Crohns Disease Holistic Treatments Ebook
The association of Crohn's disease and cancer is uncommon, with an overall prevalence of 0.45 45 . Carcinoma in Crohn's disease is associated with strictures, extensive disease and onset of the disease before the age of 30 years. Sandmeier reported 3 patients with cancer in Crohn's disease from a database of 661 patients between 1993 and 2001 only one patient had a rectal localisation (signet ring cell variant) 4 years after a subtotal colectomy with ileosig-moid anastomosis 45 . Connell et al. 46 , in a review on 2500 patients with Crohn's disease from 1940 to 1992, described 15 patients who developed a carcinoma of the lower gastrointestinal tract. Thirteen patients had a cancer in the upper third of the rectum (one), in the lower third of the rectum (seven) and in the anus (five patients). Patients with a cancer arising in the rectum had long-standing severe anorectal disease with a stricture in four, a fistula in four, a proctitis in one and an abscess in two patients. Nikias et...
Small bowel follow through May reveal fibrosis or strictures (string sign of Kantor), deep ulceration (rose-thorn), cobblestone mucosa (see Fig. 8). Endoscopy (OGD, colonoscopy) and biopsy May help to differentiate between ulcerative colitis and Crohn's disease, useful monitoring for malignancy and disease progression. M Acute exacerbation Fluid resuscitation, IV or oral corticosteroids, antibiotics, analgesia, high-dose 5-ASA analogues, e.g. mesalazine, sulphasalazine may induce a remission in Crohn's disease. DVT prophylaxis is important if unwell. Elemental diet may induce remission (more often used in children). Parenteral nutrition may be necessary. Long-term Steroids for acute exacerbations, regular 5-ASA analogues to number of relapses in Crohn's colitis. Alternatively, steroid-sparing agents (e.g. azathioprine, 6-mercaptopurine, methotrexate, infliximab). Advice Stop smoking, dietitian referral. Education and advice (e.g. from IBD nurse specialists).
Seven years have elapsed since the first edition of this book was published and we have been amazed at the new developments relevant to diseases affecting the colon, rectum, and anus that have occurred in that relatively short span of time. Some of these developments have been an outgrowth of the increased knowledge of the disease process and the underlying genetic factors that influence it. Others are a reflection of more sophisticated modalities of investigation such as intrarectal ultrasonographic assessment of rectal carcinoma and positron emission tomography (PET) scanning for recurrent carcinoma or improved therapeutic options such as sphincter-saving operations and newer procedures for fecal incontinence. Added to this is the yet undefined and still controversial role of laparo-scopic operations to manage a host of colon and rectal disorders. This proliferation of knowledge has prompted a major revision of the last edition of this book. Parts have been entirely rewritten...
Most colorectal cancers develop from polyps (adenoma-carcinoma sequence). However, other tumours may develop when dysplasia in the mucosa arises, such as in long-standing ulcerative colitis, Crohn's disease, flat adenomatous disease and perhaps in some cases of hereditary non-polyposis colorectal cancer (HNPCC) patients (dysplasia-carcinoma sequence). In praxis, stage and grading of the tumour itself as well as mobility, size and level of the rectal cancer are facts that must be accepted by the surgeon, and they all influence outcome. Newer studies with a multimodal concept including neoadjuvant therapy seem to be promising 13,14 .
Extensive jejunal resection, Crohn's disease, partial gastrectomy, congestive heart failure, Whipple's disease, scleroderma, amyloid, diabetic enteropathy, systemic bacterial infection, lymphoma, salazopyrine Inflammatory diseases tuberculosis, Crohn's disease, psoriasis, exfoliative dermatitis, malaria Metabolic disease homocystinuria
MMR vaccine is administered as a single 0.5 ml dose at 12-15 months of age, with a booster given at 3-5 years of age in the United Kingdom and during infancy and preschool in other industrialised countries. The safety of these vaccines should not be questioned, as the causal relationship between MMR and autism and Crohn disease remains unproven.
In pivotal studies, large numbers of patients are studied so that their diverse clinical characteristics can imitate better the ordinary patient population than in earlier, more selective, trials. When a variety of concomitant factors (e.g. other diagnoses, wider degree of disease severity, concomitant medications, etc.) are suspected, and may interact with drug tolerability or efficacy, then patients may be stratified into randomization groups according to the presence or absence of such factors. For example, patients with Crohn's disease might be stratified according to whether or not they also have cutaneous manifestations, and each stratum then randomized to active or placebo for a total of four treatment groups, although only two test treatments. Separate statistical analyses for the strata can then be planned, and the study size adjusted accordingly. The efficacy of the new drug may be found to be restricted to one or more particular patient subset(s). Regulatory authorities...
