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INFLAMMATORY BOWEL DISEASE (IBD)
ULCERATIVE COLITIS AND CROHN’S DISEASE
INTRODUCTION
Inflammation can occur anywhere in the body. On the skin, it can cause
redness or a sore, in the joints it leads to arthritis. In the digestive tract,
inflammation can be an acute process, such as from an intestinal
infection/flu or even a stomach ulcer caused by aspirin. Chronic intestinal
inflammation is usually due to Crohn’s Disease or Ulcerative Colitis (UC),
the two major Inflammatory Bowel Diseases (IBD).
Crohn’s Disease is an inflammatory process within the gastrointestinal tract
that can occur anywhere from the mouth to the anus, but more typically
affects sections of the large intestine (colon) and/or lower portions of the
small intestine (ileum). The inflammation forms ulcers or sores that involve
the entire thickness of the affected intestine. It can be patchy in its
distribution, leaving normal areas in between inflamed ones.
In Ulcerative Colitis (UC), inflammation develops in the inner more
superficial lining of only the colon (the colon is the same thing as the large
intestine). Ulcerative colitis always involves the lower portions of the colon
(the rectum) and from there can spread to involve other higher segments
of the colon in a continuous fashion. If the rectum is the only area that is
inflamed, the condition is referred to as ulcerative proctitis.
HOW COMMON IS IBD?
It is estimated that there are nearly 1,500,000 Americans with either
ulcerative colitis or Crohn’s disease, roughly half of that number for each
disease. These diseases are often diagnosed before age 30, although they
can occur at any age. There is a greater incidence in Caucasians and in Jews.
WHAT IS THE CAUSE OF IBD?
The ultimate cause of IBD is unknown, but there seem to be several factors
that play a role.
1. Genetics: Up to 25% of patients with IBD have family members who
also have been diagnosed with inflammatory bowel disease. The
pattern of inheritance is indirect; rather than a parent, there may be
a cousin, aunt, or uncle who have been diagnosed. There are many
genes that have been shown to be assiciated with IBD, highlighting
exciting ongoing genetic research. The overall risk for a child of a
patient with IBD developing the disease is approximately 2-6%.
2. Altered Immune Function: There are a number of abnormalities in
the immune system that have been identified in the inflammatory
process. There is extensive ongoing worldwide research in this area
which has led to effective new medications targeted at the altered
areas of the immune pathways.
3. Infection/Environment: A specific bacterial or viral infection or
environmental exposure is probably not the specific cause of IBD but
may act as a triggering event to initiate the inflammation or a
propagating factor stimulating ongoing inflammation. Possible
offending agents could include infecting organisms or some of the
myriad of bacteria that normall inhabit the GI tract.
4. Stress, anxiety, and diet are often quieried by patients with IBD but
these factors do not cause IBD but may play an indirect role in
accentuating flares of the disease.
Putting this all together, in a genetically susceptible person, a triggering
event (infection or other) stimulates the body's immune system to
inappropriately cause inflammation in the digestive tract. Bacteria and
possibly food in the gut probably also have a role in continued
inflammation. The inflammation causes damage to the intestines which
responsible for the symptoms of the disease.
SYMPTOMS OF IBD
Crohn’s Disease. The location of inflammation, the amount of intestine
affected, and other complications such as scarring or narrowing of the
bowel (strictures) and the presence of abnormal communication between
two areas (fistula) determine the type of problems that a patient will
experience. Active inflammation usually causes diarrhea, abdominal pain,
bloody stools, low-grade fever, and weight loss. Areas of scarring or
narrowing (stricture) usually lead to abdominal pain often with bloating,
distention and sometimes nausea, vomiting and weight loss. Abdominal
pain in patients with Crohn’s Disease can occur anywhere in the abdomen,
but is commonly located around the belly button or the right lower
abdomen. A fistula occurs when inflammation in a loop of bowel erodes
into whatever is positioned next to it - creating a hole or a tunnel between
these two structures. A fistula can occur between two loops of bowel or
between the bowel and the bladder, the vagina, or the skin. Fistulas around
the anal area are fairly common. These fistulas can lead to infection,
bleeding, pain, and drainage.
Ulcerative Colitis. The type and degree of symptoms depend on the
amount of colon that is inflamed and the severity of the inflammation.
Most patients experience bleeding with bowel movements. Bloody
diarrhea is seen if the inflammation involves more that just the lower few
inches of the colon/rectum. Passage of the bowel movements may be
painful and often associated with a sensation of incomplete evacuation of
feces. A sense of urgency to defecate is common. Constipation can be a
symptom if just the rectum is involved (proctitis). In these patients,
constipation with straining and blood on the stools mimics hemorrhoidal
bleeding. Loss of appetite, weight loss and low-grade fever often indicate
active inflammation.
