David Baxter PhD
Late Founder
Crohn's disease: Managing symptoms
Mayo Clinic
Retrieved October 2012
There is no cure for Crohn's disease. But treatments and diet and lifestyle changes help many people function well.
Definition
August 9, 2011
Crohn's disease is an inflammatory bowel disease (IBD). It causes inflammation of the lining of your digestive tract, which can lead to abdominal pain, severe diarrhea and even malnutrition. Inflammation caused by Crohn's disease can involve different areas of the digestive tract in different people.
The inflammation caused by Crohn's disease often spreads deep into the layers of affected bowel tissue. Like ulcerative colitis, another common IBD, Crohn's disease can be both painful and debilitating, and sometimes may lead to life-threatening complications.
While there's no known cure for Crohn's disease, therapies can greatly reduce the signs and symptoms of Crohn's disease and even bring about long-term remission. With treatment, many people with Crohn's disease are able to function well.
Symptoms
Inflammation of Crohn's disease may involve different areas in different people. In some people, just the small intestine is affected. In others, it's confined to the colon (part of the large intestine). The most common areas affected by Crohn's disease are the last part of the small intestine (ileum) and the colon. Inflammation may be confined to the bowel wall, which can lead to scarring (stenosis), or inflammation may spread through the bowel wall (fistula).
Signs and symptoms of Crohn's disease can range from mild to severe and may develop gradually or come on suddenly, without warning. You may also have periods of time when you have no signs or symptoms (remission). When the disease is active, signs and symptoms may include:
Other signs and symptoms
People with severe Crohn's disease may also experience:
When to see a doctor
See your doctor if you have persistent changes in your bowel habits or if you have any of the signs and symptoms of Crohn's disease, such as:
Causes
The exact cause of Crohn's disease remains unknown. Previously, diet and stress were suspected, but now doctors know that although these factors may aggravate existing Crohn's disease, they don't cause it. Now, researchers believe that a number of factors, such as heredity and a malfunctioning immune system, play a role in the development of Crohn's disease.
Risk factors
Risk factors for Crohn's disease may include:
Complications
Crohn's disease may lead to one or more of the following complications:
Tests and diagnosis
Your doctor will likely diagnose Crohn's disease only after ruling out other possible causes for your signs and symptoms, including irritable bowel syndrome (IBS), diverticulitis and colon cancer. To help confirm a diagnosis of Crohn's disease, you may have one or more of the following tests and procedures:
Treatments and drugs There is currently no cure for Crohn's disease, and there is no one treatment that works for everyone.
The goal of medical treatment is to reduce the inflammation that triggers your signs and symptoms. It is also to improve long-term prognosis by limiting complications. In the best cases, this may lead not only to symptom relief but also to long-term remission. Treatment for Crohn's disease usually involves drug therapy or, in certain cases, surgery.
Anti-inflammatory drugs
Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. They include:
Immune system suppressors
These drugs also reduce inflammation, but they target your immune system rather than directly treating inflammation. By suppressing the immune response, inflammation is also reduced. Sometimes, these drugs are used in combination. For example, a combination of azathioprine and infliximab has been shown to work better than either drug alone in some people. Immunosuppressant drugs include:
Medications and cancer risk
Immune system suppressors also are associated with a small risk of developing cancer such as lymphoma. These include azathioprine, mercaptopurine, methotrexate, infliximab, adalimumab, certolizumab pegol and others. The risk may be due to the immune system suppression that these medications cause. While these medications do increase risk, they may be necessary for people with Crohn's disease to improve quality of life and avoid surgery or hospitalization. Work with your doctor to determine which medications are right for you.
Antibiotics
Antibiotics can reduce the amount of drainage and sometimes heal fistulas and abscesses in people with Crohn's disease. Researchers also believe antibiotics help reduce harmful intestinal bacteria and suppress the intestine's immune system, which can trigger symptoms. However, there's no strong evidence that antibiotics are effective for Crohn's disease. Frequently prescribed antibiotics include:
Other medications
In addition to controlling inflammation, some medications may help relieve your signs and symptoms. Depending on the severity of your Crohn's disease, your doctor may recommend one or more of the following:
Future medications
New medications are in development and in clinical trial. If your Crohn's disease isn't well controlled with current medications, ask your doctor if there are clinical trials available to you.
Surgery
If diet and lifestyle changes, drug therapy or other treatments don't relieve your signs and symptoms, your doctor may recommend surgery.
During surgery, your surgeon removes a damaged portion of your digestive tract and then reconnects the healthy sections. In addition, surgery may also be used to close fistulas and drain abscesses. A common procedure for Crohn's is strictureplasty, which widens a segment of the intestine that has become too narrow.
The benefits of surgery for Crohn's are usually temporary. The disease often recurs, frequently near the reconnected tissue or elsewhere in the digestive tract. Up to 3 of 4 people with Crohn's disease eventually need some type of surgery. Many will also need a second procedure or more. The best approach is to follow surgery with medication to minimize the risk of recurrence.
Cancer surveillance
Screening for colon cancer may need to be done more frequently because people who have Crohn's disease that affects the colon have an increased risk of colon cancer. General colon cancer screening guidelines call for a colonoscopy every 10 years beginning at age 50. Ask your doctor if you need to have this test done sooner and more frequently.
