Crohn's Disease

This article discusses the definition, possible causes, symptoms, diagnosis, complications and treatment of Crohn's Disease, as well as the emotional impact it has on patients. Includes endoscopic photos and video.
• Article added January 18, 2004

Topics Discussed in This Article •  What is Crohn's Disease? •  Complications of Crohn's •  What Causes Crohn's? •  What is the Treatment? •  What are the Symptoms? •  Emotional Factors •  How is Crohn's Diagnosed? •  Sources and Credits

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For other well-written, easy-to-understand articles about Crohn's Disease, read the Crohn's and Colitis Foundation of America's article entitled  Introduction to Crohn's Disease    and Health Talk's article entitled  Crohn's Disease Basics

What is Crohn's Disease?

The disease is named after Dr. Burrill Crohn. In 1932, Dr. Crohn and two colleagues, Dr. Leon Ginzburg and Dr. Gordon Oppenheimer, published a landmark paper describing the features of what is known today as Crohn's disease.

Crohn's disease causes inflammation in the small intestine. It usually occurs in the lower part of the small intestine, called the ileum, but it can affect any part of the digestive tract, from the mouth to the anus. The inflammation extends deep into the lining of the affected organ. The inflammation can cause pain and can make the intestines empty frequently, resulting in diarrhea.

Crohn's disease is an inflammatory bowel disease (IBD), the general name for diseases that cause inflammation in the intes- tines. Crohn's disease can be difficult to diagnose because its symptoms are similar to other intestinal disorders such as irritable bowel syndrome (IBS) and another type of IBD called ulcerative colitis. Ulcerative colitis causes inflammation and ulcers in the top layer of the lining of the large intestine.

Anyone can develop Crohn's disease. It affects men and women almost equally, and children can develop the disease as well. About 20 percent of Crohn's disease patients have a close family member with an inflammatory bowel disease.  [Top]

What Causes Crohn's Disease?

Theories about what causes Crohn's disease abound, but none has been proven. The most popular theory is that the body's immune system reacts to a virus or a bacterium by causing ongoing inflammation in the intestine. People with Crohn's dis- ease tend to have abnormalities of the immune system, but doctors do not know whether these abnormalities are a cause or result of the disease. It is known, however, that Crohn's disease is not caused by emotional distress.

What are the Symptoms?

The most common symptoms of Crohn's disease are abdominal pain, often in the lower right area, and diarrhea. Rectal bleeding, weight loss, and fever may also occur. Bleeding may be serious and persistent, leading to anemia. Children with Crohn's disease may suffer delayed development and stunted growth.  [Top]

How is Crohn's Disease Diagnosed?

A thorough physical exam and a series of tests is be required to diagnose Crohn's disease.

Blood tests may be done to check for anemia, which could indi- cate bleeding in the intestines. Blood tests may also uncover a high white blood cell count, which is a sign of inflammation some- where in the body. By testing a stool sample, the doctor can tell if there is bleeding or infection in the intestines.

The doctor may do an upper gastrointestinal (GI) series to look at the small intestine. For this test, the patient drinks barium, a chalky solution that coats the lining of the small intestine, before x-rays are taken. The barium shows up white on x-ray film, revealing inflammation or other abnormalities in the intestine.

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The doctor may also do a colonoscopy. For this test, the doctor inserts an endoscope – a long, flexible, lighted tube linked to a computer and TV monitor – into the anus to see the inside of the large intestine. The doctor will be able to see any inflammation or bleeding. During the exam, the doctor may do a biopsy, which involves taking a sample of tissue from the lining of the intestine to view with a microscope.

If these tests show Crohn's disease, more x-rays of both the upper and lower digestive tract may be necessary to see how much is affected by the disease.  [Top]

In order to view the video, you must have a media player installed on your computer. The media players most often used are:

Endoscopy  video courtesy of  Gastrolab • The Gastrointestinal Site    Gastrolab is a medical research centre in Vasa, Finland dedicated to endoscopic examinations of the digestive canal. The centre was founded in 1983. Videos are used with permission.

View an endoscopy video of Crohn's in the sigmoid colon.

What Are the Complications of Crohn's Disease?

