Crohn's Disease - Symptoms

Symptoms of Crohn's disease depend on the location and extent of the process, and on the type of course - acute or chronic.

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Extraintestinal manifestations of Crohn's disease

Walfish (1992) divides extraintestinal manifestations of Crohn's disease into three main groups.

1. Manifestations corresponding to the activity of the pathological process in the intestine, caused by immunobiological processes and activation of microbial flora: peripheral arthritis, episcleritis, aphthous stomatitis, erythema nodosum, gangrenous pyoderma. These complications are observed more often with damage to the large intestine.
2. Manifestations that are presumably genetically associated with the HLA B27 genotype: ankylosing spondylitis, sacroiliitis, uveitis, primary sclerosing cholangitis.
3. Lesions directly related to the pathology of the intestine itself:

• kidney stones arising due to a disruption of uric acid metabolism, alkalization of urine and excessive absorption of oxalates in the intestine;
• malabsorption syndrome;
• gallstones formed due to impaired reabsorption of bile salts in the ileum;
• secondary amyloidosis, developing against the background of a long-term inflammatory and purulent process.

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Acute Crohn's disease

The acute form of Crohn's disease is observed less frequently. As a rule, the pathological process is localized in the terminal section of the ileum. The characteristic clinical signs of the acute form of Crohn's disease are:

• increasing pain in the right lower quadrant of the abdomen;
• nausea, vomiting;
• diarrhea, often with blood;
• flatulence;
• increased body temperature, often with chills;
• thickened, painful terminal ileum;
• leukocytosis, increased ESR.

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Chronic Crohn's disease

The chronic form of Crohn's disease is the most common. Its manifestations vary depending on the localization of the inflammatory process.

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Small intestinal localization

The clinical symptoms of this form can be divided into a group of general and local symptoms.

General symptoms are caused by intoxication and malabsorption syndrome and include: weakness, malaise, decreased performance, increased body temperature to subfebrile, weight loss, edema (due to protein loss), hypovitaminosis (bleeding gums, cracks in the corners of the mouth, pellagroma dermatitis, deterioration of twilight vision), pain in bones and joints (depletion of calcium salts), trophic disorders (dry skin, hair loss, brittle nails), adrenal insufficiency (skin pigmentation, hypotension), thyroid gland (lethargy, puffiness of the face), sex glands (menstrual irregularities, impotence), parathyroid glands (tetany, osteomalacia, bone fractures), pituitary gland (polyuria with low urine density, thirst).

Local symptoms:

1. Periodic, and later constant dull pain (with damage to the duodenum - in the right epigastric region, jejunum - in the left upper and middle part of the abdomen, ileum - in the right lower quadrant of the abdomen).
2. The stool is semi-liquid, liquid, foamy, sometimes with an admixture of mucus and blood.
3. In case of intestinal stenosis - signs of partial intestinal obstruction (cramping pain, nausea, vomiting, gas and stool retention).
4. When palpating the abdomen, there is pain and a tumor-like formation in the terminal section of the ileum; if other sections are affected, there is pain in the umbilical region.
5. Formation of internal fistulas opening into the abdominal cavity (interloop, between the ileum and cecum, gall bladder and urinary bladder), and external fistulas opening into the lumbar and inguinal regions.
6. Intestinal bleeding (melena) is possible.

Taking into account the above-described symptoms, it is advisable to distinguish four main types of regional enteritis (Walfish, 1992):

• inflammatory - characterized by pain in the right lower quadrant of the abdomen and tenderness upon palpation of this area (especially the ileum terminale), which, with pronounced symptoms, resembles acute appendicitis;
• obstructive - develops with intestinal stenosis, symptoms of recurrent partial obstruction appear with severe spastic abdominal pain, bloating, constipation and vomiting;
• diffuse jejunoileitis - characterized by pain in the right iliac region, tenderness on palpation in the umbilical and right iliac region; sometimes symptoms of partial intestinal obstruction; gradual weight loss and even severe exhaustion;
• abdominal fistulas and abscesses - are usually detected in the late stages of the disease, accompanied by fever, abdominal pain, general exhaustion. Fistulas can be intestinal-intestinal, intestinal-vesical, intestinal-retroperitoneal, intestinal-cutaneous.