Lifestyle and home remedies
Sometimes you may feel helpless when facing Crohn's disease. But changes in your diet and lifestyle may help control your symptoms and lengthen the time between flare-ups.
Diet
There's no firm evidence that what you eat actually causes inflammatory bowel disease. But certain foods and beverages can aggravate your signs and symptoms, especially during a flare-up. If you think eating certain foods make your condition worse, keep a food diary to keep track of what you're eating as well as how you feel. If you discover some foods are causing your symptoms to flare, it's a good idea to try eliminating those foods. Here are some suggestions that may help:
Smoking
Smoking increases your risk of developing Crohn's disease, and once you have it, smoking can make the condition worse. People with Crohn's disease who smoke are more likely to have relapses, need medications and repeat surgeries. Quitting smoking can improve the overall health of your digestive tract, as well as provide many other health benefits.
Stress
Although stress doesn't cause Crohn's disease, it can make your signs and symptoms worse and may trigger flare-ups. Stressful events can range from minor annoyances to a move, job loss or the death of a loved one.
When you're stressed, your normal digestive process changes. Your stomach empties more slowly and secretes more acid. Stress can also speed or slow the passage of intestinal contents. It may also cause changes in intestinal tissue itself.
Although it's not always possible to avoid stress, you can learn ways to help manage it. Some of these include:
Alternative medicine
Many people with digestive disorders have used some form of complementary or alternative therapy. Some commonly used therapies include:
Side effects and ineffectiveness of conventional therapies are primary reasons for seeking alternative care.
The majority of alternative therapies aren't regulated by the FDA. Manufacturers can claim that their therapies are safe and effective but don't need to prove it. In some cases that means you'll end up paying for products that don't work. For example, studies done on fish oil and on probiotics for the treatment of Crohn's haven't shown benefits to using these products. What's more, even natural herbs and supplements can have side effects and cause dangerous interactions. Tell your doctor if you decide to try any herbal supplement.
Some people may find acupuncture or hypnosis helpful for the management of Crohn's, but neither therapy has been well studied for this use.
Unlike probiotics ? which are beneficial live bacteria that you consume ? prebiotics are natural compounds found in plants, such as artichokes, that help fuel beneficial intestinal bacteria. An initial study on prebiotics had promising results. More studies are under way.
Coping and support
Crohn's disease doesn't just affect you physically ? it takes an emotional toll as well. If signs and symptoms are severe, your life may revolve around a constant need to run to the toilet. In some cases, you may barely be able to leave the house. When you do, you might worry about an accident, and this anxiety only makes your symptoms worse.
Even if your symptoms are mild, gas and abdominal pain can make it difficult to be out in public. You may also feel hampered by dietary restrictions or embarrassed by the nature of your disease. All of these factors ? isolation, embarrassment and anxiety ? can severely alter your life. Sometimes they may lead to depression.
Educate yourself, and connect
One of the best ways to be more in control is to find out as much as possible about Crohn's disease. Organizations such as the Crohn's and Colitis Foundation of America (CCFA) have chapters across the country to provide information and access to support groups. Your doctor, nurse or dietitian can locate the chapter nearest you, or you can contact the organization directly at 888-MY-GUT-PAIN (888-694-8872) or on its website.
Although support groups aren't for everyone, they can provide valuable information about your condition as well as emotional support. Group members frequently know about the latest medical treatments or integrative therapies. You may also find it reassuring to be among people who understand what you're going through.
Some people find it helpful to consult a psychologist or psychiatrist who's familiar with inflammatory bowel disease and the emotional difficulties that it can cause. Although living with Crohn's disease can be discouraging, research is ongoing and the outlook is brighter than it was a few years ago.
Managing complications and symptoms
References
Mayo Clinic
Retrieved October 2012
There is no cure for Crohn's disease. But treatments and diet and lifestyle changes help many people function well.
Definition
August 9, 2011
Crohn's disease is an inflammatory bowel disease (IBD). It causes inflammation of the lining of your digestive tract, which can lead to abdominal pain, severe diarrhea and even malnutrition. Inflammation caused by Crohn's disease can involve different areas of the digestive tract in different people.
The inflammation caused by Crohn's disease often spreads deep into the layers of affected bowel tissue. Like ulcerative colitis, another common IBD, Crohn's disease can be both painful and debilitating, and sometimes may lead to life-threatening complications.
While there's no known cure for Crohn's disease, therapies can greatly reduce the signs and symptoms of Crohn's disease and even bring about long-term remission. With treatment, many people with Crohn's disease are able to function well.
Symptoms
Inflammation of Crohn's disease may involve different areas in different people. In some people, just the small intestine is affected. In others, it's confined to the colon (part of the large intestine). The most common areas affected by Crohn's disease are the last part of the small intestine (ileum) and the colon. Inflammation may be confined to the bowel wall, which can lead to scarring (stenosis), or inflammation may spread through the bowel wall (fistula).
