Crohn disease
Chronic Colitis

Author: roberta giovannini
Date: 14/01/2008



Crohn_disease is a chronic transmural inflammation that may involve any part of the DIGESTIVE TRACT from MOUTH to ANUS, mostly found in the ILEUM, the CECUM, and the COLON. In Crohn disease, the inflammation, extending through the intestinal wall from the MUCOSA to the serosa, is characteristically asymmetric and segmental. Epithelioid GRANULOMAS may be seen in some patients."

Crohn's disease (also known as regional enteritis) is a chronic, episodic, inflammatory condition of the gastrointestinal tract characterized by transmural inflammation (affecting the entire wall of the involved bowel) and skip lesions (areas of inflammation with areas of normal lining between). Crohn's disease is a type of inflammatory bowel disease (IBD) and can affect any part of the gastrointestinal tract from mouth to anus; as a result, the symptoms of Crohn's disease vary between affected individuals. The main gastrointestinal symptoms are abdominal pain, diarrhea (which may be bloody) or constipation, and weight loss. Crohn's disease can also cause complications outside of the gastrointestinal tract such as skin rashes, arthritis, and inflammation of the eye .


The incidence of Crohn's disease has been ascertained from population studies in Norway and the United States and is similar at 6 to 7.1:100,000. Crohn's disease is more common in northern countries, and shows a higher preponderance in northern areas of the same country. The incidence of Crohn's disease in North America is 6:100,000, and is thought to be similar in Europe, but lower in Asia and Africa.
Crohn's disease has a bimodal distribution in incidence as a function of age: the disease tends to strike people in their teens and twenties, and people in their fifties through seventies. It is rare in early childhood. There is no association with gender, social class or occupation. Parents, siblings or children of people with Crohn's disease are 3 to 20 times more likely to develop the disease. Twin studies show a concordance of greater than 55% for Crohn's disease.

Influence of age at diagnosis on site and clinical type of disease

Familial aggregation in Crohn disease:increased age-adjusted risk and concordance in clinical characteristics


Many people with Crohn's disease have symptoms for years prior to the diagnosis. The usual onset is between 15 and 30 years of age, with a slight increase in prevalence in women (1:1.2).Because of the patchy nature of the gastrointestinal disease and the depth of tissue involvement, initial symptoms can be more vague than with ulcerative colitis . People with Crohn's disease will go through periods of flare-ups and remission.

  • Gastrointestinal symptoms

Abdominal pain may be the initial symptom of Crohn's disease. The pain is commonly cramp-like and may be relieved by defecation. It is often accompanied by diarrhea, which may or may not be bloody, though constipation is not uncommon especially in those who have had surgery. The nature of the diarrhea in Crohn's disease depends on the part of the small intestine or colon that is involved. Ileitis typically results in large-volume watery feces. Colitis may result in a smaller volume of feces of higher frequency. Fecal consistency may range from solid to watery. In severe cases, an individual may have more than 20 bowel movements per day and may need to awaken at night to defecate. Visible bleeding in the feces is less common in Crohn's disease than in ulcerative colitis, but may be seen in the setting of Crohn's colitis. Bloody bowel movements are typically intermittent, and may be bright or dark red in colour. In the setting of severe Crohn's colitis, bleeding may be copious. Flatus and bloating may also add to the intestinal discomfort.
Symptoms caused by intestinal stenosis are also common in Crohn's disease. Abdominal pain is often most severe in areas of the bowel with stenoses. In the setting of severe stenosis, vomiting and nausea may indicate the beginnings of small bowel obstruction. Crohn's disease may also be associated with primary sclerosing cholangitis , a type of inflammation of the bile ducts.
Perianal discomfort may also be prominent in Crohn's disease. Itchiness or pain around the anus may be suggestive of inflammation, fistulization or abscess around the anal area or anal fissure. Perianal skin tags are also common in Crohn's disease. Fecal incontinence may accompany peri-anal Crohn's disease. At the opposite end of the gastrointestinal tract, the mouth may be affected by non-healing sores ("aphthous ulcers" ). Rarely, the esophagus, and stomach may be involved in Crohn's disease. These can cause symptoms including difficulty swallowing (odynophagia), upper abdominal pain, and vomiting.

  • Systemic symptoms

Crohn's disease, like many other chronic, inflammatory diseases, can cause a variety of systemic symptoms. Among children, growth failure is common. Many children are first diagnosed with Crohn's disease based on inability to maintain growth. As Crohn's disease may manifest at the time of the growth spurt in puberty, up to 30% of children with Crohn's disease may have retardation of growth. Fever may also be present, though fevers greater than 38.5 °C (101.3 °F) are uncommon unless there is a complication such as an abscess Among older individuals, Crohn's disease may manifest as weight loss. This is usually related to decreased food intake, since individuals with intestinal symptoms from Crohn's disease often feel better when they do not eat and might lose their appetite. People with extensive small intestine disease may also have malabsorption of carbohydrates or lipids , which can further exacerbate weight loss.

