Understanding the Remission and Relapse Cycle in Crohn’s Disease

Crohn’s disease is a chronic inflammatory bowel disease that causes inflammation in the digestive tract. This leads to severe diarrhea, abdominal cramping and pain, weight loss, fatigue, and malnutrition. Inflammation caused by this condition involves several different areas of the digestive tract. The affected area varies from person to person. Crohn’s disease causes swelling and irritation in the lining of the gastrointestinal tract, commonly affecting the end of the small intestine and the beginning of the colon or large intestine. Since Crohn’s is a chronic disease, most people will experience these symptoms on and off for the rest of their life. Symptom-free periods in Crohns Disease are known as remissions, and the periods during which there is a flare-up of symptoms are known as relapses. Here’s everything you need to know for understanding the remission and relapse cycle in Crohn’s disease.

Understanding the Remission Cycle of Crohn’s Disease

There is no cure for Crohn’s disease, but the condition can be managed with treatment. The primary goal of treatment in people affected by Crohn’s is to achieve and maintain periods of remission.(1,2,3) A remission period is when the symptoms of Crohn’s either improve or disappear altogether. Various doctors have different definitions for these remission periods, and there are different ways of describing these symptom-free periods.(4,5)

According to the parameters used to describe this period, remission can mean different things. Some of the different types of Crohn’s remission include:

Clinical Remission: This is the most commonly used term to describe a period of remission. This term means that either your Crohn’s symptoms have gone away or there has been an improvement. However, you may still continue to have inflammation in your digestive tract.(6)

Endoscopic Remission: The next type of remission is endoscopic remission. If your doctor tells you that you are in endoscopic remission, then it means that there is no evidence of inflammation in the gastrointestinal tract based on diagnostic tests like sigmoidoscopy or colonoscopy.(7)

Histological Remission: There is no agreed-upon definition for histological remission, and it typically refers to decreased inflammation combined with healing in the lining of the digestive tract.(8)

Radiographic Remission: This type of remission indicates that there is no sign of inflammation observed on imaging scans like an MRI scan and other similar scans of the gastrointestinal tract.(9)

Some other factors that your doctor will look for to confirm that you are in a stage of remission include:

Looking At The Normal Markers Of Inflammation – fecal and blood tests should show no signs of inflammation.

Symptoms of Crohn’s Disease – the common symptoms of Crohn’s disease like diarrhea, abdominal pain, and bloody stools should either disappear altogether or get milder once you are in remission.

Duration – how long does a period of remission last? A remission period can last for anywhere between a couple of months to many years. Nevertheless, symptoms tend to come back at some point in time.(10)

Therapy During Remission Period of Crohn’s Disease

If you are in remission, it does not mean that your treatment will be halted. You will need to continue taking your medications to help prevent a new flare-up or relapse of your symptoms and to avoid any potential complications.

Some of the commonly prescribed medications that are used to maintain a period of remission include:

Immunomodulators such as azathioprine (brand name Azasan). Immunomodulators are prescribed if other treatments for Crohn’s do not work for you.

Aminosalicylates (5-ASAs): Medications such as sulfasalazine (brand name Azulfidine) work by blocking certain pathways that decrease the inflammation in the intestinal lining.(11)

Diet for Maintaining Remission of Crohn’s Disease

In order to prolong your remission period, doctors recommend following a healthy and well-balanced diet. Some of these recommended diets are as follows:

Low FODMAP Diet: FODMAPs stand for “fermentable oligo-, di-, monosaccharides, and polyols.”(12) These are a type of carbohydrates that are found in certain foods such as beans and wheat. Low-FODMAP diets are known to provide significant benefits for people with digestive disorders such as Crohn’s disease. Foods that contain natural sugars like xylitol and sorbitol, chickpeas, garlic, wheat, and lentils, are some of the foods that come under the FODMAP diet.(13)

Gluten-Free Diet: Gluten is a protein that is commonly found in grains like rye, barley, and wheat. Many people with Crohn’s disease have experienced significant improvements in their symptoms after cutting out gluten from their diet.

Low Fiber Diet: Restricting high fiber foods like popcorn, nuts, and whole grains has been found to relieve the symptoms of Crohn’s like abdominal pain and diarrhea.

Mediterranean Diet: This type of diet is rich in vegetables, fruits, fish, olive oil, low-fat dairy products, and a limited amount of red meat. The Mediterranean diet has also been found to alleviate Crohn’s symptoms.(14,15)

Special Carbohydrate Diet: This type of customized diet eliminates certain sugars, fiber, and certain grains to make it easier for the stomach to process.

