1. Crohn's Disease
(CD)
Presented By:
Uttara Singh

2. Introduction
• Crohn’s Disease is an idiopathic, chronic, transmural
inflammatory process of the bowel that can affect
any part of the gastro intestinal tract from the mouth
to the anus.
• Most cases involve the small bowel, particularly the
terminal ileum.

3. History
• 1806: First reported case of Crohn’s by Combe and
Sanders to the Royal College of Physicians in London,
England.
• 1913: Surgical evidence of the disease reported in the
paper ‘Chronic Intestinal Enteritis’ written by Dr.
Kennedy.
• Described in 1932 by Crohn, Ginsburg, and
Oppenheimer of Mount Sinai Hospital in New York.

4. Prevalence
• Higher number of cases of Crohn’s disease found in
western industrialized nations.
• Males and females are equally affected.
• Smokers are three times more likely to develop Crohn's
disease.
• Crohn's disease affects between 400,000 and 600,000
people in North America.
• Prevalence estimates for Northern Europe have ranged
from 27–48 per 100,000.
• Crohn's disease tends to present initially in the teens
and twenties.
• Malathi and Shivabalan reported CD cases in Southern
India.

5. Classification of CD
On the area of the gastrointestinal tract which it
affects:
• Ileocolic Crohn's disease: Affects both the ileum
and the large intestine (50%)
• Crohn's ileitis: Affects the ileum only (30%)
• Crohn's colitis: Affects the large intestine,
accounts for the remaining twenty percent of
cases.

6. Distribution of gastrointestinal Crohn's
disease :Data from American
Gastroenterological Association

7. Classification of CD
On the behavior of disease as it progresses:
• Stricturing disease causes narrowing of the bowel
which may lead to bowel obstruction or changes in the
caliber of the feces.
Stricturing

8. Classification of CD
• Penetrating disease creates abnormal passage ways between
the bowel and other structures such as the skin.
• Inflammatory disease causes inflammation without causing
strictures or fistulae.
Inflammatory Penetrating

9. Symptoms
• Onset of Crohn's disease is between 15-30
years of age.
• People with Crohn's disease will go through
periods of flare-ups and remission.

10. Endoscopy image of colon showing
serpiginous ulcer in Crohn's disease

11. Gastrointestinal Symptoms
• Abdominal pain,diarrhoea, flatulence, bloating, perianal
discomfort .
• People who have had surgery often end up with short
bowel syndrome of the gastrointestinal tract.
• Ileitis results in large volume watery feces & colitis result
in a smaller volume of feces of higher frequency.
• In severe cases, an individual may have more than 20
bowel movements per day and may need to awaken at
night to defecate.
• The mouth may be affected by non-healing sores
(aphthous ulcers).
• Difficulty in swallowing (dysphagia).

12. Systemic Symptoms
• Up to 30% of children with Crohn's disease have retardation
of growth.
• Among older individuals, Crohn's disease may manifest as
weight loss related to decreased food intake
• People with extensive small intestine disease also have
malabsorption of carbohydrates or lipids, which can further
exacerbate weight loss.

13. Extraintestinal Symptoms
• Crohn's disease also increases the risk of blood clots;
painful swelling of the lower legs can be a sign of
deep venous thrombosis.
• Difficult breathing may be a result of pulmonary
embolism.
• Autoimmune hemolytic anemia, a condition in which
the immune system attacks the red blood cells.

14. Causes of Crohn’s Disaese
Genetics
• The disease runs in families then 30 times more likely to
develop CD.
• Mutations in the NOD2 /CARD15 gene are associated with
Crohn's disease.
• Over 30 genes that show genetics play a role in the disease,
either directly through causation or indirectly as with a
mediator variable.
• Anomalies in the XBP1 gene have recently been identified as
a factor, pointing towards a role for the unfolded protein
response pathway of the endoplasmatic reticulum in
inflammatory bowel diseases.
NOD2 : nucleotide-binding oligomerization domain containing 2
CARD15 :Cathapse Activation Recruitment Domain

15. Environmental Factors
• Smoking has been shown to increase the risk of the return of active
disease, or "flares".
• Hormonal contraception in the US in the 1960s is linked with a
dramatic increase in the incidence rate of Crohn's disease.
Immune System
• Crohn's disease is thought to be an autoimmune disease, with
inflammation stimulated by an over-active Th1 cytokine response.
• Recent gene to be implicated in Crohn's disease is ATG16L1, which
may induce autophagy and hinder the body's ability to attack
invasive bacteria.

