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Inflammatory Bowel Disease:
Medical And Surgical
Treatment
JASSIN M. JOURIA, MD
DR. JASSIN M. JOURIA IS A MEDICAL DOCTOR, PROFESSOR
OF ACADEMIC MEDICINE, AND MEDICAL AUTHOR. HE
GRADUATED FROM ROSS UNIVERSITY SCHOOL OF
MEDICINE AND HAS COMPLETED HIS CLINICAL CLERKSHIP
TRAINING
IN
VARIOUS
TEACHING
HOSPITALS
THROUGHOUT NEW YORK, INCLUDING KING’S COUNTY
HOSPITAL CENTER AND BROOKDALE MEDICAL CENTER,
AMONG OTHERS. DR. JOURIA HAS PASSED ALL USMLE
MEDICAL BOARD EXAMS, AND HAS SERVED AS A TEST PREP TUTOR AND INSTRUCTOR FOR KAPLAN.
HE HAS DEVELOPED SEVERAL MEDICAL COURSES AND CURRICULA FOR A VARIETY OF EDUCATIONAL
INSTITUTIONS. DR. JOURIA HAS ALSO SERVED ON MULTIPLE LEVELS IN THE ACADEMIC FIELD
INCLUDING FACULTY MEMBER AND DEPARTMENT CHAIR. DR. JOURIA CONTINUES TO SERVES AS A
SUBJECT MATTER EXPERT FOR SEVERAL CONTINUING EDUCATION ORGANIZATIONS COVERING
MULTIPLE BASIC MEDICAL SCIENCES. HE HAS ALSO DEVELOPED SEVERAL CONTINUING MEDICAL
EDUCATION COURSES COVERING VARIOUS TOPICS IN CLINICAL MEDICINE. RECENTLY, DR. JOURIA
HAS BEEN CONTRACTED BY THE UNIVERSITY OF MIAMI/JACKSON MEMORIAL HOSPITAL’S
DEPARTMENT OF SURGERY TO DEVELOP AN E-MODULE TRAINING SERIES FOR TRAUMA PATIENT
MANAGEMENT. DR. JOURIA IS CURRENTLY AUTHORING AN ACADEMIC TEXTBOOK ON HUMAN
ANATOMY & PHYSIOLOGY.
Abstract
Although there is no singular known cause for inflammatory bowel disease,
medical research is providing new treatments and reducing mortality rates
associated with the disease at a rapid pace. Inflammatory bowel disease is
the name given to a variety of gastrointestinal disorders that cause similar
symptoms and impact a patient's quality of life. There is no cure, but
symptomatic relief can be found with a variety of treatments, including
medical, surgical, and nutritional. As with many diseases, a multi-faceted
approach is commonly the best approach for successful treatment of
inflammatory bowel disease.
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Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 4 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Pharmacy content is 1 hour.
Statement of Learning Need
Health clinicians need to be able to differentiate between Ulcerative Colitis
and Crohn's Disease, as well as be able to describe the clinical
manifestations and potential effects of each on the gastrointestinal tract.
Understanding the common causes and symptoms of inflammatory bowel
disease, including the role that genetics may play and complications of the
disease is essential for a clear understanding of the four types of medical
and surgical techniques commonly used during treatment. Clinicians
supporting nutritional therapies and other health or group support resources
for patients and family members can be used during the treatment of
inflammatory bowel disease.
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Course Purpose
To provide health clinicians with knowledge of the potential causes of
inflammatory bowel disease to improve the chances that this illness can be
successfully treated or prevented.
Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1.
The current, primary goal of medical therapies for treatment of
inflammatory bowel disease is
a.
b.
c.
d.
2.
to cure the disease without surgery.
to maintain remission of symptoms for as long as possible.
educating patient’s on how to live with their symptoms.
finding herbal, non-pharmaceutical drugs to treat symptoms.
True or False: Olsalazine is more commonly used for ulcerative
colitis, even though diarrhea may be a cause side effect of the
drug.
a. True
b. False
3.
Patients who take __________________ for treatment of
inflammatory bowel disease should also take a folic acid
supplement.
a.
b.
c.
d.
4.
Which of the following medications has been found to be
effective in treating inflammation associated with Crohn’s
disease?
a.
b.
c.
d.
5.
mesalamine
sulfasalazine
balsalazide
olsalazine
Balsalazide
Mesalamine
Olsalazine
Sulfasalazine
Oral medications are beneficial because once a patient with IBD
receives a prescription drug for oral administration
a.
b.
c.
d.
the
the
the
the
patient takes the drug without further instruction.
drug is easy for providers to monitor daily.
drug is easy for the patient to administer.
patient may take the drug only when symptomatic.
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Introduction
Inflammatory bowel disease cannot be cured completely through treatment.
There are various medical therapies available that can help with control of
symptoms and can reduce inflammation in the intestinal tract. Patients with
Crohn’s disease or ulcerative colitis often need more than one type of
medication and usually, the response to these drugs is beneficial in relieving
many of the discomforts of the disease. Medical therapies may be
administered as oral agents, through subcutaneous or intramuscular
injection, as rectal preparations or intravenously when necessary. The type
and route of administration varies with the kind of drug and the severity of
patient symptoms. When medical therapies are unsuccessful, the severity of
the disease has increased, or a patient has developed complications of IBD,
surgical intervention may be necessary to remove portions of the diseased
intestinal tract and to eliminate many of the problems that can occur. One of
the main goals of treatment for IBD is to help patients achieve this state of
remission and to maintain it for long periods to improve quality of life and to
prevent symptoms from returning.
Medical Therapies For Inflammatory Bowel Disease
The main purposes of using medical
therapies to treat IBD are to help
patients achieve states of remission in
which they are less likely to suffer from
negative symptoms and flares. Because
inflammatory bowel diseases are not
cured through medical therapies, goals
often consist of trying to maintain
periods of remission for as long as
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possible. Even when a patient has achieved a state of remission, he/she
often needs to continue seeing a health clinician for disease monitoring.
During remission, a patient may visit the clinician every few months for a
check up and to review medical therapies and ensure that they are working
properly. During times of disease flares, the affected patient often needs to
see a clinician much more often and may need to make prescription changes
to find the correct type and dose of medication to effectively treat
symptoms; medical treatments for IBD are reviewed here.1,15,16,19-25,30-36,73-84
For some people, medications provide freedom from symptoms and help to
induce remission. Additionally, there are many people with IBD who are
prescribed medication regimens that are successful but they do need to
continue taking their medications as prescribed in order to maintain a state
of remission. Sometimes, a disease flare can be triggered when an individual
stops taking medication or is not taking medication as prescribed. This may
occur because of a number of factors related to a patient’s specific situation.
For example, a patient may become so busy that he/she forgets to take a
medication dose for several consecutive days and, combined with increased
lifestyle stress, develops symptoms associated with a disease flare.
Medical therapies are successful enough for some people at maintaining
remission that they stop taking their medication over time because they
believe that the problem has been remedied and they do not understand
that stopping therapy will often cause symptom recurrence. The importance
of maintaining the prescribed regimen of medical therapy, including with
taking medications as prescribed and discussing medication changes first
with a health clinician, should be included as part of patient education to
prevent disease flares and to maintain remission as long as possible.
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Oral Medication
There are many different types of drugs available for management of IBD.
The difference in how they are delivered and the routes of administration
vary but administration is typically related to the formulation of the drugs,
how they are best absorbed and maintained. Another consideration is the
severity of a patient’s symptoms, which can indicate the type of drug
prescribed, and how well a patient responds to a medication. Oral
medications are beneficial in that once they are obtained through a
prescription, they are administered easily. A patient taking oral medications
often takes them independently while at home. A patient may need
instruction regarding the appropriate ways to take these drugs; for instance,
some oral preparations are better tolerated when taken with food. Some
patients may also need reminders if they must take their doses of these
drugs multiple times per day. Anyone who is given a prescription for oral
medications to use for IBD treatment should be educated about the side
effects of the drugs and the signs or symptoms that indicate they need to
call to a health clinician.
Aminosalicylates
One of the most commonly prescribed drugs for management of IBD is
aminosalicylates, which are sometimes known as 5-ASA. The primary mode
of action of 5-ASA is the control of inflammation, which is why they are often
prescribed for cases of inflammatory bowel disease, including during times
when extra-intestinal symptoms of inflammation are present, such as when
IBD causes symptoms of arthritis. Sulfasalazine is often the main drug
prescribed, which is a combination of aminosalicylate and sulfa antibiotics.
Aminosalicylate drugs, such as mesalamine, balsalazide, or olsalazine may
also be prescribed for some patients who do not tolerate sulfasalazine. These
drugs are more commonly used for treatment of ulcerative colitis and are
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less commonly used in Crohn’s disease; however, sulfasalazine has been
shown to be effective in treating inflammation associated with Crohn’s
disease.
Olsalazine is given orally in divided doses of up to 1 g per day, depending on
symptoms. It is more commonly used for ulcerative colitis, even though it
may cause side effects of diarrhea. Balsalazide, when given as an oral
capsule, is administered as 2.25 g daily in adults for up to 12 weeks.
Balsalazide may also be given in smaller doses when ulcerative colitis
develops in children and adolescents. Some mesalamine preparations are
coated so that they will be available as extended release. This delays the
absorption of the drug in the small intestine until it has a chance to reach
some of the distal areas of the small bowel. All of these medications are
considered to have almost the same effectiveness as sulfasalazine but they
are associated with fewer side effects.
Aminosalicylates or 5-ASA work to control inflammation in the intestinal tract
by inhibiting prostaglandins, which are lipid compounds that can affect the
inflammatory process, and leukotrienes, which are types of inflammatory
mediators; this action thereby inhibits part of the inflammatory cascade. 5ASA works very quickly and is absorbed rapidly in the lumen of the small
intestine. While it is usually given as an oral preparation, it must be
formulated as an extended release product to delay its absorption slightly
following intake.
Sulfasalazine was one of the earliest forms of aminosalicylate drugs; its
combination with sulfapyridine can help to fend off infection in the gut, if
present. When sulfasalazine is administered, the gut microbiota split the
aminosalicylic acid from the sulfapyridine. While it is frequently prescribed,
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there are many who do not tolerate sulfasalazine well because it is a sulfa
medication. For some, allergies to sulfa drugs prevent them from using this
medicine as a viable option for treatment of IBD. For others, the side effects
of sulfapyridine are strong enough that drug discontinuation and starting
again with another type of aminosalicylate that does not contain sulfa is
preferable. Some common side effects that have been seen specifically with
sulfasalazine include nausea, dyspepsia, and headache, as well as impaired
folate absorption and low sperm counts in men. Most people who begin
taking sulfasalazine must start at a lower dose and gradually increase the
amount until it reaches the therapeutic level.
Sulfasalazine is best tolerated when it is given with food. The American
College of Gastroenterology (ACG) recommends a dose of up to 4 to 6 g
initially for the management of ulcerative colitis. To improve tolerance, it
may be started at a low dose and gradually increased. Maintenance doses
for ulcerative colitis are 2 g sulfasalazine daily, given in divided doses as
long as the drug is tolerated. For treatment of Crohn’s disease, the
recommended dose of sulfasalazine ranges from 3 to 6 g daily, given orally
as tolerated. Sulfasalazine is associated with folate depletion, and can
potentially cause folate-deficiency anemia with regular use. Therefore,
patients who take sulfasalazine for treatment of IBD should also take a folic
acid supplement.
Other formulations of aminosalicylates that may be used instead of
sulfasalazine are available as extended-release forms when administered
orally. The delayed release factor allows the drug to move through the
gastrointestinal tract without being broken down and absorbed too quickly
so that it can reach the distal ileum. With an extended or delayed release
formulation drug, a patient may not need to take the drug as often, and
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these drugs may only be administered once or twice a day. Some side
effects that have been seen with aminosalicylate drugs include excess
diarrhea, gas, nausea, abdominal pain and cramping, and dizziness and
headache. Most of these side effects are contained with lower doses of the
drug, and serious side effects are rare.
Corticosteroids
Oral corticosteroids are designed to reduce inflammation and control pain
associated with various forms of inflammatory bowel disease. Corticosteroids
have been shown to be beneficial during severe flares and for short-term
use, but long-term use of these types of drugs may have more limited
effectiveness. As a result, corticosteroids are never prescribed as
maintenance medications for IBD; other drugs should be prescribed for longterm or chronic use with use of corticosteroids relegated to acute disease
exacerbation. When used for acute flare up of symptoms, corticosteroids can
reduce inflammation and swelling, but they are often considered to be more
effective when combined with other drugs, such as immunosuppressive
agents.
Long-term use of corticosteroids also puts patients at risk of severe
complications, including osteoporosis and blood glucose abnormalities. Many
of these abnormalities, particularly reduction in bone mineral density, are
seen relatively quickly after starting corticosteroid therapy, often within the
first six months of use. Other adverse events that have been noted with
frequent corticosteroid use include an increased risk of infection.
Corticosteroid use may also cause overall growth retardation, particularly
when the drugs are used in pediatric patients. Use of the drug may lead to
hypertension, poor wound healing, and frequent relapses once the
medication has worn off. The drugs also must be tapered off when
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discontinuing, rather than stopping them abruptly. Additionally, use of these
types of drugs typically requires nutrient supplements, including those of
vitamin D and calcium, which are often depleted with corticosteroid
administration. The side effects associated with corticosteroids must be
considered when contemplating these types of drugs for management of
inflammatory bowel disease.
Prednisone is an oral preparation of corticosteroid that may be administered
with IBD symptom exacerbation. Another similar formulation is prednisolone,
which is also available orally. These drugs may be taken by a patient at
home and are prescribed for use for a specified period; they may be used
with mild to moderate symptoms of IBD. Patients must be instructed
carefully on use of corticosteroids to ensure that the prescribed dose is taken
at the suggested times and is not stopped suddenly. The full treatment of
the drug is given over a period of 1 to 4 weeks, depending on a patient’s
condition, the existing symptoms, the severity of the disease, and whether a
patient has had these drugs in the recent past.
