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Crohn'S Disease

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Autor:  anton  08 November 2010
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Crohn's disease is named after Burrill B. Crohn, the physician who described the disease in a paper written in 1972. Crohn’s disease can also be referred to as Morbus Crohn's, Granulomatous Enteritis, Regional Enteritis, or Terminal Ileitis. Attacks of Crohn’s disease may affect patients in their teens or early twenties, and tend to recur throughout the individual's life.

The History of Crohn’s Disease

Crohn’s disease is an inflammatory bowel disease of an undetermined cause that afflicts more than five-hundred thousand people in the United States and is not biased in regards to whom it strikes. People unlucky enough to get Crohn’s Disease include the old and young; rich as well as poor; men, women, and children of white, black, and Asian descent; the disease does not discriminate against age, social class, gender or color. Crohn’s primarily attacks the digestive system in the areas of the ileum, which is part of the small intestine and the large intestine (also known as the colon), but can occur in any section of the gastrointestinal tract. Although Crohn’s disease afflicts all age groups, initial diagnosis generally occurs before the age of thirty.

Throughout historical medical literature, during the 19th century, various cases were reported by physicians describing what is known as Crohn’s disease today. Although it was not named until 1932, the first reported case of Crohn’s Disease was in 1806 by Doctors Combe and Sanders to the Royal College of Physicians in London, England (Crohn’s Disease History, 2001). Seventeen years later an Edinburgh physician by the name of John Abercrombie documented one hundred forty-four cases in which there was a clearly outlined difference in ileal and colonic diseases. In comparison to known facts of Crohn’s Disease today, the Edinburgh physician was most likely describing Crohn’s and ulcerative colitis, another inflammatory bowel disease.

Almost a hundred years later, in 1913, there was surgical evidence of the disease as reported in the paper ‘Chronic Intestinal Enteritis’ written by Dr. Kennedy Dalziel, a Scottish physician working at the Western Infirmary in Glasgow. The most famous report came in 1932 from research done at Mount Sinai Hospital in New York. Dr. Burrill B. Crohn first presented a paper titled ‘Terminal Ileitis’ to the 83rd Annual Session of the American Medical Association. The paper listed information on fourteen surgical cases mostly operated on by surgeon, Dr. A. A. Berg. The paper prompted more medical research in the area, which lead to the three-man team of gastroenterological Drs. Burrill B. Crohn, Leon Ginzburg, and Gordon D. Oppenheimer. The three doctors studied the disease of the ileum that was once thought to be intestinal tuberculosis (NFIC, 1983). Crohn, Ginsberg, and Oppenheimer later presented their paper ‘Regional Ileitis.’ The threesome recorded cases of "non specific granulomas of the intestine" (Crohn’s Disease History, 2001).

There was no appropriate medical terminology to describe the many manifestations of the disease. It was in England that the name Crohn’s was widely used by local physicians (Crohn’s Disease History, 2001). In the western world, the disease was called "Terminal Ileitis" for many years. The name involving the word ‘terminal’ frightened patients although the disease was not fatal with treatment (NFIC, 1983). Later, the name "Regional Ileitis" came into use, but as it was discovered that the disease could in fact involve any area of the gastrointestinal tract, not just the terminal ileum, the name Crohn’s was gradually used widespread (Crohn’s Disease History, 2001). The disease is referred to as Crohn’s due to the fact that Burrill B. Crohn’s name was the first listed in the landmark paper (Researchers, 2001). Dr. Berg unfortunately did not want his name published on the important paper, if he had, Crohn’s would be known by a different name today (Crohn’s Disease History, 2001).

It wasn’t till May 2001 that the first gene for Crohn’s disease was identified. The discovery was made by a team of Inflammatory Bowel Disease researches led by Dr. Judy Cho, an assistant professor of medicine and a researcher in the Martin Boyer Laboratories at the University of Chicago, and Dr. Gabriel Nuňez, an assistant professor of pathology at the University of Michigan (Researchers, 2001). To collaborate the findings of the American based scientists, an independent research team in France released their findings showing that they had found the same gene. The French research team was lead by Dr. Jean-Pierre Hugot and Dr. Gilles Thomas.

