Crohn's Disease by Dr Harsh Shah, Kaizen Hospital, Ahmedabad, India
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Crohn's disease is an inflammatory bowel disease. It is commonly misdiagnosed as either appendicitis, Tuberculosis or perianal fistulas.
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Crohn's Disease by Dr Harsh Shah, Kaizen Hospital, Ahmedabad, India
- 1. Crohn’s Disease Are we missing the diagnosis ? Dr. Harsh Shah MS, FMAS, DNB, MCh(GI) GI & HPB Surgeon Kaizen Hospital, Institute of GE, Ahmedabad, India
- 2. Inflammatory bowel disease • Crohn’s disease • Ulcerative colitis • Indeterminate colitis
- 3. Case 1: Acute Appendicitis • 26 year Male • Pain in right iliac fossa – 3 days • Fever – low grade, occasional • No vomiting • On & off diarrhea – 2 months • O/E: RIF tenderness, No fever
- 4. Investigation • Hb – 9.2 g% • TLC – 11000 • P78, L20 • ESR – 60 mm/1st hour • Urine, RFT - Normal
- 5. USG Abdomen • Inflammed appendix. Probe tenderness present. • Thickened wall of terminal ileum & cecum • CT Scan not done • Appendicectomy performed.
- 6. Post-operative course • Uneventful • Patient discharged on day 2 • HPE – Acute appendicitis
- 7. Follow-up • Presented to OPD with wound infection on POD-5 • Stitch opened Fecal discharge • No fever. Taking diet. Passing motions. Fecal fistula draining 150ml per day
- 8. What went wrong ? • History of diarrhea for 2 months • Hb - Low • Thickened cecum & terminal ileum on USG • CT Scan: Thickened terminal ileum/cecum. • Colonoscopy : Biopsy from cecum & terminal ileum Crohn’s Disease
- 9. CT Scan
- 10. Learning Point • Careful history taking in acute appendicitis • When in doubt – CT scan
- 11. Case 2: Fistula in Ano • 38 year/Male • Perianal pus discharge - 3 months • Taken antibiotics (Ciplox + Metro) course twice O/E: • Low perianal fistula • Internal opening at 6 o’clock • Operated for Fistulotomy
- 12. Post-operative course • Uneventful • Wound healed in 1 month Follow-up • Two fistula opening in perianal region away from previous site • One was high fistula other was low fistula on MR Fistulogram
- 13. Further treatment • Underwent seton placement for high fistula & fistulotomy for low fistula 3 months later • Patient developed one more high fistula
- 14. What should be done ? • Biopsy of the fistula tract Crohn’s Disease Learning Point • Recurrent perianal fistula – Biopsy of the fistula tract
- 15. Case 3: Intestinal Tuberculosis • 68 year female • Pain abdomen, wt loss x 6 months • USG Abdomen: Thickening in ileo-cecal region • Started on ATT empirically, No biopsy • Abdominal distension, Vomiting x 2 months
- 16. Clinical Examination • Signs of small bowel obstruction • X-ray
- 17. Surgery • Laparotomy • Dilated small bowel • Terminal ileum & cecum resected • Anastomosis done
- 18. Post-operative course • Uneventful • Discharged on POD-6 • Biopsy: – Non-caseating granuloma – AFB stain negative – s/o crohn’s disease • Started on Azathioprine • Doing well
- 19. Learning Point • Never start ATT without biopsy confirmation
- 20. CROHN’S DISEASE Also Known as regional ileitis
- 21. Overview • Dr Bernard Crohn, 1932 • Chronic non-specific inflammation of GIT involving all the layers • Course is relapsing & remitting • Can involve any part from mouth to anus • Propensity for ileo-cecal region • F>M, Bimodal age distribution
- 22. Aetiology & Pathogenesis Genetic susceptibility Environmental factors Host Immune Response Crohn’s Disease
- 23. Clinical features • Pain abdomen • Diarrhoea • Anemia • Low grade fever • Weight loss • Fatigue/malaise
- 25. Disease Behaviour Pain Diarrhoea Malnutrition Bloating Nausea Vomiting Type of fistula Enteric Urinary Genital Cutaneous Inflammatory Stricturing Fistulizing
- 26. Diagnosis Ileo-colonoscopy • Skip lesions Biopsy – Transmural inflammation – Epithelioid Non- caseating granulomas
- 27. CT Enterography
- 28. Ancillary Investigations • ESR/CRP • ASCA (Anti-saccharomyces cerevisae) • Fecal calprotectin
- 29. Treatment • Disease can be controlled, not cured • Relapses are common • Preserve the bowel
- 30. Medical Treatment • Induction of remission – Steroids – Anti-TNF(Infliximab) – Antibiotics • Maintenance of remission – Azathioprine – Infliximab • Nutrition
- 32. Side to side anastomosis
- 33. Take Home messages • Ileocecal region most common site • Site & behaviour variable • Relapsing course • Commonly confused with intestinal TB • Colonoscopic biopsy confirmatory • Immunomodulators & judicious use of surgery