Crohn’s disease is an inflammatory bowel disease. It can affect any part of the digestive tract, leading to ulcers. Depending on the symptoms presented by the patient and the evolution of the disease, medical treatment, surgery, or both, will be indicated.
Crohn’s disease: what is it and what are its causes?
It is a chronic inflammatory bowel disease that can affect any part of the digestive tract, from the mouth to the anus, producing small and multiple ulcers that can cross the entire thickness of the intestinal wall. These are the most important differences with another inflammatory disease, ulcerative colitis, although in some cases it can be difficult to distinguish them. It causes very high health care costs.
It is not known why this disease occurs, although it is possibly triggered by the association of several factors, including genetic factors in about 20%, and also immunological (the body’s defense system), bacterial (intestinal flora or microbiota), or dietary factors.
Prevalence of Crohn’s disease and risk factors
Crohn’s disease occurs more frequently in young adults and is more common in developed countries. Moreover, it continues to increase markedly. The best known risk factor that we can act on is smoking. Smokers are at greater risk of developing the disease and of having more and more severe inflammatory flares.
Symptoms and diagnosis of Crohn’s disease
Crohn’s disease can produce abdominal pain, fever, diarrhea or the appearance of fistulas, among other symptoms. Sometimes there is also inflammation of other organs such as joints, skin or eyes.
It develops in crises or inflammatory outbreaks of more or less severity with periods of stability between them and can originate abnormal communications between the intestine and the skin or between different zones of the intestine (fistulas), accumulations of pus (abscesses) and also narrowings that make difficult the passage of the intestinal content (stenosis). The part of the intestine most frequently affected is the end of the small intestine (ileum) and the beginning of the colon (cecum), followed by the colon and rectum, but it can appear in other sections, or in several simultaneously. Occasionally it affects the anus, and may cause fistula discharge, which can be complex, pain or bleeding.
If Crohn’s disease is suspected, the diagnosis can be made by digestive endoscopy (colonoscopy or capsule endoscopy), intestinal radiological studies or, more recently, intestinal magnetic resonance imaging (Entero-magnetic resonance imaging), as well as different types of blood and stool tests.
Treatment of Crohn’s disease
The initial treatment of Crohn’s disease is medical. The disease is not cured but it can be significantly relieved and may even be free of flare-ups for years. It includes the use of anti-inflammatory drugs and corticosteroids or 5-ASA (Mesalazine) and sometimes antibiotics. Corticosteroids have many side effects and are therefore tried to be reduced or eliminated when possible.
Severe disease outbreaks require hospitalization and sometimes the use of special medications such as immunosuppressants, so-called biological treatments, or artificial nutrition to rest the bowel. Collaboration between different specialists, including coloproctologists, is necessary for the correct orientation of patient treatment.
When is surgery required for Crohn’s disease?
Surgical intervention is required in at least 50 to 70% of patients and may be indicated as an emergency measure in the event of serious complications such as bleeding, obstruction or perforation of the intestine, but much more frequently in those with a chronic form of the disease due to failure of medical treatment, complications, frequent or severe flare-ups, or serious side effects derived from the use of medications.
Other indications are the existence or suspicion of cancer or nutritional alterations. In addition, surgery is frequently required for anal problems, mainly abscesses or fistulas. Surgery is not the last resort in the treatment of this disease and should be indicated by consensus between the gastroenterologist and the surgeon treating the patient.
What does surgery for Crohn’s disease consist of?
Surgery for Crohn’s disease usually requires the removal of the portion or portions of the intestine causing the problem. Although they should be the least aggressive possible in this disease, and the minimum intestine necessary should be removed, often with the use of laparoscopic surgery, when there are fistulas or severe involvement, the intervention can be a technical challenge that requires an experienced colorectal surgeon.
On other occasions, when there are only small narrowings causing the symptoms, we can widen them without the need to remove the intestine (plasty). Since surgery is not curative and it is possible that a patient may be operated on several times during his life, it is important to preserve as much of the intestine as possible to avoid future nutritional problems. It is possible that the patient may need to wear a stoma (evacuation bag) at some point, temporarily or permanently.
When the anus is affected, it is sometimes necessary to empty pus accumulations (abscesses) and place small rubber drains similar to piercings, to avoid discomfort and complications. Sometimes it is necessary to treat anal narrowing, fissures, and more frequently, fistulas to the skin, or to neighboring organs, such as the vagina in women.
Postoperative Crohn’s disease
The postoperative course of Crohn’s disease is variable depending on the type of intervention, its complexity and the patient’s previous condition (medications, nutrition). The most important complications, although infrequent, are intestinal suture failure or the appearance of fistulas. But, in general, and given that the disease affects young patients, recovery is good, and when the problems that indicated surgery are corrected, the patient improves his condition and quality of life, which can be normal between outbreaks.
After the intervention, and in agreement with the gastroenterologist, it will be necessary to continue certain medical treatments aimed at the existing disease in other areas or to prevent its appearance, as well as to continue with check-ups and follow-up. The patient should refrain from smoking. To learn more about the disease, patient opinions and expert advice, it is interesting to establish a relationship with regional associations of patients with Crohn’s and ulcerative colitis or the national confederation of patients’ associations.