Crohn’s Disease

Also indexed as: Granulomatous Ileitis, Ileocolitis, Regional Enteritis

Crohn’s disease is a poorly understood inflammatory condition that usually affects the final part of the small intestine and the beginning section of the colon. It often causes bloody stools and malabsorption problems.

Checklist for Crohn’s Disease

Rating Nutritional Supplements Herbs
3Stars Fish oil (enteric-coated, free-fatty-acid form)
Vitamin D		  
2Stars Multivitamin-mineral (for prevention or treatment of deficiency only)
Saccharomyces boulardii
Zinc		  
1Star Enzymes
Folic acid
Lipase
Vitamin A
Vitamin B12		 Agrimony
Aloe
Chamomile
Cranesbill
Green tea
Licorice
Marshmallow
Oak
Slippery elm
Witch hazel
Yarrow
3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star An herb is primarily supported by traditional use, or the herb or supplement has little scientific support and/or minimal health benefit.

What are the symptoms of Crohn’s disease? Chronic diarrhea with abdominal pain, fever, loss of appetite, weight loss, and a sense of fullness in the abdomen are the most common symptoms. About one-third of people with Crohn’s have a history of anal fissures (linear ulcers on the margin of the anus) or fistulas (abnormal tube-like passages from the rectum to the surface of the anus).

How is it treated? Diarrhea and cramps may be treated with anticholinergic drugs, such as loperamide (Imodium®), diphenoxylate (Lomotil®), or codeine. Anal irritation and loose stools may sometimes be improved by giving methylcellulose (e.g., Citrucel®) or psyllium preparations (e.g., Fiberall®, Konsyl®, Metamucil®, Perdiem®). Sulfasalazine (Azulfidine®) is used in patients with mild to moderate colitis. Corticosteroids may be used during acute exacerbations, although long-term corticosteroid therapy does more harm than good. Certain immunosuppressive drugs may also be effective, including azathioprine (Imuran®) and 6-mercaptopurine (6-MP, Purinethol®). Secondary infections are managed with antibiotics.

Dietary changes that may be helpful: A person with Crohn’s disease might consume more sugar than the average healthy person.1 A high-fiber, low-sugar diet led to a 79% reduction in hospitalizations compared with no dietary change in one group of people with Crohn’s disease.2 Another trial compared the effects of high- and low-sugar diets in people with Crohn’s disease.3 People with a more active disease were reported to fare better on the low-sugar diet than those eating more sugar. Several people on the high-sugar diet had to stop eating sugar because their disease grew worse. While details of how sugar injures the intestine are still being uncovered, doctors often suggest eliminating all sugar (including soft drinks and processed foods with added sugar) from the diets of those with Crohn’s disease.

A diet high in animal protein and fat (from foods other than fish) has been linked to Crohn’s disease in preliminary research.4 As with many other health conditions, it may be beneficial to eat less meat and dairy fat and more fruits and vegetables.

Some people with Crohn’s disease have food allergies and have been reported to do better when they avoid foods to which they are allergic. One study found that people with Crohn’s disease are most likely to react to cereals, dairy, and yeast.5 Increasingly, baker’s yeast (found in bread and other bakery goods) has been implicated as a possible trigger for Crohn’s disease.6 Yeast and some cheeses are high in histamine, which is involved in an allergenic response. People with Crohn’s disease lack the ability to break down histamine at a normal rate,7 so the link between yeast and dairy consumption and Crohn’s disease occurrence may not be coincidental. However, the allergy theory cannot account for all, or even most, cases of Crohn’s disease.

Elemental diets contain amino acids (rather than whole proteins, which can stimulate allergic reactions) and are therefore considered hypoallergenic. They have been used extensively as primary therapy in people with Crohn’s disease,8 9 10 with remission rates comparable to those of steroid drugs. Nevertheless, diets containing intact proteins derived from dairy and wheat have proven equally effective at controlling the symptoms of Crohn’s disease.11 12 13 Until more is known, it is premature to conclude that food allergy plays a significant role in the development of Crohn’s disease or that a hypoallergenic diet is any more likely to help than a diet whose protein is only partially broken down.

