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Pediatric Crohn Disease Surgery Workup

  • Author: Patricia A Valusek, MD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
 
Updated: Dec 07, 2015
 

Laboratory Studies

Stool specimens are sent for 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 calcium and magnesium studies, 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, vitamin A levels, and vitamin D levels may be assessed.

Liver function test results may be elevated, either 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.

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Imaging Studies

Computed tomography (CT) should be the first radiologic procedure performed in patients with acute inflammatory symptoms (see the image below). CT may show bowel-wall thickening, mesenteric edema, abscesses, or fistulas.

CT scan in a patient with terminal ileal Crohn disCT scan in a patient with terminal ileal Crohn disease shows an enteroenteral fistula (arrow) between loops of diseased small intestine.

Small-bowel contrast and enteroclysis studies may be valuable in demonstrating the distribution of small-bowel disease (see the image below).[18] Mucosal fissures, bowel fistulas, strictures, and obstructions can be visualized. The terminal ileum may be narrowed and thickened, with a characteristic pipe appearance.

A teenaged patient with Crohn disease underwent a A teenaged patient with Crohn disease underwent a contrast-enhanced upper-GI study with small-bowel follow-through. Several loops of small bowel are in the pelvis. Note 1 loop of distal bowel with a thickened wall (solid arrow), which is contrasted with a less involved loop of bowel in which the intestinal wall is not thickened at all (dotted arrow).

In several studies, magnetic resonance imaging (MRI) has been shown to yield a higher sensitivity and specificity than ileocolonoscopy (criterion standard) for both the diagnosis of Crohn disease (CD) and the determination of its severity.[19, 20, 21]

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Diagnostic Procedures

Endoscopic visualization and biopsy are essential in the diagnosis of CD.

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 help differentiate the process from other inflammatory conditions.

Given the increased risk of colorectal cancer in patients with inflammatory bowel disease (IBD), colonoscopy may have a role in cancer surveillance, though this practice remains controversial.

Upper gastrointestinal (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.

Despite extensive workup, 10% of patients with isolated Crohn colitis have an indeterminate colitis, with features of both CD and ulcerative colitis (UC). If these patients undergo long-term follow-up, small-bowel disease characteristic of CD ultimately develops.

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Histologic Findings

Microscopically, CD is 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 CD. Proliferative stromal and nodular inflammatory changes occur in the bowel wall, leading to a thick firm appearance and, ultimately, strictures.

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Contributor Information and Disclosures
Author

Patricia A Valusek, MD Pediatric Surgery Fellow, Department of Surgery, Children's Mercy Hospital

Patricia A Valusek, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

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: Academic 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, Southeastern Surgical Congress

Disclosure: Nothing to disclose.

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.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Gail E Besner, MD Chief, Department of Pediatric Surgery, Principal Investigator, Center for Perinatal Research, Director, Pediatric Surgery Training Program, Associate Burn Director, Nationwide Children’s Hospital; H William Clatworthy, Jr, Professor of Surgery, Department of Surgery, Ohio State University College of Medicine

Gail E Besner, MD is a member of the following medical societies: American Surgical Association, Alpha Omega Alpha, American Academy of Pediatrics, American Burn Association, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Medical Womens 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, Society of University Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Harsh Grewal, MD, FACS, FAAP Professor of Surgery, Cooper Medical School of Rowan University; Chief, Division of Pediatric Surgery, Cooper University Hospital

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, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, Southwestern Surgical Congress, Eastern Association for the Surgery of Trauma, Children's Oncology Group, International Pediatric Endosurgery Group

Disclosure: Nothing to disclose.

Additional Contributors

Denis D Bensard, MD, FACS, FAAP Director of Pediatric Surgery and Trauma, Attending Surgeon in Adult and Pediatric Acute Care Surgery, Attending Surgeon in Adult and Pediatric Surgical Critical Care, Denver Health Medical Center; Professor of Surgery, University of Colorado School of Medicine; Associate Program Director, General Surgery Residency, Attending Surgeon, Children's Hospital Colorado

Denis D Bensard, MD, FACS, FAAP is a member of the following medical societies: American Association for the Surgery of Trauma, Alpha Omega Alpha, Society of American Gastrointestinal and Endoscopic Surgeons, Southwestern Surgical Congress, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, Society of University Surgeons

Disclosure: Nothing to disclose.

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Laparoscopic view depicts creeping fat along the mesentery of the terminal ileum.
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, CO). Note that the ligation of the mesentery proceeds near the border of the ileum rather than at the base of the mesentery.
CT scan in a patient with terminal ileal Crohn disease shows an enteroenteral fistula (arrow) between loops of diseased small intestine.
A teenaged patient with Crohn disease underwent a contrast-enhanced upper-GI study with small-bowel follow-through. Several loops of small bowel are in the pelvis. Note 1 loop of distal bowel with a thickened wall (solid arrow), which is contrasted with a less involved loop of bowel in which the intestinal wall is not thickened at all (dotted arrow).
Table 1. Differentiating Characteristics of Crohn Disease and Ulcerative Colitis
Characteristic Crohn Disease Ulcerative Colitis
DistributionEntire gastrointestinal tractColon only
Skip lesionsContinuous involvement proximally from rectum
PathologyFull thicknessMucosa only
Granulomas (50%)No granulomas
RadiologyEntire gastrointestinal tractColon only
Skip lesionsContinuous involvement proximally from rectum
Fistulas, abscesses, fibrotic stricturesMucosal disease only
PresentationBleedingUncommonCommon
ObstructionCommonUncommon
FistulaCommonUncommon
Weight lossCommonUncommon
Perianal diseaseCommonUncommon
Cancer riskControversial1% per year starting 10 years after diagnosis (estimated)
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