Fast Crohns Disease Cure

Cured My Crohns

If you've ever gotten the fateful diagnosis you've got Crohns, you will know the massive upset that it can have on your way of life and how you feel about yourself and your relationship to other people. If you talk to your doctor about natural diets or some other method of curing your Crohns disease they will tell you that there is no way to fix it. However, there is often more to the story than modern medicine will tell you. New Age medicine is not a bunch of nonsense that hokey people subscribe to; New Age medicine fills in the gaps of knowledge that we have with modern medicine and helps us understand what is going on with our bodies. You will learn how to cure Crohns from someone who has cured it himself and has lived for over 10 years completely free of disease!

Cured My Crohns Summary

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No More Crohn's Disease

If you are looking for an easy, safe, and affordable way to get rid of Chron's disease, you need No More Crohn's Disease by Cathy Rubert. Cathy used to suffer from this terrible disease too, but when she discovered the techniques she shares in No More Crohn's Disease, she was able to heal herself in the safest and most natural way. You will learn about these 4 main natural steps that will immediately get rid of the pain in your lower abdomen. You will learn the single cheap ingredient that will bring your body's digestive system back in balance. This ingredient has the power to eliminate your pain in just days, no matter how bad your condition is. You too can start living a life free from Chrons disease with the help of her book.

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Another Crohn Disease Subtyping System

Some doctors also distinguish subtypes of Crohn disease as inflammatory, fistulizing, and obstructing. This classification scheme is not always precise, since obstructing disease often also has characteristics of inflammation and vice versa. The classification refers to the predominant symptoms how the disease primarily presents itself. However, an individual may have a bowel obstruction and or inflammatory mass and or one or more fistulas. Fistulas are the most difficult complication of Crohn disease many are refractory to medical treatment, and surgical correction often does not stop other fistulas from occurring. Figure 1.5 shows the intestinal complications of Crohn disease widespread inflammation, fistula, stricture, and abscess.

Crohns Disease

Bowel Cancer Effecting Lymph Nodes

Crohn's disease may involve segments of the whole GI tract. However, Crohn's disease most often affects the terminal ileum and the proximal colon. Unlike ulcerative colitis, Crohn's disease typically affects the GI tract in a discontinuous way (so-called skip CT usually misses the early stages of Crohn's disease (Biancone et al. 2003). With progression of the disease, mural thickening and luminal narrowing occur. The outer contour of the colon wall is irregular. The degree of contrast enhancement of the bowel wall correlates with the severity of the disease (Gore et al. 1996). As a result of the hyperemia from the inflammatory process, the local mesenteric vessels are dilated and widely spaced, which has been described as the comb sign. A progressive increase in higher-density pericolic fat is called fibrofatty proliferation and is an attempt by the body to contain the inflammatory process, resulting in separation of the bowel loops. Usually, multiple mesenteric lymph nodes, measuring...

Preface and Acknowledgments

Bloom that I had been diagnosed with Crohn disease in 1988, and that the physician I had chosen to assist me as a collaborating expert author was the gastroenterologist who has provided my care since then. My recollection of broaching the subject of working together on this book with Dr. Ronald Vender is vivid. It was December 1997, in an examination room in his new office. Since the previous February I had been fighting the worst flare-up of Crohn disease I had ever experienced. We had tried to beat back the attack with high doses of my standard mesalamine drugs Asacol and sulfasalazine, three different antibiotics, steroids, and immunoregulators. Today, I am feeling much better. This project has been, to some degree, an exercise in healing as well as one in better understanding. I hope it provides the same benefit for others who suffer from Crohn disease or ulcerative colitis. Deep thanks to Dr. Ronald Vender, both for his collaboration on this project and for his...

The Difficulty of Diagnosis

The diagnosis of inflammatory bowel disease may be made quickly or may take a relatively long period of time, depending on the symptoms people have when they first visit a doctor because of distress. These signs (what the doctor finds) and symptoms (what the patient experiences) vary, depending on whether the inflammatory bowel disease is Crohn disease or ulcerative colitis and on where in the digestive system the disease is located. In order to make a diagnosis of Crohn disease or ulcerative colitis, a doctor needs to take a careful medical history, perform a thorough physical examination, and possibly order a number of laboratory tests and diagnostic procedures. Although the outward symptoms of Crohn disease and ulcerative colitis are often the same, the ways in which the diseases manifest themselves both within the gastrointestinal tract and throughout the body are very different, as we will see in chapter 3. As knowledge grows about how the two diseases behave differently at a...

