Crohn's Disease

Definition
Crohn's disease, a type of inflammatory bowel disease (IBD), is a condition in which
the lining of your digestive tract becomes inflamed, causing severe diarrhea and
abdominal pain. The inflammation often spreads deep into the layers of affected
tissue. Like ulcerative colitis, another common IBD, Crohn's disease can be both
painful and debilitating and sometimes may lead to life-threatening complication.

While there's no known medical cure for Crohn's disease, therapies can greatly reduce
the signs and symptoms of Crohn's disease and even bring about a long-term
remission. With these therapies, many people afflicted with Crohn's disease are able
to function normally in their everyday lives.

Symptoms

Crohn's disease
Signs and symptoms of Crohn's disease can range from mild to severe and may
develop gradually or come on suddenly, without warning. They include:

 Diarrhea. The inflammation that occurs in Crohn's disease causes cells in the affected
areas of your intestine to secrete large amounts of water and salt. Because the colon can't
completely absorb this excess fluid, you develop diarrhea. Intensified intestinal cramping
also can contribute to loose stools. In mild cases, stools may simply be looser or more
frequent than usual. But people with severe disease may have dozens of bowel movements a
day, affecting both sleep and ordinary activities.
 Abdominal pain and cramping. Inflammation and ulceration may cause the walls of portions
of your bowel to swell and eventually thicken with scar tissue. This affects the normal
movement of intestinal tract contents through your digestive tract and may lead to pain and
cramping. Mild Crohn's disease usually causes slight to moderate intestinal discomfort, but
in more serious cases, the pain may be severe and occur with nausea and vomiting.
 Blood in your stool. Food moving through your digestive tract can cause inflamed tissue to
bleed, or your bowel may also bleed on its own. You might notice bright red blood in the
toilet bowl or darker blood mixed with your stool. You can also have bleeding you don't see
(occult blood). In severe disease, bleeding is often serious and ongoing.
 Ulcers. Crohn's disease begins as small, scattered sores on the surface of the intestine.
Eventually these sores may become large ulcers that penetrate deep into — and sometimes
through — the intestinal walls. You may also have ulcers in your mouth similar to canker
sores.
 Reduced appetite and weight loss. Abdominal pain and cramping and the inflammatory
reaction in the wall of your bowel can affect both your appetite and your ability to digest
and absorb food.
 Fistula or abscess. Inflammation from Crohn's disease may tunnel through the wall of the
bowel into adjacent organs, such as the bladder or vagina, creating an abnormal
connection called a fistula. This can also lead to an abscess, a swollen, pus-filled sore. The
fistula may also tunnel out through your skin. A common place for this type of fistula is in
the area around the anus. When this occurs, it's called perianal fistula.

Other signs and symptoms

People with severe Crohn's disease may experience fever and fatigue as well as
problems that occur outside the digestive tract, including arthritis, eye inflammation,
skin disorders, and inflammation of the liver or bile ducts. Children with Crohn's
disease may have delayed growth or sexual development.

The course of Crohn's disease varies greatly. You may have long periods without
signs and symptoms, or you may have recurrent episodes of abdominal pain, diarrhea,
and sometimes fever or bleeding.

Causes
Crohn's disease begins with inflammation, most often in the lower part of the small
intestine (ileum) or in the colon, but sometimes in the rectum, stomach, esophagus or
mouth. Unlike ulcerative colitis, in which inflammation occurs uniformly throughout
an affected area, Crohn's disease can develop in several places simultaneously, with
healthy tissue in between. In time, large ulcers that extend deep into the intestinal wall
may develop in the inflamed areas.

No one is quite sure what triggers inflammation in Crohn's disease, but there's a
consensus as to what doesn't cause it. Researchers no longer believe that stress and
diet are the main culprits, although both factors can often aggravate symptoms.
Instead, current thinking focuses on the following possibilities:
  Immune system. It's possible that a virus or bacterium may cause Crohn's
disease. When your immune system tries to fight off the invading
microorganism, the digestive tract becomes inflamed. One microorganism that
may be involved in the development of Crohn's is Mycobacterium avium
subspecies paratuberculosis (MAP), a bacterium that causes intestinal disease
in cattle. Researchers have found MAP in the blood and intestinal tissue of
many people with Crohn's disease, but only rarely in people with ulcerative
colitis.

