Crohn's Disease

Crohn's Disease: Overview

Alternative Names: Regional Enteritis or Ileitis.

Crohn's Disease causes inflammation in the small intestine.  Crohn's disease usually occurs in the lower part of the small intestine, called the ileum, but it can affect any part of the digestive tract, from the mouth to the anus.  The inflammation extends deep into the lining of the affected organ.  The inflammation can cause pain and can make the intestines empty frequently, resulting in diarrhea.

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Ulcerative colitis and Crohn's disease are known as the inflammatory bowel diseases (IBD).  When the intestinal immune system does not function properly, many white blood cells accumulate in the inner lining (mucosa) of the gut.  The white cells then release chemicals that lead to tissue injury in the form of inflammation.  This inflammation of the mucosa can cause diarrhea, which is the most common symptom of IBD, with or without intestinal complications.

Both Crohn's disease and ulcerative colitis are chronic diseases that involve inflammation of the gastrointestinal tract.  However, ulcerative colitis only affects the colon (large intestine), while Crohn's disease can affect the entire digestive system, from the mouth to the anus.

Causes and Development

The precise cause of IBD remains unknown.  These diseases are believed to be caused by a combination of genetic and non-genetic, or environmental factors (such as infections) that interact with the body's immune system.

The two primary sites for Crohn's disease are the ileum, which is the last portion of the small bowel (ileitis, regional enteritis), and the colon (Crohn's colitis).  The condition begins as small, microscopic nests of inflammation which persist and smolder.  The lining of the bowel can then become ulcerated and the bowel wall thickened.  Eventually, the bowel may become narrowed or obstructed and surgery may be needed.

Signs and Symptoms

It is important to note that not only does Crohn's disease affect the small intestine and large intestine, it can also affect the mouth, esophagus, stomach and the anus.

Diagnosis and Tests

The diagnosis is suggested by signs and symptoms.  Additional testing to help make the diagnosis may include barium X-rays of the upper and lower GI tract, flexible sigmoidoscopy, and sometimes colonoscopy.  The last two tests permit a direct examination of the colon with a lighted tube inserted through the anus.  During these tests, biopsies may be obtained to help make a diagnosis.  Laboratory tests are also helpful and include evaluation of the blood and stool.

Because Crohn's disease often mimics other conditions and symptoms may vary widely, the correct diagnosis of Crohn's disease may take some time.

Laboratory Findings

  • Leukocytosis and increased sedimentation rate occur during the acute inflammatory phase.
  • Hypochromic, microcytic anaemia due to chronic blood loss.
  • Occult blood in stool due to intestinal mucosal bleeding
  • Decreased serum albumin and total protein due to loss of protein from the intestinal mucosa and to impaired dietary intake.
  • Increased alkaline phosphatase, serum glutamic-oxaloacetic transminase (SGOT) (AST {aspartate aminotransferase}) or bilirubin due to associated liver disease.
  • Increased urine oxalate and calcium oxalate renal calculi due to increased colonic absorption of dietary oxalate.

Treatment and Prevention

Patients with Crohn's disease have very individual food intolerances.  For some, they are lactose intolerant and feel better avoiding dairy products; for others, they avoid raw vegetables.  There is no one prescription for all patients with Crohn's disease in terms of what to avoid.

Interestingly, drug therapies used to fight the ulcer-causing bacteria Helicobacter Pylori may also help treat Crohn's disease.  Researchers have reported that "after treatment [with antibiotics against H.  Pylori], clinical remission [of Crohn's disease] was achieved in all patients", regardless of the type of therapy received.  At the same time, H. pylori infection was eradicated in 28 of the 30 infected patients.

"What this shows is that by eradicating H. pylori infection... we achieved a remission of Crohn's disease," Dr. Mantzaris explained.  The authors stress that their findings do not mean that H. pylori causes Crohn's disease.  But it does raise the issue of "whether regimens aimed at eradicating H. pylori in infected patients with Crohn's disease may also achieve remission of Crohn's disease."

Complications

Complications include Peritonitis, Gastrointestinal bleeding, Impaired intestinal absorption, Amyloidosis, Arthritissynovial fluid similar to that of rheumatoid arthritis, but with negative rheumatoid factor, Ankylosing spondylitis.

Signs, symptoms & indicators of Crohn's Disease:

Lab Values - Cells

Lab Values - Chemistries

Symptoms - Abdomen

Moderate/major/severe mid-abdomen pain after food

Pain usually begins within an hour of eating and is most often around the navel, the lower-right abdomen, or both.  The area is usually painful to the touch.

Moderate/major/severe right iliac pain after food

Pain usually begins within an hour of eating and is most often around the navel, the lower-right abdomen, or both.  The area is usually painful to the touch.

