Crohn's disease is a chronic inflammatory condition that causes ongoing inflammation of the intestinal tract at any point from the mouth to the rectum. It is similar to ulcerative colitis, another inflammatory bowel disease. But ulcerative colitis is usually confined to the innermost layer of the large intestine and rectum. Crohn's disease can occur anywhere in the intestine, often in patches surrounded by healthy tissue, and can spread deeper into the tissues. Symptoms include chronic bloody or watery diarrhea, abdominal pain, fever, and loss of appetite. Symptoms tend to come and go, with the disease becoming active or going into remission several times during the person's lifetime.
Crohn's disease can cause intestinal obstructions, ulcers (most often in the lower part of the small intestine, the large intestine, or the rectum), fistulas (hollow passages from one part of the intestine to another), and anal fissures (a crack in the anus or the skin around the anus that can lead to infection). In addition, people with Crohn's disease are at risk of malnutrition, because their intestine cannot absorb all the nutrients they need from their diet.
Crohn's develops mostly between the ages of 20 to 40, although children and older adults may also develop the condition. There is no cure for Crohn's disease. Medication and diets can help control the condition and sometimes bring about long-term remission. Some people with Crohn's disease will require surgery to remove part of the digestive tract at some point in their lives. However, surgery does not cure the disease.
The primary goal in treating Crohn's disease is to control acute flares of the disease and to maintain remission for as long as possible. The specific type of treatment often depends on how severe the symptoms are. For example, people with mild-to-moderate symptoms are usually treated with medications that reduce swelling and suppress the immune system. More severe cases may require surgery.
Many people with inflammatory bowel diseases use complementary and alternative remedies in addition to prescription medications. Preliminary studies suggest that lifestyle changes, dietary adjustments (such as eating a rich variety of fruits and vegetables and avoiding saturated fat and sugar), and specific herbs and supplements may be useful additions to treatment.
Many people with Crohn's disease report that stress makes their symptoms worse. Relaxation techniques and mind/body exercises, such as yoga, tai chi, and meditation, are worth considering, particularly when used with other forms of treatment. In addition, studies suggest that hypnosis may improve immune function, increase relaxation, reduce stress, and ease feelings of anxiety.
Exercise helps people with Crohn's disease, both in terms of maintaining health and reducing stress. Exercise is considered safe for people with Crohn's disease, but anyone with a chronic illness should talk to their doctor before starting a new exercise or fitness regimen. It is especially important for people with Crohn's disease to drink water before and during exercise to prevent dehydration. Avoid extreme changes in body temperature during exercise.
Cigarette smoking is a risk factor for Crohn's disease and studies have shown that it may worsen symptoms. If you smoke, you should quit. Ask your doctor for help.
Although medications cannot cure Crohn's disease, they can reduce symptoms and help you control your condition. Sometimes, they can bring on remission of the disease for a while. Medications commonly used to treat Crohn's disease include:
- Sulfasalazine (Azulfidine) -- An older drug that reduces inflammation during acute flare ups and is usually taken with folic acid. Side effects include abdominal discomfort, nausea, and lowered sperm count. Sulfasalazine can be effective, but newer drugs are available.
- Mesalamine (Asacol, Rowasa) -- This drug reduces inflammation during acute flare ups and helps prevent recurrences. It generally has fewer side effects that sulfasalazine.
- Corticosteroids (such as budesonide, prednisone, and prednisolone) -- These drugs can reduce inflammation throughout your body but have many side effects, including acne, and an increased risk of infection, osteoporosis, high blood pressure, excessive hair growth, diabetes, and disorders of the eye including glaucoma and cataracts. Budesonide (Entocort) may have fewer side effects. Corticosteroids also suppress your body's production of the hormone cortisol and cannot be stopped abruptly. They are not for long-term use, but may be used to control flares.
