Who Gets Crohn's Disease?

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Crohn's disease appears early in life; approximately one-sixth of patients have symptoms before 15 years of age. Although the cause is unknown, doctors suspect a genetic influence, since many members of the same family may be affected.

 

Crohn's disease affects the Jewish population more than the general population.

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Source: John Hopkins Medicine

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Causes

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The exact cause of Crohn's disease remains unknown. Previously, diet and stress were suspected, but now doctors know that these factors may aggravate, but don't cause, Crohn's disease. Several factors, such as heredity and a malfunctioning immune system, likely play a role in its development.

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• Immune system. It's possible that a virus or bacterium may trigger Crohn's disease; however, scientists have yet to identify such a trigger. When your immune system tries to fight off the invading microorganism, an abnormal immune response causes the immune system to attack the cells in the digestive tract, too.

• Heredity.  Crohn's is more common in people who have family members with the disease, so genes may play a role in making people more susceptible. However, most people with Crohn's disease don't have a family history of the disease.

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Source: Mayo Clinic

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What are the symptoms of Crohn's Disease?

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In Crohn's disease, any part of your small or large intestine can be involved, and it may be continuous or may involve multiple segments. In some people, the disease is confined to the colon, which is part of the large intestine.

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Signs and symptoms of Crohn's disease can range from mild to severe. They usually develop gradually, but sometimes will come on suddenly, without warning. You may also have periods of time when you have no signs or symptoms (remission).

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When the disease is active, signs and symptoms may include:

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• Diarrhea

• Fever

• Fatigue

• Abdominal pain and cramping

• Blood in your stool

• Mouth sores

• Reduced appetite and weight loss

• Pain or drainage near or around the anus due to inflammation from a tunnel into the skin (fistula)

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Source: Mayo Clinic

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Other signs and symptoms

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People with severe Crohn's disease may also experience:

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• Inflammation of skin, eyes and joints

• Inflammation of the liver or bile ducts

• Kidney stones

• Iron deficiency (anemia)

• Delayed growth or sexual development, in children

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Source: Mayo Clinic​

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Risk factors

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Risk factors for Crohn's disease may include:

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• Age.  Crohn's disease can occur at any age, but you're likely to develop the condition when you're young. Most people who develop Crohn's disease are diagnosed before they're around 30 years old.

• Ethnicity.  Although Crohn's disease can affect any ethnic group, whites have the highest risk, especially people of Eastern European (Ashkenazi) Jewish descent. However, the incidence of Crohn's disease is increasing among Black people who live in North America and the United Kingdom.

• Family history.  You're at higher risk if you have a first-degree relative, such as a parent, sibling or child, with the disease. As many as 1 in 5 people with Crohn's disease has a family member with the disease.

• Cigarette smoking.  Cigarette smoking is the most important controllable risk factor for developing Crohn's disease. Smoking also leads to more-severe disease and a greater risk of having surgery. If you smoke, it's important to stop.

• Nonsteroidal anti-inflammatory medications. These include ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve), diclofenac sodium and others. While they do not cause Crohn's disease, they can lead to inflammation of the bowel that makes Crohn's disease worse.

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Source: Mayo Clinic

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Complications

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Crohn's disease may lead to one or more of the following complications:

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• Bowel obstruction.  Crohn's disease can affect the entire thickness of the intestinal wall. Over time, parts of the bowel can scar and narrow, which may block the flow of digestive contents. You may require surgery to remove the diseased portion of your bowel.

• Ulcers.  Chronic inflammation can lead to open sores (ulcers) anywhere in your digestive tract, including your mouth and anus, and in the genital area (perineum).

• Fistulas.  Sometimes ulcers can extend completely through the intestinal wall, creating a fistula — an abnormal connection between different body parts. Fistulas can develop between your intestine and your skin, or between your intestine and another organ. Fistulas near or around the anal area (perianal) are the most common kind.

  When fistulas develop in the abdomen, food may bypass areas of the bowel that are necessary for absorption. Fistulas may form between loops of bowel, in the bladder or vagina, or through the skin, causing continuous drainage of bowel contents to your skin.

