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What is Crohn's Disease?
Crohn's disease is a chronic inflammatory disease of the digestive system that may affect any area of the gastrointestinal tract from the mouth to the anus. Various parts of the bowel may be affected by Crohn's disease either in continuity or as separate areas. It frequently affects the terminal ileum (the end of the small intestine), especially the section that joins with the large intestine or colon, which may also often be affected.
The inflammation involves the full thickness of the bowel wall and consists of swelling, dilated blood vessels, and loss of fluid into the tissues.
Onset of Crohn's disease may occur at any age, however, it most frequently first occurs in young people, and about 10% of newly diagnosed cases are in children under age 10. Once a diagnosis of Crohn's disease is made, various treatments are employed that help relieve symptoms, but as yet there is no cure. The Crohn's experience can differ widely. Some people never develop complications, some only strictures, some abdominal abscesses, and others only peri-anal and intestinal fistulas.
Incidence of this disease varies throughout the world but has been increasing significantly in recent years.
Intestinal Anatomy
Any area of the digestive tract, from the mouth to the anus, can be affected by Crohn's disease. Click to Enlarge
To better understand Crohn's disease, a basic explanation of the gastrointestinal (GI) tract is essential. The upper part of the GI tract includes the mouth, esophagus, stomach, and duodenum. Other vital components are the liver, pancreas, and spleen. The lower part of the digestive tract is the intestine, which is approximately 8 meters long and consists of two parts: the small bowel/intestine (about 6 meters in length), and the large bowel/intestine or colon (about 2 meters). The small bowel is roughly divided into two parts. The upper portion is the jejunum and the lower is the ileum. The colon is divided into various segments, starting at the cecum and ending in the rectum at the anus.
The principal function of the small intestine is to digest and absorb all the dietary nutrients, including proteins, carbohydrates, fats, vitamins, and minerals. The colon serves mainly to absorb water. The small and large intestines work together in co-operation with the liver and the pancreas to break down complex foods and to extract the right amount of each nutrient.
The intestine has a thin inner lining, the mucosa, and beneath this is an area called the submucosa, where the blood vessels and lymph channels run. Surrounding this is a thick muscular wall, covered on the outside by a thin membrane called the serosa. The muscle of the bowel contracts to mix the food and also to propel the bowel contents and promote the passage of food. Although most individuals are aware of intestinal motility only through having bowel movements, motility occurs constantly and is particularly prominent after meals. Ordinarily a person is not aware of bowel contractions, and a meal passes through the digestive tract in 24 to 40 hours.
What Causes Crohn's Disease?
The cause of Crohn's disease is not known. Bacterial and viral causes have been searched for but never confirmed. Dietary and possible allergenic factors have also been excluded. Although emotional factors are not a cause of Crohn's, they may have an impact on the course of the disease. Environmental, genetic, and immunological factors have been researched at length. Conclusions drawn at this time indicate that many of these factors could play a role in Crohn's disease. Further research is essential to find the true cause of this chronic disease.
What are the Symptoms of Crohn's Disease?
The most common symptom of Crohn's disease is diarrhea. Crohn's disease may prevent the proper absorption of food, resulting in diarrhea and the precipitous elimination of fat and other foodstuffs, leading to weight loss. The intestine may become narrowed and obstructed. When Crohn's is located in the colon, the normal function of water re-absorption is impaired, resulting in frequent, liquid stools. Since the lining of the colon can also be ulcerated, the diarrhea often contains blood. In the later stages of the disease the colon can become narrowed and shortened, with decreased absorption of water, fecal urgency, and poor control of bowel function.
Abdominal pain is another common symptom. The intestine has a muscular coat that is subject to muscle spasm, as are muscles elsewhere in the body. However, the inflamed bowel sends more signals to the bowel's richly supplied nerve elements, making it even more irritable and subject to spasm. Often, the pain due to intestinal spasm is cramping in nature. Additionally, pressure can build up behind the narrowed intestine and produce cramps. Occasionally, the narrowing is so severe that a blockage of the intestine occurs, requiring immediate medical - and less frequently surgical - attention. A sudden, short, severe type of pain at the opening of the rectum is called tenesmus and results from inflammation and spasm in the rectum.
Fever is a frequent accompaniment of inflammation of any type and is common in Crohn's. Weight loss is common due to the bowel's inability to absorb sufficient nutrition. In children, a failure or delay in growth and maturity may result.
