Clinical signs and symptoms

Moles, Warts and Skin Tags Removal

Skin Tags Removal By Dr. Davidson

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The initial clinical presentation of Crohn's disease may be subtle, variable, non-specific and easily overlooked. Common symptoms include abdominal pain, diarrhea and/or weight loss.103 A plateau in linear growth, delayed pubertal development, perianal lesions, fever, pallor, hematochezia and digital clubbing may also be present.103 Crohn's disease may affect any area of the gastrointestinal tract from the lips to the perianal area. In a study on Scottish children and adolescents with Crohn's disease,116 approximately 30% of patients had disease limited to the terminal ileum, 20% of patients had exclusive colonic involvement and 50% of patients had both ileal and colonic involvement. In a more recent population-based study in Wisconsin, at the time of diagnosis isolated ileal disease was identified in 25% and ileocolonic involvement was found in 29%. About one-third of children had colonic involvement and 14% had disease in the upper gastrointestinal tract.18 The inflammation associated with ulcerative colitis is limited to the colon, with the exception of mild inflammation in the ileum, termed 'backwash ileitis'.

The constellation of abdominal pain, diarrhea, poor appetite and weight loss represents the classic presentation of Crohn's disease in children of any age group.103 Frequently, the onset of pain is insidious and intermittent. Families and care providers often dismiss the symptoms as an acute illness, or a condition related to anxiety. In some individuals, anorexia may be the primary manifestation prompting an evaluation for anorexia nervosa or an eating disorder. Laboratory studies may suggest chronic inflammation, but up to 20% of children with IBD have a normal erythrocyte sedimentation rate. A summary of the prevalence of various clinical presentations from two separate studies is shown in Table 23.2. Abdominal pain is the most common single symptom at presentation, and may be periumbilical or localized to the right lower quadrant or to the lower abdomen. Grossly bloody diarrhea or extraintestinal manifestations signify colonic involvement. When diarrhea is predominant without visible blood or the patient has clubbing, one should suspect small-bowel involvement. Uncontrolled gastrointestinal hemorrhage is rare in Crohn's disease, but may occur with an ileal ulcer.

Clinical case 1

A 6-year-old boy developed swollen lips (Figure 23.1) and painful ulcers in his mouth. He denied any history of abdominal pain, but his weight was decreased. An upper gastrointestinal series with small-bowel follow-through was normal. He had a history of anal fissures in the past and because of hard stools, he had been treated with stool softeners. An upper endoscopy and colonoscopy did not reveal evidence of inflammation, but a biopsy of the buccal mucosa demonstrated granulo-matous cheilitis. He was treated with oral prednisone and metronidazole, with an initial improvement. He developed hepatitis while taking 6-mercaptopurine. Three infusions of infliximab were not effective. His perianal disease improved with a course of 20 hyperbaric oxygen sessions. Nutritional therapy with nightly nasogastric tube feedings for 2

Swollen Lips Oral Crohns
Figure 23.1 Swollen lips in a child with Crohn's disease involving the oral mucosa.

Points of interest

  • 1) Crohn's disease may present in any region of the gastrointestinal tract;
  • 2) One-third of patients with Crohn's disease do not respond to infliximab;
  • 3) Nutritional therapy is important adjunctive therapy.

Impaired linear growth and concomitant delay in sexual maturation are important clinical manifestations in children with Crohn's disease, that may precede the onset of intestinal symptoms by 12-18 months.103 In a prospective study of children with IBD,117 30% of children with Crohn's disease had growth delay, which was defined as a fall in the height centile of more than 0.3 standard deviation per year, a growth velocity of less than 5 cm per year, or a decrease in the growth velocity of > 2 cm compared with the preceeding year. About 50% of children had evidence of decreased height velocity prior to the diagnosis of Crohn's disease.118 Delayed linear growth velocity and sexual maturation may be related to a chronically insufficient dietary intake and/or an increased energy requirements related to chronic inflammation or fever.118,119 Anorexia occurs in 30% of children with Crohn's disease and may be related to upper gastrointestinal tract involvement.120 Studies in a rat colitis model demonstrated that TNF-a inhibited maturation of growth plate chondrocytes,121 suggesting that some proinflammatory cytokines years has contributed to his maintaining his weight and growth, but he has been unable to tolerate sufficient caloric intake to have catchup growth. Five years after his initial presentation, he has developed chronic inflammatory changes in the colon.

