Crohn’s Disease – The Healing Space Clinic

Crohn's Disease

BASICS

DESCRIPTION

An idiopathic inflammatory disease of the small intestine (60%), the colon (20%) or both; involving all of the layers of the bowel, but most commonly involving the terminal ileum. It is a slowly progressive and recurrent disease with prominent involvement of multiple regions of the intestine with normal sections in between.

System(s) affected: Gastrointestinal
Genetics: 15% of patients have first-degree relatives with inflammatory bowel disease. Family members develop the disease with similar patterns and similar age of onset.
Incidence/Prevalence in USA:
- More common in Caucasians than African-Americans or Asians
- More common in Jews
- 20-100/100,000 prevalence
Predominant age:
- Most cases 15-25 age of onset
- Second smaller peak in ages 55-65
Predominant sex: Female > Male (slightly)

SIGNS AND SYMPTOMS

All forms of Crohn's
- Diarrhea occurs in most patients
- Abdominal pain in two-thirds
- Weight loss
- Abdominal tenderness often less than expected, in view of symptoms
- Abdominal mass (occasionally)
- Fistula - perirectal, bladder, skin, vagina
- Extraluminal disease (10%) skin, iritis, arthritis, sclerosing cholangitis
Small bowel disease only
- Diarrhea prominent, including nocturnal
- Vague abdominal pain frequent. Only half of patients with abdominal pain have associated tenderness, not relieved with evacuation and often aggravated by food.
- Intestinal obstruction in 1/3. Cramping abdominal pain precedes for months.
- Bleeding in 20%, rarely massive
- Perianal disease, including fistulae
- Internal fistulae
- Arthritis 5%
Colon disease only
- Diarrhea prominent, including nocturnal
- Hematochezia
- Abdominal pain in 1/2, often relieved by stooling
- Perianal disease in 40%, fistulae
- Weight loss prominent
- Megacolon occurs in about 10%
- Arthritis in 20%
- Intestinal obstruction occasional
Colon and small bowel disease
- Intestinal obstruction much more common
- Arthritis 5%

CAUSES

Idiopathic
Aggravated by bacterial infection
Aggravated by inflammatory cascade
Aggravated by smoking cessation

RISK FACTORS

More cigarette smokers than expected

DIAGNOSIS

LABORATORY

Elevated sedimentation rate
Anemia common
Albumin decreased in severe cases
Serum electrolytes imbalance
Specific nutrient deficiency: B12, fat soluble vitamins, folate

Drugs that may alter lab results: Sulfa drugs may lower folate after years of administration
Disorders that may alter lab results: All tests are non-specific, similar degrees of disease from other causes produce similar changes

PATHOLOGICAL FINDINGS

Involvement of all layers of gut wall with inflammation in > 95% cases at least focal areas
Skip areas in 80% (a normal segment between two involved segments)
Granuloma in 15%
Fat hypertrophy following mesenteric vessels in 50% of small bowel disease

SPECIAL TESTS

Colonoscopy is most helpful. The colon is not uniformly involved. The typical lesion is nodular with undermined pus filled mucosal ulcers. Strictures commonly present, occasionally preventing passage of the endoscope. The terminal ileum often has aphthous ulcers and may have nodularity. Small bowel proximal to an anastomosis is a very common site of recurrence.

IMAGING

Barium x-rays - enema and small bowel
- Loss of smooth mucosa, undermined ulcers prominent
- Narrowed lumen in most involved segments of small bowel
- Fistulae from involved segment to other bowel loops, bladder, vagina or external
- Skip areas, multiple lesions common
- Failure to reflux into ileum on barium enema (not specific)
- Ulcers undermining mucosa
- Small bowel ulcerated wall
- Narrowed lumen
- Fistula to other parts of intestine
Plain x-rays
- Intestinal obstruction
- Toxic patient with colon disease, toxic megacolon
- Evaluation of arthritis
- Sacroiliitis
CT Scans
- Define thickening of bowel wall if lumen not narrowed
- Define abscess cavities and fistulae
- Identify extensive perirectal disease

DIAGNOSTIC PROCEDURES

Ileoscopy and enteroscopy
The constellation of barium-identified distribution of lesions, endoscopic findings, and biopsies usually establish the diagnosis
Biopsies of mucosa in involved areas usually compatible with diagnosis, but not diagnostic. Helps rule out other causes.

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient customary, inpatient for complications or special treatments
Progressive disease - average patient requires surgery each 4-7 years

GENERAL MEASURES

Attention to maintaining weight and nutrition
Monitor severe cases for fat malabsorption
Perirectal disease, sitz baths, soap and water after stooling, surgical drainage of perirectal abscesses, surgical treatment of recurrent fistulae if medical management fails
Extracolonic disease (uveitis, arthritis, dermatitis, sclerosing cholangitis) managed as other diseases in that special area
Folate supplements often needed

SURGICAL MEASURES

Indications for surgery:
- Severe recurrent hemorrhage
- Inability to thrive
- Abscess
- Total or recurrent intestinal obstruction
- Toxic megacolon or extensive disease
- Symptomatic fistulae other than rectal
- Failure of ostomy to function after ³1 year

ACTIVITY

Full activity as tolerated

DIET

Usually no restrictions
If fat malabsorption, diminish fat in diet
If strictures or recurrent obstruction, avoid highly fibrous substances
If diarrhea prominent, increase dietary fiber (sometimes recommended), decrease fat

PATIENT EDUCATION

An important part of management. Crohn's and Colitis Foundation of America Inc, 11th floor, Park Ave South, NY 10016, Phone (800)343-3637. Joining local chapters recommended.

FOLLOW UP

PREVENTION/AVOIDANCE

Ongoing care with available physician
Consultant for review; long term advice

POSSIBLE COMPLICATIONS

Progression nearly certain - both expansion of old lesions and new lesions occur
Recurrence after operation nearly certain, usually occurs in gut segment most proximal to anastomoses
Fistulae occur about 15% of patients; perirectal, cutaneous, enterovaginal, enterovesicular are all seen
Extraluminal disease occurs in 10% with skin, uveal tract, joint, and biliary tract disease most common. All fairly specific in pattern; do not parallel activity of the luminal disease.
Extensive colon disease associated with increased risk of adenocarcinoma
Colon perforation and massive bleeding
Toxic megacolon

EXPECTED COURSE AND PROGNOSIS

Average patient has surgery each 7 years; >4 surgeries, expect short-bowel syndrome
Expect disease to recur
Majority will have normal life (work, children, full activities); overall life is shortened

MISCELLANEOUS

ASSOCIATED CONDITIONS

Viral gastroenteritis may be more devastating
Arthritis of two types - similar to rheumatoid and spondylitis
Variety of skin lesions, erythema nodosum, non-specific rashes, pyoderma gangrenosum
Uveal tract disease rare but related
Sclerosing cholangitis in about 10%, manifest from mild liver test abnormalities including pericholangitis on biopsy to full syndrome
Pigment gallstones are increased with ileal disease

AGE-RELATED FACTORS

Pediatric: Rare
Geriatric: N/A
Others: Occurs at any age

PREGNANCY

Reversible male sterility after long time on sulfasalazine - folate defers
No contraindications to pregnancy

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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