Crohn’s Disease

Crohn’s disease is a chronic inflammatory bowel disease (IBD) among the highest prevalence and incidence reported in the
that can affect any area of the gastrointestinal tract, from the world, with approximately 135,000 diagnosed individuals.
mouth to the anus, either in continuity or as isolated areas.
The inflammation can involve the inner mucosal lining, up to Symptoms/Complications
the full thickness of the bowel wall, and consists of swelling, Diarrhea, rectal bleeding, pain, and weight loss are common
dilated blood vessels, and loss of fluid into the tissues. It often recurring symptoms of Crohn’s disease. Inflammation
occurs at the lower end of the small intestine (terminal ileum), decreases the intestine’s absorptive surfaces, triggering watery
which joins with the large intestine (colon). stools that can lead to fecal urgency and poor control of bowel
Crohn’s disease can arise at any age, commonly occurring function. Constipation can also develop, as the body struggles
in young people. About 10% of newly diagnosed cases each to maintain normal bowel function.
year are in children. Although there are various treatments to The intestine may narrow and shorten, whereby
help ease symptoms and induce remission, there is currently contents cannot completely pass through the digestive tract
no cure. There is an increased risk of a Crohn’s disease (obstruction). Abdominal pain is a frequent symptom,
diagnosis for some ethnic groups, and for those who have a resulting from the muscle spasms of the inflamed intestine, or
family member with the condition. Although Crohn’s disease from a build-up of pressure behind a narrowed section of the
is currently the proper name for the condition, sometimes bowel. Fever may accompany the inflammation. In children,
you might hear older terms, such as regional enteritis, a delay in growth and maturity may result, so close attention
terminal ileitis, granulomatous colitis, or ileocolitis, used to medical and nutritional management of the disease is
interchangeably. particularly important.
Crohn’s disease has many similarities to ulcerative colitis, Low red blood cell count (anemia) can result from blood
another IBD. The main differences between Crohn’s disease loss due to ulcerations in the intestine and from general
and ulcerative colitis are that in Crohn’s disease inflammation malnutrition due to decreased nutrient absorption and the
can affect any part of the digestive tract and extend into the debilitating effects of the disease. These conditions may also
muscle wall, whereas ulcerative colitis occurs only in the cause depletion of blood proteins.
surface of the colon lining. Fissures may form in the rectum and anus, producing an
The cause of Crohn’s disease is undetermined but there is accumulation of large pus pockets or abscesses, leading to
considerable research evidence suggesting that interactions severe pain and fever. An abnormal, tunnel-like connection
among environmental factors, intestinal microorganisms, between the intestine and the skin (fistula) may occur near the
immune dysregulation, and genetic predisposition are opening of the rectum, between loops of intestine within the
responsible. abdomen, or between the intestine and the abdominal wall,
A diagnosis of Crohn’s disease can occur at any point in life, particularly following surgery.
with the highest occurrence of diagnoses in young children Crohn’s disease is a systemic disease, meaning that it affects
and for those around 40-50 years of age. Currently, Canada has other parts of the body in addition to the intestinal tract. Some

