• Chron disease ➔ transmural inflammation ➔  fissures, abscesses, fistulas, adhesions

  • Can form fistulas involving bladder, vagina, intestine

• Can affect any part of GI (mouth to anus but MC in terminal ileum/colon)

• ↓ bile acid reabsorption ➔ steatorrhea and ↓ fat soluble vitamin absorption (AEDK)

• Inflamed ileum ➔ ↓ B12 absorption ➔ megaloblastic anemia

• ↑ amyloid production can ➔ amyloidosis

• Smoking worsens disease

SSX

• Chronic with acute flares

• Chronic watery diarrhea - usually without blood

• Classically RLQ abd pain/cramping

• Perianal fistula/abscess (may be first sign)

• Oral ulcers

• Stones: 

  • Gallbladder (small bowel disease ➔ ↓ reabsorption of bile salts ➔ cholesterol not used for bile acids ➔ stones)

  • Urolithiasis (altered fat absorption ➔ altered Ca absorption ➔ ↑ kidney stones)

• ± fever, weight loss, palpable mass (2° to adhesions)

DX

• Endoscopy: ileocolonoscopy shows discontinuous inflammation (skip lesions), cobblestone appearance; biopsy shows inflammation histology

• Preferred imaging is MRI or CT with small bowel enterography (MRE > CRE)

• Serology has low sensitivity but Anti-Saccharomyces cerevisiae antibodies (ASCA) MC in Chron's than pANCA

• ↑ fecal calprotectin or lactoferrin (intestinal inflammation) - can be used to monitor

• Mod-severe/high risk:

  • Young (<30) and smoking

  • Perianal/extra-intestinal manifestations

  • ↑ CRP/fecal calprotectin

  • Colonoscopy shows deep ulcers or long segments of bowel involvement

TX:

• Antidiarrheal medications for only for mild Chron

• Oral lesion sx relief with topical triamcinolone acetonide

Mild/low risk pts: tx flare with steroids then step up to biologics/immunomodulators

• Mild flare & disease limited to ileum/proximal colon: 

  • Controlled ileal release budesonide for 12 weeks

    • If relapse occurs while tapering, continue budesonide for 3-6mo and add 5-ASA immunomodulator

    • Mesalamine best for ileocolonic involvement

• Mild flare & diffuse colitis/left-sided colonic disease: 

  • PO prednisone 40mg x1wk, taper off over 1-2mo

    • Or sulfasalazine x16wks

    • Sulfasalazine best for colitis 

• Once remission is achieved (flare controlled): ileocolonoscopy q 6-12mo

  • Can start immunomodulators or continue sulfasalazine (if remission achieved with it)

Mod-severe/high risk pts: start with biologics and immunomodulators

• Biologics (anti-TNF)

  • Infliximab (IV q8weeks) or Adalimumab (SQ q2wks)

    • Pts that responded to but lose response to infliximab/adalimumab get Certolizumab (SQ q4wks)

• Immunomodulators (maintenance)

  • Azathioprine or 6-mercaptopurine

    • Requires regular monitoring for toxicity

• Acute flares requiring immediate sx relief

  • PO prednisone (no more than 8wks)

    • Steroids are not for maintenance

Most pts with Chron will require surgery

• Bowel resection or for complications (obstruction, intraABD/perianal abscess) 

• Inflammation of mucosal layer, MC involving rectum, extending proximally and continuously to colon

• Can ➔ strictures and colorectal cancer

• Smoking appears to be protective

• Associated with primary sclerosing cholangitis (UC >CD)

SSX

• Gradual onset of worsening diarrhea (± blood, mucus)

• Colicky ABD pain/cramping (can be severe)

• Tenesmus, urgency, incontinence

• ± anemia or HX of transient rectal bleed (wks/mos prior to presentation)

• Physical exam typically normal in mild cases

• BOLO severe bleeding, toxic megacolon ➔ perforation

DX

• Mild: <4 BM/d

• Moderate: >4 BM/d, mild anemia

• Severe: > 6B<, anemia, systemic toxicity (sick)

• ↑ ESR

• ↑ fecal calprotectin or lactoferrin (intestinal inflammation)

• Serology has low sensitivity but pANCA MC in UC than ASCA 

• Endoscopy with biopsy shows loss of vascular markings; biopsy shows crypt abscesses/branching/atrophy, shortening and disarray

• Flexible sigmoidoscopy can be done in acute severe colitis

TX

Mild-mod confined to rectum

• Mesalamine suppository, enema if proctosigmoiditis (>18cm from anal verge into sigmoid colon)

  • PO mesalamine if can't tolerate PR

  • Or topical PR budesonide/hydrocortisone

Mild-mod colitis

• Mesalamine PR

• AND PO 5-ASA (sulfasalazine or mesalamine)

Severe UC: start with biologics and immunomodulators

• Biologics

  • Infliximab (IV q8weeks) or Adalimumab (SQ q2wks)

• Immunomodulators (maintenance)

  • Azathioprine or 6-mercaptopurine (or MTX with folic acid)

    • Requires regular monitoring for toxicity

• Acute flares requiring immediate sx relief:

  • PO prednisone (no more than 8wks)

    • Steroids are not for maintenance

Surgery can be curative

• Proctocolectomy