Inflammatory Bowel Disease (IBD): Overview

">
What is Inflammatory Bowel Disease : Overview?Statistics on Inflammatory Bowel Disease : OverviewSymptoms of Inflammatory Bowel Disease : OverviewHow is Inflammatory Bowel Disease : Overview Diagnosed?How is Inflammatory Bowel Disease : Overview Treated?Inflammatory Bowel Disease : Overview ReferencesWhat is Inflammatory Bowel Disease : Overview?

Inflammatory bowel disease (IBD) refers to a group of conditions characterised by recurring inflammation of the gastrointestinal organs. The two main types of IBD are:

Ulcerative colitis: Characterised by inflammation confined to the mucous membranes of the colon (bowel) and rectum;Crohn's disease: Characterised by inflammation of any of the gastrointestinal organs.
 

For more information on ulcerative colitis, see Ulcerative Colitis.

For more information on Crohn's disease, see Crohn's Disease.

These conditions occur because the immune system does not function properly. They are typically incurable and require lifelong treatment. Other conditions that fall under the banner of IBD but which do not involve immune system dysfunction include:

IBD - type unclassified: This diagnosis is given to approximately 5% of individuals with IBD because their disease shows features of both ulcerative colitis and Crohn's disease on investigation;Indeterminate colitis: A diagnosis given when the doctor has diagnosed colitis, but the type (ulcerative or infective) cannot be determined;Infectious IBD: Inflammation of the colon caused by infection;Ischaemic IBD: Inflammation of the colon caused by lack of blood flow (ischaemia);Radiation-induced IBD;Medication-induced IBD.

Statistics on Inflammatory Bowel Disease : Overview

IBD is a prevalent condition in Australia, affecting an estimated 61,000 individuals at any given time. IBD is more prevalent in Australia than epilepsy or road traffic accidents, and has a similar prevalence to type 1 diabetes and schizophrenia. In 2005, more than 1,600 new cases of IBD were diagnosed.

Symptoms of Inflammatory Bowel Disease : Overview

Quality of life (QoL)

IBD is a severely debilitating condition that has a significant impact on an individual's daily wellbeing and functioning. Those with active disease (disease that causes symptoms) experience greater quality-of-life (QoL) impairment compared to those in remission (with asymptomatic disease), and QoL is further impaired by worsening symptoms. The disability and lost quality of life caused by IBD are comparable to the effects of a broken rib or sternum, mild arthritis, asthma or the amputation of an arm. IBD is associated with a greater burden of disability than type 1 diabetes and epilepsy. Its debilitating and life-shortening effects are also greater than those associated with chronic back pain, rheumatic heart disease and mental retardation.

In one European study, three quarters of respondents reported they were unable to engage in normal leisure activities as a result of their IBD symptoms. IBD produces symptoms that typically include pain, vomiting, diarrhoea, bleeding, fatigue, anal irritation and itchiness, flatulence and bloating. Many of these symptoms are considered 'socially unacceptable', and individuals with IBD may feel stigmatised as a result of their symptoms and subsequently experience low self-esteem.

Lost quality of life is costed using DALYs/QALYs (disability adjusted life years and quality adjusted life years, respectively). Using the DALYs model, the cost of IBD-associated reduced quality of life was estimated at $2.4 billion in Australia in 2005. However, evidence suggests that health practitioners rarely enquire about the impact of IBD symptoms on quality of life, indicating that QoL is rarely addressed in the management of IBD. In a European study, nearly half the respondents reported that their doctor did not discuss the impact of their disease on QoL.

Psychological health

IBD is associated with considerable adverse psychological and psychosocial effects. The condition may cause emotional distress and impair QoL as a result of:

Loss of energy;Sleep difficulties, which typically worsen with increasing IBD symptoms;Loss of control;Issues associated with body image, including feeling dirty, which are exacerbated in patients who require an ostomy;Pain;Conflict related to work, education or family;Isolation and fear, including fear about the future and fear of being in public in case of a diarrhoea attack; andLack of information about their condition.

Individuals with IBD are more likely to experience depression and appear to have higher rates of other mood disorders such as panic and anxiety. These disorders impair the individuals' QoL and response to treatment. Individuals with IBD require emotional support from health professionals, family members and informal carers to help them cope with the impact of IBD. This may be particularly true for children and adolescents.

Children and adolescents

There are serious psychological effects associated with IBD in childhood, including depression, anxiety, social isolation and negative self-image. For children and adolescents with IBD, these conditions can affect the establishment of identity, social skills and cognitive abilities, which typically develop in in childhood and adolescence. Dietary restrictions may also impact on their quality of life, as can guilt related to being a burden because of their condition. 

The symptoms of IBD, including altered appearance and faecal incontinence, can cause social embarrassment and withdrawal. Children with ulcerative colitis appear to be more affected by bowel symptoms, while for those with Crohn's, systemic symptoms and appearance changes were the key areas of concern. There are also gender differences in the factors affecting psychological health, with boys being more concerned about short stature and reduced strength, and girls more concerned about weight gain.

Young IBD sufferers are often reluctant to discuss their symptoms and may deny that IBD interferes with their lives. Issues such as anger and frustration associated with their symptoms and treatment may only be drawn out after persistent questioning. Children may limit their activities to ensure they are close to a toilet at all times. However, frequent toilet trips may cause embarrassment and result in the child feeling stigmatised by peers. Growth failure, which causes the child to be smaller than usual for their age, and the side effects of medications used to treat IBD (e.g. facial swelling, acne) may cause embarrassment and stigmatisation. Children may also face discrimination from teachers who lack awareness of their condition. Adolescents with IBD may avoid sexual intimacy due to their symptoms, and experience greater difficulties in the transition to adult life.

Social support, particularly support provided by family, appears to help adolescents cope psychologically with their condition. In one study, a positive maternal relationship was associated with reduced rates of depression, functional disability and bowel movement, while family dysfunction was associated with increased pain and frequency of bowel movements.

Unsurprisingly, a child's IBD severity is also associated with psychological distress in their parents. Parents of children with IBD should consider how their child's condition is affecting them, and talk to their child's doctor about steps that can be taken to reduce any negative QoL affects.

Economic productivity

IBD onset usually occurs at 15–40 years of age, a time when individuals are economically and educationally productive. At this time of life, individuals often have significant educational and financial commitments and IBD can considerably impair a person's ability to meet their life commitments in the short term. Interruptions to work and education can also have ongoing adverse impacts on their ability to participate in the workforce and on their earnings. In a European study, approximately two thirds of IBD patients reported that their symptoms adversely affected their ability to work. Amongst individuals with Crohn's disease, in the year after diagnosis 25% require time off work due to symptoms of their disease, and 15% are unable to participate in the workforce 5–10 years after diagnosis because of Crohn's disease.

Workplace productivity

There is a significant loss of productivity amongst individuals with IBD, which includes absenteeism due to illness and medical appointments, early retirement and reduced productivity throughout working life (e.g. a person may only be able to cope with part-time work). On average, individuals with IBD are absent from work 7.2 days each year as a result of IBD. While the majority of sick leave is paid by the employer, 22–29% of time off work is unpaid and results in lost wages for the individual with IBD. Carers of people with IBD may also need to take time off work to provide assistance. 

As individuals with IBD need ready access to a toilet, they may be prevented from working in certain occupations, including outdoor work environments, jobs requiring lengthy travel and production lines. IBD patients may also face workplace discrimination which limits opportunities for career development.

In Australia, IBD-associated absenteeism is estimated to cost $52.3 million each year, the majority of which ($44.1 million) is borne by employers. In addition, an annual cost of $204.2 million is associated with lost earnings for early workplace separation and retirement.

Educational attainment

The impact of IBD on educational attainment is particularly problematic when IBD begins in childhood. A Scottish study reported that 57% of children with IBD were absent from school for a period of ≥ 2 months at some point in their school life. This resulted in delays completing end of school exams for ~7% of children, and created a need for additional tuition or home schooling arrangements for some. A British study reported that 17% of children with IBD were unable to sit school exams as a result of their condition. Absenteeism from school may limit the child's ability to complete schooling or affect their educational attainment if they do manage to graduate.

Cost

IBD creates significant direct healthcare costs, the majority of which are covered out-of-pocket. In addition to the financial impact of lost productivity and days off work, individuals with IBD typically need to directly pay for some of their medical expenses (e.g. outpatient care and medicines), as well as to pay for informal care (e.g. someone to accompany them to the clinic) and transport to services. An average person with IBD will spend almost $600 each year on out-of-pocket expenses associated with managing their condition.

Systemic health

The symptoms of IBD can have a significant impact on an individual's overall health. In particular, gastrointestinal symptoms such as persistent vomiting and diarrhoea can adversely affect an individual's nutritional status and affect nutrient absorption and appetite. Weight loss and anaemia may occur as a result. Both major types of IBD (Crohn's disease and ulcerative colitis) are associated with extra-intestinal symptoms (symptoms affecting body systems other than the gastrointestinal system) including eye, joint and skin symptoms.

How is Inflammatory Bowel Disease : Overview Diagnosed?

Differentiating between types of inflammatory bowel disease

The symptoms of various forms of IBD are often similar and may also mimic other non-inflammatory conditions (e.g. appendicitis, irritable bowel syndrome). However, some differences in the appearance of the disease can be used to differentiate the two major forms of IBD.

