Crohns Disease

*The information on this website is not intended to diagnose, treat, cure or prevent any disease.

WHAT IS CROHN'S DISEASE?

Crohn’s disease is an inflammatory bowel disease, similar to ulcerative colitis, however it has some distinct differences from ulcerative colitis. While ulcerative colitis is restricted to the colon, Crohn’s disease can affect any region of the intestinal tract, extending from the mouth to the anus, with gaps of healthy tissue in between affected regions. It is a chronic inflammatory condition whose symptoms can appear or disappear, depending on many bodily factors.

When patients have symptoms, the condition is called “active” and times without symptoms present are called “remission.” If a patient in remission begins showing symptoms again, this is called “relapse.” A relapse of symptoms does not necessarily mean that the condition has worsened, only that something has triggered the inflammation. Crohn’s disease can develop in either children or adults, but patients with diagnosed disease as children tend to have more severe disease over the course of their lifetimes. It is difficult to treat Crohn’s disease effectively because how it presents in patients varies widely. There are multiple subtypes of Crohn’s disease, including those that cause inflammation in the higher intestine versus the colon, and children can sometimes have different symptoms than adults.

COMMON SYMPTOMS

The most common symptoms are abdominal pain, diarrhea, and weight loss. Complications of Crohn’s disease can include intestinal tears and fistulas, which are large holes that can cause seepage into the abdominal cavity. The upper gastrointestinal tract, including the stomach and esophagus, can also be inflamed in some patients.

Major GI symptoms include:

Chronic diarrhea
Weight loss
Abdominal cramps
Straining to defecate/constipation
Urgent defecations
Rectal pain and/or bleeding
Loss of appetite
Anal fissures
Intestinal/anal abscesses
Intestinal strictures

Other more general symptoms include:

Oral ulcers
Intestinal/stomach ulcers
Anemia
Inflammation of the eye
Failure to thrive in children
Rashes/Eczema
Liver and gallbladder inflammation
Arthritis
Kidney disease
Pancreatitis

DIAGNOSIS

Crohn’s disease can be diagnosed with endoscopy that extends into the intestines. This may be performed either via the colon or into the upper GI tract via the mouth and esophagus. This allows direct visualization of the intestinal wall and obtaining small tissue samples (called biopsies). Biopsies allow a definitive diagnosis of Crohn’s disease. As an alternative to standard endoscopy, video capsule endoscopy can also be performed, in which a small camera contained in a capsule is swallowed and the images are transmitted to an external receiver. This allows visualization of the entire GI tract, something not feasible with standard endoscopy.

Ultrasound and magnetic resonance enterography (similar to MRI) can also diagnose the condition. Of these diagnostic methods, MRE is the most sensitive. Although there is a genetic component to Crohn’s disease, no single genetic test exists. Different types of Crohn’s disease activate different genes, so if a genetic test becomes available, it will likely involve a group of related genes.

Other lab tests which may be beneficial in diagnosing Crohn’s disease or guiding therapy may include:

Systemic bloodwork to assess:
- Electrolyte levels
- Red blood cell counts
- Inflammatory markers like C-reactive protein
- Serum albumin levels (a blood protein which is lost during intestinal inflammation)
Fecal analysis

TREATMENTS

There is no cure available for Crohn’s disease, so treatment is focused on controlling symptoms. For the most severe cases, a liquid diet may be necessary to prevent symptoms, but most cases don’t require such drastic intervention. Most patients can control their symptoms with one of the medicines currently available, although some of these medicines can cause undesirable side effects. Current drugs are immunosuppressants or anti-inflammatories. The immunosuppressants attempt to treat the underlying cause of Crohn’s disease, while the anti-inflammatories treat the symptoms. Since there is no cure, the goal for most patients is remission of symptoms. Stem cell transplantation has the potential to control particularly severe inflammation and prevent patients from needing surgery due to intestinal damage. This treatment is still in its infancy, though, and is not yet a common treatment for Crohn’s disease. Surgery is commonly needed for severe disease, and many patients require multiple surgeries over their lives. The frequency of surgery in Crohn’s disease patients will likely increase over time, because the number of diagnosed people with Crohn’s disease has increased in recent years.

Pharmaceuticals:

Corticosteroids: Corticosteroids are powerful anti-inflammatories which are most useful during acute flare ups. Due to their side effect profile, they are not used for maintenance therapy once inflammation is back under control.
5-aminosalicylates: Drugs like sulfasalazine can be useful in keeping ulcerative colitis in remission, particularly in mild to moderate cases.
Immunosuppressants: There are now a number of drugs available which target the immune system and pathways leading to inflammation. Many of these drugs are derived from human antibodies to target tumor necrosis factor (TNF) – a major inflammatory compound which is overactive in ulcerative colitis. Examples of immunosuppressive drugs used include:
- Azathioprine
- Infliximab
- Adalimumab
- Methotrexate
- Natalizumab
- Ustekinumab
Antibiotics: In some patients, antibiotics may be needed due to infections which can occur from the severe damage to the colon.
Analgesics: Pain management can be very important. Although inflammation is a major component of ulcerative colitis, it is important to avoid Non-Steroid Anti-inflammatories like ibuprofen or naproxen which can cause further damage to the intestines. Acetaminophen is a much safe option.
Stool bulking agents: Supplements like psyllium husk can help control diarrhea by adding bulk to the stool
Anti-diarrheal medications: Some over-the-counter drugs like Imodium A-D can be helpful in controlling diarrhea

Surgery

The majority of Crohn’s patients will require surgery at some point due to failure of medical management. Unlike ulcerative colitis, in which a colectomy can remove the affected tissue entirely, the diffuse/patchy nature of Crohn’s disease makes surgical treatment less definitive. Although affected regions of the intestines can be removed, inflammation near the removed sections may occur later. In some instances, surgery may be required in order to removed intestinal sections in danger of perforating, or to address abscesses, but unfortunately continued recurrence of Crohn’s disease is likely.

