MyCrohnsandColitisTeam.com

DRUGS & CONDITIONS

WHAT IS CROHN'S DISEASE?

Crohn's disease or Crohn's is a condition that causes chronic or long-lasting inflammation of the digestive or gastrointestinal (GI) tract. Although Crohn's can affect any part of the GI tract, the parts most commonly affected are the small and large intestine (bowel).

Crohn's disease is a chronic and constantly changing disease. It progresses over time, especially during the first 10 years after diagnosis. This progress often involves a change from only inflammation to more structural changes in the intestines or bowel. The progression of Crohn's disease is different from person to person. Crohn's may progress more rapidly for some people, while others may have more gradual changes.

The exact cause of Crohn's is not known. Most likely, this disease is caused by a combination of environmental and genetic factors. However, scientists propose that the Crohn's-related inflammation occurs when the body's immune system mistakes helpful bacteria that normally live in the intestines, for harmful bacteria. This can cause white blood cells that usually only fight harmful bacteria to move into the intestine and release substances that cause inflammation. This inflammation can then lead to ulcers (sores) and damage to the healthy intestines.

Crohn's is one type of inflammatory bowel disease (IBD). Another type is ulcerative colitis. Two big differences between Crohn's and ulcerative colitis are the depth and location of the damage to the intestines.

For example, Crohn's can damage all the layers of the intestinal wall while ulcerative colitis usually only damages the inner lining of the intestinal wall. Also, in Crohn's, there are often healthy sections of intestine in between the damaged sections. But, in ulcerative colitis, the damage is usually continuous or connected with no healthy sections in between.

While symptoms may vary, it is sometimes difficult to tell whether someone has Crohn's or ulcerative colitis. When this happens, those who are affected are said to have indeterminate colitis.

References

Crohn's and Colitis Foundation of America. Disease Information. About Crohn's. http://www.ccfa.org/info/about/crohns

National Digestive Diseases Information Clearinghouse. Crohn's Disease. http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/#caus


Last Modified Date: June 30, 2010 © Accordant Health Services, a CVS Health company. All rights reserved. This article has been reviewed for accuracy by a member of the Accordant Health Services Medical Advisory Team. This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with any questions or concerns you may have regarding your condition. Use of this online service is subject to the disclaimer and the terms and conditions.

DRUGS & CONDITIONS

WHO GETS INFLAMMATORY BOWEL DISEASE?

Inflammatory bowel disease (IBD) affects about one million Americans. IBD is the general term used to describe chronic or long-lasting diseases that cause inflammation of the intestines. About half of those affected with IBD have Crohn's disease or Crohn's. And the other half have a related disease called ulcerative colitis.

The number of women diagnosed with Crohn's is slightly higher than the number of men affected by the disease. Although Crohn's can occur at any age, the age group most often affected is made up of adolescents and young adults. Children under 18 years of age make up 10 percent of those affected. Cases of Crohn's disease have been reported in infants less than 1 year old.

Crohn's tends to run in families. If you have a relative with Crohn's, your risk of developing it is 10 times greater than that of the general population. And your risk becomes 30 times greater if that relative is a brother or sister.

Because of the family connection, scientists have been looking for a genetic link to Crohn's. What they found was that people with Crohn's were more likely to have an abnormal change or mutation in the NOD2 gene and a polymorphism or abnormality in the SLC224A gene. Even though these are exciting discoveries, it is not yet possible to predict who will develop Crohn's and who will not. That may be because there are added genes, not yet identified, that also contribute to the development of Crohn's.

American Jews of European descent are four to five times more likely to develop IBD than others. Occurrence of Crohn's is the highest in Caucasians, followed by African Americans. The disease location within the GI tract is similar for all racial groups.

IBD seems to be a disease found mostly in the developed world, especially in the United States and Europe. When groups of people move from underdeveloped to developed nations, the frequency of IBD increases. It is also more common in urban areas and northern climates.

There is a strong connection between Crohn's disease and smoking. In fact, smokers are twice as likely to develop Crohn's compared to non-smokers. And Crohn's flares or relapses with severe pain are more common in those with Crohn's who smoke. Smoking increases the risk of disease recurrence and the need for a second surgery after Crohn's related bowel surgery. Secondhand exposure to smoke in childhood may also increase the risk of Crohn's occurrence.

Some studies have shown that infection or serious illness in mother or child during pregnancy leads to a four times greater risk of the child developing IBD. Infants from low socioeconomic homes also have a three times greater risk for IBD.

References

Crohn's and Colitis Foundation of America. About the epidemiology of IBD. http://www.ccfa.org/about/press/epidemiologyfacts

National Digestive Diseases Information Clearinghouse (NDDIC). Crohn's disease. http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/

Sands BE. Crohn's Disease. In Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed. 2002. Elsevier.

Crohn's and Colitis Foundation of America. Disease Information. About Crohn's. http://www.ccfa.org/info/about/crohns

Loftus EV, Jr. Clinical epidemiology of inflammatory bowel disease: incidence, prevalence, and environmental influences: changing pattern over the course of the disease. BUT 2001;49:777-782.

Birrenbach T, Blocker U. Inflammatory bowel disease and smoking; A review of epidemiology, pathophysiology, and therapeutic implications. Inflamm Bowel Dis. 2004;10(6):848-859.


