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Crohn's Disease

Updated: Nov 4, 2022

Inflammation can occur at any point anywhere from your mouth to your bum. This may relate to a genetic susceptibility or result from environmental factors. Homozygosity for the NOD2 gene has shown a 20- to 40-fold increase for the risk of developing Crohns disease. Environmental factors include smoking, oral contraceptive use, antibiotic use, regular use of NSAIDs, and urban environment. Pets and farm animals actually decrease risk, as does sharing a bedroom, having more than two siblings, high fiber intake, fruit consumption, and physical activity.


When Crohns is suspected, often the goal is distinguishing between non-inflammatory and inflammatory bowel disease, and then if inflammatory, distinguishing between Crohn's and ulcerative colitis.



Most cases are diagnosed in the second to fourth decade, but can be discovered in children or even later. While race and higher education are associated with increased prevalence, but overall incidence is growing.


Symptoms depend on where the Crohns is most significant in the bowel. For example, when in the ileum and colon, symptoms are more #diarrhea, cramping, abdominal pain, and weight loss. This is the most common form, but also quite common are inflammatory findings within the colon only. Here clients will also experience diarrhea, but lesions are more prominent so rectal bleeding, perirectal abscesses, fistulas, and perirectal ulcers are experienced with colon-exclusive Crohn's. When only in the small bowel, complications include fistula and abscess formation and when in gastroduodenal region, then anorexia, weight loss, nausea and vomiting are common, but this form overall is rare.


Crohn's disease can present insidiously but may also present in a much more acute and toxic way. Diarrhea, abdominal pain, rectal bleeding, fever, weight loss, and fatigue are classic symptoms, but certainly the practitioner will ask about nocturnal symptoms, urgency, food intolerance, travel, medications, smoking status, and family history of inflammatory bowel disease, and eye, joint, or skin symptoms. Fistulas and abscess are common and aren't just in the bum, but potentially the eyes, joints and skin.


When we suspect Crohn's, we are typically also considering irritable bowel syndrome, ischemic colitis, lymphoma, sarcoidosis, ulcerative colitis, Celiac disease, chronic pancreatitis, pancreatic insufficiency, colorectal cancer, diverticulitis, and various infections.


How Do I Know?


Your clinician will order a fecal calprotectin if they are concerned you may have Crohn's disease and this may spare you from more invasive testing. Other blood tests such as a complete blood count, a complete metabolic panel, a pregnancy test, C-reactive protein level, erythrocyte sedimentation rate, and stool studies for C. diff are also evaluated, alongside ova and parasites, and potentially a stool culture. These results can support the diagnosis, help monitor its severity, and determine alternative diagnoses. Measuring a cRP, fecal calprotectin, and stool lactoferrin can help assess the disease and likely eliminate need for further diagnostic testing, such as endoscopy.


Anemia is common though, so this should be monitored throughout. Deficiencies in folate, iron and vitamin D3 are also common, so these should be routinely evaluated. If surgery proves necessary and extensive sections of the bowel are removed then vitamin B12 deficiency is likely and should be monitored.


Endoscopic testing does allow for direct visualization of and access to the bowel lumen. If lesions are identified these can be better understood regarding their pathology, and ultimately this testing allows for monitoring of the success or failure of therapy. Endoscopic testing, with exception of capsule endoscopy, allows for biopsy and therapeutic interventions.


CT scans, MRIs and ultrasounds really can be helpful in the management of Crohn's disease. If the client has a sort of acute or toxic presentation, then a standard CT should be the first test. If diagnostic testing is necessary and it isn't as toxic, then an ileocolonoscopy with biopsy is often recommended. An esophagogastroduodenoscopy is often used with children. These can help identify the severity of the disease so a comprehensive treatment plan can be created. If these aren't helpful in diagnosis and clinical symptoms are still pointing towards Crohn's disease, then a capsule endoscopy may be a great next step. If this is also negative, then Crohn's disease is very unlikely.


What is Common Treatment for Crohn's?


Treating the inflammatory process is important as well as any complications that may present along the way, right, because many clients also suffer with abscesses, fistulas, strictures, and intestinal obstructions. Remission is the ultimate goal. There are a number of consequences for those who suffer with Crohn's so minimizing these is an important part of the treatment plan as well. Greater risk of course comes with more significant medications whether corticosteroids, immunomodulators, and biologics - all approaches that are outside my interest and therefore scope to counsel clients, but many other primary care practitioners may be a great resource here, if not your gastrointestinal specialist. Surgery may be a more advanced step in controlling the manifestation of Crohn's disease.


My goal would be to identify the trigger in causing the underlying inflammation. Cancer and osteoporosis are real concerns, as are nutritional deficiencies, depression, infection, and even clots. Screening for cancer does change when one has an inflammatory bowel disease which may be managed by your PCP.


References

Veauthier, B. & Hornecker, J. R. (2018). Crohn's disease: Diagnosis and management. American Family Physician, 98(11), 661-669.



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