Crohn’s Disease – Overview
Gastroenterology & GI Surgery
Crohn’s disease is a disease which is known as inflammatory bowel disease (IBD) and inflammation is caused of the digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition. Different areas of the digestive tract in different people can be involved due to the inflammation caused by Crohn’s disease.
Crohn’s disease when causing inflammation often spreads deep into the layers of affected bowel tissue. Crohn’s disease can be both painful and debilitating, and sometimes life-threatening complications may also occur.
While cure for Crohn’s disease is not known, signs and symptoms are reduced greatly by therapies and even bring about long-term remission. Many people with Crohn’s disease are able to function well with the treatment.
Only the last segment of the small intestine (ileum) is affected in some people who are having Crohn’s disease. While in others, the disease is restricted to the colon that is part of the large intestine. The last part of the small intestine and the colon are the most common areas which are affected by Crohn’s disease.
Signs and symptoms of Crohn’s disease can be ranging from mild to severe. They usually develop moderately, but sometimes without any warning it will come on suddenly. There might be times when having no signs or symptoms (remission).
Signs and symptoms when the disease is active may include:
- Abdominal pain and cramping
- Blood in your stool
- Mouth sores
- Appetite and weight loss reduced
- Pain or drainage near or around the anus due to inflammation from a tunnel into the skin (fistula)
Other signs and symptoms
People affected with severe Crohn’s disease also may experience:
- Skin, eyes and joints inflammation
- Liver or bile ducts inflammation
- Growth or sexual development, in children delayed
When to see a doctor
Doctor should be contacted when changes in bowel habits are consistent or if having any of the signs and symptoms of Crohn’s disease, such as:
- Abdominal pain
- Blood in your stool
- Ongoing bouts of diarrhea that don’t respond to over-the-counter (OTC) medications
- Fever lasting more than a day or two with no explanation
- Weight loss with no explanation
The specific cause of having Crohn’s disease remains unknown. Diet and stress were suspected previously, but now doctors know that these factors may provoke but cannot be the cause of Crohn’s disease. Heredity and a malfunctioning immune system are a number of factors to likely play a role in its development.
- A virus or bacterium can possibly be a trigger to Crohn’s disease. When the immune system is trying to fight off the invading microorganism, an immune response which is abnormal causes the immune system to attack the cells in the digestive tract, too.
- Crohn’s is more common in people who have family history with the disease, so a role is played by the genes in making people more susceptible. However, family history may not be a factor for most people with Crohn’s disease
Crohn’s disease risk factors may include:
- Crohn’s disease can happen at any age, but it is likely that the condition will be developed when young. Before the age of 30 years, most people who develop Crohn’s disease are diagnosed
- Although any ethnic group can be affected by Crohn’s disease, whites have the highest risk, including people of Eastern European (Ashkenazi) Jewish descent. However, among blacks who live in North America and the United Kingdom the incidence rate of developing Crohn’s disease is increasing.
- The risk is higher if a close relative, such as a parent, sibling or child, have been diagnosed with the disease. Around 1 in 5 people with Crohn’s disease have a family member having the disease.
- Cigarette smoking is the most important controllable risk factor for developing Crohn’s disease is cigarette smoking. More-severe disease and a greater risk of having surgery can be due to smoking. It’s important to stop if smoking.
- Medications which are Nonsteroidal anti-inflammatory may be taken which include ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve), diclofenac sodium (Voltaren) and others. While Crohn’s disease is not caused by this, but it can lead to inflammation of the bowel that makes Crohn’s disease worse.
- Area of residence also plays a role that is if living in an urban area or in an industrialized country, it is more likely to develop Crohn’s disease. This recommends that environmental factors, including a diet high in fat or refined foods, may play a role in Crohn’s disease.
One or more of the following complications may lead to Crohn’s disease:
- The thickness of the intestinal wall is affected by the Crohn’s disease. Over the period of time, parts of the bowel can scar and narrow, which might block the flow of digestive contents. Surgery may be required to remove the diseased portion of the bowel.
