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[1][2][4][5]
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[1][2][3][4][5]
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[1][2][4][5]
Low-grade fever Is a constitutional symptom of Crohn's disease[1][2][4][5]
Fatigability Is a constitutional symptom of Crohn's disease but may also be secondary to anemia resulting from nutrition deficiency[1][4]
Blood and mucus diarrhea Can occur when the disease involves colitis[1][3][4]
Urgency to defecate Again can occur when there is colitis[1]
Anorexia Is a constitutional symptom that occurs in active Crohn's disease[1][2][3][4][5]
Nausea Can occur in the presence of intestinal obstruction and gastroduodenal region involvement[1][4]
Vomiting Can be a presenting symptom of intestinal obstruction and gastroduodenal region involvement[1][4]
Perirectal pain Can occur in when there is perirectal involvement and fissure formation[1]
Constipation Can result secondary to intestinal obstruction[1]
Abdominal distension Can be one of the presenting symptoms of intestinal obstruction[1]
History of recurrent urinary tract infections Occurs due to the presence of enterovesical fistulae[1]
Pneumaturia Occurs due to the presence of enterovesical fistulae[1]
Feculent soiling of the skin Results from enterocutaneous fistulae[1]
Feculent vaginal discharge Occurs due to the presence of enterovaginal fistulae[1]
References
  1. COLLEDGE NR(Ed)WALKER BR(Ed)RALSTON SH(Ed). Davidson's Principles and Practice of Medicine, 21st Edition; Churchill Livingstone, Elsevier;2010; 897-901
  2. LONGMORE M,WILKINSON I,DAVIDSON E,FOULKES A,MAFI A. Oxford Handbook of Clinical Medicine. Eighth edition. Oxford University press; 2011; 274-275
  3. AVINASH B, DUTTA AK, CHACKO A. Pediatric inflammatory bowel disease in South India. Indian Pediatr [online] 2009 Jul, 46(7):639-40 [viewed 10 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19638665
  4. WILKINS T,JARVIS K,PATEL J. Diagnosis and Management of Crohn's Disease. Am Fam Physician[online] 2011 Dec 15;84(12):1365-1375[viewed on 10 June 2014] Available from;http://www.aafp.org/afp/2011/1215/p1365.html#sec-1
  5. STANGE EF, TRAVIS SP, VERMEIRE S, BEGLINGER C, KUPCINSKAS L, GEBOES K, BARAKAUSKIENE A, VILLANACCI V, VON HERBAY A, WARREN BF, GASCHE C, TILG H, SCHREIBER SW, SCHöLMERICH J, REINISCH W. European evidence based consensus on the diagnosis and management of Crohn's disease: definitions and diagnosis Gut [online] 2006 Mar, 55(Suppl 1):i1-i15 [viewed 10 June 2014] Available from: doi:10.1136/gut.2005.081950a

Examination

Fact Explanation
Apthous ulcers Are seen in examination of the mouth. These appear together with or before intestinal manifestations occur[1][2]
Pale conjunctiva Is seen in patients who are anemic[1][2][3]
Finger clubbing Is an extraintestinal manifestation of Crohn's disease[1][2][3]
Erythema nodosum Presents as painful, purplish nodules usually over the shins. is also an extraintestinal manifestation of Crohn's disease[1][2][3]
Distended abdomen Can be a manifestation of intestinal obstruction[1][2]
Abdominal tenderness Could be due to active disease or presence of intra-abdominal inflammatory mass or abscess[1][2][4]
Intar-abdominal mass Could be due to an intra-abdominal inflammatory mass or an abscess[1][2][4]
Perianal fistulae Entrocutaneous fistulae are seen in the perianal region of patients with Crohn's disease[1][2][4]
References
  1. COLLEDGE NR(Ed)WALKER BR(Ed)RALSTON SH(Ed). Davidson's Principles and Practice of Medicine, 21st Edition; Churchill Livingstone, Elsevier;2010; 897-901
  2. LONGMORE M,WILKINSON I,DAVIDSON E,FOULKES A,MAFI A. Oxford Handbook of Clinical Medicine. Eighth edition. Oxford University press; 2011; 274-275
  3. WILKINS T,JARVIS K,PATEL J. Diagnosis and Management of Crohn's Disease. Am Fam Physician[online] 2011 Dec 15;84(12):1365-1375[viewed on 10 June 2014] Available from;http://www.aafp.org/afp/2011/1215/p1365.html#sec-1
  4. STANGE EF, TRAVIS SP, VERMEIRE S, BEGLINGER C, KUPCINSKAS L, GEBOES K, BARAKAUSKIENE A, VILLANACCI V, VON HERBAY A, WARREN BF, GASCHE C, TILG H, SCHREIBER SW, SCHöLMERICH J, REINISCH W. European evidence based consensus on the diagnosis and management of Crohn's disease: definitions and diagnosis Gut [online] 2006 Mar, 55(Suppl 1):i1-i15 [viewed 10 June 2014] Available from: doi:10.1136/gut.2005.081950a

