This chronic inflammatory disease of the gastrointestinal tract is more likely to affect whites than blacks and women than men. Its precise etiology and pathogenesis continue to elude investigators. Although many of the symptoms are similar to ulcerative co-litis, severe complications are more frequent in Crohn's disease and surgery is not curative, as it is in ulcerative colitis. A number of medications, including immunosuppressives, are successful in management.

How does Crohn's disease usually present?

The onset and initial clinical manifestations of Crohn's disease tend to be subtle, with a number of constitutional symptoms. These include malaise, fatigue, low-grade fever, anorexia, and weight loss. More specific GI symptoms may include diarrhea, abdominal pain -- most often in the right lower quadrant -- bleeding, nausea, and vomiting. A frequent clinical presentation is intestinal obstruction with its associated symptoms. Patients may present with pain and drainage associated with an anal fissure, perirectal abscess, or fistula.

Various extra intestinal manifestations also occur in Crohn's disease: aphthous ulceration of the oral mucosa, various forms of arthritis, ankylosing spondylitis, uveitis, pericholangitis, chronic active hepatitis, sclerosing cholangitis, cholesterol gallstones, calcium oxalate kidney stones, erythema nodosum, and pyoderma gangrenosum. Patients with Crohn's disease may also present with electrolyte abnormalities, hypoalbuminemia, and iron deficiency.

What are the indications for surgical intervention?

The three most common indications for surgery are intestinal obstruction, septic complications, and failure of medical therapy. Intestinal obstruction may be acute, subacute, or chronic and result from a single strictured segment of bowel or from multiple scattered diseased segments. The obstruction can be partial, high-grade, or complete, developing at any level of the alimentary tract, most commonly the small intestine.

Abscesses, fistulae, inflammatory masses, and intestinal perforation are the septic complications that may require surgical intervention. Patients with sepsis secondary to intra-abdominal abscess should undergo laparotomy with drainage, resection, and construction of a stoma, followed in several weeks by reanastomosis. Surgery for a symptomatic fistula should be done as a single-stage re-section and anastomosis if there is no clinically significant abscess present. Patients with free perforation should undergo resection of the involved segment with formation of a stoma followed in several weeks with restoration of continuity.

Medical failure is considered to have occurred in patients who have not responded to high-dose IV steroids, whose symptoms recur shortly after tapering steroids, who develop serious steroid-related complications on maximal steroid therapy, and those who do not respond to or cannot tolerate immunosuppressive therapy. Less frequent indications include hemorrhage, fulminant colitis, toxic megacolon, and growth retardation in pediatric patients who fail to respond to drag therapy and nutritional support.

Last updated Jan 4/07