eMedicine Specialties > Pediatrics: Surgery > General Surgery

Crohn Disease: Surgical Perspective: Workup

Author: Patricia A Valusek, MD, Pediatric Surgical Scholar, Department of Surgery, Children's Mercy Hospital; Staff Physician, Department of Surgery, Hennepin County Medical Center
Coauthor(s): Amina M Bhatia, MD, Fellow, Department of Pediatric Surgery, Emory University School of Medicine; George W Holcomb III, MD, Surgeon-in-Chief, Professor, Department of Pediatric Surgery, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine
Contributor Information and Disclosures

Updated: Jul 6, 2006

Workup

Laboratory Studies

  • Stool specimens are sent for an investigation of possible infectious causes for the patient's symptoms.
  • Laboratory examinations may demonstrate manifestations of the disease, such as anemia of chronic disease, evidence of malnutrition, or an increased sedimentation rate or C-reactive protein level.
  • A complete blood cell count may show anemia caused by iron, vitamin B12, or folic acid deficiency.
  • Albumin and prealbumin levels reflect levels of nutrition. Deficiencies of trace elements such as zinc, selenium, and copper are common.
  • Electrolyte analysis, with a determination of calcium and magnesium levels, can help in assessing level of hydration, renal function, and malabsorption.
  • Fat malabsorption may lead to decreased levels of the fat-soluble vitamins. Therefore, prothrombin times and vitamin A and vitamin D levels may be assessed.
  • Results of liver function tests may be elevated transiently because of inflammation or chronically because of sclerosing cholangitis.
  • Amylase and lipase levels may be elevated because of drug-induced pancreatitis. Azathioprine, 6-mercaptopurine, and 5-aminosalacylic acid can all cause pancreatitis.

Imaging Studies

  • CT scanning should be the first radiologic procedure performed in patients with acute inflammatory symptoms (see Image 4).
  • CT scanning may show bowel-wall thickening, mesenteric edema, abscesses, or fistulas.
  • Small-bowel contrast-enhanced and enteroclysis studies may be valuable in demonstrating the distribution of small bowel disease (see Image 5). Mucosal fissures, bowel fistulas, strictures, and obstructions can be visualized. The terminal ileum may be narrowed and thickened, with a characteristic pipe appearance
  • In recent studies, MRI had high sensitivity and specificity for both the diagnosis of Crohn disease and the assessment of severity compared with the criterion standard of ileocolonoscopy.

Diagnostic Procedures

  • 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 fistulas, and to obtain biopsy samples to differentiate this 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, though this practice remains controversial.
  • Upper-gastrointestinal endoscopy may be used to diagnose gastroduodenal disease. It is recommended for all children regardless of the presence or absence of upper-gastrointestinal symptoms.
  • Despite extensive workup, 10% of patients with isolated Crohn colitis have an indeterminate colitis with features of both Crohn disease and ulcerative colitis. If these patients undergo long-term follow-up, small-bowel disease characteristic of Crohn disease ultimately develops.

Histologic Findings

Crohn disease is microscopically characterized by transmural inflammation of all layers of the bowel wall. In the mucosa, cryptitis, crypt abscesses, basal plasmacytosis, and crypt ulcers are commonly observed. Noncaseating granulomas in the bowel wall are characteristic but not pathognomonic of Crohn disease. Proliferative stromal and nodular inflammatory changes occur in the bowel wall, leading to a thick, firm appearance and, ultimately, strictures.

More on Crohn Disease: Surgical Perspective

Overview: Crohn Disease: Surgical Perspective
Workup: Crohn Disease: Surgical Perspective
Treatment: Crohn Disease: Surgical Perspective
Follow-up: Crohn Disease: Surgical Perspective
Multimedia: Crohn Disease: Surgical Perspective
References
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Further Reading

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Keywords

Crohn disease, Crohn's disease, regional ileitis, inflammatory bowel disease, IBD, Crohn's inflammation, Crohn inflammation, Crohn colitis, Crohn's colitis, toxic megacolon

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Contributor Information and Disclosures

Author

Patricia A Valusek, MD, Pediatric Surgical Scholar, Department of Surgery, Children's Mercy Hospital; Staff Physician, Department of Surgery, Hennepin County Medical Center
Patricia A Valusek, MD is a member of the following medical societies: Alpha Omega Alpha and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Amina M Bhatia, MD, Fellow, Department of Pediatric Surgery, Emory University School of Medicine
Amina M Bhatia, MD is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.

George W Holcomb III, MD, Surgeon-in-Chief, Professor, Department of Pediatric Surgery, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine
George W Holcomb III, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, American Surgical Association, Association for Academic Surgery, Society of American Gastrointestinal and Endoscopic Surgeons, Society of University Surgeons, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.

Medical Editor

Denis Bensard, MD, Director, Pediatric Trauma, Division of Pediatric Surgery, Children's Hospital of Denver; Associate Professor, University of Colorado Health Sciences Center
Denis Bensard, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, and Society of University Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Gail E Besner, MD, Professor of Surgery and Pediatrics, Department of Surgery, Ohio State University College of Medicine and Public Health; Director, Pediatric Surgical Research, Department of Surgery, Children's Hospital
Gail E Besner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Burn Association, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Medical Women's Association, American Pediatric Surgical Association, Association for Academic Surgery, Federation of American Societies for Experimental Biology, Society of Critical Care Medicine, Society of Surgical Oncology, and Society of University Surgeons
Disclosure: Nothing to disclose.

CME Editor

H Biemann Othersen Jr, MD, Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery, Medical University of South Carolina
H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American Thoracic Society, British Association of Paediatric Surgeons, Pediatric Oncology Group, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

Chief Editor

Harsh Grewal, MD, FACS, FAAP, Professor of Surgery and Pediatrics, Temple University School of Medicine; Chief, Section of Pediatric Surgery, Temple University Children's Medical Center
Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education, Children's Oncology Group, Eastern Association for the Surgery of Trauma, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, and Southwestern Surgical Congress
Disclosure: Nothing to disclose.

 
 
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