Localization in the colon (granulomatous colitis)

Main clinical symptoms:

1. Abdominal pain of a cramping nature, occurring after eating and before defecation. Constant pain during movements, bending of the body (caused by the development of the adhesion process) is also possible. The pain is localized along the course of the large intestine (in the lateral and lower parts of the abdomen).
2. Severe diarrhea (liquid or mushy stool up to 10-12 times a day with blood). Some patients have a strong urge to defecate at night or in the morning.
3. Paleness, dryness of the skin, decreased turgor and elasticity.
4. When examining the abdomen, a decrease in the tone of the muscles of the anterior abdominal wall is revealed, palpation along the colon is accompanied by significant pain. The sigmoid colon is most often determined as a tourniquet, which is explained by the infiltration of its wall.
5. Anal fissures are observed in 80% of patients. The features that distinguish them from ordinary fissures are: different localization, often multiple character, significantly less painfulness, laxity of granulation, absence of rigid scar edges, spasm of the sphincter.
6. During digital examination, if the anal canal walls are involved in the process, edematous tissues are palpated, and a decrease in sphincter tone can often be detected. After removing the finger, a gaping anus and leakage of intestinal contents, usually purulent and bloody, are observed. In the presence of cracks and fistulas, especially with extensive purulent ischiorectal leaks, complete destruction of the fibers of the sphincter is possible.
7. An important diagnostic sign is fistulas associated with the intestine and infiltrates of the abdominal cavity. Fistulas of the rectum in Crohn's disease, even with a long existence, are rarely accompanied by scarring and are most often surrounded by infiltrated tissues with polyp-like altered, infiltrated mucous membrane in the area of the internal opening and flaccid "labial-protruding" outward granulations around the external opening.

Sometimes the disease manifests itself only as a sluggish ulcer of the anal canal, often spreading to the skin.

Fistulas can be internal (interintestinal, intestinal-vesical, gastrointestinal, etc.) and external, originating from different parts of the digestive tract. The cause of fistula formation is a transmural inflammatory process involving the serous membrane, causing the formation of adhesions between adjacent organs. Since in the case of inflammation there is usually ulceration of the type of ulcers-cracks, deeply penetrating the intestinal wall, and sometimes beyond it, it is in this place that penetrations are formed with the development of internal or external fistulas.

Infiltrates of the abdominal cavity are immobile, painful formations, usually fixed to the posterior or anterior abdominal wall. The most typical localization of the infiltrate is in the right iliac region, often in the area of the scar after appendectomy. Due to the frequent breakthrough of pus into the surrounding tissue and the transition of the inflammatory process to the surrounding tissues, the clinical picture is supplemented by symptoms of psoas syndrome.

Depending on the localization of the pathological process, ileocolitis, colitis, and anal forms are distinguished. The process can affect one or several areas of the intestine (single- or multifocal lesion) and proceed as an ulcerative, sclerotic, or fistulous variant.

Combined lesions of the small and large intestine

This form of Crohn's disease is manifested by a combination of symptoms characteristic of terminal ileitis and symptoms of colon damage. G. A. Grigorieva (1994) indicates that when the pathological process is localized in the ileum and right sections of the colon, pain in the right half of the abdomen and subfebrile body temperature predominate; some patients experience symptoms of malabsorption. With diffuse damage to the colon in combination with damage to the terminal section of the ileum, the clinical picture is dominated by symptoms of total colitis.

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Localization in the upper gastrointestinal tract

Isolated lesions of the upper gastrointestinal tract in Crohn's disease are very rare; there is often a combination of this localization with lesions of the small and large intestines.

The clinical picture of Crohn's disease with localization of the pathological process in the esophagus, stomach, duodenum at the initial stages resembles the clinical picture of chronic esophagitis, chronic gastritis, duodenitis, respectively. When the stomach and duodenum are affected, the clinical manifestations may be similar to the clinical picture of gastric ulcer and duodenal ulcer (ulcer-like syndrome), and there is often blood in the vomit. As the disease progresses, weakness, subfebrile body temperature, weight loss, and anemia join in.

Complications of Crohn's disease

Complications of Crohn's disease include: perforation of ulcers, acute toxic dilatation of the colon, intestinal bleeding, fistulas, intestinal strictures. Perforation of ulcers is often covered due to damage to the serous membrane of the intestine and the formation of adhesions with the omentum and intestinal loops.

Massive bleeding manifests itself depending on the localization by vomiting "coffee grounds", melena or scarlet blood during defecation. Bleeding is caused by ulceration of the intestine and damage to a large vessel.

Strictures of the small and large intestines are observed in approximately 20-25% of cases. They manifest themselves as cramping abdominal pain, flatulence, constipation, and clinical signs of partial intestinal obstruction.

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