Crohn's Disease
What is Crohn’s Disease?
Crohn's Disease is a serious inflammatory disease of the gastrointestinal (GI) tract. It predominates in the lower part of the small intestine (ileum) and the large intestine (colon). In other cases, only the colon is involved. . Sometimes, inflammation also may affect any section (mouth, esophagus, stomach, duodenum, appendix, or anus) of the GI tract.
Crohn's Disease usually causes diarrhea, crampy abdominal pain, often fever, and at times rectal bleeding. Loss of appetite and subsequent weight loss also may occur. Symptoms may range from mild to severe, but in general people with Crohn's Disease can lead active and productive lives.
Crohn's Disease is a chronic condition and may recur at various times over a lifetime. Some people have long periods of remission, sometimes for years, when they are free of symptoms. There is no way to predict when a remission may occur or when symptoms will return. We don't know its cause. Medication currently available decreases inflammation and usually controls the symptoms, but does not provide a cure.
Because Crohn's Disease behaves similarly to Ulcerative Colitis, from which it may be difficult to differentiate, the two disorders are grouped together as Inflammatory Bowel Disease (IBD). Inflammatory bowel disease (IBD) is a group of chronic disorders that cause inflammation or ulceration in the small and large intestines. Most often IBD is classified as Ulcerative Colitis or Crohn's Disease.
In Crohn's Disease, all layers of the intestine are involved and the inflammation that extends into the deeper layers of the intestinal wall, and there can be normal healthy bowel in between patches of diseased bowel. In contrast, Ulcerative Colitis affects only the innermost lining (mucosa) of the colon and rectum in a continuous manner. Depending on where the involvement occurs, Crohn's Disease may be referred to as Ileitis, Regional Eenteritis, Proctitis or Colitis, etc. To lessen the confusion, the term Crohn's Ddisease can be used to identify the disease wherever it occurs in the body (ileum, colon, rectum, anus, stomach, duodenum, etc.).
It is referred to as Crohn's Disease because Burrill B. Crohn was the first name in a three-author landmark paper, published in 1932, which described the disease.
Ulcerative Colitis and Crohn's Disease cause similar symptoms that often resemble other conditions such as Irritable Bowel Syndrome (Spastic Colitis). The correct diagnosis may take some time.
How common is Inflammatory Bowel Disease (IBD)?
It is estimated that there are up to 1,000,000 Americans with lBD. Males and females appear to be affected equally. While Crohn's Disease afflicts people of all ages, it is primarily a disease of the young. Most cases are diagnosed before age 30, but the disease can occur in the sixth, seventh, and later decades.
What causes Crohn's Disease and who gets it?
There are many theories about what causes Crohn's Disease, but none has been proven. Researchers do not know what causes this disease. They do not believe it is caused by emotional stress or by food, or that it is transmitted directly from person to person. But studies have shown that 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 affects males and females equally and appears to run in some families.
One theory is that some agent, perhaps a virus or a bacterium, affects the body's immune system to trigger an inflammatory reaction in the intestinal wall.
A major thrust of CCFA (Crohn’s & Colitis Foundation of America) -sponsored research has been carried out in the fields of immunology; the study of the body's immune defense system; microbiology; the study of microscopic organisms with the power to cause disease; and genetics.
Many scientists now believe that the interaction of an outside agent (such as a virus or bacterium) with the body's immune system may trigger the disease, or that such an agent may cause damage to the intestinal wall, initiating or accelerating the disease process. Research has shown that, in IBD, the body's defenses are operating against some substance in the body, perhaps in the digestive tract, which they recognize as foreign. These foreign substances (antigens) may themselves cause the inflammation, or they may stimulate the body's defenses to produce an inflammation that continues without control.
Although there is a lot of evidence that patients with this disease have abnormalities of the immune system, doctors do not know whether the immune problems are a cause or a result of the disease. Doctors believe, however, that there is little proof that Crohn's Disease is caused by emotional distress or by an unhappy childhood.
Is Crohn’s Disease inherited?
We know that Crohn's Disease tends to run in families. Studies have shown that about 20 to 25 percent of patients may have a close relative with either Crohn's or Ulcerative Colitis. There does not seem to be any clear-cut pattern to this familial clustering. Research actively continues in an attempt to establish a link to specific genes governing its transmission. At this time, there is no way to predict which, if any, family members will develop Crohn's disease.
What are the symptoms of Crohn’s Disease?
