Crohn's Disease

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Most people diagnosed with Crohn's complain of crampy abdominal pain an hour or two after eating, diarrhea, nausea, and a gradual decrease in their sense of well-being. Fever, abdominal tenderness, night sweats, rectal pain or rectal bleeding, and anemia are less common symptoms. The abdominal pain is often localized in the right, lower quadrant, the location of the end of the ileum (also known as the "terminal ileum." When the disease is active, Crohn's disease sufferers often lose weight because nausea, fear of abdominal cramps, and diarrhea lead them to eat less. The chronic inflammation often leads to fatigue and malaise with weight loss. They also lose weight because swelling and fibrosis narrow the intestines. Lack of absorptive surface for nutrients, bacterial overgrowth in the intestine, and poor intestinal motion and reduced length of bowel after surgery can also lead to weight loss and malnutrion. Often, the symptoms of Crohn's disease seem vague and may drag on for some time before diagnosis. In children, the first sign of Crohn's disease may be delayed growth.

The symptoms of Crohn's disease depend on the areas of the bowels involved. Patients with ileitis, Crohn's disease at the bottom three fifths of the small intestine, generally suffer abdominal pain and diarrhea. The symptoms are similar for people who have damage to the linings of both the ileum and the jejunum, the middle part of the small intestine, called Crohn's enteritis or ileojejunitis. Crohn's disease involving both the lower part of the small intestine and the colon, or ileocolitis, generally causes cramps, abdominal pain, nausea, and diarrhea but also bloody stools. The cramping after meals may be caused by partial obstruction and inflammation of the small bowel. About 80 percent of patients with ileitis or ileocolitis develop diarrhea with an increase in daily bowel movements. Crohn's colitis, or inflammation confined to the colon, causes abdominal pain and bloody diarrhea. Crohn's disease in the ileum or the colon may lead to abscesses, fistulas, and bowel obstruction. Of these different types of Crohn's disease, ileitis and ileocolitis are the most common forms of the disease.

Crohn's symptoms also depend upon the extent of inflammatory damage to organs. About 30 percent of patients have inflammatory Crohn's disease, or damage to the mucosa, the first layer of the lining of the organs, and to the supporting connective tissue under it. Others suffer a more advanced form of the disease, called fistulizing or perforating Crohn's disease. In these cases, inflammation extends through the wall of the intestines leading to intra-abdominal fistulas, or abnormal passages through which fluids, secretions, and abscesses can pass. This type of Crohn's disease, known as internal or intra-abdominal fistulizing disease, affects about 20 percent of people with the disease. It does not include fistulas involving the anus, rectum and perineal region (region surrounding the anus and including the genitals).

Perineal or perianal disease (known as "Perianal Crohn's disease") occurs in about one third of patients and can become disabling if not treated aggressively. These include swelling of the anal sphincter or development of fissures and ulcers in the sphincter, causing bleeding and pain with defecation. Perirectal abscesses can cause fever, pain, or pus in the anal area. If fistulas have developed, mucus or pus may drain from openings into the skin surrounding the anus. Patients with perianal Crohn's disease frequently need surgical drainage of the abscesses and fistulas that form. Perianal Crohn's disease can involve the vagina. Fistulas from the rectum can let air and often stool pass through the vagina. This complication almost always requires surgery.

The third type of Crohn's is called stenosing or stricturing Crohn's disease. About 50 percent of patients with Crohn's disease affecting the lower portion of the small intestine follow this route. Early in the course of the disease, patients develop thickening, stiffening, and scarring. The narrowing of the small bowel may eventually result in a small bowel obstruction. The symptoms of obstruction are severe painful cramping, vomiting, nausea, and abdominal distention. As a consequence of chronic narrowing of the small intestine, fistulas or perforations of the bowel wall may develop. Most patients with stenosing Crohn's disease will require surgery, usually 7 to 10 years after the onset of Crohn's disease.

This section also contains information on symptoms outside the gastrointestinal tract.

Symptoms outside the gastrointestinal tract

Many other organs can be affected by Crohn's disease or the medications used to treat Crohn's disease. This section contains more information on the most common findings:

  • Skin symptoms
  • Eye symptoms
  • Mouth symptoms
  • Joint pain
  • Bone loss
  • Kidney problems
  • Liver symptoms
  • Pancreas symptoms
  • Skin symptoms

    Many skin conditions have been associated with Crohn's disease. The two most common conditions are erythema nodosum and pyoderma gangrenosum. Erythema nodosum appears as small, tender, red nodules under the skin, often accompanied by fever and transitory arthritic symptoms. The most common location for erythema nodosum is on the front surface of the lower legs.

