Alternative Ways to Treat Crohns Disease
Antibody formation can be seen with long-term use and is inversely proportional to total infliximab dose. The concern regarding the development of antibodies to infliximab with long-term use follows the observation that 13 of Crohn's patients treated with repeated infusions had indeed formed antibodies 22 . As expected, loss of clinical efficacy accompanies the antibody formation, as does the development of infusion-related chest pain, bronchospasm, and anaphylactic shock. The development of antibodies can be reduced by treating the patients on a scheduled, regular basis (i.e., every 8 weeks) and with the concomitant use of low-dose im-munosuppressants 16 .
Crohn's disease is a systemic inflammatory disorder affecting the entire GI tract. Although Crohn's disease most commonly affects the distal alimentary tract, esophageal involvement does occur. One study of patients without esophageal symptoms showed evidence of esophageal involvement in 5 by upper endoscopy (21). The typical findings are small, punctuate ulcerations in the esophageal mucosa. Rarely, fissures may form leading to fistula formation with adjacent organs. When patients are symptomatic, the typical symptoms are dysphagia, odynophagia, and epigastric discomfort. See Chapter 20 for further discussion of Crohn's disease.
Crohn's disease small bowel resection is usually reserved for those individuals for whom medical treatment has failed or who are suffering complications, e.g., obstruction (due to strictures), peri-intestinal abscess, fistula formation or perforation. Essentially, the extent of resection is limited to the macroscopically involved intestine as extensive resection does not reduce the risk of recurrent lesions and may lead to short bowel syndrome if subsequent resections are necessary.
An appendiceal abscess (which usually develops three days after a bout of acute appendicitis) can usually be palpated by a combination of abdominal and rectal examination. Differential diagnoses of an appendiceal mass also include carcinoma of the caecum, Crohn's terminal ileitis and ovarian carcinoma.
Pathologically, colorectal cancers from HNPCC patients are characterized by poor differentiation, mucin production, Crohn's-like reaction, and an intense lymphocytic infiltrate (Jass et al, 1994). Even though some of these characteristics (mucin and poor differentiation) indicate a worse prognosis, HNPCC patients with colorectal cancer have been reported to have a better prognosis stage for stage than patients with sporadic colorectal cancer (Watson et al, 1998 Lynch and de la Chapelle, 1999). It is important to note that adenomas do occur in patients with HNPCC. Currently it is believed that adenomas in patients with HNPCC progress to carcinoma more quickly than do adenomas in patients with sporadic colorectal cancer.
Full thickness biopsy is a peroperative or laparoscopic biopsy (muscularis-containing biopsy) used to diagnose motility disturbances. One incision is situated below the umbilicus, and one in the left fossa. The bowel loop is identified laparoscopically, and will then be exteriorized through the incision below the umbilicus. The full thickness biopsy of at least 10X10 mm will then be taken with a surgical knife. The bowel loop is closed with absorbable sutures, and repositioned into the abdomen (56). Drawbacks of biopsies taken at surgery are the manipulation of the patients' diet (fasting), and the bowel preparation or preoperative treatment with antibiotics (29,58). Biopsies taken at surgery have the advantage of larger sample size than endoscopic biopsies, and various analyses may be applied such as molecular typing of bacteria in intestinal tissue of Crohn's patients (59).
