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Crohn's Disease

Crohn's disease is a condition where inflammation and swelling in your digestive system can cause pain, diarrhea and weight loss. At Sinai Health, we understand the disease can be hard to predict when it comes to flare-ups and periods of remission. We are here to support all of our patients throughout their IBD journey.

Key Facts

  • Crohn's disease can affect the lining of the bowel as well as the deeper layers. It is also characterized by "skip lesions" — areas with ulcers separated by areas of healthy bowel.
  • Crohn’s disease can affect any part of the gastrointestinal system, but for many people with Crohn's disease, the terminal ileum (the end of the small bowel and the beginning of the colon) is affected.
  • While Crohn's disease tends to begin in childhood or adolescence, some people with Crohn’s disease don’t experience their first symptoms until after age 40.

Disease Location

Crohn’s disease symptoms and treatment can be influenced by where the disease is located:

  • Terminal Ileal disease occurs where the small bowel joins the colon. Symptoms include bloating, cramping and the inability to tolerate fibrous foods (fresh fruits, vegetables).
  • Small bowel disease occurs across multiple areas of the small bowel. The diseased segments become severely narrowed resulting in symptoms of obstruction.
  • Colon disease refers to inflammation of the colon and/or rectum, and can also occur in the anal region (perianal disease).

Disease Behaviour

  • Fistulizing Crohn’s disease: In some cases, ulcers extend through the bowel wall, creating a tunnel to another part of the intestine or another organ. This is called a fistula.
  • Penetrating Crohn’s disease: Patients with Crohn’s disease can develop abscesses (collection of pus) in the abdomen or pelvis.
  • Non-fistulizing, non-penetrating Crohn’s disease: This refers to Crohn’s disease without fistulas or abscesses.

Common symptoms of Crohn’s disease include:

  • Diarrhea
  • Abdominal cramping and weight loss
  • Fatigue
  • Perianal disease (abscesses, fissures, fistulas)
  • Nausea and vomiting
  • Bloating or a feeling of fullness in the abdomen

Medicine is used to control the chronic intestinal inflammation that causes the symptoms of Crohn’s. The success of the medication is determined by its ability to suppress the inflammation and eliminate symptoms (known as remission) without causing significant side effects.

There are four main categories of medications used to treat Crohn’s disease:

  • Corticosteroids: These medications help keep the immune system in check and are effective for short-term control of flare-ups. They are not recommended for long-term or maintenance use due to side effects.
  • Immunomodulators: These medications modify the activity of the immune system to prevent ongoing inflammation. They are generally used to maintain remission in some individuals.
  • Antibiotics: Antibiotics are used to treat complications of Crohn’s such as abscesses and fistula. They are also sometimes used to treat other symptoms of Crohn’s.
  • Biologic therapies: These are the newest treatments for Crohn’s and IBD. These are options for people with moderate to severe disease who have not responded well to conventional therapies. 

In some cases, patients with Crohn’s disease require surgery. The type of surgery will depend on where the disease is located.

Terminal ileal disease  

The surgery for terminal ileal disease involves anileocolic resection, which is the removal of the end of the small bowel and beginning of the colon with the two ends being joined back together.

If there is infection or severe inflammation in the area of bowel resection, there may be a need for a temporary ostomy to allow the joined area to rest. An ostomy, also referred to as a stoma, is a surgically created opening, usually on the abdominal wall, for the drainage of body wastes.

Small bowel disease

Surgical options for small bowel disease include:

  • Resection: This procedure is generally recommended for individuals where the disease involves long segments of bowel and who have not had resections in the past. It involves taking out the portion of the bowel with disease.
  • Anastomosis: This procedure involves joining the bowel back together.
  • Stricturoplasty: This procedure is generally recommended for individuals with multiple short segments of disease or for individuals who are at risk of short bowel syndrome (previous multiple resections resulting in a shortened small bowel). It involves opening up narrowed areas without actually removing them.

Of note, the decision between resections and stricturoplasty is generally made at the time of surgery, based on the status of the bowel and which option is technically feasible.

Colon disease

When Crohn's disease appears in the colon, the major consideration is whether or not the rectum is involved. Surgical options for colon disease include:

  • Ileorectal anastomosis: This procedure is generally recommended when the colon is inflamed and the rectum is not. The procedure involves removing the colon and joining the small bowel or ileum to the rectum.
  • Proctocolectomy: This procedure is recommended when the rectum is diseased along with the colon. It involves removing the rectum and colon and creating a permanent ileostomy for intestinal waste to pass externally.

Perianal disease

Crohn's disease can also occur in the anal region. This is known as perianal disease and can result in fistulas, fissures and abscesses. Medical therapy is often the first course of action. If medical therapy fails, surgery is often recommended and can include:

  • Insertion of draining setons to prevent abscess formation
  • A diverting ileostomy to allow the perianal area to heal
  • A proctectomy, which involves removing the rectum to create a permanent ostomy

Ostomy

A stoma, also referred to as an ostomy, is a surgically created opening, usually on the abdominal wall, for the drainage of body wastes.

Temporary stomas may be used in the following circumstances:

  • emergency or semi-urgent operations where there is an infection in the abdomen and a primary resection and joining of the bowel is felt to be unsafe until the infection subsides
  • perianal sepsis or infection that requires that the stool be diverted to allow for healing
  • post-operative complications such as leaks from bowel join (anastomoses).

In general, if the rectum and anus are normal or minimally affected with disease, permanent stomas are not needed.

Ileocolic Resection

View this video for helpful information on Ileocolic resection for Crohn's disease by TVASurg - The Toronto Video Atlas of Surgery.