What is Crohn's disease?

Crohn's disease is a systemic inflammatory disease. It primarily affects the gastrointestinal tract, but in most patients also exhibits a number of extra-intestinal symptoms. In the intestinal tract, Crohn's disease can appear anywhere from the mouth to the anus. Crohn's disease is characterized by a chronic inflammatory response, where immune activity increases in the body, as if in reaction to an infection, but this immune activity does not dampen down again, i.e. the immune stimulus does not go away.

Crohn's affects most people in the prime of life. 60% of Crohn's disease sufferers are under 30 years old. Also, a dramatic rise in the incidence of Crohn's disease in children has been seen in recent years, with up to one-sixth of cases appearing in people under 20 years old. People of middle or old age are less likely to develop Crohn's disease.

Intestinal symptoms.

Intestinal symptoms of Crohn's disease are many, and most of these symptoms are debilitating. People with Crohn's disease usually suffer from a combination of one or more of the following symptoms.

• Intestinal stricturing. Crohn's disease inevitably results in scarring of the intestines. This scarring builds up over time, leading eventually to a narrowing, or stricturing, of the intestine. This stricturing cannot be stopped in most cases of Crohn's disease, and eventually the width of the intestinal passage can become as narrow as one tenth of an inch. Since all food must pass through these strictures, and the area around the strictures is badly inflamed, strictures can be intensely painful. Often, food is unable to pass through such a small gap, and returns back up the intestinal tract to be vomited out.
• Intestinal obstruction. Eventually, stricturing can get so bad that the intestine is too narrow for food to pass through. Small pieces of food get jammed in the blocked area, but the intestine continues to try to push the food through. The intestines are obstructed. The pain of intestinal obstruction is excruciating. Obstruction can be highly dangerous, because it can lead to rupturing of the intestines. When the intestines rupture, the contents of the intestine (food, bacteria) flow out into the abdominal cavity, leading to peritonitis, which can be fatal if not treated immediately.
• Fistulas. A fistula is an abnormal growth of tissue between internal organs. Fistulas can grow between loops of intestine, or between the intestines and any one or more of the bladder, the anus, the vagina, the external skin, etc.
• Ulceration. Ulceration of the lining of the intestine can cause severe pain. If present in the lower GI tract, ulcers can lead to severe loss of blood in faeces. Ulcers can also appear in the mouth.
• Nausea and vomiting. All of the above symptoms can lead to pain and nausea, causing the sufferers alimentary canal to evacuate itself.
• Diarrhea. Many sufferers of Crohn's disease experience chronic diarrhea, which can result in haemorrhoids and rectal pain, inability to stray far from a bathroom, and the acute social embarrassment of "accidents", which may happen at any time (for this reason, many Crohn's sufferers carry spare underwear).

Extra-intestinal symptoms.

As well as the primary intestinal symptoms, there are many secondary inflammatory symptoms of Crohn's disease. Among these are

• Arthritis. Inflammation of the joints resulting from Crohn's disease ranges from mild to severe. In mild cases, chronic joint pain and stiffness are the usual result. In severe cases, destruction of the tissue of joints and connecting bones are the consequence, leading to a severe impairment of mobility and extreme pain. Arthritis in Crohn's disease does not respect age, and children with Crohn's disease are as likely to have arthritis as older patients.
• Uveitis. Uveitis is an inflammation of the muscle in the eye which is responsible for dilation of the pupil. In mild cases, the sufferer experiences pain when moving from darkness to light and vice versa, and an inability to focus the eyes without pain. In severe cases, the tissues of the eye can be permanently damaged.
• Erythema nodosum. This condition is experienced by up to 10% of Crohn's patients, usually manifests itself on the legs. Large angry red welts appear on the legs, and can be extremely painful, as well as being unsightly.
• Stones. Crohn's sufferers have a much higher risk of developing gallstones. Also, Crohn's sufferers have a greatly increased risk of developing oxalate kidney stones, another extemely painful condition perhaps requiring surgery.
• Granulomatous hepatitis. Granulomas(scarring) can also form in the liver, leading to reduced hepatic function.
• Increased risk of colorectal cancer. Sufferers of Crohn's disease have been documented to have a higher likelihood of developing intestinal cancers.

The consequences of Crohn's disease for nutrition.

The nutritional consequences of Crohn's disease are many, and once a Crohn's sufferer begins to experience malnutrition, this further reduces their ability to restore themselves to health.

• Cachexia. Bodily emaciation in Crohn's disease can be severe. Fat and muscle tissue are catabolized by the body in order to fuel the chronic inflammatory response. The eventual result is severe loss of weight and emaciation.
• Vitamin deficiency. Inflammation or surgical removal of the intestines leads to an inability to absorb essential vitamins. The vitamin deficiency most often experienced by Crohn's sufferers is with vitamin B12, normally absorbed in the terminal ileum. The latter is the section of the intestines most often removed surgically. Other vitamins can also be affected, especially fat soluble vitamins.
• Anaemia. If a Crohn's sufferer experiences a deficiency of vitamin B12, the result is anaemia, since vitamin B12 is necessary for absorption of Iron. Anaemia has a wide variety of extremely serious consequences for the body.
• Total Parenteral Nutrition. Crohn's sufferers can be so badly affected by the disease that they are incapable of absorbing sufficient nutrients from their diet. This can, for example, happen after a large number of surgeries, leading to "short bowel syndrome". The only solution in this case is "Enteral Nutrition" (EN), where the sufferer is either fed intravenously through a hole in the chest, or is fed by a tube which goes from the mouth or nose to the stomach. EN is administered for 4 to 5 hours at a time, usually while the sufferer is sleeping. EN is most commonly used with children who suffer from Crohn's disease, since their growing bodies have greater nutritional requirements.
• Physical retardation of children Children who suffer from Crohn's disease have been clearly demonstrated to suffer from both growth retardation and from retardation of sexual maturity, most likely due to severe hormone imbalance. This hormone imbalance can result from malnutrition, or from immunosuppressive treatments administered, or from both.
• Malabsorption of fats. Because of the inability to reabsorb bile salts, Crohn's patients suffer from fat malabsorption, instead passing fat out in their feces. This also increases diarrhea.

