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What is Crohn’s disease?
Crohn’s disease is an ongoing disorder that causes
inflammation of the digestive tract, also referred to as
the 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.
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.
Is pregnancy safe for women with Crohn's disease?
Research has shown that the course of pregnancy and delivery
is usually not impaired in women with Crohn’s disease.
Even so, women with Crohn’s disease should discuss
the matter with their doctors before pregnancy. Most children
born to women with Crohn’s disease are unaffected.
Children who do get the disease are sometimes more severely
affected than adults, with slowed growth and delayed sexual
development in some cases.
To read the rest of this article, and related materials
from The National Institute of Diabetes and Digestive and
Kidney Diseases (NIDDK), please click here: http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/index.htm
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