The rectum and its opening (the anus) may become a focal point for inflammation, with the formation of painful inflamed slits in the skin and superficial tissues, called anal fissures. Large pus pockets or abscesses may accumulate, producing severe pain and fever. An abnormal connection between the intestine and the skin may occur. When this communication is near the opening of the rectum, it is referred to as an anal fistula. Fistulae also may occur - only in Crohn's disease - between the intestine and the abdominal wall, particularly after surgery, or between loops of intestine within the abdomen.
Anemia, or low red blood cell count, frequently occurs from blood loss due to the ulcerations in the lining of the intestine. Occasionally, blood loss may be so severe as to require blood transfusions. Blood proteins may be depleted due to loss of blood serum into the bowel and also due to a general state of malnutrition secondary to the debilitating effects of the disease.
Arthritis, skin problems, liver disease, kidney stones, and eye inflammation are among the other manifestations of Crohn's disease outside of the digestive tract.
How is the Disease Diagnosed?
Unfortunately, the diagnosis of Crohn's disease is sometimes delayed. Malfunction of the intestinal tract may occur from a wide variety of causes, and the symptoms - diarrhea, cramps, and unintentional weight loss - may be very similar to other conditions. The accurate diagnosis of Crohn's disease is essential, as other diseases must be excluded.
A careful evaluation of the history of the illness is the first step to a correct diagnosis. How the disease began and subsequent problems are fitted into a meaningful record. The nature of the diarrhea, type of abdominal pain, as well as the characteristics and quantity of rectal bleeding are all useful details in arriving at a proper initial diagnosis.
Scopes may be performed to determine the nature and extent of the disease. In these procedures, the intestinal tract is viewed with an instrument that enters the body via the anus (colonoscopy/sigmoidoscopy) or mouth (endoscopy). The scope is made of a hollow, flexible tube with a tiny light and video camera. Sometimes the terminal ileum can be visualized with the colonoscope. These procedures require some advance bowel preparation and may be uncomfortable. The advantage of these procedures is that any time during the examination a biopsy may be taken, and the tissue sent for analysis.
An indirect procedure, less commonly performed, involves a barium enema that is administered prior to an X-ray to help view the contours of the bowel more readily. The last portion of the small intestine is important in Crohn's disease and can be seen either by working the barium back into the terminal ileum during a barium enema, or by drinking barium and following it through the small intestine (small bowel follow through) with a series of x-rays.
In addition, examination of the blood for its various constituents is necessary. The stool is examined for infectious agents and for hidden blood. Blood tests are valuable in determining the extent of the disease (e.g. degree of anemia or protein loss). On rare occasions, the diagnosis is made at surgery.
Ultrasound and CT scan are helpful in looking for complications of Crohn's disease but are not useful in making the primary diagnosis.
How is the Disease Treated?
The treatment of Crohn's disease is multi-faceted, including managing the symptoms and consequences of the disease along with therapies targeted to reduce the underlying inflammation.
Rest & Nutrition
Specialized diets, easy to digest meal substitutes (elemental formulations), and fasting can achieve incremental degrees of bowel rest. Nutrition is one of the most important components of digestive health and, as Crohn's disease compromises nutrient absorption, the patient must direct extra attention to special diets and supplements. Some foods may irritate and increase symptoms even though they do not affect the disease course. During fasting, intravenous feeding (total parenteral nutrition) may be required to allow for complete bowel rest. Prescribed vitamin and mineral supplements may improve anemia. Occasionally, a blood transfusion may be necessary. A registered dietitian can help set up an effective, personalized nutrition plan.
Symptomatic Control
A number of treatments exist to address diarrhea and pain. Anti-diarrheal medications directed at preventing cramps and controlling defecation work in different ways. One group alters the muscle activity of the intestine, slowing down content transit, and the other group adjusts stool looseness and frequency by soaking up (binding) water, so the stool is firmer. For painful symptoms not controlled by other drugs, analgesics can be helpful, with acetaminophen being the preferred choice.
Extra-intestinal symptoms of Crohn's disease may require targeted medications and referrals to other specialists. If anxiety and stress are major factors, a program of stress management may be valuable.
Click here to view our information on Stress Management.
Anti-Inflammatory Therapy
Anti-Inflammatory Therapy comes in many forms, using various body systems to effect relief. Your physician may prescribe any of the following medications alone or in combination. It could take some time to find the right mix for you as each case of Crohn's disease is unique.