  • Extraintestinal symptoms

In addition to systemic and gastrointestinal involvement, Crohn's disease can affect many other organ systems.Inflammation of the interior portion of the eye, known as uveitis , can cause eye pain, especially when exposed to light (photophobia). Inflammation may also involve the white part of the eye (sclera), a condition called episcleritis. Both episcleritis and uveitis can lead to loss of vision if untreated.

Crohn's disease is associated with a type of rheumatologic disease known as seronegative spondyloarthropathy . This group of diseases is characterized by inflammation of one or more joints (arthritis) or muscle insertions (enthesitis). The arthritis can affect larger joints such as the knee or shoulder or may exclusively involve the small joints of the hand and feet. The arthritis may also involve the spine, leading to ankylosing spondylitis if the entire spine is involved or simply sacroiliitis if only the lower spine is involved. The symptoms of arthritis include painful, warm, swollen, stiff joints and loss of joint mobility or function.
Crohn's disease may also involve the skin, blood, and endocrine system. One type of skin manifestation, erythema nodosum , presents as red nodules usually appearing on the shins. Erythema nodosum is due to inflammation of the underlying subcutaneous tissue and is characterized by septal panniculitis. Another skin lesion, pyoderma gangrenosum, is typically a painful ulcerating nodule. Crohn's disease also increases the risk of blood clots; painful swelling of the lower legs can be a sign of deep venous thrombosis , while difficulty breathing may be a result of pulmonary embolism. Autoimmune hemolytic anemia, a condition in which the immune system attacks the red blood cells, is also more common in Crohn's disease and may cause fatigue, pallor, and other symptoms common in anemia. Clubbing, a deformity of the ends of the fingers, may also be a result of Crohn's disease. Finally, Crohn's disease may cause osteoporosis, or thinning of the bones. Individuals with osteoporosis are at increased risk of bone fractures.
Crohn's disease can also cause neurological complications (reportedly in up to 15% of patients).The most common of these are seizures, stroke, myopathy, peripheral neuropathy, headache and depression.
Crohn's patients often also have issues with Small bowel bacterial overgrowth syndrome, which has similar symptoms.


Crohn's disease can mimic ulcerative colitis on endoscopy. This endoscopic image is of Crohn's colitis showing diffuse loss of mucosal architecture, friability of mucosa in sigmoid colon and exudate on wall, all of which can be found with ulcerative colitis.
The diagnosis of Crohn's disease can sometimes be challenging, and a number of tests are often required to assist the physician in making the diagnosis. Sometimes even with all the tests the Crohn's does not show itself. A colonoscopy has about a 70% chance of showing the disease and the rest of the tests go down in percentage. Disease in the small bowel can not be seen through some of the regular tests; for example, a colonoscopy can't get there.

  • Endoscopy

A colonoscopy is the best test for making the diagnosis of Crohn's disease as it allows direct visualization of the colon and the terminal ileum, identifying the pattern of disease involvement. Occasionally, the colonoscope can travel past the terminal ileum but it varies from patient to patient. During the procedure, the gastroenterologist can also perform a biopsy, taking small samples of tissue for laboratory analysis which may help confirm a diagnosis. As 30% of Crohn's disease involves only the ileum, cannulation of the terminal ileum is required in making the diagnosis. Finding a patchy distribution of disease, with involvement of the colon or ileum but not the rectum, is suggestive of Crohn's disease, as are other endoscopic stigmata.
Wireless capsule endoscopy is a technique where a small capsule with a built-in camera is swallowed, the camera takes serial pictures of the entire gastrointestinal tract and is passed in the patient's faeces. It has been used in the search for Crohn's disease in the small bowel, which cannot be reached with colonoscopy or gastroscopy.The utility of capsule endoscopy for this, however, is still uncertain.

A small bowel follow-through may suggest the diagnosis of Crohn's disease and is useful when the disease involves only the small intestine. Because colonoscopy and gastroscopy allow direct visualization of only the terminal ileum and beginning of the duodenum, they cannot be used to evaluate the remainder of the small intestine. As a result, a barium follow-through x-ray, wherein barium sulfate suspension is ingested and fluoroscopic images of the bowel are taken over time, is useful for looking for inflammation and narrowing of the small bowel. Barium enemas, in which barium is inserted into the rectum and fluoroscopy used to image the bowel, are rarely used in the work-up of Crohn's disease due to the advent of colonoscopy. They remain useful for identifying anatomical abnormalities when strictures of the colon are too small for a colonoscope to pass through, or in the detection of colonic fistulae.
CT and MRI scans are useful for evaluating the small bowel with enteroclysis protocols. They are additionally useful for looking for intra-abdominal complications of Crohn's disease such as abscesses, small bowel obstruction, or fistulae. Magnetic resonance imaging (MRI) are another option for imaging the small bowel as well as looking for complications, though it is more expensive and less readily available.

