Perianal Crohn's Disease
Treatment, causes, symptoms, diagnosis
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Crohn's disease and alcohol
There seems to be a great deal of confusion about the role that alcohol has on Crohn’s disease. The confusion exists not just among patients and caregivers, but the role of alcohol in Crohn’s disease is one that is unclear even among physicians in the scientific literature. Some sources report that drinking alcohol is a major precipitant of the disease (i.e. it brings on a flare of Crohn’s) while others say that alcohol is completely safe. If you are newly diagnosed with Crohn’s disease, or if you have a handle on the disease and simply want to know more, this article describes the latest research on Crohn's disease and alcohol and gives you the information that you need to decide what lifestyle choice is best for you.
In fact, patients with Crohn’s disease often ask of the primary care doctors and gastroenterologists caring for them if there is a type of alcohol, if any type at all, that could be consumed without symptoms. Sadly, a survey of the medical and scientific literature by the authors of the study (and by the author of this article two years later) yields very little in terms of guidance for doctors or their patients. Because of the lack of scientific evidence and a desire to provide some answers to their patients, Hey and authors studied the role that alcohol may play in Crohn’s disease.
In this first-of-its-kind study, Danish researchers followed a small group of Crohn’s disease sufferers who had achieved a stable remission and also a group of healthy volunteers without Crohn’s disease.1 These individuals consumed either red wine, white wine, Smirnoff Ice, Elephant Beer or pure alcohol. The first finding and perhaps the most powerful finding of the study, is that healthy volunteers did not report any pain after consuming any alcoholic beverage, but many of the patients with Crohn’s disease did, in fact, report abdominal pain after drinking alcohol. While the number of subjects in the study was small (20 Crohn’s disease patients and 12 healthy volunteers), the difference between the two groups was statistically significant. While there was some indication from the study data that drinking an alcoholic beverage with a higher sugar content caused pain in more Crohn’s disease patients than drinking pure alcohol, the study was too small to draw any real conclusions about sugar content in alcohol and Crohn’s disease.
What important conclusions can be drawn from this work? Well, there are several. First, this landmark study (while having severe limitations scientifically) opens the door on an issue that is very important to patients with Crohn’s disease namely, “can I drink alcohol with Crohn’s disease?” A particularly frank discussion about the current state of Crohn’s disease and alcohol research was recently published a London gastroenterologist by the name of Bjarnason.2 In his editorial, Dr. Bjarnason states of the Hey paper that it is an “excellent start towards unravelling [sic] the effects of alcohol on the intestinal tract in Crohn’s disease.” However several weaknesses in the paper were also described. The weaknesses of the study were clearly described be El-Tawil in the same journal.3 Everyone agrees that the concept behind the 2007 Hey study was good and hope that more research is done in the area. So far, however, it does not seem to have done so.
The second important result from the Hey study is that it appears that some people with Crohn’s disease do experience pain as a result of consuming alcohol and alcoholic beverages. While no healthy volunteers had pain, about half the volunteers with Crohn’s disease did. Therefore when patients with Crohn’s disease report pain after drinking alcohol, they are not alone. Third, not all patients with Crohn’s disease had pain after consuming alcohol. This is an important finding, if not somewhat confusing.
In some people with Crohn’s disease, alcohol causes symptoms and in others it does not.
This finding speaks directly to the finding that most patients with Crohn’s disease have concluded based on their own experience: no single diet is right for every patient. Unfortunately, each patient that has managed to get their Crohn’s disease under control is the best source for determining what causes symptoms and what foods are “safe.” Even for those patients that have recently been diagnosed with Crohn’s disease and are looking for information about diet, it is likely that even before the diagnosis existed, certain foods and beverages caused symptoms while others did not. For those patients that have not had much experience with alcohol, the safest approach is abstinence. After all, patients with Crohn’s disease have no symptoms from alcohol if they do not consume alcohol at all. If patients choose not to abstain from alcohol, then moderation is important. Also, drink one kind of alcoholic beverage at any one time and see if it causes pain, or not.
Symptoms of Crohn's disease does not mean that alcohol has caused inflammation of the gastrointestinal tract.
Notice that what we have been discussing is pain. Note that pain in Crohn’s disease does not mean clinical relapse or even serious inflammation in the gut. The Hey study used pain as the symptom and did not measure actual relapse or inflammation which, incidentally, was one of the major criticisms of the study.3 The issue of whether alcohol induces a flare of Crohn’s disease is even less clear than if it causes pain. Presumably most people (without serious alcohol dependence issues) will not choose to experience pain in order to take a drink, so the pain endpoint is useful. However, even if pain does occur, this does not necessarily mean a full Crohn’s disease flare is about to begin.
Does alcohol affect remission or the active disease process of Chrohn's disease
While relatively little is known about Crohn’s disease and alcohol during remission, even less is known about alcohol consumption during active disease. In most cases, patients with an active Crohn’s disease are not going to drink alcoholic beverages—the experience is quite unpleasant and the strong tendency is to give the gastrointestinal system a “break.” However, it seems that alcohol is not good for the intestinal mucosa (the lining of the gut) and should probably be avoided in active Crohn’s disease. Studies in humans and animals have shown that the gut becomes “leaky” when alcohol is applied and can itself stoke up inflammatory processes.4 Alcohol can also damage the lining of the gut, as result shown in healthy volunteers and those abusing alcohol.5 We do not know, however, the effect this would have in patients with Crohn’s disease though the assumption is that it would be just as bad, if not worse.
