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Crohn's disease

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Crohn's disease
SpecialtyGastroenterology Edit this on Wikidata
H&E section of non-caseating granuloma seen in the colon of a patient with Crohn's disease.

Crohn's disease (also known as regional enteritis or CD) is a chronic, episodic disease which can affect any part of the gastrointestinal tract from mouth to anus. Because it is a systemic disease, it can also cause complications outside of the gastrointestinal tract.[1][2] The main gastrointestinal symptoms are abdominal pain and diarrhea, which may be bloody. Symptoms outside the gastrointestinal tract include skin rashes, arthritis, and ulcers in the mouth.

Crohn's disease is a type of inflammatory bowel disease (IBD). IBD occurs when the immune system contributes to damage of the gastrointestinal tract by causing inflammation. Crohn's disease can be difficult to distinguish from other forms of IBD such as ulcerative colitis. Because of the name, IBD can be confused with irritable bowel syndrome (IBS), a less serious condition.

Crohn's disease affects between 400,000 and 600,000 people in North America[3] Prevalence estimates for Northern Europe have ranged from 27–48/100,000.[4]

Although the cause of Crohn's disease is not known, it is widely believed to be an autoimmune disease. There is a genetic component to susceptibility, and the disease may be triggered in a susceptible person by environmental factors. Unlike the other major type of IBD, ulcerative colitis, there is no known medical or surgical cure for Crohn's disease.[5] Many medical treatments are however available for Crohn's disease with a goal of keeping the disease in remission.[6]

The disease was named after Burrill Bernard Crohn, an American gastroenterologist. In 1932, Crohn and two colleagues first described a series of patients with inflammation of the terminal ileum, the most common area affected in patients with Crohn's disease.[7]

Clinical manifestations

The three most common sites of intestinal involvement in Crohn's disease are ileal, ileocolic and colonic.[1]
Distribution of gastrointestinal Crohn's disease. Based on data from American Gastroenterological Association.

Many patients with Crohn's disease have symptoms for years prior to the diagnosis.[8] Because of the patchy nature of the gastrointestinal disease and the depth of tissue involvement, initial symptoms can be more vague than with ulcerative colitis.

There are three phenotypes, or categories of disease presentation in Crohn's disease: stricturing disease (which causes narrowing of the bowel), penetrating disease (which causes fistulae or abnormal connections of the bowel), and inflammatory disease (which causes primarily inflammation.[9]

Crohn's disease may be classified according to the extent of involvement of the gastrointestinal tract:

  • Crohn's ileitis: Crohn's disease usually includes involvement of the ileum, the portion of the small intestine that joins to the large intestine. Thirty percent of cases involve only the illeum.
  • Crohn's colitis or colonic Crohn's disease: Crohn's disease may affect the large intestine, in which case it becomes particularly difficult to distinguish it from ulcerative colitis. Twenty percent of cases involve only the colon.
  • Ileocolic Crohn's disease: The disease may affect both the ileum and the large intestine. Fifty percent of cases involve both the ileum and the colon.
  • Peri-anal Crohn's disease: The disease may affect the area around the anus.
  • Other: Crohn's disease may affect any portion of the gastrointestinal tract.

Common initial symptoms of Crohn's disease include the following:[6]

Gastrointestinal symptoms

  • Abdominal pain: A common symptom is abdominal pain of a crampy nature, as the inflammation associated with Crohn's disease can result in stenosis, localized inflammatory strictures, or areas of narrowing of the bowel. Over time, these areas may develop fibrosis, leading to fixed areas of stenosis. The pain may occur anywhere in the abdomen, and, as it is related to areas of stenosis, may be relieved by defecation. In the setting of severe stenosis, vomiting and nausea may indicate the beginnings of small bowel obstruction.[10]
  • Diarrhea: The nature of the diarrhea in Crohn's disease depends on the part of the small intestine and colon that is involved. Ileitis typically results in large volume watery feces. Colonic Crohn's disease may result in smaller volume feces of higher frequency. Consistency may range from solid to watery. In severe cases, the patient may have more than 20 bowel movements per day, and the need may awaken the patient at night. Fecal incontinence may accompany peri-anal Crohn's disease.[6][1] [10][11]
  • Bloody diarrhea: Gross bleeding in the feces is less common in Crohn's disease than in ulcerative colitis, but may be seen in the setting of Crohn's colitis.[1] Bloody bowel movements are typically intermittent, and may be bright or dark red in colour. In the setting of severe Crohn's colitis, bleeding may be severe.[10]
  • Peri-anal discomfort: Itchiness or pain around the anus may be suggestive of inflammation, fistulization or abscess around the anal area.[1]
  • Flatus and bloating.[10]
  • Rarely, the esophagus, and stomach may be involved in Crohn's disease. These can cause symptoms including odynophagia(difficulty swallowing), upper abdominal pain, and vomiting.[12]

