Gaining Insight Into Crohn’s Disease, Intestinal Inflammation

Dr. Stephan Targan is a professor of medicine at UCLA and director of Cedars-Sinai Medical Center’s gastroenterology division and its inflammatory bowel disease center. He spoke to Health about Crohn’s, a debilitating disease that affects between 400,000 to 750,000 Americans and is on the rise.

Question: What is Crohn’s, and why are we seeing more of it today than ever before?

Answer: Crohn’s is a chronic inflammation of the intestine that causes people to have diarrhea, pain and weight loss. I like to describe it as a case of Montezuma’s revenge that doesn’t go away. It can range from mild to very aggressive. It’s not considered fatal, but some of the patients who have it might wish they were dead. It can burrow all the way through the intestines and appear anywhere in the gastrointestinal tract from the mouth to the anus. We don’t know why it’s more prevalent today, but we do know it’s the interplay between genetic susceptibility and the environmental factors that trigger this, and we think it’s an over-response to our own intestinal bacteria.

To give an example, a family goes down to Mexico and they all get “tourista.” They come back and everyone gets better, except one patient who’s genetically susceptible. That person doesn’t get better, and eventually he’s found to have colitis [inflammation of the colon]. That’s not an uncommon way it first presents, by the way.

Q: So you’ve got some nasty symptoms that won’t go away. Your doctor gives you a round of antibiotics, but it doesn’t help. What’s your next step?

A: Sometimes it’s difficult to diagnose. There are three different ways to test for it: X-rays; blood tests, in which we look for certain antibodies; and colonoscopies, in which a long, flexible lighted tube linked to a computer and TV monitor is inserted into the anus to see the inside of the large intestine. It will show if there’s ulceration, redness and inflammation of the intestinal lining. The specialist you’re going to need to see for this is a gastroenterologist.

Q: What does a diagnosis of Crohn’s mean for a person’s lifestyle?

A: It depends. We can get the majority of people into remissions that last years, depending on the severity of the disease. The key is the cost to your body--some of the side effects of the drugs, especially with the steroid prednisone, can be horrendous, from disfigurement (hair growth, puffy face, hump on the back due to fatty deposits under the skin) to calcium bone loss and cataracts. There’s also a new drug called Remicade, an engineered antibody to one of the proteins that causes Crohn’s in at least two-thirds of patients. Sometimes Crohn’s can be treated with antibiotics. If a patient is resistant to the drugs that are available, we may resort to surgery.

Q: Does that mean removing the entire intestine or colon?

A: Not necessarily. You go in and find the diseased area, remove it and hook the intestine back up. It works, and people become better. The problem is that patients invariably have a recurrence, some right away, some after years. We don’t know why, but it usually recurs at the surgery site.

Q: Then what?

A: Then we may have to do an ileostomy, which is where we bring out the ilium, the last part of the small bowel, onto the abdominal wall and the fecal content goes into a bag. If you bring out part of the colon, that’s called a colostomy. If the inflammation is localized in the colon, we can remove it and see a lot of improvement. But if it’s in both the colon and the intestine, the surgery isn’t as successful. Crohn’s can also appear in the colon, stomach, esophagus, mouth and anal area. There are people walking around who can’t sit down in a chair; their whole anal area has holes.

Q: Who’s most at risk for Crohn’s?

A: Children who get it young tend to have more severe cases, but generally it’s a disease of young people in their teens, 20s and 30s. There’s another peak in people 50 or older, but they tend to have a milder version of it. It can run in families.

Those most at risk appear to be Middle European Ashkenazi Jews who have a sibling with Crohn’s. They have a 9% higher risk. Why? It may be the gene pool. Before modern sanitation, those who survived were the ones whose bodies could get rid of bacteria very quickly. But such a hyperactive immune system isn’t needed anymore. Another example is Asia. People in China, Korea and Japan didn’t have Crohn’s before, but as they’ve westernized, in diet and everything else, they begin to get it. It is a disease that seems to come with industrialization in the modern world.

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For more information:

Crohn’s & Colitis Foundation of America Inc., (800) 932-2423, https://www.ccfa.org.

Pediatric Crohn’s & Colitis Assn. Inc., (617) 489-5954, https://pcca.hypermart.net.

Inflammatory Bowel Disease Center at Cedars-Sinai Medical Center, (310) 423-4100.

National Digestive Diseases Information Clearinghouse (part of the National Institutes of Health), 2 Information Way, Bethesda, MD 20892-3570.