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The treatments for ulcerative colitis and Crohn’s disease are often very similar. The oral agents that we have, such as the five Aminosalicylates, prednisone, and the biologics work for both treatments.
Lifestyle is very important in any disease process, but in particular with Crohn’s disease. Smoking is a very, very, very important risk factor that anyone with Crohn’s disease should absolutely eliminate. Crohn’s disease has been repeatedly shown to be associated with many complications of Crohn’s disease. So if you take someone with Crohn’s disease and they are a smoker, they’re more likely to develop strictures or blockages. They’re more likely to develop fistulas. They’re more likely to have complications that are more likely to require surgery. So I highly recommend that all my patients with Crohn’s disease immediately stop cigarettes. Physical activity is very important. Patients with Crohn’s disease should maintain an active lifestyle and try to get regular physical activity.
Thanks to developments in the area of inflammatory bowel disease, patients with Crohn’s disease can lead very normal lives. Thankfully, we have very effective and safe treatments for patients with Crohn’s disease. We have learned a lot over the years about Crohn’s disease, and we’re now able to educate our patients better, treat them better, monitor their disease in ways that we weren’t able to do before. And so I think with all of the research and all the developments that science and medicine, have seen in the last several decades, we are able to see people living very normal, happy, productive lives.
So patients ask, “how long do I need to be on these medications?” That’s a very good question. It really depends. It depends what kind of medications patients are on. Certain medications we’re able to wean off. Whereas other medications, we like to keep long term. In general, what patients need to understand is Crohn’s disease is a chronic autoimmune condition. Meaning, if you stop your medications it is very likely that the inflammation will recur and you may not be symptomatic right off the bat. And so a lot of patients say, but I’m doing really well. Unfortunately, over time the inflammation builds up, and then patients get into trouble once it’s too late. And so I always encourage patients that when they found the medication that works for them as long as their doctor deems it to be safe long term, that they should stay on the medication, assuming they don’t have any side effects or there’d been no complications. Because once you get Crohn’s disease under control, it’s very, very important to keep the treatment on board. Oftentimes patients get tired of being on a medication. The problem is that when you stop sometimes these medications, they may not necessarily work again down the road if you try to use them again. And so it’s very important to work closely with your physician to make sure that a treatment, regimen is developed that suits your quality of life, your personality, your needs, your disease severity and that you can be on long term.
Especially in our female patients there’s questions about the effects of Crohn’s disease on fertility and the effects of Crohn’s disease during pregnancy. So in terms of fertility, the most important thing is that the Crohn’s disease is well controlled. Well controlled, Crohn’s disease is the best thing one can do chances of fertility. Certain medications of course can affect fertility, men or women. And so that’s something that people need to discuss with their doctor if they are trying to get pregnant. In terms of pregnancy, the most important thing when it comes to the health of the baby is the health of the mother. So a pregnant person with Crohn’s disease must make sure the disease is well controlled during the course of the pregnancy and there are a number of different medications that now have been shown to be very, very safe during pregnancy. And so a person should consult with their doctor, their OBGYN and their gastroenterologist, to come up with a regimen that is both safe and effective to make sure that the disease is controlled during pregnancy. I would not recommend for someone who’s got poorly controlled Crohn’s disease to get pregnant. It’s advisable to get the disease under control before trying to get pregnant.
Moderate amounts of social alcohol should be fine in Crohn’s disease. There are certain diets and dietary plans that may call for complete elimination of alcohol during the diet, such as exclusive enteral nutrition. During that period, you’re essentially strictly on protein shakes to rest the bowel. And in that specific treatment algorithm alcohol is not recommended most of the time, however, when patients are in remission and their disease is well controlled, social alcohol, is acceptable.
So diet is very important in Crohn’s disease. Traditionally patients have been told “don’t worry about it, eat whatever you want.” But now we have a lot of research and data that shows that what you eat plays a very, very important role in your response to medications and the overall course of Crohn’s disease. One specific diet for example, that is gaining a lot of attention lately due to research and great outcomes. Is this specific carbohydrate diet. We call it the SCD Diet. Basically a diet that is lactose free, grain free, gluten free, and a lot of other components such as avoidance of processed food. And when patients adhere to this specific carbohydrate diet, they see remarkable improvements in their overall energy and their disease severity and response to treatment. For patients with really severe disease, a exclusive enteral nutrition, basically supplements protein shakes exclusive to the digestive tract, have been shown to be very effective in calming the digestive tract’s inflammation and improving outcomes. Both of these diets, you could read about it online, but it’s highly recommended that you see a dietician with expertise in this because we want to make sure that you’re getting enough nutrients, enough nutrition. We don’t want you to be losing the weight on these diets.
