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Crohn's Disease

Crohn's disease, a type of inflammatory bowel disease, may affect any part of the GI tract but usually involves the terminal ileum. The disease extends through all layers of the intestinal wall and may involve regional lymph nodes and the mesentery.

Crohn's disease occurs equally among both sexes and is more common in Jewish individuals. Onset of the disease is usually before age 30.

Crohn's disease has a varied nomenclature. When it affects only the small bowel, it's also known as regional enteritis. If the disorder also involves the colon or only affects the colon, it's known as Crohn's disease of the colon. (Crohn's disease of the colon also has been termed granulomatous colitis, an inaccurate term because not all patients develop granulomas.)

Causes

The exact cause is not known, but it is thought that the body's immune system overreacts to a virus or bacterium, causing ongoing inflammation in the bowel. Inflammatory bowel disease tends to run in families.

Smoking increases the risk of Crohn's disease, and it is more likely in people who eat a high-sugar, low-fibre diet.

Signs and Symptoms

Generally, the patient reports gradual onset of signs and symptoms, marked by periods of remission and exacerbation. Because signs and symptoms may be intermittent, the patient may postpone seeking medical attention for some time.

The patient typically complains of fatigue, fever, abdominal pain, diarrhea (usually without obvious bleeding) and, occasionally, weight loss. Questioning may reveal that diarrhea worsens after emotional upset or ingestion of poorly tolerated foods, such as milk, fatty foods, and spices.

The patient with regional enteritis, often a young adult, may report similar signs and symptoms as well as anorexia, nausea, and vomiting. Typically, this patient describes his abdominal pain as steady, colicky, or cramping. It usually occurs in the right lower abdominal quadrant.

On inspection, the patient's stool may appear soft or semiliquid, without gross blood (a distinguishipg clinical feature from the bloody diarrhea seen in ulcerative colitis). Palpation may reveal tenderness in the right lower abdominal quadrant; it may also disclose an abdominal mass, indicating adherent loops of bowel.

Diagnostic tests

Laboratory analysis to detect occult blood in stools is usually positive.

Small-bowel X-rays may show irregular mucosa ulceration, and stiffening.

Barium enema that reveals the string sign (segments of stricture separated by normal bowel) supports the diagnosis. This test may also show fissures and narrowing of the lumen.

Sigmoidoscopy and colonoscopy may show patchy areas of inflammation, thus helping to rule out ulcerative colitis. These studies may also reveal the characteristic coarse irregularity (cobblestone appearance; of the mucosal surface. When the colon is involved discrete ulcerations may be evident.

Biopsy, performed during sigmoidoscopy or colonoscopy, reveals granulomas in up to half of all specimens.

Laboratory test findings indicate increased white blood cell count and erythrocyte sedimentation rate. Other findings include hypokalemia, hypocalcemia hypomagnesemia, and decreased hemoglobin (Hb) level.

Treatment

Effective management of Crohn's disease requires drug therapy and significant lifestyle changes, including physical rest and dietary restrictions. In debilitated patients, treatment includes total parenteral nutrition to maintain nutrition while resting the bowel.

Drug therapy, designed to combat inflammation and relieve symptoms, may include:

  • corticosteroids, such as prednisone, to reduce signs and symptoms of diarrhea, pain, and bleeding by decreasing inflammation.
  • immunosuppressant agents such as azathioprine to suppress the body's response to antigens
  • sulfasalazine or mesalamine (alone or together) to reduce inflammation
  • metronidazole to treat perianal complications
  • antidiarrheals, such as diphenoxylate and atropine, to combat diarrhea (contraindicated in patients with significant bowel obstruction)
  • narcotics to control pain and diarrhea.

Lifestyle changes, such as stress reduction and reduced physical activity, help to rest the bowel, giving it time to heal. Dietary changes that decrease bowel activity while still providing adequate calories and nutrition are also essential. Dietary modifications include elimination of high-fiber foods (no fruits or vegetables) and foods that irritate the mucosa (such as dairy products, and spicy and fatty foods). Foods that stimulate excessive intestinal activity (such as carbonated or caffeine-containing beverages) should also be avoided. Vitamins may be prescribed to compensate for the bowel's inability to absorb nutrients.

If complications develop, surgery may be required. Indications for surgery include bowel perforation, massive hemorrhage, fistulas, or acute intestinal obstruction. Colectomy with ileostomy is often necessary in patients with extensive disease of the large intestine and rectum.



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