16. Microbes
• A.V. Singh et al. have suggested that Mycobacterium avium
subspecies paratuberculosis (MAP) were identified in 100% of
subjects with CD ;75% of attendants of MAP infected animals were
positive.
• Psychrotrophic bacteria such as Yersinia spp and Listeria spp
contribute to Crohn’s disease.
Mycobacterium avium subspecies paratuberculosis
colonies from stool sample of Crohn’s disease patient

17. Pathophysiology
• Biopsies of the colon are taken to confirm the diagnosis.
• Crohn's disease shows a transmural pattern of inflammation,
showing entire depth of the intestinal wall.
• Ulceration is an outcome seen in highly active disease.
• Inflammation is characterized by focal infiltration of
neutrophils, a type of inflammatory cell, into the epithelium.
• These neutrophils leading to inflammation or abscess .
• Granulomas known as giant cells, are found in 50% cases of
Crohn's disease.

18. Pathophysiology of CD
Crohn’s Disease

19. Section of Colectomy Showing
Transmural Inflammation

20. Intestinal Complications of Crohn's Disease
Sore or Ulcer
• The cells in lining of the intestines are shed and replaced on a
regular basis in a healthy body.
• When the lining of the intestine is irritated, cells may be shed
more frequently, causing ulcers.
• The sores and ulcers are most common in ileum, colon or
rectum.
• Ulcers can be serious if they go through the intestines and
damage an artery.
• This can lead to life-threatening bleeding.

21. Intestinal Complications of Crohn's
Disease
Fistula
• Sores and ulcers can become deep and form tunnel through
the tissues of nearby organs:
 The rectum
 Other parts of the intestine
 The bladder
 The vagina
 The skin.
• These tunnels are called "fistulas," and can become infected.
• Fistulas require special treatment, such as medication or even
surgery.

22. Intestinal Complications of Crohn's
Disease
Abscess
• An abscess is a collection of pus that has formed as a result of fistula due
to an infection.
• An abscess must be drained in order to heal or surgery may be
recommended to remove the infected portion of bowel.
Bowel Obstruction
• The most common complication of Crohn's disease is blockage of the
intestine, known as a bowel obstruction occurs in up to 30 % of people.
• A bowel obstruction occurs because the disease tends to thicken the
intestinal wall with swelling and scar tissue, narrowing or even blocking
the passage.

23. Intestinal Complications of Crohn's
Disease
Cancer
• Crohn's disease may increase risk of developing cancer.
• If the inflammation is mainly in small intestine, risk of cancer
of the small intestine is increased.
• The risk of cancer gets higher as great as 32 times the normal
rate if the whole colon is involved.

24. Intestinal Complications of Crohn's
Disease
Perforation
• A perforation is a hole in the bowel.
• The size, location, and seriousness of the hole can vary.
• Small perforations often seal themselves off.
• More serious bowel perforations may require a surgery and
removal of the damaged area.
Toxic Megacolon
• More serious complications of Crohn's disease is called "toxic
megacolon," which occurs when the large intestine stops
working and expands suddenly.
• This can cause it to bleed excessively, or even rupture which
can be very dangerous.

