Crohn Disease Dr. P. R. - PowerPoint Presentation

1. Crohn DiseaseDr. P. R. Sisir

2. The term inflammatory bowel disease (IBD) is used to represent two distinctive disorders of idiopathic chronic intestinal inflammation: Crohn disease and ulcerative colitis. Crohn disease, an idiopathic, chronic inflammatory disorder of the bowel, involves any region of the alimentary tract from the mouth to the anus. Although there are many similarities between ulcerative colitis and Crohn disease, there are also major differences in the clinical course and distribution of the disease in the GI tract Introduction

3. IntroductionBurrill Bernard Crohn, an American Gastroenterologist, made the first major advance to identify the disease.1884 – 1983He, in 1932, together with two colleagues at Mount Sinai Hospital in New York, described a series of patients with inflammation of the terminal ileum of the small intestine, the area most commonly affected by the illness.

4. Compared to adult-onset disease, pediatric Crohn disease is more likely to have extensive anatomic involvement. At initial presentation, >50% of patients have disease that involves ileum and colon (ileocolitis), 20% have exclusively colonic disease, and upper GI involvement (esophagus, stomach, duodenum) is seen in up to 30% of children. Isolated small bowel disease is much less common in the pediatric population compared to adults. Isolated colonic disease is common in children <8 yr of age and may be indistinguishable from ulcerative colitis. Anatomic location of disease tends to extend over time in children.Crohn disease tends to have a bimodal age distribution, with the 1st peak beginning in the teenage years. The incidence of Crohn disease has been increasing, whereas that of ulcerative colitis has been stable.Introduction

5. Crohn disease can be characterized as inflammatory, stricturing, or penetrating. Patients with small bowel disease are more likely to have an obstructive pattern (most commonly with right lower quadrant pain) characterized by fibro-stenosis, and those with colonic disease are more likely to have symptoms resulting from inflammation (diarrhoea, bleeding, cramping). Fever, malaise, and easy fatigability are common. Growth failure with delayed bone maturation and delayed sexual development can precede other symptoms by 1 or 2 yr and is at least twice as likely to occur with Crohn disease as with ulcerative colitis.Children can present with growth failure as the only manifestation of Crohn disease. Causes of growth failure include inadequate caloric intake, suboptimal absorption or excessive loss of nutrients, the effects of chronic inflammation on bone metabolism and appetite, and the use of corticosteroids during treatment.Clinical manifestation

6. Primary or secondary amenorrhea and pubertal delay are common.In contrast to ulcerative colitis, perianal disease is common (tags, fistula, abscess). Gastric or duodenal involvement may be associated with recurrent vomiting and epigastric pain. Partial small bowel obstruction, usually secondary to narrowing of the bowel lumen from inflammation or stricture, can cause symptoms of cramping abdominal pain (especially with meals), borborygmus, and intermittent abdominal distention. Stricture should be suspected if the child notes relief of symptoms in association with a sudden sensation of gurgling of intestinal contents through a localized region of the abdomen.Clinical manifestation

7. Extraintestinal manifestations occur more commonly with Crohn disease than with ulcerative colitis; those that are especially associated with Crohn disease include oral aphthous ulcers, peripheral arthritis, erythema nodosum, digital clubbing, episcleritis, renal stones (uric acid, oxalate), and gallstones. Any of the extraintestinal disorders as in IBD can occur with Crohn disease .The peripheral arthritis is non-deforming. The occurrence of extraintestinal manifestations usually correlates with the presence of colitis.Clinical manifestation

8. Extensive involvement of small bowel, especially in association with surgical resection, can lead to short bowel syndrome, which is rare in children. Complications of terminal ileal dysfunction or resection include bile acid malabsorption with secondary diarrhea and vitamin B12 malabsorption. Chronic steatorrhea can lead to oxaluria with secondary renal stones.Increasing calcium intake can actually decrease the risk renal stones secondary to ileal inflammation. The risk of cholelithiasis is also increased secondary to bile acid depletion.Clinical manifestation

9. A disorder with this diversity of manifestations can have a major impact on an affected child's lifestyle. Fortunately, the majority of children with Crohn disease are able to continue with their normal activities, having to limit activity only during periods of increased symptoms.Clinical manifestation

10. PRIMARY PRESENTING SYMPTOMDIAGNOSTIC CONSIDERATIONSRight lower quadrant abdominal pain, with or without massAppendicitis, infection (e.g., Campylobacter, Yersinia spp.), lymphoma, intussusception, mesenteric adenitis, Meckel diverticulum, ovarian cystChronic periumbilical or epigastric abdominal painIrritable bowel syndrome, constipation, lactose intolerance, peptic diseaseRectal bleeding, no diarrheaFissure, polyp, Meckel diverticulum, rectal ulcer syndromeBloody diarrheaInfection, hemolytic-uremic syndrome, Henoch-Schönlein purpura, ischemic bowel, radiation colitisWatery diarrheaIrritable bowel syndrome, lactose intolerance, giardiasis, Cryptosporidium infection, sorbitol, laxativesD. D.

11. PRIMARY PRESENTING SYMPTOMDIAGNOSTIC CONSIDERATIONSPerirectal diseaseFissure, hemorrhoid (rare), streptococcal infection, condyloma (rare)Growth delayEndocrinopathyAnorexia, weight lossAnorexia nervosaArthritisCollagen vascular disease, infectionLiver abnormalitiesChronic hepatitisD. D.

12. The diagnosis of Crohn disease depends on finding typical clinical features of the disorder (history, physical examination, laboratory studies, and endoscopic or radiologic findings), ruling out specific entities that mimic Crohn disease, and demonstrating chronicity. The history can include any combination of abdominal pain (especially right lower quadrant), diarrhea, vomiting, anorexia, weight loss, growth retardation, and extraintestinal manifestations. Only 25% initially have the triad of diarrhea, weight loss, and abdominal pain. Most do not have diarrhea, and only 25% have GI bleeding.Diagnosis

13. Children with Crohn disease often appear chronically ill. They commonly have weight loss and growth failure, and they are often malnourished. The earliest of sign of growth failure is decreased height velocity, which can be present in up to 88% of prepubertal patients with Crohn disease and typically precedes symptoms. Children with Crohn disease often appear pale, with decreased energy level and poor appetite; the latter finding sometimes results from an association between meals and abdominal pain or diarrhea.There may be abdominal tenderness that is either diffuse or localized to the right lower quadrant.Diagnosis

14. A complete blood cell count commonly demonstrates anemia, often with a component of iron deficiency. Although the erythrocyte sedimentation rate is often elevated, it may be normal; an elevated platelet count is common. The white blood cell count may be normal or mildly elevated. The serum albumin level may be low, indicating small bowel inflammation or protein-losing enteropathy. Fecal calprotectin or lactoferrin is often elevated.The small and large bowel and the upper GI tract should be examined by both endoscopic and radiologic studies in the child with suspected Crohn disease. Oesophago-gastro-duodenoscopy and ileo-colonoscopy should be performed to properly assess the upper GI tract, terminal ileum, and entire colon.Diagnosis

15. Treatment ? Crohn disease cannot be cured by medical or surgical therapyThe aim of treatment is to relieve symptoms and prevent complications of chronic inflammation (anemia, growth failure), prevent relapse, minimize corticosteroid exposure, and, if possible, effect mucosal healing.

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