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Crohn's Disease

Crohn's disease is an ongoing disorder that causes inflammation of the
digestive tract, i.e. gastrointestinal (GI) tract. Crohn's disease can affect
any area of the GI tract, from the mouth to the anus, but it most
commonly affects the lower part of the small intestine, called the ileum.
The swelling extends deep into the lining of the affected organ. The
swelling can cause pain and can make the intestines empty frequently,
resulting in diarrhea.

Crohn's disease is an inflammatory bowel disease, the general name for
diseases that cause swelling in the intestines. Because the symptoms of
Crohn's disease are similar to other intestinal disorders, such as irritable
bowel syndrome and ulcerative colitis, it can be difficult to diagnose.
Ulcerative colitis causes inflammation and ulcers in the top layer of the
lining of the large intestine. In Crohn's disease, all layers of the intestine
may be involved, and normal healthy bowel can be found between sections
of diseased bowel.

Crohn's disease affects men and women equally and seems to run in some
families. About 20 percent of people with Crohn's disease have a blood
relative with some form of inflammatory bowel disease, most often a
brother or sister and sometimes a parent or child. Crohn's disease can
occur in people of all age groups, but it is more often diagnosed in people
between the ages of 20 and 30. People of Jewish heritage have an
increased risk of developing Crohn's disease, and African Americans are at
decreased risk for developing Crohn's disease.

Crohn's disease may also be called ileitis or enteritis.

What causes Crohn's disease?

Several theories exist about what causes Crohn's disease, but none have
been proven. The human immune system is made from cells and different
proteins that protect people from infection. The most popular theory is
that the body's immune system reacts abnormally in people with Crohn's
disease, mistaking bacteria, foods, and other substances for being
foreign. The immune system's response is to attack these “invaders.”
During this process, white blood cells accumulate in the lining of the
intestines, producing chronic inflammation, which leads to ulcerations and
bowel injury.

Scientists do not know if the abnormality in the functioning of the immune
system in people with Crohn's disease is a cause, or a result, of the
disease. Research shows that the inflammation seen in the GI tract of
people with Crohn's disease involves several factors: the genes the patient
has inherited, the immune system itself, and the environment. Foreign
substances, also referred to as antigens, are found in the environment.
One possible cause for inflammation may be the body's reaction to these
antigens, or that the antigens themselves are the cause for the
inflammation. Some scientists think that a protein produced by the
immune system, called anti-tumor necrosis factor (TNF), may be a possible
cause for the inflammation associated with Crohn's disease.

What are the symptoms?

The most common symptoms of Crohn's disease are abdominal pain,
often in the lower right area, and diarrhea. Rectal bleeding, weight loss,
arthritis, skin problems, and fever may also occur. Bleeding may be
serious and persistent, leading to anemia. Children with Crohn's disease
may suffer delayed development and stunted growth. The range and
severity of symptoms varies.

How is Crohn's disease diagnosed?

A thorough physical exam and a series of tests may be required to
diagnose Crohn's disease.

Blood tests may be done to check for anemia, which could indicate
bleeding in the intestines. Blood tests may also uncover a high white blood
cell count, which is a sign of inflammation somewhere in the body. By
testing a stool sample, the doctor can tell if there is bleeding or infection in
the intestines.

The doctor may do an upper GI series to look at the small intestine. For
this test, the person drinks barium, a chalky solution that coats the lining
of the small intestine, before x rays are taken. The barium shows up white
on x-ray film, revealing inflammation or other abnormalities in the
intestine. If these tests show Crohn's disease, more x rays of both the
upper and lower digestive tract may be necessary to see how much of the
GI tract is affected by the disease.

The doctor may also do a visual exam of the colon by performing either a
sigmoidoscopy or a colonoscopy. For both of these tests, the doctor
inserts a long, flexible, lighted tube linked to a computer and TV monitor
into the anus. A sigmoidoscopy allows the doctor to examine the lining of
the lower part of the large intestine, while a colonoscopy allows the doctor
to examine the lining of the entire large intestine. The doctor will be able
to see any inflammation or bleeding during either of these exams,
although a colonoscopy is usually a better test because the doctor can see
the entire large intestine. The doctor may also do a biopsy, which involves
taking a sample of tissue from the lining of the intestine to view with a
microscope.