Feature

Crohn's disease

Ulcerative colitis

Site affected by inflammation

Any part of the gastrointestinal system, but most commonly the ileum (last section of the small intestine) and colon (large intestine/bowel);Transmural inflammation (affecting all layers of the intestinal wall);The rectum is often spared;Perianal involvement (when the anus and surrounding area are affected) is common.

 

Confined to the colon (large intestine/bowel);Superficial inflammation confined to the mucosal or outer layer of the intestinal wall;The rectum is typically involved and inflammation typically extends from the rectum;Perianal involvement is rare.

Symptoms

Abdominal pain;Weight loss and possibly anorexia;Diarrhoea, typically chronic or nocturnal (occurring at night);Systemic symptoms, including malaise and fever.Bloody diarrhoea;Abdominal pain;Faecal urgency;Tenesmus (constant urge to pass a stool but inability to do so).

Pattern of disease

Discontinuous or patchy inflammation: Healthy areas of intestine are found next to diseased sections;Cobblestoning: Areas of intestinal mucosa have a cobblestone appearance;Deep fissuring: Deep tears in the lining of the intestines or anus.

 

Continuous/diffuse inflammation (there are no areas of healthy intestine in the diseased section),although discontinuous pattern may occur after treatment if the treatment causes some sections of the intestine to heal and not others.

 

Abscess

Present.  Absent

Ulcer

Linear ulcers.Bleeding ulcers.

Granulomas (collections of inflamed cells), strictures (narrow areas of the bowel) and fistulae (abnormal connections between to body organs)

Common.Uncommon.

Smoking

Smoking increases the risk.Smoking reduces the risk.

Extra-intestinal manifestations

Occur more commonly.Occur less commonly, but affect up to 40% of those with ulcerative colitis.

  

How is Inflammatory Bowel Disease : Overview Treated?

Lifestyle management

Smoking cessation

Smoking is a risk factor for Crohn's disease and plays an important (but not well understood) role in the pathogenesis of IBD. Smokers are more likely to develop Crohn's disease, and smokers with Crohn's have a poorer prognosis compared to non-smokers, including a greater risk of surgery and recurrence. Smoking cessation reduces the risk of relapse by 65%. This is similar to the extent to which medicinal treatment of Crohn's disease reduces the risk of symptoms. Quitting smoking plays an important role in the management of IBD (particularly Crohn's disease). If you are trying to quit smoking, remember that nicotine is highly addictive and quitting without professional support is difficult. You may need support from your doctor or referral to services that can help you attempt to quit smoking.

Smoking appears to decrease the risk of developing ulcerative colitis, though the reasons for this are not well understood. However, due to the wide range of adverse health effects associated with smoking, individuals should not continue smoking to control ulcerative colitis.

For more information on smoking cessation, see Strategies for Quitting Smoking.

Social support

Social support helps people cope with IBD, possibly by reducing social isolation and unfounded fears, and increasing feelings of control. Individuals value open communication about their disease and support from family members and, for adolescents, support from their peers. Programs aimed at increasing social support have had a positive effect on quality of life for individuals with IBD. There also appears to be an important role for programs that increase open communication about IBD and its symptoms. If you have difficulty communicating with others about IBD, talk to a health professional for advice. Your doctor may be able to facilitate a discussion about IBD, for example with other members of you family.

Developing relationships with other children who have IBD can be beneficial for children. One study examined quality of life in children with IBD before and after attending an IBD summer camp. Overall, the children's quality of life improved with camp attendance. Specifically, they reported improved social functioning, bowel symptoms and reduced treatment-related stress, which was thought to occur due to their illness being 'normalised' through the camp experience. Another program, in which adolescent girls with IBD and their mothers attended monthly support groups discussing issues such as transition to college, intimacy and dating, reported improved emotional and social functioning in the girls, as well as improved quality of life.

If you have difficulty coping with IBD, ask your doctor to refer you to a support group.There are also a range of web-based resources for children and adolescents with IBD, through which they can interact with other IBD sufferers and access information about their condition, although it is unknown whether children who access web-based resources experience quality of life improvements.

Coping strategies

Coping strategies are cognitive and behavioural changes that help an individual to manage their disease, symptoms and treatment. There is conflicting evidence regarding the impact of various coping strategies on quality of life for individuals with IBD. Some studies in adults and adolescents have found that negative coping strategies (e.g. self-pitying, social withdrawal and resignation) are associated with reduced quality of life. Reduced problem-solving and reduced positive reappraisal of their condition were also associated with reduced quality of life. Conversely, a positive outlook for the future amongst adolescents was associated with improved quality of life.

Interventions that aim to develop coping skills and strategies appear to have an important role in improving quality of life for people with IBD. A lifestyle program involving stress management, education and self-care was associated with improved quality of life and reduced anxiety in adults. A range of other lifestyle programs may be used in the management of IBD, including:

Relaxation;Exercise, which may help reduce stress and symptoms associated with IBD, and also plays an important role in avoiding complications (e.g. reduced bone mineral density, reduced immune response and psychological ill health);Sleep hygiene, with the aim of overcoming the sleeping difficulties that commonly arise in patients with IBD and impair their psychological wellbeing.

Nutritional interventions

Interventions to address nutritional deficiencies

Nutritional deficiencies are common in individuals with IBD. The doctor is likely to conduct a full nutritional assessment so that they can identify and correct any nutritional deficiencies. This is an important component of IBD management. A dietitian is commonly part of the multi-disciplinary IBD management team. You may be asked to complete a questionnaire to help the doctor or dietitian assess nutritional status. The doctor may also wish to conduct tests to determine whether or not you have micronutrient deficiencies, including:

Calcium;Vitamin D and other vitamins;Zinc;Iron;Vitamin B12: This deficiency is particularly common in individuals with Crohn's disease.

Nutritional support to correct deficiencies is an important component of IBD treatment. This may involve taking supplements or modifying your diet. Folate supplementation may also be used. Individuals with IBD who take folate supplements appear to have a lower risk of colorectal cancer.

Macronutrient support (i.e. support to increase calorie intake) is necessary for individuals with IBD who:

Have lost ≥ 15% of their BMI or body weight;Have reduced absorption in the gut (e.g. in short bowel syndrome, when parts of the intestine have been removed);Are children experiencing growth failure or delayed growth, which may be treated with macronutrient support.

In these cases, total parenteral nutrition (feeding via an intravenous drip) may be necessary. High energy or protein supplements may also be used to prevent macronutrient loss.

Tube feeding

Nutritional interventions are not effective for inducing remission (controlling the symptoms) of acute ulcerative colitis. However, exclusive enteral feeding (feeding via a tube into the gut) is a commonly used and effective method of inducing remission of active Crohn's disease. The strongest evidence for exclusive enteral nutrition is in the treatment of childhood Crohn's, which achieves remission in 60–80% of children. In children, tube feeding is more effective than corticosteroid medications for induction of remission. It is also effective in adults, though current evidence suggests corticosteroids are more effective for adults.

Lactose-free diet

Some individuals with colitis develop lactose intolerance as a result of their condition. This contributes to symptoms such as flatulence and bloating. A lactose-free diet may provide symptom relief for individuals with lactose intolerance. Avoiding dairy foods is not associated with any benefits in lactose-tolerant individuals. 

Others

A range of other nutritional interventions are used in the management of IBD. These include:

Oral probiotics (tablets containing beneficial bacteria): There is limited evidence that probiotics are effective in the treatment and maintenance of ulcerative colitis, and there is no evidence supporting their use in the management of Crohn's disease. However, they may have a role to play in preventing a less common form of IBD;Fish oil and other foods rich in omega 3 fatty acids are associated with reduced mucosal inflammation in individuals with IBD, but there is not yet enough evidence to support the routine use of fish oil supplementation.

Education and access to health services

Being educated and informed about IBD can help affected individuals and their families to cope with the condition. Being able to access health services in times of need is also an important component of coping. For example, an individual with IBD may require urgent access to their doctor in the event of a flare-up to avoid going to the emergency department. However, obtaining an urgent appointment can sometimes be difficult. Talk to your doctor about IBD and material you can read to get more information about the condition, as well as how to best arrange an urgent appointment in the event of a flare-up.

The vast majority of individuals with IBD believe that adequate information about their condition is important, but only about half the people with IBD get as much information as they feel they need. Read any material available at the clinic (e.g. posters, leaflets) and ask your doctor for written material or websites you can read at home. This may include information about IBD, how the condition is treated, and steps you can take to manage your condition. If you are thinking about using surgery to treat IBD, make sure you get written information about the procedure from your doctor. Your doctor may be able to organise for you to talk to someone else who has had the same type of surgery so you can hear about their experience with the operation.

Psychotherapy

IBD can be severely debilitating and often has a psychological impact; however, there is conflicting evidence regarding the effectiveness of psychotherapy at improving symptoms or quality of life for individuals with IBD. Current evidence suggests that psychotherapy has a role in improving quality of life and psychological health, but does not impact on symptoms. For example, interventions such as cognitive behavioural therapy, relaxation and stress management have been associated with favourable effects on psychological disorders (depression, anxiety), coping and psychosocial functioning, but have rarely been associated with improvements in gastrointestinal symptoms. Psychotherapy interventions appear to have greater effectiveness in adolescents than in adults.

