeroscopy may show superflclal aphLhous and llnear ulcers 8arlum enema xray may be
used lf sympLoms seem predomlnanLly colonlc (eg dlarrhea) and may show reflux of barlum lnLo Lhe Lermlnal
lleum wlLh lrregularlLy nodularlLy sLlffness wall Lhlckenlng and a narrowed lumen ulfferenLlal dlagnoses ln
paLlenLs wlLh slmllar xray flndlngs lnclude cancer of Lhe cecum lleal carclnold lymphoma sysLemlc vascullLls
radlaLlon enLerlLls lleocecal 18 and ameboma
ln aLyplcal cases (eg predomlnanLly dlarrhea wlLh mlnlmal paln) evaluaLlon ls slmllar Lo suspecLed uC wlLh
colonoscopy (lncludlng blopsy sampllng for enLerlc paLhogens and when posslble vlsuallzaLlon of Lhe
Lermlnal lleum) upper Cl endoscopy may ldenLlfy subLle gasLroduodenal lnvolvemenL even ln Lhe absence of
upper Cl sympLoms
LaboraLory LesLs should be done Lo screen for anemla hypoalbumlnemla and elecLrolyLe abnormallLles Llver
funcLlon LesLs should be done elevaLed alkallne phosphaLase and gluLamyl LranspepLldase levels ln paLlenLs
wlLh ma[or colonlc lnvolvemenL suggesL posslble prlmary scleroslng cholanglLls LeukocyLosls or lncreased
levels of acuLephase reacLanLs (eg LS8 CreacLlve proLeln) are nonspeclflc buL may be used serlally Lo monlLor
dlsease acLlvlLy
erlnuclear anLlneuLrophll cyLoplasmlc anLlbodles are presenL ln 60 Lo 70 of paLlenLs wlLh uC and ln only 3 Lo
20 of paLlenLs wlLh Crohns dlsease AnLl5occbotomyces cetevlsloeanLlbodles are relaLlvely speclflc for
Crohns dlsease Powever Lhese LesLs do noL rellably separaLe Lhe 2 dlseases 1hey have uncerLaln value ln
cases of lndeLermlnaLe collLls and are noL recommended for rouLlne dlagnosls
9rognos|s
LsLabllshed Crohns dlsease ls rarely cured buL ls characLerlzed by lnLermlLLenL exacerbaLlons and remlsslons
Some paLlenLs have severe dlsease wlLh frequenL deblllLaLlng perlods of paln Powever wlLh [udlclous medlcal
Lherapy and where approprlaLe surglcal Lherapy mosL paLlenLs funcLlon well and adapL successfully ulsease
relaLed morLallLy ls very low Cl cancer lncludlng cancer of Lhe colon and small bowel ls Lhe leadlng cause of
excess Crohns dlseaserelaLed morLallLy
1reatment
O Loperamlde
or anLlspasmodlcs for sympLom rellef
O 3Amlnosallcyllc acld (3ASA) or anLlbloLlcs
O CLher drugs dependlng on sympLoms and severlLy
O SomeLlmes surgery
ueLalls of speclflc drugs and dosages are dlscussed on p see lnflammaLory 8owel ulsease (l8u) 1reaLmenL
6enero/ monoqement Cramps and dlarrhea may be relleved by oral admlnlsLraLlon ofloperamlde
2 Lo 4 mg or anLlspasmodlc drugs up Lo 4 Llmes/day (ldeally before meals) Such sympLomaLlc LreaLmenL ls
safe excepL ln cases of severe acuLe Crohns collLls whlch may progress Lo Loxlc megacolon as ln uC
Pydrophlllc muclllolds (eg meLhylcellulose or psylllum preparaLlons) someLlmes help prevenL anal lrrlLaLlon by
lncreaslng sLool flrmness uleLary roughage ls Lo be avolded ln sLrlcLurlng dlsease or acLlve colonlc
lnflammaLlon