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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.
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.
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.
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.
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.
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. (See For More Information
for the names of such organizations.)
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.
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.
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.
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.
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