CROHN CROHN ’s DISEASE ’s DISEASE Defini Defini tion tion Granulomatous inflammatory disease, non specific, Granulomatous inflammatory disease, non specific, producing necrosis and scaring producing necrosis and scaring o o f segments of f segments of gastrointestinal tract, which is chronic and gastrointestinal tract, which is chronic and develops in recurring episodes develops in recurring episodes : : Acute phase (inflammation) Acute phase (inflammation) = = deep ulcers deep ulcers +/- perfora +/- perfora tions tions with abscess formation and adhesions to adjacent with abscess formation and adhesions to adjacent structures structures Chronic phase (fibrotic) Chronic phase (fibrotic) = = stricture formation stricture formation. Epidemiolog Epidemiolog y y High incidence in Scandinavia, High incidence in Scandinavia, N-V Europe N-V Europe and and N-E N-E of of North North Ameri Ameri ca ca Maximum incidence Maximum incidence 20-30 20-30y; More in Caucasians and Jewish population More in Caucasians and Jewish population More in women More in women
CROHN ’s DISEASE. Defini tion Granulomatous inflammatory disease, non specific, producing necrosis and scaring o f segments of gastrointestinal tract, which is chronic and develops in recurring episodes : - PowerPoint PPT Presentation
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CROHNCROHN’s DISEASE’s DISEASEDefiniDefinitiontion Granulomatous inflammatory disease, non specific, Granulomatous inflammatory disease, non specific,
producing necrosis and scaring producing necrosis and scaring oof segments of f segments of gastrointestinal tract, which is chronic and develops gastrointestinal tract, which is chronic and develops in recurring episodes in recurring episodes :: Acute phase (inflammation)Acute phase (inflammation) = = deep ulcers deep ulcers +/- perfora+/- perforations tions
with abscess formation and adhesions to adjacent structures with abscess formation and adhesions to adjacent structures Chronic phase (fibrotic) Chronic phase (fibrotic) = = stricture formationstricture formation..
EpidemiologEpidemiologyy High incidence in Scandinavia, High incidence in Scandinavia, N-V Europe N-V Europe and and N-E N-E of of
North North AmeriAmericaca Maximum incidence Maximum incidence 20-30 20-30yy;; More in Caucasians and Jewish population More in Caucasians and Jewish population More in women More in women
GeneticGenetic:: Both twins develop diseaseBoth twins develop disease;; Higher chance for an individual with familial clustering of Higher chance for an individual with familial clustering of
Crohn’sCrohn’s;; InfectiousInfectious::
SugeSugested by the presence of granuloma sted by the presence of granuloma There is evidence for: viruses, bacteria and mycobacteriaThere is evidence for: viruses, bacteria and mycobacteria CConcomitentoncomitent infections infections – E. coli, Clostridi – E. coli, Clostridiaa, Campylobacter., Campylobacter.
AlergiesAlergies:: AlergenAlergens in food and inhaled (fungus, molds) – anamnestic data, s in food and inhaled (fungus, molds) – anamnestic data,
alergic testing and more favorable results with specific alergic testing and more favorable results with specific hyposensitisationhyposensitisation
FoodFood:: Elimination of wElimination of weaeath flour and sugar = evident augmentationth flour and sugar = evident augmentation
CROHNCROHN’s DISEASE’s DISEASE
Immunological Immunological Association with: arthritis, eritema nodosum: Association with: arthritis, eritema nodosum:
complex Ag-Ab should be present complex Ag-Ab should be present Presence of Ab against different Ag structures Presence of Ab against different Ag structures
and increase concentration of IgAand increase concentration of IgA;; Inflammatory infiltration and epitheliod Inflammatory infiltration and epitheliod
granuloma formation = high level immune cell granuloma formation = high level immune cell mediated reaction against Ag structuresmediated reaction against Ag structures;;
Corticoids and immune suppresive medication are Corticoids and immune suppresive medication are highly effected in Crohn’s diseasehighly effected in Crohn’s disease; ;
Probable: immune changes at the level of the Probable: immune changes at the level of the mucosa with hyperactive immune response mucosa with hyperactive immune response against foreign Ag with cross reaction and against foreign Ag with cross reaction and nonspecific tisular injury (innocent nonspecific tisular injury (innocent bystander) bystander)