The Value of a Second Opinion

This is especially true if the original diagnosis is made by an internist or family practitioner who does not see many new cases of Crohn disease or ulcerative colitis in the course of a year. Whenever possible, an individual should have a complete examination performed by a gastroenterologist, who sees patients with these diseases on a daily basis.

The Supporting Cast Liver Gallbladder and Pancreas

How and Why the Digestive System Malfunctions in People with Crohn Disease or Ulcerative Colitis The major pathology of the intestinal tract in a person with Crohn disease or ulcerative colitis is chronic inflammation. Inflammation is a natural response when the body's immune system attacks a foreign entity (antigen). Inflammation is characterized by four conditions heat, redness, pain and swelling. The antigen can be viral, bacterial, parasitic, or chemical it can be a foreign physical object such as a wood splinter or foreign tissue such as a transplanted organ. But with Crohn disease or ulcerative colitis, there is no obvious immediate antigen at hand. The immune response seems inappropriate the body creates inflammation with no reason to do so. In cases of Crohn disease or ulcerative colitis, the inflammation occurs in the inside of the gastrointestinal tract. The inflammatory process also causes damage to the cellular structure of the intestine. In ulcerative colitis, the...

The Immunology Contribution

AIDS research has furthered our understanding of how the immune system works and also of how it doesn't work properly in diseases such as Crohn disease and ulcerative colitis. Inflammatory bowel disease is the result of abnormal control of the immune response to environmental triggers. These triggers may include the bacteria that occur naturally in a person's own gastrointestinal tract.

Nutritional Complications

Poor nutrition and even malnutrition are a constant threat to individuals with Crohn disease or ulcerative colitis for a number of reasons. Dietary absorption is hindered, especially in those with Crohn disease of the small intestine and those who have bacterial overgrowth. Absorption occurs mostly in the the jejunum. People who suffer jejunoileitis, or who have had part of this region removed surgically because of the disease, suffer from poor nutrition and weight loss. Supplements contain sufficient nutritional components such that even a tiny fraction actually absorbed in other areas of the intestine is enough. In many people with Crohn disease of the ileum, the ileocecal valve is not functioning properly, for any of a number of reasons. For example, in Crohn ileocolitis, the ileocecal valve itself is often diseased. A fistula may form between the small intestine and the colon, bypassing the ileocecal valve. During surgery to remove a badly diseased ileum, the diseased ileocecal...

The Question of Fiber

Low-fiber diets are often prescribed for individuals with Crohn disease or ulcerative colitis, the belief being that a low-fiber diet may reduce diarrhea by reducing the mechanical stimulation in the intestines, and also reduce irritation of the bowel mucosa by undigestible components. A low-fiber diet is prescribed for individuals with partial obstruction due to Crohn disease, so the undigestable fiber does not become lodged in the narrowed portion of the intestine, causing a complete obstruction. Individuals with this condition should stay away from foods that cannot be fully digested such as corn, nuts, seeds, popcorn, and some vegetables used in Chinese food, including snow peas, water chestnuts, and bamboo shoots.

The Mind Body Connection

It is almost shocking today to read medical literature from the first half of this century, when doctors were starting to put names to the confluence of symptoms we now know as Crohn disease and ulcerative colitis. At one time the ulcerative colitis personality was seriously discussed, and even now some people retain the misperception that these disorders are psychosomatic, brought on by underlying psychological problems. Today, we are only at the beginning of a true understanding of mind-body interactions and how they affect diseases. We now know that individuals can't give themselves ulcerative colitis or Crohn disease. But we also know that the way an individual responds psychologically and emotionally to IBD or to any chronic illness, for that matter can have an effect on treatment and on quality of life. We know, too, that stress does have an effect on the body, making it more difficult for the immune system to do its work.

