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Crohn's Disease

What is Crohn’s Disease?

Crohn’s Disease is one of the two main diseases that fit into a disease category called Inflammatory Bowel Disease or IBD. This is a disease that results in diarrhea and abdominal pain because the body’s own immune system is recognizing parts of the GI tract as foreign and mounting a response. In the sister disease, Ulcerative Colitis (UC), the attack is mainly on the colon, but Crohn's can attack anywhere from mouth to anus. Crohn’s is considered the more damaging of the two types.

The incidence of Crohn’s disease has been increasing in America, now up to 13 cases in 100,000 compared with 6 per 100,000 in Asia. Nobody knows what triggers the body to recognize it’s lining as foreign. There are thought to be genetic factors as well as exposure to an inciting stimulus that “turn on” the immune system. Both UC and Crohn’s are less prevalent in countries where food sources are less processed. Industrialized diet, smoking, antibiotics, and stress all may play some role. About 15-30% of patient have other family members afflicted.

Unlike ulcerative colitis that always involves the rectum, Crohn’s Disease will frequently involve the last part of the small bowel, called the “terminal ileum”, before it empties into the large bowel. Functionally, this results in pain in the right lower abdomen. It can be confusing as this is where appendicitis pain appears—but a CT scan rule out appendicitis in most cases. As mentioned above, Crohn’s disease can involve large bowel, small bowel and even the upper GI tract. The inflammation is “transmural” which means it can extend all the way through the bowel wall. These tunnels or “fistula” can extend to other organs like bladder or vagina, or even up to the skin. The fistula are very common around the rectum in this disease.

Treatments will vary depending on the amount of tissue involved and level of damage. Because of the chronic nature of this condition, the disease rarely “goes away”, although with age it can “burn itself out”, becoming less prominent over time.

What are the symptoms of Crohn’s Disease?

Most often patients come in with vague abdominal pain and diarrhea. Unlike ulcerative colitis, this diarrhea is not usually blood tinged.

  • Initial onset of symptoms is usually in the teens and early 20’s, but sometimes Crohn’s can manifest in childhood. These early cases are best managed by a Pediatric Gastroenterologist.
  • There is sometimes a second peak of Crohn’s disease in the 60’s-70’s for reasons no one knows.
  • Despite treatment, these episodes will exacerbate or “flare”, and then go away for weeks or months. Initial symptoms can be vague and mimic intestinal flu, so diagnosis is often delayed. Maintenance medication is often needed to prevent long term complications.
  • The abdominal pain may be mostly in the right lower abdomen or involve the entire belly.
  • Fever and chills can be present, and a predisposition to infection is increased.
  • Weight loss is seen in 65-75% of patients.
  • Anemia may be noted on lab analysis.
  • The diarrhea in Crohn’s disease is usually watery and painful.
  • Liver function tests can increase if patients also develop an associated inflammation of the bile ducts (primary sclerosing cholangitis).
  • Skin redness and ulcers can occur.
  • Eye inflammation and light sensitivity can be seen.
  • Arthritis is common, particularly where the spine meets the hip.
  • Intestinal blockage occasional occurs, leading to a rapid worsening of symptoms.

How is Crohn’s Disease diagnosed?

Your primary care provider or gastroenterologist may order stool studies to rule out infection and look for parasites and white blood cells.

X-rays , barium studies or CT scans can be helpful and appraising the level of involvement. Findings can include narrowed areas (stricture or stenosis) or fistula formation from organ or organ, or skin.

A colonoscopy will be required to check the appearance of the inflammation in the colon and obtain confirmatory biopsies.

There may be blood markers and measure of inflammation that can be checked. For example a C-reactive protein is a blood marker that corresponds to the overall inflammation in the body (also increases with COVID), and fecal calprotectin levels use the stool to answer the same question. These can be used to monitor for treatment too.

Your gastroenterologist will want to check your colon periodically after a period of years to look for cancer and other lesions. The risk is about 8% after 20 years and 18% after 30 years.

How is Crohn’s Disease treated?

There are several non-pharmacologic treatments:

  • Avoid stress as much as practical. Rest is key.
  • Avoid dairy and milk proteins as these can worsen the diarrhea.
  • Avoid excessive fiber in the diet—these are called low residue diets, and help the gut cope with the inflammation.
  • Avoid other trigger foods particular to you.
  • Smoking can often trigger a Crohn’s flare.
  • Drugs such as steroids can calm down the inflammation but typically the disease reflares when they are stopped . The same is true of antibiotics.
  • Special preparations of aspirin-like drugs, such as mesalamine, can be used to calm inflammation. Because Crohn’s can involve the bowel segmentally, often these aspirin-like medications have to have a special formula to release the medication where it is needed. Pentasa, for example, releases the 5-ASA/mesalamine throughout the GI tract, where as Asacol is designed to release in the colon only.
  • Immunomodulating agents like methotrexate and azothioprine can work like chemotherapy to blunt the immune response to the gut lining, This has to be balanced against the risk of infection and toxicity.
  • Newer agents, such as biologics, include: Infliximab (Remicade), Adalimumab (Humira), Vedolizumab (Entyvio), Ustekinumab (Stelara) and Tofacitinib (Xeljanz) can modify the immune response to the disease.
    • They tend to be more effective and rapid acting than other agents.
    • These also can increase the risk of opportunistic infections and very rarely certain types of cancer (PML, and lymphoma/skin cancers).
    • They can be more expensive than the other agents.
  • About 50-80% of Crohn’s disease patient will require some sort of surgery through their lifetime.
    • Surgery may involve a partial removal of a diseased segment of small bowel, a fistulous tract or segmental removal of the rectum/colon.
    • Bowel resection is usually followed by initiation of immunomodulators or other biologics to prevent early recurrence of disease/complications.
What to do if you suspect you have Crohn’s Disease?

See your local gastroenterologist to help make the diagnosis and get started on a therapy that is right for you. Our goal is give you therapy to result in long-lasting remissions, maintenance of your independence, and a better quality of life while minimizing medication side effects.

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