Crohn Disease Workup

  • Author: Priya Rangasamy, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Jun 16, 2011
 

Approach Consideration

Laboratory data for Crohn disease are nonspecific and are of value principally in assisting with management. Laboratory values may be used as surrogate markers for inflammation and nutritional status and to screen for deficiencies of vitamins and minerals. Serologic studies have been proposed to help differentiate Crohn disease from ulcerative colitis.

The preferred imaging examinations are plain radiography, double-contrast barium enema examination, and single-contrast upper GI series with small bowel follow-though or enteroclysis with computed tomography (CT) and double-contrast evaluation of the small bowel. Ultrasonography and magnetic resonance imaging (MRI) can be used as adjuncts if radiation exposure is an issue in monitoring disease activity.

For more information, see Imaging in Crohn Disease.

Endoscopic visualization and biopsy are essential in the diagnosis of Crohn disease. Colonoscopy with intubation of the terminal ileum is used to evaluate the extent of disease, to demonstrate strictures and fistulae, and to obtain biopsy samples to help differentiate the process from other inflammatory conditions. Given the increased risk of colorectal cancer in patients with inflammatory bowel disease, colonoscopy may have a role in cancer surveillance, although this practice remains controversial. Upper GI endoscopy may be used to diagnose gastroduodenal disease. It is recommended for all children regardless of the presence or absence of upper GI symptoms.

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Complete Blood Cell Count

A complete blood cell count is useful for the detection of anemia, which may be due to multiple causes, including chronic inflammation, iron malabsorption, chronic blood loss, and malabsorption of vitamin B-12 or folate. Leukocytosis may be due to chronic inflammation, abscess, or steroid treatment.

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Chemistry Panel

Electrolyte analysis can help in assessing level of hydration and renal function. Hypoalbuminemia is a common laboratory finding in patients with Crohn disease. Additional common deficiencies include iron and micronutrients (eg, folic acid, vitamin B-12, serum iron, total iron binding capacity, calcium, and magnesium). Liver function test results may be elevated, either transiently because of inflammation or chronically because of sclerosing cholangitis.

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Inflammatory Markers

Acute inflammatory markers, such as C-reactive protein (CRP) and orosomucoid, correlate closely with disease activity. The erythrocyte sedimentation rate (ESR) is often elevated in patients with Crohn disease. The ESR is thought to be more helpful in assessing the disease activity of Crohn colitis than ileitis. However, a normal ESR or CRP should not deter further evaluation in a suspicious case.

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Stool Samples

Stool samples should be tested for the presence of white blood cells, occult blood, routine pathogens, ova, parasites, and Clostridium difficile toxin. These studies should also be checked to rule out infectious etiologies during relapses and before initiating immunosuppressive agents.[12]

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Serologic Testing

Two serologic tests are available to attempt to differentiate ulcerative colitis from Crohn disease. Antibodies to the yeast Saccharomyces cerevisiae (i.e., anti-S cerevisiae antibodies [ASCA]) are found more commonly in Crohn disease, whereas perinuclear antineutrophil cytoplasmic antibody (p-ANCA), a myeloperoxidase antigen, is found more commonly in ulcerative colitis. Therefore, test results positive for ASCA and negative for p-ANCA antigen suggest a diagnosis of Crohn disease; conversely, test results positive for p-ANCA antigen and negative for ASCA suggest the diagnosis of ulcerative colitis. However, these tests are recommended only as an adjunct to clinical diagnosis, as results are not specific and have been found to be positive in other bowel diseases. Patients with Crohn disease whose condition is ASCA-positive have a higher rate of surgery and require surgery earlier in the course of the disease, independent of the area of involvement.[2, 3, 12]

Additional serologic markers such as Escherichia coli anti-ompC (outer membrane porin C) can be found in greater than 50% of Crohn disease cases, and in only a small percentage of ulcerative colitis cases. Pseudomonas fluorescens (anti-12) may be found in greater than 50% of Crohn disease cases and in only 10% of ulcerative colitis cases. Flagellin like antigen (anti-Cbir1) is associated independently with small bowel, intestinal penetrating, and fibrostenosing disease. These tests further increase sensitivity and diagnostic value.

