Crohn’s Disease

Crohn’s Disease

What is Crohn’s disease?

Crohn’s disease, which is also known as Crohn disease, is an inflammatory bowel (IBD) disease. It is chronic and causes breaks in the intestinal lining known as ulcerations. The small and large intestines are predominately affected, but the entire digestive system (gastrointestinal tract (GI)) from the mouth to the anus can also be impacted.

Crohn’s disease is named after the physician, Dr Burrill Bernard Crohn, who initially described the condition in 1932. It is also known as colitis, terminal ileitis, regional enteritis, ileitis or granulomatous enteritis.

Crohn’s disease is closely related to a different inflammatory condition involving only the colon and not the entire digestive tract, this condition is known as ulcerative colitis. These conditions are known as inflammatory bowel diseases, both of which have no cure. A number of people tend to confuse the two conditions although they are not the same thing. Both of the diseases will, however, fluctuate between remission (inactivity) and relapse (activity).

Crohn’s disease results in the digestive tract becoming inflamed, this typically leads to fatigue, severe diarrhoea, malnutrition and weight loss. The inflammation that is caused by the disease will spread into the layers of tissue that are affected and inflamed. This is often extremely painful and can be debilitating for the sufferer. Crohn’s disease can be life-threatening.

As stated, there is no cure for Crohn’s disease, however, there are a number of therapies that are able to significantly reduce its symptoms and in some cases, result in long-term remission. A number of patients who suffer from the condition are able to live healthy and normal lives.

More research into Crohn’s disease is needed as researchers are still unsure as to how the disease begins, who is more at risk of developing it and what the best method of treatment is. There have, however, been some major breakthroughs in the treatment of Crohn’s recently thanks to advances in technology.  

Human digestive system

What is the difference between Crohn’s disease and ulcerative colitis?

Crohn’s disease and ulcerative colitis

These two conditions are two different kinds of IBD (inflammatory bowel disease). They have very similar characteristics and as such, are often confused with one another. However, they are separate diseases and affect different areas of one’s digestive tract.

The following are some characteristics that Crohn’s disease and ulcerative colitis have in common:

  • The initial symptoms and signs of both of the conditions seem to be extremely similar. These include:
    • Abdominal pain
    • Diarrhoea
    • Rectal bleeding
    • Fatigue
    • Fever
    • Cramping
  • Both of the conditions tend to occur in people who are between the ages of 15 and 35 years old and have a family member has suffered from one of the diseases (i.e. a family history of the disease).
  • The conditions both affect women and men equally.
  • Despite years of research, researchers are still unsure as to what causes either of the diseases. In both diseases, it appears that an overactive immune system is a contributing cause, however, there are a number of other factors that have key roles to play.

The differences between the two conditions are as follows:

Crohn’s disease

  • The inflammation may form anywhere in the gastrointestinal (digestive) tract, ranging from the mouth to the rectum.
  • Tends to affect the final section of the small intestine (known as the ileum).
  • Can form in patches
  • May extend throughout the entire depth of the bowel wall
  • Roughly 67% of people who have the condition and are in remission will suffer from at least one relapse in the following five years.

Ulcerative colitis (UC)

  • Limited to only the rectum and colon (large intestine)
  • Tends to appear in a pattern that is continuous
  • The inflammation will occur in the innermost intestinal lining
  • Roughly 30% of those who have been diagnosed with the condition and are in remission suffer from a relapse within the following year

What is the difference between IBD and IBS?

It is vital that you do not confuse IBD (inflammatory bowel disease) with IBS (irritable bowel syndrome). IBS is not a chronic disease, whereas IBD is. IBS affects the bowel via muscle contractions whereas IBD affects the bowel through intestinal inflammation. IBS does not result in ulcers or damage to the bowel, it is a far less severe condition and is also known as spastic bowel or spastic colon. IBD on the other hand results in chronic swelling of the digestive tract. Both the conditions, can, however, result in rectal bleeding, fatigue, constipation or the need to urgently have a bowel movement.

What are the symptoms of Crohn’s disease?

Some of those who suffer from Crohn's disease only have the last section of their small intestine, known as the ileum, affected. In other people, the disease is typically confined to their colon, this is part of the large intestine. The areas that are most commonly affected by the disease are the colon and the last section of the small intestine (ileum).

The symptoms of Crohn's disease tend to vary and can range between mild and severe. The symptoms seem to develop gradually, however, in some cases they can suddenly appear with little or no warning. The patient may also go into periods of remission where they will experience very few (if any) symptoms followed by periods where they will suffer from a relapse as the symptoms tend to re-emerge.

