Inflammatory bowel disease ( IBD ) has two major variants, Crohn’s disease ( CD ) is one of them. It causes inflammation of the digestive tract. Most of the Crohn’s disease patients are present with severe diarrhoea, abdominal pain, weight loss and malnutrition. For past few decades health sectors are looking for a definitive cure. But results were not satisfactory. In 2020 new studies announced that cure for Crohn’s disease is not impossible.
Crohn’s disease is affecting every part of the digestive tract. But it’s differ from patient to patient. Not like Ulcerative colitis, the other main type of IBD, Crohn’s disease causes deep ulcers in digestive tract. It is a chronic debilitating disorder. And it gives various complications as well. Previously practiced methods for treatment are dietary modifications and immune suppression therapies. Those methods could improve patient’s quality of life.
Crohn’s disease is generally affect through out whole digestive tract. But these clinical picture varies from person to person. The most common affected part is end of the small intestine ( ileum ) and large intestine ( colon ). Anal region is also has a high susceptibility. Generally these patients have,
- Mouth ulcers
- Abdominal pain and cramps
- Blood mixed with stool
- Reduced appetite
- Loss of weight
- Pain around anus
Other than these symptoms, there are symptoms that not related to digestive tract. That makes this, a disease affecting all systems in the body. Those are,
- Eyes related – Uveitis, Episcleritis, Conjunctivitis ( red eyes )
- Bone related – Back pain, Ankylosing Spondylitis, Joint pain, Osteoporosis
- Skin related – Erythema Nodosum, Pyoderma gangrenosum ( Skin ulcers and rashes )
- Liver related – Fatty liver, Chronic hepatitis, Cirrhosis
- Bile tract related – Gall stones
- Kidney related – kidney stones
- Blood related – Venous thrombosis ( forming blood clots within veins ), anaemia
It’s still doubtful about how this can occur. But studies identified several possible factors to cause Crohn’s disease. Those are,
Scientists noted that Crohn’ disease is common with patients who have a family member with the disease. And recently they have identified CARD-15 gene mutations can cause Crohn’s disease. CARD-15 gene includes in immune cells in digestive tract ( macrophages ). And it helps them to identify harmful bacteria. But not all the patients with the disease have a family history of Crohn’s disease.
Their mechanisms are alteration in the normal gut flora, increase ability to bind harmful bacteria with digestive tract, producing more and more bacterial antigens to overactive with body immune system and disrupt gut barriers for harmful bacteria.
Over Active Gut Immune System
Due to the over activity, body’s immune cells produce chemicals to destroy bacteria. But over secretion of these chemical is harmful to digestive tract cells also. So these cells are damaged.
Previously identified cause for Crohn’s disease is this. Although Diet, stress, smoking have contribution for the disease, they are not affected directly to the disease.
Crohn’s disease is more prevalent in younger ages. Less number of cases were diagnosed in old ages. Most cases are noted before 30s. But all the age groups can get affected.
Disease can affect any ethnicity. But researches showed that whites are more common found with the disease including Eastern Europe Jewish descents. But black people in North America and United Kingdom also have higher number of cases compared with others.
If you have a family member ( a parent, sibling, child ) with the disease, there’s a high chance of you to get the disease. According to recorded cases there are 1 in 5 cases have positive family member.
Smoking can exacerbates the disease. And recurrence after surgical treatment is also increased. Basically most Crohn’s disease patients are smokers.
Non Steroidal Anti Inflammatory Drugs
Ibuprofen, Diclofenac sodium, Naproxen sodium are common drugs in this class. It shows that these drugs can initiate and flares up the established disease also. Recurrent ingestion leading to inflammation of the bowel may be the leading cause.
This may be surprising fact. According to recorded cases, poor and large families lives in crowded places have lower risk of developing CD. Experts think that “clean” environments makes people less exposed to harmful pathogens and non harmful pathogens like helminths. So it seems to alter the immune system.
Many foods or food components like high sugar, fat are known to associated with Crohn’s disease. But results from numerous studies give equal risks when define each others. However breastfeeding is a known protective factor to reduce transmission the disease to children.
Chronic stress and depression are know causes to occur relapses in established diseases.