Fear of Colo Rectal Cancer

Because those with Crohn disease and ulcerative colitis have an increased rate of colo-rectal cancer, affected individuals may develop a major fear of that disease. The increase in incidence The recommendation is that those with colitis begin to have regularly scheduled screening colonoscopies beginning eight years after diagnosis and those with Crohn disease fifteen years after diagnosis. People with Crohn disease who have significant disease in the colon are often screened beginning eight years after diagnosis, as if they had colitis.

Other Research into New Medications

Omega-3 fatty acids, such as those found in fish oils, may reduce the level of leukotrienes, which play a role in inflammation. Small studies show some improvement in people with active ulcerative colitis, although not in maintaining remission in colitis. Another study showed that omega-3 fatty acids did maintain remission in those with Crohn disease. who become steroid dependent, while reducing the side effects and long-term risks of more traditional steroids. These drugs are quickly cleared from the bloodstream, and have shown results similar to prednisone in inducing remission in both Crohn disease and ulcerative colitis. Budesonide is currently available in some countries although not in the United States both as a capsule and as an enema preparation. Work is also being done on a delayed-release capsule to treat ileal disease in patients with Crohn disease. Nicotine is also being studied. Although most individuals with ulcerative colitis are nonsmokers, a higher proportion of...

Appendix C Other Web Sites

Because the Web is constantly changing, the best way to get to the newest, most exciting Web pages is to do a search. Simply ask your browser to search Crohn's or colitis. In January 1999, a search of the word Crohn's found that the top 10 matches had 3,534 hits. A large number of these were personal Web pages created by newly diagnosed individuals wanting to set up communication links to others, then creating resource guides from all of the responses they got (many were not very good). One site definitely worth a look is Keith's Crohn's Chronical, a graphics-heavy on-line newspaper devoted to the support of Crohn's patients. This site is best viewed with Netscape.

Diagnostic Procedures

In Crohn disease with active involvement of the colon, changes to the colon wall appear as ulcerations that can run from tiny and shallow to large and deep, as well as erosions in the colon lining. Skip areas of healthy tissue often appear between areas of diseased tissue. Deep linear ulcerations alternating with areas of healing mucosa cause the classic cobblestone pattern of Crohn colitis. Colonoscopy, a more thorough examination of the large intestine, allows visualization of the entire colon and of the terminal ileum, which is helpful in distinguishing Crohn disease from ulcerative colitis. A colonoscope is longer than a sigmoidoscope. Electronic imaging making use of microchips and screen projection is replacing the older fiber-optic technology. Medications given before the examination make it quite tolerable. However, because of the medication, people typically will need to take a day off from work and will require a ride home after the procedure. Enough barium is inserted to...

Mind Body Medicine and IBD

Mind body therapies can be quite useful they can help individuals with Crohn disease or ulcerative colitis manage pain, can contribute to a sense of well-being, and can give sufferers some feeling of control in a situation where, in medical terms, they have little or none. While there is no proof that these therapies can undo the cellular damage done by inflammatory bowel disease, much anecdotal evidence suggests that such techniques can provide great relief for many with IBD. The sense of spiritual healing can greatly reduce the fear, anxiety, and depression that often accompany a chronic illness such as Crohn disease or ulcerative colitis, and can thus enhance the quality of life for an individual who lives with these conditions.

The Nine Varieties of Inflammatory Bowel Disease

If a diagnosis of either Crohn disease or ulcerative colitis is made, a subtype name will often be given. Various systems are used to categorize patients and their diseases. These categories are all somewhat arbitrary. Some people find them useful, while others do not. Whatever the categorization scheme, the various subtypes of Crohn disease or ulcerative colitis should not be thought of as separate diseases but rather as variations on a theme. The subtypes of Crohn disease and ulcerative colitis given here are used to define the location of disease within the intestinal system. The types of disease have different symptoms and different treatment regimens these will be discussed in later chapters. Crohn Disease Five Categories While Crohn disease lesions can appear anywhere in the gastrointestinal tract, from the mouth to the anus, lesions in the mouth or esophogus rarely appear unless disease also occurs farther down in the gastrointestinal system. The five subtypes of Crohn disease...

