Crohn’s Diagnosis and Treatment.
Crohn’s disease (CD) is a disorder of uncertain etiology that is characterized by inflammation of the gastrointestinal tract and may involve the entire gastrointestinal tract from the mouth to the anal region. Approximately 80 percent of patients will have small intestinal involvement, usually in the distal or terminal ileum, the last portion of small intestine before reaching the colon.
About 50 percent of patients will have ileocolitis, which refers to involvement of both the ileum (small intestine) and colon (large intestine). Only about 20 percent have disease limited to the colon. About 1/3 of patients will have peri-anal involvement. Only 5 to 15 percent have predominant involvement of the mouth or gastroduodenal area, while even fewer patients have involvement of the esophagus and upper small bowel.
Gastrointestinal patients can have symptoms for many years prior to diagnosis. Fatigue, prolonged diarrhea with abdominal pain, weight loss, fever, with or without gross rectal bleeding are the hallmarks of the disease.
Fistulas are tracts or communications that connect two organs. Common sites for fistulas connect the intestine to urinary bladder (enterovesical), to skin (enterocutaneous), to bowel (enteroenteric), and to the vagina (enterovaginal). The clinical manifestation of the fistula depends upon the area of involvement.
Peri-anal disease can be a manifestation including perianal pain, drainage from large skin folds, anal fissures (cuts), perirectal abscesses, and anorectal fistulas.
Severe oral involvement may present with ulcers or pain in the mouth and gums. Esophageal involvement may present with discomfort when swallowing. Gallstones may form as abnormalities in bile metabolism may predispose to gallstones.
Gastroduodenal CD, seen in up to 15 percent of patients, may present with upper abdominal pain, nausea, and/or vomiting after eating. This may be similar symptoms to those of gastric ulcer disease.
Fatigue is a common feature of CD. Weight loss is often related to decreased oral intake since patients with obstructing segments of bowel feel better when they do not eat. Weight loss may also be related to malabsorption.
Extra-Intestinal Manifestations (affecting organs other then intestines). Examples include, arthritis and joint pains, eye problems, skin disorders, kidney problems, clotting disorders, B12 Vitamin deficiency, Osteoporosis and even lung involvement.
Early symptoms of CD are mild and nonspecific. Other possible diagnoses may include irritable bowel syndrome (IBS), lactose intolerance, infectious colitis, and ulcerative colitis.
A consistent history of right lower quadrant pain, prolonged diarrhea, bleeding, fever, and family history of inflammatory bowel disease IBD and abnormal laboratory tests (anemia, iron deficiency, B12 deficiency) may lead one to suspect Crohn’s disease.
The diagnosis of Crohn’s disease (CD) is usually established with endoscopic findings or imaging studies in a patient with a compatible clinical history. Lab studies and stool testing are also important. A colonoscopy can be performed with the objective to get into the terminal ileum for biopsies (this is the last portion of small intestine commonly involved). An upper endoscopy can be performed to evaluate other symptoms.
Imaging with CT scans and/or special MRI scanning in addition to x-rays taken when swallowing contrast can help identify intestinal involvement (inflammation, strictures or narrowing or abnormal communications/fistulas, mentioned earlier. Wireless camera pills (capsule endoscopy) that you swallow also may play a role.
The typical course of the disease is intermittent exacerbation of symptoms followed by periods of remission.
Approximately 10 to 20 percent of patients experience a prolonged remission after initial presentation. One study found that 53 percent of patients developed stricturing or penetrating disease at 10 years follow-up. Predictors of a severe course include age less than 40, the presence of perianal or rectal disease, smoking and initial requirement for steroids.
The American College of Gastroenterology has found up to 80 percent of patients require hospitalization during the course of their disease. For most patients, symptoms are chronic and intermittent, while a smaller subset of patients have either a continuous course of active disease or experience prolonged remission.
Many patients with CD ultimately require surgical intervention with intestinal resection because of intractability of symptoms, obstruction, or perforation. The five-year rate of symptomatic, post-operative recurrence is approximately 50 percent.
Step-up therapy typically starts with less potent medications that are often associated with fewer side effects. More potent and potentially more toxic medications are used only if the initial therapies have failed.
Top-down therapy starts with more potent therapies, such as biologic therapy and/or immunomodulator therapy, relatively early in the course of the disease before patients become prednisone or steroid dependent.
Decision on treatment is based on disease involvement and severity and a combined decision making with the patient and provider.
The treatment goal for patients with Crohn disease is to achieve remission (endoscopic, histologic, and clinical remission) by demonstrating complete mucosal healing.
Available data do not support clinical effectiveness of probiotic therapy for either initial treatment or maintenance therapy.
Patients may have an increased frequency of acquired lactose intolerance. If lactose intolerance is suspected, we suggest an empiric trial of lactose avoidance.
Routine health maintenance, including screening and prevention of other diseases as well as monitoring for side effects of therapy in patients with inflammatory bowel disease is required.
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Siegel CA, Horton H, Siegel LS, et al. A validated web-based tool to display individualised Crohn’s disease predicted outcomes based on clinical, serologic and genetic variables. Aliment Pharmacol Ther 2016; 43:262.
Tremaine WJ, Hanauer SB, Katz S, et al. Budesonide CIR capsules (once or twice daily divided-dose) in active Crohn’s disease: a randomized placebo-controlled study in the United States. Am J Gastroenterol 2002; 97:1748.