MOFFITT GI REPORT PEARLS 4/12/17: Crohn Disease and TPN!

Hey Everyone! Great GI report today. Thanks to Amanda for presenting the case of a young man with Crohn disease with acute abdominal pain who was found to have an intestinal abscess, possible fistula, and also possibly recurrent c diff! Pearls below:

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Top Pearls:

  1. Large joint arthritis without destruction is the most common extra-intestinal manifestation of Crohn disease.
  2. Early TPN is recommended in hospitalized patients with severe Crohn disease.
  3. In patients with Crohn disease who have had a bowel resection, the most common site of disease recurrence is at the site of anastomosis.

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For those who want more info:

Crohn disease can affect the entire GI tract including oral ulcers, esophageal involvement, and perianal disease.

Extra-intestinal Crohn manifestations:

  • Arthritis (most common, 20%, large joints without destruction)
  • Skin manifestations (10% of patients have EN or PG)
  • Anterior uveitis (5% of patients)
  • PSC (5% of patients)
  • Thromboembolism (venous and arterial)
  • ILD
  • Renal stones
  • B12 deficiency
  • AA Amyloid

Complications of Crohn disease:

  • Malabsorption
  • GI bleeding (gross bleeding less common than in UC)
  • Phlegmon: walled off inflammatory mass without infection
  • Abscess
  • Fistula (50% within 20 years)
  • Stricture/SBO
  • Bowel perforation/peritonitis

For severe Crohn disease, management consists of bowel rest, parenteral nutrition, and IV glucocorticoids. Remember that unlike in UC, 5-ASA formulations have not been shown to be helpful in severe Crohn disease.

*Pearl: SBO in a patient with Crohn disease may be entirely due to a Crohn flare! Don’t forget to start steroids while you’re consulting surgery for the SBO.

*Pearl: From Dr. Ostroff, early TPN should be initiated in patients with severe Crohn disease who are admitted because nutritional deficiency will impair intestinal and other healing. Patients with severe Crohn disease won’t absorb sufficient enteral nutrition. Remember to check an albumin/prealbumin level!

Unfortunately, parenteral nutrition has not been shown to help induce disease remission.

TPN complications:

  • Increased risk of bacterial/fungal bloodstream infection
  • Metabolic effects: hyperglycemia, electrolyte disturbance, nutrient excess/deficiency, refeeding syndrome, Wernicke encephalopathy, hepatic dysfunction

*Pearl: In patients with Crohn disease who have had a bowel resection, disease recurrence is most common at the site of anastomosis!

 

Evernote: https://www.evernote.com/shard/s272/sh/7f85d074-e67d-4db7-b6db-ec894b98b025/20616ffd6a980cd7df32d4e520d0674a

 

Have a great day everyone!

SamMy

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