Crohn's Disease: Difference between revisions

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== Definition/Description  ==
== Introduction ==
[[File:Crohn's Disease.png|thumb|CD chronic inflammation GI tract]]
Crohn disease (CD) and ulcerative colitis (UC) are both conditions commonly referred to as [[Irritable Bowel Syndrome|inflammatory bowel disease]] (IBD). CD causes chronic inflammation of the gastrointestinal tract. In Crohn disease, the inflammation extends through the entire thickness of the bowel wall from the mucosa to the serosa.


[[Image:What is Crohn's disease.jpg|frame|right|200px|Gastrointestinal Tract in which Crohn's Disease affects]] Crohn’s disease is a form of inflammatory bowel disease (IBD) that causes inflammation to the lining of the digestive or gastrointestinal (GI) tract <ref name="NDDIC">National Digestive Diseases Information Clearinghouse (NDDIC). Crohn’s disease. http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/ (accessed 4 March 2010).</ref> and may be a result of an immune system malfunction. The immune system sees the bacteria and organisms that lie within the GI tract and intestines and mistakes them for outside invaders to the body. In response to this, the body produces extra white blood cells to the GI tract to fight off the invaders, which creates inflammation within the lining of the tract. Chronic inflammation may result in ulcerations within the layers of the tract <ref name="Living with Crohn's">Living with Crohn’s Disease. Inside Crohn’s disease. https://www.livingwithcrohnsdisease.com/livingwithcrohnsdisease/crohns_disease/inside_crohns.html (accessed 4 March 2010)</ref>. The inflammation can occur to any portion of the GI tract, from mouth to anus and can affect all layers of the intestinal tract while healthy bowel layers may be interspaced between the diseased portions of the bowel.<ref>Crohn's Disease Answers. What is Crohn's Disease. http://crohnsdiseaseanswers.com/1.-what-is-crohns-disease-what-is-crohns-disease.HTM (accessed 5 April 2010). </ref>
CD is a serious chronic inflammatory disorder that is difficult to diagnose and manage. The disease has a relapsing and remitting course. Many relapses can cause Crohn disease to progress from mild to moderate to severe penetrating (fistulization) or stricturing disease. There is no cure and most patients experience a poor quality of life..<ref name=":0">Ranasinghe IR, Hsu R. Crohn disease. Available: https://www.ncbi.nlm.nih.gov/books/NBK436021/<nowiki/>(accessed 1.10.2022)</ref>


The most commonly affected portion of GI tract affected is the lower portion of the small intestine, or ileum <ref name="NDDIC" />.&nbsp; Due to the inflammation, abdominal pain, diarrhea and malnutrition can be a result <ref name="mayo">MayoClinic.  Crohn’s Disease.  http://mayoclinic.com/health/crohns-disease/DS00104/DSECTION=causes (accessed 4 March 2010)</ref>.&nbsp; Crohn’s disease is also referred to as granulomatous enteritis or colitis, ileitis, regional enteritis, or terminal ileitis. This disease is similar in some aspects to ulcerative colitis, but the difference lies in the fact that ulcerative colitis produces inflammation only within the colon or rectum while Crohn’s disease produces inflammation within the colon, rectum, small intestine, stomach, mouth and esophagus. The inflammation caused by Crohn’s disease has the potential to affect the deeper layers more than ulcerative colitis <ref name="MedicineNet">MedicineNet.  Crohn’s Disease.  http://www.medicinenet.com/crohns_disease/page2.htm (accessed 4 March 2010)</ref>.&nbsp; While these two conditions are very similar, approximately 10 percent of individuals are unable to pinpoint whether the disease process is ulcerative colitis or Crohn’s disease. For these individuals, they are then diagnosed with indeterminate colitis <ref name="CCFA">Crohn’s and Colitis Foundation of America (CCFA).  About Crohn’s Disease.  http://ccfa.org/info/about/crohns (accessed 4 March 2010)</ref>.  
== Etiology ==
The cause of CD is not known but genetics seem to play a role as does the environmental affects on the immune system.


== Prevalence  ==
The gut bacteria of people with Crohn’s disease changes but it still isn’t clear if the change is caused by inflammation.
[[Image:CD map.jpeg|frame|right|100px|Geographic Distribution of Crohn's Disease)]]Crohn’s disease affects approximately 500,000 to two million people in the United States, equally affecting men and women <ref name="MedicineNet" />.&nbsp; This disease may occur in individuals of all age, but has characteristically affected adolescents and young adults between 15-35 of age. It is estimated that 10 percent of individuals affected are under the age of 18. Crohn’s has been found to affect American Jews of European descent four to five times more than the general population. The prevalence among whites is 149 per 100,000 with a steady increase in incidence among African Americans. Hispanics and Asian have a lower prevalence than do African Americans and whites. There has been a potential link between living environment and the incidence of Crohn’s disease, where there are more reports amongst urban and northern climates than rural and southern climates. Similarly, this disease tends to be more predominant in the US and Europe <ref name="CCFA" />.
== Characteristics/Clinical Presentation  ==


There is no cure for this condition and Crohn’s disease alters between periods of remission and relapse. Crohn’s typically appears around adolescence and early adulthood and there is potential of Crohn’s disease to run in families <ref name="MedicineNet" />.&nbsp; About 20-25% of individuals affected with Crohn’s disease have a close relative who is affected with ulcerative colitis or Crohn’s disease. If an individual has a relative with Crohn’s, the risk of this individual is 10 times higher than the general population, while a brother or sister link increases the risk to 30 times higher than the general population. Current researchers have identified an abnormal genetic mutation on gene NOD2/CARD 15 which reduces the ability of the body to distinguish harmful bacteria. This mutation is found twice as often in individuals affected with Crohn’s versus the general population <ref name="CCFA" />.<br>
Possibly a diet full of highly processed foods like sugary drinks and fast food, may increase the risk of developing Crohn’s. Crohn’s is not infectious. <ref name=":1">Crohns and Colitis Australia CD Available:https://crohnsandcolitis.org.au/about-crohns-colitis/crohns-disease/about-crohns-disease/ (accessed 1.10.2022)</ref>[[File:Crohn.png|thumb|531x531px|The 3 most common sites of intestinal involvement in CD (L) compared to the areas affected by ''ulcerative colitis'' (''R'').|alt=|center]]
== Epidemiology ==
[[Image:CD map.jpeg|World Distribution of CD|alt=|thumb]]
CD is most prevalent in the western developed world in North America, northern Europe, and New Zealand.


