CROHN’S DISEASE
Crohn’s disease is a disorder that causes inflammation of the gastrointestinal (GI) tract. Crohn’s disease may also be called regional ileitis or enteritis. Crohn’s disease can affect any area of the GI tract, from the mouth to the anus, but it most commonly affects the lower part of the small intestine, called the ileum. The next most commonly affected area is the colon and anus. In Crohn’s disease the inflammation extends deep into the lining of the affected bowel. The inner lining becomes ulcerated and the bowel wall thickens. This can result in abdominal pain, diarrhea and some bleeding or passage of mucus from the bowel. One of the hallmarks of this condition is the tendency to have areas of normal bowel interspersed between segments of diseased intestine (called skip lesions).
Crohn’s disease is an inflammatory bowel disease, and needs to be distinguished from a related disorder, Ulcerative Colitis. Ulcerative Colitis causes inflammation and ulcers only in the inner lining of the colon and the disease is confined to the colon and rectum in a continuous pattern. Sometimes it can be difficult to determine from which of these two entities the patient is suffering.
Crohn’s disease affects men and women equally and seems to run in some families. About 20 percent of people with Crohn’s disease have a blood relative with some form of inflammatory bowel disease. Crohn’s disease can occur in people of all age groups, but it is more often diagnosed in people between the ages of 20 and 30. People of Jewish heritage have an increased risk of developing Crohn’s disease, and African Americans are at decreased risk for developing Crohn’s disease.
Several theories exist about what causes Crohn’s disease, but none have been proven. The human immune system is made from cells and different proteins that protect people from infection. The most popular theory is that the body’s immune system reacts abnormally in people with Crohn’s disease, mistaking bacteria, foods, and other substances for being foreign. The immune system’s response is to attack these “invaders.” During this process, white blood cells accumulate in the lining of the intestines, producing chronic inflammation, which leads to ulcerations and bowel injury.
Scientists do not know if the abnormality in the functioning of the immune system in people with Crohn’s disease is a cause, or a result, of the disease. Research shows that the inflammation seen in the GI tract results from several factors: the genes the patient has inherited, the immune system itself, and the environment
What are the symptoms?
The most common symptoms of Crohn’s disease are abdominal pain, often in the lower right portion of the abdomen, and diarrhea. Rectal bleeding, weight loss, arthritis, skin problems, and fever may also occur. Bleeding may be serious and persistent, leading to anemia. Children with Crohn’s disease may suffer delayed development and stunted growth. The range and severity of symptoms varies. About 12-20% of Crohn’s patients develop anal manifestations of the disease which include fissures, abscesses, fistulas, large skin tags and occasionally anal stenosis.
If the disease progresses in the bowel it can lead to narrowing of the bowel opening causing a chronic blockage and inhibiting the patient from eating normally. Other long term complications that can arise from the bowel ulcerations are abscess formation outside the bowel and bowel fistulas. A fistula is an abnormal connection between the bowel lumen and another organ. This could be to another loop of bowel, or the bladder or even erode through onto the skin (enterocutaneous fistula).
How is Crohn's disease diagnosed?
A thorough physical exam and a series of tests may be required to diagnose Crohn’s disease. Blood tests may be done to check for anemia, which could indicate bleeding in the intestines. Blood tests may also uncover a high white blood cell count, which is a sign of inflammation somewhere in the body. There are other more sophisticated blood tests looking for certain antigens that are more common in patients with inflammatory bowel disease.
The most direct way to make the diagnosis of Crohn’s disease is with a series of endoscopic and radiologic studies. Patients who are suspected of harboring Crohn’s disease will usually be advised to undergo both an upper endoscopy and a colonoscopy. These studies will give the doctor a direct view of the esophagus, stomach and first part of the small intestine and then the entire colon and last portion of the small intestine (the ileum). Any suspicious area can be biopsied through the scope and the tissue examined for evidence of inflammation consistent with Crohn’s disease. A CT scan of the abdomen will often be done to look for areas of inflammation or infection that could be due to Crohn’s disease. Additional x-ray studies may, at times, be ordered. These may include an Upper GI Series and small bowel contrast study. This test involves swallowing some barium and a series of x-rays are then taken of the esophagus, stomach and small intestine to look for areas of ulceration or narrowing which might be consistent with Crohn’s disease. Likewise, barium can be instilled through the rectum to fill the entire colon in order to evaluate that portion of the intestine with another series of x-rays.
How is Crohn's disease treated?
There is no cure for Crohn’s disease at the present time. Fortunately, however, in the majority of patients the disease and it manifestations can be controlled for extended periods of time with medications. These medications work by decreasing or removing the inflammatory response in the bowel wall reducing the symptoms. There are a variety of medications that can be utilized for Crohn’s disease. The medical management of Crohn’s is usually directed by a gastroenterologist who is an expert in the long term care of these patients.
When is Surgery Necessary?
Even with expert care, some Crohn’s patients may go on to develop complications of their disease such as obstruction, abscess formation or fistulas. These problems usually necessitate an operation to resolve. It is in this role that the surgeon’s at Fairfax Colon and Rectal Surgery excel. We have a vast experience in performing the often technically challenging surgeries that are required in these cases. Most of these operations involve removing a limited amount of affected intestine and reconnecting the two ends of healthy bowel. In the appropriate setting, the operation may be accomplished laproscopically leaving the patient with the least amount of visible scars. Due to their disease, pre-operative Crohn’s patients are often malnourished and/or on high doses of steroids. They have often been suffering with pain and infection for an extended period of time. Once recovered from their surgery, these patients are uniformly astounded by the improvement in their state of well being.
The anorectal manifestations of this disease can be challenging to manage and should be evaluated by a specialist in colon and rectal surgery. These patients may develop abscesses that require drainage or fistulas that require extensive experience to evaluate and care for. A minimalist approach is usually best to avoid any compromise of the patient’s continence.