GASTRODUODENAL CROHN’S DISEASE

Inflammatory bowel disease (IBD) is an immune-mediated chronic intestinal condition. Ulcerative

colitis (UC) and Crohn’s disease (CD) are the two major types of IBD. Active CD is characterized by
focal inflammation and formation of fistula tracts, which resolve by fibrosis and stricturing of the
bowel. The bowel wall thickens and becomes narrowed and fibrotic, leading to chronic, recurrent
bowel obstructions. Although CD usually presents as acute or chronic bowel inflammation, the
inflammatory process evolves toward one of two patterns of disease: a fibrostenotic obstructing
pattern or a penetrating fistulous pattern, each with different treatments and prognoses. The site
of disease influences the clinical manifestations. (Harrison’s Principles of Internal Medicine 20 th
ed. p. 2263, 2264).
Harrison’s
 Genetic susceptibility
Principles of
 Microbial flora
Etiology Internal
 Immune dysregulation
Medicine 20th
 Environmental factors
ed. P. 2259
 The highest incidence rates of CD and UC have been
reported in northern Europe, the United Kingdom,
and North America.
 Peak incidence of UC and CD is in the second to
fourth decades, with 78% of CD studies and 51% of
UC studies reporting the highest incidence among
those age 20–29 years old.
 A second modest rise in incidence occurs between Harrison’s
the seventh and ninth decades of life. Principles of
Epidemiology  The female-to-male ratio ranges from 0.51 to 1.58 Internal
for UC studies and 0.34 to 1.65 for CD studies, Medicine 20th
suggesting that the diagnosis of IBD is not gender- ed. P. 2258
specific.
 The greatest incidence of IBD is among white and
Jewish people, but the incidence of IBD in Hispanic
and Asian people is increasing, as noted above.
 Urban areas have a higher prevalence of IBD than
rural areas, and high socioeconomic classes have a
higher prevalence than lower socioeconomic classes.
Harrison’s
 Second to fourth decades
Principles of
Non-modifiable risk  Seventh to ninth decades
Internal
factors OR predisposing  RF for developing CA: long duration and extensive
Medicine 20th
factors disease, bypassed colon segment, colon strictures,
ed. P. 2258,
PSC, family history of colon cancer.
2276
Harrison’s
Principles of
 Smoking
Modifiable risk factors OR Internal
 OCP use
precipitating factors Medicine 20th
 Antibiotic use in the first year of life
ed. P. 2258,
2276
Pathophysiology  Under physiologic conditions, homeostasis Harrison’s
 normally exists between the commensal
microbiota, epithelial cells that line the interior of
the intestines and immune cells within the tissues.
Each of these three major host compartments that
function together as an integrated
“supraorganism” (microbiota, IECs, and immune
cells) are affected by specific environmental (e.g.,
smoking, antibiotics, enteropathogens) and
genetic factors that, in a susceptible host,
cumulatively and interactively disrupt homeostasis
Principles of
during the course of one’s life, which in so doing
Internal
culminates in a chronic state of dysregulated
Medicine 20th
inflammation; that is IBD.
ed. P. 2259,
 IBD is currently considered an inappropriate
2260
immune response to the endogenous
(autochthonous) commensal microbiota within
the intestines, with or without some component
of autoimmunity. During the course of infections
or other environmental stimuli in the normal host,
full activation of the lymphoid tissues in the
intestines occurs but is rapidly superseded by
dampening of the immune response and tissue
repair. In IBD such processes may not be regulated
normally.
History (Subjective  Active CD: focal inflammation and formation of Harrison’s
complaints) fistula tracts, which resolve by fibrosis and Principles of
stricturing of the bowel. The bowel wall thickens and Internal
becomes narrowed and fibrotic, leading to chronic, Medicine 20th
recurrent bowel obstructions. ed. P. 2263,
 Usual presentation of ileocolitis is a chronic history 2264
of recurrent episodes of right lower quadrant pain
and diarrhea.
- Sometimes the initial presentation mimics
acute appendicitis with pronounced right
