Crohns Disease and Fibromyalgia

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Crohn’s disease is a condition marked by severe inflammation of the intestines. Specific areas of inflammation vary among affected individuals. For example, some people only experience inflammation in their small intestine, whereas others experience it only in the colon (a portion of the large intestine). However, the most commonly affected areas among all individuals with Crohn’s disease include the ileum (the end part of the small intestine) and the colon. When inflammation is limited only to the intestinal wall, it can result in scarring and stenosis (blockage) of the intestines. When it spreads through the bowel wall, it can result in what is known as a fistula, or abnormal connection between two body parts.

No one knows exactly what causes Crohn’s disease. Although diet and stress have been known to aggravate the condition, they do not cause it to develop. Some researchers believe that a virus or bacteria may lead to the development of Crohn’s disease, by triggering the body’s immune system to abnormally attack the digestive tract. In addition, individuals with a family history of Crohn’s disease are more likely to develop it than those who have no family history, which suggests that genetic influences may also play a role.

In terms of risk factors, a few common factors have been identified in addition to family history. Most individuals with Crohn’s disease are diagnosed before the age of 30, although it can occur at any age. Race and ethnicity are also risk factors. Whites have the highest risk of developing Crohn’s disease; however, white individuals of eastern European descent (in particular Ashkenazi Jewish descent) have the greatest risk. In addition, cigarette smoking also increases the risk of developing Crohn’s disease, and is the most controllable risk factor. Individuals who smoke not only run a higher risk of developing Crohn’s disease, but they also tend to have more severe symptoms. Finally, individuals who live in urban areas or in industrialized countries, as well as those in northern climates, are more likely to develop Crohn’s disease.

Just like its presentation, the symptoms of Crohn’s disease vary among individuals and may occur suddenly or gradually over time. Individuals with Crohn’s disease may also go into remission, which is a period of  no symptoms at all. However, when Crohn’s disease is active, the most common symptoms include diarrhea, abdominal pain and cramping, blood in the stool, ulcers, decreased appetite, and weight loss. Other, less-common symptoms include fever, fatigue, arthritis, inflammation of the eyes, mouth sores, skin disorders, liver and bile duct inflammation, and delayed grown or sexual development (in children)

A number of complications can arise from Crohn’s disease. Since it affects the thickness of the intestinal walls, it can cause parts of the intestines to thicken and narrow, which may result in blockage of the flow through the intestines. This can require surgery to remove the diseased intestine. In addition, open sores (ulcers) can develop in the mouth, anus, genital area, and digestive tract. Fistulas can also occur, creating abnormal connections between the intestines and skin, or the intestines and other organs, such as the bladder and vagina. The can cause food to bypass crucial areas of the digestive system as it travels through the bowel, which can lead to decreased nutrient absorption. Fistulas can also become infected and form life-threatening abscess. In addition, Crohn’s disease increase can result in decreased appetite and weight loss, which can lead to malnutrition and anemia. Crohn’s disease also increases the risk of colon cancer, arthritis, kidney and gall stones, and osteoporosis.

The diagnosis of Crohn’s disease is usually one of exclusion, and made only after the possibility of irritable bowel syndrome, diverticulitis (painful inflammation of small folds and pounces lining the intestines), and colon cancer have been ruled out. Testing will usually involve blood tests to check for anemia, testing a stool sample to look for the presence of blood, colonoscopy (viewing the entire colon with a thin, flexible, lighted tube attached to a tiny camera), computerized tomography scan (CT scan; a non-invasive, detailed x-ray procedure used to take pictures of areas inside the body), magnetic resonance imaging (MRI; a non-invasive imaging test that uses radio waves and magnetic fields to take detailed pictures of areas inside the body), and other possible procedures.

Unfortunately, there is no cure for Crohn’s disease and no universally-effective treatment option for all individuals. Overall, the goal of treatment for Crohn’s disease is to reduce the inflammation that leads to its symptoms. This can be done with certain anti-inflammatory drugs, including sulfasalazine (Azulfidine), mesalamine (Asacol, Rowasa), and corticosteroids. Sulfasalazine is most effective for individuals’ whose Crohn’s disease affects the colon, whereas mesalamine causes fewer side effects but is usually ineffective for individuals who have disease in the small intestine. Although corticosteroids are effective at reducing inflammation, they have numerous side effects, including generalized swelling, excessive facial hair, night sweats, insomnia, and hyperactivity. They are also not recommended for long-term use.

