REGIONAL ENTERITIS (Crohn’s Disease) DEFINITION It is a granulomatous, non-caseating (transmural) inflammatory condition of the ileum commonly and of the colon often. It is independent of age, sex, socioeconomic status and geographic areas.

1. en love da Homoeopathy
REGIONAL
ENTERITIS
(Crohn’s
Disease)

2. REGIONAL
ENTERITIS
(Crohn’s
Disease)

3. REGIONALENTERITIS(Crohn’s
Disease)
DEFINITION
• It is a granulomatous, non-
caseating (transmural)
inflammatorycondition of
the ileumcommonly and of
the colon often.
• It is independent of age, sex,
socioeconomic status and
geographicareas.

4. • Rarely other parts of the
GIT likecolon, jejunum,
stomach, duodenum,
oesophagus can get
involved.
• Small bowel alone is
involved in 30%cases; in
50% cases bothsmall and
large bowels are involved.
• Terminal ileumis most
commonly
INCIDENCE
• Incidenceis 5/1,00,000;
prevalence is 50/1,00,000.
• It is common in North
America and north
Europe.
• Common in females

5. AETIOLOGY
• Unknown, but a familial
and infective nature is
thought of.
• Increasedautoantibodies.
• Dietand food allergy.
• It is slightly more common
in females.
• DNA of Mycobacterium
para tuberculosis
• Focal ischaemia as a
vasculitis
• monozygotictwins
• Genes NOD2/CARD15
in chromosome 16q12
has got strong
associationwith
Crohn‘s disease.
• CARD15 is expressed
in Paneth cells of the
ileum.
• Smoking is related to
Crohn‘s diseaseas
aetiology, as for
relapseand for
exacerbations

6. .
PATHOLOGY
• Transmural inflammation
↓
Granulomaformationwith
linear snake likeulcers -
Cicatrisation
↓
Thickening of the bowel wall
(Hose pipe pattern)
↓
Adhesions - Fistulaformation.
• There is increased mucous
membrane permeability
↓
antigen inducedcell-mediated
inflammatoryresponse
↓
release of cytokines like TNF,
interleukin 2
↓
defect in suppressor T cell
↓
granuloma and other
pathology

7. • Fibrosis, stricture formation,
deep ulcers, oedema of mucosa
betweenulcer areas
↓
whichlooks like ‘cobble stone’,
↓
skipped normal areas in between,
serosal opacity, mesenteric fat
stranding,
↓
enlargedmesentericlymph nodes
↓
abscesses in the mesentery
↓
fistula are the pathology

8. • Mesenteryis thickened,
oedematous, with enlarged
lymph glands
• whichwill neither break
nor calcify
• Rarely jejunum, stomach
and other parts of GIT like
oral cavity, oesophagus are
involved.
• In colon (30%), it is
commonly observedin
caecumand ascending
colon.
• Toxic megacolon with
acutecolitis eventhough
rare, can occur in Crohn‘s
disease.

9. GROSSFEATURES
• Small mucosalaphthous
ulcers are earliest gross
feature.
• Disease may be
inflammatory, stricturing or
perforating types
• Noncaseating giant cell
granuloma with chronic
inflammationof all layers

10. MICROSCOPICFEATURES
• focal arterial blocks in
muscularis propriaare
the microscopicfeatures.
• Extensive fat wrapping
aroundbowel
• whichis been thickened,
firm, rubbery,
incompressible,
segmental is typical.

11. CLINICALFEATURES
• It is common in young age
group.
• Abdominal pain& diarrhoea
is the initial slow insidious
presentation. Thereis also
asymptomaticperiod in
between.
• Diarrhoea is usually less
severewithout blood, pus or
mucous.
• Mild fever, weight loss,
lethargy.
• Crohn’s diseasemay
present as tender, firm,
resonantmass in right iliac
fossa
• Obstruction, fistula
formation, often
perforation
• Bleeding whichis usually
chronic but occasionally
massivecan occur.
• Perianal diseasewith
fissure, fistula, and abscess
• Extra- intestinal
manifestations

12. PRESENTATION
a. Acute presentations :
• It mimics acuteappen
dicitis withsevere
diarrhoea.
• Oftenthere will be
localised or diffuse
peritonitis.
• b. ChronicCrohn’s:
First stage
• Mild diarrhoea,
• colicky pain,
• fever,
• anaemia,
• mass in right iliac fossa
whichis tender, firm,
nonmobile along with
recurrent perianal
abscess.

