Crohn’s Disease

1 What is Crohn’s Disease?

Crohn's disease is an inflammatory bowel disease (IBD) which causes chronic inflammation of gastrointestinal tract.

Often entire layers of affected tissues are inflamed.

Crohn's disease is characterized by

  • abdominal pain,
  • severe diarrhea,
  • tiredness,
  • weight loss
  • malnutrition

Different people have inflammation in different segment of the gastrointestinal tract.

Crohn's disease can be unbearably painful and may cause fatal complications.

There is no cure for Crohn's disease but medications provide symptomatic relief as well as prolong the period of remission.

crohn's

2 Symptoms

Symptoms of Crohn's disease usually develop slowly and range from mild to severe. Sometimes, symptoms may appear abruptly.

Crohn's disease can affect any part of the digestive tract but it mostly occurs in the last segment of the small intestine (ileum) and the colon (part of the large intestine).

You may not experience any signs or symptoms (remission period). Signs and symptoms include:

  • Diarrhea often accompanied by intestinal cramp
  • Low grade fever probably due to inflammation and infection
  • Extreme tiredness
  • Mild to severe abdominal pain and cramping along with nausea and vomiting.
  • Blood in your stool
  • Mouth ulcers
  • Loss of appetite and weight loss
  • Perianal disease: Inflammation near the anus caused by a tunnel into the skin (fistula)

People may also experience:

  • Inflammation of skin, eyes and joints
  • Inflammation of the liver or bile ducts
  • Retarded growth or sexual development, in children

When to see a doctor?

Visit your doctor if your bowel habits have changed or if you experience following:

  • Abdominal pain
  • Blood in your stool
  • Diarrhea unresponsive to over-the-counter (OTC) medications
  • Unexplained fever more than a day or two
  • Unintentional weight loss

3 Causes

The causes of Crohn's disease have not been identified. Diet and stress were believed to cause Crohn's disease but now they are established as exacerbating factors.

Different factors, such as abnormal immune system and hereditary, are believed to be responsible for development of Crohn's disease.

Immune system

While trying to destroy the invading virus or bacteria, the immune system may attack cells in digestive tract causing Crohn's disease.

Heredity

People who have family history of Crohn's disease are likely to develop the disease.

4 Making a Diagnosis

No tests for diagnosis of Crohn's disease are available.

You may be referred to a gastroenterologist (doctor who treats digestive diseases) by your primary care doctor.

How to prepare yourself for the visit?

Getting prepared for the visit can optimize the therapy and help make the visit more fruitful. List out all the symptoms.

Write down your key medical information. Write down the names of all your medications, vitamins or supplements. Ask a friend or a family member to accompany you during the visit.

Make a list of the questions to ask your doctor

Some typical questions can be:

  • What could be possible causes of my symptoms?
  • What are the tests needed?
  • Do these tests require any special preparation?
  • How long will my condition last?
  • What are my treatment options and their side effects?
  • Do I need to avoid any medications?
  • Do I need to follow any dietary restrictions?
  • Is my child likely to develop it?

What your doctor wants to know?

A clear talk with your doctor can optimize the therapy and improve the outcomes. Prepare yourself to answer some essential questions from your doctor. Your doctor might ask you typical questions like:

  • When did the symptoms start appearing and how severe are they?
  • Have your symptoms been continuous or off and on?
  • Do your symptoms affect your daily activities?
  • Does anything improve or aggravate your symptoms?
  • Are you a smoker?
  • How often you take nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or diclofenac?

Diagnosis is confirmed when other probable causes have been eliminated. 

You doctor may combine following tests to diagnose Crohn's disease:

Blood tests

  • Tests for anemia or infection: Your doctor may recommend blood tests to check for anemia, reduced red blood cell counts, or signs of infection.
  • Fecal occult blood test: Stool test may be tested for hidden blood in your stool.

Procedures

  • Colonoscopy: A slender, flexible, lighted tube attached with camera is used to examine your colon. Your doctor may obtain samples of tissue (biopsy) for tests in laboratory. Presence of granulomas (group of inflammatory cells) confirms Crohn's disease.
  • Flexible sigmoidoscopy: A slender, flexible, lighted tube is used to check the last segment of your colon, called sigmoid.
  • Computerized tomography (CT): A CT scan of entire bowel along with tissues outside bowel is performed to examine those areas. CT enterography, a special type of CT scan, provides fine and better images of small bowel.
  • Magnetic resonance imaging (MRI): An MRI uses a magnetic field and radio waves to create images of organs and tissues. MRI is usually performed to examine a fistula around the anal area (pelvic MRI) or the small intestine (MR Enterography).
  • Capsule endoscopy: In this test, a capsule containing camera is swallowed. The picture taken by the camera is viewed to check if there are any signs of Crohn's disease. The camera is excreted through feces.
  • Double-balloon endoscopy: It uses a longer scope instead of standard scope to examine the areas of small bowel where standard scopes are unable to reach. It is opted when capsule endoscopy shows abnormality but the condition is not diagnosed.
  • Small bowel imaging: This imaging test checks the part of small bowel which can't be examined by colonoscopy. X-ray, CT or MRI images of your small intestine are taken once you have drunk liquid containing barium.

