Crohn’s Disease

What is Crohn’s disease?

Crohn’s disease is a chronic inflammatory bowel disease. Inflammatory bowel disease (IBD) is a collective term used to describe illnesses that cause inflammation of the gastrointestinal tract. Ulcerative colitis and Crohn’s disease are the two most common of these illnesses. Unlike Ulcerative colitis, where the site of ulcer or inflammation is usually in the large bowel, Crohn’s disease can cause inflammation in one or more parts of the gastrointestinal tract lining, anywhere from mouth to anus. Crohn’s disease is typically characterised by affected segments of the gut being separated by apparently normal areas. The inflammation can cause scarring which can result in the walls of the bowel to thicken; this thickening of the walls is called a stricture. Crohn’s disease results in periods of remission and relapse.

How common is Crohn’s disease?

Crohn’s disease can affect any age group, usually from age eight years and onwards, however, childhood cases are increasing and sometimes they can be as young as five. It is rarely diagnosed in very early childhood. It can affect any race and gender. The prevalence of Crohn’s disease is estimated to be around 50 to100 per 100,000 people, therefore affects about 60,000 people in the UK. It can affect people at any age but the incidence is higher in 15 to 30 year olds. Approximately 25% of newly diagnosed cases of Crohn’s disease are in paediatric patients.

What are the common symptoms?

Crohn’s disease is a chronic disease; therefore can cause a variety of symptoms which can be slow starting and long lasting. Symptoms may include abdominal pain, urgent diarrhoea (sometimes with blood and/or mucous) and rectal bleeding. Poor appetite caused by a combination of inflammation and pain, this leads to poor growth in children and often significant weight loss. Symptoms may affect some people worse than others and is not uncommon to feel generally tired and lethargic.

What causes IBD?

There is no definitive answer to this, many theories have been put forward, and possible suggested causes include, genetic factors, diet, smoking, infectious agents, role of antigens and abnormal immune responses have also so been proposed as possible contributors to the disease.

Can other parts of the body be affected?

Inflammation of the liver can occur although this is rare in paediatric patients. Mouth ulcers, thickening of the lips, skin rashes and sore eyes may also features. These symptoms are generally easily treated but it is important to inform your health care professional of any unusual physical changes you may notice.

Will I get better?

Crohn’s disease is a chronic illness, so it cannot be completely eliminated. However, there are steps which can be taken to manage the disease, therefore minimise its effects and prevent a relapse. Crohn’s disease symptoms and severity can vary in different patients therefore patient treatment may also differ. Health care professionals will prescribe the most suitable form of treatment for an individual in order to meet their specific needs. Once treatment has started symptoms will begin to improve and the aim then will be to maintain remission so you can continue with day to day life without disruption.

What investigations may be needed?

If Crohn’s disease is suspected a combination of investigations will be carried out to confirm the diagnosis. Blood tests are particularly useful as they can measure a number of different factors in order to monitor your condition There are several tests that can be carried out in order for the doctor to make an accurate diagnosis and start you on the most suitable treatment.

• Blood tests
  These are carried out first and are often continued to be carried out regularly to monitor your treatment. They are able identify inflammatory markers to show if inflammations has occurred. These tests can also show if you have developed anaemia through persistent blood loss in stools. Mineral levels may also be measured as prolonged diarrhoea can cause levels drop and electrolyte imbalance. Although blood tests can show if there is any inflammation they are unable to provide an indication of where the inflammation is occurring, further investigations will be needed to confirm where the affected sites are.
• Stool samples
  Samples are commonly taken. They are disliked by patients but are necessary as examination of the samples can rule out the possibility of other infections which display similar symptoms to Crohn’s. Tests can also be carried out on these samples to ensure certain foods are being absorbed normally in the gut.
• Barium studies
  You will be asked not to eat or drink for a few hours before this is carried out. Barium is a dye which can be seen on an X-ray. You will be asked to drink some of the dye, the barium will then move through your gut, and a series of X-ray pictures will be taken. The X-rays can help determine where the inflamed or narrowed areas of the gut are.
• Colonoscopy and Endoscopy
  These both enable the doctor to see inside your gut. Endoscopies require a small fibre optic camera to be inserted via the mouth, down into the small intestine. Colonoscopy is where the tube is inserted through the bottom and can view the large intestine up to the point where it joins the small intestine. These both enable the doctor to see the lining of the gut on a screen. Biopsies can be taken at the same time; these are small scrapings taken from the lining which can later be analysed under a microscope.