Low Red, Processed Meats Diet: Many people with Crohn’s disease have found that when they restrict the intake of beef and other red meats, including hot dogs, bacon, and lunch meat, they do not experience too many flare-ups.

However, as of today, none of these diets have been scientifically proven to be successful in maintaining remission, but they are known to work for some people. Nevertheless, you should not make any changes to your diet before consulting your doctor or dietitian.

Understanding the Relapse Cycle of Crohn’s Disease

Even while undergoing treatment for Crohn’s disease, most people end up experiencing flare-ups of their symptoms. These periods during which their disease symptoms become active or more aggressive, are known as relapses. It is not always possible to pinpoint the exact cause of a flare-up, but they happen every now and then, even when you continue the treatment and medications as prescribed.(16)

There are many factors that are believed to trigger these flare-ups. Here are some preventative measures you can take to avoid going into a relapse of Crohn’s:

Do Not Stop Your Medications: Most people who are diagnosed with Crohn’s disease have to take daily medications, even when they are in remission. While it is not uncommon to miss a dose every now and then, but going for long periods of not taking your medications can also cause a relapse.

Control Your Stress: Stressful situations have become a part of our daily lives. However, if you have Crohn’s disease, then stress can cause a flare-up. Of course, it is impossible to suddenly eliminate all stress from one’s life, using relaxation techniques like meditation and deep breathing can help alter the way in which your body reacts to stressful situations.(17)

Restrict The Use Of Antibiotics: Using antibiotics have been found to change the standard bacteria that live in the intestine. This increases the risk of inflammation and symptom flare-ups in people with digestive conditions like Crohn’s disease.(18)

Stop Smoking: Research has found that people who smoke experience more flares than those who do not.(19)

Avoid Taking Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Some of the most commonly used NSAIDs drugs are aspirin, ibuprofen (brand name Motrin, Advil), and naproxen (brand name Aleve). These are known to be possible triggers for a Crohn’s relapse.(20)

Have a Balanced Diet: Many people experience diet-related triggers for relapse. While no particular type of food is known to aggravate the symptoms, but every person is different, and the potential flare triggers also vary from person to person. Maintaining a food diary to identify such food-related triggers can help you modify your diet.

Crohn’s Symptoms During a Relapse

When you experience a relapse of the disease, your symptoms can vary. You may experience mild diarrhea and abdominal cramping to severe abdominal pain and even bowel blockage. You may even experience the same types of digestive issues you faced when you were initially diagnosed. You may also develop new symptoms during a relapse. Some of the common symptoms during a flare-up of Crohn’s disease include:

  • Frequent bowel movements
  • Mild to severe diarrhea
  • Abdominal pain and cramping
  • Blood in the stool
  • Weight loss
  • Nausea and vomiting
  • Duration of relapse: A relapse can last from several weeks to a couple of months.

Treatment of a Relapse

There are two major types of treatment for Crohn’s disease – medications and surgery.

Medications

Medications prescribed for treating Crohn’s disease aim to reduce inflammation in the digestive tract. Certain medications treat the relapses, while other medicines help maintain the disease in remission once the symptoms disappear.

Some of the most common drugs used for treating Crohn’s relapses include:

Amino salicylates: This class of drugs helps reduce inflammation and work well for moderate forms of the disease and aims to prevent relapses. These medications are most effective for Crohn’s disease that is primarily in the colon.

Corticosteroids: This powerful class of anti-inflammatory drugs are used to manage flares, but can only be used for a short period of time. This is because of the high risk of side effects such as mood swings, weight gain, and weakened bones.(21)

Immunomodulators: These medications help dampen the response of the immune system and help reduce the inflammation. Your doctor will put you on immunomodulators if amino salicylates do not work for you.

Antibiotics: These medications are prescribed to prevent and treat any infections in the gastrointestinal tract.

Biologic drugs: A relatively new class of drugs, these medications target certain proteins in the body that cause inflammation. Biologics are available in the form of injections or infusions that will be administered under the skin.(22)

Surgery

Surgical intervention is also an option, but it is usually only used on people whose condition does no improve with medication, or those who stop responding to the medications after some time. It is estimated that nearly 75 percent of all people with Crohn’s will go on o need surgery.(23)

Surgery can also be used to open up a part of the intestine in cases of intestinal blockage. It is also used for the removal of a damaged part of the intestine.

Conclusion

Crohn’s disease is an unpredictable condition, and it affects different people in different ways. The relapse and remission cycle of Crohn’s disease varies depending on your triggers and symptoms. It is best to work with your doctor to prevent relapses and to try to prolong the remission periods.

References:

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