Quality of Life of Patients With Crohn’s Disease After Surgery

Introduction:

Crohn's disease is inflammation of the gastrointestinal tract (mouth to anus). The incidence of Crohn's disease is increasing and is now five to ten per one lakh, with a prevalence of 50 to 100 per one lakh. It most commonly starts at 10 to 19 years or 20 to 29 years of life. Although many patients require surgery and hospital admission for other reasons with substantial associated morbidity, the majority have an excellent work record and pursue a normal life.

What Is Crohn’s Disease?

Crohn's disease is a chronic inflammatory disease that involves the ileum, colon, and jejunum.

• Crohn’s disease is increasing day by day.

• It affects females more than males.

• This disease can affect any age group.

• Crohn’s disease is more common in smokers.

• The entire bowel wall is edematous and thickened, with deep ulcers.

• These deep ulcers may also penetrate the bowel wall to initiate abscesses involving the bowel, bladder, uterus, vagina, and perineum (area between thighs).

• The mesenteric lymph nodes are enlarged, and the mesentery (tissue that connects the intestine to the abdomen wall) is thickened.

What Causes Crohn’s Disease?

Crohn’s disease has both environmental and genetic components. These are three factors that cause Crohn's disease;

• Genetics - Crohn’s disease is common in Ashkenazi Jews. Crohn’s disease is associated with genetic defects in innate immunity. It is thought that irritable bowel disease develops because these genetically susceptible individuals mount an inflammatory response to environmental triggers, such as intestinal bacteria. This leads to inflammation of the intestine, which causes tissue damage.

• Environmental - Crohn’s disease is more common in smokers. Crohn’s disease is associated with a low-residue, high-refined sugar diet.

• Dysbiosis - There is emerging evidence that the virome and mycobiome (fungal species) may be important in developing irritable bowel disease. Commensal gut microbiota is altered in Crohn's disease.

What Are the Signs and Symptoms of Crohn’s Disease?

The following are the major symptoms of Crohn's disease;

• Abdominal pain.

• Diarrhea.

• Weight loss.

• The pain is often associated with diarrhea, which is usually watery and does not contain blood or mucus.

• Almost all patients lose weight because they avoid food since eating provokes pain.

• Weight loss may be due to malabsorption, and some patients present with fat, protein, or vitamin deficiencies.

• Anemia (deficiency of hemoglobin).

• Glossitis (inflammation of the tongue).

• Angular stomatitis (inflammation and scaly patches at the corner of mouth and lips).

Following are the signs of Crohn's disease;

• Crohn's disease may obstruct the intestine.

• Perianal disease (a disease that affects the anal canal or rectum).

• Rectal sparing (inflammation higher in the bowel but not in the rectum).

• The patient presents with an isolated perianal disease, vomiting from jejunal stricture, or severe oral ulceration.

• Physical examination reveals evidence of weight loss.

• Abdominal tenderness is generally palpated near the inflamed area.

• An abdominal mass may be palpable.

• Thickened bowel.

• Intra abdominal abscess.

• Fistula.

What Is the Complication of Crohn’s Disease?

The following are the complications of Crohn’s disease:

1. Life-Threatening Colonic Inflammation -Most extreme cases, the colon dilates, and bacteria enter the portal and systemic circulation. This complication arises most commonly during the first attack of colitis. Severe colonic inflammation with toxic dilatation is a surgical emergency and most often requires colectomy (colon removal).

2. Hemorrhage - Leakage of blood due to rupture of the major artery is rare but can occur in Crohn's disease.

3. Fistulae - These are specific to Crohn’s disease. It is the abnormal connection made between body structure. Enteroenteric fistulae can cause diarrhea and malabsorption. Enterovesical fistulation causes recurrent urinary infections. An enterovaginal fistula causes a vaginal discharge.

4. Cancer - The risk of cancer increases with the duration and extent of uncontrolled colonic inflammation. This patient has long-standing extensive colitis and is at the highest risk.

5. Extra Intestinal Complication - Extraintestinal complications are more common in irritable bowel diseases such as

• Mouth ulcers.
• Fatty liver.
• Liver abscess.
• Arthritis.
• Gallstones.

What Is the Treatment of Crohn’s Disease?

