Chrohn's Disease

Question 1

Define

Answer 1

A chronic relapsing-remitting, non-infectious inflammatory disease of the GIT

Affects any part of the GI tract mouth to anus

Transmural and most commonly affects the distal ileum and proximal colon
* Subsequently, strictures and fistulae may develop between adjacent loops of bowel, between bowel and skin, or to other organs (e.g. vagina, bladder).
* Smoking increases risk of Crohn’s (whereas in UC it is decreased)

Question 2

Presentation

Answer 2

Growth failure - v.common

Delayed puberty - v.common

Classical presentation:
1. Abdominal pain (crampy)
2. Diarrhoea
3. Weight loss

General ill health:
* Fever
* Lethargy
* Weight loss

Extra-intestinal manifestations:
* Oral lesions or perianal skin tags
* Uveitis
* Arthralgia
* Erythema nodosum (or pyoderma gangrenosum)

Lethargy and general ill health WITHOUT GI symptoms can be presenting features in older children

It may be mistaken for psychological problems and can mimic anorexia nervosa

Question 3

Investigation

Answer 3

• Abdominal examination: MUST examine perianal area!
• Basic observations
• Biopsy = non-caseating epithelioid cell granulomata
• FBC (including iron, B12 and folate)
• CRP and ESR
• Stool MC&S- (NOTE: Faecal calprotectin- faecal WBC marker for adults)
• Upper GI and small bowel contrast scan
• Colonoscopy and biopsy (cobblestones
• Assess impact on daily functioning (anxiety, depression)
• Stopping smoking (reduce risk of relapse
• Assess risk of osteoporosis

Question 4

Management

Answer 4

Induce remission:

Nutritional management -> effective in 85-100% patients (crohns.org)
* Replace diet with whole protein modular diet – excessively liquid, for 6-8 weeks
* May need NG if the child struggles to drink that much
* Products are easily digested, provide all nutrients needed to replace lost weight

Pharmacological management à steroids (prednisolone) may be used to induce remission

Maintain remission – you can use steroids, but these have long-term consequences…
* Aminosalicylates (e.g. mesalazine)
* Immunosuppressive drugs (azathioprine, methotrexate, mercaptopurine)
1. Azathioprine cannot be given to people with a TPMT mutation
2. Must not have live vaccines
3. Must have pneumococcal and influenza vaccines

• Anti-TNF antibodies in biologic therapies (e.g. infliximab)
• Surgery for complications – obstruction, fistula, abscess, severe localized disease unresponsive to treatment
• SUPPORT → www.chronsandcolitis.org.uk – has information leaflet and grants available
• Educate on features of flare-ups
• Medical therapies require monitoring of biochemical measures (e.g. ferritin, B12, calcium and vitamin D)

Question 5

Complication

Answer 5

Relapse is COMMON

Malnourished children are at increased risk of growth failure and delayed pubertal development

Malnutrition, malabsorption, failure to thrive

Intestinal strictures, fistula, perianal disease, acute dilatation and perforation of GIT

Bowel cancer

Prognosis
* Lifelong condition with periods of relapse and remission (recurrent cycles of inflammation)
* Long term prognosis for Crohn’s beginning in childhood is GOOD
* Most people live normal lives, despite occasionally relapsing

Question 6

PACES counselling

Answer 6

Explain the diagnosis (a disease with an unknown cause that causes inflammation of the digestive system leading to malabsorption and bloody diarrhoea)

Explain that it is a life-long condition and there is always a risk of relapse

Reassure that there are many medications that can be used to settle down the inflammation any time it flares up (and explain that they will be seen by a gastroenterologist)

Explain complications (malabsorption and bowel cancer)

Support: Crohn’s and Colitis UK