In one trial, people with Crohn’s disease were asked which foods aggravated their symptoms.14 Those without ileostomies found nuts, raw fruit, and tomatoes to be most problematic, though responses varied from person to person, and other reports have displayed different lists.15 (Ileostomies are surgical passages through the wall of the abdomen into the intestine that allow the intestinal contents to bypass the rectum and drain into a bag worn on the abdomen.) People with Crohn’s disease wishing to identify and avoid potential allergens should consult a doctor.

There is preliminary evidence that people who eat fast foods at least two times per week more than triple their risk of developing Crohn’s disease.16

Lifestyle changes that may be helpful: People with Crohn’s disease are more likely to smoke, and there is evidence that continuing to smoke increases the rate of disease relapse.17

Nutritional supplements that may be helpful: Vitamin Dmalabsorption is common in Crohn’s18 and can lead to a deficiency of the vitamin.19 Successful treatment with vitamin D for osteomalacia (bone brittleness caused by vitamin D deficiency) triggered by Crohn’s disease has been reported.20 Another study found 1,000 IU per day of vitamin D prevented bone loss in people with Crohn’s, while an unsupplemented group experienced significant bone loss.21 A doctor should evaluate vitamin D status and suggest the right level of vitamin D supplements.

Inflammation within the gut occurs in people suffering from Crohn’s disease. EPA and DHA, the omega-3 fatty acids found in fish oil, have anti-inflammatory activity. A two-year trial compared the effects of having people with Crohn’s disease eat 3.5 to 7 ounces of fish high in EPA and DHA per day or having them eat a diet low in fish.22 In that trial, the fish-eating group had a 20% relapse rate compared with 58% among those not eating fish. Salmon, herring, mackerel, albacore tuna, and sardines are all high in EPA and DHA.

In a double-blind trial, people with Crohn’s disease who took supplements providing 2.7 g of EPA/DHA per day had a recurrence rate of 26% after one year, compared to a 59% recurrence rate among those taking placebo. 23 Participants in this study used a special enteric-coated, “free-fatty-acid” form of EPA/DHA taken from fish oil. Other blinded trials using other fish oil supplements that were neither enteric-coated nor in the free-fatty-acid form have reported no clinical improvement.24 25 These disparate outcomes suggest that the enteric-coated, free-fatty-acid form may have important advantages, including the reported elimination of gastrointestinal symptoms that often result from taking regular fish oil supplements.26 Unfortunately, enteric-coated “free-fatty-acid” fish oil is not commercially available at this time.

In double-blind research, diarrhea caused by Crohn’s disease has partially responded to supplementation with the beneficial bacterium Saccharomyces boulardii.27 Although the amount used in this trial, 250 mg taken three times per day, was helpful, as much as 500 mg taken four times per day has been administered in research successfully using Saccharomyces boulardii as a supplement with people suffering from other forms of diarrhea.28

Crohn’s disease often leads to malabsorption. As a result, deficiencies of many nutrients are common. For this reason, it makes sense for people with Crohn’s disease to take a high potency multivitamin-mineral supplement. In particular, deficiencies in zinc, folic acid, vitamin B12, vitamin D, and iron have been reported.29 30 31 Zinc, folic acid, and vitamin B12 are all needed to repair intestinal cells damaged by Crohn’s disease. Some doctors recommend 25 to 50 mg of zinc (balanced with 2 to 4 mg of copper), 800 mcg of folic acid, and 800 mcg of vitamin B12. Iron status should be evaluated by a doctor before considering supplementation.

Vitamin A is needed for the growth and repair of cells that line both the small and large intestine.32 At least two case reports describe people with Crohn’s disease who have responded to vitamin A supplementation.33 34 However, in one trial, vitamin A supplementation failed to maintain remission of the disease.35 Therefore, although some doctors recommend 50,000 IU per day for adults with Crohn’s disease, this approach remains unproven. An amount this high should never be taken without qualified guidance, nor should it be given to a woman who is or could become pregnant.

People with Crohn’s disease may be deficient in pancreatic enzymes, including lipase.36 In theory, supplementing with enzymes might improve the nutrient malabsorption that is often associated with Crohn’s disease. However, people with Crohn’s disease considering supplementation with enzymes should consult a doctor.

