4.3. Initial Clinical Symptoms
General manifestations
Weight loss is a common symptom of Crohn’s disease, affecting approximately 48.5% of patients, often in conjunction with chronic diarrhea, malnutrition, or Koenig’s
[14]
. The chronic inflammation and malabsorption disorders characteristic of Crohn’s disease contribute to nutritional deficiencies, leading to progressive weight loss and muscle wasting
[15]
. Effective management of this weight loss relies on individualized nutritional support and control of inflammation through appropriate medical treatment
[15]
.
About 3% of patients have a persistent fever. This symptom is often considered a pseudo-infectious manifestation, reflecting a systemic inflammatory response related to disease activity
[14]
. The presence of fever sometimes complicates the clinical picture, requiring a rigorous differential diagnosis to rule out possible infections or other inflammatory conditions
[16]
.
Digestive symptoms
Gastrointestinal symptoms, such as chronic diarrhea, abdominal pain, and unintentional weight loss and conditions affecting the anal and perineal areas, are the main indicators of Crohn’s disease’s early symptoms. Accurate diagnosis is frequently delayed by these symptoms’ variability and resemblance to other gastrointestinal disorders. To enable prompt diagnosis and efficient treatment plans, a more thorough comprehension of these early manifestations is necessary.
Clinical presentations in Africa are comparable to those reported in Western cohorts, with ano-perineal lesions like fissures, fistulas, and abscesses, anemia, and abdominal pain associated with ileal involvement often bloody. Fever, nausea, vomiting, and even childhood growth retardation are examples of systemic symptoms
[17]
.
In our study, chronic diarrhea was one of the predominant initial manifestations of Crohn’s disease, being documented in approximately 61% of people diagnosed with this disease. This symptom is often associated with malabsorption syndrome, which can lead to nutritional deficiencies and significant weight loss
[16]
[18]
. This diarrhea tends to be nearly constant and is often accompanied by spasmodic or cramp-like pain
[19]
.
Abdominal pain is observed in 46% of our patients, manifesting diffusely or locally, particularly in the right iliac fossa. This discomfort frequently results from an active inflammatory process or a subocclusive phenomenon associated with segmental involvement of the intestine
[18]
[20]
.
A global meta-analysis demonstrates that approximately 75% to 80% of patients experience abdominal pain at their first consultation
[21]
.
Koenig’s syndrome, characterized by postprandial abdominal pain accompanied by borborygmi and subsequent relief after the expulsion of gas or stool, is recognized in 20% of our study. This syndrome is indicative of stenotic involvement of the ileum and often indicates a stenotic progression (B2) according to the Montreal classification
[18]
.
However, data from the African continent remain very limited in the literature due to the small number of published studies, which often take the form of isolated case reports or retrospective regional series.
Anoperineal involvement
In our Moroccan cohort (14%), the prevalence of anoperineal involvement was substantially lower than in other African studies (30% - 50%). Studies, where incidence rates typically range between 30% and 50%
[22]
, and South Africa (up to 50%)
[23]
. In contrast, large European cohorts such as GETAID (France) and ENEIDA (Spain) report anoperal involvement in approximately 20% to 30% of cases
[24]
[25]
.
Anorectal fistulas are the main manifestation of an anoperineal lesion, occurring in 71.8% of affected individuals. In our series, 69% of these fistulas were complex, frequently classified as transsphincteric or intersphincteric, thus presenting significant therapeutic obstacles
[26]
.
Anal fissures and perineal abscesses are encountered less frequently, each being identified in approximately 9.3% of the patient population. These conditions are generally correlated with the presence of fistulas, which highlight a significant inflammatory attack on the perineum
[18]
.
Anal stenosis is documented in 6.2% of cases, while fibrotic oedematous changes are observed in 12.5% of patients, reflecting the presence of localized chronic inflammation. Finally, proctitis associated with these conditions, even in the absence of classic anoperineal lesions, is frequently observed, suggesting inflammatory pathology of the rectal mucosa
[18]
.
Osteoarticular involvement
More than 80% of cases in the study population have musculoskeletal disorders, making them the most prevalent Extraintestinal Manifestation (EIM) in Crohn’s disease patients. This finding is consistent with data in the literature, which identify musculoskeletal manifestations as the most common EIM in chronic inflammatory bowel diseases
[14]
[26]
including a recent Moroccan study in which 35% of Crohn’s patients presented these symptoms
[27]
, Similarly, a meta-analysis conducted in the EMRO region (which includes North Africa) estimates that the prevalence of arthritis/arthralgia is approximately 13.5% in patients diagnosed with Crohn’s disease
[28]
.