(redish), inert(redish), inert friabile;friabile; Limits: very clearly delimited Limits: very clearly delimited Diseased areaDiseased areass are separated are separated
lymph node hlymph node hypertrophy ypertrophy Sometimes more extensive Sometimes more extensive
then bowel lesionsthen bowel lesions
CROHNCROHN’s ’s DISEASEDISEASE
PrePresence of sence of ulcer ulcer and and ulcerations ulcerations – – can be can be very small or serpent very small or serpent like + transverse ulcers like + transverse ulcers producing the image of producing the image of islands (islands (cobblestone);cobblestone);
FiFissures and ulcers are ssures and ulcers are the origin of fistulas the origin of fistulas (entero-enteric, entero-(entero-enteric, entero-colic, entero-cutaneous, colic, entero-cutaneous, entero-vezical, entero-entero-vezical, entero-vaginal)vaginal)
BOALA CROHNBOALA CROHN
pseudopolpseudopolyyppss
Fibrosis, sclerosis, structure formationFibrosis, sclerosis, structure formation Bowel wall very thick (up to 1cm) Bowel wall very thick (up to 1cm) Structures, short or long, unic or multipleStructures, short or long, unic or multiple;; Advanced stages: on long continuous stenosisAdvanced stages: on long continuous stenosis
CROHNCROHN’s DISEASE’s DISEASE
MMyycroscopcroscopy: y: cchharacteristic = aracteristic = granulomgranuloma with a with epitepithelioid giganto helioid giganto cellular cells cellular cells ::
Never caseous necrosis≠tuberculosisNever caseous necrosis≠tuberculosis;; Same inflammation in regional lymphnodesSame inflammation in regional lymphnodes
Inflammatory infiltration is found Inflammatory infiltration is found through all strata of the bowel wallthrough all strata of the bowel wall;;
CROHNCROHN’s DISEASE’s DISEASE SSyymptommptomss
InsidiosInsidios onset but mai also be sudden onset but mai also be sudden;; A. A. symptoms associtaed with bowel problemssymptoms associtaed with bowel problems
PAIN PAIN Dull pain, medium intensity in the RLQ Dull pain, medium intensity in the RLQ Colicky when associated with obstruction: may be Colicky when associated with obstruction: may be
projected in the upper abdomenprojected in the upper abdomen.. DIARHEADIARHEA
4-6/4-6/dayday – – watery or semisolidwatery or semisolid Proportional to extent of lesions and activity of diseaseProportional to extent of lesions and activity of disease;; Bleeding per rectum: distal lesionsBleeding per rectum: distal lesions..
NAUSEA, VOMITING, BORBORISMNAUSEA, VOMITING, BORBORISM.. B. general symptomsB. general symptoms
fefeverver 38 38 00C, +/- C, +/- chillschills Weight loss: diarhhea plus reduced surface for nutrient Weight loss: diarhhea plus reduced surface for nutrient
recto-vaginal – recto-vaginal – symptoms symptoms and visible on direct and visible on direct examinationexamination..
in the gallbladder: similar in the gallbladder: similar with acute cholecistitiswith acute cholecistitis
retroperitoneal – retroperitoneal – diffuse diffuse celulitis (very severe but celulitis (very severe but very rare)very rare)
CROHNCROHN’s DISEASE’s DISEASE
ParaclinicParaclinicalal LabLab
anemia – anemia – most oftem microcytic, hypochromc most oftem microcytic, hypochromc but macrocytic anemia can develop (B12 deficit) but macrocytic anemia can develop (B12 deficit)
leucocitoleucocitosissis In acute phaseIn acute phase iin complican complicationstions (ab (abssces, fistulces, fistulaa))
trombocitotrombocitosissis ESR increasedESR increased;; Electrolite embalance due to diarheaElectrolite embalance due to diarhea
RadiologRadiology - barium y - barium mealmeal
Alternation of normal and affected Alternation of normal and affected areasareas
Ulcers: deep in the wall aspect of Ulcers: deep in the wall aspect of rose thorn associating 3 aspectsrose thorn associating 3 aspects PseudopolypsPseudopolyps;; Small spiculiform lateral ulcerationsSmall spiculiform lateral ulcerations Large ulcers Large ulcers ;;IRREGULAR COBLESTONE IRREGULAR COBLESTONE
Advanced stages Advanced stages No more foldsNo more folds;; Rigid stenotic tube Rigid stenotic tube Stenosis + distended segments aboveStenosis + distended segments above;; FistulasFistulas..
