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The gastrointestinal tract, folded neatly within the abdomen, is about 30 feet long. That’s almost nearly three stories from one end to the other. Humans, to put it simply, have a whole lot of digestive system, most of which—about 22 feet—is dedicated to the difficult, complex job of breaking down and absorbing nutrients. This might lend some perspective into Crohn’s disease, an often painful, sometimes debilitating inflammatory disease that can evolve the entire digestive system. It’s not an easy condition to have or to treat, but medical science is continually finding new ways to keep Crohn’s symptoms in check.
What is Crohn's disease?
Crohn’s disease (CD) is an inflammatory condition of the digestive tract. Along with ulcerative colitis (UC), Crohn’s disease is an inflammatory bowel disease (IBD) marked by inflammation caused by an inappropriate response by the immune system.
In ulcerative colitis, the inflammation is limited to the inner lining of the colon, with involvement of just the rectum in some cases, and the entire colon in other cases, and anywhere in between. The inflammation caused by Crohn’s disease, however, can spread deep into digestive system tissues, and the inflammatory response can unpredictably target any part of the digestive system from the mouth to the anus. The most common inflammation site is the lower part of the small intestine (ileum) and the colon, but the mouth, esophagus, upper small intestine, and anus can also be subject to inflammation. In half of all patients, Crohn’s affects both the small bowel and the colon.
Crohn’s disease (named after Dr. Burrill B. Crohn, who first described the disease in 1932), also called ileitis or regional enteritis, follows an unpredictable cycle of relapses and remissions. Each relapse can cause pain, diarrhea, malnutrition, and weight loss. Inflammatory relapses usually target specific areas of the intestines, leaving other areas untouched and healthy.
Over time, the damage Crohn’s inflicts on the intestinal tissues can lead to complications such as infections, abscesses, tunnels (fistulae), obstruction (stricturing), holes (perforations), and intestinal or colorectal cancer. Crohn’s patients are also at a higher risk for osteoporosis, anemia, blood clots, and depression. However, Crohn’s disease is only rarely fatal, but Crohn’s patients have a slightly higher mortality rate because of the risk of cancer or infections.
In 25-40% of all patients, Crohn’s also causes problems outside the digestive system, particularly the skin and eyes. One out of four patients first notices there’s a problem when the disease manifests outside the digestive system.
Researchers haven’t found the cause of Crohn’s disease. The major risk factor is genetic—one in five people diagnosed with Crohn’s have a relative with IBD. Scientists believe that active flare-ups are induced by an environmental trigger such as a microorganism, food, or some other substance that fires up the immune system. They have not been able to find specific triggers, but they have recognized risk factors such as smoking, oral contraceptives, NSAIDs (nonsteroidal anti-inflammatory drugs such as aspirin), and pregnancy.
The National Institutes of Health estimate that half a million people in the U.S. have Crohn’s disease. Most are first diagnosed with the condition between the ages of 15 and 35, but a surprisingly high number of people are first diagnosed in their 50’s or 60’s.
There is no cure for Crohn’s disease. However, several treatments can manage the symptoms of a flare-up, induce remission faster, and keep relapses at bay.
How is Crohn's disease diagnosed?
The diagnosis of Crohn’s disease is based on endoscopic examination of the small and large intestine, imaging, and biopsy. Most patients will first bring their problem to a general practitioner, but the final diagnosis and management of the condition will be performed by a gastroenterologist, a doctor who specializes in diseases of the digestive system.
People usually first seek help during an active flare-up. The red flag symptoms of Crohn’s in its active phase are:.
- Abdominal pain
- Diarrhea (particularly if it occurs at night)
- Reduced appetite
- Blood in the stools
- Lesions around the anus
- Weight loss
- Fatigue
- Fever
These symptoms can typically last for months if left untreated.
