J-e:eated Ta:Ttta-a S|aat-2tt8-J.Sc.-46Introduct|onO Cioln's Disease is an idiopailic, clionic,iiansmuialinflammaioiy piocess of ile bowel ilai can affeci anypaii ofile gasiio iniesiinaliiaci fiom ile mouil ioile anus.O Mosicasesinvolveilesmall bowel, paiiiculailyileieiminal ileum|storyO io: Fiisi iepoiiedcase ofCioln's by Combe andSandeis io ile Royal College of Plysicians inLondon, EnglandO ii: Suigical evidence of ile disease iepoiied in ilepapei 'ClionicIniesiinal Enieiiiis' wiiiienbyDi.Kennedy Dalziel ai ile Wesiein Infiimaiy inGlasgowO Desciibed in i: by Cioln, Ginsbuig, andOppenleimei of Mouni Sinai Hospiial in NewYoil9reva|enceO Higleinumbei of casesof Cioln'sdiseasefoundinwesiein indusiiialized naiions.O Males and females aie equally affecied.O Smoleis aie iliee iimes moie lilely io develop Cioln'sdisease.O Cioln's disease affecis beiween oo,ooo andoo,ooopeople in Noiil Ameiica.O Pievalence esiimaies foi Noiilein Euiope lave iangedfiom:- pei ioo,ooo.OCioln's disease iends io pieseni iniiially in ile ieensand iweniies.|ass|f|cat|onCioln's disease can be caiegoiized by ile aiea ofile gasiioiniesiinal iiaci wlicl ii affecis:O Ileocolic Cioln's disease: Affecis boil ileileumand ile laige iniesiine (o%)O Cioln's ileiiis: Affecis ile ileumonly (o%)O Cioln's coliiis: Affecis ile laige iniesiine,accounisfoi ile iemainingiweniypeiceniofcases.ulsLrlbuLlon of aasLrolnLesLlnal Crohns dlseasedaLa from Amerlcan CasLroenLeroloalcal AssoclaLlon|ass|f|cat|onCioln's disease may also be caiegoiized by ile belavioiof disease as ii piogiesses:O Siiiciuiing disease causes naiiowing of ile bowelwlicl may lead io bowel obsiiuciion oi clanges in ilecalibei of ile feces.Stvituving|ass|f|cat|onOPeneiiaiing disease cieaies abnoimal passage ways beiween ile boweland oilei siiuciuies sucl as ile slin.OInflammaioiy disease causes inflammaiion wiiloui causing siiiciuiesoi fisiulae.Inflammaioiy PeneiiaiingymptomsO Onsei of Cioln's disease is beiween i-o yeais of age.O People wiil Cioln's disease will go iliougl peiiods offlaie-ups and iemission.ndoscopv lmaae of colon showlna serplalnous ulcer ln Crohns dlseaseastro|ntest|na|ymptomsO Abdominal pain accompanied by diaiiloea(may oi may noi be bloody), flaiulence, bloaiing, peiianaldiscomfoii . O People wlo lave lad suigeiy ofien end up wiil sloii bowel syndiome of ile gasiioiniesiinal iiaci.O Ileiiisiesulis in laige volume waieiy feces 8 coliiis iesuli in a smallei volume of feces of liglei fiequency. OIn seveie cases, an individual may lave moie ilan :o bowel movemenis pei day and may need io awalen ai nigli io defecaie.O Tle mouil may be affecied by non-lealing soies (aplilous ulceis).O Difficuliy in swallowing (dysplagia).ystem|cymptomsOp io o% of clildien wiil Cioln's disease laveieiaidaiion of giowil.O Among oldei individuals, Cioln's disease may manifesi asweigli loss ielaied io decieased food inialeO People wiilexiensivesmall iniesiinedisease alsolavemalabsoipiion of caibolydiaies oi lipids, wlicl canfuiilei exaceibaie weigli loss.tra|ntest|na| ymptomsO nI!ammationoI thintviovpovtionoI thv, knownasuvitis, anausvpain&thwhitpavt oI thv, aonditiona!!d pis!vitis.Epis!vitis Uvitistra|ntest|na| ymptomsO Cioln's disease is associaied wiil seionegaiivespondyloaiiliopaily;inflammaiionof ioinis oi muscle,osieopoiosis,neuiological complicaiions lile seizuies,myopaily, peiipleial neuiopaily .O Anlylosing spondyliiis include painful, waim, swollen, siiffioinis and loss of ioini mobiliiy oi funciion.nkv!osing