Crohns Disease

Hayley Aanestad

What is Crohns Disease?

A disease that causes inflammation and irritation in the
GI tract.
Most commonly affects the ileum of the small intestine.
No known cure.

Sauer, C. Crohns Disease

What is Crohns Disease cont.

Inflammation extends deep into the lining of the
affected part of the GI tract.
Swelling and ulceration can cause pain and can make
the intestine empty frequently, resulting in diarrhea.
Chronic inflammation can cause scar tissue to build up in
the intestine, creating a narrow passageway that can
slow the movement of food, causing pain or cramps.

Sauer, C, Crohns Disease

Crohns Disease vs. Ulcerative

Colitis
Irritable Bowel Disease (IBD): The
general term for diseases that cause
inflammation and irritation to the
intestines.
Crohns Disease is a type of IBD.

The other type of IBD is Ulcerative

Colitis.
Both have similar signs and symptoms,
but each affect a different part of the GI
tract.

Sauer, C, Crohns Disease

Inflammatory Bowel DiseaseFebruary ;2011

Healthy vs. Crohns Disease

Cheifetz, A, Crohns Disease (Diagnosis)

Etiology
Remains largely unexplained, although there have been
major advances in the understanding of the pathogenic
mechanisms underlying the intestinal inflammation.
Factors involved include:
Genetic predisposition
External environment
Intestinal microbial flora

Immune System
Appendectomy

Lichtenstein, G , Crohn's Disease: the complete guide to medical management

Etiology: Genetic Predisposition

Still ongoing research as to whether or not genetics are

a factor in the development of CD.
A first clue to the possible role of a genetic factor of CD
was the observed discrepancy in disease incidence
among different populations.
CD is a relatively common disorder in North America and
Europe

Lichtenstein, G , Crohn's Disease: the complete guide to medical management

Etiology: Environmental Factors

Epidemiological studies suggest that the prevalence of
CD is higher in industrialized countries.
This has been explained by the "hygiene hypothesis," or
the lack of exposure to microbial antigens early in life
due to changing sanitation conditions.
A variety of environmental factors are considered to be
risk factors for CD including:
Smoking
Drugs
Diet

Lichtenstein, G , Crohn's Disease: the complete guide to medical management

Smoking

Patients who smoke or have smoked in the past are at a

high risk for developing CD.
History of smoking also has deleterious effects on the
course of the CD, including greater recurrence after
surgical and endoscopic procedures, more operations
and complications, and a reduced quality of life.

Lichtenstein, G , Crohn's Disease: the complete guide to medical management

Drugs

Although the relationship is controversial, it is believed

that oral contraceptives are associated with CD.
Thought to cause the formation of blood clots causing
intestinal necrosis.

Lichtenstein, G , Crohn's Disease: the complete guide to medical management

Diet
Several potential biological mechanisms for how diet
may be involved in the etiology include: modification of
inflammatory processes, alteration of gut microbiota,
and toxic actions of nutrients on the mucosa.
Proteins, lipids, fiber, phytochemicals, and minerals have
the potential to modify each of these aspects

Effects of diet on inflammation may involve the

consumption of different groups of polyunsaturated fatty
acids (PUFAs)

de Silva, P , 'Is Diet Involved in the Etiology of Ulcerative Colitis and Crohns
Disease?

Diet cont.: Potential Mechanisms

of the diet in the etiology of IBD
Dietary Agent

Potential Mechanisms

PUFAs

Altering the production of mediators of inflammation

including prostaglandins,
leukotrienes and lipoxins, together with effects
on nuclear receptors, including peroxisome
proliferator-activated receptor expression

Effects on the composition of the gut microbiota

Bactericidal properties

Fiber (Soluble)

Substrate for gut microflora that synthesize

short-chain fatty acids, which are the
energy source for colonocytes and have
direct effects on mucosal healing

Sulfur

Metabolized to anionic sulfides that impair the ability of

colonocytes to utilize short-chain fatty acids as an
energy source.

Selenium

Constituent of the enzyme glutathione peroxidase,

which reduces reactive oxygen species

Vitamin D

Modulation of pro-inflammatory T cell function

de Silva, P , 'Is Diet Involved in the Etiology of Ulcerative Colitis and Crohns
Disease?