Table 23.2 Prevalence of clinical presentations in Crohn's disease from two studies (references 103 and 166)

Clinical symptoms Percentage (n=386)103 Percentage (n=40)166

Abdominal pain



Weight loss






Blood in the stool



Perianal lesions






Growth failure



Mouth ulcers






Skin lesions



*Prevalence was not specified may be a factor in the growth delay observed in children with Crohn's disease.

Anemia is present in 25-85% of patients with Crohn's disease,122 many of whom have anemia of chronic disease. Iron deficiency anemia is micro-cytic and may result from gastrointestinal blood loss, malabsorption of iron in the duodenum and jejunum because of inflammation and/or a lack of adequate oral intake. Folate deficiency causes a megaloblastic anemia, but frequently folate deficiency is associated with iron deficiency as well, and the indices may not be macrocytic. Folate deficiency is most commonly due to nutritional causes, but patients who take sulfasalazine are at increased risk for developing folate deficiency. For that reason, sulfasalazine is always prescribed with folate supplementation. Vitamin B12 is absorbed in the ileum; deficiencies are usually related to lack of absorption, related to inflammatory changes, fibrosis or resection. Because many years may be required to deplete vitamin B12 stores in an individual who has a normal reserve, the development of deficiency is often insidious. Children with ileal disease should be monitored for vitamin B12 deficiency by measuring serum levels. Clinical manifestations of the disease -anemia, dermatitis, cheilitis, decreased serum transaminases, peripheral neuritis, irritability and posterior column signs - do not develop for many months.

Clinical case 2

A 13-year-old girl was referred for evaluation of lower abdominal pain, diarrhea and a perirectal abscess. She had had intermittent abdominal pain from infancy but about 1 year prior to evaluation noted an increase in frequency and intensity. Her pediatrician recommended a lactose-restricted diet and the pain completely resolved. Two months prior to her referral to a pediatric gastroenterologist, she developed a perirectal abscess that was drained by a surgeon. The abscess healed slowly. She reported having 4-5 loose stools daily, but never noticed any blood. Her appetite was good and her rate of growth was not changed. There was no family history of IBD but her mother has Sjogren's syndrome, a maternal second cousin has juvenile dermatomyositis and her maternal grandfather has rheumatoid arthritis. Her physical examination was normal with the exception of a well-healed surgical incision about 4 cm from the anus. Her weight was 25% for age; her height was 50% for age. A complete blood count (CBC), erythrocyte sedimentation rate (ESR) and liver function tests were normal. An upper gastro-intestinal radiograph with small-bowel follow-through was read as normal. Over the next 10 weeks she continued to experience intermittent crampy abdominal pain and occasional loose stools. She noted some blood on the paper after wiping and the perianal abscess would drain intermittently. However, over this period of time she continued to gain weight. An ileocolonoscopy revealed a normal-appearing ileum and right colon with multiple aphthoid lesions in the left colon and erythema in the rectum. Biopsies identified an active and chronic ileitis with granulomas but no evidence for ulceration, as well as microscopic changes of chronic and active inflammatory changes in the left colon with erosions.