Mild/moderate/significant/severe meal-induced pain

Pain usually begins within an hour of eating and is most often around the navel, the lower right abdomen, or both.  Usually painful to the touch.

Symptoms - Bowel Movements

Counter-indicators
Counter-indicators

Symptoms - Food - General

Symptoms - Gas-Int - General

Symptoms - Metabolic

Symptoms - Reproductive - General

Genital sores

Medical illnesses such as Crohn's Disease can on occasion cause genital lesions.

Conditions that suggest Crohn's Disease:

Autoimmune

Ankylosing Spondylitis

Bowel inflammation is somehow tied to the development of ankylosing spondylitis and this is the reason why people with Crohn's disease or ulcerative colitis are at increased risk of the illness.

Counter-indicators
Gluten Sensitivity / Celiac Disease

Having been diagnosed with celiac disease implies a much lower chance of Crohn's disease being the explanation for one's symptoms.

Circulation

Diet

Digestion

Heartburn / GERD / Acid Reflux

Crohn's disease is a chronic ailment that causes inflammation and injury in the colon and other parts of the gastrointestinal tract, including the esophagus.

Counter-indicators

Infections

Canker Sores (Aphthous Ulcers)

Crohn's disease causes inflammation of the gut, leading to ulcers developing in both the stomach and mouth.

Lab Values

Elevated Homocysteine Levels

Homocysteine levels are increased in patients with Crohn's disease.  [Am J Gastroenterol.  2000 Dec;95(12): pp.3498-502]

Nutrients

Folic Acid Deficiency

All inflammatory bowel disease patients are prone to low serum folate levels.

Symptoms - Gas-Int - General

Counter-indicators

Tumors, Malignant

Small Intestine Cancer

Adenocarcinoma of the small bowel is associated with Crohn's disease, which usually occurs in the lower part of the small intestine (the ileum).  The inflammation extends deep into the lining of the affected organ, causing pain and making the intestines empty frequently, resulting in diarrhea.  For those with Crohn's disease, the risk of developing small intestinal cancer is 6 times greater than for those without it.  Additional risk factors for those with Crohn's disease include:

  • Being male
  • Having a long history of Crohn's
  • Fistulous disease that is associated with Crohn's
  • Surgical removal of part of the bowel.

Risk factors for Crohn's Disease:

Autoimmune

Childhood

Past and future vaccination or past vaccinations

Based on a study of 3,545 people who received live measles vaccine as children, their rate of developing ulcerative colitis was 2.5 times higher (3 times higher for Crohn's) compared to an unvaccinated group.

Circulation

Hormones

Infections

Bacterial Dysbiosis

During the early 1980s, exaggerated immunologic responses to components of the normal fecal flora were proposed as possible mechanisms behind inflammatory bowel disease.  Little progress has been made in confirming or disproving this theory, although bacterial overgrowth of the jejunum has been found in 30% of patients hospitalized for Crohn's disease, in which it contributes to diarrhea and malabsorption.  The demonstration of increased intestinal permeability in patients with active Crohn's disease and in healthy first degree relatives suggests the existence of a preexisting abnormality, such as dysbiosis, that allows an exaggerated immune response to normal gut contents to occur.

Elimination diets can induce remission in Crohn's disease as effectively as prednisone.  The primary bacteriologic effect of elemental diets is to lower the concentration of Lactobacilli in the stool drastically without altering levels of other bacteria.

Medical Procedures

Appendix removed after/appendix removed before age 20

A study reported in the January 2003 issue of the journal Gastroenterology found that people who had their appendix removed were 47% more likely to develop Crohn's disease than those who did not have the surgery.

A much larger study followed 709,353 appendectomy patients in Sweden and Denmark for up to 41 years.  It found that "Children who underwent an appendectomy before the age of 10 years were not at an increased risk, whereas appendectomies at all age groups above the age of 10 years were associated with a significantly elevated risk of Crohn's disease".  The risk of developing Crohn's Disease is at least 3 times higher within a year of undergoing an appendectomy.

Symptoms - Food - Intake

(Low/high) dairy product consumption

Johne's disease is an infection that cows pass on to humans as irritable bowel syndrome.  Johne's disease has no cure and costs dairy producers over $1.5 billion each year [Source: USDA].  The bacterium, Mycobacterium avium paratuberculosis (MAP) causing Johne's is not killed by pasteurization and is passed onto consumers in milk, cheese and ice cream.  Forty million Americans have irritable bowels and over 500,000 have gone on to develop Crohn's disease.

