Crohn's Disease

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CROHN'S DISEASE

WESTERN MEDICINE

DEFINITION

Crohn's disease is a chronic non-specific idiopathic gastrointestinal inflammatory disease first reported by Dr. Burrill Bernard Crohn in 1932. Crohn's disease may affect any part of the gastrointestinal tract, but is most common in the ileum and colon.

Crohn's disease is referred to as regional enteritis, if characterized by segments of diseased bowel with sharp borders on the affected regions, ileitis if only the ileum is involved, or ileocolitis if both the ileum and the colon are involved.

ETIOLOGY

Crohn's disease has no known etiology. Many factors have been suggested, but none are proven. Possible risk factors include immunologic factors, infectious agents (such as bacteria, virus or ameba), and dietary factors (including chemicals and drugs). Crohn's disease usually begins before age 35, with peak incidence between age 14 and 24.

CLINICAL MANIFESTATION

Crohn's disease usually begins with aphthoid ulcerations of the mouth, abdominal pain, diarrhea, fever, and anorexia and weight loss. As inflammation continues, patients may develop a right lower quadrant mass or fullness that mimics appendicitis. The mass is palpable during physical examination.

Some patients may experience intestinal stenosis and partial obstruction characterized by severe colic, abdominal distention, and constipation and vomiting. Pus, mucous and blood may be present in the stool if the rectum is involved. Chronic cases of stenosis and obstruction will lead to scarring, luminal narrowing and stricture formation. In the severe cases of Crohn's disease, abdominal fistulas and abscess may develop causing fever, painful abdominal masses and generalized malnutrition and muscle wasting. Fistulas may remain in the gastrointestinal tract, or it may invade the surrounding area such as the stomach, the peritoneum and the urinary bladder. Though rare, cancer has been observed in chronic Crohn's patients.

In addition to various gastrointestinal symptoms, Crohn's disease is often associated with other complications involving the eyes, mouth, skin and joints. These complications may be caused by immunologic response, microbiologic concomitants, genetic interrelationships, or simply due to unknown reasons. Involvement of the eyes includes episcleritis. Mouth lesions include aphthous stomatitis. Skin problems include erythema nodosum, pyoderma gangrenosum and pustular lesions. Joint involvement is characterized by arthritis of the larger joints such as knees, ankles, hips and elbows. Other complications include ankylosing spondylitis, sacroiliitis and cholangitis.

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DIAGNOSIS

Definitive diagnosis is made by barium-enema X ray, which demonstrates thickening of the bowel wall, narrowing of ileal lumen, separation of the bowel loops and formation of the fistulas. Colonoscopy can be clone to confirm the diagnosis via direct visualization of the ulcers and fissures. Biopsy is also an option to confirm the diagnosis or to rule out cancer.

Other laboratory exams are non-specific but help to assess the severity of the illness. Anemia is common due to loss of blood, folate or chronic disease itself. Electrolyte imbalance is common with severe diarrhea. Hypoalbuminemia is commonly associated with malabsorption and malnutrition. Lastly, fatty liver or cholangitis may cause liver enzyme abnormalities.

TREATMENT

Since there is no known etiology for Crohn's disease, there is no specific therapy available. Drug treatment focuses on relieving the symptoms and are divided into the following classes:

I. Antidiarrheal. Diarrhea is commonly treated with diphenoxylate (Lomotil), loperamide (Imodium), and other drugs containing codeine or opium. The most common side effects of these drugs are dizziness, drowsiness and sedation. Drugs containing codeine and opium may also cause dependence with long-term use. In addition, antidiarrheal drugs must be given with caution because they may cause toxic megacolon, an emergency condition characterized by dilation of the colon.

