Crohn's Disease

Etiology:

Although the exact cause is unknown, the following are believed to be likely causes:

  • Genetics (seen more often in the Jewish population; chromosomes 16, 12, 6, and 14 are main areas of linkage being studied—recently 21 new genes for Crohn's have been identified, several related to promotion of inflammation.)
  • Smoking (doubles the risk of Crohn's)
  • Infectious agents
  • Immunological factors

Signs/Symptoms:
The range and severity of symptoms varies.

Common symptoms include:

  • Abdominal Pain (often in the lower right area)
  • Diarrhea (loose, watery, or frequent bowel movements)

Other symptoms may include:

  • Rectal bleeding
  • Weight Loss
  • Arthritis
  • Skin Problems
  • Fever
  • Loss of Appetite
  • Fatigue

Children with Crohn's may suffer delays in both growth and sexual development.

Method of Diagnosis:

Diagnosis of Crohn's begins by taking a complete family and personal medical history, which is followed by a physical examination.

No laboratory test specifically identifies Crohn's disease, but blood tests may show anemia, abnormally high numbers of white blood cells, low levels of the protein albumin, and other indicators of inflammation such as an elevated level of C-reactive protein.

A colonoscopy and a biopsy are usually the first tests performed after a physical examination and blood tests have been completed.

A sigmoidoscopy may also be used which is when the doctor inserts a flexible instrument into the rectum and the lower part of the colon to visually see if there is inflammation and how much. Crohn's disease can also almost always be detected on x-rays after barium is swallowed.

Risk Factors:

Modifiable:

  • Smoking

Non-Modifiable:

  • Genetics
  • Immunological factors

Prevention:

  • Nothing an individual does makes them get Crohn's disease, it is important to know if you are at risk and be aware that smoking can increase your chances of developing Crohn's.

Supplements Commonly Used:

During flareups it is recommended to take the following supplements:

  • Vitamin D
  • Zinc
  • Calcium
  • Magnesium
  • Folate
  • Vitamin B-12
  • Iron

Labs Appropriate to Disease:
Normal Values Range:

Common lab values take in a Crohn's patient:

Laboratory Normal Range Adult Values
Albumin 3.6-5.0 g/dL
Prealbumin 19-43 mg/dL
Hemoglobin 12-16 g/dL women; 13.5-17.5 g/dL men
Hematocrit 37% to 47% women; 40% to 54% men
Mean corpuscular volume 84-96 fL
Mean corpuscular hemoglobin 31.5% to 36%
Mean corpuscular hemoglobin concentration 27-34 pg
Red cell distribution width 11.6% to 16.5%
Total iron-binding capacity 250-460 mcg/dL
Ferritin 10-150 ng/mL (women); 12-300 ng/mL (men)
Transferrin 200-400 mg/dL
Vitamin B-12 100-700 ng/mL
Folate 2-20 mm3
Glucose 70-110 mg/dL
Blood urea nitrogen 8-26 mg/dL
Creatinine 0.6-1.3 mg/dL
Sodium 135-155 mmol/L
Potassium 3.5-5.5 mmol/L
Phosphorus 2.5-4.5 mmol/L
Chloride 98-108 mmol/L
Magnesium 0.70-1.15 mmol/L
Zinc 11-23 mmol/L
Calcium 8.7-10.2 mg/dL
CO2 24-30 mmol/L
Osmolality 275-295 mOsm/kg H2O
C-reactive protein <1 mg/L
Erythrocyte sedimentation rate (ESR) <17 mm/hr women; <15 mm/hr men
Lactoferrin (stool specimen) Negative
Antisacchromyces antibodies Negative
Antineutrophil cytoplasmic antibodies Negative
Folate 2-20 mm3
Vitamin B-12 100-700 ng/mL
Vitamin C 0.50-1.40 mg/dL (plamsa)
25 hydroxy-Vitamin D 16-74 ng/mL
Vitamin K 10.4-12.8 slc (Use also prothrombin levels)
Vitamin A 30-80 mg/dL
Plasma Zinc >70 ug/dL

Values in the Disease:

Laboratory tests commonly used to eliminate the possibility of bacterial, viral and parasitic causes of diarrhea. Blood tests may be performed to check for anemia, which could suggest bleeding in the colon or rectum. Blood tests also may detect a high WBC count, which indicates the presence of inflammation somewhere in the body. However, Crohn's disease cannot be diagnosed via a blood test. Researchers have been investigating a number of markers in the blood that may be elevated in people with Crohn's, but these haven't yet been accepted as sufficiently accurate to allow doctors to make a definitive diagnosis.