"Mycobacterium paratuberculosis RNA was found in 100% of Crohn's disease patients, compared with 0% of controls." [Mishina, Proceedings National Academy of Sciences USA: 93: September, 1996]

The bacterium (MAP) does not cause tuberculosis in humans, but there is growing evidence linking it to Crohn's disease.  British tests, released in January 2000, showed that Mycobacterium paratuberculosis can survive pasteurization, prompting the USDA to re-examine 1999 tests that showed pasteurization kills it.

August 5th, 2003, London: British scientists have found a link between Crohn's disease and MAP.  Professor John Hermon-Taylor and his team at St George's Hospital Medical School in London said they had detected MAP bacteria in 92% of patients with Crohn's disease, but in only 26% of patients in a control group.

"The rate of detection of MAP in individuals with Crohn's disease is highly significant and implicates this pathogen in disease causation," they said in the Journal of Clinical Microbiology.  They called for Crohn's to be made a reportable disease, for more stringent milk pasteurization, for tests for MAP in dairy herds, and procedures for reducing MAP infection on farms.

Hermon-Taylor said an unexpected finding of the research showed that patients suffering from irritable bowel syndrome (IBS) may also be infected with MAP.  "In animals, MAP inflames the nerves of the gut," he said.  "Recent work from Sweden shows that people with IBS also have inflamed gut nerves.  There is a real chance that the MAP bug may be inflaming people's gut nerves and causing IBS."

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Crohn's Disease suggests the following may be present:

Autoimmune

Infections

Bacterial Dysbiosis

During the early 1980s, exaggerated immunologic responses to components of the normal fecal flora were proposed as possible mechanisms behind inflammatory bowel disease.  Little progress has been made in confirming or disproving this theory, although bacterial overgrowth of the jejunum has been found in 30% of patients hospitalized for Crohn's disease, in which it contributes to diarrhea and malabsorption.  The demonstration of increased intestinal permeability in patients with active Crohn's disease and in healthy first degree relatives suggests the existence of a preexisting abnormality, such as dysbiosis, that allows an exaggerated immune response to normal gut contents to occur.

Elimination diets can induce remission in Crohn's disease as effectively as prednisone.  The primary bacteriologic effect of elemental diets is to lower the concentration of Lactobacilli in the stool drastically without altering levels of other bacteria.

Crohn's Disease can lead to:

Diet

Digestion

Nutrients

Folic Acid Deficiency

All inflammatory bowel disease patients are prone to low serum folate levels.

Tumors, Malignant

Colon Cancer

Inflammatory bowel disease increases the risk of colon cancer.

Recommendations for Crohn's Disease:

Amino Acid / Protein

Not recommended
Glutamine

Although glutamine is known to play a role in small intestine function, in Crohn's disease at least two studies have shown it to be mildly harmful.  [J Parenter Enteral Nutr 24:196, 2000]

However, there are those who believe it to be beneficial, and advise 1,000mg L-glutamine twice a day.  More research is needed.

Botanical

Robert's Formula

See the link between Crohn's and Slippery Elm.

Slippery Elm

Slippery elm's soothing mucilage effect has been used for disorders of the gastrointestinal tract.  It is part of the herbal combination called "Robert's Formula", which is widely prized by naturopathic physicians for such intestinal inflammations as gastritis, Crohn's disease, and ulcerative colitis.  For digestive disorders, taking 500-1,000mg of powder tid is often recommended.  It may be used in lozenge form as well.

Diet

Dairy Products Avoidance

Mycobacterium paratuberculosis (Para-T) RNA (a bacteria causing Johne's disease in cows) was found in 100% of Crohn's disease patients, compared with 0% of controls.

This bacteria becomes cultured in milk, and is not destroyed by normal pasteurization.  Para-T crosses the species barrier to infect and cause disease in humans.  Occasionally, the milk-borne bacteria will begin to grow in the human host, and irritable bowel syndrome and Crohn's disease results.  The USDA estimates that 30% of America's dairy herds contain cows infected with Para-T.

Therapeutic Fasting

Fasting is an important element of treatment if a sustained remission is to be expected.

Gluten-free Diet

See the link between Crohn's and Sugar Avoidance / Reduction.

Sugar Avoidance / Reduction

Elaine Gottschall, author of Breaking the Vicious Cycle, has proposed that gut dysbiosis is a major cause of Crohn's disease, with small and large bowel fermentation being a key component.  She has used a Specific Carbohydrate Diet (SCD) restricted in disaccharide sugars and devoid of cereal grains to alter gut flora.  When digestion of carbohydrates such as starches and some sugars is impaired, these items are poorly absorbed.  Yeast and bacteria can then overgrow in response to these newly available nutrients, increasing toxic by-products and mucus production, resulting in further injury to the small intestine and malabsorption.  Digestion is worsened – thus "the vicious cycle".  The purpose of the SCD is to deprive the microbial world in the small intestine of food it needs to overpopulate and irritate.

