Crohn's Disease
Living with Crohn's
Named for Burrill B. Crohn, a New York gastroenterologist who identified a pattern of intestinal inflammation in his patients, Crohn's disease is one of several chronic digestive tract aliments, including colitis. The cause of Crohn's, which most often makes its first appearance in young adults, has not yet been identified.
At the outset, Crohn's is marked by abdominal pain, cramping (usually on the right side), diarrhea, and often fever, fatigue, and weight loss. While some cases of Crohn's disappear on their own, the disease may progress, leading to intestinal blockage, ulceration, and infection. Between half and three quarters of people with Crohn's eventually require surgery to remove the affected portion of the intestine, usually more than five years after symptoms first appear.
Treatment focuses on relieving symptoms by changes in diet, stress reduction, drug therapy, and, as the last resort, surgery. Recent innovations in drug treatment include antibacterial medications (the same sort used to treat the ulcer-causing Helicobacter pylori), timed-release anti-inflammatory agents, which seem to produce fewer side effects than standard steroid therapies, and newer immunotherapeutic agents.
Pronunciation
KRONE's disease
Synonyms and Abbreviations
- Granulomatous colitis
- Regional enteritis
- Regional ileitis
- Regional colitis
- Regional ileocolitis
- Inflammatory bowel disease
- IBD
Detailed Description
In the early stages of Crohn's disease, tiny lesions called aphthoid ulcers form on the intestinal walls. Over time, the lesions grow together and the intestinal wall takes on a cobblestone appearance, with diseased areas separated by healthy segments.
Crohn's most often affects the ileum (where the large and small intestine join) though it can affect the any part of the digestive tract, from mouth to anus. As Crohn's progresses, the inflammation affects all layers of the intestinal walls, making them thick and inflexible, sometimes leading to strictures, obstructions, abscess formations, bowel perforations, and hemorrhage.
Surrounding tissues and lymph nodes can also become inflamed. If the perianal area is affected, there might be fissures (painful cracks in the anus). Inflamed pouches or tunnels, called fistulae, may also occur.
How Common Is Crohn's Disease?
An estimated one million Americans have Crohn's disease, and approximately 15,000 new cases are diagnosed each year. While the disease can develop at any age, symptoms most often appear in young adults in their 20s. Ninety percent of people who develop Crohn's will do so before the age of 40.
Some studies have suggested that women are more likely than men to develop Crohn's; others have shown that women tend to have more severe as well as more secondary symptoms.
Established Causes
There is no established cause of Crohn's disease, though genetic factors seem to play a role. Between 10% and15% of people with Crohn's have a family history of the disease; another 5% to 7% of people with Crohn's have a family history of ulcerative colitis, another chronic intestinal tract disease.
Theoretical Causes
Crohn's disease seems to be caused by a combination of heredity and environmental factors. Some research has suggested that it is an autoimmune disorder.
Risk Factors
There may be an increased risk among people of Jewish descent and among those with a history of food allergies.
Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.
Symptoms and Diagnosis
Symptoms of Crohn's disease include:
- Abdominal pain (especially the right-lower quadrant)
- Chronic diarrhea
- Weight loss
- Low-grade fever
- Fatigue
- Rectal bleeding
- Fistulas and perirectal abscesses
Less common symptoms include:
- Non-swelling joint pain and arthritis, sacroiliitis
- Skin rashes
- Photophobia
- Persistent mouth ulcers
Children who develop Crohn's disease may suffer delayed development and stunted growth.
How Crohn's Disease Is Diagnosed
Your doctor will first discuss your symptoms with you, to see if they are characteristic of Crohn's. The disease is then diagnosed using endoscopic exams (to look at the inside of your intestine), X-ray imaging, and laboratory tests.
Laboratory Work
There is no definitive blood test for Crohn's, but some abnormalities suggest its presence. An increased white blood cell count is a sign of inflammation somewhere in the body. Anemia suggests internal bleeding or the malabsorption of nutrients, triggered by damage to the intestinal tract. Blood levels of ferritin, calcium, zinc, and magnesium also tend to be low in people with Crohn's.
Your doctor will probably also take a stool sample to test for the presence of blood, another indicator of Crohn's.
Other tests
If Crohn's is suspected, you'll probably have a sigmoidoscopy or colonoscopy, in which an endoscope, or lighted tube linked to a video monitor, is used to look at the inside of the intestines. Your doctor will look for the irritation and inflammation characteristic of Crohn's. Often the doctor will also remove a small piece of tissue for biopsy. Newer antibody tests are now available which may assist with diagnosis.
