Differences in clinical features of Crohn’s disease and intestinal tuberculosis

AIM: To investigate the clinical features of Crohn’s disease(CD) and intestinal tuberculosis(ITB) with a scoring system that we have developed.METHODS: A total of 25 CD and 40 ITB patients were prospectively enrolled from August 2011 to July 2012.Their characteristics and clinical features were recorded. Laboratory, endoscopic, histologic and radiographic features were determined. The features with a high specificity were selected to establish a scoring system. The features supporting CD scored +1, and those supporting ITB scored-1; each patient received a final total score. A receiver operating characteristic(ROC) curve was used to determine the best cut-off value for distinguishing CD from ITB.RESULTS: Based on a high specificity of differentiating between CD and ITB, 12 features, including longitudinal ulcers, nodular hyperplasia, cobblestone-like mucosa, intestinal diseases, intestinal fistula, the target sign, the comb sign, night sweats, the purified protein derivative test, the interferon-γ release assay(T-SPOT.TB), ring ulcers and ulcer scars, were selected for the scoring system. The results showed that the average total score of the CD group was 3.12 ± 1.740, the average total score of the ITB group was-2.58 ± 0.984, the best cutoff value for the ROC curve was-0.5, and the diagnostic area under the curve was 0.997, which was statistically significant(P < 0.001). The patients whose total scores were higher than-0.5 were diagnosed with CD; otherwise, patients were diagnosed with ITB. Overall, the diagnostic accuracy rate and misdiagnosis rate of this scoring system were 97% and 3%, respectively. CONCLUSION: Some clinical features are valuable for CD and ITB diagnosis. The described scoring system is key to differentiating between CD and ITB.     

Abnormal pancreatic imaging in Crohn’s disease: prevalence and clinical features

Background This study aimed to delineate the incidence and the clinical features of abnormal pancreatic imaging in patients suffering from Crohns disease.Methods The subjects of this retrospective study were 255 patients with Crohns disease who were treated at our unit and who were followed-up for more than 3 years.Results Sixteen of the 255 Crohns disease patients (6.3%) had morphological abnormalities of the pancreas. The cumulative incidence of abnormal pancreatic imaging as a complication of Crohns disease was 5.2% at 5 years and 6.3% at 10 years after the initial diagnosis of Crohns disease. Four of the patients with Crohns disease already showed abnormal pancreatic imaging at the initial examination. Morphological examinations of the pancreas showed that none of the sixteen suffered from severe conditions. The abnormal pancreatic imaging was unrelated to the therapeutic regimens employed for Crohns disease or to its activity. When patients with Crohns disease with and without abnormal pancreatic imaging were compared, there were no significant differences in any of the background clinical features of Crohns disease. When we compared pancreatic imaging according to the type of Crohns disease, in the solely aphthous ulcerations type, the occurrence of abnormal pancreatic imaging was significantly higher (P = 0.02) than that in the other types. In 7 patients who had suffered from Crohns disease for more than 10 years, the clinical course of abnormal pancreatic imaging was not progressive, regardless of the progression of Crohns disease.Conclusions It is suggested that abnormal pancreatic imaging is not serious a complication of Crohns disease, and is unrelated to the course of Crohns disease.     

Clinical features and oncological outcomes of intestinal cancers associated with ulcerative colitis and Crohn’s disease

Journal of Gastroenterology - Patients with longstanding inflammatory bowel disease are at high risk of developing intestinal cancers. In this study, we aimed to elucidate the differences between...     

Infectious etiopathogenesis of Crohn’s disease

Important advances during the last decade have been made in understanding the complex etiopathogenesis of Crohn’s disease(CD).While many gaps in our knowledge still exist,it has been suggested that the etiology of CD is multifactorial including genetic,environmental and infectious factors.The most widely accepted theory states that CD is caused by an aggressive immune response to infectious agents in genetically predisposed individuals.The rise of genome-wide association studies allowed the identification of loci and genetic variants in several components of host innate and adaptive immune responses to microorganisms in the gut,highlighting an implication of intestinal microbiota in CD etiology.Moreover,numerous independent studies reported a dysbiosis,i.e.,a modification of intestinal microbiota composition,with an imbalance between the abundance of beneficial and harmful bacteria.Although microorganisms including viruses,yeasts,fungi and bacteria have been postulated as potential CD pathogens,based on epidemiological,clinicopathological,genetic and experimental evidence,their precise role in this disease is not clearly defined.This review summarizes the current knowledge of the infectious agents associated with an increased risk of developing CD.Therapeutic approaches to modulate the intestinal dysbiosis and to target the putative CD-associated pathogens,as well as their potential mechanisms of action are also discussed.     