    Pyoderma gangrenosum usually starts as a small discrete ulcer on the legs resembling a bug bite. However, these ulcers can progress and become quite large and tender and may be associated with destruction of the surrounding skin and soft tissues. The affected area often appears purple-red at the edges and can have a significant amount of pus draining from the open wound.

    Crohn's disease patients can also develop enterocutaneous fistulas, fistula tracts from the affected bowel to the skin. In addition, medications used to treat Crohn's disease can result in rashes.

    Eye symptoms

    Crohn's disease is associated with three main eye conditions: uveitis, episcleritis, and keratoconjunctivitis. Uveitis, or inflammation of all or part of the uvea (the iris, ciliar body, and choroids), can result in blurred vision, eye pain, and headaches. Episcleritis, inflammation of the outermost layers of the eye, often presents as red, burning eyes. Keratoconjunctivitis sicca is caused by a vitamin A deficiency and is characterized by dryness of the cornea due to lack of tears, resulting in burning and itchy eyes.

    Mouth symptoms

    Crohn's disease patients can have a number of oral lesions resulting from the disease itself or associated vitamin deficiencies. Aphthous ulcers are the most common and are frequently called canker sores. They are painful, small ulcers that are often located on the gums, lower lip, or on the tongue.

    Joint pain

    Patients with Crohn's disease, particularly of the colon, can develop several forms of arthritis. Patients can develop a migratory arthritis that affects the large joints, including the knees, ankles, hips, wrists, and elbows. The discomfort associated with this arthritis often moves from one joint to another. There are two patterns of peripheral joint inflammatory arthritis. Type I peripheral arthritis involves less than five large joints, and how inflamed they are depends on how active the intestinal disease is. Type II peripheral arthritis involves five or more small joints, with inflammation that tends to be independent of disease activity. Patients can also develop sacroileitis, inflammation of the lower back, which often presents as back pain and stiffness. Ankylosing spondylitis, a more severe form of inflammation in the spine, can also be seen in Crohn's disease patients. Successful treatment of the bowel disease often results in improvement in many of the arthritic symptoms.

    Bone loss

    Bone loss is a common finding in patients with Crohn's disease. The patients at highest risk are older female patients with lower body mass. The bone loss is probably due to a combination of factors. Active Crohn's disease itself is associated with increased bone loss. In addition, corticosteroids can increase bone loss and prevent new bone formation. Patients with extensive small intestinal disease may have decreased calcium and vitamin D absorption. Bone loss can manifest as osteoporosis, osteopenia, and osteomalacia. Bone loss can lead to increased risk of fractures, altered posture, loss of height, and back pain.

    Kidney problems

    The most common kidney problem associated with Crohn's disease is kidney stones. Two types of kidney stones are seen in Crohn's disease. Calcium oxalate stones are seen in patients with extensive surgical excisions of the ileum. In addition, uric acid stones can be seen in patients with extensive surgical excisions due to increased dehydration. Occasionally, kidney stones can get stuck in the ureters and cause hydronephrosis, a backup of urine into a kidney resulting in swelling and possible bladder infection. Medications that are used to treat Crohn's disease can adversely affect the kidneys; these include cyclosporine, sulfasalazine, and 5-aminosalicylates (mesalamine).

    Liver symptoms

    Patients with Crohn's disease are more susceptible to gallstones and primary sclerosing cholangitis, or inflammation and narrowing of the bile ducts. Gallstones are more common in patients who have had extensive disease or removal of their ileum. Gallstones can be associated with no symptoms or progress to pain in the upper portion of the abdomen (usually including the right mid back and right side), nausea, vomiting, and fever. Primary sclerosing cholangitis is more common in men than women. It may present with just abnormal laboratory liver tests but can cause fatigue, abdominal pain, fever, jaundice, and even lead to cirrhosis and liver failure. Some patients need liver transplants.

    Pancreas symptoms

    Although rare, pancreatitis-or inflammation of the pancreas-can develop in patients with Crohn's disease as a result of a gallstone blocking the drainage of the pancreas or as a complication of treatment with 6-mercaptopurine, azathioprine, or mesalamine. Warning signs include severe abdominal pain in the mid-abdomen, nausea, and vomiting.

    Last reviewed on 6/4/09

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