Surgery in colorectal inflammatory bowel disease - the surgical management of colorectal Crohn's disease is similar to that in the small intestine (see Chapter 4) namely, surgical intervention is reserved for those in whom medical management has failed (i.e., minimal resection of the diseased segment) or who are suffering complications, e.g., obstruction, pericolic abscess, fistula, etc. As in Crohn's disease, close liaison between surgeons and physicians is required in the management of ulcerative colitis. Emergency surgery is needed in cases of acute severe colitis and or toxic megacolon. The procedure of choice is a subtotal colectomy and end ileostomy with the
Ulcerative colitis Ulcerative colitis is different from Crohn disease in that it has a different pattern of intestinal involvement. It begins in the rectum and progresses proxi-mally in a continuous fashion (Fig. 9.34). Fistulas are hardly ever seen. Up to 10 of all patients per year develop colon cancer, typically after several years of disease, which is why a total colectomy is often performed. Nowadays colorectal surgeons can preserve the patient's anal sphincter and build a new rectal pouch from small bowel, so that the
The cause of the dysfunction or problem is diagnosed, the wrong treatment may be prescribed, leading to an unfavorable outcome. The assessment should include the following vital signs hydration status abdominal status perianal or peristomal skin integrity frequency of bowel movements in the previous 2 weeks consistency of stool (liquid, soft formed, or hard and hard to eliminate) number of impactions since cancer diagnosis appetite (ranging from 3 big meals per day to only sips of liquid) daily fluid intake daily fiber intake medications currently being taken, particularly those that affect bowel elimination presence of abdominal pain or cramping concomitant diseases that affect bowel function (e.g., diabetes, Crohn's disease, and irritable bowel syndrome) presence of abdominal distention frequency of bowel movements before cancer diagnosis usual time of day that bowel movements occur effective corrective measures previously used for bowel problems extent of cancer current treatments...
Crohn's disease is an inflammatory disease of the GI tract, of unknown etiology. It is characterized by mucosal ulceration that extends through all layers of the digestive tract wall and is not limited to any one area of the GI system from mouth to anus. Approximately 10 of patients with Crohn's disease have pharyngeal involvement. Most commonly, ulcerative lesions are seen on the pharyngeal walls. The epidemiology, pathogenesis, diagnosis, treatment, and prognosis are discussed in more detail in Chapter 20.
A wide range of animal models have been applied to studies on IBD. Naturally occurring animal models have been important tools in studies related to human ulcerative colitis and Crohn's disease. IBD-like symptoms have also been induced chemically. The application of such chemicals may induce ulceration of the intestinal mucosa as well as several immunological responses that are typical to IBD in humans. Simple methods for T-cell induced onset of IBD may be initiated by di-nitro chlorobenzene (DNCP) as described by Glick and Falchuk (127). This method involves both systemic and local application of DNCP. Other chemically induced forms of IBD may be induced by intra
Multiple diseases can present with findings similar to those seen with Adamantiades-Behget's disease and should be considered when a patient presents with recurrent oral or genital ulcers, inflammatory eye disease, or other manifestations of vasculitis. Included in the differential diagnosis are systemic lupus erythematosus (Chapter 1), seronegative spondyloarthropathies, inflammatory bowel disease (Crohn's or ulcerative colitis) (Chapter 20), herpes or other viral infections (Chapter 10), other forms of vasculitis (Chapter 8), and inflammatory skin diseases such as pemphigus vulgaris or pemphigoid lesions (Chapter 37). All patients presenting with oral and genital ulcerations should undergo testing for herpes simplex virus using culture or polymerase chain reaction methods, to ensure that viral infection is not present.
Anal canal carcinoma a squamous cell carcinoma with variable degrees of squamous, basa-loid (synonym cloacogenic non-keratinising small cell squamous carcinoma) and ductular differentiation. Proximal canal cancers are poorly differentiated and basaloid whereas distal anal cancers are well differentiated and more overtly squamous in character. There is an increased incidence in Crohn's disease, smoking, immunosuppression and sexually transmitted diseases. At diagnosis, many have spread through sphincteric muscle into adjacent soft tissues (vagina, urethra etc.) and 5-10 have haematogenous metastases to liver, lung and skin. Primary therapy is concurrent radio- chemotherapy with good preservation of anal sphincter function and tumour response. Abdominoperineal or exenterative resection is reserved for extensive (e.g., vaginal involvement), recurrent or non-responsive tumours. Inguinal node disease may require block dissection of the groin. Many arise in the vicinity of the dentate line...
MSI-high colorectal cancers have a distinct clinicopathologic phenotype (Kim et al, 1994 Jass et al, 1998 Alexander et al, 2001). MSI-high colorectal cancers are more frequent in younger patients. Most are right-sided (proximal to the splenic flexure), bulky (large) tumors, with an exophytic growth pattern are poorly differentiated, with signet-ring-cell, mucinous, medullary, or variegated (mixed) histologic subtypes have an intense lym-phocytic response with Crohn's-like lymphoid reaction (lymphoid follicles with germinal centers at the tumor edge) and peritumoral and intratumoral lymphocytosis and show an expanding (pushing) invasive pattern at the margins. However, one third of colorectal carcinomas with MSI do not have these histologic characteristics.
