Crohn's Disease

2006-10-12T14:22:00.000-07:00

Crohn's Disease: What it is

Crohn's disease is a type of inflammatory bowel disease (IBD), named for one of the physicians who first described the disease. Crohn’s disease is an ongoing disorder that causes inflammation of the digestive tract, also referred to as the gastrointestinal (GI) tract. Crohn’s disease can affect any area of the GI tract, from the mouth to the anus, but it most commonly affects the lower part of the small intestine, called the ileum. The swelling extends deep into the lining of the affected organ. The swelling can cause pain and can make the intestines empty frequently, resulting in diarrhea.
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Because the symptoms of Crohn’s disease are similar to other intestinal disorders, such as irritable bowel syndrome and ulcerative colitis, it can be difficult to diagnose. Ulcerative colitis causes inflammation and ulcers in the top layer of the lining of the large intestine. In Crohn’s disease, all layers of the intestine may be involved, and normal healthy bowel can be found between sections of diseased bowel.
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Crohn’s disease affects men and women equally and seems to run in some families. About 20 percent of people with Crohn’s disease have a blood relative with some form of inflammatory bowel disease, most often a brother or sister and sometimes a parent or child. Crohn’s disease can occur in people of all age groups, but it is more often diagnosed in people between the ages of 20 and 30. People of Jewish heritage have an increased risk of developing Crohn’s disease, and African Americans are at decreased risk for developing Crohn’s disease.
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Because it is a systemic disease, it can also cause complications outside of the gastrointestinal tract. The main gastrointestinal symptoms are abdominal pain and diarrhea, which may be bloody.
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Many patients with Crohn's disease have symptoms for years prior to the diagnosis. Because of the patchy nature of the gastrointestinal disease and the depth of tissue involvement, initial symptoms can be more vague than with ulcerative colitis.

Crohn's disease may be classified according to the extent of involvement of the gastrointestinal tract:
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..1. Crohn's ileitis affecting the area the ileum
..2. Crohn's colitis affecting the colon
..3. Ileocolic Crohn's disease: The disease may affect both.the ileum and the large intestine. Fifty percent of cases involve both the ileum and the colon
..4. Peri-anal Crohn's disease: The disease may affect the area around the anus.
..5. Other:

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Digestive Diseases Library

2006-10-12T11:05:00.000-07:00

Causes and Symptoms of Crohn's Disease

What causes Crohn's disease?
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Several theories exist about what causes Crohn’s disease, but none have been proven. The human immune system is made from cells and different proteins that protect people from infection. The most popular theory is that the body’s immune system reacts abnormally in people with Crohn’s disease, mistaking bacteria, foods, and other substances for being foreign. The immune system’s response is to attack these “invaders.” During this process, white blood cells accumulate in the lining of the intestines, producing chronic inflammation, which leads to ulcerations and bowel injury.
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Scientists do not know if the abnormality in the functioning of the immune system in people with Crohn’s disease is a cause, or a result, of the disease. Research shows that the inflammation seen in the GI tract of people with Crohn’s disease involves several factors:
.....1. the genes the patient has inherited;
.....2. the immune system itself; and
.....3. the environment.

Foreign substances, also referred to as antigens, are found in the environment. One possible cause for inflammation may be the body’s reaction to these antigens, or that the antigens themselves are the cause for the inflammation. Some scientists think that a protein produced by the immune system, called anti-tumor necrosis factor (TNF), may be a possible cause for the inflammation associated with Crohn’s disease.

This is one study of the cause of Crohn's Disease:

Chronic intestinal inflammation can develop via many different mechanisms, which strongly suggests that Crohn's disease and ulcerative colitis are heterogeneous diseases with similar final common pathways. This heterogeneity exists at genetic, phenotypic, immunologic, bacteriologic and therapeutic levels. It is highly likely that each IBD subtype will have unique responses to various treatments, explaining the lack of a universal therapeutic response to any single agent, but raising the possibility that treatment tailored for a specific subtype is highly likely to succeed.

