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Ulcerative Colitis,
Crohn’s Disease
And Other
Inflammatory Bowel
Diseases
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 no singular known cause for inflammatory bowel disease
exists, medical research has led to new treatments and a reduction in
mortality rates associated with the disease. Inflammatory bowel
disease includes 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
multifaceted approach is commonly the best 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.
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 etiology, diagnosis
and treatment of inflammatory bowel disease.
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.
Inflammatory bowel disease (IBD) is actually a group of
disorders that
a.
b.
c.
d.
2.
similarly cause inflammation in the gastrointestinal tract.
affect the same areas of the intestine.
respond treatment in the same way.
All of the above
True or False: All types of IBD develop along the
gastrointestinal tract in the areas of the small or large
intestines.
a. True
b. False
3.
Two of the most common types of inflammatory bowel
disease (IBD) are
a.
b.
c.
d.
4.
proctitis and Crohn’s disease.
proctosigmoiditis and proctitis.
colitis and sclerosing cholangitis.
colitis and Crohn’s disease.
Sclerosing cholangitis causes inflammation and scarring
within the
a.
b.
c.
d.
5.
ulcerative
ulcerative
ulcerative
ulcerative
the cecum.
bile ducts.
descending colon.
the ileum.
_________________ is a chronic condition that causes
inflammation of the intestinal tract with concomitant
ulcerations of the intestinal mucosa.
a.
b.
c.
d.
Ulcerative proctosigmoiditis
Behcet’s disease
Ulcerative colitis
Sclerosing cholangitis
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Introduction
The chronic gastrointestinal condition of inflammatory bowel disease
(IBD) is a recurring disease characterized by inflammation, tissue
deterioration, and ulceration in different regions of the gastrointestinal
system. The most common types of IBD are ulcerative colitis and
Crohn’s disease. The different types of IBDs may develop anywhere
along the gastrointestinal tract from the mouth to the anus, although
most cases are confined to areas of the small or large intestines.
Inflammatory bowel disease causes periods of active illness in which
affected persons suffer from multiple symptoms that include pain and
diarrhea, followed by periods of remission, in which there are few to
no symptoms at all. The chronic nature of the disease has confounded
physicians who have researched its causes and the most appropriate
forms of treatment to be able to induce remission and alleviate some
of the debilitating symptoms.
Overview Of Inflammatory Bowel Disease
Inflammatory bowel disease is actually a group of disorders that all
cause similar effects of inflammation in the gastrointestinal tract. The
diseases that are classified as IBD often produce similar symptoms,
but they also have variations in their causes, the areas of the intestine
involved, and their response to treatments. Two of the most common
types of IBD are ulcerative colitis and Crohn’s disease. Although there
are varying conditions that fall under the classification of being
inflammatory bowel diseases, ulcerative colitis and Crohn’s are the
most well known conditions of IBD because they are the most
common. Both of these diseases cause intestinal inflammation, pain,
and tissue damage in the gastrointestinal tract. Ulcerative colitis
primarily affects the large intestine, while Crohn’s disease is most
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common in the small intestine, but can occur anywhere along the
digestive tract. Inflammatory bowel disease has been, at times,
confused with some other conditions that affect the gastrointestinal
tract, including irritable bowel syndrome and general colitis. While
these conditions may be disabling to those who suffer from them, they
are not the same as inflammatory bowel diseases, which require
extensive treatment and daily management when symptoms develop.
Inflammatory bowel disease is characterized by fluctuations in the
course of the disease that involve periods of acute symptoms followed
by periods of remission when few or no symptoms are present. During
a disease flare the symptoms reappear; a flare can be brief with
symptoms lasting for a few days, or the flare could last for months.1
There is greater risk of tissue damage, disease complications, or
possibly permanent harm to the patient, when a flare episode becomes
prolonged and symptoms persist.
The type and extent of the symptoms that occur during a flare vary
between people, as well as the inflammatory bowel disease type.
Some people experience debilitating symptoms that affect their ability
to live a normal life, while others exhibit mild symptoms that are
uncomfortable but that are short lived. Common symptoms that
develop during disease flares for people with IBD include diarrhea and
urgent bowel movements, rectal bleeding, abdominal pain and
cramping, fever, fatigue, nausea and vomiting, and weight loss. The
main goals of treatment for IBD symptoms are to induce periods of
remission (in which few of these symptoms are present), and to
maintain remission for as long as possible.
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Ulcerative Colitis
Ulcerative colitis, a chronic condition that causes inflammation of the
intestinal tract with concomitant ulcerations of the intestinal mucosa,
was first recognized approximately 150 years ago as a distinct disease.
Although clinicians have long recognized the existence of this
particular type of inflammatory bowel disease, the underlying causes
and the specific forms of treatment are areas where knowledge
continues to develop.
Ulcerative colitis typically only causes inflammation of the large
intestine and the rectum; alternatively, the small intestine remains
largely unaffected. The exact cause of ulcerative colitis and the
reasons why some people develop the condition are not known, but
research suggests potential environmental or genetic causes. People
who develop ulcerative colitis often have a family member with IBD;
up to 25 percent of people with ulcerative colitis have a first-degree
relative with some form of inflammatory bowel disease. The
combination of family history of the disease and environmental
triggers, such as infection or smoking cessation, can lead to
development of ulcerative colitis.2
An environmental trigger, such as a period of illness or stress, can lead
to a period of intense symptoms, further ulcer development and a flare
episode. Normally, the person with ulcerative colitis struggles with
painful symptoms during times of flares, but these are often on an
intermittent basis. The disease has periods of remission and
exacerbation when symptoms are present. A trigger that causes a flare
activates the immune system, causing an autoimmune response in
which the body attacks the lining of the large intestine and/or the
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rectum, leading to tissue breakdown and ulcer formation. As
discussed, there are various situations and substances that can lead to
disease flares.
Although stress is known to be a triggering factor for a disease flare,
uncontrolled stress is not the cause of ulcerative colitis or of any other
type of IBD. Some people who experience intense emotional stress
may suffer from digestive symptoms; the term stress ulcer has even
been used among some in the lay public to describe a stomach or
intestinal ulcer that develops as a result of stress. While stress and
intense emotions associated with difficult situations can be
overwhelming and can lead to health issues, it is important to
understand that IBD develops due to other causes related to the
gastrointestinal tract and inflammation, not solely because of stress.
Stress and tension can trigger disease flares and so stressors should
be managed to prevent symptom recurrence.
Ulcerative colitis most often occurs in adolescents, young adults, and
those of middle age. It is most commonly diagnosed between the ages
of 15 and 40 years, and again after age 60. It is less commonly
diagnosed for the first time in adults of middle age to older adulthood;
however, a diagnosis at a younger age, combined with the ongoing
need for the treatment of flares and active disease, may mean that the
condition in an affected patient will persist throughout adulthood.
