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Inflammatory Bowel Disease Crohn Disease.pdf

Abbas Mushtaq Ali
Abbas Mushtaq Ali

Inflammatory Bowel Disease Crohn Disease.pdf IBD according to step up to medicine reference

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Inflammatory Bowel Disease Crohn Disease (Regional Enteritis) A. General Characteristics 1. Crohn disease is a chronic transmural inflammatory disease that can affect any part of the GI tract (mouth to anus) but most commonly involves the small bowel (terminal ileum). 2. Distribution: There are three major patterns of disease: a. Forty percent of patients have disease in the terminal ileum and cecum. b. Thirty percent of patients have disease confined to the small intestine. c. Twenty-five percent of patients have disease confined to the colon. d. Rarely, other parts of GI tract may be involved (stomach, mouth, esophagus). 3. Pathology a. Terminal ileum is the hallmark location, but other sites of GI tract may also be involved. b. Skip lesionsdiscontinuous involvement c. Fistulae d. Luminal strictures e. Noncaseating granulomas f. Transmural thickening and inflammation (full-thickness wall involvement) results in narrowing of the lumen. g. Mesenteric fat creeping onto the antimesenteric border of small bowel. Quick HIT Crohn disease has a chronic, indolent course characterized by unpredictable flares and remissions. The effectiveness of medical treatment decreases with advancing disease, and complications eventually develop, requiring surgery. There is no cure, and recurrence is common even after surgery. B. Clinical Features 1. Diarrhea (usually without blood) 2. Malabsorption and weight loss (common) 3. Abdominal pain (usually RLQ), nausea, and vomiting 4. Fever, malaise 5. Extraintestinal manifestations in 15% to 20% of cases (uveitis, arthritis, ankylosing spondylitis, erythema nodosum, pyoderma gangrenosum, aphthous oral ulcers, cholelithiasis, and nephrolithiasis) (see also Clinical Pearl 3-8)
C. Diagnosis 1. Endoscopy (sigmoidoscopy or colonoscopy) with biopsytypical findings are aphthous ulcers, cobblestone appearance, pseudopolyps, patchy (skip) lesions. 2. Barium enema 3. Upper GI with small bowel follow-through CLINICAL PEARL 3-8 Extraintestinal Manifestations of IBD Eye lesions Episcleritisparallels bowel disease activity Anterior uveitisindependent course Skin lesions Erythema nodosumespecially in Crohn disease; parallels bowel disease activity Pyoderma gangrenosumespecially in UC; parallels bowel disease activity in 50% of cases. Arthritismost common extraintestinal manifestation of IBD Migratory monoarticular arthritisparallels bowel disease activity (coincides with exacerbation of colitis) Ankylosing spondylitispatients with UC have a 30 times greater incidence of ankylosing spondylitis than the general population; the course is independent of the colitis. Sacroiliitisdoes not parallel bowel disease activity Thromboembolic hypercoagulable statecan lead to deep venous thrombosis (DVT), pulmonary embolism (PE), or a cardiovascular accident (CVA) Idiopathic thrombocytopenic purpura Osteoporosis Gallstones in Crohn disease (ileal involvement) Sclerosing cholangitis in UC D. Complications 1. Fistulaebetween colon and other segments of intestine (enteroenteral), bladder (enterovesical), vagina (enterovaginal), and skin (enterocutaneous) 2. Anorectal disease (in 30% of patients)fissures, abscesses, perianal fistulas 3. SBO (in 20% to 30% of patients) is the most common indication for surgery. a. Initially, it is due to edema and spasm of bowel with intermittent signs of obstruction; later, scarring and thickening of bowel cause chronic narrowing of lumen. 4. Malignancyincreased risk of colonic and small bowel tumors (but less common than risk of malignancy in UC). 5. Malabsorption of vitamin B12 and bile acids (both occur in terminal ileum). 6. Cholelithiasis may occur secondary to decreased bile acid absorption. 7. Nephrolithiasisincreased colonic absorption of dietary oxalate can lead to calcium oxalate kidney stones. 8. Aphthous ulcers of lips, gingiva, and buccal mucosa (common) 9. Toxic megacolonless common in Crohn disease than in UC
10. Growth retardation 11. Narcotic abuse, psychosocial issues due to chronicity, and often disabling nature of the disease Quick HIT Patients may have vague abdominal pain and diarrhea for years before a diagnosis of Crohn disease is considered. E. Treatment 1. Medical a. Systemic corticosteroids (prednisone)used as initial therapy for low-risk patients with diffuse disease or left-sided colon disease. Attempt taper when clinically improved. If unable to taper, consider immunosuppressant or biologic agent (below) b. Budesonideused in low-risk patients with mild disease in ileum or right colon. Attempt taper when clinically improved. If unable to taper, consider immunosuppressant or biologic agent (below). c. Biologic agent (TNF inhibitor) can be used as monotherapy or in combination with thiopurine (azathioprine or 6-mercaptopurine) or methotrexate in patients with moderate to severe disease. 2. Surgical (eventually required in most patients) a. Reserved for complications of Crohn disease or for those who have persistent symptoms despite best medical management b. Involves segmental resection of involved bowel c. Disease recurrence after surgery is high. Up to 50% of patients experience disease recurrence at 10 years postoperatively. d. Indications for surgery include SBO, fistulae (especially between bowel and bladder or vagina), disabling disease, and perforation or abscess. 3. Nutritional supplementation and supportparenteral nutrition is sometimes necessary.

