CROHN DISEASE
Crohn’s disease is characterized by inflammation and scarring that can involve any part of the digestive tract. Although it affects everything from mouth to anus, it often involves the last part of the small intestine called terminal ileum. Some patients admit primarily with anorectal (anus and rectum) involvement, which is the last part of the large intestine. The treatment of Crohn’s disease is long, requires patience, and sometimes it is not possible to fully treat the patients.
The digestive system is an organ system that performs the tasks of transporting, digesting, absorbing and removing the nutrients. These infection and wounds always start from the innermost layer of the digestive tract (mucosa). Then, the disease progresses and disease involvement spreads to all the layers of the intestine. Therefore, nutrient digestion and absorption are disrupted.
CAUSES
Main reason of Crohn’s Disease is unknown. Recent studies showed that immune system problems and bacterial infections increase the risk of Crohn’s Disease development. Relatives of individuals with inflammatory intestine disease also have increased risk of suffering from this disease.
FINDINGS
Crohn’s Disease may present itself as a celiac disease or anus disease or with both. Disease is generally manifested with complications.
These are;
1. High fever and abdominal pain due to intraabdominal abscess (suppuration) related to intestinal infection,
2. In the long term; wounds and small bowel stenosis due to infection and bowel obstruction as a result,
3. Formation of an abnormal connection called fistula between small bowel and another part of the intestines, another organ such as urinary bladder or between the skin is very common for this disease. As a result, serious infection and undernutrition develops in the patients,
Fistul openings on the abdominal skin and groin region where stool comes out in a Crohn’s Disease patient who was previously operated due to intraabdominal abscess
4. Multiple and frequently recurring abscesses and perianal fistulas are observed around the anus.
Multiple perianal fistula opening in a Crohn’s Disease patient
Pouch is placed to small intestine fistulas that open to the abdominal skin in the same patient
OTHER GENERAL SYMPTOMS IN CROHN’S DISEASE;
Abdominal cramps
Abdominal pain
Persistent diarrhea
High fever
Lack of appetite, weakness, fatigue, anaemia
Wounds in the mouth, joint paint, skin rash
Nausea and vomiting
Chronic constipation
Bleeding with bowel movement
Weight loss
Anal flow
Anus abscess
Anal cracks
MEDICAL TREATMENT
Medication is the first choice unless emergency surgery is necessary. There are many treatment options available for the first step and they help the patient to keep the disease under control for a long time. The most common initial treatments are anti-inflammatory and anti-infective medications administered orally or anally. Depending on the severity of the disease, medicines containing steroids may also be added to the treatment. In recent years, the use of anti-TNF drugs has also been promising for these patients. Aspirin and rheumatic drugs should be avoided in Crohn’s patients because dietary restriction is not a definite benefit and leads to an increased episode frequency.
SURGICAL TREATMENT
Surgical treatments may be necessary in cases of disease related complications or anal diseases. Emergency surgery is performed when a puncture or blockage in the intestine occurs. The most common operation is the end-to-end re-ligation of the intestine after removing the last portion of the intestines, which has frequent involvement. Abdominal surgery is also mandatory for intra-abdominal and skin fistulas that do not improve with medical treatment.
The abscesses formed around the anus are opened and drained. Large scale surgeries should be avoided for perianal fistulas. In these fistulas, the fistula is tried to be removed with a small band called seton and the infection is controlled. In severe cases, stool must be removed from abdominal skin (stoma) in order to treat the infection around the anus.
FOLLOW UP TREATMENT
It is important to have a good follow up with your physician in this period. Thus, a good treatment plan can be designed to control the symptoms. If you suffer from Crohn’s Disease, you should receive lifelong treatment. In case your colon is also involved by Crohn’s Disease, there is an increased risk of large bowel cancer. This risk starts to increase 8-10 years after the colon involvement. These patients require regular colonoscopic examination and follow up.
HOW CAN I REDUCE THE RISK OF RELAPSE?
The disease will frequently relapse in patients who do not use their medications regularly or stop the treatment. It is vitally important to listen to the recommendations of your physician. Smoking is a risk factor threatening all organs for everybody. If you are a smoker, you are advised to quit. For Crohn’s patients, smoking increases episode, whereas quitting will reduce them.
WHAT IS ULCERATIVE COLITIS?