Approximately 5 percent of first-time cases of ulcerative colitis are
diagnosed after age 60.3 The condition is also more likely to develop in
industrialized countries, particularly in the United States and Europe;
the increased incidences of ulcerative colitis found in these countries
are thought to be partially associated with diet.
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The inflammation that develops with ulcerative colitis affects the lining
of the colon, most often the layers closest to the intestinal lumen. This
inflammation can occur anywhere in the large intestine; it may only
develop in small patches or it could affect the entire colon. In some
cases, the rectum is involved as well, or the rectum may be the only
site involved at all. The inflammation causes tissue breakdown of the
colon’s mucosal layer, leading to sores and ulcers that may contain
pus, mucus, or blood. The inflammation and ulcerations are not
present at all times; in fact, they may be in various stages of healing,
depending on whether the person is in disease remission. During a
flare, the inflammation and tissue damage causes multiple symptoms
of abdominal pain, diarrhea and an increased need for a bowel
movement. The loose stools often contain pus and blood, and episodes
of diarrhea may occur many times in a day.
In addition to the classic symptoms associated with ulcerative colitis
(diarrhea, abdominal pain, weight loss, and rectal bleeding), the
affected patient may suffer from extra-intestinal symptoms that are
unrelated to the gastrointestinal tract. There are a number of
conditions affecting the liver and the gall bladder that may develop
with ulcerative colitis. These illnesses may be more likely to develop
because of the close proximity of these organs with the intestinal tract.
A small percentage of patients develop sclerosing cholangitis, which
causes inflammation and scarring within the bile ducts. Other
complications commonly seen with these organs include fatty liver
disease, gallstones, chronic hepatitis, and pancreatitis.4 Extraintestinal manifestations that may be seen with ulcerative colitis that
are beyond those affecting the liver, gallbladder, or pancreas include
joint and muscle pain, septic arthritis, erythema nodosum (small, red
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bumps, swelling, and inflammation most commonly seen on the fronts
of the legs), irritation of the iris of the eye, kidney stones, and deep
vein thrombosis.5
Although symptoms can encumber those patients affected with
ulcerative colitis, their intensity and severity may fluctuate throughout
the course of the disease. When symptoms do develop, their effects
are related to the area of the intestinal tract most affected. In the case
of ulcerative colitis, because the disease affects the colon and/or the
rectum, the patient with the disease will most often suffer from the
effects that occur when the large intestine and the rectum are
damaged and are not working properly.
Large Intestine
Also known as the colon or the large bowel, the large intestine makes
up a significant portion of the final segment of the gastrointestinal
tract. The large intestine is the main site of fluid absorption from fecal
matter before it is expelled from the body. The large intestine consists
of several parts and connects with the small intestine at the cecum;
from that point, it is made up of the ascending colon, the transverse
colon, the descending colon, and the sigmoid colon, which precedes
the rectum and the anus. The large intestine is approximately 2½
inches in diameter and is roughly 7½ feet long.
When inflammation develops within the large intestine, it can impact
how well the various areas of the colon are able to perform their
routine duties. The inflammatory process is complex, designed as the
body’s response to exposure to certain antigens and as a form of
protection.
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It is well known that inflammation can develop as the body’s response
to its own cells in an autoimmune process or as a result of
dysregulation of the normal course of cell-mediated or humoral
immunity. When inflammation occurs with ulcerative colitis, it may be
the result of various factors. The initial triggering factor stimulates the
immune system to respond by sending certain substances to the site.
In the case of ulcerative colitis, this site is somewhere in the colon or
the rectum.
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Once activated, the immune system initially sends macrophages to the
area, which are designed to engulf and destroy antigens. The
activation of these macrophages stimulates the release of more
cytokines, leading to the inflammatory cascade, which is the continued
activation and release of cells of the immune system to protect the
body.
Cytokines are produced by the cells of the immune system, mainly the
B cells, T cells, NK cells, and macrophages. The T-helper cells are
responsible for producing many cytokines, therefore, inflammatory
processes associated with different types of IBD may be driven by
either T-helper 1 (Th1) cells or T-helper 2 (Th2) cells.6 In the case of
ulcerative colitis, the disease is said to have a Th2-like mediated
response, based on the types of cytokines released.3,6 There are a
number of different cytokines that may be released during the
inflammatory process, and each one plays a specific role. Some
cytokines are responsible for inducing inflammation and are considered
to be pro-inflammatory cytokines. Interleukin-1 (IL-1), for example,
stimulates various cells to initiate inflammation and stimulates the
hypothalamus to increase body temperature when inflammation is
developing. Tumor necrosis factor-alpha (TNF-) also further induces
inflammation and promotes fever in the affected individual.24
Alternatively, some cytokines are designed to suppress the
inflammatory response once it occurs. Interleukin-4 promotes the
growth of B cells, while IL-10 inhibits some of the work of
macrophages, thereby restraining further inflammation. The role of
these cytokines is to initiate repair and healing of tissue when
inflammation has developed. One of the main reasons for the
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inflammatory response within the body is to increase blood flow to the
affected site, so areas that are inflamed become red and warm.
Nearby blood vessels dilate to increase blood flow, which can also
increase the risk of bleeding if the tissue becomes friable and breaks
down.
The inflammation that develops
with ulcerative colitis is
associated with a breakdown of
intestinal tissue that leads to
ulcers in the gastrointestinal
tract. The triggering event leads
to an inflammatory response,
leading to the release of
immune cells and inflammatory
mediators, which only prolongs
the inflammatory response. It is
thought that this derangement
of the inflammatory response
occurs as a result of the
patient’s immune system response and subsequent inflammation
development. It is also possible bacterial flora present in the intestinal
tract of the patient with ulcerative colitis plays a role in affecting the
integrity of the mucosal lining of the large intestine, which may make
it more prone to tissue breakdown and ulcer formation.3 As mentioned
above, a person with ulcerative colitis can develop inflammation and
ulcers in any part of the large intestine. The condition ranges in
severity from affecting only one portion of the large intestine to
causing inflammation and lesions throughout the entire colon.
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The lining of the intestinal tract consists of four main layers: the
mucosa, the submucosa, the muscularis layer, and the adventitious
layer. While most areas of the gastrointestinal tract consist of these
four layers, the cells of the large intestine contain some different
elements within its layers. In comparison to some other areas, the
cells of the mucosal layer in the large intestine are simple columnar
epithelial cells, which are densely packed. The intestinal lumen of the
large intestine does not contain villi; the intestinal villi are part of the
mucosa of the small intestine. The mucosal layer also contains many
goblet cells, which are responsible for secreting mucus into the
intestinal tract to keep the surface lubricated. The mucosal layer also
contains many crypts, which are chambers that extend down toward
the submucosal layer. Stem cells are located in the middle or at the
bottom of these crypts, and are responsible for creating new epithelial
cells.8
The submucosa contains connective tissue, as well as nerves and
blood vessels. These elements provide a supportive framework for the
other layers of the large intestine. The muscularis layer contains
smooth muscles that are responsible for the contractions of the colon
that move materials and feces along the intestinal tract.9 The outer
layer, which is the adventitious layer, is responsible for secreting
mucus to keep its surface lubricated so that it does not adhere to other
nearby organs.