Etiology: Intestinal Microbial

Flora

One theory in the pathogenesis of CD is the balance

between protective and harmful intestinal bacteria.
Patients with CD have increased numbers of harmful
bacteria (Clostridium perfringens and enterobacteriaceae)
and decreased numbers of beneficial bacteria
(Bifidobacteria).

Andoh, A , 'Recent Advances in Molecular Approaches to Gut Microbiota in

Inflammatory Bowel Disease '

Etiology: Immune System

Pro-Inflammatory T-cells and their secreted cytokines

have been seen to be involved in intestinal
inflammation.
T-cells and inflammatory complexes can have a constant
immune response, creating chronic inflammation.

Mudter, J , 'Insight into Crohns disease pathomorphology'

Etiology: Appendectomy

There have been many studies examining the

relationship between CD and appendectomies. Two
theories that have been proposed are:
symptoms of CD and appendicitis can be similar, and many
diagnoses of appendicitis can mask an undiagnosed CD
removal of the appendix causes an imbalance of the gut
immune system, which may be responsible for initiating the
disease

Lichtenstein, G , Crohn's Disease: the complete guide to medical management

Nutrition Diagnosis
Malnutrition occurs in up to 85% of CD patients and is
associated with many nutritional deficiencies including:
Energy
Protein
Iron
Folate
Calcium
Vitamin B12
Magnesium
Zinc
Fat-soluble vitamins
Lomer M.C.E., Gourgey R. & Whelan K. (2014)Current practice in relation to
nutritional assessment and dietary management of enteral nutrition in adults with
Crohns disease

Nutrition Diagnosis cont.

Mechanisms include:
Impaired nutrient absorption as a result of inflammation or
surgical resection
Reduced nutrient intake as a result of poor appetite or food
avoidance
Drug-nutrient interactions
Increased nutritional requirements as a result of
inflammation and diarrhea resulting in fluid loss and
electrolyte loss

Lomer M.C.E., Gourgey R. & Whelan K. (2014)Current practice in relation to

nutritional assessment and dietary management of enteral nutrition in adults with
Crohns disease

Nutritional Treatment
Nutritional assessment and dietary management in CD
play an important role in patient treatment.
These include identifying and treating macronutrient and
micronutrient deficiencies, educating about dietary
requirements, and counseling about restrictions and other
nutritional problems during relapse and remission

Reduce inflammation and bowel irritation through

nutritionally rich foods that nourish and heal the bowel.
This will allow for restoration of nutrition status, bowel rest,
and overall improved health.

Dalessandro, T , What to Eat with IBD

Lomer M.C.E., Gourgey R. & Whelan K. (2014)Current practice in relation to
nutritional assessment and dietary management of enteral nutrition in adults with
Crohns disease.

Nutritional Treatment cont.

Tips for eating with CD:
1. Eat fruits and vegetables that soothe the bowel and avoid
ones that irritate.
2. Choose grains and breads rich in soluble fiber and avoid
those high in insoluble fiber.
3. Avoid an excess of dairy, which promotes mucous production,
but obtain other sources of calcium.
4. Avoid fried, processed, and cured foods that irritate the
bowel and cause diarrhea.
5. Cook healthy, nutrient-rich foods that are easily digested and
absorbed.
6. Choose oily fish over meat and replenish essential oils that
coat the bowel and reduce inflammation.
7. Replace losses with the proper supplements in necessary
forms and amounts.

Dalessandro, T , What to Eat with IBD

Sample Menu
For the average adult with Crohns Disease
Breakfast:

Applesauce Muffins with Streusel Topping

cup canola oil
4 tbs. melted butter
cup packed brown sugar
1 cup unsweetened applesauce
2 large eggs
1 tsp vanilla
1 cups all-purpose flour
cup oat flour

- These muffins are

packed with soluble
fiber from the
applesauce and oat
flour to help slow
digestion in the
gut.

2 tsp. baking powder

tsp. salt
1 tsp cinnamon

tsp. pumpkin pie spice

Dalessandro, T , What to Eat with IBD

- The soluble fiber

also helps the
intestine absorb
water.

Sample Menu
Lunch:

Harvest Vegetable Soup

2 tbs. olive oil

- Parsnips, carrots,
squash, and potato make
this soup rich in vitamins.

