CROHN'S DISEASE

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 occur in the bowel movements, making them bulky and foul smelling. It 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). The 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, had paid 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 respond 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 have 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).

TREATMENT

Patients with Crohn's disease should be on a diet having no free fats, but one providing plenty of essential fatty acids through the use of grains, legumes, and nuts if these foods can be tolerated (20).

The intestinal flora may be changed in order that toxic products will not be produced. In order to do that, the diet must be such that refuse left in the colon will not cause putrefaction. All animal products should be eliminated, as they tend to putrify in the colon. The colon must be kept empty by the use of high residue foods, enemas, and the application of brief cold compresses to the abdomen. Laxatives must be strictly eliminated as they cause congestion and irritation. Since the residue of breakfast will be found in the colon within seven to nine hours after breakfast is eaten, it is best for the colon to be cleansed of breakfast before lying down to sleep at 10:00 P.M. Ideally the bowels should move after each meal and should have about the consistency of soft ice cream. A formed stool is always an evidence of stagnation in the bowel. The toxic materials produced from these residues are capable of causing much suffering. If necessary, these patients should have enemas twice a day. The enema should be at about 115 F., and from one to two quarts be used at a time. High temperatures are stimulating to the lining membranes and promote health. High temperatures also relieve pain. A water temperature of 120* will discourage bleeding by the same principle that "hot lap packs" are used in surgery to discourage diffuse bleeding, as from a torn liver. Burning of tissues will not occur below 123 F.

The use of liberal quantities of complex carbohydrates such as found in fruits, vegetables, and whole grains is of such a character as to promote a luxurious growth of aciduric flora. Dextrinized grains are most efficient for this purpose. Grains may be dextrinized prior to the cooking process in cereals or breads, etc. and bread may be made into melba toast by putting whole wheat bread slices directly on the oven rack, turning the oven on at its lowest possible temperature setting, and allowing the bread to dry out for several hours.

Sunbaths should be taken when possible, exposing the entire skin surface, which helps to increase resistance and to develop immunity. Plenty of water should be taken by mouth to encourage proper cleansing of the blood and the gastrointestinal tract.

A bland, low-fat diet should be instituted. All foods should be chewed well, or mashed with a fork, or pureed in a blender. We especially recommend avoiding milk, most particularly cheese. We advise abolishing all foods that have been highly milled. There should be no free-fats, no fried foods, no sugar, and no extremely hot or cold foods. Avoid any gas-forming foods such as cabbage, corn, certain greens, pickles, relishes of all kinds skins of apples and potatoes, and legumes. It is well to try an elimination diet to determine if one is sensitive to any group of the most common foods causing sensitivity: milk and all dairy products including whey products, sodium lactate, sodium casenate, and all other milk residues; coffee, tea, colas, and chocolate; citrus fruits and juices; corn, wheat, and rice (may use oatmeal and millet); all other animal products (pork, eggs, beef, fish, chicken, etc.); strawberries; apples, and lettuce, cane sugar; onion, garlic, nuts, peanuts, alcohol and beer; yeast, tomatoes, potatoes and tobacco).

Two meals a day are preferable to three, as proper digestion and assimilation are more important to maintain good nutrition than is the quantity of food taken or the number of meals eaten. No spices or food additives, dyes, colorings, conditioners, or other additives are allowed. The principal foods should be fruits, vegetables and whole grains and anything added to the food should be looked at with great suspicion.

EXERCISE is excellent and should include walking and gardening if these are available. There should be strict avoidance of all drugs, as drugs almost invariably irritate the gastrointestinal tract. Drugs generally fail to accomplish any striking therapeutic results (21). It is not necessary to take acidophilis bacteria, as these do no apparent good.

The long-term use of corticosteroids is contra-indicated. Antidiarrheal medications cause narrowing of the small bowel and can result in obstruction. Surgery for Crohn's disease should be avoided except in the treatment of life-threatening complications. At least 50% of patients can date the onset of rapid progression of the disease and worsening of their symptoms to the first operation (22).

REFERENCES

1. Acta Hepato Gastroenterology 26:257-259, 1979
2. Modern Medicine, February-March, 1980, page 23
3. Beeson and McDermott. Textbook of Medicine. Philadelphia: W.B. Saunders, 15th Edition, p. 1560
4. South African Medical Journal 47:1400-1406 ' August 11, 1973
5. New England Journal of Medicine 289:1099-1103, 1973
6. British Medical Journal, July 10, 1976, page 87
7. Hepato-Gastroenterology 26:257-259, 1979
8. American Journal of Clinical Nutrition 32:1898-1901, 1979
9. British Medical Journal, September 29, 1929
10. Digestion 20:323-326, 1980
11. British Medical Journal, April 9, 1977, page 929
12. Gut 11:338-343, 1970
13. Southern Medical Journal, 71(8)935-948, August 1978
14. British Medical Journal, June 11, 1977
15. American journal of Clinical Nutrition 24:1608-1673, September 1971
16. Psychosomatic Medicine 32:153-166, 1970
17. Gastroenterology 69:618, 1975
18. Lancet 2:215, 1976
19. Journal of American Medical Association 236:2213. November 8. 1976