Sandbox/v23

Management

The algorithm is based on the American Journal of Gastroenterology guidelines for management of Crohn's disease in adults.

Characterize the symptoms: ❑ Abdominal pain ❑ Chronic diarrhea or nocturnal diarrhea ▸ Onset, duration, pattern, character (bloody, mucous, or watery) ❑ Nausea ❑ Vomiting ❑ Bloating/Abdominal distention ❑ Constipation/Obstipation ❑ Fever ❑ Malaise ❑ Loss of appetite ❑ Loss of weight ❑ Rectal bleeding ❑ Painful defecation ❑ Altered mental status Extraintestinal symptoms: ❑ Skin lesions ❑ Oral pain ❑ Odynophagia and dysphagia ❑ Joint pains ❑ Burning micturition ❑ Cough, breathlessness ❑ Eye pain, blurring of vision Obtain detailed history: ❑ Recent travel H/O ❑ Recent drug H/O ❑ Abdominal/pelvic radiation H/O ❑ Family H/O ❑ Systemic illness H/O

Assess volume status: ❑ General condition ❑ Thirst ❑ Pulse ❑ Blood pressure ❑ Eyes ❑ Mucosa Examine the patient: ❑ Skin (swelling, pain, erythema or ulceration) ❑ Oral cavity (ulcers) ❑ Respiratory system (wheezing or crackles) ❑ Cardiovascular system ❑ Abdomen (mass, distension or tenderness) ❑ Anorectal (perianal skin tags, sinus tracts or bleeding) ❑ Eye (swelling, pain, edema or vision loss) ❑ Musculoskeletal (Axial, large and small joints)

Order tests: ❑ Complete blood count (CBC) ❑ Erythrocyte sedimentation rate (ESR) ❑ C-reactive protein (CRP) ❑ Serum electrolytes ❑ Serum iron and vitamin B12 levels ❑ Stool analysis (occult blood, WBC's, calprotectin, lactoferrin, culture, ova and parasites) ❑ Stool for Clostridium difficile toxin ❑ Urinalysis ❑ BUN ❑ Creatinine ❑ Serum glucose ❑ Liver function tests

Confirmatory diagnostic tests: ❑ Colonoscopy and biopsy ❑ Upper GI scopy and biopsy ❑ Computed tomography (CT) ❑ Barium enema(length and location of strictures) ❑ Upper gastrointestinal series with small bowel follow through (SBFT) ❑ Magnetic resonance imaging (enterography) ❑Wireless capsule endoscopy

Findings suggestive of Crohn's disease: ❑ Discontinuous lesions ❑ Biopsy (Transmural inflammation, noncaseating granuloma) ❑ Cobblestoning (Serpiginous and linear ulcer) ❑ Normal rectum ❑ Isolated terminal ileum involvenent ❑ Aphthous ulcers ❑ Negative stool examination for infectious causes

Assessment of severity

Mild to moderate ❑ Ambulatory patients ❑ Tolerating oral diet ❑ No dehydration ❑ No toxicity ❑ No abdominal tenderness or mass ❑ No obstruction ❑ Weight loss <10 percent

Moderate to severe ❑ Fever ❑ Intermittent nausea or vomiting ❑ Mild to moderate dehydration ❑ Anemia ❑ Abdominal pain and tenderness ❑ No obstruction ❑ Weight loss > 10 percent

Severe to fulminant ❑ High fever ❑ Persistent vomiting ❑ Severe dehydration ❑ Significant peritoneal signs ❑ Evidence of abscess ❑ Intestinal obstruction ❑ Cachexia