Title: Clinical Symptoms and Work up for Crohns Disease
1Clinical Symptoms and Work up for Crohns Disease
- Kristen Covert
- Surgery Clerkship
- April 17, 2007
2- The patient is a 25-year-old white male, who you
note has presented intermittently since age 16
with complaints of abdominal pain, anorexia,
weight loss, diarrhea and impaired linear growth.
Previous studies have been inconclusive. He
presents today with postprandial abdominal pain
and vomiting x 1-2 days. The patient is febrile
but other vital signs are wnl. He now complains
of RLQ tenderness without appreciated mass. A
rectal exam reveals several perianal skin tags.
Initial labs are only significant for an elevated
white count and anemia.
3- So
- What is included in your differential diagnosis?
- What are the characteristic signs/symptoms
denoted by this clinical vignette? - How do you work-up this patient?
- What laboratory tests do you want to order?
- What imaging studies do you order at this time?
4Differential Diagnosis
- Early symptoms of Crohns are mild and
nonspecific. - Diagnosis of lactose intolerance or IBS is often
made with subsequent studies revealing the
underlying diagnosis - Yersinia, shigella, salmonella, E. Coli, and
amebiasis to be excluded in pts with new-onset
symptom - Careful with NSAID induced colitis b/c is also
characterized by SB/colonic ulcers, erosion, or
strictures that tend to be severe in the terminal
ileum/R colon
5Demographics
- Incidence 3.6 8.8 per 100,000
- Median age at diagnosis 30 (ranging from early
childhood through entire lifespan) - Increased risk in Caucasians, first-degree
relatives - Unlike UC, cigarette smoking is strongly
associated with the development of crohns
disease, resistance to medical therapy, and early
disease relapse. - Interestingly enough, most studies have found
breast-feeding to be protective
6General Considerations
- Crohns disease is a transmural process serosal
involvement results in adhesion of the inflamed
bowel to other loops of bowel or other adjacent
organs. Also can result in fibrosis, stricture
formation - Crohns may involve the entire GI tract from
mouth to perianal area - 1/3 of cases in terminal ileum
- 50 of cases in terminal ileum and proximal
ascending colon - 20 Colon only
- Chronic illness with exacerbations and remissions
- Treatment is directed both toward symptomatic
improvement and controlling the disease process
7Clinical Signs and Symptoms
- The clinical manifestations of Crohns disease
are much more variable than those of UC because
of - Transmural involvement
- Variability of the extent of disease
- The clinical presentation depends on
- Which segments of the GI tract are predominantly
affected - The intensity of the inflammation
- The presence/absence of specific complications
- Diarrhea, abdominal pain, weight loss, and fever
are the typical clinical manifestations - Crampy abdominal pain - transmural nature of the
inflammatory process leads to fibrotic strictures
often leading to repeated episodes of SBO/CO - Diarrhea - secondary to excessive fluid secretion
and impaired fluid absorption - Palpable, tender mass in lower abdomen -
represents thickened or matted loops of inflamed
intestine - Weight loss (secondary to malabsorption and not
eating) - Poor growth - (common in children, may be seen
before other features of disease become evident
8Clinical Manifestations
- Abscess
- Intestinal Obstruction
- Perforation and Fistulae
- 33-50 risk after 10-20 yrs
- Communications that connect two epithelial-lined
organs manifested by fevers, chills, and a tender
abdominal mass - Majority are asymptomatic and require no specific
therapy - Infliximab injections Surgical therapy
- Perianal disease 1/3 of pts demonstrate
perianal pain and drainage from - Large skin tags
- Anal fissures
- perirectal abscesses
- Anorectal fistulae
- Oral involvement pts may present with aphthous
ulcers
9Clinical Manifestations
- Eye Involvement uveitis, iritis, episcleritis
- Skin disorders erythema nodosum, pyoderma
gangrenosum - Primary sclerosing cholangitis
- Complications related to malabsorption
- Bile salt malabsorption leading to diarrhea and
predisposition to gallstones - Steatorrhea
- Nephrolithiasis Steatorrhea and volume
depletion secondary to diarrhea can promote the
development of both urate or calcium oxalate
stones - Malignancy - Colon cancer - Screening
colonoscopy to detect dysplasia or cancer is
recommended with a h/o 8 or more years of Crohns
colitis.