Association of idiopathic inflammatory myopathy and Crohn’s disease

We describe a rare case of concurrent polymyositis and Crohn’s disease in a female patient. A 69-year-old female presented in December 2007 with a 5-month history of proximal muscle weakness, pain, fatigue and difficulty in walking and swallowing. Blood tests revealed elevated creatine kinase (3,429 U/l) and lactate dehydrogenase (2,013 U/l) levels. Magnetic resonance imaging found lumbar disc protrusion. Review by immunologists showed a diagnosis of idiopathic inflammatory myopathy. Though electromyography and muscle biopsy at this point were non-specific, corticosteroid treatment was commenced. Her condition worsened precipitously leading to hospitalisation under immunologists. As the provisional diagnosis was polymyositis, we commenced 1.5 mg/kg per day corticosteroid but her muscle power did not improve. Recurrent abdominal symptoms lead to ultrasonography showing intestinal inflammation. While tumour markers were elevated, thorough investigation failed to identify a tumour. Corticosteroid therapy was continued. Persistent abdominal symptoms lead to repeat colonoscopy and biopsy confirming Crohn’s disease. Repeat electromyography and muscle biopsy confirmed the diagnosis of polymyositis. Her corticosteroids were tapered off and 5-aminosalicylic acid and azathioprine were started. Her myositic symptoms gradually abated with improvement in her Crohn’s disease. She is now able to walk independently and takes 8 mg/day corticosteroids and her muscle enzyme levels are normal. Remember rare systemic associations when dealing with immune-mediated disease. Consider myositis in the differential diagnosis of Crohn’s disease associated myopathy. Treating Crohn’s disease may lead to improvement in steroid-resistant myositis where the two are associated.     

Coexistence of Crohn’s disease in a patient with systemic lupus erythematosus

The concurrence of inflammatory bowel disease with systemic lupus erythematosus (SLE) is rare. The concomitant diagnosis of Crohn’s disease and SLE is even more rare. The patient, a 40-year-old woman, was admitted to our hospital because of relapsing episodes of abdominal pain, diarrheas upper and lower extremities arthralgias, Raynaud’s phenomenon with positive antinuclear antibodies, and fever for the last 2 years. The patient was diagnosed elsewhere with SLE and treated with hydroxychloroquine. Her medical history also included tonsillectomy and total hip replacement after a car accident. Family history was unremarkable. Physical examination was unremarkable except of very mild pain at lower left abdominal quadrant. Laboratory tests showed erythrocyte sedimentation rate at 32 mm/h, C-reactive protein at 36 mg/dl, positive rheumatoid factor, and increased C3, C4, positive antinuclear antibodies with the presence of anti-Sm and anti-RNP antibodies. Ileocolonoscopy revealed colonic inflammation with ulcers and pseudopolyps. Subsequent biopsies were diagnostic of Crohn’s disease. Patient was diagnosed with Crohn’s colitis concomitant to systemic lupus erythematosus and was started on therapy with azathioprine 2 mg/Kg, methylprednisolone 16 mg/d with slow tapering, mesalazine 1.5 g/day, and hydroxychloroquine. Patient is in excellent health status on the six-month follow-up.     

Diagnosis and monitoring of postoperative recurrence in Crohn’s disease

Despite advances in medical management, many patients with Crohn’s disease (CD) require intestinal surgery throughout their lives. Surgery is not a cure, and postoperative recurrence is common in patients with CD. Ileocolonoscopy has been considered to be the gold standard in the diagnosis and monitoring of postoperative recurrence. However, the optimal monitoring strategy for postoperative recurrence has yet to be established. Capsule endoscopy and cross-sectional imaging techniques, including ultrasonography, computed tomography and MRI, have been used in the postoperative setting, and their usefulness in the monitoring of disease activity has been evaluated in recent clinical trials. The value of fecal markers, such as calprotectin and lactoferrin, has been also assessed in several studies. This review was to identify optimized methods for the diagnosis and monitoring of postoperative recurrence in CD.     