particularparticular Terminal ileum – rigid cordTerminal ileum – rigid cord;; CecumCecum – – filling defect on the inner filling defect on the inner
border + retractionborder + retraction..
EndoscopEndoscopy GOLD y GOLD STANDARDSTANDARD Small lesions + biopsy + Small lesions + biopsy +
extent of lesions + monitorextent of lesions + monitor RRectoscopia:ectoscopia:
75% normal;75% normal; Coblestones aspectCoblestones aspect Ulcers or stenosisUlcers or stenosis friable mucosa that bleeds on friable mucosa that bleeds on
touchtouch.. CColonoscopolonoscopyy – – similar + similar +
ileum!!!ileum!!! GastroscopyGastroscopy
BiopsBiopsy y Deep + multipleDeep + multiple Even in normal areaEven in normal area..
Young pt with diarhhea, abdominal pain I RLQ (often) Young pt with diarhhea, abdominal pain I RLQ (often) +/- mass on palpation +/- fissure or fistula perianal.+/- mass on palpation +/- fissure or fistula perianal...
RadilogyRadilogy segmentarsegmentaryy, discontinu, discontinuous lesions and asymetric lesionous lesions and asymetric lesion;; Deep transmural ulcersDeep transmural ulcers;; „„cobblestone”, „string sign”, pcobblestone”, „string sign”, presence of resence of
pseudopolipilor;pseudopolipilor; Stenosis and fistulaStenosis and fistula..
EEndoscopndoscopyy Skip lesionsSkip lesions;; Multiple ulcers associated with edematous mucosa +/- Multiple ulcers associated with edematous mucosa +/-
stenosis stenosis PathologyPathology
epitepithhelio-giganto-celularelio-giganto-celular granuloma granuloma;; llyymmphphoocytes and cytes and plasmplasma cells infiltration - suggestivea cells infiltration - suggestive
diseasedisease Ulcerative colitisUlcerative colitis Colonic cahnges in laxative abuse Colonic cahnges in laxative abuse
Watery diarrhea in a person that uses laxatives Watery diarrhea in a person that uses laxatives Rx – loss of haustrations and signs of iritable Rx – loss of haustrations and signs of iritable
AbAbscess formation scess formation FistulFistula a StenoStenosis sis
InflamatorInflamatory or scarsy or scars;; Incomplete obstructionIncomplete obstruction
GI Bleeding - mostly from GI Bleeding - mostly from colic origincolic origin
PerforaPerforation: free tion: free perforation with peritonitis perforation with peritonitis is very unusualis very unusual..
Toxic megacolon – rare but Toxic megacolon – rare but very serious diseasevery serious disease Toxic statusToxic status + fe + feverver + + major major
abdominal painabdominal pain + + bloody and bloody and mucus diarrhea + abdominal mucus diarrhea + abdominal distensiondistension
RX massive distension and RX massive distension and destructuringdestructuring
Complications - generalComplications - general
EExtraintestinalxtraintestinal may be considered part of the may be considered part of the disease or complications if severe disease or complications if severe CutanCutaneous, joints, liver, small vessels (thromboembolic eous, joints, liver, small vessels (thromboembolic
Urinary lithiasis Urinary lithiasis Obstructions due to mechanical compression of urethersObstructions due to mechanical compression of urethers;;
NeuropsyhicNeuropsyhic:: Sciesures or tetany due to hypoC and hypoMg Sciesures or tetany due to hypoC and hypoMg AnorexiaAnorexia PsihosisPsihosis..
