Crohns Disease

Crohn's Disease Objectives 1.Differentiate typical ulcerative colitis and Crohn’s Disease in terms of history,pathology,X-ray findings,treatment and risk of cancer. 2.Discuss the role of Surgery in the treatment of patients with Ulcerative Colitis who have the following complications:intractability,toxic megacolon,cancer,perforation and bleeding. 3.Discuss the role of surgery in the treatment of patients with Crohn’s disease who have the following complications:fistula,obstruction,bleeding and stricture. 4.Discuss the conservative treatment of Ulcerative colitis and Crohn’s Disease. Crohn's disease is an inflammatory disorder that can involve any part of the digestive system. It can be difficult to diagnose because its symptoms can be confused with other, more common disorders, such as irritable bowel syndrome. In some cases it may be difficult to distinguish from ulcerative colitis, but fortunately the treatment for these disorders is similar. Symptoms of Crohn's Disease Symptoms of Crohn's disease range from normal bowel habits to urgency, cramping and watery or bloody diarrhea. Patients also may have abdominal pain resulting from bowel narrowing or obstruction. These symptoms may be accompanied by fatigue, fever and weight loss. In addition, patients may experience what are called extraintestinal manifestations. These consist of joint pain and swelling, back stiffness, mouth sores, eye pain or redness and skin rashes. They may disappear when the bowel disease is treated, or they may need to be treated separately. Crohn's disease is a lifelong disease. Typically, patients will have periods where they have few or no symptoms (remissions), but "flare-ups" are common. Advances in therapy have helped physicians improve the overall quality of life of their patients by better treating flare-ups and lengthening remissions. How Is Crohn's Disease Diagnosed? A thorough history, physical exam and series of tests are required to diagnose Crohn's disease. Blood tests are necessary to look for low blood counts (anemia) that might indicate bleeding into the intestines. A high white blood cell count might indicate intestinal inflammation. Other blood tests help with understanding a patient's nutritional status and overall health. After basic blood work is completed, the physician will run a series of tests to determine which parts of the digestive system are involved and the extent or degree of the involvement. This allows the physician to counsel the patient on a prognosis and to customize a treatment plan. The doctor may do an upper gastrointestinal or small bowel series. For this test, the patient drinks barium, a chalky solution that coats the lining of the small intestine. X-rays are then taken. The X-ray picture shows abnormalities, such as inflammation, that might suggest Crohn's disease. In some cases, the doctor also may order a computerized tomography ("CT scan") of the abdomen to further determine the extent and activity of the disease. The doctor may also do a colonoscopy. Before this test, the patient drinks a cleansing solution to clean out the colon. The doctor inserts a colonoscope (a long, flexible tube with a camera on the end of it linked to a computer) through the anus to examine the entire colon and, in some cases, the last part of the A barium X-ray of a normal bowel. small intestine (the terminal ileum). This will allow him or her to look for inflammation of these areas and, if necessary, take a sample of tissue (biopsy). Some or all of these tests may need to be repeated after a patient has been diagnosed with Crohn's disease. They are often required when there is a flare-up of the disease or a complication is suspected. What Are the Complications of Crohn's Disease? The most common complication is blockage of the intestine (also called a bowel obstruction). Blockage occurs because the disease tends to thicken the intestinal wall with swelling and scar tissue, A barium X-ray of a bowel with narrowing the passage. Crohn's disease also may tunnel through Crohn's disease. affected bowel into surrounding tissue such as the bladder, vagina, rectum, anus or skin. These tunnels, called fistulas, are common and can become infected. Treatment may involve medication and sometimes surgery. Nutritional complications are also common in Crohn's disease. These are due to problems with dietary intake, inability to absorb important nutrients and side effects of medications used to treat this disorder. Some patients may develop kidney stones. An important complication that patients develop quite commonly is osteoporosis. Osteoporosis is a condition in which the bones become porous, increasing the risk of dangerous bone fractures. This condition is increased in both men and women with Crohn's disease, especially in smokers or those who have been on steroid medications (such as prednisone). Osteoporosis can be detected by a simple test. Patients with Crohn's disease should be tested periodically for osteoporosis because it may develop at any time and can be treated. What Is the Treatment for Crohn's Disease? Not all patients with Crohn's disease are treated the same way. Treatment depends on the location and severity of a patient's disease, the presence of complications and the patient's response to previous medications. The major goals are to treat symptoms and induce remission and then keep the symptoms from coming back (maintain remission). Therapy is aimed at quieting inflammation, closing fistulas if present, correcting nutritional deficiencies and relieving symptoms. Treatment includes drugs, nutrition supplements and surgery. Treatment can help control the disease, but there is no cure. Some people have long periods of remission, sometimes years when they are free of symptoms. Unfortunately, the disease usually recurs at various times over an individual's lifetime. Although predicting when a flare-up may occur is not possible, early recognition of symptoms results in a better response to treatment. A good patient-doctor relationship is very important and needs to be lifelong since regular follow-up visits are essential. Drug Therapy The treatment of Crohn's disease depends on its severity, location and the existence of any complications. It must be individualized. Most people have mild to moderate disease and are treated with medications containing mesalamine. These medications differ based on what parts of the bowel they treat. They include sulfasalazine, Asacol®, Pentasa® and Dipentum®. They are usually well tolerated, and most have no significant side effects. Patients may experience nausea, headache and diarrhea. In cases where disease in the rectum is causing symptoms, enema or suppository therapy with mesalamine (Rowasa®) is also helpful. Mesalamine is useful both to achieve and maintain remission. Some patients may need corticosteroids (e.g., prednisone) to control inflammation and induce remission. These patients often have severe active disease or have not responded to mesalamine therapy. These drugs are very effective but have significant side effects, such as increased susceptibility to infection, mood swings, anxiety, depression, elevated blood pressure, glaucoma, cataracts and osteoporosis. Although these drugs are good for inducing remission, they have no role in maintaining remission. They are tapered once a patient has achieved remission, and a medicine such as mesalamine or a drug that suppresses the immune system is used long-term to maintain remission. Immunosuppressives (drugs that suppress the immune system) are also used to treat Crohn's disease. These medications block the inflammation that results in Crohn's disease. They should only be prescribed by physicians with experience in their use. The most commonly prescribed are 6mercaptopurine (Purinethol®) and a related drug, azathioprine (Imuran®). They are very effective but may cause side effects such as nausea, vomiting, liver problems or pancreatitis. Long-term they work by suppressing the bone marrow and, as a result, the immune response. Because of these potential side effects, frequent monitoring, including blood tests and clinic visits, are important. These medications take on average 12 to 16 weeks to work. Usually the physician will induce remission first with another medication (i.e., prednisone) and maintain remission with either azathioprine or 6-mercaptopurine. Despite these limitations, these medications are useful because they can allow patients to come off corticosteroids. Most patients tolerate them well. Methotrexate is another immunosuppressive that is sometimes used, but it also can have significant side effects, including lung, liver and blood problems. A relatively new addition to medical treatments for Crohn's disease is infliximab (Remicade®). This is the first medication approved by the U.S. Food and Drug Administration specifically for the treatment of Crohn's disease. It is an antibody that blocks tumor necrosis factor (TNF). TNF is an important cause of the inflammation in Crohn's disease. Infliximab is given intravenously and may be given to a patient once, as a series of three injections or, in rare cases, on a continuing basis. It is effective in inducing remission, but usually an immunosuppressive is required to keep patients in remission. Studies are in progress to determine the long-term effects of this medication. Other medications that can be helpful in Crohn's disease are antibiotics. Most commonly metronidazole (Flagyl®) and ciprofloxacin (Cipro®) are used. These are particularly helpful in patients with disease involving the colon or those who have fistulas. They are often used in combination with the other medications mentioned. Most symptoms will disappear once the inflammation is treated. Diarrhea and crampy abdominal pain may persist and require additional medication for control. Diarrhea is often treated with loperamide (Imodium®), diphenoxylate (Lomotil®) and codeine. However, these medications should be given under a physician's supervision because they can be dangerous if a patient uses them during a flare-up of Crohn's disease. Abdominal pain may be treated with antispasmodics such as dicyclomine (Bentyl®). Surgery Surgery to remove part of the intestine can help Crohn's disease but cannot cure it. The disease tends to recur near the area where the intestine was removed. Many patients require surgery because medical therapy has not controlled their symptoms or because complications such as blockage, abscess, perforation or bleeding into the intestines have developed. Because the disease recurs after surgery, patients must weigh the risks and benefits of the procedure and other options for medical therapy. Patients should become educated through discussions with physicians, information from reputable organizations and other patients who have faced similar circumstances. Some patients with Crohn's disease of the large intestine need to have their entire colon removed in an operation called a colectomy. A small opening is made in the abdominal wall at the tip of the ileum (part of the small intestine). This opening, called a stoma or ostomy, is where waste exits the body. The stoma is about the size of a quarter and is usually located in the right lower part of the abdomen near the beltline. A pouch is worn over the opening to collect waste, and the patient empties the pouch as needed. Most colectomy patients go on to live normal, active lives. About Diet General Recommendations The importance of diet has been a source of confusion among patients. No particular food has ever been implicated in causing Crohn's disease. Patients should eat a nutritious, well-balanced diet. Diet may have to be restricted based on symptoms or complications. Patients with strictures (narrowing in the intestine that could lead to a blockage) should restrict fiber-containing food and avoid seeds (corn, popcorn etc.). Some patients may not tolerate milk or milk products. These patients may benefit from lactase-fortified products. Patients should probably avoid foods that they know bother them and should seek specific recommendations from their physician. Supplemental Nutrition The physician may recommend commercially available nutritional supplements, especially in cases of malnutrition or in children with disease whose growth has been slowed. In cases with severe or difficult-to-treat disease, nutrition by vein with bowel rest (nothing by mouth) may be recommended. Patients who are losing weight or having diet problems should ask their physician for help or request a referral to a registered dietician Photographs Crohn's disease is seen in this segmental resection of terminal ileum to involve the center portion where the small intestinal wall is thickened and the mucosa is inflamed and ulcerated. Crohn's disease microscopically at low power magnification can be seen to involve the full thickness of the wall from the mucosa to the serosa. Granulomas are seen toward the serosal surface here. Crohn's disease microscopically at high power magnification may demonstrate granuloma formation. Special stains for infectious organisms will be negative. Crohn's disease microscopically at medium power magnification is shown with a deep fissure extending through mucosa to the submucosa. This can result in fistula and/or abscess formation. Pseudomembranous colitis appears as a tan to yellow-green exudate over an erythematous bowel mucosa **T.Subramaniam(Siva), Dept of Surgery…