Signs and symptoms of Crohn's disease can range from mild to severe and may develop gradually or come on suddenly, without warning. You may also have periods of time when you have no signs or symptoms (remission). When the disease is active, signs and symptoms may include:
- Diarrhea. The inflammation that occurs in Crohn's disease causes cells in the affected areas of your intestine to secrete large amounts of water and salt. Because the colon can't completely absorb this excess fluid, you develop diarrhea. Intensified intestinal cramping also can contribute to loose stools. Diarrhea is a common problem for people with Crohn's.
- Abdominal pain and cramping. Inflammation and ulceration may cause the walls of portions of your bowel to swell and eventually thicken with scar tissue. This affects the normal movement of contents through your digestive tract and may lead to pain and cramping. Mild Crohn's disease usually causes slight to moderate intestinal discomfort, but in more-serious cases, the pain may be severe and include nausea and vomiting.
- Blood in your stool. Food moving through your digestive tract may cause inflamed tissue to bleed, or your bowel may also bleed on its own. You might notice bright red blood in the toilet bowl or darker blood mixed with your stool. You can also have bleeding you don't see (occult blood).
- Ulcers. Crohn's disease can cause small sores on the surface of the intestine that eventually become large ulcers that penetrate deep into ? and sometimes through ? the intestinal walls. You may also have ulcers in your mouth similar to canker sores.
- Reduced appetite and weight loss. Abdominal pain and cramping and the inflammatory reaction in the wall of your bowel can affect both your appetite and your ability to digest and absorb food.
Other signs and symptoms
People with severe Crohn's disease may also experience:
- Fever
- Fatigue
- Arthritis
- Eye inflammation
- Mouth sores
- Skin disorders
- Inflammation of the liver or bile ducts
- Delayed growth or sexual development, in children
When to see a doctor
See your doctor if you have persistent changes in your bowel habits or if you have any of the signs and symptoms of Crohn's disease, such as:
- Abdominal pain
- Blood in your stool
- Ongoing bouts of diarrhea that don't respond to over-the-counter (OTC) medications
- Unexplained fever lasting more than a day or two
Causes
The exact cause of Crohn's disease remains unknown. Previously, diet and stress were suspected, but now doctors know that although these factors may aggravate existing Crohn's disease, they don't cause it. Now, researchers believe that a number of factors, such as heredity and a malfunctioning immune system, play a role in the development of Crohn's disease.
- Immune system. It's possible that a virus or bacterium may trigger Crohn's disease. When your immune system tries to fight off the invading microorganism, an abnormal immune response causes the immune system to attack the cells in the digestive tract, too.
- Heredity. Crohn's is more common in people who have family members with the disease, leading experts to suspect that one or more genes may make people more susceptible to Crohn's disease. However, most people with Crohn's disease don't have a family history of the disease.
Risk factors
Risk factors for Crohn's disease may include:
- Age. Crohn's disease can occur at any age, but you're likely to develop the condition when you're young. Most people who develop Crohn's disease are diagnosed before they're 30 years old.
- Ethnicity. Although whites have the highest risk of the disease, it can affect any ethnic group. If you're of Eastern European (Ashkenazi) Jewish descent, your risk is even higher.
- Family history. You're at higher risk if you have a close relative, such as a parent, sibling or child, with the disease. As many as 1 in 5 people with Crohn's disease has a family member with the disease.
- Cigarette smoking. Cigarette smoking is the most important controllable risk factor for developing Crohn's disease. Smoking also leads to more severe disease and a greater risk of surgery. If you smoke, stop. Discuss this with your doctor and get help. There are many smoking-cessation programs available if you are unable to quit on your own.
- Where you live. If you live in an urban area or in an industrialized country, you're more likely to develop Crohn's disease. Because Crohn's disease occurs more often among people living in cities and industrial nations, it may be that environmental factors, including a diet high in fat or refined foods, play a role in Crohn's disease. People living in northern climates also seem to have a greater risk of the disease.
Complications
Crohn's disease may lead to one or more of the following complications:
- Bowel obstruction. Crohn's disease affects the thickness of the intestinal wall. Over time, parts of the bowel can thicken and narrow, which may block the flow of digestive contents through the affected part of your intestine. Some cases require surgery to remove the diseased portion of your bowel.
- Ulcers. Chronic inflammation can lead to open sores (ulcers) anywhere in your digestive tract, including your mouth and anus, and in the genital area (perineum) and anus.
- Fistulas. Sometimes ulcers can extend completely through the intestinal wall, creating a fistula ? an abnormal connection between different parts of your intestine, between your intestine and skin, or between your intestine and another organ, such as the bladder or vagina. When internal fistulas develop, food may bypass areas of the bowel that are necessary for absorption. An external fistula can cause continuous drainage of bowel contents to your skin, and in some cases, a fistula may become infected and form an abscess, a problem that can be life-threatening if left untreated. Fistulas around the anal area (perianal) are the most common kind of fistula.
- Anal fissure. This is a crack, or cleft, in the anus or in the skin around the anus where infections can occur. It's often associated with painful bowel movements. This may lead to a perianal fistula.
- Malnutrition. Diarrhea, abdominal pain and cramping may make it difficult for you to eat or for your intestine to absorb enough nutrients to keep you nourished. Additionally, anemia is common in people with Crohn's disease.