A colonoscopy may help to diagnose Crohn's disease, an inflammatory disease of the intestine, which can be accompanied by cutaneous symptoms, particularly perineal ones, and which can be confused with HS. However, faced with anal lesions not characteristic of HS or accompanied by digestive symptoms, a diagnosis of Crohn's disease simulating HS or associated with HS should be made, as there are specific treatments for Crohn's.
One author reported on a patient with Crohn's disease and HS who showed a satisfactory outcome following treatment with azathioprine (150 mg day) and methylprednisolone (16 mg day) combined with isotretinoin (0.7 mg kg per day) and periodic administration of antibiotics 28 . Another report details a patient with multiple pustular and cystic lesions located on swollen and red labia majora. She was successfully treated with prednisolone and erythromycin for months and then long-term isotretinoin (mostly 1.0 mg kg per day) for 15 months, and no significant relapse of the so-called vulval apocrine acne occurred during a follow-up period of 10 months 29 .
Late lesions in the ano-perineal location are to be distinguished from other chronic scarring inflammations such as tuberculosis, actinomycosis, cat-scratch disease and lymphogranuloma venereum. For this region an important and difficult differential diagnosis is anal Crohn's disease (see Chap. 7).
This is caused by compromised absorption, increased excretion or increased demands or losses. Inadequate absorption can occur in malabsorption syndromes such as coeliac and Crohn's disease, with long-term use of certain medications such as phenytoin, sulfasalazine, cimetidine, antacids and OCP, in congenital malabsorption states and in blind loop syndrome (Beers et al 2003), especially when combined with suboptimal dietary intake (Carmel 2006). Significantly impaired absorption has also been observed in HIV patients (Revell et al 1991).
In vitro data has shown that nettle leaf extract (IDS 30) reduces the induction of primary T-cell responses and TNF-alpha in T-cell mediated diseases such as RA (Broer & Behnke 2002). Faecal IL-1 -beta and TNF-alpha concentrations were significantly reduced in mice with induced Crohn's disease treated with IDS 30 (Konrad et al 2005). Mice treated with nettle extract displayed fewer histological changes and general disease symptoms. The authors conclude that the effect may be due to a decrease in Th1 response and may constitute a new treatment option for prolonging remission in inflammatory bowel disease.
Haptens have been intentionally applied to develop animal models of what are presumed to be human autoimmune diseases. Neurath et al. (20) applied small amounts of the hapten, trinitrobenzene sulfonic acid (TNBS) (a derivative of TNP), to the rectal mucosa of mice. This resulted in the development of a chronic transmural colitis accompanied by diarrhea and weight loss that mimicked human Crohn's disease. Histologic examination showed abundant CD4+ T cells that produced mRNA for gamma interferon in situ. Of great interest was the observation that the colitis persisted for at least 2 mo, obviously long after all hapten-modified cells had been shed and cleared. Therefore, the T cells, initially induced by hapten-modified mucosa, were able to recognize and react against unidentified proteins on normal mucosa.
Description of first susceptibility gene for Crohn's disease (CARD15 NOD2) Compelling evidence for the interactive role of genes, bacteria, and immunity has been derived from experimental animal models of both Crohn's-like and colitis-like disease (38,39). There are now about 30 different spontaneously occurring or genetically engineered (knockout or transgenic) animal models for inflammatory bowel disease (40-42). Colonization with normal enteric microbiota is required for full expression of disease. Thus, the normal microbiota is a common factor driving the inflammatory process irrespective of the genetic underlying predisposition and immunological effector mechanism (43,44). Several different microorganisms have been demonstrated to induce colitis in animal models. These include Enterococcus faecalis, causing colitis in the antiinflammatory interleukin-10 (IL-10) knockout mice, and Bacteroides vulgatus, which induced inflammation in the HLA-B27 rat model (45,46). This evidence has...