What are the complications of Crohn's disease?

The most common complication is blockage of the intestine. Blockage
occurs because the disease tends to thicken the intestinal wall with
swelling and scar tissue, narrowing the passage. Crohn's disease may also
cause sores, or ulcers, that tunnel through the affected area into
surrounding tissues, such as the bladder, vagina, or skin. The areas
around the anus and rectum are often involved. The tunnels, called
fistulas, are a common complication and often become infected.
Sometimes fistulas can be treated with medicine, but in some cases they
may require surgery. In addition to fistulas, small tears called fissures may
develop in the lining of the mucus membrane of the anus.

Nutritional complications are common in Crohn's disease. Deficiencies of
proteins, calories, and vitamins are well documented. These deficiencies
may be caused by inadequate dietary intake, intestinal loss of protein, or
poor absorption, also referred to as malabsorption.

Other complications associated with Crohn's disease include arthritis, skin
problems, inflammation in the eyes or mouth, kidney stones, gallstones,
or other diseases of the liver and biliary system. Some of these problems
resolve during treatment for disease in the digestive system, but some
must be treated separately.

What is the treatment for Crohn's disease?

Treatment may include drugs, nutrition supplements, surgery, or a
combination of these options. The goals of treatment are to control
inflammation, correct nutritional deficiencies, and relieve symptoms like
abdominal pain, diarrhea, and rectal bleeding. At this time, treatment can
help control the disease by lowering the number of times a person
experiences a recurrence, but there is no cure. Treatment for Crohn's
disease depends on the location and severity of disease, complications,
and the person's response to previous medical treatments when treated
for reoccurring symptoms.

Some people have long periods of remission, sometimes years, when they
are free of symptoms. However, the disease usually recurs at various
times over a person's lifetime. This changing pattern of the disease means
one cannot always tell when a treatment has helped. Predicting when a
remission may occur or when symptoms will return is not possible.

Someone with Crohn's disease may need medical care for a long time, with
regular doctor visits to monitor the condition.
Drug Therapy

Anti-Inflammation Drugs. Most people are first treated with drugs
containing mesalamine, a substance that helps control inflammation.
Sulfasalazine is the most commonly used of these drugs. Patients who do
not benefit from it or who cannot tolerate it may be put on other
mesalamine-containing drugs, generally known as 5-ASA agents, such as
Asacol, Dipentum, or Pentasa. Possible side effects of mesalamine-
containing drugs include nausea, vomiting, heartburn, diarrhea, and
headache.

Cortisone or Steroids. Cortisone drugs and steroids—called
corticosteriods—provide very effective results. Prednisone is a common
generic name of one of the drugs in this group of medications. In the
beginning, when the disease it at its worst, prednisone is usually
prescribed in a large dose. The dosage is then lowered once symptoms
have been controlled. These drugs can cause serious side effects,
including greater susceptibility to infection.

Immune System Suppressors. Drugs that suppress the immune system
are also used to treat Crohn's disease. Most commonly prescribed are 6-
mercaptopurine or a related drug, azathioprine. Immunosuppressive
agents work by blocking the immune reaction that contributes to
inflammation. These drugs may cause side effects like nausea, vomiting,
and diarrhea and may lower a person's resistance to infection. When
patients are treated with a combination of corticosteroids and
immunosuppressive drugs, the dose of corticosteroids may eventually be
lowered. Some studies suggest that immunosuppressive drugs may
enhance the effectiveness of corticosteroids.

Infliximab (Remicade). This drug is the first of a group of medications
that blocks the body's inflammation response. The U.S. Food and Drug
Administration approved the drug for the treatment of moderate to severe
Crohn's disease that does not respond to standard therapies (mesalamine
substances, corticosteroids, immunosuppressive agents) and for the
treatment of open, draining fistulas. Infliximab, the first treatment
approved specifically for Crohn's disease is a TNF substance. Additional
research will need to be done in order to fully understand the range of
treatments Remicade may offer to help people with Crohn's disease.