5 Treatment

There's no cure for Crohn's disease. Medications or surgery is the treatment option for Crohn's disease.

Doctor can choose either "step-up" approach in which treatment starts with milder drugs or "top-down" approach in which stronger drugs are given initially to treat the Crohn's disease.

Treatment is aimed at reducing the inflammation, providing symptomatic relief, limiting complications and prolonging the period of remission.

Anti-inflammatory drugs

They are the first line agent in treating inflammatory bowel disease. Commonly used drugs are:

Oral 5-aminosalicylates

Drugs like sulfasalazine and mesalamine are recommended if your colon is affected since they aren't effective in treating disease in the small intestine.

These drugs, particularly sulfasalazine, cause several side effects, such as nausea, diarrhea, vomiting, heartburn and headache.

Corticosteroids

Corticosteroids like prednisone can reduce

  • inflammation,
  • relieve symptoms
  • and prolong remission.

Side effects include

  • a swollen face,
  • excessive facial hair,
  • sweating during night,
  • sleeplessness
  • and hyperactivity.

They may also cause severe side effects like

They are opted if you are unresponsive to other treatments. Budesonide, a newer type of corticosteroid, works rapidly than older ones and has fewer side effects.

Usually, corticosteroids are used for three to four months, not longer. A combination of corticosteroids and immunosuppressant may also be given to prevent the symptoms and sustain the preventive effect.

Immune suppressors

They reduce the inflammation by altering your immune function. They may be given alone or in combination. Immunosuppressant drugs are:

Azathioprine and mercaptopurine

They are commonly used in inflammatory bowel disease. While taking these drugs, your doctor monitors the side effects, such as increased risk of infection.

They may cause nausea and vomiting and serious. Severe side effects include liver or pancreatic inflammation and bone marrow suppression.

Long term side effects are rare and include certain infections and cancers, such as lymphoma and skin cancer.

Infliximab, adalimumab and certolizumab pegol

They are tumor necrosis factor (TNF) inhibitors which inhibit the inflammatory protein known as tumor necrosis factor (TNF).

They can provide relief from moderate to severe symptoms and may also induce remission. They can be prescribed if other drugs become ineffective, you are likely to develop severe Crohn's disease or if you have a fistula.

Combination of TNF inhibitors with an immunosuppressant is still controversial. Immunosuppressant can increase your risk of tuberculosis and other serious infections.

Discuss about these risks with your doctor. Your doctor may perform a skin test for tuberculosis, a chest X-ray and a test for hepatitis B prior to prescribing these medications. They can cause certain cancers, including lymphoma and skin cancers.

Methotrexate

It is usually prescribed to treat cancer, psoriasis and rheumatoid arthritis. It may be prescribed in Crohn's disease if other medications become ineffective.

Nausea, fatigue and diarrhea, and rarely, severe pneumonia are the short-term side effects. When used for longer period of time, it can cause bone marrow suppression, scarring of the liver and sometimes cancer. You will be closely monitored for side effects.

Cyclosporine and tacrolimus

These potent drugs are usually given to people who are not benefitted by other treatments. They can cure Crohn's-related fistulas.

Cyclosporine is associated with serious side effects, such as kidney and liver damage, seizures, and fatal infections. They are used for shorter period.

Natalizumab and vedolizumab

They inhibit the binding of integrins, certain immune cell molecules, to cells of your intestine.

Natalizumab is recommended for people with moderate to severe Crohn's disease with inflammation and who are unresponsive to other medications. Although rare, Natalizumab is associated with progressive multifocal leukoencephalopathy, a brain disease that usually leads to death or severe disability.

You must first be registered in a special restricted distribution program to obtain it. Vedolizumab has recently been approved for Crohn's disease. It also inhibits integrins but is not associated with a risk of brain disease.

Ustekinumab

Ustekinumab, used to treat psoriasis, has shown promising results while treating Crohn's disease.

Antibiotics

Antibiotics are likely to decrease the amount of drainage while sometimes can cure fistulas and abscesses in people with Crohn's disease.

The effectiveness of antibiotics for Crohn's disease has not been proved yet. Commonly prescribed antibiotics include:

Metronidazole

Metronidazole, once a drug of choice, is now rarely used because of side effects, such as numbness and tingling in your hands and feet and less commonly, muscle pain or weakness. Stop taking the medication if you experience these effects.

Ciprofloxacin

This drug is preferred over metronidazole and provides relief from symptoms in some people with Crohn's disease. Rarely, it can cause tendon rupture, especially when taken with corticosteroids. 

Other medications

Some other medications are used to manage your signs and symptoms. Depending upon your condition your doctor may suggest.

Anti-diarrheals

Psyllium powder or methylcellulose adds bulks to your feces and relieves mild to moderate diarrhea. If you have severe diarrhea, loperamide may be prescribed. Anti-diarrheals should only be taken if your doctor approves them.

Pain relievers

Acetaminophen can relieve mild pain. Other common pain killers, such as ibuprofen, naproxen sodium can worsen your symptoms and disease. 