After a patient has taken the full dose for the prescribed period, the patient
must taper the dose by taking a lower dose each day over a period of
several weeks until the drug can be discontinued. Even when a patient has
tapered the dose of the drug to the point of being ready to discontinue its
use, the patient should continue to use another type of medication, such as
5-ASA, to help manage symptoms once corticosteroids are no longer being
taken. This process, in addition to avoiding some severe side effects that can
occur with abrupt discontinuation of corticosteroids, can also prevent some
patients from becoming dependent on these drugs. Patients should be
educated about the common side effects of corticosteroid drugs when using
them outside of the healthcare environment. They should also be taught
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about what signs or symptoms to look for that would warrant an immediate
call to a health clinician, such as sudden episodes of psychosis or
hyperactivity, problems with sleeping and insomnia, and hyperglycemia.
Budesonide is another type of corticosteroid that may be used for some
people with IBD. It is administered orally and is said to have high first-pass
liver metabolism, meaning that its concentration is greatly reduced first by
the liver before it reaches systemic circulation. Because of this rapid
metabolism, it may have fewer side effects when compared to other types of
corticosteroids. When compared to prednisolone, budesonide has fewer side
effects, but its effects are also not as rapid as prednisolone. Because of
these results, budesonide is often reserved for treatment of mild to
moderate forms of IBD. Budesonide is administered as a short-term drug
and is given once per day during active disease. Orally, it is approved for
use to treat Crohn’s disease of the small intestine or as an enteric-coated
preparation to manage ulcerative colitis in the large intestine.
Immunomodulator Drugs
Immunomodulator drugs are those that are administered to weaken some of
the effects of the immune system. When the immune system is altered
through these drug preparations, the inflammatory response is weakened,
leading to less inflammation that typically develops with IBD. Because
symptoms of IBD may develop in relation to excessive inflammation caused
by overactivity of the immune system, immunomodulators work to control
this response. They may also be administered in conjunction with
corticosteroids during times when steroid use is high and a patient needs to
taper a dose.
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Immunomodulators are an option for treatment for patients with IBD who do
not normally respond to 5-ASA or for those who have experienced severe
side effects of other drugs. They can be quite powerful in their activity and
have been shown to help minimize inflammation in the gastrointestinal tract
that often causes debilitating symptoms of inflammatory bowel disease.
When given for IBD, immunomodulators are helpful in suppressing
inflammation; they may also be administered when a person exhibits extraintestinal symptoms of IBD, including arthritis symptoms, as they control the
inflammation associated with many autoimmune conditions as well. A
disadvantage of regular use of these types of drugs is their potential to
suppress the immune system to the point that persons taking the drug are
at risk of infection with opportunistic diseases. There is an increased risk of
developing certain types of cancer with these drugs as well, including
lymphoma, and non-melanoma skin cancer. The most commonly
administered drugs in this class, when used for treatment of IBD, are 6mercaptopurine, azathioprine, and methotrexate.
Azathioprine, one of the most commonly prescribed immunomodulators for
inflammatory bowel disease, is often prescribed for inflammation associated
with severe rheumatoid arthritis, as well as several other autoimmune
diseases, including lupus and vasculitis. The drug works by suppressing
inflammation that develops because of an autoimmune response in the
body. Azathioprine is classified as a disease-modifying anti-rheumatic drug
(DMARD); it is composed of two main compounds, 6-mercaptopurine and 6thioinosinic acid, which is considered the active components of the drug.
These metabolites of azathioprine work by inhibiting T-cell function during
the inflammatory response.
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The doses of azathioprine differ among patients, depending on the extent of
the inflammatory bowel disease, the severity of symptoms, and whether
extra-intestinal symptoms are also present. A typical dose of azathioprine is
2.5 to 3 mg/kg orally per day. 6-mercaptopurine, a derivative of
azathioprine, may also be given. Dosage of 6-mercaptopurine for
management of inflammatory bowel disease is approximately 1 to 1.5 mg/kg
per day, given orally. Because 6-mercaptopurine is a derivative of
azathioprine, 6-mercaptopurine and azathioprine have similar rates of
effectiveness and are structurally similar. They also tend to produce
comparable side effects, including headache, nausea, and vomiting, as well
as canker sores in the mouth, fever, joint pain, bone marrow suppression,
and liver inflammation. Patients who take these drugs should have routine
laboratory testing to monitor liver function tests and white blood cell counts.
Azathioprine and 6-mercaptopurine have been shown to be beneficial in
helping patients who take concomitant steroids to wean off of the
corticosteroids. They may be administered at the same time as the steroid
preparations and given simultaneously for a period – approximately a
month, depending on the amount prescribed — while the corticosteroids are
tapered off. Another benefit of these types of immunomodulators is that,
while they do take approximately 3 to 6 months to achieve their full effects,
they can be used for long periods and are ideal for prescription management
of chronic inflammatory bowel disease.
Some studies have shown that certain immunomodulators, including
azathioprine combined with TNF- blockers are just as successful as use of
corticosteroids in reducing the need for surgical intervention. A study by The
Canadian Society of Intestinal Research compared patients in Denmark who
received treatment for IBD between 1979 and 2011 and found that an
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increased use of combination azathioprine and TNF- blockers was
consistent with a decrease in the use of 5-ASA and local corticosteroids, as
well as a parallel decrease in the need for surgical intervention, particularly
among patients with Crohn’s disease. Some of the long-term effects of
immunomodulator drugs still remain to be seen, but historically they have
been beneficial for many patients with inflammatory bowel disease:
immunomodulator drugs are viable treatment options and to avoid the need
for multiple treatment modality requirements for IBD symptoms.
Methotrexate is another type of immunomodulator, which has historically
been used for the treatment of rheumatoid arthritis and lupus. It is also used
as an anti-cancer agent in that it prevents the formation of specific elements
of DNA within tumors to counteract their growth. The drug inhibits a specific
enzyme that transforms folic acid from an inactive to an active form, which
is necessary for DNA and cell replication. Its use in the control of
inflammation is more complicated, and several studies have suggested
different mechanisms of action for how the medication suppresses the
inflammatory response. Methotrexate works faster than some other
immunomodulators, including azathioprine and 6-mercaptopurine, making it
a better choice of drug in some cases.
Methotrexate may be administered orally or as subcutaneous injection, at
doses of 15 to 25 mg. Some clinicians are reluctant to use methotrexate as
a first choice for management of IBD, even though positive effects have
been shown in controlling this particular form of inflammation. Their
hesitancy could be related to the fact that its exact mechanisms of action in
suppressing inflammation are unknown, or they may choose to try therapy
with other medications first. Methotrexate has been shown to be beneficial in
managing symptoms of Crohn’s disease that is otherwise unresponsive to
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azathioprine or 6-mercaptopurine. It may also be used successfully to treat
IBD in cases where a patient is unresponsive to corticosteroid therapy or in
someone who is dependent on corticosteroids to suppress inflammation and
who needs to wean off of the drugs.
Use of methotrexate has been associated with some severe side effects, and
continued use requires frequent monitoring of laboratory values to assess for
changes. The patient taking methotrexate should have a routine complete
blood count to assess for changes in white blood cell levels, as a decreased
white blood cell count is associated with its use. Some of the other mild side
effects most commonly seen with methotrexate include nausea, vomiting,
and abnormal liver function tests. Patients who take methotrexate may need
to have routine liver function testing to ensure that the drug is not causing
further liver damage.
Methotrexate also has the potential to cause birth defects, so women who
may become pregnant must use a reliable form of birth control, and women
who are pregnant and who have IBD may not use methotrexate. Severe side
effects sometimes seen with methotrexate include nephrotoxicity and
myelosuppression, which is a decrease in bone marrow activity.
A disadvantage of the frequent use of immunomodulators is the increased
susceptibility to certain infections. Approximately 10 percent of patients who
use immunomodulators for treatment of IBD develop some form of infection,
associated with a decreased immune response. TNF- blockers may increase
the risk of some types of opportunistic infections, such as tuberculosis or
cytomegalovirus, and may increase the overall risk of sepsis. Some patients
with diabetes may also be at particular risk of infection when
immunomodulators are used for IBD.
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A study in the journal Alimentary Pharmacology and Therapeutics looked at
the risk of infection among patients using immunomodulator therapy and
who had co-existing diabetes. The study found that there was a nearly 2-fold
risk of increased infections among patients with IBD and diabetes who had
started immunomodulator therapy of azathioprine, 6-mercaptopurine, or
methotrexate within the previous 12 months of conducting the study.
Therefore, patients who have IBD and who also suffer from other extraintestinal symptoms or who have another chronic illness should be carefully
monitored while using immunosuppressive therapy to prevent additional
complications while treating inflammatory bowel disease.
There is further evidence of the increased risk of developing certain types of
cancer and lymphoproliferative disease, which describes a condition in which
a person has a significant increase in lymphocyte white blood cells and which
are often seen among those with immunosuppression. A review published in
the American Journal of Gastroenterology indicated that studies have shown
that patients taking immunomodulators azathioprine and 6-mercaptopurine
were at increased risk of lymphoproliferative malignancies; examples of such
types of cancer include lymphoma, multiple myeloma, and chronic
lymphocytic leukemia. The review also noted another study in which the risk
of a lymphoproliferative disorder was 5 times higher among those who were
given thiopurines (azathioprine and 6-mercaptopurine) for management of
IBD when compared to those who had never used these drugs. Specific
types of immunomodulators are not necessarily associated with particular
conditions, but these and many other studies indicate that their use must be
continued with caution to assess both short- and long-term effects of these
drugs.
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Biologic Therapies
Biologic therapies describe drugs that have developed from organisms and
that are prescribed for the treatment of certain diseases. As with
immunomodulator drugs, biologic therapies also work by suppressing the
inflammatory response of the immune system; they have been used
successfully for the treatment of some types of inflammatory bowel disease
and several specific kinds of biologic therapies have been approved for use
with indications given through the U.S. Food and Drug Administration (FDA).
Biologic therapies work by interfering with the body’s inflammatory response
by targeting certain immune factors that are involved with promoting
inflammation. Anti-tumor necrosis factor (TNF) drugs are classified as
biologic therapies that may be considered for some patients with IBD.
Remember that TNF is a type of cytokine excreted during the immune
response with the development of inflammation. Administration of biologic
drugs that inhibit tumor necrosis factor may further inhibit inflammation and
subsequent symptoms of IBD. There are various biologic agents that may be
administered as oral preparations for control of IBD symptoms, including
infliximab, certolizumab pegol, golimumab, and adalimumab. These drugs
are not usually administered orally and are given through injection or via
intravenous administration.
Biologic therapies work more rapidly when compared to some
immunomodulator drugs; their effects can be seen within days to weeks,
while it may take months for some people to achieve the full effectiveness of
immunomodulators. A downside of using these biologic therapies is that
when the immune system is suppressed and the body is unable to create
inflammation, the patient can be at risk of infection with other organisms.
The individual experiences immunosuppression and risk of illness because
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the body not only does not create inflammation related to IBD, but it also
does not respond to other potentially harmful antigens that could cause
other types of disease.
Antibiotics
Because inflammatory bowel disease is thought to develop in part due to
alterations in the gut microbiota, many patients with the disease benefit
from administration of antibiotics during times of disease flares. The changes
in gut microbiota often contribute to the increase in inflammation present
with IBD; consequently, antibiotics may eliminate excess harmful bacteria
and may resolve some inflammatory symptoms.
Research is ongoing about the effects of substances on the gut microbiota
and the ensuing effects on inflammation related to IBD. Prebiotics and
probiotics, found in many foods and available as supplements, have
continually been studied to determine their effects, if any, on improving
numbers of microorganisms in the gastrointestinal tract and ultimately
subduing levels of inflammation. Although research in these areas has not
found anything definite yet, the debate continues.
Alternatively, treatment with antibiotics has been shown to help some
people with IBD by altering levels of gut microbiota, treating active infection,
and managing some complications, including fissures. Antibiotics work by
decreasing concentrations of bacteria in the gastrointestinal tract. It should
be emphasized that antibiotics have been found to be more successful in
cases of Crohn’s disease, but less likely to be efficacious among those with
ulcerative colitis, except in cases of active infection or abscesses, or in cases
of sepsis or further disease complications. They can manage the overgrowth
of certain types of bacterial species that contribute to inflammation, such as
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E. coli or mycobacterium. According to Nitzan, et al., in the World Journal of
Gastroenterology, mycobacterial infection with the species Mycobacterium
avium has been thought to contribute to the development of Crohn’s
disease. Anti-tuberculosis drugs, such as isoniazid, may be given to control
levels of mycobacterium in the gut, thereby potentially reducing its
contribution to inflammation.
Antibiotics have also been shown to be useful in treating certain
complications of inflammatory bowel disease, and so may only be
administered when problems develop or during active periods of disease
symptoms. Fistulas that form when there is tunneling between the intestinal
tract and nearby organs can cause pain, inflammation, and infection, which
can be managed with antibiotics but may also require surgery. Fistulas can
occur anywhere along the gastrointestinal tract but they are most common
around the anal area. Abscesses are another complication that may be more
likely to develop with Crohn’s disease; these pockets of pus and infection
can be treated with antibiotics before they cause further damage to the
intestinal tract. Anal fissures can be particularly painful and are often red,
swollen, and inflamed, with the potential for infection, particularly with
continued exposure to fecal matter. Antibiotics may be administered to some
patients with IBD who have developed fissures to avoid infection in these
areas.
Antibiotics are also used in the treatment of pouchitis, which is inflammation
and infection that develops in the ileal pouch created during ostomy surgery.
Although antibiotics may or may not be used for management of other types
of IBD, either alone or in combination with other medications, they are a
mainstay of treatment of pouchitis. Pouchitis is thought to develop due to
various factors, most prominently because of an abnormal response of the
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immune system to intestinal bacteria. There may also be a shift in the
numbers of normal bacteria in the gut from those of the small intestine to
those of the colon, potentially leading to pouch infection due to differences in
commensal microorganisms. Pouchitis may be classified as acute or chronic
infection.
Alternatively, there are some negative consequences of antibiotic use.
Because of the increasing rate of antibiotic resistance, many patients cannot
take these drugs for prolonged periods and they may only be relegated to
times when severe symptoms are present. Continued and prolonged use of
antibiotics may decrease the susceptibility of infectious microorganisms to
these drugs and they may become ineffective over time. Some patients with
IBD are at increased risk of developing infection with C. difficile, which
causes severe diarrhea and abdominal pain. Prolonged use of antibiotics has
been connected with an increased risk of C. difficile infection. Further,
stopping antibiotics after a period of use may also increase the risk of a
rebound effect in which the symptoms that abated with antibiotic use return.