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Barium Contrast Studies

Barium contrast studies are very useful in defining the nature, distribution, and severity of Crohn disease. To obtain the most information, these studies should be performed by an experienced radiologist. Barium studies are also useful for evaluating features such as rigidity, pseudodiverticula, fistulization, and submucosal edema. The studies are noninvasive and usually well tolerated.

An upper GI series, together with a small bowel follow-through (SBFT) and spot films of the terminal ileum, is the initial diagnostic procedure of choice in most patients who present with typical symptoms of Crohn disease (see the image below). SBFT can detect alteration of the small bowel wall only indirectly, and its sensitivity in detecting marginal changes is low in comparison with direct inspection of the mucosa by endoscopy.

Image obtained during upper GI series with a smallImage obtained during upper GI series with a small bowel follow-through shows narrowing and irregularity in the distal ileum in a 16-year-old male adolescent with Crohn disease.

If the patient can tolerate barium enema, it may help in the evaluation of colonic lesions. (See the images below.)

Crohn disease. Aphthous ulcers. Double-contrast baCrohn disease. Aphthous ulcers. Double-contrast barium enema examination in Crohn colitis demonstrates numerous aphthous ulcers. Crohn disease. Crohn colitis. Double-contrast bariCrohn disease. Crohn colitis. Double-contrast barium enema study demonstrates marked ulceration, inflammatory changes, and narrowing of the right colon

Radiographic findings in both the small and large bowel parallel the clinical pattern. Edema and ulceration of the mucosa in the small bowel may appear as thickening and distortion of valvulae conniventes. Edema of the deep layers of the bowel wall results in separation of the barium-filled bowel loops. Tracking of deep ulcerations, both transversely and longitudinally, results in a cobblestone appearance. (See the image below.)

Crohn disease. Cobblestoning. Spot view of the terCrohn disease. Cobblestoning. Spot view of the terminal ileum from a small bowel follow-through study demonstrates linear longitudinal and transverse ulcerations that create a cobblestone appearance. Also, note the relatively greater involvement of the mesenteric side of the terminal ileum and the displacement of the involved loop away from the normal small bowel secondary to mesenteric inflammation and fibrofatty proliferation.

Ileitis can also manifest as a string sign on barium study secondary to spasm or, rarely, because of fibrotic stricture. (See the images below.)

Crohn disease of the terminal ileum. Small bowel fCrohn disease of the terminal ileum. Small bowel follow-through study demonstrates the string sign in the terminal ileum. Also, note pseudodiverticula of the antimesenteric wall of the terminal ileum, secondary to greater distensibility of this less-involved segment of the wall. Crohn disease. Spot view of the terminal ileum froCrohn disease. Spot view of the terminal ileum from a small bowel follow-through study demonstrates the string sign, consistent with narrowing and stricturing. Also, note a sinus tract originating from the medial wall of the terminal ileum and the involvement of the medial wall of the cecum.

Fistulae can also be detected by barium studies of the digestive tract or through injection into the opening of the suspected fistulae.[17, 18, 19] (See the image below.)

Crohn disease. Enterocolic fistula. Double-contrasCrohn disease. Enterocolic fistula. Double-contrast barium enema study demonstrates multiple fistulous tracts between the terminal ileum and the right colon adjacent to the ileocecal valve, the so-called double-tracking of the ileocecal valve.

For more information, see Imaging in Crohn Disease.

Computed Tomography

CT is helpful in the assessment of extramural complications, as well as hepatobiliary and renal complications.[17, 18, 19] It may show bowel wall thickening, mesenteric edema, abscesses, or fistulae. (See the image below.)

Crohn disease. Active small bowel inflammation. CTCrohn disease. Active small bowel inflammation. CT scan demonstrates small bowel wall thickening, mesenteric inflammatory stranding, and mesenteric adenopathy.

Small bowel contrast and enteroclysis studies may be valuable in demonstrating the distribution of small bowel disease. Mucosal fissures, bowel fistulae, strictures, and obstructions can be visualized. The terminal ileum may be narrowed and thickened, with a characteristic pipe appearance. CT enterography can be helpful in the assessment of subtle mucosal damage. CT has become the procedure of choice, not only in diagnosing Crohn disease, but also in managing abscesses. A growing body of literature shows that CT-guided percutaneous abscess drainage may obviate surgery.

For more information, see Imaging in Crohn Disease.