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Chronic intestinal inflammation results from the interactions of genetic, immunologic, microbial and environmental factors. I propose that IBD results from the failure to appropriately downregulate nonspecific inflammation initiated by an environmental trigger, such as an acute, self-limited infection or NSAID use. Normal hosts quickly clear infections of invasive enteric bacteria, downregulate innate immune responses and heal the injured mucosa without stimulating effector T-cell responses. By contrast, genetically susceptible hosts who are unable to clear an invading pathogen and/or generate tolerogenic immune response to commensal microbial agents—by mounting appropriate innate immunity, downregulating immune responses or healing the mucosal barrier—subsequently activate pathogenic T-cell responses to commensal bacteria and proceed to chronic, relapsing intestinal inflammation. Resistance to T-cell apoptosis, lack of response to downregulatory signals and continuous exposure to luminal antigens and adjuvants help sustain this inflammatory response.
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Different responses to transient intestinal injury in genetically susceptible versus genetically resistant hosts.

After nonspecific injury from an environmental trigger, such as an infection or exposure to a nonsteroidal anti-inflammatory drug (NSAID), normal hosts rapidly repair the mucosal defect and downregulate innate and T-cell immune responses with no residual tissue damage. By contrast, individuals in whom immunoregulation, epithelial barrier function or bacterial killing is defective, develop chronic inflammation that is mediated by aggressive T-cell responses to commensal bacterial antigens. Chronic inflammation is perpetuated by continued uptake of luminal antigens. With permission © American Gastroenterological Association Institute, Bethesda, MD.
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Many environmental factors can influence mucosal immune responses and enteric bacteria composition, including diet, smoking, stress, altered microenvironment and NSAID exposure. Although I postulate that self-limited, nonspecific infections can initiate the onset of chronic inflammation and reactivate quiescent disease, it is possible that a persistent pathogen could cause disease in individuals unable to clear infections (i.e. those with certain CARD15 polymorphisms), or that the commensal bacteria of some patients could acquire virulence factors (e.g. toxins, adherence and/or invasion properties) that might cause chronic intestinal inflammation. Our current lack of complete understanding of the precise molecular mechanisms of disease pathogenesis makes this topic seem to be exceedingly complex; however, it is highly likely that further insights will allow us to conceptually characterize IBD into a spectrum of related, but distinct, subgroups that have clear etiologies, pathogenic processes and predictable responses to customized therapy.

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What are the symptoms?
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The most common symptoms of Crohn’s disease are:

.....1. abdominal pain, often in the lower right area; and
.....2. diarrhea.
.....3. These also might often occur:
..........a. Rectal bleeding;
..........b. weight loss;
..........c. arthritis;
..........d. skin problems; and
..........e. fever.

Bleeding may be serious and persistent, leading to anemia. Children with Crohn’s disease may suffer delayed development and stunted growth. The range and severity of symptoms varies.

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Digestive Diseases Library

2006-10-12T10:37:00.000-07:00

Diagnosing Crohn's Disease

How is Crohn's disease diagnosed?
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A thorough physical exam and a series of tests may be required to diagnose Crohn’s disease.
Blood tests may be done to check for anemia, which could indicate bleeding in the intestines. Blood tests may also uncover a high white blood cell count, which is a sign of inflammation somewhere in the body. By testing a stool sample, the doctor can tell if there is bleeding or infection in the intestines.
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The doctor may do an upper GI series to look at the small intestine. For this test, the person drinks barium, a chalky solution that coats the lining of the small intestine, before x rays are taken. The barium shows up white on x-ray film, revealing inflammation or other abnormalities in the intestine. If these tests show Crohn’s disease, more x rays of both the upper and lower digestive tract may be necessary to see how much of the GI tract is affected by the disease.
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The doctor may also do a visual exam of the colon by performing either a sigmoidoscopy or a colonoscopy. For both of these tests, the doctor inserts a long, flexible, lighted tube linked to a computer and TV monitor into the anus. A sigmoidoscopy allows the doctor to examine the lining of the lower part of the large intestine, while a colonoscopy allows the doctor to examine the lining of the entire large intestine.