Medical therapy plays an important role. The best treatment results are obtained by establishing a team-based approach involving physicians, surgeons, radiologists, neuro-specialists, and dieticians. Crohn's disease is a lifelong condition with important psychological implications; Specialist nurses, counselors, and patient support groups have critical roles in education and coping.

The key aims of medical therapy are to

• Treat acute attacks.

• Prevent relapses.

• Prevent bowel damage.

• Prevent carcinoma.

• Select appropriate patients for surgery.

Crohn's disease is treated in the following ways -

1) Drugs -

• Glucocorticoids remain the mainstay of treatment for active Crohn's disease. The drug of the first choice in a patient with Crohn's disease is Budesonide since it has very little systemic toxicity.

• Oral Prednisolone is the treatment of choice for Crohn's disease.

• Patients who take glucocorticoids should be given calcium and vitamin D supplements.

• Antibiotics such as Metronidazole or Ciprofloxacin can aid healing.

• An antidiarrheal agent such as Loperamide, etc., improves anal function.

• An anti-inflammatory like Methotrexate drugs can be effective.

• Anti-TNF antibodies (Infliximab and Adalimumab) suppress inflammation and heal fistula and perianal disease.

• Immunosuppressive treatment with thiopurines forms the core of maintenance therapy.

• Methotrexate is also effective and can be given orally or subcutaneously once weekly.

2) Surgical Treatment -

Historical data show that around 80 out of 100 patients with Crohn’s disease undergo surgery at some stage, and 70 out of 100 patients require more than one operation during their lifetime. Emerging data demonstrate that aggressive medical therapy coupled with intense monitoring probably reduces the requirement of the surgery substantially.

• Surgical intervention by removing the colon and rectum cures the patient.

• Surgery should be as conservative as possible to minimize the loss of viable intestines and avoid creating a short bowel syndrome (intestinal failure).

• Patient counseling before surgery by doctors, nurses, and patients who have undergone similar surgery.

• The fistula may develop with active Crohn’s disease and is often associated with sepsis. The first step is to define the site by imaging (usually an MRI of the pelvis).

• Surgical exploration by an examination under anesthetic is usually required to drain the abscess.

• Operations are often necessary to deal with the fistula, abscess, or perianal disease and may also be required to relieve small or large bowel obstruction.

• Obstructing small boweldisease may require resectioning the affected tissue.

Post-Operative - The only method that has constantly been shown to reduce post-operative reoccurrence is smoking cessation. Antibiotics are effective for the short term only. The use of Thiopurines is suggested after surgery. The use of antibiotics such as metronidazole and ciprofloxacin can aid healing. Crohn's disease patients should be advised to stop smoking if in the habit.

What Is the Quality of Life of Pediatric Crohn’s Disease Patients in Relation to Surgery?

A specialized pediatric gastroenterologist should manage children with Crohn's disease and get care in a dedicated clinic. Treatment is similar to that described for adults and may require glucocorticoids, an immunosuppressive drug, biological agents, and surgery.

Surgery affects the quality of life of the child in many ways;

1) Delayed Growth and Pubertal Development - Chronic active inflammation, malabsorption, malnutrition, and long-term glucocorticoids contribute to short and delayed development, with physical and psychological consequences.

2) Metabolic Bone Disease - It is more common with chronic disease beginning in childhood, resulting from chronic inflammation, dietary deficiency, and calcium and vitamin D malabsorption.

3) Drug Side Effects and Issues - Young people are more likely to require Azathioprine or biological therapy than adults. The younger patient may not feel well, lack self-motivation, and believe that drugs are ineffective or causing the side effect.

4) Loss of Time From Education - Children can feel physically ill and exhausted, experience issues with privacy and dignity, and social isolation may all contribute.

5) Emotional Difficulties - These may result from challenges in coping with illness, a problem with forming interpersonal relationships, and issues relating to body image or sexual function.

The Aim in Treating Pediatric Patients With Crohn’s Disease:

• Induce and maintain clinical remission.

• Optimize nutrition.

• Optimize bone health in children.

• Optimize growth and pubertal progress.

• Minimize adverse drug effects.

Conclusion

Children with Crohn's disease should be properly monitored as they deal with emotional difficulties, and sexual development is crucial to optimize growth and pubertal progress. Due to frequent surgery and hospitalization, children may suffer from psychological issues. Parents should consult a psychologist if required.