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Crohn's Disease is a chronic inflammatory disease. Crohn's Disease is an ongoing disorder that causes inflammation of the digestive tract, which is also referred to as the gastrointestinal tract. It can affect any area of the GI tract, from the mouth to the anus, but it most commonly affects the lower part of the small intestine, which is called the ileum. The swelling extends deep into the lining of the affected organ. The inflammation can cause extreme pain and can also make the intestines empty, therefore resulting in diarrhea. Once the disease begins, it tends to fluctuate between the periods of inactivity and activity. “It is named after the physician who described the disease in 1932, and is also called granulomatous entiritis, colitis, regional enteritis, ileitis, or terminal ileitis” (Chiodini, Page 58).
Since Crohn's disease was first encountered, it has been theorized that the disease is caused by an infection with a mycobacterium. A mycobacterium is known as a genus of aerobic, nonmotile bacteria that contain gram-positive rods and include both parasitic and saprophytic species. The mycobacterium also contains the bacterium that causes tuberculosis and leprosy. “Medical historians suggest that Crohn's Disease may first have been described as early as 1682 to 1771, or even earlier. Reports of diseases suggestive of Crohn's Disease have appeared in many years including 1806, 1813, 1828, 1875, 1907, 1908, 1909, and 1913” (Chiodini, Page 60). Whether these cases actually were Crohn's Disease or not still remain unknown. Mycobacteria were not discovered until 1874 when a man named Gerhard Armauer Hansen described acid-fast bacilli in leprosy patients. The organism that caused tuberculosis was not discovered until 1882 and intestinal tuberculosis was not recognized until several years later. This organism that was found to cause tuberculosis was found also to be confused with Crohn's disease a number of years after the discovery. Nevertheless, a disease was evidently described in the early 1900s which was similar to intestinal tuberculosis. In 1913 Dr. Kennedy Dalziel dealt with several patients with a disease called chronic intestinal enteritis. Chronic intestinal enteritis is found to be very similar to intestinal tuberculosis and was also believed to be a “new” disorder. Dr. Dalziel drew his attention to a recently described disease in cattle called pseudotuberculosis. Dalziel states, “the histological characters and naked-eye appearances are as similar as may be to those we have found in man. In many cases the absence of acid-fast bacilli would suggest a clear distinction, but the histological characters are so similar as to justify a proposition that the disease may be the same.”
Contrary to Dalziel's view, in 1913 a man named Ignard wrote, “In many cases of hyperplastic tuberculosis of the intestine, no tubercles, giant cells, or bacilli, are found. The lesion consists of a mixture of variable proportions of tuberculous and inflammatory elements. In certain cases, the last only exists. Nevertheless, these inflammatory tumors should be classified among the tuberculous.” Ignard's view unmistakably outweighed that of Dalziel, and these “unusual intestinal diseases” became known as hyperplastic tuberculosis.
By the 1920s, the belief that intestinal tuberculosis occurred without acid-fast bacilli or caseous necrosis was slowly fading away. Therefore, a disease known as “nonspecific granulomata” had emerged. Three men named Crohn, Ginzberg, and Oppenheimer recognized regional ileitis as a separate and distinctive disease unit and displaced the belief of a mycobacterial etiology. “Professionals today do know now that hypertrophic intestinal tuberculosis and tuberculosis without caseation or demonstrable acid-fast bacilli actually do exist” (Chiodini, Page 62). These bacilli were found to be existent in a distinct disease that is known as Crohn's disease. Therefore, over the years, the notion has been recurred that Crohn's Disease might actually have some sort of mycobacterial in its origin.
Crohn's Disease usually begins in the late teens and twenties; however, in rare cases, it can develop rather early in childhood. Several theories exist about what causes Crohn's Disease, yet, none have been proven. The most popular theory is that the body's immune system, which is made from cells and various proteins that protect people from infection, reacts abnormally in people with Crohn's Disease, mistaking bacteria, foods, and other substances for being foreign to the body. The immune system's response is to attack these so called “invaders” and get rid of them as quickly as possible. During this process, white blood cells accumulate in the lining of the intestines, producing chronic inflammation, which leads to ulcerations and bowel injury.