- Immune system suppressors -- These medications decrease inflammation by suppressing the immune system. They are sometimes used in combination with steroids to reduce the dose of the steroid medication. These drugs can take several months to work, and all may have significant side effects. Drugs include azathioprine (Imuran), methotrexate (Rheumatrex), infliximab (Remicade), adalimumab (Humira), certolizumab pegol (Cimzia), natalizumab (Tysabri), and cyclosporine.
- Antibiotics -- Antibiotics may be prescribed to help treat fistulas and ulcers. Ciproflaxin (Cipro) and metronidazole (Flagyl) are most commonly used.
- Antidiarrheal medications (such as diphenoxylate, loperamide, or psyllium) -- Medications used to treat diarrhea must be used only under your doctor's supervision and with extreme caution. They can slow down the normal movements of the gastrointestinal tract and, in severe cases, may cause a life threatening complication known as toxic megacolon.
Although surgery will not cure Crohn's disease, 3 to 4 people with the condition will eventually have resections (parts of their colons removed) to close fistulas or to remove a severely damaged part of the intestine. In some cases, doctors can perform laparoscopic surgery (which uses a smaller incision), leading to fewer complications and shorter hospital stays. Strictureplasty, in which a doctor inserts a balloon into the intestine and expanded, is sometimes done when the intestine has become too narrow from scar tissue.
Complementary and Alternative Therapies
People with Crohn's disease often cannot absorb all the nutrients their bodies need, due to damage in the intestine. Abdominal pain and nausea may make it hard for them to eat. Some medications may also lower important nutrients in the body. For example, sulfasalazine reduces the body's ability to absorb folate, and corticosteroids can reduce calcium levels. Making sure you get enough nutrients is a crucial part of treating Crohn's disease. People with significant malnourishment, severe symptoms, or those awaiting surgery may require parenteral (intravenous) nutrition.
Although diet cannot cause or cure Crohn's disease, some studies suggest that people who eat foods high in saturated fat and sugar or who eat processed foods may be more likely to develop the disease. Certain foods may also reduce symptoms and make recurrences of the disease less likely.
- Eating fruits and vegetables, lowering fat, and eliminating sugar may reduce the risk of developing Crohn's disease. Although a low-fiber diet is one of the risk factors for developing Crohn's disease, some people with Crohn's disease find that fiber makes symptoms worse. If fiber bothers you, steam or bake your vegetables rather than eating them raw, and avoid high-fiber fruits, such as apples.
- Certain foods may aggravate symptoms of Crohn's disease – most often, dairy products, fats, and spicy foods. People with Crohn's disease may want to avoid these foods.
- Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes) and vegetables (such as squash and bell peppers).
- Eat foods high in B vitamins, calcium, and magnesium, such as whole grains (if not bothered by fiber), dark leafy greens (such as spinach and kale), and sea vegetables.
- Avoid refined foods, such as white breads and pastas.
- Eat 5 to 6 small meals a day.
- Avoid caffeine, alcohol, and tobacco.
- If symptoms are severe, an elemental diet may be recommended. Elemental formulas are liquid diets that contain only the basic building blocks of food and do not need to be broken down into smaller substances along the digestive tract. Some people find it hard to stick to an elemental diet, but after a period of time, often other foods can be reintroduced. One study suggests that adding omega-3 fatty acids to an elemental diet may boost its nutritional content and make it more likely that people with Crohn's disease will stick with it. Elemental diets should only be undertaking under the supervision of a physician.
Vitamins and Minerals
Because of decreased appetite, malabsorption, chronic diarrhea, side effects of medication, and surgical removal of parts of the intestine, many people with Crohn's disease don't get enough of some vitamins and minerals. In particular, people with Crohn's disease may lack adequate vitamin D, B12, and K, plus folic acid, calcium, and zinc. Your doctor may recommend that you take a multivitamin daily.
- Zinc (25 mg), folic acid (800 mcg), vitamin B12 (800 mcg) -- The body uses these vitamins and minerals to repair cells in the intestine. In addition, drugs such as sulfasalazine and methotrexate may cause levels of folic acid in the body to drop, so that you need a supplement. Getting too much zinc can be immunosuppressive, folic acid in high doses over long periods of time has had some controversial reports associating it with certain illnesses. Speak with your doctor to determine the proper type and level of supplementation for your individual case.
