Crohn Disease

Crohn Disease Definition Chronic, relapsing and immune mediated inflammatory bowel disease Asymmetric and transmural Can happen at any parts of the GIT and discontinuous Epidemiology Peaks in 2 nd and 3 rd decades of life Smaller peak in the 5 th and 7 th peak of life Slightly higher in females Causes/risk factors Idiopathic Genetic Environmental Western diet High fat, sugar and highly processed food NOD2/CARD 15 Geographical location Stronger than in UC Underdeveloped countries Accounts for 30% of risk Colder climates FHx Smoking Esp 1 st Exacerbated and increase recurrence after surgery Antibiotic use degree relatives NSAIDs ashkenazi jewish ancestry Clinical Features Usually insidious May present as an acute toxic illness Vary based on location General Chronic diarrhoea Fever Abdominal pain Most common Worse after eating Weight loss (5% of body weight) Specific Hematochezia -> chronic CD Perineal pain, drainage and fever -> perianal fistulas with or without abscess Dysphagia, odynophagia, chest pain, GERD CD Epigastric pain, nausea, vomit or gastric outlet obstruction -> gastric or duodenal CD Obstructive features -> strictures Extra intestinal manifestations Anaemia Anterior uveitis Cholelithiasis Erythema nodosum Inflammatory arthropathies Nephrolithiasis Osteoporosis Pyoderma gangrenous Scleritis Venous thromboembolism Investigations No single diagnostic test Infections should always be ruled out Y enterocolitica Lab: Increased inflammatory markers -> ESR, CRP Faecal calprotectin -> active disease Ruling out colitis Negative predictive value -> approaching 100% Less sensitive for detecting proximal small bowel inflammation pANCA and ASCA poor sensitivity and specificity is that for both? Not routine Blood tests Anaemia, folate Nutrient levels: iron, vitamin B12, folate, calcium, magnesium, albumin and LFTs CMP -> all patients -> hypoalbuminemia, hypercholesterolemia, hypocalcaemia Stool testing -> C. difficle Endoscopy Ileocoloscopy First line after bloods Gold standard Pathy or skin patterns with focal inflammation Adjust areas are normal Polypoid mucosal changes -> cobblestone appearance ulcerations Ulcerations Aphthous ulcers or deep transmural ulcers Video capsule endoscopy Evaluates small bowel CD that upper or lower endoscopy cannot reach contraindicated when structures are present Capsule can become stuck -> surgical removal Histology Chronic inflammation on Bx Granulomas – may be present Not required for diagnosis Cryptitis, crypt abscess, abundant lymphatic and plasma cells. Transmural involvement with noncaseating granulomas Noncaseating granulomas are more common than caseating granulomas Early: acute infiltrate and crypt abscess Late: chronic inflammation, crypt distortion, crypt abscess and in some subjects non-caseating granulomas Imaging Abdominal x ray String sign of Kantor Not diagnostic Suggestive and severity assessment CT or MR enterorrhaphy CTs provide the most consistent results Small bowel: inflammation, disease extent and complications Inflammation that is segmental mural hyperenhancement, bowel thickening and stratification Fistulas tracts -> enter enteral, enterocutaneous, intervaginal, uterovesical Perianal fistulas and/or abscess -> better seen on MRI Barium swallow To assess oesophageal, stomach or duodenal CD Strictures and fistulas Management No cure Medical Mild disease Antibiotics have no role Type Aims What to use Corticosteroids Most effective for inducing remission in active disease Prednisolone / Rapid inflammation control Induction Achieve remission rapidly using fast acting treatments prednisone 40 to 50 mg orally, daily in the morning until clinical response, then taper over 6 to 8 weeks to stop. If ileocecal disease Consider using enteric-coated prep of budesonide budesonide enteric-coated 9 mg orally, daily in the morning for 4 to 8 weeks, then taper over 2 to 4 weeks in 3 mg increments to sto p.