Crohn Flashcards
Fistole
- entero enterica la più comne
- va trattata chirurgicamente solo se sintomatica
Ricorda, se c’è una fistola perianale c’è un ascesso
Ascesso
Drenaggio!
- se migliora, chirurgia programmata per la fistola
- chirurgia se non migliora dopo il drenaggio
- se guarisce, solo terapia medica di routine della malattia
Nefrolitiasi
These are probably the most commonly encountered kidney complications of IBD—particularly oxalate stones. Kidney stones are more common in Crohn’s patients with disease of the small intestine than in the general population because of fat malabsorption. Fat binds to calcium, leaving oxalate (a type of salt) free to be absorbed and deposited in the kidney, where it can form into stones.
General findings
Crohn disease (CD) is an inflammatory bowel disease, the pathogenesis of which is not fully understood. The clinical presentation of CD may be similar to ulcerative colitis (UC), the other most common inflammatory bowel disease. CD mostly affects young adults and adolescents between the ages of 15 and 35. It is typically located in the terminal ileum, but can discontinuously affect the entire gastrointestinal tract and commonly leads to complications such as fistulas, abscesses, and stenosis. Clinical features include diarrhea, weight loss, and abdominal pain in the right lower quadrant (RLQ), as well as extraintestinal manifestations in the eyes, joints, or skin. It is often difficult to diagnose because there is no confirmatory test. Diagnosis is therefore based on the patient’s medical history, physical examination, lab tests, imaging (e.g., MRI), endoscopy, and serological testing. Acute episodes are treated with corticosteroids, and in severe cases, immunosuppressants may be indicated. Antibiotics and surgical intervention may be needed to help treat complications. Because the entire gastrointestinal tract may be affected, Crohn disease cannot be cured (in contrast to ulcerative colitis). The goal of treatment is thus to avoid the progression and recurrence of inflammatory episodes.
Epidemiology
Average age at diagnosis: 15–35 years
A second peak is observed around the age of 60, when 10% of cases occur. (in linea generale la RCU è più frequente)
More common in white populations and people of Jewish descent (especially Ashkenazi Jews, central European Jews)
Etiology
Cause: Unknown factors lead to an imbalance between proinflammatory and anti-inflammatory mediators.
Risk factors
1.Nicotine abuse
2.Familial predisposition (e.g., mutation of the NOD2 gene, HLA-B27 association )👓
Nicotine consumption is the only (known) controllable risk factor for Crohn disease. Therefore, quitting smoking is especially important for patients with CD!
Phatophysiology
The rectum is spared💥
-Unknown mechanisms lead to the activation of lymphatic cells (Th1) in the intestinal walls → inflammation is triggered → local tissue damage (edema, erosions/ulcers, necrosis) → obstruction, fibrotic scarring, stricture, and strangulation of the bowel
-Abscess and fistula formation: intestinal aphthous ulcers → transmural fissures and inflammation of the intestinal walls → adherence to other organs or the skin → penetration of these structures → microperforation and abscess formation → macroperforation into these structures → fistula formation
Main locations: terminal ileum and colon but it can be located anywhere between the mouth and the anus (the rectum is spared)
Clinical features
Typically, CD occurs episodically and there is a 30% risk of recurring inflammation over the span of one year. If symptoms persist for six months, the disease is considered chronic.
Perianal fistulas and abscesses are often the first signs of Crohn disease!!💥
- Skip lesions (discontinuous inflammation)
- Hypertrophic lymph nodes
- Transmural inflammation
- Non-caseating granulomas
- Giant cells
- Distinct lymphoid aggregates of the lamina propria
✔Intestinal symptoms
-Typically non-bloody, chronic diarrhea (in RCU bloody diarrhea!)
-Abdominal pain, typically in the RLQ
-Signs of malabsorption
Weight loss
Failure to thrive and growth failure in children
Anemia
1.Intestinal blood loss can cause iron deficiency anemia
2.Anemia of chronic disease
3.Vitamin B12 malabsorption due to a chronically inflamed ileum
Complications of disturbed reabsorption of bile acids
Bile acid diarrhea
Bile acid malabsorption
Steatorrhea
Deficiencies in fat-soluble vitamins
Gallstones
Kidney stones
-Abdominal mass : the solid mass is often palpable in the RLQ
-Enterocutaneous fistula formation, typically seen in the perianal region
-Clinical features of abscesses (∼ 50% of cases) and fistulas (∼ 30% of cases)
Typically involve the terminal ileum and/or perianal region
Recurrences are common
- If intestinal stenosis/strictures: possible signs of bowel obstruction/(sub‑)ileus (vomiting, obstipation)
- If perforation → signs of peritonitis
✔Extraintestinal symptoms
-Joints: enteropathic arthritis (e.g., sacroiliitis)
-Eye: iritis, episcleritis, uveitis
-Liver/bile ducts: primary sclerosing cholangitis (PSC; less common than in UC)
-Dermatologic disease
1.Erythema nodosum
2.Acrodermatitis enteropathica
3.Pyoderma gangrenosum :
Associated with various conditions, including Crohn disease, UC, rheumatoid arthritis, and trauma
Most common site: extensor side of the lower limbs
Clinical features: very painful, rapidly-progressive, red spots that can change into purulent pustules or deep ulcerated lesions with central necrosis
Therapy: immunosuppressants (corticosteroids, cyclosporine A)
4.Pyostomatitis vegetans (oral aphthae)
Diagnosis
ASCA are found in 40–80% of patients with Crohn disease and 10–20% of patients with ulcerative colitis. In ulcerative colitis, pANCA testing more commonly positive (approx. 60–80% of cases)👓, whereas only 10–30% of patients with Crohn disease test positive for pANCA. Therefore, positive ASCA and negative pANCA testing in symptomatic patients is a strong indicator of Crohn disease.