In addition to anti-inflammatory medication, immune system suppressors can help to reduce inflammation by targeting the immune system response itself. Anti-immune drugs frequently used for Crohn’s disease include azathioprine (Imuran) and mercaptopurine (Purinethiol). In addition, adults and children with severe Crohn’s disease may benefit from treatment with infliximab (Renucade). Other possible therapies include adalimumag (Humira), certolizumab pegol (Cimzia), cyclosporine (Genraf, Neoral), and natalizumab (Tysabri). It is important to note, however, that immune suppression drugs may increase the risk of developing certain cancers, including lymphoma.

Other drugs that may be of benefit to individuals with Crohn’s disease include antibiotics such as metronidazole (Flagyl) and ciprofloxacin (Cipro), as well as over-the-counter medications including anti-diarrheals, laxatives, and pain relievers. Vitamin supplements, such as vitamin B-12, calcium, and vitamin D may also be necessary for the treatment of anemia and malnourishment. Finally, diets low in dairy, fat, and fiber (for some people) can help lessen symptoms of Crohn’s disease. Stress and smoking should also be avoided.

A number of natural therapies have been investigated for their use in treating Crohn’s disease. Glutamine and lactobacillus have been studied, but neither has been shown to be helpful at improving symptoms (Den Hond et al., 1999; Akobeng et al., 2000; Zoli et al., 1995). Preliminary evidence suggests that chitosan, fish oil, fluoride, Indian frankincense, and saccharomyces boulardii might help to improve various symptoms of Crohn’s disease, but findings are inconsistent are more research is needed.

Research

The research related to fibromyalgia and Crohn’s disease is limited. A 2001 study by Palm et al. assessed the prevalence of fibromyalgia and chronic, widespread pain among patients with inflammatory bowel disease. Inflammatory bowel disease (IBD) is a general term used to collectively describe the separate conditions of Crohn’s disease and ulcerative colitis. In this study, the researchers evaluated 521 Norwegian patients with a confirmed diagnosis of either ulcerative colitis (353) or Crohn’s disease (168), in order to determine the prevalence of fibromyalgia. They found that 3.5% (18) of all patients combined met the American College of Rheumatology (ACR) criteria for a diagnosis of fibromyalgia. Prevalence rates were similar between the two conditions, with 13 (3.7%) ulcerative colitis patients meeting the criteria for fibromyalgia diagnosis, compared to five (3.0%) of the Crohn’s disease patients (Palm et al., 2001).

These prevalence rates contrast sharply with those published in a 1999 paper by Buskila et al. In that study, researchers examined 72 patients with ulcerative colitis and 41 patients with Crohn’s disease to determine the prevalence of fibromyalgia, as well as to assess pain thresholds in both groups of patients. Of the 41 patients with Crohn’s disease in this study, 49% met the ACR criteria for a diagnosis of fibromyalgia, versus 30% of the patients with ulcerative colitis. In addition, patients with Crohn’s disease reported increased tenderness and more severe and frequent fibromyalgia symptoms. They also had higher tender point counts. In contrast to the findings of Palm et al., the results of this study suggest a high prevalence of fibromyalgia among patients with Crohn’s disease.

In light of the small number of research studies that have examined the relationship between Crohn’s disease and fibromyalgia, as well as the limitations of existing studies (e.g., small sample sizes), further research is needed in order to better understand the relationship between Crohn’s disease and fibromyalgia.

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References

1.        Crohn’s Disease. The MayoClinic. August 9, 2011; Accessed June 18, 2012.

2.        Den Hond E, Hiele M, Peeters M, et al. Effect of long-term oral glutamine supplements on small intestinal permeability in patients with Crohn’s disease. J Parenter Enteral Nutr. 1999;23:7-11.

3.        Akobeng AK, Miller V, Stanton J, et al. Double-blind, randomized, controlled trial of glutamine-enriched polymeric diet in the treatment of active Crohn’s disease. J Pediatr Gastroenterol Nutr . 2000;30:78-84.

4.        Zoli G, Care M, Falco F, et al. Effect of oral glutamine on intestinal permeability and nutritional status in Crohn’s disease [abstract]. Gastroenterology. 1995;108:A766.

5.        Palm O, Moum B, Jahnsen J, Gran JT. Fibromyalgia and chronic widespread pain in patients with inflammatory bowel disease: a cross sectional population survey. J Rheumatol. 2001;28(3):590-594.

6.        Buskila D, Odes LR, Neumann L, Odes HS. Fibromyalgia in inflammatory bowel disease. J Rheumatol. 1999;26(5):1167-1171.

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