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| __NOTOC__ | | __NOTOC__ |
| {{Infobox_Disease | | | {| class="infobox" style="float:right;" |
| Name = Crohn's disease |
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| Image = Patterns of CD.svg|
| | | [[File:Siren.gif|30px|link=Crohn's disease resident survival guide]]|| <br> || <br> |
| Caption = The three most common sites of intestinal involvement in '''Crohn's disease''' are [[ileum|ileal]], ileocolic and [[colon]]ic.<ref name=Hanauer/>|
| | | [[Crohn's disease resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| DiseasesDB = 3178 |
| | |} |
| ICD10 = {{ICD10|K|50||k|50}} |
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| ICD9 = {{ICD9|555}} |
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| ICDO = |
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| OMIM = 266600 |
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| MedlinePlus = 000249 |
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| MeshID = D003424 |
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| }}
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| {{Crohn's disease}} | | {{Crohn's disease}} |
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| {{CMG}} | | {{CMG}} |
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| {{SK}} Regional enteritis | | {{SK}} Regional enteritis; Crohn disease; regional ileitis |
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| == [[Crohn's disease overview|Overview]] == | | == [[Crohn's disease overview|Overview]] == |
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| == [[Crohn's disease causes|Causes]] == | | == [[Crohn's disease causes|Causes]] == |
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| == [[Crohn's disease differential diagnosis|Differential Diagnosis]] == | | == [[Crohn's disease differential diagnosis|Differentiating Crohn's Disease from other Diseases]] == |
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| | ==[[Crohn's disease epidemiology and demographics|Epidemiology and Demographics]]== |
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| == [[Crohn's disease risk factors|Risk Factors]] == | | == [[Crohn's disease risk factors|Risk Factors]] == |
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| | ==[[Crohn's disease screening|Screening]]== |
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| == [[Crohn's disease natural history, complications and prognosis|Natural History, Complications and Prognosis]] == | | == [[Crohn's disease natural history, complications and prognosis|Natural History, Complications and Prognosis]] == |
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| == Diagnosis == | | == Diagnosis == |
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| [[Crohn's disease history and symptoms|History and Symptoms]] | [[Crohn's disease physical examination|Physical Examination]] | [[Crohn's disease laboratory tests|Laboratory tests]] | [[Crohn's disease electrocardiogram|ECG]] | [[Crohn's disease chest x ray|Chest X Ray]] |[[Crohn's disease CT|CT]] | [[Crohn's disease MRI|MRI]] | [[Crohn's disease echocardiography or ultrasound|Echocardiography or Ultrasound]] |[[Crohn's disease other imaging findings|Other imaging studies]] | [[Crohn's disease other diagnostic studies|Alternative diagnostics]] | | [[Crohn's disease history and symptoms|History and Symptoms]] | [[Crohn's disease physical examination|Physical Examination]] | [[Crohn's disease laboratory findings|Laboratory Findings]] | [[Crohn's disease CT|CT]] | [[Crohn's disease MRI|MRI]] | [[Crohn's disease other imaging findings|Other Imaging Findings]] | [[Crohn's disease other diagnostic studies|Other Diagnostic Studies]] |
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| == Treatment == | | == Treatment == |
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| [[Crohn's disease medical therapy|Medical therapy]] | [[Crohn's disease surgery|Surgical options]] | [[Crohn's disease prevention|Prevention]] | [[Crohn's disease cost-effectiveness of therapy|Financial costs]]| [[Crohn's disease future or investigational therapies|Future therapies] | | [[Crohn's disease medical therapy|Medical Therapy]] | [[Crohn's disease surgery|Surgery]] | [[Crohn's disease prevention|Prevention]] | [[Crohn's disease cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Crohn's disease future or investigational therapies|Future or Investigational Therapies]] |
| ==Diagnosis==
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| ==Diagnosis==
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| [[Image:CD colitis.jpg|150px|thumb|left|[[Colonoscopy|Endoscopic]] image of Crohn's colitis showing deep ulceration.]]
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| [[Image:CT scan gastric CD.jpg|150px|thumb|left|[[CT scan]] showing Crohn's disease in the fundus of the [[stomach]]]]
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| [[Image:CD colitis 2.jpg|thumb|left|150px|Crohn's disease can mimic [[ulcerative colitis]] on endoscopy. This [[Colonoscopy|endoscopic]] image is of Crohn's colitis showing diffuse loss of [[mucosa]]l architecture, friability of mucosa in sigmoid colon and exudate on wall, all of which can be found with ulcerative colitis.]]
