Smoking Cessation
CD is more common among smokers than non-smokers. Smoker’s also experience more severe symptoms of CS and are at a greater risk for experiencing complications related to CD and/or needing surgery. Smoking also reduces the effectiveness of CD medications resulting in more flare-ups occurring more frequently. Recurrence of the condition following surgery is also likely to occur more rapidly and at a greater severity in smokers. However, quitting all smoking immediately can also exacerbate CD symptoms and induce flare-ups. The resulting flare-ups then often act as triggers that make the patient start smoking again, to relieve their symptoms temporarily. It is not clear which ingredient in cigarettes causes CD conditions to worsen. It is believed that nicotine may be one of the ingredients, since nicotine patches and gum also induce flare-ups.
One therapy that may aid in reducing smoking behavior gradually is the antidepressant, Zyban (generic name bupropion). This therapy takes approximately one month before it is completely effective. It significantly reduces long –term smoking than other treatments such as the patch. However, this treatment does have side effects:
- Drowsiness
- Dizziness
- Headaches
- Dry mouth
- Excitability
- Excessive sweating
- Uncontrollable shaking
- Constipation
- Nausea
- Vomiting
- Weight loss
- Seizures
Cessation of smoking for just 6 months results in reduced CD flare-ups by up to 65%.
Surgery
In severe cases, surgery may be needed. Unlike in the case of Ulcerative Colitis, where removal of the diseased tissue can cure the disease, surgery can only help alleviate the symptoms or complications related to Crohn’s disease. Surgery is not used as a cure or solo treatment, but as one part of a strong, advanced multi-strategy treatment recommended by an experienced gastroenterologist. In fact, because it does not cure the disease, up to 30% of patients will need multiple surgeries over the lifetime of the disease as it reoccurs. It is typically done when the patient is experiencing transmural inflammation. Because multiple surgeries are common, the surgeon must also consider what sections of the intestine are removed, since removal of future tissue will be likely. One of the main reasons for reoperation is due to obstruction caused by stricture formation, which is excessive collagen deposits and smooth muscle cell accumulation in the bowel. Build up can often occur during wound healing, when scar collagen can cause a reduction in wound size. Excessive contraction can lead to tissue distortion and a shortening of the bowel (contracture). There are techniques that can be done during surgery to reduce the chances of stricture formation after surgery, such as strictureplasty techniques.
Another concern related to reoperation is the potential for bowel segments to adhere to other segments or to the abdominal wall. If inflammation remains, this could cause a hole to form between the adherent tissue or loops and eventually fistula formation. This can be a serious problem that can lead to death in a minority (7%) of patients. Thankfully, the occurrence of these fistulas has been significantly reduced by using a combination of nutritional dieting, medical and surgical treatments. Recently, grafts/mesh have been developed that can help reduce the occurrence of fistulas following surgery even further. Many steps must be taken to prepare for surgery. The surgeon often delays surgery until the patient is no longer experiencing inflammation related to organ damage subsides. The patient is also put on a nutritional repletion diet (enteral or parenteral diet) to reverse any malnutrition resulting from the disease. While nutritional balance is not necessary for a successful surgery, it does improve postoperative recovery. As with most surgeries, the doctor performing the procedure needs to have a clear history of the disease progression in the patient, particularly past operations. They also must be award of the severity and the spread of the disease. This is usually determined through fluoroscopic barium studies or computed tomography (CT) enterography. They should also discuss whether a temporary or permanent opening (stoma) may be needed and where to place it.
A potential risk associated with surgery is that a great portion of the small intestine will be removed. This removal can result in short bowel (gut) syndrome. Because the small intestine is where the body absorbs nutrition, removal of too much of the small intestine can cause a group of issues related to malabsorption. Symptoms include, bloating, cramping, fatigue, heartburn, excessive flatulence, vomiting and weakness.
Exclusive Enteral Nutrition
In children and adolescents, exclusive enteral nutrition or EEN is the gold standard treatment for Crohn’s disease. Treatment involves taking a whole protein formula for 100% of the child’s nutrition for 6 to 8 weeks. The child then takes on a normal diet again gradually. This treatment is used to promote growth and development. It is less common in adults. The treatment is successful in eliciting a response in nearly 80% of treated children. These results can also be obtained with corticosteroids. However, in addition to treating the disease, EEN also provides nutrition and improves healing. Improvement can be seen as soon as a few days of treatment. Successful treatment is highly influenced by the support the patient receives from the family and treating staff, especially early in treatment. There is not a lot of information on whether continuing the diet after treatment is complete has a beneficial effect on the patient.
