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Crohn's Disease Crohn's Disease (CD) is a chronic (long-term) condition that causes inflammation of the lining of the digestive

system. The disease can occur anywhere in the digestive system, that is from the mouth to the anus, but is most often seen in the ileum (the last section of the small intestine) or the colon (the large intestine). CD is a rare condition. People of all ages can be affected but most cases of CD first develop in people between 15-30 years old. CD is more common in white people and slightly more in women than men. The disease is most prevalent among Jewish people of European descent. Symptoms Common symptoms of CD include diarrhoea, blood and mucus in faeces (stools), abdominal pain and cramping (the pain is usually worse after eating), fatigue, and weight loss. Less common symptoms of CD include fever, nausea, vomiting, joint pain and swelling (arthritis), inflammation and irritation of the eyes (uveitis) and skin rashes. Causes The exact cause of CD is unknown. Research suggests a combination of the following inter-related factors: Genetics - genes that people inherit from their parents may increase the risk of developing CD (genetic susceptibility). The immune system - it appears to be responsible for the inflammation that occurs in CD. Previous infection - a previous bacterial, or viral, infection may trigger an abnormal response from the immune system. Environmental factors - With very good domestic hygiene, the intestinal immune system have not been exposed to lots of parasites and may be untrained to confront minor infections and cause inflammation more readily.

Risk factors also include smoking. People with CD who smoke usually experience more severe symptoms compared to non-smokers.. Diagnosis No single test can be used to confirm or exclude a diagnosis of CD. Hence, a series of test need to be performed to help rule out other possible causes such as ulcerative colitis (a condition which causes inflammation of the colon). Initial assessment - The GP will ask the patients about the pattern of the symptoms and check if there may be contributing cases such as diet, history of recent travel, any medication and family history of CD. To assess the general state of health the GP will measure the pulse, blood pressure, weight and height, and temperature and also perform a physical examination of the abdomen. Blood tests - These are used to assess factors like the levels of inflammation in the body, the presence of an infection and anaemia (low levels of red blood cells) which could suggest that malnourishment or problems with absorption in the small intestine. Stool sample - A sample of faeces (stool) may need to be provided to check for the presence of blood and mucus and it is also used to determine whether the symptoms are being caused by a parasite infection such as roundworm. Colonoscopy - It is a test that is used to examine the inside of the colon by inserting a long flexible tube, known as an endoscope, into the rectum (back passage) and up into the colon. The endoscope has a light and a camera on the end. The camera relays images to a video screen, allowing the level and extent of inflammation to be assessed. The endoscope can also be fitted with various surgical tools that can be used to take a number of small tissue samples from different sections of the digestive system. This is known as a biopsy. The procedure may feel uncomfortable but it is not painful. The tissue samples that are taken during the biopsy will be examined under a microscope for the distinctive cell changes that are known to occur in cases of CD. Small bowel enema (SBE) - It is a test to examine the inside of the small intestine, usually at the point where it meets the colon. This area cannot be seen using a colonoscopy. During a SBE, a local anaesthetic spray will be used to numb the inside of the nose and throat. A tube will then be passed down the nose and into the throat, before being threaded into the small intestines. This can feel unpleasant at first, but most people find that they get used to the sensation after a few minutes. A liquid called barium, will be passed down the tube which coats the lining of the small intestines. The barium helps the small intestines to show up on X-rays. A series of X-ray images will then be taken. The results of the X-rays can often highlight areas of narrowing and inflammation that have been caused by CD. After the test, the patient will be advised to drink plenty of fluid to help wash the barium out of his body. It may noticed that the stools are whiter than usual for the first few days after having a SBE. This is perfectly normal and it is nothing to worry about.

Treatment The aim is to induce and then maintain a remission. Patients with mild symptoms may require only symptomatic treatment. Steroids - They are a type of hormone medication. Hormones are groups of powerful chemicals that have a wide range of effects on the body. One such effect is to reduce inflammation. Steroids are usually only used to treat the active disease because their long-term use is associated with a range of adverse side effects. Budesonide and prednisolone are two steroids that are often used to treat CD. Aminosalicylates - They are known to reduce inflammation inside the colon. Sulfasalazine, belonging to this group of medicines, can be used as an alternative to steroids to treat mild cases of CD. Immunosuppressants - They are a type of medication to suppress the activities of the immune system in order to help reduce inflammation on a long-term basis. They are used in maintenance therapy and in combination with steroids when a person has a relapse of symptoms. Two immunosuppressants that are widely used for treating CD are azathioprine and mercaptopurine. Biological therapies - They are a new type of medication that are created using naturally occurring biological substances, such as antibodies and enzymes. Infliximab is usually only recommended in severe cases of CD that have not responded to steroid and immunosuppressant treatments, and where the person is unsuitable for surgery. It works by targeting the tumour necrosis factor (TNF) antibodies that are responsible for much of the inflammation that is associated with CD. It is given through a drip in the arm over the course of two hours. This is known as an infusion. Surgery - It is often required when the symptoms of CD cannot be controlled using medication alone. About 80% of patients will require an operation at some time during the course of the disease. Nevertheless, surgery should be avoided if possible and only minimal resections undertaken, as recurrence (15% per year) is almost inevitable. Surgery cannot cure CD but it can provide long periods of remission, often lasting several years. During surgery, the inflamed section of the digestive system is removed and the remaining part is reattached. Management A healthy diet rich in proteins and calories is important particularly if they are having trouble eating or they have lost weight. Some food may worsen symptoms and hence, vitamins and food supplements might be required. Special diets that help reduce the inflammation in the bowel can be prescribed by specialist dietician. Cigarette smoking should be stopped to prevent exacerbation of the disease. Complications of CD Bowel obstruction - Due to intensive inflammation, sections of the bowel can narrow and harden, leading to bowel contents becoming stuck in the bowel. A bowel obstruction requires immediate medical treatment. Left untreated, there is a risk that the bowel could rupture (split) which in turn can lead to internal bleeding and wide-spread infection. If a bowel obstruction is suspected, the patient will be admitted to hospital to monitor his health. In some cases, it may be possible to clear the bowel obstruction by switching him to a liquid-only diet and using medication to reduce inflammation. Otherwise surgery might be required. A temporary colostomy might be required until the bowel heals. A colostomy is an operation where a section of the colon is diverted, and attached to an opening (referred to as a stoma) in the abdominal wall. A pouch is attached to the stoma to collect waste products, such as stools. Once the bowel has healed, the colon can be reattached and the stoma sealed. Fistulas - If the digestive system becomes scarred as the result of excessive inflammation, ulcers (open sores) can develop and over time, can expand into passageways (fistulas) that can run from one part of the digestive system to the other or, in some cases, to the bladder, anus, or skin. Small fistulas usually cause no symptoms. Larger fistulas can become infected and cause symptoms such as a constant, throbbing pain, fever, blood and/or pus in faeces (stools), generally feeling very unwell. If a fistula develops on the skin (usually on, or near, the anus) it may release a foul-smelling discharge. Surgery is usually required to treat a fistula. During surgery, the fistula is cut open. They will scrape and flush out the contents of the fistula which will be laid open and flattened out. Resources References

Kumar P, Clark M. Kumar & Clark's clinical medicine. 7th ed. Edinburgh; New York: Elsevier/Saunders; 2009. Kumar K, Fausto N, et. al. Robbins and Coltran pathologic basis of disease. 8th ed. Philadelphia: WB Saunders; 2009.