The most common complication is blockage of the intestine. Blockage occurs because the disease tends to thicken the intes- tinal wall with swelling and scar tissue, narrowing the passage. Crohn's disease may also cause sores, or ulcers, that tunnel through the affected area into surrounding tissues such as the bladder, vagina, or skin. The areas around the anus and rectum are often involved. The tunnels, called fistulas, are a common complication and often become infected. Sometimes fistulas can be treated with medicine, but in some cases they require surgery.

Nutritional complications are common in Crohn's disease. Deficiencies of proteins, calories, and vitamins are well docu- mented in Crohn's disease. These deficiencies may be caused by inadequate dietary intake, intestinal loss of protein, or poor absorption (malabsorption).

What is the Treatment?

Treatment for Crohn's disease depends on the location and severity of disease, complications, and response to previous treatment. The goals of treatment are to control inflammation, correct nutritional deficiencies, and relieve symptoms like abdo- minal pain, diarrhea, and rectal bleeding. Treatment may include drugs, nutrition supplements, surgery, or a combination of these options. At this time, treatment can help control the disease, but there is no cure.

Some people have long periods of remission, sometimes years, when they are free of symptoms. However, the disease usually recurs at various times over a person's lifetime. This changing pattern of the disease means one cannot always tell when a treat- ment has helped. Predicting when a remission may occur or when symptoms will return is not possible.  [Top]

Drug Therapy

Most people are first treated with drugs containing mesalamine, a substance that helps control inflammation. Sulfasalazine is the most commonly used of these drugs. Patients who do not benefit from it or who cannot tolerate it may be put on other mesalamine-containing drugs, generally known as 5-ASA agents, such as Asacol, Dipentum, or Pentasa. Possible side effects of mesala- mine preparations include nausea, vomiting, heartburn, diarrhea, and headache.

Some patients take corticosteroids to control inflammation. These drugs are the most effective for active Crohn's disease, but they can cause serious side effects, including greater susceptibility to infection.

Drugs that suppress the immune system are also used to treat Crohn's disease. Most commonly prescribed are 6-mercapto- purine and a related drug, azathioprine. Immunosuppressive agents work by blocking the immune reaction that contributes to inflammation. These drugs may cause side effects like nausea, vomiting, and diarrhea and may lower a person's resistance to infection. When patients are treated with a combination of cortico- steroids and immunosuppressive drugs, the dose of cortico- steriods can eventually be lowered. Some studies suggest that immunosuppressive drugs may enhance the effectiveness of corticosteroids.

Antibiotics are used to treat bacterial overgrowth in the small intestine caused by stricture, fistulas, or prior surgery. For this common problem, the doctor may prescribe one or more of the following antibiotics: ampicillin, sulfonamide, cephalosporin, tetracycline, or metronidazole.

Diarrhea and crampy abdominal pain are often relieved when the inflammation subsides, but additional medication may also be necessary. Several antidiarrheal agents could be used, including diphenoxylate, loperamide, and codeine. Patients who are dehy- drated because of diarrhea will be treated with fluids and electrolytes.  [Top]

Nutrition Supplementation

The doctor may recommend nutritional supplements, especially for children whose growth has been slowed. Special high-calorie liquid formulas are sometimes used for this purpose. A small number of patients may need periods of feeding by vein. This can help patients who need extra nutrition temporarily, those whose intestines need to rest, or those whose intestines cannot absorb enough nutrition from food.

Surgery

Surgery to remove part of the intestine can help Crohn's disease but cannot cure it. The inflammation tends to return next to the area of intestine that has been removed. Many Crohn's disease patients require surgery, either to relieve symptoms that do not respond to medical therapy or to correct complications such as blockage, perforation, abscess, or bleeding in the intestine.

Some people who have Crohn's disease in the large intestine need to have their entire colon removed in an operation called a colectomy, which results in an ileostomy. A small opening is made in the front of the abdominal wall, and the tip of the ileum is brought to the skin's surface. This opening, called a stoma, is where waste exits the body. The stoma is about the size of a quarter and is usually located in the right lower part of the abdo- men near the beltline. A pouch is worn over the opening to collect waste, and the patient empties the pouch as needed. The majority of colectomy patients go on to live normal, active lives.

Sometimes only the diseased section of intestine is removed and no stoma is needed. In this operation, the intestine is cut above and below the diseased area and reconnected.