The Physical Exam

The doctor will feel gently in the right lower quadrant of the abdomen to see if there is a palpable inflammatory mass. This mass, sometimes present in Crohn disease, is caused by current acute inflammation, usually at the ileum, as well as by a thickening of the intestinal wall and scar tissue developed from chronic or recurrent inflammation. There may also be a thickening of the mesentery, the fatty tissue that holds the intestines together. The doctor will also feel along the path of the colon, up the right side, across under the diaphragm, and down the left side, searching for tender spots that signal areas of acute inflammation, which can occur either in ulcerative colitis or in Crohn disease of the colon. While people who suffer from ulcerative colitis often have a normal anal exam, those with Crohn disease can show any one of a number of abnormalities, many of which are very painful. Among these are hemorrhoids anal fissures (cracks in the lining of the anus, which are...

The Genetic Front

Statistics are helpful in looking at familial patterns of inflammatory bowel disease. Crohn disease and ulcerative colitis are familial or complex genetic diseases, as opposed to simple genetic diseases. In simple genetic diseases such as sickle cell disease or cystic fibrosis, a person who inherits a copy of the defective gene from each parent is certain to get the disease. In Crohn disease or ulcerative colitis, this is not the case. In fact, 85-90 percent of people with Crohn disease or ulcerative colitis have no relatives with either disease. At the same time, because there are fewer than one million Americans who live with inflammatory bowel disease, the 10-15 percent multiple incidence in families means that the risk of the disease is statistically higher when a family member has IBD than when the disease is not present. Ample evidence of a genetic factor exists, however. First, some populations that bred closely within their communities for many generations (Eastern European...

Lifelong Ailment

Although Crohn disease and ulcerative colitis are chronic, they are characterized by periods of remission that last for varying amounts of time, interrupted by flare-ups, when symptoms of the disease become more evident. When an individual with Crohn disease or ulcerative colitis is in the doctor's office, whether for a regular visit or for an urgent visit due to a specific change in symptoms, the examination has several components. The doctor does the following

Special Situations

Although every individual who has Crohn disease or ulcerative colitis should be considered a special situation and should be treated as an individual with unique needs, a few groups need some specific attention. A friend tells this story. Her sister's son, twelve years old, was diagnosed one spring with Crohn disease. He had been feeling progressively poorer through the previous fall and winter, with fevers, abdominal pains, and diarrhea. Always on the small side, the boy had been falling farther and farther behind his classmates in terms of height, weight, and development of secondary sex characteristics. Although frightened by the diagnosis of Crohn disease, the boy's mother was relieved at least to know what the problem was after all the testing however, she was anxious about her son going to overnight camp that summer. She called the camp director to request that her son's counselor be informed of the No problem, the director said. All of the camp's counselors knew about...

Treatment

Until the root causes of ulcerative colitis and Crohn disease are discovered and cures are found, these two maladies are best managed by an internist with some extra training in gastroenterology or by a gastroenterologist, if one is available. The arsenal of medications used to treat the symptoms of Crohn disease and ulcerative colitis grows larger all the time, the result of research into the disease process and mechanisms, and of the serendipitous discovery of helpful chemical compounds. However, as yet there is no medication that can cure either condition. Although all of the mechanisms of inflammation are not understood, currently available medications seek to influence the inflammatory cascade, reversing the organic damage caused by severe and recurrent inflammation. We continue to hope that the increased ability to treat symptoms and to curb inflammatory flare-ups early in their course will, over time, reduce the proportion of individuals with Crohn disease or ulcerative colitis...

Surgical Treatments

Indications for Surgery for Crohn Disease As with ulcerative colitis, surgery for Crohn disease sometimes must be undertaken in an emergency, but more often is classified as urgent or even elective. Unlike surgery for ulcerative colitis, however, surgery for Crohn disease is not curative it is only corrective of an immediate complication. Between two-thirds and three-quarters of individuals who suffer from Crohn disease will undergo surgery at some point. The most common surgery for individuals with Crohn disease is partial intestinal resection with reanastomosis (reconnection). This is performed to remove areas of the bowel significantly damaged by disease and can be done anywhere in the small or large intestine. Figure 5.3 shows a narrowing, called a stricture, at the terminal ileum, and figure 5.4 shows a partial resection with reanastomosis to remove the severely narrowed terminal ileum, as well as the ileocecal valve, appendix, and the cecum. Crohn disease frequently recurs above...