She was started on mesalamine and metronida-zole. She began to feel better after 1 week of therapy, but then had recurrence of crampy abdominal pain with nausea and increased frequency of stooling up to seven loose bowel movements daily. Two weeks after starting therapy, prednisone 20mg twice a day was prescribed. Metronidazole was discontinued because of dysesthesia in her hands. After 3 weeks of taking prednisone, she was quite Cushingoid, but she was passing three formed bowel movements daily and the perianal abscess was not draining. She began to taper the dose of prednisone by 5 mg/day every week. When she reached 30mg of prednisone daily, she began to have increased frequency of stool-ing and crampy abdominal pain. Because of concerns for steroid dependence, she was started on 50mg daily of 6-mercaptopurine after it was checked that her thiopurine methyl-transferase (TPMT) activity was in the normal range. A CBC and differential, liver function tests and amylase were checked weekly for 3 weeks and then monthly. She tolerated the 6-mercaptopurine well and was able to discontinue prednisone after 5 months. She was maintained on mesalamine and 6-mercaptopurine.

After 18 months of therapy, she began to develop intermittent abdominal pain and diarrhea. Her symptoms increased despite therapy with metronidazole and ciprofloxacin. She began to lose weight. Infliximab was started and 1 week after the initial infusion, she began to improve. She completed a second infusion 2 weeks after the first and a third infusion 6 weeks after the second infusion. She is now maintained on 6-mercaptopurine and an inflix-imab infusion every 8 weeks and remains without gastrointestinal symptoms.

Points of interest

  • 1) The onset of Crohn's disease is often insidious;
  • 2) Radiographic studies in the early stages of Crohn's disease may appear normal;
  • 3) Mucosal biopsy of normal-appearing endo-scopic areas may provide evidence for inflammatory bowel disease;
  • 4) Mesalamine with or without antibiotics may be effective therapy in some children with new-onset mild-to-moderate Crohn's disease, but therapy should be changed if there is not a response within 2-4 weeks;
  • 5) The inability to tolerate a taper of corti-costeroids is an indication to begin 6-mercap-topurine;
  • 6) Therapy with 6-mercaptopurine may take at least 3 months to become effective;
  • 7) When 6-mercaptopurine fails to control symptoms of Crohn's disease, infliximab should be considered. About two-thirds of adults will have an initial response to in-fliximab.

Perianal lesions may be the first presenting feature of Crohn's disease. Perianal disease associated with Crohn's disease is frequently mild with small perianal skin tags or anal fissures, but more severe problems such as perianal fistulae and abscesses may develop. Fortunately, less than 5% of children with Crohn's disease will develop a highly destructive form of perianal disease with recurrent abscesses and fistulae (Figure 23.2) involving the genitalia, and often resulting in rectal strictures.123,124 As illustrated in Case 2, the patient was thought to have a perirectal abscess, but after surgical intervention, the area did not heal. With the exception of the first 2 years of life, children with persistent perianal abscess, fissure or fistula that does not respond to topical treatment and antibiotics should be evaluated for Crohn's disease prior to the initiation of surgical therapy. Approximately one-third of children with Crohn's disease can have significant perianal abnormalities during the course of their disease.123 The most common perianal problem is skin tags which may become quite large. Some may become inflamed and painful, but for many adolescents they become a source of embarrassment. Perianal inflammatory disease may respond to antibiotics that have good anaerobic coverage, such as metronidazole, but intravenous administration is frequently required to achieve maximal healing. Non-inflamed skin

Signs And Symptoms Anal Abscess
Figure 23.2 Perianal fistula in a child with Crohn's disease. Arrow marks the opening of the fistula. The erythema is commonly seen because of the excoriation to the skin caused by the drainage onto the perineum.

tags usually do not resolve with medical treatment, and the use of topical tacrolimus or corticosteroids has not proved to be beneficial in reducing the size of the skin tags. Immunomodulators or cortico-steroids may be necessary to control mucosal inflammation which may be a contributing factor to the growth of perianal skin tags.

Extraintestinal manifestations are usually associated with colonic involvement of Crohn's disease, and may precede intestinal symptoms by many months. The commonly involved organs are joints, skin, liver, eye and bone; the manifestations are listed in Table 23.3.125,126 At least one extraintestinal manifestation is present in about 25-35% of adults with IBD.125

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    What specific clinical symptoms after eating non nutritius foods?
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