Imaging
Your doctor may also perform an upper gastrointestinal (GI) series to look at the small intestine. For this test, barium, a chalky solution that coats the lining of the small intestine, is swallowed before X-rays are taken. The barium reveals inflammation or scarring in the intestine. The barium can also be administered through the use of an enema to examine the colon (large intestine).
In some cases a physician will use a CT scan of the abdomen to look for a cavity associated with a fistula, or to look for abscesses.
Goals of Treatment
Crohn's disease can often be managed with judicious use of appropriate medication. Specific goals for the treatment of Crohn's include:
- Inducing and maintaining remission during the active phase of the disease
- Managing discomfort caused by inflammation
- Managing other symptoms, such as diarrhea
- Protecting the bowel and avoiding complications that would require surgery
- Maintaining nutritional levels
Treatment Options
A range of medications and sometimes surgery are used to treat Crohn's disease.
Drug Therapy
Anti-inflammatory medications
People with Crohn's are usually treated with anti-inflammatory agents, most commonly Azulfidine (sulfasalazine) or Asacol, Rowasa, or Pentasa (mesalamine).
If inflammation is still not controlled, a physician may prescribe corticosteroids, such as Deltasone, Orasone, or Meticorten (prednisone). These steroids are often very effective for counteracting Crohn's, but can cause serious side effects, including a greater susceptibility to infection, weight gain, and irritability.
Drugs that suppress the immune system are also used to treat Crohn's disease. Most commonly prescribed are 6-mercaptopurine and a related drug, azathioprine. Immunosuppressive agents work by blocking the immune reaction that contributes to inflammation.
Infliximab
Remicade (infliximab) is the only drug that has been approved by the FDA specifically for treatment of Crohn's. You doctor may suggest it if your symptoms don't respond to standard therapies (mesalamine substances, corticosteroids, immunosuppressive agents). Infliximab is given by IV (in one or three infusions, depending on your symptoms) and it works by neutralizing tumor necrosis factor-- the protein responsible for much of the intestinal inflammation.
Antidiarrheals
Diarrhea, cramping, and abdominal pain are usually relieved when inflammation subsides, but if your diarrhea persists, your doctor may prescribe one of several antidiarrheals, including Lomotil (diphenoxylate with atropine) and Imodium (loperamide). If your diarrhea causes dehydration, you should be treated with fluids and electrolytes.
Antibiotics
Antibiotics are used to treat bacterial overgrowth caused by stricture, fistulas, or prior surgery. Your doctor may prescribe ampicillin, sulfonamides, cephalosporins, tetracycline, or metronidazole. Metronidazole may be an effective primary treatment of perianal fistulae.
New drugs in development
- Interleukin 10: Known as IL-10, this is a cytokine that suppresses inflammation.
- Antibiotics: Now used to treat the bacterial infections that often accompany Crohn's disease, some research suggests that antibiotics might also be useful as a primary treatment for active Crohn's disease.
- Budesonide: Researchers recently identified a new corticosteroid called budesonide that appears to be as effective as other corticosteroids but causes fewer side effects.
- Zinc: Free radicals?-- molecules produced during fat metabolism, stress, and infection?-- may contribute to inflammation in Crohn's disease. The mineral zinc removes free radicals from the bloodstream.
- Methotrexate and cyclosporine (immunosuppressive drugs): One potential benefit of methotrexate and cyclosporine is that they appear to work faster than traditional immunosuppressive drugs.
- Interferon alpha: Clinical studies show the immunosuppressant interferon-alpha-2a is effective in achieving clinical remission and decreasing the symptoms of Crohn's disease.
Surgery
Between half and three quarters of people with Crohn's will undergo surgery at some point. But surgery, unfortunately, may not mean an end to symptoms; the disease can happen again next to the section of intestine that was removed. Involved sections of intestine can also develop scar tissue, causing an obstruction. Surgery may also be required to remove fistulae or treat a perforation or hemorrhage.
Managing Treatment
- For the initial mild treatment of the disease: sulfasalazine or mesalamine
- For moderate or severe disease: prednisone used concurrently with sulfasalazine or mesalamine
- Sulfasalazine or mesalamine are the maintenance drugs that you will use regularly
- Your physician will likely have other drug suggestions in treatment of the disease
- Immunosuppressant drugs (6MP/AZA) may be used as steroid-sparing agents
- Surgery, as a last resort
Possible Complications
Complications from Crohn's disease include:
- Intestinal malabsorption
- Intestinal obstruction
- Vitamin B-12 deficiency
- Formation of fistulae along intestine
- Risk of adenocarcinoma in ileum due to extensive colon disease
- Perforations along inflamed bowel/fistulae: perianal, enterocutaneous, entero-enteral
- Anemia and intestinal bleeding
- Risk of developing osteoporosis (especially when taking steroids)
- Short bowel syndrome (if too much intestine needs to be removed)
Healthcare Professionals Who May Be Involved in Treatment
Healthcare professionals involved in treating Crohn's may include:
- Family practitioners
- Internists
- Pediatricians
- Gastroenterologists
- General surgeons
- Colorectal surgeons
- Clinical immunologists
Activity and Diet Recommendations
Eating a balanced diet is especially important for people with Crohn's disease because some symptoms, including diarrhea and malabsorption caused by intestinal injury or surgery, leave people particularly prone to malnutrition. Eating small, frequent meals can reduce the severity of symptoms. Patients should also identify-- and then eliminate-- any foods that aggravate symptoms. Keeping a food diary, or written record of everything you eat, can help you figure out what triggers your discomfort. Many people find that high-fiber foods, such as salads, raw vegetables, and raw fruits, may be particularly problematic.
