Crohn's

^{Which of the following statements about Crohn’s disease is true?}

^{^{Crohn’s disease is a mucosal process, it does not extend deeper than the sub
mucosa.}
^{Terminal Ileum is the site of involvement of Crohn’s disease; it usually does
not affect the other areas of the intestine.}
^{The disease is characterized by remissions and exacerbations}
^{Increased incidence among Indians and Asians.}

Answer: The answer is (c). The Crohn’s disease is a disease of the entire
gastro-intestinal tract. Any area starting from the oral cavity to the anus can be
involved. The disease usually involves the terminal ileum most commonly. Crohn’s is a
transmural disease involving all the layers of the gastrointestinal tract. It is
characterized by remissions and exacerbations. Treatment is directed towards symptomatic
improvement and disease control. Crohn’s is highly prevalent among Europeans, North
Americans and Ashkenazi Jews.}

^{A 54 years old woman presents to the emergency room with fever since 2 days,
abdominal pain, nausea and vomiting since 2 days. She has a heart rate of 124 per minute,
respiratory rate of 32 per minute and a blood pressure of 92/48 mmHg. She appears
dehydrated. On examination of the abdomen there is guarding and severe tenderness in the
left iliac fossa. Her old medical records indicate that she has been suffering from
Crohn’s disease for the past 8 years and has been on Mesalamine and intermittent
steroids for the same.}

^{Which of the following lab findings is characteristic of her condition?}

^{^{Elevated white cell count, anemia, raised C-reactive protein levels}
^{Elevated white cell count and stool culture positive for pseudomonas}
^{Depressed white cell count and stool positive for clostridium difficile toxin.}
^{Depressed white cell count and abdominal ultrasound revealing an inflamed appendix.}

Answer: The answer is (a). The condition described is probably fistula formation on a
Crohn’s intestine. The guarding and tenderness indicate an acute peritonitis, which
is probably due to the fistula. The most diagnostic feature of this acute abdominal
condition is raised white cell count with a leftward shift. Stool culture positivity for
pseudomonas is not characteristic.}

^{The following statements about Crohn’s fistula are true except:}

^{^{Fever, chills and abdominal tenderness as in this woman, typify abdominal abscess
as a result of fistula}
^{Malnutrition is a predisposing factor for sepsis in these patients}
^{Entero-vesical fistulas can lead to recurrent urinary tract infections}
^{Crohn’s fistula can lead to malignancy.}

Answer: The answer is (d). Fever, chills and rigors typify the symptoms of abdominal
abscess due to Crohn’s fistula. These abscesses could be retroperitoneal or intra
abdominal. Patients with Crohn’s disease have chronic diarrhea and hence are prone to
malnutrition. In the setting of malnutrition these patients are prone for sepsis.
Entero-vesical fistulas are connections between the intestine and the urinary bladder and
they can lead to recurrent coliform infections of the urinary tract.}

^{The treatment of this woman’s condition includes:}

^{^{Immediate laparotomy and drainage of abscess and fistulotmy}
^{Broad spectrum antibiotics}
^{Stricturplasty}
^{Methylprednisolone with sulphasalazine}

Answer: The answer is (a). The presence of acute abdomen in this case is most likely
due to the fistula and intra abdominal abscess. This needs immediate laparotomy and
drainage of the abscess. Fistulotomy needs to be done. Broad spectrum antibiotics are
needed but do not constitute the only mode of treatment. Since there is no clinical
evidence of stricture there is no need for a stricturplasty.}