Differential Diagnoses

Fact Explanation
Ulcerative Colitis The other inflammatory bowel disease which is an important differential diagnosis[1][2]
Appendicitis Is suspected in young patients presenting with acute abdomen[1]
Diverticulitis Can present with similar clinical picture to Crohn's disease[1][2]
Amebiasis Large bowel infestation by amoebae can present with symptoms similar to Crohn's disease[1]
Irritable Bowel Syndrome Can also have similar symptoms but is diagnosed when all other possible diagnoses have been excluded[1][2]
Gastroenteritis Infectious gastroenteritis is an important differential diagnosis to be excluded[1][2]
References
  1. COLLEDGE NR(Ed)WALKER BR(Ed)RALSTON SH(Ed). Davidson's Principles and Practice of Medicine, 21st Edition; Churchill Livingstone, Elsevier;2010; 897-901
  2. CUMMINGS JR, KESHAV S, TRAVIS SP. Medical management of Crohn's disease BMJ [online] 2008 May 10, 336(7652):1062-1066 [viewed 10 June 2014] Available from: doi:10.1136/bmj.39547.603218.AE

Investigations - for Diagnosis

Fact Explanation
Stool full report Is done to exclude infectious diarrhea[1][2][5][6]
Fecal calprotectin Fecal calprotectin is found to be elevated in ileocolonic or colonic disease, but not when the disease is confined to the ileum[3][6]
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[1][2][3][5][6]
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[1][2][3][5][6]
Contrast Enhanced Computed Tomography (CECT) of abdomen Is done to assess transmural and extramural disease activity of small and large intestines[1][2][5][6]
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[1][2][3][5][6]
Barium enema May show cobblestone appearance, 'rose thorn' ulcers and colon strictures. Should not be done if there is suspicion of intestinal perforation[2][3]
Rectal endoscopic ultrasonography Is done to assess transmural and extramural disease activity[1]
Serum anti-S cerevisiae antibodies [ASCA] This is a serologic biomarker that assists in the diagnosis of Crohn's disease[4][6]
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[6]
References
  1. D’INCà R, CACCARO R. Measuring disease activity in Crohn's disease: what is currently available to the clinician Clin Exp Gastroenterol [online] :151-161 [viewed 09 June 2014] Available from: doi:10.2147/CEG.S41413
  2. COLLEDGE NR(Ed)WALKER BR(Ed)RALSTON SH(Ed). Davidson's Principles and Practice of Medicine, 21st Edition; Churchill Livingstone, Elsevier;2010; 897-901
  3. LONGMORE M,WILKINSON I,DAVIDSON E,FOULKES A,MAFI A. Oxford Handbook of Clinical Medicine. Eighth edition. Oxford University press; 2011; 274-275
  4. 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
  5. STANGE EF, TRAVIS SP, VERMEIRE S, BEGLINGER C, KUPCINSKAS L, GEBOES K, BARAKAUSKIENE A, VILLANACCI V, VON HERBAY A, WARREN BF, GASCHE C, TILG H, SCHREIBER SW, SCHöLMERICH J, REINISCH W. European evidence based consensus on the diagnosis and management of Crohn's disease: definitions and diagnosis Gut [online] 2006 Mar, 55(Suppl 1):i1-i15 [viewed 10 June 2014] Available from: doi:10.1136/gut.2005.081950a
  6. WILKINS T,JARVIS K,PATEL J. Diagnosis and Management of Crohn's Disease. Am Fam Physician[online] 2011 Dec 15;84(12):1365-1375[viewed on 10 June 2014] Available from;http://www.aafp.org/afp/2011/1215/p1365.html#sec-1