- Colon cancer. Having Crohn's disease that affects your colon increases your risk of colon cancer.
- Other health problems. In addition to inflammation and ulcers in the digestive tract, Crohn's disease can cause problems in other parts of the body, such as arthritis, inflammation of the eyes or skin, clubbing of the fingernails, kidney stones, gallstones and, occasionally, inflammation of the bile ducts. People with long-standing Crohn's disease also may develop osteoporosis, a condition that causes weak, brittle bones.
Tests and diagnosis
Your doctor will likely diagnose Crohn's disease only after ruling out other possible causes for your signs and symptoms, including irritable bowel syndrome (IBS), diverticulitis and colon cancer. To help confirm a diagnosis of Crohn's disease, you may have one or more of the following tests and procedures:
- Blood tests. Your doctor may suggest blood tests to check for anemia ? a condition in which there aren't enough red blood cells to carry adequate oxygen to your tissues ? or to check for signs of infection. Two tests that look for the presence of certain antibodies can sometimes help diagnose which type of inflammatory bowel disease you have, but not everyone with Crohn's disease has these antibodies. While your doctor may order these tests, a positive finding doesn't mean you have Crohn's disease and a negative finding doesn't mean that you're free of the disease. Because these tests aren't yet definitive, the American College of Gastroenterology doesn't currently recommend antibody or genetic testing for Crohn's disease.
- Fecal occult blood test. You may need to provide a stool sample so that your doctor can test for blood in your stool.
- Colonoscopy. This test allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis, which may help confirm a diagnosis. Some people have clusters of inflammatory cells called granulomas, which help confirm the diagnosis of Crohn's disease because granulomas don't occur with ulcerative colitis. Risks of colonoscopy include perforation of the colon wall and bleeding.
- Flexible sigmoidoscopy. In this procedure, your doctor uses a slender, flexible, lighted tube to examine the sigmoid, the last section of your colon.
- Computerized tomography (CT). You may have a CT scan, a special X-ray technique that provides more detail than a standard X-ray does. This test looks at the entire bowel as well as at tissues outside the bowel that can't be seen with other tests. Your doctor may order this scan to better understand the location and extent of your disease or to check for complications such as partial blockages, abscesses or fistulas. Although not invasive, a CT scan exposes you to more radiation than a conventional X-ray does. CT enterography is a special CT scan that provides better images of the small bowel. This test has replaced barium X-rays in many medical centers.
- Magnetic resonance imaging. An MRI scanner uses a magnetic field and radio waves to create detailed images of organs and tissues. Most MRI machines are large, tube-shaped magnets. During the test, you lie on a movable table inside the MRI machine. This test is very helpful in diagnosing and managing Crohn's disease. It's biggest advantage is that there is no radiation exposure. It's particularly useful for evaluating a fistula around the anal area (pelvic MRI) or the small intestine (MRI enterography).
- Capsule endoscopy. If you have signs and symptoms that suggest Crohn's disease but other diagnostic tests are negative, your doctor may perform capsule endoscopy. For this test you swallow a capsule that has a camera in it. The camera takes pictures, which are transmitted to a computer that you wear on your belt. The images are then downloaded, displayed on a monitor and checked for signs of Crohn's disease. Once it's made the trip through your digestive system, the camera exits your body painlessly in your stool. Capsule endoscopy is generally very safe, but if you have a partial blockage in the bowel, there's a slight chance the capsule may become lodged in your intestine. In addition, the images provided by capsule endoscopy may not be detailed enough. Endoscopy with biopsy is often still needed to confirm the diagnosis of Crohn's disease and to exclude other causes of your symptoms.
- Double balloon endoscopy. For this test, a longer scope is used to look further into the small bowel where standard endoscopes don't reach. This technique is useful when capsule endoscopy shows abnormalities, but the diagnosis is still in question. It allows for biopsy of the abnormal area. It's usually performed in specialized endoscopy centers.
- Small bowel imaging. This test looks at the part of the small bowel that can't be seen by colonoscopy. After you drink a solution containing barium, X-ray, CT or MRI images are taken of your small intestine. The test can help locate areas of narrowing or inflammation in the small bowel that are seen in Crohn's disease. The test can also help your doctor determine which type of inflammatory bowel disease you have.
- Barium enema. This diagnostic test allows your doctor to evaluate your large intestine with an X-ray. Before the test, you receive an enema with a contrast solution containing barium. The barium dye coats the lining of the bowel, creating a silhouette of your rectum, colon and a portion of your small intestine that's visible on an X-ray. This test is rarely done anymore because of the availability of colonoscopy and CT scanning.
Treatments and drugs There is currently no cure for Crohn's disease, and there is no one treatment that works for everyone.
The goal of medical treatment is to reduce the inflammation that triggers your signs and symptoms. It is also to improve long-term prognosis by limiting complications. In the best cases, this may lead not only to symptom relief but also to long-term remission. Treatment for Crohn's disease usually involves drug therapy or, in certain cases, surgery.