  In some cases, a fistula may become infected and form an abscess, which can be life-threatening if not treated.

• Anal fissure. This is a small tear in the tissue that lines the anus or in the skin around the anus where infections can occur. It's often associated with painful bowel movements and may lead to a perianal fistula.

• Malnutrition.  Diarrhea, abdominal pain and cramping may make it difficult for you to eat or for your intestine to absorb enough nutrients to keep you nourished. It's also common to develop anemia due to low iron or vitamin B-12 caused by the disease.

• Colon cancer.  Having Crohn's disease that affects your colon increases your risk of colon cancer. General colon cancer screening guidelines for people without Crohn's disease call for a colonoscopy every 10 years beginning at age 50. Ask your doctor whether you need to have this test done sooner and more frequently.

• Other health problems.  Crohn's disease can cause problems in other parts of the body. Among these problems are anemia, skin disorders, osteoporosis, arthritis, and gallbladder or liver disease.

• Medication risks.  Certain Crohn's disease drugs that act by blocking functions of the immune system are associated with a small risk of developing cancers such as lymphoma and skin cancers. They also increase risk of infection.

  Corticosteroids can be associated with a risk of osteoporosis, bone fractures, cataracts, glaucoma, diabetes and high blood pressure, among other conditions. Work with your doctor to determine risks and benefits of medications.

• Blood clots.  Crohn's disease increases the risk of blood clots in veins and arteries.

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Source: Mayo Clinic

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Diagnosis

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Your doctor will likely diagnose Crohn's disease only after ruling out other possible causes for your signs and symptoms. There is no single test to diagnose Crohn's disease.

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Source: Mayo Clinic

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Lab tests

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Your doctor will likely use a combination of tests to help confirm a diagnosis of Crohn's disease, including:

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• Blood tests. Your doctor may suggest blood tests to check for anemia — a condition in which there aren't enough red blood cells to carry adequate oxygen to your tissues — or to check for signs of infection.

• Stool studies. You may need to provide a stool sample so that your doctor can test for hidden (occult) blood or organisms, such as parasites, in your stool.

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Source: Mayo Clinic

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Testing Procedures

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• Colonoscopy.  This test allows your doctor to view your entire colon and the very end of your ileum (terminal ileum) using a thin, flexible, lighted tube with a camera at the end. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis, which may help to make a diagnosis. Clusters of inflammatory cells called granulomas, if present, help essentially confirm the diagnosis of Crohn's.

• Computerized tomography (CT).  You may have a CT scan — a special X-ray technique that provides more detail than a standard X-ray does. This test looks at the entire bowel as well as at tissues outside the bowel. CT enterography is a special CT scan that provides better images of the small bowel. This test has replaced barium X-rays in many medical centers.

• Magnetic resonance imaging (MRI).  An MRI scanner uses a magnetic field and radio waves to create detailed images of organs and tissues. MRI is particularly useful for evaluating a fistula around the anal area (pelvic MRI) or the small intestine (MR enterography).

• Capsule endoscopy.  For this test, you swallow a capsule that has a camera in it. The camera takes pictures of your small intestine and transmits them to a recorder you wear on your belt. The images are then downloaded to a computer, displayed on a monitor and checked for signs of Crohn's disease. The camera exits your body painlessly in your stool.

  You may still need endoscopy with biopsy to confirm the diagnosis of Crohn's disease. Capsule endoscopy should not be performed if there is a bowel obstruction.

• Balloon-assisted enteroscopy.  For this test, a scope is used in conjunction with a device called an overtube. This enables the doctor to look further into the small bowel where standard endoscopes don't reach. This technique is useful when capsule endoscopy shows abnormalities but the diagnosis is still in question.

