Crohn's Disease

What is Crohn’s Disease?

Crohn’s disease (CD) is a chronic disorder of the gastrointestinal (GI) tract. It is one of the disorders in the group called Inflammatory bowel diseases (IBD). It causes inflammation of the tissue of the GI tract and can impact any area from the mouth to the anus. It is most commonly found in the last part of the small intestine, (known as the ileum) and in the beginning of the colon. The inflammation can extend through the entire wall of the GI tract.

Who gets it?

About 1.4 million Americans have either Crohn’s Disease or ulcerative colitis. Anyone can develop it. Crohn’s Disease can occur at any age; though it is most common between ages 15-30. Males and females are equally affected. A second peak is in people aged 50-80.

There appears to be a genetic connection, as the disease often runs in families. The risk of developing the disease is between 5.2-22.5% if a first degree relative (parent, sibling or child) has the disease. However, no direct inheritable gene has been found.

Why does it happen?

The cause of Crohn’s Disease is unknown at this point. Researchers are working hard to determine a cause. We do know, that nothing YOU did made you develop Crohn’s Disease. You did not catch it from something. The disorder involves the body’s immune system acting inappropriately. Usually, the immune system works to protect the body from infection. An abnormal response may be related to the genes a person has, and/or something in the environment that causes the immune system to be activated when it does not need to be. Ultimately, the immune system is “turned on” and ready to fight. This can cause inflammation and damage to the lining of the GI tract, leading to symptoms. In about 80% of patients, the small intestine is affected. In 1/3 of patients, only the ileum (the last part of the small intestine) is affected.

Symptoms of Crohn's DiseaseAbdominal Pain

  • Persistent Diarrhea
  • Crampy abdominal pain
  • Fever
  • Rectal bleeding
  • Loss of appetite
  • Weight loss
  • Fatigue
  • Perianal Disease

Perianal disease occurs in over one third of patients with Crohn’s Disease. Some of the common signs and symptoms associated with Perianal disease include: Fissures (tears in the anus that lead to pain and bleeding), Pain, Skin Tags, Perirectal Abscess and Fistula.

Severity of Symptoms

Symptoms can range from mild to severe. Again, Crohn’s Disease can affect any portion of the GI tract from mouth to anus. Symptoms depend on what portion of the GI tract is affected. If your stomach and small intestine is affected, your symptoms may be different from someone else who has the disease in their colon. Sometimes, it takes many years of symptoms before the disease is diagnosed. People can go through periods of “flares” when symptoms get worse due to active disease and inflammation; and “remission” when symptoms improve.

Additional Issues Associated with Crohn's Disease

In addition to affecting the GI tract, Crohn’s Disease can cause problems outside the GI tract such as:

  • Arthritis, usually in large joints.
  • Eye problems including uveitis, iritis and episcleritis (redness, pain, itchiness).
  • Skin disorders, such as; erythema nodosum (a red nodular rash on the shins) and pyoderma gangrenosum (large painful sores form, mainly on the legs).
  • Primary sclerosing cholangitis (inflammation and scarring of the bile ducts in the liver).
  • Secondary amyloidosis (condition with proteins building up in the tissues and organs) leading to kidney problems
  • Blood clots in arteries or veins as a result of hypercoagulability
  • Kidney stones
  • Bone loss from decreased absorption of vitamin D and calcium, the risk is also increased if steroids have been used
  • Vitamin B12 deficiency

How is it diagnosed?

There is not one test or exam finding to diagnose Crohn’s Disease. It is determined based on a combination of findings. Typically, some, or all of the below will be used:

  • History of symptoms concerning for Crohn’s Disease with physical examination
  • Laboratory studies may be obtained to look at blood counts, electrolytes, markers of inflammation, liver function, kidney function and stool studies. A blood test may be ordered that measures antibody levels that help determine the difference between ulcerative colitis and Crohn’s Disease.
  • Colonoscopy to look at the tissue of the colon and last part of the small intestine, the terminal ileum. Sample of the tissue (biopsies) can be taken to be examined with a microscope.
  • Upper endoscopy to look at the esophagus (the tube that connects the mouth to the stomach), stomach and first part of the small intestine, the duodenum.
  • Imaging studies may be obtained including barium studies with an enema, a small bowel follow through, or a computed tomography (CT) or magnetic resonance imaging (MRI)

How is it treated?

