Home  Inflammatory Bowel Disease

Inflammatory Bowel Disease: Debilitating,
Painful, and Potentially Serious

~ by Jo Jordan

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For those with inflammatory bowel disease (IBD), life can be difficult and extremely trying. There is usually a great deal of pain, discomfort, and sometimes even social embarrassment as a result of the nature of the symptoms

There is no cure for IBD, but it is easiest to treat and control when diagnosed early. While it is difficult to predict the long-term effects of the disease, prognosis is often promising, there is little effect on life expectancy, and once a treatment plan has been set in place it’s possible to lead a relatively full and productive life.

IBD Stats

The CDC estimates that as many as 1.4 million people in the United States suffer from this group of conditions that includes Crohn’s disease (CD) and ulcerative colitis (UC).¹

One of the five most prevalent gastrointestinal disease burdens in the United States – with an overall health care cost of more than 1.7 billion dollars – IBD accounts for over 700,000 physician visits and 100,000 hospitalizations each year.²

As many as seventy-five percent of those with Crohn's disease and twenty-five percent of those with ulcerative colitis will eventually require surgery.³

What Is Inflammatory Bowel Disease (IBD)?

Not to be confused with irritable bowel syndrome (IBS), IBD is a group of inflammatory diseases of the colon and small intestine. Turning up at various sites in the gastrointestinal tract, these conditions – of which Crohn's disease and ulcerative colitis are the most common – cause chronic irritation and ulcers.

In a healthy body, the immune cells work to prevent infection. The immune systems in people with IBD mistake intestinal bacteria and food for foreign substances, so instead of protecting them, their immune systems attack the intestinal cells.

To fight back, the body sends out white blood cells (leukocytes, which are responsible for defending the body) into the intestinal lining. Known as a cell-mediate immune response, the result is chronic inflammation and other symptoms of IBD.

Both Crohn's disease and ulcerative colitis may cause abdominal pain, blood in the stool, diarrhea, and weight loss.

Other Types of IBD

Less common inflammatory bowel diseases include,

• Behçet’s syndrome
• Collagenous colitis
• Diversion colitis
• Indeterminate colitis
• Infectious colitis
• Ischemic colitis
• Lymphocytic colitis
• Radiation colitis

Who Gets IBD? Causes and Risk Factors

While no specific dietary, environmental, or infectious causes have been determined for IBD, certain environmental, genetic, and immunologic factors are thought to be involved.

• Especially common in older children and adolescents, IBD affects people of all ages. Onset normally occurs between fifteen and thirty years of age.
• While men and women are equally affected, UC is slightly more common in males; Crohn's disease is marginally more frequent in women.⁴
• First-degree relatives of IBD sufferers have a four- to twentyfold increased risk. The tendency to run in families is much higher in Crohn's disease than in ulcerative colitis.⁵
• Common among people of Northern European and Anglo-Saxon origin, IBD is two to four times more common in Eastern European and Russian Jews than in non-Jewish whites.⁶
• More common in developed countries, IBD occurs more frequently in urban communities than in rural areas. This suggests an association to the western lifestyle, including diet, pollution, and exposure to industrial chemicals.⁷
• Both Crohn's disease and ulcerative colitis are more common in white-collar workers (who work in artificial environments), leading researchers to speculate that work involving physical activity and being out-of-doors acts as protection against IBD.⁸
• Cigarette smoking seems to contribute to the development or worsening of Crohn's disease , which is more prevalent among smokers; ulcerative colitis is predominantly a disease of ex-smokers and non-smokers.
• Non-steroidal anti-inflammatory drugs (NSAID) may aggravate IBD.
• Some researchers believe that IBD is caused by infection.⁹

IBD Symptoms

Crohn's disease and ulcerative colitis are the two most common forms of inflammatory bowel disease. While very different diseases, they may both present with abdominal pain and cramping, bright red stool, fever, persistent diarrhea (accompanied by blood), vomiting, and weight loss. These symptoms tend to present themselves gradually over several weeks or months.

Complications from IBD

IBD is associated with other diseases and/or complaints such as arthritis, pyoderma gangrenosum (a skin condition characterized by ulcers, most commonly on the legs), and primary sclerosing cholangitis.

