Pediatric Crohn's Disease
Introduction
Introduction to Crohn's disease in children Crohn's disease in children is a chronic inflammatory granulomatous disease of the gastrointestinal tract that is more common in young people, with fibrosis and mucosal ulcers. The lesion can affect the entire digestive tract, from the mouth to any part of the anus, but mainly invades the ileum jejunum, followed by the colon, and forms a migration lesion outside the gastrointestinal tract. It forms a localized granuloma in one or more segments of the intestine, so it is also called granulomatous enteritis. In 1932, Crohn reported for the first time with Crohn's disease, which is also known as Crohn's disease. It is a disease with no specific treatment. It can be recurrent. There is very little chance of self-healing in 30 years old. In the past 10 years, the incidence of children has an increasing trend. The mild cases have a good prognosis and poor weight. The incidence of this disease is more common in Caucasians, and the age is mostly school-age children. It is often diagnosed after a long time after onset. This disease and ulcerative colitis have now been collectively referred to as inflammatory bowel disease. Lesions are more common at the end of the ileum and adjacent to the colon, often in a segmental distribution. The main clinical manifestations of abdominal pain, diarrhea, abdominal mass, fistula formation and intestinal obstruction, accompanied by fever, anemia and so on. The age of onset is mostly between 15 and 40 years old, and there are slightly more men than women. basic knowledge The proportion of illness: 0.005% Susceptible people: children Mode of infection: non-infectious Complications: intestinal obstruction anemia acute renal failure
Cause
The cause of Crohn's disease in children
Causes
The incidence of Crohn's disease in children may be related to immune abnormalities. Infection may have a role in the pathogenesis of Crohn's disease in children. Related to heredity, the disease has obvious ethnic differences and family aggregation. In terms of incidence, whites are higher than blacks, single-oval twins are higher than twins; children with Crohn's disease have a positive family history of 10%-15%; the study found that the disease has some genetic defects. The above suggests that the disease has a genetic predisposition.
Pathogenesis
Previous studies have demonstrated a relationship between a mutation in a gene on chromosome 16 and Crohn's disease. In the laboratory, animal models of inflammatory bowel disease (IBD) prepared in a sterile environment often do not exhibit IBD. Therefore, the NOD2 gene is a very good candidate for Crohn's disease susceptibility genes, and an important common virulence factor associated with Crohn's disease, immune response and intestinal bacteria.
NOD2 is a leucine-rich repeat gene that is required for the sensing of lipopolysaccharide and activates nuclear factor kappa B (NF-B) signaling pathway. Steroids inhibit the expression of NF-B as well as tumor necrosis factor and other cytokines. Activation of NF-B and accelerated expression of tumor necrosis factor in monocytes in patients with Crohn's disease. NOD2 expression is localized to monocytes, which serve as cytoplasmic receptors for pathogenic bacterial components. Lipopolysaccharide signaling in mice susceptible to colitis is defective. The diagnosis of ulcerative colitis or Crohn's disease is determined by clinical, radiological, endoscopic, and histological examinations.
Patients with uncertain colitis were excluded from the study. 6% of patients with Crohn's disease are homozygous for NOD2. Patients with ulcerative colitis did not fall into this category, and the control group did not have homozygous NOD2. NOD2 heterozygotes are present in 18% of Crohn's disease, 6% of patients with ulcerative colitis, and 8% of controls. Hampe et al. pointed out that mutations are rare, and only 6.5% of patients with Crohn's disease are homozygous.
This mutation poses a high risk for the development of Crohn's disease. There was no correlation between NOD2 and ulcerative enteritis, but NF-B activation was stronger in Crohn's disease than ulcerative enteritis.
Prevention
Pediatric Crohn's disease prevention
1. The disease is related to genetic factors, and genetic disease prevention and treatment should be done well.
2. Actively prevent and treat various bacterial infectious diseases, and the transfer of diseases caused by pathogens has been confirmed.
3. Breastfeeding should be promoted to reduce the chance of infants and young children contacting other allergens, to protect them, to rest properly, to strengthen nutrition, to correct water and electrolyte disorders, and to improve anemia and hypoproteinemia. Instruct patients to conduct psychological training and pay attention to mental health.