There is no cure at this point for Crohn’s Disease. Medicines are used to treat symptoms and to decrease inflammation and activity of the immune system so the tissue of the GI tract can heal. The goal of treatment is to “induce remission,” meaning getting symptoms and inflammation under control.  After remission is achieved, the goal is to “maintain remission”. There are multiple types of drugs used to treat Crohn’s Disease.

Aminosalicylates.
Sulfasalazine (Azulfidine); olsalazine (Dipentum); balsalazide (Colazal); mesalamine (Oral: Apriso, Asacol, Asacol HD, Lialda, Pentasa; Rectal suppository or enema: Canasa, Rowasa)

  • Amino salicylates are is thought to act locally right at the lining of the GI tract in the colon to decrease inflammation. Olsalazine and balsalazide are converted to mesalamine, the active component of sulfasalazine, in the colon. It is thought that it decreases the local inflammatory response right at tissue that is irritated.

Antibiotics. Benefits might be seen because of a small undetected infection, overgrowth of bacteria or a tiny perforation.

Corticosteroids. These can be given orally or, if symptoms are severe, through an intravenous (IV) line. Steroids suppress the immune system throughout the body. This will stop the immune system from attacking the intestinal tissue. They are often quickly effective but also associated with many side effects. This medicine is not for long term use.

Budesonide is a steroid available that does not act throughout the whole body but rather more specifically in the ileum and right colon.

Antidiarrheal medications such as loperamide (Imodium) or a bile binder like cholestyramine or colstipol can be used.

Probiotics potentially help with current inflammation and help prevent further development

Immunomodulators:

Azathioprine and 6-mercaptopurine (6-MP)

  • 6-MP is the active metabolite of azathioprine. These medicines suppress the immune response so it cannot continue to cause active inflammation.

Methotrexate

Biologic therapies

  • Inflixamab (Remicade)

Tumor necrosis factor-alpha (TNF-alpha) is a chemical the immune system produces to make inflammation more intense. The antibody (inflixamab) is given by infusion through an IV to block TNF-alpha’s activity.

  • Adalimumab (Humira)

Attaches to TNF-alpha and blocks its effects. This medicine is an injection. The first injections are given in a physician’s office, either four on one day or two given for two days, then two injections two weeks later. This completes the “induction” period. Thereafter, usually only one injection is needed every other week.

  • Certolizumab pegol (Cimzia)

Another TNF-alpha antibody. It will bind to that protein and block its effects. It is given by injection every two weeks for the first three injections and then usually once every four weeks.

Sometimes medicine does not do enough to treat Crohn’s Disease; and surgery is necessary. Often, this is an intestinal resection because of symptoms, obstruction or perforation.

What can I do about my Crohn's Disease?

In Crohn’s Disease, there can be periods of increased disease activity with symptoms and periods of remission. If you are in remission for one year, there is an 80% chance that you will remain in remission. 13% of patient will have no relapses, 20% will have relapses annually and 67% have a combination of years in relapse and remission in the first 8 years after diagnosis. Less than 5% will have a continuous active disease course.

Often people are concerned with what type of diet they should be on once diagnosed with Crohn’s Disease. There are no specific foods that will cause increased inflammation in the GI tract. However, certain foods may cause more symptoms for you and should be avoided, at least temporarily. Good nutrition is key as nutritional deficiencies are possible because of poor absorption, chronic diarrhea, decreased appetite and increased energy needs of the body because of the chronic disease.

Generally soft, bland foods may be easier to consume than spicy or high fiber foods.

