Crohn's disease

Gastroenterology

Clinicals - History

Fact Explanation
Abdominal pain This is a major symptom of Crohn's disease. It could be due to subacute intestinal obstruction or presence of an inflammatory mass or an abscess Abdominal pain
This is a major symptom of Crohn's disease. It could be due to subacute intestinal obstruction or presence of an inflammatory mass or an abscess
Diarrhea Recurrent episodes of diarrhea or prolonged diarrhea is a major symptom of Crohn's disease. Diarrhea is usually watery and devoid of blood and mucus Diarrhea
Recurrent episodes of diarrhea or prolonged diarrhea is a major symptom of Crohn's disease. Diarrhea is usually watery and devoid of blood and mucus
Weight loss Is also a major symptom of Crohn's disease.
This can be because the patient avoids food as eating provokes pain, anorexia or malabsorption
Weight loss
Is also a major symptom of Crohn's disease.
This can be because the patient avoids food as eating provokes pain, anorexia or malabsorption
Low-grade fever Is a constitutional symptom of Crohn's disease Low-grade fever
Is a constitutional symptom of Crohn's disease
Fatigability Is a constitutional symptom of Crohn's disease but may also be secondary to anemia resulting from nutrition deficiency Fatigability
Is a constitutional symptom of Crohn's disease but may also be secondary to anemia resulting from nutrition deficiency
Blood and mucus diarrhea Can occur when the disease involves colitis Blood and mucus diarrhea
Can occur when the disease involves colitis
Urgency to defecate Again can occur when there is colitis Urgency to defecate
Again can occur when there is colitis
Anorexia Is a constitutional symptom that occurs in active Crohn's disease Anorexia
Is a constitutional symptom that occurs in active Crohn's disease
Nausea Can occur in the presence of intestinal obstruction and gastroduodenal region involvement Nausea
Can occur in the presence of intestinal obstruction and gastroduodenal region involvement
Vomiting Can be a presenting symptom of intestinal obstruction and gastroduodenal region involvement Vomiting
Can be a presenting symptom of intestinal obstruction and gastroduodenal region involvement
Perirectal pain Can occur in when there is perirectal involvement and fissure formation Perirectal pain
Can occur in when there is perirectal involvement and fissure formation
Constipation Can result secondary to intestinal obstruction Constipation
Can result secondary to intestinal obstruction
Abdominal distension Can be one of the presenting symptoms of intestinal obstruction Abdominal distension
Can be one of the presenting symptoms of intestinal obstruction
History of recurrent urinary tract infections Occurs due to the presence of enterovesical fistulae History of recurrent urinary tract infections
Occurs due to the presence of enterovesical fistulae
Pneumaturia Occurs due to the presence of enterovesical fistulae Pneumaturia
Occurs due to the presence of enterovesical fistulae
Feculent soiling of the skin Results from enterocutaneous fistulae Feculent soiling of the skin
Results from enterocutaneous fistulae
Feculent vaginal discharge Occurs due to the presence of enterovaginal fistulae Feculent vaginal discharge
Occurs due to the presence of enterovaginal fistulae

Clinicals - Examination

Fact Explanation
Apthous ulcers Are seen in examination of the mouth. These appear together with or before intestinal manifestations occur Apthous ulcers
Are seen in examination of the mouth. These appear together with or before intestinal manifestations occur
Pale conjunctiva Is seen in patients who are anemic Pale conjunctiva
Is seen in patients who are anemic
Finger clubbing Is an extraintestinal manifestation of Crohn's disease Finger clubbing
Is an extraintestinal manifestation of Crohn's disease
Erythema nodosum Presents as painful, purplish nodules usually over the shins. is also an extraintestinal manifestation of Crohn's disease Erythema nodosum
Presents as painful, purplish nodules usually over the shins. is also an extraintestinal manifestation of Crohn's disease
Distended abdomen Can be a manifestation of intestinal obstruction Distended abdomen
Can be a manifestation of intestinal obstruction
Abdominal tenderness Could be due to active disease or presence of intra-abdominal inflammatory mass or abscess Abdominal tenderness
Could be due to active disease or presence of intra-abdominal inflammatory mass or abscess
Intar-abdominal mass Could be due to an intra-abdominal inflammatory mass or an abscess Intar-abdominal mass
Could be due to an intra-abdominal inflammatory mass or an abscess
Perianal fistulae Entrocutaneous fistulae are seen in the perianal region of patients with Crohn's disease Perianal fistulae
Entrocutaneous fistulae are seen in the perianal region of patients with Crohn's disease

