- Definition
Crohn’s disease is defined as (CD) is part of chronic inflammatory bowel disease (IBD),
it causes inflammation in the digestive tract of the body, creates abdominal pain, severe diarrhea,
fatigue, weight loss, and malnutrition. (CD) is described by its “transmural granulomatous
inflammation” which affects any part of the gastrointestinal tract, commonly the ileum, colon, or
both (Thia et al. 2010). (CD) is a complex immune-mediated health condition that commences
with an interaction between genetic, immunologic, microbial, and environmental factors.
Although treatments of (CD) are centered on the applications of immunosuppression, modulating
the dysregulated gastrointestinal, and systemic immune response, diet and nutrition are
increasingly recognized as key components of comprehensive (IBD) management. - Epidemiology
(CD) occurs in between 3 to 20 cases per 100,000. The spread of (CD) is focused in
industrialized countries, such as North America and Western Europe. Though there is a rising
number of (CD) patients in Asia and South America, it is still less than in North America and
Western Europe. (CD) is prominently dominant among women, its causes are related to genetic
and environmental factors which may increase the risk of the disease and lead to the aberrant gut
immune response characteristic. Patients with (CD) face significant obstacles in their lifestyles
and daily activities during both flares and remissions (Devlin et al. 2014). (CD) induce chronic
infections and a wide range of problems causing chronic diarrhea, irritable bowel syndrome
(IBS), inflammatory bowel disease (Crohn disease and ulcerative colitis), malabsorption
syndromes where food cannot be digested and absorbed. Women are 1.1-1.8 higher at risk of
getting Crohn disease. Also, the prevalence among Hispanics is about 4.1%, Asians at 5.6%,
whites at 43.6%, blacks at 29.8%, and others at 8.4% (Dotson et al. 2015). Also, two out of three
people suffering from Crohn’s disease were aged below 40 years (Dotson et al. 2015). - Aetiology
The pathological attribute of (CD) is related to its growing protease activity which leads
to inflammatory bowel disease (IBD). Several factors affect the development of (CD) in the
body; these factors are related to heredity and the breakdown of the immune system. The most
common factor in people is the heredity factor traced by the history of a patient’s family. Failure
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in the immune system could trigger the development of (CD). The significant effect of (CD) in
patients is the reduction of bone mineral density. According to Haschka et al. (2016), patients
with (CD) face a high reduction in bone mineral density different from patients with ulcerative
colitis. The attempt is by using biomarkers BGM and VICM high diagnostic accuracy to
differentiate (UC) from (CD), and “the combination of Pro-C5 together with BGM and EL-NE
biomarkers demonstrated high diagnostic accuracy to differentiate IBD from IBS patients”. In
another peer-reviewed article by Chan et al. (2013), the pathological attributes found by
researchers did not result in any correlation between an increase (BMI) and the development of
either incident (CD) or (UC).
Pathophysiology
Crohn’s disease starts with the inflammation of the crypt together with abscesses, which
progress to become focal aphthous ulcers (Chan et al. 2013). There is a development of the
mucosal lesions, which may become deep longitudinal as well as transverse ulcers that are
coupled by intervening mucosal edema, which creates a cobblestone appearance of the bowel.
The transmural spread of the inflammation may lead to lymphedema as well as thickening of the
bowel wall. The mesenteric fat that typically extends on the serosal surface of the bowel
becomes enlarged (Chan et al. 2013). Indeed, extensive inflammation can cause fibrosis and
ultimately obstruction of the bowel. Transmural spread of inflammation leads to lymphedema
and thickening of the bowel wall and mesentery. Mesenteric fat typically extends onto the
serosal surface of the bowel. Mesenteric lymph nodes often enlarge. Abscesses and fistula are
also common, which happen and extend into the skin of the anterior abdomen (Mortensen et
al. 2017).