{| class="FCK__ShowTableBorders" width="40%" cellspacing="1" cellpadding="1" border="0" align="centre"
The incidence of CD is bimodal with the onset occurring most frequently between ages 15 to 30 years and 40 to 60 years old.  
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{{#ev:youtube|Npda8xr2G-Y|300}}<ref name="Thomas">Thomas Craig. A Frank discussion on Crohn's Disease. Available at http://www.youtube.com/watch?v=Npda8xr2G-Y (last accessed 4/510)</ref>
|}
===== Typical symptoms of Crohn’s disease include:  =====
*Diarrhea
*Abdominal cramping generally in the right lower quadrant <ref name="NDDIC" />
*Fever
*Potential rectal bleeding. The rectal bleeding is potentially due to tears or fissures within the anus lining.
*Fistulas or tunnels leading from the intestines to the bladder, vagina or skin may also occur, while most occur around the anal area. The fistula has potential to produce drainage, pus, mucus or stool being excreted from the opening. These symptoms may vary between individuals and may not all be present at the same time.
*Weight loss
*Fatigue <ref name="CCFA" />
*Perianal lesions
*Stunted growth in children
*Extraintestinal manifestations <ref name="Knol">Cheifetz Adam, Moss Alan, Peppercorn Mark. Crohn’s Disease.  Knol Beta. Available at http://knol.google.com/k/crohn-s-disease#. Accessed 5 April 2010.</ref>


While Crohn’s is a chronic disease, the patients will experience bouts of flare ups and remission with the absence of symptoms <ref name="CCFA" />.  
It is more prominent in urban than rural areas.<ref name=":0" />
== Symptoms of Crohn’s Disease ==
[[File:Diarrhea.png|thumb|Diarrhea a symptom]]
While Crohn’s is a chronic disease, the patients will experience bouts of flare ups and remission with the absence of symptoms <ref name="CCFA">Crohn’s and Colitis Foundation of America (CCFA).  About Crohn’s Disease.  http://ccfa.org/info/about/crohns (accessed 4 March 2010)</ref>.  


There are different types of Crohn’s Disease dependent upon the location and disease pattern within the GI tract. [[Image:Types.jpg|thumb|right|350x250px|Types of Crohn's disease]]<ref name="John">Crohn’s Disease: Introduction. John Hopkins Medicine. Available at http://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&amp;GDL_Disease_ID=291F2209-F8A9-4011-8094-11EC9BF3100E&amp;GDL_DC_ID=D03119D7-57A3-4890-A717-CF1E7426C8BA (accessed 5 April 2010).</ref>  
Patients with flare-ups of CD usually present with abdominal pain (right lower quadrant), flatulence/bloating, diarrhea (can include mucus and blood), fever, weight loss, anemia. In acute cases, perianal abscess, perianal Crohn disease, and cutaneous fistulas can be seen.<ref name=":0" />


The different locations of Crohn’s Disease include:


=== Gastroduodenal Crohn’s Disease  ===
About 50% of individuals with Crohn’s Disease will have mild symptoms. The other half may experience more severe symptoms and pain that appears to come and go. These patients undergo painful exacerbations and potentially symptom free remissions. The remissions might last for months to years but the symptoms will eventually return<ref name="CCFA" />.&nbsp;
Located in the upper gastrointenstinal tract
*This is uncommon and symptoms occur in 5% of those diagnosed with Crohn’s  
*This affects the stomach and first part of the small intestine (duodenum)
*The symptoms associated include:


#Nausea
The below viewing is a 5 minute presentation from a clients viewpoint.  
#Los s of appetite
{| class="FCK__ShowTableBorders" width="40%" cellspacing="1" cellpadding="1" border="0" align="centre"
#Weight loss
|-
#Vomiting
| align="right" |
#Pain in upper abdomen
{{#ev:youtube|Npda8xr2G-Y|300}}<ref name="Thomas">Thomas Craig. A Frank discussion on Crohn's Disease. Available at http://www.youtube.com/watch?v=Npda8xr2G-Y (last accessed 4/510)</ref>
 
|}
=== Jejunoileitis  ===
== Types of Crohn's Disease ==
Inflammation is located in the Jejunum or Second part of small intestines
[[Image:Crohn's distribution.jpg|thumb|right|300x200px|Distribution of Crohn's Disease within the Gastrointestinal tract]][[Image:What is Crohn's disease.jpg|frame|right|200px|Gastrointestinal Tract in which Crohn's Disease affects]]There are different types of Crohn’s Disease dependent upon the location and disease pattern within the GI tract. The different locations of Crohn’s Disease include:  
*This is also uncommon in the general population of those diagnosed with Crohn’s disease
*The symptoms include:
 
#Diarrhea
#Abdominal pain (after eating)
#Malnutrition due to malabsoprtion of nutrients
#Weight loss
 
=== Ileitis  ===
Inflammation located in the last part of small intestine or ileum
*This is affects 30% of individuals diagnosed with Crohn’s disease
*The symptoms include:
 
#Diarrhea
 
=== Abdominal pain ===
Pain located in the right lower quadrant
#Weight loss
 
=== Ileocolitis  ===
Inflammation located in the ileum and colon)&nbsp;
*This is the most common form of Crohn’s disease and affects 50% of those diagnosed
*The symptoms include:
 
#Diarrhea
#Abdominal pain (right lower quadrant)
#Weight loss
 
=== Crohn’s Colitis  ===
Inflammation located in the colon
*This affects 20% of individuals diagnosed with Crohn’s disease
*The symptoms include:
 
#Diarrhea
#Rectal bleeding
#Abdominal pain
 
*The perianal disease and extraintestinal complications are more commonly associated in these individuals.
 