What is Crohn’s Disease?

Crohn's disease, also referred to as regional ileitis, is a chronic, long term, inflammatory disease that affects the digestive tract. It can affect the digestive system anywhere between the mouth and the anus, but usually affects the final section of the small intestine, the ileum. Inflammation of the inner lining of the colon and rectum is caused by Ulcerative Colitis, while Crohn's disease is an inflammation that extends into the deeper layers of the intestinal wall. Crohn's disease can also affect the also affect the colon, the regional lymph nodes, and the mesentery (outside covering of the intestines). The disease can be aggravated by a bacterial infection. It begins with the development of patches of inflammation on the intestinal wall, which can spread from one part of the digestive tract to another. It sometimes only develops in one place and does not spread any further. The inflammation causes the thickening of the intestinal wall, which sometimes causes an obstruction in these areas, or scar tissue, which narrows the passageways. The figure below represent an abnormal intestine that has been afflicted with crohn’s disease.

The Symptoms of Crohn’s Disease

The symptoms of Crohn's disease sometimes act like an appendicitis attack and can also be accompanied by the following common signs:

 Abdominal right-sided tenderness and pain

 Appetite and weight loss

 Possible diarrhea and bloody stools

 Fever

 Abdominal distention

 Nausea, vomiting, and a general sick feeling.

Crohn's disease can also appear as periodic cramps with diarrhea, and may or may not involve the obstruction of the bowel. Poorly digestible fruits and vegetables can plug the already narrowed segment of the intestine and cause an obstruction. Diarrhea may be the result from the obstruction because of poor absorption of nutrients, excessive growth of bacteria in the small bowel, or inflammation of the large intestine. The result of this could be blood in the stools, or rectal bleeding

Complications of the disease may occur in areas related to the intestinal disease (i.e., bowel perforation, abscesses, fistulae, cancer of the bowel, and intestinal hemorrhage). Or complications may occur in areas not related to the intestines (i.e.; tender, raised, reddish shin nodules; inflammation in the joints, spine, the eyes, the liver, and the bile ducts that drain the liver) (CCFA, 2005)

In one-fourth of all cases, the symptoms appear only once or twice, and the disease does not come back. If they recur, they will come back every few months or every few years for the rest of a person life, with periods of remission. If Crohn's disease continues for years: it will gradually deteriorate the bowel functioning, there will be a risk of poor absorption of nutrients, severe bleeding which can cause iron-deficiency or it could possibly increase your risk of cancer of the intestine.

The symptoms of Crohn’s disease a person gets is determined by the subtype of the disease they have. There are five subtypes of Crohn’s Disease: Gastroduodenal Crohn disease, Jejunoileitis, Ileitis, Ileocolitis, and Crohn Colitis (Zonderman, 2000).

• Gastroduodenal Crohn disease is known to affect the stomach and duodenum (beginning section of the small intestines). The main symptoms for this subtype of Crohn’s include a loss of appetite and weight loss, nausea, vomiting, and pain in the upper middle of the abdomen. Doctors initially diagnose this condition as ulcer disease. Correct diagnosis occurs when treatment for the ulcers has been unsuccessful or when the disease affects another part of the intestinal tract (Zonderman, 2000).

• Jejunoileitis is a disease of the jejunum. The jejunum is the largest section of the small intestine which is located between the duodenum and the ileum (last part of the small intestine) (Zonderman, 2000). Major symptoms include mild-to-intense abdominal pain and cramping after meals. Weight loss and malnutrition can occur due to diarrhea and malabsorption of nutrients normally absorbed in the region of the jejunum. Fistulas, "abnormal connections of the inflammation that spreads beyond the confines of the bowel wall and penetrates to adjacent loops of bowel, to other organs such as the bladder, vagina, or to the skin surface," may arise in this subset of Crohn’s Disease (NFIC, 1983).