When Crohn’s disease is in a period of relapse and is active, then the signs and symptoms may include:

  • Diarrhoea – This is a common issue for a number of people suffering from Crohn’s disease. Intestinal cramping cause by the condition can often contribute to diarrhoea.
  • Fatigue and fever – Low-grade fever is often caused by the infection and inflammation associated with Crohn’s, this often results in the patients feeling tired and as though their energy is depleted.
  • Abdominal cramping and pain – Ulceration (the formation of ulcers) and inflammation can often affect the natural movement of the digestive contents through the digestive tract. This often results in cramping and pain. The patient’s pain may vary from being slightly uncomfortable to more severe, with more severe periods of pain often being accompanied by vomiting and nausea.
  • Blood in stool – Dark blood in stools or bright red stools is sometimes seen in those suffering from Crohn’s disease. There may also be faecal occult blood present, this is blood that is present in the stool but is not visible.  
  • Mouth sores – Those with Crohn’s disease tend to experience pain from ulcers in the mouth that can be similar to those of canker sores (small and shallow sores in the mouth that can make eating and talking painful).
  • Reduced appetite and weight loss – Cramping and abdominal pain, as well as inflammation can result in the sufferer’s appetite being affected as their ability to digest food can also be impacted.
  • Perianal disease – Drainage and pain near the anus is also experienced as a result of abscesses, inflammation and infection developing between the anus and the surrounding skin, this is known as an anal fistula.

Crohn's symptoms

Other symptoms and signs

People who have a more severe case of Crohn’s disease may also suffer from:

  • Inflammation of the bile ducts and liver
  • Inflammation of the eyes, skin and joints
  • Delayed sexual development or growth (in children)

When to see a doctor

If someone suffers from persistent changes in their bowel movements or if they experience any of the below symptoms and signs associated with Crohn's disease, then they should make an appointment to see their doctor.

These symptoms include:

  • Blood in stool
  • Abdominal pain
  • Bouts of diarrhoea that are ongoing and nonresponsive to over-the-counter treatments
  • Weight loss that is unexplained
  • A fever for more than two days that is unexplained

What is the cause of Crohn’s disease?

The cause of the disease is still unknown. It was previously thought that stress and diet were the culprits for Crohn's disease, however, doctors have recently found that these are aggravating factors but do not cause the disease. There are several factors that have a role to play such as immune system malfunction or heredity factors. The following contributing factors may play vital roles in the development of the condition:

  • Immune system – Researchers believe that a bacterium or virus may be able to trigger Crohn's disease. When one’s immune system is trying to fight against an attacker or invading microorganism, this may result in an abnormal immune system response that may cause the immune system to fight off or attack cells in the gastrointestinal tract as well.
  • Heredity - Crohn's disease tends to appear more in those who have had a family member diagnosed with the condition. This suggests that genes may have a role to play in increasing one’s risk of developing the condition. However, many patients with the condition do not have a family member who has it.
  • Environmental factors – This ties in with a bacterium or virus that one’s body is exposed to that may trigger an abnormal immune system response.

Although the exact cause of the condition is still unknown, what doctors do know is that Crohn’s disease is an ongoing and chronic condition that affects the gastrointestinal (GI) / digestive tract. It can develop anywhere between the anus and the mouth and the symptoms often vary depending on the area of the digestive tract that has been affected. Symptoms can also develop in areas that do not have any relation to the digestive tract, such as the skin, eyes and joints. The condition is not contagious in any way and is not the result of something eaten or digested.

Doctors have hypothesised that the biggest culprit could be antigens. Antigens are foreign substances in one’s environment that may cause the inflammation as a result of the body’s defence system. This inflammation may then continue without the body being able to control it. Therefore, Crohn's disease is the result of an overactive response of the immune system. The inflammation of the intestines, becoming swollen, red and painful, is the direct result of this response. Thus, this inflammation causes damages to the digestive tract which in turn results in the symptoms of Crohn's disease.

What are the risk factors for Crohn’s disease?

