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Dictionary The Digestive System

Crohn'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:

  • chronic liver disease, including cirrhosis
  • arthritis
  • inflammatory ocular lesions (uveitis, conjunctivitis)
  • haemolytic anaemia
  • chronic kidney damage
  • aphthous stomatitis (mouth ulcers)
  • erythema nodosum (tender red nodules predominantly on the shin but occasionally involving the arms and other areas, that fade away very slowly)
  • pyoderma gangrenosum (skin lesions, usually found on the lower extremities, that start as tender nodules or pustules progressing to stubborn and irregular pus-discharging ulcers)

Clinical features:  < BACK TO TOP >

  • The disease is a chronic disorder with unpredictable exacerbations and remissions and diminished quality of life.
  • The presentation depends on the site and extent of the bowel affected.
  • Pain is the commonest symptom and is usually located in the right lower abdominal quadrant and may be associated with local tenderness and guarding if the parietal peritoneum is irritated by the inflammatory process.
  • The disease could mimic appendicitis and the real nature of the disease is then discovered only after laparotomy (surgical opening of the abdomen).
  • Recurrent episodes of colicky pain due to incomplete bowel obstruction (recall that the bowel lumen is narrowed) are a prominent feature, sometimes with nausea and vomiting.
  • The pain may be accompanied by diarrhoea (often without blood), fever and troublesome fatigue.
  • Steatorrhoea (abnormally fatty stools) and malabsorption are common, mainly due to interruption of the enterohepatic circulation of bile acids, which are then lost in stools and their pool eventually reduced. Bile salts also produce irritation of the colonic mucosa and in this way directly contribute to diarrhoea.
  • Loss of bile salts predisposes patients to cholesterol gallstones (bile salts keep cholesterol in solution), which are common in patients with extensive and prolonged disease.
  • Anaemia due to malabsorption of iron, folic acid and especially vitamin B12, and weight loss due to the reduction in absorptive surface are sometimes present.
  • Abscess formation is common, which may discharge pus into the intestinal lumen, bladder or vagina, creating fistulas.
  • When the rectum is involved there may be some rectal bleeding (but less common than in ulcerative colitis), rectal fissures, perirectal abscesses and rectal fistulas discharging pus onto the gluteal skin.
  • There is an increased incidence of carcinoma of the intestine in those segments affected by Crohn's disease.

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 :-
Fish oil, Probiotics, Vitamin D

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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