Complication
Complications of Crohn's disease in children Complications, intestinal obstruction, anemia, acute renal failure
Complications often occur in the late stage, such as chronic incomplete intestinal obstruction, intestinal perforation, internal hemorrhoid formation, right lower quadrant can reach the tumor, sometimes can produce rectal stenosis and anal fistula, secondary anemia, plasma albumin reduction, low calcium (low Magnesium and low zinc), vitamin D deficiency, fractures, bone pain, cholesterol cholelithiasis, calcium oxalate kidney stones, ureteral obstruction, acute renal failure and amyloidosis.
1. Gastrointestinal hemorrhage As mentioned above, if the lesion is close to the branch of the intestinal tract, and the invasion is deep, there may be recessive or dominant blood loss in the digestive tract. The total amount of major bleeding may reach 800-1000 ml, but the intermittent amount is small. More people see bleeding.
2. The main cause of digestive tract obstruction is intestinal fibrosis, edema, contracture or granuloma leading to intestinal stenosis, or intestinal adhesions, or due to inflammatory polypoid lesions in the intestine plus fecal mass blockage, etc. Domestic data suggest that up to 66.7% of patients with gastrointestinal obstruction.
3. Digestive tract perforation Because the disease invades the whole layer of the gastrointestinal wall, it is easy to cause serious damage to the whole wall. After the fissure ulcer penetrates, it can form chronic perforation and adhere to the surrounding tissue, but rarely occurs acute perforation or free perforation.
4. Abscess formation of gastrointestinal tract, chronic perforation is easy to be complicated by abdominal infection, followed by intestinal abdomen, intestinal fistula, mesenteric, subhepatic, spleen, underarms and other small abscess formation, children with high fever, chills, Persistent abdominal pain or sepsis, usually Gram-negative bacilli infection.
5. The formation of localized ileitis in the sacral tract is more likely to occur than other intestinal inflammatory diseases. For the reasons mentioned above, most of them are between the intestinal and intestinal tracts such as the small intestine and the sigmoid colon. Others also have between the intestine and the peritoneum, between the genitals and the anus. Between the week and the rectum.
6. Other rare complications are not discussed one by one. It is reported that the incidence of gastrointestinal cancer is increased in children with localized ileitis, but this is inconclusive.
7. Malnutrition water, electrolyte imbalance can cause calcium deficiency, zinc, magnesium, etc. in children, children with anorexia due to fear of abdominal pain, diarrhea, etc., more severe malnutrition, hypoproteinemia, anemia and multivitamin malabsorption; 70% Children may have lactose malabsorption, but there are also data that the disease has no significant effect on nutritional status and energy supply.
8. Growth retardation Due to nutritional status and application of therapeutic drugs, chronic dysplasia is common, bone development is slow, osteophyte calcification is incomplete, and intelligence may also be low, but the growth hormone level in children is not low. In addition, children Mental disorders such as depression may also occur.
Symptom
Symptoms of Crohn's disease in children Common symptoms Anorexia abdominal pain, fatigue, constipation, vitamin D deficiency, nausea, weight loss, diarrhea, blood in the stool, low fever
Clinically, it is characterized by abdominal pain, diarrhea, abdominal mass, fistula formation and intestinal obstruction. May be associated with fever, anemia, nutritional disorders and extraintestinal damage to joints, skin, eyes, oral mucosa, liver.
Digestive system performance
Abdominal pain: the most common symptom. Often in the right lower abdomen or umbilical hernia intermittent, often with spastic pain accompanied by bowel. Exacerbated after the meal. Temporary relief after defecation, such as persistent abdominal pain, tenderness is obvious, suggesting that expensive inflammation and peritoneal or abdominal hospital abscess formation, total abdominal pain and abdominal muscle tension, may be caused by acute perforation of the diseased intestine.
Diarrhea: a common symptom caused by inflammation of the intestinal segment of the lesion, increased peristalsis and secondary malabsorption. The diarrhea begins as an intermittent episode and is persistent in the later stage of the disease. Paste-like, generally no pus or mucus, lesions involving the lower part of the colon or rectum can have mucus bloody stools and urgency.
Abdominal mass: due to intestinal adhesions, intestinal wall and mesenteric thickening, mesenteric lymphadenopathy, internal hemorrhoids or local abscess formation. It is more common in the right lower abdomen and the umbilical cord.
Fistula formation: A fistula is formed by a transmural inflammatory lesion that penetrates the entire layer of the intestinal wall to the extraintestinal tissue or organ. Internal hemorrhoids can lead to other intestines, mesentery, bladder, ureter, vagina, retroperitoneum, etc. Fistula formation is one of the most important clinical features of Crohn's disease.