- Open sores (ulcers) can be because of chronic inflammation anywhere in the digestive tract, including the mouth and anus, and in the genital area (perineum).
- Fistula which is an abnormal connection between different body parts is created as sometimes ulcers can extend completely through the intestinal wall. Between the intestine and skin, fistulas can be developed, or between the intestine and another organ. The most common type is fistulas near or around the anal area (perianal)
Food may bypass areas of the bowel that are necessary for absorption when fistulas have developed in abdomen. Fistulas may happen between loops of bowel, into the bladder or vagina, or out through the skin, continuous drainage of bowel contents to the skin is caused
A fistula may become infected and form an abscess, which can be life-threatening if not treated, this can be in some cases.
- A small tear in the tissue that lines the anus or in the skin around the anus where infections can occur is known as anal fissure. It’s often related with painful bowel movements and may lead to a perianal fistula.
- Conditions that may make it difficult to eat or intestine to absorb enough nutrients to keep nourished are diarrhea, abdominal pain and cramping. It’s also common that anemia may be developed due to low iron or vitamin B-12 caused by the disease.
- Risk of having a colon cancer is increased if having Crohn’s disease that affects the colon. Screening guidelines for general colon cancer for people without having Crohn’s disease call for a colonoscopy every 10 years beginning at age 50. Doctor should be contacted whether this test done need to be done sooner and more frequently.
- Problems in other parts of the body can be caused by Crohn’s disease. Anemia, skin disorders, osteoporosis, arthritis, and gallbladder or liver disease are among the problems.
- Certain medications of Crohn’s disease that act by blocking functions of the immune system are related with a small risk of developing cancers such as lymphoma and skin cancers. Risk of infection is also increased.
Risk of osteoporosis, bone fractures, cataracts, glaucoma, diabetes and high blood pressure, among others can be related with corticosteroids. To determine risks and benefits of medications should be made with the doctor.
After ruling out other possible causes for signs and symptoms, the doctor is likely to diagnose Crohn’s disease. To diagnose Crohn’s disease one test only is not there.
A combination of tests is likely to be used by the doctor to help confirm a diagnosis of Crohn’s disease, including:
- Blood tests may be suggested by the doctor to check for anemia which is a condition in which there aren’t enough red blood cells to carry adequate oxygen to the tissues or to check for signs of infection. Antibody or genetic testing for Crohn’s disease is not currently recommended by expert guidelines.
- A stool sample may need to be provided so that the doctor can test for hidden (occult) blood in the stool.
- Colonoscopy test allows the doctor to view the entire colon and the very end of your ileum (terminal ileum) using a thin, flexible, lighted tube with an attached camera. During the procedure, small samples of tissue (biopsy) may also be taken by the doctor for laboratory analysis, which may help confirm a diagnosis. Granulomas which are Clusters of inflammatory cells, if present, help in confirming the diagnosis of Crohn’s.
- A CT scan a special X-ray technique that provides more detail than a standard X-ray does might be conducted. The entire bowel is looked in this test as well as at tissues outside the bowel. CT enterography is a special CT scanin which better images are provided of the small bowel. Barium X-rays has been replaced by this test in many medical centers.
- A magnetic field and radio waves are used in MRI scanner to create detailed images of organs and tissues. MRI is particularly useful for evaluating a fistula around the anal area (pelvic MRI) or the small intestine (MR enterography).
- A capsule is swallowed that has a camera in it for capsule endoscopy. Pictures of the small intestine are captured by the camera, which are transmitted to a recorder being worn on the belt. Signs of Crohn’s diseases are checked when the images are downloaded to a computer, displayed on a monitor. The camera exits the body painlessly in the stool. Endoscopy with biopsy may still be required to confirm the diagnosis of Crohn’s disease.
- A scope is used in conjunction with a device called an overtube in the test known as balloon-assisted enteroscopy. Where standard endoscopes don’t reach this will help in enabling the doctor to look further into the small bowel. When capsule endoscopy shows abnormalities, but the diagnosis is still in question, this method may be useful.
