Crohn's Disease: Diagnosis and Management

 

Am Fam Physician. 2018 Dec 1;98(11):661-669.

  Patient information: See related handout on Crohn's disease, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Crohn's disease is a chronic inflammatory condition that affects the gastrointestinal tract. It can cause lesions from mouth to anus and may result in extraintestinal complications. The prevalence of Crohn's disease is increasing in adults and children. Genetic predispositions to Crohn's disease have been identified, and specific environmental factors have been associated with its development. Common presenting symptoms include diarrhea, abdominal pain, rectal bleeding, fever, weight loss, and fatigue. Physical examination should identify unstable patients requiring immediate care, include an anorectal examination, and look for extraintestinal complications. Initial laboratory evaluation identifies inflammation and screens for alternative diagnoses. Measurement of fecal calprotectin has value to rule out disease in adults and children. Endoscopy and cross-sectional imaging are used to confirm the diagnosis and determine the extent of disease. Treatment decisions are guided by disease severity and risk of poor outcomes. Patients commonly receive corticosteroids to treat symptom flare-ups. Patients with higher-risk disease are given biologics, with or without immunomodulators, to induce and maintain remission. For children, enteral nutrition is an option for induction therapy. All patients with Crohn's disease should be counseled on smoking avoidance or cessation. Patients with Crohn's disease are at increased risk of cancer, osteoporosis, anemia, nutritional deficiencies, depression, infection, and thrombotic events. Maximizing prevention measures is essential in caring for these patients.

Crohn's disease is a chronic inflammatory condition affecting the gastrointestinal tract that often causes extraintestinal complications. Inflammation may occur at any point from mouth to anus (Table 11). Specific clinical and diagnostic characteristics distinguish Crohn's disease from ulcerative colitis1,2  (Table 21). In the United States, the prevalence is estimated at 58 per 100,000 children and 119 to 241 per 100,000 adults, and is increasing for both groups.3,4 Most cases are diagnosed in the 20s to 40s, but new cases do occur later.5 White race and higher education levels are associated with increased prevalence.4 The estimated annual economic burden to U.S. health care is $6.3 billion.6

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Fecal calprotectin is a useful test for ruling out Crohn's disease in adults.

C

14

Cross-sectional imaging techniques (i.e., computed tomography, magnetic resonance imaging, and ultrasonography) are the imaging studies of choice for evaluating Crohn's disease.

C

20, 21

Smoking cessation reduces complications experienced by patients with Crohn's disease, and all patients should be counseled not to smoke and offered cessation assistance.

B

42

Corticosteroids treat symptom flare-ups and may induce remission of Crohn's disease.

C

2, 24

Biologics, with or without immunomodulators, induce and maintain remission of Crohn's disease in moderate- to high-risk patients.

C

2


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Fecal calprotectin is a useful test for ruling out Crohn's disease in adults.

C

14

Cross-sectional imaging techniques (i.e., computed tomography, magnetic resonance imaging, and ultrasonography) are the imaging studies of choice for evaluating Crohn's disease.

C

20, 21

Smoking cessation reduces complications experienced by patients with Crohn's disease, and all patients should be counseled not to smoke and offered cessation assistance.

B

42

Corticosteroids treat symptom flare-ups and may induce remission of Crohn's disease.

C

2, 24

Biologics, with or without immunomodulators, induce and maintain remission of Crohn's disease in moderate- to high-risk patients.

C

2


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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TABLE 1

Location of Crohn's Disease and Associated Symptoms

LocationSymptomsCommentsFrequency (%)

Ileum and colon

Diarrhea, cramping, abdominal pain, weight loss

Most common form

35

Colon only

Diarrhea, rectal bleeding, perirectal abscess, fistula, perirectal ulcer

Skip lesions and arthralgias more common

32

Small bowel only

Diarrhea, cramping, abdominal pain, weight loss

Complications may include

The Authors

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BRIAN VEAUTHIER, MD, is program director at the University of Wyoming Family Medicine Residency Program, Casper....

JAIME R. HORNECKER, PharmD, BCBS, CDE, is a faculty clinical pharmacist at the University of Wyoming Family Medicine Residency Program.

Address correspondence to Brian Veauthier, MD, University of Wyoming, 1522 East A St., Casper, WY 82601 (e-mail: bveauthi@uwyo.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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