- Vitamin D (1,000 IU per day) -- The body needs vitamin D to maintain strong bones. People with Crohn's disease, especially those who take corticosteroids, often have low levels of vitamin D and are at risk for osteoporosis.
- Calcium (1,000 - 1,200 mg per day) -- Calcium is also needed for strong bones. Ask your doctor if you need a calcium supplement.
- Omega-3 fatty acids, such as those found in fish oil (2.7 g per day) -- These fats may help fight inflammation and reduce the chances of recurrence, but studies have been mixed. The study with the most positive results used a special type of fish oil – "enteric coated free fatty acid form" – that is not sold commercially. Some researchers suggest that measuring the blood levels of different types of fatty acids may help determine if fish oil would be useful. Do not take high doses of a fish oil supplement if you take blood-thinning medication.
- Probiotics, especially Saccharomyces boulardi (250 mg 3 times per day to 500 mg 4 times per day) -- One small study indicated that this type of "friendly" bacteria helped people with Crohn's disease reduce the incidence of diarrhea. However, other studies have shown mixed results. People with allergies to yeast should avoid Saccharomyces boulardi. People with very weak immune system should check with their doctor before using probiotics.
- N-acetyl glucosamine (NAG) -- Preliminary research suggests that N-acetyl glucosamine supplements or enemas may improve symptoms of inflammatory bowel disease, but more studies are needed to determine whether glucosamine would have any effect on Crohn's disease. There is some concern that NAG may raise blood sugar in patients with diabetes and may worsen asthma symptoms. NAG may interact with blood-thinning medications, such as warfarin (Coumadin) and certain cancer drugs.
- Glutamine (400 mg 4 times per day) -- Glutamine is an amino acid found in the body that that helps the intestine function properly. While there is no evidence that glutamine specifically helps reduce symptoms of Crohn's disease, it may be good for overall intestinal health. It is best to take glutamine on an empty stomach. Do not take glutamine is you are diabetic or have seizures, suffer from bouts of mania, severe liver disease with difficulty thinking or confusion, or if you are sensitive to monosodium glutamate (MSG).
Because of the presence of inflammation and the nature of the disease, Crohn's disease should not be treated with herbs alone. However, herbs may be a useful complement to traditional medical treatment. Herbs can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, you should take herbs with care, under the supervision of a health care provider.
The evidence for using herbs to treat Crohn's disease is mostly lacking. Herbs that have been used traditionally to treat inflammation within the digestive tract include:
- Slippery elm (Ulmus fulva) is a demulcent (a substance that protects irritated tissues and promotes their healing). Take 60 to 320 mg per day. One tsp. powder may be mixed with water and drunk 3 to 4 times a day. Take slippery elm at least one hour after taking other medications.
- Marshmallow (Althaea officinalis) is a demulcent and emollient (a substance that soothes mucous membranes). Drink one cup of tea 3 times per day. To make tea, steep 2 to 5 g of dried leaf or 5 g dried root in one cup boiling water. Strain and cool. Avoid marshmallow if you have diabetes. Marshmallow may interact with lithium. It may also interfere with drugs taken by mouth. Take Marshmallow at least one hour after taking oral medications.
- Curcumin or turmeric (Curcuma longa, 1 to 2 g per day) shows anti-inflammatory properties in test tubes. One small study found that people with inflammatory bowel disease who took curcumin reduced their symptoms and their need for medications. More research is needed. Curcumin may make gallbladder illnesses worse and may interact with blood-thinning medications.
- Cat's claw (Uncaria tomentosa, 250 mg per day) may help fight inflammation. Cat's claw may make leukemia, as well as autoimmune disorders, worse, and may worsen low blood pressure.