• Ileitis affects the ileum. "The main symptoms are diarrhea and cramping or pain in the right lower-middle part of the abdomen, especially after meals. Malabsorption of vitamin B12 can lead to the peripheral neuropathy (tingling of fingers and toes) and folate deficiency can hinder red blood cell development" (Zonderman, 2000). The intestines sometimes inflame so greatly that a large mass becomes apparent in the right lower abdomen. Fistulas are also common with Ileitis.

• Ileocolitis is the most common subtype of Crohn’s Disease. If affects the ileum as well as the colon. “Often the diseased areas of the ileum and colon are contiguous and involve the ileocecal valve, which sits at the junction of the ileum and cecum – the first section of the colon – and keeps the waste contents for the colon from backflushing into the small intestine" (Zonderman, 2000). Ileitis and ileocolitis have essentially the same symptoms with the addition of weight loss.

• Crohn’s (granulomatous) colitis: The area of the colon is the major organ affected. The most common systems are diarrhea, rectal bleeding, and disease around the anus usually in the form of abscess, fistulas, and ulcers. Skin lesions and joint pains are more common in this form of Crohn’s than others (CCFA, 2005).

If a patient experiences any of the above-mentioned symptoms, a doctor will perform various tests. The first being a blood test for anemia, which could indicate bleeding in the intestines and a high level of white blood cell count which indicates an infection. Secondly, a colonoscopy, where a flexible lighted tube linked to a computer and TV monitor, is inserted through the anus. The colonoscopy helps the doctor to see the entire colon and location of the inflammation. Once the doctor has determined the extent of the disease and its location he/she can prescribe medication. Another instrument used is the sigmoidiscopy, which is also inserted through the anus but only examines the lower level of the intestines. Some doctors may run upper gastrointestinal series, a small intestinal study, and a barium enema intestinal x-ray to determine the extent of the disease.

As stated earlier Crohn’s disease varies in each individual thus, a doctor will prescribe different medications depending on the individual. Medications help to alleviate the pain and help the patient cope with his/her disease. Below is a list of the main drugs used to treat Crohn’s disease:

Aminosalicylates: These include aspirin- like compounds that contain 5-aminosalicylate acid (5-ASA). Examples are sulfasalazine, mesalamine, olsalazine and balsalazide. These

drugs, can be given either orally or rectally, and alter the body's ability to launch and

maintain an inflammatory process. They are effective in treating mild-to-moderate episodes of Crohn's disease. They also are useful in preventing relapses of the disease (CCFA, 2005).

Corticosteroids: These medications, which include prednisone and prednisolone, also affect the body's ability to launch and maintain an inflammatory process. In addition,

they work to suppress the immune system. Corticosteroids are used for people with

moderate-to-severe Crohn's disease. They can be administered orally, rectally, or intravenously. They are also effective for short-term control of acute episodes, however, they are not recommended for long-term or maintenance use because of their side effects. Budesonide is a nonsystemic steroid used to treat mild-to-moderate Crohn's disease. Budesonide causes fewer side effects. If you cannot come off steroids without suffering a relapse of your symptoms, your doctor may need to add some other medications to help manage your disease (CCFA, 2005)

Immunomodulators: These include azathioprine, 6-mercaptopurine (6-MP), and

cyclosporine. This class of medications basically overrides the body's immune system so it

cannot cause ongoing inflammation. Usually given orally, immunomodulators generally are

used in people in whom aminosalicylates and corticosteroids haven't been effective or have

been only partially effective. They may be useful in reducing or eliminating dependency

on corticosteroids. They also may be effective in maintaining remission in people who haven't

responded to other medications given for this purpose. Immuno modulators may take up to

three months to begin to work (CCFA, 2005).