Clinical characteristics and long-term prognosis of elderly-onset Crohn’s disease

Objectives: This study aimed to evaluate the clinical characteristics and clinical course of Asian elderly-onset Crohn’s disease (EOCD) patients in a large well-defined cohort of South Korean IBD patients.

Materials and methods: From the Asan inflammatory bowel disease registry, we identified 29 EOCD patients (diagnosed with CD in age of 60 years or over) out of 2989?CD patients (1.0%). After excluding two patients with unclear data, 27 EOCD were matched with 108 young-onset CD (YOCD) and 108 middle age-onset CD (MOCD) for the interval from symptom onset to diagnosis (±3 years) and follow-up duration (±3 years).

Results: Females were predominant in the EOCD group (59.3%) compared to MOCD (31.5%) and YOCD (29.6%) groups (p?=?.012). In EOCD group, terminal ileal location was the most common (63.0%) at diagnosis, whereas ileocolonic location in other groups (57.4% in MOCD and 78.7% in YOCD, respectively) (p?vs. 28.7% in MOCD vs. 49.1% in YOCD, p?vs. 87.0% in MOCD vs. 89.8% in YOCD, p?p?=?.583).

Conclusions: EOCD may have a better clinical course than MOCD and YOCD, as demonstrated by the similar risk for intestinal resection despite the less frequent use of thiopurines.     

Prevention of post-operative recurrence of Crohn’s disease

Endoscopic and clinical recurrence of Crohn’s disease(CD)is a common occurrence after surgical resection.Smokers,those with perforating disease,and those with myenteric plexitis are all at higher risk of recurrence.A number of medical therapies have been shown to reduce this risk in clinical trials.Metronidazole,thiopurines and anti-tumour necrosis factors(TNFs)are all effective in reducing the risk of endoscopic or clinical recurrence of CD.Since these are preventative agents,the benefits of prophylaxis need to be weighed-against the risk of adverse events from,and costs of,therapy.Patients who are high risk for post-operative recurrence should be considered for early medical prophylaxis with an anti-TNF.Patients who have few to no risk factors are likely best served by a three-month course of antibiotics followed by tailored therapy based on endoscopy at one year.Clinical recurrence rates are variable,and methods to stratify patients into high and low risk populations combined with prophylaxis tailored to endoscopic recurrence would be an effective strategy in treating these patients.     

Natural history and long-term clinical course of Crohn’s disease

Crohn’s disease is a chronic inflammatory disease process involving different sites in the gastrointestinal tract.Occasionally,so-called metastatic disease occurs in extra-intestinal sites.Granulomatous inflammation may be detected in endoscopic biopsies or resected tissues.Genetic,epigenetic and environmental factors appear to play a role.Multiple susceptibility genes have been described in both familial and non-familial forms while the disease is phenotypically heterogeneous with a female predominance.The disorder occurs over a broad age spectrum,from early childhood to late adulthood.More than 80%are diagnosed before age 40 years usually with terminal ileal and colonic involvement.Pediatric-onset disease is more severe and more extensive,usually with a higher chance of upper gastrointestinal tract disease,compared to adult-onset disease.Long-term studies have shown that the disorder may evolve with time into more complex disease with stricture formation and penetrating disease complications(i.e.,fistula,abscess).Although prolonged remission may occur,discrete periods of symptomatic disease may re-appear over many decades suggesting recurrence or re-activation of this inflammatory process.Eventual development of a cure will likely depend on identification of an etiologic cause and a fundamental understanding of its pathogenesis.Until now,treatment has focused on removing risk factors,particularly cigarette smoking,and improving symptoms.In clinical trials,clinical remission is largely defined as improved numerical and endoscopic indices formucosal healing.Deep remissionis a conceptual,moreextendedgoal that may or may not alter the long-term natural history of the disease in selected patients,albeit at a significant risk for treatment complications,including serious and unusual opportunistic infections.     