Magnetic Resonance Imaging

In recent studies, MRI has been shown to yield a higher sensitivity and specificity than ileocolonoscopy (criterion standard) for both the diagnosis of Crohn disease and the determination of severity.[20, 21] MRI is especially useful in the evaluation of pelvic and perianal disease when investigating for evidence of perianal disease. (See the images below.)

MRI of an inflamed terminal ileum in a 10-year-oldMRI of an inflamed terminal ileum in a 10-year-old girl with Crohn disease. MRI of a small abscess on the right side of the anMRI of a small abscess on the right side of the anal sphincter in a 9-year-old boy with Crohn disease.

MRI can be superior to CT in demonstrating pelvic lesions. Because of differential water content, MRI can differentiate active inflammation from fibrosis, and can distinguish between inflammatory and (fixed) fibrostenotic lesions in Crohn disease.[17, 18, 19]

MR Enterography (MRE) and CT enterography (CTE) are being used increasingly for evaluation of the small bowel. Both of these modalities are as sensitive and specific as SBFT for detecting small bowel inflammation and may be more accurate for detecting extraenteric complications, including fistulae and abscesses.[22] MRE is a particularly attractive option because of the lack of radiation exposure.

For more information, see Imaging in Crohn Disease.

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Ultrasonography

Ultrasonography is a quick and inexpensive screening method to aid in the diagnosis of IBD or in repeated evaluation of patients for complications.[17, 18, 19] It is helpful in differentiating tubo-ovarian pathology. Abdominal ultrasonography can be used to rule out gallbladder and kidney stones. This modality can also detect enlarged lymph nodes, abscesses, stenoses, and fistulae. Rectal endoscopic ultrasonography has been used as an alternative to MRI in the assessment of perianal disease. This technique allows the differentiation of simple from complex fistulae, as well as the assessment of the tracts of the fistulae in relation to the sphincter muscle.[17, 18, 19]

For more information, see Imaging in Crohn Disease.

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Nuclear Imaging

Radionucleotide scanning may be helpful in assessing the severity and extent of the disease in patients who are too ill to undergo colonoscopy or barium studies.[17, 18, 19] Leukocytes labeled with either technetium-99m (99m Tc )-HMPAO or indium-111 (111 In) can be used to assess for active bowel inflammation in inflammatory bowel disease. Compared with the111 In label, the99m Tc HMPAO label has better imaging characteristics and can be imaged much sooner after injection. However, imaging must typically be performed within an hour after injection of99m Tc-HMPAO-labeled leukocytes, as there is normal excretion into the bowel after this time, unlike111 In-labeled leukocytes, which have no normal bowel excretion.

For more information, see Imaging in Crohn Disease.

Colonoscopy

Colonoscopy can be helpful when single-contrast barium enema has not been informative in evaluating a colonic lesion. It is useful in obtaining biopsy tissue, which helps in the differentiation of other diseases, in the evaluation of mass lesions, and in the performance of cancer surveillance. Colonoscopy also enables dilation of fibrotic strictures in patients with long-standing disease. In addition, it may be used in the postoperative period to evaluate surgical anastomoses to predict the likelihood of clinical relapse as well as the response to postoperative therapy.[2]

Upper GI endoscopy

Upper GI endoscopy with biopsy is helpful in differentiating Crohn disease from peptic ulcer disease in patients with upper GI tract symptoms. Endoscopic retrograde cholangiopancreatography (ERCP) is helpful both as a diagnostic procedure and a therapeutic tool in patients with sclerosing cholangitis and stricture formation. Endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP) may provide equally valuable information without invasive complications.

Double balloon endoscopy allows complete evaluation of the small bowel and makes distal ileal biopsies feasible. Wireless capsule endoscopy helps to identify involvement of the upper GI tract, which will occur in 40% of patients with Crohn disease. Drawbacks include the inability to take biopsies, the risk of acute obstruction in stricturing disease, and the time required for analysis.

Endoscopy can also be helpful in the detection of complications of Crohn disease. Magnifying endoscopy allows a more detailed view of the mucosal surface than conventional endoscopy. In combination with chromoendoscopy (indigo carmine), it is possible to analyze the surface staining pattern further to help identify neoplastic changes in situ.[12, 17, 18] [19]

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Contributor Information and Disclosures
Author

Priya Rangasamy, MD  Fellow, Department of Gastroenterology/Hepatology, University of Connecticut Health Center

Priya Rangasamy, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Coauthor(s)

Yung-Hsin Chen, MD  Staff Physician, Department of Radiology, Nassau University Medical Center

Yung-Hsin Chen, MD is a member of the following medical societies: American Roentgen Ray Society, Radiological Society of North America, and Society of Skeletal Radiology

Disclosure: Nothing to disclose.

