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Frans_Jozef
Monday, January 17th, 2005, 01:43 PM
Intestinal and extra-intestinal symptoms.

What is Crohn’s disease? Crohn’s disease (CD) is a chronic disease that can cause inflammation anywhere along the digestive tract from the mouth to the anus. Of all cases of CD, 45% occur in ileum and colon, 35% in just the ileum, and 20% in just the colon. Unlike ulcerative colitis (UC) (http://ibscrohns.about.com/cs/faqsuc/a/ucfaq.htm), which only affects the inner layer, CD commonly involves all layers of the intestinal wall. CD and UC are collectively called Inflammatory Bowel Disease.

What are the symptoms of CD? Common symptoms of CD include chronic diarrhea fever, abdominal pain, weight loss, and lack of appetite. Frequent diarrhea can lead to dehydration (http://ibscrohns.about.com/library/weekly/aa011701a.htm) and nutritional deficiencies. Because the colon is inflamed, it is not as efficient at absorbing water and nutrients from food.

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Fever is a characteristic of the inflammatory process, may be either high or low-grade, and presents especially during periods of active disease. Night sweats are caused by a fever spiking repeatedly during the night.

Extra-intestinal symptoms include eye inflammation, joint pains, skin rashes or lesions, fistulas and fissures. It is unclear why symptoms develop outside the digestive tract, but they often decrease in severity along with flare-ups.

Eye conditions that can occur with CD include conjunctivitis, episcleritis, uveitis, iritis and keratopathy. Most eye conditions will improve when progress is made in treating the underlying CD, but some may require treatment. Conjunctivitis, or “pink eye,” is an inflammation of the tissue covering the eye and inner surface of the eyelid and may be treated with antibiotics. Uveitis is the inflammation of the middle layer of the eye wall and symptoms include light sensitivity, pain, redness, blurred vision and headaches. Uveitis is commonly treated with corticosteroids; if left untreated it could result in glaucoma or detached retina. Inflammation in the white of the eye is called episcleritis: symptoms include pain and reddening, and treatment is with a vasoconstrictor or corticosteroid. Iritis is inflammation in the iris and symptoms include pain, light sensitivity, blurred vision, redness, decreased pupil size, and floaters. Steroids and antibiotics may be used to treat iritis. Keratophaty is an irregularity in the cornea that does not cause pain or loss of vision, and is therefore usually not treated.

Joint pains may be peripheral arthritis, which causes pain, swelling, and stiffness in the joints. The pain can migrate from one joint to the next and may last for several days or even weeks. Peripheral arthritis does not cause permanent damage to joints and will often improve when the CD is successfully treated. Treatment includes resting painful joints and applying moist heat. Other forms of arthritis may also occur with CD. (http://ibscrohns.about.com/library/weekly/aa053002a.htm)

Erythema nodosum and pyoderma gangrenosum (http://ibscrohns.about.com/library/weekly/aa111802a.htm) are skin conditions that may occur before or during a CD flare-up and improve with remission. Erythema nodosum are painful red nodules that develop on the arms or lower legs that affects more women than men. Pyoderma gangrenosum may appear as a blister on the legs or arms, usually at the site of a minor trauma such as a cut. The blister may progress into an ulcer that requires treatment with steroids or antibiotics.

A fissure (http://ibscrohns.about.com/library/weekly/aa013102a.htm) is a tear or ulcer in the lining of the anal canal and symptoms include painful bowel movements, bright red blood in toilet bowel or on paper, anal lump, and swollen skin tag. Acute fissures may be treated with Sitz baths, fiber to create softer stools, stool softeners, topical hydrocortisone, zinc oxide, petroleum jelly and topical anesthetics. A chronic fissure may need more aggressive treatment including surgery.

A fistula (http://ibscrohns.about.com/library/weekly/aa071200a.htm) is an abnormal tunnel connecting two body cavities or a body cavity to the skin. Approximately 30% of people with Crohn's Disease develop fistulas. Treatments include antibiotics, immunosuppresants, Remicade, liquid nutrition to replace solid food and surgery.

Frans_Jozef
Monday, January 17th, 2005, 01:44 PM
Types and causes of Crohn's disease.

