How I treat Crohn's disease

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ABSTRACT: A retrospective review of 16 patients suffering from Crohn's disease. All patients had been diagnosed, fully investigated and treated in hospital and were still under consultant surveillance. They consulted privately for homoeopathic treatment between 1978 and 1991.

KEY WORDS: Crohn's disease; Retrospective review; Homoeopathy; Constitutional; Local prescribing.

The nature of Crohn's disease

I have abstracted much of the following information about Crohn's disease and its conventional treatment from an excellent review by Jewell.( 1) Crohn's disease is a chronic inflammatory disorder of the gastrointestinal tract. Its aetiology is unknown. It most commonly affects the ileocaecal region, initially producing small aphthous ulcers and progressing to fissuring and fibrosis of the bowel, with strictures and fistula formation.

A survey of the disease in Aberdeen published in 1986 revealed that the average incidence in the previous 20 years was approximately 3 people per 100,000.

Aetiology

The disease is commoner in women. A recent Swedish study found there was a fivefold increase in the risk of Crohn's disease in women who were currently smoking.( 2)

Recently various strains of bacteria have been investigated as being of aetiological significance: Mycobacterium paratuberculosis, and one of the diarrhoeagenic serotypes of Escherichia coli which is enteroadherent. Researchers have recently isolated adhesive E. coli from 62% of patients with Crohn's disease and 68% with ulcerative colitis, but from only 6% of normal controls (p ó 0.0002).( 3) But, in view of Koch's postulates, these findings must be interpreted with caution until further research has been done. There has also recently been renewed interest in gut permeability as an important factor in the aetiology of Crohn's disease.( 4)

Clinical features

Symptoms include diarrhoea, abdominal pain, rectal bleeding, fever and weight loss. The complications that frequently follow include stricture formation, often leading to obstruction, fistulae, perianal lesions (fissures, abscesses, skin tags) and gall stones. There may also be acute arthritis, erythema nodosum, iron and folate deficiency.

The diagnosis is often delayed for many years and the condition misdiagnosed as irritable bowel syndrome. Confirmatory investigations include contrast radiology, sigmoidoscopy, colonoscopy, rectal biopsy, stool examination and full blood profile and biochemistry. It is important to eliminate tuberculosis.

Treatment

Conventional treatment includes analgesics, antibiotics including metronidazole, azathioprine, and corticosteroids (orally, by enema, and in severe cases intravenously). Prednisolone is the most widely used steroid: it relieves symptoms but there is no evidence that steroids alter the prognosis.(5) Sulphasalazine may be tried, and has been extensively used in the past, but it does not help iliac disease, and has no role in maintenance therapy.(6) Currently trials with new drugs are in progress.

Complications may necessitate surgery for perianal lesions and fistulae, and for obstruction, and may involve resections and even ileostomy. The condition is chronic, and most patients (75-85%) eventually need surgery, with the tendency to require further surgery at a later date. The mortality of Crohn's disease is approximately twice that expected from an age and sex-matched control population.

In view of the wide variety of symptoms and complications there should be ample scope for introducing homoeopathy into the management of the condition.

Role of homoeopathic treatment

In my experience patients consult a homoeopathic doctor in desperation because they have failed to respond to current conventional treatment. It is not simply a matter of `I don't want to take drugs' -- they will take anything that alleviates their symptoms.

The first point I emphasize to my patients, and mention in my letter to their GP, is that homoeopathy will, in their case, only be an additional from of therapy. The patient should continue taking whatever conventional medication the GP or consultant involved feels is indicated. This is mandatory if the patient is taking maintenance steroids, as it is imperative that they do not suddenly discontinue taking them when they have been on them for years, or even months.

Aims of homoeopathic treatment

-- An improvement in the patient's sense of well-being and outlook.

-- A steady decrease in the severity of their symptoms, of pain, wind and cramps, and a reduction of the number of times they have their bowels open (B.O.).

-- The ability to resume eating a full diet, and regain the weight lost on account of their illness.

-- That they may be able to reduce, and possibly ultimately discontinue the dose of corticosteroids.

-- That the patient can reduce analgesics and anti-diarrhoea drugs.

-- To provide specific therapy for surgical complications, possibly aborting abscess formation, accelerating the healing of fistulae and perianal inflammatory lesions, and prevent the need for further resections.