This is a fascinating area of investigation, because apoptosis of immune cells has been linked to both beneficial and deleterious effects. When immune cells undergo apoptosis this can be a necessary event for the host to prevent propagation of inflammation. As an example, it has been argued that Crohn's disease, a chronic relapsing form of inflammatory bowel disease, results in part from a failure of activated T-helper cells to undergo apoptosis (4). Similarly, apoptosis and consumption of infected cells by neutrophils may represent an important mechanism for elimination of pathogens. In contrast, apoptosis of infected cells has been hypothesized as a major cause for both proliferation of invasive organisms such as Shigella, and release of proinflammatory mediators (5). Additionally, death of immune cells is potentially an important feature of the immune escape of pathogens and tumor cells.
Increased permeability of the mucosal lining, allowing entry of microbial or dietary antigens, has been proposed as a possible cause in the pathophysiology of chronic inflammatory bowel disease. Interestingly, in Crohn's disease of the colon, there is abnormal permeability in apparently uninvolved proximal small intestine as well as in the colon110. Patients with Crohn's disease are subject to gastrointestinal strictures where a controlled release matrix may lodge and cause epithelial damage due to the release of concentrated drug at one site over a prolonged period of time111.
With the advent of new methodology, the identification of milk proteins and their biological activity has received more attention. Indeed, we have recently reported that human milk contains proteins such as transforming growth factor (TGF)-p 43 , osteoprotegerin 44 and soluble CD14 45 , which are involved in immune homeostasis, innate responses to bacterial components and bone metabolism. TGF-p is a multifunctional polypeptide. It acts upon a variety of different cells to regulate their growth, differentiation and survival, and plays a crucial immunoregulatory function in mechanisms of tolerance and the prevention of disease and autoimmunity 46 . TGF-p is present in milk and may be activated by acidification or mild enzymatic treatment 47 , thus it is feasible that it is activated during intestinal transit to exert a biological effect in the intestinal epithelium of the host. Furthermore, since TGF-p is present in bovine milk, we considered that it may remain biologically active after...
Bacteria, often tracking from anal glands cause infection that the body's defenses do not overcome, with fistulae developing as a complication of abscess. The latter are also a complication of Crohn's disease, where multiple perineal fistulae may develop (pepperpot perineum).
Malabsorption of cobalamin occurs in a variety of intestinal lesions in which there is colonization of the upper small intestine by faecal organisms. This may occur in patients with jejunal diverticulosis, enteroanastomosis, intestinal stricture or fistula, or with an anatomical blood loop due to Crohn's disease, tuberculosis or an operative procedure. It is not known with certainty which organisms are responsible for the consumption of cobalamin. Bacterial overgrowth in the small intestine may also cause spurious elevation of serum methylmalonate (see below). Some bacteria produce copious quantities of propionate, the immediate precursor of methylmalonate.
Besides perforated appendicitis and intussusception, the most common causes of small bowel obstruction are incarcerated hernias and adhesions. Other causes of small bowel obstruction comprise a miscellaneous group of rare conditions, such as midgut volvulus, Meckel's diverticulum, advanced stages of Crohn's disease, and bezoars. Adhesions usually result from prior surgery and are often multiple. There is an increasing tendency for initial conservative management rather than immediate operative intervention, as a proportion of cases will resolve spontaneously.
Tions that can increase susceptibility to CRC. An increased risk for CRC has been confirmed in patients with inflammatory bowel disease of significant duration (8-10 years). Ulcerative colitis is more strongly associated with cancer than Crohn's disease. The incidence of malignancy seems to augment with the extent of bowel involvement and with the severity and duration of the disease 85, 86 . The risk of carcinoma is increased with the duration of colitis it has been estimated to be more than 30 in the third decade of the disease 87 . Other clinical risk factors are a history of pelvic irradiation and non-cancer surgery. Pelvic radiotherapy, which involves mostly women treated for gynaecological neoplasms, can be relevant to the risk of rectal cancer 88 . Some evidence suggests that patients who have undergone cholecystectomy 89 and ureterosigmoidostomy 90 may have an increased chance of CRC too. A history of breast, endometrial or ovarian carcinoma 91 and no or low parity have been...
Crohn's disease may affect any part of the gastrointestinal tract, being the commonest site in the ileo-cecal region. In children, 20 of cases of Crohn's disease present with acute abdominal pain mimicking acute appendicitis (Hayes 2004). In fact, Crohn's disease may cause, though rarely, appendicitis. Parietal involvement is often discontinuous in Crohn's disease with intervals of apparently normal bowel, producing skip lesions. Another specificity of the disease is the transmural inflammation extending through all layers of the intestinal wall and involving the mesentery (Valette et al. 2001). Imaging shows stratified transmural thickening of the bowel wall usually involving distal ileum, proximal colon, as well and mesentery. The transmural pattern of the disease is often associated with an irregular thickening of the submucosa and muscular layers. The involved segment appears rigid and shows no peristalsis on US (Fig. 1.73) (Hayes 2004). Differential diagnosis with an infectious...
