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According to the Crohn’s & Colitis Foundation of America, about 700,000 Americans have Crohn’s disease. Since 1992, there has been a 74% rise in medical visits due to Crohn’s, and in 2004, the condition resulted in 57,000 hospitalizations.
Crohn’s disease causes inflammation to the lining of the digestive tract; though it is typically found in the intestines, Crohn’s inflammation can be found anywhere in the digestive tract from the mouth to the anus. Inflammation can cause scarring and permanent damage to the digestive tract, and often results in diarrhea, intense abdominal cramps, fever, and fatigue. Crohn’s disease symptoms may appear in flare-ups of varying intensity.
According to guidelines for Crohn’s disease management outlined by the Cleveland Clinic, the degrees of flare up severity are:
In addition to being categorized by degree of intensity, cases of Crohn’s diseases are categorized by location of inflammation and pattern of inflammation.
According to the Crohn’s and Colitis Foundation of America, there are 5 categorizations of Crohn’s disease based on inflammation location:
Crohn’s disease can also present itself in three patterns:
Perforating/Fistulizing. This is the most severe pattern, occurring when excessive inflammation has caused a perforation (hole) in the wall of the gastrointestinal tract. The perforation allows for the leakage of waste into the body cavity, which may result in fistulae, unordinary tubes/tissue connection that the body forms to allow for the drainage of waste. Among the most common fistulae are entero-vesical fistulae, in which waste passes from the intestine to the bladder, entero-vaginal fistulae, in which waste passes from the intestine through the vagina, and entero-enteric fistulae, in which waste passes from one section of the intestine to another.
There have been tremendous advances in treatment options for Crohn’s disease, especially in the last 10 years and has opened up new successful approaches to management and treatment of this disease. Since symptoms and manifestation of Crohn’s disease can vary significantly from person to person, with symptoms ranging from no symptoms at all to diarrhea, to bleeding and pain—treatment is very tailored to the individual. Scientific advances have resulted in a much more promising, predictable, and nuanced condition management. Research has uncovered important genetic and environmental causes of this disease—and the Food and Drug Administration, or FDA, has approved four additional therapies that have had a big impact on the treatment of Crohn’s. Outcomes for treatment have improved greatly, especially for those that suffer from more considerable inflammation and bowel involvement, or possible malnutrition, which can lead to delayed growth and development. Ability to monitor progress and efficacy of therapeutic choices has allowed us to enter a new era of positive outcomes and disease control.
Symptom managements was the old approach to Crohn’s treatment—this has changed to a goal of achieving both disease control and healing of the bowel. Those living with Crohn’s can now expect to live with very good condition control, allowing for them to plan their lives as they otherwise would, with normal life expectancy,
Though there is not yet a definitive cause of Crohn’s disease, recent research suggests that it is caused by an immune response to the body’s natural digestive bacteria, which may be triggered by a combination of environmental factors and genetic disposition.
A healthy gastrointestinal (GI) tract is lined with a mucosal membrane filled with bacteria that assist in digestion, absorption, and even normal immune system functioning. It is believed that in individuals with Crohn’s disease, there is an abnormal immune response against the gut bacteria, interfering with their ability to aid in digestion and compromising the integrity of the protective mucus membrane in which they exist. The immune response attracts immune cells to the affected area in the gastrointestinal tract, causing chronic inflammation and potentially permanent damage to the tissue of the affected areas. Research has shown that this may be caused by a genetic mutation that decreases the natural defense mechanisms of the bacteria or by a genetic pre-disposition to autoimmune diseases.
There are several risk factors known to contribute to the likelihood of developing Crohn’s disease. These include:
There is no single test to diagnose Crohn’s disease. To make a diagnosis, doctors most commonly rely on a combination of diagnostic tests, including:
The symptoms of Crohn’s disease vary in severity and can be different based on where the inflammation is located in the GI tract.
The main symptoms of Crohn’s are:
The prognosis for Crohn’s disease varies from case to case. Some people experience only one episode (flare-up), and others suffer continuously. Up to 20 percent of patients experience chronic Crohn’s disease. In rare cases, disease-free periods last for years or decades. Although Crohn’s cannot be cured even with surgery, treatments are available that can offer significant help to most patients. Crohn’s disease is rarely a direct cause of death, and most people can have a normal lifespan with this condition.