There's no clear evidence that MAP causes Crohn's disease. Some researchers
believe that a genetic susceptibility may trigger an abnormal response to the
bacterium in some people. Currently, most investigators believe that some
people with the disease develop it because of an abnormal immune response to
bacteria that normally live in the intestine.

 Heredity. About 20 percent of people with Crohn's disease have a parent,

sibling or child who also has the disease. Mutations in a gene called
NOD2/CARD15 tend to occur frequently in people with Crohn's disease and
seem to be associated with an early onset of symptoms as well as a high risk of
relapse after surgery for the disease. Scientists continue to search for other
genetic mutations that might play a role in Crohn's.

Risk factors
Crohn's disease affects about the same number of women and men. Risk factors may
include:

 Age. Crohn's disease can strike at any age, but you're likely to develop the
condition when you're young. Most people are diagnosed with Crohn's
between the ages of 20 and 30.
 Ethnicity. Although whites have the highest risk of the disease, it can affect
any ethnic group. If you're Jewish and of European descent, you're four to five
times as likely as other people are to have Crohn's disease.
 Family history. You're at higher risk if you have a close relative, such as a
parent, sibling or child, with the disease. If a brother or sister has Crohn's
disease, your risk of developing the disease is 30 times as high as the general
population's risk.
 Where you live. If you live in an urban area or in an industrialized country,
you're more likely to develop Crohn's disease. Because Crohn's disease occurs
more often among people living in cities and industrial nations, it's possible
that environmental factors, including a diet high in fat or refined foods, may
play a role. People living in Northern climates also seem to have a greater risk
of the disease.
 Smoking. If you smoke, you are far more likely to develop Crohn's disease.
Continuing to smoke after diagnosis also can make your treatment less
effective, or worsen your illness after you've been diagnosed.
 Isotretinoin (Accutane) use. Isotretinoin (Accutane) is a powerful medication
sometimes used to treat scarring cystic acne or acne that doesn't respond to
other treatments. Although cause and effect hasn't been proved, studies have
reported the development of inflammatory bowel disease with isotretinoin use.
When to seek medical advice
See your doctor if you have persistent changes in your bowel habits or if you have any
of the signs and symptoms of Crohn's disease, such as:

 Abdominal pain
 Blood in your stool
 Ongoing bouts of diarrhea that don't respond to over-the-counter (OTC)
medications
 Unexplained fever lasting more than a day or two

Your doctor may refer you to a specialist in diseases of the digestive system
(gastroenterologist).

Although Crohn's disease usually isn't fatal, it's a serious disease that, in some cases,
may cause life-threatening complications.

Tests and diagnosis

 Blood tests. Your doctor may suggest blood tests to check for anemia — a
condition in which there aren't enough red blood cells to carry adequate
oxygen to your tissues — or to check for signs of infection. Two tests that
look for the presence of certain antibodies can sometimes help diagnose which
type of inflammatory bowel disease you have, but not everyone with Crohn's
disease or ulcerative colitis has these antibodies.
 Colonoscopy. This test allows your doctor to view your entire colon using a
thin, flexible, lighted tube with an attached camera. During the procedure,
your doctor can also take small samples of tissue (biopsy) for laboratory
analysis, which may help confirm a diagnosis.

Some people have clusters of inflammatory cells called granulomas, which

confirm the diagnosis of Crohn's disease because granulomas don't occur with
ulcerative colitis. In the majority of people with Crohn's, granulomas aren't
present and diagnosis is made through biopsy and the location of the disease.
Risks of this procedure include perforation of the colon wall and bleeding.

 Flexible sigmoidoscopy. In this procedure, your doctor uses a slender,

flexible, lighted tube to examine the sigmoid, the last 2 feet of your colon. The
test usually takes just a few minutes. It's somewhat uncomfortable, and there's
a slight risk of perforating the colon wall. It may also miss problems higher up
in your colon or in your small intestine.
 Barium enema. This diagnostic test allows your doctor to evaluate your large
intestine with an X-ray. Before the test, barium, a contrast dye, is placed into
your bowel in an enema form. Sometimes, air also is added. The barium fills
and coats the lining of the bowel, creating a silhouette of your rectum, colon
and a portion of your small intestine.