Because Crohn's disease often recurs after surgery, people considering it should carefully weigh its benefits and risks com- pared with other treatments. Surgery may not be appropriate for everyone. People faced with this decision should get as much information as possible from doctors, ETs (enterostomal therapists), and other patients.

People with Crohn's disease may feel well and be free of symp- toms for substantial spans of time when their disease is not active. Despite the need to take medication for long periods of time and occasional hospitalizations, most people with Crohn's disease are able to hold jobs, raise families, and function successfully at home and in society.  [Top]

Emotional Factors and Coping With Crohn's Disease

Because body and mind are so closely interrelated, emotional stress can influence the course of Crohn's disease or, for that matter, any other chronic illness. Although people occasionally experience emotional problems before a flare-up of their disease, this does not imply that emotional stress causes the illness. There is no evidence to show that stress, anxiety, or tension is responsible for Crohn's disease. No single personality type is more prone to develop Crohn's than others, and no one "brings on" the disease by poor emotional control.

It is much more likely that the emotional distress that patients sometimes feel is a reaction to the symptoms of the disease itself. It is not surprising that some patients find it difficult to cope with a chronic illness. Such illnesses seem to pose a threat to their their entire qual- ity of life – their physical and emotional well-being, social functioning, and sense of self-esteem. Although formal psychotherapy is generally not neces- sary, some patients are helped considerably by speaking with a therapist who is knowledgeable about IBD or about chronic ill- ness in general. And one can never underestimate the positive effects of an understanding support group.

Coping techniques for dealing with Crohn's disease may take many forms. Attacks of diarrhea, pain, or gas may make people fearful of being in public places. In such a situation, some practical advance planning may help alleviate this fear. For instance, find out where the restrooms are in restaurants, shop- ping areas, theaters, and on public transportation ahead of time. Some people find it helps to carry along extra underclothing or toilet paper for particularly long trips. When venturing further afoot, always consult with your physician. Travel plans should include a large enough supply of your medication, its generic name in case you run out or lose it, and the name of physicians in the area you may be visiting.

People with Crohn's disease accept the diagnosis with a wide range of emotions. Some people are angry for a time. Others feel a sense of relief at finally knowing what it is that has made them ill. While it certainly may help to come to terms with Crohn's in a straightforward manner, since this approach may maximize your ability to be part of your health care team right from the start, every- one is different. Each person with the disease must adjust to living with Crohn's in his or her own way. There should be no guilt, no self-reproaches, or blame placed on others as one comes to grips with the illness. There are resources and information avail- able, such as local support groups and IBD education seminars. No one with Crohn's should ever feel alone. If you are a Crohn's patient reading this article, as you go about your daily life as norm- ally as possible, try pursuing some of the same actvities that you did before your diagnosis. Some days, you may not feel up to it. Other days, you will want to give it all you've got. Only you can decide what's right for you. It will help to follow your physician's instructions and maintain a positive outlook, and to take an active role in your care. That's the basic (and best) prescription.

While Crohn's is a serious chronic disease with many complica- tions, it is not considered a fatal illness. Most people with the illness may continue to lead useful and productive lives, even though they may be hospitalized from time to time, or need to take medications. In between flare-ups of the disease, many individ- uals feel well and may be relatively free of symptoms. But again, everyone is different, and it is up to the patient and physician to find the treatment that works best.

Sources and Credits

The National Digestive Diseases Information Clearinghouse   (NDDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health (NIH) under the U.S. Department of Health and Human Services. Established in 1980, the Clearing- house provides information about digestive diseases to people with digestive disorders and to their families, health care profes- sionals, and the public. NDDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about digestive diseases. Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts.

This text is not copyrighted. The Clearinghouse encourages users to duplicate and distribute as many copies as desired.
NIH Publication No. 03-3410     January 2003

Emotional Factors section of this article is reprinted from the
   Crohn's & Colitis Foundation of America web site.

Endoscopic photos courtesy of Jackson Gastroenterology  web site     Endoscopy Images Section

For other well-written, easy-to-understand articles about Crohn's Disease, read the Crohn's and Colitis Foundation of America's article entitled  Introduction to Crohn's Disease    and Health Talk's article entitled  Crohn's Disease Basics

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