Crohn's Disease Flare-ups: How to Recognize and Treat Them

When a Crohn’s disease flare-up occurs, inflammatory activity increases, and immune cells and inflammation mediators cause symptoms and complications. Between flare-ups, many people are symptom-free (remission phase); remission maintenance is a therapy that aims to prolong this phase as long as possible.

Recognizing Crohn’s flare-ups

During a flare-up, people experience symptoms similar to those in their history or new symptoms typically associated with Crohn's disease, suggesting a problem with the gastrointestinal tract. Inflammation can also begin in other parts of the body. Symptoms of Crohn's disease include:

Discomfort along the gastrointestinal tract

• Diarrhea, generally without blood
• Acute abdominal pain
• Abdominal cramps
• Inflammation around the anus with abscesses, or collections of pus

Other symptoms

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

How often do Crohn’s flare-ups occur?

The frequency and severity of flare-ups are difficult to estimate, and someone can experience a new flare-up even while taking medication. After starting medication, 30–70% of people have another flare-up within the following two years. In the first five years after beginning medication, only 20% of people experience no further flare-ups. Approximately 25% experience chronic activity, meaning a flare-up that lasts longer than six months.

Crohn’s flare-ups and disease course

Those who experience recurrent episodes early on will likely continue to have them and will experience a more severe disease course overall. For most people, Crohn's disease has a rather complicated progression. At the time of diagnosis, 1 in 3 people already has advanced inflammation. Half of all newly diagnosed people later develop a complication and must have an operation within ten years. Only 10% of those with Crohn's remain relapse-free in the long term.

Intestinal mucosa and prevention

Studies have demonstrated that healing the intestinal mucosa is beneficial for the course of Crohn's disease. A healthy mucous membrane is associated with lower rates of surgery and fewer hospitalizations. Immunosuppressants, particularly Infliximab (Remicade®), have been shown to promote long-term healing of the intestinal mucosa. Healing the intestinal mucosa prevents long-term complications and further damage to the intestinal tissue.

Treatment of acute Crohn’s flare-ups

Depending on which part of the digestive tract is affected, there are various treatment options to choose from. Doctors typically prescribe glucocorticoids for mild to moderate inflammation. Other drugs, such as sulfasalazine or 5-ASA, can also be used. If drug therapy is not sufficient to reduce the inflammation, surgery is sometimes needed to address complications.

Read more about Crohn’s disease treatment.

Treating Crohn’s pain

The following medications are used to treat pain in acute flare-ups:

• Paracetamol
• Antispasmodics
• Opioids, for a maximum of 14 days

For chronic abdominal pain and impaired everyday functioning, experts recommend medications, such as antidepressants and pregabalin, that can support mental health. Psychological treatment can also be very helpful, particularly gut-directed hypnotherapy and cognitive behavioral therapy (CBT).

Prevention of Crohn’s flare-ups

Quit smoking

Cigarette smoking triggers Crohn’s flare-ups and is the single most important determinant of Crohn's disease risk. It not only increases disease risk but also worsens disease severity and complications. Smoking also increases the likelihood of treatment failure because smoking damages intestinal flora, the intestinal wall, and signaling pathways.

Smoking cessation prevents future flare-ups by increasing the diversity of gut microbiota. Smoking cessation reduces the long-term frequency of flare-ups by 50%. Doctors will suggest smoking cessation as the initial treatment for those with Crohn's who smoke. Seek advice and support groups to quit smoking.

Medication

Doctors sometimes prescribe medication between flare-ups as remission maintenance. The following immunosuppressants can delay, prevent, or lessen the next flare-up's intensity by altering the activity of inflammatory processes.

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

Nutrition consultation

In adults, no single diet has been recommended for those with Crohn's disease or scientifically proven to reduce inflammation. Nutrition specialists advise those with specific illnesses, and some doctors also recommend nutritional advice. Treating malnutrition and maintaining a healthy weight is very important for those with Crohn's.

Mental health

Mental health disorders can exacerbate Crohn's symptoms and worsen the disease course. Flare-ups are also known to increase psychological stress. Support from psychotherapists and psychosomatic practitioners is recommended and can reduce stress.

Complementary and alternative medicine for Crohn’s disease

Complementary and alternative medicine can complement conventional medical therapies, but there is little evidence to date on application for Crohn's disease. Larger, well-designed research studies are needed to determine the effectiveness and side effects of complementary and alternative medicine for those with Crohn's.

Evidence of complementary and alternative medicine in the treatment of Crohn's disease

Fertility and Crohn’s flare-ups

There is general agreement that conceiving should be avoided during a Crohn's flare-up, as it affects female fertility and increases the risk for:

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

During a remission phase, female fertility is normal. If undergoing an operation for Crohn's disease, fertility is reduced.

If fertilization occurs during a flare-up, the flare-up continues in two-thirds of pregnant women. For some women, the flare-up even worsens after fertilization. For women who become pregnant during a flare-up, smoking cessation is of the utmost importance.

Men who would like to have children should not take sulfasalazine therapy and switch to another medication if possible.

During pregnancy, is a Crohn’s flare-up dangerous?

For pregnant women with Crohn's, a flare-up is the single most important determinant of premature birth and intrauterine infant death. It is important to continue taking medication for remission maintenance during pregnancy; if taking methotrexate, discontinue use, or switch medications, as it can damage the fetus. If fertilization occurred during remission, two-thirds of women do not experience a relapse during pregnancy.