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Crohn's disease

Also listed as: Inflammatory bowel disease - Crohn's

• Signs and Symptoms
• What Causes It?
• Risk Factors
• What to Expect at Your Provider's Office
• Preventive Care
• Treatment Options
• Other Considerations
• Supporting Research

Crohn's disease is a chronic inflammatory bowel disease that causes ongoing inflammation of the intestinal tract. It is similar to ulcerative colitis, another inflammatory bowel disease. However, while ulcerative colitis usually is confined to the innermost layer of the large intestine and rectum, Crohn's disease can occur anywhere in the intestine, often in patches surrounded by healthy tissue, and can spread deeper into the tissues. Symptoms include chronic bloody or watery diarrhea, abdominal pain, fever, and loss of appetite. Symptoms tend to wax and wane, with the disease becoming active or going into remission several times during the person's lifetime.

Crohn's disease can cause intestinal obstructions, ulcers (most often in the lower part of the small intestine, the large intestine, or the rectum), fistulas (hollow passages from one part of the intestine to another), and anal fissures (a crack in the anus or the skin around the anus that can lead to infection). In addition, people with Crohn's disease are at risk of malnutrition, because their intestine cannot absorb all the needed nutrients from their diet.

Crohn's disease affects 2 - 7 out of 100,000 people and researchers believe that these numbers are growing. It develops mostly between the ages of 15 - 40, although children and older adults may also develop the condition. There is no cure for Crohn's disease. Medication and strict diets can help control the condition. Some people with the condition will require surgery to remove part of the digestive tract at some point in their lives. However, surgery does not cure the disease.

Signs and Symptoms

The most common signs and symptoms of Crohn's disease are diarrhea and abdominal pain. The symptoms can range from mild to severe.

• Diarrhea (with or without blood)
• Abdominal pain and bloating
• Fatigue
• Poor appetite
• Weight loss
• Fever
• Nausea and vomiting
• Floating stools (which is caused by poor digestion of fat)

Crohn's disease can also be associated with other medical conditions, including arthritis, osteoporosis, eye infections, blood clots, liver disease, and skin rashes.

What Causes It?

No one is sure what causes Crohn's disease. Theories include a faulty immune system response triggered by bacteria or a virus; genetics, since about a quarter of people who have Crohn's disease also have a close relative with the disease; and a diet high in saturated fat and processed foods, since Crohn's disease is more common in the developed world. It is likely that several factors may be involved in the disease.

Risk Factors

• Jewish heritage (three to six times more likely than the general population)
• European (particularly Scandinavian) ancestry
• Family history of inflammatory bowel disease
• Cigarette smoking
• Living in an industrialized country (particularly an urban area)
• Diet high in sugar and saturated fat and low in fruit and vegetables

What to Expect at Your Provider's Office

Your doctor will perform a thorough physical exam as well as a series of tests to diagnose Crohn's disease. Blood tests may reveal anemia (due to a significant loss of blood) and a high white blood cell count (a sign of inflammation somewhere in the body). Stool samples may indicate whether there is bleeding or infection in the colon or rectum.

The following procedures may be also helpful in distinguishing between ulcerative colitis, Crohn's disease, and other inflammatory conditions.

• Colonoscopy -- A colonoscopy, in which a long, flexible, lighted tube with a camera is used to take pictures of the colon, can reveal any inflammation, bleeding, or ulcers along the entire colon wall. This procedure usually requires sedation. A sigmoidoscopy is similar but is used to examine the rectum and lower part of your colon. It can be done without sedation, but may miss inflammation higher in the colon or the small intestine.
• Capsule endoscopy -- In this test, you swallow a small capsule with a camera in it, and the camera takes pictures as it passes through the length of your digestive tract. The capsule then passes out of the body through your stool. The test is generally safe, but if there is an intestinal obstruction the capsule may become trapped. Your doctor will run other tests to make sure you do not have an obstruction before using this procedure.
• Barium enema -- This procedure examines the large intestine with an x-ray. It involves being given barium (a dye) as an enema, which coats the lining of your large intestine and rectum. It is generally not as reliable a test as colonoscopy.
• CT scans -- This imaging technique allows your doctor to look at the entire intestine and can help locate intestinal obstructions or fistulas.

