Natural Crohns Disease Treatment Book

Cured My Crohns

If you've ever gotten the fateful diagnosis you've got Crohns, you will know the massive upset that it can have on your way of life and how you feel about yourself and your relationship to other people. If you talk to your doctor about natural diets or some other method of curing your Crohns disease they will tell you that there is no way to fix it. However, there is often more to the story than modern medicine will tell you. New Age medicine is not a bunch of nonsense that hokey people subscribe to; New Age medicine fills in the gaps of knowledge that we have with modern medicine and helps us understand what is going on with our bodies. You will learn how to cure Crohns from someone who has cured it himself and has lived for over 10 years completely free of disease!

Cured My Crohns Overview

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Crohn Disease of the Esophagus

Crohn disease may affect the entire gastrointestinal tract, including the esophagus. Involvement of the esophagus alone is rare, however. Further standard tests for evaluating Crohn disease Fig. 3.45 a, b Esophageal involvement by Crohn disease Fig. 3.45 a, b Esophageal involvement by Crohn disease

Crohns Disease

Crohn's disease is a chronic inflammatory disease of the gastrointestinal (GI) tract the exact cause is still unknown. The disease was first described by Crohn, Ginzberg, and Oppenheimer in 1932. In their initial description, the disease was thought to involve only the distal ileum. We now know that Crohn's disease can involve any part of the GI tract from the mouth to the anus. Segmental involvement of the intestinal tract by a nonspecific granulomatous inflammatory process characterizes the disease. The ileum is involved in the majority of cases. In 20 percent, the disease is confined to the colon, making differentiation from ulcerative colitis, at times, a difficult clinical problem. The terms regional enteritis, terminal ileitis, granulomatous ileocolitis, and Crohn's disease are used to describe the same disease process.

Regional Enteritis

Antimesenteric Border

Other specific, more localized changes of regional enteritis have been observed surgically and pathologically. In their pioneering report in 1932, Crohn, Ginz-burg, and Oppenheimer noted on opening the intestine that a series of small linear ulcerations lying in a groove on the mesenteric side of the intestine is almost always present.27 It has also been observed that there is a close relationship between the destructive changes in the mucosa and the extent of increased mesenteric fat.28 The development of pseudodiverticula, furthermore, is probably related to eccentric skip areas.28 I have directly applied these discrete pathologic observations in regional enteritis to the radiologic alterations for a more definite diagnosis.1,2,29 The process may be identified, particularly in its early stages, as localized predominantly to the mesenteric borders of involved loops. Mesenteric border ulcers are a virtually pathog-nomonic finding in approximately 30 of patients with Crohn's disease.29...

Right Lower Quadrant Pain

Crohn's disease is a chronic disease not cured by surgical resection. Although the diseased portion of bowel may be resected with surgery, the disease can affect a previously unaffected portion of bowel at a later date. Surgical resection each time a portion of bowel is affected will eventually leave a patient with an inadequate length of bowel. With ulcerative colitis, the risk of cancer increases with the length of diagnosis. A patient has a 5 percent increased risk of colon cancer after the first 20 years of diagnosis, which increases 0.5 percent per year thereafter.4 Total abdominal colectomy is the eventual recommendation for people diagnosed with ulcerative colitis. Toxic megacolon is the main reason for which patients with ulcerative colitis will require urgent surgery. Inflammatory bowel diseases can rarely be associated with toxic megacolon. This is a diagnosis that involves nonobstructive dilatation of the colon to greater than 6 cm accompanied by fever, tachycardia,...

Evidence From In Vivo Studies With Humans

A case study of a 30-yr-old male with Crohn's disease with a very high level of micronuclei in erythrocytes (67 1000 cells) showed that this was associated with a low serum folate (1.9 ng mL normal range > 2.5 ng mL) and a low red cell folate (70 ng mL normal range > 225 ng mL). Micro-nucleus frequency was reduced to 12 1000 cells, serum folate increased to > 20 ng mL, and red cell folate increased to 1089 ng mL after 25 d with a daily oral dose of 25 mg folinic acid (23). One of the main observations of this study was that minimum spontaneous MN frequencies were observed

Sources of further information and advice

Canada Crohn's and Colitis Foundation of Canada Europe European Federation of Crohn's and Ulcerative Colitis Associations Ireland Irish Society for Colitis and Crohn's Disease Carmichael Centre, North Burnswick St., Dublin 7. Tel + 353 (0)1 872 1416 www.iscc.ie UK National Association for Colitis and Crohn's Disease 4 Beaumont House, Sutton Road, St Albans, Hertfordshire AL1 5HH, UK. Tel + 44 (0) 172 784 4296 (0) 845 130 2233 www.nacc.org.uk USA Crohn's and Colitis Foundation of America Greig ER, Rampton DS. Management of Crohn's disease, London Martin Dunitz, 2003.

Etiology and Pathogenesis

Environmental, genetic, infectious, and host factors have all been implicated as a cause of both Crohn's disease and ulcerative colitis. Among the environmental factors, smoking has been associated with an increased recurrence rate of Crohn's disease. Mycobacterium paratuberculosis and the measles virus have received recent attention and have also been considered as possible etiologies of Crohn's disease. There are few data to support a primary causative role of psychogenic factors. Immunologic factors have received greatest attention. Several mechanisms of injury have been proposed, including autoimmune destruction of the gut mucosal cells as the result of cross-reactivity with antigens from enteric bacteria as well as nonspecific immunologic injury to the gut mucosa as the result of a chronic inflammatory process for both ulcerative colitis and Crohn's disease. Cytokines, including interleukins and tumor necrosis factor, have been invoked in the perpetuation of the inflammatory...

TABLE 771 Extraintestinal Manifestations of Inflammatory Bowel Disease

Hepatobiliary disease is common in patients with inflammatory bowel disease and includes pericholangitis, chronic active hepatitis, primary sclerosing cholangitis, and cholangiocarcinoma. Gallstones are detected in up to 33 percent of patients with Crohn's disease. Ihe incidence of acute and chronic pancreatitis is increased in patients with Crohn's disease and ulcerative colitis. Vascular manifestations include thromboembolic disease, vasculitis, and arteritis. Patients with thromboembolic complications have a mortality rate of approximately 25 percent. Ihromboembolic disease is the result of a hypercoagulable state induced in patients with both Crohn's disease and ulcerative colitis and ranks as the third leading cause of death in patients afflicted with these conditions, behind peritonitis and malignancy. Malnutrition and chronic anemia are seen in many patients with long-standing Crohn's disease. Growth retardation can be seen in children. 2 Hyperoxaluria is a common and...