Investigations - Fitness for Management

Fact Explanation
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[1][2][3][6]
Erythrocyte sedimentation rate (ESR) Will be high in case of active disease[1][2][5]
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[1][2][3][4][5]
Serum electrolytes Is done to assess the baseline levels and any alterations in the presence of diarrhea or vomiting[1][2][4]
Serum albumin Will be low in active disease due to poor nutritional status and with protein-losing enteropathy[1][2][6]
Liver function tests Are done to assess the baseline liver function prior to starting treatment and during the course of treatment[1][2][4]
X-ray abdomen supine/erect view Can be done when there is suspicion of intestinal obstruction[1][2]
Chest X-ray Is done when there is suspicion of intestinal perforation because then it will show air under the diaphragm[1][2]
References
  1. COLLEDGE NR(Ed)WALKER BR(Ed)RALSTON SH(Ed). Davidson's Principles and Practice of Medicine, 21st Edition; Churchill Livingstone, Elsevier;2010; 897-901
  2. LONGMORE M,WILKINSON I,DAVIDSON E,FOULKES A,MAFI A. Oxford Handbook of Clinical Medicine. Eighth edition. Oxford University press; 2011; 274-275
  3. D’INCà R, CACCARO R. Measuring disease activity in Crohn's disease: what is currently available to the clinician Clin Exp Gastroenterol [online] :151-161 [viewed 09 June 2014] Available from: doi:10.2147/CEG.S41413
  4. CUMMINGS JR, KESHAV S, TRAVIS SP. Medical management of Crohn's disease BMJ [online] 2008 May 10, 336(7652):1062-1066 [viewed 10 June 2014] Available from: doi:10.1136/bmj.39547.603218.AE
  5. STANGE EF, TRAVIS SP, VERMEIRE S, BEGLINGER C, KUPCINSKAS L, GEBOES K, BARAKAUSKIENE A, VILLANACCI V, VON HERBAY A, WARREN BF, GASCHE C, TILG H, SCHREIBER SW, SCHöLMERICH J, REINISCH W. European evidence based consensus on the diagnosis and management of Crohn's disease: definitions and diagnosis Gut [online] 2006 Mar, 55(Suppl 1):i1-i15 [viewed 10 June 2014] Available from: doi:10.1136/gut.2005.081950a
  6. WILKINS T,JARVIS K,PATEL J. Diagnosis and Management of Crohn's Disease. Am Fam Physician[online] 2011 Dec 15;84(12):1365-1375[viewed on 10 June 2014] Available from;http://www.aafp.org/afp/2011/1215/p1365.html#sec-1

Investigations - Followup

Fact Explanation
C-reactive protein (CRP) level Is done for disease follow up to access response to treatment[1]
Fecal calprotectin Is a used as a surrogate marker of mucosal healing in follow up and assessing response to treatment[1]
Endoscopy Done to assess disease activity and extent for the purpose of adjusting or changing a patient’s treatment[1]
References
  1. D’INCà R, CACCARO R. Measuring disease activity in Crohn's disease: what is currently available to the clinician Clin Exp Gastroenterol [online] :151-161 [viewed 09 June 2014] Available from: doi:10.2147/CEG.S41413

Management - General Measures

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[1][2]
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[3]
Stop smoking Smoking cessation has shown to be beneficial for patients with Crohn's disease[4]
References
  1. LONGMORE M,WILKINSON I,DAVIDSON E,FOULKES A,MAFI A. Oxford Handbook of Clinical Medicine. Eighth edition. Oxford University press; 2011; 274-275
  2. JAMES AH. Breakfast and Crohn's disease. Br Med J [online] 1977 Apr 9, 1(6066):943-5 [viewed 10 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/856393
  3. BILSKI J, BRZOZOWSKI B, MAZUR-BIALY A, SLIWOWSKI Z, BRZOZOWSKI T. The Role of Physical Exercise in Inflammatory Bowel Disease Biomed Res Int [online] 2014:429031 [viewed 10 June 2014] Available from: doi:10.1155/2014/429031
  4. WILKINS T,JARVIS K,PATEL J. Diagnosis and Management of Crohn's Disease. Am Fam Physician[online] 2011 Dec 15;84(12):1365-1375[viewed on 10 June 2014] Available from;http://www.aafp.org/afp/2011/1215/p1365.html#sec-1

Management - Specific Treatments

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[1][2][5][6]
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[1][2][6]
Metronidazole Is given when there is super added infection[1][2][5]
Infliximab AN anti-tumour necrosis factor monoclonal antibody which can reduce Crohn's disease activity[1][2][4][5][6]
Methotrexate Can be given as a weekly intramuscular injection for induction of remission[1][2][6]
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[1][2][3][5][6]
References
  1. COLLEDGE NR(Ed)WALKER BR(Ed)RALSTON SH(Ed). Davidson's Principles and Practice of Medicine, 21st Edition; Churchill Livingstone, Elsevier;2010; 897-901
  2. LONGMORE M,WILKINSON I,DAVIDSON E,FOULKES A,MAFI A. Oxford Handbook of Clinical Medicine. Eighth edition. Oxford University press; 2011; 274-275
  3. HEIMANN TM, GREENSTEIN AJ, LEWIS B, KAUFMAN D, HEIMANN DM, AUFSES AH JR. Comparison of primary and reoperative surgery in patients with Crohns disease. Ann Surg [online] 1998 Apr, 227(4):492-5 [viewed 10 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9563535
  4. TUSKEY A, BEHM BW. Profile of ustekinumab and its potential in patients with moderate-to-severe Crohn's disease Clin Exp Gastroenterol [online] :173-179 [viewed 10 June 2014] Available from: doi:10.2147/CEG.S39518
  5. CUMMINGS JR, KESHAV S, TRAVIS SP. Medical management of Crohn's disease BMJ [online] 2008 May 10, 336(7652):1062-1066 [viewed 10 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2376027/
  6. WILKINS T,JARVIS K,PATEL J. Diagnosis and Management of Crohn's Disease. Am Fam Physician[online] 2011 Dec 15;84(12):1365-1375[viewed on 10 June 2014] Available from;http://www.aafp.org/afp/2011/1215/p1365.html#sec-1