The most common and earliest symptoms of Crohn's Disease are abdominal pain, often in the lower right area (the pain is primarily at or below the navel in the abdomen.), and diarrhea. These symptoms usually follow a meal. There also may be rectal bleeding, loss of appetite and weight, joint pains, and fever. Early signs of Crohn's Disease can include sores in the anal area, including skin tags mimicking hemorrhoids, fissures (cracks), fistulas (abnormal openings connecting the bowel to the skin surface near the anus), and abscesses. Bleeding may be serious and persistent, leading to anemia (low red blood cell count). Children may suffer delayed development and stunted growth.
What are the complications of Crohn's Disease?
The most common complication is blockage (obstruction) of the intestine. Blockage occurs because the disease tends to thicken the bowel wall with swelling and fibrous scar tissue, narrowing the passage. Crohn's Disease also may cause deep ulcer tracts that burrow all the way through the bowel wall into surrounding tissues, into adjacent segments of intestine, into other nearby organs such as the urinary bladder or vagina, or into the skin. These tunnels are called fistulas. They are a common complication and often are associated with pockets of infection or abcesses (infected areas of pus). The areas around the anus and rectum often are involved. Sometimes fistulas can be treated with medicine, but in many cases they must be treated surgically.
Crohn's Disease also can lead to complications that affect other parts of the body. These systemic complications include various forms of 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 respond to the same treatment as the bowel symptoms, but others must be treated separately.
How does Crohn's Disease affect children?
Women with Crohn's Disease who are considering having children can be comforted to know that the vast majority of such pregnancies will result in normal children. Research has shown that the course of pregnancy and delivery is usually not impaired in women with Crohn's Disease. Even so, it is a good idea for women with Crohn's Disease to discuss the matter with their doctors before pregnancy. Children who do get the disease are sometimes more severely affected than adults, with slowed growth and delayed sexual development in some cases.
How is Crohn's Disease diagnosed?
The diagnosis is suggested by the history (signs and symptoms) and additional testing to help make the diagnosis. If you have experienced chronic abdominal pain, diarrhea, fever, weight loss, and anemia, the doctor will examine you for signs of Crohn's Disease. The doctor will take a history and give you a thorough physical exam. This exam will include blood tests to find out if you are anemic as a result of blood loss, or if there is an increased number of white blood cells, suggesting an inflammatory process in your body. Examination of a stool sample can tell the doctor if there is blood loss, or if an infection by a parasite or bacteria is causing the symptoms.
A flexible sigmoidoscopy and sometimes colonoscopy is adviced. (The last two tests permit a direct examination of the colon with a lighted tube inserted through the anus. During these tests, biopsies may be obtained to help make a diagnosis.) The doctor may look inside your rectum and colon through a flexible tube (endoscope) that is inserted through the anus. During the exam, the doctor may take a sample of tissue (biopsy) from the lining of the colon to look at under the microscope.
Later, you also may receive x-ray examinations of the digestive tract to determine the nature and extent of disease. These exams may include an upper gastrointestinal (GI) series, a small intestinal study, and a barium enema intestinal x-ray. These procedures are done by putting the barium, a chalky solution, into the upper or lower intestines. The barium shows up white on x-ray film, revealing inflammation or ulceration and other abnormalities in the intestine.
If you have Crohn's Disease, you may need medical care for a long time. Your doctor also will want to test you regularly to check on your condition.
Because Crohn's Disease often mimics other conditions and symptoms may vary widely, the correct diagnosis of Crohn's Disease may take some time.
What is the treatment and medications?
Because no medical cure for Crohn's Disease exists, the goals of medical treatment are to correct nutritional deficiencies, to suppress the inflammatory response to permit healing of tissue, and to relieve the symptoms of fever, diarrhea, abdominal pain and rectal bleeding. Several groups of drugs form the mainstay of therapy for Crohn's Disease today. They are:
1. Aminosalicylates: Aspirin-like drugs, which include Sulfasalazine and Mesalanine, given both orally and rectally
2. Gorticosteroids: Prednisone and Methylprednisolone, available orally and rectally.
3. Immune disorders: Azathioprine, 6MP, Methotrexate.
4. Antibiotics: Metronidazole, Ampicillin, Ciprofloxacin, and others.
In 1998, the FDA approved Infliximab, a biologic therapy, for moderately to severely active Crohn's in patients who have had an inadequate response to conventional therapy, and for reducing the number of draining enterocutaneous fistulas. However, the effectiveness and possible side effects of Infliximab following long-term use are unclear at this time. Until further studies are done, treatment should be reserved for those who do not respond to standard medications.