13. Secondstage
• acuteor chronic intestinal
obstruction due to
cicatrisation with narrowing.
Thirdstage
• Fistula formation—
enterocolic, enteroenteric,
enterovesical,
enterocutaneous, etc.
• It is precancerous condition
but not as muchas ulcerative
collitis.
OTHER FEATURES
Extraintestinal manifestations of
Crohn’s disease™
• Skin: Erythema nodosum,
pyoderma gangre nosum
• mostcommon ™
Eyes: Iritis,
uveitis ™
• Joints: Arthritis, ankylosing
spondylitis, sacroiliitis ™
Sclerosing cholangitis,
• gallstones ™

14. • Nephrotic syndrome
• renal stones ™
• Pancreatitis,
• Chronicactive hepatitis ™
• Amyloidosis
• Aphthousulcers ™
• Blood: Anaemia,
thrombocytosis, DVT,
arterial thrombosis.
INVESTIGATION
• PlainX-rayabdomen
• ultrasoundabdomen.
• Bariummeal followthrough
or small bowel enema shows:
Straightening of valvulae
conniventes.
• Multipledefects (cobblestone
appearance).
• Cicatrisation of ileum(string
signof Kantor).

15. • Rose-thorn appearance of
thebowel wall.
• Radiologically Crohn’s
diseaseis classified as
nonstenosing type or
stenosing type.
• CT scanand CTfistulogram
is useful method.
• Colonoscopy usually shows
normal rectum; withcolon
showing aphthoidlike ulcers
and reddenedmucosal
margin.
• Deep ulcers, stricture and
fistula will be evident in late
cases.
• Colonoscopy also shows
segmental, deep, cobblestone
look.
• Blood tests for anaemia,
proteinloss, mineral and
trace element loss like
magnesium, zinc, and
selenium.

16. • There will be raised C
reactive protein and
orosomucoid in active
• Capsule endoscopyis useful
investigation, but when
stricture is present capsule
may get stuckin the narrow
part.
• MRI to diagnoseanal
disease. MR enteroclysis is
very useful to demonstrate
fistula.
• Serummarkers: 90% of
patients with Crohn’s
disease
COMPLICATION
• Intestinal obstruction ™
• Stricture ™
Bleeding ™
• Fistula formation™
• Carcinoma small and large
bowel ™
• Perianal abscess™
• Peritonitis ™
• Pericolicabscess

17. DIFF. DIAGNOSIS
• Radiation enteritis and
Yersinia enteritis.
• Ulcerative colitis, acute
appendicitis.
• Intestinal tuberculosis,
Salmonella, Shigella, CMV
• Carcinoma ileumor
caecum.
• Differential diagnosis for
mass in the right iliac fossa
• carcinoma caecum
• actinomycosis,
• appendicular
mass
• ileocaecal TB
• ectopickidney
• mesenteric
lymphadenitis

18. TREATMENT
• Medical
• Cessationof smoking
• Bed rest, protein and
vitaminsupplementations.
• Oftennasogastrictube
nutrition or TPnis required.
• Steroids are mainlyused to
induce remissionof the
diseasein initial phase.
• It is less useful for
maintenance.
• Dose is 20–40 mg
SURGERY - INDICATION
• Failure of medical
treatment.
• If patient cannot be
weaned off systemicsteroid
after 6 months.
• Intestinal obstruction
• Fistula formation, bleeding,
malignant change.
• Perforation
• fulminant colitis.
• Perianal problems.
• Crohn’s diseasechildren
with growthretardation

19. • Ileocaecal resection (common
procedure done because
commonly ileocaecal region
is involved).
• Segmental resection—
conservative resectionis
better.
• Total colectomy and
ileorectal anastomosis
• Stricturoplasty.
• Temporary ileostomy.
• Right hemicolectomyis
done occasionally.
• Emergency colectomy
• Laparoscopic resectionis
good alternative

20. REFERENCE
1. SRB's Manual of Surgery
by SriramBhat M
2. A Manual on Clinical
Surgeryby Das
3. A Concise textbookof
Surgeryby Das

21. A
Special Thanks
To A Very
Special Doctor