Crohn’s disease is also known as clonorchiasis, granulomatous enteritis, restricted enteritis, and stage-specific enteritis.
Crohn’s disease is a chronic inflammatory granulomatous disease of the gastrointestinal tract of unknown etiology. The disease and ulcerative colitis have now been referred to collectively as inflammatory bowel disease. The lesions are mostly found in the terminal ileum and adjacent colon, often in a segmental distribution. However, all segments of the GI tract from the oral cavity to the anus can be involved, with a segmental or jumping distribution. It is characterized clinically by abdominal pain, diarrhea, abdominal masses, fistula formation and intestinal obstruction, and may be accompanied by fever, anemia, nutritional disorders, and extraintestinal damage to joints, skin, eyes, oral mucosa, and liver.
The disease has a lifelong tendency to recur, and patients with severe disease have a poor prognosis. The age of onset is mostly 15-40 years old, with slightly more males than females. However, the first attack can occur in any age group without gender differences. The cause of the disease is still unknown, and it is believed that the disease may be a combination of several factors. The disease is common in Europe and the United States and has a tendency to increase, but it was previously considered rare in China, but has been reported in recent years.
Most of the disease starts slowly and has a chronic and insidious course, but a few of them have an acute onset and can manifest as acute abdomen, intestinal perforation, intestinal obstruction, etc.
1.Abdominal pain
It is the most common symptom, mostly located in the right lower abdomen or around the umbilicus, generally moderate pain, spasmodic, aggravated after meals, and can be alleviated by fasting, rest and local heat application. If the inflammation spreads to the peritoneum or acute intestinal perforation, there can be severe pain in the whole abdomen, showing the performance of acute peritonitis.
2.Diarrhea
Stool is paste-like, usually 3-4 times a day, often without pus and blood and mucus, the lesion is located in the distal colon often have mucus and blood stool.
3, abdominal mass
A mass can often be found in the right lower abdomen, relatively fixed, with poorly defined margins and pressure pain.
4.Fistula formation
is the characteristic sign of this disease.
5.Anorectal perineal lesions
6. Systemic manifestations
About one-third of the patients have intermittent low or moderate fever, and occasionally high fever. In severe cases, there may be anemia, wasting, hypoproteinemia and water-electrolyte disorders.
7. Extra-intestinal manifestations
Some patients have thrush stomatitis, erythema nodosum, pestle finger, skin ulcers, arthritis and hepatomegaly.
Laboratory and other tests.
1.Laboratory tests
Anemia is common; peripheral blood leukocytes are increased during the active phase, and blood sedimentation is accelerated; serum albumin is often decreased; fecal occult blood test is often positive; fecal lipid content is increased in those with malabsorption syndrome and there may be corresponding changes in absorption function.
2.X-ray examination
Small intestine lesion for gastrointestinal barium meal examination, colon lesion for barium enema words poor. x-ray performance for intestinal inflammatory lesions, visible mucosal folds, coarse disorder, longitudinal ulcers or fissures, cobblestone sign, pseudo-polyps, multiple development of stenosis, fistula formation and other x-ray signs; barium through the rapid and left a fine line shadow, known as the line-like sign, the sign may also be caused by severe narrowing of the intestinal lumen. Due to the deep edema of the intestinal wall, the separation of intestinal collaterals filled with barium can be seen.
3.Colonoscopy
Colonoscopy for the whole colon and the end of the ileum, the lesion is segmental (discontinuous) distribution, longitudinal or creeping ulcers, normal or hyperplastic cobblestone-like mucosa around the ulcer, narrow intestinal lumen, inflammation and formation of polyps, normal appearance of the mucosa between the diseased intestinal segments. Deep excisional biopsies of multiple parts of the lesion can sometimes reveal non-caseating necrotic granulomas or large aggregations of lymphocytes in the lamina propria of the mucosa.
Because Crohn’s disease is a generalized inflammatory disease of the intestinal wall with widespread involvement, its diagnosis often requires the interaction of X-ray and colonoscopy. X-ray can observe the whole gastrointestinal tract and show the lesions in the intestinal wall and outside the intestinal wall, so it can be complemented with colonoscopy, especially for small intestine lesions. It is still the most commonly used method for determining the nature, site and extent of small bowel lesions.
Diagnosis.