Anorectal lesions: Some patients have lesions such as fistula abscess formation and anal fissure around the anorectum.
Whole body performance
Fever: common intermittent low fever or moderate, a small number of hyperthermia with toxemia, fever caused by intestinal activity or secondary infection.
Nutritional disorders: weight loss, anemia, hypoproteinemia, vitamin deficiency, calcium deficiency and osteoporosis. Due to chronic diarrhea, loss of appetite and chronic consumption. There is a water-electrolyte disorder during the acute attack.
Parenteral performance
Some patients have clubbing, arthritis, iridocyclitis, uveitis, nodular erythema, gangrenous pyoderma, oral mucosal ulcer, peribiliary inflammation, sclerosing cholangitis, chronic hepatitis. Occasionally amyloidosis or thromboembolic disease.
Examine
Examination of Crohn's disease in children
Blood test
Peripheral blood examination is common in anemia, mostly small cell hypochromic anemia. If there is folic acid and vitamin B12 malabsorption, it can be a large cell anemia, and the peripheral blood leukocytes increase during the active period.
2. Blood test
Due to poor absorption, plasma albumin can be reduced, low calcium (low magnesium and low zinc), low vitamin D, and accelerated erythrocyte sedimentation rate. Recently, it has been reported that in the active phase of the disease, the IgG-containing cells in the colonic mucosa increase, while still The increase of cells containing IgM can be used as an identification of ulcerative colitis.
3. Fecal examination
Fecal occult blood test is often positive.
4. X-ray inspection
It should include barium meal and barium enema. The X-ray showed intestinal inflammatory lesions. In the early stage, only regular hypertrophic mucosa was seen. It showed nodular changes, intestinal tube stiffness, poor toughness, mucosal folds, longitudinal ulcers or fissures. The lesions are segmentally distributed. Due to the irritation and spasm of the lesions, the expectorant quickly passes without leaving it, called the jumping sign, and the mucosa is normal between the lesions; the tincture quickly passes through leaving a thin line of shadows. For the line-like sign, the mucosa of the lesion is erosive, the nodules are uneven, and deep, large longitudinal sacral shadows, irregular borders, and small nodules surrounding the bulge, some patients may have so-called "pebble signs", multiple semicircles, Paving stone filling and defect, it can also be seen that there is contrast agent filling in the tunnel, irregular sacral tract, especially in the end ileum and ileocecal signs. The long-term chronic children can see the widening of the intestinal mucosal folds, flat or fissure strips. The shape of the sputum, the normal texture disappears, sometimes the mucosal protrusions are "cobblestone", pseudopolyps, multiple stenosis, fistula formation, lesions of the intestinal segment are weakened or disappeared, intestinal fistula is straight and lead-tube, if there is internal fistula formation Barium shunt occurs, and ulcers Kanying.
5. Colonoscopy and biopsy
Fibrocolonoscopy is very important for the diagnosis of Crohn's disease. Endoscopic observation can not only visualize mucosal lesions, but repeated biopsy can improve the detection rate of some important evidences such as non-case granuloma and fissure ulcer. Observing mucosal inflammation and ulceration in the lesions of the colon, and taking a biopsy. The pathology confirmed that it was a non-case granuloma. The rectum and sigmoid colon lesions often have small erythema with multiple borders and clear ridges. See vertical or prolapse ulcer, normal or hyperplasia of the mucosa around the ulcer is cobblestone-like, intestinal stenosis, inflammatory polyps, mucosal appearance between the diseased intestines is normal, erythema mucosa biopsy shows edema in the superficial layer of the lamina propria Local hemorrhage and crypt rupture, some of which are reversible, some form longitudinal ulcers, biopsy found that the lamina propria of the mucosa has non-cheese necrotizing granuloma or a large number of lymphocyte aggregation, providing a basis for early diagnosis, endoscopy can also Understand the extent of disease activity, similar to X-ray angiography, if an endoscopy fails to find important performance Therefore, the diagnosis cannot be denied, and it is necessary to repeatedly select the examination according to the development of the disease, which is often considered in clinical practice.