Avoiding alcohol, cigarettes, and foods high in saturated fats can also reduce the severity of symptoms.
Considerations for Women
Pregnancy
Though Crohn's disease does not directly affect pregnancy, maintaining adequate nutrition is absolutely essential. You may want to ask your doctor about supplements. Discuss the safety of all your medications with your doctor prior to becoming pregnant.
Nursing mothers
Some drugs, like metronidazole, are excreted into breast milk. If it is taken while nursing, speak with your doctor about discontinuing breastfeeding for 12 to 24 hours to allow it to pass out of your system.
Considerations for Children and Adolescents
When children develop Crohn's disease, the primary symptoms are often joint inflammation, fever, anemia, and slow growth. Nutrition and dietary supplements are important to help children maintain normal growth.
Supplements
Fish oil: If you don't like salmon, the beneficial omega-3 fatty acids it contains are available as supplements. In a year-long study, Italian researchers gave either a placebo or fish-oil supplements (nine standard capsules a day) to 78 people with Crohn's disease. The fish-oil group had significantly fewer symptoms. [1]
Herbs
Peppermint tea relaxes the digestive tract. For something stronger, try enteric coated capsules of peppermint oil. [2]
Last updated October 1999.
Sources
1Belluzzi, A. et al. "Effects of An Enteric Coated Fish Oil Preparation on Relapses in Crohn's Disease," New England Journal of Medicine 334:1557, 1996.
2Duke, James. The Green Pharmacy. Emmaus, PA: Rodale Press, 1997.
Preventing Crohn's Disease
Since the cause of Crohn's disease is unknown, it cannot currently be prevented. There does, however, seem to be a hereditary factor in about 15% to 20% of the cases.
Self-Care Measures
While the disease is currently incurable, a myriad of treatment programs are available to manage the condition. No single standard treatment is recommended, as you might respond well to one treatment but not as well to another. Surgery resection of the bowel should be a last resort, as it is not curative. Avail yourself of different therapies to see which is the most beneficial.
- Avoid aspirin, ibuprofen, and other nonsteroidal anti-inflammatory drugs (NSAIDs). They irritate the digestive tract.
- Food sensitivities often play a role in Crohn's disease. An elimination diet might help identify the culprits causing you trouble. British researchers placed 93 people with Crohn's disease on an elimination diet that used a nutrient-rich formula instead of regular food. After two weeks, 84% reported substantial relief. Then the subjects began reintroducing regular food and noting items that caused Crohn's symptoms, notably grains (usually wheat and/or corn), dairy products, yeast, and salads.
- Eat more salmon. Crohn's is an inflammatory disease, and salmon and other cold-water fish contain omega-3 fatty acids, which have an anti-inflammatory effect.
Websites & Organizations
American Digestive Health Foundation
7910 Woodmont Avenue, 7th Floor
Bethesda, MD 20814-3015
Phone: 301-654-2635
Fax: 301-654-1140
Email: dlee@gastro.org
Crohn's & Colitis Foundation of America, Inc.
386 Park Avenue South, 17th Floor
New York, NY 10016-8804
Phone: 212-685-3440 or 800-932-2423
Fax: 212-779-4098
Email: info@ccfa.org
National Digestive Diseases Information
P.O. Box NDDIC
Bethesda, MD 20892
Phone: 301-468-6344
San Diego Crohn's and Colitis Society (SDCCS)
P.O. Box 3907
San Diego, CA 92163-1907
Voice mail: 619-525-3440
Three Rivers Endoscopy Center
725 Cherrington Parkway
Moon Township, PA 15108-4305
Phone: 412-262-1000
Fax: 412-262-2346
United Ostomy Association
36 Executive Park, Suite 120
Irvine, CA 92714
Phone: 800-826-0826 or 714-660-8624
Email: uoa@deltanet.com
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Articles
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