Biologic therapies: The newest class of drugs to be used in IBD includes infliximab.

It is indicated for people with moderately to severely active Crohn's disease who haven't

responded well to conventional therapy. It also is effective for reducing the number of fistulas.

Infliximab is an antibody that binds to tumor necrosis factor alpha (TNF-alpha), a protein in the immune system that plays a role in inflammation. The drug may be an effective strategy for tapering people off steroids, as well as for maintaining remission. Other biologic drugs are currently undergoing clinical trials for Crohn's disease (CCFA, 2005)

Antibiotics: Metronidazole, ciprofloxacin, and other antibiotics may be used when infections,

such as abscesses, occur in Crohn's disease (CCFA, 2005)

Patients with Crohn’s Disease may have only mild symptoms or long periods without symptoms. A few people have symptoms that are persistent and severe. Crohn's disease can be a frustrating and depressing condition. The persistent diarrhea that often occurs may make a person feel as if his/her life revolves around the bathroom. He/she may feel isolated, be embarrassed by the symptoms, and have a poor body image. These feelings may keep the individual from participating in work, social, and sexual activities. However, most people with the condition live high-quality, productive lives using medications to control inflammation and treat symptoms.

Epidemiology studies of Crohn’s Disease

Epidemiology studies of Crohn's disease have been conducted in many countries. They yield some important insights into the disease. These include the following:

• There is strong evidence that Crohn's disease is caused by an environmental agent.

• Incidence of Crohn's disease is increasing in most parts of Europe and North America.

• Crohn's disease is beginning to make an appearance in parts of the world that have not experienced it before.

The cause of Crohn's disease is unknown, although there is a genetic tendency to develop this disease and environmental factors are also thought to play a part. Crohn's disease may occur at any age but is most common in young adults, with most people first affected during their teens or twenties. Small proportions of patients contract the disease after they are fifty years of age.

Individual studies on the epidemiology of Crohn's disease have been conducted, mostly confined to one city, country or region of a country. Only three countries have conducted national surveys on the prevalence and incidence of Crohn's disease. These are Japan, Slovakia and Yugoslavia. There is insufficient data to develop a complete picture of the global prevalence or incidence of Crohn's disease.

Several studies studied ethnic subgroups of populations. In these studies, people whose country of origin has a low or zero prevalence of Crohn's disease have a much higher prevalence of the disease when they migrate to a country that has high prevalence of the disease. For example, Moroccans living in Belgium, West Indians living in England and Asians living in England are as much at risk of developing the disease as the indigenous populations of those countries. This provides strong evidence that a factor in the environment is involved in causing Crohn's disease. Further evidence that an environmental factor is involved is provided by studies that show that the pattern of relapse of Crohn's disease changes through the year. In this study, it was found that there was a higher rate of relapse in the autumn and winter months.

Figure 1 Is a picture of an abmoral digestive system

References:

“Crohn’s disease, History and Treatments”. (2001, June 4). Australian Crohn’s and Colitis association. http://www.acca.net.au

Hilsden RJ, et al. (1998). Complementary medicine use by patients with inflammatory bowel disease. American Journal of Gastroenterology, 93(5): 697–701.

NFIC. The Crohn’s Disease and Ulcerative Colitis Fact Book. Charles Acribner’s Sons. New York 1983.

Podolsky, D.K. (2002). Inflammatory bowel disease. New England Journal of Medicine, 347(6): 417–429.

“Researchers Find First Gene for Crohn’s Disease”. (2001, May 21). Crohn’s and Colitis Foundation of America. http://www.ccfa.org

Sewitch MJ, et al. (2001). Psychological distress, social support, and disease activity in patients with inflammatory bowel disease. American Journal of Gastroenterology, 96(5): 1470–1479.

Zonderman, Jon and Ronald Vender, M.D. Understanding Crohn Disease and Ulcerative Colitis. University Press of Mississippi. Jackson, 2000.



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