Disease complications fall into two categories: local and systemic. Local complications involve the intestinal tract itself, while systemic (or extraintestinal) problems affect other organs and/or the IBD sufferer as a whole.

Systemic complications include fever, loss of appetite, weakness, bone loss, eye disorders/inflammation of the eye, gallstones, liver and kidney disorders, mouth ulcers, severe arthritis (the most common systemic complication), and skin conditions.

In children, systemic manifestations sometimes overshadow intestinal symptoms, making the disease difficult to diagnose. Younger sufferers are at risk for growth retardation and/or delay of sexual maturation, as well as for effects from long-term use of medication.

Quality of life is normally lower with Crohn's disease patients than with ulcerative colitis sufferers as a result of post-surgery recurrences.

The most common causes of death in IBD are peritonitis (inflammation of the abdominal cavity membrane) with sepsis (bacterial infection of the bloodstream), resistancy to treatment, surgery complications, and thromboembolic disease (a blood vessel blocked by a blood clot).

Toxic megacolon, a serious complication of ulcerative colitis, can lead to perforation, sepsis, and death.

Diagnosing IBD

An IBD diagnosis is generally made through a colonoscopy and biopsy of abnormal tissue. Diagnosis often involves a combination of laboratory and radiology tests, as well as endoscopic procedures.

Laboratory tests¹⁰

• A complete blood count (CBC)
• Anti-body tests
• Liver function tests (liver and bile duct abnormalities are sometimes detected in IBD patients)
• Stool studies (bacterial infections can trigger IBD flare-ups)

Endoscopy

Endoscopic tests for specific sections of the gastrointestinal (GI) tract are used to diagnose ulcerative colitis and Crohn's disease. All use a thin, flexible tube with a lighted camera inside the tip, which enables health care providers to examine the lining of the GI tract.¹¹

Sigmoidoscopy — Examines the lining of the the sigmoid colon (the lower third of the large intestine).¹²

Colonoscopy — Examines the lining of the large intestine (colon), and can sometimes peek into the end of the small intestine.¹³

Esophagogastroduodenoscopy (EGD) — Examines the lining of the esophagus, stomach, and duodenum (first part of the small intestine).¹⁴

Capsule endoscopy — Computerized cameras in vitamin-sized capsules are swallowed to gather images of sections of the small intestine that are beyond the reach of an EGD.¹⁵

Endoscopic retrograde cholangiopancreatography (ERCP) combines the use of X-rays and an endoscope to examine the liver’s bile ducts and pancreatic duct. Under sedation, a small tube is inserted down the throat into the duodenum. A dye is injected into the duct, and an X-ray is taken.

Endoscopic ultrasound (EUS) combines endoscopy and ultrasound to obtain diagnostic images of the digestive tract and surrounding tissue and organs; in IBD patientsm this method is most often used to examine fistulas in the rectal area.

Radiographic Tests

Much of the small intestine cannot be imaged by endoscopy. Radiology is used for this part of the GI tract:

X-rays can detect blockages in both the small and large intestine.¹⁶

X-rays with barium liquid contrast are used with endoscopy to both monitor and treat IBD.

Computerized tomography scans (CT or CAT) are cross-sectional X-ray images of internal organs from various angles.

Magnetic resonance imaging scans (MRI) use magnetization and radio waves to produce images of the internal organs; MRI technology is used to evaluate perianal fistulas and abscesses in IBD patients.

White blood cell scans detect white blood cell accumulation in inflamed tissue. GI tract inflammation is characteristic of ulcerative colitis and Crohn's disease.¹⁷

Ultrasonography/ultrasound bounces high-frequency sound waves off internal tissue. Their echoes are converted into images; the technology is sometimes used with other radiological tests to examine the bowel.

Click to read more about diagnosing Crohn's disease and ulcerative colitis.

Treating IBD

Once a diagnosis has been made, your health care provider can help you establish a regular course of maintenance therapy to help control IBD symptoms, and minimize any potential long-term effects of the disease.