Because barium enema isn't as accurate as colonoscopy and doesn't allow for
biopsy, it's not the preferred way to evaluate the colon, but your doctor may
 use this test in conjunction with a sigmoidoscopy or in cases when a
colonoscopy can't be performed.

 Small bowel X-ray. This test looks at the part of the small bowel that can't be
seen by colonoscopy. After you drink barium, X-ray pictures are taken of your
small intestine. The test can help locate areas of narrowing or inflammation in
the small bowel that are seen in Crohn's disease. The test can also help your
doctor determine which type of inflammatory bowel disease you have.
 Computerized tomography (CT). Sometimes you may have a CT scan, a
special X-ray technique that provides more detail than a standard X-ray does.
This test looks at the entire bowel as well as at tissues outside the bowel that
can't be seen with other tests. Your doctor may order this scan to better
understand the location and extent of your disease or to check for
complications such as a partial blockages, abscesses or fistulas. Although not
invasive, a CT scan exposes you to more radiation than a conventional X-ray
does.
 Capsule endoscopy. If you have signs and symptoms that suggest Crohn's
disease but the usual diagnostic tests are negative, your doctor may perform
capsule endoscopy. For this test you swallow a capsule that has a camera in it.
The camera takes pictures, which are transmitted to a computer that you wear
on your belt. The images are then downloaded, displayed on a monitor and
checked for signs of Crohn's disease. Once it's made the trip through your
digestive system, the camera exits your body painlessly in your stool.

Capsule endoscopy is generally very safe, but if you have a partial blockage in
the bowel, there's a slight chance the capsule may become lodged in your
intestine. Your doctor will try to minimize the chance of this by performing
other diagnostic tests to look for a partial blockage before you have this
procedure. If the camera does become lodged in the bowel, it may need to be
surgically removed.

Complications
Crohn's disease may lead to one or more of the following complications:

 Obstruction. Crohn's disease affects the entire thickness of the intestinal wall.
Over time, parts of the bowel can thicken and narrow, which may block the
flow of digestive contents through the affected part of your intestine. Some
cases require surgery to remove the diseased portion of your bowel.
 Ulcers. Chronic inflammation can lead to open sores (ulcers) anywhere in
your digestive tract, including your mouth and anus. It's possible to have
ulcers scattered throughout your digestive tract, but many Crohn's-related
ulcers form in the lower part of the small intestine (terminal ileum) or in the
colon or rectum.
 Fistulas. Sometimes ulcers can extend completely through the intestinal wall,
creating a fistula — an abnormal connection that can occur between different
parts of your intestine, between your intestine and skin, or between your
intestine and other organs, such as the bladder and vagina.
 When internal fistulas develop, food may bypass areas of the bowel that are
necessary for absorption. External fistulas can cause continuous drainage of
bowel contents to your skin, and in some cases, fistulas may become infected
and form an abscess, a problem that can be life-threatening if left untreated.

 Anal fissure. This is a crack, or cleft, in the anus or in the skin around the
anus where infections can occur. It's often associated with painful bowel
movements.
 Malnutrition. Diarrhea, abdominal pain and cramping may make it difficult
for you to eat or for your intestine to absorb enough nutrients to keep you
nourished.
 Other health problems. In addition to inflammation and ulcers in the
digestive tract, Crohn's disease can cause problems in other parts of the body,
such as arthritis, inflammation of the eyes or skin, kidney stones, gallstones
and, occasionally, inflammation of the bile ducts. No one knows exactly what
causes these complications. Some researchers believe that the same immune
system response that produces inflammation in your intestines may cause
inflammation in other parts of your body.

People with long-standing Crohn's disease may develop osteoporosis, a

condition that causes weak, brittle bones. Although the precise reason for this
is unknown, it may be related to low levels of vitamin K, which is involved in
binding calcium to bone.

IBD and colon cancer

Having Crohn's disease increases your risk of colon cancer. Despite this increased
risk, more than 90 percent of people with inflammatory bowel disease never develop
cancer.

Your risk is greatest if you've had inflammatory bowel disease for at least eight to 10
years and if it has spread through your entire colon. You're less likely to develop
cancer if only a small part of your colon is diseased. The longer you've had the
disease and the larger the area affected, the greater your risk of colon cancer.