Among these conditions, peripheral arthralgia was reported in 26 cases, while 7 patients had acute non-erosive peripheral arthritis of the migratory oligoarthritis type. In addition, sacroiliitis or suspected axial spondyloarthropathy, suggested by inflammatory low back pain, was observed in 3 cases. These results are consistent with those of other studies, which highlight the frequency of peripheral arthritis as an EIM, often associated with active intestinal inflammation
[29]
.
Dermatological manifestations
Dermatological manifestations have been reported in 5 patients, including 4 cases of erythema nodosum and 1 case of pyoderma gangrenosum. Erythema nodosum is frequently correlated with inflammatory bowel disease activity, while pyoderma gangrenosum can occur independently of intestinal inflammatory activity
[29]
.
The prevalence rates observed (2.1% for erythema nodosum and 0.5% for pyoderma gangrenosum) are slightly lower than those documented in larger European cohorts. For example, in a cohort of 2402 people diagnosed with inflammatory bowel disease, erythema nodosum was identified in 4.0% of cases, while pyoderma gangrenosum was observed in 0.75% of cases, with a notable correlation with Crohn’s disease, female gender, and, in the case of pyoderma gangrenosum, sometimes associated with African ancestry
[30]
.
A recent review confirms that erythema nodosum and pyoderma gangrenosum are the two main skin manifestations in Crohn’s disease, one synchronized with intestinal activity, the other capable of developing independently
[31]
.
Complicated presentation at diagnosis
At the time of diagnosis, 17% of the study population had complications characteristic of Crohn’s disease, such as intra-abdominal abscesses, severe malnutrition, severe acute colitis, or acute intestinal obstruction.
The relatively high incidence of complex pathological presentations tends to be partly explained by a significant diagnostic delay, frequently observed in scenarios where access to specialized medical care is limited or when initial clinical manifestations lack specificity. In fact, a longer time between the onset of symptoms and receiving a conclusive diagnosis encourages the disease’s subtle progression toward more severe manifestations.
These findings are in line with previous research that emphasizes the detrimental effects of delayed diagnosis on the course of the disease and the frequency of complications at diagnosis. The presence of these serious manifestations highlights the importance of early screening and rapid management of Crohn’s disease in order to prevent complications and optimize clinical outcomes for patients
[32]
.
Although the study provides valuable information on the prevalence and types of clinical manifestations in Crohn’s disease, it is important to take into account the variability of these manifestations between different populations and studies. Differences in the prevalence and clinical presentation of Crohn’s disease may be caused by a number of factors, including genetic predisposition, environmental factors, and variations in disease management. Additionally, the literature highlights the necessity of a multidisciplinary approach and the significance of healthcare providers working together to maximize patient care
[33]
.
Comparison with intestinal tuberculosis in Morocco
In Morocco, Intestinal Tuberculosis (ITB) remains endemic, especially in rural areas, and often mimics Crohn’s disease, posing a significant diagnostic challenge. Differentiating between the two is critical, as management diverges fundamentally: ITB requires anti‑tuberculosis therapy, whereas Crohn’s disease relies on immunosuppressive treatment. Notably, it is increasingly dangerous to treat patients with actual Crohn’s disease using ATT or to treat TB patients with immunosuppressants in a high-TB endemic setting like Morocco
[34]
.
Local epidemiological data indicate that diagnostic delays in ITB in Morocco commonly fall within the 12 - 18 months range, comparable to the delays observed in our Crohn’s cohort (16 - 18 months) and underscoring the real-world overlap with Crohn’s diagnostic challenges
[35]
.
Clinically, both diseases present with abdominal pain, chronic diarrhea, weight loss, and a high frequency of ileo‑cecal involvement, making reliable discrimination difficult without advanced diagnostics
[34]
.
However, specific features such as complex ano‑perineal lesions (found in 13% of our patients) are rare in ITB, thereby favoring Crohn’s disease when present
[35]
.
Other manifestation
In our cohort, apart from the osteoarticular, dermatological, and ophthalmological manifestations described above, no other extraintestinal manifestations were identified. Specifically, there were no reports of cardiac, neurological, pulmonary, urinary, or hepatobiliary involvement.
The available epidemiological data, which show that these EIMs are well described in Crohn’s disease but are still comparatively uncommon, are consistent with this absence. According to a systematic review, the prevalence of the most prevalent EIMs was only 0.7% for hepatobiliary involvement, 5% for skin involvement, 2% for eye involvement, and roughly 7.9% for joint involvement
[36]
.
Depending on the study, the overall prevalence of at least one MEI in IBD patients ranges from 6% to 47%, while the estimated frequency of multiple MEIs ranges from 1% to 4%
[2]
. Even less common is pulmonary, neurological, or cardiac involvement, which typically affects fewer than 1% of patients
[37]
.
Both the low prevalence of these manifestations in the general population and the lack of systematic screening in the absence of suggestive symptoms account for their absence in our series. These findings emphasize how crucial long-term clinical monitoring is for spotting potential late-stage IBD-related issues.