Regular exercise is important.

Stop smoking. Tobacco use can worsen disease activity and increases the risk of surgery so it is time to quit.

Avoid nonsteroidal anti-inflammatory drugs, (ex. Ibuprofen or naproxen) because these can worsen disease.

Are there complications?

Because the inflammation can go through the whole thickness of the wall of the intestine, deep ulcers can form and can turn into tracts (fistulas) connecting different parts of the intestine together or connecting the intestine to the skin, vagina or bladder. Tracts do not always create fistulas connecting areas; they can also lead to a phlegmon or abscess. A phlegmon is a walled off mass of inflammation without a bacterial infection. An abscess is similar, but with the infection and pus. With inflammation, the wall of the intestine can swell leading to obstruction or blockage. This area can then scar. The blockage can lead to abdominal pain, vomiting and bloating of the abdomen.

Sometimes medicines can treat these complications but sometimes surgery is needed. Also, due to the chronic inflammation, people can develop weight loss or nutritional deficiencies from lack of absorption of calories, proteins and vitamins.

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Inflammatory Bowel Disease (IBD)

We provide comprehensive evaluation and management for our Crohn's & colitis patients 

Crohn's disease is a chronic inflammatory disease of the gastrointestinal tract. The most common areas it affects are the ileum, the lower portion of the small intestine, and the colon. Granulomatous ileitis and regional ileitis are other names for this disease. It is one of two disorders grouped in the condition called inflammatory bowel disease. The other disorder is ulcerative colitis. Crohn's disease causes inflammation of the entire thickness of the bowel wall. The cause of Crohn's is not known, but it is aggravated by bacterial infections and inflammation. Crohn's affects women slightly more often than men and appears to run in some families. About 1 to 5 per 10,000 individuals have Crohn's disease. The most commonly affected individuals are between the ages of 15 and 25 years.

Detection of Crohn's is by a flexible sigmoidoscopy, a procedure where a lighted flexible instrument is inserted into the rectum to view the lower portion of colon and rectum. Tissue samples are taken from the colon and sent for microscopic examination. Alternative detection methods are colonoscopy, a procedure similar to a flexible sigmoidoscopy but with a longer instrument, or barium enema x-ray. This is a lifelong condition in most individuals, but the disease course varies. Many individuals will not have symptoms after the first couple of attacks. Others will have recurrent symptoms. The majority of individuals with Crohn's can carry on a normal life but can expect a shorter total life expectancy. Medications can control the symptoms. This condition often requires surgery.

Living With Your Diagnosis

Abdominal pain and chronic diarrhea are the most common symptoms of Crohn's disease. The abdominal pain is usually right sided or around the navel. Eating may make the pain worse. The diarrhea can sometimes be bloody. It also can be severe enough to cause malnutrition. Other symptoms include fatigue, weight loss, loss of appetite, and fever. Symptoms are not limited to the gastrointestinal tract. About 20% of individuals will have joint pains. Others will have skin lesions.

Complications of Crohn's are many and varied. Bowel obstructions (blockages) are common. Fistulas and fissures in and around the anus and rectum can form. A fistula is an abnormal passage between two parts of the intestine or the intestine and the skin, bladder, or vagina. A fistula between two portions of bowel allows food to bypass certain areas of the bowel and causes malabsorption. A fistula between the intestine and the skin, bladder, or vagina causes continuous drainage of bowel contents onto the skin or into the bladder or vagina. This can cause infections. Fissures are cracks in the skin. Infections can be a complication of both of these conditions. 


Crohn's & Colitis Foundation of America

The Crohn's and Colitis Foundation of America is a non-profit, volunteer-driven organization dedicated to finding the cure for Crohn's disease and ulcerative colitis.

Their mission is to cure Crohn's disease and ulcerative colitis, and to improve the quality of life of children and adults affected by these diseases. Visit their website for more information.


Additional Handout

Link to Crohn's Disease- National Digestive Diseases Information Clearinghouse