What kinds of treatment are there?

The aim of treatment in Crohn’s disease is to induce remission by relieving symptoms and resolving inflammation, promoting optimal growth particularly in paediatric patients and to correct any nutritional deficiencies that may have developed. Treatment can be either dietary, drugs, surgery or a combination of these. Dietary (Nutrition therapy) is often used as a first line treatment in the management of Crohn’s disease especially paediatric Crohn’s, sometimes in conjunction with drugs. Surgery, although an option, is used as a last resort in patients which have been unresponsive to dietary and/or drug treatments. Both drugs and dietary treatments have their benefits. Drugs are easy to use and convenient; therefore aid good patient compliance and good remission rates can be achieved. However, drug resistance can be demonstrated by some patients and drugs or combinations of drugs can result in many unwanted side effects. Dietary therapy is an option for patients with Crohn’s disease, particularly paediatric patients where there are concerns regarding growth. Dietary therapy has advantages, as it can relieve symptoms without the side effects associated with drug treatments. Dietary therapy also provides essential nutritional support and can aid recovery by correcting any nutritional deficiencies that may have developed.

What drugs can be used?

There are a number of different drugs types which can be used in the treatment of Crohn’s disease, they include:

• Corticosteroids
  Steroids have an anti-inflammatory effect and can treat symptoms quickly. There are varying types, and so can target specific affected areas of the gut. A high dose is often required initially to reduce inflammation rapidly, which can be an issue as side-effects are often dose related. It is common for patients on steroids to gain weight quickly and teenagers can suffer acne breakouts as a result of such treatment. Long term usage can also result in poor growth development in children.
• Aminosalicylates
  These are used in mild to moderate Crohn’s disease and are often favoured as they have fewer side effects than corticosteroids. They work by reducing inflammation in the gut and are used to prevent the symptoms from reoccurring often being taken long tem. However they are not as quick acting as steroids. They have to be taken on a daily basis and often for many years to ensure their effectiveness. Side effects are common and include headaches, sickness and diarrhoea.
• Immunosuppressants
  These are favoured when patients need a high dose of steroids to control symptoms. They are slow to take effect and in some cases may take up to 6 months for their full benefits to be seen. The dose may need to be adjusted in order to prevent nausea and vomiting. They reduce the immune systems resistance, so patients become more susceptible to infection. Frequent blood tests are usually carried out alongside for the first few weeks of treatment, as immunosuppressants can result in a reduction in blood cell production in the body, the regular blood tests initially will help to determine a safe and effective dose quickly.
• Infliximab
  Infliximab is a fairly new drug and is licensed for the use in treatment of moderate to severely active Crohn’s disease. It is given as in infusion into the vein and the whole process can take a few hours to complete. It works by neutralising inflammatory factors in the body to help resolve symptoms. Your usual medication will probably still need to be taken afterwards to maintain remission. As it is a relatively new treatment side effects are still remain unclear however unwanted effects demonstrated in trials include nausea, headaches, facial swelling, joint/muscle pain and it can also cause infections to present more severely due to its anti-inflammatory effects.
• Antibiotics
  Antibiotics may also be used in Crohn’s disease as part of the therapy. However clear evidence supporting their use is not available As with most drug therapies, particularly with long term usage, side affects can be numerous so it is important that the correct treatment type is identified quickly to avoid prolonging these. Certain vaccinations may not be given to patients on steroids or immunosuppressants.

Will I need surgery?

Surgery is only opted for if drug and/or dietary therapies have proven unsuccessful. If the affected area of the gut is localised enough then surgery can be performed to remove the affected part of the gut and rejoin the two healthy parts. This however does not cure Crohn’s as it is still possible for it to reappear in previously unaffected areas. Surgical procedures may also be used to reduce narrowing that can result from inflammation of the gut wall.

What is dietary treatment?

Dietary therapy is increasingly being used as a first line treatment of Crohn’s disease particularly in paediatric patients. Dietary therapy has been found to be as effective as steroids with minimal if not any side effects. It also has the benefit of improving the nutritional status of the patient and promotes growth in children. The principle of dietary therapy is to administer a liquid diet for a set period of time, this can vary anywhere between 2 to 6 weeks sometimes longer in paediatric patients. The exclusive liquid diet aims to induce remission in the patient and maintain it.