Crohn’s disease

( regional enteritis)
Can affect any part of GIT from the lip to anal
verge but ileocaecal disease is the most common
site of presentation
AE/ The aetiology of Crohn’s disease is incompletely
understood but is thought to involve a complex
.interplay of genetic and environmental factors
Pathogenesis
As in UC, there is thought to be an increased
permeability of the mucous membrane. This may
lead to increased passage of luminal antigens,
.which then induce a cell-mediated inflammation
:Pathology

 Can affect any part of GI tract from the mouth to the anus

 30-40% of patients have small bowel disease alone

 40-55% of patients have both small and large intestines

disease

 15-25% of patients have colitis alone

 Crohn's disease differs from ulcerative colitis in the
areas of the bowel it involves - it most commonly
affects the last part of the small intestine and parts of
the large intestine.

 Crohn's disease generally tends to involve the entire

bowel wall
 Crohn’s disease – macroscopic features

 CD is a transmural process

 CD is segmental with skip

 In one –third of patients with CD perirectal fistulas,

fissures, abscesses, anal stenosis are present
 Crohn’s disease – macroscopic features
 mild disease is characterized by:
aphtous or small superficial ulcerations

 In more active disease:

stellate ulcerations fuse longitudinally and
transversely to demarcate island of mucosa that are
histologically normal

 Cobblestone appearance is characteristic of CD (both

endoscopically and by barium radiography)
 Signs And Symptoms
Age incidence 25- 40 , slightly more common in
female
Acute

occur in only 5% of cases

S & S resemble those of acute appendicitis but there is
usually diarrhoea before attack
Acute colitis with or without toxic megacolon can occur
but is less common than Ulcerative C.
Rarely there could be a free perforation of small
intestine resulting in local or diffuse peritonitis.
 Chronic:
- inflammatory disease is associated with loss of digestive and absorptive
surface
- History of diarrhoea over many months with attacks of intestinal colic.
- Patient may complain of pain particularly in RIF and there may be
palpable tender mass
- Intermittent fevers.
- Anaemia and weight loss
- After months of repeated attacks the affected area of intestine begins to
narrow with fibrosis causing intestinal obstruction
- With time : adhesions & Int. Obs.

trans mural fissuring

intraabdominal abscess
fistulae develop (entero enteric fistula, enero vesical ,enero
cutaneous )
IBD is associated with variety of
extraintestinal menifestation.
Almost one-third of the patients have at
least one.
 Extraintestinal manifestation
Dermatologic
1. Erythema nodosum occurs in up to 15% of CD
patients and 10% of UC patients

2. Pyoderma gangrenosum (PG) is seen in 1 to 12% of

UC patients and is less common in CD colitis. PG may
occur years before the onset of bowel symptoms.
 Extraintestinal manifestation
Rheumatologic

Peripherial arthritis developes in 15 to 20% of IBD patients, is

more common in CD.
It is asymmetric, polyarticular and migratory.
Most often affects large joints of the upper and lower extremities

Ankylosing spondylosis (AS) occurs in 10% of IBD.

Sacroilitis is symetrical, occurs equally in UC and CD, often

asymptomatic
 Extraintestinal manifestation
Ocular

The incidence of ocular complications in IBD patients is 1 to

10%
The most common is conjunctivitis, anterior uveitis,
episcleritis
 Extraintestinal manifestation
Urologic

The most frequent genitourinary complications are:

calculi, ureteral obstruction, fistulas
 Investigations

 Radiological :
Ba enema and small bowel enema :
Will show area of delay and dilatations
Terminal area when involved there may be string
sign of Kantor
Sinogram : used in fistulae.
CT scan for intra abdominal abscess.
Figure 69.11 Small bowel enema examination
showing a narrowed terminal ileum involved
with Crohn’s disease – the ‘string’ sign of
.Kantor
Sigmoidoscopy and colonscopy:
-The earliest appearance are aphthoid like ulcers
surrounded by a rim of erythematous mucosa
then become large and deeper with severity of
the disease.
-In colonic disease --- skip area

-Stricture ----- biopsy to exclude malignancy

 Treatment

During relapses
- prednisolone 40 mg /day
-5 ASA compounds

-AB ---- abscess or mass

-Azathioprime to spare steroid complications

-Nutritional support (anaemia , hypoprotenimia)

-Monoclonal Ab toward tumour necrosis factor

(infliximab)
Surgery: should be limited only for
complications.
Indication:
-Recurrent int. obst.

-Bleeding

-Perforation

-Failure of medical treatment

-Intestinal fistulae

-Fulminant colitis

-Malignant change

-Perianal disease

-
 Differences between ulcerative colitis and
Crohn’s disease
Ulcerative colitis affects the colon; Crohn’s disease can affect any part of
the gastrointestinal tract, but particularly the small and large bowel
UC is a mucosal disease, whereas CD affects the full thickness of the
bowel wall
UC produces confluent disease in the colon and rectum, whereas CD is
characterised by skip lesions
CD more commonly causes stricturing and fistulation
Granulomas may be found on histology in CD, but not in UC
CD is often associated with perianal disease, whereas this is unusual in
UC
CD affecting the terminal ileum may produce symptoms mimicking
appendicitis, but this does not occur in UC
Resection of the colon and rectum cures the patient with UC, whereas
recurrence is common after resection in CD
 Infections

Tubeculosis of intestine
1- ulcerative TB
2- Hyperplastic TB

Divericulosis