  • Blood tests

A complete blood count may reveal anemia, which may be caused either by blood loss or vitamin B12 deficiency . The latter may be seen with ileitis because vitamin B12 is absorbed in the ileum. Erythrocyte sedimentation rate, or ESR, and C-reactive protein measurements can also be useful to gauge the degree of inflammation. It is also true in patient with ilectomy done in response to the complication. Another cause of anaemia is anaemia of chronic disease, characterized by its microcytic and hypochromic anaemia . There are reasons in anaemia, including medication in treatment of inflammatory bowel disease like azathioprine can lead to cytopenia and sulfasalazine can also result in folate malabsorption, etc. Testing for anti-Saccharomyces cerevisiae antibodies (ASCA) and anti-neutrophil cytoplasmic antibodies (ANCA) has been evaluated to identify inflammatory diseases of the intestine and to differentiate Crohn's disease from ulcerative colitis.

The most common disease that mimics the symptoms of Crohn's disease is ulcerative colitis, as both are inflammatory bowel diseases that can affect the colon with similar symptoms. It is important to differentiate these diseases, since the course of the diseases and treatments may be different. In some cases, however, it may not be possible to tell the difference, in which case the disease is classified as indeterminate colitis.


The exact cause of Crohn's disease is unknown. However, genetic and environmental factors have been invoked in the pathogenesis of the disease. Mutations in the CARD15 gene (also known as the NOD2 gene) are associated with Crohn's disease and with susceptibility to certain phenotypes of disease location and activity.

Familial occurrence and inheritance studies in inflammatory bowel disease

Investigation of inheritance of chronic inflammatory bowel diseases by complex segregation analysis

Contribution of genes of the major histocompatibility complex to susceptibility and disease phenotype in inflammatory bowel disease



Recently, research has indicated that Crohn's disease has a strong genetic link. In earlier studies, only two genes were linked to Crohn's, scientists now believe there are over eight genes that show genetics play a crucial role in the disease, although environmental factors also are involved.
Abnormalities in the immune system have often been invoked as being causes of Crohn's disease. It has been hypothesized that Crohn's disease involves augmentation of the Th1 of cytokine response in inflammation. The most recent gene to be implicated in Crohn's disease is ATG16L1, which may reduce the effectiveness of autophagy, and hinder the body's ability to attack invasive bacteria.


Because Crohn's disease occurs more often among people living in cities and industrial nations, it's possible that environmental factors, including a diet high in fat or refined foods, may play a role.
Among the environmental factors:
- Diets high in sweet, fatty or refined foods may play a role.
- Smoking has been shown to increase the risk of the return of active disease, or "flares".
- Methods of hormonal contraception have also shown an association with the development of Crohn's disease.
- People living in Northern climates also seem to have a greater risk of the disease.

A variety of pathogenic bacteria were initially suspected of being causative agents of Crohn's disease. However, the current consensus is that a variety of microorganisms are simply taking advantage of their host's weakened mucosal layer and inability to clear bacteria from the intestinal walls, both symptoms of the disease. Some studies have linked Mycobacterium avium subsp. paratuberculosis to Crohn's disease, in part because it causes a very similar disease, Johne's disease , in cattle. The mannose bearing antigens, mannins, from yeast may also elicit pathogenic anti saccharomyces cerevisiae antibodies. Newer studies have linked specific strains of enteroadherent E. coli to the disease but failed to find evidence of contributions by other species.

Seroprevalence of Helicobacter pylori infection in inflammatory bowel disease:is Helicobacter pylori infection a protective factor?


Role of thrombotic vascular risk factors

Theraphy insight:vascular complications in patients with inflammatory bowel disease


Treatment is only needed for people exhibiting symptoms. The therapeutic approach to Crohn's disease is sequential: to treat acute disease and then to maintain remission. Treatment initially involves the use of medications to treat any infection and to reduce inflammation. This usually involves the use of aminosalicylate anti-inflammatory drugs and corticosteroids, and may include antibiotics.
Once remission is induced, the goal of treatment becomes maintaining remission and avoiding flares. Because of side-effects, the prolonged use of corticosteroids must be avoided. Although some people are able to maintain remission with aminosalicylates alone, many require immunosuppressive drugs.
Surgery may be required for complications such as obstructions, fistulas and/or abscesses, or if the disease does not respond to drugs within a reasonable time. For patients with an obstruction due to a stricture, two options for treatment are strictureplasty and resection of that portion of bowel. According to a retrospective review at the Cleveland Clinic, there is no statistical significance between strictureplasty alone versus strictureplasty and resection specifically in cases of duodenal involvement. In these cases, re-operation rates were 31% and 27%, respectively, indicating that strictureplasty is a safe and effective treatment for selected patients with duodenal involvement.


Crohn's disease is a chronic condition for which there is currently no cure. It is characterized by periods of improvement followed by episodes when symptoms flare up. With treatment, most people achieve a healthy height and weight, and the mortality rate for the disease is low. Crohn's disease is associated with an increased risk of small bowel and colorectal carcinoma.
Crohn's cannot be cured by surgery, though surgery does happen with blockages, whether partial or a full blockage occurs. After the first surgery, the Crohn's usually shows up at the site of the resection though it can appear in other locations. After a resection, scar tissue builds up which causes strictures. A stricture is when the intestines becomes too small to allow excrement to pass through easily which can lead to a blockage. After the first resection, another resection may be necessary within five years of the first surgery.
Many patients will have temporary stoma formations together with possible associated complications.


