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Crohn's Disease: Western and Oriental Perspectives, Part II

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Crohn's Disease: Western and Oriental Perspectives, Part II CROHN’S DISEASE I. Western Medical Designations and Treatment I.A. Nosology Crohn’s disease (also called Crohn syndrome and regional enteritis) is a type of inflammatory bowel disease (I.B.D.) that can affect any aspect of the gastrointestinal (G.I) tract, from mouth to anus. Diagnosis depends on differentiation from other types of I.B.D., including ulcerative colitis (U.C., which pairs with Crohn’s to represent the principle types), collagenous colitis, lymphocytic colitis, diversion colitis, Behcet’s disease, and indeterminate colitis. Crohn’s disease itself can be differentiated into sub-types, either based on the specific tract region affected, or based on the behavior of the disease as it progresses. In terms of regions affected, ileocolitis is a disease of both the ileum (the terminal end of the small intestine) and the large intestine; meanwhile, ileitis manifests in the ileum only; and Crohn’s colitis occurs in the large intestine only. In rare cases, Crohn’s affects only the upper small intestine and the stomach: gastroduodenal Crohn’s affects the stomach and duodenum (the proximal end of the small intestine), and jejunoileitis affects the jejunum (the region between the duodenum and ileum). Three categories of disease presentation in the progression of Crohn’s are as follows: stricturing, penetrating, and inflammatory. “Stricturing” refers to the narrowing of the bowel, which can lead to obstruction. “Penetrating” refers to the creation of abnormal passageways (fistulae) between the bowel and other structures, like the skin. “Inflammatory” indicates inflammation in the absence of strictures or fistulae. I.B. Epidemiology Studies have shown Crohn’s disease to affect about 3 out of every 1,000 people in Europe and North America. There are estimates of 780,000 Americans currently living with Crohn’s, and an additional 33,000 cases are diagnosed yearly. Rates have been increasing in recent decades, especially in the developed world. The disease is thought to be more prevalent in northern countries, especially those of Europe and North America. Rarely diagnosed in childhood, Crohn’s disease, like U.C., begins most commonly between the ages of 15-35. The disease is only slightly more prevalent in women than in men. There is a clear genetic predisposition to Crohn’s: parents, siblings, or children of people with the disease are 3 to 20 times more likely to also have the disease. Crohn’s sufferers have a slightly reduced life expectancy. © Ryan Gallagher, L.Ac. 2015 Within the community of Crohn’s patients, about half suffer from the ileocolic sub-type, while 30% are affected by ileitis, and 20% by colitis. Though the disease can attack any part of the digestive tract, regions above the lower small intestine are almost always affected in conjunction with the ileum and/or colon. I.C. Definition Crohn’s disease is a type of I.B.D. that can affect any part of the G.I. tract, from mouth to anus. Signs and symptoms include abdominal pain, diarrhea (potentially with blood), fever, weight loss, anemia, skin rashes, arthritis, eye inflammation, and fatigue. The disease is named after gastroenterologist Burrill Bernard Crohn, of New York’s Mt. Sinai Hospital, who outlined the nature of the disease in 1932. Crohn, along with two colleagues, published a case series called “Regional ileitis: a pathologic and clinical entity.” I.D. Etiology & Pathophysiology Crohn’s disease is immune-related: the body’s immune system is attacking the G.I. tract. The exact nature of the immune problem is unclear, but the latest research suggests that this does not seem to be a classic autoimmune condition (where the immune system is being triggered by the body itself); rather, environmental and bacterial factors are considered the primary triggers for the inflammatory response, and immunodeficiency seems to add to the gastrointestinal chaos. In other words, gut immunity is having difficulty differentiating self from other, and external pathogens are taking up residence, further inflaming the situation. Over time, structural damage occurs to tissues of the G.I. Crohn’s often features a transmural pattern of inflammation of the colon; this means the inflammation can span the entire depth of the intestinal wall. Ulceration is found in highly active forms of the disease. Patterns known as “skip lesions” are characteristic of Crohn’s; these patterns feature abrupt transitions between unaffected tissue and ulcerated tissue. Other characteristic pathophysiological features of Crohn’s are: a cytokine response associated with T-helper cell 17 (as opposed to the response of T-helper cell 2 in ulcerative colitis); granulomas (aggregates of macrophage derivatives known as giant cells); and chronic mucosal damage, which can manifest as blunting of the intestinal villi, atypical branching of the crypts, or change in tissue type (metaplasia). There’s some speculation that Crohn’s is not one disease, but an umbrella of diseases related to different pathogens (both