No cure for Crohn’s disease is currently available, and there is no one treatment that works for everyone. To reduce the inflammation that triggers the signs and symptoms is the goal of the medical treatment. It is also for the improvement of long-term prognosis by restricting complications. In the best cases, not only symptom relief but also to long-term remission may also be experienced.
Often the first step in the treatment of inflammatory bowel disease is anti-inflammatory drugs. They include:
- Prednisone and budesonide (Entocort EC) are corticosteroids that can help decrease inflammation in the body, but they don’t work for everyone who is having Crohn’s disease. These are generally used by doctors when there is no response to other treatments
For short-term (three to four months) symptom improvement and to induce remission corticosteroids may be used. Corticosteroids may also be used when combined with an immune system suppressor.
- Sulfasalazine (Azulfidine), which contains sulfa, and mesalamine (Asacol HD, Delzicol, others) are included in oral 5-aminosalicylates. In the past Oral 5-aminosalicylates have been used widely but now are usually considered of limited benefit.
Immune system suppressors
Inflammation is also decreased with immune system suppressors, but they target the immune system, which develops the substances that cause inflammation. For some people, a mixture of these drugs operates better than one drug alone. Immunosuppressant drugs include:
- Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol, Purixan) are drugs which are the most widely used immunosuppressants for treatment of inflammatory bowel disease. Their intake requires following up closely with the doctor and having the blood checked regularly to look for side effects, such as a lowered resistance to infection and inflammation of the liver. Nausea and vomiting may also be caused by them.
- Infliximab (Remicade), adalimumab (Humira) and certolizumab pegol (Cimzia) are drugs which are known as TNF inhibitors or biologics and works by neutralizing an immune system protein called as tumor necrosis factor (TNF).
- Methotrexate (Trexall) is a drug which is sometimes used for people with Crohn’s disease who are not responding well to other medications. Side effects should be monitored closely
- Natalizumab (Tysabri) and vedolizumab (Entyvio) are drugs which work by stopping certain immune cell molecules i.e. integrins from binding to other cells in the intestinal lining. Because natalizumab is connected with a rare but critical risk of progressive multifocal leukoencephalopathy which is a brain disease that usually results to death or severe disability. A special restricted distribution program must be enrolled in order to use it.
For Crohn’s disease, vedolizumab has been approved recently. It works like natalizumab but appears not to hold a risk of brain disease.
- Ustekinumab (Stelara) is a drug which is used for the treatment of psoriasis. It’s useful in treatment of Crohn’s disease as well and may be used when other medical treatments fail has been shown in some studies.
The amount of drainage and sometimes heal fistulas and abscesses in people with Crohn’s disease can be reduced by antibiotics. Some researchers have also thought that antibiotics can help in the reduction of harmful intestinal bacteria that may play a part in activating the intestinal immune system, leading to inflammation. Ciprofloxacin (Cipro) and metronidazole (Flagyl) are antibiotics which are prescribed frequently.
Some medications may help relieving the signs and symptoms with addition to controlling inflammation, but always doctor should be consulted before taking any over-the-counter medications. Doctor may suggest one or more of the below depending on the severity of Crohn’s disease:
- Psyllium powder (Metamucil) or methylcellulose (Citrucel) which are fiber supplements, can help relieve mild to moderate diarrhea by adding bulk to the stool. For diarrhea which is more severe, loperamide (Imodium A-D) may be effective.
- The doctor may suggest acetaminophen (Tylenol, others) for mild pain but no other common pain relievers, such as ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve). These drugs are likely to worsen the symptoms, and can make the disease worse as well.
- If having chronic intestinal bleeding, iron deficiency anemia may be developed and need to take iron supplements.
- Vitamin B-12 deficiency can be caused by Crohn’s disease. Vitamin B-12 helps in the prevention of anemia and promotes normal growth and development, and is essential for proper nerve function.
- Calcium and vitamin D supplements. Crohn’s disease and steroids are used for treatment; risk of osteoporosis can be increased, so calcium supplements with added vitamin D my need to be taken.