Ulcerative colitis (UC) is an inflammatory intestine disease with involvement in the entire large bowel (colon and rectum). Inflammation is limited to the mucosa, the innermost layer of the large bowel. UC is a chronic disease with recovery and episode intervals. Medical treatment with medication is the first option. If surgical need occurs for the patient during follow ups, it is a treatable disease unlike the Crohn’s disease.
WHAT ARE THE SYMPTOMS OF ULCERATIVE COLITIS?
Most common symptoms;
Abdominal pains in the form of cramps
Diarrhea
Rectal bleeding
Mucoid flow from anus
Fever, weakness and weight loss
Eye infections, joint pains and liver biliary tract disease symptoms (jaundice and disrupted liver function tests) accompanying these.
WHO ARE UNDER ULCERATIVE COLITIS RISK?
Although UC can occur at any age, for many patients, symptoms onset in their fourties. Rarely, disease may onset in later stages of life during 60s-70s. Female and male populations are equally affected. Having UC history in the family increases the risk.
WHAT ARE THE CAUSES OF ULCERATIVE COLITIS?
Exact causes of UC are unknown. Recent studies focus on immune system problems and bacterial infections. UC is not an infectious disease.
HOW PATIENTS ARE EVALUATED?
A comprehensive medical history must be obtained initially and a detailed physical examination must be performed. Complete colonoscopy including rectum, the last part of the large bowel, and terminal ileum, the last part of the small intestine is performed and it possible to diagnose through intestinal biopsy. Colonoscopy findings and biopsy are crucial for evaluating the severity and extent of the disease. These results will act as a guide for determining the proper treatment. Sometimes it may be difficult to differentiate UC disease from Crohn’s disease, which has only large bowel involvement.
DOES ULCERATIVE COLITIS TURN INTO CANCER?
Ulcerative Colitis is a risk factor for colorectal cancer development. Large bowel cancer develops in 3-5% of UC patients within first 10 years and in 20% within next 10 years. In these patients, before cancer, lesions containing dysplasia develop which are precursors for cancer development. Therefore, ulcerative colitis patients must have scanning colonoscopy starting from 10th year at the latest. This way when dysplasia containing lesions are detected, large bowel is surgically removed and colon cancer development is prevented.
HOW ULCERATIVE COLITIS IS TREATED?
Medication treatment is always the first option for patients diagnosed with ulcerative colitis. There are many alternatives to main treatment and others to increase the quality of life of patients. For initial treatment, anti-inflammatory drugs are administered together with steroid containing drugs. Depending on the status of the disease, these drugs can be administered orally or anally with setons or anal injections.
WHAT ARE THE SURGICAL TREATMENT OPTIONS?
In ulcerative colitis patients, surgical treatment is applied in two conditions;
Emergency Surgery
Perforation, obstruction in the colon
Excessive enlargement in the colon (Toxic megacolon)
Ceaseless bleeding
Fulminant colitis that irresponsive to medication (toxic intestine)
In these cases, patients must undergo emergency surgery. In emergency surgery, diseased large bowel is usually removed and rectum is left in place. An ileostomy is performed that enables disposal of stool by taking the ileum, the last part of the small intestine, out from the anterior abdominal wall. After patient is recovered, rectum is removed with a second surgery. An ileal pouch formed from the small intestine in order to store stool and connected to the anal canal. Following the full recovery after this surgery, previous ileostomy is closed. This way, full continuity of the intestine is provided.
Planned Surgery
Patients who do not respond to medication and have frequent episodes
Patients with joint skin lesions
Patients who have large bowel cancer or cancerous risk in colonoscopy
Must undergo planned surgery.
Colon and rectum are removed in planned surgery. Small intestine is formed into an ileal pouch and ligated to anal canal. An ileostomy is formed until this ligation (anastomosis) recovers in order to take stool out. This ileostomy is closed in the upcoming months with a small surgical operation and patient regains normal defecation function. Laparoscopic surgeries enable patients to recover faster.
WHAT SHOULD I EXPECT AFTER SURGERY?
After the surgery, defecation 5-6 times during day and 1 time at night is considered normal. Infection may develop in the newly formed rectum, i.e. ileal pouch. This condition can be successfully treated with antibiotics. Approximately 10% of patients suffering from frequent pouch infection may require removal of the pouch and switch to permanent ileostomy.
HOW SHOULD BE THE FOLLOW UP AFTER THE SURGERY?
Patients must not hinder their control after the surgery. Function and health of the pouch is evaluated during patient follow ups. Surgical treatment decision may be delayed in young women in order not to decrease conception chance.