The ulceration associated with ulcerative colitis often begins with
stimulation of the inflammatory process and the progresses to tissue
breakdown. White blood cells and other inflammatory cells travel to
the base of the crypts to form abscesses. The small abscesses that
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have formed within the crypts spread and connect with other nearby
abscesses until there is a large area of swollen and damaged tissue.
The overlying material then starts to break down and the topmost
layers of tissue are shed into the lumen. The ulceration associated with
ulcerative colitis often only affects the mucosal and submucosal layers
of the intestinal tract, but typically does not extend down into the
muscularis layer.3 The disease process associated with ulcerative
colitis differs from Crohn’s disease; with Crohn’s disease, ulcerations
can extend through all layers of the intestinal tract.
As the inflammation persists and the layers of the colon continue to
sustain damage, the mucosal and submucosal intestinal layers become
even more swollen and inflamed. There may be pseudopolyps, which
have the appearance of polyps, but are actually collections of scar
tissue that develop when ulcers are healing. Pseudopolyps are not
associated with an increased risk of colon cancer and they are typically
not removed unless they cause a blockage in the intestinal tract. The
ulcers that develop may be sporadic along the intestinal tract, but
more commonly, enough ulcerations form close together and are
eventually connected, leading to large areas of ulcerated tissue. The
disease may cover one or more segments of the large intestine,
depending on severity. In some cases, all areas of the colon are
involved. Ulcerative colitis that affects the entire large intestine,
including the ascending, transverse, descending, and sigmoid portions
is sometimes called pan-colitis.
The inflammation and ulcerations eventually spread through the
submucosa of the large intestine. Small fissures and cracks form in the
submucosa, which contribute to tissue breakdown. The tissue bleeds
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and becomes necrotic, leading to sloughing of cell debris into the
colonic lumen. Over time, scar tissue can develop and the affected
portions of the mucosa become thickened and scarred. Many times,
only partial healing occurs before the next disease flare, so the patient
has areas of ulcers in limited stages of healing alternating with fibrous,
thickened tissue.
Increased vascularity to the ulcerated portions of the intestinal tract
increases the risk of bleeding. The portions of the colon affected no
longer work properly because the tissue has become fibrous and
dense, increasing the risks of gastrointestinal complications. The
patient often develops frequent and severe diarrhea, dehydration from
a loss of fluid through the stool, and sodium imbalances from an
inability to reabsorb salt and water in the colon. Ulcerative colitis is
also associated with occasional severe complications that require
additional treatment and hospitalization.
Because ulcerative colitis primarily affects the large intestine, the
patient with this illness is at risk of several complications that are
associated with colonic damage, whether due to the physiological
breakdown of the intestinal wall and the protective mucosa, or
because of the colon’s inability to perform its normal functions due to
sustained damage from the disease. A person with ulcerative colitis is
at risk of toxic megacolon, a severe complication that can be lifethreatening if it is not contained. Toxic megacolon develops when the
lumen of the large intestine widens and dilates. Consequently,
undigested material and fecal matter cannot be moved through the
large intestine. Air and gas also build up within the colon and the
patient is at risk of colonic rupture.10 This condition causes severe
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abdominal pain and distention and the patient should seek emergency
care for help since toxic megacolon requires prompt treatment to
prevent further consequences. Prompt treatment often includes
emergency surgery. If toxic megacolon is left untreated it may be
fatal.
Bowel perforation is another potential complication that is associated
with severe cases of ulcerative colitis. When ulcers are large and deep
and inflammation is widespread, the wall of the colon can become
weakened to the point that it ruptures, spilling its contents into the
abdominal cavity. This can quickly lead to severe infection and can
become life threatening if not treated immediately. Bowel perforation
is more commonly associated with cases of toxic megacolon. When a
patient presents with possible bowel perforation, there are few medical
therapies administered once the condition is diagnosed. Instead,
emergency surgery is almost always required to remove the damaged
areas of the colon.
Ulcerative colitis and other forms of IBD that affect the large intestine
increase the risk of Clostridium difficile infection in the gastrointestinal
tract. C. difficile infection tends to cause severe diarrhea, which may
make it difficult to establish IBD versus C. difficile as the cause of
diarrhea. This infection is often a healthcare-associated infection, in
which patients contract it while in the hospital or healthcare
environment. The infection is also more common among patients who
are taking immunosuppressant medications as part of treatment for
IBD.11
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In addition to the potential complications described above, ulcerative
colitis symptoms during times of disease flares can range in severity
from mild to overwhelming. As discussed, ulcerative colitis is
characterized by ongoing periods of active symptoms followed by
periods of remission. During flares, damage from inflammation and
ulcers lead to rectal bleeding, bloody diarrhea, and destruction of the
mucosa of the large intestine. Once the flare subsides and symptoms
abate, partial healing occurs until the next flare. This partial healing of
the affected areas is what is usually involved in the next flare. The
affected portions of the large intestine are never quite free from
ulceration and diseased tissue, even if the patient is not having active
symptoms. Over time, because of the ongoing damage to the intestinal
tract, the patient with ulcerative colitis suffers from disrupted bowel
function and the large intestine no longer operates in a normal
manner.
The damage to the large intestine leaves the affected patient at risk of
fluid depletion due to abnormal absorption of water and electrolytes in
the colon. There may be subsequent electrolyte imbalances, which can
cause a variety of abnormal symptoms as well. During flares, the
patient often experiences abdominal pain and when symptoms are
worse after eating, he may choose to eat less food in order to avoid
symptom development; ultimately, this can lead to weight loss and
loss of muscle mass. Ultimately, when large areas of the colon are
affected and the patient is experiencing severe symptoms that are
significantly impacting quality of life, surgery to remove some of the
diseased portions of the bowel may be necessary as part of therapy.
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Rectum
The inflammation and tissue destruction of the large intestine seen
with ulcerative colitis can also affect the rectum; rectal involvement of
ulcerative colitis may be in addition to colonic involvement or it may
develop on its own. Approximately 46 percent of patients with
ulcerative colitis have rectal involvement, called ulcerative proctitis
when it affects only the rectum, and ulcerative proctosigmoiditis when
the sigmoid colon is also involved.12
The rectum describes the last six inches of the large intestine; it
begins just after the sigmoid colon. As stool passes through the large
intestine, it is mostly stored in the descending colon, just before
reaching the sigmoid colon. Once the descending colon is full, stool is
then passed into the rectum where it is stored until defecation. When
the stool enters the rectum, the individual typically feels the urge to
have a bowel movement. The end of the rectum terminates in the
anus, which is the opening through which stool passes with defecation.
