Crohn’s disease is a chronic inflammatory condition of the gastrointestinal tract. It can affect any part of the gastrointestinal tract, from the mouth to the anus. Periodic flares are likely to occur followed by periods of remission. The goal of treating Crohn’s disease is to prevent these flares and keep people in remission, whereby they are feeling well and have no symptoms. In some individuals, poor prognostic factors are present that may indicate a more severe disease course, such as need for hospitalization and surgery.
Some of these risk factors include:
Being diagnosed with Crohn’s disease at an early age
Crohn’s disease diagnosed under age 40 has been associated with a more severe disease course, such as need for corticosteroids and disease flares. Approximately 25% of newly diagnosed cases occur in those under the age of 20 and early onset can be predictive of a more severe course. Pediatric Crohn’s may develop due to a genetic factor. About 30% of children with Crohn's disease have a close family member who also has the disease. In addition to gastrointestinal symptoms that the disease can cause, some children with Crohn’s experience delayed puberty and some fail to grow at a normal rate. About one-third of children with Crohn’s disease do not reach their final adult height because of the disease.
Smoking appears to increase the risk of developing Crohn’s disease and can worsen the course of the disease. Those with Crohn’s who also smoke may experience more frequent flares, such as abdominal pain and diarrhea, are more likely to require surgery than non-smokers with Crohn’s, and are more likely to have Crohn’s disease come back after surgery.
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The presence of perianal or structuring disease
Perianal disease is inflammation at or near the anus. Inflammation around the anal area can cause fistulas (abnormal passages or tunnels between an organ and the body surface), abscesses (pockets of infection), skin tags, anal fissures (tears or splits in the anal canal).
Stricturing disease occurs from inflammation in the intestine that creates scar tissue that narrows the passage (called a stricture) of the intestine, causing bowel obstruction, severe cramps and vomiting. Strictures usually occur in the small intestine but can also occur in the large intestine.
The presence of perianal or structuring disease is associated with a more severe course defined by complications, need for surgery, hospitalizations, chronic active symptoms and use of steroids, immunosuppressive agents, and biologics.
Steroid use early in the course of treatment
Early use of corticosteroids (commonly called steroids) in treatment is also a predictor of poor outcome. Corticosteroids are powerful anti-inflammatory drugs used for treating Crohn's disease in adults. Because they carry significant side effects, steroids are typically reserved for those with moderate-to-severe disease or those who relapse after other therapies. They can be very effective short term therapies, but avoiding long or repeated treatments with corticosteroid is an important goal in treating Crohn’s disease. Other medications can help reduce the need for corticosteroids.
Surgery needed within the first year of treatment
The presence of deep ulcers, severe upper gastro-intestinal lesions (Crohn’s involving the stomach or esophagus, for example) or extensive small bowel disease may increase the risk of requiring surgery shortly following diagnosis. Smoking is also associated with an early need for surgery.
Approximately 60% of patients with Crohn’s disease will develop a more severe course of the disease based on the risk factors mentioned above. Even with severe symptoms, there is no standard regimen for managing Crohn’s disease and treatment must be customized to each individual.
There is a tendency to undertreat patients suffering from severe or complicated Crohn’s resulting in a failure to slow the progression of the disease. The goal of identifying poor prognostic factors, as discussed above, is to perhaps consider a a more proactive treatment regimen that may include the earlier use of immunosuppressive and/or biologic (anti-TNF) agents, rather than waiting for worsening symptoms or complications. Immunosuppressant drugs suppress or limit actions of the immune system and therefore the inflammatory response that causes Crohn's disease. The use of biologic drugs targets the inflammatory immune factor known as tumor necrosis factor (TNF).
Patients with risk factors indicating a possible poor prognosis should discuss with their doctor the advantages and disadvantages of a more proactive treatment strategy if the severity of Crohn’s disease appears to worsen.