If you've had Crohn's disease for eight or more years, see your doctor at least once a
year and ask how often you should be screened for colon cancer using routine tests,
such as a colonoscopy.

In people with Crohn's disease, the risk of other cancers also is increased, including
cancer of the anus. If you have persistent symptoms or recurrent symptoms near your
anus, your doctor may examine this area thoroughly to exclude cancer. Cancers of the
small intestine also are increased in people with Crohn's, but the overall risk of this
remains very small.

Medications and cancer risk

Immune system suppressors also are associated with a small risk of cancer
development. These include azathioprine, mercaptopurine, methotrexate, infliximab
and others. The risk may be due to the immune system suppression that these
medications cause.
Combinations of medications, such as azathioprine or mercaptopurine or methotrexate
with infliximab, may be more dangerous than may treatment with a single therapy.
While these medications do incur this increased risk, they may be necessary for
people with Crohn's disease to improve quality of life and avoid surgery or
hospitalization. Work with your doctor to determine which medications are right for
you.

Treatments and drugs

The goal of medical treatment is to reduce the inflammation that triggers your signs
and symptoms. In the best cases, this may lead not only to symptom relief but also to
long-term remission. Treatment for Crohn's disease usually involves drug therapy or,
in certain cases, surgery.

Doctors use several categories of drugs that control inflammation in different ways.
But drugs that work well for some people may not work for others, so it may take
time to find a medication that helps you. In addition, because some drugs have serious
side effects, you'll need to weigh the benefits and risks of any treatment.

Anti-inflammatory drugs
Anti-inflammatory drugs are often the first step in the treatment of inflammatory
bowel disease. They include:

 Sulfasalazine (Azulfidine). Doctors have used this drug for many years to
treat Crohn's disease. Although it can be effective in reducing symptoms of the
disease, it has a number of side effects, including nausea, vomiting, heartburn
and headache. Don't take this medication if you're allergic to sulfa
medications.
 Mesalamine (Asacol, Rowasa). This medication tends to have fewer side
effects than sulfasalazine has. You take it in tablet form or use it rectally in the
form of an enema or suppository, depending on which part of your colon is
affected.
 Corticosteroids. Corticosteroids can help reduce inflammation anywhere in
your body, but they have numerous side effects, including a puffy face,
excessive facial hair, night sweats, insomnia and hyperactivity. More serious
side effects include high blood pressure, type 2 diabetes, osteoporosis, bone
fractures, cataracts and an increased susceptibility to infections. Long-term use
of corticosteroids in children can lead to stunted growth.

Also, these medications don't work for everyone with Crohn's disease. Doctors
generally use corticosteroids only if you have moderate to severe
inflammatory bowel disease that doesn't respond to other treatments. A newer
type of corticosteroid, budesonide (Entocort EC), works faster than do
traditional steroids and appears to produce fewer side effects. Entocort EC is
effective only in Crohn's disease that involves the lower small intestine and
the first part of the large intestine (ileocolitis).

Corticosteroids aren't for long-term use. They can be used for short-term
symptom improvement for about three to four months. They're also used in
 conjunction with other medications as a means to induce remission. For
example, corticosteroids may be used with an immune system suppressor —
the corticosteroids can induce remission, while the immune system
suppressors can help maintain remission.

Occasionally your doctor may prescribe steroid enemas if you have disease in
your lower colon or rectum. These also are only for short-term use.

Immune system suppressors

These drugs also reduce inflammation, but they target your immune system rather
than treating inflammation itself. Because these drugs can be effective in treating
inflammatory bowel disease, scientists theorize that damage to digestive tissues is
caused by your body's immune response to an invading virus or bacterium or even to
your own tissue. By suppressing this response, inflammation is also reduced.
Immunosuppressant drugs include:

 Azathioprine (Imuran) and mercaptopurine (Purinethol). These are the

most widely used immunosuppressants for treatment of inflammatory bowel
disease. Although it can take up to three months for these medications to begin
to work, they help reduce signs and symptoms of IBD in general and can heal
fistulas from Crohn's disease in particular. If you're taking either of these
medications, you'll need to follow up closely with your doctor and have your
blood checked regularly to look for side effects.
 Infliximab (Remicade). This drug is specifically for adults and children with
moderate to severe Crohn's disease who don't respond to or can't tolerate other
treatments. It works by neutralizing a protein produced by your immune
system known as tumor necrosis factor (TNF). Infliximab finds TNF in your
bloodstream and removes it before it causes inflammation in your intestinal
tract and contributes to the formation of fistulas.