Marcy L Coash, DO  Staff Physician, Department of Internal Medicine, University of Connecticut

Marcy L Coash, DO is a member of the following medical societies: American Medical Student Association/Foundation and American Osteopathic Association

Disclosure: Nothing to disclose.

Spencer B Gay, MD  Professor of Radiology, Director of Body Computed Tomography, Department of Radiology, University of Virginia Health Sciences Center

Disclosure: Nothing to disclose.

John L Haddad, MD  Clinical Associate Professor, Department of Radiology, Weill Medical College of Cornell University; Director of Body MRI, Department of Radiology, Methodist Hospital in Houston

John L Haddad, MD is a member of the following medical societies: American College of Radiology, American Medical Association, and Radiological Society of North America

Disclosure: Nothing to disclose.

Eugene C Lin, MD  Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine

Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine

Disclosure: Nothing to disclose.

Dermot PB McGovern, MD, PhD, MRCP  Director of Translational Medicine, Inflammatory Bowel and Immunobiology Research Institute; Associate Professor of Medicine, David Geffen School of Medicine, UCLA, Cedars-Sinai Medical Center

Dermot PB McGovern, MD, PhD, MRCP is a member of the following medical societies: American Gastroenterological Association, American Society of Human Genetics, British Society of Gastroenterology, and Royal College of Physicians of the United Kingdom

Disclosure: UCB Honoraria Consulting; UCB Honoraria Speaking and teaching; Salix Honoraria Speaking and teaching; UCB Grant/research funds Other; Prometheus Consulting fee Consulting

Gil Y Melmed, MD  Director, Clinical Trials, Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center; Assistant Clinical Professor of Medicine, David Geffen School of Medicine at UCLA

Gil Y Melmed, MD is a member of the following medical societies: American College of Gastroenterology and American Gastroenterological Association

Disclosure: Amgen Consulting fee Consulting; Shire Honoraria Speaking and teaching; Proctor and Gamble Honoraria Speaking and teaching; UCB Consulting fee Consulting; Centocor Consulting fee Consulting; Prometheus Labs Honoraria Speaking and teaching

David I Weltman, MD  Consulting Staff, S & D Medical, LLP; Director, Department of Radiology, Southside Hospital

David I Weltman, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Association of Program Directors in Radiology, New York County Medical Society, and Radiological Society of North America

Disclosure: Nothing to disclose.

George Y Wu, MD, PhD  Professor, Department of Medicine, Director, Hepatology Section, Herman Lopata Chair in Hepatitis Research, University of Connecticut School of Medicine

George Y Wu, MD, PhD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, American Medical Association, American Society for Clinical Investigation, and Association of American Physicians

Disclosure: Springer Consulting fee Consulting; Gilead Consulting fee Review panel membership; Gilead Honoraria Speaking and teaching; Bristol-Myers Squibb Honoraria Speaking and teaching; Springer Royalty Review panel membership

Dahua Zhou, MD  Staff Physician, Department of Radiology, Nassau University Medical Center

Dahua Zhou, MD is a member of the following medical societies: Radiological Society of North America

Disclosure: Nothing to disclose.

Specialty Editor Board

Waqar A Qureshi, MD  Associate Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine and Veterans Affairs Medical Center

Waqar A Qureshi, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

BS Anand, MD  Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Bruce Buehler, MD  Professor, Department of Pediatrics and Genetics, Director RSA, University of Nebraska Medical Center

Bruce Buehler, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Pediatrics, American Association on Mental Retardation, American College of Medical Genetics, American College of Physician Executives, American Medical Association, and Nebraska Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Kathleen M Raynor, MD, Priyankha Balasundaram, MD, and Senthil Nachimuthu, MD, FACP, to the development and writing of the source articles.

References

  1. Farmer RG, Hawk WA, Turnbull RB Jr. Clinical patterns in Crohn's disease: a statistical study of 615 cases. Gastroenterology. Apr 1975;68(4 Pt 1):627-35. [Medline].