Highly individualized and dependent on the illness type, severity, and resulting symptoms, IBD treatment includes medications, dietary changes, and surgery. Counseling is sometimes recommended because the stress of chronic illness can exacerbate symptoms.

Health care providers work with IBD patients to determine the optimal combination of anti-inflammatory drugs to reduce symptoms, and to help avoid or post-pone surgery. Because the steroids commonly used to treat IBD can cause serious long-term side effects, alternative treatments are constantly being sought.

Medications

IBD medication relieves symptoms, reduces inflammation, and prevents flare-ups. To discover what works best, it may be necessary to try several different treatments and/or combinations of treatments.

~Aminosalicylates~

Mild to moderate IBD is often initially treated with aminosalicylates (antibiotics). They can minimize bacterial growth in the small intestine caused by bowel narrowing (stricture), fistulas, and/or surgery. Researchers suggest that antibiotics may also help suppress the immune system.

~Immunosuppressants ~

Deliberately induced immunosuppression – to reduce activation of the immune system – is another first line of defense for IBD and other autoimmune diseases. Medications – such as azathioprine (an immunosuppressant), 6-mercaptopurine (an immunosuppressant), methotrexate (an anti-metabolite), prednisone (a corticosteroid), or TNF inhibition (tumor necrosis factor) – work to control symptoms.

Corticosteroids:

Because they are fast acting, corticosteroids are usually given for short periods of time to treat flare-ups. Their many potentially serious side effects make them unsuitable for long-term treatment.

Immunomodulators:

Immunomodulators are also prescribed in IBD treatment. They suppress the immune system but, unlike corticosteroids, they are slow to work. Immunomodulators have few side effects and can be taken over the long-term, or in combination with corticosteroids.

~Biologic therapies ~

Changing the way IBD has traditionally been treated, TNF inhibitors – known as biologics – are used to treat both Crohn's disease and ulcerative colitis. Biologics are proteins that block inflammation-causing substances in the body. They are designed to specifically target the immune system molecules involved in the disease process, even in the case of diseases where the cause is unknown.

~Other treatments ~

Remission is the goal of IBD treatment. Once this state has been achieved, a switch to drugs with fewer potential side effects is usually made.

Prebiotics and probiotics have been spotlighted as extremely promising treatment alternatives for IBD. Some research illustrates that they are as effective as prescription drugs.¹⁸

Medication for diarrhea and pain are sometimes recommended for IBD symptoms. Fluids and minerals may be necessary for diarrhea-related dehydration. Nutritional supplements are sometimes recommended for those with Crohn's disease because mal-absorption is a serious concern.

Dietary Changes

As a result of bowel disease, food sometimes travels too quickly through the intestine to be properly absorbed. And inflammation greatly reduces the body’s ability to absorb nutrients. The cell damage and scarring (fibrosis) that accompany IBD often result in mal-absorption.

Mal-absorption can cause,¹⁹

• Anemia (resulting from a lack of iron, folate, and/or vitamin B12)
• Fatigue (resulting from a lack of calories and nutrients)
• Greasy or pale stools
• Impaired growth and development in children
• Increased frequency of loose or watery stools
• Stools containing undigested food
• Weight loss
• Osteoporosis

Intestinal surgeries and some of the medications prescribed to treat IBD can result in decreased absorption and appetite loss, which in turn contributes to nutrient deficiencies. Making dietary changes can assist in IBD symptom management. As well, the efficacy of medications can be fostered through diet.

Vitamin and mineral supplements and/or occasional vitamin injections can ease mal-absorption deficiencies.

When IBD flare-ups occur, a bland, low fiber diet can ease abdominal cramping and diarrhea. Those with Crohn's disease tend to benefit the most from an ongoing, low fiber diet. However, this kind of diet may require folic acid and vitamin C supplementation to combat possible deficiencies resulting from reducing the consumption of vegetables and fruit. In addition, magnesium and calcium deficiency is sometimes a factor for Crohn's disease sufferers who experience greasy stools (steatorrhoea).

Vitamin and mineral supplements are recommended for most children with IBD to foster healthy growth and development.

Crohn's disease sufferers are sometimes lactase deficient (the enzyme that breaks down milk products) and, therefore, find low lactose diets helpful. Nutritionally balanced liquid diets are sometimes necessary for those with severe Crohn's disease.