The doctor will be able to see any inflammation or bleeding during either of these exams, although a colonoscopy is usually a better test because the doctor can see the entire large intestine. The doctor may also do a biopsy, which involves taking a sample of tissue from the lining of the intestine to view with a microscope.
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Here is one of my colonoscopies showing many diseased areas.

To view another of my blog pages, click on Maddi's Spot, or continue with me on our study of Crohn's Disease

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Maddi's Spot

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I have just begun to form a new forum for people with digestive diseases. If you would like to learn more about these diseases, talk with people who understand what you are going through, get and give support and information, or you might want to moderate on this forum, please click to join below:
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Digestive Diseases Library

2006-10-12T10:19:00.000-07:00

Complications of Crohn's Disease

I. Crohn's Disease is:

A disease of unknown causation. Many of the following symptoms, which are outside of the gastrointestinal tract, would also be symptoms of a chronic, untreated infection. These symptoms, however, may persist in a patient with Crohn's disease, even after all identifiable infections have been sucessfully treated. If the disease is cause by an infection, that infection remains unknown. The prevalent theory is that the immune system is responding as though there were an infection, even though none is present. Crohn's disease is therefore usually regarded as an auto-immmune disease.

A systemic disease: many other organ systems aside from the gastrointestinal tract can be involved.

II. Extraintestinal symptoms include the following:
..1. Aphthous: ulcers of the mouth
..2. Opthalmic involving the eye:
..........A. Iritis or uveitis (inflammations of the eye;)
..........B. Episcleritis (inflammation of the sclera
..3. Musculoskeletal:
..........A. Seronegative arthritis, which can be a large-joint oligoarthritis (affecting one or two joints), or may affect many small joints of the hands and feet;
..........B. Ankylosing spondylitis, arthritis of the spine;
..........C. Sacroiliitis, arthritis of the lower spine.
..4. Cutaneous (related to the skin):
..........A. Erythema nodosum, painless panniculitis (inflammation of subcutaneous tissue);
..........B. Pyoderma gangrenosum, a painful ulcerating lesion involving the skin;
..5. Deep venous thrombosis and pulmonary embolism;
..6. autoimmune hemolytic anemia;
. .7. clubbing, a deformity of the ends of the fingers.
. .8. Primary Sclerosing Cholangitis: a type of inflammation of the bile ducts, occurs less commonly than in ulcerative colitis osteoporosis, or thinning of the bones.

I have Crohn's Disease with: Rheumatoid Arthritis, Iritis, Aphthous, Deep Vein Thrombosis, Osteoporosis. Oh, Pitiful!

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To learn about another disease, click on Digestive diseases Library, or continue with me on our study of Crohn's Disease.

Digestive Diseases Library

2006-10-12T10:05:00.000-07:00

Treatment for Crohn's Disease

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What is the treatment for Crohn's disease?
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Treatment may include drugs, nutrition supplements, surgery, or a combination of these options. The goals of treatment are to control inflammation, correct nutritional deficiencies, and relieve symptoms like abdominal pain, diarrhea, and rectal bleeding. At this time, treatment can help control the disease by lowering the number of times a person experiences a recurrence, but there is no cure. Treatment for Crohn’s disease depends on the location and severity of disease, complications, and the person’s response to previous medical treatments when treated for reoccurring symptoms.
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Some people have long periods of remission, sometimes years, when they are free of symptoms. However, the disease usually recurs at various times over a person’s lifetime. This changing pattern of the disease means one cannot always tell when a treatment has helped. Predicting when a remission may occur or when symptoms will return is not possible.

One way to help in having longer remission periods is to not smoke.

Smoking and Your Digestive System
Cigarette smoking causes many life-threatening diseases, including lung cancer, colon cancer, emphysema, and heart disease. Each year more than 400,000 Americans die from cigarette smoking. One in every five deaths in the United States is smoking related. Estimates show that about one-third of all adults smoke. Adult men seem to be smoking less, but women and teenagers of both sexes seem to be smoking more. Smoking affects the entire body, including the digestive system.

What are the harmful effects of smoking on my digestive system?
Smoking can harm all parts of the digestive system, contributing to such common disorders as heartburn and peptic ulcers. Smoking increases the risk of Crohn's disease, and possibly gallstones, which form when liquid stored in the gallbladder hardens into pieces of stone-like material. Smoking also damages the liver.

