- Crohn’s Disease
- Complications from Crohn’s disease
- Crohn’s disease FAQs
- Is Bloody Stool a Cause for Concern?
- CASE REPORT
- Rectal Bleeding
- Rectal bleeding is more common in ulcerative colitis
- What other conditions can cause rectal bleeding?
- How is rectal bleeding evaluated?
- How is rectal bleeding related to UC or Crohn’s treated?
- Ulcerative Colitis
This initial assessment will establish:
- The extent of the disease
- Complications such as fistulae and stricturing
- Nutritional status and deficiencies
- Bone density and the corresponding risk of conditions such as osteoporosis
There is currently no cure for Crohn’s disease, but there are many treatment options available to alleviate the symptoms. Treatment for Crohn’s disease focuses on:
- Treating the symptoms
- Minimising flare ups
- Maintaining periods of remission
With effective treatment, many people with Crohn’s disease will experience significant periods, possibly several years, without symptoms. For people with more severe forms of the condition, and for whom medications do not provide significant relief from the symptoms, surgery may be required.
Initial treatment of Crohn’s disease will usually involve the prescription of steroid medications (corticosteroids), which are used to reduce inflammation. These may take the form of tablets or injections, depending on what is determined to be suitable for the affected individual.
However, long-term usage of corticosteroids is associated with problematic side effects, which may include:
- Swelling of the face
- Unwanted weight gain
- Increased susceptibility to infections
- Bone density loss and resultant osteoporosis
When a person embarks on a course of corticosteroid medication, an aim of this treatment will usually be to reduce the dose over time, so as to minimise one’s exposure to harmful side effects.
Good to know: As an alternative to corticosteroids, some people may be prescribed a milder steroid or a type of medication called a 5-aminosalicylate. However, these tend to be less effective at alleviating gastrointestinal inflammation.
For individuals, whose growth and development may have been affected by Crohn’s disease, a polymeric (liquid) diet administered through a nasogastric tube may be recommended as an initial treatment. Many studies have been undertaken, comparing the polymeric diet to steroid medication, and it is considered an equally effective first-line treatment for Crohn’s disease.
A polymeric diet will be prescribed in order to allow the digestive system to recover from being inflamed and to support the uptake of nutrients, a process which is often compromised by the inflammation that is characteristic of Crohn’s disease.
A person who has been prescribed a polymeric diet will progress to slowly reintroducing solid foods into their diet in a controlled setting, in order to safeguard the period of remission facilitated by undertaking the liquid diet.
If a person, who is being treated with corticosteroids or the polymeric diet, experiences a flare up of their symptoms twice or more during one year, or finds that they return when their steroid dose is reduced, medicines which suppress the immune system (immunosuppressants) may be prescribed in combination with the initial course of treatment.
The immunosuppressant medications which are most commonly prescribed for the treatment of Crohn’s disease are azathioprine and mercaptopurine. They work by damping down the over-activity of the cells within the immune system. An alternative immunosuppressant medication is methotrexate. Methotrexate is not recommended for use during pregnancy.
It is vital that a blood test is performed before immunosuppressant medication is prescribed. A high score on this test relating to factors such as an elevated white blood cell count and increased lymph production, may indicate immunosuppressant toxicity, which means that these medications are not suitable for the affected individual.
People who are using immunosuppressant medication in the treatment of Crohn’s disease will undergo regular blood tests in order to ensure that the medication continues to agree with them, so that their use can be discontinued if needed, averting the presence of unwanted side effects.Possible side effects of immunosuppressant medication include:
- Nausea and vomiting
- Susceptibility to infection
- Inflammation of the pancreas (pancreatitis)
- Liver problems
- Anemia, characterised by feeling tired, breathless and weak
Biologic therapies are a type of immunosuppressant medications which use substances, such as antibodies and enzymes, to inhibit the effects of Crohn’s disease.
The development of biologic therapies therefore presents a breakthrough alternative treatment option for those who are unwilling or unable to use steroid medication. Historically, people with Crohn’s disease and other types of IBD faced a lack of effective treatment options. Corticosteroid therapy does not alleviate the symptoms of Crohn’s disease in all cases and for those whose symptoms do not respond to it, prolonged systemic corticosteroid therapy and surgery were previously the only options.
If a person responds well to biologic therapy, its benefits may include:
- Removal of the need to use steroid medication, thereby avoiding its side effects
- Prolonged periods in which the disease is in remission
- Potential delay or negation of the need for surgery to redress intestinal damage caused by Crohn’s disease
Why is biologic therapy not always offered as a first-line treatment?