Finally, the side effects of some types of antibiotics can be severe enough
that many people with inflammatory bowel disease do not want to continue
taking them, despite their benefits. Some of the more common side effects
seen with antibiotics include nausea, vomiting, headache, photosensitivity,
and thrush infection.
Despite potential side effects and complications with antibiotic use, these
drugs remain a valid part of treatment when active disease symptoms
develop. Common antibiotics prescribed for IBD include ciprofloxacin,
metronidazole, rifaximin, and clarithromycin. Some of these drugs may be
administered concomitantly for greater effectiveness. Ciprofloxacin is a
quinolone broad-spectrum antibiotic that is prescribed to manage a number
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of different types of bacterial infections. It may also be prescribed for
treatment of disease-related flares in inflammatory bowel disease, as well as
when disease complications such as intestinal abscess have developed.
A study published in the journal Gut showed that combining ciprofloxacin
with adalimumab for treatment of perianal fistulas associated with Crohn’s
disease was more effective when compared to adalimumab monotherapy.
This research further supports the concept that combining antibiotic therapy
has greater benefits in disease management in many cases, rather than
attempting to control symptoms and complications with a single drug.
Studies indicating the effectiveness of ciprofloxacin for the specific treatment
of ulcerative colitis have shown mixed results.
Metronidazole may be more effective in treating inflammation that affects
the colon when compared to treatment of the small intestine. Metronidazole
used to be one of the most frequently prescribed drugs for management of
complications associated with inflammatory bowel disease, but it has been
largely replaced by ciprofloxacin. As with ciprofloxacin, studies showing
metronidazole to be effective in managing moderate-to-severe cases of
ulcerative colitis have been met with mixed results.
Rifamixin is a broad-spectrum antibiotic that has been shown to successfully
manage infections caused by both Gram-negative and Gram-positive
bacteria. In research studies, rifamixin has been shown to induce remission
in patients with active Crohn’s disease more quickly than placebo. An
effective dose of rifamixin is 800 mg, given orally over the course of 12
weeks. Similar to metronidazole, rifamixin is often more effective in treating
disease affecting the colon.
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In addition to the systemic effects of oral medications, some people with IBD
need oral preparations that are designed as topical treatments for ulcers and
inflammation that develop in the mouth, such as in cases of orofacial Crohn’s
disease. Oral corticosteroid agents may be applied topically to mouth lesions
affecting the buccal mucosa and the lips in these cases. Additionally,
patients who suffer from Behcet’s disease and who have developed lesions in
the mouth often benefit from mouthwash rinses that can provide some pain
relief. These rinses typically contain small amounts of lidocaine to act as a
short-term anesthetic and may be particularly helpful in certain cases, such
as when mouth ulcers have caused such discomfort that the patient is
unable to eat normally.
Rectal Medication
Rectal medications, including those given as suppositories, rectal creams and
foams, or enemas are often administered for the management of rectal
bleeding and severe diarrhea. Rectal medications are most often
administered when a patient is suffering from disease that affects the lower
end of the large intestine, including the rectum, the sigmoid colon, and the
lower left side of the colon.
5-ASA is one type of medication that can be administered as a rectal
suppository or as an enema. 5-ASA is a type of aminosalicylate that is most
often administered as an oral preparation, but it must be given as an
extended-release tablet because it is otherwise too quickly absorbed in the
small intestine. When given via rectal suppository, 5-ASA has been shown to
be beneficial in managing inflammation of the rectum associated with
proctitis and in some cases where IBD impacts the sigmoid colon. Rectal
preparations of 5-ASA may be given to those patients who cannot tolerate
oral medications. They are also easy to administer and may be used for
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acute treatment of disease flares or as long-term maintenance treatment of
inflammatory bowel disease.
Rectal administration of corticosteroids may be given through enemas or
foam suppositories. Hydrocortisone is available in a form that can be
administered rectally; the drug is often combined with an isotonic solution to
be able to retain the liquid within the bowel for longer periods. An enema is
often delivered once a day, preferably at night prior to a time when the
patient will be lying down for a long period. It is usually given each night for
2 to 4 weeks and then, because its use must be tapered down, given every
other night for another 1 to 2 weeks, and then gradually discontinued until
stopped.
Budesonide, as described, is also a corticosteroid but because it is
metabolized extensively in the liver upon first pass, it causes fewer side
effects than some other steroid preparations. Budesonide is available as a
foam enema that can be administered rectally to control symptoms
associated with proctitis, proctosigmoiditis, and areas affecting the lower
segment of the large intestine. Because of its foam substance, it is
associated with greater retention and less leakage. In two randomized trials
explained by Sandborn, et al.,32 in the journal Gastroenterology, budesonide
foam administered as an enema showed a significantly greater benefit with
use when compared to placebo, including among patients with proctitis and
proctosigmoiditis, and it was equally effective when used with or without
systemic mesalamine. The dose used during the studies was 2 mg given
twice daily for 2 weeks, followed by once daily administration for another 4
weeks.
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While effective in most cases, rectal therapies also have some limitations in
that once administered, they may be difficult to retain. Administration of
suppositories, for example, is often necessary at night before the patient will
be lying down, as walking or sitting upright may cause some of the
medication to leak. Suppositories also tend to impact only the rectum and
the immediate area of use; the medication is usually not distributed into the
sigmoid colon or the large intestine. Despite some of these limitations, rectal
therapies are often very useful in managing inflammatory bowel disease that
specifically affects the rectum and sigmoid colon because they are able to be
administered directly into the site of inflammation, often providing
immediate contact with diseased areas.
At times, rectal medications may be combined with oral agents to improve
effectiveness of the medications and to control symptoms. The combination
of rectal medications and systemic drugs have been shown to improve
symptoms in patients who have concomitant disease in both the colon and
the rectum, so this may be another option for some patients who are
suffering from IBD that affects both areas.
Injection Medication
The administration of medications by injection involves inserting the
medication under the skin, either subcutaneously into the tissue directly
under the skin, or intramuscularly, in which the drug is administered into the
thicker portions of certain muscle groups. Most injectable medications given
for IBD are administered subcutaneously and may be given in the healthcare
environment or at home by the patient or a family member.
As described, biologic agents use living organisms as part of their
composition. They are comprised of antibodies that have been developed in
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a laboratory setting. Because they are specifically created in this
environment, they focus on subduing specific cytokines as part of the
inflammatory process. Biologic agents can reduce inflammation associated
with ulcerative colitis or Crohn’s disease by suppressing the immune
response, often by blocking the action of the cytokine tumor necrosis factor.
They improve inflammation and its associated symptoms and they improve
the appearance of the tissue and promote healing in the intestinal tract.
Biologic agents usually require several injections initially, followed by routine
injections for maintenance. It can take up to 2 months for symptoms to fully
resolve with some of these drugs, but with maintenance therapy, patients
who use biologic agents often achieve and maintain remission for longer
periods.
One biologic agent, certolizumab, is administered via subcutaneous injection
for control of inflammation associated with inflammatory bowel disease and
certolizumab helps maintain remission. Certolizumab may be given when a
patient does not respond to other forms of treatment of inflammation. It is
administered as a subcutaneous injection, but does not necessarily need to
be given in a healthcare center, as the affected patient can learn to selfinject the drug at home. Certolizumab is an anti-TNF biologic drug that can
help with controlling severe symptoms of Crohn’s disease, making it a good
choice for patients who are suffering from debilitating symptoms during
disease flares. It is administered at a dose of 400 mg subcutaneously. Initial
therapy involves administration of the injection once every 2 weeks until the
patient is ready for maintenance dosing, when it is given every 4 weeks.
Golimumab is also given via subcutaneous injection and the patient can
administer it after training while at home. The FDA has approved this
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particular drug for treatment of moderate to severe ulcerative colitis. A
patient who takes golimumab initially administers starter injections 3 times
and can then change to a maintenance dose of the drug once every 4 weeks.
Golimumab has been shown to decrease inflammation and to improve the
appearance of the colon with use, as seen upon colonoscopy. Patients with
ulcerative colitis who take this drug are often able to achieve remission and
sustain it for longer periods when compared with some other types of
medical therapies. Golimumab is given as 50 mg subcutaneous injection,
although it may also be administered intravenously.
Adalimumab is another type of biologic agent administered as subcutaneous
injection. As with other types of these drugs, when given as an injection, the
patient may receive the first dose by a healthcare provider but can then
administer subsequent injections at home with appropriate education. The
initial loading dose is 160 mg, followed by 80 mg the second week, and then
40 mg every 2 weeks thereafter. Adalimumab is approved for use to treat
both moderate to severe Crohn’s disease and ulcerative colitis. It is often
given when patients with inflammatory bowel disease have not responded to
other forms of treatment, including other biologic therapies.
Methotrexate, as described, is an immunomodulator that is available as an
oral preparation, but it may also be given by subcutaneous injection. A
typical dose is similar to that given orally, and ranges from 15 to 25 mg.
Subcutaneous injection of methotrexate has been shown to improve some
symptoms of inflammation in people suffering from Crohn’s disease who
have otherwise not responded to corticosteroid therapy.
Biologic therapies and immunomodulators place patients at risk of certain
side effects. Side effects include an increased risk of infection, as mentioned,
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which results from a diminished immune response from the action of the
drugs. Other side effects and adverse reactions that have been more
commonly seen with these agents include changes in liver function and
jaundice, joint pain similar to that of rheumatoid arthritis, nervous system
effects, including numbness and tingling of the extremities, weakness, or
visual disturbances, and skin and musculoskeletal reactions that are similar
in effects to lupus, including joint swelling, rash, muscle aches, and fever.
In addition to injectable medications, patients who suffer from extraintestinal symptoms of certain inflammatory bowel diseases often require
topical corticosteroids as part of treatment. As an example, a patient with
Behcet’s disease may have skin lesions and ulcers on the genitalia in
addition to ulcers and bleeding from the gastrointestinal tract. Skin and
genital ulcers associated with Behcet’s are often treated with topical
corticosteroids and topical anesthetics for pain control and reduction of
swelling and inflammation.
Along with the side effects associated with certain medications given for IBD,
there are some specific side effects associated with the injection route of
administration. Patients who receive routine injections, whether via
subcutaneous or intramuscular routes, often experience pain during the
injection, although the pain is usually brief. With intramuscular injections,
there may be ongoing muscle pain and tenderness at the injection site that
can last from several hours to a few days. Injections can also cause mild
swelling, redness, bruising, or itching at the injection site as well. While
these symptoms are typically mild and often do not negate the effects of the
medication, they must still be monitored to ensure that further complications
do not develop in the area.
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Infusion Medication
Infusion of medications for
inflammatory bowel disease is usually
done in the healthcare environment
where the drug administration can be
well controlled and a healthcare
provider can monitor the infusion site.
While there are various drug
preparations that can be administered
via infusion, these types of treatments
for IBD are often reserved for cases in
which the patient is experiencing
severe symptoms that require
hospitalization or when the complications of the disease have caused
significant illness or problems that require more focused care as well as
intravenous medicine. Some of the drugs that are normally administered
orally can be given through infusion in larger or more concentrated doses.
Intravenous corticosteroids can be administered during the acute stages of
disease, particularly when symptoms are manifested during disease flares.
Because of the requirements for intravenous administration, corticosteroids
given through this method are often administered within a healthcare
facility, often when a patient is hospitalized because of symptom severity.
Hydrocortisone is one type of corticosteroid administered as an intravenous
infusion for symptom management of IBD. It may be given as a continuous
infusion or as a bolus dose when combined with intravenous fluids,
administered twice per day. Methylprednisolone may also be given in cases
of severe exacerbation of symptoms; like hydrocortisone, it is given
intravenously either as a bolus dose twice a day or as a continuous drip.
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Because of the potential for complications associated with corticosteroids,
patients in a hospital who receive intravenous doses of these medications
often require continued monitoring for side effects, including regular checks
of blood glucose levels, changes in level of consciousness, and routine
laboratory checks of complete blood counts to assess for changes in white
blood cell levels.
Cyclosporine is an immunosuppressant agent that is sometimes prescribed
for the prevention of rejection after transplant surgery. Cyclosporine is a
type of immunomodulator therapy that blocks activation of lymphocytes to
suppress immunity. This drug is not commonly administered unless in very
severe cases of IBD, most often with Crohn’s disease, and when
complications such as fistulas have developed. It is administered
intravenously at doses of 2 to 4 mg/kg continuously. Patients who require
cyclosporine are often those who have not responded to other types of
medications or therapies and who have severe disease symptoms.
Cyclosporine is not intended for long-term use for inflammatory bowel
disease management and patients who receive the drug for short periods
and who respond well to its effects should be slowly tapered off the dose
while initializing another type of drug to take its place once it has been
discontinued. It should be used in combination with other anti-inflammatory
agents, such as azathioprine or 6-mercaptopurine. Because of its side
effects, the patient who requires initial cyclosporine therapy should be
tapered from its use as quickly as possible. It is associated with renal
toxicity, seizures, and severe hypertension. For many people who have
reached the point of needing cyclosporine, the only other option for
treatment is surgical intervention, since there has been little to no response
to other types of medical therapies.
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Infliximab is an immunosuppressant that is often used for the treatment of
IBD, as well as many other inflammatory conditions, including rheumatoid
arthritis and psoriatic arthritis. It has been approved to maintain remission
of moderate to severe Crohn’s disease and ulcerative colitis. When patients
with IBD develop fistulas, infliximab may be administered to maintain tissue
patency after they have been closed, particularly when rectovaginal fistulas
develop as a result of the disease. The standard dose of infliximab, when
given for IBD, is 5 mg/kg, given once as an intravenous infusion. Further
intravenous administrations of infliximab may be repeated after the initial
dose, but several weeks often must pass in between. Infliximab is a
formulation similar to standard infliximab; it can be administered to both
children and adults with Crohn’s disease. As with infliximab, this drug is also
administered intravenously.
