Crohns Disease Module 2: What is Crohns Disease?
Questions About Crohn's Disease
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Living with Crohn's disease can be challenging, but the more you know about this chronic condition, the better chance you have of managing Crohn's disease and minimizing flare-ups. In this program, you'll hear about some of the common questions people ask about Crohn's disease and get answers from expert Bret A. Lashner, MD, the director of the Center for Inflammatory Bowel Disease in the department of gastroenterology at Cleveland Clinic in Ohio. You'll hear about what Crohn's disease is, lifestyle changes you can make to ease Crohn's symptoms, Crohn's treatment and management guidelines, and more.
Running time: 13:09
Welcome to this Everyday Health podcast, "Common Questions About Crohn's Disease." I'm your host, Carolynn Delany.
If you've recently been diagnosed with Crohn's disease or know someone who has, you're probably searching for information that will help you understand the basics and get answers to your questions about Crohn's. Here to answer some of those questions is Dr. Bret Lashner. Dr. Lashner is the director of the Center for Inflammatory Bowel Disease in the Department of Gastroenterology at the Cleveland Clinic in Ohio. Our guest reports that he has received funding from the sponsor of this program. Thanks for being with us, Dr. Lashner.
Dr. Lashner, when you deliver a diagnosis of Crohn's disease to one of your patients, how do you explain what Crohn's is and what causes it?
Dr. Bret A. Lashner:
Well, simply put, Crohn's disease can be thought of as an inflammation of the intestine. People get ulceration anywhere in their gastrointestinal tract. Typically, these ulcerations cause pain, diarrhea, occasional bleeding, and difficulty digesting your food. We don't really know what causes Crohn's disease. We do know that there are genetic determinants of the disease — in other words, the disease runs in families — and there have been some gene mutations that have been identified as being responsible for Crohn's disease.
Interestingly, though, not everyone who has these mutations gets the disease. So one theory on the causation of Crohn's disease is that in a genetically predisposed individual, some environmental trigger causes the disease to occur, resulting in inflammation and ulceration throughout the intestine.
The disease typically affects younger people, mostly in their teens and twenties, but it can affect people well into their seventies. The incidence is rising in the United States. More and more people are getting Crohn's every year, and in fact, it's now believed that about a million people in the United States have the disease. Typically, patients with Crohn's disease will have lots of abdominal pain, mostly on the right lower quadrant of the abdomen, as well as diarrhea. Other things that can occur are bowel obstructions with nausea, abdominal pain, and maybe even some vomiting. There can also be fistulas, or abnormal communications [openings] between the bowel and other organs, like the skin. But the symptom complex in Crohn's disease is varied, and every patient is different.
I imagine one of the first questions people ask you is, Will it ever go away? Does the disease get better over time?
Unfortunately, the disease doesn't go away. If you have a diagnosis of Crohn's disease, it's a diagnosis you'll carry for the rest of your life. Many people do well for a long period of time, even a whole lifetime, but still they carry the diagnosis and have to be very careful about the disease flaring at some time in the future. So the disease doesn't go away; it may be quiescent [inactive] for a very long time, but unfortunately it does often progress.
Some people get sick frequently over the course of a lifetime, to the point where they may even need surgery. In fact, the rates of surgery and removal of pieces of the intestine in people with Crohn's disease can be as high as 80 percent over the lifetime of the disease. So it is a disease of a lifetime, but hopefully the disease can be kept under control enough so that surgery is not needed.
By the time someone gets a Crohn's diagnosis, they’ve probably been dealing with some pretty severe issues, both physically and mentally. Before you discuss treatment options with them, do you suggest other ways they can help themselves manage the disease?
Well, yes, and most of the people who are diagnosed with Crohn's disease have already instituted lifestyle changes. If they find that there is a food or a type of food that doesn't agree with them and makes their disease worse, of course they will eliminate it. Typically, people with Crohn's disease have a hard time passing nuts and seeds. That includes corn, popcorn, and seeds, like those found in tomatoes, that may get stuck in a strictured or narrowed bowel and cause obstructive-type symptoms.
We also know that cigarette smoking is very much associated with Crohn's disease. Smokers are more likely to get the disease, and smokers will also have a more aggressive course of disease. So one of the things I tell all my patients who are smokers is that they have to quit. Their Crohn's disease will be much better controlled, much more amenable to treatment, if they quit smoking.
Other conditions that a patient might develop that are associated with Crohn's disease are called extraintestinal manifestations of the disease, parts of the inflammatory process that can occur outside the GI [gastrointestinal] tract. The most common one is arthritis. We see quite frequently that people get joint pain or joint swelling at the time of a Crohn's flare. Interestingly, if we treat the bowel symptoms of Crohn's disease, these extraintestinal manifestations frequently disappear. The arthritis will get better. So we don't have to initiate therapy directly for arthritis. We can shape therapy directly for the bowel problems of Crohn's disease.
So if someone with Crohn’s did have symptoms of arthritis, should they see their general practitioner, or should they speak with their Crohn's physician?
They should speak with the gastroenterologist who is taking care of their Crohn's. There is not always a need for a referral to a joint specialist or a rheumatologist — if the GI symptoms or inflammation can be kept under control, the person's joints will probably be better off, too.