Last Modified Date: June 30, 2010 © Accordant Health Services, a CVS Health company. All rights reserved. This article has been reviewed for accuracy by a member of the Accordant Health Services Medical Advisory Team. This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with any questions or concerns you may have regarding your condition. Use of this online service is subject to the disclaimer and the terms and conditions.

DRUGS & CONDITIONS

WHAT CAUSES CROHN'S DISEASE?

The cause of Crohn's disease or Crohn's is not yet known. Theories include the immune system, environmental factors, and heredity as causes. It is quite possible that Crohn's may be caused by a combination of the three. The current widely accepted idea is that Crohn's disease is caused by an abnormal reaction of the immune system in response to bacteria that are normally present in the bowel in people with a genetic risk.

The immune system is believed to be a key factor in the development of Crohn's. One theory is that the immune system mistakes helpful bacteria that normally live in the intestine, for harmful bacteria. This case of mistaken identity may be triggered by something in the environment. The immune system then causes inflammation as part of an effort to remove what it believes is "harmful" bacteria. Then, once the immune system is turned to "on," it doesn't know how to turn itself back to "off." Another theory is that there are "triggers" in the environment that may be the direct cause of the inflammation.

Since Crohn's tends to run in families, genes that you get from your relatives may partly determine who gets this disease. For example, changes in the NOD2 gene and the SLC224A gene have been linked to Crohn's disease. But having these genetic mutations alone does not mean you will get Crohn's.

Certain foods can make symptoms worse for some people with Crohn's, but these foods do not cause the disease. Also, Crohn's is not caused by stress, tension or anxiety.

Experts believe that Crohn's is caused by a combination of genetic and environmental factors. Researchers continue to look for a cause and for better ways to improve the lives of those affected by this complex disease.

References

Crohn's and Colitis Foundation of America. About Crohn's. http://www.ccfa.org/info/about/crohns

National Digestive Diseases Information Clearinghouse. Crohn's Disease. http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/#caus


Last Modified Date: June 30, 2010 © Accordant Health Services, a CVS Health company. All rights reserved. This article has been reviewed for accuracy by a member of the Accordant Health Services Medical Advisory Team. This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with any questions or concerns you may have regarding your condition. Use of this online service is subject to the disclaimer and the terms and conditions.

DRUGS & CONDITIONS

WHAT CAN I EXPECT WITH CROHN'S DISEASE?

Despite the fact that Crohn's is a serious disease, it isn't considered fatal. However, Crohn's is a chronic disease, meaning that it is frequently lifelong. You can expect the disease to flare up sometimes and be quiet at other times. Unfortunately, there is no way to predict the course of Crohn's disease. Symptoms and outcomes are different for each individual.

The severity of the Crohn's disease process will impact the level of function and the treatment plan that each person with Crohn's will have. One person can move from one stage of the disease to another based on their current set of symptoms and level of function. It's important to discuss all Crohn's symptoms with the doctor to help them understand the level of disease involvement that you are experiencing.

  • Mild-moderate disease allows the person to be functional and able to eat and drink by mouth without much difficulty. No signs of dehydration, abdominal tenderness, or significant weight loss (>10%) are present.
  • Moderate-severe disease applies to people who did not respond to first treatment attempts or those with more significant symptoms of fever, weight loss, abdominal pain or tenderness, nausea and vomiting, or significant anemia.
  • Severe-fulminant disease refers to people with persistent severe symptoms in spite of treatment with steroids or people presenting with high fever, persistent vomiting, signs of intestinal blockage, abdominal tenderness, profound weight loss and muscle wasting, or signs of an abscess.
  • Remission refers to people who are free of symptoms or without inflammatory signs of Crohn's. This includes those who have responded to medical treatment or surgery and now experience no symptoms of Crohn's disease. Those requiring ongoing steroid therapy are usually considered "steroid dependent" and not considered to be "in remission".

Quality of life is important to consider when looking at the impact that Crohn's disease has on the future of the affected person. Quality of life is based on physical, mental, and social well being. In Crohn's disease, quality of life is measured by:

  • Ongoing bowel function and abdominal pain
  • Fatigue and a change in sleep pattern
  • Social functions such as work performance and participation in social events
  • Emotional health such as anger, irritability and depression
  • Having meaningful relationships

If you suffer from Crohn's disease, you will most likely need to take medication. There may even be periods of hospitalization. Seventy percent of people diagnosed with Crohn's will need to have surgery at some point. You may experience difficult times, but you may also experience time between flares when you feel well.

You will need to pay special attention to your diet and make lifestyle changes as needed. Working and traveling may require a bit of advance planning. There will likely be emotional issues for you to work through. Although emotions and stress do not cause Crohn's, they can affect the body and may impact the disease. To protect your health, it will be important for you to find help addressing these issues.

If you stick to your treatment plan and make sure you get proper nutrition, you can minimize some of the unpleasant effects. You can lead an active and productive life with Crohn's disease.

References

Crohn's and Colitis Foundation of America. About Crohn's. http://www.ccfa.org/info/about/crohns


Last Modified Date: June 30, 2010 © Accordant Health Services, a CVS Health company. All rights reserved. This article has been reviewed for accuracy by a member of the Accordant Health Services Medical Advisory Team. This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with any questions or concerns you may have regarding your condition. Use of this online service is subject to the disclaimer and the terms and conditions.

