Crohn's Disease

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Original Editors - Sarah Bailey Students from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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Definition/Description

Crohn’s disease is a form of inflammatory bowel disease (IBD) that causes inflammation to the lining of the digestive or gastrointestinal (GI) tract and may be a result of an immune system malfunction. The immune system sees the bacteria and organisms that lie within the GI tract and intestines and mistakes them for outside invaders to the body. In response to this, the body produces extra white blood cells to the GI tract to fight off the invaders, which creates inflammation within the lining of the tract. Chronic inflammation may result in ulcerations within the layers of the tract . The inflammation can occur to any portion of the GI tract, from mouth to anus and can affect all layers of the intestinal tract while healthy bowel layers may be interspaced between the diseased portions of the bowel.

The most commonly affected portion of GI tract affected is the lower portion of the small intestine, or ileum .  Due to the inflammation, abdominal pain, diarrhea and malnutrition can be a result .  Crohn’s disease is also referred to as granulomatous enteritis or colitis, ileitis, regional enteritis, or terminal ileitis. This disease is similar in some aspects to ulcerative colitis, but the difference lies in the fact that ulcerative colitis produces inflammation only within the colon or rectum while Crohn’s disease produces inflammation within the colon, rectum, small intestine, stomach, mouth and esophagus. The inflammation caused by Crohn’s disease has the potential to affect the deeper layers more than ulcerative colitis .  While these two conditions are very similar, approximately 10 percent of individuals are unable to pinpoint whether the disease process is ulcerative colitis or Crohn’s disease. For these individuals, they are then diagnosed with indeterminate colitis .

Prevalence

Crohn’s disease affects approximately 500,000 to two million people in the United States, equally affecting men and women .  This disease may occur in individuals of all age, but has characteristically affected adolescents and young adults between 15-35 of age. It is estimated that 10 percent of individuals affected are under the age of 18. Crohn’s has been found to affect American Jews of European descent four to five times more than the general population. The prevalence among whites is 149 per 100,000 with a

Geographic Distribution of Crohn's Disease

steady increase in incidence among African Americans. Hispanics and Asian have a lower prevalence than do African Americans and whites. There has been a potential link between living environment and the incidence of Crohn’s disease, where there are more reports amongst urban and northern climates than rural and southern climates. Similarly, this disease tends to be more predominant in the US and Europe .

Characteristics/Clinical Presentation

There is no cure for this condition and Crohn’s disease alters between periods of remission and relapse. Crohn’s typically appears around adolescence and early adulthood and there is potential of Crohn’s disease to run in families .  About 20-25% of individuals affected with Crohn’s disease have a close relative who is affected with ulcerative colitis or Crohn’s disease. If an individual has a relative with Crohn’s, the risk of this individual is 10 times higher than the general population, while a brother or sister link increases the risk to 30 times higher than the general population. Current researchers have identified an abnormal genetic mutation on gene NOD2/CARD 15 which reduces the ability of the body to distinguish harmful bacteria. This mutation is found twice as often in individuals affected with Crohn’s versus the general population .

The typical symptoms of Crohn’s disease include diarrhea, abdominal cramping generally in the right lower quadrant , fever and potential rectal bleeding. The rectal bleeding is potentially due to tears or fissures within the anus lining. Fistulas or tunnels leading from the intestines to the bladder, vagina or skin may also occur, while most occur around the anal area. The fistula has potential to produce drainage, pus, mucus or stool being excreted from the opening. These symptoms may vary between individuals and may not all be present at the same time. There is potential for weight loss and fatigue.

While Crohn’s is a chronic disease, the patients will experience bouts of flare ups and remission with the absence of symptoms .

Associated Co-morbidities

While commonly Crohn’s disease affects the GI tract, there have been instances where additional complications include arthritis, skin conditions, inflammation of the eyes and/or mouth, joints, kidney stones, gallstones and liver/biliary conditions were also reported.

The most common associated comorbidity is a blockage of the intestines. Continual blockage tends to thicken the walls of the intestine with scar tissue which further reduces the size of the passageway . Fistulasare also common due to sores or ulcers that develop into deep ulcers or tracts connecting into the bladder, vagina, skin or anal area. These fistulas are then exposed to infection.

It has been discovered that individuals with Crohn’s disease have referred pain to the low back. Approximately 25% of individuals with Crohn’s and/or irritable bowel disease have sacroilitis, polyarthritis, monarthritis of ankle, knee, elbows and/or wrists , as well as migratory arthralgias. At times, these joint conditions may even present initially before the other GI related symptoms.

Since this disease affects the absorption of nutrients, chronic individuals commonly have deficiencies of protein, calories and vitamins. This may be due to the malabsorption or overall inadequate dietary intake secondary to the patient’s attempt to limit the pain produced with eating .

