Crohn Disease


Crohn's VS Ulcerative Colitis
  Crohn's Ulcerative Colitis
Genetic predisposition NOD2. CARD I5, ATG 16L1, IL23R. Presumed genetic component
Worse with smoking Yes Possible improvement
Age at onset Bimodal: 15-25, 55-65 yr Bimodal: 20-40, 60-70 yr
Abdominal pain Sharp, focal Crampy; associated w/ bowel movement
Bowel obstruction Common Rare
Gross hematochezia Occasionally Common
Gl involvement Mouth to anus; typically terminal ileum/proximal colon. Colon only; rectum with continuous progression proximally
Pattern Segmental, transmural eccentric. Continuous, mucosal, circumferential
Ulceration Superficial to deep, linear, selpiginous. Superficial
Histology Non-caseating granulomas. Crypt Abscesses
p-ANCA (+) 20% 70%
ASCA (+) 65% 15%
Fistula/stricture Common. Uncommon
Extraintestinal manifestations uncommon. Common
lnfliximab response Often Occasionally
Colon CA risk Yes INCREASED
Surgery curative Never Often

Background

Pathophysiology

Diagnostics

Differential Diagnosis

Therapeutic Approach

Treatment

  1. Symptomatic
  2. Remission Induction (active disease)
  3.  Remission Maintenance
  4. Surgical management - indications

Prognosis

  1. Increase cancer risk
  2. Intermittent exacerbation of symptoms

Disposition

  1. Any pt w/significant abd pain or fluid and/or lytes imbalance needs admission w/surgery consult

 

Admit Orders: Crohn Disease

1. Admit to:

2. Diagnosis: Crohn’s disease.

3. Condition:

4. Vital Signs: q8h. Call physician if BP >160/90, <90/60; P >120, <50; R>25, <10; T >38.5°C

5. Activity: Up ad lib.

6. Nursing: Inputs and outputs.

7. Diet: NPO except for ice chips and medications for 48h, then low residue diet, no milk products.

8. IV Fluids: 1-2 L NS over 1-3h, then D5 ½ NS with 40 mEq KCL/L at 125 cc/hr.
 

9. Special Medications:

-Mesalamine (Asacol) 400-800 mg PO tid or mesalamine (Pentasa) 1000 mg (four 250 mg tabs) PO qid 
OR

-Sulfasalazine (Azulfidine) 0.5-1 gm PO bid; increase over 10 days to 0.5-1 gm PO qid 
OR

-Olsalazine (Dipentum) 500 mg PO bid.
 

-Infliximab (Remicade) 5 mg/kg IV over 2 hours; may repeat at 2 and 6 weeks

-Methylprednisolone (Solu-Medrol) 10-20 mg IV q6h 
OR

-Prednisone 40-60 mg PO qd 
OR

-Hydrocortisone 50-100 mg IV q6h.
 

-Metronidazole (Flagyl) 250-500 mg PO q6h.

-Vitamiine B12, 100 mcg IM for 5d, then 100-200 mcg IM q month.

-Multivitamin PO qAM or 1 ampule IV qAM.

-Folic acid 1 mg PO qd.
 

10. Extras: Abdominal x-ray series, CXR, colonoscopy. GI consult.

11. Labs: CBC, CMP, blood C&S x 2; stool Wright's stain, stool culture for enteric pathogens, C difficile antigen assay, stool ova and parasites x 3