Expert: DANIL HAMMOUDI.MD - 4/27/2004

Question
Ive had Crohns for about 15 years now, tried all sorts of medications, I respond to some, others I dont.  I get the flareups from time to time and the athritis pain that never seem to go away.  A friend recommended a nutritionist and I started seeing one last week.  He put me on a low carb/sugar diet and reccomended food high in protein.  So now I am eating more fruits and vegetables than normal and I seem to go to the restroom more often than usual.  I read somewhere that the fruits and vegetables are bad for Crohns because of the fiber. Yet my nutritionist disagrees.  I dont know who to believe now.  can anyone help me?

Answer
it is contreversial, since there is no real treatment for crohn's as yet beside treatment preventing the acute phases.
your nutritionist is doing the good thing and you will get more healthy this way and I suggest you to keep the actual diet
There are no foods known to actually injure the bowel. However, during an acute phase of the disease, bulky foods; milk, and milk products can increase diarrhea and cramping. Generally, the patient is advised to eat a well-balanced diet, with adequate protein and calories. A multivitamin and iron supplement may be recommended by the physician. Stress, anxiety, and extreme emotions may aggravate symptoms of the disorder, but are not believed to cause it or make it worse. Any chronic disease can produce a serious emotional reaction, which can usually be handled through discussion with the physician.
Hence, a low fiber diet may be recommended, especially in those patients with small intestinal disease. A liquid diet may be of benefit when symptoms are more severe. Intravenous nutrition or TPN (total peripheral nutrition) may be utilized when it is felt that the intestine needs to "rest." Supplementation of calcium, folate and vitamin B12 is helpful when malabsorption of these nutrients is apparent. The use of anti-diarrheal agents (Lomotil, Imodium) and anti-spasmotics also can help relieve symptoms of cramps and diarrhea.

some medication are working on prevention
Immuno-modulator medications

Immuno-modulators are medications that affect the body's immune system. The immune system is composed of immune cells and the proteins that they produce. These cells and proteins serve to protect the body against harmful bacteria, viruses, fungi, and other foreign invaders. Activation of the immune system causes inflammation within the tissues where the activation occurs. (Inflammation is, in fact, an important mechanism used by the immune system to defend the body.) Normally, the immune system is activated only when the body is exposed to foreign invaders. In patients with Crohn's disease and ulcerative colitis, however, the immune system is abnormally and chronically activated in the absence of any known invader.

Immuno-modulators decrease tissue inflammation by reducing the population of immune cells and/or by interfering with their production of proteins. Decreasing the activity of the immune system with immuno-modulators increases the risk of infections; however, the benefits of controlling moderate to severe Crohn's disease usually outweigh the risks of infection due to weakened immunity. Examples of immuno-modulators are 6-mercaptopurine (6-MP), azathioprine, methotrexate, and infliximab.

Azathioprine (Imuran) and 6-mercaptopurine (6-MP, Purinethol)

Azathioprine (Imuran) and 6-mercaptopurine (6-MP, Purinethol) are medications that weaken the body's immune system by reducing the population of a class of immune cells called lymphocytes. Azathioprine and 6-MP are related chemically. (Actually, azathioprine is converted into 6-MP within the body.) In high doses, these two drugs have been useful in preventing rejection of transplanted organs and in treating leukemia. In low doses, they have been used for many years to treat patients with moderate to severe Crohn's disease and ulcerative colitis.

Azathioprine and 6-MP are increasingly recognized by doctors as valuable drugs in treating Crohn's disease and ulcerative colitis. Some 70% of patients with moderate to severe disease will benefit from these drugs. Azathioprine and 6-MP are used primarily in the following situations:

Severe Crohn's disease and ulcerative colitis not responding to corticosteroids.
The presence of undesirable corticosteroid-related side effects.
Corticosteroid dependency, a condition in which patients are unable to discontinue corticosteroids without developing relapses of their disease.
Maintenance of remission.
When azathioprine and 6-MP are added to corticosteroids in the treatment of Crohn's disease not responding to corticosteroids alone, there may be an improved response. Also, smaller doses and shorter courses of corticosteroids may be able to be used. Some patients can discontinue corticosteroids altogether without experiencing relapses of their disease. This corticosteroid-lowering effect has earned azathioprine and 6-MP their reputation as "steroid-sparing" medications.

In Crohn's disease patients with severe disease who suffer frequent relapses, 5-ASA may not be sufficient, and the more potent azathioprine and 6-MP will be necessary to maintain remissions. In the lower doses used to treat Crohn's disease, the long-term side effects of azathioprine or 6- MP are less serious than those of long-term corticosteroids or repeated courses of corticosteroids.

Patients with Crohn's disease may undergo surgery to remove a segment of the intestine that is obstructed or contains a fistula. After surgical removal of the diseased segments, the patients often will be free of disease and symptoms for a while, but many eventually will have their disease recur. During these recurrences, previously healthy intestine can become inflamed. Long-term 5-ASA (such as Pentasa) and 6-MP both are effective in reducing the chances of recurrence after surgery.

Anal fistulae can develop in some patients with Crohn's disease. Anal fistulae are abnormal tracts (tunnels) that form between the small intestine or colon and the skin around the anus. Drainage of fluid and mucous from the opening of the fistula is a troublesome problem. These fistulae are difficult to treat and do not heal readily. Metronidazole (Flagyl) has been used with some success in promoting healing of these fistulae. In difficult cases, azathioprine and 6-MP may be successful in promoting healing.

Infliximab (Remicade)

Infliximab (Remicade) is an antibody that attaches to a protein called tumor necrosis factor-alpha (TNF-alpha). TNF-alpha is one of the proteins produced by immune cells during activation of the immune system. TNF-alpha, in turn, stimulates other cells of the immune system to produce and release other proteins that promote inflammation. In Crohn's disease, there is continued production of TNF-alpha as part of the immune activation. Infliximab, by attaching to TNF-alpha, blocks its activity and in so doing decreases the inflammation.

Infliximab, an antibody to TNF-alpha, is produced by the immune system of mice after the mice are injected with human TNF-alpha. The mouse antibody then is modified to make it look more like a human antibody, and this modified antibody is infliximab. Such modifications are necessary to decrease the likelihood of allergic reactions when the antibody is administered to humans. Infliximab is given by intravenous infusion over two hours. Patients are monitored throughout the infusion for adverse reactions.

In August, 1998 the United States Food and Drug Administration approved the use of infliximab for the short-term treatment of moderate to severe Crohn's disease patients who respond inadequately to corticosteroids, azathioprine, or 6-MP.

Effectiveness of infliximab

Infliximab is an effective and fast-acting drug for the treatment of active Crohn's disease. In a study involving patients with moderate to severe Crohn's disease who were not responding to corticosteroids or immuno-modulators, 65% experienced improvement in their disease after one infusion of infliximab. Some patients noticed improvement in symptoms within days of the infusion. Most patients experienced improvement within 2 weeks.

In patients who respond to infliximab, the improvements in symptoms can be dramatic. Moreover, there can be impressively rapid healing of the ulcers and the inflammation in the intestines after just one infusion.

The anal fistulae of Crohn's disease are troublesome and often difficult to treat. Infliximab has been found to be effective for treating fistulae.

hope this help
thanks
dan