Many people with IBD experience negative psychological effects and it is quite normal to be referred to psychological support services. Do not be alarmed if your doctor refers you to a psychotherapist or other specialist, or offers psychological support. The doctor may also suggest that your family should access psychological support services.

Hypnotherapy

The limited evidence available for hypnotherapy is promising. In one small study, adults who underwent hypnotherapy experienced improved quality of life and reduced inflammation of the gastrointestinal system in IBD. Hypnotherapy also holds promise for younger patients who tend to respond favourably to this treatment compared to adults; however, no studies have been done of hypnotherapy to improve IBD in children or adolescents.

Medicines

A range of medicines are used in the treatment of IBD, and many of the same medicines are used to treat ulcerative colitis and Crohn's disease. Medication adherence is vital for effective management of IBD; you must take your medicines at the correct times every day in order to treat your condition effectively. Medication non-adherence (not taking the medicines correctly) has been shown to worsen the symptoms of IBD, which in turn affects quality of life.

Aminosalicylates

Aminosalicylates are medicines that act on the mucous membranes of the gastrointestinal system to moderate their inflammatory response. They are available in a range of topical (creams and gels applied to the site of inflammation) and oral (tablets which are swallowed) formulations.

Medications are used to induce remission (relieve symptoms of active disease) and for maintenance therapy (maintaining symptom-free periods of disease) in mild to moderate cases of ulcerative colitis. For these individuals, maintenance therapy with aminosalicylates may considerably reduce the risk of colorectal cancer (by up to 75%).

While aminosalicylates are used in the treatment of Crohn's disease, they are more effective in relieving ulcerative colitis.

Corticosteroids

Corticosteroid medications inhibit the processes that cause inflammation and play an important role in inducing remission of moderate to severe, active IBD (including both Crohn's and ulcerative colitis). Oral and topical preparations are available, and a combination of the two preparations has been found to be more effective than either used alone. Topical steroids may also be used in combination with oral aminosalicylates. The dose of corticosteroids need to be reduced gradually when it is time to stop taking the medicine (e.g. because your symptoms have been relieved). Abruptly ceasing to take the medication increases the risk of your symptoms returning.

Corticosteroids are not effective agents for maintenance therapy as they cause significantly more side effects than aminosalicylates. There is also an increased risk of infection while taking steroids, as these medications suppress the immune system. Disturbed mood and sleep, cosmetic changes such as swelling and acne, and long-term effects on bone and eye health may also occur if you take corticosteroids for a long period of time. If you receive corticosteroid therapy for more than 3 months, the doctor will probably need to monitor the health of your bones, eyes and your body as a whole.

Other

Other medicines have been demonstrated to be effective in the treatment of Crohn's disease when others fail or are not tolerated, including:

Infliximab: A new medicine belonging to a group of medicines known as an anti-TNF-alpha inhibitors;Methotrexate: A folic acid antagonist sometimes used to treat cancer;Immunosuppressants: Medicines that suppress the immune system;Antibiotics: Although their use is limited to cases associated with infection.

Surgery

Surgery is usually reserved for individuals who fail to respond to other treatments. Up to 50% of people with IBD require surgery at some stage. Indications for surgery include:

Growth retardation in children;Disease that does not improve with other treatment;Severe colitis;Bowel obstruction;Stricturing disease (causing narrowing of the bowel);Suspected or diagnosed cancer.

A range of surgical techniques can be employed depending on which sections of the gastrointestinal tract are affected and extent of disease. In ulcerative colitis, a surgical procedure called colectomy (removal of the colon) may cure the condition. Surgery does not cure Crohn's disease, but may improve the symptoms.

Tips for Coping with Inflammatory Bowel Disease

IBD is typically incurable and the disease can significantly disrupt an individual's life. If you have IBD and are having difficulty coping with the symptoms, the following tips may be useful:

Prepare outings in advance to alleviate any fears you may have. This may include:Identifying where the toilets are in shopping centres and restaurants when or before you arrive;Being aware if the toilet needs to be opened with a key, as this may require more time;Carrying toilet paper with you;Carrying spare underwear with you;Create awareness among your friends and family, as there is a general lack of awareness of IBD in the community and this can contribute to inadvertent discrimination and stigmatisation. This may include:Discussing a child's condition with their teacher to make them more aware of the reasons the child needs to make frequent toilet trips;Asking the doctor or another health professional to facilitate a discussion with family members;Attending a support group with a member of your family;Find activities that you can participate in despite the limitations IBD places on you. For example, if you are unable to participate in sports, you may find handicrafts or other activities are possible;Think positively about the future and recognise the opportunities as well as the limitations that may present themselves. Cognitive behavioural therapy may help you to develop positive behaviours and thought patterns if you have trouble being positive in the face of IBD;Exercise regularly, as this can help reduce stress and may also reduce future complications which can arise because of IBD;Take your medications as prescribed by the doctor, as good medication adherence reduces the severity of symptoms and the likelihood that you will experience an acute flare-up. This is likely to have a positive psychological effect;Practise relaxation techniques;Practise good sleep hygiene;Join a support group where you can interact with other people affected by IBD;Educate yourself about your condition and the various options for treatment. This may reduce feelings such as loss of control. Your doctor can provide you with information or refer you to other sources, such as internet-based information.  
More Information

For more information on inflammatory bowel disease, including how the digestive system works, types of IBD and useful videos, see Inflammatory Bowel Disease (IBD).

 

Inflammatory Bowel Disease : Overview References

Mowat C, Cole A, Windsor A, et al. Guidelines for the management of inflammatory bowel disease in adults. Gut. 2011;60(5):571-607. [Abstract]Lichtenstein GR, Hanauer SB, Sandborn WJ. Management of Crohn's disease in adults. Am J Gastroenterol. 2009;104(2):465-83. [Abstract | Full text]The economic cost of Crohn's disease and ulcerative colitis [online]. Canberra, ACT: Access Economics; 9 June 2007 [cited 20 June 2011]. Available from: URL linkGhosh S, Mitchell R. Impact of inflammatory bowel disease on quality of life: Results of the European Federation of Crohn's and Ulcerative Colitis Associations (EFCCA) patient survey. J Crohns Colitis. 2007;1(1):10-20. [Abstract | Full text]Karwowski CA, Keljo D, Szigethy E. Strategies to improve quality of life in adolescents with inflammatory bowel disease. Inflamm Bowel Dis. 2009;15(11):1755-64. [Abstract | Full text]Walker JR, Ediger JP, Graff LA, et al. The Manitoba IBD cohort study: A population-based study of the prevalence of lifetime and 12-month anxiety and mood disorders. Am J Gastroenterol. 2008;103(8):1989-97. [Abstract]von Roon AC, Reese GE, Orchard TR, Tekkis PP. Crohn's disease. Clin Evid (Online). 2007. [Abstract | Full text]Ferguson A, Sedgwick DM, Drummond J. Morbidity of juvenile onset inflammatory bowel disease: effects on education and employment in early adult life. Gut. 1994;35(5):665-8. [Abstract | Full text]Kornbluth A, Sachar DB. Ulcerative colitis practice guidelines in adults (update): American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. 2004;99(7):1371-85. [Abstract | Full text]Langan RC, Gotsch PB, Krafczyk MA, Skillinge DD. Ulcerative colitis: Diagnosis and treatment. Am Fam Physician. 2007;76(9):1323-30. [Abstract | Full text]Geboes K. Chapter 18: Histopathology of Crohn's disease and ulcerative colitis. In: Satsangi J, Sutherland LR. Inflammatory Bowel Diseases (4th edition). New York: Churchill-Livingstone; 2003: 255-76. [Chapter | Book]Murtagh J. Crohn's disease: Patient information. Aus Doctor. 2005; June. [Full text]Williams D. Inflammatory bowel disease. Aust Doctor. 10 September 2004:31-8. [Full text]Shepanski MA, Hurd LB, Culton K, et al. Health-related quality of life improves in children and adolescents with inflammatory bowel disease after attending a camp sponsored by the Crohn's and Colitis Foundation of America. Inflamm Bowel Dis. 2005;11(2):164-70. [Abstract]Szigethy E, Hardy D, Craig AE, et al. Girls connect: Effects of a support group for teenage girls with inflammatory bowel disease and their mothers. Inflamm Bowel Dis. 2009;15(8):1127-8. [Full text]Knutson D, Greenberg G, Cronau H. Management of Crohn's disease: A practical approach. Am Fam Physician. 2003;68(4):707-14. [Abstract | Full text]Ferguson A, Glen M, Ghosh S. Crohn's disease: Nutrition and nutritional therapy. Baillières Clin Gastroenterol. 1998;12(1):93-114. [Abstract]Mallon DP, Suskind DL. Nutrition in pediatric inflammatory bowel disease. Nutr Clin Pract. 2010;25(4):335-9. [Abstract]Caprilli R, Gassull MA, Escher JC, et al. European evidence based consensus on the diagnosis and management of Crohn's disease: Special situations. Gut. 2006;55(Suppl 1):i36-58. [Abstract | Full text]Kane S, Huo D, Aikens J, Hanauer S. Medication nonadherence and the outcomes of patients with quiescent ulcerative colitis. Am J Med. 2003;114(1):39-43. [Abstract]
Related Diseases and Conditions:Crohn's DiseaseUlcerative Colitis

Connect Sign up for free newsletters Subscribe to RSS feeds Discuss on Forum
Article Dates: Modified: 26/9/2013 Created: 17/10/2011 List Diseases by Medical Area All Diseases Men's Health Diseases Women's Health Diseases Children's Health Diseases Allergy Diseases Blood Diseases Bone Diseases Brain Diseases Cancer Diseases Dental Diseases Eye Diseases Fitness Diseases Gastro Diseases Heart Diseases Hormone Diseases Infection Diseases Joints Diseases Kidney Diseases Lungs Diseases Mental Health Diseases Pain Diseases Pregnancy Diseases Skin Diseases Weight Loss Diseases
New on VMC Orange and Avocado Salad more... As the weather warms up – preparing kids for toilet training more... Dr Joe: Ear health more... Recovering from disaster and trauma more...   VMC NewslettersVMC newsletters are FREE on subscription. See VMC's previous newsletters here. Free Membership & NewslettersNot yet a member?Stay up to date with the
latest health news

Resend Activation Email -Forgot your Password?Today's medical surveyTrauma

Have you ever suffered second-hand trauma, for example after watching a disaster on TV/internet/or a loved one going through it?