Differential Diagnosis

The major diseases that should be considered in the differential diagnosis of ulcerative colitis include infectious colitis, Crohn's colitis, ischemic colitis, irradiation colitis, and pseudomembranous colitis (see Tabje. 77-2.). When the disease is limited to the rectum, particular attention should be paid to sexually acquired diseases, which are frequently seen in the male homosexual population (gay bowel disease). Some of the more common diseases in this category include rectal syphilis, gonococcal proctitis, lymphogranuloma venereum, and inflammations caused by herpes simplex virus, Entamoeba histolytica, shigella, and Campylobacter.

Dietary Fiber Obesity and the Etiology of Diabetes

Inflammatory bowel diseases (colitis and Crohn's disease) Clearly, inflammatory conditions have an immune component. In the case of Crohn's disease, there appears to be no established therapeutic or etiological role for fiber. The situation is slightly different for distal ulcerative colitis, in which fiber intake seems unrelated to incidence. However, rectal infusion of SCFAs (especially butyrate) has been reported to lead to remission, so it appears that either the generation of these acids or their delivery to the distal colon may be the issue.

TABLE 791 Vomiting and Diarrhea The Gastroenteritis Mnemonic

PHYSICAL EXAMINATION Clinical clues may also assist in making the diagnosis. In addition to evaluating the ABCs, much of the physician's initial attention should be directed toward the assessment of hydration status. Severely volume-depleted patients require immediate intervention, lest circulatory collapse be imminent. The abdominal, genitourinary, and pelvic examinations are often revealing. Physicians should search carefully for tenderness, peritoneal signs, hernias, masses, and evidence of obstruction or torsion. The findings of a careful physical examination may point toward unsuspected causes of vomiting, such as bulimia (scars on the dorsum of hands), pneumonia (consolidative findings on lung examination), or Addison's disease (hyperpigmentation). The rectal examination is important. An anal fistula may be the only clue to Crohn's disease in an otherwise healthy teenager with vomiting, or may demonstrate fecal impaction.

Intestinal Fistulae Most Will Close Spontaneously Etiology

A fistula is an abnormal communication between two epithelialized organs. Fistulization of the intestine usually is a result of an iatrogenic injury, although spontaneous fistulae may develop in inflammatory conditions such as Crohn's disease or diverticulitis. Fistulae frequently involve the small bowel and may develop among the bladder, vagina, other segments of bowel, or most commonly the skin. Regardless of the cause or location, fistula closure is inhibited by a number of conditions, which are often remembered by students and residents with the mnemonic FRIEND (Table 10-3) Foreign body, Radiation, Inflammatory bowel disease, Epithelialization, Neoplasm, and Distal obstruction.

Table 103 Conditions that Inhibit Fistula Closure

The likelihood and rate of fistula closure are related more to the presence or absence of inhibiting conditions and to nutrition than to the characteristics of the fistula itself, although a small enteral defect with a long, nonepithe-lialized fistula tract is more likely to close than is a complete disruption of the bowel that forms an epithelialized end fistula at the skin. Generally, a trial of at least 6 weeks of nonoperative management is recommended prior to considering surgical repair. In patients with Crohn's disease, treatment with infliximab, an antitumor necrosis factor antibody, may help promote and maintain fistula closure.14 If surgical repair is undertaken, takedown of the fistula with resection of the involved bowel is usually necessary. Care must be taken to correct any sources of distal obstruction and, of course, to avoid injuries that may lead to recurrent fistulization.

TABLE 1234 Causes of Diarrhea

Treatment of diarrhea will vary depending on cause. A suspicion of Hirschsprung or Crohn's disease warrants surgical consultation. Malabsorption, hemolytic-uremic syndrome, cystic fibrosis, or persistent diarrhea with weight loss and failure to thrive warrants pediatric consultation. Other causes may only require 24 h of rehydration solution and avoiding fatty or high-carbohydrate-containing foods for 2 or 3 days. Stool cultures are warranted in children with bloody diarrhea, diarrhea for more than 5 days, or toxic appearance or to track an epidemic form of illness.

Gastrointestinal Emergencies in Children 2 Years and Older

BLEEDING There are several systemic processes that can result in GI bleeding. Upper GI bleeding is usually the result of peptic ulcer disease, varices, or gastritis. Lower GI bleeding can be due to not only the previously mentioned diseases, but also due to infectious colitis, coagulopathies, ulcerative colitis, and Crohn's disease. Two other illnesses can cause abdominal pain and bleeding Henoch-Schonlein purpura (HSP) and hemolytic-uremic syndrome (HUS)

Topographic Diagnosis

Whether a lesion is located on the mesenteric side or the opposite side is an important clue in the differential diagnosis of intestinal diseases previously it could be determined only after surgical findings were available and surgical specimens obtained. Using double-balloon endoscopy, it is now possible without having to resort to surgery. When the double-balloon endoscope is used, the small intestine often forms concentric circles because of its insertion characteristics. In this case, the small intestine forms circles around the fan supported by the mesentery (Fig. 10.1.5). Under these conditions, the side facing the center of the concentric circles is the mesenteric side. When the endoscope tip is moved toward the center of the circles under fluoroscopic guidance, the wall coming into the endoscopic view is the one on the mesenteric side. In Crohn's disease, ulcers are often found longitudinally on the mesenteric side, and Meckel's diverticulum is characteristically found on the...