- Boswellia (Boswellia serrata, 1,200 mg 3 times per day for up to 8 weeks) has anti-inflammatory properties, and a few small studies suggest that it may help treat Crohn's disease. More research is needed to be sure. Boswellia may interact with other drugs and supplements, so talk to your doctor before taking it.
Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of Crohn's disease symptoms (such as diarrhea) based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each person.
Mercurius -- for foul-smelling diarrhea that may have streaks of blood accompanied by a sensation of incomplete emptying. This remedy is most appropriate for individuals who tend to feel exhausted following bowel movements, experience fluctuations in body temperature, perspire frequently, and have a thirst for cold fluids.
Podophyllum -- for explosive, gushing, painless diarrhea that worsens after eating or drinking. Exhaustion often follows bowel movements. The individuals for whom this remedy is appropriate may experience painful cramps in the lower legs and feet.
Veratrum album -- for profuse, watery diarrhea accompanied by stomach cramps, bloated abdomen, vomiting, exhaustion, and chills. The diarrhea tends to worsen as a result of eating fruit. The individual for whom this therapy is appropriate tends to crave cold liquids.
Acupuncture has long been used in Traditional Chinese Medicine to treat inflammatory bowel disease. One study in Germany found that acupuncture and moxibustion were effective specifically for treating Crohn's disease. Acupuncturists treat people with inflammatory bowel disease based on an individualized assessment of the excesses and deficiencies of qi located in various meridians. Moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points) is sometimes used because it is thought by some to reach deeper into the body than using needles alone.
Abela MB. Hypnotherapy for Crohn's disease: a promising complementary/alternative therapy. Integr Med. 2000;2(2/3):127-131.
Ahmed T, Rieder F, Fiocchi C, Achkar JP. Pathogenesis of postoperative recurrence in Crohn's disease. Gut. 2011; 60(4):553-62.
Ammon HP. Boswellic acids in chronic inflammatory diseases. Planta Med. 2006 Oct;72(12):1100-16.
Anton PA. Stress and mind-body impact on the course of inflammatory bowel diseases. Semin Gastrointest Dis. 1999;10(1):14-19.
Ball E. Exercise guidelines for patients with inflammatory bowel disease. Gastroenterol Nurs. 1998;21(3):108-111.
Belluzzi A, Boschi S, Brignola C, Munarini A, Cariani G, Miglio F. Polyunsaturated fatty acids and inflammatory bowel disease. Am J Clin Nutr. 2000;71(suppl):339S-342S.
Belluzzi A, Brignola C, Campieri M, Pera A, Boschi S, Miglioli M. Effect of an enteric-coated fish-oil preparation on relapses in Crohn's disease. N Engl J Med. 1996;334(24):1557-1560.
Bernell O, Lapidus A, Hellers G. Risk factors for surgery and postoperative recurrence in Crohn's disease. Ann Surg. 2000;231(1):38-45.
Blumenthal M, ed. Herbal Medicine. Expanded Commission E Monographs. Newton, Mass: Integrative Medicine Communications; 2000.
Bock S. Integrative medical treatment of inflammatory bowel disease. Int J Integr Med. 2000;2(5):21-29.
Brignola C, Belloli C, De Simone G, et al. Zinc supplementation restores plasma concentrations of zinc and thymulin in patients with Crohn's disease. Aliment Pharmacol Ther. 1993;7:275-280.
Butterworth AD, Thomas AG, Akobeng AK. Probiotics for induction of remission in Crohn's disease. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006634. Review.
Cho S, Cho S, Regueiro M. Postoperative Management of Crohn's Disease. Gastroenterology Clinics. 2009;38(4).
Chowers Y, Sela B, Holland R, Fidder H, Simoni FB, Bar-Meir S. Increased levels of homocysteine in patients with Crohn's disease are related to folate levels. Am J Gastroenterol. 2000;95(12):3498-3502.
Cosnes J, Beaugerie L, Carbonnel F, Gendre JP. Smoking cessation and the course of Crohn's disease: an intervention study. Gastroenterology. 2001;120(5):1093-1099.
