Crohn’s Disease – Symptoms, Risk Factors, and Prevention.

Definition

Crohn’s Disease is a condition that causes inflammation of the digestive system or gut. Crohn’s can affect any part of the gut, though the most common area affected is the end of the ileum (the last part of the small intestine), or the colon.

The areas of inflammation are often patchy with sections of normal gut in between. A patch of inflammation may be small, only a few centimetres, or extend quite a distance along part of the gut. As well as affecting the lining of the bowel, Crohn’s may also go deeper into the bowel wall. It’s one of the two main forms of Inflammatory Bowel Disease (IBD). The other is Ulcerative Colitis.

Crohn’s disease

History

Inflammatory bowel diseases were described by Giovanni Battista Morgagni (1682–1771) and by Scottish physician T. Kennedy Dalziel in 1913.

Ileitis terminalis was first described by Polish surgeon Antoni Leśniowski in 1904, although it was not conclusively distinguished from intestinal tuberculosis. In Poland, it is still called Leśniowski-Crohn’s disease. Burrill Bernard Crohn, an American gastroenterologist at New York City’s Mount Sinai Hospital, described fourteen cases in 1932, and submitted them to the American Medical Association under the rubric of “Terminal ileitis: A new clinical entity”. Later that year, he, along with colleagues Leon Ginzburg and Gordon Oppenheimer, published the case series as “Regional ileitis: a pathologic and clinical entity”. However, due to the precedence of Crohn’s name in the alphabet, it later became known in the worldwide literature as Crohn’s disease

Epidemiology

The incidence of CD in the US is 6 to 7 per 100,000 people. It is estimated that there are around 500,000 to 1 million people affected with inflammatory bowel disease in the US. The peak age of onset is between 15 and 40 years, and there is a smaller second peak between 60 and 80 years. CD is equally prevalent among men and women. It is more common in white people and Ashkenazi Jews. Some studies have shown a higher prevalence among smokers.

Types of Crohn’s Disease

The following are five types of Crohn’s disease, together with their presenting symptoms:

Ileocolitis

The most common form of Crohn’s, ileocolitis affects the end of the small intestine (the ileum) and the large intestine (the colon). Symptoms include diarrhea and cramping or pain in the right lower part or middle of the abdomen. This type is often accompanied by significant weight loss.

Ileitis

This type affects only the ileum. Symptoms are the same as ileocolitis. In severe cases, complications may include fistulas or inflammatory abscess in right lower quadrant of abdomen.

Gastroduodenal Crohn’s disease

This type affects the stomach and the beginning of the small intestine(the duodenum). Symptoms include loss of appetite, weight loss, nausea, and vomiting.

Jejunoileitis

This type is characterized by patchy areas of inflammation in the upper half of the small intestine (the jejunum). Symptoms include mild to intense abdominal pain and cramps following meals, as well as diarrhea. In severe cases or after prolonged periods, fistulas may form.

Crohn’s (granulomatous) colitis

This type affects the colon only. Symptoms include diarrhea, rectal bleeding, and disease around the anus (abscess, fistulas, ulcers). Skin lesions and joint pains are more common in this form of Crohn’s than in others

Risk factors

Risk factors for Crohn’s disease may include:

Age. Crohn’s disease can occur at any age, but you’re likely to develop the condition when you’re young. Most people who develop Crohn’s disease are diagnosed before they’re around 30 years old.

Ethnicity: Although Crohn’s disease can affect any ethnic group, whites and people of Eastern European (Ashkenazi) Jewish descent have the highest risk. However, the incidence of Crohn’s disease is increasing among blacks who live in North America and the United Kingdom.

Family history: You’re at higher risk if you have a close relative, such as a parent, sibling or child, with the disease. As many as 1 in 5 people with Crohn’s disease has a family member with the disease.

Cigarette smoking: Cigarette smoking is the most important controllable risk factor for developing Crohn’s disease. Smoking also leads to more-severe disease and a greater risk of having surgery. If you smoke, it’s important to stop.

Nonsteroidal anti-inflammatory medications: These include ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve), diclofenac sodium (Voltaren) and others. While they do not cause Crohn’s disase, they can lead to inflammation of the bowel that makes Crohn’s disease worse.

Where you live: If you live in an urban area or in an industrialized country, you’re more likely to develop Crohn’s disease. This suggests that environmental factors, including a diet high in fat or refined foods, may play a role in Crohn’s disease.

Causes of Crohn’s Disease

The cause of Crohn’s disease is unknown. However, it is likely due to

• An abnormal response of the immune system.
• Food or bacteria in the intestines, or
• Even the lining of the bowel may cause the uncontrolled inflammation associated with Crohn’s disease.

