Crohn’s Disease

What Is Crohn’s Disease?

[dropcap]C[/dropcap]rohn’s disease is an inflammatory bowel disease characterized by patchy inflamed areas involving the full thickness of the intestinal wall that can occur anywhere in the intestinal tract, in addition to, mucosal disease.

In Crohn’s disease there is ongoing immune activation which produces inflammation and ulceration but the cause is not known and the severity varies among patients. At diagnosis of Crohn’s disease, factors predictive of subsequent 5-year aggressive disease are an age below 40 years, the presence of perianal disease, and the initial requirement for steroids.¹

Dysbiosis is a factor that develops in and worsens Crohn’s disease and stress is a factor in both of these conditions. Psychological stress activates multiple physiological processes aimed at maintaining balance within the body. These physiological processes also have the capacity to influence the composition of microbial communities in the digestive tract, and research now indicates that exposure to stressful stimuli leads to gut microbiota dysbiosis.²

While the relative abundance of many different bacterial types can be altered during stressor exposure, findings in nonhuman primates and laboratory rodents, as well as humans, indicate that bacteria in the genus Lactobacillus are consistently reduced in the gut during stress.²

Q: Is there a cure for Crohn’s disease?

A: Presently, Crohn’s disease cannot be cured. This condition has a course of remissions, when symptoms subside, and flares, when symtpoms get worse. Treatment is aimed to reduce flares and promote remission.

What Is Crohn’s Disease In Celiac Disease and/or Gluten Sensitivity?

• 

  Relationship between Crohn’s disease and celiac disease. Crohn’s disease is an associated disorder of celiac disease. The two diseases share the same pathogenic immunologic response and altered intestinal permeability.³

• Relationship between Crohn’s disease and differential diagnosis. Diagnosis can be challenging because abdominal pain, diarrhea, and steatorrhea develop in Crohn’s disease and these symptoms are some of the many features of celiac disease.
• Relationship between Crohn’s disease and associated autoimmune disease. Celiac disease and Crohn’s disease show similar prevalence of associated autoimmune disease, higher than the prevalence in ulcerative colitis.³
• Relationship between Crohn’s disease and gluten. The association between celiac disease and other immune disorders may be due to the sharing of a common genetic background, such as HLA antigens. However, in a very large study, involving 909 patients with celiac disease, Ventura and his associates found that the development of immune disorders in celiac disease was clearly related to the duration of exposure to gluten.⁴
• Relationship between Crohn’s disease and zinc. Some of the symptoms of Crohn’s disease, like retarded growth and hypogonadism, have been related to hypozinchemia (low zinc level), which is a feature also common in untreated celiac disease.⁵

How Prevalent Is Crohn’s Disease In Celiac Disease and/or Gluten Sensitivity?

• The association of Crohn’s disease with celiac disease is statistically significant.⁶
• Patients with celiac disease and their relatives have a greater predisposition to Crohn’s disease versus the control population.⁷
• Researchers who analyzed a database of linked statistical records of hospital admissions and death registrations for the whole of England (from 1999 to 2011) showed that  patients with vitamin D deficiency had a significantly elevated rate of celiac disease and Crohn’s disease among others.⁸

What Are The Symptoms Of Crohn’s Disease?

Crohn’s disease is marked by these symptoms:

• Abdominal pain.
• Headache in 27.3% of Crohn’s patients with gluten sensitivity.
• Non-bloody diarrhea.
• Steatorrhea.
• Weight loss.

Complications include:

• Abscess.
• Fistulas.
• Strictures.

How Does Crohn’s Disease In Celiac Disease and/or Gluten Sensitivity Develop?

• Crohn’s disease results from an unknown pathological mechanism.
• Omega-3 fatty acid and zinc deficiencies may exacerbate Crohn’s disease.⁹
• A study investigating the reported association between vitamin D deficiency and the risk of developing immune-mediated diseases showed that  patients with vitamin D deficiency have an increased rate of Crohn’s disease.⁸

Does Crohn’s Disease Respond To Gluten-Free Diet?

Yes. Gluten free diet can normalize zinc and vitamin D levels and prevent increased morbidity (disease) from malnutrition and malignancy from untreated celiac disease in Crohn’s disease.

