PRESENTATION ON THE TOPIC:

CROHN DISEASE

Prepared by: assistant of the Department of PID:

Dyusekenova N. Zh.
 Makes the definition
Crohn's disease is a severe chronic immuno-mediated
granulomatous infl ammatory disease of the gastrointestinal
tract, which can affect all its parts, starting from the oral cavity
and ending with the rectum, with a predominant lesion of the
terminal segment of the ileum and ileocolitis in 50% of cases. It
is characterized by transmural (affecting all layers of the
digestive tube) infl ammation, lymphadenitis, ulcers and scarring
of the intestinal wall.

Gert Van Assche, Axel Dignass, Julian Panes, Laurent Beaugerie, John Karagiannis.
The second European evidence-based Consensus on the diagnosis and management
of Crohn's disease: Defi nitions and diagnosis
Tells its frequency in the population according to
age and gender
 Cases of the disease are described everywhere, but it is most
common in Northern Europe and North America (only about
300,000 patients in North America). Every year, 2-3 new cases
per 1000 people are registered.However, the number of cases
has been increasing since the 1970s, especially in developing
countries. The disease in most patients begins at the age of 15-
35 years, but there is a second peak of increased morbidity —
after 60 years. People of the Caucasian race get sick more often
than Africans or Asians. The ratio of men to women is
approximately 1.1-1.8:1 (men more often).

 Øistein Hovde, Bjørn A Moum. Epidemiology and clinical course of

Crohn's disease: Results from observational studies // World Journal of
Gastroenterology : WJG. — 2012-04-21. — Т. 18, вып. 15. — С. 1723–1731.
Explains the effect of early diagnosis on prognosis
Crohn's disease has a number of features: the Erasure
of the clinical picture, a wide range of extra-intestinal
manifestations, as a rule, a severe course of the disease
and a serious prognosis.