spondv!itisWrvLhema nodosum presenLs as red nodules on Lhe shlns ls due Lo lnflammaLlon of Lhe underlvlna subcuLaneous Llssue and ls characLerlzed bv sepLal pannlcullLlsErythema nodosumon the back and leg of a person with Crohn's DiseaseExtvaintstina!Svmptoms W9voderma aanarenosum ls Lvplcallv a palnful ulceraLlna nodule WCioln's disease also incieases ile iisl of blood clois; painful swelling of ile lowei legs can be a sign of deep venous iliombosis.W Difficuli bieailing may be a iesuli of pulmonaiy embolism. WAuioimmune lemolyiic anemia, a condiiion in wlicl ile immune sysiem aiiacls ile ied blood cells.vodvma gangvnosumon th !g oI a pvson with Cvohn'sDisasExtvaintstina!Svmptomstra|ntest|na| ymptomsO Clubbing, a defoimiiy of ile ends of ile fingeis, also be a iesuli of Cioln's disease.omp||cat|onsCioln's disease can lead io seveial meclanicalcomplicaiions wiilin ile iniesiines, includingobsiiuciion, fisiulae, and abscesses.OTstvution: Occuis fiomsiiiciuies oi adlesionswlicl naiiow ile lumen, blocling ile passage of ileiniesiinal conienis.Oistu!a: Develop beiween iwo loops of bowel,beiweenilebowel andbladdei, beiweenileboweland vagina, and beiween ile bowel and slin.OTssss: Colleciions ofinfeciion, wlicl can occuiinileabdomenoiinilepeiianal aieainCioln'sdisease suffeieis.ndoscoplc lmaae of colon cancer ldenLlfled ln Lhe slamold colon on screenlna colonoscopv for Crohnsdlseaseauses of rohn's D|saeseenet|csO Tle disease iuns in families ilen o iimes moie lilelyio develop CD.O Muiaiions in ile NOD:]CARDi gene aie associaiedwiil Cioln's disease.O Oveiogenesilaislowgeneiicsplayaioleiniledisease, eiilei diiecily iliougl causaiion oi indiiecilyas wiil a mediaioi vaiiable.O Anomalies in ile XBPi gene lave iecenily beenideniified as a facioi, poiniingiowaids a iole foi ileunfolded pioiein iesponse pailway of ileendoplasmaiic ieiiculum in inflammaioiy boweldiseases.NOD: : nucleoiide-binding oligomeiizaiion domain coniaining :CARDi :Cailapse Aciivaiion Reciuiimeni Domainnv|ronmenta|IactorsO Smoling las been slown io inciease ile iisl of ile ieiuin of aciive disease, oiflaies.O Hoimonal coniiacepiioninile Sinileiosislinledwiiladiamaiicinciease in ile incidence iaie of Cioln's disease.mmunSvstmO Cioln's disease is ilougli io be an auioimmune disease, wiil inflammaiionsiimulaied by an ovei-aciive Tli cyioline iesponse.O Receni gene io be implicaied in Cioln's disease is ATGiLi, wlicl may induceauioplagy and lindei ile body's abiliiy io aiiacl invasivebacieiia.,|crobesOA.V. Singlei al. lave suggesiedilai Mycobocteriumoviumsubspecies porotuberculosis plays a iole in Cioln's disease and iicauses a veiy similai disease, Iolne's disease, in caiile.OA siudy in :oo pui foiil ile cold-clain lypoilesis, ilai psyclioiioplic bacieiia sucl as ersinio spp and listerio sppconiiibuie io Cioln's disease. voTatvium aviumsuTspis pavatuTvu!osis o!onis Ivom stoo! samp! oI Cvohn's disas patint 9athophys|o|ogyO Biopsies of ile colon aie ialen io confiim ile diagnosis.O Cioln's disease slows a iiansmuial paiiein ofinflammaiion, meaning ilai ile inflammaiion may spanile eniiie depil of ile iniesiinal wall.Olceiaiion is an ouicome seen in liglly aciive disease.O Inflammaiion is claiacieiized by focal infiliiaiion ofneuiioplils, a iype of inflammaioiy cell, inio ileepiilelium.O Tlese neuiioplils, along wiil mononucleai cells, mayinfiliiaie inio ile ciypis leading io inflammaiion oi abscess.O Gianulomas lnown as giani cells, aie found in o% of casesand aie mosi