=== Perianal Disease  ===
 
*This occurs in 1/3 of individuals diagnosed with Crohn’s disease
*These individuals can have fistulae, fissures, abscesses or skin tags
 
#Skin tags: fleshy growths outside the anus&nbsp;<ref name="Knol" />
 
[[Image:Crohn's distribution.jpg|thumb|right|300x200px|Distribution of Crohn's Disease within the Gastrointestinal tract]]<ref name="Knol" /><br> About 50% of individuals with Crohn’s Disease will have mild symptoms. The other half may experience more severe symptoms and pain that appears to come and go. These patients undergo painful exacerbations and potentially symptom free remissions. The remissions might last for months to years but the symptoms will eventually return<ref name="CCFA" />.&nbsp; This unpredictable nature is part of what makes Crohn's so complicating. &nbsp;
 
== Associated Co-morbidities  ==
 
While commonly Crohn’s disease affects the GI tract, there have been instances where additional complications include arthritis, skin conditions, inflammation of the eyes and/or mouth, joints, kidney stones, gallstones and liver/biliary conditions were also reported. <br>
 
The most common associated comorbidity is a <u>''blockage of the intestines''</u>. Continual blockage tends to thicken the walls of the intestine with scar tissue which further reduces the size of the passageway <ref name="NDDIC" />. ''<u>Fistulas</u> ''are also common due to sores or ulcers that develop into deep ulcers or tracts connecting<ref name="CCFA" /> into the bladder, vagina, skin or anal area. These fistulas are then exposed to infection<ref name="NDDIC" />. <br>
 
It has been discovered that individuals with Crohn’s disease have ''<u>referred pain to the low back</u>''. Approximately 25% of individuals with Crohn’s and/or irritable bowel disease have sacroilitis, polyarthritis, monarthritis of ankle, knee, elbows and/or wrists <ref name="Goodman">Goodman CC, Snyder TEK. Differential Diagnosis for Physical Therapists: Screening for Referral. 4th ed. St. Louis, MO: Saunders-Elsevier; 2007</ref>, as well as migratory arthralgias. At times, these joint conditions may even present initially before the other GI related symptoms<ref name="Patho">Goodman CC, Fuller KS. Pathophysiology: Implications for the Physical Therapist. 3rd ed. St. Louis, MO: Saunders-Elsevier; 2009.</ref>.<br>
 
Since this disease affects the ''<u>absorption</u>'' of nutrients, chronically involved&nbsp;individuals commonly have deficiencies of protein, calories and vitamins. This may be due to the malabsorption or overall inadequate dietary intake secondary to the patient’s attempt to limit the pain produced with eating <ref name="NDDIC" />.<br>
 
There is a risk of ''<u>colorectal cancer</u>'' that tends to increase with an increased length of time with the disease. There is a 2% incidence of colorectal cancer after 10 years diagnosis, 9% incidence after 20 years diagnosis, and 19% incidence after 30 years of diagnosis of Crohn’s disease. A 20% mortality rate lies within the first 10 years of diagnosis in the presence of complications. Surgical removal of the Crohn’s bowel does not prevent colorectal cancer, thus putting importance on prevention and screening for early detection of colorectal cancer<ref name="Patho" />.
 
''[[Osteopenia|<u>Osteopenia</u>]] ''can occur in 50% of patients diagnosed with Crohn’s Disease and [[Osteoporosis|<u>''osteoporosis''</u>]] can occur in 15% of those diagnosed. It is thought these complications may be due to the steroid therapy , smokers, those with a more active disease as well as those individuals with low calcium and vitamin D intake. Due to this, all patients diagnosed with Crohn’s Disease should be informed of this potential complication and should be advised to take supplemental calcium and vitamin D.
 
Stones of the kidney and gallbladder are potential comorbidities. <u>''Kidney stones''</u> may occur due to the fat malabsorption and diarrhea in individuals with Crohn’s Disease. These patients may experience extreme flank or lower lateral back pain as well as blood in the urine. <u>''Gallstones''</u> may occur due to the bile acid malabsoprtion. These patients may experience right sided abdominal pain<ref name="Knol" />.  
 
== <u>Medications</u>  ==
 
There are a few classifications of drugs that can be used to help relieve the symptoms of Crohn’s disease. These include anti-inflammatory, cortisone or steroids, immune system suppressors, Infliximab (Remicade), antibiotics and anti-diarrheal/fluid replacements. <br>
 
'''''Anti-inflammatory''''' drugs are generally the initial step in relieving the symptoms, which can include Sulfasalazine, which is better for conditions within the colon<ref name="mayo" /> and is the most common. An additional type includes 5-ASA agents such as Mesalamine which has fewer side effects but is not as effective at treating the small intestine<ref name="NDDIC" />. <u><br></u>  
 
'''''Cortisone'' '''or '''''corticosteroids''' ''can be very effective by reducing inflammation within the body, but their side effects are vast including night sweats, high blood pressure, osteoporosis, bone fractures, excessive facial hair, increased susceptibility for infection and cataracts<ref name="mayo" />.&nbsp; Prednisone is typically prescribed when the disease is beginning and typically worse<ref name="NDDIC" />.
 
'''''Immune system suppressors''''' suppress the immune system which targets the immune system to reduce the inflammation within the body. Some types include Imuran or Azathioprine and Purinethol which are the most commonly used for IBD and conditions. These may also help to heal the fistulas <ref name="mayo" />.&nbsp; It should be noted that the use of immunosuppressive drugs may increase the effectiveness of corticosteroids<ref name="NDDIC" />. <u>'''<br>'''</u>
 
'''''Infliximab (Remicade)''''' is the first medication to block the inflammation response by the body. This was approved by the FDA for the treatment of moderate to severe Crohn’s disease that has failed to respond to prior conservative treatments. This medication is an anti-TNF substance or anti-tumor necrosis factor<ref name="NDDIC" />&nbsp;and neutralizes this protein that is produced by the immune system. The TNF is targeted and removed before there is the chance for inflammation to occur in the GI tract. The FDA has declared a warning to children and adolescents taking this medication or other TNF inhibitors are at an increased risk for developing cancer<ref name="mayo" /><ref name="SONIC">Susman E.. SONIC gives boost to infliximab for Crohn's. Medical Post [serial online]. November 2008;44:14. Available from: Health Module. Accessed March 4, 2010, Document ID: 1616171171.</ref>.
 
'''''Antibiotics'''''are used to treat and heal fistulas and abscesses associated with Crohn’s disease. Medications such as these may also reduce the amount of harmful bacteria within the GI tract that suppresses the intestinal immune system. Common antibiotics include Flagyl and Cipro.<u><br></u>
 
'''''Additional medications'' '''that are used to help relieve symptoms in individuals with Crohn’s disease include: anti-diarrheals to relieve the diarrhea, laxatives, pain relievers, iron supplements, vitamin B-12 shots, calcium and vitamin D. Nutrition supplements are also very important, especially in children whose growth may be slowed. This nutrition might be in the form of high-calorie liquid formulas, feedings tube or parenteral nutrition injected into the vein. This will help to overall improve the nutrition of the individual and allow their bowel to rest which may reduce inflammation for a short period of time<ref name="mayo" />.<u><br></u>
 
== Diagnostic Tests/Lab Tests/Lab Values  ==
 
The diagnosis of Crohn’s disease is made by ruling out other potential causes to explain the patient’s signs and symptoms. Some of the tests include blood tests, fecal occult blood test (FOBT), colonoscopy, flexible sigmoidoscopy, barium enema or small bowel imaging, CT of the GI tract, or a capsule endoscopy.
 