2. Antibiotics. Use of antibiotics has been helpful in patients with possible bacterial, viral or amebic infections. Metronidazole (Flagyl) is the most commonly used antibiotic and is especially helpful when treating perianal lesions. The side-effects of metronidazole (Flagyl) includes metallic taste, dyspepsia and paresthesias. Metronidazole (Flagyl) also interacts with alcohol causing such symptoms as severe nausea, vomiting and headache.
3. Salicylate drugs. These drugs suppress low-grade inflammation and are commonly used for mild to moderate Crohn's disease. Their usefulness, however, is limited by their frequent side-effect profiles. The dose-related side-effects include anorexia, dyspepsia, nausea and vomiting. Commonly used salicylate drugs include sulfasalazine (Azulfidine), olsalazine (Dipentum) and mesalamine (Pentasa).
4. Corticosteroids. Acute stages of Crohn's disease with fever, diarrhea, severe abdominal pain and tenderness may require the use of oral or IV corticosteroids. Though corticosteroids have excellent anti-inflammatory effects, long-term use may have numerous side-effects including but not limited to osteoporosis, glucose intolerance, cataract formation, fluid retention, dependence and muscle wasting.
5. Immunosuppressive drugs. Azathioprine (Imuran) and 6-mercaptopurine (Purinethol) are two immunosuppressive drugs commonly used to replace corticosteroids, heal internal and external fistulas, and in suppressing acute attacks. Common side effects include allergic reaction with fever and joint pain, pancreatitis, hepatitis and leukopenia.
6. Surgery. Because Crohn's disease is known to recur after surgery, other treatment modalities should be tried before resorting to surgery. However, if Crohn's disease is complicated with frequent intestinal obstruction or intractable abscess or fistulas, surgery may become necessary. The rate of recurrence after the first surgery is approximately 20% after 2 years, 30% after 3 years, and up to 40% to 50% after 4 years. Fortunately, recurrence is much lower after the second surgery should it be required.
ORIENTAL MEDICINE

ETIOLOGY

According to the theories of Oriental medicine, Crohn's disease may be caused by constitutional deficiencies, invasion of the exterior pathogenic factors or unbalanced diet. Constitutional deficiencies usually refer to Spleen and Kidney deficiencies. Invasion of exterior pathogenic factors refers to damp-heat in the Large Intestine. Lastly, an unbalanced diet high in raw or cold injures the Spleen and the Stomach and obstructs their functions in transforming and transporting food and nutrients.

DIFFERENTIAL DIAGNOSIS

Crohn's disease can be divided into four general categories: damp-heat, Spleen deficiency, Spleen and Kidney deficiencies, and Qi and blood stagnation.

Invasion of damp-heat in the Large Intestine is characterized by an acute and sudden onset of gastrointestinal symptoms and signs. Presence of damp-heat in the Large Intestine is illustrated by diarrhea, presence of mucus and blood in the stool, foul-smelling stool, yellow urine, and abdominal fullness and pain. Defecation is characterized by extreme urgency, tenesmus, and burning sensation of the anus after passing the stool. As heat travels upwards, patients may feel irritable, thirst and preference to drink cold water. Tongue is clark red with yellow greasy tongue coat. Pulse is wiry, slippery, or rapid.

Spleen deficiency may be due to constitutional deficiency or secondary due to excessive intake of cold and raw food. Patients with chronic Crohn's disease usually have Spleen deficiency. Spleen deficiency is characterized by the compromised ability of the Spleen to transform and transport food. Clinically, the patient will show such symptoms as frequent and severe diarrhea, watery stool with undigested food, dull abdominal pain, poor appetite, poor digestion, and gastric discomfort after food intake. Sallow facial appearance, fatigue and lethargy are due to chronic malabsorption and malnutrition. Tongue is pale with white tongue coat. Pulse is soft and weak.

Spleen and Kidney deficiencies may be due to constitutional deficiency or secondary due to the chronic nature of the illness. One diagnostic key of Spleen and Kidney deficiency is early morning diarrhea at around 5 A.M. In addition, patients may have abdominal pain that increases with cold but decreases with defecation. Patients may also have intolerance to cold and cold extremities. Tongue is pale with white tongue coat. Pulse is thready and weak.

Lastly, Qi and blood stagnation resembles an acute phase of Crohn's disease in which the patient has severe abdominal pain and fullness with a palpable mass in the right lower quadrant. This condition mimics acute appendicitis. It is essential to make a correct differential diagnosis prior to treatment. In addition, patients may also experience diarrhea, lack of appetite, muscle wasting and lethargy. Tongue is dark purple with petechia. Pulse is thready and knotted.

