My Doctor Online The Permanente Medical Group

Symptoms

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If you have Crohn's disease, your symptoms in or around the digestive system might include:

• Abdominal pain and cramping.
• Diarrhea or sudden urge to use the bathroom. You might have diarrhea up to 10 or 20 times a day. 
• Blood in your stools. Contact us immediately if you see blood in your stools because this may be a sign of a serious condition.
• Loss of appetite and weight loss.
• Fever. You might experience a slight fever, or in severe cases, a fever with other symptoms that affect your entire body. High fevers usually indicate an infection.
• Anemia (too few red blood cells). Bloody stools can decrease your iron level and may cause anemia.
• Sores in your mouth.
• Nutritional deficiencies. Nutritional deficiencies happen because your intestines may not be able to absorb nutrients from food. The common nutritional deficiencies are lowered levels of vitamin B12, folic acid and iron.

Symptoms in or around the anus may include:

• Abnormal tunnels or openings (fistulas). Fistulas sometimes form between organs (such as the bladder, vagina, or skin) because Crohn's disease causes inflammation and ulcers in the deep layers of the intestinal wall. Fistulas are usually the first sign of Crohn's disease.
• Pockets of infection (abscesses).
• Small tears in the anus (anal fissures).
• Skin tags that may resemble hemorrhoids. These are caused by inflamed skin.

Symptoms and complications outside the digestive system may include:

• Joint pain, eye problems or a skin rash. These problems are more common in Crohn's disease than ulcerative colitis, the other major inflammatory bowel disease.
• Delayed growth and sexual development. Children who have Crohn’s disease may suffer from delayed growth and sexual development.

Diagnosis

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Crohn's disease can be difficult to diagnose, and there is no single test. Crohn’s disease often goes undiagnosed for years because symptoms generally develop over time and other diseases (such as irritable bowel syndrome) have similar symptoms.

When you come in for an appointment, we will start with a discussion of your medical history. Then, we will do a physical exam and perform one or more of the following tests:

• Either a flexible sigmoidoscopy or colonoscopy will help us examine the inside of your colon (large intestine).
• Sample (biopsy) of intestinal tissue will helps us rule out other causes (such as infection) and can confirm the diagnosis of Crohn’s disease.
• Stool analysis, depending on your symptoms, will help us confirm that there is no infection. We look for blood, signs of bacterial infection, parasites, or the presence of white blood cells.  This test can also be used to distinguish Crohn’s disease from irritable bowel syndrome, a less serious condition that sometimes has similar symptoms.
• Computed tomography (CT) scan will be used for severe cases and involves an X-ray to take pictures inside your body.
• Small bowel follow-through X-ray will provide a picture of obstructions in the stomach.
• Barium enema allows us to examine the colon (large intestine). This is a rare test, but is sometimes useful.
• Magnetic resonance imaging (MRI) provides pictures of organs and structures inside your body. This test is also rarely used.

Causes and Risk Factors

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Causes

We do not know the exact cause of Crohn's disease. Research studies suggest that it may be related to an abnormal response by your immune system to certain intestinal bacteria.

Risk factors

Certain people are at greater risk of developing Crohn's disease than others. There are some risk factors (such as genetics) that can’t be changed or controlled. Other factors such as lifestyle choices can be altered to lower your risk.

• Smoking. Cigarette smoking increases your risk of developing Crohn's disease and contributes to poor health. It can also lessen the effectiveness of treatment, or worsen your symptoms.
• Family history of Crohn's disease. Your risk increases if an immediate family member, such as a parent, brother, or sister, has the disease.
• Ethnicity. People with Ashkenazi Jewish ancestry are at higher risk.
• Age. People 20 to 30 years old are at higher risk.
• Living in an urban area or in an industrialized country. Research suggests that environmental factors, including a diet high in sugar, may play a role.

Treatments

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Unfortunately, there is no cure for Crohn's disease. Home treatment methods can reduce pain and discomfort. Many people who have Crohn's disease continue to lead healthy and active lives.

Your treatment will depend on your symptoms and how severe they are. Depending on your symptoms, we will work together to choose one or more of the following treatment options:

• Home treatment
• Medications
• Complementary and alternative medicine
• Surgery

We might need to try more than one combination of treatments to ease your symptoms. Long-term treatment is usually necessary to manage Crohn’s disease. 

Home Treatment

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Home treatment for Crohn’s disease, depends on the severity of your symptoms.

We do not recommend the use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen to treat Crohn's disease. Research has linked these pain relievers with Crohn's disease flare-ups.

