Abstract
Crohn’s disease is a chronic, relapsing inflammatory disorder of the gastrointestinal tract that frequently necessitates surgical intervention due to complications such as strictures, perforations, and fistulas. Surgical procedures, while effective for addressing acute and severe manifestations of the disease, are not curative and often require subsequent medical management to prevent recurrence. This article provides an in-depth analysis of the surgical approaches to crohn’s disease, including indications, types of surgeries, postoperative care, and long-term outcomes. Additionally, the potential of homeopathic treatments as complementary therapies is explored. Homeopathy, which employs highly diluted substances to trigger the body’s natural healing responses, offers a holistic approach to symptom management and overall well-being in Crohn’s disease patients. This review examines the principles of homeopathy, commonly used remedies, and the current evidence supporting its efficacy in the context of crohn’s disease. By integrating surgical strategies with homeopathic practices, the article aims to present a comprehensive framework for enhancing patient care and improving quality of life. This multidisciplinary perspective is intended to inform clinicians, researchers, and patients about the potential benefits and limitations of combining conventional and alternative therapeutic approaches in the management of crohn’s disease.
Keywords
Crohn’s disease, inflammatory bowel disease (IBD), gastrointestinal tract, surgical intervention, strictures, fistulas, abscesses, recurrence rates, postoperative care, homeopathy, complementary medicine, alternative therapy, symptom management, holistic approach, patient outcomes, quality of life, medical management, homeopathic remedies, self-healing processes, multidisciplinary management
Introduction
- Chronic, idiopathic, transmural granulomatous inflammation of terminal ileum and adjoining colon resulting in stricture, ulceration, fistula and abscess formation.
- Crohn’s disease can involve any part of the alimentary tract from mouth to anus but most commonly affects the small intestine and colon.
- It is independent of age, sex, socioeconomic status and geographic areas.
- Rarely other parts of the git like colon, jejunum, stomach, duodenum, and oesophagus can get involved
- In 50% cases both small and large bowels are involved
- Terminal ileum is most commonly involved (60%)
Incidence
- Incidence is 5/1,00,000
- Prevalence is 501,00,000
- Common in north America and north Europe
- Common in females
Genetics
- The disease runs in families then 30 times more likely to develop cd, particularly if a first degree relative has the disease.
- Mutations in the nod2/card15 gene are associated with crohn’s disease.
- Anomalies in the xbp1gene have recently been identified as a factor, pointing towards a role for the unfolded protein response pathway of the endoplasmic reticulum in inflammatory bowel disease.
Immune System
- Crohn’s disease is thought to be an autoimmune disease, with inflammation stimulated by an overactive th1 cytokine response.
- Recent gene to be implicated in Crohn’s disease is atg16l1, which may induce autophagy and hinder the body’s ability to attack invasive bacteria.
Environmental Factors
- Smoking has been shown to increase the risk of the return of active disease or flares.
- Hormonal contraception is also linked with a dramatic increase in the incidence rate of crohn’s disease.
Microbes
- Mycobacterium avium subspecies Paratuberculosis (map)
- Yersinia spp and listeria spp contribute to crohn’s disease.
Psychological Conditions
- Anxiety
- Depression
Age
- People with 15 to 30 years of age followed by those between 50-70 years of age.
Gender
- Women and men both tend to be equally affected.
Monozygotic Twins
Others
- Pesticides, tobacco, radiations, steroidal therapy.
Pathophysiology
Etiological factors /triggering factors
Dysregulated inflammatory and immune response in genetically susceptible persons.
Amplification of immune response.
Release of inflammatory mediators
Mucosal breakdown and continuous exposure to bacterial agents.
Impaired handling of microbial antigen by the immune system
The disease process begins with oedema and thickening of mucosa
Ulcer formation begins with oedema and thickening of mucosa
As the ulcer lesions are not in contact with one another and are separated by normal tissue
Hence these clusters of ulcers tends to take on a classic
Cobblestone appearance
As the inflammation extends the muscle trophy also occur which causes fistulas, fissures and abscess
As the disease advances the bowel wall thickens and becomes fibrotic and intestinal lumen narrows.
Complete gi obstruction
Pathology
- Transmural inflammation
- Granuloma formation with linear snake like ulcers-cicatrisation
- Thickening of the bowel walls- (hose pipe pattern)
Gross appearance
- A fibrotic thickening of the intestinal wall with a narrow lumen and fat wrapping
- (encroachment of mesenteric fat around the bowel)
- Oedema in the mucosa between the ulcers gives rise to a cobblestone appearance.