Some people with heart failure, people with multiple sclerosis, and those with
cancer or a history of cancer can't take Remicade. If you're currently taking
Remicade, talk to your doctor about the potential risks. Infections including
tuberculosis and certain types of invasive fungi, such as histoplasmosis,
coccidioidomycosis and blastomycosis, have been associated with the use of
TNF-alpha inhibitors. If you have an active infection, don't take these
medications. You should have a skin test for tuberculosis before taking
infliximab and a chest X-ray if you lived or traveled extensively in areas
where tuberculosis has been found.

Also, because Remicade contains mouse protein, it can cause serious allergic
reactions in some people — reactions that may be delayed for days to weeks
after starting treatment. Once started, infliximab is often continued as long-
term therapy, although its effectiveness may wear off over time.

 Adalimumab (Humira). Adalimumab works similarly to infliximab by

blocking TNF for people with moderate to severe Crohn's disease. It's
prescribed for people who haven't been helped by infliximab or other
treatments. Adalimumab is given as an injection under the skin every other
 week, which you may be able to administer yourself. Adalimumab may reduce
the signs and symptoms of Crohn's disease and may cause remission.

However, adalimumab, like infliximab, carries a small risk of infections

including tuberculosis and certain types of invasive fungi, such as
histoplasmosis, coccidioidomycosis and blastomycosis. Your doctor will
administer a skin test for tuberculosis before you begin adalimumab treatment.
The most common side effects of adalimumab are skin irritation and pain at
the injection site, nausea, runny nose and upper respiratory infection.

 Certolizumab pegol (Cimzia). This drug was approved by the Food and Drug
Administration (FDA) in April 2008. Like infliximab and adalimumab,
certolizumab pegol works by inhibiting TNF. Certolizumab pegol is
prescribed for people with moderate to severe Crohn's who haven't been
helped by other treatments. You initially receive certolizumab pegol as one
injection every two weeks. After a few injections, if your doctor determines
it's working for you, you receive one injection a month. The most common
side effects are headache, upper respiratory infections, abdominal pain,
injection site reactions and nausea. Like other medications that inhibit TNF,
because this drug affects your immune system, you're also at risk of becoming
seriously ill with certain infections. Tuberculosis and certain types of invasive
fungi, such as histoplasmosis, coccidioidomycosis and blastomycosis, have
been associated with the use of TNF-alpha inhibitors.
 Methotrexate (Rheumatrex). This drug, normally used to treat cancer, is
sometimes used for people with Crohn's disease who don't respond well to
other medications. It starts working in about eight to 10 weeks. Short-term
side effects include nausea, fatigue and diarrhea, and rarely, it can cause
allergic pneumonia. Long-term use can lead to scarring of the liver and
sometimes to cancer. You should not try to become pregnant while taking
methotrexate. If you're taking this medication, you'll need to follow up closely
with your doctor and have your blood checked regularly to look for side
effects.
 Cyclosporine (Neoral, Sandimmune). This potent drug, which is most often
used to help heal Crohn's-related fistulas, is normally reserved for people who
don't respond well to other medications. Cyclosporine begins working in one
to two weeks — more quickly than less toxic drugs — but it has the potential
for serious side effects, such as kidney and liver damage, high blood pressure,
seizures, fatal infections and an increased risk of lymphoma. Discuss the risks
and benefits of taking cyclosporine with your doctor before beginning
treatment.
 Natalizumab (Tysabri). This drug works by inhibiting certain immune cell
molecules — integrins — from binding to other cells in your intestinal lining.
Blocking these molecules is thought to reduce chronic inflammation that
occurs when they bind to your intestinal cells. The FDA approved this drug in
January 2008 for those who have moderate to severe Crohn's disease with
evidence of inflammation and who aren't responding well to other
conventional Crohn's disease therapies. Because the drug is associated with a
rare but serious risk of multifocal leukoencephalopathy — a brain infection
that usually leads to death or severe disability — you must be enrolled in a
special restricted distribution program to use it. This program is called the
 Crohn's Disease-Tysabri Outreach Unified Commitment to Health (CD-
TOUCH) Prescribing Program.