Preventive Care

Although there is no known way to prevent Crohn's disease, the condition can usually be managed with a combination of medication, diet, and lifestyle changes. Exercise can help prevent the stress and depression that often accompany Crohn's disease, and quitting smoking can reduce symptoms. Eating a diet rich in fruit and vegetables can also help lessen symptoms.

Treatment Options

The primary goal in treating Crohn's disease is to control acute flares of the disease and to maintain remission for as long as possible. The specific type of treatment often depends on how severe the symptoms are. For example, people with mild-to-moderate symptoms are usually treated with medications that reduce swelling and suppress the immune system. More severe cases may require surgery.

Many people with inflammatory bowel diseases use complementary and alternative remedies in addition to prescription medications. Preliminary studies indicate that lifestyle changes, dietary adjustments (such as eating a rich variety of fruits and vegetables and avoiding saturated fat and sugar), and specific herbs and supplements may be useful additions to treatment.

Lifestyle

Stress

Many people with Crohn's disease report that stress makes their symptoms worse. Relaxation techniques and mind-body exercises, such as yoga, tai chi, and meditation, are worth considering, particularly when used in addition to other forms of treatment. In addition, studies suggest that hypnosis may improve immune function, increase relaxation, decrease stress, and ease feelings of anxiety.

Exercise

Exercise is helpful for those with Crohn's disease, both in terms of maintaining health and reducing stress. Although exercise is considered safe for people with Crohn's disease, anyone with a chronic illness should talk to their doctor before starting a new exercise or fitness regimen. It is especially important for people with Crohn's disease to drink water before exercising and during exercise to prevent dehydration. Extreme changes in body temperature during exercise should also be avoided.

Smoking

Cigarette smoking is a risk factor for Crohn's disease and studies have shown that it may worsen symptoms. If you smoke, you should quit.

Drug Therapies

Although medications cannot cure Crohn's disease, they can reduce symptoms and help you control your condition. Sometimes, they can induce remission of the disease for a period of time. Medications commonly used to treat Crohn's disease include:

• Sulfasalazine (Azulfidine) -- An older drug that reduces inflammation during acute flare-ups and is usually taken with folic acid. Side effects include abdominal discomfort, nausea, and lowered sperm count. Sulfasalazine can be effective, but newer drugs are available.
• Mesalamine (Asacol, Rowasa) -- This drug reduces inflammation during acute flare-ups and helps prevent recurrences, and generally has fewer side effects that sulfasalazine.
• Corticosteroids (such as budesonide, prednisone, and prednisolone) -- These drugs can reduce inflammation throughout your body but have many side effects, including acne, and an increased risk of infection, osteoporosis, high blood pressure, excessive hair growth, diabetes, and disorders of the eye including glaucoma and cataracts. Corticosteroids also suppress your body's production of the hormone cortisol and cannot be stopped abruptly. They are not for long-term use, but may be used to control flares.
• Immune system suppressors -- These medications decrease inflammation by suppressing the immune system. They are sometimes used in combination with steroids to reduce the dose of the steroid medication. These drugs can take several months to work, and all may have significant side effects. Drugs include azathioprine (Imuran), methotrexate (Rheumatrex), infliximab (Remicade), and cyclosporine. Newer drugs in this class that have fewer side effects, such as adalimumab (Humira), are being tested.
• Antibiotics -- Antibiotics may be prescribed to help treat fistulas and ulcers. Ciproflaxin (Cipro) and metronidazole (Flagyl) are most commonly used.
• Antidiarrheal medications (such as diphenoxylate, loperamide, or psyllium) -- Medications used to treat diarrhea must be used only under medical supervision and with extreme caution. They can slow down the normal movements of the gastrointestinal tract and, in severe cases, may cause a complication known as toxic megacolon.

Surgical Procedures

Although surgery will not cure Crohn's disease, three out of four people with the condition will eventually have resections (parts of their colons removed) to close fistulas or to remove a severely damaged part of your intestine. In some cases laparoscopic surgery (which uses a smaller incision) can be done, leading to fewer complications and shorter hospital stays. Strictureplasty, in which a balloon is inserted into the intestine and expanded, is sometimes done when the intestine has become too narrow from scar tissue.