Manifestations Outside the Digestive Tract. Symptoms due to the
underlying inflammatory disorder can include weight loss, fever, and loss of
appetite. In children, poor weight gain or a delayed growth pattern may be
the initial manifestation of IBD. Effects of IBD outside of the gastrointestinal
tract can occur causing certain skin rashes (pyoderma gangrenosum and
erythema nodosum) and pink eye (conjunctivitis, uveitis), joint aches, back
pain, arthritis, and certain liver conditions (sclerosing cholangitis). Anemia
is common due to bleeding, malabsorption, and dietary factors. Patients
with IBD are at risk for osteoporosis due to the affect of inflammation and
of steroids on the bones.
TESTING FOR IBD
To evaluate the lower intestine, colonoscopy is usually the test of choice
Colonoscopy allows for comfortable direct inspection of the colon and the
last portion of the small intestine (terminal ileum) using a fiberoptic scope
in a sedated patient. Crohn’s Disease appears as redness, bleeding, ulcers
or sores in a spotty distribution. Ulcerative colitis appears as confluent
redness and bleeding. An x-ray examination of the small bowel (small
bowel follow through or enteroclysis) evaluates the small intestine for
active Crohn’s Disease or stricture (narrowing) or fistula. This is performed
by drinking barium while taking abdominal x-rays as the barium flows down
the intestinal tract. A CT Scan is an x-ray technique allowing for crosssectional imaging of the abdominal structures. This can help to identify
areas of bowel wall thickening/inflammation and also look for pockets of
infection (abscess). MRI uses magnetic forces to image the body and does
not involve radiation. Both CT and MRI can evaluate the small bowel (CTenterography and MR- enterography). Endoscopic ultrasound utilizes an
ultrasound probe placed under endoscopic control to carefully evaluate the
area around the rectum for infection and inflammation, especially in
Crohn’s disease. Blood work can evaluate for anemia (low blood count)
and evaluate the liver and other parameters. Blood levels of inflammatory
markers including the white blood cell count, C-reactive protein (CRP), and
erythrocyte sedimentation rate (ESR or sed rate) can signify inflammation
or infection. Blood testing for certain IBD-related markers can sometimes
support a diagnosis in some patients.
COURSE OF IBD
Crohn’s and ulcerative colitis often follow a pattern of flares (when the
condition worsens) and remissions (when it improves). The pattern can be
quite variable, ranging from rapid and continued remission to recurrent
periods of symptoms to disabling symptoms. The goal of medical therapy is
to drive active disease into remission and then maintain remission.
MEDICATIONS TO TREAT IBD
Many different drugs are used to treat IBD. The choice of medications
depends upon the severity of disease and the area of the digestive tract
affected.
Symptomatic treatment – In addition to using medications aimed at
reducing inflammation (see below), treatments to address certain
symptoms can also be beneficial. These include anti-diarrheals (immodium,
lomotil), antispasmodics (hyoscyamine, dicyclomine), anti-nausea (zofran,
phenergan), and nutritional supplements.
Sulfasalazine (Azulfidine) - Sulfasalazine was one of the first drugs used to
treat IBD and developed when the theory was to combine an antiinflammatory with an antibiotic. This medication contains the bowel antiinflammatory 5-ASA (see below) and sulfapyridine (which basically serves to
carry the 5-ASA down into the lower gut) and has been used sucessfully for
decades. The sulfapyridine component can cause side effects in some
patients.
5-aminosalicylates (5-ASA or mesalamine) - 5-aminosalicylate (5-ASA)
drugs are available in oral forms (such as Asacol, Pentasa, Lialda, Apriso,
Colazol) and medicated enemas (Rowasa) and suppositories (Canasa). In
ulcerative colitis, these drugs are helpful in achieving and then maintaining
remission. They seem to be less potent in Crohn’s disease.
Antibiotics - Antibiotics can reduce the number of bacteria in the intestine,
and in some patients reduce inflammation. They are primarily used to treat
infections associated with Crohn’s disease (abscess) and treating Crohn’s
disease involving the perianal region. Ciprofloxacin (cipro) and flagyl
(metronidazole) are commonly used.
Probiotics – There are normally tremendous quantities of bacteria that are
peacefully and healthfully cohabitating in our colon. There can develop an
inbalance of “good and bad” bacteria causing symptoms and inflammation.
Probiotics are potentially “good” bacteria given orally to restore the
bacterial balance in a more favorable distribution. Extensive ongoing
research may help find “the best” probiotic. There are a wide variety of
commercially available probiotics most of which have not yet been tested
in IBD. Probiotics can be used and can be beneficial in some patients.
Steroids - Steroids can induce remission in patients in active ulcerative
colitis and Crohn's disease. They can be given intravenously or orally
(prednisone) or as a medicated suppository or enema. Budesonide
(Entocort) provides a beneficial steroid effect on mainly the small bowel
and is then absorbed and then most of it broken down in the liver, leaving
little to get into the blood stream. Steroids do not prolong remission and
there are many potential side effects of long-term steroid use.