Ulcerative proctitis occurs when the inflammation and lesions
associated with ulcerative colitis affect this area of the intestinal tract.
Burakoff, et al., in the book Medical Therapy of Ulcerative Colitis,
defines ulcerative proctitis as the inflammation and ulcerations of the
disease that is limited to the rectum or the first 15 to 20 cm from the
anal verge. In contrast, the patient with ulcerative proctosigmoiditis
has disease involvement of the rectum but that also extends into the
large intestine.13 A portion or all of the sigmoid colon may be involved.
The sigmoid colon is approximately 40 cm in length from where it
adjoins the rectum. Ulcerative proctitis typically causes uncomfortable
symptoms similar to those seen with ulcerative colitis affecting other
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areas. The affected patient most often experiences frequent diarrhea
and bloody stools; however, some symptoms are more pronounced
because of the effects of the disease on the rectum. Tenesmus may be
a common symptom with proctitis, which is the sudden and persistent
urge to have a bowel movement. Tenesmus may occur even if no stool
is present in the rectum and defecation is not imminent. In addition to
blood in the stool or diarrhea, the affected patient may have a mucous
discharge from the rectum that is not associated with a bowel
movement. Damage to the anal sphincter, which normally holds stool
in the body until an appropriate time for defecation, may cause
leakage of stool from the rectum when diarrhea is present.14
In contrast to the rectum, the sigmoid colon is the lower portion of the
large intestine that is situated between the descending colon and the
rectum. The sigmoid colon is the narrowest portion of the large
intestine. It appears to be S-shaped because of how it curves as it
advances toward the rectum. Ulcerative colitis rarely affects only the
sigmoid colon; the clinical manifestations of the disease usually also
include either the rectum, the left side of the large intestine, or both.
Ulcerative inflammation in the sigmoid colon may also be part of pancolitis when ulcerative colitis affects the entire large intestine.
The symptoms of ulcerative proctosigmoiditis are very similar to those
of proctitis. The affected individual often has frequent urges to have a
bowel movement and suffers from tenesmus whether stool has passed
into the rectum or not. Diarrhea, bloody stools, and mucous drainage
from the rectum are also present with proctosigmoiditis. Stool
incontinence can occur with leakage of diarrhea, which is often
embarrassing for the affected patient; the person with ulcerative colitis
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that leads to stool incontinence may avoid social activities and events
to avoid the humiliation of an accidental loss of stool.
The treatments for proctitis and proctosigmoiditis are similar to those
of ulcerative colitis that affects other portions of the colon. The patient
may benefit from systemic medications that control pain and
inflammation and that suppress the immune response. Because of the
location of the inflammation, proctitis and proctosigmoiditis are also
often managed successfully with medications that are administered
rectally, including rectal suppositories and enemas. The direct contact
of the medication with the affected tissue may result in greater pain
relief and resolution of inflammation with fewer systemic side effects
of the drugs.
Crohn’s Disease
One of the most common forms of inflammatory bowel disease is
Crohn’s disease, which affects approximately 700,000 people in the
United States. Crohn’s is a chronic disease that causes inflammation in
the intestinal tract, with periods of disease exacerbations (flares)
followed by periods of remission. However, for some people, Crohn’s
disease causes continuous symptoms that do not abate without
treatment. The disease is thought to affect men and women equally
and it most often develops during adolescence and young adulthood,
between the ages of 15 and 35 years.15 Crohn’s disease is also
sometimes referred to as regional enteritis.
There are many similarities between Crohn’s disease and ulcerative
colitis, such that the two conditions are sometimes confused. Although
Crohn’s disease affects other portions of the gastrointestinal tract
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beyond those impacted by ulcerative colitis, many of the pathological
manifestations of these two conditions are so similar that in
approximately 10 percent of patients, the actual diagnosis cannot be
determined between the two.3
As with other forms of IBD, Crohn’s disease is thought to develop due
to a combination of genetic factors and environmental triggers that
lead to disease flares. Genetic factors are thought to be more
prominent in the development of Crohn’s when compared to some
other types of inflammatory bowel diseases.16 Up to 20 percent of
people with Crohn’s disease have a relative afflicted with some type of
inflammatory bowel disease.15 The environmental triggers that lead to
disease flares can occur from any number of events, including severe
stress or infection.
Crohn’s disease is more commonly seen in industrialized countries,
including the United States and Europe, as opposed to its presence in
developing nations. Because of this, certain factors that appear within
industrialized countries, including lifestyle factors, pollution, and diet
may all play a role in acting as triggers for flares of the disease. Some
particular population groups are also at greater risk of developing
Crohn’s disease. For example, the condition targets people of
Ashkenazi Jewish descent: this population is almost 5 times at higher
risk of developing Crohn’s when compared to the general population.16
Crohn’s disease is also more commonly seen in people who are
Caucasian and is less common in those of Hispanic or Asian ethnicities.
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Unlike ulcerative colitis and some
other forms of IBD, Crohn’s disease
can cause inflammation along any
part of the gastrointestinal tract
and is not limited to specific areas.
The symptoms that each person
manifests often vary, depending on
the main area of the intestinal tract
affected. For example, an individual
with Crohn’s disease affecting the
proximal end of the small intestine
in the duodenum and jejunum may
suffer from anemia and
malnutrition due to poor nutrient
absorption because of damage to the intestinal wall. Alternatively,
someone with Crohn’s disease that impacts the majority of the
gastrointestinal tract, including the large intestine, may have lower
abdominal pain and frequent, bloody diarrhea.
In contrast to ulcerative colitis, the inflammation and ulceration that
occurs with Crohn’s disease can affect all layers of the gastrointestinal
tract. This is often described as being transmural, in which the lesions
cause full-thickness ulcerations. When the disease affects all intestinal
layers, there may be a greater risk of strictures and narrowing of the
intestinal lumen, as full-thickness lesions may be more likely to
produce scarring.
The transmural nature of the disease also increases the risk of other
gastrointestinal complications, such as intestinal abscesses and
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fistulas, which are more commonly seen with Crohn’s when compared
to some other types of IBD. The surface of the intestinal lining often
appears rough with a “cobblestone” appearance that is characteristic
of Crohn’s disease. The areas of ulceration may or may not be
consistent and close together. Some affected areas of tissue may
contain large patches of ulcerations of varying thickness, while in some
other areas, lesions are not connected and there is healthy tissue in
between. These ulcers are often referred to as skip lesions and they
are more commonly seen with Crohn’s disease, but are less often seen
with some other forms of IBD.
Although it can affect any part of the gastrointestinal tract, the
inflammation from Crohn’s most often develops in the distal portion of
the small intestine — the ileum — and the junction between the small
intestine and the cecum, known as the ileocecal region. The symptoms
of the disease and the amount of damage caused by the inflammation
may range in severity from being classified as mild with few bouts of
diarrhea or other symptoms and few complications, to severe, in which
the patient has significant symptoms that disrupt daily life and
requires extensive medical treatment.
