Crohn's Disease

What is Crohn’s disease?
Crohn's disease is a chronic inflammatory disease of the gastrointestinal (GI) tract. It is predominantly found in the small intestine and colon, but can occur anywhere in the GI tract.

In Crohn’s disease, the body’s immune system reacts as if it’s under attack. The body responds as it would to any germ or infectious process and produces a protein called TNF-alpha. This protein then causes inflammation in the intestine that leads to painful symptoms — abdominal cramping, pain and diarrhea. The disease can even injure the bowel.

What are the symptoms of Crohn’s disease?
Pain usually occurs around or beneath the navel — often in the lower right part of the abdomen — and seems to worsen after meals. Other symptoms include appetite loss, bleeding from the rectum, weight loss, fever, joint pain, fatigue and sores around the anal area. Children with Crohn’s disease sometimes have delayed growth.

This disease often has periods of worsening and of dormancy. Even when the symptoms are dormant, the disease doesn’t go away. Flare-ups can be short or long, mild or severe. In severe cases, a fistula or pathway opens between the intestinal walls or even between the intestine and the skin, vagina or bladder.

Crohn’s disease can be difficult to diagnose because the symptoms are similar to many other diseases and conditions. Other conditions that may have similar symptoms include ulcerative colitis; appendicitis; irritable bowel syndrome; diverticulitis; peptic ulcer disease; inflammation of the pancreas or gallbladder; cysts or tumors of the ovaries or fallopian tubes; pelvic inflammatory disease; intestinal cancer; and infections.

What is the prevalence of Crohn’s disease?
In the United States, about 1 million people have either Crohn’s disease or ulcerative colitis.*

What causes Crohn’s disease?
The cause is currently unknown, but there is a genetic tendency toward the disease. A parent with Crohn’s disease has about a four percent chance of having a child develop the disease.

Is there a cure for Crohn’s disease?
Crohn’s disease progresses over time and there is no cure. The earlier Crohn’s is diagnosed, the better your chances of controlling the symptoms.

How is the disease diagnosed?
Common diagnostic tools are blood tests, stool samples, barium X-rays of the intestinal tract, flexible sigmoidoscopy or colonoscopy. The physician also will take a history of your symptoms.

To help your doctor, make a diary of how often you have symptoms, what your stools are like, how often you have bowel movements, the severity of the pain and when the pain is worst.

How is Crohn’s disease treated?
Patients with Crohn’s disease can be treated medically or surgically. The medical course is symptomatic care (when symptoms flare) as well as medications to prevent flares (remission). One generally follows a step-by-step approach to medication therapy until the symptoms decline. The doctor may start with metronidazole, ciprofloxacin or aminosalicylates. If these medications don’t help, the second step is corticosteroids to provide quick relief of symptoms and a decrease in inflammation. However, these cannot be taken for long periods of time because of potential side effects of steroids.

If the corticosteroids fail or if the patient cannot stop taking them without having symptoms, the next step is an immunomodulatory agent — 6-MP or azathioprine. These aren’t used for acute flare-ups because it may take two to three months to relieve the symptoms. Blood counts must be taken to protect patients from taking too much of the medication. Instead of using immunomodulatory agents, some physicians prescribe infliximab, a monoclonal antibody against TNF. This is given through the blood vessels as one dose, or three doses followed by a maintenance-dosing schedule. This medication is very expensive, and some insurance plans won’t pay for it — the patient should check first. Finally, the physician may prescribe methotrexate.

Crohn’s disease can involve any part of the gastrointestinal tract from the mouth to the anus. So removing the inflamed part is not a cure. Surgery is reserved for complications/problems associated with Crohn's disease that do not resolve with medical management. However, in some cases, a surgeon may need to remove part of the affected bowel (small or large bowel) to allow the remainder of the bowel to rest. In other cases, some patients have strictures that block the flow of stool; in these cases, the surgeon may operate to remove the strictures.

Surgeries include removal of the small bowel and/or colon with small bowel, ileorectal or ileocolonic anastomosis.** In patients with severe fistulas, a diverting ileostomy or colostomy is a surgical option. The part of the bowel past where the ostomy is created is allowed to heal. If healing is possible, then the ostomy can be closed. Many patients who pursue this option choose to keep the ostomy because they feel that life is much improved.

To make an appointment with a Washington University colorectal surgeon, please call (314) 454-7177.

*Ulcerative colitis is a chronic inflammatory condition of the colon. It is closely related to Crohn’s disease, but is a different disease.

** Removal of the inflamed part of the distal small bowel and beginning of the colon and surgical joining of the ileum (the last division of the small intestine) directly to the remaining colon.