Sievering Surgical Clinic

Sieveringer St 9, A-1190 Vienna Tel: 328 8777

Gastroenterology Unit

Crohn's Disease

Diagnosis & Treatment

Crohn's Disease

Definition

Crohn’s disease is an idiopathic, chronic inflammation of the small and large bowel that often leads to fistula fibrosis and obstructive symptoms, which can affect the entire gastrointestinal tract from mouth to the anus. All intestinal wall layers may be involved in the process, the transmural inflammation results in thickening of the bowel wall and narrowing of the lumen. As the disease progresses, it is complicated by obstruction, fistulization by way of the sinus tracts penetrating the serosa, microperforation, abscess formation, adhesions, and malabsorption.

It is characterized by abdominal pain and diarrhoea, fever and weight loss which may be complicated by intestinal fistulization, obstruction, or both. Unpredictable flares and remissions characterize the long-term course of this illness.

Causes

The causes are still unknown. Current theories implicate the role of genetic, microbial, immunologic, environmental, dietary, vascular, and even psychosocial factors as potential causative agents. It is assumed that two or more factors together will render susceptible to the disease. Factors which may play a role include:

familiarly frequency (hereditary assessment) Diet and food components (use e.g. increased of refined carbohydrates, e.g. white sugar)
Disturbance in the immune system psychosomatic causes (conflict situations, stress) The influence of bacteria e.g. by Mycobacterium paratuberculosis of viruses one discusses

Symptoms


People exhibit a broad range of symptoms depending on the cause of their colitis. Following are some of the more common complaints:

  • Epigastric pain and right hypogastric region

  • Pain during food intake

  • Dyspepsia

  • Bloating

  • Nausea

  • Anorexia

  • Excessive gases

  • Epigastric pain

  • Frequent loose bowel movements with or without blood

  • Urgency and bowel incontinence

  • Lower abdominal discomfort or cramps

  • Fever, lethargy, and loss of appetite

  • Weight loss in chronic diarrhea and inflammatory bowel disease

 

People with inflammatory bowel disease also may exhibit the following symptoms:

  • Eye problems or pain

  • Joint problems

  • Neck or lower back pain

  • Skin changes

Diagnostics

Some diseases such as inflammatory bowel disease may mimic other conditions, and symptoms may vary widely. The correct diagnosis of inflammatory bowel disease may take some time.


Laboratory tests and imaging will help your doctor to assess the actual cause of the problem. Your doctor will decide which tests you need based on your symptoms, medical history, and clinical findings. Some of the most commonly used tests are these:

  • Lab tests: Stool samples to assess for any red blood or white blood cells, mucous cells, any ova, or parasites

  • Stool culture to detect the "bugs" causing colitis

  • Blood culture, particularly if you have fever, abdominal pain, and diarrhea

  • Full blood count and blood film (Anemia is common in inflammatory bowel disease that may be due to blood loss and iron deficiency. Anemia in people with Crohn disease may be caused by vitamin B12 deficiency.)
    Raised white cell count during activity of inflammatory bowel disease
    Raised erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) during active inflammatory bowel disease (These tests are normal in irritable bowel syndrome.)

  • Electrolyte imbalance (decreased serum sodium and potassium) and rise of blood urea in severe diarrhea and excessive fluid loss

  • Low serum albumen in severe inflammatory bowel disease due to protein loss from the inflamed intestine and impairment of liver function (This test is normal in irritable bowel syndrome.)
    Mild elevation of a panel of liver function tests. Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (AP), and or bilirubin may be present in inflammatory bowel disease (These tests are normal in irritable bowel syndrome.)
    Imaging

  • Upright x-ray of your chest and abdomen - May show free air or dilation of the colon

  • A small bowel follow-through - May demonstrate the involved segments in Crohn disease
    Barium enema may reveal in people with ulcerative colitis the extent of the disease and associated features such as narrow lumen of the large bowel, ulcers, and shortening of the bowel
    Barium enema is not indicated in people with moderate to serious colitis because it may cause perforation of the large bowel and other complications. In Crohn disease, a barium enema may help to distinguish it from ulcerative colitis.

  • Ultrasound and CT scanning - Both useful to distinguish thickened inflamed bowel loops from abscesses in the abdominal cavity Procedures

  • Sigmoidoscopy - May be diagnostic in ulcerative colitis (Tissue biopsy and further studies may help in diagnosis.)

