From the Guidelines
Diagnosing Crohn's disease acutely requires a comprehensive approach that prioritizes clinical evaluation, laboratory tests, imaging, and endoscopic procedures to promptly initiate appropriate treatment and improve patient outcomes. The initial step should involve a thorough history focusing on symptoms such as abdominal pain, diarrhea, weight loss, and fatigue, followed by a physical examination to identify abdominal tenderness, perianal disease, and extraintestinal manifestations 1.
Key components of the diagnostic process include:
- Laboratory tests: complete blood count to check for anemia and leukocytosis, inflammatory markers (C-reactive protein, erythrocyte sedimentation rate), fecal calprotectin, and stool studies to rule out infectious causes.
- Imaging studies: CT enterography or MR enterography are preferred for visualizing bowel wall thickening, skip lesions, and complications like strictures or fistulas.
- Endoscopy with biopsies: remains the gold standard for diagnosis, with colonoscopy allowing direct visualization of the colon and terminal ileum, and upper endoscopy if upper GI symptoms are present.
- Histopathological examination of biopsies: showing non-caseating granulomas, transmural inflammation, and skip lesions helps confirm the diagnosis.
During acute presentation, it is crucial to assess disease severity using tools like the Crohn’s Disease Activity Index (CDAI) and rule out complications like obstruction, perforation, or toxic megacolon that may require urgent surgical intervention 1. The diagnostic process should be expedited in acute presentations to allow prompt initiation of appropriate treatment, which may include medical management with agents such as tumor necrosis factor (TNF)-α antagonists, anti-integrin agents, or immunomodulators, as outlined in guidelines like those from the AGA and ECCO 1.
From the Research
Diagnosing Crohn's Disease
To diagnose Crohn's disease, several steps can be taken:
- Initial laboratory evaluation to identify inflammation and screen for alternative diagnoses 2
- Measurement of fecal calprotectin to rule out disease in adults and children 2
- Endoscopy and cross-sectional imaging to confirm the diagnosis and determine the extent of disease 2
- Physical examination to identify unstable patients requiring immediate care, including an anorectal examination, and to look for extraintestinal complications 2
Treatment Options for Crohn's Disease
Treatment decisions are guided by disease severity and risk of poor outcomes:
- Corticosteroids are commonly used to treat symptom flare-ups 3, 4, 5
- Biologics, with or without immunomodulators, are given to patients with higher-risk disease to induce and maintain remission 3, 6
- Enteral nutrition is an option for induction therapy in children 2
- Combination therapy with infliximab and azathioprine has been shown to be effective in achieving corticosteroid-free clinical remission 6
Management of Crohn's Disease
Effective management of Crohn's disease involves:
- Patient risk stratification, patient preference, and clinical factors in therapeutic decision-making 3
- Vaccinations to prevent infections, such as influenza, pneumonia, and herpes zoster, are important components of health maintenance for patients with Crohn's disease 3
- Counseling on smoking avoidance or cessation, as smoking can exacerbate the disease 2
- Monitoring for potential complications, such as cancer, osteoporosis, anemia, nutritional deficiencies, depression, infection, and thrombotic events 2