25. Systemic Complications of Crohn's
Disease
Osteoporosis
• Osteoporosis is a threat to people with Crohn's disease because of:
 Low calcium and vitamin D intake
 Poor absorption of nutrients in the body
 The use of corticosteroids
• In a cohort study of 6207 patients with chronic inflammatory bowel
disease, osteoporotic fractures were found in 25% of patients and
vertebral fractures in 7%; in addition, the age at fracture occurrence was
10–15 years younger than in healthy controls. A 40% increase in the
fracture risk has been reported in patients with Crohn’s disease.
• Similarly, Klaus et al. reported that 22% of 293 patients with Crohn’s
disease had one or more vertebral fractures and that 35% of patients with
vertebral fractures were younger than 30 years of age.

26. Systemic Complications of Crohn's
Disease
Joint Problems
• Up to 25 percent of people with Crohn's disease will have
joint complications.
• This may include intermittent joint tenderness or arthritis
include ankylosing spondylitis.
Ankylosing spondylitis

27. Skin Problems
• Erythema nodosum presents as red nodules on the shins is
due to inflammation of the underlying subcutaneous tissue
and is characterized by septal panniculitis.
• Skin complications occur in about 15 percent of people with
Crohn's disease.
Erythema nodosum on the back and leg of a person with Crohn's Disease

28. Systemic Complications of Crohn's
Disease
• Pyoderma gangrenosum is a painful ulcerating nodule.
• Clubbing, a deformity of the ends of the fingers, also be a
result of Crohn's disease.
Pyoderma gangrenosum on Clubbing
the leg of a person with
Crohn's Disease

29. Systemic Complications of Crohn's Disease
Eye Problems
• Eye complications occur in about 5 percent of people with
Crohn's disease. These include:
• Iritis (inflammation of the colored part of the eyes)
• Uveitis (inflammation of the middle layer of the eye)
• Episcleritis (inflammation of the white part of the eyes)
Episcleritis Uveitis

30. Diagnosis
• Crohn's disease does not diagnose with complete certainty.
• A colonoscopy is 70% effective in diagnosing the disease via
direct visualization of the colon and the terminal ileum.
• Capsule endoscopy help in endoscopic diagnosis.
• 30% of Crohn's disease involves only the ileum, cannulation of
the terminal ileum is required in making the diagnosis.

31. CT scan showing Crohn's disease in the fundus of the
stomach
Endoscopic image of Crohn's colitis showing deep
ulceration

32. Radiologic Tests
• A barium X-ray where barium sulfate suspension is ingested
and fluoroscopic images of the bowel are taken to check
inflammation and narrowing of the small bowel.
• Identifying anatomical abnormalities when strictures of the
colon are too small for a colonoscope to pass through, or in
the detection of colonic fistulae.

33. Blood Tests
• A complete blood count may reveal anemia caused either by
blood loss or vitamin B12 deficiency.
• Erythrocyte sedimentation rate(ESR) and C-reactive protein
measurements can also be useful to check the degree of
inflammation.
• Testing for anti-Saccharomyces cerevisiae antibodies (ASCA)
and anti-neutrophil cytoplasmic antibodies (ANCA) has been
evaluated to identify inflammation of the intestine.

34. Crohn's Disease & Ulcerative
Colitis
• Ulcerative colitis mimics the symptoms of Crohn's disease, as
both are inflammatory bowel diseases that can affect the
colon.
• Sometimes its not possible to tell the difference, in those case
the disease is classified as indeterminate colitis.

35. Comparisons of Various Factors in Crohn's Disease & Ulcerative
Colitis
Crohn's disease Ulcerative colitis
Terminal ileum involvement Commonly Seldom
Colon involvement Usually Always
Rectum involvement Seldom Usually
Involvement around the anus Common Seldom
No increase in rate of primary
Bile duct involvement Higher rate
sclerosing cholangitis
Patchy areas of inflammation (Skip
Distribution of Disease Continuous area of inflammation
lesions)
Deep geographic and serpiginous
Endoscopy Continuous ulcer
(snake-like) ulcers
May be transmural, deep into
Depth of inflammation Shallow, mucosal
tissues
Fistulae Common Seldom
Widely regarded as an autoimmune
Autoimmuue disease No consensus
disease
Cytokine response Associated with Th17 Vaguely associated with Th2
May have non-necrotizing non-peri- Non-peri-intestinal crypt
Granulomas on biopsy
intestinal crypt granulomas granulomas not seen
Often returns following removal of
Surgical cure Usually cured by removal of colon
affected part
Smoking Higher risk for smokers Lower risk for smokers