2 tbs. butter
1 small onion, chopped
2 parsnips, peeled and cut

1 butternut squash, peeled and

cut
1 16oz. bag baby carrots
1 white potato, peeled and cut
32 oz. vegetable or chicken broth

2 cups apple cider

3 tbs. brown sugar
1 tsp salt
heavy whipping cream
Dalessandro, T , What to Eat with IBD

- Full of beta carotene

and other antioxidants,
like vitamin C.

Sample Menu
Dinner:

Honey Mustard Salmon with

Sauted Spinach
1 pound wild salmon
2 tbs. Dijon mustard

Salmon is packed with

inflammation-fighting
omega-3 fish oils.

Spinach is one of the most

nutritious vegetables.

1 cup of spinach provides

245mg calcium, 839mg
potassium, and 14 IU of
vitamin A.

Along with nutritious,

cooked spinach is also easy
on the digestive system

2 tbs. honey
Salt and pepper
1 large bag of baby spinach
1 clove fresh garlic

1 tbs. olive oil

1 tbs. butter

Dalessandro, T , What to Eat with IBD

Sample Menu
Snack:

Vanilla Peach High-Protein Shake

1 scoop vanilla Spiru-tein
1 cup lactose-free milk or soy milk
4 slices frozen peaches
cup orange juice
Ice

- Adding protein
powder adds extra
protein and vitamins.

Dalessandro, T , What to Eat with IBD

Assessment of Patient with

Crohns Disease

Monitoring tools for CD include:

Symptom-based monitoring
Endoscopy
Laboratory based monitoring
Cross-sectional imaging

Papay, P , 'Optimising monitoring in the management of Crohn's disease: A

physician's perspective' ,

Symptom-based Monitoring
There are several scoring systems used to evaluate the severity of
symptoms in patients with CD:
Symptom-based scoring systems
Crohn's Disease Activity Index (CDAI)

Consists of eight factors, including frequency of

soft/liquid stools, severity of abdominal pain, general
well-being, presence of extraintestinal manifestations,
requirement for antidiarrheal medication, presence of
an abdominal mass, hematocrit level, and percentage
deviation from standard body weight.

HarveyBradshaw Index (HBI)

A simple index restricted to clinical parameters of

general well-being, abdominal pain, frequency of liquid
stools presence of an abdominal mass and
extraintestinal manifestations.

Inflammatory Bowel Disease Questionnaire

(IBDQ)

Incorporates social, systemic and emotional

symptoms together with bowel-related symptoms into
an activity index.
Shown to be valid and reliable across several
different language and culture settings
May have a stronger correlation with utility than the
CDAI.
A shortened version of the IBDQ has also been
developed and is considered able to detect meaningful
clinical changes in health-related quality of life.

Papay, P , 'Optimising monitoring in the management of Crohn's disease: A

physician's perspective' ,

Endoscopy

Examination of the interior of organs using an

endoscope.
Mucosal healing is an important goal in CD
management.
Several endoscopy scoring systems have been created to
facilitate consistent assessment of the severity of
mucosal damage at specific sites.

Papay, P , 'Optimising monitoring in the management of Crohn's disease: A

physician's perspective' ,

Endoscopy cont.
Endoscopic Scoring Systems
Crohn's Disease Endoscopic Index of Severity
(CDEIS)

Five segments are individually scored based on

the presence of deep or superficial ulcerations and
the extent of surface involved by disease or
ulcerations.
Scores range from 044, with a higher score
indicting greater severity.

Simple Endoscopic Score for Crohn's Disease

(SES-CD)

Five segments are individually scored based on

the presence and size of ulcers, extent of the
ulcerated surface, extent of the affected surface and
the presence and type of narrowings.
Scores range from 056, with a higher score
indicting greater severity.
SES-CD has been shown to correlate strongly with
the CDEIS and also with symptom-related
measures.

Rutgeerts score for post-operative recurrence

Lesions at the neoterminal ileum and ileocolonic

anastomosis are explored and scored on a scale
from i0 to i4.
Score has been shown to predict the duration of
symptom-free survival.