Heartburn
Heartburn is common with more than 50 million Americans having it at least once a month and about 15 million having it daily.

Heartburn is a symptom of a syndrome called gastroesophageal reflux (GER). GER is when the natural acidic juices in the stomach flow backwards into the esophagus—the tube that connects the mouth to the stomach. Acidic juices are made by the stomach to help break down food. The stomach is naturally protected from acidic juices, but the esophagus does not have the same protection. Normally, a muscular valve at the lower end of the esophagus, called the lower esophageal sphincter (LES), keeps the acids in the stomach and out of the esophagus. Smoking, however, weakens the LES, which allows stomach acid to flow into the esophagus. When stomach acid comes in contact with the esophagus, the inner lining can become injured or damaged.

Peptic Ulcer
A peptic ulcer is a sore on the lining of the stomach or duodenum, which is the beginning of the small intestine. Peptic ulcers are common: One in 10 Americans develops an ulcer at some time in his or her life. One cause of peptic ulcer is bacterial infection, but some ulcers are caused by long-term use of nonsteroidal anti-inflammatory agents (NSAIDs), like aspirin and ibuprofen (Advil). In a few cases, cancerous tumors in the stomach or pancreas can cause ulcers. Peptic ulcers are not caused by stress or eating spicy food, but these can make ulcers worse.

Research has shown that people who smoke cigarettes are more likely to develop an ulcer. If people with an ulcer keep smoking, their ulcer may not heal; or it may take longer than usual to heal. People have a better chance of their ulcer healing if they stop smoking compared to treating their ulcer with medication while still smoking. Smoking also increases people’s risk of infection from a bacterium called Helicobacter pylori and increases the risk of ulceration from alcohol and over-the-counter pain relievers.

Stomach acid also plays a part in producing ulcers. Normally, stomach acid is absorbed by the food we eat. The acid that is not absorbed by food enters the duodenum and is quickly neutralized by sodium bicarbonate, a salt-like substance made by the pancreas—an organ located next to the duodenum that aids in digestion. Some studies show that smoking reduces the amount of bicarbonate in the body, which causes problems in the neutralization of acid in the duodenum. Other studies suggest that cigarette smoking may increase the amount of acid secreted by the stomach over time.

Liver Disease
The liver is an important organ that has many tasks. The liver is responsible for processing drugs, alcohol, and other toxins and removing them from the body. Research shows that smoking harms the liver’s ability to process such substances. In some cases, if the liver has been damaged from cigarette smoking, the dose of medication necessary to treat an illness may be affected. Research also suggests that smoking can worsen liver disease caused by drinking too much alcohol.

Crohn's Disease
Crohn's disease causes swelling deep in the lining of the intestine. The disease, which causes pain and diarrhea, most often affects the small intestine, but it can occur anywhere in the digestive tract. Research shows that current and former smokers have a higher risk of developing Crohn's disease than nonsmokers. Among people with Crohn’s disease, smoking is linked with a higher rate of relapse, repeat surgery, and the need for drug therapy. Women have a higher risk of relapsing and needing surgery and treatment than men whether they are current or former smokers. Why smoking increases the risk of Crohn's disease is unknown, but some researchers believe that smoking might lower the intestines defenses, decrease blood flow to the intestines, or cause immune system changes that result in inflammation.

Gallstones
Several studies show that smoking may increase the risk of developing gallstones and that the risk may be higher for women. However, research results on this topic are not consistent and more study is needed.

Can the damage be reversed?
Some of the effects of smoking on the digestive system appear to be of short duration. For example, the effect of smoking on the pancreas’s bicarbonate production does not appear to last. Within a half-hour after smoking, the production of bicarbonate returns to normal. The effects of smoking on how the liver handles drugs also disappear when a person stops smoking. However, people who no longer smoke still remain at risk for Crohn's disease.