The diagnosis of Crohn’s disease should be considered in young and middle-aged patients with chronic recurrent right lower abdominal pain and diarrhea, abdominal mass or pressure pain, fever and other manifestations, and those who are found to have intestinal inflammatory lesions mainly in the distribution of the terminal ileum on X-ray or (and) colonoscopy.There are few uniform diagnostic criteria for Crohn’s disease, and a comprehensive analysis is mainly based on clinical manifestations or (and) colonoscopy, and a clinical diagnosis can be made in those with typical manifestations, but However, various intestinal infectious or non-infectious inflammatory diseases and intestinal tumors must be excluded. In case of difficulty in differentiation, surgical investigation is required to obtain pathological diagnosis.
Prognosis.
The disease may improve with treatment or may resolve on its own. However, most patients have recurrent and prolonged attacks, and a significant proportion of them will have more than one complication during the course of their disease and have a poor prognosis.
Treatment options
The aim of treatment is to control the disease activity, maintain the link and prevent complications.
1.General treatment
Emphasis is placed on dietary modification and nutritional supplementation, generally giving a highly nutritious and low residue diet with appropriate multivitamins such as folic acid, vitamin B12 and trace elements. Research shows that the application of the elemental diet (complete gastrointestinal nutrition), while supplementing the patient’s nutrition, can also control the activity of the lesion, especially for small intestine Crohn’s disease without local complications. Complete parenteral nutrition is only used for those with severe malnutrition, intestinal fistula and short bowel syndrome, and should not be applied for too long. If necessary, anticholinergics or antidiarrheal drugs can be used for abdominal pain and diarrhea, and broad-spectrum antibiotics can be given by intravenous route for co-infection.
2.Glucocorticoid
It is the most effective drug to control the activity of the disease and is suitable for the active stage of the disease. It is generally advocated that the initial dose should be sufficient, the course of treatment should be Chan, and the maintenance should vary from person to person. The dose is 30-40mg/d of prednisone, and up to 60mg/d in severe cases. After the disease is in remission, the dose is generally reduced gradually at a rate of 5mg per week until it is discontinued. Although the use of hormones for maintenance treatment can prolong the remission period, clinical studies have proved that it may reduce recurrence, and the long-term application of adverse reactions is too great, therefore, the application of glucocorticoids for long-term maintenance treatment is not advocated at present.
3.Aminosalicylic acid preparation
Sulfasalazine has certain efficacy in controlling the activity of mild and heavy cases, but it is mainly suitable for those whose lesions are confined to the colon. In recent years, it has been reported that mesalazine is effective in both ileum and colon, and it can be used as maintenance treatment for the period.
4.Immunosuppressant
Definitely the value of the application of immunosuppressant Crohn’s disease is a major progress of research in recent years. Azathioprine or mercaptopurine is suitable for glucocorticoid treatment is not effective or glucocorticoid-dependent chronic active cases, the addition of such drugs can gradually reduce the amount of glucocorticoids or even discontinued.
5.Other
Certain antibacterial drugs such as metronidazole and ciprofloxacin are effective in this disease, and metronidazole is more effective for those with perianal fistulas. New clinical studies have reported that some antagonists of pro-inflammatory cytokines such as TNF-α chimeric monoclonal antibodies or anti-inflammatory cytokines such as IL-10 are used in the active phase of the disease and have significant efficacy with few adverse effects.
6.Surgical treatment
The recurrence rate after surgery is high, so the indications for surgery are mainly for complications, including: complete intestinal obstruction, fistula and abscess formation, acute hole or uncontrollable massive bleeding. Note that for intestinal obstruction a distinction should be made between functional spasm caused by inflammatory activity and mechanical obstruction caused by fibrous stenosis, the former of which can mostly be relieved by fasting and aggressive medical treatment without surgery. The former can be relieved by fasting and aggressive medical treatment without surgery. Fistulas without abscess formation can be closed objectively with aggressive conservative medical treatment, while fistulas with abscess formation or failed medical treatment of fistulas are indications for surgery. The main surgical approach is resection of the diseased bowel segment. Prevention of postoperative recurrence is still a challenge, and mesalazine or metronidazole may reduce recurrence.
Safety tips
Severe cases require temporary fasting, timely correction of disorders of water and electrolyte balance, and the use of parenteral hypernutrition therapy with deep intravenous drips of glucose, compounded amino acids, emulsified fat, electrolytes and essential trace elements and vitamins, which can be gradually transitioned to an oral diet.