Crohn's disease can lead to several mechanical complications within the intestines, including obstruction, fistulae, and abscesses. Obstruction typically occurs from strictures or adhesions which narrow the lumen, blocking the passage of the intestinal contents. Fistulae can develop between two loops of bowel, between the bowel and bladder, between the bowel and vagina, and between the bowel and skin. Abscesses are walled off collections of infection, which can occur in the abdomen or in the perianal area in Crohn's disease sufferers.
Crohn's disease also increases the risk of cancer in the area of inflammation. For example, individuals with Crohn's disease involving the small bowel are at higher risk for small intestinal cancer . Similarly, people with Crohn's colitis have a relative risk of 5.6 for developing colon cancer. Screening for colon cancer with colonoscopy is recommended for anyone who has had Crohn's colitis for eight years, or more.
Individuals with Crohn's disease are at risk of malnutrition for many reasons, including decreased food intake and malabsorption. The risk increases following resection of the small bowel. Such individuals may require oral supplements to increase their caloric intake, or in severe cases, total parenteral nutrition (TPN). Most people with moderate or severe Crohn's disease are referred to a dietitian for assistance in nutrition.

Effect of exclusion diet with nutraceutical therapy in juvenile Crohn's disease. 2009

Most moderate-severe juvenile Crohn's disease (CD) patients are in a constant catabolic state resulting in poor weight gain and growth failure. Anti-inflammatory, immunomodulatory, and monoclonal antibody drugs, as well as growth hormone (GH), frequently fail to achieve sustained remission or reverse growth failure.
To test whether an exclusion diet with nutraceutical therapy (DNT) could induce sustained clinical remission and weight gain, and if so does this enhance the ability for GH to reverse growth failure.

An uncontrolled prospective case study was undertaken in six moderate- severe CD patients, two of whom had completed growth. All were treated with DNT. Adequate caloric and protein ( >or= 3g/kg/d) intake for catch up weight was prescribed. Dairy products, certain grains and carrageenan containing foods were eliminated. Nutraceuticals, consisting of fish peptides, bovine colostrum, boswellia serrata, curcumin and a multivitamin were administered daily. Lactobacillus GG, a probiotic, was administered twice weekly. Recombinant human GH (rhGH) was administered daily.

Within 2 months of starting DNT all six patients went into remission, with discontinuation of all pharmacological drugs. Three patients have remained in sustained remission for 4 to 8 years. One patient with very severe CD had recurrence of CD symptoms after being in complete remission for 18 months, one patient was in remission for 3 years but symptoms recurred when she became less compliant to DNT and one recently treated patient remains in remission after 6 months. With the addition of rhGH, the 4 growing patients had good-excellent growth response

DNT engendered prolonged remission and restoration of normal weight in moderate-severe juvenile CD patients, providing conditions that enabled rhGH to stimulate growth. These findings justify larger controlled trials to evaluate the long-term benefit of compliance to DNT in both juvenile and adult CD patients.