Crohn’s disease not only causes inflammation, pain, and tissue
damage within the gastrointestinal tract, but persons diagnosed with
this condition also tend to suffer from other systemic problems that
are not necessarily related to the intestines at all. Crohn’s disease also
tends to cause liver and gallbladder diseases, including an elevated
risk for gallstones; patients are also at increased risk of blood clots
and their associated consequences, such as stroke and pulmonary
embolism. Arthralgia and arthritis are two common extra-intestinal
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complaints; arthritis is said to affect up to 30 percent of people with
Crohn’s.17 Some people also develop skin nodules, skin ulcers that
appear similar to those seen in the intestinal tract, and psoriasis.
As with other types of IBD, research continues to uncover reasons why
some people develop Crohn’s disease, why it flares, and why the
symptoms arise. There are a number of factors that can contribute to
disease flares in susceptible people, but there are various theories as
to why some people are more susceptible to intestinal inflammation
than others.
Smoking tobacco is a factor that has been associated with increased
incidences of disease flares among those with Crohn’s disease. For
those with IBD who smoke, quitting increases the likelihood of
maintaining periods of remission. People diagnosed with Crohn’s
disease who have quit smoking have reported fewer disease flares,
while those who continue to smoke often report increased incidences
of flares, increased need for medications to control inflammation, and
a more frequent need for surgical intervention.1
Other potential factors that seem to be related to Crohn’s disease
development include alterations in specific genes in the body, which
can lead to problems with defense mechanisms that would normally
protect the intestinal lining. An abnormal response of the immune
system is another possible cause of Crohn’s development. As with
ulcerative colitis, when inflammation related to Crohn’s develops in the
intestinal tract, it is because the body is releasing certain cytokines as
part of its defense mechanisms. An alteration in the ability to release
cytokines, or a disruption in how the body recognizes certain factors as
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being foreign antigens, can all affect disease development. The Thelper cells also play a role in the inflammatory process associated
with Crohn’s disease. As described, ulcerative colitis is considered to
have a Th2-mediated response to inflammation, but Crohn’s disease
tends to exhibit a Th1 response.18 This classification is given in large
part to the types of cytokines produced by the T cells when
inflammation of Crohn’s progresses.
As discussed, Crohn’s differs from ulcerative colitis in that it can affect
any portion of the gastrointestinal tract. Although it is most commonly
seen in the ileum and at the junction of the small and large intestines,
Crohn’s disease has been seen in some patients at any area of the
gastrointestinal tract, from the anorectal area to the upper GI area of
the mouth and esophagus.
Perianal Crohn’s Disease
Perianal Crohn’s disease affects the anus and the surrounding tissues.
Perianal Crohn’s may occur as its own set of symptoms or the disease
may flare at the same time as other intestinal areas. This particular
type of Crohn’s disease is characterized by pain, inflammation,
swelling, and lesions around the anal opening, in the anal sphincter,
and on the perianal tissue. Approximately one-third of patients with
Crohn’s disease develop perianal Crohn’s symptoms.19
People with perianal Crohn’s disease often suffer from symptoms that
are similar to those that occur when the disease affects the rectum.
There may be a frequent urge to have a bowel movement, and
defecation is painful. The affected person may be incontinent of stool
from an inability to maintain normal function of the anal sphincter.
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Additionally, the individual may have pain or itching around the anus
and may pass blood, pus, or mucus with stools. Anal sphincter stenosis
may also develop with significant damage from inflammation, in which
the tissue around the anus becomes stenotic and the sphincter does
not work properly; the opening of the anus decreases in size and there
may be difficulty with passing stool. However, for many patients with
Crohn’s affecting the anus, these strictures and stenosis develop
slowly and they may adjust to routinely passing stool even when the
opening has narrowed.20
There is often great discomfort with having perianal Crohn’s disease,
whether it is because of physical manifestations that affect the ability
to have a normal bowel movement or due to social implications of this
particular type of disease. The individual may suffer embarrassment
and social anxiety because of an inability to control defecation and fear
of stool odor on clothing or of soiling the clothes from stool
incontinence. Consequently, Crohn’s disease that affects the anus,
while often only impacting one area of the gastrointestinal tract, can
still significantly diminish quality of life among affected individuals.
When the tissue around the anus becomes severely inflamed and
ulcerated, abscesses can develop in the area. These have the
appearance of large sores or boils; the tissue is red and swollen and
the sore may be filled with pus. Abscesses are extremely painful for
the affected patient. Fistulas, which occur when an abnormal channel
forms between tissues, may also develop between the anal opening
and the rectum because of deep ulcers that have formed.16 Fistulas
may also occur between the rectum and the bladder, the vagina, or
the surrounding skin. When a fistula develops, the affected person will
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often experience bleeding and mucus discharge near the opening of
the anus. Fistulas around the anus are also very painful for patients
when having a bowel movement and the fistula is likely to become
infected if not treated. These fistulas are most common in patients
with Crohn’s disease when compared to persons with other types of
inflammatory bowel diseases.
Anal fissures may also develop as a complication of Crohn’s disease
when ulcerated tissue causes skin breakdown at the anal opening. This
can cause deep grooves and cracks in the skin, which can be very
painful for the patient, particularly when having a bowel movement,
and they are more likely to develop as a result of frequent, heavy
bowel movements. The fissures can be superficial and only affect the
upper layers of skin, or they can be deep. The depth of the fissures is
related to the amount of pain it causes for the patient and its ability to
heal. Superficial fissures typically heal completely with medical
therapy.
Skin tags may appear as benign growths on the skin near or in the
anus. These are almost always non-malignant but they also remain
once they develop.20 A skin tag may appear during a disease flare but
even when symptoms have resolved, the skin tag often remains. The
skin tags are also unaffected by treatment and they typically remain,
even when other areas are healed because of treatment. Skin tags
may become irritated or inflamed, which can be uncomfortable for the
patient. Usually they are left alone because they are benign, but if
they grow large enough to affect defecation, they may need to be
removed.
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The main forms of treatment for perianal Crohn’s involve medications,
diet and lifestyle changes, and in some cases, surgical intervention.
The main goals of treatment for this specific form of Crohn’s disease
are to improve symptoms of pain and stool incontinence, control
inflammation, prevent the spread of painful and debilitating
complications, and to improve patient quality of life.