- The transmural inflammation
- (which is a key feature of cd)
- May lead to segments of bowel becoming adherent to each other and to surrounding structures, inflammatory masses with mesenteric abscesses and fistula into adjacent organs.
- The serosa is usually opaque, with thickening of the mesentery and enlarged mesenteric lymph nodes.
- Cd is characteristically discontinuous, with inflamed areas separated from the normal intestine, so-called skip lesions.
- Colonic crohn’s disease, note the normal mucosa on either side of the inflammatory stricture.
Classification
According to the region-
- Ileocolic crohns
- Ileitis crohns
- Colic crohns
- Gastroduodenal crohns
- Jejunal crohns
- Perianal crohns
1) Ileocolic crohns
Involves terminal ileum and ileocecal region
2) Ileitis crohns
Only involves the iliac part of the small intestine.
3) Colic crohns
Affects the segments of the colonic region.
4) Gastroduodenal crohns
Involves stomach and duodenum.
5) Jejunal crohns
Involves only in the upper half of the small intestine, the jejunal part.
6) Perianal crohns
Affects around the anal region.
Classification according characteristic features
Inflammatory crohns
- Affects 30% of patients, remains localized to the mucosa and submucosa, and causes diarrhoea and pain from acute partial obstruction.
Perforating Crohns
- Affects 20% of patients who have ileitis
- Aggressive transmural inflammation leads to intra-abdominal fistulae from the diseased bowel wall to another bowel loop or to a nearby organ like the urinary bladder.
Stricturing Crohns
- About 50% of patients with ileitis follow this route.
Clinical Features
- It is common in young age group
- Abdominal pain and diarrhoea is the initial slow, insidious presentation.
- There is also an asymptomatic period in between.
- Diarrhoea is usually less severe without blood, pus or mucus.
- Mild fever, weight loss, lethargy
- Crohns disease may present as a tender, firm, resonant mass in the right iliac fossa.
- Right and left lower quadrant abdominal pain.
- Diarrhoea unrelieved by defecation.
- Obstruction, fistula formation, often perforation.
- Bleeding which is usually chronic but occasionally massive can occur.
- Perianal disease with fissure, fistula, and abscess
- Extra intestinal manifestations
- Vomiting
- Inability to empty bowels dehydration as well as cramping.
- Leakage of stool
- Nutritional deficiency.
- Steatorrhea.
Presentation
A) Acute Presentation:
- It mimics acute appendicitis with severe diarrhoea
- Perforation of the small intestine resulting in localised or diffuse peritonitis.
- Fulminant colitis but this is considerably less common than in uc
B) Chronic Crohns
First stage:
- Mild diarrhoea
- Colicky pain
- Fever
- Anaemia
- Mass in right iliac fossa which is tender, firm, non-mobile along with recurrent perianal abscess.
Second stage
- Acute or chronic intestinal obstruction due to cicatrisation with narrowing.
Third stage:
Fistula formation-
- Fistulation may occur into adjacent loops of bowel – (entero enteric fistula)
- Fistulation may also occur in the bladder (ileovesical) or female genital tract, and less commonly the duodenum.
- Fistulation into the abdominal wall (enterocutaneous fistula) which more commonly occurs as a complication of abdominal surgery.
- It is a precancerous condition but not as much as ulcerative colitis.
Colitis and proctitis - Perianal abscess and fistula, rectovaginal fistula
- In severe cases the perineum may become densely fibrotic, rigid, and covered with multiple discharging openings (watering can perineum
Complications
1) Intestinal complications
- Stricture, fistula, perforation, abscess, neoplasm
2) Systemic complications
- Arthritis, ankylosing spondylitis, sclerosing episcleritis, uveitis, sclerosing cholangitis, and oxalate stones, erythema nodosum, pyoderma gangrenosum.
3) Postoperative complications
- Anastomotic recurrence, anastomotic fibro stenosis, adhesion obstruction
Diagnostic investigations
- Plain x-ray abdomen
- Ultrasound abdomen
Barium meal follow through or small bowel enema shows:
- Straightening of volvuli connivances.
- Multiple defect – cobblestone appearance
- String sign of kantor
- Rose thorn appearance of bowel wall
CT scan And CT Fistulogram
Colonoscopy– shows segmental, deep, cobblestone look
Capsule endoscopy
- But when stricture is present the capsule may get stuck in the narrow part.
MRI
- To diagnose anal disease.
- Enteroclysis is very useful to demonstrate fistula.
Blood Tests
- Anaemia
- Protein loss
- Minerals – zinc, magnesium, zinc, selenium
- Crp raised
Treatment
- Conservative
- Surgical
Conservative
- To relieve the symptoms
- To reduce the underlying cause
- To improve the health status of the individual
- Cessation of smoking
- Bed rest, protein and vitamin supplementations
- To improve the patient’s functional status and quality of life.
