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Overview |
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Definition |
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Crohn's disease is a chronic, segmental inflammation of the gastrointestinal
tract. It may involve either or both the small and large intestine, yet the
majority of cases involve the terminal ileum. Clinical presentation and numerous
possible complications correlate with anatomic location. In the general
population, about 6 to 7 per 100,000 people acquire Crohn's disease
yearly. |
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Etiology |
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The etiology of Crohn's is unknown. Various hypotheses include autoimmune,
microbial pathogen, virus, and abnormal immune response
theories. |
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Risk Factors |
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- Age—peak incidence at 15 to 25 and 55 to 65
years of age
- Jews (three to eight times more common than general
population)
- Caucasians > blacks, but gap is narrowing
- Females, slightly
- Genetic tendency
- Smokers
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Signs and Symptoms |
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- Diarrhea
- Abdominal pain, distention
- Fatigue
- Weight loss, malnutrition
- Fever
Possible symptoms:
- Diarrhea
- Bleeding
- Perianal involvement
- Fistulae
- Vomiting, nausea
- Megacolon
Extraintestinal symptoms:
- Colitic arthritis
- Ankylosing spondylitis
- Urinary tract—infections,
occlusions
- Uveitis, episcleritis, thrombosis
- Hepatitis, cirrhosis, fatty liver, pericholangitis
- Gallstones, sclerosing cholangitis
- Erythema nodosum, pyoderma gangrenosum
- Kidney stones
- Renal amyloidosis
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Differential
Diagnosis |
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- Ulcerative colitis
- Behçet's syndrome
- Appendicitis
- Irritable bowel syndrome
- Ileitis
- Amebiasis
- Diverticulitis
- Hemorrhoids, anal fissures
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Diagnosis |
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Physical Examination |
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The patient appears weak, showing signs of malnutrition. The abdomen may be
tender or distended on palpation. Auscultation reveals hyperactive bowel.
Fistulas may be apparent. |
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Laboratory Tests |
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- Blood work may show anemia, thrombocytosis, decreased hematocrit,
increased orosomucoid levels, elevated leukocyte count (sometimes indicating
abscess), malnutrition
- Elevated erythrocyte sedimentation
rate—especially in colonic disease
- Hypoalbuminemia—indicates severity and
malnutrition
- B12 and folate
deficiency
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Pathology/Pathophysiology |
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- Inflammation
- Transmural (extending from mucosa to serosa through bowel
wall)
- With fibrosis, leads to obstruction, strictures, intestinal wall
thickening, lumen narrowing
- Transmural inflammation forms transmural fissures
- Mesentery—edematous and thickened
- Cobblestoning—aphthoid ulcers enlarge and
connect to form stellate and linear ulcers, producing a nodular appearance as
ulcers are separated by areas of normal mucosa
- Fistulas—develop from base of aphthoid
ulcers
- Abscesses—crypt abscesses with neutrophil
infiltrate
- Decreased size of bile salt pool from extensive ileal resection
results in fat malabsorption
- Polymorphonuclear cells in surface epithelium
- Granulomas—in submucosa, liver, lymph nodes,
peritoneum, mesentery
- Axonal necrosis of autonomic
nerves
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Imaging |
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- Computed tomography—shows abscesses,
perforations, bowel wall thickening, perianal disease
- Barium X rays—show lesions, strictures,
ulcers, fistulae, narrowed lumen; side effect—barium
enema may induce toxic megacolon in some colitis cases
- Single contrast radiography—shows colonic
dilation with toxic megacolon
- Ultrasound— shows abscesses (used for
percutaneous drainage procedures), bowel wall thickening
- Fluoroscopy—shows thickening of mesentery,
bowel wall
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Other Diagnostic
Procedures |
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No single finding is diagnostic. Diagnosis is based on history, laboratory,
clinical, and endoscopic findings.