Crohn’s Disease of the Large Intestine
Crohn’s disease may affect the large intestine. The disease may be
isolated entirely to the colon or it may affect the large intestine in
addition to other areas of the gastrointestinal tract. When the disease
develops in the large intestine, it can be limited to specific areas of the
colon or it may cause tissue damage along the entire length of the
large intestine. Crohn’s disease that affects only the ileum and the
large intestine is known as ileocolitis. Approximately 50 percent of
people with the disease have Crohn’s ileocolitis.21
Crohn’s that affects the large intestine causes the characteristic tissue
injury and inflammation as seen in other areas of the gastrointestinal
tract. There may be abscesses and pockets of infection at various
points along the intestinal tract. Because Crohn’s can potentially cause
transmural effects, there may be damage at all layers of the lining of
the colon, from the inner mucosal layer to the outer adventitious layer.
The effects of Crohn’s in the large intestine impair its ability to carry
out normal functioning of fluid and electrolyte absorption. Since the
majority of nutrient absorption takes place in the small intestine, the
large intestine receives the leftover, undigested material. At the point
when this material reaches the large intestine, it is in liquid form. The
colon then absorbs much of the water from this material as it passes
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through. The material becomes feces by the time it reaches the
rectum, due in large part to the absorption of water and salts in the
colon and the work of the microbiota within the intestinal tract. When
damage affects the large intestine, the affected patient may suffer
from electrolyte imbalances and fluid loss.
The patient with Crohn’s disease that affects the large intestine is at
risk of several complications that impact this particular area of the
gastrointestinal tract, including intestinal blockage, abscesses, and bile
salt diarrhea. The ulcers and inflammation from Crohn’s disease can
cause scarring in the intestinal tract, leading to thickening of tissue
and potentially narrowing the lumen of the colon. The movement of
material through the colon slows, which can cause stool impaction.
Because Crohn’s disease affects all layers of the intestinal tract,
abscesses, which are pockets of infection that contain pus, can develop
in the intestinal wall and cause it to bulge.10 Abscesses are more
commonly seen in patients with Crohn’s disease when compared to
those with other types of IBD, although they can form in anyone with
an inflammatory bowel condition. Because the ileocecal region of the
intestinal tract is the main location of bile acid absorption, as well as
the most common location of ulcer development in Crohn’s disease,
bile salt diarrhea can develop in some patients. This occurs when bile
acids are not absorbed and excess fat remains in the gastrointestinal
tract. This condition leads to fat malabsorption and causes more bouts
of diarrhea.
Crohn’s that affects the large intestine is the type of the disease that
most often results in severe diarrhea, rectal bleeding, and anal
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abscesses or fistulas. While other diseased areas of the
gastrointestinal tract also cause a number of painful symptoms and
potential complications, Crohn’s that primarily affects the colon seems
to cause the highest risk of problems. Patients with Crohn’s affecting
the colon are also more likely to suffer from extra-intestinal symptoms
of the disease, including joint pain and skin lesions.1
Crohn’s Disease of the Small Intestine
The small intestine is the longest portion of the gastrointestinal tract.
Its name refers to the diameter of the intestinal lumen rather than its
length. The average length of the small intestine is approximately 20
feet long in adults. It connects with the stomach at its proximal end
and consists of three main parts, each of which has various functions.
The duodenum receives food from the stomach, which is mixed with
secretions from the pancreas and liver to promote digestion. The
second segment is the jejunum, which starts just after the duodenaljejunal flexure of the small intestine. It is in the jejunum that the
majority of nutrients are absorbed into circulation to be used by the
body. The final segment of the small intestine, the ileum, receives the
remainder of the material passing through the intestinal tract. Some
nutrient absorption takes place in the ileum as well before the rest of
the undigested material is pushed into the large intestine.
Nutrient absorption is an essential activity of the small intestine, and
damage to this area of the intestinal tract can result in several
metabolic consequences, including malnutrition, weight loss, and
wasting. The small intestine digests and absorbs nutrients through a
specific process that is carried out by its design. As food enters the
small intestine, it is known as chyme, which is mixed and moved
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through the smooth muscle
contractions of the intestine. The
luminal surface contains millions of
microscopic projections known as
microvilli, which greatly increase
the surface area of the small
intestine and which facilitate
nutrient absorption. The intestinal
wall also contains lymph channels,
which are responsible for
absorption of fats and fat-soluble
vitamins.
Patients with Crohn’s disease are
at risk of malnutrition when the inflammation and ulcers in the small
intestine disrupt absorptive processes. The majority of nutrient
absorption takes place in the duodenum and the jejunum of the small
intestine. After eating a meal, most fatty acids, amino acids from
proteins, vitamins, minerals, and glucose from carbohydrates are
absorbed in the proximal sections of the small intestine. The ileum is
primarily responsible for absorbing vitamin B12 as well as bile salts.
When ulcers and inflammation penetrate these areas of the small
intestine, the villi on the mucosal surface are damaged and can no
longer absorb nutrients properly. Likewise, fats and fat-soluble
vitamins are unable to be absorbed by the corresponding lymph
channels. The patient instead passes the nutrients along through the
rest of the digestive tract where they are eventually excreted from the
body. Malnutrition due to malabsorption in the small intestine can lead
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to a number of symptoms and problems, which can range from
electrolyte abnormalities when these nutrients are not absorbed
properly to severe weight loss and protein energy malnutrition from
loss of fat and protein. Larger sections of the small intestine affected
by Crohn’s disease result in a greater risk of malabsorption.
Additionally, some patients with severe disease have affected portions
of the small intestine surgically removed as part of treatment. This
surgical intervention, while often effective in disease management, can
contribute to malabsorption and malnutrition.
There are several subtypes of Crohn’s disease that are named based
on the area of the intestinal tract most affected. Jejunoileitis describes
Crohn’s disease that primarily affects the jejunum and the ileum of the
small intestine but few other locations. It is often confused with some
other diseases that may only impact only this portion of the intestinal
tract, such as celiac disease, irritation from use of NSAIDs, or
gastrointestinal infection. Crohn’s disease that is classified as
jejunoileitis is often much more aggressive compared to Crohn’s
disease in other locations of the gastrointestinal tract.22 The patient
with disease manifestations in this area may suffer more severe
symptoms, the disease may spread to other areas of the intestine, and
there is greater potential for complications. Ileitis describes Crohn’s
that affects only the ileum, and ileocolitis affects the ileum and the
colon. Ileocolitis is considered the most common form of Crohn’s
disease. Other subtypes describe Crohn’s that affects the stomach and
duodenum as well as the large intestine only.1
Patients with Crohn’s that primarily affects the small intestine will
usually suffer from abdominal pain, and they may also experience
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nausea and vomiting. The symptoms that develop may depend on the
area of the small intestine affected. Crohn’s that impairs the
duodenum often leads to weight loss, malnutrition, anemia, and loss of
appetite. Jejunoileitis often causes severe abdominal cramps after
eating, as well as diarrhea and an increased risk of fistula formation.