Depression, diabetes, drugs, spinal dysfunction and urinary tract infection can all cause abdominal pain although the pain may be more subacute or chronic. Abdominal pain and even tenderness can accompany diabetic ketoacidosis. Drugs that can cause abdominal pain are listed in Table 30.4 . Spinal dysfunction of the lower thoracic spine and thoracolumbar junction can cause referred pain to the abdomen (Fig 30.1). The pain is invariably unilateral, radicular in distribution, and related to activity. It can be confused with intra-abdominal problems such as biliary disease (right-sided), appendicitis and Crohn's disease (right side), diverticular disease (left-sided) and pyelonephritis.
LFTs - deranged in liver metastases or in the hepatobiliary manifestations of Crohn's disease. Barium enema - widely used investigation in colorectal disease. There will be characteristic thumbprint filling defects caused by oedematous mucosa in ischaemia infarction. The extent of ulcerative colitis can be assessed and in Crohn's disease it will show skip lesions, areas of stricturing and any fistulae. It will reveal the presence of diverticula. Barium enema is useful in the detection of large polyps and carcinomas with constricting tumours producing a characteristic apple-core lesion. However, it will not reliably define rectal lesions.
At the time of writing, there are not enough data to be able to evaluate the extent to which the CD-CV hypothesis is true. There are a number of examples of common variants for complex diseases that are known (Lohmueller et al., 2003), and also clear examples of moderate allelic heterogeneity (at NOD2 CARD15, involved in Crohn's disease Hugot et al., 2001) and functional rare variants (associated with plasma levels of HDL cholesterol and LDL, and rates of sterol absorption Cohen
Mucin in the GI tract is produced by goblet cells in the mucosa and glandular mucous cells in the submucosa. Mucin consists of a peptide core with oligosaccharide side chains O-glycosidically bound, and it has several important physiological and patho-physiological roles. It acts as lubricant, as a barrier and stabilizer for the intestinal microclimate as well as a source of energy for the microbiota. There is growing evidence that the mucin pattern may be a relevant issue to take into account in the pathophysiology of some intestinal diseases, such as ulcerative colitis, Crohn's disease, gastric and duodenal ulceration, and colon adenocarcinoma.
Percentage of tumors arise in the duodenum. One, the duodenum is the first site exposed to a variety of potentially injurious agents, both those consumed and those produced within the GI tract (bile, pancreatic secretions, stomach acid) (4). Second, duodenal adenocarcinoma may develop in anywhere from 24 to 100 of patients with FAP (15). In fact, patients with FAP have a 331-fold increase in the development of duodenal adenocarcinoma compared to the normal population (16). Third, it can be reached by upper endoscopy. In contrast, patients with Crohn's disease have an 86-fold increase in incidence of SBA (17), but the majority of these lesions occur in the ileum.
In 2001 three papers reported on the association between the gene NOD2 and Crohn's disease (an inflammatory bowel disease), however, the paths of the research that led to these independent findings were quite different. The first (Hugot et al., 2001) followed the classic research paradigm of genome-wide linkage study (which identified the pericen-tromeric region of chromosome 16), fine mapping study (where more microsatellite markers are genotyped in the linkage region) and association study. This study identified three causal mutations, a single base-pair insertion (3020Cins) and two missense variants. In contrast, the other studies (Hampe etal., 2001 Ogura etal., 2001) selected the NOD2 gene as a candidate gene based on position (within the reported linkage region), structural homology to plant apoptosis regulatory and disease resistance genes and known function of NOD proteins in recognizing bacterial components. Both studies identified the single base-pair insertion and reported...