Complementary and Alternative Therapies

People with Crohn's disease often cannot absorb all the nutrients their bodies need, due to damage in the intestine, or they find it difficult to eat because of abdominal pain and nausea. Some medications may also lower needed nutrients in the body. For example, sulfasalazine reduces the body's ability to absorb folate while corticosteroids can reduce levels of calcium. Making sure that you get enough nutrients is a crucial part of treating Crohn's disease. People with significant malnourishment, severe symptoms, or those awaiting surgery may require parenteral (intravenous) nutrition.

Nutrition

Although diet cannot cause or cure Crohn's disease, some studies suggest that people who eat foods high in saturated fat and sugar or who eat processed foods may be more likely to develop the disease. Certain foods may also reduce symptoms and make recurrences of the disease less likely.

• Eating fruits and vegetables, lowering fat, and eliminating sugar may reduce the risk of developing Crohn's disease. Although a low-fiber diet is one of the risk factors for developing Crohn's disease, some people with Crohn's disease find that fiber makes symptoms worse. If fiber bothers you, steam or bake your vegetables rather than eating them raw, and avoid high fiber fruits such as apples.
• Certain foods may aggravate symptoms of Crohn's disease – most often, dairy products, fats, and spicy foods. People with Crohn's disease may want to avoid these foods.
• Eat five or six small meals a day.
• If symptoms are severe, an elemental diet may be recommended. Elemental formulas are liquid diets that contain only the basic building blocks of food and need not be broken down into smaller substances along the digestive tract. Some people find it difficult to stick to an elemental diet, but after a period of time, often other foods can be reintroduced. One study suggests that adding omega-3 fatty acids to an elemental diet may boost its nutritional content and make it more likely that people with Crohn's disease will adhere to it.

Vitamins and Minerals

Because of decreased appetite, malabsorption, chronic diarrhea, side effects of medication, and surgical removal of parts of the digestive tract, many people with Crohn's disease have vitamin and mineral deficiencies. In particular, people with Crohn's disease may lack adequate vitamin D, B12, and K, plus folic acid, calcium, and zinc. Your doctor may recommend that you take a multivitamin daily.

Zinc (25 mg), folic acid (800 mcg), vitamin B12 (800 mcg) -- These vitamins are used by the body to repair cells in the intestine. In addition, drugs such as sulfasalazine and methotrexate may case levels of folic acid in the body to drop, requiring supplementation.

Vitamin D (1,000 IU per day) -- is necessary to maintain strong bones. People with Crohn's disease, especially those who take corticosteroids, often have low levels of vitamin D and are at risk for osteoporosis.

Fish oil (2.7 g per day) -- Omega-3 fatty acids found in fish oil may help fight inflammation and reduce the chances of recurrence, but studies have been mixed. The study with the most positive results used a special type of fish oil – "enteric-coated free-fatty-acid form" – that is not sold commercially. Some researchers suggest that measuring the blood levels of different types of fatty acids may help determine if fish oil would be useful. Do not take high doses of a fish oil supplement if you take blood-thinning medication.

Saccharomyces boulardi (250 mg three times per day to 500 mg four times per day) -- One small study indicated that this type of "good" bacteria helped people with Crohn's disease reduce the incidence of diarrhea. However, other studies have shown mixed results.

N-acetyl glucosamine -- Preliminary research suggests that N-acetyl glucosamine supplements or enemas may improve symptoms of inflammatory bowel disease, but more studies are needed to know whether glucosamine would have any effect on Crohn's disease.

Glutamine (400 mg four times per day) -- is an amino acid found in the body that that helps the intestine function properly. While there is no evidence that glutamine specifically helps reduce symptoms of Crohn's disease, it may be beneficial for overall intestinal health. Glutamine is best taken on an empty stomach. Do not take glutamine is you are diabetic or have seizures.

Herbs

Because of the presence of inflammation and the nature of the disease, Crohn's disease should not be treated with herbs alone. However, herbs may be a useful complement to traditional medical treatment. Remember that herbs can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, herbs should be taken with care, under the supervision of a health care provider.

