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Crohn's Disease
Crohn's disease is a chronic inflammatory bowel disease that can involve any part of the gastrointestinal tract from mouth to anus. It is characterized by periods of remission and relapse. Three case studies are presented where the initial diagnoses were missed, but were later found to be Crohn's disease based on histopathological findings. Key learning points are the importance of thorough history taking, use of appropriate investigations like CT scans and colonoscopy with biopsies to confirm diagnoses, and considering Crohn's disease in cases of recurrent or unusual presentations of conditions like appendicitis and fistula-in-ano. Early diagnosis and treatment with immunomodulators can help manage the disease effectively and preserve bowel function.
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Crohn's Disease
- 1. Crohn’s Disease Are wemissing the diagnosis ? Dr. Harsh Shah MS, FMAS, DNB, MCh(GI) GI & HPB Surgeon Kaizen Hospital, Institute of GE, Ahmedabad, India
- 2. Inflammatory bowel disease •Crohn’s disease • Ulcerative colitis • Indeterminate colitis
- 3. Case 1: AcuteAppendicitis • 26 year Male • Pain in right iliac fossa – 3 days • Fever – low grade, occasional • No vomiting • On & off diarrhea – 2 months • O/E: RIF tenderness, No fever
- 4. Investigation • Hb –9.2 g% • TLC – 11000 • P78, L20 • ESR – 60 mm/1st hour • Urine, RFT - Normal
- 5. USG Abdomen • Inflammedappendix. Probe tenderness present. • Thickened wall of terminal ileum & cecum • CT Scan not done • Appendicectomy performed.
- 6. Post-operative course • Uneventful •Patient discharged on day 2 • HPE – Acute appendicitis
- 7. Follow-up • Presented toOPD with wound infection on POD-5 • Stitch opened Fecal discharge • No fever. Taking diet. Passing motions. Fecal fistula draining 150ml per day
- 8. What went wrong? • History of diarrhea for 2 months • Hb - Low • Thickened cecum & terminal ileum on USG • CT Scan: Thickened terminal ileum/cecum. • Colonoscopy : Biopsy from cecum & terminal ileum Crohn’s Disease
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- 10. Learning Point • Carefulhistory taking in acute appendicitis • When in doubt – CT scan
- 11. Case 2: Fistulain Ano • 38 year/Male • Perianal pus discharge - 3 months • Taken antibiotics (Ciplox + Metro) course twice O/E: • Low perianal fistula • Internal opening at 6 o’clock • Operated for Fistulotomy
- 12. Post-operative course • Uneventful •Wound healed in 1 month Follow-up • Two fistula opening in perianal region away from previous site • One was high fistula other was low fistula on MR Fistulogram
- 13. Further treatment • Underwentseton placement for high fistula & fistulotomy for low fistula 3 months later • Patient developed one more high fistula
- 14. What should bedone ? • Biopsy of the fistula tract Crohn’s Disease Learning Point • Recurrent perianal fistula – Biopsy of the fistula tract
- 15. Case 3: IntestinalTuberculosis • 68 year female • Pain abdomen, wt loss x 6 months • USG Abdomen: Thickening in ileo-cecal region • Started on ATT empirically, No biopsy • Abdominal distension, Vomiting x 2 months
- 16. Clinical Examination • Signsof small bowel obstruction • X-ray
- 17. Surgery • Laparotomy • Dilatedsmall bowel • Terminal ileum & cecum resected • Anastomosis done
- 18. Post-operative course • Uneventful •Discharged on POD-6 • Biopsy: – Non-caseating granuloma – AFB stain negative – s/o crohn’s disease • Started on Azathioprine • Doing well
- 19. Learning Point • Neverstart ATT without biopsy confirmation
- 20. CROHN’S DISEASE Also Knownas regional ileitis
- 21. Overview • Dr BernardCrohn, 1932 • Chronic non-specific inflammation of GIT involving all the layers • Course is relapsing & remitting • Can involve any part from mouth to anus • Propensity for ileo-cecal region • F>M, Bimodal age distribution
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- 23. Clinical features • Painabdomen • Diarrhoea • Anemia • Low grade fever • Weight loss • Fatigue/malaise
- 25. Disease Behaviour Pain Diarrhoea Malnutrition Bloating Nausea Vomiting Type offistula Enteric Urinary Genital Cutaneous Inflammatory Stricturing Fistulizing
- 26. Diagnosis Ileo-colonoscopy • Skip lesions Biopsy –Transmural inflammation – Epithelioid Non- caseating granulomas
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- 28. Ancillary Investigations • ESR/CRP •ASCA (Anti-saccharomyces cerevisae) • Fecal calprotectin
- 29. Treatment • Disease canbe controlled, not cured • Relapses are common • Preserve the bowel
- 30. Medical Treatment • Inductionof remission – Steroids – Anti-TNF(Infliximab) – Antibiotics • Maintenance of remission – Azathioprine – Infliximab • Nutrition
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- 32. Side to sideanastomosis
- 33. Take Home messages •Ileocecal region most common site • Site & behaviour variable • Relapsing course • Commonly confused with intestinal TB • Colonoscopic biopsy confirmatory • Immunomodulators & judicious use of surgery