The surgery proceed due to appendicitis or mesenteric lymphadinitis is identified as a risk factor. Specifically if the surgery performed before age of 20 has an increased risk.
Features of Crohn’s disease
- Involved bowel is usually thickened and often narrowed.
- Deep ulcers and fissures can be seen in intestinal mucosa and it gives a cobblestone appearance.
- Intra abnormal fistula ( penetrating tracts form connecting bowel and abdominal cavity ) and abscess formation.
- Early aphthoid ulcers ( whitish ulcers ) in digestive tract which can be seen by colonoscopy.
- Chronic inflammation extending all the layers of the bowel.
- Granuloma formation.
- Bowel Obstruction – Chronic inflammation in the bowel leads to thickening and narrowing of the bowel. It leads to bowel obstruction which ultimately ends up in surgery.
- Ulcers in digestive tract – In Crohn’s disease ulcers can occur from mouth to anus and also in perineal regions.
- Fistula formation – A fistula is a tract forming different body parts. In Crohn’s disease fistula can be formed between bowel and other intestinal organs, bladder, uterus and even with skin. So foods leak through these tracts. This is a serious problem which also can formed with abscess.
- Anal and perianal complications – These complications are specific for Crohn’s disease. Painful fissures, fistula, haemorrhoids, skin tags, perianal abscesses are main complications.
- Malnutrition – Abdominal pain, diarrhoea may cause eating difficulties. And also absorption of nutrients is impaired. It’s common these patients to have anaemia due to low iron and B12 levels in body.
- Colonic cancers – Chronic inflammation leads to increased the bowel cancer risk in these patients. General guideline to screening for colonic cancers in every 10 years from age of 50 in non Crohn’s disease patients. So it’s better to do frequent screenings if you have Crohn’s disease.
- Drug related complications – Immune suppressing drugs used in the disease cause patients more prone to get infections. Corticosteroids are one of the main drug class used. Those can cause high blood pressure, diabetes, glaucoma, cataract and osteoporosis. You must screen for these complications regularly to prevent further damage.
There’s no diagnostic test for Crohn’s disease. There are several investigations and those can lead to possible diagnosis by excluding other possibilities.
- Full blood count ( FBC / CBC ) , Iron studies ( serum iron, ferritin levels, transferring saturation ), Folate and B12 levels to evaluate anaemia.
- ESR and CRP levels to investigate chronic inflammation in the body.
- Serum albumin levels, because low albumin level is a feature of the disease.
- Liver function tests
- Blood cultures to identify ongoing infections.
- Antibody testing like ANCA and ASCA
- Stool culture
- Clostridium defile toxin assay
- Calprotectine and Lactoferrin levels which are raised in ongoing bowel pathology.
- Colonoscopy is performed in suspected cases. In positive patients there can be seen active ulcers, cobblestone appearance. In suspected incidents two biopsies are taken from five different sites to make accurate diagnosis.
- Upper gastrointestinal endoscopy Is performed to see oesophagus and upper part of digestive tract. It allows to get an idea about the extent of the disease. This helps to plan the treatments and it determines the prognosis of the disease.
- Small bowel imaging is mandatory in suspected cases. The procedures are depend on the availability. Barium follow-through, CT scan with oral contrast, small bowel ultrasound, MRI are the methods used in. These can identify ulcers, narrowing of bowel, fissures.
- Ultrasound is a convenient, radiation free method to identify bowel activities and assess the disease.
- Perianal MRI or end anal ultrasound are used to detect disease activity around anal region.
- Capsule endoscopy is performed if radiological investigations were normal. Again this is also depend on the availability of the facility. Before doing the study, a patency capsule assessment is performed to identify bowel strictures. It is a contraindication to perform capsule endoscopy if there’s a bowel strictures.
- Radionucleiotide scans which consist of Indium or Technetium labelled blood cells are used to identify sites of the disease active. Because these sites have high cellular density compared with other parts of the body.
Currently there is no exact medical treatment method. But recent studies have come some what closure to make a new treatment method. Using methods are for reduce inflammation leads to signs and symptoms and prevent long term complications.