Systemic symptoms

As Crohn's disease involves a greater depth of tissue involvement, it can present with more systemic symptoms. These include the following:[1]

  • Fever: these are usually low grade (less than 38.5 C), unless there is a complication, such as an abscess[1]
  • Weight loss: This is usually related to decreased intake since patients with intestinal symptoms feel better when they do not eat.[13] Patients with extensive small intestine disease may have malabsorption of carbohydrates or lipids, which can further exacerbate weight loss.[14]
  • Growth failure: Many children are first diagnosed with Crohn's disease based on inability to maintain growth.[13] As Crohn's disease may manifest around the growth spurt of puberty, up to 30% of children with Crohn's disease may have retardation of growth.[15]

Extraintestinal symptoms

Crohn's disease is a disease of unknown causation. Many of the following symptoms, which are outside of the gastrointestinal tract, would also be symptoms of a chronic, untreated infection. These symptoms, however, may persist in a patient with Crohn's disease, even after all identifiable infections have been successfully treated. If the disease is cause by an infection, that infection remains unknown. The prevalent theory is that the immune system is responding as though there were an infection, even though none is present. Crohn's disease is therefore usually regarded as an auto-immune disease.

As Crohn's disease is a systemic disease, many other organ systems aside from the gastrointestinal tract can be involved. Extraintestinal symptoms include the following:[16]

Diagnosis

Endoscopic image of Crohn's colitis showing deep ulceration.
CT scan of patient showing Crohn's disease in the fundus of the stomach
Crohn's disease can mimic ulcerative colitis on endoscopy. This endoscopic image of is of Crohn's colitis showing diffuse loss of mucosal architecture, friability of mucosa in sigmoid colon and exudate on wall, all of which can be found with ulcerative colitis.

The diagnosis of Crohn's disease can sometimes be challenging,[8] and a number of tests are often required to assist the physician in making the diagnosis:[10]

  • Blood tests: A complete blood count is useful to check for anemia, which may be caused by blood loss or vitamin B12 deficiency. The latter is common with ileitis because Vitamin B-12 is absorbed in the ileum.[17]Also, erythrocyte sedimentation rate or ESR, and C-reactive protein measurements can be useful to gauge the degree of inflammation.[18]
  • Colonoscopy: A colonoscopy is the best test for making the diagnosis of Crohn's disease as it allows direct visualization of the colon and the terminal ileum, identifying the pattern of disease involvement. During the procedure, the gastroenterologist can also perform a biopsy, taking small samples of tissue for laboratory analysis which may help confirm a diagnosis. As 30% of Crohn's disease involves only the ileum,[1] cannulation of the terminal ileum is required in making the diagnosis. Finding a patchy distribution of disease, with involvement of the ileum but not the rectum, is suggestive of Crohn's disease, as are other endoscopic stigmata.[19]
  • Barium follow-through: (also known as a small bowel follow through or small bowel series). Because colonoscopy and gastroscopy allow direct visualization of only the terminal ileum and beginning of the duodenum, they cannot be used to evaluate the remainder of the small intestine. As a result, a barium follow-through x-ray, wherein barium sulfate suspension is ingested and fluoroscopic images of the bowel are taken over time, is useful for looking for inflammation and narrowing of the small bowel.[20][21]
  • Computed tomography (CT): CT scans are useful for evaluating the small bowel with enteroclysis protocols.[22]They are additionally useful for looking for intra-abdominal complications of Crohn's disease, especially abscesses. Physicians may also order this test to check for other complications such as small bowel obstructions or fistulae.[23]
  • Magnetic resonance imaging: MRI is additionally useful at imaging the small bowel as well as looking for complications, including abscesses, obstruction or fistulae.[24]
  • Wireless capsule endoscopy: Wireless capsule endoscopy is a technique where a small capsule with a camera in it is swallowed by the patient. The camera takes serial pictures of the entire gastrointestinal tract and is passed in the patient's feces. It has been used in the search for Crohn's disease in the small bowel, which cannot be reached with colonoscopy or gastroscopy.[20]The utility of capsule endoscopy for this, however, is still uncertain.[25]
  • Serology: Testing for anti-Saccharomyces cerevisiae antibodies (ASCA) and anti-neutrophil cytoplasmic antibodies (ANCA) has been evaluated to identify inflammatory diseases of the intestine[26] and to differentiate Crohn's disease from ulcerative colitis, but are not routinely used in practice.[27]
  • Barium enema: With the advent of endoscopy, barium enemas are rarely used in the work-up of Crohn's disease. They remain useful for identifying anatomical abnormalities in patients with strictures of the colon that are too small for a colonoscope to pass through, or in the detection of colonic fistulae.[28]