2012-02-21T22:32:54 - vanessa giacometti


Diet sometimes is not consider important in this disorder but it cuold be consider as effective as drugs in acute fase of disease.
Nutritional treatment was initially included in the management of Crohn’s disease because patients are often poorly nourished as a result of reduced intake and hypercatabolism. Total parenteral nutrition has been used to induce remission in this disease on the basis that it “rest the bowel”. We belive that Crohn’s disease consist of two main components: an underlying predisposition to ulceration of the gut, and a secondary immunological reaction to the passage of large amounts of foreign protein through the damage gut wall. In an attempt to treat this secondary aspect C. O. Morain, A. W. Segal and A. J. Levi gave patients an elemental diet which contains all essential nutrients but is free of all protein, nitrogen being supplied in the form of amino acids. The result were encouraging enough to warrant a prospective controlled trial of the efficacy of the treatment. They report the results of that trial, in which the therapeutic effect of an elemental diet as sole treatment of acute Crohn’s disease was compared with the response to prednisolone, the most effective conventional treatment. Crohn’s disease was diagnosed on the basis of the typical clinical and radiological features and diagnostic or compatible histological findings. The disease was cosidered to be in an active phase if the patient had a least of one either weight loss of more than 2 kg in the previous month, diarrhoea (three or more loose stools a day) abdominal pain resulting in severe limitation of activiy, abdominal wall or perianal fistulas, or a temperature exceeding 38°C for one week or if at least two of the following laboratory measurements were abnormal: haemoglobin concentration (<12.5 g/dl in men, <10.5 g/dl in women) erythrocyte sedimentation rate (> 20 mm in first hour), and serum albumin concentration (<35 g/l). Patients must not have received specific treatment in the past and were excluded if they had contraindications to the use of prednisolone. Any patient whose condition deteriorated to an extent that necessitated a change of treatment, as judged by two physicians, was withdrawn. Twenty one patients (14 men, 7 women) were admitted to the trial. All were ill enough to require hospital admission. Rectal biospsy specimens were characteristic in four and compatible with the diagnosis of Crohn’s disease in another four, in whom there were also relevant clinical and radiological features. Thirteen had the characteristic radiological apparances and clinical pictures of Crohn’s disease. All the patients had abdominal pain and diarrhoea, accompained by weight loss in 17. Eight patients had had a fever of 38°C for one week. All had a sedimentation rate greater than 20 mm in the first hour, 12 had a haemoglobin concentration of less than 12.5 g/dl (men) or 10.5 (women), and 13 had a serum albumin concentration of less than 35 g/l. After initial inpatient assessment the patients were allocated at random to one of two treatment groups. Ten were trated with prednisolone 0.75 mg/kg body weight daily for two weeks and then with reduced dosages as clinically appropriate. Eleven were treated with an elemental diet whereby all food except tea and coffe (without milk) was withdrawn and repleced with Vivonex, supplying 150-250 hJ (40-60 kcal)/kg body weight and 8-12 g of nitrogen daily. The concentration of the elemental diet was gradually increased from one third to the full recommended strength over three days to reduce side effects such as diarrhoea and abdominal colic, which occurs beacause the preparation is hyperosmolar (600 mmol). After four weeks normal food was gradually reintroduced, its consistency being increased from fluid to solid over three days. Treatment was institued in hospital but all the patients were allowed home once they had improved clinically.
Clinical symptoms and laboratory values were assessed before treatment and at weekly intervals for four weeks and then at three months. Clinical severity was quantified using prearrange scoring system based on the five items of the “simple activity index.” General wellbeing was noted as excellent, fair with no limitation of activity, poor with some limitation of activity, or very poor with considerable limitation of activity and assigned corresponding scores of zero to three. Numbers of liquid stool were recorded as fewer than three, three to five, and more than five a day and assigned corresponding scores of zero to two. Abdominal mass was noted as absent, dubious of definite and scored zero to two. Abdominal tenderness was also looked for and scored as mild (one), moderate (two), or severe (three). Complication affecting eyes, joints, skin, or fistuals were scored as one per item. The sum of these scores was called the clinical score. The higher the score the more active was the disease, and negative changes meant clinical improvement. Subsequent values were compared with baseline using Student’s t test for each group. The changes in values obtained for both groups were compared with one another by one way analysis of variance. Of the 21 patients, seven were women, of whom five were randomised to receive steroid treatment. Two patients in each treatment group were withdrawn from the study. One of these developed a steroid psychosis, and another failed to improve clinically and developed toxic megacolon. In another two cases the patients could not tolerate the elemental diet by mouth. All four patients were withdrawn in the first 10 days of treatment. Eight of the 10 steroid treated and nine of the 11 dietetically treated patients were considered to be in remission at four weeks. At three months one patient in each group was considered to be a treatment failure. Of these, the patient in the steroid treated group relapsed with symptoms as severe as on first entry to the trial and was successfully treated with an elemental diet. The other patient presented with symptoms of a free perforation two days after returning to whole food. Both groups showed similar highly significant reductions in their average clinical scores within a week, and this improvement continued throughout. There were no significant differences in the rate or degree of improvement between the two groups. Body weight also showed a consistent upward trend for the steroid treated group, but the dietetically treated group diverged significantly (p<0.05) from this pattern by the end of treatment and after three months. At that time, however, patients in the drug treatment group were still taking 10-20 mg prednisolone daily, whereas those in the other group were receiving no specific treatment. Haemoglobin concentration showed a small but significant rise by the fourth week of treatment, but at three months this was maintained only in patients given the elemental diet. Both groups showed a significant rise in serum albumin concentrations, but rises were greater in the dietetically treated group. There was a significant and comparable fall in the sedimentation rate in the two groups. This paper reports on the first controlled trial of an elemental diet in the treatment of acute Crohn’s disease, and the results show that the diet was as effective as steroids in inducing a remission: 80% of the patients in both groups were in remission by four weeks. They think it unlikely that the changes in these patients resulted from a placebo effect or simply admission to hospital. It was thought to be inappropriate to withhold treatment from these acutely ill patients, and therefore a placebo group was not included. In the national cooperative Crohn’s disease trial only 30% of patients given placebo went into remission. In another controlled trial the placebo treated group showed the same degree of disease activity after 16 weeks as they did at the outset. It is most unlikely that the therapeutic effect observed in this series was due to bed rest alone, as the median stay in hospital for both groups after beginning treatment was 12 days.
Response to treatment was monitored by a simple activity index in preference to the Crohn’s disease activity index proposed by the National Cooperative Crohn’s Disease Group. A similar simple activity index was used in three other controlled trials. The Crohn’s disease activity index depends largely on subjective variables such as general wellbeing and pain, each given different weightings, and includes as the sole laboratory investigation measurement of the packed cell volume, which bears little relation to disease activity. Concentrations of acute phase proteins, serum albumin value, and sedimentation rate are more reliable laboratory indices of disease activity. The simple index correlates well with the complex Crohn’s disease activity index. Other reports of the use of elemental diet in Crohn’s disease were uncontrolled and anecdotal. The principal difficulty of using an elemental diet is its unpalatability. But with encouragement from dietetic, nursing, and medical staff the patients do adapt, particularly when they note subjective improvement, and only two of our patients were unable to tolerate the diet; one of these was given a nasogastric line. We have monitored other patients receiving an elemental diet for six to 12 months. Although the products cost between £9 and £13 a day, the clinical improvement, greater wellbeing, and productivity of the patient provide an excellent cost: benefit ratio. Nutritional improvements are unlikely to be responsible for alleviating the symptoms of Crohn’s disease because clinical improvement starts long before positive nitrogen balance develops. Alterations in bacterial flora in the gut lumen do occur in patients taking an elemental diet, and this might have a beneficial effect. We have been unable to find any difference in faecal flora before and after treatment. The nitrogen source of Vivonex is simple amino acids. By contrast, other liquid diets contain peptides with variable length chains, and all contain come oligopeptides, which may be allergenic. Vivonex may be beneficial in one or two ways: as the components of the diet are absorbed mainly in the upper small bowel, it may act simply as a medical bypass, preventing the dietary contents and digestive enzymes having access to the inflamed, ulcerated gut, Alternatively there may be a secondary immune reponse in Crohn’s disease to exogenous protein which gains access to the gut wall through the ulcerated mucosa. This is likely because antibodies to a wide range of foreign proteins are detectable in the serum of these patients. Possibly this inflammatory immune response to exogenous protein perpetuates chronic inflammation of areas in which the mucosa is breached by acute insults which would otherwise resolve spontaneously. Elemental dietary treatment of acute exacerbations Crohn’s disease offers a therapeutically effective non-toxic alternative to conventional surgery and drugs. It merits serious consideration as the treatment of choice of acute Crohn’s disease.

