By Ryan Ungaro, MD, as told to Barbara Brody
Back when I was in medical school, I decided to specialize in gastroenterology because I thought it was a fascinating field. I still do. Inflammatory bowel disease (IBD) patients, including those with Crohn's, are particularly rewarding to treat because I really get to know them and support them closely over many years. It's my job to usher them through difficult times and get them back to enjoying a good quality of life.
As director of the Comprehensive Care for the Recently Diagnosed IBD Patient (COMPASS-IBD) program at Mount Sinai in New York, I see many people who have only recently learned that they have Crohn's. Often these patients have classic symptoms, which include diarrhea, abdominal pain, and urgency. But many don't realize there are a number of Crohn's disease symptoms, and potential complications, that aren't so obviously tied to the digestive system
Crohn's disease is an inflammatory condition. That inflammation primarily affects the intestines. But fever might be a sign of Crohn's, particularly when it happens in conjunction with other symptoms. Fever suggests systemic inflammation, which could be stemming from inflammation in the bowel.
Unexplained weight loss can also be a symptom of Crohn's because body-wide inflammation has the potential to speed up your metabolism. Meanwhile, people with Crohn's often lose weight if they aren’t absorbing nutrients like they should. That's most likely to happen when the bowel gets ulcerated or inflamed or because you have chronic diarrhea.
For that reason, weight loss could indicate new disease (in someone who hasn't yet been diagnosed) or be a sign of a flare up in someone who's been living with Crohn's for some time. In other cases, patients lose weight simply because they're eating less in an effort to avoid triggering or worsening their GI symptoms.
Fatigue is another common complaint among people with Crohn's disease. It may be linked to inflammation, but we also see it in many patients who seem to have their disease well-controlled. This is an active area of research, so hopefully we'll know more about why this happens in the future.
When someone has severe Crohn's disease or is experiencing a flare, it isn’t only their digestive system that's in trouble. Some people with Crohn's develop eye problems such as episcleritis, scleritis, and uveitis, which are different types of eye inflammation. They can cause redness and vision trouble.
Inflammation associated with Crohn's can also lead to skin symptoms, like tiny red bumps (erythema nodosum) or sores (pyoderma gangrenosum) that appear on the arms or legs.
Another possible complication is a disease of the bile ducts called primary sclerosing cholangitis. It's more common in people with ulcerative colitis (the other type of IBD), but it does occur in some people with Crohn's.
Crohn's and Other Autoimmune Ailments
Crohn's disease is an autoimmune condition. It happens when your immune system mistakenly attacks itself or responds inappropriately to a perceived invader. If you have one autoimmune disorder, the risk of having another goes up. Crohn's disease frequently overlaps with inflammatory forms of arthritis, especially ankylosing spondylitis, a condition characterized by inflammation in the joints of the lower spine and pelvis.
Psoriasis, an autoimmune disorder known for causing skin scaly patches, is also fairly common among people with Crohn's.
When someone with Crohn's develops joint pain or skin problems, we often loop in a dermatologist or rheumatologist to tease out what's going on. Sometimes the symptom turns out to be a complication of Crohn's, but you can't always chalk it up to underlying GI disease. Someone who turns out to have inflammatory arthritis or psoriasis may need specific treatment for those issues, in addition to the treatment they're getting for Crohn's.
The Importance of Personalized Care
No two people with Crohn's are alike, so treatment needs to be individualized. One of the things we consider when figuring out how to treat someone is whether or not they have extraintestinal manifestations. That means symptoms or problems that aren't limited to the gut.
For instance, someone who has Crohn's as well as psoriasis might be able to take a medication with broad anti-inflammatory action that helps both conditions. Another person with Crohn's symptoms that are confined to the GI tract might be better off with a drug that specifically targets inflammation in the gut.
I'm particularly interested in learning more about how to match each patient with the best treatment for them. At the moment, I'm conducting research funded by the National Institutes of Health aimed to predicting which patients, from the time of diagnosis, are likely to have a mild disease course versus a more severe disease that’s likely to lead to serious complications or require surgery. Right now it's often a guessing game, but if we can figure that out early on (using blood or intestinal biopsy markers) it will help us determine who needs the most aggressive treatments to keep their entire body as healthy as possible.
Ryan Ungaro, MD, director, Comprehensive Care for the Recently Diagnosed IBD Patient (COMPASS-IBD) program, Mount Sinai, New York.