Antibiotics
Antibiotics can heal fistulas and abscesses in people with Crohn's disease.
Researchers also believe antibiotics help reduce harmful intestinal bacteria and
directly suppress the intestine's immune system, which can trigger symptoms.
Frequently prescribed antibiotics include:

 Metronidazole (Flagyl). Once the most commonly used antibiotic for Crohn's
disease, metronidazole can sometimes cause serious side effects, including
numbness and tingling in your hands and feet and, occasionally, muscle pain
or weakness. If these effects occur, stop the medication and call your doctor.
Other side effects include nausea, a metallic taste in your mouth, headache,
dizziness and loss of appetite. Avoid alcoholic beverages while taking this
medication because a severe reaction may result.
 Ciprofloxacin (Cipro). This drug, which improves symptoms in some people
with Crohn's disease, is now generally preferred to metronidazole.
Ciprofloxacin may cause fainting, an irregular heartbeat, abdominal pain,
diarrhea, fatigue and, rarely, tendon problems.

Other medications
In addition to controlling inflammation, some medications may help relieve your
signs and symptoms. Depending on the severity of your Crohn's disease, your doctor
may recommend one or more of the following:

 Anti-diarrheals. A fiber supplement, such as psyllium powder (Metamucil) or

methylcellulose (Citrucel), can help relieve signs and symptoms of mild to
moderate diarrhea by adding bulk to your stool. For more severe diarrhea,
loperamide (Imodium) may be effective. Use anti-diarrheals with great caution
and only after consulting your doctor, because they increase the risk of toxic
megacolon, a life-threatening inflammation of your colon.
 Laxatives. In some cases, swelling may cause your intestines to narrow,
leading to constipation. Talk to your doctor before taking any laxatives,
because even those sold over-the-counter may be too harsh for your system.
 Pain relievers. For mild pain, your doctor may recommend acetaminophen
(Tylenol, others). Don't use nonsteroidal anti-inflammatory drugs (NSAIDs),
such as aspirin, ibuprofen (Advil, Motrin, others) or naproxen sodium (Aleve).
These are likely to make your symptoms worse.
 Iron supplements. strong> If you have chronic intestinal bleeding, you may
develop iron deficiency anemia. Taking iron supplements may help restore
your iron levels to normal and reduce this type of anemia once your bleeding
has stopped or diminished.
 Nutrition. Your doctor may recommend a special diet given via a feeding
tube (enteral) or nutrients injected into a vein (parenteral) to treat your Crohn's
disease. This can improve your overall nutrition and allow the bowel to rest.
Bowel rest can reduce inflammation in the short term. However, once regular
feeding is restarted, your signs and symptoms may return. You doctor may use
nutrition therapy short term and combine it with other medications, such as
immune system suppressors. Enteral and parenteral nutrition are typically used
 to get people healthier for surgery or when other medications fail to control
symptoms.
 Vitamin B-12 shots. Vitamin B-12 helps prevent anemia, promotes normal
growth and development, and is essential for proper nerve function. It's
absorbed in the terminal ileum, a part of the small intestine often affected by
Crohn's disease. If inflammation of your terminal ileum is interfering with
your ability to absorb this vitamin, you may need monthly B-12 shots for life.
You'll also need lifelong B-12 injections if your terminal ileum has been
removed during surgery.
 Calcium and vitamin D supplements. Most people with Crohn's disease
need to take a calcium supplement with added vitamin D. This is because
Crohn's disease itself and steroids can increase your risk of osteoporosis. Ask
your doctor if a calcium supplement is right for you.

Surgery
If diet and lifestyle changes, drug therapy or other treatments don't relieve your signs
and symptoms, your doctor may recommend surgery to remove a damaged portion of
your digestive tract or to close fistulas or remove scar tissue.