Diagnosis
Diagnostic identification of Crohn's disease in children
diagnosis
To diagnose the disease, we should consider the symptoms, signs, X-ray, endoscopy and pathological examination of the child. Even so, the diagnosis is not easy. The initial symptoms of the child are not only mild, but also the morphological changes of the lesion. It may not be obvious, so there is no abnormal discovery in a clinical examination, and the disease cannot be completely ruled out. Suspicious cases should be regularly observed dynamically, reviewed regularly, and supported evidence obtained in time. Since no examination index is specific to diagnosis, diagnosis It is often necessary to conduct comprehensive analysis based on clinical, X-ray, endoscopy and histological examinations, and to exclude infections, allergies, tumors and other intestinal diseases.
1. Clinical diagnosis of the disease is a chronic development process, clinical manifestations are complex, long-term chronic abdominal pain, diarrhea, blood in the stool, vomiting, anorexia, weight loss, growth and development and parenteral performance, should consider this disease, according to the medical history, Physical examination, laboratory examination, pathological examination, endoscopy and digestive X-ray examination results and comprehensive long-term follow-up observation to confirm the diagnosis.
2. Diagnostic criteria There is no unified diagnostic criteria for pediatric Crohn's disease. The internationally used diagnostic criteria for adult Crohn's disease [standards established by the World Health Organization (WH0)] and the Lennard- Jones standard, domestic adoption 1993 The "Diagnosis and Identification of Crohn's Disease" standard formulated by the National Symposium on Chronic Non-infectious Intestinal Diseases in Taiyuan, and the standards set by Peking Union Medical College Hospital.
(1) WH0 standard:
1 discontinuous or regional intestinal lesions.
2 The intestinal mucosa is paved with pebbles or longitudinal ulcers.
3 full-thickness inflammatory bowel disease with a mass or stenosis.
4 nodular non-case granuloma.
5 fissure or fistula formation, refractory ulcers.
6 perianal lesions, anal fistula or anal fissure, where the above 1, 2, 3 are suspected; plus one of 4, 5, 6 can be diagnosed, such as with 4, plus 1, 2, 3 The two patients can also be diagnosed, and the patients diagnosed must first exclude other related diseases.
(2) Lennard-Jones criteria: clinical manifestations of Crohn's disease, the diagnosis of this disease is considered in accordance with the following criteria.
1 First, the following diseases must be excluded:
A. Infectious enteritis: according to microbiological examination, including detection of Yersinia antibody if necessary.
B. Ischemic enteritis: According to the predisposing factors, the distribution characteristics and histological features of the lesion.
C. Radiation enteritis: according to medical history.
D. Lymphoma or cancer: According to previous celiac disease, there are suggestive radiological features and prognosis.
2 must include the following conditions:
A. Oral Anal:
a. Chronic granulomatous lesions of the lips or oral mucosa, according to physical examination and biopsy.
b. Pyloric, duodenal disease, according to radiology, endoscopy and biopsy.
c. Intestinal disease, according to radiological examination, endoscopy and surgical specimen examination.
d. Chronic anal damage, according to clinical examinations and biopsy.
B. Non-continuous lesions: the lesions are separated by normal mucosa, which may be relatively large, or there may be "skip lesions" along the long axis or circumference of the intestine, or discrete ulcers, according to Mirror, radiology and pathology.
C. Whole wall inflammation:
a. Fissuring ulcers, according to radiology and pathology.
b. Abscess, according to clinical manifestations and imaging studies.
c. fistula, according to clinical manifestations, radiological examination and pathological examination.
D. Fibrotic lesions: There may be asymmetry and multiple intestinal stenosis, and should be differentiated from the centripetal muscular thickening of ulcerative colitis, according to endoscopy, radiology and pathology.
E. Lymphoid aggregates: A small aphthous ulcer biopsy showing lymphocyte aggregation.
F. Mucus: In the case of acute inflammation, biopsy can be seen in the retention of colonic mucin, according to biopsy and surgical specimen examination.
G. Granuloma: Not only in all cases of Crohn's disease, it should be differentiated from caseous granuloma of tuberculosis, foreign body granuloma or other causes of granuloma, according to biopsy and surgical specimens.
3. National Symposium on Chronic Non-infectious Enteric Diseases (Taiyuan, 1993)
(1) Clinical diagnostic criteria: Localized ileitis occurs mostly in young adults. It is a chronic, recurrent, non-specific total intestinal inflammation of the gastrointestinal tract. The lesions are segmental and occur in the ileum. The colon (including the ileocecal area) and the perianal area are clinically diagnosed as follows.