- Signs and Symptoms:
The signs and symptoms of (CD) can range from mild to severe ones, and they can
involve the small or large intestine. The following signs and symptoms are revealed in patients
with (CD): a. Diarrhea. b. Fever c. Fatigued. Abdominal pain and cramping e. Blood in the stool.
f. Mouth sores g. Reduced appetite and weight loss. h. Pain or drainage near or around the anus
resulting from inflammation in the skin. Other signs and symptoms could reveal inflammation in
the liver or bile ducts, iron deficiency, or delayed growth of sexual development in children.
People with severe Crohn’s disease also experience inflammation in their eyes, skin, and
joints. In particular, eyes may show blurred vision, redness, and dryness (Danese et al. 2015).
The inflammation of the joint causes pain, stiffness, and redness at the joint. The patient may
also experience inflammation of the liver and bile ducts. Indeed, a study conducted by Glassner
et al. (2017) showed that 13% of the participants who experienced inflammation of the bile ducts
had Chron’s disease, which depicts a commonality. Patients with CD may also have kidney
stones due to fat malabsorption (Danese et al. 2015). - Differential Diagnosis
Ulcerative Colitis (UC) could be confused with CD. The two diseases are characterized by
inflammation of the bowel. However, ulcerative colitis affects the large intestine, colon, and rectum
while Crohn’s happens anywhere in the gut (Gecse & Vermeire, 2018). CD could also be confused
with irritable bowel syndrome as it causes persistent diarrhoea, constipation, and belly pain (Gecse &
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Vermeire, 2018). However, this IBS is not persistent and it gets better after a bowel movement.
Celiac is another condition that is associated with CD as it causes weight loss, bloating, diarrhea, and
tiredness. However, this disease is associated with taking gluten (Gecse & Vermeire, 2018).
Sometimes CD could be confused with allergies to some foods as shown by diarrhoea and nausea,
however, the main difference is that most allergies exhibit rashes and trouble in breathing as opposed
to CD (Gecse & Vermeire, 2018).
- Investigations
A study done by Chang et al. (2014) investigated the “fecal calprotectin as a diagnostic
marker to differentiate between patients with inflammatory bowel disease (IBD) and those with
irritable bowel syndrome (IBS)”. Subjects of the following characteristics were employed: “20
healthy individuals, 26 patients with IBS and 58 patients with IBD, including 22 with ulcerative
colitis (UC) and 36 with Crohn’s disease (CD)”. Analysis of Calprotectin was taken from stool
samples, and C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) were
evaluated in blood samples. The study concluded the following results; “CRP and calprotectin
levels, and the ESR were observed to be significantly higher in patients with CD and UC
compared with those of the healthy control subjects (P<0.0001). Furthermore, in patients with
IBD and IBS, significant increases in fecal calprotectin and CRP levels were observed
(694.8±685.0 µg/g in IBD vs. 85.8±136.1 µg/g in IBS and 0.851±1.200 mg/dl in IBD vs.
0.16±0.23 mg/dl in IBS, respectively; P<0.0001). The area under the receiver operating
characteristic curve analysis revealed that, in patients with IBD, the levels of fecal calprotectin
[0.931±0.029; 95% confidence interval (CI), 0.874‑0.987] were significantly higher than that of
CRP (0.865±0.041; 95% CI, 0.785‑0.946) and the ESR (0.869±0.042; 95% CI, 0.786‑0.952).
These findings indicate that fecal calprotectin may represent a novel biomarker for diagnosing
IBD and may be effective in distinguishing between IBD and IBS. The median calprotectin
concentration was 595 μg/g (95% CI, 571–1059; range, 30–1,800 μg/g) in the patients with (CD)
and 219 μg/g (95% CI, 238–756; range, 35–1810 μg/g) in the patients with (UC). The AUC was
significantly higher in the patients with (UC) 0.939; 95% CI, 0.869 than that in the patients with
(CD) (0.925; 95% CI, 0.84–1.00). The sensitivity, specificity, PPV and NPV were 86, 95, 94 and
87% in the patients with (UC), and 91, 95, 94 and 91% in those with CD, respectively”. - Orthodox Medical Treatment
There is no definite cure for (CD), but therapies and treatment are making progress in
reducing the disease’s signs and symptoms and generating long-term healing of inflammation. A
multidisciplinary approach is encouraged for the treatment process, generating impact treatment
for patients. A balanced diet of high fiber and fruits is protective against (CD) and should be
encouraged (Hou et al. 2011). There are more initiatives of using aggressive treatment in the
early stages of the disease to improve clinical outcomes in patients with risk factors predisposing
to increased disease severity (D’haens et al. 2014). Normally medications like corticosteroids,
budesonide, or mesalazine are prescribed at the beginning for induction of remission (Dignass et
al. 2010). Anti-tumor necrosis factor (TNF) immunosuppressive therapies are also used in
patients defiant to orthodox treatment. The success of the medical treatment depends on patient
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literacy, patient age, and patient’s regular visits to a gastroenterologist (Kuenzig et al. 2014;
Zelante et al. 2014).