The <u>''blood tests''</u> are used to check for anemia<ref name="mayo" />&nbsp;which would indicate inflammation within the body<ref name="NDDIC" />,&nbsp;infection, and antibodies that might be present with individuals with inflammatory bowel disease.
 
The ''<u>FOBT</u>'' assesses an individual’s stool sample for the presence of blood.
 
A ''<u>colonoscopy</u>'' allows the doctor to take a biopsy or tissue sample to determine if there is a presence of any granulomas which are common with Crohn’s disease and not ulcerative colitis.
 
[[Image:Crohn's small bowel.jpg|thumb|right|300px|Normal small bowel and Crohn's Disease small bowel through colonoscopy]]<ref name="Knol" />
 
The ''<u>flexible sigmoidoscopy</u>'' allows the doctor to assess the last portion of the colon for any biopsy samples<ref name="mayo" />. &nbsp;This allows the doctor to determine if there is any inflammation or bleeding amongst the intestines<ref name="NDDIC" />. &nbsp;''<u></u>''
 
''<u>Barium enemas</u>'' allow the doctors to assess the intestines via x-ray. The barium coats the inner lining of the GI tract to allow the lining to be visible on the x-ray. [[Image:Crohn's SBFT (1)bariumenema.jpg|thumb|left|200px|Barium enema study showing (arrows) narrowing in the small bowel from Crohn's Disease]]<ref name="Knol" />
 
A ''<u>CT</u>'' of the GI tract allows a quick look at the entire bowel in a way that cannot be seen in other diagnostic tests. This helps to assess for blockages, abscesses or fistulas.
 
The ''<u>capsule endoscopy</u>'' consists of a capsule with a small camera inside that is swallowed by the individual. The camera takes pictures every second as it travels along your GI tract. The pictures are then sent to a wireless computer belt worn by the patient that can then be taken into the doctor and downloaded for view<ref name="mayo" />.<br>
 
An outcome measure has been created to track the progress or lack of progress for individuals affected with Crohn’s disease called Crohn’s Disease Activity Index (CDAI). A score below 150 indicates a better prognosis than higher scores. This measure helps to track an individual’s progress from week to week to determine if the symptoms are better or worse. This is more of a gauge of progress and not a prognosis tool<ref name="CDAI">Crohn’s Disease Activity Index (CDAI) calculator. CDAI Online Calculator. &amp;lt;ref="http://www.ibdjohn.com/cdai/"Crohn's Disease Activity Index, CDAI (accessed 4 March 2010)</ref>.<br>
 
== Causes  ==
 
The initial cause of Crohn’s disease is unknown, but was previously thought to be caused by a person’s stress and diet. Now, it is believed that factors such as these are just aggravating components while hereditary and a malfunctioning immune system may be a part of the development of Crohn’s disease. The immunological explanation believes that immune system attempts to fight off organisms while inflaming the GI tract. In those affected with Crohn’s disease, there may be an abnormal response to the bacteria that produces the large extent of inflammation. The hereditary explanation believes there is a genetic mutation that has been found in those individuals affected with Crohn’s. Crohn’s disease produces small, shallow, scattered and crater-like erosion along the inner surface of the GI tract. As this disease progresses, the erosions become deeper and larger ulcerations that will eventually scar and create stiffness along the tract. With this stiffness, the bowel can easily become obstructed. Along the deep ulcerations, the bacterium that travels along the GI tract is diffused into adjacent organs and abdominal cavity<ref name="MedicineNet" />. <br>
 
Some research has indicated that Crohn’s disease is very similar to a condition called Johne’s disease that occurs in cattle. The difference between the two is that Johne’s disease has a known etiology which is a bacterium called Mycobacterium avium subspecies paratuberculosis or MAP. It is believed that MAP’s presence in the intestines of individuals with Crohn’s disease could be a common characteristic. It is believed that the MAP comes from the pasteurized milk consumed from cows that are infected with Johne’s disease. The pasteurization does not remove this organism and potentially is reasoning for the connection. Individuals with Crohn’s disease do not have high amounts of MAP, so the direct cause of inflammation is still unknown if the bacterium directly influences the inflammation. Some theorize that the elimination of MAP may help to improve Crohn’s disease<ref name="Bone">Bone K. Using Herbs and Diet to Beat Crohn’s Disease. Dynamic Chiropractic. 2008;4(2) 26-27.</ref>. <br>
 
== Systemic Involvement  ==
 
[[Image:Erythema nodosum.jpg|thumb|right|350px|Erythema Nodosum]]
 
Crohn’s disease may have extraintestinal symptoms, or symptoms that occur outside of the intestines. This can occur in up to 25% of patients diagnosed with Crohn’s Disease. These can include any or all of the following: <br>
 
1. '''Musculoskeletal''':
 
*[[Osteoporosis|Osteoporosis]] <br>
*[[Rheumatoid Arthritis|Arthritis]] (most commonly peripheral joints) <br>
*[[Low Back Pain|Low back pain]]<ref name="CCFA" /><br>
 
2. '''Integumentary''':<br>
 
*Erythema nodosum or painful red bumps on the skin surface<br>
*Pyoderma gangrenosum or skin ulcerations <ref name="Knol" /><br>
 
[[Image:Body complications.jpg|thumb|right|300px|Extraintestinal manifestations of Crohn's disease]]
 
3. '''Genitourinary''':<br>
 
*Kidney stones
*Liver involvement:
 
#Hepatitis
#Cirrhosis <ref name="CCFA" />
#Primary sclerosing cholangitis (PSC) or inflammation of liver ducts&nbsp;<ref name="Knol" />
 
4. '''Oral''':
 
*Sores within the mouth
 
5. '''Ophthalamic''':  
 
*Redness and itching of the eyes
*uveitis, eye pain and/or vision changes


6. '''Psychiatric''':  
<ref name="John">Crohn’s Disease: Introduction. John Hopkins Medicine. Available at http://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&amp;GDL_Disease_ID=291F2209-F8A9-4011-8094-11EC9BF3100E&amp;GDL_DC_ID=D03119D7-57A3-4890-A717-CF1E7426C8BA (accessed 5 April 2010).</ref>