Immunomodulatory agents - Immunomodulatory drugs decrease the
inflammation associated with IBD by addressing an imbalance of different
types of immune cells. The most commonly used drugs include
azathioprine, 6-mercaptopurine (6-MP or purinithol), and methotrexate.
These drugs are used for long-term control of IBD and can take 1-3 or more
months to see a therapeutic response.
Biologic Drugs
Anti –TNF (tumor necrosis factor) agents are antibody molecules that
neutralize the inflammatory mediator TNF. There are currently three antiTNF medications available. Infliximab (Remicade) was the first developed
and is given by IV infusion. It is composed of a combined mouse and human
antibody and is given by IV infusion usually every 2 months after an initial
induction period. Adalimumab (Humira) is composed of a fully humanized
antibody molecule and is given by injection usually every 2 weeks.
Certolizumab pegol (Cimzia) hooks the active portion of a human anti-TNF
antibody to a molecule (PEG) that can allow less frequent injections, every
2-4 weeks.
Natalizumab (Tysabri) is used for Crohn’s disease and blocks the egress of
white blood cells from blood vessels into the bowel, reducing inflammation.
CLINICAL TRIALS
With the cause and the cure for IBD unknown, there are extensive research
efforts underway. We have been active in IBD research for decades and
have participated in clinical trials through the spectrum of IBD medications.
Our research company, Consultants for Clinical Research
(www.ccrstudy.com phone 513-872-4549) has several ongoing clinical
trials to advance the science of IBD and allow patients to participate in
research and receive medications that would otherwise not be available to
then.
DIETARY RECOMMENDATIONS
There have not been any specific foods or dietary factors shown to cause
or flare IBD. Generally, if a food causes symptoms in an individual, it can be
avoided. It is important to maintain good overall nutrition. If malnuorished,
there can exist reduced fuction of the metabolic machinery needed to heal
the IBD and restore health. In Crohn’s disease with strictures (narrowing of
the bowel) avoiding high residue and chunky foods (corn etc) is advised to
reduce the chance of food particles obstructing the bowel at the narrowed
area.
WHAT CAUSES IBD FLARES?
Factors may include stopping or reducing medications, smoking (makes
Crohn’s disease more refractory), use of antibiotics, use of NSAIDs
(ibuprofen, naproxen and others), and gut infections. Please see our
brochure “Staying Healthy with IBD” on our website at www.ohiogi.com
under Disease Management then under Symptoms and Solutions.
IBD SURGERY
Ulcerative Colitis- Surgery for UC involves removal of the entire colon. A
permanent ileostomy can be placed or a pouch reservior created from
small bowel can be formed and sewn to the anus (ileoanal pull through)
without a permanent ileostomy. Surgery for UC is considered when the
disease is refractory to medical therapy, for colon cancer or precancer
(dysplasia) developing in the setting of chronic UC, and rarely emergently
for toxic colitis. The patient is considered cured of UC, but postoperative
complications and long term effects of having no colon are concerns.
Crohn’s Disease – There is no cure (medical or surgical) for Crohn’s disease.
Therefor, surgery for Crohn’s disease is usually used only when considered
“necessary”. Indications for surgery can include obstruction of the bowel,
refractory disease, cancer, complications of Crohn’s such as fistuala or
abscess or perforation. Statastically, about 80 percent of patients with
Crohn's disease will require an operation at some time but newer more
potent medications now used may be reducing the rate of surgery and the
postoperative recurrence of Crohn’s (historically 90% with time).
CANCER RISK IN IBD
There is an increased incidence of colon cancer in patients with ulcerative
colitis and Crohn’s disease when it significantly affects the colon . The
factors increasing this risk are the length of time a person has had the
disease and the amount of colon involved. If only a limited amount of colon
is involved, the overall risk of colon cancer may be only slightly increased.
The longer a person has had IBD, the greater the risk. The disease is usually
present for greater than eight years before any increased risk is recognized.
To try to minimize the risk of colon cancer, a patient with chronic IBD will
undergo periodic colonoscopy to obtain biopsies. The biopsies are
evaluated for dysplasia (pre-cancerous changes) and cancer.
PSYCHOSOCIAL ISSUES
As with any chronic illness, IBD can affect ones’ activities, lifestyle,
emotions, relationships and more. Attention to the impact of IBD on the
psychosocial situation and vissa versa is an important part of
comprehensive care.
CROHN’S AND COLITIS FOUNDATION OF AMERICA (CCFA)
The CCFA is a national organization devoted to the interest of patients and
significant others with Ulcerative Colitis and Crohn’s Disease. In Cincinnati,
we have an active CCFA chapter that offers educational brochures,
seminars, support groups, and fund raising events that are planned with an
eye toward fun and sociability. The CCFA phone number is 513-772-3550.
The CCFA website is www.ccfa.org.
COLONOSCOPY PHOTO OF NORMAL COLON
COLONOSCOPY PHOTO OF CROHN’S DISEASE
COLONOSCOPY PHOTO OF ULCERATIVE COLITIS