Pathophysiology of Stone Formation

Small bowel diseases Crohn's disease Terminal ileum resection Drugs Estrogens Ceftriaxone Other conditions predisposing to gall bladder disease Insulin-resistant diabetes predisposes to cholelithiasis. A Swedish study showed that the prevalence of gall stones in Crohn's disease was twice that seen in the general population. Cirrhosis is another major risk factor for gall stones. The incidence of gall stone formation in cirrhosis is 10 times that seen in the general population. The incidence increases with the severity of cirrhosis, being worse in Child's class B and C disease and in patients with higher body mass index. High estrogen level and reduced hepatic synthesis and transport of bile salts are reasons for the increased risk in cirrhosis. The Physicians' Health Study showed that 30 minutes of endurance-type exercise five times per week prevents approximately one-third of cases of symptomatic gall stones in men. The Nurses' Health Study confirmed the same trend in women.

Compounds That May Alter Folate Levels Metabolism

Sulfasalazine is used to treat ulcerative colitis and Crohn's disease. Folate deficiency often occurs in patients with inflammatory bowel disease, and risk may be worsened by treatment with sulfasalazine. This drug inhibits the intestinal absorption of folate, as well as enzymatic activity of dihydrofolate reductase, MTHFR, and serine hydroxymethylase (41). The drug is classified as pregnancy category B. Several case reports have suggested a terato-genic effect of the drug. A child with cleft lip and palate and hydrocephalus was born to a woman who had taken sulfasalazine prior to and throughout her pregnancy for treatment of ulcerative colitis (42). Stillborn twins were born to a woman with Crohn's disease who had taken the drug throughout her pregnancy one twin had a polycystic kidney on the left side and the other twin was missing both kidneys and ureters, had hypoplastic lungs and bladder, as well as undescended testes (43). A second case reported by these authors (43) described a...

Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) consists of two major illnesses, ulcerative colitis and Crohn's disease, which are chronic disorders of the intestine of unknown origin. Both diseases exhibit chronic inflammatory changes consisting of an intense infiltration of macrophages and lymphocytes with large numbers of plasma cells. In ulcerative colitis, the pathological changes include diffuse inflammation with mucosal ulcers. Involvement is restricted primarily to the mucosa, and not to deeper layers, such as muscle. In Crohn's disease, the inflammatory infiltrate frequently forms granulomas and may extend through all layers of the bowel wall. In both diseases, chronic inflammatory changes dominate the histological picture. However, Crohn's disease and ulcerative colitis can also exhibit acute inflammatory components. In active inflammatory bowel disease, there is a constant movement of acute inflammatory cells, including neutrophils and monocytes, from the circulation into the inflamed...

Immunoglobulin synthesis and secretion

Intestinal mononuclear cells from healthy mucosa normally secrete large amounts of IgA. In IBD, IgG cells are increased relative to IgA cells and are present in deeper tissue layers. The mucosal immune system exhibits a markedly heightened IgG immune response because of defective or altered immuno-regulation. In IBD, intestinal and peripheral blood mononuclear cells secrete increased immunoglobulin, particularly of the IgG isotype. The greatest increase in spontaneous IgG secretion is seen in ulcerative colitis where intestinal mononuclear cells secrete predominantly IgGl and IgG3. Crohn's disease intestinal mononuclear cells also exhibit increased IgGl, but secrete IgG2 rather than IgG3 (Figure 2). IgGl and IgG3 antibodies, which are increased in ulcerative colitis, are more potent activators of complement and opsonins than are IgG2 and IgG4. They are the major antibodies produced in response to protein antigens. IgG2, on the other hand, is the predominant antibody that responds to...

Complement pathway activation

Activated C3b deposited apically on the surface epithelium of involved mucosa. No deposits were seen in 31 matched noninflamed specimens or in 94 (16 of 17) of healthy controls. Strong colocalization of IgGl, activated C3b, and terminal complement complex was shown in 36 (4 of 11) of ulcerative colitis patients. Moreover, increased vascular deposition of terminal complement complexes occurred in both ulcerative colitis and Crohn's disease. Both C3 and C4 levels are elevated in jejunal perfusates of Crohn's disease patients when compared to healthy controls. Complement activation may initiate acute as well as chronic destruction of intestinal tissues and may result in the enhanced activation of granulocytes and macrophages leading to the increased release of potent chemotactic molecules by neutrophils (Figure 3).

Granulocyte and macrophage function

Peripheral blood granulocytes and monocytes isolated and radiolabeled with indium-11 1 in vitro and reinjected into patients, migrate to inflamed areas of the intestine. In one study, more than 90 of radiolabeled phagocytes accumulated rapidly in the inflamed intestine of 91 (20 of 22) of Crohn's disease patients. A further study on 15 patients with ulcerative colitis showed enhanced migration of similar cells into areas of inflamed bowel. The migration of leukocytes from the vascular lumen into the inflamed bowel is mediated through adhesion molecules, particularly LFA-1 (lymphocyte function-associated antigen 1, CDlla), which binds to ICAM-1 (intercellular adhesion molecule 1, CD54). In IBD, the expression of ICAM-1 on endothelial cells is increased and is accompanied by an increase of CDlla on mononuclear phagocytes (Figure 4).

Leukotriene synthesis

IBD mucosa produces larger quantities of lipoxygenase and cyclooxygenase products than normal mucosa. Lipid extracts of TBD mucosa contain large amounts of LTB4, up to 50-fold as much as normal mucosa. Levels of LTB4 are markedly higher in rectal dialysates from ulcerative colitis patients and decrease to normal levels after treatment with prednisolone. Crohn's colitis mucosa produces a three-fold increase in sulfidoleukotrienes (LTC4, LTD4, LTE4) compared to normal mucosa.

Animal models of inflammation induced by gene disruption

Cadherins are transraembranous glycoproteins that mediate cell adhesion. The cytoplasmic domain of N-cadherin includes a 3-catenin which, in turn, binds an a-catenin. The catenin-cadherin complexes regulate a variety of cell functions, including proliferation, polarity and migration. Disruptions of these interactions result in the development of IBD that closely resembles Crohn's disease. Chimeric mice, generated from normal blastocysts and genetically manipulated embryonic stem (ES) cells, have been used to study N-cadherin function. These B6< - 129 SV chimeric mice have patches of ES cell-derived, as well as the normal B6-derived, crypt villous units. The ES cell lineage is distinguished from the B6 cells by their ability to bind to Ulex europeus agglutinin type 1. Promoters are available that specifically express genes localized to the intestinal epithelium. ES cells transfected with such a promoter, the fatty acid binding promoter (Fabpi), linked to the negative cadherin (NCAD)...