Drug treatments for Crohn's disease

There are many drugs used in the treatment of Crohn's disease. All are "maintenance" drugs, i.e. they suppress the symptoms of Crohn's disease, but do not address what causes those symptoms. Most have extremely serious side effects. The most commonly used drugs are

• Steroids. Steroids work by interfering with the inflammatory response, and are used in the control of flares of Crohn's disease. Unfortunately, they also interfere with most everything else in the body, and can cause hypertension, hormone imbalance (e.g. women can grow facial hair when taking steroids), bone loss, severe adrenal impairment, fluid retention, salt loss, extreme mood swings, growth retardation in children, pregnancy abnormalities, etc, etc, etc.
• Azathioprine. This immunosuppressant is used after liver transplant surgery to suppress the immune system so that it does not reject the transplanted organ. It is usually administered to patients who do not respond to high doses of steroids. It works by preventing cloning of the stem cells in the bone marrow, thus interfering with the immune system at a fundamental level. In Crohn's disease, the drug must be administered for several months before it takes effect, and is administered for periods of years. People receiving Azathioprine treatment must undergo weekly or bi-weekly blood checks. Increased susceptibility to serious infection is an inherent risk in the use of Azathioprine.
• Cyclosporine This immunosuppressant is used after heart, liver and kidney transplants to prevent rejection of transplanted organs. Increased susceptibility to serious infection is an inherent risk in the use of Cyclosporine.
• 6-Mercaptopurine (6-MP) This immunosuppressant, related to Azathioprine, is used after organ-transplant surgery to prevent rejection of transplanted organs. It is usually administered to patients who do not respond to high doses of steroids. It works by preventing cloning of the stem cells in the bone marrow, thus interfering with the immune system at a fundamental level. In Crohn's disease, the drug must be administered for several months before it takes effect, and is administered for periods of years. People receiving 6-MP treatment must undergo weekly or bi-weekly blood checks. Observed side effects in patients include pancreatitis, bone marrow depression, allergic reactions, drug hepatitis, neoplasms and lymphoma of the brain. Increased susceptibility to serious infection is an inherent risk in the use of 6-MP.
• 5-aminosalicylic acid (5-ASA) The 5-ASA group of drugs, including mesalazine (Asacol, Pentasa, Salofalk), olsalazine (Dipentum) and sulphasalazine (Salazopyrin), is useful in mild to moderate cases of Crohn's disease, and also useful in lowering the risk of relapse after surgery. Although the mechanism of action of 5-ASA drugs is currently "unknown", it is interesting to note that the 5-ASA drugs are related to 4-ASA, an antibiotic which in the past was used for treatment of Mycobacterium tuberculosis infection. There is currently under way a clinical trial to test the efficacy of 4-ASA for Crohn's disease.
• Metronidazole (Flagyl) This antibiotic is also used for the treatment of Crohn's disease, particularly for the closure of fistulae. Clinical trials have shown that treatment with metronidazole alone closes fistulae in 40% of cases, and reduces discharge in a further 20%. However, long-term treatment with metronidazole can cause neurological side-effects, e.g. tingling or loss of sensation to extremities. See Metronidazole in the treatment of Crohn disease. Results of a controlled randomized prospective study.

Surgical treatment of Crohn's disease

Three quarters (75%) of Crohn's disease patients require surgery at some stage of their lives. Surgery does not cure the disease, and the majority of patients relapse after surgery. Thus surgery for Crohn's disease is only a crisis management technique. Re-occurence of the need for surgery occurs in a high proportion of these patients, because the intestinal scarring which results from reconstructive surgery inevitably leads to further stricturing and obstruction. It is an axiom in the Crohn's community that "surgery only leads to more surgery". 11% of all Crohn's patients require three or more surgeries, inevitably leading to "short bowel syndrome" and lifetime dependency on Enteral Nutrition.

The most common surgical procedures are

• Resection. Resection involves removal of a section of the intestine, because of stricturing, obstruction, ulceration, and other structural damage caused by scarring.
• Fistula closure. Fistulas can become highly dangerous, and require that they be removed and the ends closed off.
• Colectomy. This procedure, most commonly used on sufferers of Crohn's-colitis, involves the surgical removal of the entirety of the colon.
• Ostomies. Frequently, the intestines and/or colon of the sufferer become so diseased that they are incapable of functioning. In these cases, the lower section of the gastrointestinal tract, from the ileum (ileostomy) or the colon (colostomy) to the rectum, is disconnected. The upper half of the intestine is connected to an exit hole (stoma) in the wall of the abdomen. Faeces are then excreted through this hole, and go to a collection bag which hangs against the outside of the abdomen.

Fatalities from Crohn's disease

While treatment of Crohn's disease has improved in recent decades, death from Crohn's disease is still possible. The National Institutes of Health state that there were "fewer than 1,000 deaths" from Inflammatory Bowel Disease (which includes both Crohn's disease and Ulcerative Colitis) in 1987. In the latest epidemiology study from Olmsted county, Minnesota, it was reported that the cause of death of 35% of Crohn's disease patients were related to Crohn's disease. That study says :-

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