| Clinical findings | • Gastrointestinal: abdominal pain, nonbloody diarrhea, oral ulcers, malabsorption, weight loss, fistula/abscess formation, perianal disease • Extraintestinal: ◦ Musculoskeletal: arthritis ◦ Ophthalmic: uveitis, scleritis, episcleritis ◦ Skin: erythema nodosum, pyoderma gangrenosum (less common) | | --- | --- | | Diagnosis | • Leukocytosis, iron deficiency, ↑ inflammatory markers • B12 deficiency if terminal ileum involved • Endoscopy: ◦ Focal ulcerations next to normal mucosa (eg, cobblestoning) ◦ Skip lesions, rectal sparing • Radiography: strictures, bowel wall thickening | | Treatment | • Corticosteroids, azathioprine, anti-TNF therapies (eg, infliximab) |
<aside> 💡 smoking is the only major modifiable risk factor that affects the severity and progression of Crohn disease.
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Smoking is strongly associated with an increased need for hospitalizations and intestinal surgery as well as failure of biologic therapy. Other risk factors for severe disease include young age (<30 years) at diagnosis, extensive anatomic involvement, perianal disease, deep ulcerations, strictures, fistulization, and prior intestinal surgery.
DM, obesity aren’t RF for severe crohn’s
In addition to standard Crohn disease management (eg, anti-TNF inhibitors, glucocorticoids), patients with a Rectovaginal fistula may require surgical correction.
Prednisone therapy is the best next step in management of this patient with signs and symptoms of moderate to severe Crohn disease. Clinical severity can be determined based on assessment of symptoms, which in this case include fever and abdominal pain, both of which are consistent with moderate to severe disease. Disease activity is largely based on patient-reported symptoms and is a spectrum from clinical remission to mild, moderate, severe, or fulminant disease. Patients with mild disease may have minimal weight loss but no systemic symptoms, while patients with moderate to severe disease can present with abdominal pain, gastrointestinal bleeding, nausea or vomiting, and fever. Fulminant disease is marked by the presence of severe symptoms despite the use of steroids or biologic agents, and it is often associated with complications including abscess formation, peritonitis, stricture, or bowel obstruction. In addition to clinical severity, patients should be assigned to either low, moderate, or high-risk groups based on their age, extent of disease, level of inflammatory markers, history of bowel resections, and extraintestinal manifestations, among other criteria. This patient with a history of numerous bowel resections and mucosal irregularity on endoscopy should be assigned to the high-risk group. For patients with symptoms requiring immediate treatment, oral steroids using either prednisone or budesonide for a course of 4 to 8 weeks is often utilized, but these medications are typically only used as a bridge prior to initiation of medications with fewer long-term side effects. In this case, treatment with prednisone to induce short-term remission is warranted.
Cyclosporine therapy (Choice B) is sometimes used for patients with fistula in the setting of Crohn disease, although biologic agents are typically preferred. Cyclosporine does not generally induce remission and therefore should not be used in this case.
Infliximab therapy (Choice C) is considered a first-line choice for inducing remission in patients with moderate to severe Crohn disease, especially those with fistulizing disease, although it is almost always used in combination with another immunomodulator such as azathioprine, methotrexate, or 6-mercaptopurine. Additionally, these medications frequently take several weeks to work, and steroids induce remission of symptoms faster.