Crohn's Disease- Cancer/Oncology, Gastroenterology, Pediatrics

Crohn’s disease, or Crohn’s ileitis, is an inflammatory bowel disease (IBD). This chronic disease can affect any part of the digestive tract, causing inflammation and subsequent irritative symptoms like diarrhea and abdominal pain.

The severity of the disease and symptoms can vary widely from one person to another, and it can even lead to life-threatening complications in some people. There’s still no definitive cure for Crohn’s disease, however, there are several effective treatments available to control the symptoms and maintain a good quality of life. If your GP suspect you have Crohn’s, they will refer you to a gastronetologist.

Symptoms

Crohn’s disease can affect any part of your digestive tract. Depending on the size and location of the inflamed segments, symptoms may defer. The most frequently affected segments of the digestive tract are the colon and the last segment of the small bowel.

Some people might only experience mild symptoms, however, in many others, the disease can become debilitating. People who have Crohn’s disease might not always have symptoms and the symptoms can come and go in waves (flare-ups). They usually start gradually, but can also appear suddenly without any warning.

Crohn’s disease is a systematic disease, which means that it affects the whole body, and not just the digestive system. Therefore, symptoms can be described as either digestive or systematic:

Digestive symptoms

• Abdominal pain
• Diarrhea
• Bloody stools
• Oral ulcers (sores)
• Reduced appetite

Systematic symptoms

• Fever
• Fatigue
• Skin rashes
• Eye inflammation
• Joint pain

You should see a gastroenterologist if you develop alarming symptoms, such as bloody stools, fever, or an unexplained weight loss, or if you have persistent abnormal bowel movements.

Causes

Crohn’s disease is a complicated entity and doctors are still not exactly sure what causes it, but there are some theories. Hereditary and immunological factors are thought to play a role:

• Immune response: Crohn’s disease might be triggered by an immune response to an invading pathogen. An abnormal immune response might take place in at-risk individuals, and the immune system might attack your own bowels while trying to defend itself against the pathogen
• Genetics: If you have a relative who has Crohn’s, then you have a higher risk of having the condition. This has lead doctors to believe that there’s a hereditary component to Crohn’s disease.

Stress was thought previously to be the cause of Crohn’s disease, but now doctors believe that stress exacerbates the symptoms and is not the direct cause itself.

Risk Factors

Doctors have identified a few factors that put you at a higher risk of developing Crohn’s disease:

• Younger age (20-30 years)
• Eastern European (Ashkenazi) Jewish descent
• Family history of Crohn’s
• Smoking
• Using nonsteroidal anti-inflammatory drugs (NSAID)
• Living in a more industrialized country

The fact that people living in industrialized countries or urban areas suggests that the environment and diet might play an important role in the pathogenesis of Crohn’s disease.

Complications

In addition to the typical signs and symptoms of Crohn’s disease listed above, many people who have the condition might develop one or more of the following complications:

• Ulcers: Commonly known as mouth “sores” that appear frequently in the oral cavity, but can, however, occur in any part of your digestive tract.
• Bowel obstruction: The inflammation caused by Crohn’s disease can cause the bowel wall to become thick, which prevents digested food from advancing. This is called bowel obstruction, and it can be a life-threatening complication and might require surgery.
• Fistulas: A fistula is an abnormal connection between your intestines and another part of your body (like your skin). Think of it as a small tube that connects your intestines to your skin. This most frequently happens with the skin around your anus, and the condition is called “perianal fistula”. It appears as a small hole in the skin that can discharge digestive secretions and even fecal material. In some people, the fistula can connect the bowels to other organs like the urinary bladder or vagina, releasing fecal material into them.
• Anal fissure: This is a painful persistent tear in the skin covering your anal orifice.
• Malnutrition: Persistent inflammation of the bowels can sometimes prevent essential nutrients from being fully absorbed, leading to malnutrition. This can subsequently lead to conditions such as anemia due to iron or vitamin B-12 deficiency.
• Colon cancer: If you have Crohn’s disease, you are at a higher risk of developing colorectal cancer.  Regular screening colonoscopy is recommended to catch the disease early on.
• Systematic complications: These include joint inflammation, eye inflammation, anemia, skin rashes, osteoporosis, and diseases of the biliary tract.

Diagnosis

If your gastroenterologist suspects that you might have Crohn’s based on your symptoms, they might order one or more of the following tests to confirm their suspicion and rule out other possible conditions that might be causing your symptoms:

Laboratory tests

• Routine blood work: Your doctor might order some blood tests to assess if you have anemia and check if there’s ongoing inflammation in your body. These tests are not specific for Crohn’s, however, they give our doctor an idea about your general condition.
• Fecal occult blood test: This is a test done on your stool to check if there’s any microscopic blood.