Are there different forms of CD? Physicians may use different terms to describe CD, depending on what part of the digestive tract is affected.

The most common form of CD is ileocolits, which affects the ileum (http://ibscrohns.about.com/library/glossary/bldef-ileum.htm) (lower end of the small intestine) and the colon (large intestine). Symptoms of this type of CD include diarrhea, cramping pain in the lower right or middle abdomen, and substantial weight loss. In some cases the diseased areas in the ileum and the colon may be contiguous, affecting the ileocecal valve that connects the two sections.

Ileitis, also known as fistulizing or perforating CD, affects only the ileum. Diarrhea, cramping pain in the the lower right or middle abdomen, and discomfort a few hours after eating a meal are common symptoms.

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This type of CD can lead to nutritional deficiencies in B12, causing tingling in the fingers or toes (peripheral neuropathy), or folate (http://ibscrohns.about.com/library/weekly/aa071201a.htm), which may result in anemia (http://ibscrohns.about.com/library/weekly/aa100401a.htm). Complications can include fistulas or abscesses in the right lower quadrant.

Gastroduodenal CD affects the stomach and duodenum (http://ibscrohns.about.com/library/glossary/bldef-duodenum.htm) (first part of the small intestine). Symptoms include loss of appetite, weight loss, nausea, and vomiting. Vomiting may be a sign of obstruction in narrowed portions of the small intestine. This form of CD is sometimes misdiagnosed as an ulcer (http://ibscrohns.about.com/library/glossary/bldef-ulcer.htm), with the CD being discovered after ulcer treatments are ineffective in relieving symptoms.

Jejunoileitis is characterized by intermittent areas of inflammation in the jejunum (http://ibscrohns.about.com/library/glossary/bldef-jejunum.htm) (middle section of the small intestine). Symptoms include crampy pain after meals, diarrhea, and abdominal pain that can vary from mild to intense. Complications of jejunoileitis include fistulas (http://ibscrohns.about.com/library/glossary/bldef-fistula.htm) and malnutrition caused by poor absorption of nutrients.

Crohn's colitis (CC), sometimes called granulomatous colitis, affects only the colon and is sometimes confused with UC. However, there are two distinct differences between CC and UC: inflammation in UC is always contiguous, while in CC it is intermittent throughout the colon, and UC always affects the rectum while CC may not. Symptoms include diarrhea, bleeding from the rectum, and abscesses, fistulas, or ulcers around the anus (http://ibscrohns.about.com/library/glossary/bldef-anus.htm). Peripheral arthritis and skin conditions are found more frequently with CC than the other types of CD.

What causes CD? Scientists are not certain what causes CD, so it is known as an idiopathic disease, or a disease with unknown cause. However, there are theories about the origins of CD.

CD is an autoimmune disease, or a disease that is triggered by the immune system. The medical community has noticed seasonal flare-ups (in the spring or autumn) in people with IBD. One theory is that this is a IgE-mediated allergic response (http://ibscrohns.about.com/library/weekly/aa101200a.htm).

IgE is a type of immunoglobulin isotype, which is a special protein that helps inactivate organisms that may cause disease. The function of IgE is to bind itself to an antigen and inactivate or remove offending foreign substance. However, IgE tends to attach itself to receptors on mast cells which triggers allergy symptoms such as a runny nose. If an antigen binds itself to one of these IgE cells, the mast cells are activated, and release histamine, heparin, cytokines, leukotrines, and other chemicals.

The presense of leukotrines attracts a new type of cell called an eosinophil. These cells fight off the allergic response, but the chemicals that they use to do so are toxic to the body as well as to the invading infection. The connection between eosinophils and IBD is that three of the four toxic compounds that are released by eosinophil cells are found in in the stool of IBD patients.

A controversial theory is that the bacteria M. paratuberculosis (http://ibscrohns.about.com/library/weekly/aa053101a.htm) can also cause CD in humans. One study conducted on intestinal tissue removed during surgery from patients with CD, UC or without IBD found that 65% of the CD patient samples contained the bacteria, contrasting with only 12.5% of non-IBD patients. The researchers conclude that the bacteria may play a role in some cases of Crohn's disease.