Now let's get to treatments. What treatments are available to treat Crohn's disease?
There are a wide variety of treatments for Crohn's disease. I should also say that there are medical therapies and surgical therapies, and we think of Crohn's disease treatment as being a continuum, a lifetime of treatment where surgery and medicine may be needed at different times to help control the inflammation.
There are many medical therapies available, like aminosalicylates — the 5-ASA medications [which contain 5-aminosalicylic acid] — steroids, antibiotics, immunosuppressants. These are drugs that have been around for many years or decades.
But the newer agents that have gotten a lot of attention in the last 10 years are biologic therapies. Biologic therapies are genetically engineered proteins, usually antibodies, that are directed against a specific component of the inflammatory process. Specifically, we have Remicade (infliximab), Humira (adalimumab), and Cimzia (certolizumab pegol), which are all genetically engineered compounds that bind to and inactivate TNF, or tumor necrosis factor. We know that TNF is a very bad actor in Crohn's disease, giving people many of their symptoms and causing a lot of the inflammation. If you can neutralize TNF, some of that will disappear.
Unfortunately, these biologic agents do not work on everyone with Crohn's disease, but at least half of patients who are started on biologic agents feel significantly better afterward. And over the course of time, it's been shown that we may even change the natural history of the disease with biologic agents. People on long-term biologic treatment have fewer hospitalizations due to their Crohn's disease, less need for surgery, and less need for steroids.
And there is yet another biologic agent available for Crohn's disease, called Tysabri (natalizumab). Tysabri is a drug that interferes with the trafficking of white blood cells from the bloodstream into the lining of the GI tract. By interfering with that trafficking, you're not immunosuppressing somebody, you're not killing off any cells, but you're keeping these bad inflammatory cells out of the GI tract and keeping them in the bloodstream where they can't do any damage. [Editor's note: Tysabri, which is approved by the FDA for the treatment of certain types of multiple sclerosis and Crohn's disease, has been associated with a rare brain disease and must be taken only under strict guidelines. Get details on .
These drugs really have been a breakthrough in our treatment of Crohn's disease, but we're still looking for a cure. These drugs control the inflammation but do not cure the disease. Nor does surgery cure the disease. Even if all the Crohn's disease is removed surgically, the disease invariably comes back. Because you're not cured of your disease just by surgery, we frequently confine surgeries just to patients who absolutely need them. If they have a bowel obstruction, only the piece of bowel causing the obstruction is removed. We don't do surgery just for having Crohn's disease. Everybody gets a trial of medical therapy first.
Great information. When you're seeing a patient, how do you go about selecting a treatment plan for them?
Well, as we said earlier, Crohn's is a very variable disease. Everybody has different symptoms, and we can tell right from the beginning that some people will not respond to anything except surgery, and they go right to surgery. For those who have more mild disease, I might give them a nonbiologic treatment [such as an aminosalicylate]. That would save patients the need for a biologic agent and reserve the biologic agent for people who are sicker, who have more active disease and more severe complications. Our decisions about treatment depend on where the disease is located in the GI tract; how much inflammation there is, as opposed to stricture or a narrowing or a fistula; and how severe the patient's symptoms are — whether they're mild, moderate, or severe. I consider all of these things before I choose which therapy or combination of therapies would be best for a patient.
What's the best way to handle a sudden Crohn's attack?
I think the best way is to consult your gastroenterologist as soon as possible. If there's no time for that, then you need to go to an emergency room. Sudden Crohn's attacks can be very severe and can blossom out of control very quickly if they're not handled properly. Patients often know there's an emergency when the pain is more severe than they can handle, or the diarrhea is much worse than ever, or they're losing a lot of weight. These are all indications that they need help right away.
But remember, I said earlier that Crohn's disease is a disease of a lifetime, so even when we get people well, we need to keep them on maintenance therapy tokeepthem well over time. Our hope is that these maintenance therapies will work and blunt the attack of flares that might occur in the future, or even prevent them altogether. So very frequently we'll see patients with Crohn's disease feeling well but on long-term maintenance therapy to keep them well, and hopefully that will work to keep them out of places like the emergency room or from needing to get in touch with their physician right away.
As we're wrapping up here, I'd like to know whether there are any new, up-and-coming treatments for Crohn's disease.
Yes, there are. A lot of research is going on in this area at the drug companies. The most promising agents coming down the pike are newer biologic agents, but these agents are not necessarily directed to the TNF [tumor necrosis factor] pathways. These are antibodies that are directed to other pathways in the inflammatory process. We're going to see ustekinumab [Stelara, a medication currently approved for the treatment of psoriasis] in the very near future. That study is being completed now. Ustekinumab is an antibody directed at different inflammatory pathways from TNF.
We're going to see vedolizumab, which is another biologic directed at the trafficking of white blood cells through the GI tract, and there are many, many more medications on the horizon. So Crohn's patients should know that drug companies are still working to find better treatments and hopefully, in coming years, a cure.
Dr. Lashner, thanks for an informative discussion.
You're very welcome.
You've been listening to an Everyday Health podcast, "Common Questions About Crohn's Disease," with Dr. Bret Lashner of the Cleveland Clinic.
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