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Source: Mayo Clinic

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Imaging Scans

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An imaging scan is a noninvasive diagnostic procedure that allows your doctor to obtain detailed images of the affected area. A computed tomography (CT) scan uses powerful X-ray technology to produce the images. Other imaging scans your doctor may recommend include:

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• Double Contrast Barium Enema X-ray. This is a specialized X-ray, using a contrast material to highlight the affected area. During the X-ray, your doctor can clearly see the right colon and the ileum (part of the small intestine), the two areas most often involved in Crohn's disease. Before the procedure, you will need to clear your colon of any stool. Preparations may include a liquid diet, enema or laxative. During a barium enema:

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1. A barium preparation (contrast material) is inserted through a rectal tube.

2. The barium outlines the colon, highlighting any abnormalities.

3. An X-ray is taken.

4. Your doctor can look for evidence of Crohn's disease.

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• Small Bowel Series. This is a fast, safe procedure for visualizing the small bowel. During this procedure:

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1. You drink a barium preparation.

2. Overhead X-rays are taken at frequent intervals.

3. When the barium reaches your small intestine, a fluoroscopy is performed. A fluoroscopy is a specialized X-ray that takes real-time, moving images of your internal structures.

4. During the fluoroscopy, you will be moved into various positions.

5. These X-rays reveal the extent of the disease and where any obstructions are located.

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• Enteroclysis. This is a more invasive, complex diagnostic procedure. However, it is more sensitive at detecting certain abnormalities. You may be sedated and the doctor will pass a tube through your nose and into your gastrointestinal tract. It is similar to a double-contrast barium enema.

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• Flexible Sigmoidoscopy. Two common endoscopic procedures for diagnosing Crohn's disease are a flexible sigmoidoscopy and a colonoscopy. A flexible sigmoidoscopy examines the rectum and lower colon. A sigmoidoscope is a specialized endoscope that is a thin, flexible lighted tube that your doctor inserts inside you to see the affected area. A flexible sigmoidoscopy examines the rectum and lower colon. During the procedure:

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1. Your colon must be clear of stool so your doctor has good visibility. Preparations may include a liquid diet, enema and laxatives.

2. Your doctor inserts the sigmoidoscope through the rectum and into the anus and large intestine.

3. A biopsy forceps may be inserted through the scope in order to remove a small sample of tissue for further analysis.

4. The procedure may cause some cramping or discomfort.

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• Colonoscopy.  A colonoscopy examines the rectum and the entire colon. A colonoscopy allows for visualization further into the bowel than the sigmoidoscopy, in order to assess the progression of the disease and determine an effective course of therapy.During a colonoscopy:

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1. Your colon must be clear of stool so your doctor has good visibility. Preparations may include a liquid diet, enema and laxatives.

2. You are sedated before the procedure.

3. Your doctor inserts the colonoscope through the rectum and into the anus and large intestine.

4. A biopsy forceps may be inserted through the scope in order to remove a small sample of tissue for further analysis.

5. The procedure may cause some cramping or discomfort.

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Source: John Hopkins Medicine

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Treatment

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There is currently no cure for Crohn's disease, and there is no single treatment that works for everyone. One goal of medical treatment is to reduce the inflammation that triggers your signs and symptoms. Another goal is to improve long-term prognosis by limiting complications. In the best cases, this may lead not only to symptom relief but also to long-term remission.

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• Anti-inflammatory drugs Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. They include:​​​

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• Corticosteroids. Corticosteroids such as prednisone and budesonide (Entocort EC) can help reduce inflammation in your body, but they don't work for everyone with Crohn's disease. Doctors generally use them only if you don't respond to other treatments. Corticosteroids may be used for short-term (three to four months) symptom improvement and to induce remission. Corticosteroids may also be used in combination with an immune system suppressor.

• Oral 5-aminosalicylates. These drugs include sulfasalazine (Azulfidine), which contains sulfa, and mesalamine (Asacol HD, Delzicol, others). Oral 5-aminosalicylates have been widely used in the past but now are generally considered of very limited benefit.

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• Immune system suppressors. These drugs also reduce inflammation, but they target your immune system, which produces the substances that cause inflammation. For some people, a combination of these drugs works better than one drug alone.Immune system suppressors include:​

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• Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol, Purixan). These are the most widely used immunosuppressants for treatment of inflammatory bowel disease. Taking them requires that you follow up closely with your doctor and have your blood checked regularly to look for side effects, such as a lowered resistance to infection and inflammation of the liver. They may also cause nausea and vomiting.

