Crohns disease

Crohn's Disease is a chronic inflammatory disease of the alimentary tract and it can involve any part of it - from the mouth to the anus. It typically affects the terminal ileum and well demarcated areas of large bowel with relatively normal bowel. It is often associated with auto-immune disorders outside the bowel, such as aphthous stomatitis and rheumatoid arthritis. Given the high incidence of irritable bowel syndrome among Americans, this can also be a complicating factor.

Symptoms

Crohn's patients typically suffer from chronic diarrhea and disrupted digestion, making it difficult for sufferers in the acute phase of the disease to eat and/or digest food. The inflammation can be extremely painful and debilitating. Other common complications of Crohn's include fistulas of the colon, hemorrhoids, lipid absorption problems, and anemia.

Incidence

The disease typically first appears in a sufferer by age 30 or so, though it is not unknown for symptoms to first appear quite late in life. It quite commonly appears in childhood. Estimates suggest that up to 60,000 people in the UK (about 1 in 1200) and 1,000,000 Americans have the disease (around 1 in 300). Some ethnic groups (such as Ashkenazi Jews) have significantly higher rates of prevalence than others. Increased rates of disease have also been noted in some families, leading to speculation of a possible genetic link, especially in the HLA-B27 MHC allele. Epidemiological research indicates that Crohn's is a disease of civilization, in other words, the incidence of the disease is much higher in industrialized countries than elsewhere. However, Crohn's symptoms are typically diagnosed over a long period of time, in order to establish a pattern; in countries where medical help is expensive or less available, it may be difficult to arrive at a diagnosis.

Causes

Mycobacterial infection

The disease has long been suspected of being due to a Mycobacterium because of the similarity of many features to human tuberculosis and veterinary Johne's Disease. Mycobacterium avium subspecies paratuberculosis (MAP), which causes Johne's disease in cattle, is a primary area of research for many scientists and doctors involved in Crohn's disease. This remains a controversial area of research, although recent studies have lent more credence to the theory, and government agencies in some countries have begun investigations into the possibility.

Nearly all practicing physicians and many researchers are not willing to accept that MAP is a primary cause of Crohn's. Dozens of studies have been done in which evidence of MAP infection could not be found in tissue and blood samples of Crohn's patients. However, other studies have been performed which (with more stringent methodology) showing that MAP was found in up to 90% of the Crohn's patients in the study. Mycobacteria are known to be fastidious, which means they are extremely difficult to grow in culture. Therefore, unless very stringent precautions are taken, cultures for mycobacteria can underestimate the presence of the bacterium.

For this reason, PCR is a more promising technique than culture. Researchers have identified an insertion sequence called IS900 that is unique to the MAP organism, and many studies have been performed using PCR to test for the presence of MAP. However, the problem with PCR is that it will detect dead or near-dead ("non viable") MAP organisms, so often times a combination of PCR and careful culture is needed to prove that MAP is present.

Researchers using PCR and careful culture have found that live MAP bacteria are present in significant numbers of Crohn's patients, and other studies using PCR and culture have shown that live MAP bacteria are present in significant pertentages of pasteurized milk in the United States, the UK, and the Czech Republic.

Complications

The bowel shows segmental "hose pipe" thickening and shows full thickness chronic inflammation, giant cell granulomas, and fissures with acute inflammation. Fistula formation is quite common in Crohn's. Bowel obstruction is a known complication which may require surgical resection. Approximately 50% of surgical cases require additional surgery within five years because the disease tends to reappear at the site where the bowel was rejoined, and some patients eventually develop short bowel syndrome which makes it extremely difficult to digest food. For this reason, surgery is considered by many doctors only as a last resort in the treatment of Crohn's.

Treatment

There is currently no cure for Crohn's; treatment for Crohn's disease is mainly symptomatic. Some patients find some foods (such as foods high in fiber, and dairy foods) make their symptoms worse, but the disease cannot be controlled simply through diet modifications. Therapies include treatment with anti-inflammatory drugs that act in the intestines, and, if symptoms cannot be controlled with other drugs, with steroids (although long-term steroid therapy is discouraged because of its well-known side effects). In advanced cases a bowel resection may be required.

A well-established group of drugs, especially in the mild-to-moderate disease, are salicylates - 5-ASA derivates - 5-aminosalicylic acid compounds such as sulfasalazine (brand name Asacol), mesalamine (brand name Pentasa), olsalazine, and balsalazide. Immunomodulating drugs such as azathioprine and mercaptopurine as well as infliximab (brand name Remicade) are given mainly in moderate-to-severe cases. Research trials are being conducted on treatment with drugs in the same family as thalidomide.

Risks

Some patients can be treated with the existing drugs quite effectively and can go into long-term remission, sufficient to allow the sufferer to lead a normal life. Patients are at somewhat larger risk of colon cancers, and should have regular colonoscopies both to check for precancerous growths and to monitor the success of treatment. It does not seem to have as great a risk of malignancy compared to ulcerative colitis.

Related Illnesses

Crohn's disease and ulcerative colitis are quite distinct diseases but in practice there are sometimes difficulties distinguishing between them, especially in mild cases - these are usually simply classified as "chronic inflammatory bowel disease".

Misdiagnosis

Crohn's disease is often misdiagnosed as food poisoning, gastroenteritis, appendicitis (due to the common locus of pain in the lower right-hand quadrant of the abdomen), and irritable bowel syndrome.

Discovery

Crohn's disease was first described by Giovanni Battista Morgagni (1682-1771), and subsequent cases were described by John Berg in 1898, and by Polish surgeon Antoni Leśniowski in 1904. Scottish physician T. Kennedy Dalziel described nine cases in 1913. Burrill Bernard Crohn, an American gastroenterologist, described fourteen cases in 1932, characterizing the disease as "Terminal ileitis: A new clinical entity"; the description was changed to "Regional ileitis" on publication. It is by virtue of alphabetization rather than contribution that Crohn's name appeared as first author: because this was the first time the condition was reported in a widely-read journal, and the disease has come to be known as Crohn's disease for reasons of publicity rather than precedence.

Other Names

In Poland the disease is known as Leśniowski-Crohn disease.