Complications of Crohn’s disease are variable. There are complications such as nutritional deficiencies because patients with Crohn’s disease have inflammation of the digestive tract. They may have vitamin deficiencies, nutritional deficiencies. Those are very important to make sure that they’re dealt with. Patients with Crohn’s disease should be on multivitamins, their nutrient levels should be checked by their physician regularly, and replenished. Other complications of Crohn’s disease include blockages, so intestinal blockages, we call them strictures. And those are very serious and those need to be dealt with. If there’s active inflammation still, we are able to relieve the obstruction with immunosuppressants and patients do not require surgery. But occasionally if they’ve had inflammation for a very, very long time, then those strictures are what we call fibrotic, they’re basically scarred. Sometimes surgery is necessary to remove that area so that patients can move on with their treatment. Infections are another potential complication. If patients develop an abscess, which is basically a collection of bacteria or puss as a result of a Fistula, which is an abnormal connection between bowels of intestine that result from inflammation. That needs to be addressed with antibiotics, sometimes surgical drainage, where we relieve the abscess surgically. Those are the main complications of Crohn’s disease.
Crohn’s disease is an inflammatory bowel disease. Essentially it’s an autoimmune disorder. We don’t know exactly all the details of why people get Crohn’s disease, but we’ve come a long way over the last decade or two. Essentially Crohn’s disease can affect anywhere from the mouth all the way down to the anus. So people can have Crohn’s disease of the small intestine. That’s about, I would say about 80% of people have CroHn’s disease that is limited to their small intestine. There’s about 50% of people who have Crohn’s disease that is just in their colon. Okay. And there are minority of Crohn’s disease patients that it only affects the upper digestive tract so the stomach or the upper intestines. There are a number of symptoms that people can have with Crohn’s disease. It can start out as something as simple as just fatigue or a little bit of anemia. Weight loss can be the only symptom. And then there are more substantial symptoms such as abdominal pain. One can have nausea, vomiting, there’s a blockage. Diarrhea is a very common symptom in patients with Crohn’s disease. And occasionally they also get bleeding. Rectal bleeding. So those are some of the main symptoms that patients with Crohn’s disease can experience.
So Crohn’s disease, as I mentioned can affect different parts of the digestive tract. We have what we call Crohn’s Colitis, which is Crohn’s, specifically of the colon. There’s Crohn’s ileocolitis, which means Crohn’s disease that affects the last portion of the small intestine as well as the colon. And then there’s just small bowel Crohn’s disease. That’s the most common type of Crohn’s disease that affects anywhere in the small bowel. Minority of patients may have Crohn’s disease that is isolated to the upper digestive tract, so the esophagus or the stomach or the upper digestive intestines. In terms of the presentation, there are different phenotypes, different kinds. There’s inflammatory Crohn’s disease where there’s inflammation in those different parts that I just described. There’s what we call fibrostenosing Crohn’s disease. Those are people who the inflammation causes narrowing of the intestines and they often are predisposed to blockages what we call bowel obstructions. The other form of Crohn’s disease, is what we call fistulizing Crohn’s disease, fistulizing Crohn’s disease, one of the most severe forms of Crohn’s disease. And that’s where the inflammation actually causes basically a burrowing of the inflammation from one intestine through to another part of the intestine. And you get connections between, say, the colon and the small intestine, and you can get connection between the intestine, other organs such as the bladder. And that can cause a lot of morbidity.
So an abscess is basically a collection of puss or bacteria, and in patients who have the fistulizing type of Crohn’s disease with inflammation, essentially causes a burrowing type of a hole through their intestines. The bacteria from the digestive tract forms a collection and that can be very dangerous and may require antibiotics and even potentially surgery to drain that area.
So Crohn’s disease can affect people of all ages. They can start at a very early age, and typically though it presents in the second and third decade of life. And so we see a lot of teenagers, early adults presenting with symptoms of Crohn’s disease. Now keep in mind, most of the time, Crohn’s disease just doesn’t appear overnight. People tend to have inflammation that’s smoldering and progresses and eventually to develop symptoms. So the early signs of Crohn’s disease could be poor weight gain as a child, not meeting your milestones. As you get older, it could just be fatigue and inability to gain weight or grow appropriately. And then symptoms of abdominal pain, diarrhea, rectal bleeding can occur. And in the more severe forms, people can have severe anemia, fevers, bowel obstructions or blockages or intra-abdominal infections from the fistulizing type of Crohn’s where they get abscesses in their digestive tract.
There are a number of conditions that can mimic Crohn’s disease. In certain parts of the world tuberculosis is very prevalent and it can mimic symptoms of Crohn’s disease. There are other conditions that are inflammatory diseases of the bowel, such as microscopic colitis that can cause symptoms that may be similar to Crohn’s disease, such as abdominal pain or diarrhea. Celiac disease is another condition that can present with similar symptoms, namely weight loss, diarrhea, abdominal pain. However, on imaging, blood tests, and endoscopy or colonoscopy, one can differentiate the two conditions.
So there’s approximately 1.4 million people with inflammatory bowel disease as a whole in the United States. So about 50/50 Crohn’s disease and ulcerative colitis, which is another form of inflammatory bowel disease, anywhere between two to about 20% per hundred thousand life years. So very technical terms. Essentially, it’s a fairly common disorder in the United States. In certain populations we see it more. In Caucasians in European western European, Jewish background we also see more prevalence of Crohn’s disease.