Malabrobtion with consequences on growthMalabrobtion with consequences on growth.. Amiloidosis (visceral and renal) – after 10 years of Amiloidosis (visceral and renal) – after 10 years of
evolutionevolution EEndocrine:ndocrine:
amenoreea, infertilitamenoreea, infertilityy, , late puberty late puberty Small bowel or colonic cancer – after many years Small bowel or colonic cancer – after many years
TREATMENT TREATMENT Medical Medical GeneralGeneral
Bed restBed rest PsihoterapPsihoterapyy;; DietaryDietary
hhyypercaloric, percaloric, hperproteic, vitaminehperproteic, vitaminess (folic, A, D, K, C, B12) (folic, A, D, K, C, B12) andand mineral mineralss (Ca++, (Ca++, Mg++, K+, Fe++, Zn+Mg++, K+, Fe++, Zn++);+);
EXCLUDEEXCLUDE:: Food with many Food with many
fibers )mostly in pt with fibers )mostly in pt with stenosisstenosis;;
Milk – intolerance Milk – intolerance ;; Lipids in case of Lipids in case of
malabsorbtion of lipidsmalabsorbtion of lipids.. MAJOR situations- TPN MAJOR situations- TPN
Limited resection of involved bowelLimited resection of involved bowel Enterostomy – end later resectionEnterostomy – end later resection
TREATMENTTREATMENT A. Crohn ileocolicA. Crohn ileocolic IndicaIndicationstions::
fistula;fistula; obstrucobstructiontion;;;;
Percutaneous drainage and resections Percutaneous drainage and resections
TREATMENTTREATMENT B. B. Colonic Crohn Colonic Crohn IndicaIndicationtion
samesame;; megacolon toxic.megacolon toxic.
3 operaţii:3 operaţii: proctocolectomproctocolectomyy ((abdomino-perinealabdomino-perineal) with permanent ) with permanent
ileostomyileostomy;; Total colectomy and ileostomy but rectum in placeTotal colectomy and ileostomy but rectum in place;; Total colectomy plus ileorectal anastomosisTotal colectomy plus ileorectal anastomosis..
TREATMENTTREATMENT Anal and perianalAnal and perianal TTreatment of the abscess and fistula + reatment of the abscess and fistula +
treatment of Crohnstreatment of Crohns.. If refractory disease n the rectum - If refractory disease n the rectum -
proctectomyproctectomy
TREATMENTTREATMENT ObstructionObstruction
ileon:ileon: Ileon resectionIleon resection;; Ileo-cecal resectionIleo-cecal resection By passBy pass..
colon:colon: by-pass;by-pass; IleostomIleostomy or colostomyy or colostomy..
Long term complicationLong term complication CancerCancer
High risk for pt with long term Crohns, High risk for pt with long term Crohns, strictures and scleroiss cholangitis strictures and scleroiss cholangitis
Onset 18-30yOnset 18-30y Under 18 very severeUnder 18 very severe;; Over 50 very unusualOver 50 very unusual..
More often in male ptMore often in male pt
UCUC Genetic factors Genetic factors
Family clusteringFamily clustering;; Possible implication of a defect in IgA productionPossible implication of a defect in IgA production
InfectionInfection Numerous germs isolated but not clearNumerous germs isolated but not clear;; Atb not very goodAtb not very good;; Probably secondary and cause of recurrence Probably secondary and cause of recurrence ..
EnzimaticEnzimatic Increased synthesis of lizozim – destroys the Increased synthesis of lizozim – destroys the
protective mucusprotective mucus;; Not clear if primary or secundary Not clear if primary or secundary ..
