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The Digestive SystemCrohn's Disease Synonyms : Clinical features, Diagnosis, Management, Prognosis, Nutrition, Herbs, This disease is characterised by localised areas of
non-specific, granulomatous inflammation of the bowel. Early descriptions of
Crohn’s disease emphasised the sharply demarcated
transmural (referring to involvement of the entire bowel wall) inflammation
and thickening of the terminal ileum, giving rise to the designation terminal
ileitis. Recognition that other sharply delineated small intestinal
segments might be affected, with intervening unaffected (‘skipped? areas,
led to the alternative name regional enteritis. It
is now clear that this disease may affect any
level of the alimentary tract even mouth; thus the name Crohn’s disease
is preferred, although this term is not descriptive. Moreover, active cases of
Crohn’s disease are often accompanied by extraintestinal
complications which are described later. Thus, Crohn’s disease must be
viewed as a systemic disease with
predominant gastrointestinal involvement. The
sites most commonly involved are, in order of frequency, terminal ileum and
right side of the colon, colon alone (so called Crohn’s colitis), terminal
ileum alone, ileum and jejunum, and it is most common between the ages of 10
and 40 years, equally affecting both sexes. The prevalence (current number of
cases) is estimated at 20-40 per 100,000 population. The influence of genetic factors in Crohn’s disease is well documented, but the
exact mode of inheritance is still not clear. The cause of Crohn’s disease is unknown, but the following factors could be important: infective agents (because of the chronic granulomatous inflammatory nature of the disease); recently it has been suggested that infection with Mycobacterium paratuberculosis may provoke an abnormal immune response in predisposed individuals
abnormal
immunological responses due to some unrecognised abnormality (antibodies
against intestinal epithelial cells have been identified on several occasions,
deposition of immune complexes might be responsible for extraintestinal
manifestations and abnormalities in cell-mediated immunity have also been
shown) Characteristically
the entire wall of the bowel is swollen, thickened, rubbery and elastic
(‘garden hose-like?. There are deep
ulcers which often appear as linear fissures so that the mucosa between
them is described as coarse and nodular (‘cobblestoned?/i>).
The deep ulcers may penetrate through the bowel wall to initiate abscesses
(localised accumulations of pus) or fistulas
(abnormal tunnel-like communications). Fistulas may develop between adjacent
loops of bowel (usually) or between affected segments of the bowel and the
bladder, uterus or vagina (uncommonly). A classic feature of Crohn’s disease is the sharp
demarcation of diseased bowel segments from adjacent uninvolved bowel.
Affected segments are referred to as ‘skip?b style="mso-bidi-font-weight:normal">
lesions because segments between them are essentially normal. The
microscopic features of Crohn’s disease, non-caseating
granulomas (no central areas of caseous necrosis as found in similar
granulomas of tuberculosis) are characteristic, consisting of focal
micronodular aggregates of various types of macrophages, lymphocytes and giant
cells formed after fusion of several macrophages. The mesenteric lymph nodes
are enlarged and the mesentery involved as well and thickened. The
process can affect various extra-intestinal
tissues, giving rise to the following syndromes:
Clinical features: < BACK TO TOP >
Diagnosis: < BACK TO TOP >
The
extent of the disease is assessed by a barium meal and follow-through, as well
as barium enema examination.
The
barium meal examination may show alteration of the mucosal pattern and
ulceration as an irregular hazy margin (sometimes described as ‘hair
brush?appearance) or the pathognomonic ‘string
sign?/i> due to marked narrowing of a segment of the affected bowel.
Endoscopy
of the stomach and duodenum is performed if the barium studies indicate any
abnormality of these organs.
Colonoscopy
is routinely carried out since most patients have involvement of the caecum,
and biopsies usually confirm the diagnosis.
White
blood cells labelled with 99mTc may be used to locate areas of active inflammation on abdominal
gamma-camera scans if other tests are inconclusive (note that this technique
is not specific to any disease as it only assesses the location and extent of
active inflammation).
Blood
tests may show moderate anaemia (iron deficient, B12
deficient and haemolytic in type), raised ESR and leukocytosis (non-specific
signs of inflammation), liver function tests (discussed later) reveal the
extent of liver involvement. Management < BACK TO TOP > It is essential to restore and maintain the patient’s nutritional status with appropriate high protein, high energy diet. Foods most often blamed for aggravating existing symptoms are milk and milk products, spicy foods, fats and sugars and wheat.
Supplements
of iron, folic acid, vitamin B12 and vitamin D are useful.
Troublesome
diarrhoea can be suppressed by loperamide [Imodium], but only if absolutely
necessary.
In
general, Crohn’s disease is less responsive to treatment than ulcerative
colitis.
Corticosteroids
(hydrocortisone in the form of rectal foam [Colifoam], prednisolone applied
topically in the form of enema or suppositories [Predsol] or given orally
[Delta-Cortef, Panafcortelone, Solone]), as well as sulphasalazine [Salazopyrin],
mesalazine [Mesalal] and olsalazine [Dipentum] can be useful.
Immunosuppressive
treatment with azathioprine [Imuran, Thioprine], mercaptopurine [Puri-Nethol],
methotrexate [Ledertrexate, Methoblastin] and cyclosporine [Sandimmun, Neoral]
appears to be effective if combined with corticosteroids, when dosage of
steroids can be reduced (important to decrease the occurrence of their side
effects).
In
cases of proven abscesses or fistulas, antibiotics such as metronidazole
[Flagyl, Metrogyl] or ciprofloxacine [Ciproxin] are prescribed to suppress
bacterial infection.
Infliximab
[Remicade] is the first genetically-engineered drug to be approved for
Crohn’s disease in Australia. The drug is made from a specially developed
antibody (termed a monoclonal antibody), which acts against tumour necrosis
factor (TNF), a major chemical mediator in the inflammatory process that
causes inflammatory bowel disease. Recent trials of this drug indicate that
they may help patients with moderate to severe Crohn’s disease that has not
responded well to other treatments. It is given by intravenous infusion in one
dose, that can be repeated in necessary after few weeks. Such treatment is
unfortunately very expensive.
Surgical
treatment is performed in cases of intestinal obstruction which does not
resolve spontaneously, symptomatic fistula to the bladder, vagina or skin,
persistent anal fistulas and abscesses (approximately 70% of patients require
at least one operation during the course of their disease).
The
prognosis is not as favourable as for ulcerative colitis, with mortality rates
of 5-10% (most deaths are caused by peritonitis and sepsis). Prognosis < BACK TO TOP >
Nutrition < BACK TO TOP > Nutrition that alleviate or prevent Crohn's Disease :- Herbs < BACK TO TOP > Herbs that alleviate or prevent Crohn's Disease :- Baptisia tinctoria ( Wild indigo), Boswellia serrata (Salai guggal), Camellia sinensis ( Green tea), Curcuma longa ( Turmeric), Ginkgo biloba ( Ginkgo), Hydrastis canadensis (Goldenseal), Mentha piperita (Peppermint), Ulmus fulva (Slippery elm), Uncaria tomentosa (Cat's claw) (source : -) |
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