  Yes, I sought help from a counsellor/other professional

  Yes, I talked through it with loved ones

  Yes, but I was too embarrassed to talk about it

  No

  Other (please comment)

Comment:

What is 2 + 2 =

View Results » Current Sponsors About Virtualmedicalcentre.com

Australia�s leading source for trustworthy medical information written by health professionals.

Please be aware that we do not give advice on your individual medical condition,
if you want advice please see your treating physician.

Virtual Medical Centre © 2002 - 2013 | Privacy Policy Last updated 1 Nov 2013

Parenting information is available at Parenthub.com.au

About Us Careers Advertise with us Advertising policy Contact Us Copyright Information Corrections Editorial Advisory Board Investor Information Partners Sitemap Terms of Use User-generated Content ^ Back to Top   Partners and Accreditations This site complies with the HONcode standard for trustworthy health information:
verify here. For banner advertising
Website and videos by

Titan Web Clients
Web Design Perth Virtual Medical Centre Home Medical Centres Men's Health Women's Health Children's Health Allergy Blood Bone Brain Cancer   Dental Eye Fitness Gastro Heart Hormone Infection Joints   Kidney Lungs Mental Health Nutrition Pain Pregnancy Skin Weight Loss Medical A-Z Medical A-Z A B C D
E F G H
I  J  K  L
M N O P
Q R S T
U V W X
Y Z Medical Information Health Topics Anatomy Devices Diseases Doctor Videos Drugs Health & Lifestyle Investigations   Medical Dictionary My Experiences Symptoms Supplements Supportive Care Tools Treatments Useful Links News News & Events Latest News Events   Newsletter Newsletters   Lifestyles Health and Lifestyles Exercise Family General Mental Health Nutrition Occupational Health and Safety   Pregnancy Preventative Health Recipes Sexuality Sleep Smoking and Alcohol Win Competitions Current Competitions Competition Winners   Health Professionals Health Professionals Editorial Advisory Board Conferences Events Case Studies Research & Trials   Publications Consult Magazine Pro Newsletters Pro Membership

Read more detailed and referenced information written by Australian health professionals, make sure you select health professional in the signup form!

Sign up Login About VMC | Contact Us | Sitemap Follow us on:

Crohns Disease (Inflammatory Bowel Disease)

Crohn's Disease (Inflammatory Bowel Disease) VMC Members[close] Login Email Address / Username Password Forgot your password? Resend Activation Email Not yet a member? Stay up to date with
the latest health news

Are you a Health Professional? Read more detailed and referenced information written by Australian health professionals, make sure you select health professional in the signup form!

Virtual Medical CentreDiseasesCrohn's Disease (Inflammatory Bowel Disease) Crohn's Disease (Inflammatory Bowel Disease)
What is Crohn's Disease?Statistics on Crohn's DiseaseRisk Factors for Crohn's DiseaseProgression of Crohn's DiseaseSymptoms of Crohn's DiseaseClinical Examination of Crohn's DiseaseHow is Crohn's Disease Diagnosed?Prognosis of Crohn's DiseaseCrohn's Disease PreventionHow is Crohn's Disease Treated?Crohn's Disease ReferencesWhat is Crohn's Disease?

Virtual Medical Centre VideoWatch a video on Crohn's and Colitis

Crohn's disease is a form of inflammatory bowel disease characterised by chronic inflammation of the gastrointestinal tract, which occurs in a discontinuous pattern (there are sections of healthy and diseased tissue). The inflammation is transmural, meaning it affects all layers of mucous membrane forming the gastrointestinal wall. Other types of inflammatory bowel disease such as ulcerative colitis cause superficial inflammation, meaning that they affect only the outer layer of the gastrointestinal wall.

In Crohn's disease, inflammation can affect any of the gastrointestinal organs, from the mouth to the anus. However, it typically occurs in the terminal ileum (last section of the small intestine), in which case it is also referred to as terminal ileitis. The ileum (small intestine), colon (bowel or large intestine) and perianal region (the anus and surrounding area) are also commonly involved. 

For more information on the anatomy of the gastrointestinal system, see Gastrointestinal System.

When inflammation is limited to the colon, the disease is known as ulcerative colitis, another form of inflammatory bowel disease, thought to have similar causes. If both the small and large intestine are affected, the disease is known as ileocolitis. When other gastrointestinal organs (e.g. stomach, mouth) are affected, the condition is called Crohn's disease.

Crohn's disease can be further categorised depending on the extent and severity of symptoms as:

Mild: Describes a person with limited complications. Weight loss is minimal (< 10%) and the person can tolerate swallowing oral medication;Moderate–severe: Describes mild Crohn's disease which does not improve with an initial course of medicine, or mild disease accompanied by complications such as fever, abdominal pain or tenderness, significant weight loss, nausea and vomiting or anaemia;Severe–fulminant: Describes a person with Crohn's disease being treated with steroid medication who experiences persistent symptoms, or one with severe complications including persistent vomiting, high fever, bowel obstruction or abscess, cachexia (severe weakness or muscle wasting) or rebound tenderness (pain when the abdomen is touched);Remission: Refers to Crohn's disease which is asymptomatic or does not produce inflammation of the gastrointestinal tract, including cases that have responded to treatment with medicine or surgery.

Statistics on Crohn's Disease

Crohn's disease is predominantly a disease of the Western world. It is an important cause of illness in Australia, where it affects approximately 50 per 100,000 people. The disease has become more common over time. For example, a number of European and North American countries experienced a doubling in new cases of Crohn's in the four decades between 1955 and 1995. However, the proportion of individuals affected by Crohn's disease varies widely between countries. For example, 0.7 new cases each year were reported for every 100,000 people in Croatia, compared to 15.6 new cases per 100,000 people in Canada. 

Evidence shows that females are slightly more likely than males to develop Crohn's disease.

Disease onset typically occurs in adolescence or early adulthood (between the ages of 15 and 30 years). The condition is rare in children aged less than 5 years. A review of studies from the United States reported the average age at Crohn's diagnosis to be 33–39 years of age.

The age distribution of Crohn's is often described as bi-modal, meaning that there are two age groups in which diagnosis of the disease peaks (a large peak in the 20–30 year age group and a smaller peak in the 60–70 year age group). But many studies have also reported unimodal distribution (a single peak) with incidence peaking in the 20–30 year age group and declining thereafter.

Risk Factors for Crohn's Disease

The cause of Crohn's disease is unknown, but various immunological, genetic and environmental factors are thought to have a role.

Immunological factors

Although the causes of Crohn's disease are poorly understood, the disorder is thought to be due, at least in part, to irregularities in the components of the immune system that regulate the mucous membranes of the gut. According to this hypothesis, disordered activities of T cells (blood cells that participate in the body's immune responses) underpin the immune system irregularities.

Infectious factors

Infectious causes of Crohn's disease are also suspected. Many infectious agents have been investigated in the past; however, a particular organism that causes Crohn's disease has not been identified and theories which explain Crohn's disease as an infectious condition remain controversial. Research examining the role of Mycobacterium paratuberculosis as an infectious cause of Crohn's disease is currently underway in Australia.

Genetic factors

There is evidence that Crohn's disease is a genetic condition (at least in part), in that relatives of individuals with Crohn's disease have an increased risk of developing the condition; 5–20% of individuals with Crohn's have a family history of the disease. In up to 35% of cases where one monozygotic (identical) twin has Crohn's disease, the other identical twin is also affected. However, the genetics of Crohn's disease are complex and have not yet been fully explained.

Many potential genes that might be involved in causing Crohn's disease have been identified. Mutations in the NOD2/CARD15 gene on chromosome 16, which plays an important role in defence of the mucous membranes because it recognises bacteria, have been implicated in causing Crohn's disease and are particularly likely to be associated with Crohn's disease affecting the ileum (small intestine). However, only 30% of individuals with Crohn's disease have such mutations, and some 20% of those who do not have Crohn's also have such mutations.

Crohn's disease is more prevalent amongst Caucasians compared to other ethnic populations. However, there is also evidence that this association may be caused by environmental rather than genetic factors, as environmental factors differ considerably between the geographic locations of various ethnic groups.

