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Crohn's Disease (Regional Enteritis)

Tuesday, 25 January 2011

Crohn's disease, also known as regional enteritis or granulomatous colitis, is an inflammation of any part of the gastrointestinal tract that involves all the layers of the intestinal wall. Most commonly it affects the terminal ileum and proximal colon. But it can affect any part of the G.I tract.

The disease was named after Dr. Burrill Bernard Crohn, who was an American gastroenterologist. In 1932, Dr Crohn and two other colleagues published a landmark paper describing the features of the disease.
What are the risk factors of Crohn's disease ?
1. Smokers are at a higher risk of having Crohn's disease. Smoking is the most important risk factor.]
2. Age: most individuals are diagnosed at the age of 20-30.
3. Race: Ashkenazi Jews are at a higher risk.
4. Individuals who have a first-degree relative (parents, siblings or children) diagnosed with Crohn's disease.
5. Eating a diet rich in fats, low in fibre and high in refined sugar increases the risk.

The exact cause of Crohn's disease is unknown. It is believed that it is due to a combination of genetic factors, environmental factors and immunologic abnormalities.

What are the symptoms of Crohn's disease ?

The symptoms depend on the region of the GIT affected. There are two main categories for presentation:
- Acute Crohn's disease: it occurs in only 5% of the cases and it resembles acute appendicitis.
- Chronic Crohn's disease:
The patient usually presents with a history of diarrhoea (that may be associated with blood in stools) that had been extending over many months, occuring in bouts accompanied by intestinal colic. Weight loss, intermittent fever and anaemia can be present. 
After repeated attacks of inflammation, the affected area of the intestine begins to narrow with fibrosis and causes obstructive symptoms. 

What are the complications of Crohn's disease ?
Complications include small bowel obstruction, fistula formation, perforation, abscess formation, rectal hemorrhage, colorectal cancer.
Systemic complications of Crohn's disease are shown in this image:

Here is an image of erythema nodosum, which can occur in Crohn's disease and Ulcerative colitis:

Now it's time to discuss the diagnosis and treatment of Crohn's disease.

How is Crohn's disease diagnosed ?
From the patient's history and physical examination, a doctor will suspect the presence of Crohn's disease. Investigations can be done to help confirm the diagnosis as:
- Full blood count.
- Colonoscopy.
- Barium enema.
- CT / MRI.

What is the treatment of Crohn's disease ?
Based on the fact that Crohn's disease is an inflammatory disease, then the treatment will involve suppressing the inflammatory reaction so that the intestines will heal and symptoms will be relieved. This is done by the use of drugs.

When symptoms are under control, this is referred to as a state of remission. 
Drugs used to induce remission and prevent relapses include:
- Steroids: the mainstay of treatment. They suppress the immune system and helps to relief inflammation. Prednisone and methylprednisolone are available orally and rectally. Side effects can limit their uses.

- Antibiotics: they are used in patients presenting with an abscess. Metronidazole is used as it is believed that it suppresses the body's immunity.

- Immune system suppressors: as Azathioprine (Imuran) or mercaptopurine (6-MP). These drugs are the standard maintenance therapy. They are effective and useful in patients who suffer from steroids side effects or experience multiple relapses.

- Infliximab (Remicade): given to those who had not responded to conventional treatment or those who are at a higher risk of surgical interventions. 

- Good nutritional support. A well balanced diet is important for inducing remission.

In some cases, surgery plays a role in the treatment of Crohn's disease.

What are the indications of surgery for a patient having Crohn's disease ?
Although surgery is not curative in Crohn's disease, but it is a must in the following conditions:
- In case of failure of medical treatment.
- Occurence of complications as perforation, hemorrhage, fistula, abscess.
- In case of recurrent intestinal obstruction due to strictures.

Advices about the patient's diet and lifestyle:
Reduce stress and live a peaceful stress-free life. Drink an adequate amount of water. Avoid:
- Spicy foods.
- Fatty foods.
- Caffeine drinks.
- Carbonated beverages.

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