*Emotional distress <ref name="CCFA" /><br>
# '''Gastroduodenal Crohn’s Disease:''' Located in the upper gastrointenstinal tract and affects the stomach and first part of the small intestine (duodenum).  This is uncommon and symptoms occur in 5% of those diagnosed with Crohn’s. 
# '''Jejunoileitis''': This is also uncommon in the general population of those diagnosed with Crohn’s disease.  Inflammation is located in the Jejunum or Second part of small intestines. 
# '''Ileitis:''' Inflammation located in the last part of small intestine or ileum and affects 30% of individuals diagnosed with Crohn’s disease. 
# '''Ileocolitis:''' This is the most common form of Crohn’s disease and affects 50% of those diagnosed with inflammation located in the ileum and colon. 
# '''Crohn’s Colitis:''' This affects 20% of individuals diagnosed with Crohn’s disease with inflammation located in the colon.  The perianal disease and extraintestinal complications are more commonly associated in these individuals. 
# '''Perianal Disease:''' This occurs in 1/3 of individuals diagnosed with Crohn’s disease.  These individuals can have fistulae, fissures, abscesses or skin tags (fleshy growths outside the anus)&nbsp;<ref name="Knol">Cheifetz Adam, Moss Alan, Peppercorn Mark. Crohn’s Disease.  Knol Beta. Available at http://knol.google.com/k/crohn-s-disease#. Accessed 5 April 2010.</ref>


== Medical Management (current best evidence)  ==
<ref name="Knol" />


The mail goal of medical therapy is to better regulate the patient’s immune system<ref name="CCFA" />. Additional goals for treatment in Crohn’s Disease include: inducing remission, maintain remission, improve the patient’s quality of life and minimize toxicity. <br>
== Complications ==


<br>The specific treatment of Crohn’s Disease is dependent upon several factors, including the location, severity of disease, type of disease, complications of Crohn’s and the individual’s response to prior medical treatments. There is a current “step up” therapy that is used for individuals with Crohn’s disease. <br>
[[Image:Body complications.jpg|thumb|right|300px|Extraintestinal manifestations of Crohn's disease]]CD is a systemic disease and has manifold intestinal and extra-intestinal complications. Examples include:


This approach involves:<br>  
* Stricture formation, fistulae and abscesses
* Colorectal carcinoma
* Ankylosing spondylitis
* Erythema nodosum, pyoderma gangrenosum
* Kidney and gall stones
* Anemia
* Hypercoagulable state
* Osteoporosis
* Eye inflammation<ref name=":0" /><br>


*Patients first treated with medications with fewer side effects that may not be as effective as the stronger medications<br>
== Diagnosis ==
*As the disease progresses, the treatment becomes more intense involving medications that are more powerful with potentially more toxicity levels<ref name="Knol" />.<br>


[[Image:Crohn's pyramid.jpg|thumb|center|300x200px|Traditional Crohn's treatment pyramid]]<ref name="Knol" /><br>  
The diagnosis is made by ruling out other potential causes. Investigations include: blood tests, fecal occult blood test, colonoscopy, flexible sigmoidoscopy, barium enema or small bowel imaging, CT of the GI tract, or a capsule endoscopy.<ref name="Knol" />  


It is estimated that 2/3 of individuals affected with Crohn’s will need surgery at some point within their lives. This becomes a necessary treatment plan when medications and conservative treatment has failed. The surgery is used either to relieve the symptoms or correct complications secondary to perforation, abscess, blockage, or bleeding into the intestines. The surgery can often times improve the symptoms but may never treat or heal the condition. Crohn’s disease often reoccurs after surgery, so the benefits and complications should be weighed appropriately by the patient when choosing the course of action<ref name="NDDIC" />.<br>  
Many CD patients who develop complications require surgery and possibly multiple procedures in time. Once a patient has had surgery, surveillance endoscopy is recommended in six to 12 months. If there is no endoscopic recurrence, ileocolonoscopy should be repeated in 1 to 3 years.<ref name=":0" />  


Some indications for surgery include:<br>
== Treatment/Management ==
[[File:Methotrexate.jpg|thumb|Methotrexate]]
The medical treatment is roughly grouped into two classes:


*Perforation of intestines<br>
# Mild to moderate disease can be treated by oral mesalamine, [[DMARDs in the Management of Rheumatoid Arthritis|immunomodulators]], methotrexate, and [[Corticosteroid Medication|steroids]].
*Fistula that cannot be medically managed<br>
# Moderate to severe disease will be best treated using a combination of immunomodulators and [[BDMARDs in the Management of Rheumatoid Arthritis|biologics]] or biologics alone.
*Abcess<br>
*Uncontrollable bleeding from intestine<br>
*Cancer or precancer<br>
*Toxic magacolon – a potentially lethal form of acute colitis<br>
*Failure of medical therapy<br>


<br>  
* Dietician involvement is recommended and nutritional supplementation are highly recommended before and during the treatment of Crohn disease.
* Poor pregnancy outcomes are associated with active CD. Disease flares should be treated aggressively in pregnancy<ref>Kalla R, Ventham NT, Satsangi J, Arnott ID. Crohn’s disease. Bmj. 2014 Nov 19;349. Available:https://www.bmj.com/content/349/bmj.g6670 (accessed 1.10.2022)</ref>
* Mental health counseling for  may be needed depression
* Sound education about CD and best ways to live with the conditions, for example: Avoid NSAIDs as they may exacerbate disease; Manage mild diarrhea with antidiarrheals; Avoid smoking; heed dietician advice.<ref name=":0" />


There are multiple surgical processes that can be used for individuals with Crohn’s Disease. These include: <br>
== Physical Therapy Management  ==
Individuals may need physiotherapy to treat the following.


