Clinical Symptoms and Work up for Crohns Disease - PowerPoint PPT Presentation

1 / 19
About This Presentation
Title:

Clinical Symptoms and Work up for Crohns Disease

Description:

Poor growth - (common in children, may be seen before other features of disease become evident ... Colon cancer - Screening colonoscopy to detect dysplasia or ... – PowerPoint PPT presentation

Number of Views:163
Avg rating:3.0/5.0
Slides: 20
Provided by: richard150
Category:

less

Transcript and Presenter's Notes

Title: Clinical Symptoms and Work up for Crohns Disease


1
Clinical 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?

4
Differential 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

5
Demographics
  • 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

6
General 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

7
Clinical 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

8
Clinical 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

9
Clinical 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.

10
Essentials 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

11
Diagnosis 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

12
DiagnosisImaging 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

13
DiagnosisImaging 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

14
DiagnosisColonoscopy / Endoscopy Offers the
advantage of obtaining mucosal biopsies
  • Granulomas in 25
  • Apthous ulcers, linear or stellate ulcers
  • Strictures
  • Cobblestone appearance
  • Skip lesions
  • Pseudopolyps

15
DiagnosisColonoscopy / 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

16
DiagnosisAntibody 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

17
Distinguishing 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.

18
Treatment 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

19
Clinical 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
Write a Comment
User Comments (0)
About PowerShow.com