  2. Kornbluth A, Sachar DB, Salomon P. Crohn's disease. In: Feldman M, Scharschmidt BF, Sleisenger MH, eds. Sleisenger & Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, and Management. Vol 2. 6th. Philadelphia, Pa: WB Saunders Co; 1998:1708-34.

  3. Panes J, Gomollon F, Taxonera C, et al. Crohn's disease: a review of current treatment with a focus on biologics. Drugs. 2007;67(17):2511-37.

  4. Tierney LM. Crohn's disease. In: Tierney LM, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis and Treatment. 40th ed. New York, NY: McGraw-Hill Professional Publishing; 2001:638-42.

  5. D'Haens G, Baert F, van Assche G, et al. Early combined immunosuppression or conventional management in patients with newly diagnosed Crohn's disease: an open randomised trial. Lancet. Feb 23 2008;371(9613):660-7.

  6. Thoreson R, Cullen JJ. Pathophysiology of inflammatory bowel disease: an overview. Surg Clin North Am. Jun 2007;87(3):575-85.

  7. Sandborn WJ, Hanauer SB, Rutgeerts P, et al. Adalimumab for maintenance treatment of Crohn's disease: results of the CLASSIC II trial. Gut. Sep 2007;56(9):1232-9. [Full Text].

  8. Lindberg E, Järnerot G, Huitfeldt B. Smoking in Crohn's disease: effect on localisation and clinical course. Gut. Jun 1992;33(6):779-82.

  9. D'Souza S, Levy E, Mack D, Israel D, Lambrette P, Ghadirian P. Dietary patterns and risk for Crohn's disease in children. Inflamm Bowel Dis. Mar 2008;14(3):367-73.

  10. Davis RL, Kramarz P, Bohlke K, Benson P, Thompson RS, Mullooly J, et al. Measles-mumps-rubella and other measles-containing vaccines do not increase the risk for inflammatory bowel disease: a case-control study from the Vaccine Safety Datalink project. Arch Pediatr Adolesc Med. Mar 2001;155(3):354-9.

  11. Reif S, Lavy A, Keter D, Broide E, Niv Y, Halak A, et al. Appendectomy is more frequent but not a risk factor in Crohn's disease while being protective in ulcerative colitis: a comparison of surgical procedures in inflammatory bowel disease. Am J Gastroenterol. Mar 2001;96(3):829-32.

  12. Nikolaus S, Schreiber S. Diagnostics of inflammatory bowel disease. Gastroenterology. Nov 2007;133(5):1670-89. [Full Text].

  13. Duerr RH. Update on the genetics of inflammatory bowel disease. J Clin Gastroenterol. Nov-Dec 2003;37(5):358-67.

  14. Fiocchi C. Inflammatory bowel disease: etiology and pathogenesis. Gastroenterology. Jul 1998;115(1):182-205.

  15. Friedman S, Blumberg RS. Inflammatory bowel disease. In: Braunwald E, Fauci AS, Kasper DS, et al, eds. Harrison's Principles of Internal Medicine. Vol 2. 15th ed. New York, NY: McGraw-Hill Professional Publishing; 2001:1679-91.

  16. Danese S, Semeraro S, Papa A, et al. Extraintestinal manifestations in inflammatory bowel disease. World J Gastroenterol. Dec 14 2005;11(46):7227-36. [Full Text].

  17. Mackalski BA, Bernstein CN. New diagnostic imaging tools for inflammatory bowel disease. Gut. May 2006;55(5):733-41.

  18. Saibeni S, Rondonotti E, Iozzelli A, et al. Imaging of the small bowel in Crohn's disease: a review of old and new techniques. World J Gastroenterol. Jun 28 2007;13(24):3279-87.

  19. Schreyer AG, Seitz J, Feuerbach S, Rogler G, Herfarth H. Modern imaging using computer tomography and magnetic resonance imaging for inflammatory bowel disease (IBD) AU1. Inflamm Bowel Dis. Jan 2004;10(1):45-54.

  20. Pilleul F, Godefroy C, Yzebe-Beziat D, Dugougeat-Pilleul F, Lachaux A, Valette PJ. Magnetic resonance imaging in Crohn's disease. Gastroenterol Clin Biol. Aug-Sep 2005;29(8-9):803-8.