The genetic component of IBD was initially suggested by early reports of familial aggregation of these diseases. In 1934, Crohn and colleagues reported the first familial aggregation of CD. In the 1950s and 1960s many other groups confirmed that IBD are more familial than expected by chance. On average, 6-8 of UC patients and 8-10 of CD patients have at least one affected relative (for review see Russell and Satsangi, 2004). Interestingly, values as high as 20 or more have been reported in children, suggesting that either pediatric CD is more genetic or that familial environmental risk factors are important. The non-random distribution of the affected siblings within sibships with multiple cases strongly argues for the second hypothesis of an environmental factor shared by nuclear family members (Hugot et al., 2003b). Crohn's disease Ulcerative colitis Total cases
In the intervening mucosa give important diagnostic clues. For example, ulcerative colitis is mucosal and diffuse, Crohn's disease segmental and transmural with intervening aphthous ulcers, chronic ischaemic stricture is preferentially located at the splenic flexure and clostridium difficle infection shows mucosal pseudomembranes. Non-neoplastic colonic specimens therefore require sequential labelled blocks of abnormal and normal (e.g., every 10 cm) areas. As the mucosa is arranged in transverse folds, long-axis blocks are taken. Longitudinal limits are transverse sectioned to look for disease involvement and although mesenteric nodes are usually reactive only, they may show helpful diagnostic pointers such as granulomas in Crohn's disease. In ischaemic conditions, mesenteric vessels are also sampled for signs of vasculitis or embolic thrombi. Some vascular anomalies, e.g., angiodysplasia of the colon, may require close liaison with the surgical and radiological teams necessitating...
The histological similarities and co-occurrence of HS and Crohn's disease have led to speculation that treatments used for Crohn's disease may have a role in the management of HS as well. This is further supported by the beneficial effects of biologics in HS (see Chap. 20). Methotrexate is another drug used in Crohn's disease that has been evaluated in a small open case series. The results were variable, and although individual patients experienced some relief from symptoms, an overall evaluation suggested only
L-glutamine enemas, twice daily for 7 days, have been shown to reduce mucosal damage and inflammation in experimental models of colitis in rats (Kaya et al 1999) however, preliminary trials in humans have not confirmed benefit. A 4-week study on 18 children with active Crohn's disease fed a glutamine-enriched polymeric diet (Akobeng et al 2000) and another 4-week study on 14 patients taking 7 g glutamine three times daily (Hond et al 1999a) showed similarly negative results. Longer term studies may provide more convincing results however, it is possible that glutamine only stabilises gut barrier function under certain conditions and more research is required to elucidate these.
Stomatitis refers to an inflammatory process involving the mucous membrane of the mouth that may manifest itself through a variety of signs and symptoms including erythema, vesiculation, bulla formation, desquamation, sloughing, ulceration, pseudomembrane formation, and associated discomfort. Stomatitis may arise due to factors that may be of either local, isolated conditions or of systemic origin. For example, a solitary oral ulcer with a history of a recurrent pattern may be classified as recurrent aphthous stomatitis, a purely local phenomenon. Another clinically-similar-appearing lesion, on the other hand, may represent an oral mucosal manifestation of a more generalized disease process such as Crohn's disease. Stomatitis may involve any site in the oral cavity, including the vermillion of the lips, labial buccal mucosa, dorsal ventral tongue, floor of mouth and hard soft palate, and gingivae. Patients will generally relate a history of recurrence of similar lesions. One of the...
Imaging may also be used in cases where other complications are suspected, and may help to distinguish internal disease such as Crohn's disease from HS. Crohn's disease tracts are different from HS fistulas because they tend to connect with the bowel or anorectal area. In HS the tracts are mostly superficial in location. In patients where Crohn's disease is suspected a computed tomography examination may help to determine inflammatory changes to the bowel. Tuberculosis can also produce sinus tracts and fistulas and they also tend to be deeper in
Biologic therapy in HS 5, 8-11 . (CD Crohn's disease, CR case report, CS case series, HS hidradenitis suppurativa, PC personal communication, UC ulcerative colitis) While the etiology and pathogenesis of HS remain largely unknown, the disease has been shown to occur in association with other disorders of follicular occlusion, such as acne conglo-bata and dissecting cellulitis of the scalp. In these disorders, follicular occlusion leads to overgrowth of bacteria and subsequent neutrophilic inflammation. Many observations have been reported regarding the role of androgens hormones, obesity, and genetics, which may in addition influence the clinical picture 3, 4 . It is the reported association with Crohn's disease (CD), however, which has led to speculation and opportunities for novel management. It has been postulated that the two conditions share similar pathological immune mechanisms, such as increased levels of tumor necrosis factor alpha (TNFa) and neutrophilic...