Where appropriate I advise on modifying the patient's life style, on reducing stress, and on diet. I also discuss their smoking habits, though in this series only one acted on my advice on smoking.

Homoeopathic prescribing symptoms

As in all homoeopathic prescribing one must look for unusual symptoms peculiar to the patient, tending to discard symptoms common to the disease. We also have to ignore symptoms produced by the conventional medication that is currently being taken. Unless one has complete responsibility for the patient it would be unethical and irresponsible to instruct them to discontinue conventional treatment so that we could start again with an uncomplicated picture of their symptoms. Consequently, some symptoms, such as thirst, dry mouth, nausea, etc., may have to be ignored. I tend to discount them unless they are strikingly prominent.

Prescribing

When I can identify the patient's constitutional medicine (and often it is not clear cut) or the medicine that covers the totality of symptoms, I prescribe it in a 30c or 200c potency, to be repeated according to the patient's response, at intervals of 314 days. I also prescribe a `local' medicine that specifically matches the bowel symptoms, to be taken frequently in low potency on the intervening days (i.e. 3c-6c, hourly-2 hourly). My reason for this is that in private practice patients come long distances, often with difficulty, and unless very well motivated towards homoeopathic treatment will not re-attend and pay a second consultation fee unless they obtained significant improvement following their first visit. Hence the use of a local medicine which should predictably alleviate some symptoms, and possibly lessen the severity of any aggravation, should it occur.

I also use the bowel nosodes:

-- Proteus, if there has been prolonged nervous strain or cramps.

-- Dys. Co., where nervous tension or anticipatory fears are prominent.

-- Gaertner, where there is marked weight loss and malnutrition, and where Phosphorus has proved very effective,

I prescribed Tuberculinum on 3 occasions, and in 2 cases the patient asked for a second dose as they felt it had made a significant improvement.

In future I intend using more frequently:

-- Tub. bov., because of the similarity between Crohn's disease and tuberculosis, which often confuses diagnosis, and because Mycobacterium paratuberculosis, which organism causes a granulomatous intestinal inflammation (Johne's disease) in farm animals, has been isolated from a few patients with Crohn's disease,

-- a nosode of E. Coli using, if obtainable, a preparation made from the enteroadherent serotype of the diarrhoeagenic strain (isopathy),( 3) providing further research confirms the aetiological significance of this organism in Crohn's disease.

I assume that the patient who did not keep her follow-up appointment had not benefited from my treatment. I have learned that it is naive to think that the patients must be improving or they would have come for further help; they may have gone to another homoeopathic doctor, and I have known of several such cases!

Summary of medicines prescribed

The constitutional medicines which apparently were most effective were, in order of frequency, and number of cases.

Phosphorus 7 (44%)

Acid phos. 6 (38%)

Nux vomica 4 (25%)

Lycopodium 2 (13%)

Pulsatilla 1 (6%)

The most effective `local' medicines were:

Podophyllum (10) 63%

Aloes (6) 38%

It will be noted that some patients required, and responded to, two different constitutional medicines during their course of treatment.

Comments

Both Phosphorus and Acid phos. produced debilitating painless diarrhoea -- hence their usefulness in cases of Crohn's disease where pain associated with defaecation is minimal. Interestingly, Hahnemann only proved Phosphorus some time after he had published the provings of Acid phos. in his Materia Medica Pura. Already over 70 years old, and living in Paris, he was only treating chronic illnesses, which frequently did not respond to the medicines he had available. He began to formulate his theory of chronic disease, and tested 15 extra medicines, including Phosphorus, to meet his need.(7)

Prescribing indications for local medicines

Podophyllum is indicated for profuse morning diarrhoea when the stool is particularly malodorous. A useful aide-memoire is:

Profuse Offensive Dawn

Aloes is effective for abdominal distension with rectal insecurity -- unsure whether flatus or faeces will be passed. (Case 1: `I daren't pass wind'.)

Gambogia has similar distension, but more borborygmi, more tenesmus, and the stool is more forcibly and suddenly ejected.

The multiplicity of drugs used in Case 1 is because her treatment extended over 14 years and she had multiple pathology.