Crohn’s disease can be a very serious condition if not dealt with and treated appropriately. However, there are so many great medications nowadays that most patients with Crohn’s disease are able to lead relatively normal lives. Decades ago, patients with Crohn’s disease, would end up in the hospital when they had a flare of their disease. Now patients can see their physicians and usually get outpatient care to control their symptoms. And we have great safe medications now that can control Crohn’s disease for many, many, many years. So patients with Crohn’s disease have a very good prognosis. They can lead normal lives and their life expectancy is not necessarily shorter than anybody else. There are people who run their own companies, very successful people who have Crohn’s disease, and you wouldn’t know it.
Diagnosing Crohn’s disease can be easy when It’s clear cut. But in certain situations, Crohn’s disease diagnosis can be fairly challenging. And it’s very, very important that before one commits to a life of diagnosis with Crohn’s disease and chronic immunosuppressant medications, that the appropriate tests have been done to make sure that this is in fact Crohn’s disease and not an infection or some other cause of the patient’s symptoms. Oftentimes, a test is done and it could be a false positive test result. And patients are put on medications that they stay on for very, very long time. So if there is a doubt, if there’s some inconsistencies, I always recommend for patients to seek specialized medical attention, whether it’s in the form of a gastroenterologist who specializes in Crohn’s disease or seeing inflammatory bowel disease specialist to make sure that all the pieces of the puzzle are put together and the diagnosis is accurate before starting on immunosuppressants.
The symptoms and the manifestations of Crohn’s disease are very treatable. It’s really reassuring. Nowadays, we have a large armamentarium of treatment options. And most patients were able to get, to respond and to actually go into remission. And majority of the symptoms and even the complications of Crohn’s disease are now treatable and reversible.
So because Crohn’s disease affects the entire digestive tract, potentially it can interfere with absorption of nutrients. In children, that may mean stunting growth and malnutrition. In addition, oftentimes once a patient is diagnosed with Crohn’s disease as a child, some of the medications are in and of themselves, causing stunting of growth such as steroids. So occasionally patients, children, or even adults who get diagnosed with Crohn’s disease must be put on steroids, at least in the short term, to get their disease under control. And that can stunt growth. And so really we have two components. One is the actual disease itself and the effects on the digestive tract is has, in terms of preventing absorption of food. Secondly, we have symptoms that prevent people, especially kids, from wanting to eat, being able to eat. And so that’s the actual disease component. And then the treatments also, are such that it’s particular steroids, they that can stunt growth.
So there’s a number of over the counter therapies that have been reported to be helpful. Probiotics have been studied and seem to be helpful in modulating the gut microbiome. There are a number of different kinds. I specifically like a specific brand by the name of VSL number three that is a prescription strength probiotic that has been studied extensively and seems to be very helpful in this specific population. Other over the counter medications or supplements I should say are turmeric or curcumin, which is an anti-inflammatory agent that’s been studied and it seems to be very helpful in inflammatory bowel disease conditions. Omega three fatty acids, have also been studied and they also seem to help with inflammatory bowel disease and Crohn’s disease, specifically.
There’s no cure however, there are excellent treatments now available, which means people can lead relatively normal lives. The treatments include five ASAs, or aminosalicylates. Those are mild forms of immunosuppressants and they target the digestive tract directly. Those are usually our starting medications. The next set of medications that are often used are antibiotics. Certain types of Crohn’s disease, antibiotics such as Ciprofloxacin and flagyl have been shown to be very effective. Steroids, whether they be systemic conventional corticosteroids such as prednisone or non-systemic steroids such as budesonide are also very helpful, especially in the acute phase where patients are really, really sick. We don’t like to use steroids long term because they have a lot of potential side effects. However, in the short term, they’re very affecting getting control over patients’ disease.
The next step up from there are immuno modulators. Those are medications that have been around for a long time. They’re in the pill form, such as azathioprine or 6-MP, and they’re a very effective form of immunosuppressants. And they help in certain situations. The newer kids on the block, if you may, over the last, say, 10 or 15 years, our biologics. Those are stronger, more sophisticated immunosuppressants. Sometimes they’re in the form of an infusion such as Remicade, or they’re in the form of an injection such as Humira or Adalimumab. These are medications that target very, very specific components of the inflammatory process and help patients with Crohn’s disease. And what’s great is there are newer and newer medications coming out regularly, and they’re even better than the ones we had before. And so for someone who getting diagnosed, or who was recently diagnosed with Crohn’s disease, they should be relatively optimistic because there really is a very large armamentarium of treatment and patients are often in remission and lead very normal lives.
Steroids are basically anti-inflammatory medications that suppress your immune system. Since Crohn’s disease is an autoimmune disease, where the immune system is for one reason or another, acting inappropriately in attacking one’s own body. Intestines specifically by using medications such as steroids namely Prednisone, or budesonide is another form of steroids, that suppresses the immune system. Unfortunately, these medications not only suppress the immune system, but have effects on other organs as well.
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