Anti-inflammatory drugs
Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. They include:
- Sulfasalazine (Azulfidine). Although this drug isn't always effective for treating Crohn's disease, it may be of some help for Crohn's that affects the colon. It has a number of side effects, including nausea, vomiting, heartburn and headache. Don't take this medication if you're allergic to sulfa medications.
- Mesalamine (Asacol, Rowasa). This medication is less likely to cause side effects than sulfasalazine, but possible side effects include nausea, vomiting, heartburn, diarrhea and headache. You take it in tablet form or use it rectally in the form of an enema or suppository, depending on which part of your colon is affected. This medication is generally ineffective for disease involving the small intestine.
- Corticosteroids. Corticosteroids can help reduce inflammation anywhere in your body, but they have numerous side effects, including a puffy face, excessive facial hair, night sweats, insomnia and hyperactivity. More-serious side effects include high blood pressure, diabetes, osteoporosis, bone fractures, cataracts, glaucoma and an increased susceptibility to infections. Long-term use of corticosteroids in children can lead to stunted growth.
Also, these medications don't work for everyone with Crohn's disease. Doctors generally use corticosteroids only if you have moderate to severe inflammatory bowel disease that doesn't respond to other treatments. A newer type of corticosteroid, budesonide (Entocort EC), works faster than do traditional steroids and appears to produce fewer side effects. Entocort EC is effective only in Crohn's disease that involves the lower small intestine and the first part of the large intestine.
Corticosteroids aren't for long-term use. But, they can be used for short-term (three to four months) symptom improvement and to induce remission. Corticosteroids also may be used with an immune system suppressor ? the corticosteroids can induce remission, while the immune system suppressors can help maintain remission.
Immune system suppressors
These drugs also reduce inflammation, but they target your immune system rather than directly treating inflammation. By suppressing the immune response, inflammation is also reduced. Sometimes, these drugs are used in combination. For example, a combination of azathioprine and infliximab has been shown to work better than either drug alone in some people. Immunosuppressant drugs include:
- Azathioprine (Imuran) and mercaptopurine (Purinethol). These are the most widely used immunosuppressants for treatment of inflammatory bowel disease. If you're taking either of these medications, you'll need to follow up closely with your doctor and have your blood checked regularly to look for side effects, such as a lowered resistance to infection. These drugs may also cause nausea and vomiting.
- Infliximab (Remicade). This drug is for adults and children with moderate to severe Crohn's disease. It may be used soon after diagnosis, particularly if your doctor suspects that you're likely to have more severe Crohn's disease or if you have a fistula. It's also used after other drugs have failed. It may be combined with an immunosuppressant in some people, but this practice is somewhat controversial. Infliximab works by neutralizing a protein produced by your immune system known as tumor necrosis factor (TNF). Infliximab finds TNF in your bloodstream and removes it before it causes inflammation in your intestinal tract.
Some people with heart failure, people with multiple sclerosis, and those with cancer or a history of cancer can't take infliximab or the other members of this class (adalimumab and certolizumab pegol). Talk to your doctor about the potential risks of taking infliximab. Tuberculosis and other serious infections have been associated with the use of immune-suppressing drugs. If you have an active infection, don't take these medications. You should have a skin test for tuberculosis, a chest X-ray and a test for hepatitis B before taking infliximab. - Adalimumab (Humira). Adalimumab works similarly to infliximab by blocking TNF for people with moderate to severe Crohn's disease. It can be used soon after you're diagnosed if you have a fistula, or if you have more severe Crohn's disease. It also may be used after other medications have failed to improve your symptoms. Adalimumab may be used instead of infliximab or certoluzimab pegol, or it can be used if infliximab or certoluzimab pegol stop working. Adalimumab may reduce the signs and symptoms of Crohn's disease and may cause remission.
However, adalimumab, like infliximab, carries a small risk of infections, including tuberculosis and serious fungal infections. You should have a skin test for tuberculosis, a chest X-ray and a test for hepatitis B before taking infliximab. The most common side effects of adalimumab are skin irritation and pain at the injection site, nausea, runny nose, and upper respiratory infection. - Certolizumab pegol (Cimzia). Approved by the Food and Drug Administration (FDA) for the treatment of Crohn's disease, certolizumab pegol works by inhibiting TNF. Certolizumab pegol is prescribed for people with moderate to severe Crohn's disease. Certolizumab pegol may be used instead of infliximab or adalimumab, or it can be used if infliximab or adalimumab stop working. Common side effects include headache, upper respiratory infections, abdominal pain, nausea and reactions at the injection site. Like other medications that inhibit TNF, because this drug affects your immune system, you're also at risk of becoming seriously ill with certain infections, such as tuberculosis. You should have a skin test for tuberculosis, a chest X-ray and a test for hepatitis B before starting certolizumab pegol.
- Methotrexate (Rheumatrex). This drug, which is used to treat cancer, psoriasis and rheumatoid arthritis, is sometimes used for people with Crohn's disease who don't respond well to other medications. Short-term side effects include nausea, fatigue and diarrhea, and rarely, it can cause potentially life-threatening pneumonia. Long-term use can lead to scarring of the liver and sometimes to cancer. Avoid becoming pregnant while taking methotrexate. If you're taking this medication, follow up closely with your doctor and have your blood checked regularly to look for side effects.