Summary

In general the aims of homoeopathic treatment (vide supra) appear to have been achieved, certainly in the cases described above, where the follow-up time was adequate to make a reasonable assessment. In case 9 a relapse, leading to a serious deterioration requiring surgery, coincided with the patient discontinuing taking any homoeopathic medicine.

In every case (except Case 11), where there was a follow-up consultation, the patient claimed they had made a significant improvement.

One patient reported that when she had last attended hospital, and told her surgeon that she had been taking homoeopathic medicines, and was now so much better, he evidenced some hostility, until he had sigmoidoscoped her; he then said he had to admit that there was a marked improvement since her previous visit.

In conclusion, I am glad I was invited to describe `How I treat Crohn's disease', and not `How should Crohn's disease be treated?" -- there might be some disparity!

Case histories

Case 1. Female, 56 years old, 23-year history of Crohn's, referred by her GP. 4 resections (1955,'62, '71 '73). First attended 26.4.78. `Professor of surgery told me that there was very little large intestine left, and much of small bowel had been removed and that each operation shortens the gut and makes recovery less likely.' Multiple allergies to antibiotics. Had severe reaction to tetracycline which produced cramps, severe diarrhoea and vomiting leading to collapse, unconsciousness and admission to hospital requiring intravenous infusion, and inpatient treatment for one month. Still attending hospital monthly. Her medication was folic acid, multivitamins and injections of vitamin B12.

Complaining of:

Painless urgent diarrhoea, B.O., 5-10 x daily (occasionally x 20). Watery, foamy, occasionally formed stool. No blood. No rectal incontinence but she `daren't pass wind'.

`Burning in stomach, after eating anything, only relieved by ice cold milk'. Insatiable thirst. Drinks pints till bloated, `but it doesn't quench my thirst'.

Prescribing features:

Chilly, intolerant of the cold, and feels cold internally (except stomach).

Needs hot water bottles.

Gets feverish attacks and rigors.

Very weak and exhausted.

`Thunder headaches', vertigo, spontaneous bruises. As a person she was artistic, sympathetic, `moved by sunset, and music'. Hyper-sensitive to sound -- but she had no irrational fears: a typical Phosphorus type.

26.4.78 Rx. ( 1) Phos 30c 200c 3 days later

( 2) Podophyllum 12 every 2 hours in attacks of diarrhoea.

As she lived 125 miles (200 Km) away across country, most consultations that followed were by telephone.

10.5.78. `Podophyllum marvellous. Makes the stool slightly formed after 3 hours'.

RX Podophyllum 30c.

30.5.78. `Podophyllum 30c works better then 200c. No diarrhoea for 2 days -- unprecedented in 20 years. Thrilled'.

Rx Podophyllum 30c as required.

27.8.78. Urgent `phone call `No B.O. for 21 hours -- is that all right?'!

Developing very severe cramps and spasms of body and limbs.

Rx Cuprum 30c rid.

She later wrote to report Cuprum was very effective.

During 1979 she found China 30c eased her episodes of abdominal distension. Acid phos. 12c helped her lassitude, and she had Morgan Gaertner 30c (single dose).

By 1980 B.O. 3-5 x daily. She had resumed all social activities which had been abandoned in the decade before taking homoeopathic medicines. She was still taking her conventional medication and using homoeopathic medicines as well, when required. In the next 11 years I saw her twice (1983) and she 'phoned me 10 times.

In 1983 she developed an ischiorectal abscess which did not heal. `The pus soaked the dressings 4 times daily' until she took Hepar sulph. 6c qid, followed by Silicea 10M 2 days later.

`The effect was dramatic'.

1984 Similar episode and response. 24.1.92. 'Phoned.

Relapse of rectal abscesses, and diarrhoea, uncontrolled by Podophyllum.

Finds Carbo veg. helps her wind.

B.O. x 8 daily.

Rx ( 1) Aloes 6c qid -- 30c for diarrhoea.

( 2) Gambogia 6c if || Aloes.

5.2.92. Diarrhoea not responding to Aloes. Gambogia -- `it really works'. 17.6.92. Attended.

Recurrence of rectal abscesses and diarrhoea.

Rx ( 1) Tuberculinum 10M x 1, and a week later start

( 2) E. Coli 30 daily x 7, reducing to weekly doses. Now aged 70 years, has angina and circulatory problems.