1 typical clinical manifestations: recurrent right lower abdomen or umbilical pain, may be accompanied by vomiting, diarrhea or constipation, occasional aphthous stomatitis, sometimes abdominal inflammatory mass in the corresponding part, may be accompanied by intestinal obstruction, Complications such as fistula, abdominal cavity or perianal abscess may or may not be accompanied by systemic symptoms such as fever, polyarthritis, iridocyclitis, skin lesions, sclerosing cholangitis, amyloidosis, malnutrition, development Obstacles and so on.
2X-ray manifestations: inflammatory lesions of the gastrointestinal tract, such as fissure ulcers, cobblestone signs, pseudopolyps, single or multiple stenosis, fistula formation, etc., lesions are segmental distribution, CT can show thickening of the intestinal wall Intestinal fistula, pelvic or abdominal abscess.
3 endoscopy: visible leaping distribution of longitudinal or claudication ulcers, normal or hyperplasia of the surrounding mucosa cobblestone-like, or lesion biopsy with non-cheese necrotizing granuloma or a large number of lymphocytes, with 1 clinically suspicious, If you have 1 and 2 or 3 at the same time, you can diagnose the disease clinically. Acute appendicitis should be excluded in acute attacks. Intestinal tuberculosis should be excluded in the case of chronic recurrent episodes. Ulcerative colitis should be excluded except for colonic lesions. At the time, a pathological diagnosis should be obtained by surgical exploration.
(2) Pathological diagnosis criteria:
1 There is no cheese-like necrosis in the intestinal wall and mesenteric lymph nodes.
2 mirror features:
A. Segmental lesions, total wall inflammation.
B. Fissure ulcers.
C. Submucosal height is widened (edema, lymphatic vessels, vasodilatation, fibrous tissue, lymphoid tissue proliferation, etc.).
D. Lymphocyte aggregation.
E. Sarcoid-like granuloma, diagnosed: with any 4 under 1 and 2, suspicious: pathological examination results with basic pathological diagnosis but no mesenteric lymph node specimens.
4. Diagnostic criteria established by Peking Union Medical College Hospital
(1) The typical clinical symptoms are considered the possibility of localized ileitis.
(2) X-ray manifestations of gastrointestinal inflammatory lesions such as fissure ulcers, cobblestone signs, pseudopolyps, multiple stenosis, fistula formation, etc., lesions are segmental distribution; CT shows thickening of the intestinal wall, pelvic or abdominal abscess .
(3) The endoscope can be seen as a longitudinally distributed or longitudinal ulcer with a leaping pattern, and the surrounding mucosa is normal or hyperplasia.
(4) Non-caseous necrotizing granuloma or other pathological basis, with the above (1) and (2) or (3) and pathological supporters can be diagnosed.
Differential diagnosis
The disease needs to be differentiated from chronic intestinal infections such as dysentery, enteritis, tuberculosis and parasites, ulcerative colitis, immunodeficiency diseases with intestinal symptoms and tumors (such as non-Hodgkin's lymphoma), and local ileitis in clinical In the diagnosis, the symptoms are usually slow, the symptoms are not typical, and the test results are not specific and have certain difficulties. Especially the pediatric patients may be less accurate in describing their symptoms and more likely to be confused with other diseases. Therefore, it is very important to make necessary identification with other diseases. Mainly identified with intestinal parasitic diseases, intestinal tuberculosis, infectious bowel disease, acute appendicitis, abdominal epilepsy, viral gastroenteritis, ulcerative colitis.
1. Intestinal tuberculosis (intestinal tuberculosis) The number of tuberculosis patients in China is not small. For long-term low fever, intestinal tuberculosis lesions are located at the end of the ileum and ileocecal, the clinical process is slow, the right lower quadrant pain is also the most common, and the limited back The identification of enteritis is relatively difficult, and the X-ray performance is also very similar. Chronic diseases such as abdominal inflammatory masses should exclude intestinal tuberculosis. In other areas, there are tuberculosis lesions, mostly intestinal tuberculosis, and histological examination shows caseous granulomatous lesions. And often detect acid-fast bacilli, but intestinal tuberculosis is rare in children, often accompanied by tuberculosis symptoms such as low fever, night sweats, fatigue, anorexia, etc., can show alternating diarrhea and constipation, weight loss, PPD skin test showed strong positive reaction, angiography Or endoscopic lesions rarely invade only the end of the ileum, but more ileocecal nodules are uneven, erosion, deformation, mucosal ulcers are mostly ring-shaped, different sizes, can be fused, intestinal tube shortening deformation, colonoscopy And biopsy can help identify, such as biopsy can get caseous necrotizing granuloma, it is very supportive of intestinal tuberculosis diagnosis, if still can not identify, you can try anti-tuberculosis treatment .