DRUGS & CONDITIONS

MEDICINES USED IN MANAGING CROHN'S DISEASE

If you have Crohn's disease (Crohn's), you probably already know about the symptoms of your disease. You may not understand all the treatment options. Your doctor can now choose from a number of medicines available to manage your illness effectively. The long-term goals of treatment are to keep you in remission (free from Crohn's symptoms) and avoid long-term toxicity and as many medication side effects as possible. Most people need a combination of several medicines to achieve these goals. The treatment you and your doctor choose depends upon the following details about your Crohn's.

  • Where the inflammation is in your intestine
  • How severe your disease is
  • What disease complications you have
  • How you've responded to previous treatments

Your doctor has several different types of medicine to treat your Crohn's. Some medicines work to manage your symptoms and don't affect the underlying disease. Other medicines work to put you in remission or keep you in remission.

Managing Your Symptoms

The following treatments may help relieve your Crohn's symptoms. However, always talk to your doctor before starting to take any of these medicines.

  • Antidiarrheals — fiber supplements (such as psyllium powder) can add bulk to your stool and may help control diarrhea.
  • Laxatives — may sometimes be recommended by your doctor; however, even over-the-counter laxative medicines may be too harsh for your system.
  • Pain relievers — your doctor may recommend acetaminophen. Avoid medicines containing aspirin, ibuprofen or naproxen sodium because they may worsen your symptoms.
  • Iron supplements — Crohn's can cause long-term intestinal bleeding and low iron in your blood. Low iron levels can cause anemia, a condition in which your blood lacks enough healthy red blood cells. Iron supplements may help.
  • Vitamin B12 injections — inflammation in your terminal ileum may interfere with your ability to absorb vitamin B12. This vitamin helps to prevent anemia and is essential for other vital functions.

Achieving and Maintaining Remission

NOTE: Omega 3 fatty acids have been tested to see if they prevent flares in people who are in medically-induced remission. The results show that fish oil is probably not effective at keeping people in remission.

Aminosalicylates are usually the first medicines doctors use to treat mild to moderate flare-ups, prevent relapses and keep your Crohn's disease in remission. These medicines contain mesalamine, the aspirin like ingredient which reduces inflammation in the intestine. Studies show that 5-aminosalicylic acid (5-ASA) may be protective against colorectal cancer in patients with inflammatory bowel disease (IBD).

Your doctor will prescribe a form of medicine selected to reach the sections of your intestines that are affected by Crohn's. You might take one form of aminosalicylate by mouth. You might take other forms rectally, in a suppository or enema. Each form is designed to deliver the medicine to a different part of your intestine. Some common aminosalicylates include the following.

  • Sulfasalazine (Azulfidine®)
  • Mesalamine (Asacol®, Lialda®, Pentasa®)
  • Olsalazine (Dipentum®)
  • Balsalazide (Colazal®)

Doctors have used sulfasalazine to treat Crohn's effectively for years. However, it has significant side effects for some people. Side effects of sulfasalazine include headache, nausea, rash, vomiting and heartburn. Tell your doctor and do not take sulfasalazine if you are allergic to sulfa medicines. Almost 90% of the people who cannot tolerate sulfasalazine are able to take one of the other aminosalicylates.

Antibiotics can help relieve the symptoms of Crohn's disease by reducing the number of bacteria in your intestine. Bacteria play an important role in Crohn's. In addition, antibiotics may help reduce immune system activity and inflammation. One specific antibiotic, metronidazole, may also be used on a short term basis (3 months or less) to maintain remission of Crohn's symptoms after surgery. Antibiotics also help to heal abscesses (pockets of infection) and fistulas. Fistulas are tunnels or connections into surrounding tissue between parts of the body that don't normally connect.

The two most commonly prescribed antibiotics for Crohn's are metronidazole and ciprofloxacin. Metronidazole is usually given by mouth as a pill when used in treatment of Crohn's disease. Ciprofloxacin is available to be taken by mouth or through a vein. The common side effects of metronidazole can be serious and include the following:

  • Nausea, diarrhea and vomiting
  • Dizziness and headaches
  • Loss of appetite
  • Metallic taste
  • Tingling/numbness in the hands and feet
  • Muscle pain or weakness

If you should develop tingling or muscle weakness, stop taking the antibiotic medicine and notify your doctor as soon as possible.

Doctors consider ciprofloxacin, which rarely has serious side effects, safer than metronidazole. Rifaximin is a new antibiotic that shows promise for targeting bacteria associated with Crohn's; however further research is needed to confirm whether this new antibiotic therapy will work in treatment of Crohn's.

Corticosteroids, commonly referred to as "steroids," are not the same steroids that some athletes abuse. Steroids are powerful, fast-acting, anti-inflammatory medicines doctors use to control flare-ups. Steroids help bring your Crohn's disease into remission. They don't maintain remission or prevent a relapse, and therefore are best used only as short term (3 months or less) therapy for Crohn's disease. Your doctor may prescribe steroids if you have moderate to severe Crohn's that has not responded to other treatments.

Doctors generally prescribe steroids for short periods of time in the smallest dose possible because their long-term use may cause serious side effects. People with Crohn's who respond to steroids usually begin to do so within three weeks.

The main steroid medicines doctors use to treat Crohn's are:

  • Prednisone
  • Methylprednisolone
  • Hydrocortisone

You might take these steroids orally, but some people do not respond to oral forms of the medicines. You might take other forms of steroids rectally in an enema, foam or suppository. Or you might take still other forms through a vein.

