Crohn's disease: symptoms

Symptoms of Crohn's disease depend on the localization and prevalence of the process, on the variant of the course - acute or chronic.

[1], [2]

Extraintestinal signs of Crohn's disease

Extraintestinal manifestations of Crohn's disease Walfish (1992) divides 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 more common with lesions of the large intestine.
2. Manifestations that are supposedly genetically related to the genotype HLA B27: ankylosing spondylitis, sacroiliitis, uveitis, primary sclerosing cholangitis.
3. Lesions directly related to the pathology of the intestine itself:

• kidney stones arising in connection with a violation of uric acid metabolism, alkalinization of urine and excessive absorption in the intestines of oxalates;
• malabsorption syndrome;
• gallstones formed in connection with a violation of the reabsorption of bile salts in the ileum;
• secondary amyloidosis, which develops against a background of prolonged inflammatory and purulent process.

[3], [4], [5], [6]

Acute form of Crohn's disease

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

• growing pains in the right lower quadrant of the abdomen;
• nausea, vomiting;
• diarrhea, often with an admixture of blood;
• flatulence;
• fever, often with chills;
• thickened painful terminal segment of the ileum;
• leukocytosis, an increase in ESR.

[7], [8]

Chronic form of Crohn's disease

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

[9], [10]

Small intestinal localization

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

Common symptoms are due to intoxication and malabsorption syndrome and include: weakness, malaise, decreased performance, fever to subfebrile, weight loss, swelling (due to protein loss), hypovitaminosis (bleeding gums, cracks in the corners of the mouth, pellagic dermatitis, worsening of twilight vision) , pain in bones and joints (impoverishment of calcium salts), trophic disorders (dry skin, hair loss, brittle nails), adrenal insufficiency (skin pigmentation, hypotension), thyroid (braked) spine, puffiness of the face), gonads (violation of menstruation, impotence) paraschitovvdnyh glands (tetany, osteomalacia, bone fractures), pituitary (polyuria low density urine, thirst).

Local symptoms:

1. Periodic, and later constant dull pains (with lesions of the duodenum - in the right epigastric region, jejunum - in the left upper and middle abdomen, ileum - in the right lower quadrant of the abdomen).
2. The chair is semi-liquid, liquid, foamy, sometimes with an admixture of mucus, blood.
3. With intestinal stenosis, signs of partial intestinal obstruction (cramping pain, nausea, vomiting, gas retention, stools).
4. When palpation of the abdomen - soreness and tumor-like formation in the terminal section of the ileum, with the defeat of other departments - pain in the peripodal region.
5. Formation of fistulas internal, opening into the abdominal cavity (inter-loop, between the ileum and caecum, bile and bladder), and external, opening into the lumbar and inguinal area.
6. Intestinal bleeding is possible (melena).

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

• inflammatory - characterized by pain in the right lower quadrant of the abdomen and painful on palpation of this area (especially ileum terminale), which, in severe symptoms, resembles acute appendicitis;
• obstructive - develops with stenosis of the intestine, there is a symptomatic of recurrent partial obstruction with severe spastic pain in the abdomen, its swelling, constipation and vomiting;
• diffuse ejinoileitis - characterized by pains in the right iliac region, painfulness during palpation in the perigapic and right iliac region; sometimes symptomatic of partial intestinal obstruction; the weight loss and even exhaustion gradually develop;
• abdominal fistulas and abscesses - are usually found in the late stages of the disease, accompanied by fever, abdominal pain, general exhaustion. Fistulas can be intestinal, intestinal-urinoid, intestinal-retroperitoneal, intestinal-cutaneous.

Localization in the large intestine (granulomatous colitis)

Main clinical symptoms:

1. Pain in abdominal cramping, arising after eating and before defecation. There are also permanent pain in the movements, torso of the trunk (due to the development of adhesive process). The pain is localized in the course of the large intestine (in the lateral and lower abdomen).
2. Severe diarrhea (liquid or mushy stool up to 10-12 times a day with an admixture of blood). Some patients have expressed desires for defecation at night or in the morning.
3. Pale, dry skin, reduce its turgor and elasticity.
4. When examining the abdomen revealed a decrease in the tone of the muscles of the anterior abdominal wall, palpation along the colon is accompanied by considerable soreness. The sigmoid colon is most often defined as a tourniquet, which is explained by the infiltration of its wall.
5. Anal fissures are noted in 80% of patients. Features that distinguish them from ordinary cracks: different localization, often multiple nature, significantly less pain, sluggish granulation, lack of rigid scar tissue, spasm of the sphincter.
6. When finger research in case of involvement in the process of the walls of the anal canal, palpable tissues are palpable, it is often possible to determine the decrease in the tone of the sphincter. After the extraction of the finger, the anus is gaping and the intestinal contents leak, usually purulent-bloody. In the presence of cracks and fistulas, especially with extensive purulent ischiorectal fouling, complete destruction of the pulp fibers is possible.
7. An important diagnostic feature is fistula associated with the intestine, and infiltrates of the abdominal cavity. Fistulas of the rectum in Crohn's disease, even with prolonged existence, are rarely accompanied by scarring and are often surrounded by infiltrated tissues with a polyp-shaped, infiltrated mucosa in the region of the inner orifice, and laminar "labial-protruding" outward granulations around the external opening.

Sometimes the disease manifests itself only by the sluggish ulcer of the anal canal with a frequent transition to the skin.

The fistulas can be internal (intestinal, intestinal-vesical, gastrointestinal, etc.) and external, coming from different parts of the digestive tract. The cause of fistula formation is a transmural inflammatory process involving the serous cover, which causes the formation of adhesions between nearby organs. Since in the case of inflammation usually there is ulceration in the type of ulcer-cracks that penetrate deeply into the wall of the intestine, and sometimes beyond its limits, just at this point penetration develops with the development of internal or external fistula.

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 in the right iliac region, often in the area of the scar after appendectomy. In connection with the frequent breakthrough of pus into the surrounding cellulose and the transition of the inflammatory process to the surrounding tissues, the clinical picture is supplemented by the symptoms of psoas-syndrome.

Depending on the localization of the pathological process, Ileocolitis, colitis, and anal form are distinguished. The process can capture one or more areas of the intestine (single or multifocal lesion) and proceed according to the type of ulcerative, sclerotic or fistulous variant.

Combined lesion of small and large intestine

This form of Crohn's disease is manifested by a combination of symptoms inherent in terminal ileitis, and symptoms of colon lesions. GA Grigorieva (1994) indicates that when the pathological process is localized in the ileum and the right parts of the colon, pain in the right side of the abdomen and subfebrile body temperature prevail; in some patients, symptoms of malabsorption are observed. In case of diffuse lesions of the large intestine in combination with the terminal terminal of the ileum, symptomatic of total colitis prevails in the clinical picture.

[11], [12], [13], [14]

Localization in the upper gastrointestinal tract

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

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

Complications of Crohn's disease

Complications of Crohn's disease include: perforation of ulcers, acute toxic dilatation of the colon, intestinal bleeding, fistula, intestinal stricture. Perforation of ulcers is often covered in connection with the lesion of the serous shell of the intestine and the formation of adhesions with the gland and loops of the intestine.

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

Strictures of the small and large intestine are observed in approximately 20-25% of cases. They manifest cramping pains in the abdomen, flatulence, constipation, a clinic of partial intestinal obstruction.

[15], [16], [17], [18], [19]