Abdominal cramps and diarrhea may be helped by drugs. The drug Sulfasalazine often lessens the inflammation, especially in the colon. This drug can be used for as long as needed, and it can be used along with other drugs. Side effects such as nausea, vomiting, weight loss, heartburn, diarrhea, and headache occur in a small percentage of cases. Patients who do not do well on Sulfasalazine often do very well on related drugs known as Mesalamine or 5-ASA agents. More serious cases may require steroid drugs, antibiotics, or drugs that affect the body's immune system such as Azathioprine or 6-Mercaptopurine (6-MP).
Is nutrition important in Crohn’s Disease?
Good nutrition is essential in any chronic disease but especially in this illness, which is characterized by reduced appetite, poor absorption, and diarrhea, all of which rob the body of fluids, nutrients, vitamins, and minerals. Restoration and maintenance of proper nutrition is a vital part of the medical management of Crohn's Disease.
Large doses of vitamins are useless and may even cause harmful side effects.
While foods appear to play no role in causing the disease, soft, bland foods may cause less discomfort than spicy or high-fiber foods when the disease is active. Except for restricting milk in lactose-intolerant patients, most gastroenterologists try to be flexible in planning the diets of their Crohn's patients.
Your doctor may recommend nutritional supplements, especially for children with growth retardation. Special high-calorie liquid formulas are sometimes used for this purpose. A small number of patients may need periods of feeding by vein. This can help patients who temporarily need extra nutrition, those whose bowels need to rest, or those whose bowels cannot absorb enough nourishment from food taken by mouth.
Follow a good nutritious diet and try to avoid any foods that seem to make your symptoms worse.
Can emotional stress trigger attacks of Crohn's Disease?
Because body and mind are so closely interrelated, emotional stress can influence the course of Crohn's Disease, or any other illness. Although acute emotional problems occasionally precede the onset or recurrence of Crohn's this sequence does not imply cause and effect. It is much more likely that emotional distress sometimes frit by people with Crohn's is a reaction to the symptoms of the disease itself. Persons with Crohn's should receive understanding and emotional support from their families and physicians. Some patients are helped considerably by a therapist knowledgeable about inflammatory bowel disease or about chronic illness in general. CCFA offers local support groups to help patients and their families cope with IBD.
Is surgery often necessary?
Crohn's Disease can be helped by surgery, but it cannot be cured by surgery. Surgery becomes necessary in Crohn's Disease when medication can no longer control the symptoms, or when there is an intestinal obstruction, blockage, perforation, abscess, or bleeding or other complication.
Drainage of abscesses or Resection (removal of a section of bowel) due to blockage are common surgical procedures. In most cases, the diseased segment of bowel is removed by cutting above and below the diseased area of the bowel and the two ends of healthy bowel are reconnected. This is called Resection and Anastomosis. While this surgery may allow many symptom-free years, it is not considered a cure for Crohn's Disease because the disease frequently recurs at or near the site of anastomosis.
Infrequently some people must have their colons removed (Colectomy) and an Ileostomy created. An Ileostomy may also be required when surgery is performed for Crohn's Disease of the colon, if the rectum is diseased and cannot be utilized for an Anastomosis. In an Ileostomy, a small opening is made in the front of the abdominal wall, and the tip of the lower small intestine (ileum) is brought to the skin's surface. This opening, called a stoma, is about the size of a quarter or a 50-cent piece. It usually is located in the right lower corner of the abdomen in the area of the beltline. A bag is worn over the opening to collect waste, and the patient empties the bag periodically. The majority of patients go on to live normal, active lives with an Ileostomy.
The fact that Crohn's Disease often recurs after surgery makes it very important for the patient and doctor to consider carefully the benefits and risks of surgery compared with other treatments. Remember, most people with this disease continue to lead useful and productive lives. Between periods of disease activity, patients may feel quite well and be free of symptoms. Even though there may be long-term needs for medicine and even periods of hospitalization, most patients are able to hold productive jobs, marry, raise families, and function successfully at home and in society.
Is it possible to lead a normal life with Crohn’s Disease?
While it is a serious chronic disease, Crohn's is not considered a fatal illness. Most people with the illness continue to lead useful and productive lives, even though they may be hospitalized from time to time, and may need to take medications. In between exacerbations of disease, most people feel well and are relatively free of symptoms.
Even though no medical cure for this disease exists at this time, research and educational programs funded by CCFA (Crohn’s & Colitis Foundation of America) have already improved the health and quality of life of people with Crohn's Disease. Through CCFA's continuing research efforts, much more will be learned and a cure will be found.