Living with Crohns Disease

03.30.10

Most people living with Crohns disease find that periods of remission (when they are free from symptoms) are longer and more frequent than periods of acute illness. This has never been truer than it is today, when doctors have large and growing arsenal of treatment options to prescribe.

The severity of Crohns disease can be measured objectively with indexes that chart symptoms, including:
•    The number of bowel movements per day
•    Appetite level
•    Fever
•    Number of days in a month when an individual must modify his or her work, home, or social schedule because of diarrhea, fatigue, fever, and other symptoms

Severity can also be measured subjectively, through a doctor’s assessment of an individual’s general state of being (such as whether he or she is angry, depressed, in pain, or embarrassed by needing to use the toilet frequently in social or business situations).There is considerable variation in how people with Crohns disease experience their illness.

An individual whose radiological examinations reveal an extent of disease that would seem to be debilitating may lead a relatively normal life, while a person with few objective signs of disease may find his or her symptoms totally debilitating, both physically and mentally.Although Crohns disease is a chronic (long-term) inflammatory bowel disease, it is not a constant disease.

That is, Crohns disease is characterized by acute flare-ups of symptoms followed by remissions that last for varying periods of time. Each individual’s pattern of symptoms is different, and conscientious doctors treat patients according to their reported symptoms rather than the results of laboratory tests or radiological exams. Diarrhea, pain, and fever-along with fatigue, chills, and possibly vomiting-come and go, sometimes in waves and sometimes in sharp bursts.

Flare-ups can occur out of the blue, following a viral illness such as a head cold, or during times of extreme personal, business, or social stress. People with Crohns disease may feel well and be free of symptoms for substantial spans of time when their disease is not active. Despite the need to take medication for long periods of time and occasional hospitalizations, most people with Crohns disease are able to hold jobs, raise families, and function successfully at home and in society.

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Laparoscopic Surgery For Crohns Disease

03.21.10

The rate of conversion from laparoscopic to open surgery was 11.2 percent. Laparoscopic procedures took longer to perform compared with open procedures, with a weighted mean difference of 25.54 minutes. Patients who underwent laparoscopic surgery had a more rapid recovery of bowel function, with a weighted mean difference of 0.75 days  and were able to tolerate oral intake earlier, with a weighted mean difference of 1.43 days .

The duration of hospitalization was shorter, with a weighted mean difference of 1.82 days. Morbidity was lower for laparoscopic procedures compared with open procedures (odds ratio, 0.57; 95 percent confidence interval, 0.37-0.87). The rate of disease recurrence was similar for both laparoscopic and open surgery.

Laparoscopic surgery for Crohns disease takes longer to perform, but there are significant short-term benefits to the patient. The morbidity also is lower, and the rate of disease recurrence is similar. Therefore, laparoscopic surgery for Crohns disease is both safe and feasible.

An effort was made to assess the feasibility, safety, and outcome of laparoscopic procedures performed in patients with Crohns disease. Methods: A prospectively maintained laparoscopic database was analyzed regarding operation time, intra- and postoperative complications, conversion to laparotomy, and length of hospitalization.

Fifty-one patients (23 males and 28 females) with a mean age of 36 (20-79) years underwent a laparoscopic or laparoscopic-assisted procedure for Crohns disease. The indications included terminal ileitis in 31 patients, colitis in 11, perianal disease in four, duodenal Crohns disease in three, and rectovaginal and rectourethral fistula in one patient each.

Thirty-two patients underwent an ileocolic resection; total abdominal colectomy with ileorectal anastomosis was performed in six patients with end ileostomy in one, take down of end ileostomy and ileorectal anastomosis in three, duodenal bypass gastrojejunostomy in three, and loop ileostomy in six patients.

Results: The mean operating time was 2.4 (0.6-4.5) h and the mean length of hospital stay was 5.1 (3-18) days. Eight complications were noted in seven patients (14%), which included enterotomy in two patients, bleeding in two, stoma obstruction in two, pelvic sepsis in one, and efferent limb obstruction in one. The procedure was converted to laparotomy in seven patients (14%) due to a large inflammatory mass in five and to bleeding in two patients; there was no mortality.