Papay, P , 'Optimising monitoring in the management of Crohn's disease: A

physician's perspective' ,

Laboratory based monitoring

Multiple biomarkers that reflect the presence of active

inflammation have been identified; however, only a few
of them have been proven to be useful in CD.
C-reactive protein (CRP) , is inexpensive to measure with a
readily available blood test.
Fecal calprotectin and lactoferrin are other proteins that
have been studied in IBD and CD.
Both biomarkers can be assayed directly in stool using
ELISA-based testing.

Papay, P , 'Optimising monitoring in the management of Crohn's disease: A

physician's perspective' ,

Cross-sectional imaging
Cross-sectional imaging tools are important in CD for
establishing disease severity and extent, as well as
ruling out complications.
Can aid in diagnosis and guide therapeutic strategies
Allows assessment of entire small bowel to rule out
complications such as stenosis or penetrating disease

Various cross-sectional imaging tools are available

including:
MRI
Ultrasonography
CT
Papay, P , 'Optimising monitoring in the management of Crohn's disease: A
physician's perspective' ,

Medications for CD
Medication regimens are prescribed according to the
location and stage of the disease activity.

Some of the common medications for CD include:

Corticosteroids: short-term anti-inflammatory
immunosuppressants used for treatment of acutemanifestations
in all disease stages
Antibiotics: used in all stages of disease activity to treat
inflammation, abscesses, fistulas, and perianal CD
In severe CD, metronidazole and ciprofloxacin are often given
concurrently

Aminosalicylate (5-ASA) anti-inflammatory agents:

primarily targets the colon
mesalazine that targets different sites in the GI tract

Azathioprine or methotrexate: immunomodulators that

interrupt the immune response and reduce inflammation

Caple, C, ;Crohn's Disease: Inducing/Maintaining Remission with

MedicationsNovember ;2013

Summary
Crohns Disease is a disease that causes inflammation and
irritation in the GI tract.

No exact cause of the disease, but can be affected by many

different factors.
Malnutrition is a common nutrition diagnosis involved with
Crohns Disease.
Nutritional treatment for patients with Crohns involves
eating foods that will reduce inflammation and be absorbed
easily.
Assessments for Crohns include Symptom-based
monitoring, endoscopy, laboratory-based monitoring, and
cross-sectional imaging.
Common medications for Crohns disease are
corticosteroids, antibiotics, aminosalicylate (5-ASA) antiinflammatory agents, and azathioprine

Work Cited

Andoh, A , 'Recent Advances in Molecular Approaches to Gut Microbiota in Inflammatory Bowel Disease ' , 15 ( ):
Current Pharmaceutical Design2009; 2066 2073

Caple, C, ;Crohn's Disease: Inducing/Maintaining Remission with MedicationsNovember ;2013 ; Available from:
http://eds.b.ebscohost.com.proxy.library.ohiou.edu/eds/pdfviewer/pdfviewer?vid=14&sid=d581e249-b61c-4814a45f-b44a4fc47d56%40sessionmgr112&hid=122 (Accessed October 2014 ).

Sauer, C, Crohn's Disease December ;2011 ; Available from: http://permanent.access.gpo.gov/gpo22797/Crohns508.pdf (Accessed October 2014 ).

Cheiftetz, A, Crohn's Disease (Diagnosis)January ;2012 ; Available from: http://healthfts.blogspot.com/2012/01/crohns-disease-diagnosis.html (Accessed October 2014 ).

de Silva, P , 'Is Diet Involved in the Etiology of Ulcerative Colitis and Crohns Disease? A Review of the Experimental
and Epidemiological Literature' , 12 ( 1 ): Inflammatory Bowel Disease Monitor2011; 14 - 21

Inflammatory Bowel Disease February ;2011 ; Available from:

http://iconsinmedicine.wordpress.com/2011/02/28/inflammatory-bowel-disease/ (Accessed October 2014 ).

Lichtenstein, G , Crohn's Disease: the complete guide to medical management Thorofare : ; ed , Vol . ;.New Jersey ;
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Lomer M.C.E., Gourgey R. & Whelan K. (2014) Current practice in relation to nutritional assessment and dietary
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Mudter, J , 'Insight into Crohns disease pathomorphology' , ( ): Abdominal Imaging2012; 921 926

Papay, P , 'Optimising monitoring in the management of Crohn's disease: A physician's perspective' , 7 ( ): Journal of
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Dalessandro, T , What to Eat with IBD ; : 1 ed , Vol .1.New York ; 2006.