Anal fissures are tears in the lining of the anal canal and are quite common in Crohn’s disease. The goal of therapy is to reduce pain associated with the fissure and to decrease spasm of the anal sphincter. Treatment of diarrhea is typically beneficial. It is also helpful to soak in a sitz bath (bath of warm water) for 15 to 20 minutes a couple of times a day or after bowel movements. You should also be careful to keep the skin around the anus clean and dry. I also recommend patients clean with pre-moistened tissues following bowel movements. When these measures are not enough to heal an anal fissure, medical therapy is often necessary. Most studies have looked at metronidazole, an antibiotic, for the treatment of anal fissures in Crohn’s disease. Topical nitroglycerine can also be considered as a treatment if antibiotics are not successful although there have not been any controlled trials evaluating topical nitroglycerine in Crohn’s disease patients. The topical nitroglycerine increases blood flow locally and reduces spasms of the anal sphincter, which may facilitate healing of anal fissures. Q2. I have just had blood tests with a positive ANA (speckled) and a titer of 1:80. I’ve had Crohn’s for 30 years and several surgeries, but I’ve been in remission many years. Does the ANA test mean the Crohn’s is active, or does it mean I may have lupus? A positive ANA test does not mean that your Crohn’s disease is active or that you have lupus. The ANA test measures antinuclear antibodies in your blood. These antibodies are produced by the immune system and attack your body’s own tissues rather than foreign toxins. Sometimes, ANA tests become weakly positive, as yours is, following infliximab (Remicade) use. It does not become meaningful for diagnosis unless you also have physical symptoms like joint pains and/or muscle aches. On its own, the ANA test does not provide a significant amount of information. Q3. I have been battling anal fissures due to my Crohn’s. It hurts, and all I do is take Percocet (oxycodone and acetaminophen) for the pain. My doctors don’t seem to want to do anything to help me. Do you have any suggestions? Yes, you should see an experienced colorectal surgeon who can thoroughly evaluate your condition and offer a treatment plan. Fissures related to Crohn’s disease sometimes can be treated with nitroglycerin ointment, although the effects are temporary and headaches can be a side effect of this treatment. Also, there could be hidden fistulas that are causing your pain, which need to be dealt with surgically and medically. The biologic therapy Remicade (infliximab) is particularly good for perianal fissures and fistulas. Large, ulcerating fissures related to Crohn’s disease may not respond to medical intervention and will require an ileostomy, in which the end of the small intestine is surgically diverted out to the skin. Stool empties into an external bag, away from the ulcerated area, until the fissures heal. Q4. My daughter is 20 years old and was diagnosed with Crohn’s disease about two years ago. She went through a series of medications with no permanent relief of symptoms. She was put on 6-MP and Remicade (infliximab) in November of 2006. She was taken off the 6-MP but is still on the Remicade (every eight weeks). She is experiencing severe joint discomfort, rash on her legs, tiredness and low-grade fever. Blood work showed that her sed rate is 90. She went to see her doctor and he said that she is developing antibodies to the Remicade and increased her frequency of getting Remicade to every six weeks. Wouldn’t this just increase the antibodies that her body is making and make her joints hurt more and make her other problems worse? Or is the Remicade not working anymore? Should she be on a different therapy? Your daughter seems to be developing a lupus-like syndrome that some patients on Remicade get. (Lupus-like syndrome is a medical condition that resembles the chronic autoimmune disorder lupus, but has a different cause.) This syndrome is not necessarily due to antibodies to infliximab, but to antibodies against DNA (anti-nuclear antibodies or anti-double strand DNA antibodies). The treatment of lupus-like syndrome should not include increasing the frequency of Remicade. In fact, perhaps the Remicade should be stopped. If her Crohn’s disease flares, then Humira (adalimumab) or Cimzia (certolizumab) would be acceptable alternatives to Remicade. Q5. I’m surprised that there is no mention of the Specific Carbohydrate Diet as an effective treatment for Crohn’s. That’s what we used to treat our daughter with great results and no side effects. Why isn’t this approach mainstream? The diet you mention prohibits grain, lactose and sucrose. Its supporters say it treats the symptoms of Crohn’s, colitis and other conditions by reducing harmful bacteria in the gut. While this, and other diets, may work for Crohn’s disease, they have never been tested scientifically. Interestingly, about one-third of patients with active Crohn’s disease who enter a placebo-controlled trial improve with the placebo, even though it has no active ingredients. Until the scientific trials are done, alternative approaches to patient care will not be adapted into mainstream medicine. The Crohn’s & Colitis Foundation of America has more information on the use of this diet for Crohn’s and colitis patients.