lower quadrant pain, a palpable mass, fever,
and leukocytosis.
- Pain is usually colicky; it precedes and is
relieved by defecation.
- Weight loss is common (10–20% of body
weight) and develops as a consequence of
diarrhea, anorexia, and fear of eating.
 Bowel obstruction may take several forms.
- Early stages: bowel wall edema and spasm
produce intermittent obstructive
manifestations and increasing symptoms of
postprandial pain.
- Chronic: persistent inflammation gradually
 progresses to fibrostenotic narrowing and
stricture. Diarrhea will decrease and be
replaced by chronic bowel obstruction.
 Stricturing can occur in the colon in 4–16% of
patients and produce symptoms of bowel
obstruction. If the endoscopist is unable to traverse
a stricture in Crohn’s colitis, surgical resection
should be considered, especially if the patient has
symptoms of chronic obstruction.
- Colonic disease may fistulize into the stomach
or duodenum, causing feculent vomiting, or to
the proximal or mid-small bowel, causing
malabsorption by “short circuiting” and
bacterial overgrowth.
Harrison’s
 Symptoms and signs of upper GI tract disease Principles of
include nausea, vomiting, and epigastric pain. Internal
PE Findings
 Patients with advanced gastroduodenal CD may Medicine 20th
develop a chronic gastric outlet obstruction. ed. P. 2263,
2264
 Laboratory abnormalities: elevated ESR and CRP.
 Severe disease: hypoalbuminemia, anemia, and
leukocytosis.
 Fecal calprotectin and lactoferrin levels:
distinguish IBD from IBS, assess whether CD is
active, and to detect postoperative recurrence of
CD.
 Endoscopic features: rectal sparing, aphthous
Harrison’s
ulcerations, fistulas, and skip lesions.
Diagnostic tests to Principles of
 Wireless capsule endoscopy (WCE) allows direct
request and its expected Internal
visualization of the entire small-bowel mucosa.
findings or results Medicine 20th
 Early radiographic findings: thickened folds and
ed. P. 2265
aphthous ulcerations. “Cobblestoning” from
longitudinal and transverse ulcerations most
frequently involves the small bowel.
 The earliest macroscopic findings of colonic CD are
aphthous ulcers. As the disease progresses,
aphthous ulcers become enlarged, deeper, and
occasionally connected to one another, forming
longitudinal stellate, serpiginous, and linear ulcers.
Medical treatment  Infliximab (anti-TNF): chimeric monoclonal Harrison’s
(include the drug antibody which binds w/ high affinity to the Principles of
classification, mechanism soluble and transmembrane forms of tumour Internal
of action, dosage, route, necrosis factor-α (TNF-α) thereby inhibiting Medicine 20th
and frequency) binding of TNF-α to its receptors.  Initially, 5 mg/kg ed. P. 2272
by infusion over at least 2 hr, repeated at 2 wk MIMS PH
after 1st infusion. No further doses should be
 given if there is no response after 2 doses.
Responders: Maintenance: 5 mg/kg at 6 wk after
initial dose then 8 wkly thereafter.
Harrison’s
Principles of
Internal
 Surgical resection of the diseased segment
Surgical treatment Medicine 20th
 Stricturoplasty
ed. P. 2273,
2274

Harrison’s
Principles of
 Bowel rest
Nonpharmacological Internal
 TPN
treatment Medicine 20th
 Enteral nutrition
ed. P. 2273

 Serosal adhesions
 Fistula formation Harrison’s
 Perforation Principles of
 Peritonitis Internal
Complications
 Intaabdominal and pelvic abscess Medicine 20th
 Intestinal obstruction ed. P. 2265
 Massive hemorrhage
 malabsorption
Harrison’s
Principles of
Internal
Prevention  Environmental factor modification
Medicine 20th
ed. P. 2259

 Because CD is a transmural process, serosal

adhesions develop that provide direct pathways
for fistula formation and reduce the incidence of
free perforation.
Harrison’s
 Perforation occurs in 1–2% of patients. The
Principles of
peritonitis of free perforation, especially colonic,
Prognosis or outcome Internal
may be fatal.
Medicine 20th
 Intraabdominal and pelvic abscesses occur in 10–
ed. P. 2265
30% of patients.
 Other complications: intestinal obstruction in 40%,
massive hemorrhage, malabsorption, and severe
perianal disease