In Crohn's disease, surgery can provide years of remission at best. At the least, it may
provide a temporary improvement in your signs and symptoms. During surgery, your
surgeon removes a damaged portion of your digestive tract and then reconnects the
healthy sections. He or she may also close fistulas or drain abscesses. One of the most
common surgeries for Crohn's is strictureplasty, a procedure that widens a segment
of the intestine that has become too narrow. Laparoscopic surgery using small
incisions can lead to improved outcomes and shorter hospital stays for some people
with Crohn's disease.

Even so, the benefits of surgery for Crohn's are only temporary. The disease often
recurs, frequently near the reconnected tissue or elsewhere in the digestive tract.
Nearly three of four people with Crohn's disease eventually need some type of
surgery. Of those, as many as half will need a second procedure, and still others may
require a third operation. The best approach is to follow surgery with medication to
minimize the risk of recurrence.

Lifestyle and home remedies

Sometimes you may feel helpless when facing Crohn's disease. But changes in your
diet and lifestyle may help control your symptoms and lengthen the time between
flare-ups.

Diet
There's no firm evidence that what you eat actually causes inflammatory bowel
disease. But certain foods and beverages can aggravate your signs and symptoms,
especially during a flare-up in your condition. It's a good idea to try eliminating from
your diet anything that seems to make your signs and symptoms worse. Here are some
suggestions that may help:
  Limit dairy products. Like many people with inflammatory bowel disease,
you may find that problems, such as diarrhea, abdominal pain and gas,
improve when you limit or eliminate dairy products. You may be lactose
intolerant — that is, your body can't digest the milk sugar (lactose) in dairy
foods. If so, try substituting yogurt or low-lactose cheeses, such as Swiss and
cheddar, for milk. Or use an enzyme product, such as Lactaid, to help break
down lactose.

In some cases, though, you may need to eliminate dairy foods completely. If
you need help, a registered dietitian can help you design a healthy diet that's
low in lactose. Keep in mind that with limiting your dairy intake, you'll need
to find other sources of calcium, such as supplements.

 Try low-fat foods. If you have Crohn's disease of the small intestine, you may
not be able to digest or absorb fat normally. Instead, fat passes through your
intestine, making your diarrhea worse. Foods that may be especially
troublesome include butter, margarine, peanut butter, nuts, mayonnaise,
avocados, cream, ice cream, fried foods, chocolate and red meat.
 Experiment with fiber. For most people, high-fiber foods, such as fresh fruits
and vegetables and whole grains, are the foundation of a healthy diet. But if
you have inflammatory bowel disease, fiber may make diarrhea, pain and gas
worse. If raw fruits and vegetables bother you, try steaming, baking or stewing
them. You may also find that you can tolerate some fruits and vegetables, but
not others. In general, you may have more problems with foods in the cabbage
family, such as broccoli and cauliflower, and with very crunchy foods such as
raw apples and carrots.
 Avoid problem foods. Eliminate any other foods that seem to make your
signs and symptoms worse. These may include "gassy" foods such as beans,
cabbage and broccoli, raw fruit juices and fruits — especially citrus fruits —
spicy food, popcorn, alcohol, caffeine, and foods and drinks that contain
caffeine, such as chocolate and soda.
 Eat small meals. You may find you feel better eating five or six small meals
rather than two or three larger ones.
 Drink plenty of liquids. Try to drink plenty of fluids daily. Water is best.
Alcohol and beverages that contain caffeine stimulate your intestines and can
make diarrhea worse, while carbonated drinks frequently produce gas.
 Consider multivitamins. Because Crohn's disease can interfere with your
ability to absorb nutrients and because your diet may be limited, multivitamin
and mineral supplements are often helpful.
 Talk to a dietitian. If you begin to lose weight or your diet has become very
limited, talk to a registered dietitian.

Stress
Although stress doesn't cause Crohn's disease, it can make your signs and symptoms
much worse and may trigger flare-ups. Stressful events can range from minor
annoyances to a move, job loss or the death of a loved one.