In cases of very severe colitis, such as in fulminant ulcerative colitis, an
affected patient may need intravenous infusion of several medications. There
may be times when a patient’s initial presentation is for treatment of
fulminant colitis or another complication of inflammatory bowel disease,
such as toxic megacolon or severe bleeding, when IBD has never actually
been diagnosed. When this occurs, the patient often needs emergency
intervention to correct fluid and blood loss. This often includes fluid
resuscitation with administration of large amounts of crystalline fluids to
replace volume that may have been depleted through diarrhea, vomiting, or
bleeding. A patient often needs intravenous, high-dose corticosteroids to
manage the present inflammation, along with administration of electrolytes
to correct imbalances. Blood transfusions are often necessary in cases of
massive hemorrhage; antibiotics are typically administered intravenously to
manage infection. When the patient is in a life-threatening situation and
needs surgery, fluid administration is given according to preparatory
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guidelines for care to ensure that the patient is prepared and ready for
surgery as quickly as possible.
Administration of medications through infusion has its own risks and
benefits. While patients with intravenous access can receive medication
quickly and the drugs often take action rapidly to start relieving symptoms,
there are some adverse effects associated with the use of intravenous lines
and central lines. Patients are at increased risk of infection with
administration of drugs through this route. When administering biologic
therapies and immunomodulators in particular, the risk is even higher
because of the effects of these drugs on the immune system. A patient may
be in danger of a bloodstream infection or sepsis if the infection enters the
body through the intravenous line and spreads through the bloodstream or
through lymph circulation. Some people also experience hypersensitivity
reactions or even anaphylactic reactions when receiving intravenous drugs.
Because these medications take effect quickly, they can just as quickly
cause adverse reactions that can sometimes be life threatening. Fortunately,
most intravenous preparations are administered in the healthcare
environment where the patient can be monitored for immediate side effects,
but this potential reaction should always be considered whenever giving any
intravenous preparations to patients for IBD treatment.
The health clinician should assess a patient’s medical history prior to
administering medications for IBD, which can disclose contraindications of
administration. A patient with a current infection should be monitored closely
and drug administration delayed, as bacterial infection is a contraindication
to receiving immunomodulator and biologic drugs. Potential patients should
also be screened for hepatitis or tuberculosis infection as well.
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Despite the possible consequences associated with infusion of certain drugs,
these medications remain a common form of treatment of complicated cases
of IBD. Patients who do not respond to oral or injectable preparations may
respond to infused medications instead, providing another option for medical
treatment.
Surgical Approaches For Inflammatory Bowel Disease
At times, surgery is indicated for people
with inflammatory bowel disease who
have not responded to traditional forms
of treatment though medication. There
are a number of surgical procedures
that may be included as part of
treatment for Crohn’s disease or
ulcerative colitis. Although some forms
of IBD have overlapping symptoms, the
surgical treatments for these diseases
are not always the same. For some
people with ulcerative colitis, the
surgical interventions needed to control
the disease may actually be contraindicated in cases of Crohn’s disease. Still,
surgery is a viable option for controlling the symptoms that develop during
flares and to remove the diseased portions of the intestinal tract that are
most affected by inflammatory bowel disease.1-3,20,21,33-35,53,103-113
For some, surgery is done when medical therapies have been unable to
control symptoms of the disease and the patient’s quality of life is suffering.
Additionally, some patients with chronic, long-term forms of IBD eventually
take maximum doses of drugs and have few other options. Surgical
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intervention often provides a means of controlling symptoms for the long
term and being able to decrease or even eliminate the use of some
medications.
Approximately 25 to 40 percent of people with ulcerative colitis eventually
have surgery as either a medical treatment for the disease or to manage a
complication. Additionally, up to 75 percent of people with Crohn’s disease
eventually require some form of surgery, either as an elective option or
because of severe consequences of the disease.
Surgery is often done to remove the diseased parts of the intestine that
cause the most symptoms. For some people, this means removing a
significant portion of the small or large intestine, which can lead to problems
with nutrient absorption and may necessitate a colostomy or ileostomy: a
stoma on the abdominal wall in which the body excretes stool into a bag.
Despite the complications and outcomes associated with this process, as well
as the reality of living without a portion of the intestinal tract, many people
with inflammatory bowel disease choose to undergo surgery because
removal of the portions of the intestine causing the problems will mean a
significant decrease in symptoms or possibly even permanent symptom
remission. The decision of whether to move forward with surgery to promote
remission of symptoms is one that is decided on an individual basis after
examining all of the factors involved.
Many patients with inflammatory bowel disease choose to undergo corrective
surgery at early points in the disease process, rather than wait to manage
the condition through medical therapies. Even though surgery is invasive
and has its risks, it may be an option for patients with IBD because it
ultimately offers them better outcomes. While at one time surgery was only
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reserved for the most severe cases of IBD, many patients are electing to
undergo surgery to combat milder forms of these diseases, which can
prevent many complications that can develop when symptoms or the disease
process itself is not well managed. For many people, surgery provides the
chance for improved quality of life and living either disease-free or with
considerably fewer symptoms than their current conditions allow.
Proctocolectomy
Proctocolectomy describes surgery done to remove the colon, the rectum,
and the anus. The procedure is often considered to be the only absolute cure
for conditions such as ulcerative colitis, but it is so extensive and complex
that it is not always taken on as a method of treatment unless a patient has
not responded to other forms of treatment or when serious and life
threatening complications have developed.
The individual undergoing proctocolectomy requires a permanent ileostomy
after the surgery, in which the lower portion of the small intestine — the
ileum — is connected to a stoma where it can drain outside of the body.
When this type of surgery is done, it is known as total proctocolectomy with
permanent ileostomy. Because the rectum and anus have been removed,
the patient must have an area in which to contain and release stool. In some
cases, an internal pouch may be placed in the lower abdomen; this pouch
eliminates the need for an external ileostomy and its associated stoma and
bag. The pouch must be emptied through a tube to clear stool from the
body.
During surgery, the surgeon enters the abdominal cavity and removes the
colon, including the main body of the large intestine, as well as the sigmoid
colon and the rectum. The end of the ileum is then brought to an opening in
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the abdominal wall to create a stoma for release of stool. If the anus is
removed during the surgery, the ileostomy will be permanent, but if the
anus is preserved, the ileostomy can be a temporary measure until the rest
of the bowel has healed. This is followed by a later surgery for anastomosis.
Although proctocolectomy involves the removal of a significant amount of
the large intestine in most cases, for some people, particularly those with
Crohn’s disease, only affected portions of the bowel and/or rectum are
removed. When this occurs, the surgeon identifies the diseased areas that
are most affected and removes them, leaving healthy tissue behind, when it
is present. When a total proctocolectomy is not required, the patient does
not need an ileostomy. This is more commonly performed in those with
Crohn’s disease; alternatively, people with ulcerative colitis more frequently
need to undergo total proctocolectomy. The CCFA states that up to 40
percent of people with ulcerative colitis will need to undergo
proctocolectomy.
Proctocolectomy is often performed as an open procedure, but it is
increasingly available as a laparoscopic procedure as well. Because many
patients with IBD use medications such as immunomodulators or biologic
agents that can depress the immune system, they may already be at
increased risk of infection or other complications following surgery. A
laparoscopic procedure can reduce some of the risks of infection associated
with an open procedure. A study in the journal Inflammatory Bowel Disease
found that laparoscopic total proctocolectomy (performed through
laparotomy) is a safe alternative to proctocolectomy and that patients with
laparoscopic-assisted procedures suffer fewer complications of infection and
reduced wound complications. This type of surgery may therefore be an
option for some patients with ulcerative colitis, as there is a decreased risk
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of complications with an earlier return of bowel function and a shorter
hospital stay.
Pain medications administered after surgery can help to control some of the
discomfort that occurs but should be limited to those that do not irritate the
gastrointestinal lining. For example, non-steroidal anti-inflammatory agents
such as ibuprofen, while effectively controlling some inflammation and pain
associated with surgery, should be avoided once the patient is able to take
oral pain medications, as these drugs can irritate the stomach lining and
worsen symptoms of inflammatory bowel disease.
The risks associated with proctocolectomy are increased when the procedure
is performed in an emergent situation. However, even scheduled, elective
proctocolectomies are not without some risk, and are associated with an
approximate 20 percent overall morbidity. Some complications associated
with this type of surgery include hemorrhage, wound contamination, and
sepsis, as well as sexual and bladder dysfunction due to nerve damage.
Because patients with ulcerative colitis and Crohn’s disease are at increased
risk of colon cancer, colectomy may also be performed to remove cancerous
tissue if malignancy has developed. The removal of tissue is often necessary
when the cells demonstrate hyperplasia, which is an unnatural growth of
tissue that may occur because of cancerous cell proliferation. If a biopsy has
been performed already that has confirmed malignancy, surgical intervention
may have two outcomes: removal of the diseased portion of the intestinal
tract that is ulcerated and that is causing symptoms, and removal of the
cancerous tissue to prevent metastasis and further growth.
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There are also some patients who undergo colectomy as a prophylaxis for
colon cancer. According to Bayless and Hanauer,59 authors of the book
Advanced Therapy of Inflammatory Bowel Disease, total proctocolectomy is
the most effective means of minimizing the risk of colorectal cancer in
patients with IBD. Despite the success of eliminating potential locations for
colorectal cancer development by removing the large intestine, the process,
when used as prophylaxis, it often met with mixed reviews. There currently
is a certain amount of controversy surrounding prophylactic surgery for
prevention of cancer, particularly when the surgery is performed in patients
who have mild forms of IBD and few symptoms. The risks associated with
surgery, along with the change in quality of life following the procedure, are
sometimes too extensive to promote a surgical procedure that may prevent
cancer. Alternatively, patients who have several risk factors and who also
struggle with symptoms of the disease may benefit from surgery, which can
help with disease management in addition to reducing cancer risk.
Ileostomy
Ileostomy surgery involves the
creation of a stoma, or opening of the
small intestine, outside of the body.
The body drains waste through the
stoma instead of passing it on to the
large intestine for excretion the anus.
This type of surgery is normally done
when there is disease of the colon
that affects a person’s ability to pass
fecal matter through the large
intestine for defecation. For patients
with inflammatory bowel disease, an
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ileostomy is often created following surgery to remove the large intestine.
A patient with IBD who is undergoing an ileostomy may have had surgery
previously in an attempt to correct some of the effects of the disease. The
affected individual may have already had part of the gastrointestinal tract
removed, such as through colectomy, in which the large intestine has been
removed, or through surgical removal of a portion of the small intestine,
known as a small bowel resection. The placement of an ileostomy often
comes at a time when other measures for treatment of IBD have not been
successful.
An ileostomy may or may not be permanent for the affected patient. If part
of the large intestine or the rectum is still present, the patient may have the
ileostomy for a period of time and may then undergo reanastomosis to
connect the portion of the ileum that was previously the stoma with the
other end of the intestinal tract. A temporary ileostomy may be indicated in
cases where the patient needs to undergo a period of bowel rest so that the
large intestine can settle and heal. The patient who has a temporary
ileostomy must still have part of the rectum left to be able to use it again
after reanastomosis. If the patient has had the colon, rectum, and anus
surgically removed through another surgery, the ileostomy is then
permanent because it becomes the only method of defecation for the
patient.
During ileostomy surgery, the surgeon creates an opening in the abdominal
wall. This opening is usually on the lower right side of the patient’s
abdomen. The end of the small intestine at the level of the ileum is brought
up to the opening and connected there to create the stoma.
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The most common type of ileostomy surgery is the Brooke ileostomy, often
considered a standard form of surgical treatment for management of
ulcerative colitis and Crohn’s disease. With this procedure, the surgeon
creates an opening in the abdominal wall and forms a stoma with the end of
the ileum. The edges of the intestine are pulled through the opening and
then turned back and connected to the skin so that there is a smooth
surface with the opening in the middle. Persons with this type of ileostomy
must wear a collection bag for stool at all times because they cannot control
stool output from the stoma and it will otherwise leak out of the opening of
the abdomen.
Although the Brooke ileostomy is one of the most common surgical
procedures used to create an ileostomy, it is often met with resistance from
patients and it is becoming less popular as a surgical alternative. In most
cases, creation of this type of ileostomy is permanent and the patient must
have a stoma and ileostomy bag. Depending on the patient’s age and
activity levels, this may be an unacceptable option. For example, a patient
who was diagnosed with Crohn’s disease at a young age may opt to have
surgery during young adulthood, but having an ileostomy with an external
pouch may cause embarrassment or could interfere with some activities.
A continent ileostomy, also called an abdominal pouch, can sometimes be
performed for patients with ulcerative colitis. This procedure involves the
creation of a pouch within the abdominal cavity when part of the ileum is
turned back onto itself and sewn into place. Wastes collect within this pouch,
rather than outside of the body, so that the patient does not need to wear
an ileostomy bag. A small port extends from the pouch through the
abdominal wall. To empty the pouch, the patient inserts a tube through the
port to drain the waste from the body.
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The benefits of having a continent ileostomy are that the patient retains
much of his stool continence and is not dependent on an external ileostomy
bag to collect waste. Unfortunately, there are a number of complications
associated with this specific procedure, often because of the location of the
pouch and the port that extends outside of the body. Patients have been
seen with further inflammation of the gastrointestinal tract and/or the pouch
itself, malabsorption problems, and severe diarrhea following this procedure;
there is also a risk for fistula formation between the pouch and the skin.
Despite these drawbacks, this type of surgery is a viable option for many
patients, particularly those who have previously had an ileostomy and would
like to restore stool continence.
A third type of ileostomy procedure, which may also be used for
management of ulcerative colitis, is the ileo-anal reservoir, which is also
called a J-pouch or ileal pouch anal anastomosis (IPAA). The procedure is
done when the patient must have the entire colon and the rectum removed,
but the anus is preserved. Most patients with Crohn’s disease are not
candidates for this type of surgery and in order for it to be successful, the
patient must have a functioning anal sphincter to be able to control the
passage of waste. However, there are many surgeons who agree that this
type of surgery is a first-line option for management of ulcerative colitis.
During the process of creating an ileo-anal reservoir, after the colon and
rectum have been removed, the end of the ileum is looped back on itself to
form a J. This is the reservoir that is then connected to the anus. Waste
collects in the reservoir and the patient rids the waste from the body
through defecation using the anal sphincter muscles. The procedure is
typically done in at least 2 stages to remove the bowel and to create the
pouch; often, the entire process takes several months to complete, as there
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must be at least 3 months between the time of the colectomy and the
creation of the reservoir. Often the patient requires a temporary ileostomy in
which stool empties through a stoma on the abdominal wall into an attached
bag. The ileostomy is usually required to allow the tissue of the ileo-anal
sphincter and the pouch to heal.