Anti Inflammatory Drugs
Prednisolone and Budesonide are main drugs used in this category. Those are used mainly to induce a remission. And only recommends to use for short time frames like 3 -4 months. Over all remission/response rate is vary from 60% to 90% depending on type, site and extent of the disease. But generally these category of drugs are not recommended for patients with penetrating disease like fistula and with perianal infections.
Sulfasalazine and Mesalamine are the main drug classes. These drugs are used earlier. But currently less practicing because new studies showed that there’s a less benefits of using.
These drugs are help to maintain the remission. But not good at inducing the remission. Currently these drug classes are commonly practicing. They can suppress our immune system and prevent the disease relapses. Corticosteroids act as a bridging therapy with these drugs. Because these drugs take 2 to 3 months to give results.
Azathioprine and Mercaptopurine
These drugs are the commonest treatment method in inflammatory bowel disease ( IBD ). But after you starting to take these, its advisable to check your blood levels to avoid getting g infections and early detect liver toxicity.
Mainly used in treatment for rheumatoid arthritis. But currently practicing in treatment for IBD when not responding to other medications. But you need to attend regular follow-ups to prevent treatment related complications.
The new treatment for Crohn’s disease is biologics. Currently doctors use this drugs to treat moderate to severe cases. But not everyone is suitable for this. Before starting biologics you have to undergo certain procedures to check your suitability.
Infliximab, Adalimumab, Certolizumab are currently practicing drugs. TNF ( Tumour Necrosing Factor ) is a protein that initiates inflammatory response. These drugs can block this protein.
Natalizumab and Vedolizumab
These drugs act differently from TNF inhibitors. They inhibit Integrin, a molecule produced from inflammatory cells. Vedolizumab is safer than Natalizumab. Because Natalizumab has ability destroy our brain cells.
Most recently introduced drug as a biologic. Earlier this is used to treat psoriasis. But currently doctors recommend this drug for severe IBDs which are not responding to other medications. However in rare instances this drug can affect the brain also.
Ciprofloxacin and Metronidazole are common antibiotics. These are used to treat associated complications like perianal fistula and abscesses. Some experts think that antibiotics also help to destroy harmful bacteria in digestive tract which over activate the immune system.
Crohn’s disease associates with lot of complications. So in addition to treat for the disease, it’s better to address the complications as well. Most of these drugs are over the counter medications. So before taking these drugs you should take advice from your doctor.
- Anti diarrhoeal drugs – stool bulking agents like fiber supplements ( psyllium powder, methylcellulose ) are good for mild to moderate diseases. Loperamide is the choice in severe conditions.
- Analgesics – Acetaminophens are the doctor’s choice in mild pain. Ibuprofen or Naproxen sodium are not good choices. Because those can exaggerate symptoms.
- Iron and Vitamin B12 supplements – Because of malabsorption associated with Crohn’s disease, nutrition deficiencies are common. And intestinal bleeding also can cause anaemia. Because of that supplements are essential.
- Calcium and Vitamin D supplements – Both Crohn’s disease itself and drugs cause osteoporosis. Therefore we need to take measures to prevent this.
Your bowel is at a haywire with active Crohn’s disease. It’s important to rest your bowel. But with the same time you have to have good nutrition. To solve both these problems your doctor may recommend enteral ( through naso-gastric tube ) or parenteral ( through a large vein ) nutrition. The choice between both procedures is a clinical judgement. It depends on severity of the disease, other comorbid conditions you have.
Enteral nutrition is good to maintain your bowel functions. But if the disease is very severe or malnutrition is difficult to manage with oral foods, parenteral nutrition is the best choice.
If the scans show bowel strictures, better to take low fiber diet. Because high fiber make bulky foods. So it’s high chance of bowel obstruction.
Studies prior to introduce biologics suggest that 80% Crohn’s disease patients have to undergo a surgical procedure some time of their disease. And also its recommend to avoid if possible or undergo minimal resection. Experts advice is surgical treatment is not a permanent method to treat. Even after a surgical procedure also disease can recur. So you have to maintain proper medical treatments also.
