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Crohn’s Disease

April 16, 2012

by A.Cline

INTRODUCTION

Named after Dr. Burrill B. Crohn, Crohn’s Disease is defined as a chronic inflammation and ulceration of the bowel mucosa with marked thickening and scarring of the bowel wall.  A form of Inflammatory Bowel Disease (IBD) , Crohn’s can be both painful and debilitating, and may lead to life-threatening complications.  Crohn’s disease may occur in people of all ages, but is primarily a disease of adolescents and young adults ages 15-35.  Being a person with a family member living with Chron’s, I became more interested in the scope of the disease, and wanted to learn more about it.  For people suffering from, and living with  Crohn’s disease, learning about it is an important step toward taking charge of the illness.  The more informed you are, the better you will be able to conform and adapt to the disease.  As you continue to read you will learn about the causes, symptoms, diagnostics, treatments, and some research and support groups to help inform and support the patient and family members living with Crohn’s Disease.

PATHOGENESIS

Crohn’s Disease is a chronic disorder that causes inflammation of the digestive or gastrointestinal (GI) tract. The GI tract is a series of hollow organs joined in a long, twisting tube from the mouth to the anus.  The movement of muscles in the GI tract, along with the release of hormones and enzymes, allows for the digestion of food.  In Crohn’s disease, the inflammation of the GI tract can cause pain and can make the bowel empty frequently, resulting in diarrhea.  Chronic inflammation may produce scar tissue that builds up inside of the intestine, creating a narrowed passageway that can slow the movement of food through the intestine.  A stricture, as this narrowing is called, can cause pain or cramping.  Although it can affect any area of the GI tract from the mouth to the anus, Crohn’s most commonly affects the last part of the small intestine (ileum) and/or the colon.

Crohn’s disease is an inflammatory bowel disease (IBD), the general name for diseases that cause inflammation and irritation to the intestines.  This disease, and Chronic ulcerative colitis are often grouped together under IBD.  Both diseases tend to be chronic, with periodic flare-ups involving cramplike abdominal pain and diarrhea, followed by periods of the disease in an inactive state.  Approximately 10 percent of colitis cases are unable to be pinpointed as either ulcerative colitis, or crohn’s disease and are called indeterminate colitis (Crohn’s and Colitis Foundation of America). Pictured below is a healthy colon verse a diseased colon.

The symptoms and complications of crohn’s disease can be different, depending on what part of the GI tract is affected.  Based on the area involved, Crohn’s is divided into five different types:

Ileocolitis:  This is the most common form of Crohn’s. It affects the ileum and colon (as stated previously), and can cause cramping or pain in the right lower part or middle of the abdomen.  It can also be accompanied by significant weight loss.

Ileitis: This form only affects the ileum.  The symptoms of this form can be comparable to those of Ileocolitis. In this form, fistulas or inflammatory abscesses may form in the right lower quadrant of the abdomen.

Gastroduodenal Crohn’s Disease:  This form affects the stomach and the duodenum, which is the first part of the small intestine.  Symptoms include weight loss, nausea, and loss of appetite.  If vomiting occurs, this may indicate that narrowed segments of the bowel are obstructed (stricture).

Jejunoileitis:  This form produces patch areas of inflammation in the jejunum.  The jejunum is the upper half of the small intestine.  Symptoms of this type include abdominal pain (ranging from mild to severe), cramps following meals, and diarrhea.  Fistulas have also been known to form in some cases.

Crohn’s (granulomatous) colitis:  This form affects the colon only.  Symptoms include diarrhea, rectal bleeding, and disease around the anus (abscesses, fistulas, and ulcers).  Skin lesions are more common in this form that in any other forms of Crohn’s disease.

All of the signs and symptoms of crohn’s can range from mild to severe, and can develop gradually or suddenly, without warning.  There may also be periods of time when you have no signs or symptoms.  However, when the disease is active, the main signs and symptoms may include:

  • Diarrhea
  • Abdominal pain and cramping
  • Bloody stools
  • Ulcers
  • Reduced appetite and weight loss
  • pain with passing stool (tenesmus)
Other symptoms may include:
  • Fever
  • Fatigue
  • Arthritis
  • Eye inflammation
  • Mouth sores
  • Skin disorders
  • Inflammation of the liver or bile ducts
  • Delayed growth in sexual development (in children)

ETIOLOGY

Although considerable progress has been made in IBD research, the cause of crohn’s disease is still not known (Crohn’s and colitis foundation of America).  Researchers believe is is the result of an abnormal reaction by the body’s immune system.  In a normal, healthy person, the immune system would protect them from infection by identifying and destroying bacteria, viruses, and other harmful substances.  Researchers feel that in a person with crohn’s disease, the immune system attacks bacteria, food and other substances that are actually harmless, or even beneficial to the body.  During this process, white blood cells accumulate in the lining of the intestines, and can produce chronic inflammation leading to ulcers, sores, or injury (National Digestive Diseases Information Clearinghouse).

What is known about crohn’s disease is that it is an autoimmune disorder.  This is a condition in which your body’s immune system mistakenly attacks and destroys healthy body tissue.  The following seem to play a role in Crohn’s disease:

  • Genetics
  • Enviromental factors
  • Body over-reacting to normal flora in the intestines

Some risk factors include:

  • A family history of Crohn’s. Studies have shown that about 20-25 percent of patients may have a close relative with either Crohn’s or Ulcerative colitis.
  • Jewish people
  • Smoking
  • Age (most people are diagnosed before they are 30)
  • Where you live- Urban or industrialized areas are more common for Crohn’s disease, possibly due to enviromental factors or a diet high in fat or refined foods

DIAGNOSIS

There is no single test that can establish the diagnosis of Crohn’s disease with complete certainty. Doctors must use a combination of information from the patient’s history and a physical exam to evaluate the patient.  A physical exam done by a medical doctor would include blood tests and stool tests.  Blood tests can be used to look for anemia caused by the bleeding.  These tests may also uncover a high white blood cell count, which is a common sign of inflammation or infection somewhere in the body.  A stool test is commonly used to rule out other causes of GI diseases, such as infection.  They can also show if there is bleeding in the intestines.

Other tests may be performed by a gastroenterologist.  This is a doctor who specializes in digestive diseases.  These tests are usually performed at a hospital or outpatient center:

Flexible sigmoidoscopy and colonoscopy:  These tests help diagnose Crohn’s and help to determine how much of the GI tract is affected.  A colonoscopy is the most commonly used test to specifically diagnose Crohn’s.  It is used to view the ileum, rectum, and the entire colon, while flexible sigmoidoscopy is used to view just the lower colon and rectum.  These tests are performed while the patient is in a twilight state. Cramping or bloating may occur during the first hour after the test, but a full recovery is expected by the next day.

These tests are performed at a hospital or outpatient center by an x-ray technician, and the images would be interpreted by a radiologist:

Computerized Tomography (CT) Scan:   This method uses a combination of x-rays and computer technology to create 3-D images.  The person must drink a barium solution, and must be injected with a special dye prior to the scan.

Upper GI series:  This may be done to look at the small intestine. Again, the patient must drink barium liquid prior to the test.  This will coat the small intestine, making signs of Crohn’s disease show up more clearly on x-rays.

Lower GI series:  This may be done to look at the large intestine.  After the patient is instructed to follow a clear, liquid diet for 1-3 days prior to the procedure, and given an enema to flush the bowel, the large intestine is filled with barium. This makes signs of Crohn’s disease show up more clearly on x-rays.

Some other common tests used to diagnose Crohn’s are Magnetic Resonance Imaging (MRI), Capsule Endoscopy, Double Balloon Endoscopy, or Enteroscopy.

TREATMENT

There is currently no cure for Crohn’s Disease and there is no single treatment that works for everyone.  The goal of the medical treatment, however, is to suppress the inflammatory response.  It is also to improve long-term prognosis by limiting complications.  In best cases, this may lead not only to symptom relief but also to long-term remission.  There are two goals to accomplish in treatment of Crohn’s disease.  The first goal, to bring the inflammatory symptoms under control, is known as inducing remission.  Secondly, medical therapy is used to decrease the frequency of disease flares.  This is known as maintaining remission, or maintenance.