HERBAL TREATMENT

I. DAMP-HEAT IN THE XIA JlAO (LOWER BURNER).

Clinical Manifestation

An acute and sudden onset of gastrointestinal symptoms and signs, diarrhea, presence of mucous and blood in the stool, foul-smelling stool, yellow urine, abdominal fullness and pain, extreme urgency to defecate tenesmus, and burning sensation of the anus after passing the stool, irritable, thirst, preference to drink cold water, clark red tongue, yellow greasy tongue coat; wiry, slippery, or rapid pulse.

Herbal Formula:

I. Peony Combination (Shao Yao Tang). This formula eliminates damp-heat and toxin from the Xia Jiao (Lower Jiao) and is commonly used to treat inflammation of the intestines.

Modification:

Excessive heat and toxin: add pulsatilla (bai tou weng) and dandelion (pu gong ying).

Excessive damp: add coix (yi yi ren) and poria (fu ling).

Abdominal fullness and swelling: add scirpus (sang leng) and zedoaria (e zhu).

II. SPLEEN DEFICIENCY

Clinical Manifestation:

Frequent and severe diarrhea, watery stool with undigested food, dull abdominal pain, poor appetite, poor digestion, and gastric discomfort after food intake, sallow facial appearance, fatigue, lethargy, pale tongue with white tongue coat, and soft and weak pulse.

Herbal Formula:

I. Ginseng & Atractylodes Formula (Shen Ling Bai Zhu San).This formula tonifies and Qi and strengthens the Spleen and the Stomach. It may be used for chronic diarrhea due to enteritis.

Crohn's Formula #1: This herbal formula is called a Yan Fan (an experienced formula). It is not a classic herbal formula, but one designed with years of clinical experience specifically for treating chronic Crohn's disease with deficiencies of Qi, blood, Spleen and Kidney. Ingredients and dosage is as follows: salvia (dan shen) 15g, red peony (chi shao) 12g, white peony (bai shao) 12g, white atractylodes (bai zhu) 9g, angelica sinensis (dang gui) 12g, carthamus (hong hua) 9g, cnidium (chuan xiong) 9g, codonopsis (dang shen) 12g, aurantium fruit (zhi ke) 9g, saussurea (mu xiang) 9g, citrus peel (chen pi) 9g, pinellia (ban xia) 9g and licorice (gan cao) 4g.

Modification:

Poor appetite: add crataegus (sha zha), massa medicata fermenta (shen qu) and barley sprouts (mai ya).

Watery diarrhea due to Spleen deficiency with interior cold: add Decoction to Regulate the Spleen and Stomach (Li Zhong Wan) plus prepared aconite (fu zi) and cinnamon bark (rou gui).

III. SPLEEN AND KIDNEY DEFICIENCIES

Clinical Manifestation

Early morning diarrhea at around 5 A.M., abdominal pain which increases with cold but decreases with defecation, aversion to cold, cold extremities; pale tongue with white tongue coat; thready and weak pulse.

Herbal Formula

Pills of Four Miraculous Drugs (Si Shen Wan).This is an effective herbal formula to treat diarrhea due to Spleen and Kidney deficiencies. Codonopsis (dang shen) and white atractylodes (bai zhu) are added to increase its overall effect to tonify Qi and strengthen the Spleen.

Modification:

Severe diarrhea: add terminalia (he zi), rubrum halloysitum (chi shi zi), and limonitum (yu liang shi).

Cold extremities: add prepared aconite (fu zi) and cinnamon bark (rou gui).

IV. Qi and blood stagnation

Clinical Manifestation:

Severe abdominal pain and fullness with a palpable mass in the right lower quadrant, diarrhea, lack of appetite, muscle wasting, lethargy, dark purple tongue with petechia; thready and knotted pulse.

Herbal Formula:

Tangkuei & Corydalis Combination (Ge Xia Zhu Yu Tang).This formula is commonly used to relieve pain in the abdominal region due to Qi and blood stagnation.