Despite its increasing popularity, there are some complications specifically
associated with this procedure. In the short-term period just following
surgery, the patient is at increased risk of pelvic infection due to leakage
from the anastomosis site. Chronic complications that have been seen with
this procedure include small bowel obstruction due to adhesions, infection or
poor healing of the pouch, and pouchitis, which describes inflammation
within the pouch tissue and is one of the most common complications of this
surgery. A small percentage of patients who have IPAA go on to develop
symptoms of Crohn’s disease in the remaining small intestine or the ileal
pouch.
The patient who undergoes ileostomy is at certain risks because of the
invasiveness of the procedure. As with any type of surgery, the patient is at
risk of infection, often at the surgical site, when microorganisms invade the
tissue and it becomes inflamed and infected. A surgical-site infection most
often occurs within 30 days after surgery. Other general complications
associated with surgery that must be considered include an increased risk of
blood clots and risk for pneumonia.
There are also risks involved with ileostomy that are specifically related to
the procedure. Patients who undergo ileostomy are at greater risk of
intestinal blockage if scar tissue develops in the area around the stoma or
within the nearby intestinal tract. The tissue may become inflamed and
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fibrous, causing it to thicken, which can make passage of stool through the
intestinal tract and the stoma more difficult. Because the tissue has been
manipulated to create the stoma and the ileostomy, and the patient may
already have fragile intestinal tissue if IBD is present, there is an increased
risk of intestinal bleeding and blood loss from the stoma site. The intestinal
tissue and the mucosa of the stoma can break down and bleed; additionally,
the surgical area and suture line can break open and cause further bleeding.
The stool output from an ileostomy is much more watery and contains more
liquid when compared with stool that leaves the rectum. This is because the
feces do not pass through the colon, which is the main location where fluid
and salt are reabsorbed, causing feces to have more bulk and to be formed.
Without the routine uptake of fluid in the colon, the feces that exit the
ileostomy are often liquid and runny. As a result, patients with ileostomies
are at greater risk of dehydration and may need to increase fluid intake to
avoid serious consequences. Further, many people complain that the stool
output from an ileostomy has a strong odor and that there is more gas
emitted from the stoma. Avoiding certain foods that are more likely to cause
gas, such as broccoli or cabbage, can control this. These patients should
limit intake of carbonated beverages, which contribute more air to the
intestinal tract, and avoid drinking with a straw, which also introduces air
with swallowing.
Initially, the patient may need to avoid excess fiber in the diet, as too much
can lead to dehydration. Eventually, most patients with ileostomies are able
to follow regular diets without many restrictions, but during the first several
weeks after surgery, there are a few constraints needed. In addition to
avoiding extra fiber, patients must avoid foods that could obstruct the stoma
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site, including items that contain seeds or husks, such as corn, celery, and
beans.
Because the stool empties into a bag, the patient must learn how to care for
the bag, emptying of stool, and the skin at the stoma site. The bag may
need to be emptied of stool several times per day, particularly if stool is
liquid. The patient is taught how to care for the colostomy bag, keep it clean
on the outside of the bag, and reapply a new bag when needed. Most
ileostomy bags can be emptied when using the bathroom, with the contents
of the bag emptied directly into the toilet. The bottom of the bag is kept
closed with a clip or with Velcro closure.
The skin around the stoma site may become irritated, particularly when it
remains in frequent contact with stool in the ileostomy bag. Skin irritation
also occurs more often when the bag is not well connected to the skin or
when the patient uses tape or some other form of adherent to try to keep
the bag connected to the skin. Changing the pouch too often or not often
enough can also result in skin irritation, so it is important for the patient to
follow all of the guidelines provided to keep the area as clean and healthy as
possible. Otherwise, the stoma site should be cleaned regularly, but the
patient should not apply emollients or creams to the site in an attempt to
keep it lubricated or moist. These products can impact how well the stoma
pouch stays connected to the skin, and in some cases they may cause
further irritation.
Bowel Resection
A bowel resection involves removal of the intestine; when the small intestine
is involved, it is called a small bowel resection and when the colon is
involved, it is called a large bowel resection or colectomy. The surgery may
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involve removal of part of only part of the bowel or it may involve removal of
the entire bowel. The amount of the intestinal tract removed depends on the
extent of IBD present. The resection is done so that when the diseased part
of the intestine is removed, the patient should most likely be free of
symptoms of IBD. If cancer has been detected or if the patient has evidence
of tissue dysplasia, as seen with colonoscopy, colectomy involves removal of
the affected tissue as well, which reduces the chance that malignancy will
spread. In some cases, where cancer is confirmed, the patient may need to
have surrounding lymph nodes removed as well.
A bowel resection may be performed as an open procedure or it can be done
laparoscopically. Obviously, with a laparoscopic procedure, the process is
less invasive and often leads to a shorter recovery time and less pain for the
patient. There are few scars when compared to the larger, vertical scar
associated with open bowel resection; however, even for patients who
undergo a standard or open process, the recovery time in the hospital can
be fairly rapid if there are few complications.
As with proctocolectomy, patients with ulcerative colitis may undergo a
bowel resection when they have not responded to other traditional forms of
medical therapy. When symptoms recur as soon as medication is decreased
or discontinued or when disease flares become so debilitating that there are
no other options for treatment, surgery is usually discussed as the next step
of treatment. For patients with Crohn’s disease, a bowel resection is most
often necessary when complications have developed that must be treated
surgically, such as through severe disease symptoms, strictures, or abscess
development. Unfortunately for some people with Crohn’s disease, removal
of a portion of the intestinal tract through a bowel resection does not
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entirely eliminate the disease, and Crohn’s inflammation and ulcerations can
recur in the portions of the intestinal tract that remain behind.
There are different types of bowel resection that may be performed,
depending on the amount of tissue involved and the patient’s disease
process. A sub-total colectomy describes a type of bowel resection in which
only part of the large intestine is removed. It may involve removal of most
or all of the large intestine, but leave behind the rectum and the anus. A
subtotal colectomy is often performed in cases where urgent surgery is
needed to prevent further complications that could be life threatening. It
may also be an option when a patient has disease that only affects one
portion of the bowel, which can be removed while keeping other areas of the
intestinal tract intact. Most people who undergo a sub-total colectomy still
need an ileostomy on a temporary basis to allow the intestinal tract to heal.
When Crohn’s disease affects the small intestine, a small bowel resection
may be needed to remove some diseased tissue. The most common type of
small bowel resection for Crohn’s disease is an ileocolic resection, because
the ileum is the area most often affected by the disease. During this
procedure, the surgeon removes the terminal ileum and part of the right side
of the colon. The remainder of the small intestine is connected directly to the
remaining portion of the large intestine. There may be times when a
temporary ostomy is needed following this surgery, but in most cases, the
patient can resume regular bowel function with time.
A large bowel resection may be necessary for some patients with Crohn’s
disease that affects the colon, although it is more common in patients with
ulcerative colitis. A large bowel resection can describe a sub-total colectomy,
total proctocolectomy, or ileal pouch anal anastomosis procedure. As with
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any type of surgery, the patient is at risk of problems during the postoperative period, including surgical site infections, poor wound healing, and
problems with digestion and absorption. Patients with IBD who have used
biologic agents and drugs that affect the immune system may be at risk of
infection following surgery as well. Many of the indications for bowel
resection are similar to those for proctocolectomy and ileostomy surgeries,
and the complications of this procedure are comparable as well.
Strictureplasty
Strictures, or the narrowing of the intestinal tract due to thickening of areas
of the bowel wall, can cause multiple complications and may need to be
surgically removed. As discussed, strictures develop when inflammation from
inflammatory bowel disease causes scarring and fibrosis in the intestinal
mucosa. The scar tissue is thicker than normal and does not function in the
same manner as healthy tissue. Eventually, the affected area narrows, and
the lumen of the intestinal tract become smaller. Strictures are more
commonly seen with Crohn’s disease and they can happen anywhere along
the intestinal tract.
Strictures have the potential to cause harm in that they can cause partial or
complete obstruction of the intestine, which causes the passage of intestinal
contents to slow or even stop altogether. The area distal to the obstruction
may also become dilated in response when the bowel attempts to
compensate by increasing the strength of contractions and areas of the
intestinal wall are weakened. Further complications associated with
strictures can then result in bowel perforation and intestinal abscesses.
Strictures are sometimes treated with balloon dilatation, in which a balloontipped catheter is threaded to the stricture site and the balloon is expanded.
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This action widens the sclerosed area by breaking up the tissue and
expanding the size of the lumen. Depending on the location of the strictures,
though, balloon dilatation may not be available, particularly if the balloon
catheter cannot reach the strictures.
Surgery through strictureplasty is necessary in cases where strictures have
caused complications with movement of food through the intestinal tract and
when other complications associated with intestinal obstruction have
developed. Surgery to correct strictures involves the surgical resection of an
area of the bowel where the strictures are present. It may mean removing a
significant portion of the intestinal tract if the strictures are large and
encompass a greater area.
Strictureplasty is a procedure that removes only the area affected by
resecting the actual strictures. During strictureplasty, the surgeon makes a
lengthwise incision along the stricture to release some of the thickened
tissue and to enlarge the size of the intestinal lumen. Once the lumen of the
intestinal tract has been widened, the tissue is sewn closed to maintain the
new size. Strictureplasty may be performed when strictures are affecting
several areas of the intestinal tract and removal of the portion of the
intestine affected would mean removing a significant area of the bowel. In
some cases, patients may have already had surgery for bowel resection and
may have strictures develop in the remaining intestine. Strictureplasty can
correct the size of the intestinal lumen in these cases when removal of more
of the bowel is not feasible.
One of the more common techniques of strictureplasty is the Heineke–
Mikulicz technique, in which an incision is made horizontally along the length
of the intestine. The incision is centered over the area where the stricture is
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present and the ends of the incision extend past either end of the stricture
into healthy intestinal tissue. An article by Pocivavsek, et al.,111 in the
journal Inflammatory Bowel Disease noted that by extending the incision
into the healthy tissue on the proximal and distal ends of the stricture,
healthy tissue is drawn toward the stricture site to add to the intestinal
lumen circumference. The resection of the stricture tissue in this manner
then increases the diameter of the lumen and also improves the rate at
which the tissue is able to heal.
Colostomy
Similar to ileostomy, colostomy involves the formation of a stoma in the
abdominal wall through which stool output is released. The end of the stoma
is created by the large intestine and feces are excreted through this opening
instead of from the rectum and the anus. The intestinal tract beyond the site
of the stoma has been removed. The patient with a colostomy must wear a
bag attached to the skin and covering the stoma site to be able to collect
stool. A colostomy may be a temporary measure that a patient has for a
period of time following surgery and as part of treatment; alternatively, a
colostomy is a permanent method of stool excretion for many patients who
have had surgery to correct some complications of an inflammatory bowel.
Colostomy may be performed for people with ulcerative colitis or those with
Crohn’s disease affecting the large intestine. A colostomy differs from an
ileostomy in that because the large intestine is responsible for fluid
absorption, the absorption of most nutrients from food remains unaffected
because the small intestine is intact. Depending on the amount of the large
intestine that is removed, the appearance of stool can differ. The area that is
left must continue to absorb more fluid, but if there is little to no large bowel
remaining after surgery, there will be more liquid in the stool because the
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body is unable to absorb remaining fluid from the feces. Alternatively, when
much of the large intestine remains after surgery, the stool output from the
colostomy is more formed.
There are different sub-categories of colostomies and the type of surgery
performed differs depending on an individual patient’s condition and the
severity of the disease. A transverse colostomy involves the transverse
segment of the colon, which is located just after the ascending colon. This
type of colostomy is performed in the middle or center of the abdomen or
toward the right side. A temporary colostomy may be performed with a
transverse colostomy to prevent stool from reaching a distal area of the
colon that has been resected or repaired. The stool is diverted through the
colostomy until the distal area heals and then the ends are reconnected
later.
Transverse colostomy consists of two different kinds: a loop colostomy and a
double-barrel colostomy. During a loop transverse colostomy, a loop of the
bowel creates the stoma and there are actually two small openings that look
like one stoma opening. One opening is for removal of wastes and stool and
the other inactive portion leads to the rectum. This second opening may
exude some mucus during bowel movements.
A double-barrel transverse colostomy involves complete division of the bowel
wall and both ends are brought to the surface of the abdomen to form two
stomas. One of the openings releases stool, while the other is inactive. The
inactive portion may be enclosed within the abdomen, in which it is
bypassed completely and non-functional. Because a transverse colostomy is
performed at the more proximal end of the large intestine, stool output is
often liquid and soft since it has spent less time in the colon. The patient is
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at greater risk of skin irritation at the stoma site because the stool is more
acidic and can cause skin breakdown.
An ascending colostomy is performed on the right side of the abdomen,
removing the ascending portion of the large intestine. As with the transverse
colostomy, stool output from an ascending colostomy is mostly liquid
because it is done at the very beginning of the colon. Because of the high
levels of digestive enzymes present in the stool, the patient with a colostomy
in this area is also at greater risk of skin breakdown and irritation at the
stoma site.
Colostomies located in the lower portion of the large intestine are done when
the descending or sigmoid portions of the colon are removed. These result in
stoma sites that are lower on the left side of the abdomen. The stool output
is mostly formed and is similar in appearance and consistency to that of
stool from the rectum. These types of colostomies may also be double-barrel
colostomies or they may only have one end with a stoma.
People who have undergone colostomies must wear exterior bags attached
to the skin to collect feces. Because there are no muscles to control the
passage of stool from the stoma, the fecal contents spill out of the stoma to
collect in the bag. It is therefore important for the patient to always wear a
collection bag to prevent leakage of stool and soiling of clothing from stool
output. The patient may experience problems with odor and gas, which can
be remedied with diet. Dehydration is also a concern because of fluid loss
through the ostomy opening, particularly with ascending or transverse
colostomies. Many of the requirements needed to maintain the attached bag
and to clean the skin around the stoma are similar to ileostomies and have
been discussed.
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While colostomy surgery is invasive and typically requires a significant life
change because of the ostomy and required bag, for many patients with
IBD, a colostomy is a step toward health and healing. For those who have
suffered from symptoms and complications of ulcerative colitis or ileocolitis,
surgery for colostomy means no longer managing these problems. Most
people, following colostomy, can live full and normal lives.