• Methotrexate (Trexall). This drug is sometimes used for people with Crohn's disease who don't respond well to other medications. You will need to be followed closely for side effects.

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• Biologics. This class of therapies targets proteins made by the immune system. Types of biologics used to treat Crohn's disease included:​​​

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• Ustekinumab (Stelara). This was recently approved to treat Crohn's disease by interfering with the action of an interleukin, which is a protein involved in inflammation.

• Natalizumab (Tysabri) and vedolizumab (Entyvio). These drugs work by stopping certain immune cell molecules — integrins — from binding to other cells in your intestinal lining. Because natalizumab is associated with a rare but serious risk of progressive multifocal leukoencephalopathy — a brain disease that usually leads to death or severe disability — you must be enrolled in a special restricted distribution program to use it.Vedolizumab recently was approved for Crohn's disease. It works like natalizumab but appears not to carry a risk of brain disease.

• Infliximab (Remicade), adalimumab (Humira) and certolizumab pegol (Cimzia).  Also known as TNF inhibitors, these drugs work by neutralizing an immune system protein known as tumor necrosis factor (TNF).

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• Antibiotics.  Antibiotics can reduce the amount of drainage from fistulas and abscesses and sometimes heal them in people with Crohn's disease. Some researchers also think that antibiotics help reduce harmful intestinal bacteria that may play a role in activating the intestinal immune system, leading to inflammation. Frequently prescribed antibiotics include ciprofloxacin (Cipro) and metronidazole (Flagyl).

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• Other medications. In addition to controlling inflammation, some medications may help relieve your signs and symptoms, but always talk to your doctor before taking any over-the-counter medications. Depending on the severity of your Crohn's disease, your doctor may recommend one or more of the following:​​​​

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• Pain relievers. For mild pain, your doctor may recommend acetaminophen (Tylenol, others) — but not other common pain relievers, such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve). These drugs are likely to make your symptoms worse and can make your disease worse as well.

• Anti-diarrheals. A fiber supplement, such as psyllium powder (Metamucil) or methylcellulose (Citrucel), can help relieve mild to moderate diarrhea by adding bulk to your stool. For more severe diarrhea, loperamide (Imodium A-D) may be effective.

• ​Vitamins and supplements. If you're not absorbing enough nutrients, your doctor may recommend vitamins and nutritional supplements.

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Source: Mayo Clinic

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Nutrition therapy

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Your doctor may recommend a special diet given by mouth or a feeding tube (enteral nutrition) or nutrients infused into a vein (parenteral nutrition) to treat your Crohn's disease. This can improve your overall nutrition and allow the bowel to rest.

 

Bowel rest can reduce inflammation in the short term. Your doctor may use nutrition therapy short term and combine it with medications, such as immune system suppressors.

 

Enteral and parenteral nutrition are typically used to get people healthier prior to surgery or when other medications fail to control symptoms. Your doctor may also recommend a low residue or low-fiber diet to reduce the risk of intestinal blockage if you have a narrowed bowel (stricture). A low residue diet is designed to reduce the size and number of your stools.

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Source: Mayo Clinic

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Surgery

 

If diet and lifestyle changes, drug therapy, or other treatments don't relieve your signs and symptoms, your doctor may recommend surgery. Nearly half of those with Crohn's disease will require at least one surgery. However, surgery does not cure Crohn's disease.

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During surgery, your surgeon removes a damaged portion of your digestive tract and then reconnects the healthy sections. Surgery may also be used to close fistulas and drain abscesses.

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The benefits of surgery for Crohn's disease are usually temporary. The disease often recurs, frequently near the reconnected tissue. The best approach is to follow surgery with medication to minimize the risk of recurrence.

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Source: Mayo Clinic

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Lifestyle and Home Remedies

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Sometimes you may feel helpless when facing Crohn's disease. But changes in your diet and lifestyle may help control your symptoms and lengthen the time between flare-ups.