( 3) Advise as to which homoeopathic medicine to use, depending on predominant symptoms.

Discussion

Although not now enjoying good health, her health in the last 14 years since she had homoeopathic treatment has been far better than in the previous 23 years, during which time she had 4 resections and 4 operations on account of abscesses. She attributes this improvement to homoeopathy, and I confess I have to agree with her.

Case 9. Female, aged 24 years, diagnosed as suffering from Crohn's disease 6 years before she first saw me on 3.9.84. She was still under a gastroenterologist who had fully investigated her. She was 1.63m (5'4") tall and weighed 54 kg (8st. 11lb.) and she smoked 5-10 cigarettes daily. Although taking a high roughage diet she found it had not significantly helped. She complained of diarrhoea and recurrent abdominal pain.

Despite taking Salazopyrin (sulphasalazine) 500 mg x 8 daily for the previous 5 years continuously, she still had her bowels open (B.O.) 10-18 x daily, predictably more frequently in the morning. The stools were bulky and malodorous.

She was a chilly woman, who liked warm rooms, loved heat waves and sun bathing. She wanted company, bruised easily, was thirsty and liked salty foods.

3.09.84.

Rx ( 1) Phosphorus 30c weekly (single dose).

( 2) Podophyllum 3c qid.

( 3) Continue Salazopyrin x 8 daily.

I also suggested she tried a wheat exclusion diet for 5 days and gave her instructions concerning her cigarette smoking.

1.10.84. `Feeling very much improved, 50% better'. B.O. only 5-8 x daily, and stool more formed, and less fluid.

No change on wheat free diet.

`After each dose of Phosphorus I improve noticeably for next 24 hours'.

Rx ( 1) Phosphorus 30c alternate mornings, reducing to 3rd or 4th morning if improvement.

( 2) Phodophyllum 3c qid.

( 3) Continue Salazopyrin x 8 daily.

26.11.84. Still feeling 50% improved -- (husband agrees).

B.O. 5-8 x daily though a change in bowel habit.

Diarrhoea no longer a.m., but `immediate urge after a mouthful of food, or any hot drink. Must have B.O. within a minute, or possibly an accident'. Feels need of Phosphorus every 48 hours.

Rx Phosphorus 30c alt. die.

Replace Podophyllum with Aloes 3c qid.

Salazopyrin x 8 daily -- suggest asking her GP if she could try reducing this dose.

11.02.85. Without reference to her GP she stopped Salazopyrin completely the day following her last consultation, apparently without any untoward reaction: `I haven't missed them at all'.

B.O. 5-6 daily, twice a.m. before work, 3-4 x p.m. after work. Diarrhoea no longer urgent after food. Abdominal pain now minimal, only before urge to stool and eased after defaecation.

`I now dare to go to places where there may not be a toilet'.

Rx Phosphorus 10M x 1.

Resume Phosphorus 30c after a week, if required, at 2-3 day intervals.

Aloes 3c tid.

11.05.85. Case demonstration at Selly Oak Hospital Tutorial.

Relapsing -- `not feeling so good'.

13.05.85. Rx Tub. bov. 10M x 1.
17.06.85. `Very much improved after Tub. bov.', `60% improvement'.
B.O. 2-3 x a.m. and 2-3 x p.m.

Rx Continue Phosphorus 30c and Aloes 3c as before.

1.10.85. `Now 65% improved'.

B.O. x 2 before 9 a.m. -- and occasionally no B.O. in the evening.

Asking for a second dose of Tub. bov.

Attending fertility clinic.

Rx ( 1) Tub. bov. 10M x 1.

( 2) Phosphorus 30c 3 x weekly.

Trial Podophyllum 200c in 2 weeks time.

11.02.86. Letter cancelling her appointment `because I felt so well..., I am expecting a baby in May, and being pregnant has seemed to help my complaint, but I cannot thank you enough for helping me to get better. Some days I do not need to go to the toilet at all, which is quite different from a year ago. I am still taking the tablets you prescribed'.