- Cyclosporine (Gengraf, Neoral, Sandimmune). This potent drug, often used to help heal Crohn's-related fistulas, is normally reserved for people who haven't responded well to other medications. Cyclosporine has the potential for serious side effects, such as kidney and liver damage, seizures, and fatal infections. This medication isn't for long-term use.
- Natalizumab (Tysabri). This drug works by inhibiting certain immune cell molecules ? integrins ? from binding to other cells in your intestinal lining. Blocking these molecules is thought to reduce chronic inflammation that occurs when they bind to your intestinal cells. Natalizumab is approved for people with moderate to severe Crohn's disease with evidence of inflammation and who aren't responding well to other conventional Crohn's disease therapies including TNF blockers and immunomodulators. Because the drug is associated with a rare, but serious, risk of multifocal leukoencephalopathy ? a brain infection that usually leads to death or severe disability ? you must be enrolled in a special restricted distribution program to use it.
Medications and cancer risk
Immune system suppressors also are associated with a small risk of developing cancer such as lymphoma. These include azathioprine, mercaptopurine, methotrexate, infliximab, adalimumab, certolizumab pegol and others. The risk may be due to the immune system suppression that these medications cause. While these medications do increase risk, they may be necessary for people with Crohn's disease to improve quality of life and avoid surgery or hospitalization. Work with your doctor to determine which medications are right for you.
Antibiotics
Antibiotics can reduce the amount of drainage and sometimes heal fistulas and abscesses in people with Crohn's disease. Researchers also believe antibiotics help reduce harmful intestinal bacteria and suppress the intestine's immune system, which can trigger symptoms. However, there's no strong evidence that antibiotics are effective for Crohn's disease. Frequently prescribed antibiotics include:
- Metronidazole (Flagyl). Once the most commonly used antibiotic for Crohn's disease, metronidazole can cause serious side effects, including numbness and tingling in your hands and feet and, occasionally, muscle pain or weakness. If these effects occur, stop the medication and call your doctor.
- Ciprofloxacin (Cipro). This drug, which improves symptoms in some people with Crohn's disease, is now generally preferred to metronidazole. A rare side effect of this medication is tendon rupture.
Other medications
In addition to controlling inflammation, some medications may help relieve your signs and symptoms. Depending on the severity of your Crohn's disease, your doctor may recommend one or more of the following:
- Anti-diarrheals. A fiber supplement, such as psyllium powder (Metamucil) or methylcellulose (Citrucel), can help relieve mild to moderate diarrhea by adding bulk to your stool. For more severe diarrhea, loperamide (Imodium) may be effective. Use anti-diarrheals with caution and only after consulting your doctor.
- Laxatives. In some cases, swelling may cause your intestines to narrow, leading to constipation. Talk to your doctor before taking any laxatives, because even those sold over-the-counter may be too harsh for your system.
- Pain relievers. For mild pain, your doctor may recommend acetaminophen (Tylenol, others). Avoid aspirin, ibuprofen (Advil, Motrin, others) and naproxen (Aleve). These are likely to make your symptoms worse.
- Iron supplements. If you have chronic intestinal bleeding, you may develop iron deficiency anemia. Taking iron supplements may help restore your iron levels to normal and reduce this type of anemia once your bleeding has stopped or diminished.
- Nutrition. Your doctor may recommend a special diet given via a feeding tube (enteral nutrition) or nutrients injected into a vein (parenteral nutrition) to treat your Crohn's disease. This can improve your overall nutrition and allow the bowel to rest. Bowel rest can reduce inflammation in the short term. However, once regular feeding is restarted, your signs and symptoms may return. Your doctor may use nutrition therapy short term and combine it with other medications, such as immune system suppressors. Enteral and parenteral nutrition are typically used to get people healthier for surgery or when other medications fail to control symptoms. Your doctor may also recommend a low residue or low-fiber diet if you have a narrowed bowel (stricture) to try to reduce the risk of a blockage. A low residue diet is one that's designed to reduce the size and number of your stools.
- Vitamin B-12 shots. Vitamin B-12 helps prevent anemia, promotes normal growth and development, and is essential for proper nerve function. It's absorbed in the terminal ileum, a part of the small intestine often affected by Crohn's disease. If inflammation of your terminal ileum is interfering with your ability to absorb this vitamin, you may need monthly B-12 shots for life. You'll also need lifelong B-12 injections if your terminal ileum has been removed during surgery.
- Calcium and vitamin D supplements. You may need to take a calcium supplement with added vitamin D. This is because Crohn's disease and steroids used to treat it can increase your risk of osteoporosis. Ask your doctor if a calcium supplement is right for you.
Future medications
New medications are in development and in clinical trial. If your Crohn's disease isn't well controlled with current medications, ask your doctor if there are clinical trials available to you.
Surgery
If diet and lifestyle changes, drug therapy or other treatments don't relieve your signs and symptoms, your doctor may recommend surgery.
During surgery, your surgeon removes a damaged portion of your digestive tract and then reconnects the healthy sections. In addition, surgery may also be used to close fistulas and drain abscesses. A common procedure for Crohn's is strictureplasty, which widens a segment of the intestine that has become too narrow.
