Crohn's disease

Question 1

Defintion

Answer 1

Disorder of the GIT of unknown etiology associated with transmural inflammation

Question 2

Epidemiology

Answer 2

Diagnosis generally 15-40, second peak in >60
Equal gender ratio
+Whites
?+Smokers

Question 3

Pathophysiology

Answer 3

Inflammatory infiltrate around intestinal crypts->ulceration->non caseating granulomas->all layers.
Hyperemia, edema->bowel spasm, thickening, scarring, narrowing and strictures->fistulas, sinus, perforation, abscess. Deficient absorptive capacity.
Poor bile acid reabsorption when involvement of ileum->steatorrhea, Xfat soluble vitamin absorption, gall stones. ++Fat in stool binds to calcium, +Oxalate absorption and predisposing to oxalate kidney stone formation.

Question 4

History

Answer 4

Abdominal pain
Prolonged diarrhea
Perianal lesions
Bowel obstruction
Blood in stool
Fever, fatigue, weight loss
Abdominal tenderness, mass
Oral lesions
Erythema nodosum, pyoderma gangrenosum

Question 5

Risk factors

Answer 5

Age 15-40
Family history
White
Smoking
OCP
Not breastfed
NSAID

Question 6

Invetsigations

Answer 6

FBC->anemia, leukocytosis, thrombocytosis
Iron studeies
Serum B12->normal or low
Serum folate->normal or low
CMP, UEC, albumin->low Ca, low albumin, low cholesterol
+CRP/ESR
Stool MCS
Plain AXR->dilitation, calcification, sacroilitis, abscesses
CT/MRI abdomen->skip lesions, bowel wall thickening, inflammation, abscess, fistula

Consider:
Colonoscopy
Small bowel follow through

Question 7

Findings on endoscopy

Answer 7

Apthous ulcers
Cobblestining
Discontinuous lesions

Question 8

Activity index

Answer 8

1. Liquid stools
2. Abdominal pain
3. General well being
4. Complications
   - >Apthous ulcers
   - >Iritis, uveitis
   - >Arthralgia, arthritis
   - >Erythema nodosum, pyoderma gangrenosum
   - >Fissures, fistula, abscess
   - >Fever
5. Antidiarrheal medications
6. Abdominal mass
7. Reduced hematocrit
8. Deviation of weight

Question 9

Define mild disease

Answer 9

Ambulatory, eating and drinking without dehydration, toxicity, abdominal
tenderness, painful mass, obstruction or >10% weight loss

Question 10

Define moderate disease

Answer 10

Failure of response to mild medical therapies or fevers, significant weight
loss, abdominal pain or tenderness, intermittent nausea and vomiting
(without obstructive findings) or significant anemia

Question 11

Define severe to fulminant

Answer 11

Persistent symptoms despite use of corticosteroids as outpatient or high
fevers, persistent vomiting, evidence of intestinal obstruction, rebound
tenderness, cachexia, evidence of abscess

Question 12

Induction therapy for mild disease

Answer 12

Prednisilone PO 40-60mg daily, until clinical response, taper over 8-12 weeks or Budesonide

Question 13

Acute management of severe disease

Answer 13

Admission
IVF->NS + glucose + KCl
IV hydrocortisone->switch to oral prednisilone when response
Metronidazole IV
Monitor temperature, BP, pulse, Stool chart
Daily FBC, UEC, ESR/CRP
Consider need for transfusion/parenteral nutrition
If no response consider surgery

If refractory to steroids/side effects->
Infliximab
Azathioprine->steroid sparing
Mercaptopurine
Methotrexate + folic acid

For perianal:
MRI + EUA
Oral antibiotics
Immunosuppressants
Infliximab
Surgery + seton insertion

Question 14

Medical therapy overview

Answer 14

1. Nutrition and lifestyle
2. Antimicrobials
3. Anti-inflammatory
4. Imunomodulators
5. Anti-TNF

Question 15

Maintenence

Answer 15

1. Azathioprine or mercaptopurine, if X effective->methotrexate + folic acid
2. Fistulating/perianal->metronidazole + Azathioprine or infliximab
3. Cholestyramine
4. Loperamide
5. Fluids/low residue/elemental diet in flare up
6. Smoking cessation
7. Regular diet, may need supplementation

Question 16

Surgical indications, options, complications

Answer 16

Indications:

1. Relieve symptoms refractory to medical therapy->pain, obstruction, weight loss
2. +QOL when SE from medical therapy

Bowel resection, stricturoplasty, abscess drainage

May develop short bowel