In a cross sectional study of patients with inflammatory bowel disease, 65.6% of all patients, who attempted a gluten free diet, described an improvement of their gastrointestinal symptoms and 38.3% reported fewer or less severe IBD flares. In patients currently attempting a gluten free diet, excellent adherence was associated with significant improvement of fatigue.¹⁰

Note: Caraway is particularly helpful to reduce inflammation and improve healing of inflammatory colitis. Please see below under Carminatives, Step #6.

6 Steps To Improve Crohn’s Disease In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both Crohn’s disease and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.¹¹
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.¹²
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.¹²
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.¹².
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.¹²
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.¹²
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.¹²[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4[/dropcap] Manage Your Medications Safely:

[box type=”shadow” ]

Certain medications cause zinc and vitamin D deficiencies which may promote Crohn’s disease. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below and how to supplement for the depleted nutrients. Do not stop prescribed medications without supervision.

This is not a complete listing.

ANTACIDS / ULCER MEDICATIONS

• Pepcid®, Tagamet®, Zantac® deplete Zinc, Vitamin D.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete Vitamin D, Zinc.

ANTIBIOTICS disrupt intestinal permeability which complicates celiac disease.

•  Tetracyclines deplete Zinc.
• Cipro depletes Zinc.

ANTI-INFLAMMATORIES disrupt intestinal permeability which complicates celiac disease.

• Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Vitamin D, Zinc.

ANTICONVULSANTS

• Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Vitamin D, Zinc.

ANTIVIRAL AGENTS

• Zidovudine (Retrovir®, AZT and other related drugs) deplete Zinc.

BRONCHODILATORS

• Inhaled corticosteroid inhalers (Flovent, Pulmicort and others) that are breathed in on a daily basis as a long term therapy to reduce inflammation in airways depleteVitamin D .

CARDIOVASCULAR DRUGS

• Antihypertensives (Catapres®, Aldomet) deplete Zinc.
• ACE Inhibitors (Capoten®, Vasotec®, Monopril® and others) deplete Zinc.

CHOLESTEROL DRUGS

• Colestid® and Questran® deplete Vitamin D.

DIURETICS

• Thiazide Diuretics (Hydrochlorothiazide, Enduron®, Diuril®, Lozol®, Zaroxolyn®, Hygroton® and others) deplete Zinc.
• Loop Diuretics (Lasix®, Bumex®, Edecrin®) depletes Zinc.
• Potassium Sparing Diuretics (Midamor®, Aldactone®, Dyrenium® and others) deplete Zinc.

FEMALE HORMONES disrupt intestinal permeability which complicate celiac disease.

• Oral Contraceptives (Norinyl®, Ortho-Novum®, Triphasil®, and others) deplete Zinc.
• Oral Estrogen/Hormone Replacement (Evista®, Prempro®, Premarin®, Estratab® and others) deplete  Zinc. [/box]

WEIGHT LOSS DRUGS THAT BIND FAT also interfere with absorption of some nutrients.

• Zenicol (Orlistat®) depletes Vitamin D.

• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Chelated zinc as prescribed but do not take at same time as calcium because they compete for absorption.
• Vitamin D3 as prescribed following blood test for status.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Caraway, in addition to being carminative, is particularly helpful in healing the gut mucosa including severe inflammation and ulcerations, having these properties: anti-inflammatory, anti-spasm, antimicrobial, antioxidant,  and immunomodulatory (ability to modify or regulate immune functions).¹³
• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps: Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Crohn’s Disease In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Prevalence of a gluten-free diet and improvement of clinical symptoms in patients with inflammatory bowel diseases.” This cross-sectional study investigating the widespread acceptance in the United States of maintaining a gluten-free diet without an underlying diagnosis of celiac disease found that in a large group of patients with inflammatory bowel disease (IBD), a substantial number had attempted a gluten free diet, of whom the majority had some form of improvement in gastrointestinal symptoms. Testing a gluten free diet in clinical practice in patients with significant intestinal symptoms, which are not solely explained by the degree of intestinal inflammation, has the potential to be a safe and highly efficient therapeutic approach.