Diagnosis of SBA is often difficult and delayed because of the vague and nonspecific signs and symptoms. Distal lesions may present with an obstructive pattern that may be seen on plain films. However, this finding is nonspecific. Esophagogastroduodenoscopy (EGD) may sometimes be diagnostic for proximal duodenal lesions, but will obviously miss more distal lesions (9). One advantage of EGD over other diagnostic modalities is the ability to biopsy tumors or excise polyps. On the other end, the ileocecal valve can be intubated with the colonoscope and lesions of the terminal ileum can be visualized and biopsied in 20 to 30 of patients (1). Extended enteroscopy, though not widely available, can allow visualization of up to 70 of the small bowel mucosa (12). Contrast radiography, upper GI series with small bowel follow-through, is commonly employed to visualize luminal defects (1). Subtle abnormalities suggestive of intestinal neoplasia can be detected, as well as mass lesions or...
Obstructive enterocolitis continuous or segmental areas of inflammation or ulceration adjacent to or distant from an obstructing distal lesion, e.g., annular carcinoma or diverticulosis. Small bowel may also be involved with mimicry of Crohn's disease. A dilated, thinned caecal pouch can become ischaemic and perforate. Diverticulosis very common in Western society due to a low-fibre diet, high intraluminal pressure and subsequent transmural mucosal herniation in the sigmoid colon through points of vessel entry from the mesentery. Presentation is with altered bowel habit, per rectum bleeding, left iliac fossa pain or a mass. The latter implies diverticulitis with possible perforation and peri-colonic reaction abscess formation. Portal pyaemia, liver abscesses and peritonitis can ensue. The diverticular segment is thickened and contracted with muscle coat hypertrophy and visible diver-ticular pouches in the muscularis and mesenteric fat. They may be filled and obstructed with faecal or...
One of the major clues to MS etiology comes from analysis of the remarkable worldwide pattern of MS. This shows a crude but inconsistent north-south gradient in North America and Europe a lower prevalence in most of Asia, Africa, and South America (although many of these studies are less than definitive because of uncertainty about the completeness of case ascertainment) and a reverse south-north gradient in Australia and New Zealand (Chapters 1 and 2). This nonrandom pattern is different from that seen with many other acute or chronic autoimmune diseases of the central and peripheral nervous systems (PNS), such as acute disseminated encephalomyelitis (ADEM), the Guillain-Barre syndrome (GBS), and chronic inflammatory demyelinating polyneuropathy (CIDP) however, a similar worldwide pattern can be seen for type 1 diabetes in Europe and other allergic or autoimmune disorders such as Crohn's disease are not randomly distributed (15).
The type of histopathology resection specimen received is dictated by the nature of any previous operations and the current disease process, its distribution and degree of local spread within the organ and to adjacent structures. Resection surgery must provide adequate clearance of longitudinal and deep circumferential radial margins. It must also take into account the lymphovascular supply to achieve satisfactory anastomoses and the regional lymph node drainage for an adequate radical cancer operation. Site location within any given organ may influence the nature of the pathological abnormality and surgical procedure undertaken, e.g., anterior resection for high rectal cancer versus abdominoperineal resection for low rectal cancer, or mid-oesophagus (squamous carcinoma) versus distal oesophagus (adenocarcinoma). Multifocal distribution may be seen in both inflammatory (Crohn's disease) and neoplastic (malignant lymphoma) disorders. Inflammatory disease can be mucosa confined...
Of HS, the efficacy of anti-inflammatory drugs, of anti-tumor necrosis factor (TNF) drugs, and the significant association with Crohn's disease all point to an abnormality of immune and or inflammatory mechanisms in HS. The number of candidates is large, including abnormalities of innate immunity, e.g., NOD, TLR, and deficiencies of natural antibacterial substances such as defensins and cathelicidins (see Chaps. 6, 12). The potential usefulness of anti-inflammatory and immunosuppressive therapy in HS may therefore have a broader scope than is reflected in existing literature.
|The Fastest Way To End Digestive Pain Forever|
Download Instructions for No More Crohn's Disease
There is no place where you can download No More Crohn's Disease for free and also you should not channel your time and effort into something illegal.