The evidence for using herbs to treat Crohn's disease is mostly lacking. Among the herbs that have been used traditionally to treat inflammation within the digestive tract are:

• Slippery elm ( Ulmus fulva) is a demulcent (protects irritated tissues and promotes their healing). Take 60 -320 mg per day. One tsp. powder may be mixed with water and drunk three to four times a day.
• Marshmallow (Althaea officinalis) is a demulcent and emollient; drink one cup of tea three times per day. To make tea, steep 2 - 5 g of dried leaf or 5 g dried root in one cup boiling water. Strain and cool. Avoid marshmallow if you have diabetes.
• Cat's claw ( Uncaria tomentosa , 250 mg per day) is an anti-inflammatory.
• Boswellia ( Boswellia serrata , 1,200 mg three times per day for up to 8 weeks) has anti-inflammatory properties, and a few small studies suggest that it may be effective in treating Crohn's disease. However, more research is needed to be sure. Bsowellia may interact with other drugs and supplements, so talk to your doctor before taking it.

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of Crohn's disease symptoms (such as diarrhea) based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

• Mercurius -- for foul-smelling diarrhea that may have streaks of blood accompanied by a sensation of incomplete emptying. This remedy is most appropriate for individuals who tend to feel exhausted following bowel movements, experience fluctuations in body temperature, perspire frequently, and have a thirst for cold fluids.
• Podophyllum -- for explosive, gushing, painless diarrhea that worsens after eating or drinking. Exhaustion often follows bowel movements, and the individuals for whom this remedy is appropriate may experience painful cramps in the lower legs and feet.
• Veratrum album -- for profuse, watery diarrhea accompanied by stomach cramps, bloated abdomen, vomiting, exhaustion, and chills. The diarrhea tends to worsen as a result of eating fruit. The individual for whom this therapy is appropriate tends to crave cold liquids.

Acupuncture

Acupuncture has long been used in Traditional Chinese Medicine to treat inflammatory bowel disease. One study in Germany found that acupuncture and moxibustion were effective specifically for treating Crohn's disease. Acupuncturists treat people with inflammatory bowel disease based on an individualized assessment of the excesses and deficiencies of qi located in various meridians. Moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points) is used because its effect is thought to reach deeper into the body than using needles alone.

Other Considerations

Pregnancy

Women who are in remission at the time of conception generally have normal pregnancies and healthy babies. However, women with active disease are more prone to miscarriages, spontaneous abortions, and stillbirths. Symptoms often get worse during pregnancy. For this reason, women with active Crohn's disease who are or wish to become pregnant should continue medications under the guidance of their doctor. Corticosteroids or sulfasalazine are considered relatively safe during this time.

Pregnant women should avoid high doses of vitamins. An obstetrician can provide instructions regarding taking multivitamins during pregnancy. The herbs cat's claw ( Uncaria tomentosa ) and turmeric ( Curcuma longa ) are not recommended during pregnancy or breastfeeding.

Prognosis and Complications

A number of complications can develop from Crohn's disease. Many can be successfully treated.

• Narrowing of the colon, which may cause obstruction
• Perforation of the colon
• Abscesses (pus-filled pockets of infection) in the colon
• Toxic megacolon (grossly swollen colon that may rupture)
• Fistulas (abnormal hollow passages that lead from one part of the intestine to another, or to other organs)
• Infection of the blood (sepsis)
• Colon cancer
• Nutritional problems (including weight loss and reduced muscle mass)
• Joint pain and arthritis
• Osteoporosis (bone loss)
• Gallstones
• Eye infections/inflammation
• Mouth ulcers, gum inflammation, and dental cavities
• Liver damage
• Blood clots
• Depression and anxiety
• Anemia

Although there is no cure for Crohn's disease, many people with the disease lead active lives by controlling their symptoms with medication. Over time, however, Crohn's disease is less responsive to treatment. Within 10 years of diagnosis, 71% of people will need surgical removal of the affected intestine, and many experience at least one relapse in any 10-year period.

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• Review Date: 3/18/2007
• Reviewed By: Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

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