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| The diagnosis of Crohn's disease can sometimes be challenging,<ref name=Pimentel/> and a number of tests are often required to assist the physician in making the diagnosis.<ref name=emed/> Sometimes even with all the tests the Crohn's does not show itself. A colonoscopy has about a 70% chance of showing the disease and the rest of the tests go down in percentage. Disease in the small bowel can not be seen through some of the regular tests; for example, a colonoscopy can't get there.
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| ;Endoscopy
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| A [[colonoscopy]] is the best test for making the diagnosis of Crohn's disease as it allows direct visualization of the colon and the [[terminal ileum]], identifying the pattern of disease involvement. Occasionally, the colonoscope can travel past the terminal ileum but it varies from patient to patient. During the procedure, the [[gastroenterologist]] can also perform a [[biopsy]], taking small samples of tissue for laboratory analysis which may help confirm a diagnosis. As 30% of Crohn's disease involves only the ileum,<ref name=Hanauer/> [[cannula]]tion of the terminal ileum is required in making the diagnosis. Finding a patchy distribution of disease, with involvement of the colon or ileum but not the [[rectum]], is suggestive of Crohn's disease, as are other endoscopic stigmata.<!--
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| --><ref>{{cite journal | last = Lee | first = S. D. | coauthors = R. D. Cohen | year = 2002 | month = march | title = Endoscopy in inflammatory bowel disease | journal = Gastroenterology Clinics of North America | volume = 31 | issue = 1 | pages = 119-32 | id = PMID 12122727 }}</ref>
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| [[Wireless capsule endoscopy]] is a technique where a small capsule with a built-in camera is swallowed, the camera takes serial pictures of the entire gastrointestinal tract and is passed in the patient's faeces. It has been used in the search for Crohn's disease in the small bowel, which cannot be reached with colonoscopy or gastroscopy.<!--
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| --><ref name="Hara2006"/><!--
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| -->The utility of capsule endoscopy for this, however, is still uncertain.<!--
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| --><ref>{{cite journal | last = Triester | first = Stuart L. | coauthors = Jonathan A. Leighton, Grigoris I. Leontiadis, Suryakanth R. Gurudu, David E. Fleische, Amy K. Hara, Russell I. Heigh, Arthur D. Shiff, and Virender K. Sharma | year = 2006 | month = May | title = A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohn's disease | journal = The American Journal of Gastroenterology | volume = 101 | issue = 5 | pages = 954-64 | doi =10.1111/j.1572-0241.2006.00506.x | id = PMID 16696781 }}</ref>
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| ;Radiologic tests
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| A [[barium follow-through|small bowel follow-through]] may suggest the diagnosis of Crohn's disease and is useful when the disease involves only the small intestine. Because colonoscopy and [[Esophagogastroduodenoscopy|gastroscopy]] allow direct visualization of only the terminal ileum and beginning of the [[duodenum]], they cannot be used to evaluate the remainder of the small intestine. As a result, a [[barium follow-through]] x-ray, wherein [[barium sulfate]] suspension is ingested and [[fluoroscopy|fluoroscopic]] images of the bowel are taken over time, is useful for looking for inflammation and narrowing of the small bowel.<!--
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| --><ref name="Hara2006">{{cite journal | last = Hara | first = Amy K. | coauthors = Jonathan A. Leighton, Russell I. Heigh, Virender K. Sharma, Alvin C. Silva, Giovanni De Petris, Joseph G. Hentz and David E. Fleischer | year = 2006 | month = January | title = Crohn disease of the small bowel: preliminary comparison among CT enterography, capsule endoscopy, small-bowel follow-through, and ileoscopy | journal = Radiology | volume = 238 | issue = 1 | pages = 128-34 | doi =10.1148/radiol.2381050296 | id = PMID 16373764 }}</ref><!--
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| --><ref>{{cite journal | last = Dixon | first = P.M. | coauthors = M.E. Roulston and D.J. Nolan | year = 1993 | month = January | title = The small bowel enema: a ten year review | journal = Clinical Radiology | volume = 47 | issue = 1 | pages = 46-8 | doi =10.1016/S0009-9260(05)81213-9 | id = PMID 8428417 }}</ref> Barium enemas, in which barium is inserted into the rectum and fluoroscopy used to image the bowel, are rarely used in the work-up of Crohn's disease due to the advent of colonoscopy. They remain useful for identifying anatomical abnormalities when strictures of the colon are too small for a colonoscope to pass through, or in the detection of colonic fistulae.<!--
