What is Crohn's disease?
Crohn's disease is a chronic inflammatory process primarily involving the intestinal tract. Although it may involve any part of the digestive tract from the mouth to the anus, it most commonly affects the last part of the small intestine (ileum) and/or the large intestine (colon and rectum).
Crohn's disease is a chronic condition and may recur at various times over a lifetime. Some people have long periods of remission, sometimes for years, when they are free of symptoms. There is no way to predict when a remission may occur or when symptoms will return.
What are the symptoms of Crohn's disease?
Crohn's disease can affect any part of the intestine, symptoms may vary greatly from patient to patient. Common symptoms include cramping, abdominal pain, diarrhea, fever, weight loss, and bloating. Not all patients experience all of these symptoms, and some may experience none of them. Other symptoms may include anal pain or drainage, skin lesions, rectal abscess, fissure, and joint pain (arthritis).
Who does it affect?
Any age group may be affected, but the majority of patients are young adults between 16 and 40 years old. Crohn's disease occurs most commonly in people living in northern climates. It affects men and women equally and appears to be common in some families. About 20 percent of people with Crohn's disease have a relative, most often a brother or sister, and sometimes a parent or child, with some form of inflammatory bowel disease.
Crohn's disease and a similar condition called ulcerative colitis are often grouped together as inflammatory bowel disease. The two diseases afflict an estimated two million individuals in the U.S.
What causes Crohn's disease?
The exact cause is not known. However, current theories center on an immunologic (the body's defense system) and/or bacterial cause. Crohn's disease is not contagious, but it does have a slight genetic (inherited) tendency. An x-ray study of the small intestine may be used to diagnose Crohn's disease.
How is Crohn's disease treated?
Initial treatment is almost always with medication. There is no "cure" for Crohn's disease, but medical therapy with one or more drugs provides a means to treat early Crohn's disease and relieve its symptoms. The most common drugs prescribed are corticosteroids, such as prednisone and methylprednisolone, and various anti-inflammatory agents.
Other drugs occasionally used include 6-mercaptopurine and azathioprine, which are immunosuppressive. Metronidazole, an antibiotic with immune system effects, is frequently helpful in patients with anal disease.
In more advanced or complicated cases of Crohn's disease, surgery may be recommended. Emergency surgery is sometimes necessary when complications, such as a perforation of the intestine, obstruction (blockage) of the bowel, or significant bleeding occur with Crohn's disease. Other less urgent indications for surgery may include abscess formation, fistulas (abnormal communications from the intestine), severe anal disease or persistence of the disease despite appropriate drug treatment.
Not all patients with these or other complications require surgery. This decision is best reached through consultation with your gastroenterologist and your colon and rectal surgeon.
Shouldn't surgery for Crohn's disease be avoided at all costs?
While it is true that medical treatment is preferred as the initial form of therapy, it is important to realize that surgery is eventually required in up to three-fourths of all patients with Crohn's. Many patients have suffered unnecessarily due to a mistaken belief that surgery for Crohn's disease is dangerous or that it inevitably leads to complications.
Surgery is not "curative," although many patients never require additional operations. A conservative approach is frequently taken, with a limited resection of intestine (removal of the diseased portion of the bowel) being the most common procedure.
Surgery often provides effective long-term relief of symptoms and frequently limits or eliminates the need for ongoing use of prescribed medications. Surgical therapy is best conducted by a physician skilled and experienced in the management of Crohn's disease.
What is ulcerative colitis?
Ulcerative colitis is an inflammation of the lining of the large bowel (colon and rectum). Symptoms include rectal bleeding, diarrhea, abdominal cramps, weight loss, and fevers. In addition, patients who have had extensive ulcerative colitis for many years are at an increased risk to develop large bowel cancer. The cause of ulcerative colitis remains unknown.
How is ulcerative colitis treated?
Initial treatment of ulcerative colitis is medical, using antibiotics and anti-inflammatory medications such as aminosalicylates. If these fail, prednisone can be used for a short period of time but long-term use can be associated with significant side effects. If prednisone is ineffective or cannot be discontinued, immunomodulators such as 6-mercaptopurine or azathioprine can be used to control active disease that does not merit hospitalization. In order to maintain control of the disease, aminosalicylates or immunomodulators are used on a long-term basis. "Flare-ups" of the disease can often be treated by increasing the dosage of medications or adding new medications. Hospitalization may be necessary to put the bowel to rest and deliver steriods directly into the blood stream.
When is surgery necessary?
Surgery is indicated for patients who have life-threatening complications of inflammatory bowel diseases, such as massive bleeding, perforation, or infection. It may also be necessary for those who have the chronic form of the disease, which fails to improve with medical therapy. It is important the patient be comfortable that all reasonable medical therapy has been attempted prior to considering surgical therapy. In addition, patients who have long-standing ulcerative colitis may be candidates for removal of the large bowel, because of the increased risk of developing cancer. More often, these patients are followed carefully with repeated colonoscopy and biopsy, and surgery is recommended only if precancerous signs are identified.
What operations are available?
Historically, the standard operation for ulcerative colitis has been removal of the entire colon, rectum, and anus. This operation is called a proctocolectomy and may be performed in one or more stages. It eliminates the disease and removes all risk of developing cancer in the colon or rectum. However, this operation requires creation of a Brooke ileostomy (bringing the end of the remaining bowel through the abdomen wall) and long-term use of an appliance on the abdominal wall to collect waste from the bowel.
The continent ileostomy is similar to a Brooke ileostomy, but an internal reservoir is created. The bowel still comes through the abdominal wall, but an external appliance is not required. Instead, the internal reservoir is drained three to four times a day by inserting a tube into the reservoir. This option eliminates the risks of cancer and risks of recurrent persistent colitis, but the internal reservoir may begin to leak and require another surgical procedure to revise the reservoir.
Some patients may be treated by removal of the colon, with preservation of the rectum and anus. The small bowel can then be reconnected to the rectum and continence preserved. This avoids an ileostomy, but the risks of ongoing active colitis, increased stool frequency, urgency, and cancer in the retained rectum remain.
Are there other surgical alternatives?
The ileoanal procedure is the most common surgical treatment for the management of ulcerative colitis. This procedure removes all of the colon and rectum, but preserves the anal canal. The rectum is replaced with small bowel, which is refashioned to form a small pouch. Usually, a temporary ileostomy is created, but this is closed several months later. The pouch acts as a reservoir to help decrease the stool frequency. This maintains a normal route of defecation, but most patients experience five to ten bowel movements per day. This operation all but eliminates the risk of recurrent ulcerative colitis and allows the patient to have a normal route of evacuation. Patients can develop inflammation of the pouch (pouchitis), which usually responds to antibiotic treatment. In a small percentage of patients, the pouch fails to function properly and may have to be removed. If the pouch is removed, a permanent ileostomy will likely be necessary.
Which alternative is preferred?
It is important to recognize that none of these alternatives makes a patient with ulcerative colitis normal. Each alternative has perceivable advantages and disadvantages, which must be carefully understood by the patient prior to selecting the alternative which will allow the patient to pursue the highest quality of life.