Surgery Indications
- Failure of medical treatment
- Intestinal obstruction
- Fistula formation
- Bleeding
- Malignant tendency
- Perforation
- Fulminant colitis
- Perianal problems
Surgical Management
- Proctocolectomy / ileoanal anastomosis
- Colostomy
- Ileostomy
- Stricture plasty and resection
Crohns Disease – Homoeopathic Approach
Homeopathy offers a holistic approach to managing crohn’s disease, a chronic inflammatory bowel disease characterized by inflammation of the digestive tract. Homeopathic treatments aim to stimulate the body’s self-healing abilities, focusing on individualized care. Here are some key aspects of the homeopathic approach to crohn’s disease:
Key Principles
Individualization: homeopathy tailors treatments to the individual, taking into account the unique symptoms, emotional state, and overall health of the person.
Holistic Care: the approach considers the physical, mental, and emotional aspects of the patient’s condition.
Minimization of Side Effects: homeopathic remedies are highly diluted, aiming to minimize adverse effects and avoid suppressing symptoms.
Commonly Used Remedies:
Arsenicum album, Aloe socotrina, Nux vomica, Mercurius corrosivus, Sulphur.
Case Taking
- A detailed case history is crucial in homeopathy. The homeopath will inquire about:
- The exact nature and timing of symptoms
- Triggers and factors that worsen or alleviate symptoms
- Emotional and psychological state
- Overall health, lifestyle, and medical history
Treatment Plan
Initial Consultation: a thorough assessment to understand the patient’s complete symptom picture.
Remedy Selection: based on the totality of symptoms, a specific remedy or a combination of remedies is selected.
Follow-up: regular follow-ups to monitor progress and make adjustments to the treatment plan as needed.
Homoeopathic Therapeutics – IBD
1) Merc cor
- For blood and mucus in stool in ulcerative colitis mercurius corrosivus is the medicine to treat patients suffering from ulcerative colitis.
- This medicine is suited to those patients in whom blood and shreds of mucus membranes are passed along with the stool.
- The patient has a constant urge to pass stool that is scanty, hot and has an offensive odour.
- There is a recurrent urge of stool with no satisfaction.
- There are cutting pains in the rectum accompanying the passage of stool.
2) Phosphorous
- For ulcerative colitis with stool containing blood and greenish mucus
- Phosphorus is indicated to those patients in whom there is blood stained stool with green mucus and contains extreme offensiveness.
- The complaint gets aggravated in the morning
3) Aloes
- For crohn’s disease with loose stool
- Aloe socotrina is among the top remedies for crohn’s disease in those patients who suffered from loose stool which worse immediately after eating or drinking anything.
- There is a sudden urge to pass stool and the patient has to rush to the toilet to pass the stool.
- There are cutting pains in the lower abdomen which get worse before and during passing stool and relief after passing the stool.
- Faintness usually follows stool.
- This medicine can also be prescribed to control the diarrhoea that gets worse due to the intake of beer.
4) Podophylum
- For crohn’s disease with diarrhoea
- Podophylum peltatum is given for crohn’s disease with diarrhoea and when the stool is watery, greenish and very offensive.
- The diarrhoea mainly gets worse in the morning but in the evening, the stool is normal.
- There is prolapse of rectum before or during stool.
- The patient is thirsty for large quantities of cold water
- Gambogia
- For IBD with diarrhoea Gambogia is a rare and very beneficial remedy for diarrhoea in inflammatory bowel disease.
- The stool is very profuse, watery and involuntarily passes out.
- Diarrhoea is worse in hot weather.
5) Ars alb
- For ulcerative colitis with stool of offensive odour and blood
- Arsenicum album is suited to those patients who suffered from offensive and dark coloured blood stool which is aggravated at night and the patient feels lethargic.
- There is constant burning pain in the abdomen and rectum.
- Patients are relieved by warm drinks
6) Carcinosinum
- Carcinosinum may be considered in cases of ulcerative colitis when it is developed or symptoms of ulcerative colitis are worsened after suppressed emotions, especially resentment, anger, and grief—this homeopathic medicine for colitis targets to address the physical symptoms as well as the emotional imbalances.
- Carcinosinum is often considered when one experiences physical as well as mental exhaustion due to chronic ulcerative colitis symptoms.
- It is often indicated when the symptoms are persistent and not responding well to conventional treatments and also if there is a history of cancer in the family.
- In homeopathic practice, familial predispositions and genetic tendencies are often integral to remedy selection.
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