Nutritional Therapy For IBD Management
Nutritional therapy is a mainstay of treatment and management of
inflammatory bowel diseases. The use of nutritional therapy started when
these diseases were first being discovered, as clinicians recognized the
impact of chronic bowel inflammation on overall patient nutrition and sought
to prevent weight loss and malnutrition as consequences of inflammatory
bowel diseases. Further, the Western diet, which is high in fat, protein, and
sugar, as well as is often presented in very large portion sizes, contributes to
the obesity epidemic well known throughout many industrialized countries.
There is a correlation between the rising incidences of IBD and intake of
foods mainly found in Western diets. Many of the additives involved,
including emulsifying agents and complex carbohydrates have been shown
to have damaging effects on intestinal tissues. The role of nutrition therapy
in both the prevention and management of inflammatory bowel diseases
cannot be underestimated.10,14-18,89,93-95
Types of diets and supplements have varied over the years, with some
patients being told to eat or avoid certain substances based on available
research at the time. Research is ongoing in this area to determine what
types of foods and nutrients should be avoided or included in the diets of
people with IBD. For example, some healthcare providers recommend the
use of probiotics to increase intestinal bacteria and to possibly help with
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controlling diarrhea. Probiotics are often
available by eating more yogurt or
sauerkraut or consuming foods containing
them. However, research has not confirmed
that probiotic use is entirely beneficial for
patients with IBD.
Inflammatory bowel disease increases the
risk of malnutrition due to problems with
nutrient absorption and an increase in fluid
loss through diarrhea and vomiting that
often accompanies the disease. People with
Crohn’s disease, in particular, often suffer from malnutrition because of
absorption problems. Dehydration is common with many patients with IBD
because of loss of fluid and electrolytes through frequent diarrhea. Because
of this, the person diagnosed with IBD should receive nutritional therapy and
counseling to determine the most appropriate diet, to calculate appropriate
fluid intake, and to prevent malnutrition, vitamin or mineral deficiencies, or
electrolyte imbalances.
It is therefore important to include nutritional therapy as part of treatment
for IBD. A well-balanced diet that includes regular intake of whole grains,
fruits, vegetables, and low-fat meat and dairy can ensure that the patient is
taking in enough vitamins and nutrients that he needs. There is not one
exact diet specifically for IBD. Some people suffer from more symptoms
after eating certain foods, so the exact types of foods and the amounts need
to be individualized according to patient needs. The affected patient may
need to discern which foods cause more gas and diarrhea and which foods
are safe to eat. Additionally, to reduce excess abdominal pain and diarrhea
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from certain foods, the patient should avoid very spicy or greasy foods that
would be more likely to cause stomach upset, as well as avoid foods that are
considered to be empty-calorie foods: those that contain large amounts of
sugar or high-fructose corn syrup and therefore plenty of calories, but with
few nutrients.
Other foods that have been shown to cause problems in patients with
inflammatory bowel diseases include high-fiber foods, such as stringy fruits
and vegetables, citrus fruits that contain pith, or vegetables such as celery
or corn that have fibrous components and husks that are not broken down in
the intestinal tract. Fiber is still an important component of good health, and
people with IBD should not avoid all sources of fiber. Instead, choosing a
variety of fruits and vegetables that contain fiber will help to ensure
adequate fiber intake. Some people feel better by eating cooked fruits and
vegetables, rather than raw, cold ones. Cooking vegetables makes digestion
a little easier. All seeds found in fruits and vegetables should be removed
before eating. Although whole grains are often recommended as excellent
sources of fiber, whole-grain breads and pastas may cause problems during
disease flares for those with IBD. Most people with IBD can tolerate eating
white bread or pasta that has been enriched with iron and vitamins,
particularly during times of excessive disease symptoms.
While dairy products are beneficial for many people as excellent sources of
nutrients, some people with IBD do not tolerate dairy because of lactose
intolerance. When determining the most appropriate foods for the diet, each
individual patient with IBD will need to determine whether dairy products
cause more gas and diarrhea or if they are well tolerated. They should be
included in the diet if they do not cause problems but if they must be
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avoided, affected patients should use lactase products and dietary
supplements.
Some other foods are known as trigger foods and should also be avoided in
cases where they cause problems. Again, not everyone with inflammatory
bowel diseases has the same trigger foods. For example, someone with
ulcerative colitis may be able to tolerate eating fast food while another
person with the same diagnosis may not tolerate the extra fat found in fast
foods. Trigger foods are individualized to each condition. Some types of
foods that are more likely to trigger disease flares in some people include
products that contain wheat gluten; sugar alcohols, including items that
contain sorbitol or mannitol; high-fat foods, including fast foods and full-fat
dairy products, and high-fructose corn syrup.
In addition to eating foods that contain plenty of nutrients and avoiding
foods that are more likely to cause symptoms, people with IBD can follow
certain eating guidelines to help prevent further problems. Eating smaller
meals throughout the day may help some people to be more comfortable,
rather than consuming three large meals a day. Eating in a relaxed setting
can also be beneficial; this helps the individual to lessen stress associated
with eating and prevents rapid food consumption, which can lead to in
increase of air intake. Increasing intake of fluids can also help to prevent
dehydration due to chronic diarrhea. The best fluids to choose are those that
do not add much sugar and that are caffeine free and contain no alcohol.
Examples include water, fruit juices that have been diluted with water, and
sugar-free sports drinks that contain some electrolytes.
As previously discussed, keeping a food diary may be helpful for some
people with inflammatory bowel disease. A food diary records the types and
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amounts of foods the individual eats, as well as any specific responses to
certain foods, and the timing of disease flares. If any foods or fluids are
included that are not normally a part of the diet, these are noted in the diary
as well. The purpose of keeping a food diary is to find a correlation between
food consumption and symptoms. In some cases, the diary can help to
pinpoint what items exacerbate IBD symptoms and those that potentially
lead to disease flares. Even if the individual is unable to correlate certain
foods with actual disease symptoms, keeping a diary can sometimes identify
those substances that should be avoided in the diet because they worsen
symptoms. There is often no specific method or template to use when
keeping a food diary, but an affected patient may get ideas about how best
to record intake by working with a registered dietitian.
Some patients with IBD benefit from taking a multivitamin or iron
supplement to combat anemia or vitamin deficiencies they may have
developed because of the disease. Supplementation of specific nutrients is
often effective in controlling many symptoms associated with nutrient
shortages. For example, a patient who is taking corticosteroids is at risk of
loss in bone mineral density and osteoporosis with continued use and he
may have difficulties with taking in enough dairy products in his diet.
Supplementation with calcium and vitamin D in this case may help to
prevent further bone loss and could support and protect the patient’s bones
and teeth.
It is important to remember that, while vitamin and mineral supplements
can provide many of the nutrients that a patient may be missing,
supplements should not replace food. Further, some people are sensitive to
the effects of supplements in the gastrointestinal tract, such as when pills
are taken on an empty stomach. If a patient is unable to take in enough
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food by eating and is starting to rely only on vitamin supplements to prevent
complications, further nutrition support is most likely necessary. However,
for some, the routine flares of inflammatory bowel diseases may cause such
nutritional imbalances that further nutrition support is necessary.
There are some patients that do no tolerate many foods because eating
leads to disease flares and excessive symptoms; they are also more likely to
lose weight and become dehydrated due to diarrhea and fluid loss. In these
patients, enteral nutrition support may be considered as an option to
improve nutrient intake. Some studies have shown that the use of enteral
nutrition is beneficial in helping patients with IBD achieve states of remission
for longer periods. In some cases, patients with IBD who have become
dependent on corticosteroids for management of symptoms have also
benefitted from enteral nutrition therapy in that the nutritional support
helped to reduce their need for the drugs and they were able to achieve
symptom relief.
The use of exclusive enteral nutrition
(EEN) has been used to improve
symptoms of IBD and to reduce
negative effects such as wasting and
poor nutrient tolerance. Exclusive
enteral nutrition describes the
process of providing enteral formula
to a patient through a feeding tube
as the exclusive form of nutrition,
without ingestion of any other oral
food, with the exception of some
water or small amounts of other
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beverages. A review by Kansal, et al., in Gastroenterology Research and
Practice examined the use of EEN in controlling symptoms of Crohn’s disease
in some patients.16 The review showed that certain types of formula used
with EEN, in particular polymeric formulas, have induced states of remission
in patients with Crohn’s disease more quickly when compared to oral
nutrition therapy alone. In particular, the EEN was able to modify gut
microbiota and it had anti-inflammatory effects; it was shown to promote
mucosal healing and there was also some evidence that EEN lengthened
overall periods of remission.
In particular, EEN has been shown to be effective for children, adolescents,
and young adults living with Crohn’s disease. It is often a prescribed form of
treatment for this population because of the effects of the disease on growth
and development with these age groups. For example, malabsorption
associated with Crohn’s can lead to poor muscle and skeletal development
and use of corticosteroids for treatment of inflammation can increase the
risk of osteoporosis. Therefore, implementing EEN for this population can
reduce some of the harmful effects of the disease and its associated
therapeutic interventions.
Exclusive enteral nutrition is administered using a specific type of formula
that has been created for the affected patient, based on his nutritional
status. The formula is most often administered through a nasogastric tube
that is placed in the nose and threaded to the stomach; however, it may
also be consumed as an oral supplement. There are no other foods or
beverages, excluding water, that are consumed during the time of EEN. The
enteral nutrition is then administered exclusively over a given period of time,
often over eight weeks, for every meal of the day. It may be gradually
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tapered off at the end of treatment while the patient starts to incorporate
regular foods into the diet again.
In very severe cases of inflammatory bowel diseases, total parenteral
therapy (TPN), which is administered through a central line, may be needed
to prevent muscle wasting and protein energy malnutrition. However, due to
the cost of TPN and the associated risks, including increased risks of
infection and hyperglycemia, as well as risks from the use of a central line
such as blood clots and hemorrhage, this line of treatment is often only used
when the patient needs bowel rest, has a condition such as short bowel
syndrome that has caused problems with malabsorption, or has not
responded to other forms of nutritional and medical therapy.
Nutrition therapy is almost always more effective in managing symptoms of
IBD when combined with medical therapy through medication. This is so
whether nutrition therapy is done through oral intake of specific foods, the
use of supplements and vitamin-mineral preparations, or enteral feedings.
Nutrition support can promote healing in some areas and it usually prevents
many of the problems of malnutrition, osteoporosis, and electrolyte balances
often seen with patients with IBD. Further, nutritional therapy can help to
relieve some of the uncomfortable symptoms that often occur with IBD,
including severe diarrhea or weight loss, thereby helping the patient to be
more comfortable.
Counseling with a registered dietitian may be needed to determine the
appropriate amount of protein and fat in the diet, which often exceeds that
of standard diets, in order to prevent weight loss and muscle wasting. When
a child or adolescent has been diagnosed with inflammatory bowel disease,
nutritional counseling is especially important to prevent delays in growth and
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development. Children are measured on a growth curve to track their height
and weight and to ensure that they are progressively growing in proportion
to their age. However, because of the effects of IBD and poor absorption and
ensuing malnutrition, many children do not follow the growth chart in terms
of appropriate growth. They may also be behind in normal developmental
tasks and activities because of poor nutritional intake and due to missing
nutrients in the diet. A nutritionist can help the parents of a child or teen
with IBD to ensure that he gets enough food in his diet or that he is taking
in enough nutrients (through regular food intake or through enteral
feedings) to prevent weight loss and growth retardation. The exact amounts
of calories and nutrients often need to be carefully calculated through a
series of nutritional formulas to determine the most appropriate needs for
individual patients.
Inflammatory Bowel Disease Prognosis
Prognosis for inflammatory bowel diseases can vary considerably, depending
on the type of disease, the extent of inflammation and the amount of
damage that has occurred, and the length of time that the affected patient
has had the condition. For some, IBD may only cause a single episode of
inflammation and symptoms. Alternatively, some people struggle with
ongoing episodes of disease flares and they have severe symptoms that are
difficult to manage. It is not clear why there is such variety with disease
severity between the types of inflammatory bowel disease. This section
briefly discusses the prognosis of IBD and its sequelae.1-13
In cases of Crohn’s disease, almost 20 percent of patients have a chronic
form of the condition that results in long-term and continuous episodes of
flares and periods of remission. Most people diagnosed with Crohn’s disease
have normal life spans; Crohn’s disease, unless it causes severe
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complications because of extensive damage from the disease, usually is not
life threatening. Alternatively, about 50 percent of people with ulcerative
colitis have mild symptoms and the remaining 50 percent go on to develop
severe forms of the disease.
People with inflammatory bowel disease, including ulcerative colitis and
Crohn’s disease that impacts the large intestine, are at an increased risk of
developing colorectal cancer. The risk is greater among those who already
have a family history of colon cancer. Additionally, people with Crohn’s
disease that affects the small intestine are at greater risk of developing
cancer in the small intestine, although the cancers that form in this portion
of the gastrointestinal tract are rare to begin with. Other factors that have
been shown to be related to increased risk of colorectal cancer in patients
with IBD include duration of the disease, as a longer disease duration
increases the cancer risk; the extent of the disease, as larger areas of the
intestinal tract affected by IBD increase risk; age of onset of IBD diagnosis,
as early age of onset (before 20 years) increases the chances of cancer
development; and the amount of inflammation present, as larger amounts of
inflammation contribute to increased risk. Additionally, some studies have
shown that people with inflammatory bowel disease and concomitant
primary sclerosing cholangitis, which describes scarring and narrowing of the
bile ducts, are also at increased risk of cancer.
Patients with IBD should have routine colonoscopies to monitor and detect
changes that could indicate cancer development. Rectal bleeding is often a
sign of colon cancer among those in the general population who do not have
IBD. Because rectal bleeding could indicate a symptom of inflammation
among persons with IBD, potential signs of colon cancer may not always be
so obvious. Colonoscopy is recommended once every 1 to 2 years starting
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approximately 8 to 10 years after a diagnosis of IBD to consistently monitor
the intestinal environment and to assess for signs of colon cancer.
There is no cure for ulcerative colitis or Crohn’s disease. Treatment focuses
on management of symptoms, preventing the disease from progressing, and
maintaining the patient’s quality of life. Control of inflammatory bowel
disease requires routine follow up with a healthcare provider to determine
the progression of the disease, whether the medications prescribed are
effective, and if the patient is experiencing complications. The patient must
also make lifestyle changes, such as by monitoring nutritional intake and
activity levels, to promote the highest quality of life while living with the
disease. With regular medical care and adherence to drug therapy, the
patient with IBD can live an active life.