Symptoms of Crohn’s Disease

You may have:

• Diarrhea
• Stomach pain
• Weight loss
• Bleeding from your rectum
• Constipation
• Fatigue
• Nausea
• Fever
• Sudden and frequent need to go to the bathroom

You might not have all these. The disease affects different people in different ways. The symptoms can be mild, or they can leave you very weak. At its worst, Crohn’s can cause severe complications.

Complications of Crohn’s Disease

The most serious cases of Crohn’s can cause:

• Painful tears called fissures in the lining of the anus, mostly during bowel movements
• Fistulas (passages that form between loops of the intestine, or between the intestines and the vagina, skin, or bladder)
• Thickening of intestine walls, which makes it hard for food and waste to move
• A partly or totally blocked intestine, for which you would need medical care right away
• Open sores called ulcers in the intestines, mouth, or anus
• Malnutrition, as your body is not able to absorb enough nutrients from food
• Pain, swelling, and burning in other parts of your body, such as your skin, eyes, or joints

Diagnosis and test

You’ll probably go through a combination of exams, lab tests, and imaging studies with these goals in mind:

• Rule out other health problems that have similar symptoms
• Make a clear diagnosis of Crohn’s disease
• Determine exactly which part of the digestive tract is affected

Diagnosing Crohn’s disease: Physical Exam and History

Your doctor will begin by gathering information about your health history and conducting a physical exam. Findings that may indicate further tests are needed include:

• Diarrhea, which may be bloody
• Family history of Crohn’s disease
• Fever
• Pain and tenderness in the abdomen

Diagnosing Crohn’s Disease: Lab Tests

Your doctor may request lab tests in order to look for any problems that might be linked to Crohn’s disease. These tests check for signs of infection, inflammation, internal bleeding, and low levels of substances such as iron, protein, or minerals. Lab tests may include:

• Blood protein levels
• Blood sedimentation rates
• Body mineral levels
• Red blood cell counts
• Stool samples to check for blood or infectious microbes
• White blood cell counts

Diagnosing Crohn’s Disease: Imaging Studies and Endoscopy

Crohn’s disease may appear anywhere along the gastrointestinal tract, from the mouth to the rectum. X-rays and other images can help identify the severity and location of Crohn’s disease. These studies may include the following:

• Barium X-rays and other X-rays
• CT scans
• Colonoscopy or sigmoidoscopy
• Video capsule endoscopy

Treatment and medications

There’s currently no cure for Crohn’s disease, but treatment can improve the symptoms.

The main aims of treatment are to:

• Reduce symptoms – known as inducing remission (remission is a period without symptoms)
• Maintain remission

In children, treatment also aims to promote healthy growth and development.

Your treatment will usually be provided by a range of healthcare professionals, including specialist doctors (such as gastroenterologists or surgeons), GPs and specialist nurses.

Reducing symptoms

If you have Crohn’s disease and it’s causing moderate or severe symptoms, this is known as an “active disease”. Treatment for active Crohn’s disease usually involves medication, but surgery is sometimes the best option.

Initial treatment

In most cases, the first treatment offered is steroid medication (corticosteroids) to reduce the inflammation. Examples of corticosteroids used for Crohn’s disease include prednisolone tablets or hydrocortisone injections.

These medications are often effective in reducing the symptoms of Crohn’s disease, but they can have significant side effects, such as:

• Weight gain
• Swelling of the face
• Increased vulnerability to infections
• Thinning and weakening of the bones (osteopenia and osteoporosis)

Because of these possible side effects, your dose will be gradually reduced when your symptoms start to improve.

If you prefer, you may be able to choose to have a milder steroid called budesonide, or a type of medication called a 5-aminosalicylate (such as mesalazine), as an alternative initial treatment. These medications have fewer side effects, but they’re less effective.

In children or young people, where there are concerns about growth and development, a special liquid diet may be recommended as an initial treatment. This is known as an elemental or polymeric diet, and it can reduce inflammation by allowing your digestive system to recover while ensuring you get all the nutrients you need.

Additional treatment

If your symptoms flare up twice or more during 12 months, or return when your steroid dose is reduced, further treatment may be necessary.

In these cases, medicines to suppress your immune system (immunosuppressants) may be combined with your initial medication. Medicines called azathioprine or mercaptopurine are most commonly used.

These medicines aren’t suitable for everyone, so a blood test should be carried out to check if you can use them. If they’re not suitable, an alternative immunosuppressant medication called methotrexate may be used.