10Essentials of Diagnosis
- Insidious Onset
- Intermittent bouts of low-grade fever
- Diarrhea
- RLQ mass and tenderness
- Perianal disease (ie abscess, fistula)
- Radiographic evidence of ulceration, strictures,
or fistulas of the GI tract
11Diagnosis Laboratory Testing
- No single symptom, sign, or diagnostic test
establishes the diagnosis of Crohns - The diagnosis is based on a complete assessment
of the clinical presentation with confirmatory
findings derived from radiographic, endoscopic,
and pathologic tests. - Laboratory Tests
- Order CBC, ESR, CRP, serum albumin
- Anemia - of chronic inflammation, blood loss,
iron deficiency, or Vit B12 malabsorption - Leukocytosis indicates inflammation, abscesses,
or corticosteroid therapy - Hypoalbuminemia secondary to intestinal protein
loss, malabsorption, bacterial overgrowth, or
chronic inflammation - Elevated ESR or CRP correlates with disease
activity - Obtain stool for routine pathogens, OP, and C.
diff toxin
12DiagnosisImaging Studies
- Upper GI series with small bowel follow-through
suggestive findings include ulcerations,
strictures, and fistulas - Demonstrates diffuse thickening of the small
bowel mucosa and separation of bowel loops
manifestation of transmural inflammation - The cobblestone appearance is produced by barium
being dispersed between the edematous inflamed
mucosa. - String sign with advance luminal narrowing or
severe spasm
13DiagnosisImaging Studies
- Barium Enema may be useful in documenting the
length and location of strictures and involved
segments not accessible by colonoscopy - Illustrates a rectum and sigmoid colon that
appear normal. - Descending colon is narrowed and has an irregular
contour with areas of ulceration. - Midtransverse colon, there is a second area of
involvement, with ulcerations, abrupt narrowing,
and irregularity consistent with a thickened
colon wall. - The colonic abnormalities seen here are classic
for Crohn's -
- Wireless Capsuled imaging of small intestine
used in patients in whom the clinical suspicion
for SB involvement is high but radiographs are
normal or nondiagnostic - Should not be used in pts with suspected
intestinal stricture since capsule may not be
able to pass, requires surgical removal
14DiagnosisColonoscopy / Endoscopy Offers the
advantage of obtaining mucosal biopsies
- Granulomas in 25
- Apthous ulcers, linear or stellate ulcers
- Strictures
- Cobblestone appearance
- Skip lesions
- Pseudopolyps
15DiagnosisColonoscopy / Endoscopy Offers the
advantage of obtaining mucosal biopsies
- Biopsy of intestine reveals granulomas in 25
highly suggestive of Crohns disease, however,
may also be seen with Yersinia, Bechets disease,
TB, and lymphoma - Ulcers are the dominant endoscopic feature in
Crohn's disease. These tend to be "skip lesions".
- panel A - Early changes may be only patchy
erythema - panel B - Aphthoid ulcers .
- panel C - Linear ulcers are seen with more
advanced disease - Panel D - culminating in very deep and long
serpiginous ulcers
16DiagnosisAntibody Testing
- A number of autoantibodies have been detected in
patients with IBD, some of which may be
clinically useful for establishing the diagnosis
and differentiating b/t Crohns and UC. - At present, is only to be used as an adjunct to
conventional testing and clinical diagnosis. - Anti-OmpC antibody potential serologic marker
of IBD - ASCA (type of yeast) - found in 60-70 of
patients with Crohns disease, but only 10-15 of
patients with UC - pANCA found in 50-70 of pts with UC, but only
5-10 of Crohns
17Distinguishing Features of CD vs. UC
- When Crohns involves the colon, it must be
distinguished from UC since both the medical and
surgical therapies can differ. - Involvement of the SB
- Sparing of the rectum
- Absence of gross bleeding
- Presence of bothersome perianal disease
- Cobblestone appearance, skip lesions, and
granulomas. - Distinction cannot be made in 10-15 of these
patients.
18Treatment of Active Disease
- Crohns disease is a chronic lifelong illness
characterized by exacerbations and periods of
remission. - Current treatment is directed toward symptomatic
improvement and controlling the disease process.
The treatment must address the specific problems
of the individual patient! - A feature of Crohns that is grossly evident and
helpful in identifying affected segments of
intestine during surgery is fat stranding
virtually pathognomonic encroachment of
mesenteric fat onto the serosal surface of the
bowel
19Clinical situations in which the diagnosis of
Crohns disease should be considered
- Presence of acute or chronic abdominal pain,
especially when localized to the RLQ - Chronic diarrhea
- Discovery of a bowel stricture or fistula arising
from the bowel - Evidence of inflammation or granulomas on
intestinal histology - Poor growth in a child
- Major Diagnostic tool Evidence of intestinal
inflammation on radiography or endoscopy