Double Balloon Endoscopy for Stenosis of the Small Intestine

First, the endoscope is advanced to the stenotic site to observe the lesions. When epithelial changes protruding into the lumen due to a tumor or inflammation are found, the differential diagnosis of lesions can be made by routine observation. In most cases, histological examination leads to definite diagnosis. When no gross change in the luminal epithelium is found in the stenosis of the small intestine, adhesion, intestinal ischemia, nonepithelial tumor, and extrinsic compression by tumor outside the intestine should be considered. When a severe stenosis makes it difficult to direct endoscopic observation of the stenotic lumen, a selective contrast-enhanced study with the balloons of the endoscope and the overtube inflated before the stenotic site allows evaluation of the degree and length of the stenosis and provides useful information for the diagnosis. After contrast enhancement, a biopsy forceps may be carefully inserted under fluoroscopic guidance to collect tissues. In cases...

Hepatobiliary Disorders

Primary sclerosing cholangitis This disorder most commonly presents in association with ulcerative colitis and less commonly with Crohn's disease or as an isolated entity. The nutritional management of the disorder is essentially like that of other cholestatic disorders in patients with Crohn's disease of the small bowel, aggressive administration of an elemental diet rich in medium-chain triglycerides may be beneficial. It is accepted, however, that endoscopic interventions should be used as needed in the case of significant biliary obstruction. For prevention of severe osteoporosis, supplementation with vitamin D and calcium is needed. Vitamin K and alendronate may be beneficial in increasing bone mineral density. Serum levels of the fat-soluble vitamins should be monitored in high-risk patients and vitamins replaced as appropriate.

Fissure In Ano Anal Fissure

Anal fissures are often associated with swelling of the surrounding tissues, producing hypertrophic papillae proximally and the characteristic sentinel pile distally. The latter is frequently misdiagnosed as an external hemorrhoid when in actuality it is the result of edema and fibrosis secondary to the ulcerating fissure. In more than 90 percent of cases, anal fissures occur in the midline posteriorly. In 10 percent of women but in only 1 percent of men, it may be in the midline anteriorly. This almost constant location of anal fissures may be because of the posterior angulation of the rectum on the anus where the posterior midline of the anorectal canal becomes the lesser curvature for the passage of stool. A fissure not located in the midline should arouse suspicion that another, potentially life-threatening cause may be involved. Such diagnostic possibilities include Crohn's disease, chronic ulcerative colitis, squamous cell carcinoma of the anus, adenocarcinoma of the rectum...

Microsatellite Instability In Hnpcc And In Sporadic

Hereditary and sporadic MSI-H CRCs share several clinicopathological characteristics. These include right-sided location, poor differentiation, a medullary or mu-cinous phenotype, and extensive lymphocytic tumor infiltration, but specific characteristics for HNPCC and sporadic tumors exist as well. 9-12 Hereditary nonpoly-posis colorectal cancer is more common in males and occurs in younger patients compared to sporadic MSI-H colorectal carcinomas. Hereditary nonpolyposis colorectal cancers show more frequently Crohn's-like lesions and peritumoral lymphocytes than sporadic MSI-H CRCs. In contrast, sporadic CRCs are more likely to show two or more tumor subclones with diverse grades of differentiation than HNPCC tumors. 10 Adenomas from HNPCC patients are more often of the MSI-H phenotype than sporadic adenomas.

Pathophysiology and Symptoms

The most common cause of protein malabsorption is so-called protein-losing enteropathy. Etiologies include diffuse mucosal disease such as celiac disease or Crohn's disease, elevated right heart pressure with resultant dilatation of lymphatics and leakage of lymph into the lumen, and colitides such as Shigella or Salmonella infections. Since protein is a relatively minor component of dietary energy compared with carbohydrate and fat, symptoms of protein malabsorption can sometimes be minimal. However, infectious colitis or exacerbations of inflammatory bowel disease often present with frequent loose stools, which may be bloody. Rare, congenital etiologies of protein malabsorption include enterokinase and trypsinogen deficiencies (Table 1).

Carbohydrate Malabsorption

Lactose intolerance Lactose intolerance is defined by the occurrence of symptoms due to the inability to digest lactose, the main carbohydrate in milk. These symptoms may include abdominal pain, bloating, diarrhea, or flatulence. Lactose malabsorption is attributed to a relative deficiency of the di-saccharidase lactase. Primary lactase deficiency is a condition in which lactase activity declines after weaning. Secondary lactose intolerance is usually due to mucosal injury associated with a condition or disease such as infectious diarrhea, Crohn's disease, or short bowel syndrome.

The Reverse Paradigm Underlying Pathology Revealed by Detection of Abnormal Nutrition

Classically, in type 2 diabetes, unexplained weight loss is a presenting complaint when polyuria is mild or absent. Moreover, with common forms of childhood gastrointestinal disorders, such as celiac sprue or Crohn's disease, arrested linear growth is often the first clue that something is clinically awry. It provokes the diagnostic inquiry that leads to the recognition of the bowel lesions. In milder presentations of cystic fibrosis, a similar growth failure occurring in infancy, can indicate an underlying pathological disorder.

Dietary and Nutritional Management of Secondary Undernutrition

The syllogism for dietary and nutritional management is to get enough nutrients into the body to restore nutritional adequacy and balance, taking any chronic barriers to uptake and retention into consideration. The blend of nutrients must be tailored to the specific absorptive or utilization problems, e.g., compensatory fat-soluble vitamins in water-miscible forms with severe fat malabsorption, and extra doses of highly available iron with chronic blood loss. These can be delivered within a dietary context with supplements and fortified vehicles in nonacute conditions. Even nondietary routes have been devised as in the treatment of vitamin D deficiency due to Crohn's disease with tanning bed ultraviolet B radiation.