For More Information
Office on Smoking and Health
National Center for Chronic Disease Prevention and Health Promotion
Mail Stop K-50
4770 Buford Highway NE.
Atlanta, GA 30341–3717
Phone: 1–800–CDC–1311 (232–1311)
Fax: 1–888–CDC–FAXX (888–232–3299)
Email: tobaccoinfo@cdc.gov
Internet: www.cdc.gov/tobacco

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National Digestive Diseases Information Clearinghouse
2 Information Way
Bethesda, MD 20892–3570
Email: nddic@info.niddk.nih.gov

The National Digestive Diseases Information Clearinghouse (NDDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1980, the Clearinghouse provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. The NDDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about digestive diseases.

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts.

This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired.

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NIH Publication No. 06–949
February 2006

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Someone with Crohn’s disease may need medical care for a long time, with regular doctor visits to monitor the condition.

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Digestive Diseases Library

2006-10-11T18:57:00.000-07:00

Drug Therapy

Anti-Inflammation Drugs. Most people are first treated with drugs containing mesalamine, a substance that helps control inflammation. Sulfasalazine is the most commonly used of these drugs. Patients who do not benefit from it or who cannot tolerate it may be put on other mesalamine-containing drugs, generally known as 5-ASA agents, such as Asacol, Dipentum, or Pentasa. Possible side effects of mesalamine-containing drugs include nausea, vomiting, heartburn, diarrhea, and headache.

Cortisone or Steroids. Cortisone drugs and steroids—called corticosteriods—provide very effective results. Prednisone is a common generic name of one of the drugs in this group of medications. In the beginning, when the disease it at its worst, prednisone is usually prescribed in a large dose. The dosage is then lowered once symptoms have been controlled. These drugs can cause serious side effects, including greater susceptibility to infection.

Immune System Suppressors. Drugs that suppress the immune system are also used to treat Crohn’s disease. Most commonly prescribed are 6-mercaptopurine or a related drug, azathioprine. Immunosuppressive agents work by blocking the immune reaction that contributes to inflammation. These drugs may cause side effects like nausea, vomiting, and diarrhea and may lower a person’s resistance to infection. When patients are treated with a combination of corticosteroids and immunosuppressive drugs, the dose of corticosteroids may eventually be lowered. Some studies suggest that immunosuppressive drugs may enhance the effectiveness of corticosteroids.

Infliximab (Remicade). This drug is the first of a group of medications that blocks the body’s inflammation response. The U.S. Food and Drug Administration approved the drug for the treatment of moderate to severe Crohn’s disease that does not respond to standard therapies (mesalamine substances, corticosteroids, immunosuppressive agents) and for the treatment of open, draining fistulas. Infliximab, the first treatment approved specifically for Crohn’s disease is a TNF substance. Additional research will need to be done in order to fully understand the range of treatments Remicade may offer to help people with Crohn’s disease.

Antibiotics. Antibiotics are used to treat bacterial overgrowth in the small intestine caused by stricture, fistulas, or prior surgery. For this common problem, the doctor may prescribe one or more of the following antibiotics: ampicillin, sulfonamide, cephalosporin, tetracycline, or metronidazole.

Anti-Diarrheal and Fluid Replacements. Diarrhea and crampy abdominal pain are often relieved when the inflammation subsides, but additional medication may also be necessary. Several antidiarrheal agents could be used, including diphenoxylate, loperamide, and codeine. Patients who are dehydrated because of diarrhea will be treated with fluids and electrolytes.

Nutrition Supplementation
The doctor may recommend nutritional supplements, especially for children whose growth has been slowed. Special high-calorie liquid formulas are sometimes used for this purpose. A small number of patients may need to be fed intravenously for a brief time through a small tube inserted into the vein of the arm. This procedure can help patients who need extra nutrition temporarily, those whose intestines need to rest, or those whose intestines cannot absorb enough nutrition from food. There are no known foods that cause Crohn’s disease. However, when people are suffering a flare in disease, foods such as bulky grains, hot spices, alcohol, and milk products may increase diarrhea and cramping.