Environmental and lifestyle factors

Smoking is a well-established risk factor for Crohn's disease. It is associated with a 3–4 times increased risk of developing the condition. Smokers also experience more severe disease when they have Crohn's; they have more frequent relapses, are more likely to be admitted to hospital, and spend more time in hospital than non-smokers with Crohn's disease. Quitting smoking reverses this disease course and is an important component of therapy for smokers.

Other environmental and lifestyle factors that may trigger disease include:

Dietary factors, particularly a high sugar content in the diet; Variations in the balance of beneficial and harmful bacteria in the gut; Living in a Western society (although the condition is becoming more prevalent in less-developed countries with increasing industrialisation); Being from a low socio-economic background: Children from families of low socio-economic status are three times more likely to develop Crohn's disease; Perinatal illness (illness immediately before or after childbirth) affecting either mother or baby is associated with a four-fold increased risk of Crohn's disease for the child.

Progression of Crohn's Disease

Crohn's disease occurs due to dysregulation of the immune response of T cells of the gastrointestinal system in genetically predisposed individuals. The complex causes of Crohn's are not well understood. The condition can be severely debilitating, and places great strain on the affected individuals as well as the public health system.

Crohn's disease usually manifests between 15 and 30 years of age, and typically follows a chronic and recurrent course (the disease goes through symptomatic and asymptomatic stages for the remainder of the person's life). An individual with Crohn's disease is likely to be affected for the rest of their life and experience periods of active, symptomatic disease, followed by periods of medical or surgical remission (periods when the disease becomes asymptomatic following surgical or medical treatments) and relapse to active disease. The majority of time with disease is spent in remission.

One study reported that a typical individual with Crohn's disease will spend 24% of their lifetime with the disease in a state of medical remission, and 27% of the time experiencing mild disease. Typically, a small proportion of the time with disease is characterised by severe manifestations, which may either: heal after treatment with medicines (1%), require ongoing treatment with medicine to relieve symptoms (4%), or be untreatable with medicines and require surgical treatment (1%). A typical person spends 41% of their time with Crohn's disease in post-surgical remission (with asymptomatic disease following surgery).

The disease course varies considerably between individuals. A minority of people (~10%) achieve lengthy remission periods. Most (73%) experience chronic recurring disease, and a considerable proportion (13%) experience unremitting disease (continuous symptoms). Existing data are insufficient to determine which people with Crohn's disease are likely to achieve prolonged remission and which are not.

In the first year after a diagnosis of Crohn's, 80% of affected individuals experience high disease activity and only 5% achieve remission, compared to 30% with high activity and 55% in remission more than 1 year after Crohn's diagnosis. 25% of individuals with Crohn's will experience active disease every year. A significant proportion (38%) require surgery within 1 year of starting to take medicine to treat Crohn's disease. The disease course is influenced by smoking, with smokers having more frequent and severe recurrence of the disease.

Individuals with Crohn's disease may experience the following complications during the course of their disease:

Adhesions: Inflammatory adhesions between diseased and healthy sections of bowel may form – that is, diseased sections of the bowel may attach to healthy sections of the bowel. This complication is particularly likely in individuals with: Transmural ulceration: Inflammation affecting several layers of the bowel walls, as opposed to superficial inflammation which affects only the outer layer of the bowel wall; and/orBowel obstruction; or A bout of toxic colitis (toxic megacolon), a potentially life-threatening complication in which the bowel widens rapidly. Surgical treatment is usually required;Bowel obstruction: Arising from stricturing (abnormal narrowing of the bowel), which may be chronic (long-term) or acute (short-term). Surgical treatment is usually required in these cases;Abscess formation: Abscesses may form and cause cavities in the mucosa (outer layer of the bowel wall) or submucosa (underlying layers of the bowel wall). The abscesses may rupture, causing bleeding. Rupture of a cavity in the mucosa can cause severe bleeding requiring urgent surgical treatment;Fistulae: Abnormal passages between two organs, or an organ and the body's surface, may form as a result of Crohn's disease. Fistulae typically involve the vagina, rectum, anus, vessels and skin. They are rarely responsive to treatment with medicines and surgery is usually required. Fistulae occur at some point in the course of disease for 20–40% of individuals with Crohn's. Recurrence rates after treatment to close fistulae are as high as 82%; Perforation and bleeding: Perforation occurs rarely, typically in response to rapid deterioration causing severe symptoms.  Perforation may cause severe bleeding requiring emergency surgery.

In children, Crohn's disease causes similar symptoms and complications, and may also lead to marked growth retardation (slow growth) and delayed puberty. 15–40% of children with the disease experience growth retardation.

Symptoms of Crohn's Disease

The symptoms of Crohn's disease vary considerably, depending on the area of the gastrointestinal tract involved. Diagnosis can be difficult as symptoms develop gradually, and periods in which symptoms of Crohn's disease occur are separated by periods of remission in which there are no symptoms. Crohn's disease may not be suspected by the doctor, as in many cases the gastrointestinal tract appears normal when viewed with the assistance of radiography, colonoscopy or other techniques that enable the gastrointestinal structures to be viewed. In addition, the symptoms are similar to those that occur in other diseases of the gastrointestinal system.

Some symptoms are typical of Crohn's disease and prompt the doctor to conduct further tests which enable them to confirm or exclude Crohn's disease. These symptoms include:

Chronic diarrhoea;Abdominal pain, which may progress from intermittent to chronic over the course of the disease;Bowel obstruction;Weight loss;Unexplained fever; andNight sweats.

The following symptoms may also occur as a result of Crohn's disease:

Diarrhoea (affects 85% of Crohn's patient4 and is often chronic or nocturnal);Abdominal pain;Weight loss or anorexia; Blood or mucus in stools (faeces);Rectal bleeding;Perineal pain (pain in the area between the anus and the genitals); Nausea; Malaise (feeling unwell); Arthralgia (joint pain); Discharge; andIrritation associated with perianal fistulae (abnormal passages that form between the anus other body structures).

The doctor will probably ask whether or not you have experienced these symptoms. You will likely be asked about your history of smoking and your family history of inflammatory bowel disease. This information helps the doctor to correctly diagnose your condition.

A large proportion (14–76%) of individuals with Crohn's disease have anal and/or perianal disease, meaning that the inflammation affects the anus and surrounding tissues. The doctor is therefore likely to examine the perianal region for signs of disease. Symptoms that affect the entire body are also common, including malaise, lethargy, and fever.

Other symptoms may be present as a result of complications (as alluded to above):

Malabsorption syndromes, in which the body does not absorb nutrients from food properly. These may result in conditions such as anaemia; Fistulas and abscesses; Intestinal obstruction from strictures (narrowing of the intestines); andRectal bleeding.

Individuals with Crohn's disease may also experience extra-intestinal symptoms (i.e. symptoms that affect organs other than those in the gastrointestinal system). These include:

Eyes: About 5% of individuals with Crohn's disease have symptoms affecting their eyes. These may cause conditions such as: Uveitis (inflammation of the uvea, which is the middle part of the eye);Episcleritis (inflammation of the tissues covering the sclera, the white of the eyeball); and Recurrent conjunctivitis (inflammation of the outermost layer of the eyeball); Joints: About 25% of individuals with Crohn's disease experience symptoms of the joints, including: Arthralgia (joint pain); and Arthritis (painful inflammation of the joints);Skin: About 15% of individuals with Crohn's disease experience symptoms affecting the skin, including: Erythema nodosum (inflammation of fat cells under the skin)Pyoderma gangrenosum (characterised by skin ulcers); and Ulcers of the mucous membranes of the oral cavity;Liver disorders may also occur in individuals with Crohn's disease, and include: Sclerosing cholangitis (inflammation of the bile ducts connecting to the liver); andFatty liver or the excessive build-up of fat in liver cells, which may lead to further liver disorders such as chronic hepatitis (inflammation of the liver) and liver failure; Urogenital complications, including:   Nephrolithiasis, commonly referred to as kidney stones, characterised by the build up of small deposits (stones) in the kidneys; and Other kidney diseases; Blood vessel disorders, including: Deep vein thrombosis (a blood clot in the deep veins, usually the legs); and Pulmonary embolism (a blood clot in the lungs).

Onset is typically gradual and the symptoms are usually mild, though occasionally severe symptoms may occur rapidly. When severe symptoms occur rapidly, they may be similar to the symptoms of acute appendicitis. The doctor may need to conduct tests to distinguish between acute Crohn's disease and acute appendicitis.

Throughout the course of the disease, an individual with Crohn's may experience serious complications that require emergency treatment. These include:

Perforation of the bowel wall, which affects 1–3% of individuals with Crohn's at some stage of the disease. Perforation causes acute abdominal symptoms (e.g. severe abdominal pain). Emergency surgery is required to correct this complication;  Toxic megacolon, which affects 4.4–6.3% of individuals with Crohn's disease at some stage. It is characterised by rapid widening of the bowel, which may lead to bowel perforation and possible death if not treated surgically.

Differential diagnoses

Crohn's disease presents with symptoms common to many other conditions. The doctor must try to exclude these when making the diagnosis. Other conditions include:

Ulcerative colitis;Acute appendicitis;Small bowel obstruction;Irritable bowel syndrome;Malabsorption syndromes (failure of the body to properly absorb nutrients from food);Infectious or ischaemic colitis (inflammation of the colon due to infection or lack of blood flow);Neoplasia (tumours);Haemorrhoids (swellings in the lining of the anus, commonly called piles); andDiverticular disease (formation of small out-pouchings in the colon).