A gluten free diet questionnaire was used in 1647 patients with inflammatory bowel diseases participating in the CCFA Partners longitudinal Internet-based cohort.

RESULTS: A diagnosis of celiac disease  was reported by 10 (0.6%) respondents and 81 (4.9%) respondents reported non-celiac gluten sensitivity. Three hundred fourteen (19.1%) participants reported having previously tried a gluten free diet and 135 (8.2%) reported current use of gluten free diet. Overall 65.6% of all patients, who attempted a gluten free diet, described an improvement of their gastrointestinal symptoms and 38.3% reported fewer or less severe IBD flares. In patients currently attempting a gluten free diet, excellent adherence was associated with significant improvement of fatigue (P < 0.03).¹⁰

“Hospital admissions for vitamin D related conditions and subsequent immune-mediated disease: record-linkage studies.” This study investigating the reported association between vitamin D deficiency and the risk of developing immune-mediated diseases showed that  patients with vitamin D deficiency may have an increased risk of developing some immune-mediated diseases including Crohn’s disease, although  reverse causality or confounding cannot  be ruled out.

Researchers analyzed a database of linked statistical records of hospital admissions and death registrations for the whole of England (from 1999 to 2011). Rate ratios for immune-mediated disease were determined, comparing vitamin D deficient cohorts (individuals admitted for vitamin D deficiency or markers of vitamin D deficiency) with comparison cohorts.

After hospital admission for either vitamin D deficiency, osteomalacia or rickets, there were significantly elevated rates of Addison’s disease, ankylosing spondylitis, autoimmune hemolytic anemia, chronic active hepatitis, celiac disease, Crohn’s disease, diabetes mellitus, pemphigoid, pernicious anemia, primary biliary cirrhosis, rheumatoid arthritis, Sjogren’s syndrome, systemic lupus erythematosus, thyrotoxicosis.⁸

“Effects of Carum carvi L. (Caraway) extract and essential oil on TNBS-induced colitis in rats.” This study investigating the effects of caraway extract (CHE) and its essential oil (CEO) in an immunological model of severe colitis in rats demonstrated data suggesting that caraway fractions are both effective and possess anti-colitic activity irrespective of the dose and route of administration. This study confirms that caraway, a common herb, is beneficial for inflammatory bowel disease.

Tissue damage induced by TNBS manifested severe inflammation, hemorrhage, ulcer, and necrosis as well as thickening of colon wall in colitis control groups. TNBS model of experimental colitis is beneficial for the screening of drugs with anticolitic activity and has several similarities to pathological and clinical features of the human ulcerative colitis.

Different doses of CHE (100, 200, 400 mg/kg) and CEO (100, 200, 400 μl/kg) were administered orally and also doses of CHE (100, 400 mg/kg) and CEO (100, 400 μl/kg) were given intraperitoneally to the 6 separate groups of male Wistar rats. Administration of the doses started 6 h after induction of colitis and continued daily for 5 consecutive days. Wet colon weight/length ratio was measured and tissue damage scores as well as indices of colitis were evaluated both macroscopically and histopathologically. CHE and CEO at all doses tested were effective in reducing colon tissue lesions and colitis indices and the efficacy was nearly the same when different doses of plant fractions were administered. Administration of the steroids prednisolone (4 mg/kg by mouth), Asacol® (mesalazine microgranules 100 mg/kg) and hydrocortisone acetate 20 mg/kg intraperitoneally as references were effective in reducing colon tissue injures as well.¹³

“Inflammatory bowel disease in celiac patients.” This cross-sectional, prospective epidemiological study in a group of celiac patients, their first-degree relatives, and a control group with similar epidemiological characteristics including the relatives of patients presenting at the emergency room for acute conditions found that patients with celiac disease and their relatives have a greater predisposition to Crohn’ s disease versus the control population. In all, 86 celiac patients and 432 relatives were included, who were compared to 809 control subjects (129 patients with acute conditions and 680 first-degree relatives). Three cases of Crohn’s disease were identified among celiac patients, and 4 cases among their relatives. Only 1 case of Crohn’s disease was detected in the control group.¹⁴