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Digestive Diseases Library

2006-10-11T17:45:00.000-07:00

Surgery for Crohn's Disease

Surgery
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Two-thirds to three-quarters of patients with Crohn’s disease will require surgery at some point in their lives. Surgery becomes necessary when medications can no longer control symptoms. Surgery is used either to relieve symptoms that do not respond to medical therapy or to correct complications such as blockage, perforation, abscess, or bleeding in the intestine. Surgery to remove part of the intestine can help people with Crohn’s disease, but it is not a cure. Surgery does not eliminate the disease, and it is not uncommon for people with Crohn’s Disease to have more than one operation, as inflammation tends to return to the area next to where the diseased intestine was removed.
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Some people who have Crohn’s disease in the large intestine need to have their entire colon removed in an operation called a colectomy. A small opening is made in the front of the abdominal wall, and the tip of the ileum, which is located at the end of the small intestine, is brought to the skin’s surface. This opening, called a stoma, is where waste exits the body. The stoma is about the size of a quarter and is usually located in the right lower part of the abdomen near the beltline. A pouch is worn over the opening to collect waste, and the patient empties the pouch as needed. The majority of colectomy patients go on to live normal, active lives.

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Here are some suplies a person with a colostomy will need. There are different brand names to choose from, but this will give you an idea of what you might need:
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Sometimes only the diseased section of intestine is removed and no stoma is needed. In this operation, the intestine is cut above and below the diseased area and reconnected. If a stoma is needed due to the area of the resected portion of the diseased colon, the a stoma will be created from a protion of the non-diseased section of the colon, and colostomy supplies will be needed.

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Because Crohn’s disease often recurs after surgery, people considering it should carefully weigh its benefits and risks compared with other treatments. Surgery may not be appropriate for everyone. People faced with this decision should get as much information as possible from doctors, nurses who work with colon surgery patients (enterostomal therapists), and other patients. Patient advocacy organizations can suggest support groups and other information resources. (Scroll below For More Information for the names of such organizations.)
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People with Crohn’s disease may feel well and be free of symptoms for substantial spans of time when their disease is not active. Despite the need to take medication for long periods of time and occasional hospitalizations, most people with Crohn’s disease are able to hold jobs, raise families, and function successfully at home and in society.

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Digestive Diseases Library

2006-10-11T17:42:00.000-07:00

Diet and Crohn's Disease

Can diet control Crohn's disease?
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People with Crohn’s disease often experience a decrease in appetite, which can affect their ability to receive the daily nutrition needed for good health and healing. In addition, Crohn’s disease is associated with diarrhea and poor absorption of necessary nutrients. No special diet has been proven effective for preventing or treating Crohn’s disease, but it is very important that people who have Crohn’s disease follow a nutritious diet and avoid any foods that seem to worsen symptoms. There are no consistent dietary rules to follow that will improve a person’s symptoms.
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People should take vitamin supplements only on their doctor’s advice.

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Digestive Diseases Library

2006-10-11T15:52:00.000-07:00

Stress and Crohn's Disease

Can stress make Crohn’s disease worse?
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There is no evidence showing that stress causes Crohn’s disease. However, people with Crohn’s disease sometimes feel increased stress in their lives from having to live with a chronic illness. Some people with Crohn’s disease also report that they experience a flare in disease when they are experiencing a stressful event or situation. There is no type of person that is more likely to experience a flare in disease than another when under stress. For people who find there is a connection between their stress level and a worsening of their symptoms, using relaxation techniques, such as slow breathing, and taking special care to eat well and get enough sleep, may help them feel better.

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Digestive Diseases Library

2006-10-11T15:40:00.000-07:00

Pregnancy and Crohn's Disease

Is pregnancy safe for women with Crohn's Disease

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Research has shown that the course of pregnancy and delivery is usually not impaired in women with Crohn’s disease. Even so, women with Crohn’s disease should discuss the matter with their doctors before pregnancy. Most children born to women with Crohn’s disease are unaffected. Children who do get the disease are sometimes more severely affected than adults, with slowed growth and delayed sexual development in some cases.