Potential Effects Requiring Further Clinical Work

Inflammatory bowel disease Inflammatory bowel disease (IBD) comprises a heterogeneous group of diseases of unknown etiology (Crohn's, ulcerative colitis, and pouchitis), but here also factors related to the intestinal microflora seem to be involved, providing a rationale for the application of probio-tics. From reviewing studies on the use of probiotics in IBD it can be concluded that, although there are some promising preliminary findings, more well-planned long-term studies are needed before any firm conclusions can be drawn.

Target Nutrient Intake Achievement Failed or Impossible

To disease and malnutrition), neurological impairment preventing oral feeding, substantially increased requirements with relative anorexia (e.g., in burn cases), or chronic obstructive lung disease with severe dyspnea. However, for diseases of the pharynx, esophagus, or stomach or in cases of surgery of the esophagus, stomach, or pancreas, patients usually require intubation of the stomach or intestine by percutaneous gastrostomy or operative jeju-nostomy to allow feeding beyond the site of obstruction. If there is an abnormality of the intestinal tract, such as short bowel with more than 60 cm of available small intestine, IBD, or chronic partial bowel obstruction, diets must be delivered carefully with the aid of a pump to avoid surges of delivered fluid diets and consequent distension of the bowel. Despite careful selection, a proportion of patients expectantly fed via the nasogastric or nasoenteral route will show intolerance, complications, or inability to meet target nutrient...

Pglycoprotein Gene Polymorphisms And Their Implications In Drug Therapy And Disease

Given the role played by Pgp in protecting tissues and organs from toxicants, it would not be surprising to find that polymorphisms play a role in human susceptibility to various disease states. mdr1 knockout mice spontaneously develop a form of colitis that can be prevented by antibiotic treatment,218 suggesting that Pgp functions as a defense against bacteria or toxins in the intestine. Confirming this idea, inflammatory bowel diseases (Crohn's disease and ulcerative colitis) are linked to the missense variant A893S T,219 and patients with ulcerative colitis (but not Crohn's disease) have a higher frequency of the C3435T genotype, which results in lowered Pgp expression in the intestine.220 Anti-HIV drugs are known to be Pgp substrates, so a link between treatment efficacy and Pgp polymorphisms would not be unexpected. Although several common polymorphisms had no apparent effect on susceptibility to infection,221 they were reported to influence drug treatment222'223 however, this...

Infections Food Poisoning

The vitally important area of food poisoning is dealt with in more detail elsewhere. This section outlines the principal infections affecting the small intestine. Bacteria such as Campylobacter jejuni, enteroinva-sive Escherichia coli (EIEC), shigella, salmonella, and yersinia can cause food poisoning, which is dominantly colitic (dysentery) with a bloody, pus-containing diarrhea, by invading the mucosal surface. Enterohemorrhagic E. coli produce a bloody diarrhea secondary to adherence in the colon and toxin production. These then dominantly affect the colon. Yersinia and (non-typhoid) salmonella domi-nantly invade the lower small bowel (ileum), producing low abdominal pain and diarrhea. Yersinia infection can be acute or occasionally more chronic, mimicking Crohn's disease. Tuberculosis is another chronic infection that can affect especially the terminal ileum and mimic Crohn's disease. Other infective agents, such as enterotoxigenic E. coli (ETEC)

Balloon Dilatation and Stenting

A Stenosis of the small intestine associated with Crohn's disease B Balloon dilatation while monitoring the stenotic site through the balloon C Stenotic site after dilatation A Stenosis of the small intestine associated with Crohn's disease B Balloon dilatation while monitoring the stenotic site through the balloon C Stenotic site after dilatation

Artificial Nutritional Support

For feeding over longer time periods, a PEG tube inserted under local anesthetic offers greater comfort, toleration, ease of use, and reported improvements in nutritional status. However, costs are greater and this more invasive procedure carries a technique-related fatality of 1-2 . Minor complications include sto-mal sepsis, leaking, and outlet blockage. Peritonitis, perforation, gastrointestinal bleeding, and intestinal obstruction can occur, but are rare. Most enter-ostomy catheters are made from nonacid-hardening polyurethane or silicone and can be left in situ for up to 6 months. No consensus exists concerning the time period within which gastrostomy feeding should be initiated following stroke, but it should he considered where dysphagia is likely to persist beyond 14 days, and earlier for those intolerant of nasogastric tube feeding. In a small number of cases, enteral nutrition may be contraindicated following stroke owing to gastrointestinal bleeding resulting from severe...

Modifying the intestinal ecosystem

Linkage of the CARD15 polymorphisms and other PRR polymorphisms with a subset of human Crohn's disease incriminates defective interpretation of the local microenvironment Enteroadherent and intramucosal bacteria are increased in Crohn's disease Crohn's-like lesions that respond to antibiotics or correction of immune defect 5.4.5 Probiotic and prebiotic studies in Crohn's disease The evidence for therapeutic efficacy of probiotics in Crohn's disease is varied and inconclusive (Table 5.4). There have been very few randomised controlled clinical trials. Small patient numbers, differences in disease activity and variations in disease distribution have confounded most trials. One of the earliest studies examined the use of Saccharomyces boulardii (Biocodex Laboratories) in patients with moderately active Crohn's disease. There was a significant decrease in the Crohn's disease activity index (CDAI) compared with the control group (Plein and Hotz, 1993). S. boulardii has been used also in...

Psoas Abscess and Hematoma

Iliopsoas Abscess Crohn Disease

Psoas abscesses generally do not originate within the psoas compartment but spread here from neighboring intraabdominal structures.275 Most psoas abscesses have a pyogenic origin and generally are due to direct spread from spinal or epidural infections, bowel conditions such as Crohn's disease, diverticulitis, appendicitis, perforated colon cardinoma, and perirenal abscesses. Primary abscesses rarely occur and are usually Fig. 8-222. Pyogenic psoas abscess secondary to fistulization from Crohn's enteritis. (b) At a lower level, a fistula between the bowel involved by Crohn's disease and the iliopsoas muscle (arrow) is revealed. Fig. 8-222. Pyogenic psoas abscess secondary to fistulization from Crohn's enteritis. (b) At a lower level, a fistula between the bowel involved by Crohn's disease and the iliopsoas muscle (arrow) is revealed.

