Crohn's and Colitis. Dr. Hillary Steinhart

example, someone with Crohn’s disease may have an area of inflammation in the middle part of the small intestine (jejunum) and another area of inflammation in the large intestine, with normal intestine in between the two areas of inflammation.

       Intestinal Penetration

      In ulcerative colitis, the inflammation tends to be limited to the innermost lining of the gut, but in Crohn’s disease, the inflammation has a tendency to penetrate from the innermost lining, where inflammation and ulcers first occur, right through the deeper layers of the bowel to the outer surface (serosa). This results in a defect or hole in the bowel wall, which can lead to localized infections in the abdominal cavity (abscesses) or communications (fistulas) from the bowel into other organs or into the abdominal wall or skin. The inflammation in Crohn’s disease may also form into tiny localized collections of inflammatory cells, called granulomas, which can be seen only under the magnification provided by a microscope. These granulomas are virtually diagnostic of Crohn’s disease.

       Site Variation

      The wide variation in the sites of the gut that are affected by Crohn’s disease can lead to important differences in the ways individual patients experience the disease and the ways in which they come to medical attention. This variation in sites also affects approaches to management of the disease.

       Indeterminate Colitis Signs

      In a small proportion of individuals with inflammatory bowel disease involving the colon, it is not possible, based on the disease features, to differentiate between ulcerative colitis and Crohn’s disease. In these instances, the condition is designated as indeterminate colitis or inflammatory bowel disease of undetermined type (IBDU). In some cases of indeterminate colitis, the pattern of disease will change over time, and it will become apparent that the patient, in fact, has ulcerative colitis or Crohn’s disease. However, some patients will continue to have features of both ulcerative colitis and Crohn’s disease, and distinguishing between the two will not be possible.

      The approach to the management of the two conditions with medications is similar. Differentiation becomes much more important if surgery is contemplated as a means of treatment, as the surgical approaches in ulcerative colitis and Crohn’s disease can be quite different because of the fact that Crohn’s disease can come back after surgery in parts of the bowel that weren’t affected before surgery.

What Are the Possible Complications of IBD?

       Complications Specific to Crohn’s Disease

      •Strictures

      •Abscesses

      •Fistulas

      There are several serious complications that can occur as a result of having inflammatory bowel disease. This is where the danger lies. Some complications are common to Crohn’s disease and ulcerative colitis, whereas others are unique to one form of IBD or the other. Generally, the complications can be divided into those that occur directly from the inflammation or ulceration that occurs in the intestine and those that occur in areas of the body that are not directly connected to the intestine or directly related to the intestinal inflammation.

       Crohn’s Disease Complications: Strictures, Abscesses, and Fistulas

       Inflammation and Ulceration Complications

      Inflammation and ulcerations can lead to strictures, fistulas, and abscesses in the gut. If these complications are not properly managed, they can, in turn, lead to further tissue damage and uncontrolled infection. Death can occur if this happens. While these complications are often seen in Crohn’s disease, they are very rare in ulcerative colitis.

What are strictures?

Strictures are segments of the intestine in which the normally large internal opening becomes narrowed. This can be due to the swelling that occurs in the tissues of the intestinal wall as a result of active inflammation, similar to the swelling you get when you experience an injury, such as a broken bone. More often, the stricture is due to scarring of the intestinal tissues following repeated or ongoing episodes of inflammation and healing.

       Strictures

      Strictures are not necessarily a problem until they cause a bowel obstruction, commonly referred to as a blockage. Food or other material becomes caught in the narrowed stricture, preventing anything else from passing through. This produces back pressure in the intestine “upstream” from the stricture, causing sharp, often crampy pain, a distended abdomen, and nausea and vomiting. Sometimes there may be warning signs that a stricture may be worsening or leading to an obstruction. These signs include frequent or recurrent pain in the center of the abdomen after eating, along with a feeling of distension or bloating of the abdomen.

       Foods to Avoid When You Have an Intestinal Stricture

      •Popcorn

      •Nuts

      •Seeds

      •Corn

      •Raw vegetables

      •Skins on fruits

       Bowel Obstruction

      Not everyone with a stricture develops intestinal obstruction. If you experience a bowel obstruction that is not severe and know the symptoms, you can sometimes manage it on your own by avoiding solid food and drinking only fluids for several hours or even a few days. If you have a stricture, it is important that you avoid eating foods that aren’t easily digested and that, as a result, may get lodged in the narrowed part of the intestine. These foods include popcorn, nuts, seeds, corn, raw vegetables (particularly stringy ones like celery), and skins on fruits.

      This complication can be an emergency situation. You will usually require monitoring in a hospital setting, with intravenous fluids given to prevent dehydration and possibly the insertion of a nasogastric tube (a plastic tube inserted through the nose and down the esophagus into the stomach) to take fluid and gas out of the stomach.

       Bowel Obstruction Symptoms

      •Severe crampy pain, usually centered in the middle of the abdomen

      •Distension or bloating of the abdomen

      •Reduced number of bowel motions

      •Not passing gas

      •Nausea and vomiting

      Not all symptoms are necessarily present when a bowel obstruction has occurred, particularly if it is partial or incomplete.

      If the obstruction does not settle with these measures, then surgery is usually required to remove the strictured area of bowel. Fortunately, most obstructions that are due to Crohn’s disease strictures settle without the immediate need for surgery, but repeated obstructions usually mean that surgery is required. In that instance, the surgery can be scheduled electively so that it is performed when you are well nourished, not sick, and not on medications that might affect healing and recovery after surgery. Medications are not very effective at relieving obstruction, particularly when the narrowing is due to scarring.

       Immediate Medical Attention

      If there is fever with the stricture symptoms, if there is frequent vomiting, or if after 6 to 8 hours symptoms of the obstruction are not starting to clear, as evidenced by reduced pain, decreased abdominal distension, and resumption of normal bowel motions and passing gas, then immediate medical attention is needed.

       Abscesses

      When