36. Treatment
• Remission may be prolonged Crohn’s disease.
in
• Symptoms controlled with medication, lifestyle changes and
surgery.
• Adequately controlled Crohn's disease may not significantly
restrict daily living.
• Treatment for Crohn's disease is only when symptoms are
active and involve first treating the acute problem, then
maintaining remission.

37. Medication
• Antibiotics use to reduce inflammation .
• Prolonged use of corticosteroids has significant side.
• Alternatives include aminosalicylates alone, though only a
minority are able to maintain the treatment, and many
require immunosuppressive drugs.

38. Medicine Used in Treatment of
Crohn's Disease
• 5-aminosalicylic acid (5-ASA)
• Prednisone and methylprednisolone
• Immunomodulators such as azathioprine, mercaptopurine,
methotrexate, infliximab, adalimumab.
• Hydrocortisone should be used in severe attacks of Crohn's
disease.

39. Management of Crohn's Disease: Diagnosed by Clinical Evaluation,
Radiographic Studies, Endoscopy, Laboratory Tests and Stool Studies

40. Lifestyle Changes
• Dietary adjustments, proper hydration and
smoking cessation reduce symptoms.
• Consume balanced diet with proper portion
control & eat small meals frequently instead
of big meals.
• Do regular exercise and take enough sleep.
• Identifying foods that trigger symptoms.

41. Surgery
• Crohn's cannot be cured by surgery.
• Surgery required in case of obstructions, fistulas and/or
abscesses, or if the disease does not respond to drugs.
• After the first surgery, Crohn's usually shows up at the site of
the resection though it can appear in other locations.
• After a resection, scar tissue builds up which can cause
strictures.
• A stricture is when the intestines become too small to allow
excrement to pass through easily which can lead to a
blockage.
• For patients with an obstruction due to a stricture, two
options for treatment are strictureplasty and resection of that
portion of bowel.

42. Diet for Crohn's Disease
• Drink lots of fluid to keep body hydrated and prevent
constipation.
• Take multivitamin-mineral supplement to replace lost
nutrients .
• Eat a high fiber diet when CD is under control.
• During a flare up, limit high fiber foods and follow a low fiber
diet.
• Avoid lactose-containing foods if one has lactose intolerance
or use lactase enzymes and lactase pretreated foods.
• Try small frequent meals.
• Eating a high protein diet with lean meats, fish and eggs, may
help relieve symptoms of Crohn’s.

43. Diet for Crohn's Disease
• Take pre-digested nutritional drinks to give bowel a rest and
replenish lost nutrients.
• Limit caffeine, alcohol and sorbitol .
• Limit gas-producing foods such as broccoli, cabbage,
cauliflower, brussels sprouts, dried peas ,lentils, onions, and
carbonated drinks.
• Reduce fat intake if part of the intestines has been surgically
removed.
• If the ileum has been resected, a Vitamin B12 injection may be
required.
• Studies found that fish oil and flax seed oil may be helpful in
managing .
• The role of prebiotics such as psyllium & probiotics helpful in
the healing process.

44. Management in Crohn’s
Disease
Complex Carbohydrates
• Patients should select complex carbohydrates, which are
also a good source of fiber.
• Fresh fruit such as apples, grapefruit, oranges, plums,
blueberries, raspberries, and strawberries might be
protective for Crohn’s disease.
• Simple sugars can increase inflammation.
• High-fiber foods can cause gas, bloating, and pain in
Crohn’s disease patients.
• Commercial products Beano are available that can
reduce gas.

