eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Crohn Disease: Differential Diagnoses & Workup

Author: Andrew B Grossman, MD, Clinical Assistant Professor, Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine
Coauthor(s): Petar Mamula, MD, Assistant Professor, Department of Pediatrics, Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine
Contributor Information and Disclosures

Updated: Oct 8, 2009

Differential Diagnoses

Behcet Syndrome
Tuberculosis
Graft Versus Host Disease
Ulcerative Colitis
Henoch-Schoenlein Purpura
Irritable Bowel Syndrome
Protein Intolerance

Other Problems to Be Considered

Infection
Celiac disease
Immunodeficiency
Chronic granulomatous disease
Radiation enteritis
Ischemic enterocolitis

Workup

Laboratory Studies

  • Laboratory data for Crohn disease (CD), or Crohn's disease, are nonspecific.
  • The CBC count may reveal evidence of hypochromic microcytic anemia due to the iron deficiency anemia secondary to GI blood loss, or it may reveal normocytic anemia due to the anemia of chronic disease.
  • Levels of acute-phase reactants, the erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels are often elevated in patients with Crohn disease. However, a normal ESR or CRP level should not deter further evaluation in a suspicious case.
  • 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, magnesium).
  • Stool studies should be obtained to rule out bacterial or parasitic infection.
  • Serologic testing for inflammatory bowel disease is available. Immunoglobulin A (IgA) and immunoglobulin G (IgG) antibodies to anti-Saccharomyces cerevisiae (ASCA) have been associated with Crohn disease, whereas perinuclear antineutrophil cytoplasmic antibody (p-ANCA) has been associated with ulcerative colitis (UC). Although these tests might assist in differentiating between Crohn disease and UC, they are not good screening tests. A retrospective review reported that serologic screening that included ASCA, perinuclear antineutrophil cytoplasmic antibody (pANCA), and antibody to Escherichia coli outer membrane porin (anti-OmpC) demonstrated a sensitivity of 60%, a specificity of 91%, and a positive predictive value of 60%.4
  • Excretion of fecal calprotectin, a protein derived from neutrophils, is increased with colorectal inflammation. Enzyme-linked immunosorbent assay for fecal calprotectin is available; the cutoff level is more than 50 mcg/g feces.

Imaging Studies

  • A single-contrast upper-GI tract radiologic series with small-bowel follow-through (SBFT) can be used to evaluate the small intestine, which cannot be reached during endoscopy (see Media file 4).

    Image obtained during upper GI series with a smal...

    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.

    [ CLOSE WINDOW ]
    Image obtained during upper GI series with a smal...

    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.

  • MR enterography (MRE) and CT enterography (CTE) are being increasingly used for evaluation of the small bowel. Both of these modalities are as sensitive and specific as SBFT for detection of small bowel inflammation and may be more accurate for detection of extraenteric complications, including fistulae and abscesses.5 MRE is a particularly attractive option because of the lack of radiation exposure.
  • MRI is especially useful in the evaluation of pelvic and perianal disease when investigating for evidence of perianal disease (see Media files 5-6).

    MRI of an inflamed terminal ileum in a 10-year-ol...

    MRI of an inflamed terminal ileum in a 10-year-old girl with Crohn disease.

    [ CLOSE WINDOW ]
    MRI of an inflamed terminal ileum in a 10-year-ol...

    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 a...

    MRI of a small abscess on the right side of the anal sphincter in a 9-year-old boy with Crohn disease.

    [ CLOSE WINDOW ]
    MRI of a small abscess on the right side of the a...

    MRI of a small abscess on the right side of the anal sphincter in a 9-year-old boy with Crohn disease.

  • Abdominal ultrasonography can be used to investigate intestinal disease and to rule out gallbladder and kidney stones.
  • Positron emission tomography is an experimental diagnostic tool.

