Crohn's disease

The is Dr Burrill Bernard Crohn (left) and James Parkinson (right) getting ready to fight out who's eponymous disease is the most important at Wrestlemania XIX.

Definition

Chronic inflammatory bowel disease. Yay!

Epidemiology

Indeed.

Pathophysiology

Nobody knows. Probably genetic. Nobody really knows though.

Risk Factors

High-sugar, low-fibre diet; anaerobes; smoking and NSAIDs may exacerbate disease.

Clinical Features

• GI - alternating diarrhoea and constipation, change in bowel habit, abdominal pain, weight loss, mouth ulcers, RIF mass, bumhole abscesses
• General - fever, malaise, anorexia, finger clubbing, shin erythema nodosum (painful purplish nodules), conjuntivitis, iritis, arthitis, ankylosing spondylitis, fatty liver and lots of others.

Investigations

Bloods

• FBC - raised platelets, raised WCC, anaemia
• ESR - raised
• CRP - raised
• U+Es - raised albumin
• LFT - signs of fatty liver
• Serum iron, B₁₂ in anaemia

Bumly

• Stool - microscopy, sensitivity and culture
• Small bowel enema - detects ileal disease
• Barium enema - 'rose-thorn' ulcers, cobblestoning and colonic strictures
• Colonoscopy - shows fissured ulcers, enables biopsy

Management

Mild attacks

Prednisolone 30mg od 1wk, 20mg/d 1mo will usually do the trick. See every 2-4 weeks. If symptoms resolve, stop prednisolone.

Severe attacks

Basically, this means they are systemically unwell and they need admission.

• Nil by mouth, hydration - 1L 0.9% saline + 2L dextrose saline/24h + 20mmol K⁺/L
• Steroids - hydrocortisone 100mg/6h iv with topical steroids for rectal disease (hydrocortisone 100mg in 0.9% saline 100ml/12h pr)
• Metronidazole - 400mg/8h po or 500mg/8h iv

You need to monitor everything: temperature, pulse, BP, stool frequency/character and all the bloods. Also, do two physical examinations a day, partly for fun but mostly because it's necessary. If they improve, move onto prednisolone. If there is no improvement, you need to start thinking about surgery.

Other treatments

Basically, the following are additional potential therapies in Crohn's: azathioprine (for steroid-sparing), sulfasalazine, methotrexate, infliximab (anti-tumour necrosis factor monoclonal antibody - try saying that when you're lashed), elemental diets (special diets with less of the stuff that sets off Crohn's) and finally:

Surgery

50-80% of Crohn's sufferers require 1 op in their lifetimes. Failure of drug therapy, intestinal obstruction, perforation, fistulae and abscesses are all indications for surgery.