Crohn's disease is a chronic, relap...

Crohn's disease is a chronic, relapsing inflammatory disorder of the alimentary canal with involvement anywhere from the cavity between the jaws to the anus. Manifestations of the disease cause considerable morbidity and social sumptuousness This article will focus onward the evaluation and management of Crohn's disease by way of the family physician.

Epidemiology, Etiology, and Pathophysiology

Crohn's disease affects approximately 380000 to 480000 bodily forms in the United States. (1) Although it may come into one's head at any age, the incidence is bimodal with a peak in the third decade of life and a smaller peak in the fifth decade. (2) The etiology of Crohn's disease is unknown, yet suggested possibilities include genetic, environmental, immunologic, and infectious causes. Theories of a genetic basis for the disease are supported according to family history and prevalence information, still no clear-cut pattern of inheritance has been established.

The incidence of Crohn's disease differs across racial and ethnic boundaries. It is more general in whites than in blacks, in women than in men and in Jewish than in non-Jewish [i]role[/i]s (3) Environmental factors must play a character in the development of Crohn's disease, because while the disease is unusual in African blacks, U.S. blacks have an incidence similar to that of whites. (2) Also, there is an association with diet, and the disease affects more smoker than reckon uponed (2,3) While etiologic evidence advises a complex interplay between many factors, pathophysiologically, Crohn's disease involves an immune connected view dysfunction. An imbalance in local mucosal production of pro-inflammatory cytokines through anti-inflammatory cytokines is theorized to cause the well-demarcated, discontinuous, transmural, ulcerative lesions characteristic of the disease. (4) Clinical features of Crohn's disease are listed in Table 15

Diagnosis

A diagnosis of Crohn's disease should be considered in any patient who nears with chronic or nocturnal diarrhea, abdominal pain, bowel obstruction, weight los ferment or night sweats. (5) However, symptoms of Crohn's disease are ofttimes insidious, and diagnosis can be difficult. Patients may have intermittent symptoms with varying periods of remission. from one side of to the other time, symptomatic periods may increase in oftenness and severity.

Crampy, intermittent pain is the most numerous common symptom of Crohn's disease. The pain may develop into a constant dull ache as the disease progresse Diarrhea is at hand in 85 percent of patients; other symptoms include hematochezia, febrile disease weight loss, malaise, nausea, and arthralgias. The differential diagnosis be pendents on the presenting complaint, and includes acute appendicitis, small bowel obstruction, ulcerative colitis, irritable bowel syndrome malabsorption syndrome infectious or ischemic colitis, neoplasia, hemorrhoids, and diverticular disease. When joint manifestations or fatigue predominates, the differential is expanded further. (6)

be deriveds from laboratory evaluation can be normal, however electrolyte abnormalities may occur secondary to diarrhea. Anemia also can be caused through malabsorption of vitamin B12, family loss, or the effect of inflammation forward the bone marrow. Patients may also have an elevated erythrocyte sedimentation rate. With the appropriate clinical presentation, the diagnosis can be glance ated by radiography, but should be confirmed at endoscopy and biopsy when possible. When the colon is involved, endoscopy reveals the characteristic sore s with normal surrounding mucosa. Radiographic studies of the small bowel may exhibit luminal narrowing, nodular contour, linear pustules or fistulas. Computed tomography (CT) may help to identify abscesses and other complications. (2)

Management of Crohn's Disease

The medical management of Crohn's disease is based forward the location and severity of disease and extra-intestinal complications (Table 2) (5) Therapy has couple goals--to treat the acute disease flare-ups and to maintain remission. Because no "gold standard" exists to define disease severity, working definitions of disease activity have been established to help guide therapy. These definitions are listed and defined in Table 35 while the various treatment options for Crohn's disease are provided in Table 4 (5)

Because the natural history of Crohn's disease is characterized through a variable course with spontaneous flare-ups and remissions, it is difficult to assay therapeutic benefit from intervention. However, based in succession evidence from therapeutic trials, guidelines for the management of Crohn's disease have been evolveed An algorithm for the medical management of Crohn's disease is provided in Figure 1 (4)

Mild to Moderate Disease

Mild to moderate Crohn's disease can be treated with a salicylate preparation, and in patients who are unresponsive, an antibiotic may help.5 reply to therapy should be evaluated after several weeks; patients who do not correspond should be treated for moderate to unadorned disease or with alternative therapy.

The salicylates include mesalamine (Rowasa) and sulfasalazine (Azulfidine). In its various preparations, mesalamine can be released in the stomach, duodenum ileum, and colon (Pentasa), or primarily in the terminal ileum and colon (Asacol). (7) as well-as; not only-but also; not only-but; not alone-but mesalamine preparations are generally more effective than placebo in improving disease symptoms and inducing remission in patients with active Crohn's disease; however, greater benefit is seen in patients with ileitis versus colitis or ileocolitis. (8) The dosage of oral mesalamine is 32 to 4 g for day.