“Seroreactivity against saccharomyces cerevisiae in patients with Crohn’s disease and celiac disease.” This study investigating whether there were anti-Saccharomyces cerevisiae antibodies (ASCA) in biopsy-confirmed celiac disease patients and patients with inflammatory bowel diseases demonstrated ASCA positivity not only in Crohn’s disease, but also in celiac disease. It is conceivable that ASCA positivity correlates with the autoimmune inflammation of the small intestines and it is a specific marker of Crohn’s disease.¹⁵

“Celiac sprue among US military veterans: associated disorders and clinical manifestations.” This study investigating the clinical manifestations of celiac disease related to malnutrition and analyzing the associations between celiac disease and other diagnoses revealed a statistically significant association of celiac disease with Crohn’s disease.¹⁶

CASE REPORT SUMMARIES

“Coexistence of Celiac and Crohn’s Disease in a Patient Presenting with Chronic Diarrhea.” This case report describes a 54-year female who presented with diarrhea and weight loss. On initial evaluation, celiac disease was diagnosed, and responded to gluten-free diet. Later on, she developed joint pains and her diarrhea recurred. Further evaluation revealed coexistence of Crohn’s disease. The treatment of Crohn’s disease  was also initiated and this led to marked improvement in the symptoms of the patient.¹⁷

Sources:

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3. Bardella MT, Elli L, De Matteis S, Floriani I, Torri V, Piodi L. Autoimmune disorders in patients affected by celiac sprue and inflammatory bowel disease. Ann Med. 2009;41(2):139-43. doi: 10.1080/07853890802378817. [↩] [↩]
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6. Delco F, El-Serag HB, Sonnenberg A. Celiac sprue among US military veterans: associated disorders and clinical manifestations. Digestive Diseases and Sciences. May 1999;44(5):966-72. [↩]
7. Masachs M, Casellas F, Malagelada JR. Inflammatory bowel disease in celiac patients. Rev Esp Enferm Dig. 2007 Aug;99(8):446-50. [↩]
8. Ramagopalan SV, Goldacre R, Disanto G, Giovannoni G, Goldacre MJ. Hospital admissions for vitamin D related conditions and subsequent immune-mediated disease: record-linkage studies. BMC Med. 2013 Jul 25;11:171. doi: 10.1186/1741-7015-11-171. [↩] [↩] [↩]
9. Kathleen Mahan and Sylvia Escott-Stump, ed. Krause’s Food, Nutrition & Diet Therapy, 10th Edition. Philadelphia, PA. USA: W.B. Saunders Company, 2000. [↩]
10. Herfarth HH, Martin CF, Sandler RS, Kappelman MD, Long MD. Prevalence of a gluten-free diet and improvement of clinical symptoms in patients with inflammatory bowel diseases. Inflamm Bowel Dis. 2014 Jul;20(7):1194-7. doi: 10.1097/MIB.0000000000000077. [↩] [↩]
11. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
12. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
13. Keshavarz A, Minaiyan M, Ghannadi A, Mahzouni P. Effects of Carum carvi L. (Caraway) extract and essential oil on TNBS-induced colitis in rats. Res Pharm Sci. 2013 Jan;8(1):1-8. [↩] [↩]
14. Masachs M, Casellas F, Malagelada JR. Inflammatory bowel disease in celiac patients. Rev Esp Enferm Dig. 2007 Aug;99(8):446-50. [↩]
15. Barta Z, Csipo I, Szabo GG, Szegedi G. Seroreactivity against saccharomyces cerevisiae in patients with Crohn’s disease and celiac disease. World Journal of Gastroenterology. Oct 2003;9(10):2308-12. [↩]
16. Delco F, El-Serag HB, Sonnenberg A. Celiac sprue among US military veterans: associated disorders and clinical manifestations. Digestive Diseases and Sciences. May 1999;44(5):966-72. [↩]
17. Lail G, Tasneem AA, Butt MO, Luck NH, Laeq SM, Abbas 1, Mubarak M. Coexistence of Celiac and Crohn’s Disease in a Patient Presenting with Chronic Diarrhea. J Coll Physicians Surg Pak. 2016 Jun;26(6):536-8. doi: 2359. [↩]