Investigations - Diagnosis

Fact Explanation
Stool full report Is done to exclude infectious diarrhea Stool full report
Is done to exclude infectious diarrhea
Fecal calprotectin Fecal calprotectin is found to be elevated in ileocolonic or colonic disease, but not when the disease is confined to the ileum Fecal calprotectin
Fecal calprotectin is found to be elevated in ileocolonic or colonic disease, but not when the disease is confined to the ileum
Colonoscopy with biopsy This is considered the gold standard for diagnosis and assessment of disease activity and extent in patients with Crohn's disease. The histological features seen on a biopsy includes patchy areas of chronic transmural inflammation, with multiple lymphoid aggregates, increased lamina propria plasma cells and lymphocytes, neutrophilic cryptitis, crypt abscesses, ulcers, noncaseating granulomas Colonoscopy with biopsy
This is considered the gold standard for diagnosis and assessment of disease activity and extent in patients with Crohn's disease. The histological features seen on a biopsy includes patchy areas of chronic transmural inflammation, with multiple lymphoid aggregates, increased lamina propria plasma cells and lymphocytes, neutrophilic cryptitis, crypt abscesses, ulcers, noncaseating granulomas
Small bowel capsule endoscopy (SBCE) This allows to explore the total length of the small bowel using a wireless capsule. This capsule is swallowed and propelled through the gastrointestinal tract by gut motility. SBCE is done when the patient has unexplained symptoms or when colonoscopy and imaging techniques prove inconclusive Small bowel capsule endoscopy (SBCE)
This allows to explore the total length of the small bowel using a wireless capsule. This capsule is swallowed and propelled through the gastrointestinal tract by gut motility. SBCE is done when the patient has unexplained symptoms or when colonoscopy and imaging techniques prove inconclusive
Contrast Enhanced Computed Tomography (CECT) of abdomen Is done to assess transmural and extramural disease activity of small and large intestines Contrast Enhanced Computed Tomography (CECT) of abdomen
Is done to assess transmural and extramural disease activity of small and large intestines
Magnetic Resonance Imaging (MRI) of abdomen Is also done to evaluate transmural and extramural disease activity of small and large intestines. Gives a better view of soft tissue than CT imaging but has limited availability compared to CT scan Magnetic Resonance Imaging (MRI) of abdomen
Is also done to evaluate transmural and extramural disease activity of small and large intestines. Gives a better view of soft tissue than CT imaging but has limited availability compared to CT scan
Barium enema May show cobblestone appearance, 'rose thorn' ulcers and colon strictures. Should not be done if there is suspicion of intestinal perforation Barium enema
May show cobblestone appearance, 'rose thorn' ulcers and colon strictures. Should not be done if there is suspicion of intestinal perforation
Rectal endoscopic ultrasonography Is done to assess transmural and extramural disease activity Rectal endoscopic ultrasonography
Is done to assess transmural and extramural disease activity
Serum anti-S cerevisiae antibodies [ASCA] This is a serologic biomarker that assists in the diagnosis of Crohn's disease Serum anti-S cerevisiae antibodies [ASCA]
This is a serologic biomarker that assists in the diagnosis of Crohn's disease
Esophagogastroduodenoscopy Done for patients with upper gastrointestinal symptoms, asymptomatic patients with iron deficiency anemia, or patients with active Crohn's disease who have a normal colonoscopy Esophagogastroduodenoscopy
Done for patients with upper gastrointestinal symptoms, asymptomatic patients with iron deficiency anemia, or patients with active Crohn's disease who have a normal colonoscopy

Investigations - Management

Fact Explanation
C-reactive protein (CRP) level Is done for disease follow up to access response to treatment C-reactive protein (CRP) level
Is done for disease follow up to access response to treatment
Fecal calprotectin Is a used as a surrogate marker of mucosal healing in follow up and assessing response to treatment Fecal calprotectin
Is a used as a surrogate marker of mucosal healing in follow up and assessing response to treatment
Endoscopy Done to assess disease activity and extent for the purpose of adjusting or changing a patient’s treatment Endoscopy
Done to assess disease activity and extent for the purpose of adjusting or changing a patient’s treatment
complete blood count (CBC) Done to detect presence of anemia. Further investigations such as blood picture, serum iron studies, serum folate etc. is done if needed depending on the findings in the CBC complete blood count (CBC)
Done to detect presence of anemia. Further investigations such as blood picture, serum iron studies, serum folate etc. is done if needed depending on the findings in the CBC
Erythrocyte sedimentation rate (ESR) Will be high in case of active disease Erythrocyte sedimentation rate (ESR)
Will be high in case of active disease
C-reactive protein (CRP) level Will also be high in the presence of active disease. CRP an be used as a very accurate marker of disease activity C-reactive protein (CRP) level
Will also be high in the presence of active disease. CRP an be used as a very accurate marker of disease activity
Serum electrolytes Is done to assess the baseline levels and any alterations in the presence of diarrhea or vomiting Serum electrolytes
Is done to assess the baseline levels and any alterations in the presence of diarrhea or vomiting
Serum albumin Will be low in active disease due to poor nutritional status and with protein-losing enteropathy Serum albumin
Will be low in active disease due to poor nutritional status and with protein-losing enteropathy
Liver function tests Are done to assess the baseline liver function prior to starting treatment and during the course of treatment Liver function tests
Are done to assess the baseline liver function prior to starting treatment and during the course of treatment
X-ray abdomen supine/erect view Can be done when there is suspicion of intestinal obstruction X-ray abdomen supine/erect view
Can be done when there is suspicion of intestinal obstruction
Chest X-ray Is done when there is suspicion of intestinal perforation because then it will show air under the diaphragm Chest X-ray
Is done when there is suspicion of intestinal perforation because then it will show air under the diaphragm