Modification:

Diarrhea: add crataegus (shan zha), terminalia (he zi) and dioscorea (shan yao)

Qi deficiency: add codonopsis (dang shen) and white atractylodes (bai zhu).

ACUPUNCTURE TREATMENT

Point Selection:

Pishu (U.B. 20), Shenshu (U.B. 23), Dachangshu (U.B. 25), Zusanli (St. 36), Zhongwan (Ren 12), Tianzhu (U.B. 10), Mingmen (Du 4), Guanyuan (Ren 4), Taixi (K. 3), Zhangmen (Liv. 13) and Shanjuxu (St. 37).

Technique:

Acupuncture points are selected according to the clinical presentation of the patients. Use moderate stimulation technique and leave the needles in for 15 to 30 minutes. Moxa may be applied to the points for 10 to 15 minutes when appropriate.

PREVENTION

Both Western and Oriental medicines recognize the importance of diet and its role in prevention and treatment of Crohn's disease. Western medicine acknowledges dietary intake of certain factors (such as excessive chemicals or lack of fiber) may be linked to increased incidence of Crohn's disease; while Oriental medicine recognizes that dietary intake with excessive cold or raw food may injure the Spleen and the Stomach. Therefore, diet plays an important role in both prevention and effective treatment of the illness. Patients should be encouraged to avoid any food that may trigger recurrence, such as certain chemicals, raw or cold food. Milk, cheese and other dairy products should be avoided, especially if the patients have lactase intolerance. High roughage raw fruits or vegetables sometimes worsen intestinal obstruction and colic and may need to be avoided. Certain over-the-counter or prescription antidiarrheal drugs may worsen the condition and create toxic megacolon. These drugs should not be taken unless supervised by a qualified health care provider. Lastly, in addition to avoiding the "wrong food," it is equally important to make sure the patients have adequate calorie and fluid intake, as malnutrition and dehydration are common problems associated with Crohn's disease.

DISCUSSION

According to Western medicine, Crohn's disease is a chronic non-specific idiopathic gastrointestinal inflammatory disease. Several etiologic factors have been suggested, but none are proven at the present time. Since there is no known cause, specific therapy is not available and all available treatment focuses on symptomatic relief. In addition, because Crohn's disease was first reported only in 1932, much work still needs to done in understanding and effectively treating this illness. Oriental medicine approaches treatment of Crohn's disease similar to treatment of abdominal pain and diarrhea. Herbs and acupuncture are effective in controlling the symptoms and signs of Crohn's disease. Optimal treatment, however, requires full cooperation of the patient to adhere strictly to the treatment and preventative guidelines.

REFERENCES

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Berkow, Robert et al. The Merck Manual of Diagnosis and Therapy 16th Edition. Merck & Co., Inc. 1992.

Hurst, J. Willis. Medicine for the Practicing Physician 4th Edition. Appleton & Lange 1996.

Bensky, Dan and Barolet, Randall. Chinese Herbal Medicine Formulas & Strategies. Eastland Press 1991.

Bensky, Dan and Gamble, Andrew. Chinese Herbal Medicine: Material Medica Revised Edition. Eastland Press 1986.

Yeung, Him-che. Handbook of Chinese Herbs. Institute of Chinese Medicine 1996.

Yeung, Him-che. Handbook of Chinese Herbal Formulas. Institute of Chinese Medicine 1996.

Chen, Gui Ting and Yang Si Wu. Practical Diagnostics and Therapeutics of Integrated Traditional Chinese and Western Medicine. Published by Medicinal and Scientific Herbology Press of China 1994.

Yang, Si Su et al. Comprehensive Clinical Manual of Traditional Chinese Medicine. Published by Beijing Scientific Press 1993.

Shu, Ji Chun et al. Study of Chinese Herbal Formula. Beijing Scientific Techniques Press 1983.

Ling, Yi Kui. Study of Chinese Herbology. Beijing Scientific Techniques Press 1983.

CAAOM.

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By John Chen

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