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Digestive Diseases Library

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2006-10-11T15:12:00.000-07:00

Hope, Research, and Information

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Hope Through Research
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The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) conducts and supports research into many kinds of digestive disorders, including Crohn’s disease. Several clinical trials are currently evaluating the efficacy and safety of different therapies for the treatment of Crohn’s disease. For a complete listing of trials being conducted, visit http://www.clinicaltrials.gov/.

For More Information

Crohn's & Colitis Foundation of America
386 Park Avenue South, 17th Floor
New York, NY 10016–8804
Phone: 1–800–932–2423 or 212–685–3440
Email: info@ccfa.org
Internet: http://www.ccfa.org/

Reach Out for Youth with Ileitis and Colitis, Inc.
84 Northgate Circle
Melville, NY 11747
Phone: Phone: 631–293–3102
Email: reachoutforyouth@reachoutforyouth.org
Internet: http://www.reachoutforyouth.org/

United Ostomy Association, Inc.
19772 MacArthur Blvd #200
Irvine, CA 92612–2405
Phone: 1–800–826–0826 or 949–660–8624
Fax: 949–660–9262
Email: uoa@deltanet.com
Internet: http://www.uoa.org/

The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this document are used only because they are considered necessary in the context of the information provided. If a product is not mentioned, the omission does not mean or imply that the product is unsatisfactory.

National Digestive Diseases Information Clearinghouse
2 Information Way
Bethesda, MD 20892–3570
Email: nddic@info.niddk.nih.gov

The National Digestive Diseases Information Clearinghouse (NDDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health under the U.S. Department of Health and Human Services. Established in 1980, the Clearinghouse provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. The NDDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about digestive diseases.

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. This publication was reviewed by the Crohn’s and Colitis foundation of America.

This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired.

To learn about another disease, click on Digestive diseases Library.

Digestive Diseases Library

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2006-09-12T11:28:00.000-07:00

Granuloma
From Wikipedia, the free encyclopedia

Classification and external resources

H&E section of non-caseating granuloma seen in the colon of a patient with Crohn's disease

ICD-9
686.1
MeSH
D006099

In medicine (anatomical pathology), a granuloma (classical Latin plural granulomata; modern anglicized plural granulomas, used throughout this article, also accepted) is a nodule consisting mainly of epithelioid macrophages and other inflammatory and immune cells as well as extracellular matrix.[1]. They are often surrounded by a lymphocyte cuff[2] or fibrosis.
Broadly speaking, granulomas form when the immune system fends off and isolates an antigen but is unable to completely destroy it. The antigen is most often an infectious pathogen or a foreign body, but in many cases the offending antigen is not apparent(as in autoimmune disorders).

Granulomas are seen in a variety of diseases, infectious and non-infectious. Infections that are characterized by the presence of granulomas include tuberculosis, leprosy, histoplasmosis, cryptococcosis, blastomycosis, coccidioidomycosis and syphilis. The major non-infectious granulomatous diseases are sarcoidosis, Crohn's disease, berylliosis, Wegener's granulomatosis, Churg-Strauss syndrome, pulmonary rheumatoid nodules and aspiration of food and other particulate material into the lung. This classification of granulomas (infectious vs. non-infectious) should be used with caution as the both an infection and aberrant or inadequate immune response may contribute in some lesions. For example it has long been suspected that sarcoidosis might be caused by Propionibacterium acnes. On the other hand, the disease also clearly displays autoimmune characteristics and is often accompanied by endocrine problems[3][4].

An important feature of granulomas is whether they contain necrosis or not. Necrosis is a medical term for "cell death". Under the microscope, dead cells appear as a mass of formless debris. A related term, "caseation" (literally: turning to cheese) refers to a form of necrosis that, to the unaided eye, appears cheese-like, and is typically (but not uniquely) a feature of the granulomas of tuberculosis. The identification of necrosis in granulomas is important because granulomas with necrosis tend to have infectious causes. There are several exceptions to this general rule, but it nevertheless remains useful in day-to-day diagnostic pathology.

