Crohn's disease

Question 1

Crohn’s Disease
* Definition

Answer 1

• one of the two major chronic inflammatory bowel
  diseases
• believed to result from an inappropriate inflammatory
  response to intestinal microbes in a geneticallysusceptible host
• typically involves the ileum and colon
• but can affect any region of the intestines (mouth to anus potential)
• inflammation is often transmural
• can be associated with intestinal granulomas, strictures and
  fistulas

Question 2

Crohn’s Disease
* Signs and Symptoms

Answer 2

• chronic diarrhoea, abdominal pain, weight loss, fever,
  rectal bleeding
• pallor, cachexia, abdominal tenderness or masses
• Extraintestinal
  * arthralgia; eye inflammation
  * failure of growth in children

Question 3

Crohn’s Disease
* Symptoms in remission

Answer 3

42-57% of CD sufferers can suffer from IBS-like S&S
on a regular basis (despite being in remission) (Simren et al,
2002)(Minderhoud et al, 2004)
* bloating, excess flatulence, abdominal pain/discomfort,
diarrhoea

Question 4

Crohn’s Disease
* Aetiological Factors

Answer 4

• Genetic predisposition (Tsianos et al, 2011)
• first-degree relatives have a 12-15 times greater risk of developing
  CD
• NOD2, IL23R and ATG16L1 genes
• Recent antibiotic usage (Card et al, 2003)
• Antibiotic exposure in early childhood (Hildebrand et al, 2008)
• Increasing latitude (Sonnenberg et al, 1991)(Khalili et al, 2012)
• Lower vitamin D status (Ananthakrishnan et al, 2012)
• Living in urban environment (Soon et al, 2012)
• Use of the OCP (Khalili et al, 2012)
• Smoking (Hovde and Moum, 2012)
• Caesarean section birth (Malmborg et al, 2012)
• Appendectomy (Andersson et al, 2003)
• Prior admission to hospital for GIT infection

Question 5

Crohn’s Disease
* Dietary Risk Factors

Answer 5

• High refined sugar intake (Thornton et al, 1979)(Katschinski et al, 1988)(Reif et al,
  1997)(Jakobsen et al, 2012)
• Decreased consumption of vegetables, fruit, wholemeal bread,
  dietary fibre and fish (Amre et al, 2007)(Jakobsen et al, 2012)
• Decreased consumption of raw fruit and vegetables (Thornton et al,
  1979)
• Consumption of low fibre diet (Gilat et al, 1987)
• Consumption of a Westernised diet high in animal meat and
  fats, dairy products and refined sugar (Asakura et al, 2008)
• Increased consumption of animal protein and a high total
  protein intake (Andersen et al, 2012)(Hou et al, 2011)
• Formula feeding in infancy and early childhood

Question 6

Crohn’s Disease
* Dysbiosis

Answer 6

• increased counts of Bacteroides and enterobacteria (Andoh et al, 2009)
• decreased populations of bifidobacteria (Favier et al, 1997)
• decreased abundance of Faecalibacterium prausnitzii and
  increased counts of E. coli (Willing et al, 2009)
• populated by more virulent E. coli strains (Baumgart et al, 2007)
• decreased diversity; lower concentrations of F. prausnitzii,
  Anaerostipes & Collinsella; increased populations of
  Fusobacterium and E. coli

Question 7

Crohn’s Disease
* Diagnosis

Answer 7

• A number of tests typically required to confirm diagnosis:
• Stool tests
• to rule out infection
• blood present?
• faecal calprotectin
• faecal lactoferrin
• Colonoscopy and endoscopy
• Imaging
• CT scans
• Barium x-ray of lower and upper bowel
• Blood tests
• signs of inflammation
• raised ESR and/or CRP

Question 8

Crohn’s Disease
* Sequelae

Answer 8

• Osteoporosis
• Kidney stones
• Gallstones
• Fatty liver

Question 9

Crohn’s Disease
* Nutritional deficiencies

Answer 9

• Zinc
• Iron
• Calcium
• Carotenoids
• Vitamin B1
• Vitamin B3
• Vitamin B6
• Vitamin B12
• Folate
• Vitamin C
• Vitamin E
• Magnesium
• Copper
• Vitamin D

Question 10

Crohn’s Disease
* Conditions Associated with

Answer 10

• SIBO (Klaus et al, 2009)
• 23% incidence of SIBO in CD patients in one study (Castiglione et al, 2000)
• Fructose malabsorption (Barrett et al, 2009)
• 61% incidence
• Lactose malabsorption (Barrett et al, 2009)
• 44-68% of CD patients malabsorb lactose (Mishkin et al, 1997)
• Clostridium difficile infection (Bossuyt et al, 2009)
• Restless Legs Syndrome

Question 11

Crohn’s Disease -Txt

Answer 11

Mucosal Healing (Baert et al, 2010)(Froslie et al, 2007)
* now considered the main objective in the treatment of CD
* mucosal healing associated with:
* reduced disease activity
* longer duration of remission
* decreased need for surgery