Living with Crohn’s disease can be stressful. Developing strategies to help you cope with your disease can make life easier. Here are some tips:
Because Crohn’s disease is relatively rare—about 700,000 Americans have this condition—and unless symptoms of Crohn’s present themselves early on, screening is not regularly done for the disease. If you experience any of the symptoms of Crohn’s disease, schedule a visit with your doctor. He or she will be able to conduct several diagnostic tests to see if your symptoms are indeed a result of Crohn’s.
You can’t prevent Crohn’s disease since its cause is not known. To learn about what might make you a higher risk for Crohn’s disease, read about its risk factors.
You can’t prevent Crohn’s disease since its cause is not known. To learn about what places you at a higher risk for Crohn’s disease, read about its risk factors. [NOTE: hyperlink to risk factors section]
A combination of treatment options can help you keep your Crohn’s under control, and help you lead a full and rewarding life. While there is no one standard treatment for Crohn’s, your doctor will work with you to find the right course of therapies for your particular case. Treatment for Crohn’s can include:
MEDICATION
Medication treating Crohn’s disease is designed to suppress your immune system’s abnormal inflammatory response that is causing your symptoms. Suppressing inflammation not only offers relief from common symptoms like fever, diarrhea, and pain, it also allows your intestinal tissues to heal.
In addition to controlling and suppressing symptoms (inducing remission), medication can also be used to decrease the frequency of symptom flare-ups (maintaining remission). With proper treatment over time, periods of remission can be extended and periods of symptom flare-ups can be reduced.
Several types of medication are being used to treat Crohn’s disease today. Some over-the-counter medications may help relieve symptoms of Crohn’s, but always speak with your doctor before taking any over-the-counter medications. Depending on the severity of your Crohn’s disease, your doctor may recommend one or more of the following:
Medications for mild to moderate Crohn’s:
Antibiotics. There is some evidence suggesting that antibiotics like metronidazole, ciproflaxin, and flagyll may be helpful in treating mild to moderate cases of Crohn’s disease. Metronidazole is the most extensively studied antibiotic in IBD (irritable bowel disease, which is a category of diseases affecting the bowel that includes Crohn’s disease). As a primary therapy for active Crohn’s, this drug has been shown to be superior to placebo (sugar pill) and equal to sulfasalazine—especially when the illness affects the colon. Antibiotics can help stop infections and heal abscesses and fistulas that happen because of Crohn’s disease.
Side effects of use of antibiotics for Crohn’s treatment may include:
5-Aminosalicylates (5-ASAs). 5-ASAs are a class of anti-inflammatory drugs that are thought to work as a topical anti-inflammatory for the GI tract. 5-aminosalicylic acid (5-ASA), is also called mesalamine. 5-ASA can be effective in treating Crohn’s disease and ulcerative colitis, which is the other condition included in the category of IBD. if the drug can be delivered topically onto the inflamed intestinal lining. For example, mesalamine (Rowasa) is an enema containing 5-ASA that is effective in treating inflammation in the rectum. However, the enema solution cannot reach high enough to treat inflammation in the upper colon and the small intestine.
Side effects of 5-Aminosalicyclates may include:
Common 5-ASAs include:
Patients taking 5-ASAs should have regular blood and liver tests to check for potential low cell count and liver complications. Side effects may include abdominal pain, headache, dizziness, and nausea.
Medications for moderate to severe Crohn’s:
Corticosteroids. Have been used for many years to treat patients with moderate to severe Crohn’s disease and ulcerative colitis and to treat patients who fail to respond to 5-ASA. Unlike 5-ASA, corticosteroids do not require direct contact with the inflamed intestinal tissues to be effective. Corticosteroids are anti-inflammatory and immunosuppressant, meaning that they reduce inflammation and work to suppress the immune system. When antibiotics and 5-ASAs fail to treat Crohn’s symptoms successfully, corticosteroids are the next-in-line drug. Corticosteroids are faster-acting than 5-ASA, and patients frequently experience improvement in their symptoms within days of beginning them. Corticosteroids, however, do not appear to be useful in maintaining remission in Crohn’s disease and ulcerative colitis or in preventing the return of Crohn’s disease after surgery. Corticosteroids may be administered in pill form, by intravenous drip (IV), as an enema, or as a rectal suppository. Caution should be used in their prescription because of the risk of the body becoming steroid-dependent.