Immunomodulatory effect of transfusion

The transfusion of various allogeneic blood components is circumstantially linked with subtle immunosuppressive effects. Whole blood transfusions may enhance renal allograft survival and reduce relapse rates of Crohn's disease. In some murine models tumor growth and bacterial infection can be

Acquired anorectal disorders

Rarely, Crohn's disease and immunodeficiency can present with laterally located anal fissures. Perianal abscess occurs commonly in infants and is treated by incision and drainage. Approximately one third of abscesses develop into a fistula-in-ano. Fistulas which persist after infancy are treated by fistulectomy. Crohn's disease should be considered in older children with multiple fistulas.

Granulomatous Disease

CROHN'S DISEASE Crohn's disease is an inflammatory disease that may affect the entire gastrointestinal tract from mouth to anus. A wide variety of oral lesions may be associated with Crohn's disease. The most common lesions are diffuse or nodular swelling of the oral and perioral tissue, a cobblestone appearance to the mucosa, and deep granulamatous ulcers surrounded by hyperplastic margins, fissuring on the midline of the lower lip. Oral lesions may be asymptomatic or painful. Additionally, angular cheilitis and submandibular lymphadenopathy can occur. Metallic dysguesia and gingival and buccal mucosal bleeding have been reported. Although these findings may be associated with any orofacial granulomatosis, it is important to note that the oral manifestations of Crohn's disease precede the gastrointestinal lesion in 30 percent of patients. 44

Duodenocolic Fistulas

Proximal Transverse Colon

Although most duodenocolic fistulas result from an infiltrating adenocarcinoma of the hepatic flexure,11 the communication may be established by ulcerative or inflammatory disease.1214 Granulomatous colitis is being increasingly recognized as an underlying cause.13,14 With the right-sided colonic involvement of this transmural inflammatory and ulcerating condition, fistulization may develop between the hepatic flexure particularly or the transverse colon and the duodenum (Figs. 10-14 through 10-16). Malabsorption may result if the small bowel is bypassed significantly, but the fistula need not be a serious complication of Crohn's disease and should not serve as an indication for surgical correction for its own sake.13-15 Intestinal tuberculosis is another chronic granulomatous disease that may result in fistulization16,17

Recent Issues Affecting The Uk Food Chain

Some preliminary evidence indicates that some cases of Crohn's disease may be linked to infection with Mycobacterium paratuberculosis, which is present in some dairy cows (11). The organism has been the subject of several studies in the UK because of the possibility of some cells surviving conventional pasteurization when levels of contamination are high. MAFF has commissioned a survey of raw and pasteurized cow's milk to determine the incidence of contamination with viable M. paratuberculosis cells.

Endoscopic Treatment of Small Intestinal Bleeding

Hemostatsis And Treatment

The second consideration is the pathophysiology of bleeding lesions in the small intestine. The usefulness of identifying an exposed vessel and the technique for accurate hemo-stasis of the exposed vessel have been demonstrated for peptic ulcers in the stomach and the duodenal bulb. Various conditions, such as Crohn's disease, Behcet's disease, and nonsteroidal antiinflammatory drug (NSAID) use, may induce ulceration in the small intestine. We rarely have identified and treated exposed vessels in patients with intestinal ulcers associated with these pathological conditions. However, intestinal Behcet's disease is often associated with deep ulcers, which can result in massive bleeding that necessitates emergency surgery. Similarly, Crohn's disease may lead to massive bleeding. Thus, treatment of ulcerative lesions requires the establishment of diagnostics to evaluate the depth and appearance of ulcers and to assess the bleeding risk, as well as therapeutic techniques for visible...

Food Intolerance and Allergy

Secondary food sensitivities are adverse reactions to food that occur as a consequence of other conditions. Examples include secondary sensitivities to gastrointestinal disorders or to drug treatment. Lactose intolerance is an adverse effect to lactose and occurs secondarily to a gastrointestinal disorder. Individuals who take antide-pressant drugs have an increased sensitivity to tyramine. Secondary food sensitivities often disappear within a few weeks after recovery from the illness or discontinuation of drug therapy. A variety of gastrointestinal illnesses can enhance the chance of developing food allergies, such as bacterial or viral gastroenteritis, cystic fibrosis, Crohn's disease, and ulcerative colitis.

Stem Cells in the Gastrointestinal Tract

Turnover of the epithelial cell lineages within the gastrointestinal tract is a constant process, occurring every two to seven days under normal homeostasis and increasing after damage. This process is regulated by multipotent stem cells, which generate all gastrointestinal epithelial cell lineages and can regenerate whole intestinal crypts and gastric glands. The stem cells of the gastrointestinal tract are as yet undefined, although it is generally agreed that they are located within a niche in the intestinal crypts and gastric glands. Studies of allophenic, tetraparental chimeric mice and targeted stem cell mutations suggest that a single stem cell undergoes an asymmetrical division to produce an identical daughter cell, thus replicating itself, and a committed progenitor cell, which further differentiates into an adult epithelial cell type. The discovery of stem cell plasticity in many tissues, including the ability of transplanted bone marrow to transdifferentiate into intestinal...

TABLE 846 Complications of Laparoscopy

SIOMAS Ihe two most common stomas placed are the ileostomy and the colostomy. Problems with these stomas can be quite debilitating. Most complications are related to technical errors as to where the stomas are placed however, there can be problems of new disease within the stoma (e.g., Crohn's disease or cancer). Possible complications include ischemia and stomal necrosis, peristomal skin irritation, peristomal hernia, and stomal prolapse.

Biochemistry on the Internet

Protein Modeling on the Internet A group of patients suffering from Crohn's disease (an inflammatory bowel disease) underwent biopsies of their intestinal mucosa in an attempt to identify the causative agent. A protein was identified that was expressed at higher levels in patients with Crohn's disease than in patients with an unrelated inflammatory bowel disease or in unaffected controls. The protein was isolated and the following partial amino acid sequence was obtained (reads left to right)

Effect of maternal immunity on the child

There is also evidence that human milk contains agents that may work as immunomodulators. Retrospective epidemiologic studies suggested that breastfed infants are at less risk of developing type I diabetes mellitus, lymphoma and Crohn's disease later in childhood. In the case of diabetes there is evidence suggesting that antibodies to a 17 amino acid peptide from bovine albumin cross-react with a protein (p69) found on the surface of certain pancreatic islets. It is also of interest that maternal renal allografts have a better survival in individuals who were breastfed rather than those that were not breastfed.