45. Proteins in Crohn’s Disease
• Proteins are very important for growth in children
and for repair of cells.
• Diarrhoea can cause protein deficiency so Crohn’s
patients may need more protein.
• One study reported that a soy protein diet was
useful for patients who were intolerant to milk
products.
• Oily fish, such as salmon and tuna, poultry & lean
meats may be particularly beneficial in Crohn’s
disease.

46. Oils in Crohn’s Disease
• Omega-3 fatty acids are important compounds for Crohn’s
disease.
• A study showed that the palmitic acid absorption-oxidation
observed for the Crohn’s patients increased from 4.4±1.1%
before the treatment period to 7.6±1.1% after treatment.
• Watkins et al. who found that 2.1±1.5% of the administered
dose of palmitic acid was excreted in breath over 6 h for
patients with mucosal disorders compared to 6.6 ±2.4% for
normal subjects.

47. Oils in Crohn’s Disease
• Andersson et al. investigated patients with Crohn’s disease,
that condition of the patients improved when consuming the
low fat diet (40gm/d), including diarrhoea, steatorrhea and
electrolyte balance.
• Weight gain was observed even though the fat intake was
significantly reduced from the mean 150 g reported in home
use.

48. Nutrient Importance in a Crohn’s
Disease Diet
• Crohn's disease patients are in danger of becoming
malnourished. The following are several reasons to consider
these findings:
• Poor digestion and malabsorption of dietary fats,
carbohydrates, water, protein, minerals and vitamins.
• During disease flare-ups chronic disease patients usually will
increase levels of energy and caloric needs for the body.
• Symptoms of abdominal pain, nausea, or lacking taste
sensations will have an ill affect on food intake resulting in
loss of appetite.

49. Food Absorption
• Food absorption is a huge issue when it comes to
patients with Crohn’s Disease.
• People that have inflammation only in the large
intestine most often absorb food normally.
• Over 40 percent of individuals diagnosed with
Crohn’s showed that they can eat enough food but
can’t absorb food adequately, especially
carbohydrates.

50. Vitamin and Mineral Deficiencies
• Individuals that have Crohn’s disease where the
ileum is affected may have a vitamin B12 deficiency
due to that they are unable to absorb enough of the
B12 vitamin from oral supplements or food intake.
• One of the most common deficiency associated with
the common Crohn’s Disease Diet and which affects
about sixty-eight percent, is the lack of vitamin D,
which supports bone formation and calcium
metabolism.
• Sahli et al. observed that 35.7% osteoporosis and
23.2% osteopenia occurred in CD patients.

51. Vitamin and Mineral Deficiencies
• Deficiency of the iron in patients with Ulcerative Colitis and
Crohn’s Disease is also common due to the loss of
blood,inflammation and ulceration of the colon.
• Potassium and magnesium deficiency occur due to
diarrhoea or vomiting.
• Trace element deficiencies are normally present in those with
poor nutritional intake and have and extensive small intestine
disease.

52. Foods to Avoid
• Dairy products
• Spicy foods
• Chocolate
• Caffeinated beverages, such as coffee, teas, and some soft
drinks
• Alcoholic beverages
• Certain raw fruits and vegetables
• Popcorn
• Fruit juices
• Beans
• Onions
• Artificial sweeteners, such as sorbitol or mannitol
• High-fat foods such as butter, red meat, avocados, nuts, and
fried foods.

53. Complementary and Alternative
Medicine
• Crohn's disease sufferers have tried complementary or
alternative therapy.These include diets, probiotics, fish
oil and other herbal and nutritional supplements.
• Acupuncture is used to treat inflammatory bowel disease
in China, and is being used more frequently in Western
society.
• Methotrexate is a folate anti-metabolite drug which is
also used for chemotherapy.
• Metronidazole and ciprofloxacin are antibiotics which
are used to treat Crohn's disease.
• Thalidomide has shown response in reversing
endoscopic evidence of disease.
• Canabis derived drugs may be used to treat Crohn's
disease with its anti-inflammatory properties.
• Probiotics include Sacchromyces boulardii and E. c oli.