The benefits of surgery for Crohn's are usually temporary. The disease often recurs, frequently near the reconnected tissue or elsewhere in the digestive tract. Up to 3 of 4 people with Crohn's disease eventually need some type of surgery. Many will also need a second procedure or more. The best approach is to follow surgery with medication to minimize the risk of recurrence.
Cancer surveillance
Screening for colon cancer may need to be done more frequently because people who have Crohn's disease that affects the colon have an increased risk of colon cancer. General colon cancer screening guidelines call for a colonoscopy every 10 years beginning at age 50. Ask your doctor if you need to have this test done sooner and more frequently.
Lifestyle and home remedies
Sometimes you may feel helpless when facing Crohn's disease. But changes in your diet and lifestyle may help control your symptoms and lengthen the time between flare-ups.
Diet
There's no firm evidence that what you eat actually causes inflammatory bowel disease. But certain foods and beverages can aggravate your signs and symptoms, especially during a flare-up. If you think eating certain foods make your condition worse, keep a food diary to keep track of what you're eating as well as how you feel. If you discover some foods are causing your symptoms to flare, it's a good idea to try eliminating those foods. Here are some suggestions that may help:
- Limit dairy products. Like many people with inflammatory bowel disease, you may find that problems, such as diarrhea, abdominal pain and gas, improve when you limit or eliminate dairy products. You may be lactose intolerant ? that is, your body can't digest the milk sugar (lactose) in dairy foods. If so, limiting dairy or using an enzyme product, such as Lactaid, will help break down lactose.
- Try low-fat foods. If you have Crohn's disease of the small intestine, you may not be able to digest or absorb fat normally. Instead, fat passes through your intestine, making your diarrhea worse. Foods that may be especially troublesome include butter, margarine, cream sauces and fried foods.
- Limit fiber, if it's a problem food. For most people, high-fiber foods, such as fresh fruits and vegetables and whole grains, are the foundation of a healthy diet. But if you have inflammatory bowel disease, fiber may make diarrhea, pain and gas worse. If raw fruits and vegetables bother you, try steaming, baking or stewing them. You may also find that you can tolerate some fruits and vegetables, but not others. In general, you may have more problems with foods in the cabbage family, such as broccoli and cauliflower, and nuts, seeds, corn and popcorn.
- Avoid problem foods. Eliminate any other foods that seem to make your signs and symptoms worse. These may include "gassy" foods such as beans, cabbage and broccoli, raw fruit juices and fruits, spicy food, popcorn, alcohol, and foods and drinks that contain caffeine, such as chocolate and soda.
- Eat small meals. You may find you feel better eating five or six small meals a day rather than two or three larger ones.
- Drink plenty of liquids. Try to drink plenty of fluids daily. Water is best. Alcohol and beverages that contain caffeine stimulate your intestines and can make diarrhea worse, while carbonated drinks frequently produce gas.
- Consider multivitamins. Because Crohn's disease can interfere with your ability to absorb nutrients and because your diet may be limited, multivitamin and mineral supplements are often helpful. Check with your doctor before taking any vitamins or supplements.
- Talk to a dietitian. If you begin to lose weight or your diet has become very limited, talk to a registered dietitian.
Smoking
Smoking increases your risk of developing Crohn's disease, and once you have it, smoking can make the condition worse. People with Crohn's disease who smoke are more likely to have relapses, need medications and repeat surgeries. Quitting smoking can improve the overall health of your digestive tract, as well as provide many other health benefits.
Stress
Although stress doesn't cause Crohn's disease, it can make your signs and symptoms worse and may trigger flare-ups. Stressful events can range from minor annoyances to a move, job loss or the death of a loved one.
When you're stressed, your normal digestive process changes. Your stomach empties more slowly and secretes more acid. Stress can also speed or slow the passage of intestinal contents. It may also cause changes in intestinal tissue itself.
Although it's not always possible to avoid stress, you can learn ways to help manage it. Some of these include:
- Exercise. Even mild exercise can help reduce stress, relieve depression and normalize bowel function. Talk to your doctor about an exercise plan that's right for you.
- Biofeedback. This stress-reduction technique may help you reduce muscle tension and slow your heart rate with the help of a feedback machine. You're then taught how to produce these changes without feedback from the machine. The goal is to help you enter a relaxed state so that you can cope more easily with stress. Biofeedback is usually taught in hospitals and medical centers.
- Regular relaxation and breathing exercises. One way to cope with stress is to regularly relax and use techniques such as deep, slow breathing to calm down. You can take classes in yoga and meditation or use books, CDs or DVDs at home.
Alternative medicine
Many people with digestive disorders have used some form of complementary or alternative therapy. Some commonly used therapies include:
- Herbal and nutritional supplements
- Probiotics
- Fish oil
- Acupuncture
Side effects and ineffectiveness of conventional therapies are primary reasons for seeking alternative care.