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| --><ref>{{cite journal | last = Carucci | first = L. R. | coauthors = M. S. Levine | year = 2002 | month = march | title = Radiographic imaging of inflammatory bowel disease | journal = Gastroenterology Clinics of North America | volume = 31 | issue = 1 | pages = 93-117 | id = PMID 12122746 }}</ref>
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| [[Computed tomography|CT]] and [[MRI]] scans are useful for evaluating the small bowel with [[enteroclysis]] protocols.<!--
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| --><ref>{{cite journal | last = Rajesh | first = A. | coauthors = D.D.T. Maglinte | year = 2006 | month = January | title = Multislice CT enteroclysis: technique and clinical applications | journal = Clinical Radiology | volume = 61 | issue = 1 | pages = 31-9 | doi =10.1016/j.crad.2005.08.006 | id = PMID 16356814 }}</ref><!--
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| -->They are additionally useful for looking for intra-abdominal complications of Crohn's disease such as [[abscess]]es, small bowel obstruction, or fistulae.<!--
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| --><ref>{{cite journal | last = Zissin | first = Rivka | coauthors = Marjorie Hertz, Alexandra Osadchy, Ben Novis and Gabriela Gayer | year = 2005 | month = February | title = Computed Tomographic Findings of Abdominal Complications of Crohn’s Disease—Pictorial Essay | journal = Canadian Association of Radiologists Journal | volume = 56 | issue = 1 | pages = 25-35 | id = PMID 15835588 | url =http://www.carj.ca/issues/2005-Feb/25/pg25.pdf | format = PDF | accessdate = 2006-07-02 }}</ref> [[Magnetic resonance imaging]] (MRI) are another option for imaging the [[small bowel]] as well as looking for complications, though it is more expensive and less readily available<!--
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| --><ref>{{cite journal | last = MacKalski | first = B. A. | coauthors = C. N. Bernstein | year = 2005 | month = May | title = New diagnostic imaging tools for inflammatory bowel disease | journal = Gut | volume = 55 | issue = 5 | pages = 733-41 | doi =10.1136/gut.2005.076612 | id = PMID 16609136 }}</ref>
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| Images shown below are courtesy of RadsWiki and copylefted
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| <div align="center">
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| <gallery heights="175" widths="175">
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| Image:Crohns-pseudosacculations-001.jpg|Abdominal x-ray of a patient with Crohn disease
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| Image:Crohns-pseudosacculations-002.jpg|Pseudosacculations in Crohn's disease
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| Image:Crohns-pseudosacculations-003.jpg|Pseudosacculations in Crohn's disease
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| Image:Crohns-pseudosacculations-004.jpg|Pseudosacculations in Crohn's disease
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| </gallery>
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| </div>
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| <gallery>
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| Image:
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| Active Crohn's disease CT 002.jpg|Active Crohn's disease CT
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| Active Crohn's disease MRI 003.jpg|Active Crohn's disease MRI
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| Active Crohn's disease MRI 004.jpg|Active Crohn's disease MRI
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| Active Crohn's disease small bowel series 001.jpg|Active Crohn's disease small bowel series
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| Image:
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| Comb3.jpg|Comb sign in Crohn's disease
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| </gallery>
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| ;Blood tests
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| A [[complete blood count]] may reveal [[anemia]], which may be caused either by blood loss or [[Cyanocobalamin|vitamin B{{ssub|12}}]] deficiency. The latter may be seen with ileitis because vitamin B{{ssub|12}} is absorbed in the [[ileum]].<!--
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| --><ref name=Goh>{{cite journal | last = Goh | first = Jason | coauthors = C. A. O'Morain | year = 2003 | month = February | title = Review article: nutrition and adult inflammatory bowel disease | journal = Alimentary Pharmacology & Therapeutics | volume = 17 | issue = 3 | pages = 307-20 | doi =10.1046/j.1365-2036.2003.01482.x | id = PMID 12562443 }}</ref><!--
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| --> [[Erythrocyte sedimentation rate]], or ESR, and [[C-reactive protein]] measurements can also be useful to gauge the degree of inflammation.<!--