Medical opinion is divided as to whether biologic therapies should be a first-line treatment option, and many doctors prefer to investigate whether a case of Crohn’s disease can be treated with corticosteroids, a liquid diet or traditional immunosuppressants initially, before considering biologic therapy.
The principal reason that some doctors prefer to prescribe traditional treatment methods first is that less is understood about the mechanism of action of biologic medications, and how different people will respond to them. Allergic reactions to the medications used in biologic therapies may occur –immediately or months after stopping treatment – and these can be life-threatening.
Methods of administration
The two medications used in biologic therapy for Crohn’s disease are Infliximab and Adalimumab.
These medications are considered to be broadly comparable in terms of their effectiveness in bringing about prolonged periods of remission and preventing the development of complications, such as intestinal obstructions, which require surgery. Both children and adults can be prescribed Infliximab but Adalimumab is only suitable for adults.
Both medications are usually prescribed on a twelve month course. After this, the need to continue will be reviewed, based on the individual’s response and the stability of the periods of remission following dosing.
Infliximab is administered as an infusion via a drip into a vein and requires one to visit a hospital to receive the medication as an outpatient procedure.
Adalimumab can be administered as an injection and one can learn to do this independently or with the help of another person, meaning that hospital visits are not necessary in order to redose. Doctors will advise on the type of medication that is appropriate in each individual case of Crohn’s disease.
The type of surgical procedure which will be prescribed in this case is called a resection. Doctors will consider performing a resection to remove the inflamed sections of the intestinal tract in cases where the symptoms of Crohn’s disease have not been alleviated by other treatments.
A resection is a major procedure and usually performed under general anaesthetic. When the inflamed sections of the intestine have been removed, the healthy sections will be stitched together.
Ileostomy (temporary or permanent)
An ileostomy is a procedure which involves diverting one’s digestive waste away from the colon in order to give the area, which has undergone a resection, a chance to heal. This can be temporary or permanent.
The type of ileostomy prescribed as an adjunct to a resection is usually a loop ileostomy, a temporary version of ileostomy, performed under general anaesthetic, which will be reversed after the body has had a chance to recover from undergoing resection surgery.
In a loop ileostomy, an opening in the lower abdominal area, called a stoma, is surgically created. An ileostomy bag, also called a colostomy bag or pouch, is then attached to the small intestine through the stoma. The bag hangs outside the body and collects the waste products that would otherwise have passed into one’s large intestine and out of one’s rectum. Normal function of the digestive system will be restored when the ileostomy is reversed.
A loop ileostomy is not always necessary as an accompaniment to a resection. One’s physician will advise on whether the procedure is needed.
A person’s lifestyle, exercise routine and diet plan will generally need to be tailored to their individual needs as determined by their condition, and may need to be adjusted according to their symptoms.
Managing Crohn’s disease can involve:
- Maintaining periods of remission
- Making lifestyle adjustments to accommodate medical appointments
- Management of pain and digestive discomfort
- Co-ordinating an appropriate lifestyle whilst undergoing treatment
- Surgery aftercare
Changing one’s diet after surgery may be necessary. A potential outcome of surgery for Crohn’s disease is short bowel syndrome, a condition in which malabsorption occurs due to lack of a functional small intestine. Short bowel syndrome, when present, develops in the recovery period after an intestinal resection. The likelihood of a person developing problems associated with malabsorption increases, the more intestinal tissue is removed.
In order to ensure that the affected person receives as much nutritional benefit from their food as possible, doctors will advise on the most appropriate food plan for each person, in order to reduce the chances of vitamin and mineral deficiencies after surgery.
Crohn’s disease is a chronic condition, which means that one must make certain adjustments to one’s lifestyle, including accepting that treatment and management of the condition will always be a part of one’s life. One may find it helpful to educate one’s loved ones and co-workers about the condition, so that they are understanding when one has to miss commitments or take time off work due to a flare-up.
People with Crohn’s disease will undergo periods when they need to attend frequent medical appointments for tests and/or treatment, and even when one is in a period of remission, one may need to attend checkups and periodic screenings for conditions, such as bowel cancer and osteoporosis, for which Crohn’s disease is a risk factor. It is therefore important to establish a good working relationship with one’s gastroenterologist.