specific foi Cioln's disease.O Tle gianulomas of Cioln's disease do noi slowcaseaiion, a cleese-lile appeaiance on micioscopicexaminaiion ilai is claiacieiisiic of gianulomas associaied9athophys|o|ogy of Inf|ammatory 8owe| D|sease/DecLlon of ColecLomvhowlna1ransmural lnflammaLlonD|agnos|sO Cioln's disease does noi diagnose wiil compleie ceiiainiy.O A colonoscopy is o% effeciive in diagnosing ile disease viadiiecivisualizaiion of ile colon and ile ieiminal ileum.O Capsule endoscopylelpin endoscopic diagnosis.Oo% of Cioln's disease involves only ile ileum,cannulaiionof ile ieiminal ileumisiequiiedinmalingile diagnosis.@ scan show|ng rohns d|sease |n the fundus of the stomachEndosopi imag oI Cvohn's o!itis showing dp u!vationad|o|og|c@estsO A baiiumX-iay wleie baiiumsulfaie suspension isingesied and fluoioscopic images of ile bowel aie ialen ioclecl inflammaiion and naiiowing of ile small bowel.O Ideniifyinganaiomical abnoimaliiies wlensiiiciuies ofile colon aie ioo small foi a colonoscope io pass iliougl,oi in ile deieciion of colonicfisiulae.8|ood@estsO A compleie blood couni may ieveal anemia caused eiileiby blood loss oi viiamin Bi: deficiency.O Eiyiliocyie sedimeniaiion iaie(ESR) and C-ieaciivepioieinmeasuiemenis canalsobeuseful ioclecliledegiee of inflammaiion.O Tesiing foi anii-occboromyces cerevisioe aniibodies(ASCA) and anii-neuiioplil cyioplasmic aniibodies(ANCA)lasbeenevaluaiedioideniifyinflammaiionofile iniesiine.rohnsD|sease U|cerat|ve o||t|s Olceiaiive coliiis mimics ile sympioms of Cioln's disease,as boil aie inflammaioiy bowel diseases ilai can affeci ilecolon.O Someiimes iis noi possible io iell ile diffeience, in ilosecase ile disease is classified as indeieiminaie coliiis.ompar|sons ofVar|ousIactors|nrohnsD|seaseU|cerat|ve o||t|sCrohn's disease Ulcerative colitis%erminal ileum involvement Commonly SeldomColon involvement Usually AlwaysRectum involvement Seldom UsuallyInvolvement around the anus Common SeldomBile duct involvementNo increase in rate of primary sclerosing cholangitisHigher rateDistribution of DiseasePatchy areas of inflammation (Skip lesions)Continuous area of inflammationEndoscopyDeep geographic and serpiginous(snake-like) ulcersContinuous ulcerDepth of inflammationMay be transmural. deep into tissuesShallow. mucosalFistulae Common SeldomAutoimmuue diseaseWidely regarded as an autoimmune diseaseNo consensusCytokine response Associated with %h17 Vaguely associated with %h2Granulomas on biopsyMay have non-necrotizing non-peri-intestinal crypt granulomasNon-peri-intestinal crypt granulomas not seenSurgical cureOften returns following removal of affected partUsually cured by removal of colonSmoking Higher risk for smokers Lower risk for smokers@reatmentO Remission may be piolonged in Cioln's disease.O Sympioms coniiolledwiilmedicaiion, lifesiyleclangesand suigeiy.O Adequaiely coniiolled Cioln's disease may noisignificanily iesiiici daily living.O Tieaimeni foi Cioln's disease is only wlen sympioms aieaciiveandinvolvefiisiiieaiingileacuiepioblem, ilenmainiaining iemission.,ed|cat|onO Aniibioiicsuse io ieduce inflammaiion .O Piolonged use of coiiicosieioids las significani side.O Alieinaiives include aminosalicylaies alone, ilougl only aminoiiiyaieableiomainiainileiieaimeni, andmanyiequiie immunosuppiessive diugs.,ed|c|neUsed|n @reatmentofrohnsD|sease O -aminosalicylic acid (-ASA) O Piednisoneand meilylpiednisoloneO Immunomodulaioissucl asazailiopiine, meicapiopuiine, meiloiiexaie, infliximab, adalimumab.O