Nutritional Significance:

Patients with Crohn's are considered to be at significant nutritional risk. Potential nutrient deficiencies include the following:

  • Energy
  • Protein
  • Fluid
  • Electrolytes
  • Iron
  • Magnesium
  • Zinc
  • Calcium
  • Vitamin D
  • Vitamin B-12
  • Folate

Food and Feeding Issues

Common Nutrition Problem Etiology of Nutrition Problem
Energy/Protein Insufficient intake
Anorexia
Fear of abdominal pain and diarrhea after eating
Increased protein needs (losses from GI tract caused by inflammation)
Catbolism (when infection or abscesses present)
Healing from surgery
Fluid and electrolytes Short bowel syndrome
Iron Blood loss, inadequate diet
Magnesium, Zinc Intestinal losses, especially from short bowel syndrome
Calcium and Vitamin D Long-term steroid use
Decreased intake of dairy foods as result of lactose-restricted diets
Vitamin B-12 Surgical resections of stomach (loss of intrinsic factor) and/or terminal ileum (site of absorption)
Folate Medications used to treat inflammatory bowel disease.

General Dietary Prescription:

When the disease is inactive, except for restricting milk products in lactose-intolerant people or restricting caffeine when severe diarrhea occurs, most doctors simply recommend a well-balanced diet to prevent nutritional deficiency. When the disease is active, it is recommended to consume bland, soft foods to prevent discomfort and to consume smaller, more frequent meals may also help.

Specific Foods to Include:

These foods are recommended for people with diarrhea and abdominal pain.

Food Group Recommended Foods Notes
Milk and Dairy Products Buttermilk, Evaportated, skim, powdered or low-fat milk. Smooth, non-fat, or low-fat yogurt. Low-fat cheeses. Low-fat ice cream. Sherbert. Choose lactose-free products if you have lactose intolerance. Lactose intolerances causes symptoms after drinking regular milk or eating foods made from milk. Symptoms include diarrhea, nausea, stomach pain, and bloating. Choose yogurt with live, active cultures. (The food label will list this information.)
Meats and Other Protein Foods Tender, well-cooked meats, poultry, fish, eggs, and soy prepared without added fat. Smooth nut butter.
Grains Bread, bagels, rolls, crackers, cereals, and pasta made from white or refined flour. Choose grain foods with less than 2g fiber per serving. The grams of dietary fiber in one serving are listed on the Nutrition label of packaged foods.
Vegetables Most well-cooked vegetables without seeds, potatoes without skin; lettuce if tolerated, strained vegetable juice. See the "Specific Foods to Avoid" chart for a list of vegetables that you should avoid when you have diarrhea or abdominal pain.
Fruits Fruit juice without pulp (except prune juice), ripe bananas or melons, most canned, soft fruits, peeled apple. Choose canned fruit in juice or light syrup. Heavy syrup has lots of sugar, which may make diarrhea worse. See the "Specific Foods to Avoid" chart for a list of fruits that you should avoid when you have diarrhea or abdominal pain.
Fats and Oils Limit fats and oils to less than 8 teaspoons per day
Beverages Water, decaffeinated coffee, caffeine-free tea, soft drinks without caffeine, rehydration beverages. Drinking beverages with sugar or corn syrup may make diarrhea worse for some people. Very sweet juices may also have this effect.

Specific Foods to Avoid:

These foods are not recommended for people with diarrhea and abdominal pain. If you do not have symptoms, you may eat them.

Food Group Foods Not Recommended
Milk and Dairy Products Yogurt with berries, orange or lemon rind, or nuts. Whole milk. Half-and-half, cream, sour cream. Ice cream (unless it is low-fat or nonfat.)
Meats and Other Protein Foods Fried meats, including sausage and bacon. Luncheon meats, such as bologna or salami. Hot dogs. Tough or chewy cuts of meat. Fried eggs. All dried beans, peas, and nuts. Chunky nut butters.
Grains Whole wheat or whole grain breads, rolls, crackers, or pasta. Brown rice and wild rice. Cereals made from whole grain. Any grain foods made with seeds or nuts.
Vegetables Beets, broccoli, brussel sprouts, cabbage, sauerkraut, cauliflower, corn, greens (mustard, trunip, collards), spinach, lima beans, mushrooms, okra, onions, parsnips, peppers, potato skins, winter squash.
Fruits All raw fruits except peeled apple, ripe bananas, and melon. Canned berries, canned cherries, dried fruits (including raisins), prune juice.
Fats and Oils Do not have more than 8 teaspoons per day.
Beverages Beverage with caffeine, such as coffee, tea, cola, some sport drinks. Alcoholic drinks. Avoid sweet fruit juices and soft drinks or other beverages made with sugar or corn syrup if they make diarrhea worse.
Others Sugar alcohols (sorbitol, mannitol, xylitol) cause diarrhea in some people. These ingredients are often found in sugarless gums and candies, as well as some medications.