Scientists do not know if this abnormality in the functioning of the immune system in people with Crohn's Disease is a cause or a result of the disease. Research shows that the inflammation seen in the GI tract of people with Crohn's disease involves several factors: the genes in which the patient has inherited, the immune system itself, and the environment. Foreign substances, also referred to as antigens, are found in the environment, which makes it extremely harmful to live in such an environment. One possible cause for inflammation may as well be the body's reaction to these antigens, or the antigens themselves as the cause for this inflammation. Some scientists think that a protein produced by the immune system, called the anti-tumor necrosis factor, may be another possible cause for the inflammation linked to Crohn's Disease. Although diet may have an affect on the symptoms in patients with Crohn's Disease, it is unlikely that diet is responsible for the disease. Crohn's disease, nevertheless, is certainly not contagious.
In the early stages, Crohn's Disease causes small, scattered, shallow, crater-like areas on the inner surface of the bowel. “These erosions are called aphthous ulcers. Eventually, the erosions become deeper and larger, and soon become true ulcers that cause scarring and stiffness of the bowel” (Gomez, Page 28). As the disease progresses, the bowel becomes increasingly narrowed. Deep ulcers can puncture holes in the walls of the bowel, and bacteria from within the bowel can spread to infect nearby organs and the surrounding abdominal space.
When Crohn's Disease narrows the small intestine to the point of obstruction, it stops the flow of the contents through the intestine. Sometimes, the obstruction can be caused immediately by poorly-digestible fruits or vegetables that block the already-narrowed segment of the intestine. When the intestine is obstructed, digested food, fluid and gas from the stomach and the small intestine, cannot pass into the colon.
Deep ulcers can puncture actual holes into the walls of the small intestine and the colon, and create a tunnel between the intestine and the adjacent organs of the body. “If the ulcer tunnel reaches a neighboring empty space inside the abdominal cavity, a collection of infected pus, or an abdominal sore, is then formed. Patients with abdominal sores can develop tender abdominal masses, high fevers, and abdominal pain. When the ulcer tunnels into a nearby organ, a channel, or fistula, is formed” (Gomez, Page 34). The formation of a channel between the intestine and the bladder can cause frequent urinary tract infections and can also cause difficulty in the passage of gas and feces during urination. If a canal forms between the intestine and the skin, pus and mucous emerge from a small painful opening on the skin of the stomach. The development of a channel between the colon and the vagina causes gas and feces to emerge through the vagina. The existence of a channel from the intestines to the anus leads to a discharge of mucous and pus from the channel's opening around the anus.
Crohn's Disease can also cause complications. Complications of Crohn's Disease may be related or unrelated to the inflammation within the intestine. “Intestinal complications of Crohn's Disease include obstruction and teat of the small intestine, abscesses, or collections of pus, fistulae, also called channels, and intestinal bleeding” (Gomez, Page 38). Massive distention or dilatation of the colon, and rupture or perforation of the intestine is potentially life-threatening complications. Both generally require surgery, but fortunately, these two complications are rare. Recent data suggests that there is an increased risk of cancer of the small intestine and colon in patients with long-standing Crohn's Disease. Nutritional complications are common in Crohn's Disease. Deficiencies of proteins, calories, and vitamins are well documented. These deficiencies may be caused by inadequate dietary intake, intestinal loss of protein, or poor absorption. Other complications associated with Crohn's Disease include arthritis, skin problems, inflammation in the eyes or mouth, kidney stones, gallstones, as well as other diseases of the liver and biliary system.
The range and severity of symptoms of Crohn's Disease varies. The symptoms can be very obvious, or on the other hand, very subtle. The most common types of symptoms of Crohn's Disease are abdominal pain, which is often in the lower right area, as well as diarrhea. Rectal bleeding, weight loss, arthritis, skin problems, and severe fever may also occur. Bleeding may be serious and persistent, which can then lead to anemia. Children with Crohn's Disease may suffer delayed development and stunted growth. The range and severity of symptoms varies. The symptoms of Crohn's Disease are dependent on the location, the extent, and the severity of the inflammation. The different subtypes of Crohn's Disease have different symptoms.