PsiPsihhosomaticosomatic PPaattients areients are more psichological more psichologicallyly vulnerable to vulnerable to
conflictconflict;; Emotional problems involved in onset and Emotional problems involved in onset and
maintenance of new episodesmaintenance of new episodes
Shortening of the length;Shortening of the length; Narrow lumen;Narrow lumen; No haustrations;No haustrations; Thick wall (due to the muscle Thick wall (due to the muscle
layer);layer); Fulminant diseaseFulminant disease
Very dilated bowel.Very dilated bowel. SevereSevere
with incomplete healing with incomplete healing of the mucosa;of the mucosa;
Thin mucosa;Thin mucosa;
UCUC Particular aspects – affects only the mucosa of the Particular aspects – affects only the mucosa of the
rectum and the colonrectum and the colon First rectum then colonFirst rectum then colon The lower the segment the more aggressive the disease;The lower the segment the more aggressive the disease; The lesions are continuous;The lesions are continuous;
UCUC MicroscopyMicroscopy::
Dilation of vessels folllowed by haemmorhage;Dilation of vessels folllowed by haemmorhage; limfocites and plasmocites;limfocites and plasmocites; Deep glands are full of neutrophils – abcess of Deep glands are full of neutrophils – abcess of
the crypts – ulcerations and pseudopolips.the crypts – ulcerations and pseudopolips. histology:histology:
Granulocyte infiltration is specificGranulocyte infiltration is specific If inflammation spreads to all layers – toxic If inflammation spreads to all layers – toxic
diarrhea:diarrhea: First in 30-50% cases;First in 30-50% cases; Main symptom 4/5;Main symptom 4/5; Feces in a sero-hematic liquid full of pussFeces in a sero-hematic liquid full of puss 2-3 up to 15-20 stools/day;2-3 up to 15-20 stools/day; Sometimes just blood per anumSometimes just blood per anum
Abd pain:Abd pain: Colicky – left sideColicky – left side characteristic:characteristic:
tenesmus;tenesmus; No more pain after a stool is passed.No more pain after a stool is passed.
GeneralGeneral FeverFever –septic; –septic; Weight lossWeight loss;; Vomiting;Vomiting; Tachycardia - Tachycardia - depending on amount of lost fluids depending on amount of lost fluids..
UCUC Clinical examClinical exam abdomen:abdomen:
inspection:inspection: reduction of reduction of
subcutaneous tissue;subcutaneous tissue;bloating - especially bloating - especially suprasuprauumbilicalmbilical - - installation may installation may highlight acute toxic highlight acute toxic dilatation of the colondilatation of the colon..
percution:percution: timpanism increased in timpanism increased in
the case of toxic the case of toxic dilatation of the colon;dilatation of the colon;
exudate in the rectal exudate in the rectal mucosa, or the presence of mucosa, or the presence of blood, mucus, pus;blood, mucus, pus;
highlights other highlights other injuries:injuries:cancer, hemorrhoids, cancer, hemorrhoids, abscesses, fistulas, etc..abscesses, fistulas, etc..
UCUC
stool:stool: in severe forms, in severe forms,
extensive:extensive:stools are unformed, with stools are unformed, with feces floating in a serous feces floating in a serous fluid, blood mixed with fluid, blood mixed with mucus and pus;mucus and pus;
bulky stools with much bulky stools with much blood.blood.in mild formsin mild forms
stool can be formed with stool can be formed with blood and mucus;blood and mucus;in forms limited to the in forms limited to the rectum:rectum:stools, wrapped in blood stools, wrapped in blood and mucus;and mucus;
emissions of blood and emissions of blood and mucus without stool.mucus without stool.
detection detection of of systemic systemic events:events:
eye;eye;articulation;articulation;skin.skin.
UCUC
LaboratoryLaboratory:: leukocytosis - active phases;leukocytosis - active phases; anemia;anemia; hypoalbuminemia;hypoalbuminemia; electrolytes:electrolytes:
significant changes only in severe significant changes only in severe forms;forms; lowering of Na +, K +, Cl-, Mg + lowering of Na +, K +, Cl-, Mg + +;+;
UCUC Radiology Radiology
Simple x-ray or Simple x-ray or radioscopyradioscopy
Always first Always first (perforation, (perforation, incontinence)incontinence)
Spondilitis is the only Spondilitis is the only one that can persist one that can persist after surgery and after surgery and medical treatmentmedical treatment..
respiratory or digestive tract infectionsrespiratory or digestive tract infections;; 4. 4. follow upfollow up..