When you're stressed, your normal digestive process changes. Your stomach empties
more slowly and secretes more acids. Stress can also speed or slow the passage of
intestinal contents. It may also cause changes in intestinal tissue itself.
Although it's not always possible to avoid stress, you can learn ways to help manage
it. Some of these include:

 Exercise. Even mild exercise can help reduce stress, relieve depression and
normalize bowel function. Talk to your doctor about an exercise plan that's
right for you.
 Biofeedback. This stress-reduction technique helps you reduce muscle tension
and slow your heart rate with the help of a feedback machine. You're then
taught how to produce these changes yourself. The goal is to help you enter a
relaxed state so that you can cope more easily with stress. Biofeedback is
usually taught in hospitals and medical centers.
 Regular relaxation and breathing exercises. An effective way to cope with
stress from Crohn's disease is to regularly relax and exercise. You can take
classes in yoga and meditation or practice at home using books or tapes.

You can also practice progressive relaxation exercises. These help relax the
muscles in your body, one by one. Start by tightening the muscles in your feet,
then concentrate on slowly letting all the tension go. Next, tighten and relax
your calves. Continue until muscles in your body, including those in your eyes
and scalp, are completely relaxed.

Deep breathing also can help you relax. Most adults breathe from their chests.
But you become calmer when you breathe from your diaphragm — the muscle
that separates your chest from your abdomen. When you inhale, allow your
belly to expand with air; when you exhale, your abdomen naturally contracts.
Deep breathing can also help relax your abdominal muscles, which may lead
to more normal bowel activity.

 Hypnosis. Hypnosis may reduce abdominal pain and bloating. A trained

professional teaches you how to enter a relaxed state and then guides you as
you imagine your intestinal muscles becoming smooth and calm.
 Other techniques. Set aside at least 20 minutes a day for any activity you find
relaxing — listening to music, reading, playing computer games or just
soaking in a warm bath.

Coping and support

Crohn's disease doesn't just affect you physically — it takes an emotional toll as well.
If signs and symptoms are severe, your life may revolve around a constant need to run
to the toilet. In some cases, you may barely be able to leave the house. When you do,
you might worry about an accident, and this anxiety only makes your symptoms
worse.

Even if your symptoms are mild, gas and abdominal pain can make it difficult to be
out in public. You may also feel hampered by dietary restrictions or embarrassed by
the nature of your disease. All of these factors — isolation, embarrassment and
anxiety — can severely alter your life. Sometimes they may lead to depression.
Educate yourself, and connect
One of the best ways to feel more in control is to find out as much as possible about
Crohn's disease. Organizations such as the Crohn's and Colitis Foundation of America
(CCFA) have chapters set up across the country to provide information and access to
support groups. Your doctor, nurse or dietitian can locate the chapter nearest you, or
you can contact the organization directly.

Although support groups aren't for everyone, they can provide valuable information
about your condition as well as emotional support. Group members frequently know
about the latest medical treatments or integrative therapies. You may also find it
reassuring to be among people who understand what you're going through.

Some people find it helpful to consult a psychologist or psychiatrist who's familiar

with inflammatory bowel disease and the emotional difficulties it can cause. Although
living with Crohn's disease can be discouraging, the outlook is brighter than it was
even just a few years ago.

Alternative medicine
Many people are interested in nontraditional approaches to healing, especially when
standard treatments produce intolerable side effects or aren't able to provide an
improvement. To address this interest, the National Institutes of Health established the
National Center for Complementary and Alternative Medicine (NCCAM), which
provides guidance and research.

Most complementary and alternative therapies don't simply address a problem with
the body. Instead, they focus on the entire person — body, mind and spirit. As a
result, they can be especially effective at reducing stress, alleviating the side effects of
conventional treatments and improving quality of life.

Studies have found that more than half the people with either Crohn's disease or
ulcerative colitis have used some form of complementary or alternative therapy. The
most common complementary therapies tried were herbal and nutritional
supplements, probiotics and fish oil. Side effects and ineffectiveness of conventional
therapies are primary reasons for seeking alternative care. Only about two-thirds
report their alternative or complementary therapy use to their doctors, however.

The majority of these therapies aren't regulated as medications by the FDA.

Manufacturers can claim that their therapies are safe and effective but don't need to
prove it. Because even natural herbs can have side effects and cause dangerous
interactions, be sure to let your doctor know before you try any alternative or
complementary therapies.

NCCAM's findings are available on its Web site. You can also talk to information
specialists at the center's clearinghouse by calling 888-644-6226 between 8:30 a.m.
and 5 p.m. Eastern time.