When Crohn’s affects the ileum, there is often severe diarrhea and
cramping, accompanied by significant weight loss and an increased
risk of fistula and abscess formation.23
Other significant complications can develop as well when Crohn’s
affects the small intestine. For some patients, bacterial overgrowth can
occur in the small intestine when the normal amounts of bacteria
present expand and multiply. Most people with this condition develop
abdominal pain, bloating, excess gas, and diarrhea. The symptoms
may or may not differ much from symptoms experienced during a
disease flare, which may make it difficult to diagnose based on
symptoms alone. Bacterial overgrowth typically requires treatment
with antibiotics to return the levels
of microorganisms back to normal.
Small bowel obstruction describes
a condition in which there is
narrowing or blockage of an area of
the small intestine leading to
slowed transit of food and chyme
through the digestive tract and
impaired nutrient absorption. The
patient with Crohn’s disease
affecting the small intestine is at
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risk of small bowel obstruction due to damage in the intestinal lining
that causes strictures and tissue thickening. The inflammation of the
disease leads to fibrotic changes that eventually narrow the size of the
intestinal lumen.
Because the small intestine is so long and is centrally located along the
gastrointestinal tract, the ability to reach strictures and areas of tissue
damage through endoscopy may be limited. A report in the journal
Neurogastroenterology & Motility described small bowel strictures as
“unresponsive to medical management, necessitating surgical
intervention.”24 When strictures develop, small intestinal motility is
slowed significantly; this can be quite problematic for the affected
individual, as it can cause intestinal obstruction, malabsorption, and
malnutrition. As stated, the condition typically requires surgery to
correct because of its location within the intestinal tract.
Unfortunately, Crohn’s most commonly affects the small intestine,
meaning that patients are at risk of some very serious consequences.
The central location of the small intestine and its important work of
digestion and absorption indicate that disease development in this
area can be destructive to the affected patient’s overall health and
quality of life.
Gastroduodenal Crohn’s Disease
Gastroduodenal Crohn’s disease is a subtype of the condition in which
inflammation, ulcers, and scarring develop in the stomach and in the
duodenum of the small intestine. The antrum of the stomach, which is
the largest and lowest portion of the stomach that stores ingested
food, is the most common area involved with this type of Crohn’s,
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along with the most proximal portion of the small intestine. The
manifestations of gastroduodenal Crohn’s disease are often nonspecific and may be mistaken for another condition, particularly if
Crohn’s has not been diagnosed elsewhere in the intestinal tract.
Gastroduodenal Crohn’s disease often has symptoms and
manifestations similar to H. pylori infection, peptic ulcer disease,
gastroenteritis, or Zollinger-Ellison syndrome, a condition in which
there is overproduction of gastric acid and peptic ulcers in the stomach
due to a pancreatic tumor.25
People who develop primarily gastroduodenal Crohn’s often have
difficulties with eating and may experience anorexia and nausea with
consequent weight loss.1 Scarred tissue in the duodenum may restrict
the passage of food as the stomach empties into the small intestine
and the patient may suffer from increased nausea and vomiting as a
result. Other symptoms commonly associated with Crohn’s disease in
this area include fatigue, early satiety, dyspepsia described as a
feeling of indigestion, and epigastric pain, particularly after eating.
Although Crohn’s disease most commonly affects the small and large
intestines, a number of patients have mild concomitant inflammation
in the stomach and duodenum. A report in the Video Journal and
Encyclopedia of GI Endoscopy stated that 20 to 60 percent of patients
with Crohn’s disease undergoing upper endoscopy manifest mild
inflammation and gastritis in the stomach and duodenum; however,
severe inflammation that causes symptoms of Crohn’s that affects this
area of the intestinal tract accounts for only 4 percent of cases.26 Most
people who develop Crohn’s disease in the stomach have inflammation
and Crohn’s ulcerations in other parts of the intestinal tract as well; if
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the inflammation is only found in the stomach, it is often a precursor
to disease development in other areas.25
Gastroduodenal Crohn’s disease causes thickening in the folds of the
stomach as well as the characteristically bumpy, cobblestone
appearance associated with Crohn’s disease. The tissues in the
affected areas, often the antrum and the duodenum, become
thickened and digestion and food passage slows. There is inflammation
that worsens during time of disease flares, and tissue breakdown leads
to ulcerations forming within the stomach cavity and on the interior
lining of the duodenum. The affected areas of the stomach pouch
cannot distend with food intake because they are thickened. The tissue
is erythematous, friable, and easily prone to breakdown and bleeding,
and fissures or cracks may form, most often at the junction of the
head of the duodenum.25
Crohn’s disease that affects the stomach is treated with similar
medical therapies as those used for treatment of the disease in other
areas of the gastrointestinal tract, including systemic corticosteroids,
immunomodulator drugs, and biologic therapies. If H. pylori infection
is present, the patient may need antibiotics to control the spread of
the infection. Additionally, most patients with stomach manifestations
benefit from proton pump inhibitor medications to control stomach
acid secretion. These drugs are often effective in controlling excess
gastric acid secretion, but they do not reduce inflammation present
with the disease. Therefore, most patients have success in treating
gastroduodenal Crohn’s disease with a combination of therapies to
suppress gastric acid production and to reduce inflammation and pain.
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Gastroduodenal Crohn’s disease increases the risk of gastric outlet
obstruction, which occurs as a blockage at the opening between the
stomach and the small intestine. The effects of Crohn’s can cause
stricture formation when inflammation and lesions affect the lower
portion of the stomach, the pyloric sphincter, or the duodenum. The
tissue is thickened and does not transport food in a normal manner
needed for digestion. The affected patient often suffers from
gastroesophageal reflux, frequent vomiting after meals, early satiety,
and pain in the area of the stomach.27 Consequently, the person can
suffer from significant weight loss and dehydration as well as
continued pain and symptoms of gastritis. The condition must be
corrected quickly to prevent further health deterioration.
When strictures develop to cause obstruction, endoscopic balloon
dilatation may be effective in widening the affected area and it reduces
the need for surgical intervention. If gastric outlet obstruction causes
enough problems with digestion and results in pain and malabsorption
that is ongoing despite attempts at dilatation, the patient may need
surgery to remove some of the diseased areas and to widen any
strictures that have developed. Approximately one-third of patients
with gastroduodenal Crohn’s disease eventually require surgery to
manage complications of this particular type of IBD.25
Crohn’s Disease of the Esophagus
Crohn’s disease that develops in the esophagus is a rare form of the
illness: of all the locations throughout the gastrointestinal system
where Crohn’s disease develops, the esophagus seems to be the area
least affected.28 The lesions and inflammation that occur in other parts
of the intestinal tract with Crohn’s disease can also develop in the
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esophagus anywhere from the pharynx at the back of the throat to the
lower esophageal sphincter connecting the esophagus to the stomach.
Esophageal Crohn’s disease may sometimes be confused with other
inflammatory illnesses of the esophagus, most often gastroesophageal
reflux disease.