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• Diet. There's no firm evidence that what you eat actually causes inflammatory bowel disease. But certain foods and beverages can aggravate your signs and symptoms, especially during a flare-up. It can be helpful to keep a food diary to track what you're eating, as well as how you feel. If you discover that some foods are causing your symptoms to flare, you can try eliminating them. Here are some general dietary suggestions that may help to manage your condition:

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• Limit dairy products. Many people with inflammatory bowel disease find that problems such as diarrhea, abdominal pain and gas improve by limiting or eliminating dairy products. You may be lactose intolerant — that is, your body can't digest the milk sugar (lactose) in dairy foods. Using an enzyme product such as Lactaid may help.

• Eat small meals. You may find that you feel better eating five or six small meals a day rather than two or three larger ones.

• Drink plenty of liquids. Try to drink plenty of fluids daily. Water is best. Alcohol and beverages that contain caffeine stimulate your intestines and can make diarrhea worse, while carbonated drinks frequently produce gas.

• Consider multivitamins.  Because Crohn's disease can interfere with your ability to absorb nutrients and because your diet may be limited, multivitamin and mineral supplements are often helpful. Check with your doctor before taking any vitamins or supplements.

• Talk to a dietitian.  If you begin to lose weight or your diet has become very limited, talk to a registered dietitian.

 

• Smoking. Smoking increases your risk of developing Crohn's disease, and once you have it, smoking can make it worse. People with Crohn's disease who smoke are more likely to have relapses and need medications and repeat surgeries. Quitting smoking can improve the overall health of your digestive tract, as well as provide many other health benefits.

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• Stress.  Although stress doesn't cause Crohn's disease, it can make your signs and symptoms worse and may trigger flare-ups. Although it's not always possible to avoid stress, you can learn ways to help manage it, such as:​

 

• Exercise.  Even mild exercise can help reduce stress, relieve depression and normalize bowel function. Talk to your doctor about an exercise plan that's right for you. 

• Biofeedback. This stress-reduction technique may help you decrease muscle tension and slow your heart rate with the help of a feedback machine. The goal is to help you enter a relaxed state so that you can cope more easily with stress.

• Regular relaxation and breathing exercises. One way to cope with stress is to regularly relax and use techniques such as deep, slow breathing to calm down. You can take classes in yoga and meditation or use books, CDs or DVDs at home.

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Source: Mayo Clinic

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Alternative Medicine

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Many people with Crohn's disease have used some form of complementary and alternative medicine to treat their condition. However, there are few well-designed studies of the safety and effectiveness of these treatments.

 

Source: Mayo Clinic

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Coping and Support

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Crohn's disease doesn't just affect you physically — it takes an emotional toll as well. If signs and symptoms are severe, your life may revolve around a constant need to run to the toilet. Even if your symptoms are mild, gas and abdominal pain can make it difficult to be out in public. All of these factors can alter your life and may lead to depression. Here are some things you can do:

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• Be informed.  One of the best ways to be more in control is to find out as much as possible about Crohn's disease. Look for information from the Crohn's & Colitis Foundation.

• Join a support group.  Although support groups aren't for everyone, they can provide valuable information about your condition as well as emotional support. Group members frequently know about the latest medical treatments or integrative therapies.  You may also find it reassuring to be among others with Crohn's disease.

• Talk to a therapist.  Some people find it helpful to consult a mental health professional who's familiar with inflammatory bowel disease and the emotional difficulties it can cause.

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Although living with Crohn's disease can be discouraging, research is ongoing and the outlook is improving.

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Source: Mayo Clinic

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Possible Links Between Celiac , Crohn's , and IBD

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Some early studies found that people with celiac disease were at much higher risk—potentially as high as a 10-fold increase in risk—of also being diagnosed with either Crohn's disease or ulcerative colitis.  However, more recent research has indicated that those with IBD have rates of celiac disease that are similar to those in the general population.