Comparison to ulcerative colitis and other diseases

The most common disease that mimics the symptoms of Crohn's disease is ulcerative colitis, as both are inflammatory bowel diseases that can affect the colon with similar symptoms. It is important to differentiate these diseases, since the course of the diseases and treatments may be different. In some cases, however, it may not be possible to tell the difference, in which case the disease is classified as indeterminate colitis.

The following are differences between the two conditions:[6][1][10]

Comparisons of various factors in Crohn's disease and ulcerative colitis
Crohn's disease Ulcerative colitis
Involves terminal ileum? Commonly Seldom
Involves colon? Usually Always
Involves rectum? Seldom Usually[29]
Involvement around the anus? Common[30] Seldom
Bile duct involvement? Lower rate of primary sclerosing cholangitis Higher rate[31]
Distribution of Disease Patchy areas of inflammation Continuous area of inflammation[29]
Endoscopy Linear and serpiginous (snake-like) ulcers Continuous ulcer
Depth of inflammation May be transmural, deep into tissues[30] [1] Shallow, mucosal
Fistulae, abnormal passageways between organs Common[30] Seldom
Stenosis, narrowing of the intestine Common Seldom
autoimmune disease? Widely regarded as an autoimmune disease No consensus
Cytokine response Associated with Th1 Vaguely associated with Th2
Granuloma on biopsy Can have granuloma [30] Granuloma uncommon [29]
Surgical cure? Often returns following removal of affected part Usually cured by removal of colon
Smoking Higher risk for smokers Lower risk for smokers [29]

Epidemiology and causes

The incidence of Crohn's disease has been ascertained from population studies in Norway and the United States and is similar at 6 to 7.1:100,000.[32][33] It has been established that Crohn's disease is more common in northern countries, and shows a higher preponderance in northern areas of the same country.[34] The incidence of Crohn's disease in North America is 6:100 000, and is thought to be similar in Europe, but lower in Asia and Africa[32] It also has a higher incidence in Ashkenazi Jews.[6]

Crohn's disease has a bimodal distribution in incidence as a function of age: the disease tends to strike people in their teens and twenties, and people in their fifties through seventies.[1][10]

The exact cause of Crohn's disease is unknown. However, genetic and environmental factors have been invoked in the pathogenesis of the disease:

Schematic of NOD2 CARD15 gene, which is associated with certain disease patterns in Crohn's disease
  • Heredity: Parents, siblings or children of people with Crohn's disease are 3 to 20 times more likely to develop the disease.[35] Twin studies show a concordance of greater than 55% for Crohn's disease.[36] Mutations in a gene called NOD2/CARD15 are associated with Crohn's disease[37] and with susceptibility to certain phenotypes of disease location and activity.[38] Further studies are in progress to delineate the contribution of this gene.
  • Immune system: Abnormalities in the immune system have often been invoked as causes of Crohn's disease. It has been hypothesized that Crohn's disease involves augmentation of the Th1 system of cytokine response in inflammation.[39] Also, as the colon is rich in bacteria, many infectious agents have been invoked as causes of Crohn's disease, including Mycobacterium avium subspecies paratuberculosis.[40]
  • Environment: Many environmental factors have also been hypothesized as causes or risk factors for Crohn's disease. These include the following:
    • A diet high in fatty or refined foods, may play a role, but this is anecdotal and based on the fact that Crohn's disease has a higher incidence in industrialized countries.
    • Smoking, which may increase the risk of Crohn's flares.[41]
    • Oral contraceptives have shown an association with the development of Crohn's disease.[42]

Pathology

H and E section of colectomy showing transmural inflammation.

Because very little of the small intestine can be visualized through colonoscopy or gastroscopy, the following discussion is focused on Crohn's colitis.

At the time of colonoscopy, biopsies of the colon are often taken in order to confirm the diagnosis. There are certain characteristic features of the pathology seen that point toward Crohn's disease. Crohn's disease shows a transmural pattern of inflammation, meaning that the inflammation may span the entire depth of the intestinal wall.[1] Biopsies of the affected colon may show the following features:[43]

  • Mucosal inflammation: focal infiltration of neutrophils, a type of inflammatory cell, into the epithelium, usually the area overlying lymphoid aggregates
  • This proceeds to the infiltration of neutrophils and mononuclear cells into the crypts resulting in inflammation, termed cryptitis, or the formation of small abscesses, termed crypt abscesses.
  • Ulceration is an outcome seen in highly active disease. Typically, there is an abrupt transition between unaffected tissue and the ulcer.
  • Chronic mucosal damage results in blunting of the intestinal villi, atypical branching of the crypts, and metaplasia or change in the tissue type
  • Paneth cells, which is a cell type normally found in the small intestine, but rarely in the distal colon, may develop in a process called Paneth cell metaplasia
  • Transmural inflammation results with inflammation and the formation of lymphoid aggregates throughout the wall of the colon
  • Granulomas, aggregates of macrophage derivatives known as giant cells, are found in 50% of cases. The granulomas of Crohn's disease do not show "caseation", a cheese-like appearance on microscopic examination that is characteristic of granulomas associated with infections such as tuberculosis.

Treatment

Main article: Treatment of Crohn's disease
Main article: Biological therapy for inflammatory bowel disease

The therapeutic approach to Crohn's disease is sequential: to treat acute disease, and then to maintain remission. Treatment initially involves the use of medications to treat any infection and to reduce inflammation. This usually involves the use of aminosalicylate anti-inflammatory drugs and corticosteroids, and may include antibiotics. Surgery may be required for complications such as obstructions or abcesses, or if the disease does not respond to drugs within a reasonable time.

Once remission is induced, the goal of treatment becomes maintenance of remission, avoiding the return of active disease, or "flares." Because of side-effects, the prolonged use of corticosteroids must be avoided. Although some patients are able to maintain remission with aminosalicylates alone, many require immunosuppressive drugs.[30]

Drugs used

The treatment of Crohn's disease is discussed under the article treatment of Crohn's disease. The following types of drugs are used:

Research on medications in progress

Egg of Trichuris spp. whipworm. Trichuris suis or pig whipworm has been investigated for treatment of Crohn's disease.

Many clinical trials have been recently completed or are ongoing for new therapies for Crohn's disease. They include the following:

Surgery

Surgery is generally reserved for complications of Crohn's disease, or when disease that resists treatment with drugs is confined to one location that can be removed.[1] Oftentimes surgery is used to manage:

In the case of fibrostenotic strictures, strictureplasty - the expansion of the stricture - is sometimes performed. Otherwise, and for other complications, resection and anastomosis - the removal of the affected section of intestine and the rejoining of the healthy sections - is the surgery usually performed for Crohn's disease (e.g., ileocolonic resection). Neither surgery cures Crohn's disease, as recurrence often reappears in previously unaffected areas of the intestine.[52]

Small intestine transplants are experimental as of yet, and are usually only done when the patient is at risk of short bowel syndrome due to repeated resection surgeries.