Conclusion: Laparoscopic surgery is a feasible, versatile, and safe modality in the surgical management of Crohns disease. Despite the often-malnourished state of these steroid-dependent patients with intraabdominal inflammatory conditions, morbidity, procedural length, and length-of-hospitalization data are all similar to results previously reported for less-challenging laparoscopic colorectal procedures.

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Ischemic Colitis

03.13.10

Ischemic Colitis is a medical condition in which inflammation and injury of the large intestine result from inadequate blood supply. Although uncommon in the general population, ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel ischemia.

Causes of the reduced blood flow can include changes in the systemic circulation (e.g. low blood pressure) or local factors such as constriction of blood vessels or a blood clot. In most cases, no specific cause can be identified.Ischemic colitis is usually suspected on the basis of the clinical setting, physical examination, and laboratory test results; the diagnosis can be confirmed via endoscopy.

Ischemic colitis can span a wide spectrum of severity; most patients are treated supportively and recover fully, while a minority with very severe ischemia may develop sepsis and become critically ill.Patients with mild to moderate ischemic colitis are usually treated with IV fluids, analgesia, and bowel rest (that is, no food or water by mouth) until the symptoms resolve.

Those with severe ischemia who develop complications such as sepsis, intestinal gangrene, or bowel perforation may require more aggressive interventions such as surgery and intensive care. Most patients make a full recovery; occasionally, after severe ischemia, patients may develop long-term complications such as a stricture or chronic colitis.

Ischemic colitis is injury of the large intestine that results from an interruption of its blood supply.
•    Abdominal pain and bloody stools are common.
•    Colonoscopy is usually done.
•    Most people get better with fluids given intravenously and nothing to eat, but a few require surgery.

Ischemic colitis results from a temporary blockage of blood flow through arteries that supply the large intestine. Often doctors cannot find a cause for the reduced blood flow, but it is more common among people with heart and blood vessel disease, people who have had surgery on their aorta, or people who have problems with increased blood clotting.

Ischemic colitis affects primarily people who are 60 or older.Blockage of blood flow damages the inside lining and inner layers of the wall of the large intestine, causing ulcers (sores) in the lining of the large intestine, which can bleed. Usually, the person experiences abdominal pain. The pain is felt more often on the left side, but it can occur anywhere in the abdomen.

The person frequently passes loose stools that are often accompanied by dark red clots. Sometimes bright red blood is passed without stool. Low-grade fevers (usually below 100° F [37.7° C]) are common.A doctor may suspect ischemic colitis on the basis of the symptoms of pain and bleeding, especially in a person older than 60. People with ischemic colitis are hospitalized.

Initially, the person is given neither fluids nor food by mouth so that the intestine can rest. Instead, fluids, electrolytes, and nutrients are given intravenously. Antibiotics are often given to prevent infection that might follow the inflammation.

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Infectious Colitis

03.05.10

Infectious colitis: A variety of “bugs” may cause colitis. They have developed a variety of ways to overcome our natural defenses and ultimately cause colitis. The germs include these:

•    Bacteria: Commonly found in food or contaminated water, bacteria may produce toxins that trigger intestinal cells to secrete salt and water and interfere with their normal functions. Salmonella, Shigella species, Campylobacter jejuni, and Clostridium are examples of bacteria associated with infectious colitis.
•    Viruses: Viruses such as rotavirus or Norwalk can damage the mucous membrane lining your intestine and disturb fluid absorption.
•    Protozoa: People infected with these tiny organisms may show no symptoms (carrier state), or they may have chronic, mild, loose, bowel movements or acute severe dysentery. Colitis due to E histolytica, also known as amebiasis, has become an important sexually transmitted disease in homosexual men.

Types of colitis include ulcerative colitis, Crohn’s colitis, diversion colitis, ischemic colitis, infectious colitis, fulminant colitis, chemical colitis, microscopic colitis, lymphocytic colitis, and atypical colitis. The risk of developing infectious colitis varies considerably throughout the world and depends on local conditions. Populations in developing countries often live in ramshackle housing without good sanitation. Colon infections are readily transmitted in this setting.