Treatment may include anti-inflammatory drugs, which is the first step in the treatment of
bowel disease. This may include Corticosteroids such as prednisone and budesonide (Entocort
EC) and Oral 5-aminosalicylates such as sulfasalazine (Azulfidine) (Bernell et al. 2000; Dasariet
al. 2011). Another set of treatments are the immune suppressors, which prevent continued
inflammation, which may include Azathioprine (Azasan, Imuran) and mercaptopurine
(Purinethol, Puritan), but they may cause vomiting and Methotrexate (Trexall) (Colombel et al.
2010; Delaney et al. 2003). This set of drugs requires a regular check of blood for side effects.
Biologics are also used to treat the disease that works by preventing some immune cell
molecules from binding to other types of drugs. They may include Natalizumab, Infliximab
(Remicade), and Ustekinumab (Stelara). Antibiotics could also be used such as ciprofloxacin
(Cipro) and metronidazole (Flagyl), which help to reduce the bacterial load in the intestine,
which could activate the immune system (Chande et al. 2013; Kuenzig et al. 2014).
Surgical treatments are recommended for failed “medical therapies, recurrent intestinal
obstruction, malnutrition and for septic complications such as perforations and abscesses”
(Dasari et al. 2011). Surgical treatments restrict unexpected complications including complex
perianal disease and internal fistulas (Baumgart & Sandborn, 2012), and refine the quality of life
(Delaney et al. 2003).
- Natural Medicine
The common natural medicine advised for (CD) is exclusive enteral nutrition (EEN).
This form of nutrition is administered for 6 to 8 weeks. It consists of utilizing protein as a
leading ingredient for a first-line therapy to induce remission in children with active (CD).
(EEN) provides a significant amount of nutritional benefits and provides superior mucosal
healing in comparison to steroids. It was recorded that recovery occurred in days and it was
advised that alternative therapy must be suggested in the absence of a response within 2-4 weeks.
Studies showed that there is no variance between polymeric and elemental (amino acid). EEN is
considered important as it leads to a constant flow of formula, which leads to better absorption of
nutrients and lessens stomach pain and vomiting, which is associated with Crohn’s disease
( Kammermeier et al. 2014). EEN is also associated with increased remission rate and faster
healing of the gastrointestinal tract. - Prognosis & Complications
A study done on 480 patients was conducted by Veleso et al. (2001)y using the Markov
chain analysis it was reported that “patients with ileal disease had a greater need for surgical and
a lesser need for immunosuppressive treatment; patients with the ileocolonic disease were
diagnosed at an earlier age and showed a lower probability of remaining in remission during the
disease course; patients with colonic disease needed less surgical or steroid treatments; patients
with the intestinal penetrating disease were frequently submitted to abdominal surgery, whereas
those with the anal-penetrating disease often needed immunosuppressive treatment.
Approximately 40% of the patients were in clinical remission at any time, but only about 10%
maintained a long-term remission free of steroids after their initial presentation. A more benign
clinical course could be predicted in patients who stay in remission in the year after diagnosis.
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The grouping of patients with (CD) according to the Vienna Classification and/or the clinical
activity in the year after diagnosis is useful in predicting the subsequent course of the disease.
- Resources List
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