Hydiocoiiisone slould be used in seveie aiiacls of Cioln's disease. ,anagement ofrohnsD|sease D|agnosedby||n|ca|va|uat|on ad|ograph|c tud|es ndoscopyLaboratory@estsandtoo|tud|esL|festy|ehangesO Dieiaiy adiusimenis, piopei lydiaiion and smoling cessaiion ieducesympioms.O Have a balanced diei wiil piopei poiiion coniiol 8 eai small meals fiequenilyinsiead of big meals.O Do iegulai exeicise andiale enougl sleep.O Ideniifying foods ilai iiiggei sympioms.SuvgvvO Cioln's cannoi be cuied by suigeiy.O Suigeiyiequiiedincase of obsiiuciions, fisiulasand]oi abscesses, oi if iledisease does noi iespond io diugs.O Afiei ile fiisi suigeiy, Cioln's usually slows up ai ile siie of ile ieseciionilougl ii can appeai in oilei locaiions.O Afiei a ieseciion, scai iissue builds up wlicl can cause siiiciuies.O A siiiciuie is wlen ile iniesiines become ioo small io allow exciemeni io passiliougl easily wlicl can lead io a bloclage.O Foi paiienis wiil an obsiiuciion due io a siiiciuie, iwo opiions foi iieaimeniaie siiiciuieplasiy and ieseciion of ilai poiiion of bowel.D|etforrohnsD|seaseO Diinl lois of fluid io leep body lydiaied and pieveni consiipaiion.O Tale muliiviiamin-mineial supplemeni io ieplace losi nuiiienis .O Eai a ligl fibei diei wlen CDis undei coniiol. O Duiing a flaie up, limii ligl fibei foods and follow a low fibei diei.O Avoid laciose-coniaining foods if one las laciose inioleiance oi use laciase enzymes and laciase pieiieaied foods.O Tiy small fiequeni meals. O Eaiing a ligl pioiein diei wiil lean meais, fisl and eggs, may lelp ielieve sympioms of Cioln's.O Tale pie-digesied nuiiiiional diinls io givebowel a iesi and ieplenisl losi nuiiienis.O Limii caffeine, alcolol and soibiiol . O Limii gas-pioducing foods sucl as bioccoli, cabbage, cauliflowei, biusselsspiouis, diied peas ,leniils, onions, and caibonaied diinls. O Reduce fai iniale if paii of ile iniesiines las been suigically iemoved. O If ile ileum las been iesecied, a Viiamin Bi: inieciion may be iequiied.O Siudies found ilai fisl oil and flax seed oil may be lelpful in managing . O Tle iole of piebioiics sucl as psyllium 8 piobioiics lelpful in ile lealing piocess. D|etary,anagement |n rohn's D|seaseComp!x CavTohvdvatsO Paiienisslouldseleci complexcaibolydiaies, wliclaie also a good souice of fibei.OFiesl fiuii sucl as apples, giapefiuii, oianges, plums,bluebeiiies, iaspbeiiies, andsiiawbeiiiesmigli bepioieciive foi Cioln's disease.OSimple sugais can inciease inflammaiion.O Higl-fibei foods can cause gas, bloaiing, and pain inCioln's disease paiienis.O Commeicial pioducis Beanoaieavailableilai canieduce gas.9rote|ns|nrohn'sD|seaseO Pioieins aie veiy impoiiani foi giowil in clildien and foiiepaii of cells.O Diaiiloea can cause pioiein deficiency so Cioln's paiienismay need moie pioiein.O One siudy iepoiied ilai a soy pioiein diei was useful foipaiienis wlo weie inioleiani io mill pioducis.O Oily fisl, sucl as salmon and iuna, pouliiy 8 lean meaismay be paiiiculaily beneficial in Cioln's disease.||s |n rohn's D|seaseOOmega- faiiy acids aie impoiiani compoundsfoi Cioln's disease.OA siudy slowed ilai ile palmiiic acid absoipiion-oxidaiion obseivedfoi ile Cioln's paiienis incieased fiom .i.i% befoie ile iieaimenipeiiod io .i.i%afiei iieaimeni.OTlis compaies favouiably wiil Wailins ei al. wlo found ilai :.ii.%of ile adminisieied dose of palmiiic acid was excieied in bieail ovei lfoi paiienis wiilmucosal disoideis compaiedio .:.