There are many possible side effects of steroids, ranging from mild to quite serious. Some side effects can develop early. The side effects of steroids tend to increase with higher doses and longer treatment periods. For some people the side effects of steroids outweigh their benefits.

Doctors can use budesonide, a newer type of oral steroid, to target a specific area of the body. If your Crohn's is between the end of the small intestine and the beginning of the large intestine (ileitis and ileocolitis), your doctor might prescribe budesonide to treat the area. Budesonide is unique in that 90 percent of its effect is limited to the intestine. This medicine causes fewer side effects than a steroid that affects the entire body. Budesonide has not been proven to be a long-term treatment and does not appear to work to maintain remission beyond 3-6 months.

Immunomodulators also reduce inflammation by quieting the activity of the immune system. If your treatment with aminosalicylates and steroids is not effective or only partially effective, your doctor might prescribe immuno-modulators for the treatment of moderate to severe Crohn's. They are often used to achieve remission or to maintain remission of Crohn's. Often doctors supplement immunomodulators with other medicines, such as aminosalicylates and steroids, in the early treatment of Crohn's disease.

Azathioprine (Imuran®) and 6-mercaptopurine (6-MP) are two similar types of immunomodulators. These medicines tend to act slowly. They may take up to 17 weeks to deliver their full effect. You might take these medicines orally to keep your Crohn's in remission. These medications can have some serious side effects such as pancreatitis and liver toxicity and therefore it is important to have your lab work checked to monitor for these negative side effects. In addition, use of these immunomodulators are associated with an increased risk of serious infection. There is also a small increased risk of lymphoma, a type of cancer.

Methotrexate is another immunomodulator doctors may use to bring Crohn's into remission and maintain remission. You might take methotrexate by weekly injections. Methotrexate is more rapid-acting than azathioprine or 6-MP.

Tacrolimus and mycophenolate mofetil are two other immunomodulators that are rarely used in treatment of Crohn's. Tacrolimus is considered for short-term treatment of perianal disease, but does require long-term maintenance with one of the other immunomodulators. Cyclosporine is not recommended in treatment of Crohn's because of the many side effects that it causes.

The side effects of immunomodulators vary and can be serious. If you take one of these medicines to treat Crohn's, your doctor will discuss the possible side effects and explain any tests necessary to manage your health.

Biologic therapies are newer immunomodulators made from living organisms. They reduce inflammation by targeting a specific protein or other molecular structure that is not working correctly. Because of this targeting ability, biologic therapies can be more efficient than other medicines and their side effects can be less widespread. These medications are very expensive, but have shown to work to induce and maintain remission of moderate to severe Crohn's disease. TNF inhibitors are associated with increased risk of serious infections. Therefore, live vaccines should not be used in patients being treated with TNF inhibitors. In addition, use of these immunomodulators are associated with a small increased risk of lymphoma, a type of cancer.

Infliximab is the first biologic to be approved by the Food and Drug Administration (FDA) for use in Crohn's. Infliximab is made of 75 percent human and 25 percent mouse protein. It works by binding to and preventing the activity of tumor necrosis factor (TNF), a protein that promotes inflammation in the intestine and elsewhere in the body. In other words, infliximab finds TNF in your bloodstream and blocks it before it can cause inflammation in your gastrointestinal tract.Doctors use infliximab to relieve symptoms and maintain remission with people who have moderate to severe Crohn's that has not responded to other forms of therapy. Doctors also use infliximab to treat Crohn's fistulas. Fistulas are tunnels or connections into surrounding tissue between parts of the body that don't normally connect. Infliximab is delivered slowly through a vein.

The FDA approved two other biologics, adalimumab and certolizumab pegol, for people with moderate to severe Crohn's who haven't responded to other treatments. They also bind to and inactivate TNF. These medications work in a similar way, but are injected under the skin. Natalizumab is a biologic used to treat moderate to severely active Crohn's patients who do not respond to, or are unable to tolerate, conventional and anti-TNF disease therapies. If receiving natalizumab, it is important to monitor for symptoms of a serious adverse effect called progressive multifocal leukoencephalopathy (PML). Symptoms of this disorder include weakness on one side of the body, changes in vision, memory, thinking, and personality.

The most common side effects of biologic therapies include infusion or injection site reactions, upper respiratory infections, and allergic reactions. Biologic agents also come with a small risk of more serious side effects including serious infections and lymphoma.

Doctors now have many medicines to treat your Crohn's disease. Researchers are working hard to develop and test other new medicines. The results are very encouraging for treating Crohn's in the future.

References

Crohn's Disease. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; February 2006. NIH Publication No. 06-3410. http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/index.htm Accessed February 17, 2007

Tamboli CP. Current medical therapy for chronic inflammatory bowel diseases. Surg Clin North Am. 2007;87(3):697-725.

