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Crohn's Disease

Table of Contents


What is Crohn's Disease ?

Crohn's disease is a chronic inflammatory disease of the intestines. It primarily causes ulcerations in the small and large intestines, but can affect the digestive system anywhere between the mouth and the anus. It is named after the physician who described the disease in a landmark paper written in 1932. It is also called Morbus Crohn's, Granulomatous enteritis, Regional enteritis, or Terminal ileitis. The disease is found in equal frequency in men and women, and usually affects young patients in their teens or early twenties. Once the disease begins, it tends to be a chronic, recurrent condition with periods of remission and disease exacerbation. The disease tends to be more common in relatives of patients with Crohn's disease.

What causes Crohn's Disease ?

The cause of Crohn's disease is unknown. Some scientists suspect that infection by certain bacteria, such as strains of mycobacterium, may be the cause of Crohn's disease. To date, there has been no convincing evidence that the disease is caused by infection. Crohn's disease is not contagious. Although diet may affect the symptoms in patients with Crohn's disease, it appears unlikely that diet is responsible for the onset of the disease.

Currently, Crohn's disease is believed to be related to abnormalities in the response of the body's immune system to the bowel contents. The body's immune system is composed of cells and proteins that normally protect the body from infections or other foreign invaders. In normal individuals, no immune response will be directed against food, bacteria, and other substances in the intestines. In patients with Crohn's disease, the immune system seems to react actively to a variety of substances and/or bacteria in the intestines, causing inflammation, bowel injury, and ulcerations. This abnormally active immune system is believed to be genetically inherited. First degree relatives of patients with Crohn's disease (brothers, sisters, sons and daughters) are more likely to develop the disease. Furthermore, certain chromosome markers have been found in patients with Crohn's disease. Chromosomes are components in the cells where all the genetic information of the body is stored.

What are the symptoms of Crohn's Disease ?

The terminal ileum is commonly involved in Crohn's disease. Since the terminal ileum is located adjacent the appendix, right-sided abdominal pain and tenderness mimicking appendicitis is common. The pain of Crohn's disease can also be crampy in nature, and may reflect bowel obstruction.

Diarrhea is also common. Diarrhea may be a result of a partial bowel obstruction, excessive growth of bacteria in the small bowel, poor absorption of nutrients and bile acids and inflammation of the large intestine. The diarrhea may be bloody and associated with abdominal pain and cramps. Rectal bleeding and bloody diarrhea are common. While massive bleeding (hemorrhage) from Crohn's ulcer is rare, it can occur.

Diseases affecting the anus are common. Up to one third of patients with Crohn's disease may have diseases involving the anal area. Anal diseases include tears of the anal tissue (fissures), infections (abscesses) adjacent to the anus and draining abnormal passages or tubes (fistulae) between the inside of the anus and the surrounding skin.

What are the complications of Crohn's Disease ?

Complications of Crohn's disease may be related to the intestinal disease or occur in areas unrelated to the intestines (extra-intestinal). Intestinal complications of Crohn's disease include bowel obstruction, bowel perforation, formation of pus collections (abscesses), fistulae, cancer of the bowel and intestinal hemorrhage. Extra-intestinal complications include tender, raised, reddish skin nodules (erythema nodosum) and inflammation of the following areas; the joints (arthritis) and spine (spondylitis), the eyes (uveitis and episceritis), the liver (hepatitis), and the bile ducts (sclerosing cholangitis) that drain the liver.

Progressive scarring and inflammation of the bowel causes narrowing. Sometimes, obstruction can be acutely caused by the ingestion of poorly digestible fruit or vegetables that plug the already narrowed segment of the intestine. Symptoms of obstruction include crampy abdominal pain, abdominal distention (enlargement), nausea and vomiting.

As the inflammatory ulcer burrows through the bowel wall, it may tunnel into adjacent structures. If the ulcer tract reaches an adjacent empty space inside the abdomen, a collection of infected material (abscess) is formed. Patients with abdominal abscesses may develop spiking fevers and tender abdominal masses. When the ulcer burrows into an adjacent organ, a fistula, or tube, is formed. When a fistula, or tube, develops between the bowel and the bladder, the patient can develop recurrent urinary infections, and passage of air and feces in the urine. A fistula can also occur between the intestine and the skin, leading to the discharge of pus or mucus through a small painful opening on the skin of the abdomen.

Massive dilatation (opening) of the colon (megacolon) and rupture of the intestine (perforation) are potentially life-threatening complications. Both situations generally require surgery. Fortunately, these two complications are rare.

Recent data suggest that there is an increased risk of cancer of the small and the large intestines (colon) in patients with long-standing Crohn's disease. Cancer of the small intestine is very rare. However, cancer of the colon occurs more frequently than previously thought.

Areas of extra-intestinal complications include the skin, joints, spine, eyes, liver and bile ducts. Skin lesions include the presence of painful red raised spots on the legs (erythema nodosum) and an ulcerating skin condition generally found around the ankles (pyoderma gangrenosa). Painful red eye conditions (uveitis, episcleritis) can cause visual difficulties. Active arthritis can cause pain, swelling, and stiffness of the joints of the extremities. Inflammation of the low back (sacroiliac joint arthritis) and of the spine (ankylosing spondylitis) can cause pain and stiffness of the spine. Inflammation of the liver (hepatitis) or bile ducts (primary sclerosing cholangitis) can also occur. Sclerosing cholangitis causes narrowing and obstruction of the ducts draining the liver, and can lead to yellow skin, recurrent bacterial infections, and liver cirrhosis and failure. Sclerosing cholangitis with liver failure is one of the reasons a liver transplant is performed.

What are the treatment options for Crohn's Disease ?

Symptoms and severity of the disease vary among patients. Patients with minimal disease activity with mild or no symptoms may not need treatment. Patients whose disease is in remission (where symptoms are absent) also may not need treatment. Most patients with Crohn's disease will experience periodic increases in activity of the disease when symptoms of abdominal pain, fever, diarrhea, and rectal bleeding worsen. Medications are then used to bring the active disease into remission. Medications for the treatment of active Crohn's disease include salicylate preparations, corticosteroids, antibiotics, and medications that suppress body immunity. The decision regarding which treatments are used is based on the location and the severity of the disease. Patients with advanced disease causing persistent bowel obstruction, abscess, and fistulae may need surgery.

General measures which may help control Crohn's disease include dietary changes and supplementation. Since fiber is poorly digestible, it can exacerbate symptoms of partial bowel obstruction. Hence, a low fiber diet may be recommended, especially in those patients with small bowel disease. A liquid diet may be of benefit when symptoms are more severe. Intravenous nutrition or TPN (total peripheral nutrition) may be utilized when it is felt that total bowel rest is necessary. Supplementation of calcium, folate and vitamin B12 is helpful when malabsorption of these nutrients is apparent. The use of antidiarrheal agents and antispasmotics can also help relieve symptoms of cramps and diarrhea.

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