- Proctoscopy—if abnormal, rules out irritable
bowel syndrome; may reveal aphthoid ulcers
- Colonoscopy—shows extent of mucosal disease,
lesions, strictures, ulcers; biopsies taken may reveal granulomas,
inflammation
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Treatment Options |
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Treatment Strategy |
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Although some treatments delay recurrence, all treatments, including surgery,
are strictly palliative. |
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Drug Therapies |
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Corticosteroids—prevents/suppresses inflammation;
first rule out abscesses, can cause sepsis; ineffective maintenance therapy;
side effects, osteoporosis and cataract formation; dose reduced by concurrent
immunosuppressive and antidiarrheal drugs.
- Prednisone—20 to 40 mg/day for 10 to 14 days,
taper by 5 mg every 7 to 10 days after four to six weeks or maintain at 5 to 10
mg/day for chronic activity; one- to three-week response time
- Parenteral corticosteroids—for severe
symptoms
Sulfasalazine—500 mg bid increasing to 3 to 4 g/day
if tolerated, take with folic acid 1 mg/day; mainstay for colonic involvement;
three- to four-week response time; side
effects—dyspepsia, nausea, neutropenia, hemolysis, may
be controlled with lower dose; active agent is 5-ASA.
- Oral 5-ASA—(e.g., mesalamine up to 4.8
mg/day), three- to four-week response time; prolongs remission; well
tolerated
- Enema or suppository 5-ASA—(e.g.,
mesalamine); six-week response time
Immunosuppressives—block lymphocyte activation,
proliferation, and effector mechanisms; for patients refractory to other
treatments.
- 6-mercaptopurine or azathioprine—begin at 50
mg/day, increasing to 2 mg/kg/day if tolerated; three-month response time; with
ileal resection; side effects—leukopenia, hepatitis,
pancreatitis, rash
- Methotrexate—25 mg/week intramuscularly for
three months then change to oral and taper, take with folic acid 1 mg/day; side
effects—leukopenia, pneumonitis, liver abnormalities,
requiring liver biopsy after 1,500 mg total dose
- Cyclosporine—5 to 7.5 mg/kg/day; few days
response time but frequent renal toxicity
Antidiarrheal drugs—loperamide and diphenoxylate;
cholestyramine (4 g/day or bid ) and a low-fat diet for ileal resection; risk of
toxic megacolon with severe disease; limit addictive agents; bran and psyllium
good stabilizers
Broad-spectrum antibiotic therapy—for abscesses,
colitis, ileocolitis, ileal resection, perianal disease (e.g., metronidazole 10
mg/kg/day); two- to four-week response time; side effects include nausea,
anorexia, paresthesias (reversible, dose dependent); six-month use may prolong
remission.
Psychotropic agents and support groups for psychosocial
pressures. |
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Surgical Procedures |
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Indicated in 70% of patients; for abscesses, fistula, obstruction, toxic
megacolon, recurrent hemorrhaging, and failure of medical management; not
curative. Repeated surgeries may be required, with possible consequence of short
bowel syndrome. |
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Complementary and Alternative
Therapies |
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Although the etiology of Crohn's disease is not understood, nutritional
support and herbal therapies can be very effective at minimizing the sequelae of
malabsorption as well as possibly facilitating the healing of gut mucosa.
Specifically, nutrition and herbs can enhance the integrity of the intestinal
mucosa by possibly restoring the mucosal barrier and reducing intestinal
permeability. Homeopathy may be helpful in acute cases. Mind-body therapies,
such as meditation, yoga, and tai chi may help reduce the frequency and severity
of exacerbations. |
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Nutrition |
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- Eliminate all known allergens in addition to highly allergenic foods
linked to Crohn's disease, specifically, wheat, corn, and dairy. Eliminate
pro-inflammatory foods and saturated fats such as caffeine (including
chocolate), animal products, sugar, and alcohol.
- Consider an elimination/challenge or a five-day rotation
diet.
- Increase fiber and omega-3 oils (e.g., flaxseed oil, 1
tbsp./day).
- Normalize gut microflora with supplementation of acidophilus (one
capsule with meals).
- Replace vitamins and minerals associated with malabsorption syndromes:
A (50,000 IU/day), E (400 to 600 IU/day), B12 (1,200 mcg/day), folate
(800 mcg, 1,200 mcg/day with sulfasalazine use), C (1,000 mg tid), calcium
(1,000 mg/day), magnesium (400 mg/day), zinc (30 to 40 mg/day), selenium (200
mcg/day).