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Inflammatory Bowel Disease Crohn Disease.pdf

  • 1. Inflammatory Bowel Disease Crohn Disease (Regional Enteritis) A. General Characteristics 1. Crohn disease is a chronic transmural inflammatory disease that can affect any part of the GI tract (mouth to anus) but most commonly involves the small bowel (terminal ileum). 2. Distribution: There are three major patterns of disease: a. Forty percent of patients have disease in the terminal ileum and cecum. b. Thirty percent of patients have disease confined to the small intestine. c. Twenty-five percent of patients have disease confined to the colon. d. Rarely, other parts of GI tract may be involved (stomach, mouth, esophagus). 3. Pathology a. Terminal ileum is the hallmark location, but other sites of GI tract may also be involved. b. Skip lesionsdiscontinuous involvement c. Fistulae d. Luminal strictures e. Noncaseating granulomas f. Transmural thickening and inflammation (full-thickness wall involvement) results in narrowing of the lumen. g. Mesenteric fat creeping onto the antimesenteric border of small bowel. Quick HIT Crohn disease has a chronic, indolent course characterized by unpredictable flares and remissions. The effectiveness of medical treatment decreases with advancing disease, and complications eventually develop, requiring surgery. There is no cure, and recurrence is common even after surgery. B. Clinical Features 1. Diarrhea (usually without blood) 2. Malabsorption and weight loss (common) 3. Abdominal pain (usually RLQ), nausea, and vomiting 4. Fever, malaise 5. Extraintestinal manifestations in 15% to 20% of cases (uveitis, arthritis, ankylosing spondylitis, erythema nodosum, pyoderma gangrenosum, aphthous oral ulcers, cholelithiasis, and nephrolithiasis) (see also Clinical Pearl 3-8)
  • 2. C. Diagnosis 1. Endoscopy (sigmoidoscopy or colonoscopy) with biopsytypical findings are aphthous ulcers, cobblestone appearance, pseudopolyps, patchy (skip) lesions. 2. Barium enema 3. Upper GI with small bowel follow-through CLINICAL PEARL 3-8 Extraintestinal Manifestations of IBD Eye lesions Episcleritisparallels bowel disease activity Anterior uveitisindependent course Skin lesions Erythema nodosumespecially in Crohn disease; parallels bowel disease activity Pyoderma gangrenosumespecially in UC; parallels bowel disease activity in 50% of cases. Arthritismost common extraintestinal manifestation of IBD Migratory monoarticular arthritisparallels bowel disease activity (coincides with exacerbation of colitis) Ankylosing spondylitispatients with UC have a 30 times greater incidence of ankylosing spondylitis than the general population; the course is independent of the colitis. Sacroiliitisdoes not parallel bowel disease activity Thromboembolic hypercoagulable statecan lead to deep venous thrombosis (DVT), pulmonary embolism (PE), or a cardiovascular accident (CVA) Idiopathic thrombocytopenic purpura Osteoporosis Gallstones in Crohn disease (ileal involvement) Sclerosing cholangitis in UC D. Complications 1. Fistulaebetween colon and other segments of intestine (enteroenteral), bladder (enterovesical), vagina (enterovaginal), and skin (enterocutaneous) 2. Anorectal disease (in 30% of patients)fissures, abscesses, perianal fistulas 3. SBO (in 20% to 30% of patients) is the most common indication for surgery. a. Initially, it is due to edema and spasm of bowel with intermittent signs of obstruction; later, scarring and thickening of bowel cause chronic narrowing of lumen. 4. Malignancyincreased risk of colonic and small bowel tumors (but less common than risk of malignancy in UC). 5. Malabsorption of vitamin B12 and bile acids (both occur in terminal ileum). 6. Cholelithiasis may occur secondary to decreased bile acid absorption. 7. Nephrolithiasisincreased colonic absorption of dietary oxalate can lead to calcium oxalate kidney stones. 8. Aphthous ulcers of lips, gingiva, and buccal mucosa (common) 9. Toxic megacolonless common in Crohn disease than in UC
  • 3. 10. Growth retardation 11. Narcotic abuse, psychosocial issues due to chronicity, and often disabling nature of the disease Quick HIT Patients may have vague abdominal pain and diarrhea for years before a diagnosis of Crohn disease is considered. E. Treatment 1. Medical a. Systemic corticosteroids (prednisone)used as initial therapy for low-risk patients with diffuse disease or left-sided colon disease. Attempt taper when clinically improved. If unable to taper, consider immunosuppressant or biologic agent (below) b. Budesonideused in low-risk patients with mild disease in ileum or right colon. Attempt taper when clinically improved. If unable to taper, consider immunosuppressant or biologic agent (below). c. Biologic agent (TNF inhibitor) can be used as monotherapy or in combination with thiopurine (azathioprine or 6-mercaptopurine) or methotrexate in patients with moderate to severe disease. 2. Surgical (eventually required in most patients) a. Reserved for complications of Crohn disease or for those who have persistent symptoms despite best medical management b. Involves segmental resection of involved bowel c. Disease recurrence after surgery is high. Up to 50% of patients experience disease recurrence at 10 years postoperatively. d. Indications for surgery include SBO, fistulae (especially between bowel and bladder or vagina), disabling disease, and perforation or abscess. 3. Nutritional supplementation and supportparenteral nutrition is sometimes necessary.