Procedures

  • The development of flexible, small-caliber endoscopes has allowed for colonoscopic evaluation of pediatric patients of all ages, including infants.
    • Colonoscopy with several colonic and terminal ileal biopsies is invaluable and considered a standard in the diagnosis of Crohn disease.
    • Upper endoscopy, or esophagogastroduodenoscopy (EGD), should be part of the first-line investigation in all new cases of suspected Crohn disease. It is useful in planning therapy and in differentiating between Crohn disease and UC, especially if granulomas are present. Clinically significant upper-tract inflammation can be present in the absence of upper-GI symptoms.
  • Video capsule endoscopy is being increasingly used to evaluate for small-bowel Crohn disease in children. A dissolvable patency capsule or small bowel imaging should be performed first to ensure no area of narrowing or stricture where the capsule might obstruct is present.

Histologic Findings

  • The microscopic findings of intestinal biopsy samples consist of edema, inflammation (mononuclear and polymorphonuclear), cryptitis and crypt abscesses, architectural crypt changes, and transmural extension of the inflammation (see Media file 2).

    Histologic features of chronic colitis with crypt...

    Histologic features of chronic colitis with crypt atrophy and branching, and lymphocytic infiltrate. Hematoxylin-eosin staining. Courtesy of Dr E. Ruchelli.

    [ CLOSE WINDOW ]
    Histologic features of chronic colitis with crypt...

    Histologic features of chronic colitis with crypt atrophy and branching, and lymphocytic infiltrate. Hematoxylin-eosin staining. Courtesy of Dr E. Ruchelli.

  • The presence of granulomas may be helpful in differentiating between UC and Crohn disease, but granulomas are present in only about 30% of biopsy specimens obtained from patients with Crohn disease. See Media file 3.

    Colonic granuloma in a patient with Crohn disease...

    Colonic granuloma in a patient with Crohn disease. Hematoxylin-eosin staining. Courtesy of Dr E. Ruchelli.

    [ CLOSE WINDOW ]
    Colonic granuloma in a patient with Crohn disease...

    Colonic granuloma in a patient with Crohn disease. Hematoxylin-eosin staining. Courtesy of Dr E. Ruchelli.

Staging

  • Multiple scoring systems incorporating the patient's history, physical findings, and laboratory data have been developed to assess disease activity in adults with Crohn disease.
  • The Pediatric Crohn Disease Activity Index (PCDAI) was developed and validated in 1990. Its results are correlated with the physician's global assessment and with the modified Harvey-Bradshaw index, and it has significant interobserver reliability. The important difference between this index and the Crohn Disease Activity Index (CDAI), which was developed for use in adults with Crohn disease, is the inclusion of growth parameters in the score.

More on Crohn Disease

Overview: Crohn Disease
Differential Diagnoses & Workup: Crohn Disease
Treatment & Medication: Crohn Disease
Follow-up: Crohn Disease
Multimedia: Crohn Disease
References
[ CLOSE WINDOW ]

References

  1. Kugathasan S, Judd RH, Hoffmann RG, et al. Epidemiologic and clinical characteristics of children with newly diagnosed inflammatory bowel disease in Wisconsin: a statewide population-based study. J Pediatr. Oct 2003;143(4):525-31. [Medline].

  2. Griffiths AM, Buller HB. Inflammatory bowel diseases. In: Walker WA, Durie P, eds. Textbook of Pediatric Gastrointestinal Diseases. 3rd ed. 2000.

  3. Tysk C, Lindberg E, Jarnerot G, Floderus-Myrhed B. Ulcerative colitis and Crohn's disease in an unselected population of monozygotic and dizygotic twins. A study of heritability and the influence of smoking. Gut. Jul 1988;29(7):990-6. [Medline].

  4. Zholudev A, Zurakowski D, Young W, Leichtner A, Bousvaros A. Serologic testing with ANCA, ASCA, and anti-OmpC in children and young adults with Crohn's disease and ulcerative colitis: diagnostic value and correlation with disease phenotype. Am J Gastroenterol. Nov 2004;99(11):2235-41. [Medline].

  5. 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. [Medline].

  6. 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. [Medline].

  7. Akobeng AK, Gardener E. Oral 5-aminosalicylic acid for maintenance of medically-induced remission in Crohn's Disease. Cochrane Database Syst Rev. 2005;(1):CD003715. [Medline].

  8. 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. [Medline].

  9. 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. [Medline].