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of these extra-intestinal manifestations include arthritis, skin when following these guidelines, Crohn’s patients could be
problems, liver disease, kidney stones, and eye inflammation. falling short of nutrient needs due to the effects of an inflamed
You may be at an increased risk for colorectal cancer if intestine. Studies show that poor nutrition is prevalent in
you have disease located within the colon for 10-15 years or Crohn’s patients, who should direct extra attention to special
more. If this is the case for you, regular screening should begin diets and supplements. We encourage those who have Crohn’s
at an earlier age and on a more vigilant schedule than that disease to consult a registered dietitian, who can help set up
recommended for the general population. an effective, personalized nutrition plan by addressing disease-
specific deficiencies. If bleeding is excessive, problems such
Diagnosis as anemia may occur, and modifications to the diet will be
Blood tests are helpful in assessing the activity level of necessary to compensate for this.
the inflammation, the potential of developing anemia from Some foods may irritate and increase symptoms even
ongoing bleeding, and the nutritional state of an individual. though they do not affect the disease course. Specialized diets,
Stool sample analysis can sometimes be helpful. Your easy-to-digest meal substitutes (elemental formulations), and
physician will determine which among several procedures are fasting can achieve incremental degrees of bowel rest. During
best to assess your intestinal symptoms, based on your medical fasting, intravenous feeding (total parenteral nutrition, TPN)
history. may be required to allow for complete bowel rest.
While used less often, X-rays can be helpful to observe the
shape and function of the digestive tract. When needed for Symptomatic Medication Therapy
the upper GI area, you will have to drink a liquid that coats A number of treatments exist to address diarrhea and
the walls of the esophagus and stomach. This drink contains pain. Dietary adjustment may be beneficial and antidiarrheal
barium, which shows up as bright white on X-rays, providing medications have a major role to play. For painful symptoms
a contrasting picture of the shape and function of the upper not controlled by other drugs, analgesics can be helpful, with
GI tract during the X-ray. When requested to provide details acetaminophen (Tylenol®) being the preferred choice. Those
of the lower GI tract, you will undergo a barium-containing with IBD should avoid non-steroidal anti-inflammatory drugs
enema to allow your physician to view the contours of the (NSAIDs), as these can irritate the lining of the intestinal tract.
bowel. There are two types of antidiarrheal medications directed at
Endoscopy might help to determine the nature and extent preventing cramps and controlling defecation.
of the disease. In these procedures, the physician inserts an One group alters the muscle activity of the intestine, slowing
instrument into the body via the mouth (gastroscopy) or anus down content transit. These include: non-narcotic loperamide
(sigmoidoscopy/colonoscopy) to allow for visualization of (Imodium®); narcotic agents diphenoxylate (Lomotil®), codeine,
various areas within the digestive tract. The scopes are made of opium tincture and paregoric (camphor/opium); and anti-
a hollow, flexible tube with a tiny light and video camera. An spasmodic agents hyoscyamine sulfate (Levsin®), dicyclomine
advantage of these procedures over a barium X-ray or virtual (Bentylol®), propantheline (Pro-Banthine®), and hyoscine
colonoscopy using computed tomography (CT) scan is that butylbromide (Buscopan®).
a physician can biopsy suspicious looking tissue at any time The other group adjusts stool looseness and frequency by
during the examination for subsequent laboratory analysis. soaking up (binding to) water, regulating stool consistency so
Depending on what part of your digestive tract is affected, it is of a form and consistency that is easy to pass. These work
magnetic resonance imaging (MRI) may be useful. in different ways; some, such as Metamucil® or Prodiem®, come
Once all of this testing is complete and other possible from plant fibres, whereas cholestyramine resin (Questran®) is a
conditions are ruled out, your physician might make a bile salt binder. Plant fibres are also useful for constipation, due
diagnosis of Crohn’s disease. to their stool regulating effects.
Extra-intestinal symptoms of Crohn’s disease, such as
Management arthritis or inflamed eyes, may require targeted medications
The treatment of Crohn’s disease is multi-faceted; it includes and referrals to other specialists. If anxiety and stress are major
managing the symptoms and consequences of the disease along factors, a program addressing this may be valuable. (Ask for our
with therapies targeted to reduce the underlying inflammation. pamphlet on Stress Management.)
Individuals with Crohn’s may be anemic from a combination
Dietary and Lifestyle Modifications of factors, such as chronic blood loss or malabsorption of
Nutrition is a primary component of digestive health and certain vitamins and minerals. Iron supplements could help
it is important to follow Canada’s Food Guide. However, even improve this condition, with oral heme iron polypeptide (e.g.,