However, in industrialised countries, most inhabitants live in a sanitary environment but other practices facilitate germ transmission such as large-scale food production, distribution retailing practice (fast-food chains…). Hospitalised patients, infants in day care centres, travellers also exhibit an increased susceptibility for infection. vIn most patients coming to the general practitioner or specialist with a history of acute (short history, less than one week) watery diarrhoea with blood or mucus (dysentery), it will be possible to make a diagnosis fairly easily.

Watery diarrhoea is more often of viral aetiology, and at routine bacteriological investigation, cultures will be negative. Watery diarrhoea is the result of a disturbed balance between intestinal secretion and absorption. Viruses can infect and kill villous tip enterocytes and by doing so disturb absorption. Diarrhoea with blood is more often of bacterial origin.

Production of bloody stools means a mucosal break caused by entero-invasive bacteria. Acute bloody diarrhoea however usually begins with watery diarrhoea. Some bacteria can also induce either acute diarrhoea or acute bloody diarrhoea. The differential diagnosis between infectious colitis and other types of colitis is sometimes difficult : in patients coming from tropical or subtropical countries where infections are more likely, a diagnosis of chronic idiopathic inflammatory bowel disease must be made cautiously ; whenever more than one person has been acutely ill at the same moment, a diagnosis of chronic inflammatory bowel disease is unlikely and food poisoning has to be considered; immuno-compromised patients ; elderly patients where one has to consider diverticular disease, ischaemia, malignancy, or a colitis — like picture due to drugs.

Drugs are indeed a common cause of diarrhoea and colitis.

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Gastroduodenal Crohns Disease

02.27.10

In anatomy, the gastroduodenal artery is a small blood vessel in the abdomen.It supplies blood to the pylorus (distal part of the stomach) and the proximal part of the duodenum.It arises from the common hepatic artery and terminates in a bifurcation, when it splits into the right gastroepiploic artery and the anterior superior pancreaticoduodenal artery.

Crohns disease involving the gastric outlet and proximal duodenum, resulting in gastric outlet obstruction. Image on the right shows a view of the stricture as seen through a translucent dilating balloon, which has been inflated in the stricture.

1. Melatonin protection against ethanol-induced gastroduodenal injury was investigated in duodenumligated rats.
2. Melatonin, injected i.p. 30 min before administration of 1 ml of absolute ethanol, given by gavage, significantly decreased ethanol-induced macroscopic, histological and biochemical changes in the gastroduodenal mucosa.
3. Ethanol-induced lesions were detectable as haemorrhagic streaks. Ethanol administration damaged 36% and 25% of the total gastric and duodenal surface, respectively.

Melatonin treatment reduced ethanol-induced gastric and duodenal damage to 14% and 8%, respectively. When indomethacin was given together with ethanol, the gastric damaged area was 44% of the total surface, while the duodenal damaged area was 35%; melatonin administration reduced the damage to only 13% of the total gastric surface and to 12% of total duodenal surface.

4. Both stomach and duodenum of ethanol-treated animals showed polymorphonuclear leukocyte (PMN) infiltration. The number of PMN increased more than 600 and 200 times in stomach and duodenum, respectively, following ethanol administration. Melatonin treatment reduced ethanol-induced PMN infiltration by 38% in the stomach and 20% in the duodenum. In indomethacin-ethanol-treated rats, the number of PMN increased by 875% compared to control group in the stomach and by 264% in duodenum. Melatonin administration reduced the indomethacin-ethanol-induced PMN rise by 57% in the stomach and 40% in the duodenum.

5. Gastroduodenal total glutathione (tGSH) concentration and glutathione reductase (GSSG-Rd) activity were significantly reduced following ethanol and indomethacin-ethanol administration. Melatonin ameliorated both the decrease in tGSH concentration as well as the reduction of GSSG-Rd activity elicited by ethanol both in the stomach and duodenum; melatonin was effective against indomethacin-ethanol-induced damage only in the stomach.

6. Ethanol-induced gastroduodenal damage is believed to be mediated by the generation of free radicals. Recently, a number of in vivo and in vitro experiments have shown melatonin to be an effective antioxidant and free radical scavenger; thus, we conclude that the protection by melatonin against ethanol-induced gastroduodenal injury is due, at least in part, to its radical scavenging activity.