- Eliminate refined, processed products that may compromise gut
mucosa.
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Herbs |
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Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or
tinctures (alcohol extraction, unless otherwise noted). Dose for teas is 1
heaping teaspoon herb/cup water steeped for 10 minutes (roots need 20
minutes).
- Robert's Formula is a traditional herbal blend that may help to soothe
intestinal tissues, restore the integrity of the intestinal barrier, and reduce
inflammation. Robert's Formula: marshmallow root (Althaea officinalis),
wild indigo (Baptisia tinctoria), coneflower (Echinacea purpurea),
geranium (Geranium maculatum), goldenseal (Hydrastis canadensis),
poke root (Phytolacca americana), comfrey (Symphytum officinale),
slippery elm (Ulmus fulva), cabbage powder, pancreatin, and niacinamide.
Two capsules bid to qid.
- Flavonoids can help reduce inflammation and minimize reactions to food
sensitivities. Quercetin (500 mg) before meals.
- Marshmallow tea (1 qt. daily) is soothing. Make a cold-water
extraction by soaking 1 heaping tablespoon of root in 1 quart of cold water
overnight. Drink throughout the day.
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Homeopathy |
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An experienced homeopath would consider an individual's constitutional type
to prescribe a more specific remedy and potency. Some of the most common acute
remedies are listed below. Acute dose is three to five pellets of 12X to 30C
every one to four hours until symptoms resolve.
- Aloe for gushing diarrhea with clumps of mucus; sense of
weakness and venous congestion in the anus
- China officinalis for diarrhea with bloating and rumbling
ameliorated by hard pressure
- Podophyllum for explosive, foul, watery diarrhea that may be
yellow, pasty, mucus-filled, or bloody
- Mercurius vivus for offensive stools accompanied by a sensation
of fullness
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Acupuncture |
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May help normalize digestive function |
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Massage |
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May help relieve stress |
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Patient Monitoring |
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Closely monitor patients during periods of active disease. Counseling and
support may be necessary due to long duration of active disease and
chronicity. |
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Other
Considerations |
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Complications/Sequelae |
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- Obstruction—from adhesions, scarring, mucosal
thickening, muscular hyperplasia
- Abscesses—15% to 20% of patients; occur in
terminal ileum, liver, spleen, site of anastomosis
- Fistulas—20% to 40% of patients; commonly
enteroenteric or enterocutaneous; usually involves terminal ileum
- Colon cancer—with colonic Crohn's only;
younger onset, higher incidence than general population, increases with
duration
- Perianal disease—ulcers, abscesses, fistulas;
may destroy anal sphincter
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Prognosis |
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- Within 10 years of diagnosis, 60% to 70% of patients have surgery,
with a 70% rate of recurrence at one year
- Periods of remission
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Pregnancy |
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- Spontaneous abortion—slightly higher (12.2%
versus 9.9%); premature births and defects—similar to
general population
- Corticosteroids and sulfasalazine—considered
relatively safe
- Sulfasalazine causes reversible male sterility
- Immunosuppressive drugs are teratogenic
- Inactive Crohn's disease at conception usually remains inactive
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References |
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Dambro MR. Griffith's 5-Minute Clinical Consult. 1999 ed. Baltimore,
Md: Lippincott Williams & Wilkins, Inc.; 1999.
Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison' s Principles
of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998.
Morrison, R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993:15, 121, 305.
Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed.
Rocklin, Calif: Prima Publishing; 1998:243, 250.
Rakel RE, ed. Conn's Current Therapy. 50th ed. Philadelphia, Pa: W.B.
Saunders; 1998.
Washington Manual of Medical Therapeutics. 29th ed. Philadelphia, Pa:
Lippincott-Raven Publishers, 1998.
Werbach M. Nutritional Influences on Illness. New Canaan, Conn: Keats
Publishing Inc; 1987: 142-148.
Yamada T. Textbook of Gastroenterology. 2nd ed. Philadelphia, Pa:
Lippincott-Raven Publishers;
1995. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |