Crohns disease

What's the relationship?

Case A 25 YRS old male presented with central abdominal pain associated with low grade fever And intermittent attacks of diarrhrea that come and go in a weekly pattern . The pt. was anorexic and metioned a gradual weight loss over the past few months . also the pt. is smoker since

he was 17 .

Case discussed

A 25 YRS old male presented with central abdominal pain associated with low grade fever And intermittent attacks of diarrhrea that come and go in a weekly pattern . The pt. was anorexic and metioned a gradual weight loss over the past few months . also the pt. is smoker since

he was 17 .

! Lets go DDX

Bacterial enteritis Viral enteritis Ulcerative colitis Tumor Crohn's disease

So what's the approach?? Full history : the pain questions , diarrhea , stool

characteristics , family Hx of similar condition, social habits including smoking .

Clinical examination Lab investigations : complete blood picture showed ( megaloblastic anemia?) elevated ESR and CRP , folic acid and Cu defeciency GSE for presence of bacteria . Stool occult blood test

Approach

Colonoscopy , CT scan , X-RAY with barium enema . (no mass , but narrowing of bowel lumen)

inflammation

Edema and

fibrosis

Narrowed lumen

Of the wall of intestine

ATENDOSCOPY

(if possible)

What to see ?? • Mucosa : small ulcers coalesce to

form long serpentine linear ulcers . The mucosa between the ulcers is inflamed and edematous , having a cobble-stone appearance .

Ulcers and stones

They love this one: the sharp demarcation of diseased bowel segments from the adjacent non involved

essentially normal bowel .

Ulcers or fissures?? • The superficial ulcer may penetrate deeply to

form deep fissures , these may extend further causing fistulae between the affected intestinal segment and :

• Bowel loops• Vagina • Bladder • Skin of abdomen

Biopsy taken for

bacteriologic and

pathologic studies

The Bx results

GO microscopically • Acute mucosal inflammation ; neutrophils in the

epithelium and in the crypts (crypt abscesses )

GO microscopically • Chronic mucosal damage : this is

villous blunting in SI , and crypt irregularity in the LI .

• Ulcerations• Trans-mural chronic inflammation :

lymphocytes and plasma cells fill all the layers

Non caseating granuloma

GO microscopically

• Other changes ; duplication and thickening of musc. mucosae. And also fibrosis of submucosa , musc. Propria and serosa .

• Dysplastic changes in the mucosal epithelial cells : this is imp. In long standing disease , may be focal or widesprad , increase with time

this increases the risk of CA . Esp. that of colon

C / F• Colicky abdominal pain • Intermittent attacks of diarrhea • Fever lasting weeks or months • Anorexia , Wt loss • Anemia in colon involvement

Complications of Crohn's • Fibrosing strictures : causing intestinal

obstruction ( symptoms ?)• Fistulae to ; normal bowel , vagina , bladder• Extensive involvement of small intestine :

causing protein losing enteropathy , pernicious anemia (?) , steatorrhea (?) and generalized malabsorption .

EXTRA-INTESTINAL MANIFESTATIONS

• Arthritis • Finger clubbing• Erythema nodosum• Primary sclerosing cholangitis• renal disorders (how ?)

• systemic amyloidosis • increased incidence of CA of GIT

Ureter trapped in inflamed

bowel

narrowingUrine

back to kidneys

Hydronephrosis

Cigarette smoking is a risk factor for Crohns DR, Bernard Crohn

Clubbing is an extra intestinal manifestation

for CrohnsCobble stone pavements

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