  • Colonoscopy - Helps by ruling out more serious disorders (The doctor usually takes tissue biopsies for further studies to assess the cause underlying your symptoms

Complications


Complications observed in active Crohn's patient are:

  • Fistula (with approx.. 30-50% of the patients) Fistulae are connectionsthat developed spontaneously between boweland the skin (external fistula) or to an nebourghing intestinal organ(internal fistulal). They have a bad healing tendency and recurre often. Fistula are usually relative painless.
    Note: In the presence of fistula one should always supsect Crohn's disease!

  • Abscess formation (with approx.. 20% of the patients)
    Abscesses are accumulations of pus in non-drained tissue .
    Abscesses are seen mostly around trhe ano-retal region and are e extremely painful.

  • Intestinal obstruction (Ileus)
    The intestine catch can be both consequence of a scar formation, and through an inflammatory swelling conditionally its. In the latter case it can itself by one conservative therapy regress (see below), an operation can then avoided become

  • Conglomerate tumour If ignited intestine loops stick together with one another, the impression develops for one Tumefaction formation. One speaks then of a conglomerate tumor. This can as
    "are already noticeable gropable roller" with the physical investigation. It acts not around a malicious new formation!

  • Intestinal perforation is a life-threatening complication that requires immediatesurgery

  • Intestine bleeding: Blood lost are usually controlled with blood transfusions. In rare cases an surgery may become necessary. .

Conservative treatment

  • parenteral nutrition, Antibiose (see below)
  • Vegetable fiber realms nutrition

The goal of the therapy consists of reducing the symptoms the intervals between to extend the disease thrusts to avoid complications requiring surgery

The nutrition of disease Crohn patients should calorie and protein-yieldingly, easily absorbably and sugar-free its. Incompatible food is absolutely too avoid. With solid complaints an artificial nutrition can become necessary.

The medicamentous (conservative) therapy is limited with small complaints on the gift of failure-decreasing medicines (Antidiarrhoika), e.g. Imodium.

During the disease thrusts Kortikosteroide often become (oral or intravenous) begun, particularly with infestation of the small intestine. The therapy with Salazosulfapyridin (Azulfidine) can take place in the form of tablets, suppository or enema and becomes


Large intestine infestation prefers. If this treatment does not show a success, a medicine can are used, which suppresses the function of the immune system (e.g. Imurek).

A likewise well effective means, particularly with Fistelbildungen and abscesses, is Metronidazol. A preventive therapy between the illness thrusts should not to be accomplished, since their success could not become secured so far.

A psychosomatische support should take place apart from the medicamentous therapy and in the illness-free interval to be continued.

Surgical risk increases:
1. Older over 75
2. predominance
3. Smoker
4. Alkohol abuse
5. Chronic lung illness

Surgery

With approx.. 80% of the patients become after approx.. 10 years duration of the disease more operationally Interference necessarily. An absolute necessity for operation exists with one Intestine catch (Ileus), an intestine break-through (perforation) and heavy bleedings. Here the operation must take place immediately. An operational interference should with abscesses, Fisteln and conglomerate tumors as for a long time as possible to be postponed, there those Complication rate is high. In each case the Darmresektion must with an operation economically to be accomplished, since a healing is not possible.

Subsequent treatment of a case of routine
1. p.o. Day in the evening: Stomach probe ex, schluckweise dte
3. p.o. Day: Structure of food
5. p.o. Day: Distance on the left of paracolisch inserted Robinsondrainage,
up to then: parenteral nutrition necessarily in principle: perioperative antibiotic prophylaxis with broadband antibiotic or Metronidazol

General anaesthesia

Possible complications
1. Bowel paralysis .
2. Pneumonia.
3. Anastomosis leakage
4. Wound complication
5. Thromboembolic complications

Prognosis:

Although Crohn's disease is chronic with recurrent relapses, appropriate medical and surgical therapy helps patients to have a reasonable quality of life with only a slight reduction in life expectancy.

Medical therapy becomes less effective with time, and surgery for underlying complications is required in nearly two thirds of patients at some point in their disease.

The mortality rate increases with the duration of the disease, and GI tract cancer is the leading cause of disease-related death.

Acute regional enteritis, which is often discovered during laparotomy for suspected appendicitis, has an excellent prognosis. The acute episode is treated conservatively, and two thirds of patients may not have subsequent evidence of regional enteritis.

More information

E-Medicine
http://www.emedicine.com

| 25.01.2011 | Read more | Print |

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