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Fistulizing Crohns Disease

02.19.10

Fistulas are common in Crohns disease. A population-based study has shown a cumulative risk of 33% after 10 years and 50% after 20 years. Perianal fistulas were the most common (54%). Medical therapy is the main option for perianal fistula once abscesses, if present, have been drained, and should include antibiotics (both ciprofloxacin and metronidazole) and immunomodulators.

Infliximab should be reserved for refractory patients. Surgery is often necessary for internal fistulas. The appropriate treatment of patients with fistulas in the setting of Crohns disease requires a knowledge of the specific medical and surgical literature of fistulizing Crohn’s. The patient with symptomatic fistulizing Crohns disease may respond differently to specific medical therapy than a patient with symptomatic obstructing Crohns disease.

Certain medications that are useful for the treatment of patients with obstructive Crohns disease may not be helpful in the treatment of fistulas in patients with fistulizing Crohns disease (e.g., corticosteroids and mesalamine); in fact, some medications are believed to be detrimental (e.g., corticosteroids). Few studies have been performed to assess the efficacy of specific medications on fistulas directly.

To date, there has been only one published prospective randomized controlled trial that was designed to assess the efficacy and safety of a specific medication on fistulas in patients with Crohns disease; it showed clinical efficacy over placebo in a statistically significant manner. The judicious use of surgery remains an integral part of the management of certain presentations of fistulizing Crohns disease, and the appropriate integration of surgical and medical therapy is of paramount importance in the management of these patients.

This review provides an overview of pertinent medical and surgical literature as it pertains to management of patients with fistulizing Crohns disease. Remicade was also shown to be effective in reducing the number of open, draining fistulas, a painful complication of Crohns disease in which deep openings burrow from the bowel wall through the surface of the skin, causing drainage of mucous and/or fecal material. Remicade is the first product documented to reduce the number of open fistulas in a controlled clinical trial.

In a clinical study of 94 patients with fistulizing Crohns disease (42 patients had single fistula and 52 patients had multiple fistulas), 68 percent of those treated at the recommended dose of Remicade experienced closure of at least 50 percent of fistula(s) for four weeks or more compared with 26 percent of placebo-treated patients. More than one-half (55 percent) of patients with single or multiple fistula(s) treated with Remicade experienced a clinical effect demonstrated clinical response to treatment with Remicade developed an abscess in the area of the fistula between eight and 16 weeks after the last infusion.

“Remicade represents a significant advance in the treatment of Crohns disease,” said Stephen Hanauer, M.D., University of Chicago Medical Center, department of gastroenterology, and a principal investigator in the clinical trials. “These patients suffer terribly and we physicians now have an important option available to treat them.”

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Excercise and Crohns Disease

02.14.10

Canadian researchers found that for people with mild Crohns disease, taking a walk a few times per week helped boost their well-being and quality of life.Crohns disease is a chronic disorder that causes inflammation throughout the digestive tract.

Symptoms, which include diarrhea, abdominal pain and rectal bleeding, tend to flare-up periodically, and then go into periods of remission.There has been some concern that exercise could exacerbate these problems because of its potential effects on functioning in the digestive tract. However, studies have not shown this to be true.For the new study, Victor Ng and colleagues at the University of Western Ontario recruited 32 adults with Crohns disease.

All were either in remission or were suffering only mild symptoms.For three months, half of the study participants walked for 30 minutes, three days per week. The rest maintained their usual lifestyle. At the beginning and end of the study, all patients completed questionnaires on their symptoms, overall well-being and quality of life.At the end of the trial, the researchers found, the exercise group reported improved symptoms and gave higher ratings to their quality of life. In contrast, symptoms worsened in the comparison group.

The findings are published in the Clinical Journal of Sports Medicine.

“Exercise benefits almost everyone and chronic disease patients are no exception,” study co-author Dr. Wanda Millard told Reuters Health.

Though some doctors have been hesitant to recommend exercise for Crohns disease, light exercise like moderate walking is unlikely to have significant effects on patients’ intestinal function, Millard noted.She pointed out that there are several professional athletes with Crohns disease.

That being said, however, Millard cautioned that this and other studies of exercise and Crohns disease have included only patients in remission or with mild symptoms.