Are there any side effects or interactions? Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful: Doctors sometimes use a combination of herbs to soothe inflammation throughout the digestive tract. One formula contains marshmallow, slippery elm, cranesbill, and several other herbs.37 Marshmallow and slippery elm are mucilaginous plants that help soothe inflamed tissues. Cranesbill is an astringent. Clinical trials using this combination have not been conducted.

A variety of anti-inflammatory herbs historically have been recommended by doctors for people with Crohn’s disease. These include yarrow, chamomile, licorice, and aloe juice. Cathartic preparations of aloe should be avoided. No research has been conducted to validate the use of these herbs for Crohn’s disease.

Tannin-containing herbs may be helpful to decrease diarrhea during acute flare-ups and have been used for this purpose in traditional medicine. A preliminary trial using isolated tannins in the course of usual drug therapy for Crohn’s disease found them to be more effective for reducing diarrhea than was no additional treatment.38 Tannin-containing herbs of potential benefit include agrimony (Agrimonia spp.), green tea, oak, witch hazel, and cranesbill. Use of such herbs should be discontinued before the diarrhea is completely resolved; otherwise the disease may be aggravated.

Are there any side effects or interactions? Refer to the individual herb for information about any side effects or interactions.

References:

1. Mayberry JF, Rhodes J. Epidemiological aspects of Crohn’s disease: a review of the literature. Gut 1984;886–99.

2. Heaton KW, Thornton JR, Emmett PM. Treatment of Crohn’s disease with an unrefined-carbohydrate, fibre-rich diet. BMJ 1979;2(6193):764–6.

3. Brandes JW, Lorenz-Meyer H. Sugar free diet: a new perspective in the treatment of Crohn disease? Randomized, control study. Z Gastroneterol 1981;19:1–12.

4. Shoda R, Masueda K, Yamato S, Umeda N. Epidemiologic analysis of Crohn’s disease in Japan: increased dietary intake of n-6 polyunsaturated fatty acids and animal protein relates to the increased incidence of Crohn’s disease in Japan. Am J Clin Nutr 1996;63:741–5.

5. Riordan AM, Hunter JO, Cowan RE, et al. Treatment of active Crohn’s disease by exclusion diet: East Anglian Multicentre Controlled Trial. Lancet 1993;342:1131–4.

6. Alic M. Baker’s yeast in Crohn’s disease—can it kill you? Am J Gastroenterol 1999;94:1711 [letter/review].

7. Wantke F, Gotz M, Jarisch R. Dietary treatment of Crohn’s disease. Lancet 1994;343:113 [letter].

8. O’Morain C, Segal AW, Levi AJ. Elemental diet as primary treatment of acute Crohn’s disease: a controlled trial. Br Med J (Clin Res Ed) 1984;288:1859–62.

9. Gorard DA, Hunt JB, Payne-James JJ, et al. Initial response and subsequent course of Crohn’s disease treated with elemental diet or prednisolone. Gut 1993;34:1198–202.

10. Teahon K, Pearson M, Levi AJ, Bjarnason I. Practical aspects of enteral nutrition in the management of Crohn’s disease. JPEN J Parenter Enteral Nutr 1995;19:365–8.

11. Raouf AH, Hildrey V, Daniel J, et al. Enteral feeding as sole treatment for Crohn’s disease: controlled trial of whole protein v amino acid based feed and a case study of dietary challenge. Gut 1991;32:702–7.

12. Rigaud D, Cosnes J, Le Quintrec Y, et al. Controlled trial comparing two types of enteral nutrition in treatment of active Crohn’s disease: elemental versus polymeric diet. Gut 1991;32:1492–7.

13. Park RH, Galloway A, Danesh BJ, et al. Double-blind controlled trial comparing elemental and polymeric diets as primary therapy in active Crohn’s disease. Eur J Gastroenterol Hepatol 1991;32:1492–7.

14. McDonald PJ, Fazio VW. What can Crohn’s patients eat? Eur J Clin Nutr 1988;42:703–8.

15. Gaby AR. Commentary. Nutr Healing 1998;January:1,10–1 [review].

16. Persson PG, Ahlbom A, Hellers G. Diet and inflammatory bowel disease: a case-control study. Epidemiology 1992;3:47–52.

17. Cottone M, Rosselli M, Orlando A, et al. Smoking habits and recurrence in Crohn’s disease. Gastroenterol 1994;106:643–8.