Crohn's Disease is known to be a chronic low-grade inflammation of the terminal ileum. “Approximately 70% to 80% of patients who have Crohn's Disease require surgical resection of the diseased intestine” (Trachter, Page 60). However, the difficulties that are caused by the disease usually are not ended by surgical involvement. Most patients will suffer recurrences, which require further surgical procedures. It is quite common that patients who are living with this constant chronic pain are in and out of hospitals all throughout their lives. Studies show that there is an approximate 6% chance of death resulting from Crohn's Disease, which is substantially low considering what is really involved in some of the treatment of the disease. Twenty-five years after the original description, Crohn and Yarnis wrote, "From this small beginning we have witnessed the evolution of a Frankenstein monster that, if not threatening to life, frequently results in serious illness, often prolonged and debilitating” (Chiodini, Page 61).
Crohn's Disease can be diagnosed in a few different ways. A thorough physical exam and a series of tests may be required to diagnose Crohn's Disease. Blood tests may be done to check for anemia, which could indicate bleeding in the intestines. Blood tests may also uncover a high white blood cell count, which is a sign of inflammation somewhere in the body. By testing what is known as a tool sample, the doctor is able to tell if there is bleeding or infection in the intestines.
The doctor may do an upper GI series, which allows him to look more closely at the small intestine. For this test, the person drinks barium, which is 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 an inflammation or any other abnormalities in the intestine. If these tests show Crohn's Disease, more x-rays of both the upper and lower digestive tracts may be necessary to see how much of the GI tract is affected by the disease.
The doctor may also do a visual exam of the colon by performing either a sigmoidoscopy or a colonoscopy. For both of these tests, the doctor inserts a long, flexible, lighted tube linked to a computer and TV monitor into the anus. A sigmoidoscopy allows the doctor to examine the lining of the lower part of the large intestine, while a colonoscopy allows the doctor to examine the lining of the entire intestine. The doctor will be able to see any inflammation or bleeding during either of these exams. However, a colonoscopy is usually a better test because the doctor can see the entire large intestine, which is extremely beneficial. The doctor may also do a biopsy, which involves taking a sample of tissue from the lining of the intestine to view with a microscope.
Most recently, video capsule endoscopy has been added to the list of diagnostic tests for diagnosing Crohn's Disease. For video capsule endoscopy, a capsule containing a miniature video camera is swallowed. As the capsule travels through the small intestine, it sends video images of the lining of the small intestine to a receiver carried on a belt at the waist. The images are downloaded and then reviewed on a computer. The value of video capsule endoscopy is that it can identify the early, mild, abnormalities of Crohn's Disease.
The symptoms and severity of Crohn's vary among the patients. Patients with mild or no symptoms may not need treatment at all. “Patients with Crohn's Disease will typically experience periods of relapse, or worsening of inflammation, followed by periods of remission, or reduced inflammation, that can last up to months or even years” (Gomez, Page 63). 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 treatment has helped or not. Predicting when a remission may occur or when symptoms will return is simply impossible.
Treatment may include drugs, nutrition supplements, surgery, or a combination of these options. The goals of treatment are to control inflammation, correct nutritional deficiencies, and relieve symptoms including abdominal pain, diarrhea, and rectal bleeding. At this time, treatment can help control the disease by lowering the number of times a person experiences a recurrence; however, there is no cure. Treatment for Crohn's Disease depends on the location and severity of the disease, certain complications, and the person's response to previous medical treatments when treated for reoccurring symptoms.
Most people are first treated with drugs containing mesalamine, which is a substance that helps control inflammation. Sulfasalazine is the most commonly used of these drugs. Patients who do not benefit from sulfasalazine or who cannot tolerate it may be put on other mesalamine-containing drugs that are generally known as 5-ASA agents. Such 5-ASA agents are known as Asacol, Dipentum, or Pentasa. Cortisone drugs and steroids, which are called corticosteroids, provide very effective results; however, these drugs can have serious affects. The dosage is therefore lowered once the symptoms are controlled. Drugs that suppress the immune system are also used to treat Crohn's Disease. “The most commonly prescribed drugs that are used today are 6-mercaptopurine or a related drug called azathioprine. Immunosuppressive agents work by blocking the immune reaction that contributes to inflammation. Remicade may, in addition, help people with Crohn's Disease” (Gomez, Page 65). “Antibiotics are used to treat bacterial overgrowth in the small intestine that is caused by stricture, fistulas, or prior surgery. For this common problem, the doctor can prescribe one or more of the following antibiotics: ampicillin, sulfonamide, cephalosporin, tetracycline, or metronidazole” (Chiodini, Page 55).