*Bowel resection in which the affected parts of the intestines are removed and the healthier portions are then reattached.  
# Crohn’s disease is associated with [[arthritis]], notably arthritis of the [[Spondyloarthritis|lumbar spine]] and [[Sacroiliac Joint Syndrome|sacroiliac joints]]. Though arthritis usually affects [[Older People - An Introduction|older people]], Crohn's-related arthritis is common in young people with the disease.<ref>Enzine articles The Link Between Crohn's Disease And Lower Back Pain  Available:https://ezinearticles.com/?The-Link-Between-Crohns-Disease-And-Lower-Back-Pain&id=7654760 (accessed 1.10.2022)</ref> When a patient presents to physical therapy with low back, sacroiliac or hip pain, it is vital for the therapist to screen for potential organic sources of the pain and for a history of inflammatory bowel disease. See links re treatment.
*Proctocolectomy and Ostomy where the individual may need the whole colon and rectum removed. These patients will need a stoma where the stool can then exit the body via pouch or bag.  
# CD prevents correct absorption of [[Nutrition|nutrient]]<nowiki/>s through the intestines into the body. [[Vitamin D Deficiency|Vitamin D]] and calcium are key nutrients for bone health, and deficiency can lead to [[osteoporosis]]. Osteoporosis often leads to [[Insufficiency Fracture|insufficiency fractures]] eg in the vertebrae. Vertebral fractures can cause changes in [[Thoracic Hyperkyphosis|spinal curvature]], leaving other vertebrae more susceptible to fracture. Pain may result from the fracture itself, inflammation and/or [[Biomechanics|biomechanical]] changes. Educate clients regarding osteoporosis.
*Stricturoplasty is the removal of the strictures or scarred narrowings of the intestines. This will widen the portions and will allow intestinal contents to pass through<ref name="Knol" />. <br>
# Hydration is very important in patient’s with Crohn’s disease so the therapist should be aware of signs of dehydration when exercising, for example headache, dry lips, disorientation. 
# Exercise prescriptions have the ability to boost the immune system, reduce depression, and improve the body image of the patient. In addition to providing this exercise program, therapists can better create coping mechanisms as well as techniques to manage the unexpectedness of Crohn’s Disease<ref name="Patho">Goodman CC, Fuller KS. Pathophysiology: Implications for the Physical Therapist. 3rd ed. St. Louis, MO: Saunders-Elsevier; 2009.</ref>.


== Physical Therapy Management (current best evidence) ==
== Outcome Measures ==
An outcome measure has been created to track the progress or lack of progress for individuals affected with Crohn’s disease called Crohn’s Disease Activity Index (CDAI). A score below 150 indicates a better prognosis than higher scores. This measure helps to track an individual’s progress from week to week to determine if the symptoms are better or worse. This is more of a gauge of progress and not a prognosis tool<ref name="CDAI">Crohn’s Disease Activity Index (CDAI) calculator. CDAI Online Calculator. &amp;lt;ref="http://www.ibdjohn.com/cdai/"Crohn's Disease Activity Index, CDAI (accessed 4 March 2010)</ref>.<br>


Crohn’s disease is associated with periumbilical pain and referred low back pain. Individuals may also experience pain in the lower right quadrant and potential associated iliopsoas abscess due to an inflammatory mass that may create hip, buttock, thigh, or knee pain. When a patient presents to physical therapy with unknown origin of low back, sacroiliac or hip pain, it is vital for the therapist to screen for potential organic sources of the pain and is even more important in patients with a history of inflammatory bowel disease. <br>
== Dietary Management  ==
 
Diet is a confusing topic with a lot of conflicting information. Patients need talk with an accredited dietitian to find what’s right for them and their CD.<ref name=":1" />
Since individuals with Crohn’s disease might also have associated low bone mineral content and a high potential for [[Osteoporosis|osteoporosis]], it is important for the therapist to provide education on osteoporosis and its prevention. <br>
 
Hydration is very important in patient’s with Crohn’s disease so the therapist should be aware of signs of dehydration, including headache, dry lips, brittle nails and hair, dry hands and disorientation. <br>
 
Due to the complexity of Crohn’s Disease, patients might be predisposed to emotional stress that could exacerbate the prior symptoms. In knowing this, the therapist has the availability to accept the patient’s feelings, validate the disease to the patient as well as prescribing an exercise program to better the outcome for the patient. These exercises have the ability to boost the immune system, reduce depression, and improve the body image of the patient. In addition to providing this exercise program, therapists can better create coping mechanisms as well as techniques to manage the unexpectedness of Crohn’s Disease<ref name="Patho" />. <br>
 
== Dietary Management (current best evidence)  ==
 
An elemental diet that includes food broken down into basic components like amino acids, vitamins, sugars, etc can help improve the symptoms associated with Crohn’s disease. There has also been improvements found in individuals who are placed on diets free of dairy, gluten and yeast products. Herbs have also been studied to determine effectiveness of relief of symptoms.<br>
 
Additional ways to better manage the symptoms may include changes to your diet. Some key points include:<br>
 
*Eating smaller meals and at more frequent intervals
*Reducing the amount of greasy, fatty foods that may produce diarrhea and gas
*Limit consumption of milk and dairy products
*Reduce the amount of carbohydrates that are poorly digested that may cause diarrhea, gas, bloating, cramps
*Restrict the intake of high-fiber foods such as nuts, seeds, corn, and popcorn<ref name="CCFA" />. <br><br>


== Differential Diagnosis  ==
== Differential Diagnosis  ==


The symptoms above are not specific to Crohn’s disease and have potential to be seen in other conditions. Differential diagnoses can include the following:<br>
The symptoms above are not specific to Crohn’s disease and have potential to be seen in other conditions. Differential diagnoses can include the following:


*
* Infection with amoebas


Infectious causes – bacterial, viral, or parasitic infection.
* [[Behcet Disease|Behcet disease]]
 
* [[Celiac Disease (Coeliac Disease)|Celiac]] disease
*Ischemia – low blood flow to the small intestine or colon, usually seen in older patients
* Intestinal carcinoid
*Medication – non-steroidal anti-inflammatories, antibiotics, birth control pills
* Intestinal [[tuberculosis]]
*Diverticulitis – infection of a diverticulum (outpouching of colon) that can present with left lower quadrant pain and fever
* Mesenteric ischemia
*Appendicitis – usually presents with right lower quadrant abdominal pain and fever
* Ulcerative colitis
*Irritable bowel syndrome – can cause severe diarrhea and abdominal pain
== Viewing ==
*Lactose intolerance – can cause diarrhea, bloating, and abdominal pain. Patients with Crohn’s disease can also have lactose intolerance.
*Celiac disease – sensitivity to gluten (wheat) which can cause diarrhea and bloating.
*Gallstones
*Cancer, lymphoma
*Diseases that affect other organs in the abdomen also need to be considered such as:
*Endometriosis, pelvic inflammatory disease, ectopic pregnancy, ruptured ovarian cyst
*Kidney stones, bladder or kidney infections<ref name="Knol" />
 