Mayo Clinic Web site. Crohn's Disease. http://www.mayoclinic.com/health/crohns-disease/DS00104/DSECTION=9 Accessed July 24, 2007

Crohn's & Colitis Foundation of America Web site. Intestinal Complications. http://www.ccfa.org/info/about/complications/intestinalcomplications Accessed July 26, 2007

Crohn's & Colitis Foundation of America Web site. Aminosalicylates. http://www.ccfa.org/info/treatment/aminosalicylates Accessed July 26, 2007

Achkar JP. Inflammatory Bowel Disease: The American College of Gastroenterology Web site. http://www.acg.gi.org/patients/gihealth/ibd.asp Accessed July 24, 2007

Crohn's & Colitis Foundation of America Web site. Antibiotics. http://www.ccfa.org/info/treatment/antibiotics Accessed July 26, 2007

Crohn's & Colitis Foundation of America Web site. About Crohn's Disease. http://www.ccfa.org/info/about/crohns Accessed July 24, 2007

Crohn's & Colitis Foundation of America Web site. Corticosteroids http://www.ccfa.org/info/treatment/corticosteroids Accessed July 26, 2007

Crohn's & Colitis Foundation of America Web site. Immunomodulators. http://www.ccfa.org/info/treatment/immunomodulators Accessed July 26, 2007

Crohn's & Colitis Foundation of America Web site. Biologic Therapies. http://www.ccfa.org/info/treatment/biologics Accessed July 26, 2007


Last Modified Date: June 30, 2010 © Accordant Health Services, a CVS Health company. All rights reserved. This article has been reviewed for accuracy by a member of the Accordant Health Services Medical Advisory Team. This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with any questions or concerns you may have regarding your condition. Use of this online service is subject to the disclaimer and the terms and conditions.

DRUGS & CONDITIONS

GUT FEELINGS: THE MIND-BODY CONNECTION

Topics:

If you've ever felt your insides twist in knots before a big speech, you know the stomach listens carefully to the brain. In fact, the entire digestive system is closely tuned to a person's emotions and state of mind, says William E. Whitehead, PhD, a professor of medicine and co-director of the Center for Functional GI and Motility Disorders at the University of North Carolina. People with irritable bowel syndrome often suffer flare-ups during times of stress and anxiety, and even perfectly healthy people can worry their way to stomach pain, nausea, diarrhea, constipation, or other problems. Even if a doctor can't find anything physically wrong, the misery is real.

Listening to your gut

It may surprise many people to learn that the gut actually contains as many neurons (nerve cells) as the spinal cord. In an article in the medical journal Gut, author J. D. Woods and colleagues compare this network -- known as the enteric nervous system, or ENS -- to a "local mini-brain" storing a library of programs for different patterns of gut behavior." Woods and colleagues compare the ENS to a microcomputer with its own independent software, "whereas the brain is like a larger mainframe with extended memory and processing circuits that receive information from and issue commands to the enteric computer."

With all these messages, the connection between the brain and the digestive system is a busy two-way street. The central nervous system releases chemicals (acetylcholine and adrenaline) that tell the stomach when to produce acid, when to churn, and when to rest. Similar signals help guide the movements of the intestines. The digestive system responds by sending electrical messages to the brain, creating such sensations as hunger, fullness, pain, nausea, discomfort, and possibly sadness and joy.

As strange as it sounds, our guts just might help shape our moods, says Emeran Mayer, MD, a gastroenterologist and the chairman of the Collaborative Centers for Integrative Medicine at the University of California at Los Angeles. Mayer points to the vagus nerve, essentially a large electrical cable that runs between the brain and the digestive system. "Doctors once believed the nerve's main job was controlling acid production in the stomach," Mayer says. "But 95 percent of the fibers go the other direction -- from the gut to the brain."

Nobody knows exactly what messages travel along this cable, but scientists have found that stimulating the nerve at different frequencies can cause either anxiety or a strong sense of well being. Perhaps the term "gut feeling" isn't just a figure of speech after all.

Mayer suggests another intriguing possibility: Prozac and similar antidepressants may actually work on the gut, not the brain. Drugs known as SSRIs (short for selective serotonin reuptake inhibitors) ease depression by enhancing levels of serotonin. Most experts assume it's the extra serotonin in the brain that helps improve mood. But 95 percent of the serotonin in the body actually lies within the digestive system. Perhaps, Mayer says, SSRIs do their job by boosting serotonin in the gut and changing the signals along the vagus nerve.

The stress alarm

Whatever messages may be passing back and forth, they can easily become garbled in times of stress. When the brain senses a threat, real or imagined, it sounds the alarm by flooding the body with adrenaline and another hormone called CRF (short for corticotropin-releasing factor). These hormones trigger the "fight or flight" response -- helpful back in the days when humans had to run from lions, but a potential liability when we lose a job or go through a divorce.

If you suffer from frequent emotional distress -- perhaps because of extreme stress, depression, or anxiety -- the unrelenting flood of adrenaline and CRF will take a toll on your digestive system. For one thing, the hormones can make the cells in the stomach and intestines extra-sensitive to pain. As a result, normal contractions and movements can become excruciating. The new signals can also disrupt the motion of the intestines, causing bouts of constipation or diarrhea.

Functional disease in a dysfunctional world

Because of the close connection between the brain and many abdominal disorders, a multinational team of investigators, specialists, and federal research agencies convened in the mid-1980s to develop criteria for diagnosing more than 20 digestive disorders known as "Functional Gastrointestinal Disorders," or FGIDs. A "functional" disease, in this case, means a disturbance in GI function that it isn't related to any injury, infection, or other obvious physical problem. These criteria, which include persistent constipation, diarrhea, bloating, abdominal pain, or irritable bowel syndrome unrelated to a diagnosable physical disorder, were updated by an international team known as the Rome II Committee, which called for a classification system of these disorders based on clusters of common symptoms.

