Treating complications

The most likely complications of Crohn's disease are abscesses, fistulas, and obstructions. These are usually managed with medications and surgery.

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Abscesses: The terminal ileum is the most likely point of origin for abscesses. Abscesses occur in 15 to 20 percent of patients with Crohn's disease. The symptoms of an abscess are fever and abdominal pain. A high white cell count may be found in a blood test. Abscesses are first treated with antibiotics and drainage. If abscesses persist, further measures may be required. Further drainage may be accomplished through radiology-directed procedures. After bowel rest with total parenteral nutrition, the involved bowel segments are removed surgically.

Fistulas: Fistulas generally occur in about 20 to 40 percent of patients with Crohn's disease. Generally, these abnormal passages are formed when a deep abscess penetrates into an adjacent organ or the skin. The terminal ileum of the small intestine is the bowel segment more frequently involved. Another common site of fistula formation is the perianal area.

Symptoms of fistulas are usually diarrhea, weight loss, and nutritional deficiencies indicating inadequate absorption of dietary nutrients. Fistulas that cause no symptoms do not require treatment. Closure may be induced with total parenteral nutrition or immunosuppressive therapy, including Remicade. Recurrence may be a problem after cessation of therapy, however. Surgery to remove the damaged segment of bowel and close the fistula is sometimes necessary, if fistulas do not close and heal with drug treatment or if they recur.

Obstructions: Obstruction of the small intestine is a common complication of Crohn's disease and a major indication for surgery. As a result of acute inflammation, the wall of the small bowel thickens and scarring may occur, obstructing the flow of intestinal contents. The symptoms of a bowel obstruction are abdominal pain, rumbling sounds in the stomach, and diarrhea, which worsen after eating. Nausea and vomiting may accompany episodes of prolonged pain and diarrhea. These symptoms may disappear with fasting. Depending on the location of the obstruction, barium studies, CT scans, and colonoscopy may be useful in evaluating the location of the obstruction and areas of narrowing in the intestines.

The initial treatment for an obstruction is to give nothing by mouth, suction out the stomach through a nasogastric tube, and provide intravenous fluids. Steroid drugs may help reduce inflammation. If the obstruction is not clear with this treatment, surgery to remove the obstruction or the bowel segment may become necessary.

Perianal disease: Anal fissures and ulcers in the anal canal resulting in abscesses and fistula are difficult complications of Crohn's disease. The openings of the fistulas are commonly in the skin in the perianal area, but they may appear in the groin, vulva, and scrotum. Painful abscesses (exacerbated by defecation, sitting, or walking) and fever may accompany this complication. Severe or persistent disease leading to repeated surgical procedures can damage the anal sphincter and result in fecal incontinence.

Treatment is aimed at relief of symptoms and preservation of the anal sphincter. Fistulas that are not causing symptoms need no treatment. Sitz baths and antibiotics may be the first form of treatment. The 5-ASA compounds are helpful in one third of patients, and Remicade has led to healing or improvement of fistulas in 60 percent of patients. Surgery is an option if none of these treatments result in management of this painful complication.

Colon cancer: The risk of colon cancer is increased in patients with Crohn's disease involving the colon. Those who have had Crohn's disease for eight to 10 years should undergo colonoscopy screening at two- to three-year intervals. Crohn's patients battling the illness for 20 years or more should be screened for colon cancer every one to two years. During such a screening colonoscopy in the Crohn's patient, taking at least 30 biopsy samples of the colon lining is recommended.