Another study conducted by Teahon K, Smethurst P, Pearson M, Levi AJ, Bjarnason from Medical Research Council Clinical Research Centre, Harrow, Middlesex, England, confirmed that elemental diet is important for inflammation and also intestinal permeability.
This study examines whether treatment of acute Crohn's disease with an elemental diet improves intestinal integrity and inflammation as assessed by a 51Cr-labeled ethylenediaminetetraacetatic acid (EDTA) permeability test and the fecal excretion of 111In-labeled autologous leukocytes, respectively. Thirty-four patients with active Crohn's disease completed a 4-week treatment course with an elemental diet. Active disease was characterized by increased intestinal permeability [24-hour urineexcretion of orally administered 51Cr-EDTA, 6.4% +/- 0.6% (mean +/- SE); normal, less than 3.0%] and by high fecal excretion of 111In-labeled leukocytes (14.2% +/- 1.1%; normal, less than 1.0%). Twenty-seven (80%) went into clinical remission, usually within a week of starting treatment. After 4 weeks of treatment, there was a significant decrease in both the urine excretion of 51Cr-EDTA (to 3.4% +/- 0.5%; P less than 0.01) and the fecal excretion of 111In (to 5.7% +/- 1.0%; P less than 0.001), indicating that such treatment is not just symptomatic. A framework for the mechanism by which elemental diet works, centering around the importance of the integrity of the intestinal barrier function, is proposed, and also appears to provide a logical explanation for some relapses of the disease

Diet is not only important during the acute fase. Thirty-two patients with Crohn’s disease were treated with a fibre-rich, unrefined-carbohydrate diet in addition to conventional management and followed for a mean of four years and four months. Their clinical coursa was compared retrospectively with that of 32 matched patients who had received no dietary instruction. Hospital admission were significantly fewer and shorter in the hospital compared with 533 days in the non-diet-treated control group. Whereas five of the controls required intestinal operation, only one diet-treated patient needed surgery. This is in strong contrast to general experience with this disease. Treatment with a fibre-rich, unrefined-carbohydrate diet appears to have a favourable effect on the course of Crohn’s disease and does not lead to intestinal obstruction.