  21. Florie J, Horsthuis K, Hommes DW, Nio CY, Reitsma JB, van Deventer SJ. Magnetic resonance imaging compared with ileocolonoscopy in evaluating disease severity in Crohn's disease. Clin Gastroenterol Hepatol. Dec 2005;3(12):1221-8.

  22. Lee SS, Kim AY, Yang SK, et al. Crohn disease of the small bowel: comparison of CT enterography, MR enterography, and small-bowel follow-through as diagnostic techniques. Radiology. Jun 2009;251(3):751-61.

  23. Robinson M. Optimizing therapy for inflammatory bowel disease. Am J Gastroenterol. Dec 1997;92(12 suppl):12S-17S.

  24. Lim WC, Hanauer S. Aminosalicylates for induction of remission or response in Crohn's disease. Cochrane Database Syst Rev. Dec 8 2010;CD008870. [Medline].

  25. Ford AC, Sandborn WJ, Khan KJ, Hanauer SB, Talley NJ, Moayyedi P. Efficacy of biological therapies in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol. Apr 2011;106(4):644-59. [Medline].

  26. Turner D, Grossman AB, Rosh J, et al. Methotrexate following unsuccessful thiopurine therapy in pediatric Crohn's disease. Am J Gastroenterol. Dec 2007;102(12):2804-12 quiz 2803, 2813.

  27. Targan SR, Hanauer SB, van Deventer SJ, et al. A short-term study of chimeric monoclonal antibody cA2 to tumor necrosis factor alpha for Crohn's disease. Crohn's Disease cA2 Study Group. N Engl J Med. Oct 9 1997;337(15):1029-35. [Full Text].

  28. Present DH, Rutgeerts P, Targan S, et al. Infliximab for the treatment of fistulas in patients with Crohn's disease. N Engl J Med. May 6 1999;340(18):1398-405. [Full Text].

  29. Peyrin-Biroulet L, Laclotte C, Bigard MA. Adalimumab maintenance therapy for Crohn's disease with intolerance or lost response to infliximab: an open-label study. Aliment Pharmacol Ther. Mar 15 2007;25(6):675-80. [Full Text].

  30. Sandborn WJ, Rutgeerts P, Enns R, et al. Adalimumab induction therapy for Crohn disease previously treated with infliximab: a randomized trial. Ann Intern Med. Jun 19 2007;146(12):829-38. [Full Text].

  31. Peppercorn MA. Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults. UpToDate. September 15, 2008;[Full Text].

  32. [Best Evidence] Valentine JF, Fedorak RN, Feagan B, Fredlund P, Schmitt R, Ni P, et al. Steroid-sparing properties of sargramostim in patients with corticosteroid-dependent Crohn's disease: a randomised, double-blind, placebo-controlled, phase 2 study. Gut. Oct 2009;58(10):1354-62.

  33. Borrelli O, Cordischi L, Cirulli M, et al. Polymeric diet alone versus corticosteroids in the treatment of active pediatric Crohn's disease: a randomized controlled open-label trial. Clin Gastroenterol Hepatol. Jun 2006;4(6):744-53.

  34. Harpavat M, Keljo DJ, Regueiro MD. Metabolic bone disease in inflammatory bowel disease. J Clin Gastroenterol. Mar 2004;38(3):218-24.

  35. Heuschkel R. Enteral nutrition in Crohn disease: more than just calories. J Pediatr Gastroenterol Nutr. Mar 2004;38(3):239-41.

  36. Razack R, Seidner DL. Nutrition in inflammatory bowel disease. Curr Opin Gastroenterol. Jul 2007;23(4):400-5.

  37. Markowitz J, Markowitz JE, Bousvaros A, Crandall W, Faubion W, Kirschner BS. Workshop report: prevention of postoperative recurrence in Crohn's disease. J Pediatr Gastroenterol Nutr. Aug 2005;41(2):145-51.

  38. Ewe K, Herfarth C, Malchow H, Jesdinsky HJ. Postoperative recurrence of Crohn's disease in relation to radicality of operation and sulfasalazine prophylaxis: a multicenter trial. Digestion. 1989;42(4):224-32.

  39. Alós R, Hinojosa J. Timing of surgery in Crohn's disease: a key issue in the management. World J Gastroenterol. Sep 28 2008;14(36):5532-9.

  40. Simillis C, Yamamoto T, Reese GE, Umegae S, Matsumoto K, Darzi AW. A meta-analysis comparing incidence of recurrence and indication for reoperation after surgery for perforating versus nonperforating Crohn's disease. Am J Gastroenterol. Jan 2008;103(1):196-205.