Adalimumab-induced interstitial pneumonia in a patient with Crohn’s disease

There are several reports of anti-tumor necrosis factor(TNF)-induced lung disease,especially in patients with rheumatologic diseases.Adalimumab is an antiTNF drug used to induce and maintain remission in patients with immune-mediated diseases,such as Crohn’s disease.Although pulmonary disorders could be an extra-intestinal manifestation of inflammatory bowel disease,biologic therapy could also be a cause of lung injury.Only few cases of adalimumab-induced lung toxicity have been reported,and the majority of them were in patients with rheumatologic diseases.Lung injury secondary to anti-TNF therapy should,after ruling out other etiologies,be considered in patients who have a temporal association between the onset of respiratory symptoms and the exposure to these drugs.A compatible pattern in the biopsy and the clinical improvement after discontinuation of the anti-TNF drug would strongly support the diagnosis.     

Cutaneous polyarteritis nodosa in a patient with Crohn’s disease

A 19-year-old Japanese woman with a 4-year history of Crohn’s disease (CD) developed high fever, polyarthralgia, and painful subcutaneous nodules of the legs. A skin biopsy showed panarteritis with fibrinoid necrosis in the deep dermis. Endoscopic examination showed aphthous lesions in the entire colon. She was diagnosed with cutaneous polyarteritis nodosa (PAN) associated with CD. Steroid therapy improved her symptoms. To our knowledge, this is the first Japanese case of cutaneous PAN associated with CD.     

Postoperative Crohn’s disease: prevention and treatment

Crohn’s disease is a chronic, relapsing–remitting inflammatory disease of the intestinal tract that commonly requires surgical treatment. Unfortunately, the majority of patients will ultimately develop postoperative disease recurrence and require subsequent surgery. A number of medications have been researched for the maintenance of postoperative remission. Of these, few have demonstrated consistent efficacy. A recently published randomized, controlled trial indicated that infliximab is effective in the maintenance of postoperative remission.     

Differentiation of Crohn’s disease from intestinal tuberculosis in India in 2010

Differentiating intestinal tuberculosis from Crohn’s disease (CD) is an important clinical challenge of considerable therapeutic significance. The problem is of greatest magnitude in countries where tuberculosis continues to be highly prevalent, and where the incidence of CD is increasing. The final clinical diagnosis is based on a combination of the clinical history with endoscopic studies, culture and polymerase chain reaction for Mycobacterium tuberculosis, biopsy pathology, radiological investigations a...     

Indications and results of side-to-side isoperistaltic strictureplasty in Crohn’s disease

PURPOSE Strictureplasty has commonly been used for short stenotic tracts, but it has rarely been applied to stenoses longer than 10 cm. Michelassi proposed a side-to-side isoperistaltic strictureplasty for single or multiple strictures that affected long bowel tracts. The experience and results obtained to date with this type of strictureplasty are limited. We therefore decided to review the cases in which we performed this procedure.METHODS Thirty-one patients, aged 21 to 66 years, underwent this operation between August 1996 and October 2002. Indications for surgery included subocclusion in 22 patients, malnutrition in 9 patients, and fistula or abscess in 6 patients. Two side-to-side isoperistaltic strictureplasties have been performed in jejunum, 6 in jejunum-ileum, 16 in the proximal ileum, 1 in terminal ileum, and 6 in the ileo-cecal tract.RESULTS The average length of side-to-side isoperistaltic strictureplasty as 32.1 cm (range, 10–54 cm). Sixteen patients also underwent concomitant bowel resection and 17 patients have received additional strictureplasty. There was no perioperative mortality, nor were there any postoperative complications requiring reoperation.In all patients intestinal occlusion and malnutrition were resolved. Decrease of activity indices was observed in 62.3 percent of patients within 6 months after surgery. At an average follow-up of 26.4 months, six patients required reoperation, but in only one of them did the recurrence involve a previous strictureplasty site. In that case the side-to-side isoperistaltic strictureplasty was soft and was without signs of inflammation or stenosis.CONCLUSIONS Side-to-side isoperistaltic strictureplasty seems to provide a technical solution leading to improvement when long intestinal inflamed tract are treated. Longer follow-up and larger experience is needed to validate this observation.