Crohn's

Crohn's

1. Symtoms

   • PAIN
     • Localised (commonly R.illiac fossa)
     • Referred (peri-umbilical)
   • Weightloss
   • Change in bowel habit
     • Diarrhoea
       • Bile acid Diarrhhoea
       • Small bile bacteria over growth
       • Inflammatory Disease
   • Mouth ulcers
   • Anal skin tags
   • Extra intestnal manifestations
     • Eyes
       • Range
         • Dry gritty eyes- uevitis (iris, choroid (vascular surface of the eye), cillary body)
     • Joints
     • Skin
       • Erythema nedosum
         • Eruptive phase
           • PAIN, aches, fever, arthragia
         • Rash
           • Red nodules, 2-3days (lasts 2-6 weeks)
           • week 1: tense, hard, PAINFUL
           • Week 2: fluctuant, non supprative/ulcerative
         • Inflammation of the fat layer cells under the skin
       • Pyoderma gangrenosum
         • Pustule/nodule
           • Raised inflammatory border and boggy necrotic base
           • Breks down to form an ulcer
         • Often presents painlessly
         • Smell
   • Fatigue

2. clinical features

   • Anaemia
     • Normo/Normo (anaemia of chronic disease)
     • Macrocytic /Megaloblastic (B12 deficiency/
     • Microcytic (iron defficiency)
   • EIM
     • Dry Griity eyes
   • Localised abdominal pain/tenderness
   • Generally appear unwell
   • Ahthous ulcer (in mouth)
   • Increased Bowel Sounds
   • Localised (RIF) Inflammatory Mass

3. Investigations

   • Blood tests
     • FBC
       • ↓ Hb, ↑ WCC, ↑↑ Plts,
     • inflammatory markers
       • ↑ CRP, ↑ ESR
     • U&E's
       • Derranged ( ↑ urea/↑creatine - dehydration)
     • Ferritin/Transferrin, B12, Folate
   • Stool test
     • Faecal calprotectin
     • Faecal lactoferrin
   • Radiology
     • Colonoscopy/endoscopy
       • + Biopsy
     • Contrast CT
     • MRI (known crohn's)
     • Barium Follow through

4. Management

   • Diet modification
     • ↓ Residue Diet, Elemental diet, Polymeric Diet
   • Pharmacologial
     • No evidence of obstruction
       • Loperamide
       • Codiene
     • Cholestyramine (good for D++ prevents Bile salts entering colon)
     • Acute attacks
       • Corticosteriods (e.g. prednisolone 30-40mg or budesonide in mild attacks)
       • Azathioprine
         • The prodrug for mer-capto-purine, inhibiting an enzyme required for the synthesis of purine hindering DNA synthesis. predominantly inhibits the proliferation of cells, especially fast-growing cells without a method of nucleotide salvage ("recycling"), such as lymphocytes.(Two types of lymphocytes, T cells and B cells, are particularly affected by the inhibition of purine synthesis.)
       • Metronidazole in colonic and perianal disease
       • Monoclonal Anti-bodies
         • Infliximab, Adalimimab
           • MOA: Binds to and inhiits the action of TNF-a (a ctokine in the inflammatory pathway) so TNF-a can't bind to its receptor
   • Surgical
     • Avoided if possible: Unless filure of medical heray, complications e.g. abcess, obstruction, fistua, perforations,failure to thrive (in children)
   • Smoking cessation

5. Pathophysiology

   • Transmural ulceraions
     • Leading to cobblestone appearance
   • Skip lesions (Discontinous dilations
   • Granulomas
   • Mouth-Anus
   • Paneth cell metaplasia
   • Complicatios
     • Fistula
     • Lumenal stenosis
       • sub-acute obstruction
       • Strictures

6. Epidemiology

   • 1 in 1000
   • >Caucasians