“Patients with moderate or severe symptoms of their Crohns disease should not engage in an exercise program until their symptoms are better controlled,” she advised. Most people are successful with the basic formula of dieting and exercise. A smaller number need the addition of medication. A small percentage fail in all of those methods. So the big question is what should those who are overweight do to get back to an acceptable weight?
Unfortunately, there is no easy answer.

Those who have failed exercise, dieting and weight loss medication have a big problem to overcome. They most likely have problems exercising because of their weight or other health problems. It can likely help manage it, if for nothing else it can reduce stress.Depression is often an issue because of failing weight loss programs. Medications either have too many side effects or just are not working.

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Early Stage Symptoms of Crohns

02.06.10

The most common early symptoms of Crohns disease are chronic diarrhea (which sometimes is bloody), crampy abdominal pain, fever, loss of appetite, and weight loss. Symptoms may continue for days or weeks and may resolve without treatment.

Complete and permanent recovery after a single attack is extremely rare. Crohns disease almost always flares up at irregular intervals throughout a person’s life. Flare-ups can be mild or severe, brief or prolonged. Severe flare-ups can lead to intense pain, dehydration, and blood loss. Why the symptoms come and go and what triggers new flare-ups or determines their severity is not known. Recurrent inflammation tends to appear in the same area of the intestine, but it may spread to adjacent areas after a diseased segment has been removed surgically.

Common complications of inflammation include scarring that can produce intestinal blockage (obstruction) and deep ulcers penetrating through the bowel wall that can create pus-filled pockets of infection (abscesses) or abnormal connecting channels between the intestine and other organs (fistulas). Fistulas may connect two different parts of the intestine. Fistulas also may connect the intestine and bladder or the intestine and the skin surface, especially around the anus.

Although fistulas from the small intestine are common, wide-open holes (perforations) are rare. When the large intestine is affected extensively by Crohns disease, rectal bleeding commonly occurs. After many years, the risk of colon cancer (cancer of the large intestine) is greatly increased. About one third of people who develop Crohns disease have problems around the anus, especially fistulas and cracks (fissures) in the lining of the mucus membrane of the anus.

Crohns disease may lead to complications in other parts of the body. These complications include gallstones, inadequate absorption of nutrients, urinary tract infections, kidney stones, and deposits of the protein amyloid in several organs (amyloidosis). When Crohns disease causes a flare-up of gastrointestinal symptoms, the person may also experience inflammation of the joints (arthritis), inflammation of the whites of the eyes (episcleritis), mouth sores (aphthous stomatitis), inflamed skin nodules on the arms and legs (erythema nodosum), and blue-red skin sores containing pus (pyoderma gangrenosum). Even when Crohns disease is not causing a flare-up of gastrointestinal symptoms, the person still may experience pyoderma gangrenosum, while inflammation of the spine (ankylosing spondylitis), inflammation of the pelvic joints (sacroiliitis), inflammation inside the eye (uveitis), or inflammation of the bile ducts (primary sclerosing cholangitis) are liable to occur entirely without relation to the clinical activity of the bowel disease.

In children, gastrointestinal symptoms such as abdominal pain and diarrhea often are not the main symptoms and may not appear at all. Instead, the main symptoms may be slow growth, joint inflammation, fever, or weakness and fatigue resulting from anemia.

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Crohns Disease and Zofran

01.29.10

Zofran is VERY effective for severe nausea. The only downside is the cost, its expensive. I get so nauseated that I cannot move or talk. Zofran is the only medicine that works.

Best of all, I had no side effects with Zofran. When I was in the hospital, the doctors were aware that I was allergic to Compazine. In the ER I was given Zofran in my IV. When I was admitted to the hospital, I told the doctors several times that I could not tolerate Compazine. Then I started throwing up (later found Crohn’s to be in my esphogus and I have gastroparesis).

The doctor told me “You can take the Compazine or put up with the symptoms. It’s up to you to decide what is worse.” I could not move, I could not talk, even breathing was causing me to heave.

So I took the Compazine–never again! I started loosing all feeling in my body. I got disorientated. I felt like I was floating, and had no control of myself. This lasted for at least 8 hours until the drug wore off.  Then the doctors put me on Phenegran–yuck! I took half a tablet and was so tired, that I slept for 12 hours.