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Still, there does appear to be some association between the two conditions, and genetics may explain part of that association. Recent genetic research has found that celiac disease and Crohn's disease share four genes that appear to raise risk for both conditions.6 In addition, researchers have identified genes that appear to raise risk both for celiac and for ulcerative colitis.

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Both IBD and celiac disease are considered autoimmune diseases, which means they involve a mistaken attack by your immune system on a part of your body. Both conditions also appear to involve problematic changes in your intestinal microbiome (the bacteria that live in your large intestine), that may cause or support inflammation.

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Source: Very Well Health

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IBD, Crohn's and Gluten Sensitivity May Be More Commonly Related

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Non-celiac gluten sensitivity may be more likely than celiac disease in people with Crohn's disease or ulcerative colitis, several studies show.

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For example, a group of doctors in Italy and the United Kingdom surveyed their inflammatory bowel disease patients and found that 28% of them believed they had gluten sensitivity , meaning their symptoms seemed to worsen when they ate gluten-containing foods.7 Only 6% of these people were following the gluten-free diet at the time of the survey, though. The researchers also found that so-called "self-reported non-celiac gluten sensitivity" was associated with more severe Crohn's disease, and they called for additional studies to determine whether the gluten-free diet would help in these cases.

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In a 2014 report, clinicians in Japan (where celiac disease is quite rare) screened 172 people who had inflammatory bowel disease for antibodies to gluten via blood tests and compared those people to 190 control subjects.8 They found that 13% of those with inflammatory bowel disease also tested positive for anti-gluten antibodies. However, only three of those people carried one of the two main celiac disease genes, and none of them had damage to their small intestines, so none of them actually had celiac disease.

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Nonetheless, eight of those with inflammatory bowel disease who also tested positive for antibodies to gluten started the gluten-free diet (another eight people from the same group followed a gluten-containing diet, and served as control subjects). After six months on the gluten-free diet, those eight people had fewer symptoms—especially diarrhea—than the control subjects, the study reported. No one in either group developed celiac disease.

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Source: Very Well Health

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So Can the Gluten-Free Diet Help in IBD and Crohn's?

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Maybe it can, even if you don't have celiac disease. In several cases (including in the studies above), doctors have noted that the gluten-free diet improved or resolved inflammatory bowel disease symptoms, even in people who definitely didn't have celiac disease. People with Crohn's disease were especially likely to benefit.

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For example, in a case study published in 2013, Dr. David Perlmutter (of Grain Brain fame) reported on a patient who had been diagnosed with Crohn's disease, and who hadn't gotten any better with normal treatments for Crohn's.9 Based on blood tests that showed his body was producing antibodies to the gluten protein and to other components of wheat, barley, and rye, the man was diagnosed with non-celiac gluten sensitivity and started the gluten-free diet.

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This "led after six weeks to a complete cessation of diarrhea," the clinicians wrote. "Upon continuation of the gluten-free diet, not only did stool consistency become normal, but the patient also started gaining weight. On follow-up one year later the patient was back to a normal state and had regained more than 80% of his lost weight." His Crohn's disease had gone into remission on the gluten-free diet.

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Researchers from the University of North Carolina found similar (if somewhat less dramatic) benefits when they queried 1,647 people with inflammatory bowel disease about whether they had tried the gluten-free diet.2 A total of 19% said they had tried it previously, and 8% said they were still using the diet. Overall, nearly two-thirds of those who had tried to eat gluten-free said the diet improved their digestive symptoms, and 28% reported fewer or less severe IBD flares. Plus, those who were following the diet at the time of the survey said it helped their fatigue significantly.

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The researchers said it was possible that non-gluten compounds present in gluten grains (as opposed to the gluten protein itself) might cause intestinal inflammation in people with IBD, and eating gluten-free might help alleviate this inflammation (and the symptoms associated with it). They said their study "strongly suggests a potential role of this diet" in some IBD patients, but that more research is needed to determine who can benefit most.

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So yes, it's possible that the gluten-free diet may help to alleviate symptoms of inflammatory bowel disease, even in people who don't have celiac disease. If you're wondering whether you might benefit, talk to your doctor about trying the diet.

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Source: Very Well Health

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