New presentation

New presentation of Crohn's disease

ECCO Statement 7E (CD 2016)

Terminal ileitis resembling Crohn’s disease found at a laparotomy for suspected appendicitis should not routinely be resected [EL5]

Coincidental ileitis noted at surgery

ECCO statement 2A (CD 2016)

Symptoms of CD are heterogeneous, but commonly include abdominal pain, weight loss and chronic diarrhoea. These symptoms should raise the suspicion of CD, especially in young patients. Systemic symptoms of malaise, anorexia, or fever are common [EL5]

Further information

Symptoms

General Practitioner

ECCO statement 2C (CD 2016)

A full history should include detailed questioning about the onset of symptoms, recent travel, food intolerances, medication (including antibiotics and non-steroidal anti-inflammatory drugs), and history of appendectomy [EL5]. Particular attention should be paid to well proven risk factors including smoking, family history, and recent infectious gastroenteritis [EL1]

ECCO statement 2D (CD 2016)

Careful questioning about nocturnal symptoms, features of extraintestinal manifestations involving the mouth, skin, eye, or joints, episodes of perianal abscess, or anal fissure is needed. General examination include all the following: general wellbeing, pulse rate, blood pressure, temperature, abdominal tenderness or distension, palpable masses, perineal and oral inspection, digital rectal examination, and measurement of body mass index [EL5]

Further information

  • History includes IBD-specific questions
  • Examination to look for weight loss; dehydration; oral ulceration & angular stomatitis; erythema nodosum or pyoderma gangrenosum; arthritis; abdominal mass or fistula; perianal fistula & anal fissure, rectal examination
  • Patients may require urgent treatment prior to investigations (see relevant algorithm)
  • Consider admission if fever or marked abdominal tenderness
Specialist

ECCO statement 2E (CD 2016)

Check for signs of acute and/or chronic inflammatory response, anaemia, fluid depletion, and signs of malnutrition or malabsorption [EL5]. Initial laboratory investigations should include CRP [EL2], and full blood count [EL2]. Other markers of inflammation may also be used such as faecal calprotectin [EL1] or erythrocyte sedimentation rate [EL5]. Microbiological testing for infectious diarrhoea including Clostridium difficile toxin is recommended [EL2]. Additional stool tests may be needed for some patients, especially those who have travelled abroad [EL5]

ECCO statement 4C (CD 2016)

Serum CRP levels and faecal markers, such calprotectin or lactoferrin can be used to guide therapy and short-term follow-up [EL2] and to predict clinical relapse [EL2]. Faecal calprotectin can help to differentiate CD from IBS [EL2]

Further information

  • CRP (responds rapidly, t½ 19h) & ESR
  • FBC & haematinics
  • Creatinine, urea & electrolytes
  • LFT
  • Stool for C. difficile toxin and MC&S; 3x ova, cysts & parasites if recent tropical travel; and calprotectin or lactoferrin if available
  • CXR and γ-interferon assay for TB if intestinal TB suspected
Baseline investigations

ECCO statement 2B (CD 2016)

A single gold standard for the diagnosis of CD is not available. The diagnosis is confirmed by clinical evaluation and a combination of endoscopic, histological, radiological, and/or biochemical investigations. Genetic or serological testing is currently not recommended for routine diagnosis of CD [EL5]

Symptom-directed investigations

  • Enteric infection
  • Bacterial overgrowth
  • Bile salt malabsorbtion
  • IBS
  • Gall stone disease
  • Causes of iron deficiency anaemia
  • NSAID-induced enteritis
  • Behçet's disease, depending on ethnicity
Consider alternate diagnoses

Questions to ask

  • Do you have any discharge? Is this just mucus, or faecal soiling?
  • Do you have pain in/near the anus (suggesting an abscess)? If so, do you have fever/feel unwell?
  • Do you have sharp anal pain on opening your bowels (suggesting a fissure)?
  • Have you ever had a perianal fistula before?

The Perianal Crohn’s Disease Activity Index provides appropriate questions and allows an objective disease scale to be calculated.