The oral controlled drug delivery concept may embrace dosage forms that release the active agent in a predictable manner over a desired period of time as well as delivery systems designed to liberate the drug locally at specific sites within the gastrointestinal tract. To justify the high costs of developing a macromolecular prodrug for oral drug delivery, the prodrug must provide a superior solution to a drug delivery problem not easily resolved by conventional formulation techniques. Drug delivery to the colon may constitute such a niche. There are various colonic disorders, including ulcerative colitis and Crohn's disease, that warrant delivery of effective amounts of drug compounds such as anti-inflammatory agents selectively to the diseased site. Further, it has been suggested that the large bowel may offer an opportunity for systemic absorption of peptide-like drugs (Saffran et al., 1986 Gruber et al., 1987). Van den Mooter and Kinget (1995) and Sinha and Kumria (2001) have...
D Chronic relapsing and remitting inflammatory disease of the large bowel. Together with Crohn's disease, this is known as inflammatory bowel disease. Macro Mucosal inflammation initially involving rectum and may extend prox-imally to involve the entire colon (pancolitis), no skip lesions as in Crohn's, red granular mucosa with superficial ulceration and pseudopolyps (islands of non-ulcerated swollen mucosa).
The ileal pouch-anal anastomosis (IPAA) (also called ileoanal anastomosis, ileoanal reservoir, and ileoanal pull-through) is a technique originally described by Ravich and Sabiston in 1948. It was devised to remove the entire colon while maintaining intestinal continuity, avoiding a permanent ileostomy, and maintaining continence. The operation is usually performed in patients with ulcerative colitis or familial ade-nomatous polyposis syndrome (FAPS). Patients with Crohn's disease are not good candidates for IPAA because of the potential for recurrent disease, including fistulas, strictures, and abscesses, and a subsequent higher incidence of pouch failure. A proctocolectomy is performed to about 8 cm above the peritoneal reflection with a rectal mucosectomy. The terminal ileum is used to construct an ileal reservoir or pouch to maintain continence. Various ileal pouch configurations have been used, including J, S, W, and lateral isoperistaltic (side-to-side) types. Straight ileal...
In cancers from other gastrointestinal sites, MSI tumours show a low frequency of p53 mutations, less lymph node involvement and a better prognosis 8, 12 they also show a higher risk of multiple neoplasia 15 . From a morphologic point of view, MSI-H carcinomas show distinctive features they are generally located in the proximal colon, show high grades and are more frequently mucinous, medullary or undifferentiated carcinomas with a marked Crohn like inflammatory infiltrate, and a high number of
A series of alpha-D-mannopyranose-containing dendrimers were synthesised using the convergent reaction scheme and were investigated with respect to the efficiency of these dendrimers in inhibiting the binding of a lectin to a purified yeast mannan fraction which is found in the serum of patients with Crohn's disease and may cause
Malabsorption of dietary folate occurs in tropical sprue, in gluten-induced enteropathy in children and in adults, when it is associated with dermatitis herpetiformis. In the rare congenital syndrome of selective malabsorption of folate, there is an associated defect of folate transport into the cerebrospinal fluid, and these patients show megaloblastic anaemia, responding to physiological doses of folic acid given parenterally but not orally. These patients also show mental retardation, convulsions and other central nervous system abnormalities. Minor degrees of malabsorption may also occur following jejunal resection or partial gastrectomy, in Crohn's disease and in systemic infections but, in these conditions, if severe deficiency occurs, it is usually largely due to poor nutrition.
Some hosts are not necessarily more at risk of developing diarrhea, but when they do develop diarrhea the consequences are worse compared with the average host. Such persons include those with underlying gastrointestinal diseases, such as Crohn's disease and ulcerative colitis, and persons with an ileostomy. Dehydration in such patients is an important concern. Elderly patients with diarrhea might become confused and forget to rehydrate themselves or they might continue diuretic therapy in the face of developing dehydration. Small children and infants are at special risk of becoming dehydrated when they develop diarrhea. On the other hand, travelers' diarrhea in the healthy adult is usually not dehydrating (Ericsson and DuPont, 1993).
The beneficial effect is exploited in transplant surgery where immunosuppression can improve allograft survival.40 Already in 1973, Opelz etal. in their seminal paper documented improved renal transplant sur-vival.41 Peters et al. reported on the reduced recurrence of Crohn's disease in patients receiving multiple blood transfusions.42
Ileostomies may be performed for multiple reasons including temporarily diverting the stream of intestinal contents in patients with surgery involving the more distal small bowel or colon. Removal of the colon may necessitate creation of a permanent stoma. Everting the distal end of the ileum and bringing it through the anterior abdominal wall creates a permanent stoma. Various abnormalities of the stoma may include adhesions, prolapse (Fig. 5.34), parastomal herniation, and recurrent disease (especially Crohn's disease) at the stomal site.