  10. [Guideline] Strong SA, Koltun WA, Hyman NH, Buie WD. Practice parameters for the surgical management of Crohn's disease. Dis Colon Rectum. Nov 2007;50(11):1735-46. [Medline]. [Full Text].

  11. von Allmen D, Markowitz JE, York A, Mamula P, Shepanski M, Baldassano R. Laparoscopic-assisted bowel resection offers advantages over open surgery for treatment of segmental Crohn's disease in children. J Pediatr Surg. Jun 2003;38(6):963-5. [Medline].

  12. Alfadhli AA, McDonald JW, Feagan BG. Methotrexate for induction of remission in refractory Crohn's disease. Cochrane Database Syst Rev. 2005;CD003459. [Medline].

  13. Beattie RM. Enteral nutrition as primary therapy in childhood Crohn's disease: control of intestinal inflammation and anabolic response. JPEN J Parenter Enteral Nutr. Jul-Aug 2005;29(4 Suppl):S151-5; discussion S155-9, S184-8. [Medline].

  14. Belluzzi A, Brignola C, Campieri M, et al. Effect of an enteric-coated fish-oil preparation on relapses in Crohn's disease. N Engl J Med. Jun 13 1996;334(24):1557-60. [Medline].

  15. Castellaneta SP, Afzal NA, Greenberg M, et al. Diagnostic role of upper gastrointestinal endoscopy in pediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr. Sep 2004;39(3):257-61. [Medline].

  16. Colombel JF, Sandborn WJ, Rutgeerts P, et al. Adalimumab for maintenance of clinical response and remission in patients with Crohn's disease: the CHARM trial. Gastroenterology. Jan 2007;132(1):52-65. [Medline].

  17. Crandall WV, Mackner LM. Infusion reactions to infliximab in children and adolescents: frequency, outcome and a predictive model. Aliment Pharmacol Ther. Jan 2003;17(1):75-84. [Medline].

  18. Danzi JT. Extraintestinal manifestations of idiopathic inflammatory bowel disease. Arch Intern Med. Feb 1988;148(2):297-302. [Medline].

  19. Debray D, Pariente D, Urvoas E, et al. Sclerosing cholangitis in children. J Pediatr. Jan 1994;124(1):49-56. [Medline].

  20. Devroede GJ, Taylor WF, Sauer WG, et al. Cancer risk and life expectancy of children with ulcerative colitis. N Engl J Med. Jul 1 1971;285(1):17-21. [Medline].

  21. Durno CA, Sherman P, Williams T, et al. Magnetic resonance imaging to distinguish the type and severity of pediatric inflammatory bowel diseases. J Pediatr Gastroenterol Nutr. Feb 2000;30(2):170-4. [Medline].

  22. Escher JC, Taminiau JA, Nieuwenhuis EE, et al. Treatment of inflammatory bowel disease in childhood: best available evidence. Inflamm Bowel Dis. Jan 2003;9(1):34-58. [Medline].

  23. Fagerberg UL, Loof L, Myrdal U, et al. Colorectal inflammation is well predicted by fecal calprotectin in children with gastrointestinal symptoms. J Pediatr Gastroenterol Nutr. Apr 2005;40(4):450-5. [Medline].

  24. Frokjaer JB, Larsen E, Steffensen E, et al. Magnetic resonance imaging of the small bowel in Crohn's disease. Scand J Gastroenterol. Jul 2005;40(7):832-42. [Medline].

  25. Garland CF, Lilienfeld AM, Mendeloff AI, et al. Incidence rates of ulcerative colitis and Crohn's disease in fifteen areas of the United States. Gastroenterology. Dec 1981;81(6):1115-24. [Medline].

  26. Griffiths AM, Nguyen P, Smith C, MacMillan JH, Sherman PM. Growth and clinical course of children with Crohn's disease. Gut. Jul 1993;34(7):939-43. [Medline].

  27. Guilhon de Araujo Sant'Anna AM, et al. Wireless capsule endoscopy for obscure small-bowel disorders: final results of the first pediatric controlled trial. Clin Gastroenterol Hepatol. Mar 2005;3(3):264-70. [Medline].

  28. Hanauer SB, Stromberg U. Oral Pentasa in the treatment of active Crohn's disease: A meta-analysis of double-blind, placebo-controlled trials. Clin Gastroenterol Hepatol. May 2004;2(5):379-88. [Medline].