Diet and lifestyle

There is no evidence that diet causes or cures Crohn's disease, but many patients with Crohn's disease note that certain foods improve or worsen their symptoms. Fish oil has been found to be effective in reducing the chance of relapse in less severe cases.[53] Patients with lactose intolerance due to small bowel disease may benefit from avoiding lactose-containing foods. Many diets have been proposed for treatment of Crohn's disease, and many do improve symptoms, but none have been proven to actually cure Crohn's disease.[54] Stress can make symptoms of Crohn's disease worse. Patients with Crohn's disease can find that their symptoms improve if they control the stress in their lives.

Because the terminal ileum is the most common site of involvement and is the site for vitamin B12 absorption, patients with Crohn's disease are at risk for vitamin B12 deficiency and may need supplementation.

Complementary and alternative medicine

More than half of patients with Crohn's disease have tried complementary or alternative therapy.[55] These include diets, probiotics, fish oil and other herbal and nutritional supplements. The benefit of these medications is uncertain.

Complications

Crohn's disease can lead to the following complications:[6][1] [10]

  • Obstruction: Crohn's disease may have a fibrostenotic phenotype, meaning that patients have a tendency to form fibrous tissue. This may result in strictures, and small bowel obstruction. Often, surgical treatment is required.
  • Fistulae: Patients with Crohn's disease can develop fistulas or passageways between two structures that are ordinarily not attached. These can be between two loops of bowel, between the bowel and bladder, between the bowel and vagina, and between the bowel and skin. Treatment of fistulae may be medical (with azathioprine, infliximab and parenteral nutrition) or may require surgery. This can be a cause of significant discomfort for patients.
  • Abscesses are walled off collections of infection and can occur in the abdomen or in the peri-anal area in patients with Crohn's disease. They typically present with fevers or abdominal pain. These require treatment with antibiotics and may require drainage or surgery in order to evacuate the infected focus.
Endoscopic image of colon cancer identified in sigmoid colon on screening colonoscopy for Crohn's disease.
  • Cancer: Having Crohn's disease increases the risk of cancer in the area of inflammation. For example, patients with Crohn's disease involving the small bowel are at higher risk for small intestinal cancer. Similarly, patients with Crohn's colitis are at a higher risk for colon cancer. As colonoscopy is an excellent tool to detect precursor lesions to colon cancer, screening for colon cancer is recommended for all patients who have had Crohn's colitis for at least eight years.[56]
  • Malnutrition: Patients with Crohn's disease are at risk for malnutrition, due to many reasons, including decreased intake, and malabsorption. They are especially at risk if they have had previous resection of the small bowel. Patients may require oral supplements to increase their caloric intake, or, in severe cases, may require total parenteral nutrition or TPN. Most patients with severe Crohn's disease are referred to a dietician for assistance in nutrition.[57]
  • Other health problems:

History and name

Inflammatory bowel diseases were described by Giovanni Battista Morgagni (1682-1771), by Polish surgeon Antoni Leśniowski in 1904 (leading to the use of the eponym "Leśniowski-Crohn disease" in Poland) and by Scottish physician T. Kennedy Dalziel in 1913.[60]

Burrill Bernard Crohn, an American gastroenterologist at Mount Sinai Hospital, described fourteen cases in 1932, and submitted them to the American Medical Association under the rubrick of "Terminal ileitis: A new clinical entity". Later that year, he, along with colleagues Leon Ginzburg and Gordon Oppenheimer published the case series as "Regional ileitis: a pathologic and clinical entity",[7].

See also

References

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General Information
Organizations
Communities
  • IBD Club An information service for people suffering from inflammatory bowel disease offering medically qualified patient information
  • IBDForum.com A website designed for use by Doctors and other healthcare professionals specialising in the management of Inflammatory Bowel Disease
  • CrohnsZone.org UK based Crohn's and colitis support network
  • IBD Sucks An online forum for people with Colitis, Crohn's, and IBS
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