A medical history, physical exam, and lab tests are used to indicate if a diagnosis of Crohn’s is worth pursuing. The medical history can help identify the signs of Crohn’s, rule out other conditions, and identify any manifestations of the disease outside the digestive system. A physical examination and vital signs that will help the doctor determine how stable the patient is. Blood tests will be performed to test for infections, anemia, or nutritional deficiency. Fecal tests may be used to identify blood in the stool, rule out possible infections, and identify a substance, calprotectin, that typically signifies active Crohn’s disease.
The definitive method for diagnosing Crohn’s disease is to examine the tissues of the intestines through endoscopy/colonoscopy, CT or MRI imaging, and microscopic analysis of a tissue sample (biopsy). .
To view the digestive tract, the doctor will either rely on a colonoscopy, enteroscopy, or capsule endoscopy. In a colonoscopy, the doctor inserts a tube into the colon to examine the lining of the colon for signs of Crohn’s. An endoscope is inserted through the mouth and allows the gastroenterologist to view the lining of the stomach and first part of the small intestine. For capsule endoscopy, the patient swallows a pill-sized video camera. As it passes through the digestive tract, the doctor can view the lining of the stomach, small bowel, and colon.
Endoscopy also allows the doctor to remove a sample of diseased tissue for microscopic examination. A pathologist will examine this tissue sample for characteristic tissue and cellular signs of Crohn’s disease.
A CT scan or MRI may be used to provide more detail about how the disease is affecting deeper tissues in the gastrointestinal system. Barium X-rays are seldom used, and usually only if the doctor suspects that the bowels are obstructed.
Crohn's disease treatment options
Crohn’s treatment has several goals: improving patients' symptoms and quality of life, reducing inflammation, and avoiding complications of long standing, active Crohns'. Treatment will depend on the severity and extent of the condition, location, age of the patient, and the risk for complications.
Medications
Medications are the first-line treatment for controlling inflammation and preventing flare-ups. Some medications reduce inflammation by blocking the body’s ability to produce inflammatory substances. For more severe or unresponsive Crohn’s disease, medications that suppress the immune system will be used. Other medications will be used to treat symptoms such as diarrhea or complications such as anemia.
Diet therapy
Nutritional therapy may be used during flare-ups to help manage symptoms and avoid malnutrition. Therapy may include a special diet, dietary supplements, or intravenous feeding.
Surgery
Traditionally, over 50% of Crohns patients will need surgery in their lifetime, however with newer medications out for treatment, this rate has been decreasing. Most will be due to complications such as an abscess, fistula, or perforation. Some, however, will have a diseased part of their small intestine or colon removed. A strictureplasty may be used to widen areas in the intestine that are obstructed.
Lifestyle changes
Lifestyle changes will be required, particularly dietary changes, mostly focused on increasing nutrition, taking supplements, and avoiding foods that worsen symptoms.
Support
Depression, anxiety, poor self-image, low quality of life, and relationship problems are common complications of Crohn’s disease. Support groups and counseling are important foundations of living with the condition.
Crohn's disease medications
Medications are used to induce remission and reduce symptoms during an active flare and then preventing relapse in the remission phase.
Aminosalicylates
The first-line therapy for Crohn’s flare-ups in patients with mild to moderate Crohn’s disease are aminosalicylates. The exact mechanism of action of these medications is not entirely known, however they appear to prevent the immune system's production....at the level of the intestinal lining. They can be used both during a relapse and taken regularly during remission to prevent relapse. The most commonly used are sulfasalazine and mesalamine, but a doctor may prescribe an alternative such as balsalazide. Both mesalamine and sulfasalazine are taken as tablets, but mesalamine can be delivered directly to the rectum or colon as a suppository or enema.
Corticosteroids
Corticosteroids are used in the short-term to rapidly alleviate symptoms and induce remission of active Crohn’s disease in patients with moderate to severe Crohn’s disease. Most patients will be given oral corticosteroids, but steroids can also be delivered as a suppository, rectal foam, or enema. Prednisone is the drug of choice, but a newer generation budesonide has far fewer side effects, as it is almost exclusively delivered to the lining of the intestines, and not absorbed into the bloodstream.