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| --><ref>{{cite journal | last = Chamouard | first = Patrick | coauthors = Zoe Richert, Nicolas Meyer, Gabriel Rahmi, René Baumann | year = April | month = 2006 | title = Diagnostic Value of C-Reactive Protein for Predicting Activity Level of Crohn's Disease | journal = Clinical Gastroenterology and Hepatology | doi =10.1016/j.cgh.2006.02.003 | id = PMID 16630759 }} Epub ahead of print</ref> It is also true in patient with ilectomy done in response to the complication. Another cause of anaemia is anaemia of chronic disease, characterized by its microcytic and hypochromic anaemia. There are reasons in anaemia, including medication in treatment of inflammatory bowel disease like azathioprine can lead to cytopenia and sulfasalazine can also result in folate malabsorption, etc. Testing for anti-''[[Saccharomyces cerevisiae]]'' antibodies (ASCA) and [[anti-neutrophil cytoplasmic antibody|anti-neutrophil cytoplasmic antibodies]] (ANCA) has been evaluated to identify inflammatory diseases of the intestine<!--
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| --><ref>{{cite journal | last = Kaila | first = B. | coauthors = K. Orr and C. N. Bernstein | year = 2005 | month = December | title = The anti-Saccharomyces cerevisiae antibody assay in a province-wide practice: accurate in identifying cases of Crohn's disease and predicting inflammatory disease | journal = The Canadian Journal of Gastroenterology | volume = 19 | issue = 12 | pages = 717-21 | id = PMID 16341311 | url =http://www.pulsus.com/Gastro/19_12/kail_ed.htm | accessdate = 2006-07-02 }}</ref><!--
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| --> and to differentiate Crohn's disease from ulcerative colitis.<!--
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| --><ref>{{cite journal | last = Israeli | first = E. | coauthors = I. Grotto, B. Gilburd, R. D. Balicer, E. Goldin, A. Wiik and Y. Shoenfeld | year = 2005 | month = September | title = Anti-Saccharomyces cerevisiae and antineutrophil cytoplasmic antibodies as predictors of inflammatory bowel disease | journal = Gut | volume = 54 | issue = 9 | pages = 1232-6 | doi =10.1136/gut.2004.060228 | id = PMID 16099791 }}</ref>
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| ==Risk Factors==
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| Although the cause of Crohn's disease is not known, it is believed to be an [[autoimmunity|autoimmune disease]] that is [[genetics|genetically]] linked. The highest relative risk occurs in siblings, affecting males and females equally. Smokers are three times more likely to get Crohn's disease.
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| Unlike the other major type of IBD, [[ulcerative colitis]], there is no known medical or [[surgery|surgical]] cure for Crohn's disease.<ref>{{cite web|first= M Bashar|last= Al-Ataie|coauthors=Vishwanath N Shenoy|publisher=eMedicine|title=Ulcerative colitis|url=http://www.emedicine.com/med/topic2336.htm|accessdate=2006-07-02|
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| date=2005-10-04}}</ref> Instead, a number of medical treatments are utilized with the goal of putting and keeping the disease in [[remission (medicine)|remission]]. These include [[mesalazine|5-aminosalicylic acid]] (5-ASA) formulations (Pentasa capsules, Asacol tablets, Lialda tablets, Rowasa retention enemas), [[prednisone|steroid]] medications, immunomodulators (such as [[azathioprine]], [[mercaptopurine]] (6-MP), and [[methotrexate]]), and newer [[biological therapy for inflammatory bowel disease|biological]] medications, such as [[infliximab]] (Remicade) and [[adalimumab]] (Humira).<ref name=Podolsky>{{Cite journal|last=Podolsky|first= Daniel K.|title=Inflammatory bowel disease|journal=New England Journal of Medicine|month=August|year=2002|volume=346|issue=6|pages=417-29
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| |url=http://content.nejm.org/cgi/content/extract/347/6/417|accessdate=2006-07-02|id=PMID 12167685}}</ref>Also in January 2008 the U.S. Food and Drug Administration approved a new biologic known as [[natalizumab]] (Tysabri) for both induction of remission and maintenance of remission in moderate and severe Crohns Disease.
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| ==Treatment==
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| {{main|Treatment of Crohn's disease|Biological therapy for inflammatory bowel disease}}
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| Treatment is only needed for people exhibiting symptoms. The therapeutic approach to Crohn's disease is sequential: to treat [[acute (medical)|acute]] disease and then to maintain [[remission]]. Treatment initially involves the use of medications to treat any infection and to reduce inflammation. This usually involves the use of aminosalicylate anti-inflammatory drugs and corticosteroids, and may include antibiotics.