I could not keep my eyes open! I only would trust Zofran. I am not messing with any other medicine. Zofran works and is worth every penny. I have Crohns disease and I find that MMJ helps with the vomitting and the stomach cramps. MMJ has even kept me out of the hospital several times.

I often find it helps better than other prescibed medicines, such as prednisone or zofran, What do other crohn’s or GI patients think? mikessss, usually heavy indicas and indica concentrates do the trick for me, they stop the symptoms in their tracks, unfortunately I am still on lots of meds, hoping to taper of some in the coming months. Zofran is used to treat or prevent the nausea and vomiting that may occur after therapy with anticancer medicines (chemotherapy) or radiation, or after surgery.

If you vomit within 30 minutes after taking this medicine, take the same amount of medicine again. If vomiting continues, check with your doctor. Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention. Chest pain, pain, redness, or burning at place of injection, shortness of breath, skin rash, hives, and/or itching, tightness in chest, troubled breathing, wheezing.

Other side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. However, check with your doctor if any of the following side effects continue or are bothersome:
More common
Constipation, diarrhea, fever, headache
Less common

Abdominal pain or stomach cramps, burning, tingling, or prickling sensations, dizziness or lightheadedness , drowsiness, dryness of mouth, feeling cold, itching , unusual tiredness or weakness
Other side effects not listed above may also occur in some patients. If you notice any other effects, check with your doctor.

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Crohns Disease Surgery

01.17.10

Crohns disease can cause a variety of symptoms of gastrointestinal distress.

The three classic (though not specific) symptoms of inflammatory bowel disease are:
•    Persistent or recurrent diarrhea (possibly with blood, mucus, or pus)
•    Abdominal pain
•    Fever

There also may be signs and symptoms unrelated to the gastrointestinal tract. A doctor will obtain a complete medical history and perform a thorough physical examination, along with laboratory and diagnostic tests, to diagnose Crohns disease. The examination and other tests are necessary to rule out a number of transient conditions, such as viral, bacterial, or parasitic infection, that cause symptoms similar to Crohns disease.

Diarrhea
In cases of Crohns disease, patients often experience frequent loose or watery bowel movements. The stool is occasionally accompanied by thick, dark blood (not bright red smears of blood, which usually result from a bleeding hemorrhoid). There is less mucus or pus in the stool than in cases of ulcerative colitis.

Pain
Patients may experience crampy, achy, or even sharp pain in the affected area. Most often, patients with Crohns disease feel pain on the lower right side of the abdomen (lower right quadrant) and just below the bellybutton. This is because the majority of cases of Crohns disease involve disease in the terminal ileum, where the small intestine meets the large intestine. The terminal ileum crosses from left to right just above the beltline, and joins the large intestine in the lower right quadrant. The type of pain associated with Crohns disease depends on what part of the GI tract is affected. Disease in the terminal ileum generally causes sharp pain, while disease in the colon causes more crampy pain, similar to that that of ulcerative colitis. Pain is sometimes relieved (temporarily) after a bowel movement.

Fever
Crohn’s is an inflammatory disease, and one of the key characteristics of the inflammatory process is fever. (The others are pain, swelling, and redness.) Some individuals with Crohns disease suffer a high fever, especially during the acute phase of a flare-up. Others run a persistent, low-grade fever. Fever may be accompanied by irritability and fatigue. Sometimes, the fever recurs each day, especially late in the day, then repeatedly breaks during sleep, causing night sweats.

Signs and Symptoms Unrelated To The GI Tract
A number of signs and symptoms that do not involve the gastrointestinal tract can occur with Crohns disease. These may occur at the same time as the intestinal symptoms, or may be experienced weeks or even months before any intestinal symptoms are noticed. If your doctor suspects inflammatory bowel disease, he or she will ask you detailed questions about whether or not these extra-intestinal symptoms have appeared:
•    Reddening and inflammation of the eye (iritis)
•    Joint pain (usually in the large joints of the knees, ankles, elbows, wrists, and shoulders), which sometimes migrates from one joint to another (migrating arthralgia)
•    Skin lesions, including tender red nodules on the shins or calves (erythema nodosum)
•    Sores inside the mouth (aphthous ulcers)

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