2. Ulcerative colitis Ulcerative colitis occurs in the colorectal local ileitis should be distinguished from ulcerative colitis, compared with ulcerative colitis, the incidence of localized ileitis and bloody stools is lower, lesions occur more often In the ileum, it is sometimes difficult to distinguish the two in clinical practice. The latter often begins with rectal disease, and the reperfusion spreads. The symptoms are mainly pus and blood. The abdominal pain is not obvious. The diffuse granules of the colon mucosa are uneven, congested, and more. Divergence in the formation of shallow erosion or ulcers, shallow ulcers, and more bleeding, but the signs of fistula or pebbles are not seen, pathological ulcerative colitis and more granuloma formation for identification.
3. Acute appendicitis (acute appendicitis) Children may have acute appendicitis episodes. When the disease occurs in the right lower quadrant, it may be like acute appendicitis. In the acute stage, it is easy to be misdiagnosed as acute appendicitis, but acute appendicitis usually has an acute onset, non-chronic process, fever. High fever, right lower abdomen pain is confined to the wheat point and its surroundings, the disease progresses rapidly, accompanied by nausea, vomiting is obvious, the body is marked with tenderness, blood leukocytes are significantly elevated, generally no low fever, history of diarrhea, antibiotic treatment is positive The effect is that some need surgery. It is generally easy to identify with localized ileitis. However, it is also due to insufficient stagnation surgery. It is found to be a case of surgical failure caused by localized ileitis. If the pathological changes of appendicitis are found to be inconsistent with the symptoms during surgery, Carefully explore the end of the illiterate.
4. Acute hemorrhagic necrotic enteritis is also a segmental distribution. The disease is more common in children and young people. It has regional and seasonal characteristics. Abdominal pain is mostly in the left upper abdomen, mainly in the left middle abdomen, and blood in the stool is more common. It is bloody or dark red paste-like feces, has a stench smell, obvious symptoms of poisoning, short course of disease, and rarely relapse.
5.Cancer of blindgut (cancer of blindgut) is more than 40 years old, is progressive development, the right lower abdomen is common, firm and nodular, X-ray barium enema examination shows filling defects in the cecum, biopsy can be Confirmed diagnosis.
6. Intestinal parasitic diseases Children can suffer from a variety of parasitic infections, mostly with intestinal ascariasis, parasites have the ability to move, often cause abdominal pain in children with umbilical cord or unfixed parts, symptoms vary, and the pain is light and heavy.
7. Infectious intestinal diseases such as bacterial dysentery, etc., generally have a history of unclean diet, accompanied by abdominal pain, vomiting, fever, chills, mucus pus or pus and blood, rapid development of the disease, stool culture may find pathogenic bacteria, It is easier to distinguish.
8. Abdominal epilepsy can show paroxysmal umbilical pain, pain is sharp tingling, other symptoms are not prominent, seizures can be accompanied by changes in consciousness, there are certain incentives, EEG can detect abnormal waveforms, and intestinal examination No signs of mucosal lesions.
9. Peptic ulcer disease in the upper digestive tract ileitis should pay attention to the identification of peptic ulcer, peptic ulcer is a common disease, children also occur, the symptoms of upper abdominal pain, with acid reflux, hernia, may have hematemesis However, the weight loss is not obvious, no fever, there are many single mucosal ulcers under gastroscope, the ulcer is round, the border is neat, there are few nodules around, the mucosa next to the ulcer is normal, and the morphology is not like ileitis. The disease should also be identified with the following diseases, such as intestinal lymphoma, recurrent abdominal pain, protein-losing enteropathy, arthritis, rheumatoid arthritis, anal stenosis and growth and development disorders, according to the history and physical examination of most diseases can be Identification, if necessary, endoscopy and X-ray barium meal or barium enema examination for identification, should be differentiated from penetrating inflammation of the intestinal wall: invasion of the large intestine and small intestine, occurs under 1 year old, deep penetrating ulcer, histology Similar to localized ileitis, however, the disease can be completely restored without recurrence.