Immunosuppressants (immunomodulators)
If corticosteroids do not resolve symptoms or the patient is unable to take steroids, guidelines call for using off-label drugs that suppress the immune system: thiopurines (azathioprine or mercaptopurine) or methotrexate. Thiopurines take longer to produce remission, so they are mainly used to maintain remission, while methotrexate is another option when corticosteroids don't work. Tacrolimus and cyclosporine are other off-label immunosuppressants that might be used to treat Crohn’s flare-ups. Tacrolimus can also be applied topically to treat Crohn’s flare-ups in the mouth or reactive skin ulcers due to Crohn’s.
Monoclonal antibodies
When corticosteroids and immunosuppressants fail to resolve symptoms, doctors will turn to antibodies, also called “biologics.” The immune system uses many proteins to “signal” instructions or carry out important functions. Monoclonal antibodies are designed to “glue” to these substances, effectively shutting them down. These medications in general, produce symptom improvement in roughly 50-70% of patients, and remission in 40-50-%.
Biologics are administered as injections or intravenous infusions. They are usually given every few weeks, up to every eight weeks. If a biologic is discontinued during remission, there is a danger that the body will develop immunity to it, making it ineffective during the next flare-up.
Monoclonal antibodies are classified by the protein they attach to and shut down. The first line of antibody therapy for Crohn’s disease are anti-TNF (tumor necrosis factor) antibodies. They shut down the protein that signals immune cells to go on the attack. These include Remicade (infliximab), Humira (adalimumab), or Cimzia (certolizumab pegol). Unlike the immunomodulators, the anti-TNF antibodies work fairly quickly. Interestingly, they have been shown to be even more effective when combined with a thiopurine, however this can also increase the risk of infections and cancer.
Entyvio (vedolizumab) and Tysabri (natalizumab) are the next line of therapies. They dial back the immune response by attaching to integrin, a protein that white blood cells use to glue themselves to the lining of a blood vessel to exit the bloodstream. As a result, white blood cells aren’t able to migrate out of blood vessels and congregate around intestinal tissues to cause damage.
Finally, another drug therapy for Crohn’s is Stelara (ustekinumab), an antibody that targets interleukin, a molecule that signals immune cells—leukocytes—to start dividing and produce more leukocytes.
Other medications
Antibiotics such as metronidazole or ciprofloxacin are sometimes used to treat Crohn's flare-ups, but the data regarding their use in Crohns disease is equivocal. However, intestinal infections, abscesses, fistulae, and Clostridium difficile infections are common complications of Crohn’s disease, so antibiotics are a normal part of living with the condition. Other medications used to treat complications include pain relievers, antidiarrheal medications, and iron, B12, or other supplements.
What is the best medication for Crohn's disease?
Healthcare professionals follow guidelines in prescribing medications for Crohn’s disease. They will choose drugs based on the severity of the condition, other illnesses, the patient’s history with Crohn’s disease medications, and their tolerance for side effects. Unfortunately, most drugs used to treat Crohn’s are not successful with all patients. There is, then, no “best” medication for Crohn’s disease. Ultimately, the best medications are the ones that calm or prevent flare-ups with the least harmful side effects.