Children

Diagnosis of Crohn's disease may be slightly more difficult in children. In general the disease has similar symptoms, with the following additional symptoms characteristic of Crohn's disease in childhood:

Growth failure or delayed growth, the extent of which correlates to the severity of gastrointestinal symptoms of the disease. Children with more severe symptoms have greater delays or impairments in growth compared to children with mild symptoms; Delayed puberty and development of secondary sex characteristics (non-genital characteristics of men and women); andPsychological symptoms including increased rates of depression and anxiety.

Clinical Examination of Crohn's Disease

There are few physical signs of Crohn's disease other than weight loss and general ill health, in particular pallor (pale skin) or cachexia (muscle wasting). There may also be perianal fissures, fistula or abscesses (e.g. small lumps around the anus); the doctor may examine the anus to check for these. There may be signs of extra-gastrointestinal involvement affecting the eyes, skin or joints. The doctor may also wish to examine a stool sample to check for blood.

How is Crohn's Disease Diagnosed?

Because the symptoms of Crohn's disease are also common in other diseases, the doctor will usually need to conduct a range of tests to confirm or exclude Crohn's disease as the cause of your symptoms. The doctor will begin with simple tests, which may include:

Full blood count: A test that analyses the makeup of the blood, including the proportion of red and white blood cells, and the amount of haemoglobin (responsible for transporting oxygen in the blood); Tests to assess markers of inflammation; Liver tests if the liver is thought to be affected;Blood cultures if sepsis (infection) is suspected; Stool cultures may be needed if you are experiencing diarrhoea, to exclude infectious causes; orElectrolyte tests: Electrolyte levels may be disturbed due to dehydration from diarrhoea.

Imaging and other tests may also be used in the diagnosis of Crohn's disease. These include:

X-rays;Biopsy: The removal of small sections of tissue for microscopic evaluation. In Crohn's disease, an endoscope is used to guide the removal of tissue from the ileum (small intestine);Endoscopy: The use of a long, flexible tube with a camera on the end to view hollow internal cavities. Endoscopy is often used in the diagnosis of Crohn's disease. Colonoscopy (use of an endoscope to view the colon) is the most commonly used technique, though the ileum and upper gastrointestinal tract (e.g. oesophagus) may also be viewed with endoscopy. Colonoscopy helps the doctor distinguish between Crohn's disease and ulcerative colitis, and is typically used in conjunction with biopsy;Capsule endoscopy: Endoscopic capsules are swallowed and move through the gastrointestinal tract. Any part of the gastrointestinal tract can be viewed with capsule endoscopy, but the capsules cannot be used to assist biopsy (removal of tissues); andComputed tomography: X-rays are used to produce computer-generated images of the body's internal structures. This technique allows the doctor to assess all layers of the bowel wall, unlike endoscopic techniques which only enable visualisation of the outer layer of the bowel wall.

Prognosis of Crohn's Disease

Crohn's disease is a lifelong condition. Despite being characterised by periods of active symptomatic disease and asymptomatic remission, individuals with Crohn's disease typically experience severe debilitation as a result of the condition. For example, in the first year after diagnosis, 25% of individuals with Crohn's require time off work, and after 5–10 years of disease, 15% are unable to work.

Many individuals achieve periods of remission with treatment, though a significant proportion require surgical treatment; 50% will undergo surgery to induce remission in the first 10 years of disease, and 70–80% will require surgery in their lifetime.

Individuals with Crohn's disease have an increased risk of colorectal and small bowel cancer. There is also evidence of an increased risk of mortality in individuals with Crohn's disease.

Crohn's Disease Prevention

Crohn's disease cannot be prevented. Correctly taking the medication prescribed by your doctor is the key measure for preventing acute recurrence of the disease.

How is Crohn's Disease Treated?

Crohn's disease is a lifelong condition and treatment aims to induce remission (relieve inflammation and associated symptoms), in order to improve the individual's quality of life and allow them to return to normal daily activities. Minimising the adverse effects of treatment is also an important goal, as many of the treatments for Crohn's disease have side effects.

Medicine

Taking medicine alongside lifestyle modifications is the mainstay of treatment for Crohn's disease. Surgery tends to be reserved for those individuals with chronic obstructive complications (e.g. stricturing). The primary aims of treatment are to treat acute flare-ups when they occur, and induce and maintain remission of symptoms following a flare-up.

Treatment varies according to the severity and anatomical site of disease (e.g. whether the stomach or colon is affected). Similar medications are used as in the treatment of ulcerative colitis (the other major form of inflammatory bowel disease), namely:

Oral corticosteroids: Medicines used to treat a range of inflammatory conditions, including severe inflammation. They are typically used to treat active flare ups and may also be used in ongoing maintenance therapy;Aminosalicylate preparations: Medicines used to treat inflammatory bowel disease in mild-to-moderate cases. They are typically used for ongoing maintenance therapy, rather than to induce remission.

Appropriate treatments differ for adults and children because of the need to attain appropriate growth and pubertal development in children (corticosteroid use in children is associated with delayed growth and puberty). However, there is a general lack of evidence regarding the effectiveness of different treatment options in children.

Aminosalicylates

Aminosalicylates may be used to induce remission of a flare up of Crohn's disease, though evidence suggests that they not as effective as corticosteroids for inducing remission. In addition, many people do not tolerate aminosalicylate medications due to side effects. But if aminosalicylates have effectively treated your condition in the past and you were able to tolerate the side effects, your doctor may prescribe them for treatment of an acute flare up.

Aminosalicylates may also be used for maintenance therapy, particularly following surgery to induce remission. For individuals who have a high risk of relapse (experiencing an acute flare up in the future), including those who have had surgery more than once in the past, immunosuppressive medications may be more effective for maintenance therapy. However, evidence suggests that maintenance therapy with aminosalicylates reduces the risk of colorectal cancer, and for this reason aminosalicylates may be preferred.

Aminosalicylates are not used to treat Crohn's disease in childhood.

Corticosteroids

Corticosteroid medications are the most effective and most commonly used treatment for inducing remission of an active flare up of Crohn's disease. In severe cases complicated by fistulae, corticosteroids are rarely effective; however, they may be taken to reduce inflammation prior to surgery, which is usually required to close fistulae.

The choice of medicine depends on the severity and site of disease. Budesonide, prednisolone or methylprednisolone are the corticosteroids most commonly used in the treatment of Crohn's disease. Budesonide is slightly less effective than either prednisolone or methylprednisolone, but is associated with fewer side effects. It is recommended for achieving remission of mild-to-moderate cases of Crohn's disease confined to the colon and ileum (small and large intestine). The prescribing doctor will determine the best dose and frequency for you. Always take the medicines as prescribed by the doctor.

If your Crohn's disease is severe or affects a more extensive area of the gastrointestinal system (structures above the colon and ileum, for example the stomach of oesophagus) prednisolone or methylprednisolone will probably be prescribed to induce remission. While more effective than budesonide, prednisolone or methylprednisolone are more likely to induce side effects such as bleeding and infection. The doctor will consider the risk of side effects in relation to the expected benefits of you taking the medicine before prescribing prednisolone or methylprednisolone, and will determine the best dose and frequency of taking the medication for you. Always take the medicines as prescribed by the doctor.

Corticosteroids are not usually prescribed for maintenance therapy if remission is achieved using medicines (as opposed to surgery).

In children, corticosteroids are not generally used as they are less effective in inducing remission compared to enteral feeding (feeding through a tube inserted in the throat).

Antibiotics

Antibiotics have been trialled as a treatment for Crohn's disease, both alone and in combination with aminosalicylates or corticosteroids. However, there is limited evidence regarding their effectiveness and they are associated with adverse side effects. Antibiotics are therefore not generally recommended for treating Crohn's disease, but may be used if you also have an infection.

Antibiotics are not used to treat Crohn's disease in children.

Immunosuppressive agents

Immunosuppressive medications called azathioprine and mercaptopurine are effective for inducing remission of Crohn's disease, but are associated with many, often serious, side effects. Treatment for at least 17 weeks is necessary for maximum effectiveness.

Azathioprine may be used as maintenance therapy once remission is achieved using an immunosuppressive agent. It is usually only prescribed to individuals who cannot use corticosteroids to treat their Crohn's disease (either because corticosteroids are ineffective or because they produce intolerable side effects), because azathioprine is associated with serious adverse events including myelodysplastic syndrome, a blood disorder that can be fatal. If you take azathioprine for maintenance therapy, you will need to have your blood tested regularly to check for signs of myelodysplastic syndrome developing.

Mercaptopurine may be used for maintenance therapy following surgical remission, but is only recommended for individuals with a high risk of recurrence, including those who have undergone > 1 surgical procedure.

Immunosuppressive agents are not used to treat children with Crohn's disease

Methotrexate

Methotrexate, a medicine administered by injection and often used in cancer treatment, is a further option for inducing remission of an acute flare up in adults with Crohn's disease which does not heal after treatment with aminosalicylates, corticosteroids or immunosuppressive agents. The medicine is only used when other medicines fail to treat Crohn's disease, as methotrexate is associated with serious side effects, including liver disorders. If you are prescribed this medicine, you will need to have your liver function tested regularly to ensure the medicine is not damaging your liver.