Travelling with Crohn’s disease will require advance planning in order to ensure that one has, or is able to access, the pharmaceuticals that one is using to manage the condition. It is recommended that one identifies in advance how to seek medical attention in one’s destination location in the event of a flare-up.
Knowing the location of nearby restrooms can be helpful to people with Crohn’s disease as one is prone to diarrhea and may need to access a restroom rapidly. Checking the location of public restrooms in advance when visiting a new area is recommended, in order to ensure that toilets are accessible when needed.
It is important for everybody to engage in a certain amount of physical activity in order to maintain a healthy body. This includes people who are affected by Crohn’s disease. However, inflammation, fatigue and urgency are all factors which mean that an individual with Crohn’s disease will need to identify the appropriate fitness plan for them. Physical activity which is too intense may exacerbate the inflammation in people affected by Crohn’s disease.
There has not been significant research into the ideal types and intensities of physical activity for different levels of severity of Crohn’s disease. However, a recent review of current research suggests that a personalized exercise plan would be ideal.
This should be devised taking into account factors such as:
- Fitness level
- Exercise goals
- Severity of one’s Crohn’s disease and associated needs, such as proximity to restrooms
The types of activity which have been found convenient and helpful for people with Crohn’s disease, include:
- Aerobic activity, especially walking
- Muscular resistance training, which can be carried out at home, if necessary
There is currently no dietary template to follow in order to minimize the symptoms of Crohn’s disease. Individuals react differently to different foodstuffs, and everybody will find it helpful to avoid particular foods, which appear to aggravate their symptoms.
However, there are some general principles which are widely acknowledged to be helpful in preventing flare-ups of Crohn’s disease symptoms, including:
- Eating smaller meals which are easier to digest
- Drinking plenty of water
- Keeping a food diary to ensure a balanced diet and to track adverse reactions to particular foods
- Monitoring one’s fiber intake to discern whether high-fiber products trigger one’s symptoms
- Choosing low-fat products
- Avoiding foods which produce excessive bloating and gas
Complications from Crohn’s disease
In addition to experiencing the immediate symptoms of Crohn’s disease, people with the condition are also predisposed to further health complications.Related conditions which commonly affect people with Crohn’s disease include:
This condition is also referred to as bowel obstruction. Over time, the inflammation of the digestive tract in people with Crohn’s disease can cause the wall of the affected area(s) of the small or large intestine to thicken permanently. This can cause the intestine to become blocked. Intestinal obstructions can be fatal if left untreated and often require surgical removal.
This is a tear or sore which can occur in the anal canal. Anal fissures are common in people with Crohn’s disease, due to the trauma which is caused to the area by frequent bowel movements.
An anal abscess is an infected cavity filled with pus. Abscesses can affect the anus or rectum as a result of the internal glands in the anus becoming infected. This is likely to occur in people with Crohn’s disease, as the tissue in this area is often traumatized due to frequent bowel movements.
The inflammation caused by Crohn’s disease often creates ulcers, leaks and abscesses in the bowel wall. The more severe the inflammation, the more likely it is that one of these abrasions will develop into a hole, which then forms a fistula. A fistula is a tunnel which forms between two parts of the bowel or between the bowel and the outer skin or between the bowel and other surrounding hollow areas or organs, such as the bladder or vagina, which are not normally connected to the bowel.
The larger a fistula is, the more likely it is to become infected. This can cause problems like irritation of the skin and leakage of feces into or from the space which has been connected to the bowel. If you suspect you may have this condition, you can get a free symptom assessment by downloading the Ada app.
Iron deficiency anaemia
This condition often occurs in people with Crohn’s disease, due to the bleeding in the digestive tract, and because malabsorption can cause a person’s iron levels to become deficient. It is associated with shortness of breath, fatigue and a pale complexion.
Read more about Ireon Deficiency Anemia “
Osteoporosis is a disorder of the skeleton, in which the structure of the bones becomes porous. This can lead to the bones becoming weak, fragile and prone to painful fractures (breaks). In people with Crohn’s disease, osteoporosis can occur due to the intestines failing to absorb sufficient nutrients to support healthy bone growth, or due to the use of steroid medication, which may be used in the treatment of Crohn’s disease.
Read more about Osteoporosis “
Vitamin B12 deficiency
Often signalled by fatigue and a lack of energy, vitamin B12 deficiency is likely to occur in people with Crohn’s disease due to malabsorption.