Medical Procedures

• Colonoscopy: This is perhaps the most important test in diagnosing Crohn’s disease. Your gastroenterologist will give you a sedative, and while you lay sedated on your side, they will insert a flexible scope through your anus and push it all the way across the whole length of your colon. The scope resembles a thick cord, and it has a camera at its tip and is connected to a screen. As the doctor goes further along your colon, they check to see any abnormalities on the screen. Biopsies might also be taken from the colon and sent to the lab to confirm Crohn’s disease.
• CT scanning: Computed Tomography (CT) scanning can be used to view your bowels and assess for any abnormalities.
• MRI: Magnetic resonance imaging (MRI) is also used to view the bowels and is especially valuable in assessing fistulas.
• Capsule endoscopy: The large intestine (colon) can be viewed using colonoscopy, however, to view the small intestines, doctors use capsule endoscopy. This is a small capsule that contains a camera. You swallow it, and it takes pictures of your whole digestive system, including the small intestines.

Other procedures, such as balloon-assisted enteroscopy, can be used to further assess the digestive tract if needed, however, they are not routinely performed.

Treatment

Unfortunately, there’s still no definitive cure for Crohn’s disease, however, there are several effective treatments available to control the symptoms and prevent complications:

Anti-inflammatory drugs

Your doctor will usually start by prescribing one of these medications that reduce inflammation:

• Corticosteroids: Steroids, such as prednisone, are very effective in reducing inflammation, however, they are not effective in everyone, and are usually only prescribed for short courses.
• 5-aminosalicylates: Sulfasalazine and mesalamine have been previously used, however, there are superior choices today.

Immunosuppressant drugs

Since the immune system is involved in the pathogenesis of Crohn’s disease, immunosuppressant drugs have been extensively used for treatment:

• Azathioprine and mercaptopurine: These drugs are perhaps the most widely prescribed immunosuppressants to treat Crohn’s. Side effects can include an increased risk of developing infections, inflammation of the liver, nausea, and vomiting. These drugs should be regularly monitored by blood tests that your doctor will order.
• TNF-inhibitors: These include infliximab (Remicade), adalimumab (Humira), and other drugs that inhibit the Tumor Necrosis Factor (TNF), which is a molecule involved in several immunological pathways.
• Methotrexate: Some doctors might prescribe methotrexate as an additional therapy, however, close monitoring of side effects is required
• Anti-integrins: Drugs such as natalizumab (Tysabri) and vedolizumab (Entyvio) work by inhibiting integrins, which are immune molecules involved in inflammation.

Ustekinumab (Stelara): Some evidence suggests that this psoriasis drug can be used to treat Crohn’s in patients who don’t respond to therapy.

Other medications

• Anti-diarrheals: If your disease is causing your recurrent diarrhea, there are several medications that can be used to bulk your stools.
• Pain killers: If you have occasional abdominal pain, your doctor might prescribe some pain medications to control the symptoms.
• Supplements: Depending on your blood work, you might need nutritional supplements, such as Vitamin D, B-12, or iron supplements.
• Antibiotics: If your Crohn’s disease is complicated with a fistula or an abscess, your doctor might prescribe a course of antibiotics to treat it.

Surgery

If treatment fails, and your symptoms become debilitating, your doctor might suggest surgery as a last resort. A surgeon will resect the inflamed part of the bowels that’s causing your symptoms. Surgery is also effective in treating fistulas and abscesses.

Unfortunately, the disease tends to recur after surgery, and you will most likely be required to continue medical treatment as well.

Home remedies

A few simple changes in your diet and lifestyle can usually help you control your symptoms and avoid flare-ups:

• Diet: You should try to avoid dairy products, fatty foods, and trigger foods, such as spices, alcohol, and caffeine. Try eating smaller portions that are lower in fat. Foods that are high in fiber such as cabbage and broccoli may exacerbate your symptoms, so it might be best to limit them in your diet.
• Smoking: If you smoke, you are more likely to have more flare-ups and a worse disease course.
• Stress: There are some strong links between stress and inflammatory bowel diseases. Try relaxation techniques to relieve stress, and maybe reduce your symptoms.

Crohn’s disease is a lifelong illness, yet, people who have it can definitely live a happy productive life. Even though the disease can be debilitating at times, following a proper treatment plan and regularly checking with your gastroenterologist can help reduce flare-ups, and make the disease more bearable.

Sources:

• 10.1136/gutjnl-2011-301971
• bidmc.org/centers-and-departments/digestive-disease-center/services-and-programs/inflammatory-bowel-disease-program/crohnsdiseasefaq
• cdc.gov/ibd/data-statistics.htm
• cdc.gov/ibd/ibd-epidemiology.htm
• ccfa.org/assets/pdfs/updatedibdfactbook.pdf
• crohnsandcolitis.com/crohns
• link.springer.com/chapter/10.1007/978-3-319-23066-5_1
• https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-prognosis-of-crohn-disease-in-adults
• https://www.uptodate.com/contents/overview-of-medical-management-of-high-risk-adult-patients-with-moderate-to-severe-crohn-disease
• https://www.uptodate.com/contents/overview-of-the-medical-management-of-mild-low-risk-crohn-disease-in-adults

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