Reccomended Prescription Drug Therapy:

Although Crohn's disease has no known cure, many treatments help reduce inflammation and relieve symptoms.

Anti-Inflammation Drugs
Most people are first treated with drugs containing mesalamine, a substance that helps control inflammation. Sulfasalazine is the most commonly used of these drugs. Patients who do not benefit from it or who cannot tolerate it may be put on other mesalamin-containing drugs, generally known as 5-ASA agents, such as Asacol, Dipentum, or Pentasa. Possible side effects of mesalamine-containing drugs include nausea, vomiting, heartburn, diarrhea, and headache.

Cortisone or Steroids
Cortisone drugs and steroids, called corticosteroids, provide very effective results. Prednisone is a common generic name of one of the drugs in this group of medications. In the beginning, when the disease is at its worst, prednisone is usually prescribed in a large dose. The dosage is then lowered once symptoms have been controlled. These drugs can cause serious side effects, including greater susceptibility to infection.

Immune System Suppressors
Drugs that suppress the immune system are also used to treat Crohn's disease. Most commonly prescribed are 6-mercaptopurine or a related drug, azathioprine. Immunosuppressive agents work by blocking the immune reaction that contributes to inflammation. These drugs may cause side effects like nausea, vomitting, and diarrhea and may lower a person's resistance to infection. When patients are treated with a combination or corticosteroids and immunosuppressive durgs, the dose of corticosteroids may eventually be lowered. Some studies suggest that immunosuppressive drugs may enhance the effectiveness of corticosteroids.

Infliximab (Remicade)
This drug is the first of a group of medications that blocks the body's inflammation response. The U.S. Food and Drug Administration approved the drug for the treatment of moderate to severe Crohn's disease that does not respond to standard therapies (mesalamine substances, corticosterioids, immunosuppressive agents) and for the treatment of open, draining fistuals. Infliximab, the first treatment approved specifically for Crohn's disease is a TNF substance. Additional research will need to be done in order to fully understand the range of treatments Remicade may offer to help people with Crohn's disease.

Antibiotics
Antibiotics are used to treat bacterial overgrowth in the small intestine caused by stricture, fistulas, or prior surgery. For this common problem, the doctor may prescribe one or more of the following antibiotics: ampicillin, sulfonamide, cephalosporin, tetracycline, or metronidazole.

Anti-Diarrheal and Fluid Replacements
Diarrhea and crampy abdominal pain are often relieved when the inflammation subsides, but additional medication may also be necessary. Several antidiarrheal agents could be used, including diphenoxylate, loperamide, and codeine. Patients who are dehydrated because of diarrhea will be treated with fluids and electrolytes.
Potential Food and Drug Interactions:

General Nutrition Education Objectives or Goals:

Goals for patients with Crohn's disease are as follows:

  • Identify symptoms that interfere with adequate oral intake, including the following:
  • Anorexia
  • Altered Taste
  • Pain
  • Diarrhea
  • The patient will make necessary nutrition interventions to correct or compensate for malabsorption secondary to loss of bowel function, secondary bacterial overgrowth, inflammation, or surgical resection.
  • The patient will have nutrition therapy that will meet increased nutritional requirements, correct nutritional deficiencies, and compensate for increased nutritional losses, thereby accomplishing nutrition goals.
  • The patient will understand and make appropriate interventions to address potential drug-nutrient interactions.
  • Eat small meals or snacks every 3 or 4 hours
  • When the patient has symptoms, stick to the recommended foods. These foods are lower in fiber. When diarrhea decreases, the patient may have small amounts of whole grain foods and higher fiber fruits and vegetables. Patient should try them one at a time. If abdominal pain or diarrhea occurs, stop eating the new food and try it again at a later date.
  • Drink enough fluids to prevent dehydration. Aim for at least 8 cups of fluid each day.
  • Eat foods that have added probiotics and prebiotics. Ask your RD for good choices.
  • Use a multivitamin. You may need more of some vitamins and minerals than you do when you are healthy. Ask your RD about taking supplements.
  • During periods when you don't have symptoms, include whole grains and a variety of fruits and vegetables in your eating plan. Start new foods one at a time, in small amounts.

Edited By: Patricia O'Neal

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