  29. Hildebrand H, Karlberg J, Kristiansson B. Longitudinal growth in children and adolescents with inflammatory bowel disease. J Pediatr Gastroenterol Nutr. Feb 1994;18(2):165-73. [Medline].

  30. Hyams J, Crandall W, Kugathasan S, et al. Induction and maintenance infliximab therapy for the treatment of moderate-to-severe Crohn's disease in children. Gastroenterology. Mar 2007;132(3):863-73; quiz 1165-6. [Medline].

  31. Hyams JS, Markowitz J, Treem W. Characterization of hepatic abnormalities in children with inflammatory bowel disease. Inflamm Bowel Dis. 1995;1:27-33.

  32. Hyams JS, Wyzga N, Kreutzer DL, et al. Alterations in bone metabolism in children with inflammatory bowel disease: an in vitro study. J Pediatr Gastroenterol Nutr. Mar 1997;24(3):289-95. [Medline].

  33. Jacobstein DA, Markowitz JE, Kirschner BS, et al. Premedication and infusion reactions with infliximab: results from a pediatric inflammatory bowel disease consortium. Inflamm Bowel Dis. May 2005;11(5):442-6. [Medline].

  34. Khan K, Schwarzenberg SJ, Sharp H, et al. Role of serology and routine laboratory tests in childhood inflammatory bowel disease. Inflamm Bowel Dis. Sep 2002;8(5):325-9. [Medline].

  35. Kirschner BS. Safety of azathioprine and 6-mercaptopurine in pediatric patients with inflammatory bowel disease. Gastroenterology. Oct 1998;115(4):813-21. [Medline].

  36. Kugathasan S, Loizides A, Babusukumar U, et al. Comparative phenotypic and CARD15 mutational analysis among African American, Hispanic, and White children with Crohn's disease. Inflamm Bowel Dis. Jul 2005;11(7):631-8. [Medline].

  37. Lenaerts C, Roy CC, Vaillancourt M, et al. High incidence of upper gastrointestinal tract involvement in children with Crohn disease. Pediatrics. May 1989;83(5):777-81. [Medline].

  38. Levine A, Broide E, Stein M, et al. Evaluation of oral budesonide for treatment of mild and moderate exacerbations of Crohn's disease in children. J Pediatr. Jan 2002;140(1):75-80. [Medline].

  39. Lofberg R, Rutgeerts P, Malchow H, et al. Budesonide prolongs time to relapse in ileal and ileocaecal Crohn's disease. A placebo controlled one year study. Gut. Jul 1996;39(1):82-6. [Medline].

  40. Markowitz J, Daum F, Aiges H, et al. Perianal disease in children and adolescents with Crohn's disease. Gastroenterology. May 1984;86(5 Pt 1):829-33. [Medline].

  41. Markowitz J, Grancher K, Kohn N, et al. A multicenter trial of 6-mercaptopurine and prednisone in children with newly diagnosed Crohn's disease. Gastroenterology. Oct 2000;119(4):895-902. [Medline].

  42. McLeod RS, Churchill DN. Urolithiasis complicating inflammatory bowel disease. J Urol. Sep 1992;148(3 Pt 2):974-8. [Medline].

  43. Miele E, Markowitz JE, Mamula P, Baldassano RN. Human antichimeric antibody in children and young adults with inflammatory bowel disease receiving infliximab. J Pediatr Gastroenterol Nutr. May 2004;38(5):502-8. [Medline].

  44. Ogura Y, Bonen DK, Inohara N, et al. A frameshift mutation in NOD2 associated with susceptibility to Crohn's disease. Nature. May 31 2001;411(6837):603-6. [Medline].

  45. Peacock K, Porn U, Howman-Giles R, et al. 99mTc-stannous colloid white cell scintigraphy in childhood inflammatory bowel disease. J Nucl Med. Feb 2004;45(2):261-5. [Medline].

  46. Polito JM 2nd, Childs B, Mellits ED, et al. Crohn's disease: influence of age at diagnosis on site and clinical type of disease. Gastroenterology. Sep 1996;111(3):580-6. [Medline].

