Updated: 1/15/2019

Crohn Disease

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  • A 15-year-old girl presents with severe, crampy, abdominal pain, and associated diarrhea. This is not her first episode. She reports another episode 7 weeks ago and several before that. The diarrhea is bloody. She also complains of painful oral lesions, which have been present for two days. A sigmoidoscopy was performed. On exam she has two small aphthous ulcers in her mouth.
Introduction
  • Definition
    • characterized by inflammation of the GI tract with subsequent tissue damage
      • may be an abnormal response to normal intestinal bacterial flora
      • may invlove any portion of the GI track
        • usually in intestines (especially the ileocecal region)
        • NON-contiguous pattern
  • Epidemiology
    • risk factors 
      • most common in whites and Ashkenazi Jews
      • often presents in patients in their early 20's
  • Associated conditions 
    • erythema nodosum
    • uveitis
    • migratory polyarthritis
    • ankylosing spondylitis
    • calcium oxalate renal calculi
      • due to ↑ absorption of oxalate
Presentation
  • Symptoms
    • RLQ colicky abdominal pain
    • watery diarrhea
    • weight loss
    • obstruction
    • low grade fever
  • Physical exam
    • aphthous ulcers in mouth
    • perianal fissures / fistulas
Evaluation
  • Barium enema
    • linear ulcers
    • edema of the bowel
    • bowel wall thickening ("string sign") 
  • Colonoscopy with biopsy
    • aphthoid, linear stellate ulcers
    • cobblestone mucosa 
    • skip lesions
    • creeping fat on gross dissection is pathognomonic
    • microscopic appearance
      • transmural inflammation
      • noncaseating granulomas
      • lymphoid aggregates
Treatment
  • Pharmacologic
    • corticosteroids 
    • sulfasalazine/mesalamine
    • immunosuppresants
      • includes
        • azathioprine
        • cyclosporine
    • infliximab
      • monoclonal antibody to TNF-alpha
  • Surgical
    • colon resection
      • indications
        • only in refractory disease
    • complications
      • perforation, a possible risk during surgical excision
Complications
  • Strictures
  • Malabsorption
    • due to bile salt deficiency resulting in nutritional depletion
  • Cancer
    • less likely than with ulcerative colitis
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.GI.89) A 27-year-old female has a history of periodic bloody diarrhea over several years. Colonoscopy shows sigmoid colon inflammation, and the patient complains of joint pain in her knees and ankles. You suspect inflammatory bowel disease. Which of the following would suggest a diagnosis of Crohn disease: Review Topic

QID: 101146
1

Left lower quadrant pain

1%

(1/153)

2

Jaundice

3%

(4/153)

3

Loss of large bowel haustra

5%

(8/153)

4

Mucosal and submucosal ulcerations

22%

(34/153)

5

Perianal fistula

67%

(103/153)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(M1.GI.8) A 22-year-old Caucasian female presents with severe right lower quadrant pain, malaise, and diarrhea. The physician performs an endoscopy and finds disease involvement in the terminal ileum, noting that that the disease process is patchy with normal intervening mucosa. The entire wall of the region is thickened and inflamed, which may directly lead to formation of: Review Topic

QID: 101065
1

Fistulas

93%

(14/15)

2

Toxic megacolon

0%

(0/15)

3

Widening of the intestinal lumen

0%

(0/15)

4

Plummer-Vinson syndrome

7%

(1/15)

5

Paneth cell metaplasia

0%

(0/15)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(M1.GI.27) A 28-year-old Caucasian women with a 10 pack-year history of smoking presents with diarrhea and right, lower quadrant colicky pain. You note tender, red nodules on her shins. Radiograph imaging after barium study is shown in Figure A. What is the most likely diagnosis? Review Topic

QID: 101084
FIGURES:
1

Ulcerative colitis

14%

(4/28)

2

Irritable bowel syndrome

0%

(0/28)

3

Celiac disease

7%

(2/28)

4

Hirschprung disease

4%

(1/28)

5

Crohns disease

64%

(18/28)

M1

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PREFERRED RESPONSE 5
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