Side effects of these immunosuppressants can include:

• Nausea and vomiting
• Increased vulnerability to infection
• Pancreatitis
• Feeling tired, breathless and weak, which is caused by anaemia
• Liver problems

During the course of medication, you’ll have regular blood tests to check for serious side effects.

The immunosuppressants azathioprine and mercaptopurine are considered safe in pregnancy and breastfeeding. Women can continue to use these drugs when trying to start a family and during pregnancy.

However, methotrexate must not be taken for at least six months before trying for a baby, as this drug is known to cause birth defects. This applies to both men and women. It must also be avoided while you’re breastfeeding.

It’s important to speak to your doctor if you’re planning a pregnancy or if you become pregnant during your course of treatment for Crohn’s disease.

Surgery

• Surgery may be recommended to reduce your symptoms if your healthcare team feel the benefits outweigh the risks.
• In many cases, a type of surgery called a resection is used. This involves removing the inflamed area of the intestine and stitching the healthy sections together.
• In some cases, your doctor may recommend a procedure called an ileostomy to temporarily divert digestive waste away from the inflamed colon (large intestine) to give it a chance to heal.
• During this operation, the end of the small intestine (the ileum) is disconnected from the colon and re-routed through a hole made in the abdomen, which is known as a stoma. An external bag is attached to the opening to collect waste products.
• Once the colon has sufficiently recovered – usually after several months – a second operation will be needed to close the stoma and re-attach the small intestine to the colon.

Maintaining remission

• Remission is a period when you don’t have any symptoms or your symptoms are mild. During these periods, you can choose whether or not to use medication to help maintain this.
• If you decide not to have further treatment, you should be advised about attending regular follow-up appointments and which symptoms to look out for. These symptoms include unintended weight loss, abdominal pain and diarrhoea.
• If you choose to have treatment, this will usually involve immunosuppressants. Corticosteroids aren’t recommended for maintaining remission.

Prevention of Crohn’s Disease

Crohn’s disease cannot be prevented, because the cause is unknown. But you can take steps to reduce the severity of the disease. However, these healthy lifestyle strategies may help minimize your risk of Crohn’s disease:

Eat a well-balanced diet: Reducing the intake of certain foods, particularly meats and foods high in trans fats and refined sugar, can help lower your risk of getting Crohn’s. Instead, consume a diet high in vegetables, fruits, saturated fats, omega-3s from animal sources and fiber.

You should also add traditionally fermented foods to your meals, as they can help balance the ratio of good to bad bacteria in your gut.

In fact, avoid processed foods in general, and focus on eating wholesome organic foods instead. They may contain emulsifiers that have been linked to both ulcerative colitis and Crohn’s disease.

Artificial flavors, colors and preservatives in these foods may also lead to inflammation and wreak havoc on your health.

If you already have Crohn’s disease, however, there are certain healthy foods that you must reduce or avoid, as they may strain your digestion, which can worsen the painful symptoms or promote flare-ups. Some examples are raw nuts, dairy and high-fiber foods.

Avoid or quit smoking: Smoking is the biggest preventable factor in developing Crohn’s disease. Smokers who get Crohn’s disease are found to have more relapses, require more medications and repeat surgeries, and suffer more severe complications.

By avoiding or stopping smoking, not only will the health of your digestive tract improve, but you can prevent a host of other diseases as well. Read some effective strategies to help you quit smoking.

Manage stress: Stress, in and of itself, is not considered a cause of Crohn’s disease, but it has been found to influence your digestive process and overall risk of illness.

When you’re stressed, your stomach empties more slowly, secreting more acid. It speeds up or slows down the passage of intestinal contents, and causes intestinal tissue changes as well.3

Note that chronic stress leads to inflammation, and has even been linked to diseases like cancer. Stress can worsen Crohn’s disease symptoms and trigger flare-ups. For this reason, employ effective stress managing techniques, such as exercises, meditation, breathing techniques, yoga, EFT, or even Grounding.

Drink enough water: If your intestines don’t get enough fluids, they cannot perform their duties properly. You’ll know if you’re getting enough water by checking the color of your urine (ideally, it should be a light yellow color). Avoid alcohol and caffeinated beverages, especially if you already have a high risk for this illness.

Optimize your vitamin D levels: Vitamin D helps your body produce over 200 antimicrobial peptides that help fight all sorts of infections. Since experts believe Crohn’s disease has an infectious component, this is a simple strategy that can lower your risk. In fact vitamin D is nearly as effective as animal-based omega-3 fats in countering IBD.