Methotrexate may be used for maintenance therapy, but will only be prescribed when other medicines cannot be used (either due to side effects or because they fail to treat Crohn's disease effectively).

Note that if you are pregnant or wish to conceive (men and women), you should not take methotrexate. Tell your doctor if you become pregnant or wish to conceive while taking methotrexate.   

Methotrexate is not used to treat children with Crohn's disease.

Tumour necrosis factor alpha inhibitors (TNF-α inhibitors)

Infliximab, which belongs to a group of medicines called tumour necrosis factor alpha (TNF-α) inhibitors, is a new medicine now used in Australia as a treatment for severe Crohn's disease that does not respond to other medicines (aminosalicylates, corticosteroids, immunosuppressive agents). Infliximab is administered via infusion (via a drip inserted into a vein), and evidence shows that a single infusion of the medicine is effective in inducing remission in approximately two thirds of individuals who receive the infliximab to treat an acute flare up.

Infliximab is used in maintenance therapy, and 60% of individuals who achieve remission using infliximab will maintain remission if treated with 8-weekly infusions of the medicine.

In the short term, infliximab is not associated with adverse side effects; however, more evidence is needed to determine the safety of this medicine when used for long-term maintenance therapy. Repeated use for maintenance therapy may be limited in many individuals because they have adverse reactions to the infusion. These include pruritis (itching), nausea and flushing.

Infliximab suppresses the immune system, which makes it unsuitable for treating patients with septicaemia. Because of its immunosuppressive effect, infliximab predisposes individuals taking the medicine to infectious complications such as tuberculosis. Individuals treated with infliximab have a 4–5 times greater risk of tuberculosis, and must be screened for tuberculosis before commencing infliximab treatment. Infliximab should be used with caution by individuals with congestive heart failure, so it is important to tell your doctor if you have heart problems.

Note that infliximab is not subsidised under the Pharmaceutical Benefits Scheme (PBS), so cost may limit its use.

The effects of TNF-α inhibitors in children have not yet been studied.

Lifestyle measures

Education and support

Crohn's disease can severely affect quality of life and impair your ability to carry out normal daily activities, which can considerably affect your psychological wellbeing. Taking medicine to treat the symptoms of your disease may therefore not be enough to ensure your overall wellbeing, and further measures such as education and support may be required. Be sure to ask your doctor any questions you may have about Crohn's disease and for tips that might help you cope with the disease. For example, the doctor may be able to advise you of relaxation techniques and simple exercises that can help you cope with the disease. You may also wish to join a support group where you can meet, talk to and find support from other people with Crohn's disease, and your doctor will be able to refer you to such a group.

Smoking cessation

Non-smokers with Crohn's disease experience greater periods of remission, and quitting smoking is associated with lower relapse rates and reduced use of medicine to maintain remission. If you smoke, it is important to quit as this will help improve your Crohn's disease. However, be aware that the nicotine contained in cigarettes is addictive and many people require counselling or other forms of support to help them quit smoking. You are more likely to quit smoking if you have such support, so talk to your doctor about strategies that can help you quit and places where you can access support.

Nutritional interventions

Nutritional interventions (treatments that modify the diet), are used in Crohn's disease therapy to both induce and maintain remission. Nutritional interventions may also be used to restore nutritional deficiencies arising because of the disease. These deficiencies may be macronutrient (e.g. anorexia, cachexia) or micronutrient (e.g. anaemia) deficiencies, or both.

Providing macronutrient support (support to consume more energy/calories) may improve growth in children. Micronutrient deficiencies should be identified and corrected through supplementation (e.g. vitamin tablets) with the aim of improving conditions caused by nutritional deficiency such as anaemia. Folate supplements may also be given to individuals with Crohn's disease, as evidence indicates that taking folate supplements reduces the risk of developing colon cancer.

In addition, elemental diets (consuming easily digestible foods only) and enteral nutrition (tube feeding) have an established role in the treatment of inflammatory symptoms of Crohn's disease in children. Elemental diets are also an option for inducing and maintaining remission in adult patients. While they are less effective than corticosteroid treatment for adults, they are associated with fewer side effects. There is no evidence that other nutritional interventions are effective in treating Crohn's disease.

Individuals who may be prescribed enteral nutrition to induce remission include those:

With partial obstruction of the small bowel;With severe Crohn's disease involving the perianal region and causing pain;Who fail to achieve remission with corticosteroid therapy;With borderline intestinal failure; orChildren with active Crohn's disease causing growth failure.

Fish oil supplementation

There is promising evidence for fish oil capsules as maintenance therapy for Crohn's disease. However, further studies are needed to confirm the effectiveness of fish oil therapy and it is not currently recommended for routine use.

Monitoring for colorectal cancer

As mentioned previously, long-standing Crohn's disease is associated with an increased risk of colorectal cancer, although there are a lack of guidelines regarding monitoring for colorectal cancer in individuals with Crohn's disease. In general, frequent monitoring by colonoscopy is recommended from 10 years after the onset of disease. The appropriate monitoring interval varies depending on the extent and severity of disease. Your doctor will advise you how often you should undergo monitoring for colorectal cancer.

Surgical treatment

Surgical treatment is required by the vast majority of individuals with Crohn's disease at some time in their life. Its use is reserved for disease that does not improve with other, non-surgical treatments, or where the adverse side effects of pharmacologic treatments outweigh the benefits. Surgery is typically delayed until complications such as fistulae, abscess and obstruction occur. Reasons for surgery can be classified as elective and urgent, and include:

Elective: Fistulae, with or without abscess;Obstruction of the gastrointestinal tract;When treatment with medicines fails;Cancerous tumours; orGrowth retardation in children;Urgent: Perforation of the bowel or other gastrointestinal structure;Bleeding; orToxic colitis or megacolon (rapid widening of the colon due to inflammation).

Elective reasons are the most common for surgery. While these procedures are considered elective, there is evidence suggesting that early surgery (elective as opposed to urgent) is associated with significantly reduced complications of Crohn's disease in adults.  In children, the use of surgical interventions requires further studies, but current evidence supports the use of surgery in pre-pubertal children with Crohn's disease that fails to respond to other treatments. Surgery is also an option for children experiencing growth retardation.

Many different surgical techniques are performed for the treatment of Crohn's disease. The surgical procedure used depends on the anatomical site and features of the individual's disease.

Abscess drainage

Individuals whose Crohn's disease is complicated by abscesses may undergo surgery to drain the abscesses. In this case, laparotomy is likely to be used – the surgeon will gain access to the abscesses via an incision in your abdomen.  If abscesses recur, drainage will need to be performed again and the doctor may also recommend bowel resection (see below).

Strictureplasty

Strictureplasty is a conservative surgical technique requiring removal of smaller sections of the bowel compared to bowel resection (see below). It is now a preferred approach for managing Crohn's disease in individuals with obstruction caused by strictures. The procedure involves diseased sections of the bowel being cut away to relieve obstructive symptoms. Healthy sections of the bowel are re-attached with stitches. The treatment improves food tolerance and enables weight gain.

Individuals who undergo strictureplasty may need a second operation in the future. The need for reoperation is similar to the need with bowel resection, although strictureplasty is associated with fewer side effects and illness compared to bowel resection. It is important that individuals undergo thorough assessment to rule out non-Crohn's disease causes for their symptoms before undergoing strictureplasty. For example, the doctor may use CT scans or colonoscopy to view the gastrointestinal organs before performing strictureplasty.

Individuals who are likely to benefit from strictureplasty include those:

With diffuse (widespread) disease affecting the small bowel involving multiple strictures (sections in which the bowel is narrowed);With stricture formation following major bowel resection (surgery);Who develop strictures early in the course of Crohn's disease;Who experience rapid recurrence of obstructive symptoms following treatment;With short bowel syndrome (a malabsorption syndrome that occurs as a result of removal or dysfunction of the small intestine) and stricture formation; orWith strictures in the duodenoum (the first section of the small intestine connecting to the stomach).

The procedure is contraindicated (cannot be performed) in people with:

Perforation of the small bowel;Inflammation due to infection of the bowel tissues;Fistulae when the surgery is to be carried out near the site of the fistula;Multiple stricture in a short section of bowel;Strictures close to a site selected for surgery;Strictures affecting the colon;Infectious complications; orUnfavourable anatomy (abnormally-shaped or positioned organs, or structures in the gastrointestinal tract which make surgery more risky).

Bowel resection

Bowel resection is a surgical procedure in which diseased sections of the bowel are removed and healthy sites joined together. The amount of bowel removed depends on the extent of disease. Mini-resections are preferred over radical resection in order to prevent short bowel syndrome. The procedures may be conducted by laparoscopy (minimally invasive, camera-guided surgery), laparotomy (surgery performed through an incision in the abdomen) or open surgery. Laparoscopy is typically preferred as it is less invasive and involves shorter post-operative recovery periods. 

Resection may be undertaken for people with:

Abscess that fails to heal following drainage: In these cases, abscess drainage by laparotomy is performed again before surgical resection of the diseased area of bowel. The surgery may be delayed if large sections of non-diseased bowel will be lost as a result of surgery; Bowel obstruction, either acute or chronic: These complications often fail to respond to other treatments. Early surgical intervention is recommended for individuals with obstructive complications;  Ileocaecal disease (disease affecting the junction between the small and large intestine).