If you are experiencing mild symptoms, we recommend trying:

• Antidiarrheal medicines. Over-the-counter and prescription medicines may help with diarrhea. We can help you to decide which medicines are best suited to help address your symptoms.
• Topical medicines (suppository, enema, or foam). These may help with rectal discomfort. Please discuss with us which of these medicines is best suited to help address your symptoms.
• Changes to your diet. Avoid certain foods (milk, alcohol, spicy foods, or high fiber foods) that seem to trigger your symptoms. Eat a balanced diet with plenty of fruits, vegetables, and whole grains.

Prescription Medications

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Medication treatment for Crohn's disease depends on:

• How severe your symptoms are.
• Which parts of the intestines are affected.
• Whether you are experiencing any complications.

Types of medications

If you are experiencing mild or moderate symptoms, we may recommend:

• Aminosalicylates. These are the most commonly prescribed medicines to help relieve symptoms from mild Crohn's disease.

If you are experiencing moderate to severe symptoms, we may recommend:

• Corticosteroids. These medicines may be added to your treatment plan if symptoms continue. Corticosteroids usually stop symptoms and put the disease in remission by suppressing the immune system. We don’t recommend corticosteroids for long-term treatment because of their potential side effects.
• Immunomodulator medicines. These are very strong medicines that suppress the immune system to prevent inflammation. They are prescribed for severe symptoms that do not respond to aminosalicylates.
• Biologic therapies. These medicines block your body's inflammatory response and help reduce inflammation in your colon (large intestine). An infliximab may be prescribed if immunomodulator medicines do not work. However, infliximabs may not be the best choice for everyone because they have potential risks (serious allergic reactions and increased risk of infection) and are not appropriate for people with certain conditions (heart failure, multiple sclerosis, cancer or a history of cancer).

Corticosteroid side effects

Possible short-term side effects of taking corticosteroids include:

• Increased risk of infection
• High blood pressure (hypertension)

Possible long-term side effects of taking corticosteroids include:

• Weight gain
• Acne
• Mood swings
• Psychosis
• Increased facial hair
• Osteoporosis
• Cataracts
• Higher blood sugar level
• Bone damage (aseptic necrosis)

For more information on corticosteroids and Crohn’s disease, see Crohn's and Colitis Foundation

Surgery

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Surgery is not a common treatment for Crohn's disease, but may be recommended in certain situations:

• When medicines cannot control a person’s symptoms.
• When you have serious side effects from medicines.
• When you have severe bleeding that requires ongoing blood transfusions.
• When your symptoms can only be controlled with long-term use of corticosteroids.
• If you have complications such as abscesses or tears (fissures) in the anal area, abnormal connections (fistulas) between the intestines and other internal organs, or holes (perforations) in your colon (large intestine).
• If cancer or precancerous tissue (dysplasia) is found during a colonoscopy or biopsy.

Surgery options

• Resection. This involves removing the diseased portion of the intestines and reattaching the healthy ends. This type of surgery does not cure Crohn's disease, which often comes back near the surgery site.
• Strictureplasty. This involves widening the intestine to decrease obstruction of the bowels. This is sometimes done at the same time as resection or when a person has had resection in the past.
• Proctocolectomy and ileostomy. This involves removing the colon (large intestine) and rectum and leaving the lower end of the small intestine (the ileum). The anus is sewn closed, and a small opening called a stoma is made in the skin of the lower abdomen. The ileum is connected to the stoma, creating an opening to the outside of the body, where stool empties into a small plastic pouch called an ostomy bag that is applied to the skin around the stoma.
• Balloon dilation. This is a non-surgical procedure that involves using an endoscope (long, thin tube with a video camera on the end) to make part of the intestine wider.

Complementary and Alternative Medicines

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Because there is no cure for Crohn's disease, many people consider complementary or alternative medicines to help ease symptoms. While not all of these therapies have been proven equally effective for Crohn's disease, many may improve your overall well-being.

If you are interested in trying complementary and alternative medicines, we strongly recommend that you consult with us first. Certain alternative medicines, vitamins, or nutritional supplements can have side effects or contraindications when taken with prescription or over-the-counter medicines. We can work together to manage your medications.

Some of the common complementary therapies include:

• Nutritional supplements (probiotics and fish oils)
• Vitamin supplements (vitamins D and B12)

Scientists are just beginning to document the benefits of mind-body and herbal approaches for chronic health issues like Crohn's disease. You can try some complementary and alternative approaches to see if they help reduce your symptoms.

We recommend that complementary and alternative approaches be combined with a healthy diet and a regular exercise routine.