An important issue is the fate of the rectum after subtotal colectomy for UC or Crohn's disease. Johnson et al. 48 studied a series of 1439 patients with UC. A surgical resection was performed in 374 patients (26 ) 172 patients underwent subtotal colectomy with mucous fistula. Ten patients (3.6 ) developed a rectal cancer. In this study the cumulative risk of developing a rectal cancer in the rectal stump reached 17 27 years after disease onset. Winther et al. 50 studied 42 patients with a closed rectal stump after surgery for UC or Crohn's disease. The median duration of the disease was 8.3 years (1.3-34 years). The Authors showed no endoscopic or histological signs of dysplasia or carcinoma and no mutation of p53 gene in any biopsy or lavage fluid. However, 78 and 43 of the patients showed moderate to severe mucosal inflammation and rectal stump involution respectively. For this reason a role of adjuvant markers to improve cancer surveillance in this subgroup of patients is...
A Most commonly a severe flare of ulcerative colitis, but also may occur in Crohn's disease, pseudomembraneous colitis and other infective colitides. A R Crohn's or ulcerative colitis, Clostridium difficile infection, amoebiasis and other infections such as Salmonella. E May occur in 3-10 of patients with ulcerative colitis, less common in Crohn's and generally rare in infective aetiologies.
The term ileocecitis, proposed by PuYlaert et al. (1989), defines those bacterial enteritises that affect primarily the ileocecal region, mimicking clinically appendicitis. Yersinia, Campylobacter, and Salmonella are the most frequent infective organisms. In these cases, diarrhea is often absent or moderate. Sonographic diagnosis of these entities may avoid a significant number of unnecessary laparotomies. Sonographic findings consist of mural thickening of the terminal ileon, ileocecal valve, and the cecum, and the presence of multiple enlarged mesenteric lymph nodes. The thickened ileon appears mostly hypoechoic related to mucosal follicular hyperplasia. This finding may help differentiate it from Crohn's disease, which exhibits a transmural affectation. Abnormalities often extended along the proximal colon, giving rise to a prominent haustral pattern on the longitudinal view. The exaggeration of the haustrations leads to the accordion sign (Fig. 1.72). In many cases the appendix...
Non-specific symptoms, such as abdominal pain and malaise, are common. Intermittent diarrhea is the most common symptom of intestinal involvement and may alternate with constipation. The stool may occasionally contain blood and mucus. Frank schistosomal dysentery is uncommon (Cheever, 1978). A severe form of intestinal involvement is colonic polyposis (El Masry et al., 1986). This condition generally effects young males and, in addition to bloody diarrhea, protein-losing enteropathy, hypo-kalemia and severe dehydration are often found. On sigmoidoscopy and biopsy, intense granulomatous inflammation with parasite ova is found. Occasionally, inflammatory masses are observed along the colon and need to be differentiated from malignant lesions (Mohamed et al., 1990). Intestinal schistosomiasis is most commonly confused clinically with ulcerative colitis or Crohn's disease and occasional abdominal tuberculosis. The condition responds well to effective antiparasitic treatment.
Therapeutic options are either to insert a drainage tube under CT or ultrasound guidance or to proceed to laparotomy. If there is a large fistulous communication, then the surgical option would be favoured. Although the origin of the abscess is probably diverticular, the differential diagnosis includes a perforating colonic tumour and Crohn's colitis.
In some disorders such as sickle cell disease, gluten-induced enteropathy (coeliac syndrome) and dermatitis herpetiformis, hyposplenism occurs frequently it is seen less frequently in Crohn's disease, ulcerative colitis and essential thrombocy-thaemia, and it occurs only occasionally in the other conditions listed in Table 21.2. Congenital absence of the spleen is rare and may be associated with organ transposition and with severe malformations of the heart and lungs.
A gastroenterostomy, usually gastrojejunostomy, may be performed as a drainage procedure with vagotomy for peptic ulcer disease and in patients with unresectable antral carcinomas and other conditions that may lead to antral narrowing, such as Crohn's disease. In the past, simple gastroenterostomy was a commonly performed procedure for PUD, although it was abandoned owing to the high ulcer recurrence rate. An anastomosis is generally made between the jejunum and the greater curvature of the stomach, as far as possible from the pylorus, in a side-to-side fashion, although other configurations are sometimes used (Figs. 3.35 and 3.36). The jejunum may be brought either to the anterior wall of the stomach superior to the omentum or to the
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