A special diet may be recommended by the doctor via a feeding tube (enteral nutrition) or nutrients injected into a vein (parenteral nutrition) to treat the Crohn’s disease. Overall nutrition can be improved with this and allow the bowel to rest. Inflammation can be reduced with bowel rest in the short term.
Nutrition therapy may be used by the doctor in short term and combine it with medications, such as immune system suppressors. To get people healthier prior to surgery or when other medications fail to control symptoms enteral and parenteral nutrition are used typically.
A low residue or low-fiber diet may also be suggested by the doctor to decrease the risk of intestinal blockage if having a narrowed bowel (stricture). To reduce the size and number of the stools, low residue diet is designed.
If signs and symptoms are not relieved with diet and lifestyle changes, drug therapy or other treatments, the doctor may recommend surgery. Nearly 50 percent of those having Crohn’s disease will need at least one surgery. However, Crohn’s disease is not cured by surgery.
During surgery, a damaged portion of the digestive tract is removed by the surgeon and then the healthy sections are reconnected. To close fistulas and drain abscesses, surgery may be used.
The benefits of surgery are generally not permanent for Crohn’s disease. Frequently near the reconnected tissue this disease recurs often. Following surgery with medication to reduce the risk of recurrence is the best approach for this.
Lifestyle and home remedies
Sometimes feeling of helplessness may be felt when facing Crohn’s disease. To control the symptoms and lengthen the time between flare-ups changes in diet and lifestyle may help.
Evidence of what to eat actually cause inflammatory bowel disease is not exact. Signs and symptoms can aggravate but in certain foods and beverages, especially during a flare-up.
A food diary kept may be helpful to keep track of what is being eaten, as well as how it is felt. Some foods are discovered which are causing the symptoms to flare, try eliminating them. Below are some suggestions that may help:
- Problems such as diarrhea, abdominal pain and gas with many people who are having inflammatory bowel disease have improved by limiting or eliminating dairy products. If lactose intolerant that is, the body can’t digest the milk sugar (lactose) in dairy foods. Usage of Lactaid, an enzyme product, may help.
- If having Crohn’s disease of the small intestine, digesting or absorbing fat normally may be difficult. But the fat passes through the intestine, making the diarrhea worse. Butter, margarine, cream sauces and fried foods should be avoided.
- High-fiber foods, such as fresh fruits and vegetables and whole grains, may make the symptoms worse if having inflammatory bowel disease. Try steaming, baking or stewing if raw fruits and vegetables bother.
In general, problems with foods in the cabbage family may be more, such as broccoli and cauliflower, and nuts, seeds, corn and popcorn. Limiting fiber or going on a low residue diet if having a narrowing of your bowel (stricture) may be instructed to be done.
- Signs and symptoms may become worse due to Spicy foods, alcohol, and caffeine
Other dietary measures
- Eating five or six small meals a day rather than two or three larger ones may help to feel better.
- Plenty of fluids daily should be drunk. Water is best. Alcohol and beverages that have caffeine stimulate the intestines and can make diarrhea worse, while carbonated drinks continuously produce gas.
- The ability to absorb nutrients may be interfered due to Crohn’s disease and because the diet may be limited, multivitamin and mineral supplements are often helpful. Doctor should be consulted before taking any vitamins or supplements.
- If beginning to lose weight or diet has become very limited, registered dietitian should be consulted.
Risk of developing Crohn’s disease is increased by smoking, and once it is there, smoking can make it worse. People with Crohn’s disease who smoke are more likely to have relapses and medications may be required and repetitive surgeries. The overall health of the digestive tract can be improved by quitting smoking, as well as provide many other health benefits.
Crohn’s disease is not caused by stress but it can make the signs and symptoms worse and may trigger flare-ups. Although avoiding stress may not always be possible, ways can be learnt to help manage it, such as:
- Even mild exercise can help minimize stress, relieve depression and normalize bowel function. Doctor should be contacted about an exercise plan that’s right.