Chronic Illness

Individuals who have Crohn disease or ulcerative colitis must constantly marshal their strength. If you are such a person, while it is not necessary to baby yourself, it is important to carry out the regimens of daily living that in the past have helped you to maintain maximum health. These include (1) sticking to the diet that works for you (2) getting enough sleep, even if you Having a chronically ill family member is stressful for every person in the household. At the same time, the family is the central unit in the support system for any person who suffers from Crohn disease, ulcerative colitis, or any other chronic illness. Regardless of which family member is ill, Crohn disease or ulcerative colitis is debilitating for the entire family. Flare-ups often occur suddenly, causing plans to be changed. Outings may need to be planned around proximity to toilet facilities. Travel is sometimes difficult, as changes in water and food, as well as sleep disturbances caused by jet lag, can...

Body Image

Although there are typically few, if any, outward signs that an individual has Crohn disease or ulcerative colitis, feelings about body image constitute an important psychological component of IBD. A person may worry constantly about disrupting the social or business flow of the day because of the need to use the toilet many times and may fear losing bowel control and soiling clothes. Steroids can have outward physical effects, such as facial mooning, an increase in facial hair, and skin blemishes. And those who have had an ostomy may wear apparatus, albeit under clothing. Body image is a special issue for adolescents with Crohn disease or ulcerative colitis. Many have some degree of retardation in growth and sexual maturation, this occurring at a time of heightened awareness regarding their own physical characteristics and concerns about whether they are perceived as attractive.

Genetics

To date, no gene has been identified that alone is sufficient for the development of either Crohn disease or ulcerative colitis. Currently, most genetic research is focused on chromosomes 12 and 16, although there is some research being done on chromosome ip, 3, 4 and 6 as well. The research methodology is one that looks for genetic marker variations on these genes that show up in pairs of relatives siblings or cousins who have IBD more often than would be expected by chance. Recent research at Johns Hopkins University and the University of Chicago has identified families with abnormalities on chromosomes ip, 3q, 4q and 16. Researchers in Toronto have demonstrated a link between Crohn disease and a major histocompatibility complex on chromosome 6. Histocompatibility is the compatibility between a tissue donor and a recipient. An abnormality in histocompatibility could be what causes the autoimmune effect, in which an individual's immune system believes that his or her own tissue is a...

Infections

Are Crohn disease and ulcerative colitis infectious diseases Are they the manifestations of systemic responses to acute infectious episodes Are they the human manifestation of Mycobacterium paratuberculosis (M. paratuberculosis), which causes Johne's (pronounced yonez) disease in cattle Part of the reason it is often difficult to diagnose inflammatory bowel disease is that its symptoms so closely resemble those of a number of other diseases. Crohn disease is so much like ileocecal tuberculosis as to be almost indistinguishable from it. Indeed, before Dr. Burrill Crohn and his colleagues described the entire group of symptoms and found them all in a population, what is now known as Crohn disease was given the diagnosis of tuberculosis. Of course, today, a simple skin test will show whether there are antibodies to the human tuberculosis organism. M. paratuberculosis infects many mammals, including primates. Both Johne's disease and Crohn disease are epidemic in Scotland. The only thing...

Biological Therapies

In late 1998, the Food and Drug Administration approved the first medication solely for treatment of Crohn disease. The drug, infliximab (trade name Remicade), ushered in a new wave of potential biologic therapies to treat IBD. Infliximab is a chimeric monoclonal antibody, a human-made protein designed to target a specific biological substance in this case, human tumor necrosis factor alpha (TNF-alpha). TNF, which occurs naturally in the body, has been shown to be one of the major culprits in the intestinal inflammatory process characteristic of IBD. The FDA approved infliximab for two specific uses. The first is to treat Crohn disease that is refractory to standard treatment and that renders individuals steroid dependent, meaning that a flare-up occurs on successive attempts to taper off steroids. For this purpose, a single two-hour infusion of infliximab is given. One small trial of CDP571 had been reported by mid 1999. In it, twenty individuals with moderate Crohn disease were...