Surgery is of course another main treatment that can be used to its advantage, but can also be used to its disadvantage. Surgery is used whether to relieve symptoms that do not respond to medical therapy, or to correct implications such as blockage, perforation, abscess, or excessive bleeding in the intestine. Surgery in order to remove part of the intestine can help people with Crohn's Disease; however, it is not a cure. Surgery does not eliminate the disease, and it is not uncommon for people with Crohn's Disease to have more than one serious operation as inflammation tends to return to the area next to where the diseased intestine was removed. Because Crohn's Disease often recurs after surgery, people considering another surgery should carefully weigh its benefits and risks and compare it with other treatments that can be used in place of surgery because it is true that surgery may not be appropriate for everyone. People faced with this great decision should get as much information as possible from their doctors or nurses who work with colon surgery patients and other patients as well. This is a very serious decision that must be made for the safety and comfort of the patient with the disease.
The doctor may also recommend nutritional supplements. Nutritional supplements are especially useful for children whose growth has been slowed down due to the disease. Special high-calorie liquid formulas are sometimes used for this purpose. A small number of patients may need to be fed intravenously for a brief time through a small tube that is inserted into the vein of the arm. This procedure can help patients in many ways because it helps those who need extra nutrition temporarily, those whose intestines need to rest, and those whose intestines cannot absorb enough nutrition from food as well. There are no known foods that actually cause Crohn's Disease; however, when people are suffering from the disease, foods such as bulky grains, hot spices, alcohol, and milk products may increase symptoms including diarrhea and cramping.
“Crohn's Disease occurs with its highest prevalence throughout the United States, the United Kingdom, and Scandinavia. The disease is less frequent, however, in Central Europe and is rarely reported in Africa, Asia, and South America. This is due to the fact that disease is hardly ever reported in underdeveloped countries” (Chiodini, Page 60). “Throughout the United States of America, the rate is somewhere between 3.1 to 13.5 per 100,000 population, and is between 0.3 to 7.3 in other countries where the disease is reported” (Chiodini, Pages 35-36). Many reports are disagreeing, but the number of people diagnosed with Crohn's Disease in the United States and in other countries as well has been increasing rapidly over the years. Studies show that generally, the prevalence of disease appears to have somewhat alleviated in most countries. However, tuberculosis as well as leprosy occurs the most in certain areas where Crohn's Disease is rarely seen and the diseases are with low frequency where Crohn's Disease is most frequent.
The National Institute of Diabetes and Digestive and Kidney Diseases conduct and support research into many kinds of digestive disorders including Crohn's Disease. Several clinical trials are currently evaluating the efficacy and safety of different therapies for the treatment of Crohn's disease.
“Although Crohn's disease was first described as a segmental disease of the small intestine in 1960, it was soon recognized that this same disorder affected the colon and has been confused with ulcerative colitis. Recently, the lesions of Crohn's disease have been recognized in all of the following: the mouth, larynx, esophagus, stomach, skin, muscle, synovial tissue, and bone” (Chiodini, Page 39). “Crohn's disease can be considered a newly recognized disease because it contains a clinical and pathological description that dates back only to the 1960s. Although the terms Crohn's disease, Crohn's colitis, Crohn's ileitis, and regional ileitis have been around for quite a while, there is great uncertainty as to the accuracy of these diagnoses prior to 1960” (Gomez, Page 40). To this date, Crohn's disease and ulcerative colitis continue to be confused clinically and the term inflammatory bowel disease (IBD) was developed to comprise both diseases. Therefore, it is clear that discoveries about this disease are still being experimented and tested, and new information is arising from day to day. Although Crohn's Disease continues to be researched, it is known that it is a serious disease, and even though it does not work out in all cases, it should be treated and taken care of as quickly as possible.
Chiodini, R. J. (1989) Crohn's disease and the mycobacterioses: a review and comparison of two disease entitie.
Saibil, F. (2003) Crohn's disease and everything you need to know (your personal health).
Trachter, A. B. and Wodnicki, H. (2001) Coping with Crohn's disease: manage your physical symptoms and overcome the emotional challenges.
Gomez, J. (2000) Positive options for Crohn's disease: self-help and treatment.