== Case Reports  ==
 
*[[Crohn's Disease Case Study|Crohn's Disease Case Study]]
*Barlow S. Case study: A 16 year old male with bone density losses resulting from Crohn's disease. Synergy [serial online]. January 2003;21. Available from: ProQuest Nursing &amp; Allied Health Source. Accessed April 6, 2010, Document ID: 347682641. [http://proquest.umi.com.libproxy.bellarmine.edu/pqdweb?index=10&did=347682641&SrchMode=2&sid=3&Fmt=4&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1270600427&clientId=1870 Case study:A 16 year old male with bone density losses resulting from Crohn's disease] <br>
*Arumugam R, Brandt ML, Jaksic T, Gilger M. Crohn's disease presenting as chronic constipation: A case report. Clinical Pediatrics [serial online]. 2000;39:369-71. Available from: Health Module. Accessed April 6, 2010, Document ID: 55518839. [http://proquest.umi.com.libproxy.bellarmine.edu/pqdweb?index=18&did=55518839&SrchMode=2&sid=3&Fmt=4&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1270600620&clientId=1870 Crohn's disease presenting as chronic constipation: A case report] <br>
*Holaday M, Smith KE, Robertson S, Dallas J. An atypical eating disorder with Crohn's disease in a fifteen-year-old male: A case study. Adolescence [serial online]. 1994;29:865-73. Available from: Research Library Core. Accessed April 6, 2010, Document ID: 1499994.[http://proquest.umi.com.libproxy.bellarmine.edu/pqdweb?index=22&did=1499994&SrchMode=1&sid=3&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1270600774&clientId=1870 An atypical eating disorder with Crohn's disease in a fifteen-year-old male: A case study] <br>
*Ogram AE, Sobanko JF, Nigra TP. Metastatic cutaneous Crohn's disease of the face: a case report and review of the literature. Cutis. 2010;85:25-7. Available from: Pubmed. Acessed April 6, 2010. [http://www.ncbi.nlm.nih.gov/pubmed/20184208 Metastatic cutaneous Crohn's disease of the face: a case report and review of the literature] <br>
 
== Resources    ==
 
Crohn's &amp; Colitis Foundation of America: [http://www.CCFA.org Crohn's &amp; Colitis Foundation of America]
 
Living with Crohn's Disease: [http://www.livingwithcrohnsdisease.com Living with Crohn's Disease]  
 
National Digestive Diseases Information Clearinghouse (NDDIC): [http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/ Crohn's Disease]  
 
CDAI Calculator: [http://www.ibdjohn.com/cdai/ Crohn's Disease Activity Index Calculator]
 
== Presentations  ==
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14 minutes of informative viewing below
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[[Category:Autoimmune Disorders]]
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[[Category:Non Communicable Diseases]]
[[Category:Non Communicable Diseases]]
[[Category:Genetic Disorders]]
[[Category:Rheumatology]]

Latest revision as of 16:43, 9 September 2023

Original Editors - Sarah Bailey from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Sarah Bailey, Laura Ritchie, Lucinda hampton, Admin, Kim Jackson, Dave Pariser, Elaine Lonnemann, WikiSysop, Sehriban Ozmen, 127.0.0.1, Wendy Walker and Manisha Shrestha  

Introduction[edit | edit source]

CD chronic inflammation GI tract

Crohn disease (CD) and ulcerative colitis (UC) are both conditions commonly referred to as inflammatory bowel disease (IBD). CD causes chronic inflammation of the gastrointestinal tract. In Crohn disease, the inflammation extends through the entire thickness of the bowel wall from the mucosa to the serosa.

CD is a serious chronic inflammatory disorder that is difficult to diagnose and manage. The disease has a relapsing and remitting course. Many relapses can cause Crohn disease to progress from mild to moderate to severe penetrating (fistulization) or stricturing disease. There is no cure and most patients experience a poor quality of life..[1]

Etiology[edit | edit source]

The cause of CD is not known but genetics seem to play a role as does the environmental affects on the immune system.

The gut bacteria of people with Crohn’s disease changes but it still isn’t clear if the change is caused by inflammation.

Possibly a diet full of highly processed foods like sugary drinks and fast food, may increase the risk of developing Crohn’s. Crohn’s is not infectious. [2]

The 3 most common sites of intestinal involvement in CD (L) compared to the areas affected by ulcerative colitis (R).

Epidemiology[edit | edit source]

World Distribution of CD

CD is most prevalent in the western developed world in North America, northern Europe, and New Zealand.

The incidence of CD is bimodal with the onset occurring most frequently between ages 15 to 30 years and 40 to 60 years old.

It is more prominent in urban than rural areas.[1]

Symptoms of Crohn’s Disease[edit | edit source]

Diarrhea a symptom

While Crohn’s is a chronic disease, the patients will experience bouts of flare ups and remission with the absence of symptoms [3].

Patients with flare-ups of CD usually present with abdominal pain (right lower quadrant), flatulence/bloating, diarrhea (can include mucus and blood), fever, weight loss, anemia. In acute cases, perianal abscess, perianal Crohn disease, and cutaneous fistulas can be seen.[1]


About 50% of individuals with Crohn’s Disease will have mild symptoms. The other half may experience more severe symptoms and pain that appears to come and go. These patients undergo painful exacerbations and potentially symptom free remissions. The remissions might last for months to years but the symptoms will eventually return[3]. 

The below viewing is a 5 minute presentation from a clients viewpoint.

[4]

Types of Crohn's Disease[edit | edit source]

Distribution of Crohn's Disease within the Gastrointestinal tract
Gastrointestinal Tract in which Crohn's Disease affects

There are different types of Crohn’s Disease dependent upon the location and disease pattern within the GI tract. The different locations of Crohn’s Disease include:

[5]

  1. Gastroduodenal Crohn’s Disease: Located in the upper gastrointenstinal tract and affects the stomach and first part of the small intestine (duodenum). This is uncommon and symptoms occur in 5% of those diagnosed with Crohn’s.
  2. Jejunoileitis: This is also uncommon in the general population of those diagnosed with Crohn’s disease. Inflammation is located in the Jejunum or Second part of small intestines.
  3. Ileitis: Inflammation located in the last part of small intestine or ileum and affects 30% of individuals diagnosed with Crohn’s disease.
  4. Ileocolitis: This is the most common form of Crohn’s disease and affects 50% of those diagnosed with inflammation located in the ileum and colon.
  5. Crohn’s Colitis: This affects 20% of individuals diagnosed with Crohn’s disease with inflammation located in the colon. The perianal disease and extraintestinal complications are more commonly associated in these individuals.
  6. Perianal Disease: This occurs in 1/3 of individuals diagnosed with Crohn’s disease. These individuals can have fistulae, fissures, abscesses or skin tags (fleshy growths outside the anus) [6]