| Best medications for Crohn’s disease | ||||
|---|---|---|---|---|
| Drug Name | Drug Class | Administration Route | Standard Dosage | Common Side Effects |
| Prednisone | Corticosteroid | Oral | 40 mg per day to be tapered off over several weeks | Fluid retention, increased blood pressure, behavior and mood changes |
| Uceris (budesonide ER) | Corticosteroid | Oral | One 9 mg tablet taken once per day for eight weeks | Headache, nausea, upper abdominal pain |
| Azulfidine (sulfasalazine) | 5-aminosalicylate | Oral, rectal, or enema | Four 500 mg tablets daily | Stomach upset, nausea, diarrhea |
| Imuran (azathioprine) | Immunosuppressant | Oral | Dose depends on weight | Bone marrow suppression, abdominal pain, nausea |
| Purinethol (6-mercaptopurine) | Immunosuppressant | Oral | Dose depends on weight | Bone marrow suppression, abdominal pain, nausea |
| Methotrexate | Immunosuppressant (antimetabolite) | Subcutaneous or intramuscular injection | Up to 1 ml of 50 mg/ml once weekly | Low white blood cell counts, nausea, abdominal pain |
| Remicade (infliximab) | Tumor necrosis factor alpha inhibitor | Intravenous infusion | Given in weeks 0, 2, and 6 and then every 8 weeks. Dose depends on weight | Infections, headache, abdominal pain |
| Entyvio (vedolizumab) | Integrin receptor antagonist | Intravenous infusion | 300 mg at 0, 2, and 6 weeks then every 8 weeks | Headache, joint pain, fever |
| Stelara (ustekinumab) | Anti-interleukin | Subcutaneous injection | First dose administered intravenously, followed by subcutaneous injections every 8 weeks. Dose depends on weight | Infections, vomiting, fatigue |
Many of the standard dosages above are from the U.S. Food and Drug Administration (FDA) or the American College of Gastroenterology (ACG) Guideline: Crohn’s Disease. Dosage is determined by your doctor based on your medical condition, response to treatment, age, and weight. Other possible side effects exist. This is not a complete list.
What are the common side effects of Crohn's disease medication?
All medications may have side effects, and different classes of medications have different side effects. However, this is not a complete list, and you should consult with your healthcare professional for possible side effects and drug interactions based on your specific situation.
Aminosalicylates are generally safe medications. Sulfasalazine, however, cannot be used by people who are allergic to sulfa. Side effects include headache, abdominal pain, nausea, rash, and loss of appetite.
Continual use of corticosteroids over several weeks will produce side effects in most people including mood and behavior changes, aggressiveness, increased appetite, weight gain, high blood pressure, high blood sugar, acne, and cataracts. Steroids also weaken the immune system, so people on steroids are more vulnerable to infections.
Immunomodulators weaken the immune system and suppress the bone marrow’s production of white blood cells (myelosuppression), so the most serious side effect is leaving the patient vulnerable to infections or cancer. Other severe side effects might include damage to organs such as the liver, kidneys, and lungs.
Monoclonal antibodies that suppress the immune system also leave patients vulnerable to potentially serious infections, pancreatitis, and cancer. Other serious side effects include arthritis, liver problems, and severe allergic reactions such as a lupus-like reaction or potentially life-threatening skin reactions. Because antibodies are given as intravenous infusions, most people will experience temporary site reactions to the injection such as redness or pain.
What is the best home remedy for Crohn's disease?
There is no question that living with Crohn’s disease will involve lifestyle and dietary changes. With the right medical treatment and lifestyle changes, many patients can go into remission for long periods of time, manage flare-ups, and achieve a high quality of life.
Stop smoking
Smoking worsens Crohn’s disease symptoms, it’s worth quitting.
Eat nutritious foods
Crohn’s disease can result in nutritional deficits, so eat a balanced diet and avoid junk food.
Avoid foods that make symptoms worse
Every person with Crohn’s has some food that worsens symptoms, but there is no single food that everyone should avoid. Avoid any food that doesn’t work for you. A low residue diet is recommended for Crohn’s disease. The most common foods that cause symptoms are spicy foods, dairy, high-fiber foods, caffeine, and alcohol.
Eat small meals
Eat several small meals a day to help reduce symptoms.
Take dietary supplements
Your most important job is adequate nutrition. If your diet is compromised, consider taking dietary supplements.
Drink fluids
Make sure you drink plenty of fluids, especially if you have diarrhea.