Dear KL, Hunter JO. Colonoscopic hydrostatic balloon dilation of Crohn's strictures. J Clin Gastroenterol. 2001;33(4):315-318.
Farmer M, Petras RE, Hunt LE, Janosky JE, Galadiuk S. The importance of diagnostic accuracy in colonic inflammatory bowel disease. Am J Gastroenterol. 2000; 95(11):3184-3188.
Favier C, Neut C, Mizon C, Cortot A, Colombel JF, Mizon J. Fecal ß-D-Galactosidase production and Bifidobacteria are decreased in Crohn's disease. Dig Dis Sci. 1997;42(4):817-822.
Feagan BG, Fedorak RN, Irvine EJ, et al. A comparison of methotrexate with placebo for the maintenance of remission in Crohn's disease. N Engl J Med. 2000;342:1627-1632.
Feagan BG, Sandborn WJ, Mittmann U, Bar-Meir S, D'Haens G, Bradette M, et al. Omega-3 free fatty acids for the maintenance of remission in Crohn disease: the EPIC Randomized Controlled Trials. JAMA. 2008 Apr 9;299(14):1690-7.
Ferri: Practical Guide to the Care of the Medical Patient, 8th ed. St. Louis, MO: Mosby. 2010.
Geerling BJ, Badart-Smook A, Stockbrügger RW, Brummer R-JM. Comprehensive nutritional status in recently diagnosed patients with inflammatory bowel disease compared with population controls. Eur J Clin Nutr. 2000;54:514-521.
Geerling BJ, Houwelingen AC, Badart-Smook A, Stockbrügger RW, Brummer R-JM. The relation between antioxidant status and alterations in fatty acid profile in patients with Crohn disease and controls. Scand J Gastroenterol. 1999a;34:1108-1116.
Geerling BJ, Stockbrugger RW, Brummer R-JM. Nutrition and inflammatory bowel disease: an update. Scand J Gastroenterol. 1999c;34(suppl 230):95-105.
Gilman J, Shanahan F, Cashman KD. Determinants of vitamin D status in adult Crohn's disease patients, with particular emphasis on supplemental vitamin D use. Eur J Clin Nutr. 2006 Jul;60(7):889-96.
Gionchetti P, Rizzello F, Venturi A, Campieri M. Probiotics in infective diarrhea and inflammatory bowel diseases. J Gastroenterol Hepatol. 2000;15:489-493.
Gupta I, Parihar A, Malhotra P, Singh GB, Ludtke R, Safayhi H, Ammon HPT. Effects of Boswellia serrata gum resin in patients with ulcerative colitis. Eur J Med Res. 1997;2:37-43.
Haas l, McClain C, Varilek G. Complementary and alternative medicine and gastrointestinal diseases. Curr Opin Gastroenterol. 2000;16:188-196.
Hampe J, Cuthbert A, Croucher JP, et al. Association between insertion mutation in NOD2 gene Crohn's disease in German and British populations. Lancet. 2001; 357:1925-1928.
Harper JWW, Welch MP, Sinanan MN, Wahbeh GT, Lee SD. Co-morbid diabetes in patients with Crohn's disease predicts a greater need for surgical intervention. Aliment Pharmacol Ther. 2012; 35(1):126-32.
Heilpern D, Szilagyi A. Manipulation of intestinal microbial flora for therapeutic benefit in inflammatory bowel diseases: review of clinical trials of probiotics, pre-biotics and synbiotics. Rev Recent Clin Trials. 2008 Sep;3(3):167-84. Review.
Heuschkel RB, Menache CC, Megerian JT, Baird AE. Enteral nutrition and corticosteroids in the treatment of acute Crohn's disease in children. J Pediatr Gastroenterol Nutr. 2000;31(1):8-15.
Joachim G. The relationship between habits of food consumption and reported reactions to food in people with inflammatory bowel disease—testing the limits. Nutr Health. 1999;13(2):69-83.
Jonas WB, Jacobs J. Healing with Homeopathy: The Doctors' Guide. New York, NY: Warner Books; 1996: 220.
