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Crohn's disease

Definition

Crohn's disease is a form of inflammatory bowel disease (IBD). It usually affects the intestines, but may occur anywhere from the mouth to the end of the rectum (anus).

See also: Ulcerative colitis

Alternative Names

Inflammatory bowel disease - Crohn's disease; Regional enteritis; Ileitis; Granulomatous ileocolitis; IBD- Crohn's disease

Causes, incidence, and risk factors

While the exact cause of Crohn's disease is unknown, the condition is linked to a problem with the body's immune system response.

Normally, the immune system helps protect the body, but with Crohn's disease the immune system can't tell the difference between normal body tissue and foreign substances. The result is an overactive immune response that leads to chronic inflammation. This is called an autoimmune disorder.

People with Crohn's disease have ongoing (chronic) inflammation of the gastrointestinal tract. Crohn's disease may occur in any area of the digestive tract. There can be healthy patches of tissue between diseased areas. The inflammation causes the intestinal wall to become thick.

There are different types of Crohn's disease, depending on the part of the gastrointestinal tract that is affected. Crohn's disease may involve the small intestine, the large intestine, the rectum, or the mouth.

A person's genes and environmental factors seem to play a role in the development of Crohn's disease. The body may be overreacting to normal bacteria in the intestines.

The disease may occur at any age, but it usually occurs in people between ages 15 - 35. Risk factors include:

• Family history of Crohn's disease
• Jewish ancestry
• Smoking

Symptoms

Symptoms depend on what part of the gastrointestinal tract is affected. Symptoms range from mild to severe, and can come and go with periods of flare-ups.

The main symptoms of Crohn's disease are:

• Crampy abdominal (belly area) pain
• Fever
• Fatigue
• Loss of appetite
• Pain with passing stool (tenesmus)
• Persistent, watery diarrhea
• Unintentional weight loss

Other symptoms may include:

• Constipation
• Eye inflammation
• Fistulas (usually around the rectal area, may cause draining of pus, mucus, or stools)
• Joint pain
• Liver inflammation
• Mouth ulcers
• Rectal bleeding and bloody stools
• Skin lumps or sores (ulcers)
• Swollen gums

Signs and tests

A physical examination may reveal an abdominal mass or tenderness, skin rash, swollen joints, or mouth ulcers. Tests to diagnose Crohn's disease include:

• Barium enema
• Colonoscopy
• Computed tomography (CT scan) of the abdomen
• Endoscopy, including capsule endoscopy
• Magnetic resonance imaging (MRI) of the abdomen
• Sigmoidoscopy
• Enteroscopy
• Upper GI series

A stool culture may be done to rule out other possible causes of the symptoms.

This disease may also alter the results of the following tests:

• Albumin
• C-reactive protein
• Erythrocyte sedimentation rate
• Fecal fat
• Hemoglobin
• Liver function tests
• White blood cell count

Treatment

DIET AND NUTRITION

No specific diet has been shown to improve or worsen symptoms in Crohn's disease. Specific food problems may vary from person to person.

You should eat a well-balanced, healthy diet. It is important for you to get enough calories, protein, and essential nutrients from a variety of food groups.

Certain types of foods may worsen diarrhea and gas symptoms. The problem is more likely during periods when symptoms are present. Possible changes you can make to your diet include:

• Eat small amounts of food throughout the day.
• Drink lots of water (drink small amounts often throughout the day).
• Avoid high-fiber foods (bran, beans, nuts, seeds, and popcorn).
• Avoid fatty, greasy or fried foods and sauces (butter, margarine, and heavy cream).
• If your body does not digest dairy foods well, limit dairy products. Try low-lactose cheeses, such as Swiss and cheddar, and an enzyme product, such as Lactaid, to help break down lactose.
• Avoid foods that you know cause you gas, such as beans, spicy food, cabbage, broccoli, cauliflower, raw fruit juices and fruits -- especially citrus fruits.

People who have a blockage of the intestines may need to avoid raw fruits and vegetables and other high-fiber foods.

Ask your doctor about extra vitamins and minerals you may need:

• Iron supplements (if you are anemic)
• Calcium and vitamin D supplements to help keep your bones strong
• Vitamin B12 to prevent anemia

STRESS

You may feel worried, embarrassed, or even sad and depressed about having a bowel accident. Other stressful events in your life, such as moving, a job loss, or the loss of a loved one can cause digestive problems.