Inflammatory drugs are often the first step in treatment of IBD, or Crohn’s disease. These include:

  • Sulfasalazine
  • Mesalamine
  • Corticosteroids (used for short-term and to induce remission, have many side effects)

Immune System repressors are also drugs that reduce inflammation, but they target your immune system rather than directly treating inflammation.  When you suppress the immune response, inflammation is also reduced. These drugs include:

  • Azathioprine
  • Mercaptopurine
  • Infliximab (Remicade)
  • Adalimumab (Humira)
  • Certolizumab pegol (Cimzia)
  • Methotrexate (Rheumatrex)
  • Cyclosporine
  • Natalizumab (Tysabri)

Antibiotics can reduce the amount of drainage and sometimes heal fistulas and abscesses in people with Crohn’s disease. Frequently prescribed antibiotics include:

  • Metronidazole (Flagyl)
  • Ciprofloxacin (Cipro)

These following medications are also used to relieve signs and symptoms:

  • Anti-diarrheals
  • Laxatives
  • Pain relievers
  • Iron Supplements
  • Nutrition via feeding tube
  • Vitamin B-12 Shots
  • Calcium and Vitamin D supplements

Aside from medications, a well-balanced healthy diet is a key component in treatment of Crohn’s disease.  It is important to get enough calories, protein, and essential nutrients from a variety of food groups.  To help ease symptoms, a person could eat small amounts of food throughout the day, drink lots of water, avoid high-fiber foods, avoid fatty or greasy foods and sauces, limit dairy products, and avoid food known to cause gas (such as beans).

If medications do not work, a type of surgery known as a bowel resection may be needed to remove a damaged or diseased part of the intestine. This however, still does not cure  the condition. A surgery may be indicated in the following situations:

  • Bleeding or hemorrhaging
  • Failure to grow (in children)
  • Fistulas
  • Infections
  • Narrowing of intestine (stricture)

Incidence and Mortality

Crohn’s disease usually has a chronic course regardless of the site of involvement.  A 15 year survival rate of 93.7% has been reported for the general population (Medscape 2011), but the risk of death and complications in Crohn’s disease increases with the duration of the illness.  Over time, 10% of patients will be disabled by this disease (Medscape 2011). Although Crohn’s disease is a chronic condition with recurring relapse, those with appropriate medical treatment and surgical therapy can live a reasonably normal life.  These people have an overall good prognosis and extremely low risk of fatal outcome.

According to Medscape reference in 2011, the prevalence of Crohn’s disease in the United States is approximately 7 cases per 100,000 people.  The incidence and prevalence have increased steadily over the last 5 decades.  The rate of this disease in women is now 1.1-1.8 times higher than that in men.  In the United States in 2003, the pediatric male to female ratio was 1.6-1.

Early studies of mortality of patients with Crohn’s disease suggested that the mortality was significantly higher than the general population, especially in patients diagnosed before the age of 20 years and also in the first 3 years after diagnosis (Medscape).

RESEARCH, CHARITIES, and SUPPORT GROUPS

Crohn’s Online

Get one to one education and free support from a personal patient advocate. This patient advocate will provide you with educational information about Crohn’s, information about resources available to people with Crohn’s, and advice on how to make the most of your time with your gastroenterologist. This website can provide you with information you need to know about Crohn’s, and will help you find a gastroenterologist.

Crohn’s and Colitis Foundation of America

The Crohn’s and Colitis Foundation of America is a non-profit, volunteer-driven organization dedicated to finding the cure for Crohn’s disease and ulcerative colitis.  Four decades ago, the Crohn’s & Colitis Foundation created the field of Crohn’s disease and ulcerative colitis research. Today, the Foundation funds cutting-edge studies at major medical institutions, nurtures investigators at the early stages of their careers, and finances underdeveloped areas of research. “Take Steps” is the foundations largest fundraising event. Participants raise funds and awareness throughout the year and come together to celebrate the steps that have been taken towards a cure.

Crohn’s Disease Forum

A community of friends, connected by their lives being affected by IBD – either personally or with someone they care about, and they welcome new members to the forum. They offer support, understanding, and friendship. However, please note they are not doctors, and any experiences, advice, and tips shared or given should be checked out with your medical care provider before acting upon.

MDJunction- People Helping People

This website offers an online support group for various types of medical conditions, including Crohn’s disease.  This site also offers a list of doctors and health insurance companies in your area.

RESOURCES

Medscape Reference- Crohn Disease. http://emedicine.medscape.com/

Crohn’s and Colitis Foundation of America. http://www.ccfa.org/

PubMed Health- Crohn’s Disease. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001295

Mayo Clinic- Crohn’s Disease. http://www.mayoclinic.com

National Digestive Diseases Information Clearinghouse- Crohn’s Disease. http://digestive.niddk.nih.gov/ddiseases/pubs/crohns

Crowley, Leonard V. Essentials of Human Disease. Jones and Bartlett Publishers.2011

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