Perianal symptoms

  • Diarrhoea and bowel frequency
  • Urgency to defecate
  • Rectal bleeding
Colonic symptoms

  • Weight loss / malabsorbtion
  • (Post-prandial) abdominal pain
  • Diarrhoea
  • Vomiting
  • Abdominal distension
Small bowel symptoms

  • Dyspepsia
  • Nausea
  • Weight loss
  • Oesophageal symptoms, e.g. odynophagia, dysphagia
Foregut symptoms

ECCO statement 2F (CD 2016)

For suspected CD, ileocolonoscopy and biopsies from the terminal ileum as well as each colonic segment to look for microscopic evidence of CD are first line procedures to establish the diagnosis [EL1]. Irrespective of the findings at ileocolonoscopy, further investigation is recommended to examine the location and extent of CD in the small bowel [EL5]. Whether upper GI endoscopy should be routinely performed in asymptomatic adult patients is still debated [EL5]

ECCO statement 3 (CD 2016)

For a reliable diagnosis of CD a minimum of two biopsies from five sites around the colon (including the rectum) as well as from the ileum should be obtained [EL5]

Further information

  • If severe active disease, perform flexible sigmoidoscopy (take 2 biopsies) rather than ileo-colonoscopy, to reduce risk of iatrogenic perforation and request AXR (exclude bowel dilatation)
Colonoscopy

ECCO statement 2G (CD 2016)

Cross-sectional imaging (MRI and CT enterography) and trans-abdominal ultrasonography (US) are complementary to endoscopy and offer the opportunity to detect and stage inflammatory, obstructive and fistulising CD [EL1]. Radiation exposure should be considered when selecting techniques, especially to monitor follow-up [EL4]. Because of the lower sensitivity of barium studies, alternative techniques are preferred if available

ECCO statement 2H (CD 2016)

MRI, CT and US have a high accuracy for the diagnosis of small bowel stenosis [EL2], penetrating complications [EL1], and may assist differentiation between predominantly inflammatory and fibrotic strictures [EL5]

ECCO statement 2I (CD 2016)

Small bowel capsule endoscopy (SBCE) should be reserved for patients in whom the clinical suspicion for CD remains high despite negative evaluations with ileocolonoscopy and radiological examinations (SBE/SBFT or CTE or MRI) [EL2]. SBCE has a high negative predictive value for small bowel CD [EL4]. Device assisted enteroscopy may be performed in expert hands if histological diagnosis is needed [EL3] or when endoscopic therapy is indicated, including dilatation of strictures, retrieval of impacted capsules, and treatment of bleeding [EL4]

Further information

  • Oral contrast usually acceptable (enteroclysis not required). The MaRIA score provides objective measure of MRI findings
  • Ultrasound acceptable alternative if local expertise
  • Capsule endoscopy used if high clinical suspicion persists despite normal 1st-line investigations; double balloon enteroscopy used if biopsy or dilatation of suspected involved areas of small bowel required
Small bowel imaging

  • Perform gastroscopy
  • Biopsies should be taken from duodenum, antrum and gastric body
  • Test for Helicobacter pylori
Gastroscopy

ECCO statement 4B (CD 2016)

The course of CD may be predicted by clinical factors at diagnosis and/or endoscopic findings. This should be taken into account when determining a therapeutic strategy [EL2]

ECCO statement 5A (CD 2016)

The presence of active inflammation due to CD should be confirmed before initiating or changing medical therapy

ECCO statement 4A (CD 2016)

The use of the Montréal classification of CD is advocated, until more advanced classification is available. Genetic tests or serological markers should currently not be used to classify CD in clinical practice [EL2]

Further information

Crohn's disease is diagnosed using a combination of clinical presentation, serological, radiological, endoscopic & histological appearances, demonstrating discontinuous, often granulomatous inflammation. Macroscopic features for the diagnosis of Crohn's disease are shown:-

Crohn's disease can be classified by the Montréal classification (rarely used in practice)

  • Most clinicians classify by extent and activity: consider further tests to stage disease
  • The Lémann score is being developed to provide a comprehensive, objective measure of damage

When reviewing this algorithm, bear in mind the following:

  • Course of disease – initial presentation, frequency & severity of flares
  • Extent of disease
  • Effectiveness and tolerance of previous treatments
  • Presence of biologic or endoscopic signs of inflammation

At this stage:

Active Crohn's disease confirmed

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