What is Crohn’s disease?
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.
What causes Crohn's disease?
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.
What are the symptoms?
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.
How is Crohn's disease diagnosed?
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.
What are the complications of Crohn's disease?
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.
What is the treatment for Crohn's disease?
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.
Can diet control Crohn's disease?
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.
Can stress make Crohn’s disease worse?
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.
Is pregnancy safe for women with Crohn's disease?
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.