Joos S, Brinkhaus B, Maluche C, Maupai N, Kohnen R, Kraehmer N, Hahn EG, Schuppan D. Acupuncture and moxibustion in the treatment of active Crohn's disease: a randomized controlled study. Digestion. 2004;69(3):131-9.
Keane J, Gershon S, Wise RP et al. Tuberculosis associated with infliximab, a tumor necrosis factor alpha-neutralizing agent. N Engl J Med. 2001;345(15):1098-1104.
Kozuch PL, Hanauer SB. Treatment of inflammatory bowel disease: a review of medical therapy. World J Gastroenterol. 2008 Jan 21;14(3):354-77. Review.
Kuroki F, Iida M, Tominaga M, et al. Multiple vitamin status in Crohn's disease. Dig Dis Sci. 1993;38(9):1614-1618.
Latella G, Sferra R, Vetuschi A, Zanninelli G, D'Angelo A, Catitti V, Caprilli R, Gaudio E. Prevention of colonic fibrosis by Boswellia and Scutellaria extracts in rats with colitis induced by 2,4,5-trinitrobenzene sulphonic acid. Eur J Clin Invest. 2008 Jun;38(6):410-20.
Levy E, Rizwan Y, Thibault L, et al. Altered lipid profile, lipoprotein composition, and oxidant and antioxidant status in pediatric Crohn disease. Am J Clin Nutr. 2000;71:807-815.
Lewis JD, Fisher RL. Nutrition support in inflammatory bowel disease. Med Clin North Am. 1994;78(6):1443-1456.
Loudon CP, Corroll V, Butcher J, Rawsthorne P, Bernstein CN. The effects of physical exercise on patients with Crohn's disease. Am J Gastroenterol. 1999;94(3):697-703.
Macdonald A. Omega-3 fatty acids as adjunctive therapy in Crohn’s disease. Gastroenterol Nurs. 2006 Jul-Aug;29(4):295-301.
Malin M, Suomalainen H, Saxelin M, Isolauri E. Promotion of IgA immune response in patients with Crohn's disease by oral bacteriotherapy with Lactobacillus GG. Ann Nutr Metab. 1996;40:137-145.
Marrero F, Qadeer M, Lashner B. Severe Complications of Inflammatory Bowel Disease. Medical Clinics of North America. 2008;92(3).
Mendall MA, Gunasekera AV, John BJ, Kumar D. Is obesity a risk for Crohn's disease. Dig Dis Sci. 2011; 56(3):837-44.
Messaris E, Chandolias N, Grand D, Pricolo V. Role of magnetic resonance enterography in the management of Crohn's disease. Arch Surg. 2010;145(5):471-5.
Msika S, Iannelli A, Deroide G, et al. Can laparoscopy reduce hospital stay in the treatment of Crohn's disease? Dis Colon Rectum. 2001;44(11):1661-1666.
Mulder TPJ, Van Der Sluys Veer A, Verspaget HW, et al. Effect of oral zinc supplementation on metallothionein and superoxide dismutase concentrations in patients with inflammatory bowel disease. J Gastroenterol Hepatol. 1994;9:472-477.
Nerich V, Jantchou P, Boutron-Ruault MC, et al. Low exposure to sunlight is a risk factor for Crohn's disease. Aliment Pharmacol Ther. 2011; 33(8):940-5.
Nielsen AA, Jorgensen LG, Nielsen JN, Eivindson M, Gronbaek H, Vind I, et al. Omega-3 fatty acids inhibit an increase of proinflammatory cytokines in patients with active Crohn's disease compared with omega-6 fatty acids. Aliment Pharmacol Ther. 2005 Dec;22(11-12):1121-8.
Onken JE, Greer PK, Calingaert B, Hale LP. Bromelain treatment decreases secretion of pro-inflammatory cytokines and chemokines by colon biopsies in vitro. Clin Immunol. 2008 Mar;126(3):345-52.