5-ASA The medication used to reduce inflammation in Crohn's disease, with the longest record of success, is 5-ASA (5-aminosalicylic acid) medication. 5-ASA medications include mesalamine (Asacol®, Mesasal®, Mezavant®, Pentasa®, Salofalk®) and olsalazine sodium (Dipentum®), all taken orally in the forms of tablets and capsules. Depending on the location of your disease, you may be required to administer 5-ASA mesalamine (Pentasa®, Salofalk®) rectally, in the forms of enemas or suppositories. A combination of 5-ASA and sulfa antibiotic is available orally as sulfasalazine (Salazopyrin®). 5-ASA helps to settle the acute inflammation and, when taken on a long-term basis, it tends to keep the inflammation inactive, so it is important to keep up your medicine regime even if your symptoms disappear and you feel well again. 5-ASA medication, both alone and in combination, is very safe and well tolerated for long-term use.
Corticosteroids To reduce inflammation in more severe cases of Crohn's disease, corticosteroids may help. These are prednisone and budesonide (Entocort®) taken orally, although prednisone tends to have greater side effects. For topical relief of Crohn's disease in the colon, budesonide (Entocort®) and hydrocortisone (Betnesol®, Cortenema®, Cortifoam™, Proctofoam®) are available in rectal formulations (enemas, foams, and suppositories). In hospital, hydrocortisone (Solu-Cortef®) and methylprednisolone (Solu-Medrol®) are administered intravenously.
Antibiotics The most widely prescribed antibiotics are ciprofloxacin (Cipro®) and metronidazole (Flagyl®, Florazole ER®). Broad-spectrum antibiotics are important in treating secondary manifestations of the disease such as peri-anal abscess and fistulae.
Immunosuppressive Agents These drugs are used to treat both ileal and colonic Crohn's and to reduce dependence on steroids and include azathioprine (Imuran®), cyclosporine, mercaptopurine/6-MP (Purinethol®), and methotrexate sodium.
Biologics Monoclonal antibodies are a class of medications now used to treat Crohn's disease when older medications fail to relieve symptoms. Infliximab (Remicade®) has been in use since 2001 for moderate to severe or fistulizing Crohn's disease. Patients receive infliximab through regular intravenous infusions, about every eight weeks. A newer medication in this class, adalimumab (Humira®), has a different delivery system in that patients can administer the medication themselves, without the need to attend an infusion centre. Adalimumab is for reducing signs and symptoms, and for inducing and maintaining clinical remission of moderately to severely active Crohn's disease in adult patients who have had an inadequate response to conventional therapy, including corticosteroids and/or immunosuppressants, and for those patients who have also lost response to, or are intolerant to, infliximab.
What Place has Surgery?
An unfortunate feature of Crohn's disease is the fact that there is a high recurrence rate, even though all visible and microscopic disease has been removed. For this reason, surgery is best limited to two situations: complications and failure of medical management. Complications requiring surgery may be obstruction, fistulae, or abscess formation. It is more difficult to determine when medical management is not adequate. Such factors as the patient's ability to work, look after family, nutritional status, and other factors have to be considered in relation to the possible benefits of surgery. A decision to proceed with surgery is made after careful consultation between doctor and patient.
Is Crohn's Disease Hereditary?
Crohn's disease is not a hereditary disease in that it is not passed from parent to child like some diseases are. There is, however, a familial incidence so that in the extended family there may be more than one person with the disease. Some genetic markers have been identified but these are not entirely conclusive. There are also certain ethnic groups with a high incidence of Crohn's disease and some with a very low incidence.
Is There Anything New?
With better diagnosis, improved nutrition, and improved surgical technique the management of Crohn's disease is better today than previously. The cause remains a mystery and a great deal of research is still necessary.
More Information
For the latest information on this and other conditions of the digestive tract, you may wish to consider joining The Canadian Society of Intestinal Research for just $20 annually. In doing so, you will receive the Society's newsletter, The Inside Tract®, on a bi-monthly basis which offers a wealth of information including the latest gastrointestinal research, medication reviews, nutrition updates, new technologies, helpful hints, explanations of digestive conditions, healthcare news, and much more.
Are you taking prescription medication for any of the following stomach problems/symptoms:
Stomach pain or discomfort
Heartburn
Sour taste in mouth/acid regurgitation
Excessive burping/belching
Increased abdominal bloating
Nausea
Early satiety
If you answer yes to any one of the symptoms listed above then take this test to see if your current medication is adequately controlling your stomach symptoms.
The PASS Test
PPI* Acid Symptom Suppression Test
*PPI is short for proton pump inhibitor, a class of medication used to suppress the acid in your stomach. These include Losec®, Nexium®, Pantoloc®, Pariet™, and Prevacid®.
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