Management - Supportive

Fact Explanation
Special diets Elemental diets are made by mixing single amino acids and are antigen free. These have shown some beneficial effect in inducing remission in active disease. Alow residue diet may also help to control disease activity but alone is not effective in controlling disease activity Special diets
Elemental diets are made by mixing single amino acids and are antigen free. These have shown some beneficial effect in inducing remission in active disease. Alow residue diet may also help to control disease activity but alone is not effective in controlling disease activity
Regular physical exercise Some studies have shown that regular exercise is beneficial for patients with Crohn's disease by producing effects such as improving immunological response, psychological health, nutritional status, bone mineral density and reversing the decrease of muscle mass and strength Regular physical exercise
Some studies have shown that regular exercise is beneficial for patients with Crohn's disease by producing effects such as improving immunological response, psychological health, nutritional status, bone mineral density and reversing the decrease of muscle mass and strength
Stop smoking Smoking cessation has shown to be beneficial for patients with Crohn's disease Stop smoking
Smoking cessation has shown to be beneficial for patients with Crohn's disease

Management - Specific

Fact Explanation
Coticosteroids Prednisolone is given orally in mild attacks. in severe attacks hydrocortisone is given intravenously initially, which is changed to prednisolone with improvement Coticosteroids
Prednisolone is given orally in mild attacks. in severe attacks hydrocortisone is given intravenously initially, which is changed to prednisolone with improvement
Azathioprine Is a drug which has a steroid sparing effect and is useful for those having side effects to steroids or has multiple rapid relapses Azathioprine
Is a drug which has a steroid sparing effect and is useful for those having side effects to steroids or has multiple rapid relapses
Metronidazole Is given when there is super added infection Metronidazole
Is given when there is super added infection
Infliximab AN anti-tumour necrosis factor monoclonal antibody which can reduce Crohn's disease activity Infliximab
AN anti-tumour necrosis factor monoclonal antibody which can reduce Crohn's disease activity
Methotrexate Can be given as a weekly intramuscular injection for induction of remission Methotrexate
Can be given as a weekly intramuscular injection for induction of remission
Surgical treatment Is not curative done to rest distal bowel with temporary ileostomy or limited resection of areas with worst disease activity. Indications for surgery include failure to respond to medical treatment, intestinal obstruction form strictures, intestinal perforation, complications such as fistulae,abscess etc Surgical treatment
Is not curative done to rest distal bowel with temporary ileostomy or limited resection of areas with worst disease activity. Indications for surgery include failure to respond to medical treatment, intestinal obstruction form strictures, intestinal perforation, complications such as fistulae,abscess etc

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  1. A SPECIAL MEETING REVIEW EDITION: Clinical Research Highlights in IBD: Diagnosis and Anti-Tumor Necrosis Factor Monitoring: Digestive Disease Week 2013May 18–21, 2013 • Orlando, FloridaSpecial Reporting on:• Serological and Inflammatory IBD Marker Prevalence As Function of Age in a Large Cohort of Patients Presenting IBD-Like Gastrointestinal Symptoms• Prevalence of Antibodies to Adalimumab (ATA) and Correlation Between ATA and Low Serum Drug Concentration on CRP and Clinical Symptoms in a Prospective Sample of IBD Patients• Serum Adalimumab Levels and Antibodies Correlate with Endoscopic Intestinal Inflammation and Inflammatory Markers in Patients with Inflammatory Bowel Disease• Comparison of Early Measurement of Infliximab and Antibodies-to-Infliximab Serum Levels with Standard Trough Analysis• Trough Levels and Antidrug Antibodies Predict Safety and Success of Restarting Infliximab After a Long Drug Holiday• A Multi-Center Observational Study in Community Gastroenterology Practices Evaluating the Clinical Usage of Testing for Serum Levels of Infliximab and Antibodies to Infliximab• Preoperative Serum Biologic Levels Do Not Impact Postoperative Outcomes in Ulcerative Colitis• Higher Preoperative Serum Biologic Levels Are Associated with Postoperative Complications in Crohn’s Disease PatientsWith Expert Commentary by:William J. Sandborn, MDProfessor and Chief, Division of GastroenterologyDirector, UCSD IBD CenterUC San Diego Health SystemLa Jolla, California Gastroenterol Hepatol (N Y) [online] 2013 Aug, 9(8 Suppl 4):1-16 [viewed 10 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4032550
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