Digestive Disorders > IBD > Crohn's Disease

Crohn's disease flare-ups: Recognizing and treating them

Dr. med. Andre Sommer

Dr. med. Andre Sommer

When a Crohn’s flare-up occurs, the inflammatory activity in the body increases, and immune defense cells and inflammation mediators trigger symptoms and complications. Between flare-ups, many patients are symptom-free, and the aim is to maintain this phase as long as possible through specific therapy. This article describes flare-ups and their meaning, prevention, and therapy.

How to recognize a flare-up?

During a flare-up, the patient experiences symptoms similar to those in their history or new symptoms associated with Crohn's disease. Typical symptoms suggest a problem in the gastrointestinal tract. Inflammation can also become active in other parts of the body. The symptoms involved with Crohn's disease include:

Discomfort in the gastrointestinal tract

  • Diarrhea (generally without blood)
  • Acute stomach pain
  • Stomach cramps
  • Weight loss
  • Purulent inflammation or altered passages in the anus

Other symptoms

  • Fever
  • Joint pain
  • Eye inflammation
  • Skin changes
  • Ulcer-like changes in the mouth

How often do flare-ups occur?

The number and severity of the flare-ups are difficult to estimate for the individual patient. In principle, every patient can experience a new flare-up even under therapy. After starting drug therapy, 30–70 percent experience another flare-up in the following two years. Only about a fifth of patients experience no further flare-ups in the first five years. Almost 25 percent experience chronic activity: A flare-up lasts longer than six months with such patients.

What do flare-ups say about the course of the disease?

Those who suffer from recurring episodes early on will likely suffer from episodes later and experience a more complicated and difficult course. In most cases, Crohn's disease has a rather complicated course. When diagnosing it, a third of the patients already have advanced inflammation. Half of all newly diagnosed people later develop a bowel complication and have to be operated on within ten years. Only 10 percent of Crohn's patients remain relapse-free in the long term.

Can intestinal mucosa prevent a flare-up?

Studies from recent years have shown that healing the intestinal mucosa is beneficial for the course of Crohn's disease. A healthy mucous membrane is therefore associated with lower surgery rates and fewer hospital stays. It seems to prevent other damage to the intestinal tissue and also long-term complications. It is currently still being investigated to what extent the healing of the intestinal mucosa can be used as a marker for therapy control.

How is an acute flare-up treated?

Measures against flare-ups

Depending on the affected region of the body, there are different therapy options to choose from. Many doctors use glucocorticoids for mild and moderate inflammatory activities. Other drugs such as sulfasalazine or 5-ASA can also be used for increased inflammatory activities. If drug therapy is insufficient, surgery is often indicated.

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Measures against pain

The following drugs are used to treat pain in acute Crohn's disease:

  • Paracetamol
  • Antispasmodics
  • Opioids (for a maximum of 14 days)

For chronic abdominal pain and low disease activity, experts recommend drugs that work in the brain, including antidepressants and pregabalin. Psychological treatment can also help, such as

  • Gut-directed hypnotherapy
  • Cognitive behavioral therapy

How can a flare-up be prevented?

Quitting smoking

Quitting smoking is seen by scientists as a proven measure to prevent flare-ups. The frequency of flare-ups can be halved in the long term by not smoking. Therefore, all Crohn's patients should receive advice and support on quitting smoking.

Medications

Doctors prescribe medication between flare-ups for some patients. The patient's symptom-free condition should be maintained this way (remission-maintaining therapy).

Medications used:

  • Azathioprine
  • 6-Mercaptopurin
  • Methotrexat
  • Anti-TNF antibodies

These drugs control and keep our immune system at bay (immunosuppressants). They control and change the activity of the immune cells and other inflammatory processes. In doing so, they can delay, prevent, or dampen the next flare-up.

Nutrition consultation

Specialists give advice on specific illnesses or malnutrition. It should be noted that in adults, no special diet for patients with Crohn's disease has been scientifically proven. Nevertheless, doctors recommend nutritional advice to suitable patients. The treatment of malnutrition and being underweight is of the greatest importance, here.

Psychological advice

Mental disorders can worsen the course of Crohn's disease. Contact with psychotherapists and psychosomatic practitioners is therefore recommended. In addition, a flare-up increases psychological stress, which is something a therapist can help with.

What approaches are there in complementary medicine?

Complementary medicine procedures can complement conventional medicine therapies. For most of the proposals, there are no studies based on today's scientific standards that have examined the effectiveness and side effects.

Overview of complementary medicine in the treatment of Crohn's disease

Application Background information
Acupuncture Effect proven in only one study with decrease in disease activity
Arthemisia absintum (wormwood) Positive effects against acute flare-ups in individual studies
Boswellia serrata (frankincense) No effect in two known studies
Probiotics So far, the effect has mainly been demonstrated for ulcerative colitis, but there is no evidence of positive effect for Crohn's disease
Omega-3 fatty acids Possibly positive effects to prevent relapses when taken as an enteric capsule form
Trichuris suis ova (TSO) No evidence of positive effects

What options should be considered for children with relapses?

In addition to the classic symptoms, children also experience other signs that characterize Crohn's disease:

  • Slower growth (growth retardation)
  • Delayed puberty

Otherwise, the same therapeutic principles apply to children as to adults. The current guideline for the treatment of Crohn's disease emphasizes nutritional therapies as an additional option. They should be considered when deciding on therapy for children and adolescents, but they do not replace drug therapy between flare-ups. Even in acute episodes, children and adolescents are advised to use special nutritional therapy instead of classic therapy with glucocorticoids.

Does a flare-up affect fertility?

During the active phase of Crohn's disease, women’s fertility appears to be impaired. During an episode, patients are at increased risk for:

  • Loss of the fetus
  • Stillbirth
  • Premature birth
  • Low birth weight
  • Developmental disorders in the child

If fertilization takes place during a flare-up, the flare-up persists in two thirds of the patients. For some, the flare-up worsens after fertilization. Operations for Crohn's disease reduce the chance of pregnancy. In the flare-up-free phase, a woman’s fertility is not restricted. Men who want to have children should not receive sulfasalazine therapy and should switch to another medication if possible.

Is a flare-up dangerous for the child during pregnancy?

A flare-up during pregnancy is the biggest risk factor for premature babies or intrauterine infant death for women with Crohn's disease. Therefore, drug therapy between relapses is continued even during pregnancy. Only the drug methotrexate needs to be discontinued or changed, as it can damage the fetus. If fertilization took place in a relapse-free phase, two-thirds of patients do not experience an relapse during pregnancy.

Adler, G., 2013. Morbus Crohn-colitis ulcerosa. Springer-Verlag. Downloaded online on 02/08/2018 from: https://bit.ly/2P5G90X (Google Books)

Raspe, H., Conrad, S. and Muche-Borowski, C., 2009. Evidenzbasierte und interdisziplinär konsentierte Versorgungspfade für Patientinnen und Patienten mit Morbus Crohn oder Colitis ulcerosa. Zeitschrift für Gastroenterologie, 47(06), pp.541-562. Downloaded online on 02/08/2018 from: https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0028-1109323

Dr. med. Andre Sommer

Dr. med. Andre Sommer

I’m André, a medical doctor from Berlin. Together with a team of medical doctors, nutritionists and data scientists we empower people to understand digestive issues with our app Cara.

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