Diet is also involved in maintenance of remission.
Twenty patients with Crohn's disease took part in a controlled trial in which remission was maintained by either an unrefined carbohydrate fibre rich diet or a diet which excluded specific foods to which a patient was intolerant. 7 out of the 10 patients on the exclusion diet remained in remission for 6 months compared with none out of the 10 on an unrefined carbohydrate fibre rich diet (p<0•05, Fisher's exact test). In an uncontrolled study an exclusion diet allowed 51 out of 77 patients to remain well on the diet alone for periods of up to 51 months, and with an average annual relapse rate of less than 10%.
The incidence of Crohn’s disease is increasing in industrialised nations, but the condition is almost unknown is developing countries. Food is major factor affecting the intestinal environment, and the considerable change in dietary habits during this century may explan why Crohn’s disease has become more common. In 1976 workes in Marburg and Düsseldorf reported that before developing Crohn’s disease patients had eaten more refined sugar and food containing it than matched controls. In these studies dietary data were collected up to 12 years after diagnosis. It is doubtful whether people recall their eating habits of many previously with any accuracy. Furtheromore, neither study included information on dietary fibre, although a low-fibre diet has been suggested as causal factor. In view of continuing ignorance about the cause of Crohn’s disease, J. R. Thornton, P. M. Hemmet and K. W. Eaton decided to investigate the possible role of dietary fibre and at the same time to see if these German result could be confirmed with improved methods. Thirty consecutive newly diagnosed patients was studied. The diagnosis of Crohn’s disease was made by experience gastroenterologists and supported by tipical radiogical changes and often by histological examination of tissue. All patients were interviewed within three months of diagnosis. The median duration of symptoms before diagnosis was five months. A single dietitian used the dietary history method to question each patient about his or her habitual, pre-illess diet. Using a specially designed questionnaire, she determined the frequency of consumption and the size of helpings of each of a comprehensive range of food and drinks. Special care was taken with items containing refined sugar or dietary fibre. Refined sugar was defined as any fibre-depleted sugar, including brown sugar. These data were analysed by computer, using a programme specially compiled from the recent edition of McCance and Widdowson’s food tables, to determine the average daily intake of different food components. These tables are the first to contain values for dietary fibre as opposed to crude fibre, which is an accurate measurement. Control subject were otherwise healthy people who had recently attended the fracture clinic with minor fractures or orthopaedic conditions. They were matched for age ( 5 years), sex, social class, and marital status, and were closely similar to the patients in height and weight. The controls were interviewed about their diet in the same manner as the patients. Neither group was informed of the purpose or possible findings of the study. The statistiscal significance of differences was calculated by Student’s t test or the Wilcoxon rank sum test for paired data, as appropriate. The patients’ intake of refined sugar (median 122 g/day) was considerably grater than the controls’ (median 65 g/day, P <0.002; fig 1). Table II shows that the patients consistently took more sugar in both food and drinks. Intake was higher in both sexes and with all sites of disease. Sugar consumption was similar in patients whose symptoms had lasted for more and less than 12 months before diagnosis (median 112 and 128 g/day respectively). The patients ate more carbohydrate than the controls but this difference was almost entirely due to their greater consuption of sugar. The two groups ate almost identical quantities of protein and fat. Dietary fibre intake in the patients (17.3  0.6 g/day) slightly lower than in the control (19.2  0.9 g/day, P < 0.05), and the patients ate considerably raw fruit and vegetable fibre (median 0.6 g/day * 2.3 g/day in controls; P < 0.001). As with sugar, this finding was independent of sex, the site of disease, or the duration of symptoms. Thus median raw fibre intakes in patients who had had symptoms for more and less than 12 months before diagnosis were 0.6 and 0.7 g/day respectively. Intakes of cereal fibre and cooked fruit and vegetable fibre were similar in patients and controls. There was no significant difference in the drinking of alcohol or the consumption of conrflakes. This study confirm that people who develop Crohn’s disease habitually eat more refined sugar than healthly people and also shows that they eat less raw fruit and vegetables. Data should be more reliable than those from previous studies since they are derived from newly diagnosed patients. Moreover, the patients’ symptoms were usually of only a few months’ duration. The differences are unlikely to be due to atypical dietary habits in the control subject. Their median sugar intake of 65 g/day is identical to that obtained in a recent survey of randomly selected, Cambridgeshire villagers, using weighed measurements of food intake (when adjusted to the appropriate sex ratio). The National Food Survey estimated that the average refined sugar intake of the British population is 79 g/day. Similarly, dietary fibre intake averaged 19.9 g/day in the villagers and 20.4 g/day in the National Food Survey, whereas our controls are 19.2 g/day. It might be argued that patients may gradually modify their diets in the months and years before their symptoms become troublesome, eating more sugar to try and counteract weight loss or lassitude and eating less raw food to counteract loose stools. But the data do not support this suggestion. There was no difference in the intake of sugar or of raw fruit and vegetables between patients with recent and longer-lasting symptoms. The German studies found that after the onset disease patients ate less, not more, sugar. These eating habits therefore seem to precede the disease. Data lend some support to suggestions that the development of Crohn’s disease is favoured by a low intake of dietary fibre. The difference in total fibre intakes was relatively slight (and there was no difference in cereal fibre), but there was a pronounced difference in the consumption of fibre from raw fruit and vegetables. This is consistent with the idea that a low intake of raw fruit and vegetables is a causal factor. It has been reported that patients with Crohn’s disease eat signifantly more cornflakes at breakfast than controls. In common with three other studies, this study could not confirm this finding. How eating habits, such as those identified in this study, predispose to Crohn’s disease is uncertain and will remain so until the pathogenesis of the disease is understood. A role for diet does not exclude the involvement of a virus or bacterium. Dietary influences may alter the milieu of the intestinal lumen of modify the intestinal flora and so promote the growth of an infective agent or its invasion of the gut wall. The dietary tendencies shown in this study may help to explain the recent emergence of the disease and its rarity in communities eating simple, traditional diets. At a pratical level, reversing these eating habits might be helpful in the management of this intractable condition.

The Lancet, Volume 326, Issue 8448, Pages 177 - 180, 27 July 1985
Gastroenterology. 1988 Mar;94(3):603-10.
Gastroenterology. 1981 Jan;80(1):10-5.
British Medical Journal, Volume 288.

2011-06-14T21:05:50 - Annamaria Vernone

Mycobacterium avium subsp. paratuberculosis, Genetic Susceptibility to Crohn's Disease, and Sardinians: the Way Ahead [Journal of Clinical Microbiology, October 2005]

The present study was performed to determine what proportion of people in Sardinia with or without Crohn's disease were infected with Mycobacterium avium subspecies paratuberculosis and had a preponderance of allelic variants of Nod2, an intracellular protein involved in Crohn's disease susceptibility.