Among the disorders the committee examined is irritable bowel syndrome (IBS), a very common and perplexing malady often characterized by painful cramps, bloating, and constipation alternating with diarrhea. If you have "functional" IBS, you may feel that "dysfunctional" is a much more apt term.

Emotional distress alone can't cause IBS -- the source of the disorder is still unknown -- but stress or a mood disorder may worsen the symptoms. In fact, few other conditions provide such a clear illustration of the link between the mind and the body. An Australian study found that chronic distress -- arising from such traumas as divorce, lawsuits, serious illnesses, or job troubles -- accounted for 97 percent of all changes in IBS symptoms. Interestingly, short-term swings in mood don't seem to have much effect on IBS, which explains why many people still suffer symptoms on relatively calm, relaxing days.

In a similar manner, strange messages along the gut-brain axis also seem to be a major cause of "functional" dyspepsia, or indigestion. People with dyspepsia often experience the discomfort of constant ulcer pain without actually having ulcers. Stress definitely makes the symptoms worse, but the effect isn't nearly as dramatic as with irritable bowel syndrome. If adding stress to functional dyspepsia is like throwing woodchips on a fire, combining stress with IBS is like dousing a blaze with gasoline.

The influence of the mind on the gut goes beyond functional diseases. For instance, people with Crohn's disease or ulcerative colitis -- two conditions with clearly physical origins -- often suffer flareups during times of emotional stress. In one survey, 68 percent of people with basically healthy digestive systems said stress gives them stomachaches.

Setting your mind on relief

So what can you do if your mind and your digestive system aren't getting along? One thing you shouldn't do is suffer silently. Ask your doctor if you would be a good candidate for cognitive behavioral therapy, interpersonal therapy, relaxation therapy, or another form of counseling. In several studies, these treatments have been shown to give IBS patients more relief than standard medical therapies. You might even consider hypnosis or self-hypnosis.

While rarely used in the United States, hypnosis is a popular -- and apparently effective -- treatment for IBS in Europe, Whitehead says. Preliminary studies suggest it may also help ease functional dyspepsia.

It's worth noting that Prozac and other SSRIs may help calm the stomach. Small doses of a tricyclic antidepressant -- too small to affect mood -- can lessen stomach pain, presumably by blocking pain messages.

There's another reason to go to the doctor: Simply hearing you're not crazy or gravely ill may be a great source of comfort. "Reassurance from a physician is probably the most effective treatment [for IBS]," Mayer says.

Supportive docs will never go out of style, but even better treatments for IBS and other functional disorders may soon be on the way. Researchers are currently studying medications designed to block the release of CRF, the hormone that helps translate stress into stomach trouble.

But you don't have to wait for new medications to get better. Do what you can to avoid stress and work closely with your doctor. With a little luck, your gut feelings will be much more pleasant.

-- Chris Woolston, M.S., is a health and medical writer with a master's degree in biology. He is a contributing editor at Consumer Health Interactive, and was the staff writer at Hippocrates, a magazine for physicians. He has also covered science issues for Time Inc. Health, WebMD, and the Chronicle of Higher Education. His reporting on occupational health earned him an award from the Northern California Society of Professional Journalists.

References

D.A. Drossman. The functional gastroinestinal disorders and the Rome II process. Gut, September 1999, Volume 45, Supplement II.

Babette S. Duncan, Pharm.D., Walter "Buzz" Stewart, Ph.D., MPH. Gastrointestinal Disorders. Innovative Medical Research (IMR), AdvancePCS.

Emeran Mayer, telephone interview.

Rome II: A Multinational Consensus Document on Functional Gastrointestinal Disorders. Gut: An International Journal of Gastroenterology and Hepatology. September 1999, No. II, Vol. 45.

UCLA-The Inside TRAK. Does stress cause IBS or similar disorders in other parts of the GI tract?

J.D. Wood et al. Fundamentals of neurogastroenterology. Gut, September 1999. Volume 45. Supplement II.

William Whitehead, telephone interview.

Wilhelmsen I. The role of psychosocial factors in gastrointestinal disorders. Gut. December 2000

Wilhelmsen I. Brain-gut axis as an example of the bio-psycho-social model. Gut.

Reviewed by George W. Meyer, MD, FACP, a staff gastroenterologist at Kaiser Permanente in Sacramento, Calif.; and John Inadomi, MD, a gastroenterologist and assistant professor of medicine at the University of Michigan Medical Center.


Last updated July 20, 2009

Copyright © 2001 Consumer Health Interactive

DRUGS & CONDITIONS

CROHN'S DISEASE AND STRESS

Although there is no evidence that stress, anxiety, or tension can actually cause Crohn's disease, your body and mind work so closely together that the stress in your life can influence the course of your disease. Stress might be caused by lots of things, from those little annoying events that keep happening every day to big events like the loss of a job or a loved one. Infections, smoking, and even some of the medications you take might lead to extra stress, too.

Some or all of your stress might result from coping with a chronic condition like Crohn's disease. You might feel angry, alone, and like your entire quality of life is gone. And while each individual must deal with Crohn's disease in his or her own way, the sooner you can come to terms, take control, and become a part of your health team, the better.

If you feel like there is a connection between your stress level and a worsening of your symptoms, talk to your doctor. Remember that you are not alone, and that the resources and information to help you overcome stress and the challenges of your disease are available.