The disease has a recurrent course and almost all

patients have at least one relapse within 20 years. This
requires constant dynamic monitoring of the patient
to correct therapy and detect complications of the
disease.
Tells common complications according to
their durations
Surgical complications:
Perforation of the intestinal wall with the development of
intraperitoneal abscesses, peritonitis, internal and external
fistulas, strictures, abdominal adhesions.
Chronic inflammation and scar tissue development leads to
narrowing of the intestinal lumen and intestinal obstruction.
Ulcers of the mucosa lead to vascular damage and bleeding into
the intestinal lumen.
Toxic megacolon in rare cases (less often than with ulcerative
colitis).
Fistulous passages into the bladder or uterus cause infections,
air and feces from the bladder or vagina.
 Explains causes with their mechanisms
Among the causes are called hereditary or genetic, infectious, and
immunological factors.
Genetic factors: frequent detection of the disease in homozygous twins
and siblings. In about 17 % of cases, patients have blood relatives who also
suffer from this disease. Frequent combination of Crohn's disease and
Bekhterev's disease. However, a direct link to any HLA antigen has not yet
been found.
Infectious factors: their role is not fully confirmed, but the introduction of
intestinal flushes to laboratory rats can cause disease in the latter. There
have been suggestions of a viral or bacterial nature.
Immunological factors: systemic organ damage in Crohn's disease suggests
the autoimmune nature of the disease. The mechanism of violations is the
presence of a specific antigen in the lumen of the intestine/blood of
patients, which leads to the activation of T-lymphocytes, cellular
macrophages, fibroblasts — to the production of antibodies, cytokines,
prostaglandins, free atomic oxygen, which cause various tissue damage.
Disease Ontology release 2019-05-13
 Explains risk group at risk with their rationales
Young age
Smoking
Living in urban areas
Isotretinoin (Roaccutane) - a drug for scarring cystic
acne
Close relative with Crohn's disease
Whites of European descent and Jews are at increased
risk.
Explains the typical symptom complex
 Weight loss is observed in a significant number of patients and is caused first
by anorexia and increased pain after eating, and in advanced cases, and the
syndrome of malabsorption in the intestine, which develops both after surgery
and as a result of the length of the process.
 The absorption of fats, proteins, carbohydrates and vitamins (B12 and A, D) is
disrupted. In patients with extended or multiple lesions, with fistulas between
the small and large intestines, severe steatorrhea develops. In patients with
localization of the process in the ileocecal angle, the disease can begin with a
high temperature, pain in the right iliac region, the appearance of a palpable
mass there, which can lead to a false diagnosis of appendicitis and unjustified
surgery.
 The clinical study at the first treatment is not very informative, isolated
findings are aphthous stomatitis, sensitivity and palpable mass in the right iliac
region, fistulas and abscesses in the area of the anal opening. Much more
interesting are extra-intestinal manifestations, numerous and diverse.
:Explains symptoms with their mechanisms
 Extra-intestinal manifestations:
In Crohn's disease, many organs and systems are involved in
the pathological process with the development of:
Eyes: - conjunctivitis, keratitis, uveitis
Oral cavity: - aphthous stomatitis
Joint — monoarthritis, ankylosing spondylitis
The skin, Nodular erythema, angitis, gangrenous pyoderma
Liver-biliary ducts — Fatty degeneration of the liver,
sclerosing cholangitis, cholelithiasis, cirrhosis,
cholangiocarcinoma.
Kidneys-nephrolithiasis, pyelonephritis, cystitis,
hydronephrosis, amyloidosis of the kidneys
Explains the characteristics of symptoms
according to disease period:
Localization in the colon (granulomatous colitis) Cramping pains that
occur after eating before deflation. bopi are possible during
movements, localized along the large intestine Severe diarrhea (10-12
times a day with an admixture of blood). Pallor, dry skin, decreased
turgor and elasticity. Reduced muscle tone of the anterior abdominal
wall, pain during nalpation. In 80% of patients, anal fissures are
observed. With a finger study, edematous tissues of the walls of the
anal canal, a decrease in sphincter tone. After extraction, the gaping of
the anus and leakage of intestinal contents, usually purulent-bloody in
nature. An important sign, fistulas of the rectum, with long-term
existence, is rarely scarred and more often they are surrounded by
infiltrated tissues with a polypoid-shaped, infiltrated mucous
membrane in the area of ​the internal opening and sluggish “lip-like”
protruding outward granulations around the external opening.
Explains the characteristics of symptoms
according to disease period:
Damage to the small intestine:
General symptoms are due to intoxication and malabsorption
syndrome: Weakness, malaise - Weight loss, swelling,
hypovitaminosis Pain in the bones and joints Trophic disorders
Adrenal insufficiency - Pituitary insufficiency (polyuria with low
urine density, thirst)
Local symptoms: periodic, and later constant dull pain. The stupa
is semi-thin, fluid, foamy, sometimes with an admixture of mucus,