Frans_Jozef
Monday, January 17th, 2005, 01:45 PM
The tests used to make a diagnosis.

How Is CD diagnosed? Several tests may be used by physicians to diagnose CD. If a physician suspects that IBD is the cause of symptoms, testing will help determine if it is CD or UC.

Barium enema. (http://ibscrohns.about.com/library/tests/blbariumenema.htm) A barium enema (or lower gastrointestinal series) uses barium sulfate and air to outline the lining of the rectum and colon. The barium is given in an enema which is then 'held' inside the colon while X-rays are taken. Intestinal abnormalities may appear as dark silhouettes or patterns along the intestinal lining on the X-ray. A barium enema can be performed as an outpatient procedure, and usually takes about 45 minutes. The enema might be uncomfortable, but the X-rays are completely painless.

Upper GI Series (http://ibscrohns.about.com/library/tests/bluppergiseries.htm) An upper gastrointestinal (upper GI) series utilizes X-rays to find problems in the esophagus, stomach, and duodenum.

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Sometimes it may be used to examine the small intestine. When the barium is swallowed, it coats the inside of the upper digestive tract, making them show up clearly on an X-ray. Using a flouroscope, a radiologist will watch the barium move through the digestive system while noting any problems and taking X-rays. The entire test can take 1 to 2 hours and is not uncomfortable. Blockages, abnormal growths, ulcers, scar tissue and hernias can be found with an upper GI series.

Stool culture. A physician may want to rule out other causes for bloody diarrhea, such as a bacterial infection, with a stool culture. Stool must be collected into a specimen jar and brought to a laboratory for testing in a culture. If any bacteria grow in the culture, the scientists can test it to determine what it is and how best to treat it.

Blood tests. A blood test may be used to determine a white blood cell count or if anemia (http://ibscrohns.about.com/library/weekly/aa100401a.htm) is present. Repeated bouts of bloody diarrhea may cause some people to become anemic. A white blood cell count gives physicians an indication that inflammation is taking place somewhere inside the body. An elevated white blood cell count does not tell physicians where in the body the inflammation is located, and anemia could be from one of several causes. However, both tests provide clues for physicians to use when making a diagnosis.

Fecal occult blood test. (http://ibscrohns.about.com/library/tests/blfecalblood.htm) Even though the blood in the stool may be visible to the naked eye, a physician may decide to include a fecal occult blood test. This test can detect bleeding from almost anywhere in the digestive tract. The stool collection may be done at home without any discomfort and returned to the physician or laboratory for testing.

Sigmoidoscopy. (http://ibscrohns.about.com/library/tests/blsigmoidoscopy.htm) A sigmoidoscopy is a way for a doctor to examine the last one third of the large intestine, which includes the rectum and sigmoid colon. To clear out the colon, patients may be asked to use laxatives or an enema, or have only liquid foods on the day of the test. A flexible viewing tube with a lens and light source on the end, called a sigmoidoscope, is used. A biopsy may be taken during the procedure, which will be tested to help the physician determine the cause of any inflammation. This procedure may be done either in a hospital setting or in a doctor’s office and takes about 15-30 minutes. A sigmoidoscopy is uncomfortable, but it is not painful.

Colonoscopy. (http://ibscrohns.about.com/library/tests/blcolonoscopy.htm) A colonoscopy is used to examine the inside of the colon beyond the areas a sigmoidoscopy can reach. This test uses a colonoscope, which is a flexible tube with lenses, a tiny TV camera and a light at the end. The intestine must be empty for the procedure, and physicians may prescribe one of several ways to prep (http://ibscrohns.about.com/library/weekly/aa032102a.htm) the bowel including GoLytely, Phospho-Soda and/or a liquid diet. Biopsies may be taken during the test, which is done in a hospital outpatient setting and may take up to 1 ½ hours. During the procedure patients are normally sedated or given “twilight sleep” so that they do not feel any pain or even remember the test.

Other tests may be used by physicians as needed to diagnose CD, or rule out other potential diagnoses.

Frans_Jozef
Monday, January 17th, 2005, 01:46 PM
Prescription medications used to treat CD.