18. Leichtmann GA, Bengoa JM, Bolt MJG, Sitrin MD. Intestinal absorption of cholecalciferol and 25-hydrocycholecalciferol in patients with both Crohn’s disease and intestinal resection. Am J Clin Nutr 1991;54:548–52.

19. Harris AD, Brown R, Heatley RV, et al. Vitamin D status in Crohn’s disease: association with nutrition and disease activity. Gut 1985;26:1197–203.

20. Driscoll RH, Meredith SC, Sitrin M, Rosenberg IH. Vitamin D deficiency and bone disease in patients with Crohn’s disease. Gastroenterol 1982;83:1252–8.

21. Vogelsang H, Ferenci P, Resch H, et al. Prevention of bone mineral loss in patients with Crohn’s disease by long-term oral vitamin D supplementation. Eur J Gastroenterol Hepatol 1995;7:609–14.

22. Mate J, Castanos R, Garcia-Samaniego J, Pajares JM. Does dietary fish oil maintain the remission of Crohn’s disease: a case control study. Gastroenterology 1991;100:A228 [abstract].

23. Belluzzi A, Brignola C, Campieri M, et al. Effect of an enteric-coated fish-oil preparation on relapses in Crohn’s disease. N Engl J Med 1996;334:1557–60.

24. Lorenz R, Weber PC, Szimnau P, et al. Supplementation with n-3 fatty acids from fish oil in chronic inflammatory bowel disease—a randomized, placebo-controlled, double-blind cross-over trial. J Intern Med Suppl 1989;225:225–32.

25. Lorenz-Meyer H, Bauer P Nicolay C, et al. Omega-3 fatty acids and low carbohydrate diet for maintenance of remission in Crohn’s disease. A randomized controlled multicenter trial. Study Group Members (German Crohn’s Disease Study Group). Scand J Gastroenterol 1996;31:778–85.

26. Belluzzi A, Brignola C, Campieri M, et al. Effects of new fish oil derivative on fatty acid phospholipid-membrane pattern in a group of Crohn’s disease patients. Dig Dis Sci 1994;39:2589–94.

27. Plein K, Hotz J. Therapeutic effects of Saccharomyces boulardii on mild residual symptoms in a stable phase of Crohn’s disease with special respect to chronic diarrhea—a pilot study. Z Gastroenterol 1993;31:129–34.

28. Bleichner G, Blehaut H, Mentec H, Moyse D. Saccharomyces boulardii prevents diarrhea in critically ill tube-fed patients. A muticenter, randomized, double-blind placebo-controlled trial. Intensive Care Med 1997;23:517–23.

29. Imes S, Plinchbeck BR, Dinwoodie A, et al. Iron, folate, vitamin B-12, zinc, and copper status in out-patients with Crohn’s disease: effect of diet counseling. J Am Dietet Assoc 1987;87:928–30.

30. Sandstead HH. Zinc deficiency in Crohn’s disease. Nutr Rev 1982;40:109–12.

31. Driscoll RH Jr, Meredith SC, Sitrin M, et al. Vitamin D deficiency and bone disease in patients with Crohn’s disease. Gastroenterology 1982;83:1252–8.

32. Dvorak AM. Vitamin A in Crohn’s disease. Lancet 1980;i:1303–4.

33. Skogh M, Sundquist T, Tagesson C. Vitamin A in Crohn’s disease. Lancet 1980; i:766 [letter].

34. Dvorak AM. Vitamin A in Crohn’s Disease. Lancet 1980;i:1303–4 [letter].

35. Wright JP, Mee AS, Parfitt A, et al. Vitamin A therapy inpatients with Crohn’s disease. Gastroenterology 1985;88:512–4.

36. Hegnhoj J, Hansen CP, Rannem T, et al. Pancreatic function in Crohn’s disease. Gut 1990;31:1076–9.

37. Pizzorno JE, Murray MT. Textbook of Natural Medicine. London: Churchill Livingstone, 1999, 1335–49.

38. Plein K, Burkard G, Hotz J. Treatment of chronic diarrhea in Crohn disease. A pilot study of the clinical effect of tannin albuminate and ethacridine lactate. Fortschr Med 1993;111:114–8 [in German].