Colorectal Cancer Background and aetiology

Chronic inflammatory conditions often predispose to car-cinogenesis and in the colon and rectum this is best demonstrated by chronic UC. The risk of developing malignancy is related to the duration and extent of colitis. An approximate incidence of 10 per annum after a decade of extensive colitis is often cited. However, careful surveillance for dysplasia and precursor lesions followed by colectomy can reduce this risk. Similar risks and surveillance strategies apply to Crohn's colitis.

The pathogenesis of IBD

Both Crohn's disease and ulcerative colitis represent the clinical outcome of a complex interaction of immune, genetic, and environmental factors. The normal physiological response to indigenous micro-organisms is one of immunological quiescence. Deviations from this, and in particular, genetically-influenced aberrant immune responses to luminal antigens are now recognised to underlie IBD. The intestinal barrier can be impaired in IBD. Defects in epithelial barrier function may precede the onset of inflammation and lead to persistent immune activation (Irvine and Marshall, 2000). Leukocyte recruitment from the gut vasculature contributes to the initiation and perpetuation of mucosal inflammatory responses. Upregulation of various transcription factors including nuclear factor (NF)-kB, the master coordinator of immune responses to danger signals, drives the subsequent excessive local release of a diverse array of immune mediators. These include cytokines, growth factors, reactive...

Epidemiology

IBD presents in a bimodal manner as pertains to age, first in late adolescence or early adulthood and a smaller peak in the fifth decade of life. The sexes are equally affected by ulcerative colitis in adults, the incidence of Crohn's disease is 20-30 higher in women. In terms of trends in disease over time, the incidence of ulcerative colitis remained stable during the second half of the twentieth century Crohn's disease has demonstrated a marked increase across all age groups since 1950. Although IBD can affect all races, Caucasians are affected significantly more than Africans or people of African origin. Colonic risk of cancer from inflammatory bowel disease (Crohn's disease and ulcerative colitis) A high rate of concordance among Swedish mono-zygotic twins versus dizygotic twins has been reported for Crohn's disease (44 vs 3.8 ). In the same study, the incidence rate observed in monozy-gotic twins for ulcerative colitis was 6.3 . These data, although supportive of a genetic role,...

Future trends

Although naturally occurring probiotics may have insufficient efficacy in Crohn's disease, the genetic modification of commensal bacteria for the site-specific delivery of therapeutic molecules represents a realistic pharmabiotic strategy. Proof of principle has already been demonstrated in animal models of enterocolitis. Genetically engineered Lactococcus lactis has been used to deliver anti-inflammatory IL-10 or the cytoprotective trefoil factor locally to the gut (Steidler et al., 2000 Vandenbroucke et al., 2004). The safety issues related to genetic modification have been addressed by replacing the thymidylate synthase (thy A) gene in L. lactis with a synthetic therapeutic transgene. When the modified bacteria are deprived of thymine or thymidine they are not viable. Neither thymine nor thymidine are readily available in the external environment, thereby limiting the viability of the excreted organism. Moreover, the transgene would be eliminated from the bacterial genome if the...

Pathology

The most important pathologic feature of Crohn's disease is the involvement of all the layers of the bowel and extension into mesenteric lymph nodes. In addition, the disease is discontinuous, with normal areas of bowel (skip areas) located between one or more involved areas. On gross inspection, the bowel wall is thickened subsequent luminal narrowing results in stenosis and obstruction of the intestine. The mesenteric fat often extends over the bowel wall (creeping fat). The appearance of the mucosa varies with the extent and severity of the disease. Longitudinal, deep ulcerations are characteristic. These often penetrate the bowel wall, resulting in fissures, fistulas, and abscesses. Late in the disease, a cobblestone appearance of the mucosa results from the criss-crossing of these ulcers with intervening normal mucosa. Microscopically, there is an inflammatory reaction that extends through all layers of the intestine but is most marked in the submucosa. This inflammatory response...

Bowel Disorders

In inflammatory bowel disease (IBD) high fiber diets have no special part to play in the management of Crohn's disease where enteral feeding (with formula low-residue, low-fiber preparations) is especially beneficial where there is acute extensive small bowel disease. In ulcerative colitis specific dietary advice is usually unnecessary though fiber supplements may be of benefit in patients whose disease is limited to proctitis (inflammation of the rectum).

Etiology

Mechanical small bowel obstruction (SBO) is one of the most common problems for which the general surgeon is consulted. Although incarcerated groin hernias were the most common cause of SBO in the past, the increase in elective hernia repairs as well as laparotomies over the last several decades have led to adhesions being by far the most common cause of SBO in adults. Hernias are still a common cause of SBO as are Crohn's disease, small bowel neoplasms, radiation enteritis, and miscellaneous other causes such as volvulus, foreign bodies, and gallstone ileus4 (Table 10-1). Ileus, or functional bowel obstruction, is also in the differential diagnosis of many patients. In addition to dehydration and electrolyte abnormalities from fluid losses, the most important complication of SBO is small bowel strangulation due to closed loop obstruction.

Fistula

The diagnosis of diverticular abscess requires investigation because other factors can result in a fistula, namely Crohn's disease. Surgery is the most appropriate course of action with a diverticular fistula, involving resection of the diseased section of colon, repair to the other organ and a primary anastomosis. Alternatively, if a primary anastomosis is not appropriate, a colostomy will allow the fistula to heal and the bowel to be rested.

Fistulainano

The so-called 'cryptoglandular hypothesis' ascribes the aetiology of fistula-in-ano to the glands that sit in the inter-sphincteric space around the anal canal. Spread of sepsis from an infected gland leads to perianal abscess which usually presents acutely (see above). Epithelialisation of the track leads to establishment of a fistula-in-ano. A classification of fistulas by the late Sir Alan Parks in 1976, described four main groups intersphincteric, transsphincteric, supras-phincteric and extrasphincteric. A full assessment of a fistula-in-ano requires the identification of the internal and external openings, the primary track, any secondary extension and any diseases complicating the situation. Extensions occur in approximately 10-15 of patients, and are more prevalent in recurrent or Crohn's fistulas.