What medications are used to treat CD? There are several types of medications that are frequently used to treat CD, including sulfasalazine (Azulfadine), mesalamine (Asacol, Pentasa), azathioprine (Imuran), 6-MP (Purinethol), cyclosporine, methotrexate, infliximab (Remicade) and corticosteroids (prednisone).

Sulfasalazine (Azulfadine) (http://ibscrohns.about.com/cs/sulfasalazine/). Sulfasalazine is known as a 5-ASA compound, and is the combination of two drugs:sulfapyridine and an aspirin-like compound. It works to reduce the inflammation in the colon and then as a maintenance therapy to maintain remission. This drug has an extensive history of use for CD, and is considered safe to take for long periods of time. Common side effects (http://ibscrohns.about.com/library/sideeffects/blsulfasalazine.htm)–often caused by sensitivity to the sulfa component–include nausea, headache, diarrhea and abdominal pain.

Mesalamine (Asacol, Pentasa) and Olsazine (Dipentum) (http://ibscrohns.about.com/library/weekly/aa011002a.htm). Mesalamine and olsazine are the next generation of 5-ASA compounds, and do not contain the sulfa component.

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These newer 5-ASA drugs are as effective as sulfasalazine, but tend to have fewer side effects (http://ibscrohns.about.com/library/sideeffects/bloralmesalamine.htm). Mesalamine is found to be most effective in mild or moderate cases of CD. Additionally, mesalamine has been shown to decrease the chances of a relapse after surgery for CD.

Azathioprine (Imuran), 6-mercaptopurine (Purinethol, 6-MP) and cyclosporine A (Sandimmune, Neoral) (http://ibscrohns.about.com/cs/immunosuppressants). Azathioprine, 6-MP and cyclosporine are immunosuppressants—a class of drugs that is used to inhibit the immune system. Because CD is an autoimmune disease, suppressing the immune system may lessen symptoms, but also leaves the body more susceptible to infection. Azathioprine and 6-MP have a long history of use for CD, but they are slow acting, and can take 3 to 6 months to induce remission. Therefore these drugs are often combined with another faster-acting drug, such as a corticosteroid. Cyclosporine is quicker, and high doses may induce remission in 1 to 2 weeks, but serious side effects (http://ibscrohns.about.com/library/sideeffects/blcyclosporin.htm) include, kidney damage, liver inflammation, and serious infections.

Methotrexate (Folex, Rheumatrex). Methotrexate is given by injection and tends to induce remission in 8 to 10 weeks. Side effects (http://ibscrohns.about.com/library/sideeffects/blmethotrexate.htm) range from mild symptoms of nausea, fatigue and vomiting to more serious conditions in bone marrow and the liver. Methotrexate may also cause congenital abnormalities and even death in fetuses, so pregnancy should be avoided, by both men and women, during therapy.

Corticosteroids (prednisone, methylprednisolone, etc.) (http://ibscrohns.about.com/library/meds/blprednisonefaq.htm). Corticosteroids are similar to cortisol, a steroid the body produces in the adrenal gland. This fast-acting drug (http://ibscrohns.about.com/library/weekly/aa052100a.htm) reduces inflammation in the body and is usually prescribed to curb an acute flare-up. Corticosteroids are usually given in the lowest possible dosage for the shortest amount of time to reduce incidence of side effects (http://ibscrohns.about.com/library/sideeffects/blprednisone.htm). Care must be taken when lessening the dosage because the body stops or decreases its own production of cortisol during drug therapy. Slowly tapering the amount of the corticosteroids taken daily allows the body to begin producing it again on its own.

Infliximab (Remicade) (http://ibscrohns.about.com/library/meds/blremicadefaq.htm). Infliximab is a monoclonal antibody that stops tumor necrosis factor alpha (TNF-alpha) from being used by the body. TNF-alpha is found in higher than normal amounts in people with Crohn's disease. Infliximab is given by infusion in a hospital or doctor's office setting. Side effects (http://ibscrohns.about.com/library/sideeffects/blremicade.htm) include abdominal pain, nausea, fatigue, vomiting and rarely, infection..

