Crohn’s Disease: An Overview of Crohn’s Disease
Guest: Dr. Mark H. DeLegge – Gastroenterology & Hepatology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am talking with Dr. Mark DeLegge who is the director of the Digestive Disease Center at MUSC. Dr. DeLegge, a really common GI illness is Crohn’s disease. What is exactly is that illness?
Dr. Mark DeLegge: Crohn’s disease, we think, is a process where your body’s own immune system attacks certain portions of your body. With Crohn’s disease, those parts of your body are usually your intestines, your colon. It can be your stomach, your esophagus, or even your mouth. Interestingly, some patients with Crohn’s disease also have what we call extra GI symptoms. What that means is, outside the GI tract, where they can have problems with arthritis. They can have problems with inflammation of the eyes or, perhaps, inflammation of the skin. So, it is a huge disease that usually affects the gastrointestinal tract but also can affect some other organs.
Dr. Linda Austin: What triggers that?
Dr. Mark DeLegge: We have no idea. There are a number of theories and investigations currently looking at the cause. Some people feel that exposure, or being exposed to, some bacteria or virus sets this whole process in motion and once it is initiated, once it starts, you start to develop inflammation in the bowel, in the small intestine, in the stomach and so on, that can lead to ulcers forming there, bleeding and pain. Some other people think that there are no bacteria or virus that is involved and that, in fact, this is all programmed in you genetically, as you are born you have this set up inside you and at a certain age, the disease begins.
Dr. Linda Austin: What age, typically, is that?
Dr. Mark DeLegge: We usually see this presenting in younger patients. It is not unusual to see this in a pediatric population, meaning 5, 6, 7, 8, 9, 10 years of age, or in your teens, or perhaps in your 20s. You can develop it later on in life but that is unusual.
Dr. Linda Austin: I would imagine if it were something inborn that it would run in certain families. Is that the case?
Dr. Mark DeLegge: In fact, it is. When we look at Crohn’s disease and you trace families back, you do not always have a lot of history. Some people do not know what diseases other people in their family had. But, there seems to be a pretty strong relationship between other family members having had Crohn’s disease, or a form of Crohn’s disease, and then the patient developing Crohn’s disease. So, if I woke up one day and I knew my brother or my sister had Crohn’s disease, I would be at a lot more risk for developing it than someone else who has nobody in the family with Crohn’s disease.
Dr. Linda Austin: What are the earliest symptoms?
Dr. Mark DeLegge: Usually the earliest symptoms focus around loose stools, meaning diarrhea, abdominal pain. The abdominal pain can start off as something light or subtle, meaning some pain in the left lower part of your abdomen or perhaps in the right lower part. But, that pain tends to become worse over time and, again, the loose stools we talked about, many patients will also see some blood in their stool, and most patients will develop a fever. Now, that is very difficult, if you woke up one day and had the flu and you had nausea, vomiting, diarrhea and a fever with some abdominal pain, I am not saying that you have Crohn’s disease but, certainly, if that never went away, if this went on for weeks, you would have to say to yourself there is something else going on here that is not the flu.
Dr. Linda Austin: Now, irritable bowel syndrome can also present with diarrhea and with stomach aches. Is there anything that distinguishes those two illnesses in the beginning of the course of treatment?
Dr. Mark DeLegge: Sometimes in the beginning, they can be very similar in their symptoms. Usually, though, when you look at patients with irritable bowel syndrome or what we call spastic bowel, those patients, if you talk to them and say, do you have to get up in the middle of the night to use the bathroom, do you wake up in the middle of the night with abdominal pain, that you have to get out of bed and hold your belly and take some medication? They do not. The patient with Crohn’s disease would. We would not expect, ever, to see blood in the stool in someone with irritable bowel syndrome since that is a problem with spasms in the intestine, whereas we would in somebody with Crohn’s disease. We call Crohn’s disease inflammatory bowel disease or IBD, and irritable bowel syndrome IBS. I guess we do that to make it difficult. But, the IBD, or inflammatory patients generally have a fever, often have rectal bleeding and their pain can be anytime, anywhere, anyplace, meaning even in the middle of the evening.
Dr. Linda Austin: I think of IBS as being stress related. As a psychiatrist, I often hear of IBS symptoms in patients with anxiety disorders. Is there any relationship to stress in Crohn’s disease?
Dr. Mark DeLegge: There is a lot of controversy regarding that, but I have my own personal opinions and also what I have read in the literature. I think that many of my patients with Crohn’s disease also have irritable bowel syndrome. So, when you are looking at those patients, you are thinking, well, they have Crohn’s disease, is stress making it any worse? The answer is they most likely have both and the stress is making the irritable bowel syndrome worse which can give them worse abdominal pain, more diarrhea, and it can make you think that the Crohn’s disease is getting worse. So, when you are in that kind of situation, you have to separate the two and decide which one of the two you are going to treat, or adjust your treatment.
Dr. Linda Austin: How do you make the diagnosis of Crohn’s?
Dr. Mark DeLegge: There are laboratory tests available today that we can draw and have a pretty good idea about the fact that you do, or do not, have Crohn’s disease, but they are not perfect. The ultimate diagnosis is made on biopsy. So, if you had Crohn’s disease in your colon, we would do a colonoscopy in which we would pass a lighted instrument up through your rectum, under sedation, and we would look at the lining of your colon and we would take biopsies. The biopsies have some very distinctive features that the pathologists can see and say, this is Crohn’s disease. If it was in your small intestine, we may actually do an upper endoscopy, through your mouth, and look into your small intestine and take biopsies, for the same diagnosis.
Dr. Linda Austin: But, it is fundamentally a microscopic diagnosis?
Dr. Mark DeLegge: Yes, fundamentally to make the diagnosis, is microscopic. Although, to your eye, which you will see, is lots of inflammation in the lining of the colon or small intestine. You may see what we call rake patterns, ulcers, almost like someone took their fingernails and came down the mucosa. You can clearly see that and say, wow, there is a lot of swelling and ulcers here, I wonder if this patient has Crohn’s disease. Then you would confirm that on the biopsy.
Dr. Linda Austin: You mentioned that it can start in the pediatric years, in childhood. What is the oldest patient you have seen who has had nuance of Crohn’s disease?
Dr. Mark DeLegge: The oldest patient that I saw was in their mid-50s who developed Crohn’s disease. Going backwards with that patient, it is hard to know whether they had symptoms earlier that just were never clearly diagnosed.
Dr. Linda Austin: I would to talk about treatment, but let’s do that in another podcast.
Dr. Mark DeLegge: Sounds great.
Dr. Linda Austin: Thanks, Dr. DeLegge.
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