microbial and environmental). This line of thinking is mainly bolstered by the discoveries of many different types of bacteria that have been linked to the disease. At the same time, underlying weakness is essential to this theory: the host’s mucosal layer is compromised and the immune system is unable to clear bacteria and pathogens from the intestinal walls. © Ryan Gallagher, L.Ac. 2015 I.E. Risk Factors About half of the risk of developing Crohn’s disease is related to genetics, with more than 70 genes found to be involved. The increased incidence of Crohn’s disease in the developed world suggests an environmental component. The disease has been associated with increased intake of animal and milk proteins (while those who consume more vegetable proteins have been shown to have less tendency toward developing the disease). Tobacco smokers are twice as likely as non-smokers to develop Crohn’s. The disease often begins after gastroenteritis. Lastly, there is some concern that the uptick in Crohn’s cases, beginning in the 1960s, has meaningfully correlated with the introduction and growth of hormonal contraception. I.F. Symptomatology Abdominal pain and diarrhea are the two most common features of Crohn’s. The nature of the diarrhea hinges on the affected intestinal region: ileitis tends to result in copious, watery stool; colitis tends to feature a smaller volume but a higher frequency. Blood in the stool is less common than in U.C., but may be seen in colitis. Other GI-related symptoms include: flatulence and bloating; itchiness or pain around the anus; perianal skin tags; fecal incontinence; and non-healing sores of the mouth. In rare cases, the throat and stomach are affected in Crohn’s; such cases might feature dysphagia, epigastric pain, and vomiting. Systemic symptoms include fever; weight loss (due either to loss of appetite or malabsorption of carbohydrates and/or lipids); and retardation of growth in children. Other organs can also be affected by Crohn’s, including the eye (blurred vision, pain, and loss of vision); the gallbladder (gallstones); the joints (arthritis); and the skin (raised nodules or ulcerating lesions). Crohn’s also increases the risk of blood clots (as in deep venous thrombosis or a pulmonary embolism) and anemia. Furthermore, Crohn’s can cause neurological complications, such as seizures, stroke, myopathy, peripheral neuropathy, headache, and depression. I.G. Differential Diagnosis One must differentiate Crohn’s disease from the following: ulcerative colitis; collagenous colitis; lymphocytic colitis; diversion colitis; Behcet’s disease; indeterminate colitis; amebiasis; appendicitis; intestinal carcinoid tumor; celiac disease; diverticulitis; gastroenteritis; giardiasis; intestinal tuberculosis; ischemia; tuberculosis; yersiniosis; lymphoma; amyloidosis; actinomycosis; histoplasmosis; and carcinoma of the cecum. © Ryan Gallagher, L.Ac. 2015 I.H. Diagnosis Colonoscopies are roughly 70% effective in diagnosing Crohn’s disease; diagnosis becomes more difficult the more proximal the affected region is, since colonoscopy allows access only to the colon and the lower portions of the small intestine. Patchy distribution of the disease (“skip lesions”) over the colon or ileum, but not the rectum, suggests a positive Crohn’s finding. X-rays can be useful when the disease solely involves the small intestine. Barium enema can be effective in identifying anatomical abnormalities (strictures and fistulae). CT and MRI scans can also add information to the diagnostic process. Lastly, blood tests can reveal anemia; assess the degree of inflammation; and isolate the presence of antibodies that serves to differentiate Crohn’s from U.C. I.J. Prognosis & Complications Crohn’s is a chronic condition without a cure. It is characterized by periods of remission and flare-ups. The disease can vary from benign to severe, and many sufferers can remain disease-free for years or decades; most with Crohn’s live a normal lifespan. In cases where remission is possible, western biomedicine recommends using medication, as well as lifestyle and dietary changes (including eating a balanced diet; eliminating trigger foods; eating small meals frequently; avoiding smoking; and practicing healthy sleep hygiene and regular exercise) to heal and prevent relapse. Long-term antibiotics are generally considered effective in Crohn’s (while not in U.C.). Anti-inflammatories like aminosalicylates and corticosteroids are used to reduce inflammation. Iron is administered in cases of anemia. A core complication of Crohn’s is structural abnormality (such as strictures, fistulae, and abscesses). In cases of partial or full blockage of the intestine, surgery is required. However, the disease often recurs at the site of the resection; also, scar tissue usually builds up at the resection site, which can cause strictures and thus blockage. Other potential complications of surgery include short bowel syndrome (SBS) and bile acid diarrhea. Crohn’s disease also increases the risk of cancer in the inflamed regions. Lastly, it can cause complications in pregnancy for both fetus and mother. © Ryan Gallagher, L.Ac. 2015 II.
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