[6]

Complications[edit | edit source]

Extraintestinal manifestations of Crohn's disease

CD is a systemic disease and has manifold intestinal and extra-intestinal complications. Examples include:

  • Stricture formation, fistulae and abscesses
  • Colorectal carcinoma
  • Ankylosing spondylitis
  • Erythema nodosum, pyoderma gangrenosum
  • Kidney and gall stones
  • Anemia
  • Hypercoagulable state
  • Osteoporosis
  • Eye inflammation[1]

Diagnosis[edit | edit source]

The diagnosis is made by ruling out other potential causes. Investigations include: blood tests, fecal occult blood test, colonoscopy, flexible sigmoidoscopy, barium enema or small bowel imaging, CT of the GI tract, or a capsule endoscopy.[6]

Many CD patients who develop complications require surgery and possibly multiple procedures in time. Once a patient has had surgery, surveillance endoscopy is recommended in six to 12 months. If there is no endoscopic recurrence, ileocolonoscopy should be repeated in 1 to 3 years.[1]

Treatment/Management[edit | edit source]

Methotrexate

The medical treatment is roughly grouped into two classes:

  1. Mild to moderate disease can be treated by oral mesalamine, immunomodulators, methotrexate, and steroids.
  2. Moderate to severe disease will be best treated using a combination of immunomodulators and biologics or biologics alone.
  • Dietician involvement is recommended and nutritional supplementation are highly recommended before and during the treatment of Crohn disease.
  • Poor pregnancy outcomes are associated with active CD. Disease flares should be treated aggressively in pregnancy[7]
  • Mental health counseling for may be needed depression
  • Sound education about CD and best ways to live with the conditions, for example: Avoid NSAIDs as they may exacerbate disease; Manage mild diarrhea with antidiarrheals; Avoid smoking; heed dietician advice.[1]

Physical Therapy Management[edit | edit source]

Individuals may need physiotherapy to treat the following.

  1. Crohn’s disease is associated with arthritis, notably arthritis of the lumbar spine and sacroiliac joints. Though arthritis usually affects older people, Crohn's-related arthritis is common in young people with the disease.[8] When a patient presents to physical therapy with low back, sacroiliac or hip pain, it is vital for the therapist to screen for potential organic sources of the pain and for a history of inflammatory bowel disease. See links re treatment.
  2. CD prevents correct absorption of nutrients through the intestines into the body. Vitamin D and calcium are key nutrients for bone health, and deficiency can lead to osteoporosis. Osteoporosis often leads to insufficiency fractures eg in the vertebrae. Vertebral fractures can cause changes in spinal curvature, leaving other vertebrae more susceptible to fracture. Pain may result from the fracture itself, inflammation and/or biomechanical changes. Educate clients regarding osteoporosis.
  3. Hydration is very important in patient’s with Crohn’s disease so the therapist should be aware of signs of dehydration when exercising, for example headache, dry lips, disorientation.
  4. Exercise prescriptions have the ability to boost the immune system, reduce depression, and improve the body image of the patient. In addition to providing this exercise program, therapists can better create coping mechanisms as well as techniques to manage the unexpectedness of Crohn’s Disease[9].

Outcome Measures[edit | edit source]

An outcome measure has been created to track the progress or lack of progress for individuals affected with Crohn’s disease called Crohn’s Disease Activity Index (CDAI). A score below 150 indicates a better prognosis than higher scores. This measure helps to track an individual’s progress from week to week to determine if the symptoms are better or worse. This is more of a gauge of progress and not a prognosis tool[10].

Dietary Management[edit | edit source]

Diet is a confusing topic with a lot of conflicting information. Patients need talk with an accredited dietitian to find what’s right for them and their CD.[2]

Differential Diagnosis[edit | edit source]

The symptoms above are not specific to Crohn’s disease and have potential to be seen in other conditions. Differential diagnoses can include the following:

  • Infection with amoebas

Viewing[edit | edit source]

14 minutes of informative viewing below

http://www.youtube.com/watch?v=EeAmYqn81PQCrohn's presentation Pt 1.png
 Crohn's Disease Pt 1 of 2

View the presentation

http://www.youtube.com/watch?v=gnTZmSO5mqUCrohn's presentation Pt 2.png
 Crohn's Disease Pt 2 of 2

View the presentation

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Ranasinghe IR, Hsu R. Crohn disease. Available: https://www.ncbi.nlm.nih.gov/books/NBK436021/(accessed 1.10.2022)
  2. ↑ 2.0 2.1 Crohns and Colitis Australia CD Available:https://crohnsandcolitis.org.au/about-crohns-colitis/crohns-disease/about-crohns-disease/ (accessed 1.10.2022)
  3. ↑ 3.0 3.1 Crohn’s and Colitis Foundation of America (CCFA). About Crohn’s Disease. http://ccfa.org/info/about/crohns (accessed 4 March 2010)
  4. ↑ Thomas Craig. A Frank discussion on Crohn's Disease. Available at http://www.youtube.com/watch?v=Npda8xr2G-Y (last accessed 4/510)
  5. ↑ Crohn’s Disease: Introduction. John Hopkins Medicine. Available at http://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Disease_ID=291F2209-F8A9-4011-8094-11EC9BF3100E&GDL_DC_ID=D03119D7-57A3-4890-A717-CF1E7426C8BA (accessed 5 April 2010).
  6. ↑ 6.0 6.1 6.2 Cheifetz Adam, Moss Alan, Peppercorn Mark. Crohn’s Disease. Knol Beta. Available at http://knol.google.com/k/crohn-s-disease#. Accessed 5 April 2010.
  7. ↑ Kalla R, Ventham NT, Satsangi J, Arnott ID. Crohn’s disease. Bmj. 2014 Nov 19;349. Available:https://www.bmj.com/content/349/bmj.g6670 (accessed 1.10.2022)
  8. ↑ Enzine articles The Link Between Crohn's Disease And Lower Back Pain Available:https://ezinearticles.com/?The-Link-Between-Crohns-Disease-And-Lower-Back-Pain&id=7654760 (accessed 1.10.2022)
  9. ↑ Goodman CC, Fuller KS. Pathophysiology: Implications for the Physical Therapist. 3rd ed. St. Louis, MO: Saunders-Elsevier; 2009.
  10. ↑ Crohn’s Disease Activity Index (CDAI) calculator. CDAI Online Calculator. &lt;ref="http://www.ibdjohn.com/cdai/"Crohn's Disease Activity Index, CDAI (accessed 4 March 2010)
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