Discussion

June '92. Sad sequel. I telephoned her for information about her subsequent progress. Apparently she had enjoyed 2 years of `feeling fine', followed by a traumatic divorce, and the death of her mother. She then had an ovarian cyst removed and states that she was told in hospital that her relapse was `due to homoeopathy' (her consultant had previously upset her by his antagonism to homoeopathy, so she had ceased attending him). Whatever was told her had the effect of making her stop taking homoeopathic medicines altogether. She deteriorated, was referred to a Professor of Surgery, and this year had a colectomy and an ileostomy. She now is not taking any homoeopathic medicines, yet is not being prescribed any conventional treatment! She has re-married, and is `managing well' with her ileostomy.

Case 13. A young man of 19 years old, whose mother is Australian, first consulted me for Crohn's disease on 22.7.88.2 years previously, when on holiday in Australia, he had an emergency appendicectomy, was flown home, admitted to an English hospital on account of increasing colic. Crohn's disease was diagnosed and an ileostomy performed. His condition deteriorated, and he was warned he would probably need a colectomy; hence his interest in an alternative therapy. He hoped homoeopathic treatment would not only spare him needing a resection, but also so improve his health that he could have his ileostomy reversed.

He had been unemployed for 2 years, chiefly because of his illness. He had lost 6.3 kg (1 stone) in weight, and was now 57 kg (9 stone), and 1.75 m (5' 9") tall. He smoked approximately 19 cigarettes daily.

He had discontinued taking sulphasalazine, and used Predsol (prednisolone) suppositories 2 bd.

His presenting symptoms were extreme lassitude, and perianal discomfort because of inflammation from infections, resulting in an intermittent blood stained rectal discharge.

His significant prescribing features were: Profound lassitude, listless and apathetic in appearance, pallor.

Long-continued painless diarrhoea, stools not offensive (n.b. ileostomy). He was chilly and loved heatwaves. Craving for salt, and 3 pints (1.8 1) cold milk daily.

22.2.88. Rx Acid phos. 10M x 1.

Acid phos. 6c tid.

Continue Predsol suppositories 2bd.

Instructions about reducing smoking.

20.3.88. `60% improved, less exhausted'.

Rectal infection subsiding.

Rx Phosphorus 10M x 1.

Acid phos. 6c tid -- bd.

Predsol suppositories 2 bd.

29.4.88. `90% improvement'.

Feeling much better, `confident they will be able to close my ileostomy'.

`Feel like job hunting again; I could work a full day'.

`Rectum less sore -- discharge much less'.

`I no longer crave milk, and have halved the amount I drink'.

Rx Phosphorus 1M x 1.

Acid phos. 6c bd.

Predsol suppositories as required.

30.1.89 Returned from abroad, where he had worked in a German hotel for 4 months and enjoyed it. He had stopped all medication, although he still smoked as much as before. Still slight rectal discharge. Feeling well. Intending returning to Germany to work in a better hotel.

June '92. Unable to contact him.

Case 15. Mr. S.A., age 26 years, first attended me for homoeopathic treatment on 3.9.90. His doctor's letter stated `He has suffered from Crohn's disease since 1984. A recent barium meal and follow-through showed multiple strictures in his ileum, and I recently admitted him to hospital with subacute obstruction. He is on prednisolone 25 mg daily.' He had been on prednisolone for 6 years, initially on a smaller dose, but inexorably he had to increase it over the years, relapsing every time he cautiously tried reducing the dose. He had also taken sulphasalazine, but discontinued it as it had not helped in any way.

He was a bachelor, 1.87 m (6ft lin) tall, and weighed 66.7 kg (10 stone); he had never smoked, and had been a keen cyclist and badminton player till his illness had incapacitated him. He complained of recurrent attacks of bloating, `burning indigestion', both partially relieved by belching or passing flatus. The attacks lasted 6-7 hours and were `followed by a strange optimistic feeling'. Predsol enemas (prednisolone 20 mg) in the past had been helpful, but now were ineffective. His diarrhoea was controlled with treatment; he only had 1-2 B.O. daily.

His problem was that his condition made him feel exhausted, impatient and irritable. He said he was `a shy loner', and on questioning admitted he was a `conscientious worrier'. He stated he was `fanatically tidy", liked sympathy, was quick, decisive, but not competitive. He was stubborn, and could speak his mind. He was Warm-blooded, liked windows open and fresh air, and bruised easily. He wasn't a thirsty person, had never liked salty foods, nor had he a craving for sweets.

