Clinical Features

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The clinical course of Crohn's disease varies and in the individual patient is unpredictable. Abdominal pain, anorexia, diarrhea, and weight loss are present in 75 to 80 percent of cases. Occasionally, a patient with Crohn's disease may present with acute right-lower-quadrant abdominal pain and fever and, on examination, be found to have a mass in the right lower quadrant. More commonly, the patient experiences an insidious onset of recurrent abdominal pain, fever, and diarrhea that lasts for several years before the definitive diagnosis is established. Approximately one-third of patients develop perianal fissures or fistulas, abscesses, or rectal prolapse, particularly when there is colonic involvement. Finally, patients may also manifest complications of the disease, such as obstruction with vomiting, crampy abdominal pain, and obstipation, or an intraabdominal abscess with fever, abdominal pain, and a palpable mass. In 10 to 20 percent of patients, the extraintestinal manifestations of arthritis, uveitis, or liver disease may be presenting symptoms. Crohn's disease should also be considered in the differential diagnosis of patients with fever of unknown etiology.

The clinical course and manifestations of the disease appear to be related, partly because of its anatomic distribution; in 30 percent, the disease involves only the small bowel; in 20 percent, only the colon is involved; and in 50 percent, both the small bowel and colon are involved. A small percentage of patients present with disease involving the mouth, esophagus, and stomach. Patients with Crohn's disease of the stomach may demonstrate symptoms similar to those associated with peptic ulcer disease (see Chap.73, "Peptic Ulcer Disease and Gastritis").

The recurrence rate for all patients with Crohn's disease is 25 to 50 percent within 1 year for patients whose disease has responded to medical management; the recurrence rate is higher for those patients who require surgery. Patients with ileocolitis have the highest recurrence rate following surgery. The incidence of hematochezia and perianal disease is higher when the colon is involved, as in ileocolitis or Crohn's colitis. A slight increase in the incidence of arthritis may be associated with Crohn's colitis. Except for the additional concern of growth retardation, childhood-onset Crohn's disease seems to have a course similar to that of adult-onset disease.

Extraintestinal manifestations are seen in 25 to 30 percent of patients with Crohn's disease (see IaMe.7.7.-1), and the incidence of these complications does not differ between patients with Crohn's disease and those with ulcerative colitis. Extraintestinal manifestations are divided among arthritic (19 percent), dermatologic (4 percent), hepatobiliary (4 percent), and vascular (1.3 percent) complications. Peripheral arthropathies are commonly seen in both ulcerative colitis and Crohn's disease and tend to manifest during exacerbations of the underlying disease process. Ankylosing spondylitis can be detected in up to 20 percent of patients with inflammatory bowel disease. Symptoms may occur before, during, and after bouts of Crohn's disease or ulcerative colitis.

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