Detection and Isolation of Mycobacterium avium subspecies paratuberculosis from intestinal mucosal biopsies of patients with and without Crohn's disease in Sardinia.[Am J Gastroenterol. 2005 Jul;100(7):1529-36]

Sardinia is an island community of 1.6 million people. There are also about 3.5 million sheep and one hundred thousand cattle in which Johne's disease and Mycobacterium avium subspecies paratuberculosis infection are endemic. The present study was designed to determine what proportion of people in Sardinia attending for ileocolonoscopy with or without Crohn's disease were infected with this pathogen.

2008-03-22T15:12:47 - Gianpiero Pescarmona

ursodeoxycholic and silimarin?

ursodeoxycholic acid and Crohn's disease

Inflamm Bowel Dis. 2010 Mar;16(3):518-24.
Potential for amino acids supplementation during inflammatory bowel diseases. 2010
Coëffier M, Marion-Letellier R, Déchelotte P.

Appareil Digestif Environnement Nutrition (ADEN EA4311), Institute for Biomedical Research, European Institute for Peptide Research (IFRMP 23), Rouen University and Rouen University Hospital, Rouen, France.
The pathophysiology of inflammatory bowel diseases (IBDs) is multifactorial and involves interactions of gut luminal content with mucosal barrier and especially immune cells. Malnutrition is a frequent issue during IBD flares, especially in Crohn's disease (CD) patients, and nutritional support is frequently used to treat malnutrition but also in an attempt to modulate intestinal inflammation. The use of oral or enteral nutrition intervention in IBDs may be effective, alone or in combination with drugs, to achieve and maintain remission. However, standard diets are less effective than new-generation biotherapies and could be improved by supplementation with specific immunomodulatory amino acids. Experimental studies evaluating glutamine, the preferential substrate for enterocytes, are promising. Some clinical studies with oral glutamine in CD are until now disappointing, but new formulations and targeting could enhance glutamine efficacy at the site of mucosal lesions. The role of arginine, involved in nitric oxide and polyamines synthesis, still remains debated. However, the effects of these amino acids in IBD have been poorly documented in humans. Other candidates like glycine, cysteine, histidine, or taurine should also be evaluated in the future.

Morbo di Crohn, stenosi e ostruzioni ricorrenti
Fra i pazienti con morbo di Crohn che vengono sottoposti ad intervento chirurgico per la comparsa di stenosi, il numero di stenosi e di plastiche effettuate può predire la probabilità di ostruzioni recidivanti. Questa osservazione si deve probabilmente a fattori correlati alla malattia. La presenza di un maggior numero di stenosi intestinali di per sé non porta ad un aumento delle recidive delle ostruzioni, ma probabilmente rappresenta un marcatore della presenza di una forma patologica più grave o avanzata. E' necessario approfondire gli studi per comprendere meglio le ragioni alla base di queste associazioni, ed identificare potenziali interventi per ridurre i tassi di recidiva. (J Am Coll Surg 2009; 208: 1065-70)

Crohn per 60mila italiani. Molti i giovani
Morbo di Crohn, una patologia cronica infiammatoria del tratto gastrointestinale che colpisce un milione di persone in Nord America e in Europa, compresi 60mila italiani. Di questi, 35mila devono fare i conti con forme gravi. Ne sono affetti individui di tutte le età, ma in particolare il Crohn riguarda i giovani adulti: solitamente i primi sintomi si avvertono prima dei 40 anni. Si tratta di diarrea, crampi e dolori addominali ricorrenti, accompagnati da perdita di peso, febbre e in alcuni casi emorragie. Tra le complicazioni l'ostruzione intestinale, fistole e denutrizione. Durante il decorso della malattia il 75% dei pazienti va incontro a un intervento chirurgico causato da tali complicazioni o dalla resistenza alla terapia. Dei malati che sono costretti ad affrontare un'operazione per rimuovere una parte dell'intestino, circa la metà registra una ricaduta nel corso dei cinque anni successivi. Numeri non certo tranquillizzanti, che hanno spinto alcuni dei più eminenti esperti italiani a riunirsi per un incontro, organizzato a Parigi, dal titolo "Crohn's Diseases: Achieving Patients' Benefits": in breve, come ottenere benefici per i pazienti. E per ora la risposta è: con i farmaci, soprattutto, per tenere a bada i sintomi. Perché a oggi non esistono soluzioni terapeutiche definitive. "Si può dire che la comunità scientifica, di fronte a questa malattia - ha detto ai giornalisti intervenuti all'evento Francesco Pallone, presidente della Società italiana di Gastroenterologia - si trovi ancora ai tempi della preistoria. Sappiamo che le cause sono genetiche, ma è solo da poco tempo che abbiamo compreso il meccanismo di insorgenza del Crohn: quando si è scoperto che l'Helicobacter pylori causa l'ulcera, era diventato di gran moda tentare di trovare lo stesso tipo di stimolo patologico che potesse trovarsi alla base del morbo di Crohn".

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