  41. Shen B. Managing medical complications and recurrence after surgery for Crohn's disease. Curr Gastroenterol Rep. Dec 2008;10(6):606-11.

  42. Yamamoto T, Fazio VW, Tekkis PP. Safety and efficacy of strictureplasty for Crohn's disease: a systematic review and meta-analysis. Dis Colon Rectum. Nov 2007;50(11):1968-86.

  43. Couckuyt H, Gevers AM, Coremans G, Hiele M, Rutgeerts P. Efficacy and safety of hydrostatic balloon dilatation of ileocolonic Crohn's strictures: a prospective longterm analysis. Gut. Apr 1995;36(4):577-80.

  44. Garcia JC, Persky SE, Bonis PA, Topazian M. Abscesses in Crohn's disease: outcome of medical versus surgical treatment. J Clin Gastroenterol. May-Jun 2001;32(5):409-12.

  45. Berg DF, Bahadursingh AM, Kaminski DL, Longo WE. Acute surgical emergencies in inflammatory bowel disease. Am J Surg. Jul 2002;184(1):45-51.

  46. Kiran RP, Nisar PJ, Church JM, Fazio VW. The role of primary surgical procedure in maintaining intestinal continuity for patients with Crohn's colitis. Ann Surg. Jun 2011;253(6):1130-5. [Medline].

  47. Kamm MA, Ng SC. Perianal fistulizing Crohn's disease: a call to action. Clin Gastroenterol Hepatol. Jan 2008;6(1):7-10.

  48. Guidi L, Ratto C, Semeraro S, Roberto I, De Vitis I, Papa A. Combined therapy with infliximab and seton drainage for perianal fistulizing Crohn's disease with anal endosonographic monitoring: a single-centre experience. Tech Coloproctol. Jun 2008;12(2):111-7.

  49. Bode M, Eder S, Schürmann G. Perianal fistulas in Crohn's disease--biologicals and surgery: is it worthwhile?. Z Gastroenterol. Dec 2008;46(12):1376-83.

  50. Poritz LS, Rowe WA, Koltun WA. Remicade does not abolish the need for surgery in fistulizing Crohn's disease. Dis Colon Rectum. Jun 2002;45(6):771-5.

  51. Liu CD, Rolandelli R, Ashley SW, Evans B, Shin M, McFadden DW. Laparoscopic surgery for inflammatory bowel disease. Am Surg. Dec 1995;61(12):1054-6.

  52. Sardinha TC, Wexner SD. Laparoscopy for inflammatory bowel disease: pros and cons. World J Surg. Apr 1998;22(4):370-4.

  53. Georgeson KE, Cohen RD, Hebra A, Jona JZ, Powell DM, Rothenberg SS. Primary laparoscopic-assisted endorectal colon pull-through for Hirschsprung's disease: a new gold standard. Ann Surg. Ann Surg. May 1999;229(5):678-82; discussion 682-3.

  54. Lowney JK, Dietz DW, Birnbaum EH, Kodner IJ, Mutch MG, Fleshman JW. Is there any difference in recurrence rates in laparoscopic ileocolic resection for Crohn's disease compared with conventional surgery? A long-term, follow-up study. Dis Colon Rectum. Jan 2006;49(1):58-63.

  55. Chen HH, Wexner SD, Iroatulam AJ, Pikarsky AJ, Alabaz O, Nogueras JJ. Laparoscopic colectomy compares favorably with colectomy by laparotomy for reduction of postoperative ileus. Dis Colon Rectum. Jan 2000;43(1):61-5.

  56. Eshuis EJ, Polle SW, Slors JF, Hommes DW, Sprangers MA, Gouma DJ. Long-term surgical recurrence, morbidity, quality of life, and body image of laparoscopic-assisted vs. open ileocolic resection for Crohn's disease: a comparative study. Dis Colon Rectum. Jun 2008;51(6):858-67.

  57. Eshuis EJ, Bemelman WA, van Bodegraven AA, Sprangers MA, Bossuyt PM, van Milligen de Wit AW. Laparoscopic ileocolic resection versus infliximab treatment of distal ileitis in Crohn's disease: a randomized multicenter trial (LIR!C-trial). BMC Surg. 2008;8:15.