Antibiotics. Antibiotics are used to treat bacterial overgrowth in the small
intestine caused by stricture, fistulas, or prior surgery. For this common
problem, the doctor may prescribe one or more of the following
antibiotics: ampicillin, sulfonamide, cephalosporin, tetracycline, or
metronidazole.

Anti-Diarrheal and Fluid Replacements. Diarrhea and crampy abdominal
pain are often relieved when the inflammation subsides, but additional
medication may also be necessary. Several antidiarrheal agents could be
used, including diphenoxylate, loperamide, and codeine. Patients who are
dehydrated because of diarrhea will be treated with fluids and electrolytes.

Nutrition Supplementation

The doctor may recommend nutritional supplements, especially for children
whose growth has been slowed. Special high-calorie liquid formulas are
sometimes used for this purpose. A small number of patients may need to
be fed intravenously for a brief time through a small tube inserted into the
vein of the arm. This procedure can help patients who need extra nutrition
temporarily, those whose intestines need to rest, or those whose
intestines cannot absorb enough nutrition from food. There are no known
foods that cause Crohn's disease. However, when people are suffering a
flare in disease, foods such as bulky grains, hot spices, alcohol, and milk
products may increase diarrhea and cramping.

Surgery

Two-thirds to three-quarters of patients with Crohn's disease will require
surgery at some point in their lives. Surgery becomes necessary when
medications can no longer control symptoms. Surgery is used either to
relieve symptoms that do not respond to medical therapy or to correct
complications such as blockage, perforation, abscess, or bleeding in the
intestine. Surgery to remove part of the intestine can help people with
Crohn's disease, but it is not a cure. Surgery does not eliminate the
disease, and it is not uncommon for people with Crohn's Disease to have
more than one operation, as inflammation tends to return to the area
next to where the diseased intestine was removed.

Some people who have Crohn's disease in the large intestine need to have
their entire colon removed in an operation called a colectomy. A small
opening is made in the front of the abdominal wall, and the tip of the
ileum, which is located at the end of the small intestine, is brought to the
skin's surface. This opening, called a stoma, is where waste exits the
body. The stoma is about the size of a quarter and is usually located in
the right lower part of the abdomen near the beltline. A pouch is worn
over the opening to collect waste, and the patient empties the pouch as
needed. The majority of colectomy patients go on to live normal, active
lives.

Sometimes only the diseased section of intestine is removed and no
stoma is needed. In this operation, the intestine is cut above and below
the diseased area and reconnected.

Because Crohn's disease often recurs after surgery, people considering it
should carefully weigh its benefits and risks compared with other
treatments. Surgery may not be appropriate for everyone. People faced
with this decision should get as much information as possible from
doctors, nurses who work with colon surgery patients (enterostomal
therapists), and other patients. Patient advocacy organizations can
suggest support groups and other information resources. (See For More
Information for the names of such organizations.)

People with Crohn's disease may feel well and be free of symptoms for
substantial spans of time when their disease is not active. Despite the
need to take medication for long periods of time and occasional
hospitalizations, most people with Crohn's disease are able to hold jobs,
raise families, and function successfully at home and in society.

Can diet control Crohn's disease?

People with Crohn's disease often experience a decrease in appetite, which
can affect their ability to receive the daily nutrition needed for good health
and healing. In addition, Crohn's disease is associated with diarrhea and
poor absorption of necessary nutrients. No special diet has been proven
effective for preventing or treating Crohn's disease, but it is very
important that people who have Crohn's disease follow a nutritious diet
and avoid any foods that seem to worsen symptoms. There are no
consistent dietary rules to follow that will improve a person's symptoms.

People should take vitamin supplements only on their doctor's advice.

Can stress make Crohn's disease worse?

There is no evidence showing that stress causes Crohn's disease.
However, people with Crohn's disease sometimes feel increased stress in
their lives from having to live with a chronic illness. Some people with
Crohn's disease also report that they experience a flare in disease when
they are experiencing a stressful event or situation. There is no type of
person that is more likely to experience a flare in disease than another
when under stress. For people who find there is a connection between
their stress level and a worsening of their symptoms, using relaxation
techniques, such as slow breathing, and taking special care to eat well and
get enough sleep, may help them feel better.

Content Credit NDDIC

MEDICAL NOTES