✔Initially: if a patient has clinical features indicating CD, conduct blood and stool tests! (SOF positivo)
Confirm with endoscopy and/or radiographic imaging and/or biopsy
Perform contrast radiological studies and/or ultrasonography to assess extent, severity and complications (i.e., abscesses, fistulas or stenoses)
✔Laboratory tests
1.Blood
↑ Inflammatory markers (↑ CRP, ↑ ESR, ↑ thrombocytes, and ↑ leukocytes)
Anemia
↑ Anti-Saccharomyces cerevisiae antibody (ASCA)
2.Feces
Stool analysis to rule out gastroenteritis caused by bacteria (e.g., Clostridium difficile) or parasites
Possible detection of fecal calprotectin and/or fecal lactoferrin (These parameters are commonly used to differentiate between Crohn disease and other non‑infectious causes of gastrointestinal disorders. In addition, they are used to monitor the course of the disease or to detect recurrent episodes. Inflammation in the intestines should be suspected if fecal calprotectin is > 50 μg/g (sometimes first at levels > 100 μg/g) or if lactoferrin is > 7 μg/g. These fecal biomarkers may help avoid the need for otherwise invasive measures that assess intestinal inflammation.)
Fecal occult blood test (FOBT) to detect GI bleeding that is not visible to the eye
Imaging
1.Plain abdominal x-rays: bowel distention, pneumoperitoneum
2.Plain radiography with barium swallow (enteroclysis) (Endoscopic investigations are superior to barium studies in terms of detecting the pathology; however, barium studies can be used for evaluation of the small intestine if endoscopy is not available.)
Indication: to detect fistulas or stenoses
Findings
-String sign
-Creeping fat (proliferazione grasso mesenterico)
3.Ultrasound findings
Gastrointestinal wall thickening caused by inflammation and edema
Possible detection of abscesses/fistulas
Endoscopy
Endoscopy confirms the diagnosis, assesses the extent of the disease, differentiates CD from other diseases (e.g., ulcerative colitis, peptic ulcers, etc.), and may also be used as a therapeutic tool (e.g., dilatation of ducts, intestinal loops).
1.Ileocolonoscopy
Typical findings
Pattern of involvement: segmental/discontinuous
Macroscopic findings
Linear ulcers (“snail trails”)
Other aphthous hemorrhagic mucosa defects (pinpoint lesions)
Cobblestone sign: characteristic appearance of the mucosa (Inflamed sections followed by deep ulcerations that resemble uneven cobblestones)
Fissures, fistulas
Erythema and transmural inflammation (all mucosal layers of the intestinal wall are involved)
2.Esophagogastroduodenoscopy
Indication: to evaluate the possible involvement of the esophagus, stomach, and duodenum
Findings include aphthae on mucosa
3.Video capsule endoscopy
Is used to evaluate small bowel morphology as an adjunctive to regular endoscopy
Should be performed prior to regular endoscopy in suspected small bowel obstruction
Trattamento
- Nicotine abstinence
- Secondary lactose intolerance (approx. 30% of cases): lactose-free diet
- Malabsorption syndrome: appropriate substitution of vitamins, calories, protein, zinc, calcium
- Bile acid diarrhea: administration of ion-exchange resins to bind bile acids (e.g., cholestyramine)
- During acute episodes: avoid dietary fiber and consider parenteral nutrition
Pharmacotherapy
✔Symptomatic
-Antidiarrheal agents
Loperamide
Bile acid binders
- Topical corticosteroids
- Topical 5‑Aminosalicylic acid derivatives (5-ASA derivatives, 5-ASAs). In the case of inflammation of the distal colon
Acute episode
1.For mild to moderate disease (ambulatory, ingestion of food tolerated)
✔5-ASAs
Mesalamine (rectal, systemic)
Sulfasalazine
Apart from maintaining postoperative remission, aminosalicylic acid derivatives have been shown to have no other positive effects. However, their use is recommended because they demonstrate fewer side effects in comparison to corticosteroids.
Consider as initial treatment for patients with no systemic symptoms.
May be given in combination with corticosteroids
Indication: contraindications to corticosteroids, patients without systemic symptoms.
✔Budesonide
✔Antibiotics (metrodinazonolo, ciprofloxacina)
2.Moderate to severe disease (Unsuccessful treatment for mild to moderate disease or patients presenting with significant symptoms (e.g., abdominal tenderness and pain, nausea, vomiting, fever, weight loss, anemia)