Types

Tuberculous granuloma
A poorly formed mycobacterial granuloma
The tuberculous granuloma (caseating tubercule): central caseous necrosis bordered by giant multinucleated cells (Langhans giant cell), and surrounded by epithelioid cells aggregates, lymphocytes and fibroblasts. Granulomatous tubercules tend to confluence. Multinucleated giant cell (Langhans giant cell): 50-100 micrometres, numerous small nuclei (over 20) disposed at the periphery of the cell (crown or horseshoe), abundant eosinophilic cytoplasm. It results when activated macrophages merge. Epithelioid cells are activated macrophages resembling epithelial cells: elongated, with finely granular, pale eosinophilic (pink) cytoplasm and central, ovoid nucleus. They have indistinct shape contour and form aggregates. At the periphery are the lymphocytes (T cells) and rare plasma cells and fibroblasts. Caseous necrosis is a central area, amorphous, finely granular, eosinophilic (pink). If recent, it may contain nuclear fragments. The caseum is the result of the accumulated destruction of giant cells and epithelioid cells.
Chronic granulomatous disease
In the rare condition chronic granulomatous disease, neutrophil granulocyte function is impaired and granulomas form in various organs in response to infection, as the infection is not being contained through normal means.
Granulomas of Sarcoidosis
Granulomas seen in Sarcoidosis are nodal aggregates of epithelioid cells, similar to epithelioid tubercules of tuberculosis. However, the quantity of necrosis is low and it is noncaseating. Multinucleated giant cells of Langhans cell type and foreign-body type giant cells are present, however they are less numerous and can be star-shaped (asteroid bodies) or lamellar (Schaumann bodies). These inclusions are not sarcoidose-specific. Some fibrous tissue and lymphocytes are present on the periphery.
These granulomas can resorb or heal with a scar. In the lungs this can cause disseminated pulmonary fibrosis; in cardiac tissue they may cause impaired heart function and possibly death by heart failure.
Rheumatic myocarditis
Rheumatic fever affects all the heart tissue (rheumatic pancarditis). From all the pathological changes, only the granulomas, called Aschoff granulomas, are pathognomonic, often located perivascularly. In the centre, fibrinoid necrosis is visible. It is encompassed by lymphocytes, plasma cells, fibroblasts and individual neutrophils. Also mononuclear Anitschkow's cells (histiocytes) and characteristic Aschoff giant cells are present (these latter represent multinucleated macrophages). Anitschkow's cells appear like an owl's eye and have abundant pale eosinophilic cytoplasm with a characteristic "caterpillar" or lacy nucleole in the bright nucleus. They are often arranged in a palisade around the center. Aschoff cells have a single or multiple bean-shaped nuclei. Peripherally, fibroblasts and sclerotic fibrous tissue can be seen. The granuloma sometimes immediately borders partially fragmented muscle fibers. Ultimately, rheumatic heart disease results in a "fish mouth" appearing stenosis of the mitral valve, causing left atrial dilation, right ventricular hypertrophy, and mural thrombi. Patients are predisposed to endocarditis and CHF.
Gumma hepatitis
The less common form of the third stage of syphilis. Gummas are of different sizes: smaller ones are miliary and more numerous, while the larger ones that are more common, are solitary and elastic. Gumma can develop in different tissues and organs, especially in bones, brain, liver, skin, testis and elsewhere. Contrary to the tuberculous granuloma, in the elastic coagulative central necrosis of the gumma, which is eosinophilic and of grey yellowish colour, there is still some silhouette of the previous tissue visible. The granuloma is encompassed by the grey whitish fibrous envelope, that sometimes sends radial ribbons in the surrounding area. In between, there are lymphocytes, plasma cells and giant cells from capillaries and rare epitheloid cells, and on the periphery lymphocytes and plasma cells are present. By healing, gumma transforms in a large scar that can for example disfigure liver with deep furrows (hepar lobar syphiliticum).
Granulomas in Aspiration Pneumonia
Granulomas may form when food particles are aspirated into the lungs. Patients typically aspirate food because they have esophageal, gastric or neurologic problems. Intake of drugs that depress neurologic function may also be causal. The resultant granulomas are typically found around the airways (bronchioles) and are often accompanied by foreign-body-type multinucleated giant cells, acute inflammation or organizing pneumonia. The finding of food particles in lung biopsies is diagnostic [5]..