The below is a list of risk factors associated with Crohn's disease:

  • Age – The condition is able to occur at any age, however, younger people seem to be more susceptible to the disease. The majority of people will develop Crohn’s disease when they are younger than 30 years old.
  • Cigarette smoking – Smoking is one of the only risk factors that can be controlled. Smoking cigarettes also leads to a number of different diseases and conditions.
  • Ethnicity – The disease is able to affect anyone regardless of their ethnic group, however, Caucasians from Eastern Europe with Jewish descent seem to have a higher risk of developing Crohn's disease, the reason for this is still unknown.
  • Family history – If someone has a sibling or parent with the condition, then their risk may be increased. One in five people with Crohn's disease has a close relative with the condition.  
  • Location – Living in an industrialised or urban area may increase one’s risks of developing the condition. This theory is based on the fact that various environmental factors such as diet, may have a significant role to play in the development of Crohn's disease. Those who live in the more northern climates have also been seen to have a higher risk.  
  • Nonsteroidal anti-inflammatory medications –  Naproxen sodium (Anaprox, Aleve), ibuprofen (Advil, Motrin IB), diclofenac sodium (Solaraze, Voltaren), as well as a number of other medications have been known to lead to bowel inflammation and make Crohn's disease progress, although these medications are not a cause of the condition.

What are the complications of Crohn’s disease?

The following complications can be a direct result of Crohn’s disease:

  • Inflammation – Inflammation is often confined to the lining of the bowel (bowel wall), this can lead to the narrowing of the bowel wall, known as stenosis, or scarring. The inflammation is also able to spread through the intestinal lining, this is known as an intestinal fistula (more on this below).
  • Bowel obstruction – The thickness of the of the bowel wall can be affected by Crohn's disease. Over time, the parts of the intestine can narrow and thicken, which may result in the flow of the digestive content being blocked. This may require surgery in order to remove the infected area of the bowel.
  • Ulcers – As a result of the chronic inflammation ulcers (open sores) are able to form anywhere in the digestive tract, this may include the anus and mouth as well as the person’s genital area, between the anus and scrotum or vulva, known as the perineum.
  • Fistulas – In some cases, the ulcers are able to extend through the bowel (intestinal) wall entirely. This creates something known as a fistula which is an abnormal linking between the different parts of the body. Fistulas are able to develop between the intestine and the skin or between the intestine and an adjacent organ. A fistula forming near the anal area, known as a perianal fistula, is often the most common type of fistula associated with Crohn's disease. If a fistula develops in the patient’s abdomen, then the food digested may bypass the areas of the bowl that are needed to absorb the food. Fistulas can occur between the bladder or vagina and the loops of one’s bowel, or even through a person’s skin (as mentioned), this results in the continuous drainage of the bowel contents to the skin. In some patients, the fistulas may become infected and form a confined little pocket of pus that will collect in the tissue infected, this is known as an abscess. An abscess, if left untreated, can be life-threatening when it is in the bowels.  
  • Anal fissure – An anal fissure is a tiny tear in the lining of the anus or skin tissue around the anus. It is often found where Crohn’s disease infections occur. These often cause bowel movements that are extremely painful and can even result in an infected tunnel between the anus and the skin, known as a perianal fistula.
  • Malnutrition – Abdominal pain, cramping and diarrhoea can often make it hard for the patient to eat or for their intestine to be able to absorb the nutrients needed for nourishment. Anaemia is also a common complication associated with Crohn’s disease as a result of the low levels of iron or vitamin B-12 being absorbed.
  • Colon cancer – If Crohn’s disease affects the colon, then the person’s risk of developing colon cancer is increased. The extent of the damage done from the infection and inflammation associated with the disease will influence the level of one’s risk. Cancer can develop from the changes in the colon that form from the inflammation, as well as the presence of excluded or bypassed segments as previously mentioned.
  • Other health issues – A number of other health problems may develop as a result of Crohn’s disease in other areas of one’s body. Some of these issues include:
    • Liver or gallbladder disease - As a result of the inflammation affecting the small intestine’s ability to properly absorb the bile salts which are chemicals produced by the liver and then stored in the gallbladder (aiding in the digestion of fats and eliminating toxins from the body).
    • Osteoporosis – This is the softening of bones as a result of malnutrition and lack of calcium.
    • Anaemia – As a result of the lack of iron which is caused by malnutrition. Anaemia is a condition where the body suffers from a decrease in the number of red blood cells which results in the oxygen flow to vital organs being depleted.
  • Medication risks – There are certain drugs used to treat Crohn’s disease that work through blocking the functions of the patient’s immune system that are responsible for the inflammation. These drugs are known to increase one’s risk of developing certain cancers such as skin cancers and lymphoma. Osteoporosis, diabetes and glaucoma have been linked to corticosteroids which aid in controlling inflammation. It is best to always speak to the doctor regarding the risks of medications that are prescribed.

How does Crohn's disease affect the intestines?