C. C. SurgerySurgery 1.1. total total
proctoproctocolectomcolectomy y and permanent and permanent ileostomyileostomy
2.2. total colectomy, total colectomy, treatment of the rectal treatment of the rectal stump and stump and reestablishment of the reestablishment of the continuity of the continuity of the digestive tract 6-12 digestive tract 6-12 months latermonths later
Risc of a disease Risc of a disease progression or progression or relapserelapse
Cancer riskCancer risk.. 3. 3. total colectomy total colectomy
with ileorectal with ileorectal anastomosis in the anastomosis in the same proceduresame procedure;;
HipertroHipertrophy of the circular phy of the circular musculaturemusculature
Shortening of longitudinal Shortening of longitudinal fibersfibers;;
The result is pressure The result is pressure pockets that push the pockets that push the mucosa throus the muscle mucosa throus the muscle fibersfibers
Weak spots in the colonic Weak spots in the colonic wallwall
Diverticular diseaseDiverticular disease Weakening of the wall due to fatty inflammationWeakening of the wall due to fatty inflammation;; Low fiber intake - constipationLow fiber intake - constipation;; Psychological stress;Psychological stress;
In timeIn time:: Stasis of feces – fecaliths – ulcerations of the mucosa Stasis of feces – fecaliths – ulcerations of the mucosa
due to mechanical irritation – increase in septic due to mechanical irritation – increase in septic fenomenaefenomenae..
Closed cavity – increase in virulence of germs and Closed cavity – increase in virulence of germs and increase in mucus secretion – congestion – increase in mucus secretion – congestion – inflammation – thickening of the wallinflammation – thickening of the wall
symptomssymptoms:: Symptoms usually Symptoms usually
due to complicationsdue to complications.. ParaclinicParaclinicalal:: Barium enema, Barium enema,
colonoscopycolonoscopy
ComplicationsComplications A. DiverticulitA. Diverticulitisis
30% 30% of patients with diverticular disease of patients with diverticular disease ;; One or more diverticulaeOne or more diverticulae Due to stasis of fecesDue to stasis of feces peridiverticulitisperidiverticulitis
simptomsimptomss:: Very painful – left iliac fosaVery painful – left iliac fosa;; Irregular bowel habits;Irregular bowel habits; Bloating;Bloating; Nausea;Nausea; Fever;Fever;
Clinical examClinical exam:: Tumor mass in left iliac fosaTumor mass in left iliac fosa painfulpainful;; Lower limit of tumor can be assessed on rectal Lower limit of tumor can be assessed on rectal
digital examdigital exam Above the tumor the descending colon is short and Above the tumor the descending colon is short and
rigidrigid
CT, CT, USUS
Diverticular diseaseDiverticular disease
B. HB. Haemmorhageaemmorhage Frequent due to vecinity of vessels Frequent due to vecinity of vessels ;; More frequent in the right colonMore frequent in the right colon;; clinicclinicalal::
Large haemmorhage;Large haemmorhage; Rarely melenaRarely melena;; Reocurring frequentlyReocurring frequently..
3 s3 syyndrondromsms:: General septicGeneral septic;; Pericolic abscessPericolic abscess;; PeritonitisPeritonitis
D. D. PerforationPerforation First a pericolic abscess and then First a pericolic abscess and then
peritonitisperitonitis E. E. ObstructionObstruction
MecMechanical - due to inflammationhanical - due to inflammation clinicclinicalal::
Suboclusive syndromSuboclusive syndrom Low obstruction + feverLow obstruction + fever:: Tumor mass in the left iliac fossaTumor mass in the left iliac fossa
MedicalMedical Profilaxis of complicationsProfilaxis of complications::
Avoid constipationAvoid constipation;; No spicesNo spices;; Mild antispasticsMild antispastics;;
diverticulitdiverticulitisis High fiber intake and laxativesHigh fiber intake and laxatives;; Antiinflammatory drugsAntiinflammatory drugs AntibioticsAntibiotics..
TREATMENTTREATMENT
SurgerySurgery Segmental Segmental
resection of resection of affected colon;affected colon;
In emergency – In emergency – 2 step 2 step procedureprocedure::
Hartmann Hartmann I I followed by followed by reestablishment reestablishment of continuityof continuity
Colostomy in Colostomy in emergency emergency followed by followed by resection with resection with anastomosis anastomosis after acute fase after acute fase passespasses..