Crohn’s disease is a chronic inflammatory bowel disease that affects all its layers.
The most frequent complications are irreversible changes (narrowing of the intestinal segments, fistulas). Also, this disease is characterized by numerous extra-intestinal lesions.
The prevalence of Crohn’s disease in different countries of the world ranges from 50-150 cases per 100,000 population.
The first manifestations of the disease, as a rule, appear at a young age (15-35 years), and this can be both intestinal and extra-intestinal manifestations.
Causes of Crohn’s Disease
The causative factor of the disease is not installed. The provoking role of viruses, bacteria (for example, measles virus, mycobacterium paratuberculosis ) is assumed .
The second hypothesis is associated with the assumption that some food antigen or non-pathogenic microbial agent can cause an abnormal immune response.
The third hypothesis states that autoantigens (that is, the body’s own proteins) on the patient’s intestinal wall play the role of an instigator in the development of the disease.
In Crohn’s disease, the colon mucosa is inflamed, covered with superficial ulcerations, which causes
- abdominal pain,
- impurities of blood and mucus in the feces,
- diarrhea, often accompanied by pain during stool.
In addition, general malaise, loss of appetite and weight loss are often observed.
The presence of Crohn’s disease can be suspected with persistent or nighttime diarrhea, abdominal pain, intestinal obstruction, weight loss, fever, night sweats.
Not only the colon, but also the small intestine, as well as the stomach, esophagus and even the oral mucosa can be affected.
The incidence of fistula in Crohn’s disease ranges from 20 to 40%.
Often develop narrowing of the intestine, followed by intestinal obstruction, pseudopolyps.
Extraintestinal manifestations of Crohn’s disease include:
- skin manifestations
- joint damage,
- inflammatory diseases of the eye,
- diseases of the liver and biliary tract,
- vasculitis (inflammation of blood vessels),
- hemostatic disorders and thromboembolic complications,
- blood diseases
- disorders of bone tissue metabolism (osteoporosis- bone loss).
Crohn’s disease is a recurrent or ongoing disease that in 30% of cases gives spontaneous subsiding without treatment.
It happens that patients complain of pain in different parts of the abdomen, bloating, and often vomiting.
This is a variant of the disease with the predominant development of small bowel syndrome, which occurs with the defeat of the small intestine.
The diagnosis of Crohn’s disease is based on X-ray and endoscopic examination with a biopsy, which reveal an inflammatory lesion in one or more areas of the gastrointestinal tract, usually extending to all layers of the intestinal wall.
Leukocytes in the feces indicate inflammation of the intestinal wall. In case of diarrhea (at the onset of the disease or during relapse), the feces are examined for pathogens of intestinal infections, protozoa, helminth eggs and clostridia .
In the diagnosis of Crohn’s disease, an important role belongs to X-ray studies with contrast irrigoscopy with double contrast, the study of the passage of barium, intubation Enterography – a study of the small intestine with barium, which is injected through a nasogastric tube into the duodenum.
Scintigraphy with labeled leukocytes makes it possible to distinguish an inflammatory lesion from a non- inflammatory lesion ; it is used in cases where the clinical picture does not match the X-ray data.
Endoscopy of the upper or lower parts of the gastrointestinal tract (if necessary with a biopsy) allows you to confirm the diagnosis and clarify the location of the lesion.
With colonoscopy in patients undergoing surgery, it is possible to assess the state of the anastomoses, the probability of relapse and the effect of treatment carried out after the operation.
A biopsy can confirm the diagnosis of Crohn’s disease, in particular, distinguish it from ulcerative colitis, exclude acute colitis, identify dysplasia or cancer.
Important is the lifestyle of the patient. It is very difficult to ensure that he has less stress, but it should be remembered that stress can play a significant role in the development of relapse of Crohn’s disease.
Smoking significantly worsens the prognosis, so these patients are recommended to quit smoking.
The choice of treatment for Crohn’s disease depends primarily on the severity of the disease. To evaluate it for any one indicator is impossible, it is necessary to take into account the nature of the lesion of the gastrointestinal tract, systemic manifestations, the presence of exhaustion and the general condition.
Treatment depends on the location, severity of the lesion and the presence of complications. Preparations are selected individually, evaluating their effectiveness and tolerance over time.
Surgical treatment of Crohn’s disease is indicated for intestinal narrowing, purulent complications and the ineffectiveness of drug treatment.
With the defeat of the ileum and colon, aminosalicylic acid derivatives are prescribed orally ( mesalazine , 3.2–4 g / day , or sulfasalazine , 3–6 g / day in several doses).
With the ineffectiveness of sulfasalazine , metronidazole can help (10–20 mg / kg / day ).
Ciprofloxacin (1 g / day ) is just as effective as mesalazine .
The effectiveness of each drug is evaluated after several weeks of treatment. If the drug is effective, the treatment is continued until a remission is reached or the improvement is as good as possible, after which they switch to supportive treatment.
If the drug is ineffective, it is changed to another of the above, or go to one of the schemes shown in the moderate form of the disease.
Assign prednisone , 40-60 mg / day inside, until the symptoms disappear and the beginning of weight gain (usually this happens after 7-28 days).
In case of infection (for example, abscess ) conduct antibiotic therapy, open or percutaneous drainage.
If corticosteroids are ineffective or contraindicated, infliximab in the form of an infusion often helps ; It can also be used as an adjunct to corticosteroid therapy.
If, despite taking prednisone and infliximab , the condition in Crohn’s disease does not improve or there is high fever, frequent vomiting, intestinal obstruction, symptoms of peritoneal irritation, exhaustion, signs of abscess, hospitalization is indicated. Surgeon consultation is required in case of intestinal obstruction and the presence of a painful volume lesion in the abdominal cavity.
In the latter case, to exclude an abscess, an ultrasound is performed or computed tomography . For abscesses, percutaneous or open drainage is indicated .
If the abscess is excluded or the patient has already taken corticosteroids, then they are prescribed intravenously (as an injection or long-term infusion) in a dose equivalent to 40-60 mg of prednisone .
Probe nutrition with elemental mixtures or parenteral nutrition is prescribed if the patient cannot eat 5-7 days after the start of treatment.
With an abscess, open drainage is indicated. For fistulas and anal fissures, antibiotics, glucocorticoids, and infliximab are prescribed .
Indications for surgical treatment
Surgical treatment of Crohn’s disease is indicated in the development of complications (cicatricial strictures, abscesses) and the ineffectiveness of drug treatment.
Crohn’s disease is quite unpredictable, however, the rule remains true that in most patients the type and severity of the disease remain the same as when making a diagnosis.