%foinoimal subiecis.OA siudy by Andeisson ei al. invesiigaied paiienis wiil Cioln's disease,mosi of wlom lad been subiecied io ileal ieseciion, and compaied ileeffeci of a lowfai (o g]day) veisus a ligl fai (ioo g]day) diei.OTle geneial condiiion of ile paiienis impioved wlen consuming ilelowfai diei, including diaiiloea, sieaioiilea and eleciiolyie balance.OWeigli gain was obseived even ilougl ile fai iniale was significanilyieduced fiomile mean io g iepoiied in lome use.-utr|ent Importance |n a rohn's D|sease D|et O Cioln's disease paiienis aie in dangei of becomingmalnouiisled. Tle following aie seveial ieasons ioconsidei ilese findings:O Pooi digesiion and malabsoipiion of dieiaiy fais,caibolydiaies, waiei, pioiein, mineials and viiamins.O Duiingdiseaseflaie-upsclionicdiseasepaiienisusuallywill inciease levels of eneigy and caloiic needs foi ile body.O Sympioms of abdominal pain, nausea, oi lacling iasiesensaiions will lave an ill affeci on food iniale iesuliing inloss of appeiiie.Iood Absorpt|onO Food absoipiion is a luge issue wlen ii comes iopaiienis wiil Cioln's Disease.O Peopleilailaveinflammaiiononlyinilelaigeiniesiine mosi ofien absoib food noimally.O Ovei o peiceni of individuals diagnosedwiilCioln's slowed ilai iley can eai enougl food buican'i absoib food adequaiely, especiallycaibolydiaies.V|tam|n and ,|nera| Def|c|enc|esOAbsoipiion of viiamin and mineials vaiy depending on iype andlocaiion of ile disease.OIndividuals ilai lave Cioln's disease wleie ile ileum is affeciedmay lave a viiamin Bi: deficiency due io ilai iley aie unable ioabsoib enougl of ile Bi: viiamin fiom oial supplemenis oi foodiniale.OOne of ile mosi common deficiency associaied wiil ilecommonCioln'sDiseaseDiei andwliclaffecisaboui sixiy-eiglipeiceni, isilelaclof viiaminD, wliclsuppoiisbonefoimaiion and calcium meiabolism.ODeficiencyof ileiioninpaiieniswiillceiaiiveColiiisandCioln's Disease is also common due io ile loss ofblood,inflammaiion and ulceiaiion of ile colon.O Poiassium and magnesium deficiency occui due io diaiiloeaoi vomiiing.OTiaceelemenideficienciesaienoimallypieseniinilosewiilpooi nuiiiiionaliniale andlave andexiensive smalliniesiinedisease.IoodstoAvo|d People wiil Cioln's disease find ilai ileie aie ceiiain foods ilai seem io male ileii sympioms woise. Tlese include: ODaiiy pioducis OSpicy foods OClocolaie OCaffeinaied beveiages, sucl as coffee, ieas, and some sofi diinls OAlcololic beveiages OCeiiain iaw fiuiis and vegeiables If iaw fiuiis and vegeiables cause pioblem ilen iiy cooled oifind oilei fiuiis and vegeiables ilai don'i male ile sympioms woise. Some oilei foods ilai male ile sympioms woise in some people include: OPopcoin O Fiuii iuices OBeans OOnions OAiiificial sweeieneis, sucl as soibiiol oi manniiolOHigl-fai foods sucl as buiiei, ied meai, avocados, nuis, and fiied foods. omp|ementaryandA|ternat|ve,ed|c|neO Cioln's disease suffeieis lave iiied complemeniaiy oialieinaiive ileiapy.Tlese include dieis, piobioiics, fisloil and oilei leibal and nuiiiiional supplemenis.O Acupunciuie is used io iieai inflammaioiy boweldisease in Clina, and is being used moie fiequenily inWesiein socieiy.O Meiloiiexaie is a folaie anii-meiaboliie diug wlicl isalso used foi clemoileiapy.O Meiionidazole and cipiofloxacin aie aniibioiics wliclaie used io iieai Cioln's disease.O Tlalidomide las slown iesponse in ieveisingendoscopic evidence of disease.O CanabisdeiiveddiugsmaybeusedioiieaiCioln'sdisease wiil iis anii-inflammaioiy piopeiiies.O Piobioiics include Saccliomyces boulaidii and E. coli.