blood. With bowel stenosis, a sign of partial intestinal obstruction.
Possible intestinal bleeding (melena). On palpation, soreness and
tumor formation in the terminal ileum, with damage to the
remaining departments - pain in the umbilical region
 Explains relationship of findings in
developed process
The inflammatory process spreads to the intestinal wall mucosa,
where infiltrates (granulomas) are formed, consisting of clusters
of lymphocytes with giant Pirogov-Langhans cells in the center,
resulting in a dense intestinal wall. It is characterized by uneven
relief of the mucous membrane (a symptom of "cobblestone
pavement") with the formation of erosions and ulcers that
permeate the entire intestinal wall. Perforation of ulcers leads to
the formation of interstitial fistulas. Scarring and narrowing
contribute to the development of partial or complete intestinal
obstruction.
Characteristic histological signs of Crohn's disease include
transmural damage to the intestinal wall with the formation of
non-caseous sarcoid-like granulomas and the phenomenon of
vasculitis against the background of infiltration of the own plate
of the mucous membrane and submucosal base by lymphoid cells.
Tells all laboratory methods used for diagnois by their priority
 Blood-characteristic: anemia (with iron deficiency), leukocytosis,
thrombocytosis, acceleration of ESR and increase in C-reactive protein. There
may be a decrease in iron, serum ferritin, vitamin B12 (in the case of damage to
the proximal parts of the intestine and stomach), dysproteinemia with
hypoalbuminemia (as a result of impaired absorption in the intestine). In the
immunogram: often-increased hypergammaglobulenemia (IgG), sometimes
there is a deficit of IgA.
 Determination of ASCA (antibodies to Saccharomyces cerevisae), in complex
cases, helps to confirm diagnostics, can serve as an additional serological
marker in the diagnosis of Crohn's disease;
 Stool tests-to exclude the infectious cause of enteritis and colitis. They include
bacteriological tests for the detection of shigel, salmonel, Yersinia,
Campylobacter, Clostridium, tuberculosis Bacillus, dysentery amoeba, various
helminths and parasites.
 Determination of the level of calprotectin in the feces. Calprotectin is a protein
produced by neutrophils in the mucous membrane of the intestine. Its level is
increased in Crohn's disease and ulcerative colitis, in addition, this indicator is
increased in infectious intestinal lesions, cancer.
Tells all instrumental methods used for diagnois by their priority
 Colonoscopy and endoscopy with biopsy confirm the diagnosis
histologically. Currently, the" gold standard " for the diagnosis of Crohn's
disease is ileocolonoscopy (that is, an examination of the entire colon
and the terminal ileum). A mandatory condition is a biopsy from all
parts of the colon (at least 2) and the ileum, followed by histological
examination of the biopsies.
 It is important to write the study to disk media. The presence of video
recording allows you not to repeat the study to the patient unnecessarily.
Ileocolonoscopy with a biopsy should be performed before the start of
treatment, so as not to" blur " the endoscopic and morphological
picture. Significant progress in the diagnosis of Crohn's disease of the
small intestine is the use of an endocapsule, which allows you to
examine the small intestine, but there is no possibility of taking a
biopsy. Pathognomonic sign of Crohn's disease is "a symptom of a
cobblestone street»
Tells all instrumental methods used for diagnois by their priority
An overview x-ray of the abdominal cavity — in case of toxic stretching, it will
show bloating of the loops of the intestines, a large amount of air in their lumen.
X-ray examination of the intestine with a contrast agent (barium) helps to
identify asymmetric areas of the mucosa, places of narrowing and bloating, and
deep ulcers.
Computed tomography and ultrasonography is useful in the case when there are
intra-abdominal abscesses, palpable mass, enlarged lymph nodes of the
mesentery.
Magnetic resonance imaging of the intestines with hydrocontracting (hydro-MRI
of the intestine)is a widely used method for assessing the condition of the small
and large intestines in Kazakhstan. Allows you to assess the extent of intestinal
damage, the presence of fistulas and strictures, enlarged lymph nodes. Due to
the accumulation of contrast in the inflamed segment of the colon is an
opportunity to assess the localization of inflammation in the intestinal wall
(mucosa or more outer layers), and also to differentiate the true from
inflammatory stricture (narrowing of the lumen on the background of edema of
the bowel wall).
Histological examination of biopsies of the gastrointestinal mucosa: Sarcoid
granulomas — a pathognomonic micromorphological sign of Crohn's disease,
are detected when performing a biopsy from the gastrointestinal mucosa.
Differential diagnosis of Crohn
disease with ulcerative colitis
SIGNS CROHN DISEASE NONSPECIFIC ULCERATIVE
COLITIS

Rectal bleeding sometimes often

Stomach pain often sometimes
Internal intestinal fistula often rarely
Intestinal obstruction often never
Rectal lesion sometimes often
Small bowel lesion often never
Perianal lesion rarely often
Risk of malignancy sometimes rarely
Segmental lesion often never
Aphthous ulcers often never
Linear ulcers often never
Depth of defeat Whole intestinal wall Mucous and submucosal layers
THANK YOU FOR ATTENTION!