Crohn’s Disease Red Flags

Crohn's Disease Red Flags

Crohn’s Disease Red Flags

We are all certainly familiar with the patient who presents with abdominal pain and all of the various concerns that we mentally filter through.  We are also aware that Chronic Recurrent Abdominal Pain (CRAP) can be frustrating for patients, their families, and for us as well.  Often, once I hear that this abdominal pain has been occurring over the past several weeks I can feel my mind wander off to other tasks that need to be attended to.  As you know, part of the goal of these Morsels is to help keep us vigilant for those needles in the haystack of illness…

But, unfortunately, the chronic nature may inappropriately decrease my vigilance.  Additionally, if the child has already been “diagnosed” with CRAP, then diagnostic momentum will often undermine my vigilance even more.  Furthermore, I know that I need to help contain costs by not inappropriately ordering unwarranted tests.  Yet, I also have a little voice in the back of my mind reminding me that terrible conditions, like Crohn’s Disease, can be mistaken initially for CRAP.

So what things can help distinguish a patient with Chronic Recurrent Abdominal Pain from someone with Inflammatory Bowel Disease?

Red Flags Favoring Crohn’s Disease

  • Hematochezia
    • This is kind of a no-brainer
    • It is more commonly the presentation of those patients < 6 yrs of age.
  • Weight Loss / Problems gaining weight
    • Certainly Failure to Thrive is concerning, but it may be more subtle… ask about clothes no longer fitting.
    • Potentially useful to obtain the Growth Curve (or some historic weights) from the Pediatrician’s office.
    • This is a more common presentation of children 6 – 17 years.
  • Anemia

The combination of all three had sensitivity of 94% for Crohn’s Disease.

 Brown Flags Favoring Functional GI Disorder 

  • Associated Stress ad headaches
  • Positive family history of functional bowel disorder
  • Have vomiting.


Other Flags that may not be as colorful, but I still think are important

  • Joint Pain
    • Typically abdominal pain and joint pain makes us consider inflammatory conditions like Crohn’s, but this study actually showed no difference between those with Crohn’s and those with CRAP having joint pain.
    • Patients with Chronic Abdominal Pain often will have various other somatic complaints, but if the condition is one more of objective arthritis, I am going to worry more about Crohn’s than CRAP.
  • Waking from Sleep
    • Traditionally it is taught that CRAP won’t awake kids from sleep and that this is a concerning sign of inflammatory bowel disease.  This study did not show any difference between the two populations and their respective likelihood have having pain awake them form sleep.
  • Fever
    • Unexplained fever will always catch your attention… but make sure you are not attributing it to arthritis if there are other signs of bowel involvement.


Hopefully, by actively looking for these Red Flags you can help pick out the needle of Crohn’s Disease from the haystack of CRAP.


El-Chammas K, Majeskie A, Simpson P, Sood M, Miranda A. Red Flags in Children with Chronic Abdominal Pain and Crohn’s Disease – A Single Center Experience. J Pediatr. 2012 Oct 12. pii: S0022-3476(12)01028-1.



Gupta N, Bostrom AG, Kirschner BS, Cohen SA, Abramson O, Ferry GD, Gold BD, Winter HS, Baldassano RN, Smith T, Heyman MB. Presentation and Disease Course in Early- Compared to Later- Onset Pediatric Crohn’s Disease. American Journal of Gastroenterology. 2008; 103: 2092-2098.

Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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  1. My son had CRAP when he was approx 11-12 years old. Turned out to be H. pylori infection (although no-one else in the house had it). Took a long time to figure this out and seriously interrupted his schooling in the meantime. So perhaps should consider this too.

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