There is a risk of colorectal cancer that tends to increase with an increased length of time with the disease. There is a 2% incidence of colorectal cancer after 10 years diagnosis, 9% incidence after 20 years diagnosis, and 19% incidence after 30 years of diagnosis of Crohn’s disease. A 20% mortality rate lies within the first 10 years of diagnosis in the presence of complications. Surgical removal of the Crohn’s bowel does not prevent colorectal cancer, thus putting importance on prevention and screening for early detection of colorectal cancer.

Medications

There are a few classifications of drugs that can be used to help relieve the symptoms of Crohn’s disease. These include anti-inflammatory, cortisone or steroids, immune system suppressors, Infliximab (Remicade), antibiotics and anti-diarrheal/fluid replacements.

Anti-inflammatory drugs are generally the initial step in relieving the symptoms, which can include Sulfasalazine that is better for conditions within the colon and is the most common. An additional type includes 5-ASA agents such as Mesalamine which has fewer side effects but is not as effective at treating the small intestine.

Cortisone or corticosteroids can be very effective by reducing inflammation within the body, but there side effects are vast including night sweats, high blood pressure, osteoporosis, bone fractures, excessive facial hair increased susceptibility for infection and cataracts.  Prednisone is typically prescribed when the disease is beginning and typically worse.

Immune system suppressors suppress the immune system which targets the immune system to reduce the inflammation within the body. Some types include Imuran or Azathioprine and Purinethol which are the most commonly used for IBD and conditions. These may also help to heal the fistulas .  It should be noted that the use of immunosuppressive drugs may increase the effectiveness of corticosteroids.

Infliximab (Remicade) is the first medication to block the inflammation response by the body. This was approved by the FDA for the treatment of moderate to severe Crohn’s disease that has failed to respond to prior conservative treatments. This medication is an anti-TNF substance and neutralizes this protein that is produced by the immune system. The TNF is targeted and removed before there is the chance for inflammation to occur in the GI tract. The FDA has declared a warning to children and adolescents taking this medication or other TNF inhibitors are at an increased risk for developing cancer.

Antibiotics are used to treat and heal fistulas and abscesses associated with Crohn’s disease. Medications such as these may also reduce the amount of harmful bacteria within the GI tract that suppresses the intestinal immune system. Common antibiotics include Flagyl and Cipro.

Additional medications that are used to help reelive symptoms in individuals with Crohn’s disease include: anti-diarrheals to relieve the diarrhea, laxatives, pain relievers, iron supplements, vitamin B-12 shots, calcium and vitamin D. Nutrition supplements are also very important, especially in children whose growth may be slowed. This nutrition might be in the form of high-calorie liquid formulas, feedings tube or parenteral nutrition injected into the vein. This will help to overall improve the nutrition of the individual and allow their bowel to rest which may reduce inflammation for a short period of time.

Diagnostic Tests/Lab Tests/Lab Values

The diagnosis of Crohn’s disease is made by ruling out other potential causes to explain the patient’s signs and symptoms. Some of the tests include blood tests, fecal occult blood test (FOBT), colonoscopy, flexible sigmoidoscopy, barium enema or small bowel imaging, CT of the GI tract, or a capsule endoscopy.

The blood tests are used to check for anemia which would indicate inflammation within the body, infection, antibodies that might be present with individuals with inflammatory bowel disease. The FOBT assesses an individual’s stool sample for presence of blood. A colonoscopy allows the doctor to take a biopsy or tissue sample to determine if there is a presence of any granulomas which are common with Crohn’s disease and not ulcerative colitis. The flexible sigmoidoscopy allows the doctor to assess the last portion of the colon for any biopsy samples.  This allows the doctor to determine if there is any inflammation or bleeding amongst the intestines.  Barium enemas allow the doctors to assess the intestines via x-ray. The barium coats the inner lining of the GI tract to allow the lining to be visible on the x-ray. A CT of the GI tract allows a quick look at the entire bowel in a way that cannot be seen in other diagnostic tests. This helps to assess for blockages, asbecces or fistulas. The capsule endoscopy consists of a capsule with a small camera inside that is swallowed by the individual. The camera takes pictures every second as it travels along your GI tract. The pictures are then sent to a wireless computer belt worn by the patient that can then be taken into the doctor and downloaded for view.

An outcome measure has been created to track the progress or lack of progress for individuals affected with Crohn’s disease called Crohn’s Disease Activity Index (CDAI). A score below 150 indicates a better prognosis than higher scores. This measure helps to track an individual’s progress from week to week to determine if the symptoms are better or worse. This is more of a gauge of progress and not a prognosis tool.

Causes

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Systemic Involvement

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Medical Management (current best evidence)

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Physical Therapy Management (current best evidence)

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Alternative/Holistic Management (current best evidence)

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Differential Diagnosis

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Case Reports

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Resources

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Recent Related Research (from Pubmed)

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References

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