Read more about Vitamin B12 Deficiency “
This is a treatable, non-infectious skin condition, characterised by painful ulcers, which typically develop purple or blue edges, and may ooze fluid. They most commonly occur on the legs.
People affected by Crohn’s disease are at an increased risk of blood clots forming, which may result in deep vein thrombosis (DVT) or a pulmonary embolism if left untreated. The link between hypercoagulability and Crohn’s disease is not yet fully understood, but recent research suggests that imbalances between the levels of clotting and thinning agents in the blood caused by inflammation from Crohn’s disease, contributes to the development of the condition.
People whose Crohn’s disease affects their colon have a slightly increased risk of developing colorectal cancer. It is advisable to attend regular checkups and to undergo a colonoscopy to screen for colon cancer.
The average risk of someone developing colorectal cancer in their lifetime is about 4.5 percent.
The risk once a person has been diagnosed with Crohn’s disease is as follows:
- After 10 years, 3 percent are likely to have developed colorectal cancer
- After 20 years, 6 percent are likely to have developed colorectal cancer
- After 30 years, 8 percent are likely to have developed colorectal cancer
People with Crohn’s disease are advised to attend regular medical checkups in general, which should assist with the early identification and treatment of any associated conditions that arise.
Read more about colorectal cancer “
Pregnancy and fertility
People who are affected by Crohn’s disease can normally follow their usual treatment plan during pregnancy. Most of the medications and treatment protocols, which are normally prescribed for people with Crohn’s disease, are suitable for pregnant women, with the exception of methotrexate, a type of immunosuppressant medication.
Regarding the development of the fetus, Crohn’s disease has been associated with the following possible risks:
- Low birth weight
- Preterm delivery
- Small gestational age
It is strongly recommended that both men and women with Crohn’s disease be in a period of remission at the point of conception. This will maximize the likelihood that the pregnancy will progress with no complications, and that the fetus will develop healthily.
Crohn’s disease FAQs
Q: Does Crohn’s disease reduce one’s life expectancy?
A: In many cases, people with Crohn’s disease are able to live a normal lifespan, due to the extent to which treatments are now successfully able to mitigate the symptoms of Crohn’s disease.
Q: How is Crohn’s disease different from ulcerative colitis?
A: Ulcerative colitis is the other main form of inflammatory bowel disease (IBD) and shares several important characteristics with Crohn’s disease. They are both chronic (long-term) conditions which involve inflammation of the gut and fatigue. However, ulcerative colitis only affects the large intestine, whereas Crohn’s disease can affect any part of the gastrointestinal system.
The two conditions differ in their symptoms. People with Crohn’s disease may produce stools containing mucus, blood and/or undigested fats, whereas stool samples from people with ulcerative colitis are more likely to contain only mucus and/or blood. Tenesmus (rectal pain) is more characteristic of ulcerative colitis than Crohn’s disease, whereas fistulae and weight loss are more likely to occur in cases of Crohn’s disease. It is common for someone with Crohn’s disease to experience regular fevers, whereas this would be symptomatic of a severe flare-up in someone with ulcerative colitis.
Q: Is there a cure for Crohn’s disease?
A: There is not currently a cure for Crohn’s disease. However, many people with the condition are able to achieve periods of remission, which last years or even decades due to accessing effective treatment options. With regard to developing a cure, a recent study has built on existing research into available treatments for Crohn’s disease. The findings suggest that alternative mechanisms, which can permanently intercept the workings of the disease, may be developed by 2030.
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Is Bloody Stool a Cause for Concern?
Q1. Lately, I’ve been finding some blood in my stools. I have not changed many aspects of my lifestyle. I’m pretty concerned. I have diarrhea every once in a while, but it was not enough to set off any concern before the blood began to appear. Should I see a doctor?
Yes, you should see a doctor for blood in your stools — whether or not you have Crohn’s disease. In patients with Crohn’s, bleeding usually signifies active disease in the large bowel or the perianal area. Perianal problems in patients with Crohn’s disease include fissures, fistulas, hemorrhoidal skin tags, and perianal ulcerations. Fortunately, many of these problems can be resolved if you and your doctor initiate the proper treatment in a timely fashion. Waiting to see your doctor is not a good idea.
To give you some background, perianal fissures are tears or cracks in the skin of the anus that can cause bleeding. Fistulas are abnormal tunnel-like passages, lined with epithelial cells, between two organs; they are also a potential cause of bleeding. Hemorrhoids are lumps of tissue in the anus that contain enlarged blood vessels; they can bleed when a person is straining to have a bowel movement.
