CROHNS

DISEASE
Lauren Levy

INFLAMMATORY BOWEL DISEASE

(IBD)
2 types:
Crohns Disease (CD)
Aka regional enteritis

Ulcerative Colitis (UC)

Adults & children with IBD
may px with similar C/F;
however, children can
develop unique
complications, including
growth failure & delayed
puberty

CD is MC in whites
than in blacks and is rare in
Asian & Hispanic children

World wide distribution,

but MC in the West

~1.4 million
Americans suffer
from IBD

Epidemiology of
Crohns disease

American Jews of European

decent are 4-5x more likely
to develop IBD

Prevalence:
~7 per 100,000 people;
Incidence: ~5-10 new cases
per 100,000 people/year

Bimodal distribution:
15-30yo/50-70yo

The age-specific rate in North

America for children 10-19yo is
estimated to be ~3.5 cases per
100,000 population

CROHNS DISEASE (CD)

Chronic relapsing
inflammatory condition
Can affect any part of the
GIT from the mouth to the
anus
Terminal ileum is
involved in 50-70% of
children
Rectal sparing
Skip Lesions
Transmural (full
thickness) inflammation
Non-caseating
granulomas
Mesenteric creeping
fat

PATHOGENESIS
Multifactorial
NOD2 Polymorphisms
Acts as an intracellular receptor to
stimulate NF-kB
Chronic inflammation from T-cell activation
leading to tissue injury
After activation by Ag presentation,
unrestrained responses of Th1 cells
predominate because of defective
regulation
Th1 cytokines (IL12 & TNF-) stimulate
the inflammatory response
Type 4 HS!
Inflammatory cells recruited by these
cytokines release nonspecific inflammatory
substances (eg, arachidonic acid
metabolites, proteases, platelet activating
factor, and free radicals), which directly
injure the intestine

SIGNS & SYMPTOMS

MC sx include:

Abdom pain (usually RLQ),

Cramping, N/V
Loss of appetite Weight loss
Persistent Diarrhea (loose, watery,
frequent), usually non-bloody
Being shorter or growing more
slowly than normal
Fatigue
Chronic intermittent fever, malaise

Growth abnormalities

Most sensitive indicator =

decrease in growth velocity

Clinical picture depends on the areas

of bowel involved

GROSS
COBBLESTONE
PATHOLOGY
MUCOSA

LINEAR ULCERS

CREEPING FAT

HISTOLOG
TRANSMURAL
Y
INFLAMMATION

NON-CASEATING
GRANULOMAS

FISSURING;
LINEAR ULCERS

EXTRAINTESTINAL
MANIFESTATIONS
Skin Pyoderma gangrenosum,
erythema nodosum
Eyes Episcleritis, Uveitis
Oral ulcerations- aphthous,
stomatitis
Arthritis peripheral, spondylitis
Kidney stones MC calcium
oxalate
Gallstones

COMPLICATION
S Malabsorption/Malnutrition
Colorectal CA (Increased risk with
pancolitis)
Fistulas (can cause recurrent UTIs &
pneumaturia)
Abscesses
Strictures
More generalized pain, intermittent
colicky pain with signs of bowel
obstruction
Perianal disease

Fistula

DIFFERENTIAL DIAGNOSIS
Ulcerative colitis
Amebiasis
Appendicitis
Bacterial/Viral Gastroenteritis
Behcet disease
Celiac disease
Diverticulitis
Giardiasis
Intestinal Carcinoid tumor
Collagenous colitis
IBS
Ischemic colitis

DIAGNOSIS

Lab data is nonspecific:

CBC:
Hypochromic microcytic anemia from iron def
d/t GI blood loss
Normocytic anemia of chronic dz

Clinical Hx

Family Hx

P/E

Radiologic evaluation

Colonoscopy

Serologic testing

Acute-phase reactants (ESR, CRP) often

elevated
HYPOalbuminemia (common)

Stool studies:
R/O infection
Fecal calprotectin inflammatory marker
Serology: Anti-saccharomyces cerevisiae
Abs (ASCA):
Yeast abs that affect the epithelium of the
large intestine

DIAGNOSIS: Imaging Studies

Single-contrast upper GI series with smallbowel follow-through (SBFT)

To evaluate small
intestine (cant be
reached during
endoscopy)

Picture = Narrowing & irregularity in distal ileum

in 16yo male adolescent with CD

DIAGNOSIS: Imaging Studies

MR enterography (MRE) &
CT enterography (CTE)
Sensitive & specific as
SBFT for detection of
small bowel inflamm.
May be more accurate for
detection of extra-enteric
complications, including
fistulae & abscesses
MRE advantage = Lack of
radiation exposure!
Abdominal CT with oral
contrast

DIAGNOSIS: Imaging Studies

Barium Swallow X-Ray:

String Sign very thin

luminal contrast, usually in
terminal ileum

DIAGNOSIS: Endoscopy with

Biopsies

Colonoscopy

Upper endoscopy (esophagogastroduodenoscopy (EGD)

Part of 1st line investigation in

all new cases of suspected CD
Helps DDx btwn CD & UC

Video capsule endoscopy

Standard in the dx of CD

Increasingly being used to

evaluate small-bowel CD in
KIDS!

MRCP or ERCP

If sclerosing cholangitis is
suspected

TREATMENT

TREATMENT
Biologic agents
Infliximab (Remicade)
Anti-TNF-

Surgery

Adalimumab (Humira)

Small bowel obstruction = MC!

Intractable dz with growth
failure, or severe stenosis
Abscess req drainage
Perianal fistulae
Intractable hmg
Perforation

Anti-TNF-
For pts intolerant to
infliximab

Natalizumab (Tysabri)
Inhibits 4-integrin (WBC
adhesion)

Certolizumab (Cimzia)
Anti-TNF- + polyethylene
glycol

Indications:

NOT curative! Recurrence is

common after resection

REFERENCES
Overview of the management of Crohn disease in children and
adolescents. Athos Bousvaros, MD. UpToDate. Last Updated: May 29,
2016. http://
www.uptodate.com.auamed.idm.oclc.org/contents/overview-of-the-manag
ement-of-crohn-disease-in-children-and-adolescents?source=search_re
sult&search=crohns+disease+in+childhood&selectedTitle=1~150
Clinical manifestations of Crohn disease in children and adolescents.
Athos Bousvaros, MD; Mala Setty, MD; George H Russell, MD, MS.
UpToDate. Last Updated: May 25, 2015. http://
www.uptodate.com.auamed.idm.oclc.org/contents/clinical-manifestation
s-of-crohn-disease-in-children-and-adolescents?source=search_result&
search=crohns+disease+in+childhood&selectedTitle=2~150
Patient information: Crohn disease in children (The Basics). UpToDate.
http://
www.uptodate.com.auamed.idm.oclc.org/contents/crohn-disease-in-chil
dren-the-basics?source=search_result&search=crohns+disease+in+child
hood&selectedTitle=5~150