Few Statistics

Crohn disease and ulcerative colitis are rarely diagnosed in less developed countries. Epidemiologists people who study statistical information about health and illness have found an inverse relationship between IBD and the prevalence of infectious diarrheas, those caused by bacteria and parasites. While difficult to interpret, these statistics continue to lead researchers to think that a Western diet, which is high in animal fats and protein and relatively low in fruits, vegetables, and fiber, plays some part in the development of Crohn disease and ulcerative colitis. However, diet cannot, strictly speaking, be considered a cause, since studies have not found that those within the population at large whose intake of protein and animal fat is higher than normal have an increased incidence of inflammatory bowel disease. And, despite the fact that more Americans are eating healthier diets today than was so a generation ago, the incidence of Crohn disease continues to rise. Nor can...

Inflammatory Bowel Disease Surveillance

The cancer surveillance algorithm is augmented for high-risk patients. Patients with pancolitis for more than 7-10 years and patients with left-sided ulcerative colitis for more than 15 years are at increased risk of developing colon cancer. The current recommendation for screening colonoscopy for these groups is every 1-2 year with random biopsies of the colon (American Society of Gastrointestinal Endoscopy 1998). Patients with ulcerative colitis and Crohn's disease have an increased risk of cancer the longer the disease progresses and an approximate overall 3 risk of colon cancer has been reported (Mpofu et al. 2004). For this reason, surveillance usually begins eight years after initial diagnosis and patients are usually screened by conventional colonoscopy with polypectomy and occasionally colectomy. However, no clear evidence exists that surveillance improves colon cancer survival in this patient population (Mpofu et al. 2004). Ota et al. reported a study of 33 patients with...

Chapter Summary continued

Inflammatory bowel disease includes Crohn disease, ulcerative colitis, and colitis of indeterminate type. Crohn disease has skip lesions, has transmural involvement with formation of granulomas, and tends to form fistulas, abscesses, and sinuses. In contrast ulcerative colitis is confined to the rectum and colon, has inflammation limited to the mucosa and submucosa with crypt abscess, is more likely to have extraintestinal manifestations, and can cause toxic megacolon.

Inflammatory bowel disease

Non-specific inflammatory bowel disease comprises ulcerative colitis and Crohn's disease, each with different pathological, clinical and therapeutic aspects, but both requiring distinction from other serious bowel diseases, such as infections or ischaemia. Biological agents targeting the immuno-inflammatory response offer new therapeutic opportunities for these distressing diseases.

Proctoscopy Sigmoidoscopy Proctosigmoidoscopy

Proctoscopic examinations are used to diagnose anal hemorrhoids, rectal prolapse, abscesses, fissures, polyps, and malignancies. They can also be used to identify and evaluate inflammatory bowel diseases such as ulcerative and granulomatous colitis. Regional enteritis, intestinal ischemia, and irritable bowel syndrome can be diagnosed and assessed via proctoscopy.

Hidradenitis Suppurativa

Hidradenitis Suppurativa

This is a chronic inflammatory disease occurring on skin containing apocrine glands. It is commoner in women and occurs in the anogenital area as well as the axillae, breasts, thighs, and buttocks. It is a problem of follicular occlusion with the consequent complications of obstruction to the outflow of other apocrine and sometimes sebaceous glands (18). It can be associated with similar conditions such as conglobate acne and pilonidal sinus. Bacteria play a secondary but important role, in the inflammatory process that results leads to scarring and sinus formation. The onset of the disease is after puberty, suggesting that there is a hormonal influence. The skin lesions include comedones often with two pores (bridged comedones), pustules, tender dermal nodules, abscesses, and linear sinus tracks (Fig. 12A and B). Lesions can ulcerate and there is often a persistent purulent discharge. There may also be the complications of episodic cellulitis, fistula formation to the bladder and...