Q2. What is the possible clinical significance of the colon appearing red upon both capsule endoscopy and colonoscopy? Prior biopsies showed mild to moderate acute chronic inflammation.
Active inflammation in the intestines may result in a red appearance of the mucosa (or lining) of the intestine. There are other characteristic findings associated with active inflammation including ulceration and friability of the mucosa, which are typically seen in conjunction with red discoloration (also referred to as erythema). Mild redness without other characteristic findings of inflammation may be a non-specific finding not representative of inflammation at all. Biopsies are usually taken to confirm the presence of inflammation.
Q3. Recently I had a bout of green feces. I have only had this one time before, when I was 13 and had my first Crohn’s attack. What does this mean? What causes it? Should I be a little concerned, concerned, or very concerned?
Green stool color is no reason for concern. Most likely there is something in your diet — spinach, leafy green vegetables, or even food coloring — that is making the stool green. Green stool color is not an indication that your Crohn’s disease is active.
Q4. What is Crohn’s colitis with granulomas? I have granulomas all over inside my colon. Do I need to be worried about this?
About 10 percent of Crohn’s disease patients have granulomas (small inflamed bumps or nodules) on biopsy. Granulomas also can be seen in other diseases of the bowel like tuberculosis and sarcoidosis. As far as I know, granulomas in Crohn’s disease carry no adverse consequences in terms of complications or response to treatment.
Q5. I’ve had Crohn’s for over 30 years. I recently had a polyp removed. And after much review, it was said to be a DALM or adinoma. My doctor now wants to remove my entire colon due to the risk of colon cancer. Is this really necessary? My Crohn’s has been very inactive, but I do have scarring throughout the entire colon. But to wear a bag for the rest of my life (I’m almost 50) just seems a little extreme because I might get cancer.
Patients with inflammatory bowel disease have an increased risk of developing colon cancer compared to the general population. A DALM (dysplasia-associated lesion or mass) is a pre-malignant lesion sometimes found in patients with Crohn’s disease or ulcerative colitis. When these lesions are found on colonoscopy, removal of the colon is generally recommended because there is a high risk for additional pre-malignant or malignant lesions in the colon. Unfortunately, our ability to detect pre-malignant changes in patients with inflammatory bowel disease is imperfect. Therefore, it is important to understand and consider the risk of an undetected pre-malignant or malignant lesion if you choose not to have your colon removed.
Q6. I have had Crohn’s for seven years now, and it has been that long since my last colonoscopy. I have been taking sulfa drugs to keep it in remission (and they’ve been effective thus far). Recently, my blood work showed my vitamin D was low, so I was placed on a supplement. My doctor wants me to undergo another colonoscopy, but my last one was extremely irritating. It was like a flare-up that lasted a good week-and-a-half. If the disease is in remission, what is the purpose of going through the pain of a colonoscopy?
Patients with either ulcerative colitis or Crohn’s disease are at increased risk of developing colorectal cancer. Periodic cancer surveillance colonoscopy is recommended to minimize this risk. In the last seven years, colonoscopy preparation regimens have improved greatly and should not be as irritating as before. Also, our conscious sedation practice has improved in the last seven years, and there is less pain associated with colonoscopy.
Q7. How frequently should a Crohn’s patient have a colonoscopy to evaluate the condition of the diseased area in the colon? Are other methods effective for this purpose?
Not all Crohn’s disease patients need periodic colonoscopy. In patients who have a large portion of the large bowel (colon) affected with disease, cancer surveillance colonoscopy every one to three years is beneficial. Otherwise, I would consider colonoscopy only if there are symptoms that do not respond to Crohn’s disease therapy. This might indicate some other diagnosis, such as infection colitis or pseudomembranous colitis, which are both conditions that cause inflammation of the large intestine.
Q8. What’s your opinion on the theory that Crohn’s is an infectious disease caused by Mycobacterium avium paratuberculosis? I’ve seen testimonies from many patients on different Crohn’s message boards who have not had symptoms for years now and feel they are cured.
Mycobacterium avium paratuberculosis (MAP) has been purported to be a cause of Crohn’s disease. Unfortunately, research has not found this to be true. Only a few patients have had MAP cultured from intestinal tissue specimens and even fewer have responded to appropriate antibiotics. Still, there are some anecdotal reports of success with antibiotics aimed at these bacteria, such as rifabutin and clarithromycin. We need more research in this area.
Learn more in the Everyday Health Crohn’s Disease Center.
A 13 years old boy was admitted to the hospital because of gross hematochezia. There was nothing significant in the patient’s past medical history over the past 6 months. He reported suffering from intermittent diarrhea and abdominal pain. Also, he went from 47 kg to 40 kg during the course of 3 months. He was initially believed to have hematochezia and therefore a colonoscopy was performed. After the colonoscopy, he was sent to our hospital with suspicion of inflammatory bowel disease. At his first visit, his blood pressure, pulse rate, respiratory rate, body temperature, height and body weight were 110/65 mm/Hg, 90/min, 20/min, 36.5℃, 164.2 cm (25-50 p) and 40 kg (5-10 p), respectively. He appeared chronically ill and was pale. The physical examination upon admission showed slight pain and tenderness at the peri-umbilical region without muscular guarding. His bowel sounds were normal and the rectal examination revealed an empty ampulla with no other peculiar symptoms regarding peri-anal abscess or fistula. The laboratory investigations during the first exam were as follows: erythrocyte sedimentation rate (ESR) 84 mm/h, C-reactive protein 106 mg/L (normal 0-8 mg/L), albumin 2.8 g/dL, prothrombin time 11.5 sec, partial thromboplastin time 28.1 sec, hemoglobin 10.4 g/dL, leucocytes 9.8×109/L with normal leukocyte differentiation, and thrombocytes 489×109/L. A stool occult blood test was also performed and found to be positive. The colonoscopy showed an inflammatory bowel with multiple linear deep ulcerations, cobble stone appearances and pseudo-polyps (Fig. 1). In addition, in the MRI enterography, a diffuse bowel wall thickening was observed at the distal to terminal ileum, cecum and rectosigmoid colon. Accordingly, he was diagnosed with Crohn’s disease. His Pediatric Crohn’s disease Activity Index (PCDAI) score was 68. Initially, induction therapy was performed with oral steroids (30 mg/day) and Azathioprine (100 mg/day). He was also given 8weeks of EEN with a polymeric formula (Monowell 2,000 mL daily). After medical therapy, the abdominal pain has declined slightly and the ESR and C-reactive protein (CRP) was reduced but intermittent mild bloody stools were still observed. After the 10th day of hospitalization, approximately 1,000 mL of a fresh bloody stool and dizziness with about a 10-second loss of consciousness had occurred. At this time, his blood pressure had dropped to 80/40 mmHg. In addition, his hemoglobin levels dropped from 10.4 g/dL to 7.6 g/dL. Accordingly, 6 units blood transfusion was performed over a 24 hour time period. After the blood transfusion, his vital signs had stabilized. Based on the patient’s past history and the colonoscopy data, we presumed that this gastrointestinal hemorrhage was caused by Crohn’s disease. At that point, oral steroid treatment was changed to intravenous steroids and the patient was placed under conservative care. However, even after 10 days, due to over 500 mL of continuous massive hematochezia and repetitive hemoglobin drop, blood transfusion was needed. Thus, a bleeding focus evaluation was performed. From the GI bleeding scintigraphy, the radiotracer was found to be up taken in the mid to left upper quadrant in the abdomen and no abnormal signs were observed in the abdomen CT. A duodenal ulcer was observed in the upper endoscopy but no other acute findings were made. A colonoscopy was then performed and multiple active ulcerations in the distal ileum and inflammatory polyps and cobble stone appearance were found (Fig. 2). Ulcers and bleeding was also expected to be found; however, current active bleeding was not observed and no other bleeding focus was present. For 3 weeks, even with steroid induction and azathioprine therapy, mucosal healing was not successful. The PCDAI score was also 60, which was indicative of continued severe disease activity. Since steroid therapy was ineffective, infliximab infusion (5 mg/kg) was initiated. On the 21st day, a superior mesenteric angiography was performed. In this test, no active bleeding was observed; however, a hypervascular blush, which caused by inflammatory changes, was observed near the proximal ascending colon and ileocecal (IC) valve. To account for this, 2 superior mesenteric arteries were selected using a microcatheter and gel foam arterial embolization was successfully performed (Fig. 3 and and4).4). A hematochezia was found nowhere and the PCDAI score had decreased by 20 points. Starting on the 27th day, mucosal healing and bleeding was thought to be well managed from infliximab infusion and embolization and maintenance therapy was performed using mesalazine (4,000 mg/day). 2 weeks after the first infliximab injection, which corresponded to the 34th day of hospitalization, valve, a second infusion of infliximab (5 mg/kg) was done. However, 650 mL of massive hematochezia was observed on the 35th day of hospitalization. For the first 24 hours, the patient was given 2 units of blood. However, even with active transfusion, the massive rectal hemorrhage continued and his hemoglobin levels dropped from 12.6 gm/dL to 11.6 gm/dL. At this point, we deemed it necessary to perform surgery. To examine the precise operation scale, a second angiography was performed before the operation. The superior mesenteric artery angiography showed a hypervascular blush near the proximal ascending colon and IC valve; however, no active bleeding was observed (Fig. 5). On the 36th day of hospitalization, an ileocecectomy and hand sewn end to side anastomosis were performed. During the operation, wall edema and inflammation was found on the IC valve which was about 30 cm deep into the terminal ileum. An ileostomy was initiated to observe the inside of the lumen and a cobble like appearance, mucosal ulceration and dark blood clot was found. The lumen of the cecum was relatively clean and inflammation was not severe. Although a single bleeding point was not identified, the hemorrhage presumably originated from the diffusely multifocal ulcerated ileal mucosa. Approximately 30 cm of the terminal ileum and cecum together were cut and an ileocecectomy was performed as well as a hand swen end to side anastomosis (Fig. 6). According to the pathologic examination, the ileocecum was erythematous and multiple ulceration, transmural inflammation with perforation and small non-caseating granuloma were observed, a condition that was compatible with Crohn’s disease. No colonic diverticula were identified. After the ileocecectomy, the patient’s bleeding promptly ceased and he did not require additional blood transfusions. On the 6th postoperative day, a clear liquid diet was started and on the 7th postoperative day, a dark brown colored stool was evident; however, no more hemorrhage episodes occurred and the abdominal pain was managed, which resulted in a steady increase in food consumption. The daily dose of prednisolone was set at 30 mg/day initially and was decreased according to the clinical activity of the disease. On the 12th postoperative day, the PCDAI score was 15 and the wound had cleared; therefore, the patient was discharged. Currently, the patient is in maintenance therapy and receives only infliximab. After the hospitalization, the PCDAI score remained below 10 and disease activity was controlled. The patient has no recurrence of bleeding or evidence of Crohn’s disease and is currently in good condition.
The 1st colonoscopy. Multiple linear deep ulcerations, cobble stone appearance and pseudo-polyp at terminal ileum, which are consistent with Crohn’s disease.
The 2nd colonoscopy. Current active bleeding was not observed and no other bleeding focus was found in the scope.
The 1st superior mesenteric angiography shows increased focal staining in the ileocecal valve and proximal ascending colon.
Two superior mesenteric artery branches were selected and arterial embolization was performed.
The 2nd superior mesenteric angiography shows a hypervascular blush in the ileocecal valve and proximal ascending colon.
Specimen from ileocecal resection. Erythematous and multiple ulceration, transmural inflammation with perforation and small non-caseating granuloma are shown, a condition that is compatible with Crohn’s disease.
Rectal bleeding can be a sign of inflammatory bowel disease (IBD) or its complications.1,2 Bleeding in the digestive tract presents in a number of different ways. For example, you might notice:
- Jet black stool (also called melena).
- Bright red blood mixed with stool (also called hematochezia).
- Blood on the toilet paper or in the toilet, without stool.
Bleeding higher up in the digestive tract (esophagus, stomach) usually causes black stool. One of the main forms of IBD, Crohn’s disease, can be a possible—but uncommon—cause of black stool.3 It can be hard to notice this type of bleeding. Special stool tests may be needed to identify blood in dark stool.
Rectal bleeding is more common in ulcerative colitis
Bleeding in the lower digestive tract (last part of small intestine, colon, rectum, or anus) causes bright red blood to appear. This is a more common symptom of Crohn’s disease, which typically affects the end of the small intestine (ileum) and colon, and ulcerative colitis, the other main form of IBD which affects the colon.4 Among people with IBD, rectal bleeding is more typical of ulcerative colitis than Crohn’s disease.1 Bleeding related to inflammation in the colon often occurs along with diarrhea.5 Anal fissures and fistulas can cause bright red blood in the stool.2,4
Severe rectal bleeding (hemorrhage) can cause low blood pressure, increased heart rate, and shock.4 Hemorrhage leads to hospitalization in 1.2% of patients with Crohn’s disease and 0.1% of ulcerative colitis.4
What other conditions can cause rectal bleeding?
In general, hemorrhoids and diverticular disease are the most common causes of rectal bleeding.2,5 Other common causes include:
- Angiodysplasia of the colon (fragile blood vessels)
- Colon inflammation (colitis) from many causes
- Stomach ulcers
- Colorectal cancer
Bleeding in the lower digestive tract has been linked to taking non-steroidal anti-inflammatory drugs (NSAIDs), such as Aleve, Advil, and Motrin.4 Once you have been diagnosed with IBD, NSAIDs are not recommended.6 However, research about the link between NSAIDs and IBD is ongoing and so far, inconclusive. No studies have shown that taking these medications is a cause of IBD.7
How is rectal bleeding evaluated?
Your health care provider will evaluate rectal bleeding by asking questions, performing a physical exam, and doing some tests.
Your provider may ask questions such as:3,4,8
- What are your bowel movements like?
- Have you had any recent changes in bowel habits?
- Are your stools black or bloody? How often does this happen?
- Have you noticed blood on the toilet paper?
- Have you vomited recently? What did it look like?
- Have you had a recent colonoscopy?
- Have you had any recent trauma to the abdomen or rectum?
- What medications are you taking?
- Do you have a history of digestive or blood diseases?
- Have you been treated for prostate or pelvic cancer?
- Has anyone in your family had colon cancer?
- Have you experienced changes in weight recently?
Your health care provider may want to look at your stool.4 If you are in the hospital, you may be asked to use a special toilet or bedpan. If you are at home, your provider will instruct you on how to collect a sample.
Your provider will check your pulse and blood pressure. He or she will probably also perform a rectal examination to look for hemorrhoids, fistulas, or fissures that could cause bleeding. You may need to have blood tests to check for anemia, clotting problems, and changes in your blood chemistry.
Your health care provider may recommend a colonoscopy.2 This procedure allows your provider to see inside your digestive tract and look for the source of bleeding. Colonoscopy is helpful for people with unexplained bleeding and bleeding that continues despite treatment. Colonoscopy is especially important if you have lost weight, are anemic, are older than 40, or have a family history of colorectal cancer.
The treatment for rectal bleeding depends on the cause. When it is a symptom of IBD, treating the IBD is often an effective way to stop the bleeding.9
Similarly, bleeding due to complications from IBD is managed by treating the complication. For fissures, the first step is trying to let it heal on its own. If the fissure does not heal, medications and surgery are used. Anal fistulas also are treated with a combination of medication and surgery.
What is ulcerative colitis?
Ulcerative colitis is a chronic inflammatory disease that affects the lining of the large intestine (colon) and rectum. People with this condition have tiny ulcers and small abscesses in their colon and rectum that flare up periodically and cause bloody stools and diarrhea.
Crosscut of colon and rectum with ulcerative colitis.
Ulcerative colitis is characterized by alternating periods of flare-ups and remission in which the disease appears to have disappeared. The periods of remission can last from weeks to years.
The inflammation usually begins in the rectum and then spreads to other segments of the colon. How much of the colon is affected varies from person to person. If the inflammation is limited to the rectum, the disease may be called ulcerative proctitis. Ulcerative colitis, unlike Crohn’s disease, does not affect the esophagus, stomach or small intestine.
When grouped together, ulcerative colitis and Crohn’s disease are referred to as inflammatory bowel disease because they cause inflammation of the bowel.
Who gets ulcerative colitis?
Ulcerative colitis can be inherited. Up to 25 percent of people with inflammatory bowel disease have a first-degree relative (mother, father, brother, sister) with the disease.
What are the symptoms of ulcerative colitis?
The main symptom of ulcerative colitis is diarrhea that often becomes bloody. Occasionally, the symptoms of ulcerative colitis include severe bloody diarrhea, dehydration, abdominal pain, and fever. Other symptoms may include painful, urgent bowel movements or pus or blood in the stool. Ulcerative colitis may be associated with weight loss, joint pain, anemia (a deficiency in red blood cells), or skin lesions (sores).
What causes ulcerative colitis?
The cause of ulcerative colitis remains unknown, but it is likely caused by an abnormal response of the immune system in the gastrointestinal tract to something in the gut – food or bacteria in the intestines, or even the lining of the bowel – that causes uncontrolled inflammation.
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