To prevent dehydration, an increase in water intake is often recommended for IBD patients.

Click to read more about treating Crohn's disease and ulcerative colitis.

Surgery

While generally avoided for as long as possible, in severe cases – when the disease cannot be controlled with medication, or when complications arise – surgery may become necessary.

Options include,

• Bowel resection – involves the removal of part of the small or large intestine.
• Ostomy – the bowel is attached to an opening, a stoma, in the lower abdomen; feces are no longer passed through the rectum and anus, but through the stoma and into an external pouching system known as an ostomy bag. The pouch is worn on the outside of the body to collect waste.
• Colostomy (temporary or permanent) – is an ostomy connecting part of the colon to the front of the abdominal wall, leaving a stoma for waste on the outside surface of abdomen.
• Ileostomy (temporary or permanent) – is an ostomy bringing the end of the small intestine (the ileium) out onto the surface of the skin to construct a stoma.
• Strictureplasty – the shortening and widening of narrowed bowel segments that have developed as a result of built up scar tissue in the intestinal wall.

Click to read more about surgery for Crohn's disease and ulcerative colitis.

IBD Prognosis

While the long-term consequences of IBD cannot be speculated upon with any degree certainty, the way the disease manifests itself the year after diagnosis can be a predicator of how it will progress. For example, the absence of symptoms for a year or more following diagnosis is a good sign, but more than two attacks can predict a more problematic disease path.²⁰

Additional risks are mainly a result of severe colitis in the year following diagnosis; age of onset above fifty years of age or under twenty years of age; and the development of colorectal cancer.²¹

On the one hand, there is an increased risk of colorectal cancer; on the other hand, cancer is often caught earlier than it would normally be as a result of routine colon surveillance, making survival more likely.

The diarrhea, pain, and vomiting associated IBD can limit quality of life. However, fatalities are rare, and with proper symptom management it is possible to lead a full and active life.

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Notes:
1. Centers for Disease Control and Prevention (CDC), “Inflammatory Bowel Disease (IBD),” http://www.cdc.gov/nccdphp/dach/ibd.htm (accessed August 24, 2009).
2. Ibid.
3. Ibid.
4. Ibid.
5. The Merck Manuals Online Medical Library, “Inflammatory Bowel Disease (IBD),” http://www.merck.com/mmpe/sec02/ch018/ch018a.html (accessed August 24, 2009).
6. Ibid.
7. Centers for Disease Control and Prevention (CDC), “Inflammatory Bowel Disease (IBD),” http://www.cdc.gov/nccdphp/dach/ibd.htm (accessed August 24, 2009).
8. Ibid.
9. The State of Victoria, Australia, Reproduced from the Better Health Channel, “Fact Sheet: Crohn's and colitis - dietary considerations,” http://210.247.186.34/bhcv2/bhcpdf.nsf/ByPDF/Crohn's_and_colitis_dietary_considerations/$File/Crohn's_and_colitis_dietary_considerations.pdf (accessed August 24, 2009).
10. Mayo Clinic, “Inflammatory Bowel Disease: Overview,” http://www.mayoclinic.org/ibd/diagnosis.html (accessed August 23, 2009).
11. Ibid.
12. Ibid.
13. Ibid.
14. Ibid.
15. Ibid.
16. Ibid.
17. Ibid.
18. E. Furrie, et al, “Synbiotic therapy (Bifidobacterium longum/Synergy 1) initiates resolution of inflammation in patients with active ulcerative colitis: a randomised controlled pilot trial,” Gut 2005; 54:242-249; Copyright©2005 BMJ Publishing Group Ltd & British Society of Gastroenterology, http://gut.bmj.com/cgi/content/abstract/54/2/242 (accessed August 24, 2009).
19. The Department of Gastroenterology at Addenbrooke’s Hospital, “The Not So Rough Guide to IBD,” http://www.ibdclub.org.uk/documents/leaflets/leaflet17_(diagnosis_to_prognosis).pdf (accessed August 24, 2009).
20. Ibid.
21. Ibid.