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?

Because Crohn's disease can affect any part of the intestine, symptoms may vary greatly from patient to patient. Common symptoms include cramping, abdominal pain, diarrhoea, 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, skin lesions, rectal abscess, fissure, and joint pain (arthritis).

Common Crohn’s symptoms:

• Cramping - abdominal pain
• Diarrhoea
• Fever
• Weight loss
• Bloating
• Anal pain or drainage
• Skin lesions
• Rectal abscess
• Fissure
• Joint pain

Who does it affect?

Any age group may be affected, but the majority of patients are young adults between 16 and 40years 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.

What causes Crohn's disease?

The exact cause is not known. However, current theories centre on an immunologic (the body's defence system) and/or bacterial cause. Crohn's disease is not contagious, but it does have a slight genetic (inherited) tendency.

How is Crohn's disease diagnosed?

The two tests that are commonly used to diagnose the disease are colonoscopy (an endoscopic examination of the large bowel lining) and small bowel meal (an x-ray study of the small intestine). Either one test in any order or both tests will be undertaken depending on the nature of your symptoms. In addition, you may have blood test to check your haemoglobin and level inflammation in your circulation (inflammatory markers). An ultrasound or a CT scan may also be arranged in certain situations.

Does Crohn's disease have any complications?

Complications of Crohn's disease include:

• Abscess formation with the abdomen
  
  
• Fistula formation i.e. a communication between the bowel and skin causing pus to discharge intermittently from the skin of the abdomen or a communication with the urinary bladder leading to repeated attacks of urinary infection and possibly passage of faecal contents with the urine.
  
  
• Bowel obstruction (blockage)
  
  
• Severe bleeding
  
  
• Perforation which may occur suddenly, causing wide spread infection of the abdomen. This is an emergency requiring urgent surgery

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 prednisolone and various anti-inflammatory agents such as Pentasa or Asacol. Other drugs occasionally used as a second line treatment include azathioprine and occasionally cyclosporine A, which are strong immunosuppressive agents. 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. A decision on surgery is made by Mr Abulafi usually in consultation with the gastroenterologists.

What operations are available?

• Small bowel disease: The commonest surgical procedure performed for Crohn’s disease is a limited resection of intestine (removal of the diseased portion of the bowel). In extensive disease with multiple strictures (narrowing) in the small bowel, a stricturoplasty is performed to prevent removal of a considerable portion of the bowel. Stricturoplasty is a technique, which results in opening up and widening the narrowed parts of the bowel.
  
  
• Large bowel disease: As in small bowel disease but not stricturoplasty. Rarely, Crohn’s disease of the large bowel causes life threatening condition requiring emergency surgery to remove the whole of the large bowel (colectomy) with formation of stoma (see stoma leaflet). This can be a temporary or a permanent one and usually this will be discussed with the patient in detail prior to the surgery.
  
  
• Anal disease: Occasionally, Crohn's disease causes anal abscess/fistulae and these will be treated in the usual way (see abscess/fistulae leaflet).

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 realise that surgery is eventually required in up to three-fourths of all patients with Crohn's. Surgery often provides effective long-term relief of symptoms and frequently limits or eliminates the need for ongoing use of prescribed medications. Many patients never require additional operations. However, surgery is not "curative" and this is the reason why it is always left as a last resort when medical treatment fails or if there are complications.

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