Not recommended
Raw Food Diet

Foods that worsen diarrhea should be avoided: specific food problems may vary from person to person.  Some people may need to avoid raw fruits and vegetables.

Not recommended
Increased Fruit/Vegetable Consumption

In one trial, patients (rather than doctors) were asked which foods aggravated Crohn's disease symptoms.  Those without an ileostomy said that raw fruit and tomatoes were among the most problematic foods, though responses varied from person to person, and other reports have come up with different lists.  People with Crohn's disease wishing to identify and avoid potential problem foods should consult a doctor.

Digestion

Probiotics

Use of a good probiotic product can help keep the bacterial flora in balance and reduce inflammation.  Caution is advised with active inflammation, as bacteria may penetrate the gut wall and enter the blood stream.

Drug

Habits

Tobacco Avoidance

A study of 474 smokers with Crohn's disease found that patients who stopped smoking for more than 1 year had similar rates of flare-ups as patients who never smoked, and both groups had fewer problems than current smokers.  Quitters, for example, had a 65% lower risk of flare-up than patients who were still smoking [Gastroenterology, April 2001].  Furthermore, smoking significantly increases the likelihood for Crohn's disease symptoms after surgery, particularly in women and heavy smokers.

Lab Tests/Rule-Outs

Test for Helicobacter Pylori Infection

Drug therapies used to fight the ulcer-causing bacteria Helicobacter Pylori may help treat Crohn's disease.  Researchers recently reported that "after treatment [with antibiotics against H.  Pylori], clinical remission [of Crohn's disease] was achieved in all patients", regardless of the type of therapy received.  At the same time, H. pylori infection was eradicated in 28 of the 30 infected patients.

"What this shows is that by eradicating H. pylori infection... we achieved a remission of Crohn's disease," Dr. Mantzaris explained.  The authors stress that their findings do not mean that H. pylori causes Crohn's disease.  But it does raise the issue of "whether regimens aimed at eradicating H. pylori in infected patients with Crohn's disease may also achieve remission of Crohn's disease."

Test for Food Allergies

Finding out which foods may be triggering the inflammatory reaction is an important part of treating this disease.  Often wheat, corn, dairy, and eggs are involved as in ulcerative colitis.

Mineral

Zinc

Tissue damaged by Crohn's disease has an enhanced recovery rate with adequate zinc.

Nutrient

Superoxide Dismutase

A study from France demonstrated the use of an antioxidant called superoxide dismutase and desferoxamine (an iron chelating drug) which allowed 82% of severe Crohn's patients to go into remission.

Essential Fatty Acids

A study by Japanese researcher Kuroki found that, compared with control subjects, Crohn's patients had lower concentrations of Omega-3 essential fats and higher concentrations of the monounsaturated fatty acids Omega-7 and Omega-9.  These results indicate EFA deficiency.  Among the fatty acids that correlated with the Crohn's disease activity index, EPA and total Omega-3 polyunsaturated fatty acids showed the most significant negative correlations.  The less of these fatty acids present, the worse the disease.  [Digestive Diseases and Sciences; 1997; 42(6): pp.1137-41, Fatty Acid Patterns in Patients with Chronic Intestinal Disease, Metabolism 1996; 45(1): pp.12-23]

Fish oil, the only current means of getting EPA without equal amounts of DHA, may delay relapses in Crohn's disease due to its anti-inflammatory effect.  Dr Belluzzi, MD tried a new way of delivering the fish oil to the intestine by putting it in a capsule that would not dissolve in the stomach for at least 30 minutes.  As a result, the overall dose of fish oil could be reduced by a third and the unpleasant taste of the oil was avoided.  78 Crohn's patients took part in a trial for one year; 39 were given the fish oil and the other 39 were given a placebo in an identical capsule.

At the end of the year the doctors checked which patients were still in remission and which had experienced a flare-up of symptoms.  59% of the patients who took the fish oil were still in remission, compared with only 26% of those who were given the placebo.

About 10% of the patients who were given the fish oil dropped out of the trial because of increased diarrhea, but Dr Belluzzi believes that the coated fish oil capsules could offer an effective way to prolong remission for Crohn's patients.  The patients involved in the trial had some evidence of mild inflammation before starting the trial and that the fish oil may have helped by treating this rather than by preventing inflammation from actually starting.  He estimates that about 30-40% of Crohn's patients are likely to have a mild level of inflammation similar to those people involved in the trial.

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