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| Once remission is induced, the goal of treatment becomes maintaining remission and avoiding flares. Because of side-effects, the prolonged use of corticosteroids must be avoided. Although some people are able to maintain remission with aminosalicylates alone, many require immunosuppressive drugs.<ref name="HanauerCrohns"/>
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| On 14 January 2008 the U.S. Food and Drug Administration approved [[natalizumab]] (Tysabri) for both induction of remission and maintenance of remission in Crohns. Natalizumab is humanised monoclonal antibody (MAb), and the first alpha-4 antagonist in a new class of agents called selective adhesion-molecule (SAM) inhibitors. Alpha-4 integrin is required for leukocytes to adhere to the walls of blood vessels and migrate into the gut; natalizumab prevents leukocytes from doing that. Natalizumab was previously approved for multiple sclerosis. However, because it suppresses the immune system, natalizumab has been linked to a very rare adverse effect that is usually fatal if undetected. Leukocytes also protect the body from viruses, and 2 patients on natalizumab, who were also receiving other immuno-suppressive drugs ([[Interferon beta-1a|Avonex]] and Immuran), died of a rare brain infection, [[progressive multifocal leukoencephalopathy]]. Because of this danger, patients must be in a special monitoring program, and natalizumab is given as a mono-therapy.<ref name="FDA-Tysbari">{{cite press release|title=FDA Approves Tysabri to Treat Moderate-to-Severe Crohn's Disease|publisher=U.S. Food and Drug Administration|date=2008-01-14|url=http://www.fda.gov/bbs/topics/NEWS/2008/NEW01775.html|accessdate=2008-01-16
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| }}</ref>.As of late December 2007, more than 21,000 MS patients were receiving natalizumab mono-therapy without a single incidence of PML occurring.<ref>.http://www.elan.com/News/full.asp?ID=1091942</ref>.
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| [[Surgery]] may be required for complications such as obstructions, fistulas and/or abscesses, or if the disease does not respond to drugs within a reasonable time. For patients with an obstruction due to a stricture, two options for treatment are strictureplasty and resection of that portion of bowel. According to a retrospective review at the Cleveland Clinic, there is no [[statistical significance]] between strictureplasty alone versus strictureplasty and resection specifically in cases of duodenal involvement. In these cases, re-operation rates were 31% and 27%, respectively, indicating that strictureplasty is a safe and effective treatment for selected patients with duodenal involvement.<ref name="pmid8918424">{{cite journal | author = Ozuner G, Fazio VW, Lavery IC, Milsom JW, Strong SA | title = Reoperative rates for Crohn's disease following strictureplasty. Long-term analysis | journal = Dis. Colon Rectum | volume = 39 | issue = 11 | pages = 1199-203 | year = 1996 | pmid = 8918424 | doi = }}</ref>
| | ==Case Studies== |
| | [[Crohn's disease case study one|Case #1]] |
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| Recent studies using [[Helminthic therapy]] or [[Hookworm]]s to treat Crohn's Disease and other (non-viral) auto-immune diseases seem to yield promising results.<ref>British Medical Journal [http://gut.bmj.com/cgi/content/full/55/1/136 A proof of concept study establishing Necator americanus in Crohn’s patients and reservoir donors]</ref><ref name="Daily Mail">Daily Mail. [http://www.dailymail.co.uk/pages/live/articles/technology/technology.html?in_article_id=481875&in_page_id=1965 The bloodsucking worm that fights allergies from inside your tummy] 14-09-2007.</ref><ref>[http://www.kuro5hin.org/story/2006/4/30/91945/8971 How to cure your asthma or hayfever using hookworm - a practical guide]. 01-05-2006.</ref>
| | ==Related Chapters== |
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| ==See also==
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| * [[Small bowel bacterial overgrowth syndrome]] | | * [[Small bowel bacterial overgrowth syndrome]] |
| | | * [[Ulcerative colitis]] |
| == References ==
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| {{reflist|2}}
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| {{Crohn's}} | | {{Crohn's}} |
| {{Gastroenterology}} | | {{Gastroenterology}} |
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| [[Category:Disease]] | | [[Category:Disease]] |
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| [[Category:Conditions diagnosed by stool test]] | | [[Category:Conditions diagnosed by stool test]] |
| [[Category:Abdominal pain]] | | [[Category:Abdominal pain]] |
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