Budesonide (Entocort EC) (http://ibscrohns.about.com/library/meds/blentocortfaq.htm). is used to treat mild to moderate Crohn's disease involving the ileum and/or the ascending colon. Budesonide is a nonsystemic corticosteroid that is released into the intestine and works to reduce inflammation. Because 90% of the drug is released in the intestine and not into the bloodstream, it causes fewer side effects than other corticosteroids (i.e., prednisone). Budenoside is approved for use for up to 8 weeks and side effects include headache, respiratory infection, and nausea.

Frans_Jozef
Monday, January 17th, 2005, 01:48 PM
Surgery, risk of cancer, and pregnancy.

What types of surgery are used to treat CD? Surgery (http://ibscrohns.about.com/library/weekly/aa011002a.htm) may also be used to treat CD, usually after all available drug treatments have failed. Anywhere from 40 to 60% of CD patients who have disease in the small bowel will have surgery in the first 10 years after diagnosis. Several different types of surgery are used to treat symptoms and complications of CD, yet none are a cure.

Resection. The most common type of surgery is the resection, during which surgeons remove a diseased piece of the intestine and reconnect the two healthy ends. Resections are common, and may be repeated as the disease recurs in different sections of the intestine.

Strictureplasty. Surgeons use stricturplasty to open up narrowed sections of the intestine (strictures (http://ibscrohns.about.com/library/glossary/bldef-stricture.htm)) by making an incision lengthwise along the stricture and closing it in the opposite direction.

Ileostomy. An ileostomy is the complete removal of the colon and a creation of a stoma for eliminating waste.

Links

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A stoma is the opening in the abdomen through which waste can leave the body from the small intestine. An ostomy bag must be worn on the abdomen to catch waste materials. Continent ostomies (j-pouch, etc.) are not appropriate for CD, as the disease may re-occur in the section of the intestine used to create the continent pouch.

Should I be worried about cancer? For persons with CD, there are several factors that seem to affect the risk of developing colorectal cancer (CRC). These risks include: a young age at onset, 8 to 10 years of active disease, incidence of strictures and a history of primary sclerosing cholangitis. There are no current screening guidelines for long-standing CD as there are for UC (a colonoscopy every 1 or 2 years after 8 to 10 years of disease). However, physicians may recommend a colonoscopy every 2 to 3 years after 8 to 10 years of CD and every 1 to 2 years after 20 years of CD.

Small bowel cancer is extremely rare, but it appears to be associated with CD located in the ileum. However, more than 90% of IBD patients never develop cancer. A gastroenterologist can make an individualized assessment of cancer risk based on history, other risk factors, and the extent and duration of CD.

Is there anything that people with CD should avoid? People who smoke (http://ibscrohns.about.com/library/weekly/aa080502a.htm), or who have smoked in the past, have a higher risk of developing CD. CD patients that smoke have an increased number of relapses, repeat surgeries, and aggressive immunosuppressive treatment. People with CD are generally encouraged to stop smoking by their physicians in order to prevent flare-ups of the disease.

NSAIDs (http://ibscrohns.about.com/library/weekly/aa082301a.htm) (Non-Steroidal Anti-Inflammatory Drugs) such as ibuprofen and naproxen sodium can cause inflammation and worsen bleeding in the small intestine. They can even knock some people with IBD out of remission. People with IBD should consult with their gastroenterologist before taking NSAIDs, even those available over the counter.

Can women with CD have children? A healthy pregnancy and baby are both possible. The course of IBD throughout the term of a pregnancy tends to remain similar to the condition of the disease at the time of conception.

For women with UC and CD in remission, the risk of miscarriage, stillbirth and congenital abnormality are the same as those for healthy women. A flare-up of CD at the time of conception or during the course of the pregnancy is associated with a higher risk of miscarriage and premature birth.

Is CD inherited? There seems to be a stronger risk of inheriting CD than UC, especially in Jewish families. However, children who have one parent with Crohn's disease have only a 7-9% lifetime risk of developing the condition, and just a 10% risk of developing some form of IBD. If both parents have IBD this risk is increased to about 35%.

What is the prognosis for people with CD? With proper medical care, most people with CD lead long, productive lives. New medications and research into the causes of IBD continue to increase the quality of life for people with IBD.


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