Homoeopathy Medicine For Bladder Infiltration Of Rectosigmoid Tumor

Testicles Undescended Adult

Crohn disease frequently presents as terminal ileitis (Fig. 53.1). The edematous wall thickening (74) confined to this segment is easily separable from adjacent uninvolved loops (46). In more advanced stages (Fig. 53.2), the intestinal wall (74) becomes massively thickened and can resemble the sonographic findings of intestinal invagination. On cross sections, the thickened, edematous walls of intestinal loops can be compared to a concentric lamellation of a target ' The examiner should always look for adjacent fistular tracts or abscesses as well as for free abdominal fluid in the cul-de-sac.

Gastrointestinal Radiography

The SBF is used to diagnose a wide variety of small-intestine disorders such as abnormal positioning and Crohn's disease. Contraindications for this test include small-bowel obstruction and suspected perforations. tine. Crohn's disease, hernias, Meckel's diverticulum, and various anomalies of the small intestine can be diagnosed using this examination.

Others

Other chronic dermatologic diseases may affect the vulva. The autoimmune blistering diseases, pemphigoid and pemphigus vulgaris, are rare but can involve the vulvar skin in affected women. Behcet's disease involves the triad of genital and oral ulcers as well as ophthalmologic inflammation and may produce very painful chronic ulcers of the vulva. Crohn's disease may also cause vulvar ulcers and fissures that may precede the intestinal manifestations and therefore make diagnosis challenging (11).

Granuloma Inguinale

Other diseases in the differential diagnosis in the early ulcerative stages include other sexually transmitted ulcers, including syphilis and chancroid. Later disease with scarring and granulation tissue can be confused with hidradenitis suppurativa, Crohn's disease, and genital malignancy. The diagnosis is usually made by punch biopsy. Donovan bodies are diagnostic and appear as intracytoplasmic inclusion bodies in hystiocytes. Complications of infection include permanent genital destruction and scarring, blockage of the urinary tract from stenosis, genital depigmentation, permanent genital swelling from lymphatic scarring, and even death. Affected areas are at increased risk of developing genital cancer.

Turner Syndrome Xo

Skeletal manifestations include cubitus valgus and hip dislocation. Skin findings include narrow hyperconvex nails, pigmented nevi, and a tendency to form keloids. Bicuspid aortic valves, coarctation of the aorta, and valvular aortic stenosis are cardiac anomalies. Horseshoe kidneys may be seen. Occasionally, patients have blue sclera, cataracts, mental retardation, Crohn disease, or thyroid disorders. The congenital lymphedema resolves. Patients do not achieve an adolescent growth spurt, reaching a final height of 55 inches. Estrogen replacement is indicated.

Chancroid

The differential diagnosis includes all sexually transmitted ulcerative diseases, including HSV infection in an immunocompromised patient, as well as aphthae, Crohn's disease, and hidradenitis suppurativa. The diagnosis of chancroid is likely if the patient has one or more painful genital ulcers and the presence of painful regional lymphadenopathy and there is no evidence of T. pallidum or HIV in the ulcer exudate. The diagnosis is difficult to confirm because the appropriate culture media for H. ducreyi is generally not available. Even in the best circumstances, H. ducreyi isolation has a sensitivity no more than 80 . Gram-stain evaluation classically shows coccobacilli in groups, described as schools offish,'' or in parallel, described as railroad tracks.''

Tuberculosis

Diseases that could be confused with vulvar TB include hidradenitis suppura-tiva, late granuloma inguinale, chancroid, or Crohn's disease. Useful diagnostic tests for genital disease include hysterosalpingogram, pelvic ultrasound, laparoscopy, and hysteroscopy. Isolation of Mycobacterium tuberculosis from endometrial tissue, peritoneal fluid, menstrual fluid, or ulcer exudate provides definitive diagnosis but is difficult to observe because of low bacterial counts in these samples. Acid-fast staining shows red-stained bacilli. Tissue biopsies classically show granulomatous changes, central caseation, surrounding epithelioid cells, and Langerhans giant cells. Culture growth takes four to eight weeks. The tuberculin skin test (Mantoux test) is neither sensitive nor specific for genital TB.