- Biofeedback is a stress-reduction technique may help to minimize muscle tension and slow your heart rate with the help of a feedback machine. The aim is to help in entering a relaxed state so that coping with stress is done more easily
- Regularly relaxing and using techniques can be a way to cope with stress such as deep, slow breathing to calm down. Classes in yoga and meditation may be taken or using books, CDs or DVDs at home.
Some form of complementary and alternative medicine (CAM) is used by many people with digestive disorders. However, well-designed studies of their safety and effectiveness are few.
Some commonly used therapies may include:
- The Food and Drug Administration are not regulated majority alternative therapies. Therapies are safe and effective but the need to prove it is not needed is claimed by many manufacturers. Additionally, even natural herbs and supplements can have side effects and may cause dangerous interactions. Doctor should be consulted if deciding to try any herbal supplement.
- Some evidence to recommend that some Bifidobacterium preparations may help people with Crohn’s disease to maintain remission is available, but no benefits for treating Crohn’s disease with probiotics has been found in some studies. Research is needed more which is necessary to determine their effectiveness.
- Studies have not shown any advantages done on fish oil for the treatment of Crohn’s disease.
- For the management of Crohn’s disease, acupuncture and hypnosis may be helpful for some people, but neither therapy has been well-studied for this use.
- Not like probiotics which are beneficial live bacteria that is consumed, prebiotics are natural compounds found in plants, for example artichokes, that help in fueling beneficial intestinal bacteria. Positive results have not been shown in research of prebiotics for people with Crohn’s disease.
Coping and support
Physically and an emotional toll is taken as well because of Crohn’s disease. Life may revolve around a constant need to run to the toilet if the signs and symptoms are diagnosed to be severe. Gas and abdominal pain can make it difficult to be out in public if the symptoms are mild. All of these factors can be life altering and may lead to depression. Below are some things which can be done:
- To be more in control of the Crohn’s disease one of the best ways is to collect as much information as possible
- Although support groups aren’t for everyone, but valuable information can be provided by support groups about the condition as well as emotional support. Latest medical treatments or integrative therapies are known by the members of the group consistently. To be among others with Crohn’s disease can be found to be reassuring.
- A mental health professional should be consulted who’s familiar with inflammatory bowel disease and the emotional difficulties it can cause.
Although it may be felt discouraging living with Crohn’s disease, research is being carried on and the outlook is improving.
Preparing for appointment
Visiting family doctor or general practitioner may be the first option if symptoms are found of Crohn’s disease. Seeing a specialist may be recommended by the doctor who treats digestive diseases (gastroenterologist).
It’s a good idea to be well-prepared as appointments could be brief and a lot of information is to be discussed. Below is some information that may help in getting ready and what to be expected from the doctor.
- Anything which is required to be done in advance such as restricting the diet may need to be ensured at the time you make the appointment
- Any symptoms which are being experienced should be written down, including any that may seem unrelated to the reason for which the appointment is scheduled.
- Key personal information which might be crucial should be written down, including any major stresses or recent life changes.
- A list of all medications should be made such as, vitamins or supplements that are being taken.
- During an appointment may be difficult to remember all at once. Someone accompanying may remember something that is missed or forgot.
- Any questions to ask the doctor should be written down.
Time with the doctor is limited, so preparing a list of questions can help in making the most out of the visit. Questions should be prioritized from most important to least important in case time runs out.
In addition to the questions that have been prepared to ask the doctor, additional questions may also be asked during the appointment without hesitation.
A number of questions are likely to be asked by the doctor. Time may be reserved when getting ready for answering them and may limit the time to go over points that are prepared to want to spend more time on. The doctor may ask:
- Beginning of experiencing symptoms?
- Symptoms been persistent or off and on?
- Severity of the symptoms?
- Symptoms affecting the ability to work or do other activities?
- Anything showing improvement the symptoms?
- Anything noticed that is making the symptoms worse?
- Smoking or not?
- Any over-the-counter or prescription nonsteroidal anti-inflammatory drugs (NSAIDs) being taken for example, ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve, Anaprox), or diclofenac sodium (Voltaren)?