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Diagnosis | Treatment | Underwriting Comment

Patient History

The most common symptoms of Crohn's Disease are abdominal pain, often in the lower right area, and diarrhea. Rectal bleeding, weight loss and fever may also occur. The rectal bleeding may lead to anemia. Children with Crohn's Disease may suffer delayed development and stunted growth.

Laboratory Studies

Blood tests check for anemia, which could indicate bleeding in the intestines. Blood tests may also uncover a high white blood cell count, which is a sign of inflammation somewhere in the body. By testing a stool sample, the physician can tell if there is bleeding or infection in the intestines

The patient may need a colonoscopy. For this test, a physician inserts an endoscope--a long flexible, lighted tube linked to a computer and TV monitor--into the anus to see the inside of the large intestine. The doctor will be able to see any inflammation or bleeding. During the exam, the physician may do a biopsy, which involves taking a sample of tissue from the lining of the intestine to view with a microscope.

The patient may need an upper gastrointestinal (GI) series to look at the small intestine. For this test, the patient drinks barium, a chalky solution that coats the lining of the small intestine, before the x-ray studies. The barium shows up white on the x-ray film revealing inflammation or other abnormalities in the intestine.

If these tests show Crohn's disease, more x-rays of both the upper and lower digestive tract may be necessary to measure the extent of the disease.

IMPORTANT NOTE: The most common complication of Crohn’s Disease is blockage of the intestine. It can also cause sores, or ulcers, that tunnel through the affected area into the surrounding tissues such as bladder, vagina, or skin. The areas around the anus and rectum are often involved. The tunnels, called fistulas, are a common complication and often become infected.

Nutritional complications are common in Crohn's disease. Protein, calorie or vitamin deficiencies may be caused by inadequate dietary intake, intestinal loss of protein or poor absorption (malabsorption).

Other complications associated with Crohn's disease include arthritis, skin problems, inflammation in the eyes or mouth, kidney stones, gallstones, or other diseases of the liver and biliary system. Some of these problems resolve with treatment of the digestive system but some must be treated separately.

 

Treatment for Crohn's Disease depends on both the location and severity of disease, complications and the response to previous treatment.

The goals of treatment are to:

• Control inflammation
  
• Correct nutritional deficiencies
  
• Relieve symptoms (i.e. abdominal pain, diarrhea and rectal bleeding)

Treatment may include drugs, nutrition supplements, surgery, or a combination of these options. At this time, treatment can help control the disease but there is no cure.

Medications

Sulfasalazine (Azulfidine)
The majority of cases are first treated with drugs containing mesalamine, a substance that helps control inflammation. Sulfasalazine is the most commonly used of these drugs.

5 Aminosalicylates- ASA agents, mesalamine, Asacol, Pentasa, Rowasa
Patients who do not benefit from Sulfasalazine may be given other mesalamine containing drugs generally known as 5-ASA agents. The 5 aminosalicylates are all derivatives of sulfasalazine. These drugs include Asacol, Dipentum, or Pentasa.

Corticosteriods- Prednisone and Hydrocortisone
Patients with severe disease and those who do not respond to the 5 aminosalicylates may be treated with corticosteriods. Prednisone and hydrocortisone are two corticosteroids used to reduce inflammation. These drugs are the most effective for active Crohn's disease, but they can cause serious side effects including greater susceptibility to infection.

Immunosuppressive drugs- 6-mercaptopurine, azathioprine
Drugs that suppress the immune system are also used to treat Crohn's Disease. Immunosuppressive agents work by blocking the immune reaction that contributes to inflammation. Although these drugs have significant side effects, many times when used with corticosteriods, the dose of corticosteriods can be eventually lowered.

Remicade (infliximab)
Remicade (an anti-tumor substance) has been approved for the treatment of moderate to severe Crohn's disease that does not respond to standard therapies. It is also approved for the treatment of open, draining fistulas in the intestinal tract. This is the first drug approved by the FDA specifically for Crohn's disease.

IMPORTANT NOTE: Researchers are always looking for new treatments for Crohn's Disease. The following medications are currently undergoing clinical trials to determine if they are effective in the treatment of Crohn's Disease: interleukin 10, antibiotics, budesonide, cyclosporine, methotrexate, and zinc.

Surgery

Crohn’s Disease is universally progressive over time. The majority of cases (i.e. >70%) will eventually require surgical intervention to relieve symptoms that do not respond to medical therapy or to correct complications. These include blockage, perforation, abscess, or bleeding into the intestine. Surgery can help Crohn's Disease but cannot cure it. Unfortunately, the inflammation tends to return adjacent to the area of intestine that has been surgically removed.

IIMPORTANT NOTE: People with Crohn's Disease may feel well and be free of symptoms for substantial spans of time when their disease is not active. Despite the need to take medication for long periods of time and occasional hospitalizations, most people with Crohn's disease are able to hold jobs, raise families, and function successfully at home and in society.

1) Date of diagnosis

Crohn's disease is a chronic inflammatory disease of the large and small intestines; its cause is unknown. Like ulcerative colitis, it attacks the intestine in a "flare"/remission pattern. Unlike ulcerative colitis, Crohn's disease attacks both the large and small intestines. The attacks may include abdominal pain, bloody diarrhea and even bowel obstruction. The disease is universally progressive over time. The majority of cases (i.e. >70%) will eventually require surgical intervention. 50% of patients who have had surgery can expect a recurrence of symptoms within four years following surgery, and 30% will require a repeat surgery in five years.

IMPORTANT NOTE: The diagnosis of Crohn's disease rests on the clinical presentation (i.e. abdominal pain, diarrhea, vomiting, fever and weight loss) along with indirect (i.e. barium enema) or direct visualization of the intestines (i.e. colonoscopy).

2) Medications

Medications treat both the "flare" episodes as well as prolong the remission in Crohn's Disease. These drugs range from simple salicylates (Azulfidine, Dipentum, Asacol and Pentasa) to drugs that suppress the immune system (Imuran, Purinethol, Sandimmmune and Rheumatrex). Steroids, either orally (Prednisone) or used in enemas (Cortenema) may also be part of the client's medication schedule. Lastly, antibiotics (Flagyl) can also prove beneficial especially in patients with large intestine disease. It is important to obtain the names of all of the medications the client is taking.

3) Hospitalizations

It is important to clarify the client's "flare"/remission pattern. Significant "flares" usually involve the same symptoms that lead to the original diagnosis (i.e. abdominal pain and bloating, bloody diarrhea, vomiting, etc.) and may require hospitalization.

4) Surgery

As indicated above, the majority of patients with Crohn's disease require surgery at some point in their illness. It is important to find out both the last date of surgery and what has happened since the last surgical procedure (i.e. has there been any "flares?").

5) Complications

Underwriting Comment: Crohn's disease can affect more than the intestinal tract. It can also cause inflammation of the joints, spine, eyes, and liver.

Coming in the March 2001 RiskTutor Online Newsletter:

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