Bowel bypass

Bowel bypass, once the mainstay of surgical treatment for Crohn's disease, is now rarely used due to improvements in the safety and effectiveness of medicines and more conservative surgical techniques. It may still be used for a limited number of individuals who fail to respond to other therapies.

Colectomy

Colectomy (removal of all or part of the colon) may be used to treat individuals with Crohn's disease that fails to respond to other treatments. Unlike with ulcerative colitis, colectomy rarely cures Crohn's disease, as inflammation can reappear in other sections of the gastrointestinal tract.

More Information

For more information on inflammatory bowel disease, including how the digestive system works, types of IBD and useful videos, see Inflammatory Bowel Disease (IBD).

  

Crohn's Disease References

von Roon AC, Reese GE, Orchard TR, Tekkis PP. Crohn's disease. BMJ Clin Evid (Online). 2007. [Abstract | Full text]Murtagh J. Crohn's disease: Patient information. Aus Doctor. 2005; June. [Full text] Geboes K. Chapter 18: Histopathology of Crohn's disease and ulcerative colitis. In: Satsangi J, Sutherland LR. Inflammatory Bowel Diseases (4th edition). New York: Churchill-Livingstone; 2003: 255-76. [Chapter | Book]Knutson D, Greenberg G, Cronau H. Management of Crohn's disease: A practical approach. Am Fam Physician. 2003;68(4):707-14. [Abstract | Full text] Selby WS. Current issues in Crohn's disease. Med J Aust. 2003;178(11):532-3. [Full text]Loftus EV Jr, Schoenfeld P, Sandborn WJ. The epidemiology and natural history of Crohn's disease in population-based patient cohorts from North America: A systematic review. Aliment Pharmacol Ther. 2002;16(1):51-60. [Abstract | Full text] Shanahan F. Crohn's disease. Lancet. 2002;359(9300):62-9. [Abstract | Full text]Castori M, Grammatico P. Chapter 3: Genetics. In: Tersigni R, Prantera C (eds). Crohn's Disease: A multidisciplinary approach. Milan: Springer-Verlag; 2010: 17-25. [Book]Rizzi M. Chapter 2: Epidemiology. In: Tersigni R, Prantera C (eds). Crohn's Disease: A multidisciplinary approach. Milan: Springer-Verlag; 2010: 9-16. [Book] Lichtenstein GR, Hanauer SB, Sandborn WJ. Management of Crohn's disease in adults. Am J Gastroenterol. 2009;104(2):465-83. [Abstract | Full text]Strong SA. Surgical management of Crohn's disease. In: Holzheimer RG, Mannick JA (eds). Surgical Treatment: Evidence-based and problem-oriented. Munich: Zuckschwerdt Verlag; 2001. [Chapter | Book] Werbin N, Haddad R, Greenberg R, et al. Free perforation in Crohn's disease. Isr Med Assoc J. 2003;5(3):175-7. [Abstract | Full text]Newby EA, Sawczenko A, Thomas AG, Wilson D. Interventions for growth failure in childhood Crohn's disease. Cochrane Database Syst Rev. 2005;(3):CD003873. [Abstract | Full text] Eilam O, Goldin E, Shouval D, et al. Sclerosing cholangitis associated with Crohn's disease and autoimmune haemolytic anaemia. Postgrad Med J. 1993;69(814):656-8. [Abstract | Full text] Canbay A, Bechmann LP, Best J, et al. Crohn's disease-induced non-alcoholic fatty liver disease (NAFLD) sensitizes for severe acute hepatitis B infection and liver failure. Z Gastroenterol. 2006;44(3):245-8. [Abstract]Kane S. Urogenital complications of Crohn's disease. Am J Gastroenterol. 2006;101(12 Suppl):S640-3. [Abstract]Bernstein CN, Blanchard JF, Houston DS, Wajda A. The incidence of deep venous thrombosis and pulmonary embolism among patients with inflammatory bowel disease: A population-based cohort study. Thromb Haemost. 2001;85(3):430-4. [Abstract] Weston LA, Roberts PL, Schoetz DJ Jr, et al. Ileocolic resection for acute presentation of Crohn's disease of the ileum. Dis Colon Rectum. 1996;39(8):841-6. [Abstract] Grieco MB, Bordan DL, Geiss AC, Beil AR Jr. Toxic megacolon complicating Crohn's colitis. Ann Surg. 1980;191(1):75-80. [Abstract | Full text] Griffiths AM, Nguyen P, Smith C, et al. Growth and clinical course of children with Crohn's disease. Gut. 1993;34(7):939-43. [Abstract | Full text]Romdhane H, Karoui S, Serghini M, et al. Crohn's disease, primary sclerosing cholangitis and antiphospholipid syndrome: An uncommon association [in French]. Tunis Med. 2009;87(5):349-51. [Abstract]Leighton JA, Shen B, Baron TH, et al. ASGE guideline: Endoscopy in the diagnosis and treatment of inflammatory bowel disease. Gastrointest Endosc. 2006;63(4):558-65. [Full text] Gore RM, Balthazar EJ, Ghahremani GG, Miller FH. CT features of ulcerative colitis and Crohn's disease. AJR Am J Roentgenol. 1996;167(1):3-15. [Full text]Ferguson A, Glen M, Ghosh S. Crohn's disease: Nutrition and nutritional therapy. Baillières Clin Gastroenterol. 1998;12(1):93-114. [Abstract] Mallon DP, Suskind DL. Nutrition in pediatric inflammatory bowel disease. Nutr Clin Pract. 2010;25(4):335-9. [Abstract] Brown CJ. Heineke-Mikulicz and Finney strictureplasty in Crohn's disease. Op Tech Gen Surg. 2007;9(1):3-7. [Full text]Surgery for Crohn's disease [online]. New York, NY: Crohn's and Colitis Foundation of America; January 2009 [cited 15 June 2011]. Available from: URL link ACR appropriateness criteria: Crohn's disease [online]. Reston, VA: American College of Radiology; 2008 [cited 3 July 2011]. Available from: URL link

Connect Sign up for free newsletters Subscribe to RSS feeds Discuss on Forum
Article Dates: Modified: 19/9/2011 Reviewed: 19/9/2011 Created: 19/9/2003 List Diseases by Medical Area All Diseases Men's Health Diseases Women's Health Diseases Children's Health Diseases Allergy Diseases Blood Diseases Bone Diseases Brain Diseases Cancer Diseases Dental Diseases Eye Diseases Fitness Diseases Gastro Diseases Heart Diseases Hormone Diseases Infection Diseases Joints Diseases Kidney Diseases Lungs Diseases Mental Health Diseases Pain Diseases Pregnancy Diseases Skin Diseases Weight Loss Diseases
New on VMC Orange and Avocado Salad more... As the weather warms up – preparing kids for toilet training more... Dr Joe: Ear health more... Recovering from disaster and trauma more...   VMC NewslettersVMC newsletters are FREE on subscription. See VMC's previous newsletters here. Free Membership & NewslettersNot yet a member?Stay up to date with the
latest health news

Resend Activation Email -Forgot your Password?Today's medical surveyTrauma

Have you ever suffered second-hand trauma, for example after watching a disaster on TV/internet/or a loved one going through it?

  Yes, I sought help from a counsellor/other professional

  Yes, I talked through it with loved ones

  Yes, but I was too embarrassed to talk about it

  No

  Other (please comment)

Comment:

What is 2 + 2 =

View Results » Current Sponsors About Virtualmedicalcentre.com

Australia�s leading source for trustworthy medical information written by health professionals.

Please be aware that we do not give advice on your individual medical condition,
if you want advice please see your treating physician.

Virtual Medical Centre © 2002 - 2013 | Privacy Policy Last updated 1 Nov 2013

Parenting information is available at Parenthub.com.au

About Us Careers Advertise with us Advertising policy Contact Us Copyright Information Corrections Editorial Advisory Board Investor Information Partners Sitemap Terms of Use User-generated Content ^ Back to Top   Partners and Accreditations This site complies with the HONcode standard for trustworthy health information:
verify here. For banner advertising
Website and videos by

Titan Web Clients
Web Design Perth Virtual Medical Centre Home Medical Centres Men's Health Women's Health Children's Health Allergy Blood Bone Brain Cancer   Dental Eye Fitness Gastro Heart Hormone Infection Joints   Kidney Lungs Mental Health Nutrition Pain Pregnancy Skin Weight Loss Medical A-Z Medical A-Z A B C D
E F G H
I  J  K  L
M N O P
Q R S T
U V W X
Y Z Medical Information Health Topics Anatomy Devices Diseases Doctor Videos Drugs Health & Lifestyle Investigations   Medical Dictionary My Experiences Symptoms Supplements Supportive Care Tools Treatments Useful Links News News & Events Latest News Events   Newsletter Newsletters   Lifestyles Health and Lifestyles Exercise Family General Mental Health Nutrition Occupational Health and Safety   Pregnancy Preventative Health Recipes Sexuality Sleep Smoking and Alcohol Win Competitions Current Competitions Competition Winners   Health Professionals Health Professionals Editorial Advisory Board Conferences Events Case Studies Research & Trials   Publications Consult Magazine Pro Newsletters Pro Membership

Read more detailed and referenced information written by Australian health professionals, make sure you select health professional in the signup form!

Sign up Login About VMC | Contact Us | Sitemap Follow us on: