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Crohn´s Disease

Crohn´s disease is a chronic inflammatory disease which can involve the entire gastrointestinal tract, from the mouth to the anus. It is not possible to remove Crohn´s disease surgically, if the affected segments of the bowel are removed the disease typically recur often proximal to the resection line. The inflammation typically extends through the intestinal wall. The incience of this disease is increasing. The aetiology is so far unknown, many theories exist.

Lips.
Crohns disease can affect the gastrointestinal channel from the lips to the anus

Tongue.

Oral cavity.
Oral manifestations of Crohn´s disease are not rare. Small aphthous ulcerations are the main finding.

Suggested aetiological factors are infective agentts (Measles, vaccination against measles, Mycobacterium paratuberculosis), a high intake of sugar, stress and genetic factors.

Oesophagus
Oesophageal and gastic involvment in Crohn´s disease is quite rare.

Genetic factors are of importance. The risk of a parent or sibling of getting this disease is a least 3%, and there is a high concordance concerning monozygotic twins.

Stomach

The common age at presentation of Crohn´s disease is 15 to 35 years, but it can occur at any age.

Duodenum

Diarrhea, the main symptom of this disease, can be due to bacterial overgrowth in the small bowel, diminished water absorption in the large bowel, reduced absorption of bile acid in the distal small bowel or an elevated secretion of mucus in the distal large bowel and rectum. Steatorrhea can occur after large small bowel resection.

Ileum
About on third of all patients with Crohn´s disease have only small bowel affection at the time of presentation.

Ileum, a typical xray-finding.

The main symptoms in this disease are abdominal pain (nearly every patient), diarrhea, weight loss, rectal bleeding and peri-anal disorders.

Ileum terminale
About 40% of all patients with Crohn´s disease have their disease in the terminal ileum and caecum at presentation.

Valvula Bauhini. An ulceration in the ileocaecal valve.
Cramping right-lower quadrant pain is the common feature of Crohn´s disease at the typical localization in the distal ileum and caecum.

Caecum Aphthous ulcers.

Crohn´s disease can cause malabsorption - resulting in nutritional deficiencies (iron - iron deficiency anaemia, folate, vitamin B12, calcium - osteoporosis, magnesium and some trace elements. There is an elevated risk of gallstones dure to deficient absorption of bile-salts in the distal small bowel, and the risk of renal stones is also higher than normal.

Ascending Colon

Liver affection is not as common as in ulcerative colitis, but can occur. Fatty liver can be a result of malnutrition of total parenteral nutrition. Primary sclerosing cholangitis and cholangiocarcinoma are less common than in ulcerative colitis.

Recurrent Disease after Ileocaecal Resection
is a frequent feature of this disease. Endoscopic lesions can be seen as early as two to three months after surgery and the recurrent disease is almost always localized just proximalt to the ileocolonic anastomisis. Within one year signs of recurrence are seen in more than 70 % of the patients. Fortunately, the recurrent disease in the distal small bowel does not always cause symptoms. According to Rutgeerts et al, 85% have endoscopic recurrence three years after operation, but only about one third of all patients have symtoms. A part of the patients eventually need a new resection because of recurrent disease. 5-aminosalicylic acid, metronidazole and azathioprine have been used in the prevention of symtomatic recurrence.

Transverse Colon Mucosal scarring in an inactive Drohn´s disease.

Amyloidosis is a rare but severe complication of Crohn´s disease. Secondary amyloidosis can affact multiple organs, a.o. the kidneys, causing nephrotic syndrome and kidney failure.

Transverse Colon

Sacroilitis and ankylosing spondylitis are the main musculoskeletal complication of Crohn´s disease.

Descending Colon
Diarrhea is nearly always present when this disease affects the colon. Abdominal pain and bleeding are other common symptoms.

Sigmoid Colon
About one fourth of all patients with Crohn´s disease have only colorectal affection. Some have pancolitis - the whole of the colon is affected, and about one third have segmental affection.

Sigmoid Colon

Sigmoideoscopy and/or colonoscopy is the main diagnostic test when Crohn´s disease is suspected. It is often possible to inspect also the distal small bowel during a colonoscopic examination. Biopsies from all affected areas should be taken, and in some of the biopsies microscopic granulomas will be found.

Sigmoid Colon

Small but deep ulcers in the sigmoid colon due to Crohn´s disease

Ileorectal Anastomose

Rectum

The risk of cancer in Crohn´s disease is considered to be small, smaller than in ulcerative colitis. However, in a pancolitis due to Crohn, the risk is significant and surveillance of the same kind as in ulcerative colitis is indicated.

Anus
Anus
Perianal Crohn´s disease is often a serious manifestation. New medical treatments, including Infliximab, have reduced the need for surgical treatment, the results of which often are less satisfactory.

Extraintestinal manifestations
Erythema nodosum is the most common skin manifestation of Crohn´s disease.

Videoclip: Crohn´s disease in the sigmoid colon

Some excellent books - if You want to know more about inflammatory bowel diseases:


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April 26, 2007