Crohn's Disease

Crohn's disease is an inflammatory bowel disease (IBD). It is an illness marked by a chronic inflammation in the bowel, most commonly in the ileum (a part of the small intestine) and colon (the large intestine), but it also affects other parts of the gastrointestinal tract.

Crohn's disease can occur at any age, but most people with the disease are diagnosed before the age of 30, as teens or young adults. It is a chronic disease that returns over and over again with varying periods of remission (freedom from symptoms) between bouts of the disease. There is no cure.

The immune system of people with Crohn's disease treats food, bacteria, and other materials in the intestine as foreign or invading substances and launches an attack, sending T cells - white blood cells that coordinate the body's immune responses - into the lining of the intestines, where they produce chronic inflammation. The cells, in turn, create harmful products that lead to ulcerations and bowel injury. All layers of the bowel may be involved; sometimes there is normal healthy bowel in between patches of diseased bowel. Since the beleaguered digestive tract can't absorb food properly, those with the disease often lose weight and lack energy.

Symptoms

The typical signs of Crohn's disease range from mild to severe, but they usually include abdominal pains or cramps, and chronic diarrhea. Some sufferers have to make 15 to 20 trips to the bathroom a day. The course of the disease varies from person to person; some people have only a few episodes of Crohn's, some live with it constantly recurring.

Other classic symptoms are:

• bloating and gas;
• nausea and vomiting;
• loss of appetite;
• weight loss ;
• blood in stool.

More subtle symptoms may also appear, sometimes preceding the classic ones by months or years. These include:

• episodes of prolonged and unexplained fever;
• joint pain;
• eye pain;
• mouth ulcers;
• skin rashes.

Causes

What causes Crohn's disease is not clearly understood. A virus or bacterium may be involved in the initial stages and there may be a genetic connection, since it is an autoimmune disease (where the body attacks its own tissues) and such disease typically run in families. Also, about a quarter of those who have the disease have relatives who also have an IBD.

Diagnosis

Your doctor may take samples of stool, blood, and tissue, and order a battery of tests including an X-ray (with or without barium) and/or a colonoscopy (to examine the lining of the gastrointestinal tract).

Crohn's disease is not always easy to diagnose. About 10 percent of colitis cases are unable to be pinpointed as either Crohn's or ulcerative colitis (another IBD), and so are called indeterminate colitis.

Treatment

Because the cause of Crohn's disease is still unknown, treatment is directed at curbing the symptoms and preventing complications.

A variety of medications are used to help reduce the inflammation that triggers the symptoms. Some drugs work well for some people, but not others. It may take time to get the right combination for you, and since certain drugs have serious side effects, you'll need to weigh the benefits and risks for any treatment program.

Doctors use several categories of drugs that can help control the symptoms in different ways, including:

• anti-inflammatory medications (e.g., Asacol®, Pentasa®, Salofalk®); can be taken orally and rectally;
• corticosteroids (e.g., prednisone, budesonide); to reduce swelling and tissue damage; generally used only in moderate to severe cases that don't respond to other treatments;
• immune modifiers (e.g., azathioprine, methotrexate); also used to manage other immune diseases;
• antibiotics (e.g., Cipro®); to prevent and treat infected wounds in the bowels.
• biological response modifier such as infliximab (e.g., Remicade®); given intravenously to people with more severe symptoms and relapses, only effective for about 2/3 of patients. It works by blocking a chemical in the body know as tumour-necrosis factor (TNF), a substance that in excess leads to inflammation.

Promising new therapies are currently being explored, but are not yet available. More research is needed.

Additional medications

To help relieve your symptoms, your doctor may also recommend the following types of medications::

• antidiarrheals: such as Metamucil® as a fibre supplement or Imodium® for more severe diarrhea.;
• pain relievers : acetaminophen (e.g., Tylenol®). Do not use nonsteroidal anti-inflammatory drugs (NSAIDs) such as Aspirin®, Advil®, Motrin®, or Aleve®, which are likely to make your symptoms worse.
• iron supplements: Iron deficiency anemia can result from chronic intestinal bleeding. Supplements may help restore your iron levels to normal.
• B-12 injections: Depending on the area of your intestine that is affected and what kind of surgery you may have had, lifelong B-12 injections may be recommended.

Don't hesitate to discuss any treatment program with your doctor or pharmacist, who will help clarify what's involved and explain the effects - and possible side effects - of the recommended medications.

When surgery is required...

If the disease doesn't respond to treatment or if bowel obstruction, abscesses, or fistulas develop, surgery may be recommended to remove a diseased part of the gastrointestinal tract or to close fistulas or remove scar tissue. Surgery may provide years of remission.

Complications

Complications from Crohn's disease range from arthritis and skin problems to bowel obstruction, malnutrition, and the development of abscesses and fistulas (sores that tunnel through from the GI tract to some other organ or the skin surface). Sometimes patients become anemic (from lack of blood iron from blood loss). Other complications arise from the medications: Corticosteroids, for example, when used for a long period, can cause weight gain, eye problems (cataracts or glaucoma), and calcium loss from the bones.

If you are diagnosed with Crohn's disease, make sure you are monitored by your health provider to keep track of any developments. Typically, regular bone density scans are recommended to track the condition of your bones and periodic eye testing (by an ophthalmologist) is advised to catch possible eye problems resulting from the disease or the medications.

In addition, since people with Crohn's disease have a higher risk of intestinal cancer, it's important to be screened on a regular basis. Your doctor will tell you how often. Fortunately, this type of cancer is easily treatable if spotted in the early stages.

Living with Crohn's

If you are one of the 35,000 Canadians who have been diagnosed with Crohn's disease, you can rest assured that there are people around who will help you deal with it. Once your doctor has established a treatment program, your pharmacist will help you sort out your medications.

Keep in mind that there are therapies available that may significantly reduce your signs and symptoms and even bring about a long-term remission. For many people, it's a matter of living from day to day and trying to keep a positive attitude. Most have to learn to live with a fair amount of discomfort and an awareness that the disease comes and goes.

Here are some tips that may help you to cope:

• Information: Keep informed about the disease and the development of potential therapies. Besides your doctor and your pharmacist, other sources of information include books, the Internet, and your local support group for Crohn's disease. Research is constantly changing the face of treatment.
• Diet: Consult a registered dietician to establish a healthy meal plan. Some people find that they can lessen their symptoms by eliminating certain foods, such as fatty foods, spicy foods, and milk products that seem to make symptoms worse. Eating a diet that is high in protein but low in fibre may also help, as may eating frequent small meals (5 or 6 a day), drinking lots of water, and taking multivitamin and mineral supplements.
• Exercise: Regular (preferably daily) exercise will help normalize your bowel function and reduce your risk of becoming depressed.
• Stress: Stress can be a positive element in your life when it involves facing and overcoming challenges and not letting your condition get the better of you. If, however, you feel that stress is worsening your symptoms (or at least your perception of them), talk to your doctor about referrals to stress management classes, a psychologist, or social services. Yoga, meditation, biofeedback, progressive relaxation exercises, and hypnosis have also been used to great or lesser effect. The choice is up to you.

Although living with Crohn's disease can be overwhelming at times, try to keep in mind that therapies have significantly improved in the last few years and that the outlook is getting brighter all the time.

For more information or for support :

Crohn's and Colitis Foundation of Canada (CCFC)

www.crohnsandcolitis.ca