Reduce stress
Stress does not trigger flare-ups, but it can make symptoms worse and certainly lowers the quality of life. Practice relaxation techniques, breathing exercises, meditation, or yoga to reduce stress. Maintain good sleep hygiene by going to bed at the same time every night and removing all distractions at bedtime.
Frequently asked questions about Crohn's disease
What is the latest treatment for Crohn disease?
Emerging treatments for Crohn’s disease focus on new antibodies and small molecule drugs that suppress the overactive immune response. Both stem cell transplants to replace damaged intestinal tissues and fecal microbiota transplants to induce and maintain remission are being tested.
What is the life expectancy of someone with Crohn's disease?
Crohn’s patients have a slightly higher mortality rate because of the risk of cancer or infections, but their life expectancy, surprisingly, is statistically very close to that of the general population.
What do you take for Crohn's disease?
Crohn’s disease is treated by medications that reduce inflammation. Some medications directly block the body’s production of inflammatory substances. More severe cases are treated by medications that suppress the immune system.
What is the new drug for Crohn's?
The most recently approved drug for Crohn’s is Stelara (ustekinumab), a monoclonal antibody that shuts down the body’s production of leukocytes, a type of white blood cell that is the principal culprit in Crohn’s flare-ups.
What foods are good for Crohn's disease?
Because inadequate nutrition is a major problem with Crohn’s, it is paramount to eat nutritious foods.
What can I drink with Crohn's disease?
Fluid replacement is paramount if a Crohn’s flare-up includes diarrhea. Water is best to drink. Caffeine and alcohol may make symptoms worse. Carbonated drinks cause gas which can increase abdominal pain during a flare-up.
Can Crohn's disease kill you?
Even in patients with severe Crohn’s disease, flare-ups are very rarely fatal. However, complications associated with Crohn’s disease, such as infections or intestinal cancer, can be fatal.
Can Crohn's disease be cured by diet?
The symptoms and complications of Crohn’s disease can be managed with diet. Crohn’s disease itself, however, is not curable.
Can Crohn’s turn to cancer?
Crohn’s disease does not turn into cancer. However, people with Crohn’s have a higher risk of developing intestinal and colorectal cancer. Also, some Crohn’s disease medications seriously weaken the immune system. Because one of the principal jobs tasked to the immune system is to fight off cancers, these drugs may raise the risk of certain cancers such as lymphoma or skin cancers.
Can you have Crohn’s and not take medication?
Some people live for years and even decades before they are diagnosed with Crohn’s and begin taking medications. Once medications are started, stopping medications raises the risk of relapses. In addition, some medications, when stopped, may not be effective when restarted.
Is apple cider vinegar good for Crohn's disease?
Apple cider vinegar has not been shown to have any effect on reducing or preventing Crohn’s symptoms or flare-ups.
Is green tea good for Crohn's?
Green tea polyphenols may or may not reduce intestinal inflammation due to ulcerative colitis or Crohn’s disease, but the evidence isn’t solid.
Is Crohn’s a disability?
Disability designation and ratings vary from agency to agency. Most disability agencies, including Social Security, recognize inflammatory bowel disease (IBD) as a disability if certain conditions are met.
Does Crohn’s get worse with age?
Crohn’s disease may or may not worsen with age. It depends on how much damage is done to the gastrointestinal tract by long-term inflammation.
Related resources for Crohn's disease
- ACG Clinical Guideline: Management of Crohn’s Disease in Adults
- Aminosalicylates: Fact Sheet
- Biologics: Fact Sheet
- Corticosteroids: Fact Sheet
- Crohn Disease
- Crohn’s Disease: Diagnosis and Management
- Immunomodulators: Fact Sheet
- The Facts about Inflammatory Bowel Disease
- The Epidemiology and Natural History of Crohn's disease in Population-Based Patient Cohorts from North America: A Systematic Review