The majority of alternative therapies aren't regulated by the FDA. Manufacturers can claim that their therapies are safe and effective but don't need to prove it. In some cases that means you'll end up paying for products that don't work. For example, studies done on fish oil and on probiotics for the treatment of Crohn's haven't shown benefits to using these products. What's more, even natural herbs and supplements can have side effects and cause dangerous interactions. Tell your doctor if you decide to try any herbal supplement.
Some people may find acupuncture or hypnosis helpful for the management of Crohn's, but neither therapy has been well studied for this use.
Unlike probiotics ? which are beneficial live bacteria that you consume ? prebiotics are natural compounds found in plants, such as artichokes, that help fuel beneficial intestinal bacteria. An initial study on prebiotics had promising results. More studies are under way.
Coping and support
Crohn's disease doesn't just affect you physically ? it takes an emotional toll as well. If signs and symptoms are severe, your life may revolve around a constant need to run to the toilet. In some cases, you may barely be able to leave the house. When you do, you might worry about an accident, and this anxiety only makes your symptoms worse.
Even if your symptoms are mild, gas and abdominal pain can make it difficult to be out in public. You may also feel hampered by dietary restrictions or embarrassed by the nature of your disease. All of these factors ? isolation, embarrassment and anxiety ? can severely alter your life. Sometimes they may lead to depression.
Educate yourself, and connect
One of the best ways to be more in control is to find out as much as possible about Crohn's disease. Organizations such as the Crohn's and Colitis Foundation of America (CCFA) have chapters across the country to provide information and access to support groups. Your doctor, nurse or dietitian can locate the chapter nearest you, or you can contact the organization directly at 888-MY-GUT-PAIN (888-694-8872) or on its website.
Although support groups aren't for everyone, they can provide valuable information about your condition as well as emotional support. Group members frequently know about the latest medical treatments or integrative therapies. You may also find it reassuring to be among people who understand what you're going through.
Some people find it helpful to consult a psychologist or psychiatrist who's familiar with inflammatory bowel disease and the emotional difficulties that it can cause. Although living with Crohn's disease can be discouraging, research is ongoing and the outlook is brighter than it was a few years ago.
Managing complications and symptoms
- Diarrhea
- Intestinal obstruction
- Capsule endoscopy
- Bone health: Tips to keep your bones healthy
- Meditation: A simple, fast way to reduce stress
References
- Crohn's disease. National Institute of Diabetes and Digestive and Kidney Diseases. http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/Crohns.pdf
Accessed June 20, 2011. - Management of Crohn's disease in adults. Bethesda, Md.:American College of Gastroenterology. http://www.acg.gi.org/physicians/guidelines/CrohnsDiseaseinAdults2009.pdf Accessed June 20, 2011.
- Living with Crohn's disease. The Crohn's and Colitis Foundation of America. http://www.ccfa.org/frameviewer/?url=/media/pdf/crohns2005.pdf Accessed June 20, 2011.
- Crohn's disease. The Merck Manuals: The Merck Manual for Healthcare Professionals. http://www.merckmanuals.com/professional/print/sec02/ch018/ch018b.html Accessed June 20, 2011.
- Peppercorn MA. Clinical manifestations, diagnosis and natural history of Crohn's disease in adults. Evidence-Based Clinical Decision Support at the Point of Care | UpToDate Accessed June 20, 2011.
- Smoking and your digestive system. National Institute of Diabetes and Digestive and Kidney Diseases. http://digestive.niddk.nih.gov/ddiseases/pubs/smoking/DD-52.pdf Accessed June 23, 2011.
- Burakoff R, et al. Inflammatory bowel disease. In: Greenberger NJ, et al. Current Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy. New York, N.Y.: The McGraw Hill Medical Companies; 2009. Content Not Found Accessed June 20, 2011.
- Ford AC, et al. Glucocorticosteroid therapy in inflammatory bowel disease: Systematic review and meta-analysis. American Journal of Gastroenterology. 2011;106:590.
- Colombel JF, et al. Infliximab, azathioprine, or combination therapy for Crohn's disease. New England Journal of Medicine. 2010;362:1383.
- Rutgeerts P, et al. Biological therapies for inflammatory bowel diseases. Gastroenterology. 2009;136:1182.
- Farrell RJ, et al. Medical management of Crohn's disease in adults. Evidence-Based Clinical Decision Support at the Point of Care | UpToDate Accessed June 20, 2011.
- Korzenik JR. Investigational therapies in the medical management of Crohn's disease. Evidence-Based Clinical Decision Support at the Point of Care | UpToDate Accessed June 20, 2011.
- Ford AC, et al. Efficacy of biological therapies in inflammatory bowel disease: Systematic review and meta-analysis. American Journal of Gastroenterology. 2011;106:644.
- Enck P. Acupuncture treatment in gastrointestinal diseases: A systematic review. World Journal of Gastroenterology. 2007;13:3417.
- Markowitz J, et al. Patterns of complementary and alternative medicine use in a population of pediatric patients with inflammatory bowel disease. Inflammatory Bowel Diseases. 2004;10:599.
- Picco MF (expert opinion). Mayo Clinic, Jacksonville, Fla. July 12, 2011.
- Colorectal cancer screening guidelines. Centers for Disease Control and Prevention. CDC - Colorectal Cancer Screening Guidelines Accessed July 12, 2011.