During the initial stages of the disease, small, shallow and scattered ulcerations (also known as erosions which are crater-like), will form on the bowel’s inner surface. These ulcerations are known as aphthous ulcers and in time they will grow to be larger and deeper as they ultimately form true ulcers, which are basically deeper than regular erosions. These ulcers then cause the bowel to stiffen and scar. As Crohn's disease progresses, the intestine (bowel) will increasingly become narrowed and eventually, it will become obstructed. The deep ulcers can result in perforations, which are like punctures in the bowel wall. From here, bacteria found in the bowel can spread and infect the surrounding organs, as well as the abdominal cavity.

When Crohn's disease results in the small intestine being obstructed and the flow of contents through it cease, the obstruction is sometimes the result of poorly digested vegetables or fruit that create a plug in the segment that has already been narrowed. When this obstruction occurs, the process of digestion is impacted as food and gas cannot pass from the stomach and small intestine through to the colon. This results in the severe abdominal pain and cramps, as well as nausea and vomiting. The small intestine is narrower than the colon, thus, obstruction is more likely to occur.

Ulcers that developed may form deeply within the tissue lining, creating a tunnel (puncture hole) between the adjacent organs and the intestine. If one of these tunnels reaches through the empty space of an adjacent organ (within the abdominal cavity), then an abscess known as an abdominal abscess will form (this is a collection of pus that is infected). If an individual has an abdominal abscess, then they may develop high fevers, abdominal pain and tenderness of the abdominal masses.

Inflamed and infected intestines

The types of fistulas as mentioned in the preceding article are explained below:

  • A fistula (tunnel or channel) is the result of the deep ulcer forming a puncture hole in a surrounding organ.
  • When a fistula forms between the intestine and the bladder, known as an enteric-vesicular fistula, this can result in the patient suffering from UTIs (urinary tract infections) on a frequent basis, as well as faeces and gas passing during urination.
  • If an enteric-cutaneous fistula develops (this is a fistula between the intestine and the skin), this will cause mucous and pus to emerge from a tiny and painful opening in the abdomen’s skin.
  • If a colonic-vaginal fistula forms (this is a fistula between the colon and the vagina), this can cause faeces and gas to emerge from the vagina.
  • If an anal fistula forms (this is a fistula between the intestine and the anus), this will lead to the discharge of pus and mucous from the opening of the fistula around the area of the anus.

Anal fistula

What are the types of Crohn’s disease?

There are five types of the condition, each one affects a different area. The types are as follows:

  1. Gastroduodenal Crohn’s disease – This type affects the duodenum (this is the first area of the small intestine) and the stomach. Roughly 5% of those who have Crohn's disease are affected by this type.
  2. Jejunoileitis – This type occurs/affects the second area of the small intestine, this is known as the jejunum. Roughly 5% of those who have Crohn's disease are affected by this type.
  3. Ileitis – This is known as inflammation in the last portion of the small intestine which is known as the ileum. Roughly 30% of those who have Crohn's disease are affected by this condition.
  4. Ileocolitis – This affects the colon and the ileum and is known as the most common kind of Crohn’s disease. Roughly 50% of those who have Crohn's disease are affected by this type.
  5. Crohn’s colitis – This is similar to ulcerative colitis as both ulcerative colitis and Crohn’s colitis affect only the colon, however, Crohn’s colitis causes patches of tissue in the lining of the colon that is diseased. Roughly 20% of those who have Crohn's disease are affected by this type.

How is Crohn’s disease diagnosed?

It is likely that Crohn’s disease will be diagnosed after other diseases and causes of the symptoms and signs have been ruled out. There is no single test for Crohn’s disease to be diagnosed.

Typically, the doctor will utilise a combination of diagnostic procedures consisting of an endoscopy and a biopsy, as well as radiological testing in order to confirm that the diagnosis is Crohn's disease. The patient may have one or a combination of the below procedures and tests:

Blood tests

  • Tests for infection or anaemia – Blood tests may be conducted to check if the patient has anaemia (this is a condition where there is an insufficient amount of red blood cells in the body which leads to an inadequate amount of oxygen being transported to the organs). Blood tests can also be done to check for any infections. Currently, doctors do not recommend genetic or antibody testing for Crohn's disease.
  • Faecal occult blood test – For this test to be conducted, the patient will provide the doctor with a stool sample in order for the doctor to test the stool for any hidden blood.

Procedures

  • Colonoscopy – This is a test that allows for the doctor to see inside of the patient’s colon. For this procedure, a thin, flexible lighted tube with a camera attached to the end of it is inserted into the anus and directed through the colon while the patient is under anaesthesia. During the colonoscopy, the doctor may also obtain samples of the colon tissue, this is known as a biopsy, for the lab to analyse, this can often aid in confirming the diagnosis. If there are granulomas present, which are clusters of inflamed cells, then this often confirms the diagnosis of Crohn’s disease.
  • Flexible sigmoidoscopy – This is a procedure wherein the doctor will use a thin, flexible and lighted tube to examine the patient’s sigmoid colon, this is the last portion of the colon. Both this procedure and a colonoscopy are screening tests.
  • Magnetic resonance imaging (MRI) – This type of test makes use of radio waves and a magnetic field in order for detailed images to be created of the tissues and organs. A pelvic MRI is extremely useful when a fistula near the anus needs to be evaluated. Or if a fistula near the small intestine requires examination, a specialised MRI known as an MR enterography will be done.
  • Computerised tomography (CT) – Otherwise known as a CT scan, this test uses a specialised X-ray machine that provides the doctor with more detail when compared to the standard X-ray. This scan will provide the doctor with a view of the entire bowel and the surrounding tissues. Another kind of CT scan is known as CT enterography, this provides clearer, more detailed visual images of the patient’s small bowel. In the majority of medical centres, this test has now replaced the popular barium X-rays (barium X-rays use a metallic compound known as barium sulphate to detect any issues in the digestive tract through the use of liquid suspension ingested by the patient). CT enterography uses an intravenously injected contrast material as well as material in liquid form that is ingested to help in producing high resolution visual images of the bowels, it is a quick and painless procedure.
  • Double-balloon endoscopy – This test makes use of a long scope to move further through the small bowel in order to get a closer look at possible abnormalities, this kind of endoscope is longer than the standard one. This test cannot however, confirm the diagnosis of Crohn’s disease, it is simply one of the least invasive procedures that can be done and aids in detecting any abnormalities that may require further examination and/or testing means of an endoscopy or biopsy.
  • Capsule endoscopy – This test requires the patient to swallow a small capsule containing a camera. The camera will then take pictures which will be transmitted onto a monitor on a belt worn by the patient. These images are then downloaded and displayed on a different screen to be examined for any signs of Crohn’s disease. This camera will painlessly exit the body through the patient’s stool. Once a capsule endoscopy has been conducted, the doctor may recommend that the patient has a biopsy or endoscopy done to confirm the diagnosis.
  • Small bowel imaging – This is a kind of test that will look at the area of the small intestine (bowel) that cannot be detected in a colonoscopy. The patient will ingest a barium liquid and the doctor will use an X-ray machine, MRI or a CT scan to obtain images of the small intestine as the liquid highlights any abnormalities of the bowel. This is known as a combination technique as it uses one or more tests to confirm the diagnosis.

How is Crohn’s disease treated?

For Crohn’s disease to be treated effectively, the treatment plan will typically involve drug therapy, and in some more severe cases, surgery will be required. Crohn’s disease does not have a cure and more research on the condition is needed in order for researchers to possibly find one. There is no method of treatment that works the same for everyone. Doctors tend to use either a step-up form of treatment which starts the patient on the milder drugs first and then increases dosages or changes the type of medication prescribed over time, or a top-down form of treatment which starts the patient on the stronger drugs during the initial stages of treatment and then tapers the dosage or type of medication off over time.  

The treatment of Crohn’s disease aims to reduce the inflammation that triggers a patient’s symptoms. The treatment will also attempt to improve the long-term complications and prognosis. The most that a patient can hope for is that they are able to go into long term remission.

Anti-inflammatory drugs

These types of drugs are typically the first option of treatment for patients with IBD (inflammatory bowel disease). These drugs include:

Oral 5-aminosalicylates – These are often used when Crohn’s affects the colon, they are not effective when used in treating the disease if it has affected the small intestine. These drugs have several side effects and have recently been considered to have only a limited benefit. Some of their side effects are diarrhoea, headaches, nausea, vomiting and heartburn. Oral 5-aminosalicylates include:

    • Mesalamine - Delzicol, Asacol, Lialda, Pentasa, Apriso
    • Sulfasalazine (contains sulfa) - Azulfidine

Corticosteroids – These include the drug known as prednisone, and can help in reducing inflammation in any area of the patient’s body. These also have a number of side effects which include:

    • Night sweats
    • Puffy face
    • Insomnia
    • Excessive facial hair
    • Hyperactivity

More serious side effects include:

    • Cataracts
    • Diabetes
    • Osteoporosis
    • Bone fractures
    • Increased chances of infection

These drugs do not seem to work for every patient who has been diagnosed with Crohn’s disease. They are normally prescribed when the patient does not respond to other means of treatment. There is a new kind of corticosteroid known as budesonide (Entocort EC), this tends to work faster when compared to the more traditional steroids. This drug also has fewer side effects but is only effective in treating Crohn’s disease in specific parts of the bowel.

Corticosteroids are not intended to be used long-term, however, when they are used short-term they often result in the patient going into induced remission. Then immune suppressors aid in retaining this remission long-term.

Immune system suppressors (Immunosuppressant drugs)

These are kinds of drugs that aid in reducing inflammation. They work through targeting the patient’s immune system (the immune system causes the inflammation). In some cases, these drugs are used in combination with each other.

Immune system suppressors include:

  • Mercaptopurine (Purinethol) and azathioprine (Imuran) – These drugs are widely used in treating IBD. Should a patient take these, they should be monitored by their doctor and have regular blood tests in order for their doctor to check for any side effects, one common side effect is the patient’s resistance to potential infections being lowered.  

    When these drugs are used short-term they have been associated with the suppression of bone marrow and inflammation of the pancreas or liver. When used long-term, they can result in certain infections, as well as cancers such as skin cancer and lymphoma (these side effects are rare). They can also result in vomiting and nausea. A doctor will administer regular blood tests to check if the patient is able to take these drugs.    
  • TNF inhibitors - Adalimumab (Humira), Infliximab (Remicade) and certolizumab pegol (Cimzia) – These kinds of drugs are known as biologics or TNF inhibitors. They work through neutralising a protein made by the immune system known as TNF (tumour necrosis factor). They can also be used to reduce the symptoms of Crohn’s disease that range from mild to severe in children and adults. These drugs can often aid in inducing remission (bringing on a period of disease inactivity). Researchers are still studying these kinds of medications in order to examine and compare their various benefits and side effects.

    TNF inhibitors may be used relatively soon after diagnosis has been confirmed, particularly if the doctor thinks that Crohn’s disease is severe or the patient has a fistula. They are also used after other drugs have failed or can be combined with one or more immunosuppressant drugs (this practice is still debated in the medical profession).

    There are a number of people who are unable to take any TNF inhibitors due to pre-existing conditions. Severe infections such as tuberculosis (TB) and certain cancers such as skin cancer and lymphoma, have previously been associated with the patient using immunosuppressant drugs. It is best that the patient speaks to their doctor should they suspect they are at risk of TB or any other complications. TB can be tested for through a skin test or an X-ray of the patient’s chest.
  • Methotrexate (Rheumatrex) – This kind of drug is used for the treatment of rheumatoid arthritis, psoriasis and cancer and can also be used for those who have not responded well to other treatments for Crohn’s disease.

The short-term effects of this drugs include:          

  • Diarrhoea
  • Fatigue
  • Nausea
  • Pneumonia (very rare)

Using this drug long-term can cause:

  • Scarring of the liver
  • Bone marrow suppression
  • Cancer (very rare)

Due to the above side effects, patients are often monitored closely when taking this drug.

  • Tacrolimus (Hecoria, Antigraft XL) and cyclosporine (Neoral, Genogram, Sandimmune) – These drugs are extremely potent and are used to aid in the healing of fistulas related to Crohn’s disease. They are typically given to patients who have not responded to any other drugs. Cyclosporine is a drug that can have severe side effects which include:
    • Liver and kidney damage
    • Seizures
    • Fatal infections

These drugs are not intended to be used long-term.

  • Vedolizumab (Entyvio)and natalizumab (Tysabri) – These are drugs that work through blocking the binding of specific immune cells known as integrins with other cells found in the intestinal lining (this binding results in inflammation). The drug natalizumab has been approved for those who suffer from Crohn’s disease that is mild to severe, specifically when there is inflammation that has not responded to other drugs.

    Due to this drug being associated with the serious but rare risk of progressive multifocal leukoencephalopathy (this is a disease of the brain that can lead to severe disability or even death), the use of this drug requires patients to be enrolled in a specific program for the distribution of this drug in order to be closely monitored.

    Vedolizumab has recently been approved for the treatment of Crohn’s disease and does not have the risk of the patient developing brain disease.
  • Ustekinumab (Stelara) – This is used in the treatment of psoriasis (a long-term autoimmune disease involving abnormal patches of skin as the condition speeds up the life span of the skin cells causing them to build up rapidly on the skins surface). Studies have also shown that this drug can aid in the treatment of Crohn’s disease and can be used if other drugs do not work.

Antibiotics

These are helpful in reducing the volume of drainage associated with the abscesses and fistulas of Crohn’s disease and in some cases, antibiotics can also heal these abnormalities. Some researchers believe that the use of antibiotics can also aid in reducing the amount of the harmful bacteria in the intestines and can also have a role to play in the activation of the intestinal immune system, this activation leads to inflammation.

Antibiotics work through combatting bacterial infections by attacking the cell wall of the invading or abnormal cells, this injures the cells and prevents the bacteria from attacking and damaging the body any further.

Antibiotics may be used in combination with other medications. If infection is one of the doctor’s concerns, then antibiotics can also aid in treating this. Currently, there is no hard evidence that suggests that the use of antibiotics for Crohn’s disease is effective. The most commonly prescribed antibiotics are:

  • Metronidazole (Flagyl) – There was a stage when this drug was the most commonly prescribed antibiotic for the treatment of Crohn's disease, the issue with this drug is that it can result in severe side effects which include:
    • Muscle pain and weakness
    • Tingling or numbness in feet and hands
  • Ciprofloxacin (Cipro) – This antibiotic aids in improving the symptoms of some patients who have Crohn's disease. It is often the preferred option over metronidazole as the side effects are less severe, however, tendon rupture has been known to be a rare side effect.

Other medications

Some medications can help in reducing the inflammation and can also aid in relieving some of the patient’s symptoms. The following medications are over-the-counter (OTC) drugs that some doctors may recommend for the treatment of Crohn’s disease:

  • Antidiarrhoeals – Fibre supplements can help in relieving the symptoms of diarrhoea as they add bulk to the stool. These should only be used once the patient’s doctor has given the go-ahead. Some of these include:
    • Methylcellulose (Citrucel)
    • Psyllium powder (Metamucil)
    • Loperamide (Imodium)
  • Pain relievers – If the patient is suffering from mild pain, then their doctor may suggest they take:
    • Acetaminophen (Tylenol)

Patients will be advised not to take the following:

  • Naproxen sodium (Aleve, Anaprox)
  • Ibuprofen (Advil, Motrin IB, others)

As these can worsen the symptoms and can possibly cause the disease to progress in its severity.

  • Iron supplements – If the patient suffers from severe intestinal bleeding, they may develop anaemia from their lack of iron, they will then need to take iron supplements. These are easy to obtain from a pharmacy and should be clearly labelled.
  • Vitamin B-12 injections – Some pharmacies may need a script for these to be administered. Crohn’s disease often results in patients suffering from a deficiency of Vitamin B-12 due to their body’s ability to absorb nutrients being impaired. Vitamin B-12 can help in preventing anaemia, promoting normal and healthy development and growth and is also essential for the proper functioning of the nerves.
  • Vitamin D and calcium supplements – The steroids used in the treatment of Crohn’s disease can increase the patient’s risk of developing osteoporosis, this can be prevented through taking Vitamin D and calcium supplements as these promote bone health.

Nutrition therapy

In order for Crohn’s disease to be treated, a doctor may suggest that the patient sticks to a specialised diet that is administered through a feeding tube, this is known as enteral nutrition, or that the nutrients needed are given intravenously, this is known as parenteral nutrition (PN). This method of treatment can help in improving the patient’s overall levels of nutrients and also allow for the bowels to rest, which often results in the short-term reduction of bowel inflammation as the bowels are not aggravated further in having to digest food.

This kind of nutrition therapy may also be combined with medications such as immunosuppressants. Both enteral nutrition and parenteral nutrition are used to improve the overall health of patients before they undergo surgery or if other drugs have failed in controlling the symptoms.

A doctor may also suggest that the patient follows a low-fibre or low-residue diet in order to reduce the number of stools passed as high-fibre stools can result in intestinal blockages, particularly if they suffer from a narrowed bowel, which is known as a stricture.

Surgery

Surgery is often the last treatment option and is conducted when other diet, medications and lifestyle changes have not been effective in relieving the symptoms of Crohn’s disease. Roughly 50% of those who suffer from Crohn’s disease, will have to undergo surgery at least once. Keep in mind, surgery is not able to cure the condition.

During the surgery, the surgeon will remove the portion of the digestive tract that is damaged and then reconnects the sections that are still healthy. Surgery is also utilised to drain any abscesses or to close fistulas. The commonly used procedure for those with Crohn’s disease is known as strictureplasty. This surgery widens the segment of the patient’s intestine that has narrowed.

The surgery will alleviate the narrowing of the bowel that has resulted from the build-up of scar tissue in the intestinal wall from inflammatory bowel diseases.

The downside to surgery is that although it may offer temporary relief to symptoms, Crohn’s disease will often recur near the tissue that has been reconnected.

What are the lifestyle changes and home treatments for Crohn’s disease?

When suffering from Crohn’s disease patients can often feel helpless. However, changes in their lifestyle and diet can help them to control their symptoms and even lengthen their periods of remission. The following changes can be implemented:

Diet

Currently, there is no hard evidence that one’s diet can be a direct cause of IBD (inflammatory bowel disease), however, certain foods and drinks are able to aggravate the symptoms.

It can be extremely beneficial for the patient to have a food diary and take note of what they are eating and how this makes them feel. If it is discovered that certain foods worsen the symptoms, then it may help to eliminate them from one’s diet.

The following are some suggestions that are able to help patients with their diet:

What to avoid

  • Dairy products – These do not have to be eliminated entirely, but through limiting dairy products the patient may notice an improvement in symptoms associated with gas and bloating or even abdominal cramping. Some people are also lactose intolerant, meaning that their body cannot digest lactose found in dairy which is a milk sugar. The use of an enzyme tablet known as Lactaid can also help in this.
  • High-fat foods – When suffering from Crohn’s disease, the small intestine’s ability to absorb or digest fat is impaired. This results in fat passing straight through the intestine and worsening any diarrhoea experienced, therefore, it is best to stick to low-fat foods.
  • Fibre – Fibre should be limited as foods with a high-fibre content such as vegetables and fruit can worsen the symptoms. If the patient still wants to eat these products, they should rather cook or steam them first as this makes them easier for the body to digest. Cabbage can also be a problem food, as well as nuts, seeds, broccoli, corn and cauliflower.
  • Problem foods – Alcohol, spicy foods and caffeine can worsen symptoms as they aggravate the bowel.

Other dietary precautions and measures

  • Try to eat smaller meals more frequently – By eating smaller meals every two hours or so can be easier for the bowels to digest and lessen the symptoms of Crohn’s disease slightly.
  • Drink enough fluids – The patient needs to ensure that they are drinking enough liquids every day, particularly water. Carbonated drinks should be avoided as these result in gas and bloating which can be painful for those with Crohn’s disease.
  • Take multivitamins – The patient should first speak to their doctor before taking any supplements. Crohn’s disease can result in malnutrition which means that the body will be lacking vital nutrients, some of which can be replaced through the use of multivitamins that contain calcium, iron and vitamin B-12.
  • Speak to a dietician – Should a patient start to lose weight, a dietician can help them in finding out what foods are best for nutrition and their condition.

Smoking

Smoking cigarettes can significantly increase one’s risk of Crohn’s disease developing, and a patient who smokes and has the condition will worsen their symptoms through doing so. Quitting smoking and improve the overall health of the patient’s digestive tract.    

Stress

Stress is not a direct cause of Crohn’s disease, however, it is thought that it can worsen the symptoms and signs associated with the condition and even trigger a flare-up. The association between Crohn’s disease and stress is, however, still a controversial topic.

When someone is stressed, their digestive processes can change as their stomach may empty at a slower pace and also secrete more acid. Stress is also able to speed up the passing of the intestinal contents and can result in the intestinal tissue changes. The following are techniques that can help someone to manage stress:

  • Exercise – Exercise can help in reducing stress and even normalising the functioning of the bowel. At least 30 minutes of moderate exercise is enough to have a healthy digestive tract.
  • Biofeedback – This technique aids in reducing stress, the patient is connected to a biofeedback machine as they are helped to reach a relaxed state to reduce their muscle tension and slow down their heart rate. This will in turn teach them how to reach this state of relaxation on their own.
  • Breathing techniques – There are a number of exercises and meditation practices that can aid in educating patients on breathing techniques to aid in reducing their stress levels.

What is the outlook for Crohn’s disease?

The prognosis of Crohn’s disease tends to vary significantly between patients. The condition can range from being moderate, also known as benign, to being more severe. Patients can be situated on either side of the scale, whereas some may only experience one episode and other may suffer from the condition continuously (chronic cases). Fortunately, there are a number of treatments available and ongoing research to find out more about the condition and a potential cure.

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