Fecal transplants may be another procedure which can be performed This procedure involves transplantation of fecal material from healthy donors into the intestinal tract of people with ulcerative colitis. Changing the bacterial population can be extremely effective for relieving symptoms of Crohn’s disease.

Non-pharmaceutical/Alternative Therapies:

Many of the alternative therapies for ulcerative colitis have also shown promise for sufferers of Crohn’s disease.

Reducing GI inflammation
- Diet
  - Dietary modification
  - Elemental liquid diet
  - Low residue diets
  - Smaller, more frequent meals
  - Eliminate alcohol and caffeine
  - Increase omega-3 and Omega-6 Fatty Acids
Rebalancing GI flora
- Probiotics
- Eating fermented foods
  - Yogurt
  - Kimchi
  - Kombucha
  - Kefir
  - Tempeh
- Avoid artificial sweeteners: these may be toxic to normal GI bacteria
Relaxation training: Stress management training can significantly improve symptoms of Crohn’s disease, as well as improving anxiety and mood.
Cognitive Behavior Therapy: Psychotherapy can be extremely beneficial in ulcerative colitis due to the concomitant depression which occurs. Management of depressive symptoms through cognitive behavior therapy improved both depression scores and lessened symptoms of ulcerative colitis.
Biofeedback: This is a technique which allows a person to visualize a biologic parameter and helps them develop skills to manage that particular issue. This allows a person to reduce their own pain, and eventually, manage it without external visualization of their tension or pain.
Hypnosis
Yoga
Supplements
Magnetic field therapy
Sauna/detox
Acupuncture
Moxibustion: A traditional Chinese therapy which involves burning dried mug wort on the body. Sometimes combined with acupuncture.
Parasite Therapy: Intentional self-infection with parasites.

PREVENTION

There is no known way to prevent Crohn’s disease, since it appears to be a complex disease, however there are certain risk factors one may be able to minimize in their own lives, although some things are not able to be controlled, such as a family history of Crohn’s disease. The biggest risk factor which is not related to sex, race, age, or genetics is a history of smoking. Smokes have twice the risk of developing Crohn’s compared to non-smokers, and it also increases the risk of flare-ups and complications associated with the disease. There is also an association with Crohn’s disease and certain geographic regions. In the United States, people in the Midwest and Northeast are at higher risk of Crohn’s compared to people living in the South or in the Western US. Industrialized countries in general have a higher frequency of Crohn’s disease as well, which suggests there is something about Western lifestyles which increase the risk. Additionally, previously having had an appendectomy significantly increases the likelihood of developing Crohn’s disease. The appendix is known to harbor beneficial bacterial in the GI tract and can act as a “reserve” to repopulate the intestines if disease or medication disrupts the normal balance. Loss of this reserve may mean that intestines have a harder time staying healthy in the long-term.

The best approach to trying to minimize the risk of developing Crohn’s disease is likely by living as healthy a lifestyle as possible. Avoid smoking, exercise regularly, and eat a well-balanced diet rich in vitamins and other nutrients. Psychological well-being is also important for the management of Crohn’s disease, so learning to manage stress through meditation, yoga, and finding a work-life balance may also be helpful in preventing the development of Crohn’s disease.

CAUSES

The causes of Crohn’s disease are unclear, but there is certainly a hereditary/genetic predisposition to it, however it may occur in people without a family history as well. Like many inflammatory conditions, immune dysregulation/hyperresponsiveness seems to play a role. Intrusion of the natural intestinal bacteria with pathologic bacteria may play a role. Additional, certain infectious agents such as a yeast (fungus) called Candida tropicalis may be a trigger for Crohn’s disease, as well as a bacterium called Mycobacterium avium paratuberculosis. In cows, this bacterium is responsible for chronic inflammation of the intestine called paratuberculosis or Johne’s disease. There is speculation that exposure to this pathogen, either by contact with cows or through the consumption of dairy products. Furthermore, normal pasteurization procedures don’t seem to be effective at eliminating this bacterium from milk.

It is thought that a persistent infection from these pathogens may occur, which may have additional effects on the intestinal tract such as breakdown of the normal mucosal barrier (which permits bacteria normally contained within the small intestine to cross into the blood stream) and disruption of the balanced between harmful and beneficial bacteria. Some people who have immune dysregulation may be more likely to have activation of a white blood call (called T cells) which then promote a chronic inflammatory response from the body.

Some bacterial infections can also mimic Crohn’s disease, causing multiple lesions across the intestinal tract. Bacteria which can cause this include Salmonella, Campylobacter, Shigella, and Yersinia species. These bacteria can often persist for extended durations, causing a chronic inflammatory response.

Other theories suggest that there may not just be a single infectious agent resulting in disease, but an overall shift in the microbial flora caused by dietary changes in the 20th century (a condition called dysbiosis). If true, this theory may explain the increasing incidence of Crohn’s disease in over the last 50 years. This may also be influences by the use of antibiotics, which can dramatically disrupt the normal bacterial populations in the intestines.

Other theories include the hygiene hypothesis, which also attempts to explain a number of other immunological diseases. The hygiene hypothesis states that our clean society has prevented our immune systems from becoming appropriately trained to respond to threats, and now responds excessively to normal tissues and bacterial populations. Additionally, people living in industrialized countries tend not to carry parasites, which likely co-evolved with us and may play an important role in regulating and training our immune systems.