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.
Sandborn WJ. Crohn’s disease evaluation and treatment: clinical decision tool. Gastroenterology 2014; 147:702.
Gomollón F, Dignass A, Annese V, et al. 3rd European Evidence-based Consensus on the Diagnosis and Management of Crohn’s Disease 2016: Part 1: Diagnosis and Medical Management. J Crohns Colitis 2017; 11:3.
Mowat C, Cole A, Windsor A, et al. Guidelines for the management of inflammatory bowel disease in adults. Gut 2011; 60:571.
Lichtenstein GR, Loftus EV, Isaacs KL, et al. ACG Clinical Guideline: Management of Crohn’s Disease in Adults. Am J Gastroenterol 2018; 113:481.
Harvey RF, Bradshaw JM. A simple index of Crohn’s-disease activity. Lancet 1980; 1:514.
Vermeire S, Schreiber S, Sandborn WJ, et al. Correlation between the Crohn’s disease activity and Harvey-Bradshaw indices in assessing Crohn’s disease severity. Clin Gastroenterol Hepatol 2010; 8:357.
Koliani-Pace JL, Siegel CA. Beyond disease activity to overall disease severity in inflammatory bowel disease. Lancet Gastroenterol Hepatol 2017; 2:624.
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.
D’Haens G, Baert F, van Assche G, et al. Early combined immunosuppression or conventional management in patients with newly diagnosed Crohn’s disease: an open randomised trial. Lancet 2008; 371:660.
Hanauer SB, Sandborn W, Practice Parameters Committee of the American College of Gastroenterology. Management of Crohn’s disease in adults. Am J Gastroenterol 2001; 96:635.
Ford AC, Bernstein CN, Khan KJ, et al. Glucocorticosteroid therapy in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol 2011; 106:590.
Rutgeerts P, Löfberg R, Malchow H, et al. A comparison of budesonide with prednisolone for active Crohn’s disease. N Engl J Med 1994; 331:842.
Papi C, Luchetti R, Gili L, et al. Budesonide in the treatment of Crohn’s disease: a meta-analysis. Aliment Pharmacol Ther 2000; 14:1419.
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.
Kane SV, Schoenfeld P, Sandborn WJ, et al. The effectiveness of budesonide therapy for Crohn’s disease. Aliment Pharmacol Ther 2002; 16:1509.