Crohn’s Disease

Published on 31/05/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

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Chapter 17 Crohn’s Disease

INTRODUCTION

Description: An idiopathic inflammatory bowel disease characterized by transmural involvement resulting in severe gastrointestinal symptoms and significant morbidity.
Prevalence: Two to 10 of 10,000.
Predominant Age: 15 to 30.
Genetics: First-degree relative for 20% of patients, more common in whites and Jews.

ETIOLOGY AND PATHOGENESIS

Causes: The inflammatory process in Crohn’s disease is transmural and involves both the large and small bowel in 50% of patients.
Risk Factors: Cigarette smoking (postulated but unproved).

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Abdominal pain (80% to 85%, often lasting for days or weeks; the pain described is frequently located in the mid-abdomen or right lower quadrant, although generalized pain is often present)
• Diarrhea (voluminous, watery, with occasional blood [20%])
• Fever
• Dyspareunia
• Vulvar or perineal fissures or fistulae or occasionally vulvar granulomas
• Arthritis, sclerosing cholangitis (5% to 10%)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Irritable bowel syndrome (IBS)
• Ulcerative colitis
• Enteric pathogens
• Lymphoma
• Pelvic inflammatory disease (PID; acute episodes)
• Endometriosis

Associated Conditions: Arthritis, dyspareunia, vulvar or perineal fissures or fistulae, vulvar granulomas, erythema nodosum, and sclerosing cholangitis.

Workup and Evaluation

Laboratory: Complete blood count, sedimentation rate.
Imaging: Barium enema, upper gastrointestinal radiograph with small bowel follow-through.
Special Tests: Sigmoidoscopy, colonoscopy, or rectal biopsy.
Diagnostic Procedures: History, sigmoidoscopy, or colonoscopy; radiologic studies; or rectal biopsy.

Pathologic Findings

Transmural inflammation with ulceration and distortion. Areas of normal bowel (skip areas). Granulomas may be found in 15% of patients.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Maintenance of weight and nutrition, perineal care.
Specific Measures: Surgical therapy (resection) often required (two thirds to three fourths of patients).
Diet: No specific dietary changes indicated; increased dietary fiber sometimes recommended.
Activity: No restriction.

Drug(s) of Choice

Mesalamine (5-aminosalicylic acid), methotrexate, or azathioprine (Imuran) for maintenance and suppression.
Prednisone (20 to 40 mg PO daily, tapered after 4 to 6 weeks) or sulfasalazine or mesalamine at increased doses for acute exacerbations. Other immunosuppressives (6-mercaptopurine, azathioprine, infliximab [Remicade]) may also be used.
For acute management, antibiotics, antidiarrheals and fluid replacements may be needed.
Precautions: Folic acid supplements should be used with mesalamine.

FOLLOW-UP

Patient Monitoring: Weight and symptoms, periodic blood count, and sedimentation rate. Endoscopy to monitor disease (as needed).
Prevention/Avoidance: None.
Possible Complications: Bowel thickening, stenosis, and internal fistula formation are common. Short bowel syndromes and malabsorption are common after repeated surgery. One study found a 2.5-fold increase in the risk of colon cancer in patients with Crohn’s disease.
Expected Outcome: Need for eventual or repeated surgery very likely.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy.
ICD-9-CM Codes: 555.9.

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REFERENCES

Level II

Ekbom A, Helmick C, Zack M. Increased risk of large-bowel cancer in Crohn’s disease with colonic involvement. Lancet. 1990;336:357.

Level III

Hanauer SB, Sandborn W, Practice Parameters Committee of the American College of Gastroenterology. Management of Crohn’s disease in adults. Am J Gastroenterol. 2001;96:635.

Kornbluth A, Sachar DB, Practice Parameters Committee of the American College of Gastroenterology. Ulcerative colitis practice guidelines in adults (update): American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. 2004;99:1371.

Podolsky DK. Inflammatory bowel disease. N Engl J Med. 2002;347:417.

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