Ask your doctor or nurse for tips on how to manage your stress.

MEDICATIONS

You can take medication to treat very bad diarrhea. Loperamide (Imodium) can be bought without a prescription. Always talk to your doctor or nurse before using these drugs.

Other medicines to help with symptoms include:

• Fiber supplements may help your symptoms. You can buy psyllium powder (Metamucil) or methylcellulose (Citrucel) without a prescription. Ask your doctor about these products.
• Always talk to your doctor before using any laxative medicines.
• You may use acetaminophen (Tylenol) for mild pain.
• Drugs such as aspirin, ibuprofen (Advil, Motrin), or naproxen (Aleve, Naprosyn) may make your symptoms worse.

Your doctor may also give you a prescription for stronger pain medicines.

Medicines that may be prescribed include:

• Aminosalicylates (5-ASAs) are medicines that help control mild to moderate symptoms. Some forms of the drug are taken by mouth; others must be given rectally.
• Corticosteroids (prednisone and methylprednisolone) are used to treat moderate to severe Crohn's disease. They may be taken by mouth or inserted into the rectum.
• Medicines such as azathioprine or 6-mercaptopurine quiet the immune system's reaction.
• Antibiotics may be prescribed for abscesses or fistulas.
• Biologic therapy is used to treat patients with severe Crohn's disease that does not respond to any other types of medication. Medicines in this group include Infliximab (Remicade) and adalimumab (Humira), certolizumab (Cimzia), and natalizumab (Tysabri).

SURGERY

If medicines do not work, a type of surgery called bowel resection may be needed to remove a damaged or diseased part of the intestine or to drain an abscess. However, removing the diseased portion of the intestine does not cure the condition.

Patients who have Crohn's disease that does not respond to medications may need surgery, especially when there are complications such as:

• Bleeding (hemorrhage)
• Failure to grow (in children)
• Fistulas (abnormal connections between the intestines and another area of the body)
• Infections (abscesses)
• Narrowing (strictures) of the intestine

Some patients may need surgery to remove the entire large intestine (colon), with or without the rectum.

See also:

• Ileostomy
• Large bowel resection
• Small bowel resection
• Total abdominal colectomy
• Total proctocolectomy with ileostomy

Support Groups

The Crohn's and Colitis Foundation of America offers support groups throughout the United States. See http://www.ccfa.org/chapters/

Expectations (prognosis)

There is no cure for Crohn's disease. The condition is marked by periods of improvement followed by flare-ups of symptoms.

It is very important to stay on medications long-term to try to keep the disease symptoms from returning. If you stop or change your medications for any reason, let your doctor know right away.

You have a higher risk for small bowel and colon cancer if you have Crohn's disease.

Complications

• Abscess
• Bowel obstructions
• Complications of corticosteroid therapy, such as thinning of the bones
• Erythema nodosum
• Fistulas in the following areas:
  • Bladder
  • Skin
  • Vagina
• Impaired growth and sexual development in children
• Inflammation of the joints
• Lesions in the eye
• Nutritional deficiency (particularly vitamin B12 deficiency)
• Pyoderma gangrenosum

Calling your health care provider

Call for an appointment with your health care provider if:

• You have very bad abdominal pain
• You cannot control your diarrhea with diet changes and drugs
• You have lost weight, or a child is not gaining weight
• You have rectal bleeding, drainage, or sores
• You have a fever that lasts for more than 2 or 3 days, or a fever higher than 100.4°F without an illness
• You have nausea and vomiting that lasts for more than a day
• You have skin sores or lesions that do not heal
• You have joint pain that prevents you from doing your everyday activities
• You have side effects from any drugs prescribed for your condition

Prevention

References

Lichtenstein GR, Hanauer SB, Sandborn WJ; Practice Parameters Committee of American College of Gastroenterology. Management of Crohn's disease in adults. Am J Gastroenterol. 2009;104(2):465-483.

Fry RD, Mahmoud N, Maron DJ, Ross HM, Rombeau J. Colon and rectum. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 50.

Sands BE, Siegel CA. Crohn's disease. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger & Fordtran's Gastrointestinal and Liver Disease. 9th ed. Philadelphia, Pa: Saunders Elsevier;2010:chap 111.