The incidence of Crohn's disease is increasing rapidly, and is more common now than ulcerative colitis, showing a twenty-fold increase from 1940 to 1970.(1) Crohn's disease is also called regional ileitis. It is a chronic, progressive, inflammatory disease of the bowel. The symptoms are most commonly that of diarrhea and pain. Weight loss, fatigue, and irritability are characteristic of the disease. The bowel movements often include mucus, blood, and pus because of the infection. Fat may be found in the bowel movements, making them bulky and foul smelling. Crohn’s disease tends to get worse as time goes by, and to spread along the bowel, accounting for the alternate name of "regional ileitis."
Fifty-seven percent of cases occur in women and seventy-one percent in Jewish people. The most common age of onset is 16 to 21 years. If the patient has one or more close relatives with Crohn's disease, the person is more likely to have the disease himself.(2)
Crohn's disease can occur in any portion of the gastrointestinal tract. There may be healthy areas of bowel alternating with diseased ones. Crohn's disease is limited to the small intestine in 90% of cases, and most frequently starts with the terminal ileum.
There is usually a reduction in the motility of the small bowel. There may be times when the disease is in remission, that is, there are no symptoms discernable and the person may think that the disease is cured. During the remission, it is important to use care to follow all known health laws to prolong or permanently establish the remission. A large number of patients with Crohn's disease eventually come to some type of surgical treatment, with an operative mortality of about 6%.(3)
There are some little known clinical aspects of Crohn's disease, such as a skin involvement, the skin around the anus being most likely to become involved. Fissures, fistulas, and thickening of the anal skin tags represent the most common skin manifestations. The skin may become swollen and discolored around the anus. Ulceration of the skin of the legs may occur. The skin tags around the anus may have a typical reddish-blue color. Biochemical disturbances in the liver are occasionally seen. A large proportion of these patients and their immediate families reveal a history of allergies, including hives and asthma. With this set of symptoms, there is often an enlargement of the ends of the fingers (clubbing). Ulcers in the mouth, lesions in the eyes (uveitis), and arthritis of the large joints may all precede the bowel disease by many years.(4)
There are no proven cases of spontaneous cure of Crohn's disease. The disease may be relatively mild, but more often the symptoms soon interfere with work and pursuit of productive activity. Despite drug treatments, new manifestations develop.
Crohn's disease is relatively rare in tropical areas. In Aberdeen, it was found to be infrequent in white collar workers and in country dwellers.
Cancer of the small bowel is rare except in people who have Crohn's disease, in which it occasionally occurs.(5) Immunity is depressed in Crohn's disease.(6) Allergies, arthritis, asthma, skin involvement, and food sensitivities may all be a part of the response or lack of response of the immune system.
CAUSES OF CROHN'S DISEASE
The cause of regional enteritis is said to be unknown, but overeating, chemical poisoning, or bacterial invasion all seem to be possible factors or etiologic agents.(7)
Substantially greater numbers of people with the disease give a history of using more refined sugar, less dietary fiber, and considerably less raw fruit and vegetables than the controls. This kind of diet favors the development of Crohn's disease.(8, 9, 10)
Some investigators point out that sugary foods tend to contain more chemical additives such as dyes, flavors, stabilizers, etc. These investigators also suggest that a high sugar intake itself may influence the intestinal bacterial flora to produce compounds toxic to the intestinal lining.(11)
Seasonings and cold fluids are not well tolerated and should be omitted. Lactose (milk sugar) malabsorption has been noted in as many as seven out of eight patients with Crohn's disease.(12)
It is postulated by some that a state of increased sensitivity develops in Crohn's disease, the immune system having been previously primed. In other words, substances capable of producing allergic states were able to penetrate the lining of the bowel because of some previous conditioning by circumstances, foods, or chemical injury. It is further postulated that during the neonatal period, particularly in premature infants, there may be an absence of certain defense systems allowing the penetration of antigens. Hypersensitivity could then develop in the intestinal lymphatic system, such as in infancy with a diet of cow's milk, before the establishment of the "mucosal barrier." It is of interest that patients with ulcerative colitis, a related disease, have a high incidence of using formulas of cow's milk in infancy as compared with controls.(13) One nine year old girl can remain well of Crohn's disease as long as she avoids all milk and dairy products, ham and bacon, blueberries, and cakes containing poppy seed.(14)
The story is reported of a thirteen year old boy with Crohn's disease who did fine as long as he was given no oral foods or fluids, and only hyperalimentation (a method of feeding entirely intravenously), but had his symptoms return when he was offered ordinary foods When hyperalimentation alone was reinstituted, his symptoms again subsided, but when given prednisone he got worse again, and had pain and bloody diarrhea. The prednisone was manufactured with certain substances such as lactose, starch, sugar, paraffin, oil, or tartrazine to hold the material together.
Some observations point to the possible role of gluten in Crohn's disease. Seven of ten patients with tropical sprue responded to a gluten-free diet, four patients with regional enteritis exhibited adverse effects with 12 days of taking 20 grams of gluten maximally and 5 grams minimally.(15) It is always worth a trial on a gluten-free diet to see if it is a factor. We have seen several striking remissions on this diet, but gluten must be strictly and rigorously excluded in order to give it a fair trial.
Crohn's disease patients have a high incidence of life crises during the six-month period prior to the onset of the disease. More than half of the patients in one series had been seen by a psychiatrist at least once during their lifetimes, and approximately 20% of all patients have been in psychotherapy.(16)
A viral cause of Crohn's disease has been suggested by some recent studies.(17, 18) In one study, clusters of viral particles were found in cases of Crohn's disease which could successfully inoculate tissue cultures, indicating the possibility of a virus as a cause of the disease.(19)
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