So why surgical treatment is necessary ? Following are the indications,
- failure of medical treatment, with sustained I’ll health
- growth failure in children despite medical treatment
- presence of perianal sepsis
During surgical procedure, your surgeon removes the damaged part of the bowel and reconnect with healthy part.
Life Style Modifications
There are lots of things you can do also to control the disease. Changing life style makes action of the drug is more efficient. It reduces the symptoms and lengthens the flare-up period.
There are no actual evidence of specific diet to cause IBD. But there are foods and beverages that can cause relapses. Those are specific to individual patients. So it’s better you maintain a food diary. So you can identify what foods make you ill and avoid those. Follow these general instructions,
- Limit dairy products – most patients get relief from abdominal pain, diarrhoea and gas production after stopping dairy products.
- Use low fat foods – Crohn’s disease in small intestine make reduced absorption of fat. So if you eat high fat foods, the excess fat tend to pass out with stools. This makes diarrhoea worse.
- Limit fiber intake – high fiber diets can cause bowel obstruction. Raw vegetables and fruits have more fibers. Therefore it’s better to eat those foods after baking or stewing well.
- Avoid alcohol, spicy foods, caffeine and carbonated drinks
- Eat small meals frequently than large meals
- Drink plenty of water.
- Consider multivitamins. Because malnutrition is related with Crohn’s disease.
Smoking can increase the risk of having Crohn’s disease. It causes relapsing disease even after the surgical treatments. Quitting smoking improves your overall health.
Disease occurrence and stress has no direct connection. But chronic stress can reduce the remission period of the disease. Therefore stress management is important. Practice relaxation methods like meditation, yoga, breathing techniques. Practicing an exercise schedule can improve general wellbeing, bowel functions and also reduce the stress.
Upcoming Treatment Methods
Scientists identified that cattle have similar type of disease which cause by a bacteria called Mycobacterium avium paratuberculosis (MAP). And studies showed that some Crohn’s patients also have this infection. As a result experts are now thinking about treating MAP bacteria as a cure for the disease. The study was performed on 2018. They used antibiotics mixture that contain clarithromycin, rifabutin, and clofazimine. And the result shows that there’s a 44% decrease of disease activity within 26 weeks.
But still this method has doubts, because not all patients with the disease have MAP infection. And we still didn’t know how RHB-104 treatment method helps people to achieve remission.
AZD4205 is the new drug in the pipeline. This is a JAK-1 inhibitor. This drug’s initial testing was on rodents. And results were successful. Currently it completed Phase 1 study o healthy adults. And there are no complications. Scientists are now planning to do phase 2 studies with moderate to severe cases.
IBD- Anti Inflammatory Diet ( IBD-AID )
Researchers from UMASS Medical School performed this study. They plan to improve healthy bacteria number in gut. There by reducing the harmful bacteria. These healthy bacteria produce short chain fatty acids with IBD-AID. These fatty acids are helpful to reduce inflammation in gut. Study shows reduction of symptoms in 61% of cases within 8 weeks.
Stem Cell Transplantation
47% of Crohn’s patients have go into remission within 42 days after clinical trials with stem cell therapy. Scientists used Mesengial stem cells for this. Those cells have inherited ability to reduce body inflammation. So scientists think that transplantation of these cells is very effective in long duration. Currently this study also in phase 2 level and still not come in to practice.
Coping with the disease
Crohn’s disease is a chronic debilitating disease which affects all the systems in body. If you are a patient you know how much embarrassment you have to undergo with the disease. Frequent visits to toilets, abdominal pain and gas collection are very distressing situations. Therefore depression is a common psychological problem with Crohn’s disease.
So it’s better you get more information about the disease. Read articles, watch videos about the disease. Make the disease more familiar to you. By that you get the knowledge how to act with the situations like that.
And the next thing is never be late to take support. There are lot of support groups to disease conditions. Sharing knowledge, thoughts with a person who has same condition makes you less stressful. Even that can gives opportunity to grab new knowledge. Some times facing the disease as a group is very helpful.
If you think you need further psychological support please consult a psychologist. Doctor will guide you to be less stressful and make you strong to fight with the disease.
Keep in mind, although living with the Crohn’s disease is very distressing the new treatment methods have shown successfully results. So future will be not bad at all.