While it seems reasonable to avoid alcohol during an active flare of Crohn’s disease, the unfortunate truth is that many patients with the disease may not know they are beginning a flare. In other words, the bowel may be going through inflammatory changes a day or two before it is causing symptoms. The patient may feel fine and be enjoying remission only to find a severe clinical relapse in the following days. This is another reason that Crohn’s disease and alcohol use is a tricky subject for patients and a difficult topic to study scientifically.
Does Alcohol affect Crohn’s disease medications?
One of the biggest and clearest dangers of Crohn’s disease and alcohol is not necessarily a result of the alcohol itself but rather the effect that alcohol has on the medications used to treat and stabilize Crohn’s disease. Before modern immunosuppressive therapies, the life expectancy and quality of life for patients with Crohn’s disease was less than that enjoyed by people without the disease. However, research into the mechanisms of the disease and knowledge of medications that suppress the immune system have provided long periods without symptoms and more or less normal life and lifestyles in many cases.
Unfortunately, some of the drugs that have been used to effectively treat Crohn’s disease do not play nicely with alcohol. One of the more impressive and useful drugs used in the treatment of Crohn’s disease is azathioprine. Azathioprine is an immunosuppressant that blocks the formation and proliferation of white blood cells, which are one of the main components of the immune system and mediators of inflammation. While the drug is very powerful weapon in the fight against Crohn’s disease, azathioprine has been reported to interact with alcohol when it is consumed in high quantities.
A recent report in the World Journal of Gastroenterology describes the case of a man with Crohn’s disease (in remission) who was being successfully treated with azathioprine.6 He had three episodes of what was called binge drinking, which was defined in the study as consumption greater than 20 g per episode. For comparison, a standard alcoholic beverage in most countries contains between 10 to 15 g of alcohol. While this may seem like a low amount to be considered binge drinking, the patient did drink 800 g of alcohol during a three-day festival. This patient with Crohn’s disease who was taking azathioprine developed a serious disease called peliosis hepatis. Peliosis hepatis is a potentially serious liver disease in which the liver cells become damaged and can lead to cirrhosis and fibrosis of the liver.
In light of this information, it seems reasonable to avoid alcohol when taking certain medications. When you ask your physician about Crohn’s disease and alcohol it is important to ask her if the drugs that you are taking interact with alcohol.
Nutrition and vitamins, Crohn's disease and alcohol
While there is no miracle diet for patients with Crohn’s disease, there are certain things that are common to all patients with the disease. Generally, patients with Crohn’s disease have a decrease in appetite and eat fewer or smaller meals. Also, because of the diseases effect on the gut, the absorption of nutrients is impaired. These things become a double-edged sword over time. Not only do people with Crohn’s disease eat less, but the foods that they do eat are poorly absorbed. This is especially true during an active Crohn’s disease flare. Because of this it is extremely important to eat enough nutrients that your body needs to function properly. Also, it is quite easily for patients with Crohn’s disease to develop vitamin deficiencies especially if they have had a previous bowel surgery.
The reason that this relative nutrient and vitamin deficiency is important in a discussion of Crohn’s disease and alcohol is because alcohol tends to make people feel full, at least temporarily. This fullness from alcohol occurs even when people do not eat a reasonable, nutritious meal. Therefore alcohol consumption can fool the body into thinking it does not need food. For people that already have lower appetites, alcohol consumption can deprive the body of much needed nutrients.
Also, in patients that have moderate or severe alcohol dependency issues, vitamin deficiencies abound. Therefore, as the use of alcohol increases, the risk of vitamin deficiency increases as well. Patients with Crohn’s disease do not need another barrier to adequate vitamins intake and nutrition.
Crohn’s disease and alcohol in conclusion
Scientists are fairly tight-lipped when it comes to Crohn’s disease and alcohol because high quality scientific information is limited. It seems that if you have Crohn’s disease, it is best to carefully listen to your body. It will tell you what foods and beverages are problematic. To be most safe, it seems reasonable to avoid alcohol if you have Crohn’s disease thus eliminating your chances of alcohol-related problems. For those that still want to take the risk, conservative alcohol use is likely to be okay for some patients with Crohn’s disease, but the risk is not zero. Binge drinking and excessive alcohol use is never healthy, whether you have Crohn’s disease or not and in patients that do have the disease, excessive use can be particularly bad.
Crohn's disease and alcohol Reference List
(1) Hey H, Schmedes A, Nielsen AA, Winding P, Gronbaek H. Effects of five different alcoholic drinks on patients with Crohn's disease. Scand J Gastroenterol 2007;42:968-972.
(2) Bjarnason I. Alcohol: a friend or foe of IBD. Scand J Gastroenterol 2007;42:899-901.
(3) El-Tawal AM. Effects of five different drinks on patients with Crohn's disease. Scand J Gastroenterol 2009;44:764.
(4) Clayburgh DR, Shen L, Turner JR. A porous defense: the leaky epithelial barrier in intestinal disease. Lab Invest 2004;84:282-291.
(5) Bode C, Kugler V, Bode JC. Endotoxemia in patients with alcoholic and non-alcoholic cirrhosis and in subjects with no evidence of chronic liver disease following acute alcohol excess. J Hepatol 1987;4:8-14.
(6) Elsing C, Placke J, Herrmann T. Alcohol binging causes peliosis hepatis during azathioprine therapy in Crohn's disease. World J Gastroenterol 2007;13:4646-4648.
Written by Michael T. Sapko, M.D., Ph.D., edited by Donald Urquhart, Psychologist.This is an educational web site. It is NOT designed to diagnose nor treat but to offer understanding, ideas and options for you to discuss with your doctor first.
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