Philipsen-Geerling BJ, Brummer RJM. Nutrition in Crohn's disease. Curr Opin Clin Nutr Metab Care. 2000;3:305-309.
Rahimi R, Nikfar S, Rahimi F, Elahi B, Derakhshani S, Vafaie M, Abdollahi M. A meta-analysis on the efficacy of probiotics for maintenance of remission and prevention of clinical and endoscopic relapse in Crohn's disease. Dig Dis Sci. 2008 Sep;53(9):2524-31.
Rajapakse R, Korelitz BI. Inflammatory bowel disease during pregnancy. Current Treatment Options in Gastroenterology. 2001;4(3):245-251.
Rawsthorne P, Shanahan F, Cronin NC, et al. An international survey of the use and attitudes regarding alternative medicine by patients with inflammatory bowel disease. Am J Gastroenterol. 1999;94(5):1298-1303.
Ringel Y, Drossman DA. Psychosocial aspects of Crohn's disease. Surg Clin North Am. 2001;81(1):231-252.
Rioux JD, Daly MJ, Silverberg MS, et al. Genetic variation in the 5q31 cytokine gene cluster confers susceptibility to Crohn disease. Nat Genet. 2001;29:223-228.
Rolfe VE, Fortun PJ, Hawkey CJ, Bath-Hextall F. Probiotics for maintenance of remission in Crohn's disease. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD004826.
Russel MG. Changes in the incidence of inflammatory bowel disease: what does it mean? Eur J Intern Med. 2000;11(4):191-196.
Salvatore S, Heuschkel R, Tomlin S, et al. A pilot study of N-acetyl glucosamine, a nutritional substrate for glycosaminoglycan synthesis, in pediatric chronic inflammatory bowel disease. Aliment Pharmacol Ther. 2000;14:1567-1579.
Shanahan F. Probiotics and inflammatory bowel disease: is there a scientific rationale? Inflamm Bowel Dis. 2000;6(2):107-115.
Steger GG, Mader RM, Vogelsang H, Schöfl R, Lochs H, Ferenci P. Folate absorption in Crohn's disease. Digestion. 1994;55:234-238.
Stein RB, Lichtenstein GR, Rombeau JL. Nutrition in inflammatory bowel disease. CurrOpin Clin Nutr Metab Care. 1999;2:367-371.
Szulc P, Meunier PJ. Is vitamin K deficiency a risk factor for osteoporosis in Crohn's disease? [commentary]. Lancet. 2001;357(9273):1995-1996.
Tamaka S, Matsuo K, Sasaki T, Nakano M, Shimura H, Yamashita Y. Clinical outcomes and advantages of laparoscopic surgery for primary Crohn's disease: are they significant? Hepatogastroenterology. 2009;56(90):416-20.
Teahon K, Bjarnason I, Pearson M, Levi AJ. Ten years' experience with an elemental diet in the management of Crohn's disease. Gut. 1990;31(10):1133-1137.
Tsujikawa T, Satoh J, Katsuhiro U, et al. Clinical importance of n-3 fatty acid-rich diet and nutritional education for the maintenance of remission in Crohn's disease. Gastroenterol. 2000;35:99-104.
Ullman D. The Consumer's Guide to Homeopathy. New York, NY: Penguin Putnam; 1995: 76-77.
van Heel DA, McGovern DPB, Jewell DP. Crohn's disease: a genetic susceptibility, bacteria, and innate immunity [commentary]. Lancet. 2001;357:1902-1903.
Wilkins T, Jarvis K, Patel J. Diagnosis and management of Crohn's disease. Am Fam Physician. 2011; 84(12):1365-75.
Zachos M, Tondeur M, Griffiths AM. Enteral nutritional therapy for inducing remission of Crohn's disease (Cocrane Review). In: The Cochrane Library, 4, 2001. Oxford: Update Software.
Zurita VF, Rawls DE, Dyck WP. Nutritional support in inflammatory bowel disease. Dig Dis. 1995;13:92-107.