Pediatric Crohn Disease Surgery Clinical Presentation

Updated: Jul 26, 2019
  • Author: Patricia A Valusek, MD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
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Presentation

History and Physical Examination

Crohn disease (CD) most commonly presents in an adolescent or young adult as chronic abdominal pain, diarrhea, and weight loss. Patients who present with Crohn colitis may also have bloody diarrhea, tenesmus, or incontinence. In some cases, CD is diagnosed in children who are undergoing evaluation for delayed puberty onset or secondary amenorrhea.

About 5% of patients with CD present with only perianal symptoms. Anal fissures, the most common finding in perianal disease, often develop eccentrically rather than in the classic posterior midline position of most benign fissures. Skin tags, anal stenosis, fecal incontinence, fistula, and perianal abscesses are also common signs and symptoms of perianal disease.

In some cases, CD is discovered during treatment of one of its complications. Although more common in patients with ulcerative colitis (UC), toxic megacolon can be a life-threatening manifestation of CD. Small-bowel obstruction, intestinal perforation, intra-abdominal abscess, and enteric fistulas can also be part of the initial presentation. Because symptoms of ileitis may mimic those of appendicitis, the diagnosis may be made at the time of appendectomy.

Interestingly, the extraintestinal manifestations of CD may develop first. Many of these extraintestinal signs overlap with those of UC. Aphthous ulcerations of the buccal mucosa, lips, or tongue should alert the clinician to assess for intestinal involvement. Skin manifestations, such as erythema nodosum and pyoderma gangrenosum, occur more commonly in association with CD than in UC. These occur predominantly on the lower legs, over the tibia. [15, 16]

Ankylosing spondylitis is more common in men with CD than in women. Ocular symptoms (eg, iritis and uveitis) and hepatic involvement with chronic hepatitis or sclerosing cholangitis may be observed, though these are more commonly associated with UC than with CD. Renal calculi and cholelithiasis are complications of long-standing ileal disease. [15]

Children with CD commonly experience growth failure as an extraintestinal manifestation of inflammatory bowel disease (IBD). This growth failure results from both decreased caloric intake and the presence of circulating inflammatory cytokines. Growth failure is defined by several parameters, including height below the third percentile, a shift to a lower height percentile, and reduction in growth velocity.

Enteral feeding is the first-line treatment. However, achieving remission of the inflammation is critical to maintaining growth. If intensive medical treatment does not result in remission, surgical intervention may be warranted, particularly for isolated small bowel disease. [17]

Characteristics distinguishing CD from UC are listed in Table 1 below.

Table 1. Differentiating Characteristics of Crohn Disease and Ulcerative Colitis (Open Table in a new window)

Characteristic

Crohn Disease

Ulcerative Colitis

Distribution

Entire gastrointestinal tract

Colon only

Skip lesions

Continuous involvement proximally from rectum

Pathology

Full thickness

Mucosa only

Granulomas (50%)

No granulomas

Radiology

Entire gastrointestinal tract

Colon only

Skip lesions

Continuous involvement proximally from rectum

Fistulas, abscesses, fibrotic strictures

Mucosal disease only

Presentation

Bleeding

Uncommon

Common

Obstruction

Common

Uncommon

Fistula

Common

Uncommon

Weight loss

Common

Uncommon

Perianal disease

Common

Uncommon

Cancer risk

Controversial

1% per year starting 10 years after diagnosis (estimated)