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OptiFer® Alpha, Proferrin®) being the preferred option, due to and methotrexate sodium (Rheumatrex®). It could take up to 12
quick-acting and low side-effect profiles. Iron Isomaltoside weeks or more of therapy to see results.
1000 for injection (Monoferric™) is indicated for the treatment
of iron deficiency anemia in adults who have intolerance or Biologics
unresponsiveness to oral iron therapy. Occasionally, a blood Biologic medications are important treatment options for
transfusion may be necessary. those who have moderate to severe Crohn’s disease. These
The most widely prescribed antibiotics are ciprofloxacin products are specially developed proteins that selectively
(Cipro®) and metronidazole (Flagyl®, Florazole ER®). Broad- block molecules involved in the inflammatory process.
spectrum antibiotics are important in treating secondary Gastroenterologists routinely prescribe biologics, which include
manifestations of the disease, such as perianal abscess and infliximab (Remicade®), adalimumab (Humira®), golimumab
fistulae. (Simponi®), vedolizumab (Entyvio®), ustekinumab (Stelara®),
and most recently, two biosimilars of infliximab (Inflectra®,
Anti-Inflammatory Medication Therapy Renflexis®), to control the symptoms (induce clinical remission)
There are two goals in the treatment of Crohn’s disease: of Crohn’s disease.
to eliminate the symptoms (induce clinical remission) and to These medications are proteins, which our bodies might
prevent future disease flare-ups (remission maintenance). To identify as foreign invaders and then develop antibodies to fight
accomplish these goals, physicians aim treatment at controlling them off, which can diminish the drug’s effectiveness over time.
intestinal tract inflammation, and the natural consequence of If you stop taking the drug for some time and then try to resume
reducing and eliminating inflammation is the reduction and it, what worked wonderfully for you before might not work the
elimination of symptoms. This therapy comes in many forms, next time you take it because of these antibodies. This means
using various body systems. Your physician may prescribe any that it is extremely important that you only stop treatment
of the following medications alone or in combination. It could if your physician advises you to do so. Stopping a treatment
take some time to find the right mix for you as each case of because you are feeling well might mean that drug won’t be able
Crohn’s disease is unique. to make you feel well again.
Health Canada approved infliximab (Remicade®) in 2001
5-Aminosalicylic Acid (5-ASA) to induce clinical remission in Crohn’s disease, for ongoing
These medications are used to reduce inflammation in mild to use to maintain clinical remission, for reducing or eliminating
moderate Crohn’s disease, including mesalamine (Pentasa® and corticosteroid use, for healing and closing fistulae, and
Salofalk®), available orally in the forms of tablets and capsules. for healing the lining of the bowel wall (mucosal healing).
Depending on the location of your disease, you may be required Biosimilars of infliximab (Inflectra®, Renflexis®, Avsola™) are
to administer mesalamine rectally, in the forms of enemas or also available. (See our website for more information about
suppositories. A combination of 5-ASA and sulfa antibiotic is
available orally as sulfasalazine (Salazopyrin®).

Corticosteroids
To reduce inflammation in moderate to severe cases
of Crohn’s disease, corticosteroids might help. These are
prednisone and budesonide (Entocort®), which are taken
orally, although prednisone tends to have greater side effects.
For topical relief of Crohn’s disease in the colon, budesonide
(Entocort®) and hydrocortisone (Betnesol®, Cortenema®,
Cortifoam®, Proctofoam®) are available in rectal formulations
(enemas, foams, and suppositories). In hospital, hydrocortisone
(Solu-Cortef®) and methylprednisolone (Solu-Medrol®) can be
administered intravenously.

Immunosuppressive Agents
These drugs are used to treat both ileal and colonic Crohn’s Examples of some areas
within the intestines where
and to reduce dependence on steroids; they include azathioprine Crohn’s disease can appear.
(Imuran®), cyclosporine, mercaptopurine/6-MP (Purinethol®),

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 About the Gastrointestinal Society
biosimilars.) A fully human monoclonal antibody, The GI (Gastrointestinal) Society is a registered Canadian charity
adalimumab (Humira®), was approved in 2006 to induce committed to improving the lives of people with gastrointestinal and
liver conditions, supporting research, advocating for appropriate patient
clinical remission in Crohn’s disease and for ongoing use access to healthcare, and promoting gastrointestinal and liver health.
to maintain clinical remission. Other biologics approved
to treat Crohn’s disease are vedolizumab (Entyvio®), and Want to learn more on this subject? The Inside Tract®, the GI Society’s
quarterly newsletter, provides the latest on digestive and liver research,
ustekinumab (Stelara®). disease and disorder treatments (e.g., medications, nutrition), and a
Humira® and Simponi® are self-administered under whole lot more. If you have any kind of digestive problem, then you will
the skin (subcutaneously), at varying intervals. A want this timely, informative publication. Subscribe today!
healthcare professional administers Avsola™, Entyvio®, This pamphlet was produced in partnership with the Canadian Society
Inflectra®, Remicade®, Renflexis®, or Stelara® by of Intestinal Research under the guidance of affiliated healthcare
intravenous (IV) infusion at various intervals, depending professionals. This document is not intended to replace the knowledge,
diagnosis, or care of your physician. © Gl Society 2020. All rights reserved.
on the medication and the response.
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Sometimes a surgeon will remove severely diseased
portions of the digestive tract, but this is only as a last
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unfortunate feature of Crohn’s disease is that there
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