Why Treatment is Important

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In some cases, Crohn's disease can lead to more serious problems such as:

Malnutrition or nutritional deficiencies. If the disease has progressed for long periods of time, you may become deficient in proteins, calories, and vitamins. Nutritional supplements and medical treatment are usually effective in replacing these nutrients.

Sores or ulcers (fistulas) in the digestive system. These are abnormal passages that affect about 30 percent of people with Crohn's disease. Medical treatment can help heal small fistulas. Surgery may be recommended if you experience fever or persistent symptoms associated with large or multiple fistulas.

Abscesses or a collection of pus. Sometimes, fistulas can develop into an abscess near the intestine. If this happens, we may recommend draining the infected area.

Obstruction or intestinal blockage as a result of swelling and scar tissue. Symptoms may include cramps, stomach pain and vomiting. Medication can help reduce inflammation, but surgery might be necessary if the obstruction is severe and does not respond to treatment.

An increased risk of arthritis. There are two different kinds of arthritis:

• Peripheral arthritis affects many people who have ulcerative colitis or Crohn's disease. Symptoms include pain, swelling, and stiffness in one or more arm or leg joints (wrists, knees, and ankles). Treatment is quite effective at reducing symptoms. Peripheral arthritis does not cause permanent damage.
• Spinal arthritis (spondylitis) is rarer, but does affect some people. Symptoms include pain and stiffness in the spinal column joints, which tend to be worse in the morning. If left untreated, spinal arthritis can cause bones in the vertebral column to fuse (grow together). Physical activity and physical therapy are effective at reducing symptoms and improving range of motion in the spine.

Increased risk of developing osteoporosis. The long-term use of certain medicines, such as corticosteroids, can interfere with normal bone development and growth. If you take these corticosteroids for more than 2 to 3 months, we may recommend taking calcium and vitamin D supplements or other medicines to prevent osteoporosis. To learn more about osteoporosis and Crohn's disease, see the National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Other complications include liver disease, kidney stones, gallstones and mouth ulcers that prohibit swallowing or eating.

Lifestyle Changes

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Symptoms of Crohn’s disease can last for many years and are unfortunately not curable. However, for many people, symptoms get better with lifestyle changes and medications. There are things you can do to reduce the severity of the disease, such as:

• Take your medicines regularly. This can help reduce sudden attacks (flare-ups) and keep the disease in remission (a period without symptoms).  Many of the newer medications are long-term and can minimize or eliminate most symptoms.
• Avoid non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen for pain relief. NSAIDs have been linked to flare-ups. Instead, we recommend taking acetaminophen (Tylenol). 
• Do not smoke. Smoking cigarettes makes Crohn’s disease worse and contributes to many other health problems. If you smoke and are ready to quit, we can help.
• Eat a healthy diet.  Aim for a balanced diet with plenty of fruits, vegetables, and whole grains. 
• Avoid trigger foods. If a particular food seems to cause your symptoms to flare up, it should be avoided.  Otherwise eat a balanced diet with plenty of fruits, vegetables, and whole grains.
• Have screening tests for colorectal cancer. Having Crohn's disease may cause a slightly higher risk of developing colorectal cancer. We can discuss screening tests for colorectal cancer which can help us find cancer early, when it is easier to treat.

We can help you develop a strategy to manage your symptoms and live a healthy, active life.

Your Care with Me

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Crohn’s disease is a chronic long-term condition. Either I, or another gastroenterologist in our department, will manage your ongoing care.  I will work closely with your personal physician, who will continue to oversee your care for non-Crohn’s health issues.

Mild symptoms of Crohn’s disease can be treated at home.

If you are having symptoms that concern you, your first contact will typically be with your personal physician, who will evaluate your health and symptoms.

If specialty care is needed, your personal physician will facilitate the process of scheduling an appointment in my department. If appropriate, she or he might call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter.

During your office visit, we will discuss your medical and family history and I will perform a physical exam. I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options, and together we will create a treatment plan that is right for you.

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If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

If you have urgent concerns or issues while my office is closed, or need general medical advice, you can call the Appointment and Advice line, available 24 hours a day, 7 days a week. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

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Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

If surgery or a procedure is a treatment option

I will recommend that you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

If we proceed with surgery, I will have my Surgery Scheduler contact you to determine a surgery date and provide you with additional instructions regarding your procedure. Once your surgery is scheduled, a medical colleague of mine will contact you to conduct a preoperative medical evaluation that will assure that you are properly prepared for your surgery.

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Convenient Resources for You

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As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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