Here are some ways to help you avoid or control your stress.

  • Plan ahead for access to public restrooms and carry a change of clothing if you're concerned about diarrhea, pain, or gas.
  • Make sure, when traveling, that you include a large enough supply of your medications, and find out the name of a recommended doctor in the area you are visiting.
  • Stop smoking.
  • Become actively involved in your own treatment. Educate yourself. Fear arises from the unknown.
  • Get adequate rest and build up your energy when in remission with rest, nutrition, and appropriate exercise.
  • Talk to your doctor about a regular exercise program that works for you, since even mild exercise can help relieve stress and depression, and aid your bowel function.
  • Investigate yoga, massage, and meditation, since different kinds of techniques work better to relieve stress for some people than for others.
  • Practice progressive relaxation and/or deep-breathing exercises, helping you to relax all the muscles in your body — especially your abdominals, which may lead to more normal bowel functioning.
  • Ask your doctor about biofeedback, which can teach you how to ease muscle tension and slow your heart rate.
  • Ask your doctor about hypnosis, which can be performed by a trained expert and help you reduce abdominal pain and bloating.
  • Set aside at least 20 minutes daily to enjoy yourself, listen to music, read, walk, play games — whatever you decide — because you deserve it!

It is important for you to learn how to cope with stress. Experts say that the key is how we allow ourselves to think about the things that cause us stress. Try to distinguish between things that can and cannot be changed. When the things going on around you can't be changed, your thinking must change. In addition, you can make choices that help reduce some of life's routine stresses. This starts by identifying the stressors and then taking steps to reduce their effect on you as much as possible.


Last Modified Date: June 30, 2010 © Accordant Health Services, a CVS Health company. All rights reserved. This article has been reviewed for accuracy by a member of the Accordant Health Services Medical Advisory Team. This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with any questions or concerns you may have regarding your condition. Use of this online service is subject to the disclaimer and the terms and conditions.

DRUGS & CONDITIONS

MONITORING CROHN'S DISEASE

Keep up with regular, scheduled visits to your primary care doctor and your gastroenterologist (Crohn's specialist) to help monitor Crohn's disease (Crohn's). There may be periods of time when your Crohn's is quiet and you have few or no symptoms. At other times, your Crohn's may flare up with many symptoms or complications. A flare-up signals that Crohn's is entering an active stage.

Work with your doctors to develop a written Crohn's Action Plan based on your current treatment and symptoms. A Crohn's Action Plan should include:

  • What to do each day to manage your Crohn's
  • When to call the doctor
  • What to do for problems after doctor's office hours
  • How to handle emergencies

Report any new symptoms or changes in existing symptoms to your doctor. That way your doctor can make timely changes in your therapy to more effectively prevent and treat your Crohn's symptoms and complications. Some symptoms, conditions and complications associated with Crohn's that you may discuss with your doctor are described as follows:

  • Abdominal bloating – is a feeling of fullness or tightness in the abdomen or belly.
  • Abdominal pain and cramping – is a symptom that may be felt anywhere in the abdomen or belly. With a Crohn's flare-up, pain is typically felt in the lower right part of the abdomen or belly or above the pubic bone. And, it also may start with and be relieved by defecating or moving your bowels. It is important to note if the pain is worse when you press on your abdomen and then release the pressure. This type of pain is called rebound tenderness and can be a sign of certain types of Crohn's related problems.
  • Anal fissures – are small splits or tears in the area around the anus. Symptoms can include rectal pain, painful bowel movements and blood on the toilet tissue following a bowel movement.
  • Bone loss – is a complication that often occurs without symptoms though some people notice back pain or a change in posture. Bone mineral density screening can help identify this condition so that it can be treated.
  • Constipation – is a condition defined as infrequent or hard stools or bowel movements or difficulty passing stool or bowel movements.
  • Diarrhea – is a condition defined as loose, watery, frequent stools or bowel movements. Blood may appear in the diarrhea.
  • Dehydration – is a condition that can be caused by losing too much fluid from diarrhea, vomiting or fever. It can also be caused by not drinking enough fluids or water. Some common symptoms include dark yellow urine, passing little or no urine, or a dry, sticky feeling in your mouth.
  • Delayed growth and sexual development – can occur in children with Crohn's. This complication is determined by comparing these children with those of their same age who do not have Crohn's.
  • Eye disorders – that can be related to Crohn's may involve symptoms of pain, blurred vision, sensitivity to light, redness of the eye, irritation and inflammation. Report these promptly to your doctor.
  • Fatigue, low energy or weakness – can be the result of one or more symptoms or conditions related to Crohn's. Some of these include fever, pain, dehydration, anemia or liver problems.
  • Fever – occurs when the body temperature rises above normal. Fever is a sign of inflammation and commonly occurs during a Crohn's flare-up. The average normal body temperature is 98.6(F even though it can vary by person, activity, time of day or age.
  • Fistulas – are connections between parts of the body that don't normally connect. For example, a connection between two loops of intestine or the intestines and the bladder, vagina or skin. Symptoms can include drainage of mucus, pus or stool from an opening to the outside of the body. Some symptoms of a fistula between the intestine and bladder include frequent urinary tract infections or air in the urine.
  • Joint pain, swelling and reduced flexibility – is a common complication of Crohn's. This usually affects the large joints of the arms and legs including the elbows, wrists, knees and ankles. It often improves when the intestinal inflammation is controlled.
  • Kidney stones – can cause symptoms of sharp pain in your back or side, nausea, vomiting and blood in the urine.
  • Loss of appetite – is defined as a decreased desire to eat
  • Mouth sores – are similar to canker sores or ulcers on the gums, lips or tongue. Often these sores heal when the intestinal inflammation is controlled.
  • Nausea – is a sensation or feeling of the urge to vomit
  • Skin problems – may include tender red nodules, bumps, blisters or ulcers found mostly on the shins and ankles, but sometimes on the arms. Skin problems frequently disappear when the intestinal inflammation is controlled.
  • Unintended weight loss – is loss that does not occur "on purpose" or intentionally.
  • Urinary tract infection – causes symptoms that may include frequent or intense urges to urinate (pass urine), burning upon urination, fever, chills or pain in your back, lower abdomen or belly. Urine may be cloudy, dark, or bloody or smell different than usual.
  • Vomiting – is the forcing of contents in the stomach up and out through the mouth.