These include:
Prednisone is one of the most commonly prescribed steroids, and is known to cause remissions in 70-80% of patients. It is not effective for long-term treatment.
Specific side effects of Prednisone may include:
Budesonide is another corticosteroid that was created with the goal of having fewer side effects than prednisone and other corticosteroids. Instead of travelling throughout the whole body, budesonide is released only in the end of the small intestine and ascending colon, limiting its affects to those areas. This prevents more widespread side effects, but limits its use to only patients who have Crohn’s inflammation in those areas.
Side effects of budesonide may include:
The frequency and severity of side effects of corticosteroids depend on the dose and duration of their use. Short courses of corticosteroids, for example, usually are well tolerated with few and mild side effects. Long-term use of high doses of corticosteroids usually produces predictable and potentially serious side effects. Children need to be especially careful with use of corticosteroids as they can stunt growth.
Common side effects of corticosteroids in general include:
Prolonged use of corticosteroids can cause adrenal insufficiency, a condition where the adrenal glands are not able to produce as much cortisol—necessary for proper functioning of the body. Cortisol helps the body manage stress, infections and other functions. Symptoms of adrenal insufficiency include nausea, vomiting, and even shock. Withdrawing corticosteroids too quickly also can produce symptoms of fever, fatigue, and joint pain. Therefore, when corticosteroids are discontinued, the dose usually is tapered gradually rather than stopped abruptly. It is important to note that even after stopping corticosteroid use, the adrenal glands may continue to be produce less cortisol, which can last for several months up to two years.
Long-term use of corticosteroids can lead to osteopenia or osteoporosis—therefore increasing dietary calcium, along with a calcium supplement is important. It is also important to do regular weight-bearing exercise and not smoke.
Corticosteroids, while very effective, have predictable and potentially serious side effects, and should be used for the shortest possible length of time.
Immunosuppressants, also called immunomodulators or immune modifiers, are medications that affect the immune system—the body’s defense against harmful viruses, bacteria and other foreign invaders. When the immune system is activated, it causes inflammation where the activation occurs—part of the defensive response. Normally, activation only occurs when the body is exposed to foreign invaders, but in patients with Crohn’s, the immune system goes into over-drive and is chronically activated even when there is not invader. This class of drugs works to block actions in the immune system that are involved with the inflammatory response. Immunosuppresants work to decrease inflammation by reducing the number of immune cells—this can increase risk of infection, but can have great benefit in controlling moderate to severe Crohn’s.
Common immunosuppressants include:
Medications for severe or fulminate Crohn’s:
Anti-tumor necrosis factor-alpha (Anti-TNF-α). This type of drug works by using antibodies targeted at TNF-α, an inflammatory protein that has been found in high levels in Crohn’s disease patients, and decreases inflammation by blocking tumor necrosis factor (TNF-alpha). 1 out of 3 patients report symptom improvement within the first two doses, around 2-3 weeks. 30-50% of patients continue their success past the one-year mark, and 30-50% will need to change their medication or anti-TNF-α dosage at some point during their therapy. Anti-TNF factors put patients at a slightly higher risk of serious heart disease, autoimmune conditions, and liver disease.
Specific side effects of Adalamumab may include:
Specific side effects of natalizumab may include:
DIET & NUTRITION
While Crohn’s Disease may not be the result of bad reactions to specific foods, paying special attention to your diet may help reduce symptoms, replace lost nutrients, and promote healing.
For people diagnosed with Crohn’s disease, it is essential to maintain good nutrition because Crohn’s often reduces your appetite while increasing your body’s energy needs. Additionally, common Crohn’s symptoms like diarrhea can reduce your body’s ability to absorb protein, fat, carbohydrates, as well as water, vitamins, and minerals.
Many people who experience Crohn’s disease flare-ups find that soft, bland foods cause less discomfort than spicy or high-fiber foods. While your diet can remain flexible and should include a variety of foods from all food groups, your doctor will likely recommend restricting your intake of dairy if you are found to be lactose-intolerant.