In addition to nutritional counseling and support, the patient typically
requires psychological support and counseling. Treatment is often ongoing to
provide education and resources to patients who are undergoing therapeutic
procedures; for example, a patient preparing for surgery should receive
education and intervention so that the healthcare provider spends time
talking with the patient and discussing the procedure, explaining what to
expect during recovery, the long-term expected outcomes of the procedure,
and the patient’s expectations for the procedure.
Continued counseling and support is often necessary throughout the process
of treatment and follow-up is warranted to determine the patient’s
psychological response to the situation. Many patients diagnosed with
inflammatory bowel disease struggle with depression because of the chronic
nature of the disease. When IBD symptoms are severe, the affected patient
may struggle with feeling isolated when few people understand the
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condition. A patient may feel like a burden to others. Eating and socializing
with others is often challenging because of the effects of food and digestion
and the person may prefer to stay alone to avoid embarrassment, leading to
further isolation. Depression and anxiety about the condition can occur and
management with counseling or medication may be necessary.
Summary
Inflammatory bowel disease, consisting mainly of Crohn’s disease and
ulcerative colitis, does not have a specific cause, but research continues to
provide new treatments to reduce overall morbidity and mortality.
Inflammatory bowel disease can include a variety of gastrointestinal
disorders, all of which cause symptoms that can significantly impact a
patient's quality of life. There are a number of treatments available that can
be implemented to control disease symptoms, including medical therapies,
and surgical and nutritional interventions. While treatments may take many
forms and are often used in combination, patients with inflammatory bowel
disease have various options for management and control of this debilitating
disease.
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1.
The current, primary goal of medical therapies for treatment of
inflammatory bowel disease is
a. to cure the disease without surgery.
b. to maintain remission of symptoms for as long as possible.
c. educating patient’s on how to live with their symptoms.
d. finding herbal, non-pharmaceutical drugs to treat symptoms.
2.
True or False: Olsalazine is more commonly used for ulcerative
colitis, even though diarrhea may be a side effect of the drug.
a. True
b. False
3.
Patients who take __________________ for treatment of
inflammatory bowel disease should also take a folic acid
supplement.
a.
b.
c.
d.
4.
Which of the following medications has been found to be
effective in treating inflammation associated with Crohn’s
disease?
a.
b.
c.
d.
5.
mesalamine
sulfasalazine
balsalazide
olsalazine
Balsalazide
Mesalamine
Olsalazine
Sulfasalazine
Oral medications are beneficial because once a patient with IBD
receives a prescription drug for oral administration
a.
b.
c.
d.
the
the
the
the
patient takes the drug without further instruction.
drug is easy for providers to monitor daily.
drug is easy for the patient to administer.
patient may take the drug only when symptomatic.
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6.
The primary mode of action of 5-ASA in treating inflammatory
bowel disease is
a.
b.
c.
d.
7.
5-ASA works to control inflammation in the intestinal tract by
inhibiting ___________________, which are lipid compounds
that can affect the inflammatory process.
a.
b.
c.
d.
8.
immunomodulators
TNF- blockers
leukotrienes
prostaglandins
In addition to taking the prescribed dose of corticosteroids, a
patient must be instructed that with corticosteroids,
a.
b.
c.
d.
9.
for treating extra-intestinal symptoms of inflammation only.
the control of diarrhea.
the control of inflammation.
to control bleeding.
the prescribed dose should not be stopped suddenly.
they may be taken over time to control IBD symptoms.
the risk of infection is reduced.
they may be taken only when symptomatic.
Corticosteroids are prescribed
a.
b.
c.
d.
alone and should not be combined with other drugs.
for acute flare up of IBD symptoms.
as maintenance medications for IBD.
All of the above
10. Long-term use of corticosteroids by a patient puts the patient at
risk of severe complications, including
a.
b.
c.
d.
bone marrow suppression, and liver inflammation.
lymphoma, and non-melanoma skin cancer.
lupus and vasculitis.
osteoporosis and blood glucose abnormalities.
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11. True or False: Balsalazide may also be given in smaller doses
when ulcerative colitis develops in children and adolescents.
a. True
b. False
12. Budesonide is a corticosteroid often reserved for treatment of
mild to moderate forms of IBD because
a.
b.
c.
d.
its concentration is greatly reduced first by the liver.
it has more side effects than other corticosteroids.
of its slow metabolism.
its effects are more rapid than other corticosteroids.
13. Which of the following drugs increases the risk of developing
certain types of cancer, such as lymphoma, and non-melanoma
skin cancer?
a.
b.
c.
d.
Corticosteroids
Aminosalicylates
Immunomodulator drugs
Mesalamine
14. Patients who take _______________________ should have
routine laboratory testing to monitor liver function tests and
white blood cell counts.
a.
b.
c.
d.
aminosalicylates
corticosteroids
mesalamine and sulfasalazine
6-mercaptopurine and azathioprine
15. True or False: When the immune system is altered through
immunomodulator drugs, the inflammatory response is
weakened, leading to less inflammation that typically develops
with IBD.
a. True
b. False
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16. A disadvantage of the frequent use of immunomodulators is the
increased susceptibility
a.
b.
c.
d.
for diabetes.
to skin cancer.
to infection.
for vasculitis.
17. Biologic therapies describe drugs that have been developed from
organisms and that
a.
b.
c.
d.
work
have
have
work
slower than immunomodulator drugs.
been developed from organisms.
slow metabolism.
by exciting the immune system.
18. _________________ has the potential to cause birth defects, so
women who may become pregnant must use a reliable form of
birth control, and women who are pregnant and who have IBD
may not use it.
a.
b.
c.
d.
Budesonide
Azathioprine
Sulfasalazine
Mesalamine
19. 6-mercaptopurine and azathioprine tend to produce similar side
effects, including headache, nausea and vomiting, fever, joint
pain, and
a.
b.
c.
d.
canker sores in the mouth.
liver inflammation.
bone marrow suppression.
All of the above
20. True or False: Immunomodulators such as azathioprine and 6-
mercaptopurine can be used for long periods and are ideal for
prescription management of chronic inflammatory bowel
disease.
a. True
b. False
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21. A downside of using biologic therapies is that when the immune
system is suppressed the body
a.
b.
c.
d.
may suffer from inflammation.
may not feel the effects for months.
will suffer acute flares but not long-term flares.
does not respond to other harmful antigens.
22. Antibiotics are a mainstay of treatment for
a.
b.
c.
d.
ulcerative colitis.
pouchitis.
all types of IBD.
its direct effect on inflammation.
23. The antibiotic _______________ may be more effective in
treating inflammation that affects the colon when compared to
treatment of the small intestine.
a.
b.
c.
d.
ciprofloxacin
rifamixin
metronidazole
mesalamine
24. Negative consequences associated with the use of antibiotics
include:
a.
b.
c.
d.
stopping antibiotics increase the risk of a rebound effect.
infectious microorganisms become resistant to the antibiotic.
an increased risk of developing infection with C. difficile.
All of the above
25. True or False: Prebiotics and probiotics, found in many foods
and available as supplements, have been found to reduce levels
of inflammation and are effective in treating the symptoms of
IBD.
a. True
b. False
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26. Patients who suffer from ________________ and who have
developed lesions in the mouth often benefit from oral
corticosteroid mouthwash rinses that can provide some pain
relief.
a.
b.
c.
d.
C. difficile
ulcerative colitis
Behcet’s disease
pouchitis
27. Patients with ulcerative colitis who take ________________ are
often able to achieve remission and sustain it for longer periods
when compared with some other types of medical therapies.
a.
b.
c.
d.
certolizumab
golimumab
ciprofloxacin
mesalamine
28. For patients who have reached the point of needing _________,
the only other option for treatment is surgical intervention,
since there has been little to no response to other types of
medical therapies.
a.
b.
c.
d.
cyclosporine
ciprofloxacin
certolizumab
mesalamine
29. In cases of very severe colitis, such as in _______________, an
affected patient may need intravenous infusion of several
medications.
a.
b.
c.
d.
Crohn’s disease
Behcet’s disease
pouchitis
fulminant ulcerative colitis
30. True or False: Cyclosporine is an immunosuppressant agent that
is administered in moderate to mild cases of IBD, most often
with Crohn’s disease.
a. True
b. False
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31. Approximately _________________ of people with ulcerative
colitis eventually have surgery as either a medical treatment for
the disease or to manage a complication.
a.
b.
c.
d.
up to 75%
half
10 percent
25 to 40 percent
32. A proctocolectomy with a permanent ileostomy describes
surgery done to remove
a.
b.
c.
d.
the colon, the rectum, and the anus.
part of the colon.
the ileum and the colon.
the ileum.
33. If the anus is preserved during surgery, the ileostomy can be a
temporary measure until the rest of the bowel has healed, and
this is followed by a later surgery
a.
b.
c.
d.
for an ileostomy.
known as a laparotomy.
known as an ileocolic resection.
for anastomosis.
34. True or False: When considering immunomodulator and biologic
drugs for an IBD patient with a current infection, these drugs
should be delayed because bacterial infection is a
contraindication to receiving these drugs.
a. True
b. False
35. What procedure involves the creation of a pouch within the
abdominal cavity where part of the ileum is turned back onto
itself and sewn into place?
a.
b.
c.
d.
Colostomy
Brooke ileostomy
Continent ileostomy
Ileostomy
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36. Another type of ileostomy procedure, which may also be used
for management of ulcerative colitis, is the ileo-anal reservoir,
which is also called
a.
b.
c.
d.
a J-pouch.
an abdominal pouch.
a proctocolectomy.
an I-pouch (internal pouch).
37. A bowel resection involves removal of the intestine and when
the colon is involved, it is called
a.
b.
c.
d.
ileocolic resection.
a large bowel resection.
small bowel resection
a reanastomosis.
38. The most common type of ileostomy surgery is the __________,
often considered a standard form of surgical treatment for
management of ulcerative colitis and Crohn’s disease.
a.
b.
c.
d.
Crohn’s ileostomy
Behcet’s ileostomy
Brooke ileostomy
fulminant ileostomy
39. True or False: Removing the large intestine as prophylactic for
prevention of cancer in patients who have mild forms of IBD and
few symptoms is generally recommended to reduce cancer risk.
a. True
b. False
40. During ileostomy surgery, the surgeon creates an opening in the
abdominal wall, usually on
a.
b.
c.
d.
the
the
the
the
lower right side of the patient’s abdomen.
lower left side of the patient’s abdomen.
front of the abdomen.
patient’s left side.
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41. A patient who is taking corticosteroids is at risk of loss in bone
mineral density and osteoporosis with continued use; the
patient may supplement his diet with
a.
b.
c.
d.
complex carbohydrates
emulsifying agents
calcium and vitamin D
iron
42. True or False: There is a correlation between the rising
incidences of IBD and intake of foods mainly found in Western
diets.
a. True
b. False
CORRECT ANSWERS:
1.
The current, primary goal of medical therapies for treatment of
inflammatory bowel disease is
b. to maintain remission of symptoms for as long as possible.
pp. 5-6; ‘Because inflammatory bowel diseases are not cured
through medical therapies, goals often consist of trying to maintain
periods of remission for as long as possible.”
2.
True or False: Olsalazine is more commonly used for ulcerative
colitis, even though diarrhea may be a side effect of the drug.
a. True
p. 8: “Olsalazine is given orally in divided doses of up to 1 g per
day, depending on symptoms. It is more commonly used for
ulcerative colitis, even though it may cause side effects of
diarrhea.”
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3.
Patients who take __________________ for treatment of
inflammatory bowel disease should also take a folic acid
supplement.
b. sulfasalazine
p. 9: “Sulfasalazine is associated with folate depletion, and can
potentially cause folate-deficiency anemia with regular use.
Therefore, patients who take sulfasalazine for treatment of IBD
should also take a folic acid supplement.”
4.
Which of the following medications has been found to be
effective in treating inflammation associated with Crohn’s
disease?
d. Sulfasalazine
pp. 7-8: “Aminosalicylate drugs, such as mesalamine, balsalazide,
or olsalazine … are more commonly used for treatment of ulcerative
colitis and are less commonly used in Crohn’s disease; however,
sulfasalazine has been shown to be effective in treating
inflammation associated with Crohn’s disease.”
5.
Oral medications are beneficial because once a patient with IBD
receives a prescription drug for oral administration
c. the drug is easy for the patient to administer.
p. 7: “Oral medications are beneficial in that once they are obtained
through a prescription, they are administered easily. A patient
taking oral medications often takes them independently while at
home. A patient may need instruction regarding the appropriate
ways to take these drugs; for instance, some oral preparations are
better tolerated when taken with food. Some patients may also
need reminders if they must take their doses of these drugs
multiple times per day.”
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6.
The primary mode of action of 5-ASA in treating inflammatory
bowel disease is
c. the control of inflammation.
p. 7: “The primary mode of action of 5-ASA is the control of
inflammation, which is why they are often prescribed for cases of
inflammatory bowel disease, including during times when extraintestinal symptoms of inflammation are present, such as when IBD
causes symptoms of arthritis.”
7.
5-ASA works to control inflammation in the intestinal tract by
inhibiting ___________________, which are lipid compounds
that can affect the inflammatory process.
d. prostaglandins
p. 8: Aminosalicylates or 5-ASA work to control inflammation in the
intestinal tract by inhibiting prostaglandins, which are lipid
compounds that can affect the inflammatory process, and
leukotrienes, which are types of inflammatory mediators; this
action thereby inhibits part of the inflammatory cascade. 5-ASA
works very quickly and is absorbed rapidly in the lumen of the small
intestine.”
8.
In addition to taking the prescribed dose of corticosteroids, a
patient must be instructed that with corticosteroids,
a. the prescribed dose should not be stopped suddenly.
pp. 10-11: “Other adverse events that have been noted with
frequent corticosteroid use include an increased risk of infection….
Patients must be instructed carefully on use of corticosteroids to
ensure that the prescribed dose is taken at the suggested times and
is not stopped suddenly. The full treatment of the drug is given over
a period of 1 to 4 weeks, depending on a patient’s condition, the
existing symptoms, the severity of the disease, and whether a
patient has had these drugs in the recent past.”
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9.