I considered and eliminated Nux vom, Phosphorus, and even Arsenicum alb., as his constitutional medicine; his symptoms on balance pointed to Lycopodium, even though he did not have a pronounced 4-8 p.m. aggravation. As a minor confirmatory clue I noted that he was always frowning, until I remarked on it, and teased him until he remembered to control it.

3.9.90.

Rx ( 1) Lycopodium 30c bd until reaction (i.e. going better or worse, then withholding the medicine until it ceased acting).

( 2) Continue prednisolone 25 mg daily, unless his G.P. decided to alter the dose.

1.10.90. `Improvement 30%'. `Not feeling so worried about my condition'.

`No bloating at all -- most surprised as unprecedented'.

`Stomach pains have altered and are preceded by increased impatience and irritability'.

`My consultant has been able to reduce my steroids to 20 mg prednisolone daily'.

Rx ( 1) Lycopodium 10M x 1.

( 2) 7 days later, if required, resume Lycopodium 30c bd at 2-7 day intervals, according to response.

( 3) Nux vomica 30c q.h. for colic and excessive irritability.

( 4) Prednisolone 20 mg daily.

5.11.90. `65% improved'. `Virtually pain free last 5 weeks'. `No bloating, no burning'.

`I have resumed cycling and playing badminton'.

11.2.91. `Fine, until tried reducing prednisolone below 17.5 mg daily'.

Relapse of abdominal pain.

Rx Add Colocynthis 30c prn when attacks of colic > pressure > warm applications > doubling up. To try Mag. phos. 30c if no response to Colocynthis.

11.3.91. `80% better'.

`Only 2 mild episodes of burning abdominal pain in last month'.

Prednisolone down to 16 mg daily last 2 weeks.

29.4.91. Increase in attacks colic. No response to Colocynthis; improved on Mag. phos.

(Problem with next door neighbour who is planning to build an extension which will effectively block out his light, etc.)

Rx Proteus 10M x 1.

Prednisolone now 14 mg daily.

26.6.91. `Fine, no problems. Close on 100% fit'.

Reduced prednisoione to 13 mg daily.

`I always notice lassitude the day I reduce the prednisolone and the following day'.

Is on course of iron tablets for his anaemia.

Rx ( 1) Lycopodium 10M x 1.

( 2) Lycopodium 30c prn.

Prednisolone now 12.5 mg daily.

30.9.91. `Feeling well on 11.5 mg prednisolone for the last 2 weeks.

`An unprecedented low dose for me'.

Return of mild episodes of `burning and bloating' every 7-10 days.

Still cyclng and playing badminton.

Main concern today is relapse of his facial acne.

Rx ( 1) Natrum bromide 200c x 1.

( 2) Carbo veg. 30c trial instead of Colocynthis.

Continue Lycopodium 30c prn.

Prednisolone 11.5 mg daily.

24.2.92. Maintaining improvement and quality of life.

Recent holiday in Australia for 2 months.

Prednisolone 11.5 mg daily (was 25 for last few years).

30.6.92. Maintaining improvement.

bd = twice daily

tid = three times daily

qid = four times daily

References
(1) Jewells D. Crohn's Disease. Medicine International 1990: 79: 3275-9.

(2) Persson P-G, Ahlbom A, Hellers G. Inflammatory bowel disease and tobacco smoke -- a case-control study. GUT 1990: 31: 1377-81.

(3.) Giaffer MH, Holdsworth CD, Duerdon BI. Virulence properties of Escherichia Coli strains isolated from patients with inflammatory bowel disease. GUT 1992: 33: 646-50.

(4) Hollander D, Vadheim CM, Brettholtz E, Peterson GM, Delahunty TJ, Rotter JI. Increased intestinal permeability in patients with Crohn's disease and their relatives. Ann Intern Med 1986: 105: 883-5.

(50 Hope RA, Longmore JM, Moss PAH, Warrens AN. Oxford Handbook of Clinical Medicine 2nd edition 1990, p516.

(6) Drug Therapy Bulletin 1986, 24: 13.

(7) Hahnemann S. The Chronic Diseases. Tr. Tafel 1896. Vol. 1, p.5.

British Homoeopathic Association (BHA).

~~~~~~~~

By R.A.F. Jack

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