Symptoms of Infection

Patients who take medicines that suppress the immune system are more likely to get infections. Examples of medicines that suppress the immune system include prednisone, azathioprine (Imuran®), infliximab (Remicade®), adalimumab (Humira®),methotrexate, and 6-mercaptopurine (6-MP). It is important to talk to your doctor if you think you have an infection, especially if you take medicines that suppress the immune system and you experience any symptoms of infection such as:

  • Fever
  • Difficulty breathing
  • Vision changes
  • Drainage or oozing from a hole in the skin
  • Symptoms of a urinary tract infection such as pain or burning with urination or changes in the color or odor of your urine

Be sure to discuss your symptoms and concerns openly and honestly. Your doctor and the entire healthcare team welcome your questions and are here to help you manage your Crohn's in the best way possible.


Last Modified Date: June 30, 2010 © Accordant Health Services, a CVS Health company. All rights reserved. This article has been reviewed for accuracy by a member of the Accordant Health Services Medical Advisory Team. This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with any questions or concerns you may have regarding your condition. Use of this online service is subject to the disclaimer and the terms and conditions.

DRUGS & CONDITIONS

FOUNDATIONS AND ASSOCIATIONS

There are several foundations and associations that provide information to patients and their families about digestive diseases. These are reliable sources that provide specific information on Crohn's disease.

The Crohn's and Colitis Foundation of America

The Crohn's and Colitis Foundation of America (CCFA) is dedicated to patient education, advocacy and research into inflammatory bowel disease (IBD).

CCFA has chapters in most states. The chapters hold educational meetings and support groups for people with IBD, their families and caregivers. The national headquarters can provide contact names and phone numbers for local chapters.

Crohn's and Colitis Foundation of America, Inc.
386 Park Avenue South, 17th Floor
New York, NY 10016-8804
Telephone: (800) 932-2423
E-mail: info@ccfa.org
Home Page: http://www.ccfa.org

UC and Crohn's

This is a fun, fresh website that provides emotional support for teens. Topics range from bathroom emergencies to dealing with doctors and hospitals. Lots of video provides the feeling of a support group online. This website is sponsored by the Crohn's and Colitis Foundation of America and Starlight Starbright Children's Foundation.

UC and Crohn's
E-mail: info@ucandcrohns.org
Home Page: http://www.ucandcrohns.org

Kids IBD: Inflammatory Bowel Disease in Adolescents and Children

Supported by the Children's Digestive Health & Nutrition Foundation, this website offers parents information about the unique needs of young people with Crohn's disease and ulcerative colitis.

Home Page: http://www.kidsibd.org
Children's Digestive Health & Nutrition Foundation
1501 Bethlehem Pike
P.O. Box 6
Flourtown, PA 19031

Telephone: (215) 233-0808
E-mail: cdhn@cdhnf.org

The National Institute of Diabetes and Digestive and Kidney Diseases

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) conducts and supports research on serious diseases affecting public health and provides educational information for people with these diseases, their families and caregivers. The NIDDK is part of the National Institutes of Health (NIH), one of eight health agencies of the Public Health Service, which is under the U.S. Department of Health and Human Services.

NIDDK, NIH
Office of Communications & Public Liaison
Building 31, Room 9A06
31 Center Drive, MSC 2560
Bethesda, MD 20892-2560
Phone: (301) 496-3583

Home Page: http://www.niddk.nih.gov/

The American College of Gastroenterology

The American College of Gastroenterology (ACG) is dedicated to providing accurate health information to people with digestive diseases and to the public. A major goal is to promote patient education on gastrointestinal conditions and digestive health. The information is organized by disease state and was developed by ACG physician experts.

The American College of Gastroenterology
P.O. Box 342260
Bethesda, MD 20827-2260
Telephone: (301) 263-9000

Home Page: http://www.acg.gi.org

References

Crohn's and Colitis Foundation of America, Inc. Home page. http://www.ccfa.org

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Home page. http://www.niddk.nih.gov

The American College of Gastroenterology. Home page. http://www.acg.gi.org


Last Modified Date: June 30, 2010 © Accordant Health Services, a CVS Health company. All rights reserved. This article has been reviewed for accuracy by a member of the Accordant Health Services Medical Advisory Team. This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with any questions or concerns you may have regarding your condition. Use of this online service is subject to the disclaimer and the terms and conditions.