Iron supplements

Iron supplements are recommended since you have increased risk of developing iron deficiency anemia due to chronic intestinal bleeding.

Vitamin B-12 shots

Crohn's disease can cause Vitamin B-12 deficiency. Vitamin B-12 is required for proper functioning of nerves, preventing anemia as well as promoting normal growth and development.

Calcium and vitamin D supplements

They are commonly prescribed as Crohn's disease and steroids used to treat it are can cause osteoporosis.

Nutrition therapy

You may be given parenteral nutrition (injecting nutrients into a vein) or suggested enteral nutrition (a special diet given via a feeding tube) to treat Crohn's disease.

This allows your bowel to rest which can reduce inflammation for short period. Enteral and parenteral nutrition are usually recommended to improve health before surgery or when people are unresponsive to other medications and symptoms can't be controlled.

If you have a narrowed bowel (stricture), a low residue or low-fiber diet is suggested that reduces risk of intestinal blockage,

Surgery

Surgery is the ultimate solution and provides short term relief. Nearly half of the cases will need at least one surgery.

But surgery cannot cure the disease. During surgery, the damage segment of gastrointestinal tract is removed and the healthy sections are reconnected.

Strictureplasty is a surgical procedure for widening the narrowed intestinal segments. Recurrence is common and may be minimized by medications after surgery.

6 Alternative and Homeopathic Remedies

Complementary and alternative remedies often used for Crohn's disease are:

Herbal and nutritional supplements

Most of these supplements are not approved by the Food and Drug Administration. Discuss with your doctor before using any herbal supplement.

Probiotics

The beneficial role of probiotics is yet to be established.

Fish oil

Fish oil is found to be ineffective for Crohn's disease.

Acupuncture

The beneficial role of probiotics is yet to be established.

Prebiotics

Use of natural compounds found in plants, such as artichokes, that are useful to beneficial intestinal bacteria has not shown positive results for people with Crohn's disease.

7 Lifestyle and Coping

Controlling your diet and changing your lifestyle can help you manage symptoms and prolong remission of Crohn's disease.

Diet

Foods can exacerbate your signs and symptoms. Avoid foods that worsen your symptoms. Following strategies may be helpful:

  • Avoid dairy products. Use enzyme product such as Lactaid which can be helpful if you are lactose intolerant.
  • Avoid butter, margarine, cream sauces and fried foods.
  • Avoid high-fiber foods, such as fresh fruits and vegetables and whole grains. If you have narrowed bowel (stricture) you may need to limit fiber intake.
  • Avoid spicy foods, alcohol, and caffeine.
  • Take five to six small meals instead of two or three larger ones.
  • Do not take alcohol, caffeinated and carbonated. Increase your water intake.
  • Consider taking multivitamins.
  • Quit smoking

Stress

Stress can aggravate your symptoms and flare-ups. Here are some stress management tips:

  • Exercise regularly
  • Consider biofeedback technique that can help you feel relaxed.
  • Practice regular relaxation and breathing exercises.

Learn enough about Crohn's disease. Join a support group. Consider talking to a counselor.

8 Risk and Complications

There are several risks and complications associated with Crohn's disease.

Risks

  • Age: Individuals younger than 30 may be at a greater risk.
  • Race: People of Eastern European (Ashkenazi) and Jewish descent are at increased risk.
  • Family history: A family history increases your risk of developing the disease.
  • Cigarette smoking: You are at increased risk if you smoke. Smoking can exacerbate your condition.
  • Nonsteroidal anti-inflammatory medications: Drugs, such as ibuprofen, naproxen and diclofenac, can cause inflammation which can worsen your condition.
  • Where you live: If you live in city or in an industrialized country, your risk of Crohn's disease increases.

Complications

  • Inflammation: Inflammation of digestive tract may result in scarring and narrowing (stenosis)
  • Bowel obstruction due to chronic inflammation.
  • Ulcers may develop in your mouth and anus, and in the genital area (perineum).
  • Fistulas: Sometimes ulcers can create a fistula, an abnormal connection between two body parts. Fistulas may form between your intestine and skin, or between your intestine and another organ. Fistulas mostly develop near or around the anal area (perianal). If fistulas develop in the abdomen, food may not pass through the areas of the bowel where absorption occurs. Infections of fistulas can be life-threatening if left untreated.
  • Anal fissure: A small tear in the lining of the anus or in the skin around the anus where infections can occur. It often causes painful bowel movements and may cause a perianal fistula.
  • Malnutrition: Diarrhea, abdominal pain and cramping can interfere with absorption of nutrients. You may develop anemia due to iron or vitamin B-12 deficiency.
  • Colon cancer: Crohn's disease increases your risk of colon cancer.
  • Other health problems: Anemia, osteoporosis, and gallbladder or liver disease
  • Medication risk: Immunosuppressant can slightly increase the chance of developing cancers, such as lymphoma and skin cancers, and increase the risk of infection. Corticosteroids can cause side effects, such as osteoporosis, bone fractures, cataracts, glaucoma, diabetes and hypertension.

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