Nutritional therapy is a crucial part of Crohn’s treatment—especially in children—because inflammation of the intestines can impede absorption of nutrients, and can cause deficiencies. The Crohn’s and Colitis Foundation of America states that supplements like vitamins and minerals should be used only in addition to conventional medical treatment. Registered nutritionists or dietitians can help you put together a diet and supplement plan that ensures proper nutrition and improves digestive symptoms.
In certain cases, it may be recommended that you go on a special diet given via feeding tube, or have nutrients directly injected into your body to treat a particularly severe case of Crohn’s. This can improve health by allowing the bowel to rest and heal. This is also sometimes done prior to surgery or when other medications fail to control symptoms.
If you have a narrowed bowel, also known as a stricture, your doctor may suggest a low-fiber (sometimes called a low-residue diet) diet to reduce risk of intestinal blockage by reducing size and number of your stools.
Vitamin and mineral deficiencies are among the most common nutritional deficits that Crohn’s patients suffer. Your doctor or dietitian many recommend the following supplements:
In addition to recommending the proper supplements, your dietitian will be able to help you build a diet plan that avoids foods that exacerbate your Crohn’s symptoms. Typical inflammatory foods that you may want to avoid include:
Nutritional therapy can be a critical part of treatment no matter what stage of your condition is in. Make sure that your doctor and dietitian are in communication about what supplements you are taking in order to avoid medication interference.
SURGERY
Even with proper medication and diet, as many as two-thirds to three-quarters of people with Crohn’s disease will require surgery at some point during their lives. While surgery does not cure Crohn’s disease, it can conserve portions of your GI tract and return you to the best possible quality of life.
Surgery becomes necessary when medications can no longer control symptoms, or if you develop a fistula, fissure, or intestinal obstruction. Surgery often involves removal of the diseased segment of bowel (resection); the two ends of healthy bowel are then joined together (anastomosis). While these procedures may cause your symptoms to disappear for many years, Crohn’s frequently recurs later in life.
Your doctor may recommend surgery if other forms of therapy if symptoms have not responded to medications, diet and lifestyle modifications, and other therapies. Up to one-half of individuals with Crohn’s disease will require at least one surgery—but it is important to note that surgery does not cure Crohn’s disease.
During surgery, your surgeon may:
The benefits of surgery for Crohn’s disease are usually temporary. The disease often recurs, frequently near the reconnected tissue. Following surgery with medication can help minimize risk of recurrence.
Certain mind – body practices have been shown to reduce stress in some patients with Crohn’s disease, which may help control the severity of symptoms. These practices include:
Crohn’s disease doesn’t just affect you physically—it can take a real emotional and psychological toll too. If your condition is severe, it’s likely that your life may revolve around a constant need to be near the toilet, and even symptoms, like gas and abdominal pain can make it challenging to be in public. All of these factors may lead to anxiety and depression, but here ere are some things you can do to help:
Living with Crohn’s disease can be challenging, but research is ongoing and treatment options keep improving!
Call your doctor right away if you have been diagnosed with Crohn’s Disease and you are experiencing:
Based on your symptoms, your primary doctor will refer you to a gastroenterologist. This is a doctor who specializes in digestive disorders. If your condition requires surgery, you will be seen by a surgeon. A nutritionist or dietician can help with a dietary plan. Be sure to ask your dietitian if he or she has previous experience treating patients with Crohn’s disease before you begin consultation.
To find a gastroenterologist or surgeon in your area, visit our doctor directory. You can also look at:
To find a registered dietitian, visit the website of the American Academy of Nutrition and Dietetics.
If you’ve been diagnosed with Crohn’s here is a list of questions you might want to bring along on your follow-up visit with your doctor:
World Crohn’s and Colitis Day is May 23rd.
For the latest research information on autoimmune diseases including Crohn’s disease, visit the American Autoimmune Related Diseases Association.
For up-to-date information on digestive disorders, visit the International Foundation for Functional Gastrointestinal Disorders (IFFGD).
For current studies on Crohn’s disease, visit the National Institute of Diabetes, Digestive & Kidney Diseases.
For the contact information of doctors who specialize in digestive disorders in your area as well as connections to support groups and online communities, visit the Crohn’s and Colitis Foundation of America.
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