  47. Scholbach T, Herrero I, Scholbach J. Dynamic color Doppler sonography of intestinal wall in patients with Crohn disease compared with healthy subjects. J Pediatr Gastroenterol Nutr. Nov 2004;39(5):524-8. [Medline].

  48. Stephens MC, Baldassano RN, York A, et al. The bioavailability of oral methotrexate in children with inflammatory bowel disease. J Pediatr Gastroenterol Nutr. Apr 2005;40(4):445-9. [Medline].

  49. Thomas AG, Holly JM, Taylor F, Miller V. Insulin like growth factor-I, insulin like growth factor binding protein-1, and insulin in childhood Crohn's disease. Gut. Jul 1993;34(7):944-7. [Medline].

  50. Uhlen S, Belbouab R, Narebski K, et al. Efficacy of methotrexate in pediatric Crohn's disease: a French multicenter study. Inflamm Bowel Dis. Nov 2006;12(11):1053-7. [Medline].

  51. Vasiliauskas EA, Plevy SE, Landers CJ, et al. Perinuclear antineutrophil cytoplasmic antibodies in patients with Crohn's disease define a clinical subgroup. Gastroenterology. Jun 1996;110(6):1810-9. [Medline].

  52. Verhave M, Winter HS, Grand RJ. Azathioprine in the treatment of children with inflammatory bowel disease. J Pediatr. Nov 1990;117(5):809-14. [Medline].

  53. Wedemeyer J, Kirchhoff T, Sellge G, et al. Transcutaneous perianal sonography: a sensitive method for the detection of perianal inflammatory lesions in Crohn's disease. World J Gastroenterol. Oct 1 2004;10(19):2859-63. [Medline].

  54. Wilschanski M, Sherman P, Pencharz P, et al. Supplementary enteral nutrition maintains remission in paediatric Crohn's disease. Gut. Apr 1996;38(4):543-8. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

Crohn disease, CD, Crohn colitis, Crohn's disease, regional enteritis, granulomatous colitis, ileitis, terminal ileitis, inflammatory bowel disease, IBD, diarrhea, rectal bleeding, abdominal pain, growth failure, malnutrition, pubertal delay, bone demineralization, ulcerative colitis, UC, growth deceleration, anorexia, skin tags, fissures, abscesses, fistula, granuloma, erythema nodosum, pyoderma gangrenosum, orofacial granulomatosis, angular stomatitis, aphthous stomatitis, acrodermatitis enteropathica, alopecia, episcleritis, uveitis, iritis, conjunctivitis, arthralgia, arthritis

ankylosing spondylitis, sacroiliitis, osteopenia, osteoporosis, iron deficiency anemia, vitamin B12 deficiency anemia, folate deficiency anemia, autoimmune hemolytic anemia, thrombocytosis, thrombosis, primary sclerosing cholangitis, autoimmune hepatitis, granulomatous hepatitis, cholelithiasis, portal vein thrombosis, nephrolithiasis, obstructive uropathy, glomerulonephritis, amyloidosis, pancreatitis, granulomatous lung disease, fibrosing alveolitis, pulmonary vasculitis, pericarditis, myocarditis, vasculitis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Andrew B Grossman, MD, Clinical Assistant Professor, Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine
Andrew B Grossman, MD is a member of the following medical societies: American Gastroenterological Association, Crohns and Colitis Foundation of America, and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition
Disclosure: Nothing to disclose.

Coauthor(s)

Petar Mamula, MD, Assistant Professor, Department of Pediatrics, Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine
Petar Mamula, MD is a member of the following medical societies: American Academy of Pediatrics, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Medical Editor

Robert Baldassano, MD, Director, Center for Pediatric Inflammatory Bowel Disease, Division of Gastroenterology and Nutrition, Associate Professor, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania
Robert Baldassano, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Stefano Guandalini, MD, Director, University of Chicago Celiac Disease Program, Section Chief of Gastroenterology, Hepatology and Nutrition; Professor, Department of Pediatrics, University of Chicago Comer Children's Hospital
Stefano Guandalini, MD is a member of the following medical societies: American Gastroenterological Association, European Society for Paediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor

Chief Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.