  58. Khan KJ, Ullman TA, Ford AC, Abreu MT, Abadir A, Marshall JK, et al. Antibiotic therapy in inflammatory bowel disease: a systematic review and meta-analysis. Am J Gastroenterol. Apr 2011;106(4):661-73. [Medline].

  59. Ford AC, Bernstein CN, Khan KJ, Abreu MT, Marshall JK, Talley NJ, et al. Glucocorticosteroid therapy in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol. Apr 2011;106(4):590-9. [Medline].

 
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Colonoscopic image of a large ulcer and inflammation of the descending colon in a 12-year-old boy with Crohn disease.
Histologic features of chronic colitis with crypt atrophy and branching, and lymphocytic infiltrate. Hematoxylin-eosin staining. Courtesy of Dr E. Ruchelli.
Colonic granuloma in a patient with Crohn disease. Hematoxylin-eosin staining. Courtesy of Dr E. Ruchelli.
Postoperative photograph depicts the incisions used for laparoscopic ileocolectomy in a 14-year-old male adolescent with obstruction of the terminal ileum. Note the 2-cm incision in the right lower abdomen through which the specimen was extracted and the extracorporeal anastomosis performed. The 12-mm umbilical incision is nicely hidden in the depths of the umbilicus. A 5-mm incision is visible in the left lower abdomen, and another is in the left suprapubic region just above the top of the pants.
On this laparoscopic photograph, the mesentery of the terminal ileum is being coagulated with a sealing device (LigaSure; Valley Lab, Boulder, Colo). Note that the ligation of the mesentery proceeds near the border of the ileum rather than at the base of the mesentery.
Image obtained during upper GI series with a small bowel follow-through shows narrowing and irregularity in the distal ileum in a 16-year-old male adolescent with Crohn disease.
Crohn disease. Aphthous ulcers. Double-contrast barium enema examination in Crohn colitis demonstrates numerous aphthous ulcers.
Crohn disease. Crohn colitis. Double-contrast barium enema study demonstrates marked ulceration, inflammatory changes, and narrowing of the right colon
Crohn disease. Cobblestoning. Spot view of the terminal ileum from a small bowel follow-through study demonstrates linear longitudinal and transverse ulcerations that create a cobblestone appearance. Also, note the relatively greater involvement of the mesenteric side of the terminal ileum and the displacement of the involved loop away from the normal small bowel secondary to mesenteric inflammation and fibrofatty proliferation.
Crohn disease of the terminal ileum. Small bowel follow-through study demonstrates the string sign in the terminal ileum. Also, note pseudodiverticula of the antimesenteric wall of the terminal ileum, secondary to greater distensibility of this less-involved segment of the wall.
Crohn disease. Spot view of the terminal ileum from a small bowel follow-through study demonstrates the string sign, consistent with narrowing and stricturing. Also, note a sinus tract originating from the medial wall of the terminal ileum and the involvement of the medial wall of the cecum.
Crohn disease. Enterocolic fistula. Double-contrast barium enema study demonstrates multiple fistulous tracts between the terminal ileum and the right colon adjacent to the ileocecal valve, the so-called double-tracking of the ileocecal valve.
Crohn disease. Active small bowel inflammation. CT scan demonstrates small bowel wall thickening, mesenteric inflammatory stranding, and mesenteric adenopathy.
MRI of an inflamed terminal ileum in a 10-year-old girl with Crohn disease.
MRI of a small abscess on the right side of the anal sphincter in a 9-year-old boy with Crohn disease.
Table. Characteristics Differentiating Crohn Disease and Ulcerative Colitis
Characteristic
Crohn diseaseUlcerative colitis
DistributionEntire GI tractColon only, although gastritis recognized
Skip lesionsContinuous involvement proximally from rectum
PathologyFull thicknessMucosa only
Granulomas (30%)No granulomas
RadiologyEntire GI tractColon only
Skip lesionsContinuous involvement proximally from rectum
Fistulae, abscesses, fibrotic stricturesMucosal disease only
Cancer riskIncreasedEstimated 1% per year starting 10 years after diagnosis
Presentation
Crohn diseaseUlcerative colitis
BleedingOccasionalVery common
ObstructionCommonUncommon
FistulaCommonNone
Weight lossCommonUncommon
Perianal diseaseCommonRare
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