Corticosteroids are prescribed
b. for acute flare up of IBD symptoms.
p. 10: “Corticosteroids have been shown to be beneficial during
severe flares and for short-term use, but long-term use of these
types of drugs may have more limited effectiveness. As a result,
corticosteroids are never prescribed as maintenance medications for
IBD; …. When used for acute flare up of symptoms, corticosteroids
can reduce inflammation and swelling, but they are often
considered to be more effective when combined with other drugs,
such as immunosuppressive agents.”
10. Long-term use of corticosteroids by a patient puts the patient at
risk of severe complications, including
d. osteoporosis and blood glucose abnormalities.
p. 10: “Long-term use of corticosteroids also puts patients at risk of
severe complications, including osteoporosis and blood glucose
abnormalities.”
11. True or False: Balsalazide may also be given in smaller doses
when ulcerative colitis develops in children and adolescents.
a. True
p. 8: “Balsalazide may also be given in smaller doses when
ulcerative colitis develops in children and adolescents.”
12. Budesonide is a corticosteroid often reserved for treatment of
mild to moderate forms of IBD because
a. its concentration is greatly reduced first by the liver.
p. 12: “Budesonide is another type of corticosteroid that may be
used for some people with IBD. It is administered orally and is said
to have high first-pass liver metabolism, meaning that its
concentration is greatly reduced first by the liver before it reaches
systemic circulation.”
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13. Which of the following drugs increases the risk of developing
certain types of cancer, such as lymphoma, and non-melanoma
skin cancer?
c. Immunomodulator drugs
p. 13: “When given for IBD, immunomodulators are helpful in
suppressing inflammation; they may also be administered when a
person exhibits extra-intestinal symptoms of IBD, including arthritis
symptoms, as they control the inflammation associated with many
autoimmune conditions as well. A disadvantage of regular use of
these types of drugs is their potential to suppress the immune
system to the point that persons taking the drug are at risk of
infection with opportunistic diseases. There is an increased risk of
developing certain types of cancer with these drugs as well,
including lymphoma, and non-melanoma skin cancer.”
14. Patients who take _______________________ should have
routine laboratory testing to monitor liver function tests and
white blood cell counts.
d. 6-mercaptopurine and azathioprine
p. 14: “Because 6-mercaptopurine is a derivative of azathioprine, 6mercaptopurine and azathioprine have similar rates of effectiveness
and are structurally similar. They also tend to produce comparable
side effects, including headache, nausea, and vomiting, as well as
canker sores in the mouth, fever, joint pain, bone marrow
suppression, and liver inflammation. Patients who take these drugs
should have routine laboratory testing to monitor liver function
tests and white blood cell counts.”
15. True or False: When the immune system is altered through
immunomodulator drugs, the inflammatory response is
weakened, leading to less inflammation that typically develops
with IBD.
a. True
p. 12: “Immunomodulator drugs are those that are administered to
weaken some of the effects of the immune system. When the
immune system is altered through these drug preparations, the
inflammatory response is weakened, leading to less inflammation
that typically develops with IBD.”
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16. A disadvantage of the frequent use of immunomodulators is the
increased susceptibility
c. to infection.
p. 16: “A disadvantage of the frequent use of immunomodulators is
the increased susceptibility to certain infections.”
17. Biologic therapies describe drugs that have been developed from
organisms and that
b. have been developed from organisms.
p. 18: “Biologic therapies describe drugs that have developed from
organisms and that are prescribed for the treatment of certain
diseases.”
18. _________________ has the potential to cause birth defects, so
women who may become pregnant must use a reliable form of
birth control, and women who are pregnant and who have IBD
may not use it.
d. Mesalamine
p. 16: “Methotrexate also has the potential to cause birth defects,
so women who may become pregnant must use a reliable form of
birth control, and women who are pregnant and who have IBD may
not use methotrexate.”
19. 6-mercaptopurine and azathioprine tend to produce similar side
effects, including headache, nausea and vomiting, fever, joint
pain, and
a.
b.
c.
d.
canker sores in the mouth.
liver inflammation.
bone marrow suppression.
All of the above
p. 14: “Because 6-mercaptopurine is a derivative of azathioprine, 6mercaptopurine and azathioprine have similar rates of effectiveness
and are structurally similar. They also tend to produce comparable
side effects, including headache, nausea, and vomiting, as well as
canker sores in the mouth, fever, joint pain, bone marrow
suppression, and liver inflammation. Patients who take these drugs
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should have routine laboratory testing to monitor liver function
tests and white blood cell counts.”
20. True or False: Immunomodulators such as azathioprine and 6-
mercaptopurine can be used for long periods and are ideal for
prescription management of chronic inflammatory bowel
disease.
a. True
p. 14: “Azathioprine and 6-mercaptopurine have been shown to be
beneficial in helping patients who take concomitant steroids to
wean off of the corticosteroids. They may be administered at the
same time as the steroid preparations and given simultaneously for
a period – approximately a month, depending on the amount
prescribed — while the corticosteroids are tapered off. Another
benefit of these types of immunomodulators is that, while they do
take approximately 3 to 6 months to achieve their full effects, they
can be used for long periods and are ideal for prescription
management of chronic IBD.”
21. A downside of using biologic therapies is that when the immune
system is suppressed the body
d. does not respond to other harmful antigens.
pp. 18-19: “A downside of using these biologic therapies is that
when the immune system is suppressed and the body is unable to
create inflammation, the patient can be at risk of infection with
other organisms. The individual experiences immunosuppression
and risk of illness because the body not only does not create
inflammation related to IBD, but it also does not respond to other
potentially harmful antigens that could cause other types of
disease.”
22. Antibiotics are a mainstay of treatment for
b. pouchitis.
p. 20: “Although antibiotics may or may not be used for
management of other types of IBD, either alone or in combination
with other medications, they are a mainstay of treatment of
pouchitis.”
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23. The antibiotic _______________ may be more effective in
treating inflammation that affects the colon when compared to
treatment of the small intestine.
c. metronidazole
p. 22: “Metronidazole may be more effective in treating
inflammation that affects the colon when compared to treatment of
the small intestine.”
24. Negative consequences associated with the use of antibiotics
include:
a.
b.
c.
d.
stopping antibiotics increase the risk of a rebound effect.
infectious microorganisms become resistant to the antibiotic.
an increased risk of developing infection with C. difficile.
All of the above
p. 21: “Alternatively, there are some negative consequences of
antibiotic use. Because of the increasing rate of antibiotic
resistance, many patients cannot take these drugs for prolonged
periods and they may only be relegated to times when severe
symptoms are present. Continued and prolonged use of antibiotics
may decrease the susceptibility of infectious microorganisms to
these drugs and they may become ineffective over time. Some
patients with IBD are at increased risk of developing infection with
C. difficile, which causes severe diarrhea and abdominal pain.
Prolonged use of antibiotics has been connected with an increased
risk of C. difficile infection. Further, stopping antibiotics after a
period of use may also increase the risk of a rebound effect in which
the symptoms that abated with antibiotic use return.”
25. True or False: Prebiotics and probiotics, found in many foods
and available as supplements, have been found to reduce levels
of inflammation and are effective in treating the symptoms of
IBD.
b. False
p. 19: “Research is ongoing about the effects of substances on the
gut microbiota and the ensuing effects on inflammation related to
IBD. Prebiotics and probiotics, found in many foods and available as
supplements, have continually been studied to determine their
effects, if any, on improving numbers of microorganisms in the
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gastrointestinal tract and ultimately subduing levels of
inflammation. Although research in these areas has not found
anything definite yet, the debate continues.”
26. Patients who suffer from ________________ and who have
developed lesions in the mouth often benefit from oral
corticosteroid mouthwash rinses that can provide some pain
relief.
c. Behcet’s disease
p. 26: “Oral corticosteroid agents may be applied topically to mouth
lesions affecting the buccal mucosa and the lips in these cases.
Additionally, patients who suffer from Behcet’s disease and who
have developed lesions in the mouth often benefit from mouthwash
rinses that can provide some pain relief.”
27. Patients with ulcerative colitis who take ________________ are
often able to achieve remission and sustain it for longer periods
when compared with some other types of medical therapies.
b. golimumab
p. 27: “Golimumab has been shown to decrease inflammation and
to improve the appearance of the colon with use, as seen upon
colonoscopy. Patients with ulcerative colitis who take this drug are
often able to achieve remission and sustain it for longer periods
when compared with some other types of medical therapies.”
28. For patients who have reached the point of needing _________,
the only other option for treatment is surgical intervention,
since there has been little to no response to other types of
medical therapies.
a. cyclosporine
p. 30: “Because of its side effects, the patient who requires initial
cyclosporine therapy should be tapered from its use as quickly as
possible. It is associated with renal toxicity, seizures, and severe
hypertension. For many people who have reached the point of
needing cyclosporine, the only other option for treatment is surgical
intervention, since there has been little to no response to other
types of medical therapies.”
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29. In cases of very severe colitis, such as in _______________, an
affected patient may need intravenous infusion of several
medications.
d. fulminant ulcerative colitis
p. 31: “In cases of very severe colitis, such as in fulminant
ulcerative colitis, an affected patient may need intravenous infusion
of several medications.”
30. True or False: Cyclosporine is an immunosuppressant agent that
is administered in moderate to mild cases of IBD, most often
with Crohn’s disease.
d. False
p. 30: “Cyclosporine is a type of immunomodulator therapy that
blocks activation of lymphocytes to suppress immunity. This drug is
not commonly administered unless in very severe cases of IBD,
most often with Crohn’s disease, and when complications such as
fistulas have developed.
31. Approximately _________________ of people with ulcerative
colitis eventually have surgery as either a medical treatment for
the disease or to manage a complication.
d. 25 to 40 percent
p. 34: “Approximately 25 to 40 percent of people with ulcerative
colitis eventually have surgery as either a medical treatment for the
disease or to manage a complication. Additionally, up to 75 percent
of people with Crohn’s disease eventually require some form of
surgery, either as an elective option or because of severe
consequences of the disease.”
32. A proctocolectomy with a permanent ileostomy describes
surgery done to remove
a. the colon, the rectum, and the anus.
“Proctocolectomy describes surgery done to remove the colon, the
rectum, and the anus…. The individual undergoing proctocolectomy
requires a permanent ileostomy after the surgery, in which the
lower portion of the small intestine — the ileum — is connected to a
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stoma where it can drain outside of the body.”
33. If the anus is preserved during surgery, the ileostomy can be a
temporary measure until the rest of the bowel has healed, and
this is followed by a later surgery
d. for anastomosis.
p. 36: “If the anus is removed during the surgery, the ileostomy will
be permanent, but if the anus is preserved, the ileostomy can be a
temporary measure until the rest of the bowel has healed. This is
followed by a later surgery for anastomosis.”
34. True or False: When considering immunomodulator and biologic
drugs for an IBD patient with a current infection, these drugs
should be delayed because bacterial infection is a
contraindication to receiving these drugs.
a. True
p. 32: “A patient with a current infection should be monitored
closely and drug administration delayed, as bacterial infection is a
contraindication to receiving immunomodulator and biologic drugs.”
35. What procedure involves the creation of a pouch within the
abdominal cavity where part of the ileum is turned back onto
itself and sewn into place?
c. Continent ileostomy
p. 40: “A continent ileostomy, also called an abdominal pouch, can
sometimes be performed for patients with ulcerative colitis. This
procedure involves the creation of a pouch within the abdominal
cavity when part of the ileum is turned back onto itself and sewn
into place.”
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36. Another type of ileostomy procedure, which may also be used
for management of ulcerative colitis, is the ileo-anal reservoir,
which is also called
a. a J-pouch.
p. 41: “A third type of ileostomy procedure, which may also be used
for management of ulcerative colitis, is the ileo-anal reservoir,
which is also called a J-pouch or ileal pouch anal anastomosis
(IPAA).”
37. A bowel resection involves removal of the intestine and when
the colon is involved, it is called
b. a large bowel resection.
p. 44: “A bowel resection involves removal of the intestine; when
the small intestine is involved, it is called a small bowel resection
and when the colon is involved, it is called a large bowel resection
or colectomy.”
38. The most common type of ileostomy surgery is the __________,
often considered a standard form of surgical treatment for
management of ulcerative colitis and Crohn’s disease.
c. Brooke ileostomy
p. 40: “The most common type of ileostomy surgery is the Brooke
ileostomy, often considered a standard form of surgical treatment
for management of ulcerative colitis and Crohn’s disease.”
39. True or False: Removing the large intestine as prophylactic for
prevention of cancer in patients who have mild forms of IBD and
few symptoms is generally recommended to reduce cancer risk.
b. False
p. 38: “Despite the success of eliminating potential locations for
colorectal cancer development by removing the large intestine, the
process, when used as prophylaxis, it often met with mixed
reviews. There currently is a certain amount of controversy
surrounding prophylactic surgery for prevention of cancer,
particularly when the surgery is performed in patients who have
mild forms of IBD and few symptoms.”
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40. During ileostomy surgery, the surgeon creates an opening in the
abdominal wall, usually on
a. the lower right side of the patient’s abdomen.
p. 39: “During ileostomy surgery, the surgeon creates an opening
in the abdominal wall. This opening is usually on the lower right
side of the patient’s abdomen.”
41. A patient who is taking corticosteroids is at risk of loss in bone
mineral density and osteoporosis with continued use; the
patient may supplement his diet with
c. calcium and vitamin D
p. 56: “Some patients with IBD benefit from taking a multivitamin
or iron supplement to combat anemia or vitamin deficiencies they
may have developed because of the disease. Supplementation of
specific nutrients is often effective in controlling many symptoms
associated with nutrient shortages. For example, a patient who is
taking corticosteroids is at risk of loss in bone mineral density and
osteoporosis with continued use and he may have difficulties with
taking in enough dairy products in his diet. Supplementation with
calcium and vitamin D in this case may help to prevent further bone
loss and could support and protect the patient’s bones and teeth.”
42. True or False: There is a correlation between the rising
incidences of IBD and intake of foods mainly found in Western
diets.
a. True
p. 52. “There is a correlation between the rising incidences of IBD
and intake of foods mainly found in Western diets. Many of the
additives involved, including emulsifying agents and complex
carbohydrates have been shown to have damaging effects on
intestinal tissues. The role of nutrition therapy in both the
prevention and management of inflammatory bowel diseases
cannot be underestimated.”
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