Crohn's Disease - Clinical Features, Diagnosis and Treatment

CROHN’S DISEASE

It is a bowel disorder without any certain etiology characterized by transmural inflammation of gastrointestinal tract. It may involve any region from mouth to perianal area.

ETIOLOGY

Age: 15-25 years

No gender predilection

80% of the people have small bowel involvement.

CLINICAL MANIFESTATIONS

Abdominal pain: Frequently right lower quadrant pain, crampy, transmural nature of this disease results in fibrotic structures. These strictures can lead to intestinal obstruction.

Diarrhea: Any H/O prolonged diarrhea without bleeding points towards IBD (Inflammatory Bowel Disease)

Bleeding: presence of microscopic level of blood may be seen, however gross presence is infrequent.

Fistulas: Due to transmural inflammation sinus tracts develop leading to fistulas

Severe oral involvement may be present manifest as aphthous ulcer

Fatigue and weight loss

Extraintestinal

Arthritis or arthropathy: large joints are mostly involved
Eyes: in 5% cases uveitis, episcleritis
Skin: Erythema nodosum and pyoderma gangrenosum
Primary sclerosing cholangitis
Renal stones
Pulmonary: chronic bronchitis, bronchiolitis, sarcoidosis

DIFFERENTIAL DIAGNOSIS

Irritable bowel syndrome

Lactose intolerance

Infectious colitis

Ulcerative colitis

DIAGNOSIS

Physical examination: Pallor, weight loss, perianal skin tags, abdominal tenderness

CBC: Anemia, Iron deficiency, elevated WBC, B12 deficiency, elevated ESR or CRP

Stool specimen

Colonoscopy: Involves terminal ileum usually with skip areas of involvement, Pseudopolyps, Rectal sparing, Granulomas may be noted

Air contrast barium enema may show extent of disease

MRI to detect perianal fistulas

Radio logic imaging

On control films presence of gallstones, renal oxalate stones, and sacroiliac joint or lumbosacral spine changes should be sought

USG shows bowel hyperemia and small bowel wall thickening

Antibody Tests: Antineutrophil cytoplasmic antibodies(pANCA) and anti saccharomyces cerevisiae antibodies(ASCA)

Barium small bowel follow-through include:

mucosal ulcers

aphthous ulcers initially

deep ulcers (>3 mm depth)

longitudinal fissures

when severe leads to cobblestone appearance

may lead to sinus tracts and fistulae

string sign: tubular narrowing due to spasm or stricture depending on the chronicity

( In this picture the deep, linear ulcers (arrows) that have filled with barium in this stenosed terminal ileum are known as ‘rose-thorn ulcers’ and are typical of Crohn’s disease )

( In this picture it shows the classic appearance of Crohn’s disease in the terminal ileum – so-called ‘cobblestoning’. This is caused by extensive fissures and ulceration in between areas of intact but oedematous mucosa, resembling cobblestones (arrows) )

MANAGEMENT

Management is complex as the condition is chronic with a relapsing-remitting course. Medical management includes corticosteroids, 5-ASA preparations, immunomodulation (e.g. azathioprine, cyclosporine, methotrexate) 7. Surgical management is reserved for complications.