Cytokine production

Levels of IL-1 are increased in inflamed mucosa from patients with both Crohn's disease and ulcer- Using polymerase chain reaction, higher levels of IL-1, IL-6, and TNFa mRNA have been demonstrated in Crohn's disease and ulcerative colitis patients than in normal subjects. MacDonald and colleagues using a spot ELISA technique, demonstrated that TNFa-secreting intestinal mononuclear cells are increased in frequency in both Crohn's disease and a subgroup of ulcerative colitis patients in comparison with normal controls. These obser The spontaneous secretion of IL-6 is increased by-lamina propria mononuclear cells from ulcerative colitis patients. This secretion appears to be less marked in Crohn's disease than in ulcerative colitis. Many of the biologic activities of IL-1, IL-6, and TNFa that amplify inflammatory and immunological processes overlap. Therefore, sustained inflammation leading to tissue destruction in IBD could potentially be mediated by the potent proinflammatory...

Anorectal Abscesses

Deep Postanal Space

Most abscesses in the anorectal area are the result of obstruction of an anal gland that opens in the base of an anal crypt and normally drains into the anal canal. When obstruction occurs, the gland orifice is blocked, resulting in infection and abscess formation. An element of cryptitis can frequently be identified by anoscopic examination. A variety of diseases are associated with the development of fistulous abscesses, including Crohn's disease, carcinoma of adjacent organs, Hodgkin disease, tuberculosis, and gonococcal proctitis.

Indications

Home parenteral nutrition The main indications for HPN are Crohn's disease, ischaemic bowel disease, motility disorders, or bowel and malignant disease. Patients receiving HPN are usually younger than those who receive HETF, although there is an overlap. There are also differences between the practice of HPN in different countries. One of the main differences concerns malignant disease. In the United States, 40-50 of patients receiving HPN have been reported to have cancer, and similar if not higher percentages have been reported in some European countries, such as Italy. Early reports from the United Kingdom and Denmark suggested that only a small proportion of HPN ( 5 ) involved patients with cancer, although this has increased with time. For example, in the United Kingdom it has steadily increased so that by 2003, one in seven patients starting HPN had cancer.

Outcome

The most important predictor of outcome in patients receiving home artificial nutritional support (enteral or parenteral) is the underlying disease. Therefore, mortality statistics strongly depend on the initial indications. Nevertheless, a few conclusions can be made. First, the complications associated with artificial nutritional support vary but are reported to be responsible for less than 3-5 of deaths. Second, the outcome is dependent not only on the type of disease but also on the stage of the disease (e.g., patients with advanced HIV who start HPN are only expected to survive a few months, whereas patients with less advanced disease are expected to survive longer). Third, the outcome of patients receiving HPN and HETF for a variety of conditions is available from the British Artificial Nutrition Survey (Table 6). For patients on HPN, overall mortality at lyear is 11 , with 16 returning to oral feeding and the majority continuing with HPN. Patients with Crohn's disease often...

Acute Gastritis

Acute gastritis can be caused by a variety of exogenous and endogenous agents (Table 3.11). More often than in chronic gastritis, endoscopy reveals signs that point to the correct diagnosis (Table 3.12 Fig. 3.78). The endoscopic features do not suggest a specific causative agent of the gastritis, however. The diagnosis of acute gastritis often relies on the clinical presentation (upper abdominal pain, anorexia, nausea, vomiting) plus the en-doscopic findings, with histology showing little or no evidence of cellular infiltrate. The main role of biopsy is to distinguish between the various specific forms of gastritis (due to Crohn disease, infection, etc.).

Summary

Sigmoid Diverticulosis

Diverticular involvement by Crohn's disease. Fig. 15-67. Diverticular involvement by Crohn's disease. Fig. 15 68. Diverticular involvement by Crohn's disease. (a) Crohn's disease is evident by the indentation and ulceration on the left side of the rectum and the gross changes in the proximal sigmoid colon (arrows). Multiple diverticula are present. (a) Crohn's disease is evident by the indentation and ulceration on the left side of the rectum and the gross changes in the proximal sigmoid colon (arrows). Multiple diverticula are present. An extremely long continuous tract follows the mesenteric border of the sigmoid, descending, and transverse colon. It can be presumed that this striking paracolic localization is due to the communicating form of peridiverticulitis as a consequence of involvement by Crohn's disease. An extremely long continuous tract follows the mesenteric border of the sigmoid, descending, and transverse colon. It can be presumed that this striking...

Role of the TfR

The depletion of TfR membrane levels or the blockade of transferrin binding with TfR-specific antibodies inhibit cell proliferation probably due to inhibition of iron uptake. In addition, it has been shown that antisense oligonucleotides inhibited progression of mitogen-activated lymphocytes into the cell cycle, synchronizing the cells in G,. Similar effects were produced by the serum immunosuppressive factor from patients with Crohn's disease that has been shown to inhibit progression of phytohemagglutinin (PHA)-stimulated peripheral blood mononuclear cells (PBMCs) beyond Go G This inhibition correlated with downregulation of TfR from the cell surface, although IL-2 receptor expression and IL-2 secretion were not affected.

Bowel Rest

PN is often used when continued use of the gastrointestinal tract may not be advisable. PN may be selected for inflammatory bowel disease patients with severe acute exacerbations or for perioperative care. For patients with Crohn's disease, PN may aid the management of complications such as intestinal obstruction, fistula formation, short bowel syndrome, and severe diarrhea. Otherwise, enteral nutrition support is frequently used for nutrition support in inflammatory bowel disease with comparable efficacy. Bowel rest may also be indicated for selected enterocutaneous fistulas, which can occur as a result of complicated Crohn's disease, gastrointestinal or abdominal abscesses, abdominal surgery or trauma, ischemia, or tumors or their accompanying treatment regimens such as chemoradiation. Bowel rest can help to promote potential closure of fistulas and can improve nutritional status of these patients. Depending on the output of the fistulas, many of these patients are at risk for...