As with Crohn’s disease affecting the mouth, esophageal Crohn’s
disease is most often associated with inflammation and tissue changes
of the disease affecting other areas as well, including within the large
or small intestines. The esophageal lesions are rarely exhibited prior to
a formal Crohn’s diagnosis or as a precursor to intestinal
manifestations. In most cases, the individual with esophageal Crohn’s
has already been diagnosed with intestinal Crohn’s disease and is
managing the symptoms that develop with flares affecting that area of
the gastrointestinal tract.
Inflammation and lesions of esophageal Crohn’s are often patchy and
may be distributed throughout the esophagus, rather than being
localized to one distinct area. Many patients suffer from pain in the
back of the throat, non-cardiac chest pain, or epigastric pain,
depending on the areas of the esophagus most often affected. The
esophageal tissue is often inflamed and fragile and can bleed easily.
The affected patient may exhibit blood in the stool that has passed
through the digestive tract. Other noted manifestations are similar to
the disease in the intestinal tract and include cracks or fissures in the
esophagus, a cobblestone appearance to the tissue, thickened folds in
the tissue, and even tracheoesophageal fistula, in which tunneling
develops between the esophagus and the trachea.28
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Pain and difficulty with swallowing
are two of the more common
symptoms of this particular type of
Crohn’s. A patient may have
difficulty swallowing various
textures of foods and the patient’s
diet may become limited only to
foods that he may tolerate.
Swallowing liquids can be
problematic and there may be an
increased risk of aspiration of fluids
into the lungs when swallowing is
impaired. A patient may have the
sensation of food or an object being stuck in his throat. To avoid
weight loss and malnutrition associated with poor food intake, the
patient may need a modified diet during times of disease flares to be
able to take in enough food.
When Crohn’s disease affects the esophagus, the disease flares and
periods of remission tend to be correlated with intestinal flares. In
other words, when the individual is experiencing severe symptoms
associated with a disease flare affecting the intestine, the esophageal
symptoms will most likely present themselves at the same time.
Alternatively, when the small bowel or colonic symptoms go into
remission, the esophageal symptoms also tend to abate at the same
time.
The tissue damage and scarring that develops when Crohn’s affects
the esophagus it can lead to tissue thickening and narrowing of the
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esophagus. Strictures often develop in the esophagus when the
inflamed tissue partially heals before breaking down again. The lumen
of the esophagus eventually narrows, which can block the passage of
food and fluids into the stomach. The patient may experience difficulty
swallowing or may regurgitate food after eating. The condition is most
often treated by balloon dilatation, in which a tube is passed into the
esophagus and held at the narrowed area. The balloon is inflated at
the affected site, which stretches and opens the tissue.
Fistula formation can be a significant complication of esophageal
Crohn’s disease. According to Ji, et al. in the World Journal of
Gastroenterology, fistula formation occurs in approximately 33 percent
of patients with Crohn’s disease.29 Although the majority of fistulas
develop near the anus and the perineum, when Crohn’s affects the
esophagus, there is the potential for tunneling and connection between
the esophagus and nearby airway structures. This type of complication
can cause problems with eating and breathing normally and it requires
surgical correction to restore normal tissue. Also, a fistula may form
between the esophagus and the bronchus (esophagobronchial),
between the esophagus and the trachea (tracheoesophageal), or the
esophagus and the mediastinum (esophagomediastinal).
Fistula formation occurs when there is enough tissue damage from
ulceration or lesions that the tissue breaks down and is eroded away.
Diagnosis of an esophageal fistula requires prompt treatment to
prevent aspiration of food or saliva into the lungs. Normally, the
body’s reflexes close the epiglottis to prevent food from entering the
trachea when an individual eats or drinks, but the connection between
the esophagus and the airway can still lead to food aspiration if a
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fistula develops, which almost always leads to airway infection and
pneumonia if not rapidly treated. The patient is often fed with a
feeding tube to avoid trying to swallow food and potentially aspirating
food or fluids into the lungs. Surgical intervention is needed to correct
the defect and to close the wall between the connecting structures.
The process often requires a time of healing in which the affected
patient will have pain and difficulty eating and drinking and may need
a feeding tube for an extended period until the complication has
resolved.
Esophageal Crohn’s disease, while rare, may be underdiagnosed as a
clinical entity. Because many of its symptoms are similar to those of
other esophageal conditions, it may be incorrectly treated as another
illness. It may then take months or even years to formulate the
correct diagnosis in this case and to allow for proper treatment and
healing of the affected area.
Orofacial Crohn’s Disease
Orofacial Crohn’s disease is a rare sub-type of Crohn’s in which the
affected patient develops inflammation and ulceration in the tissues of
the mouth in a manner similar to lesions in the intestinal tract. The
symptoms of orofacial Crohn’s may appear prior to a diagnosis of
intestinal Crohn’s disease or the lesions may develop around the same
time as the wounds in the intestinal tract. The individual with orofacial
Crohn’s disease almost always has inflammation and ulcers associated
with Crohn’s in other areas of the gastrointestinal tract, such as in the
small intestine or in the colon.30
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Orofacial Crohn’s disease may be confused with other conditions that
affect the mouth; i.e., orofacial Crohn’s disease may be confused with
orofacial granulomatosis, which is a condition that causes overgrowth
of granulation tissue, primarily in the mouth. However, according to
Zbar, et al., in the Journal of Crohn’s and Colitis, the major difference
between Crohn’s disease in the mouth and orofacial granulomatosis is
that the patient with Crohn’s disease has concomitant lesions and
inflammation elsewhere in the gastrointestinal tract, while orofacial
granulomatosis typically only affects the mouth.31 Oral Crohn’s disease
rarely only affects the mouth. The patient may have mouth lesions as
an extension of intestinal Crohn’s manifestations, or the oral form of
the disease is a precursor to the development of the intestinal form.
The particular signs and symptoms of orofacial Crohn’s disease include
inflammation of the gums and buccal mucosa, swelling of the lips,
ulcerations in the folds between the inner cheek and gums, cracks and
fissures in the corners of the mouth or on the lips, mucosal tags,
periodontal disease and tooth caries, ulcerations on the hard and soft
palates, and the characteristic cobblestone appearance on the inner
lining of the cheeks.30 Often, affected patients tend to have more than
one symptom occurring at the same time.
Crohn’s disease that affects the mouth can be very painful. The
lesions, swelling, and fissures can impair food intake and cause
difficulties with other activities, including talking, drinking, or
swallowing. The patient’s sense of taste may be altered due to the
mouth sores, which can make adequate food intake difficult. The oral
lesions may make eating and swallowing painful. The patient may be
less likely to eat or drink because ingesting food or fluids and
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swallowing may be too uncomfortable. Certain foods are often avoided
entirely because they only exacerbate the pain of the condition; many
people with mouth lesions avoid any food or liquids that are irritating
to the open tissue, such as citrus fruits or drinks, spicy foods, or those
that are very salty. Sores may also impact a person’s ability to speak
clearly, as the patient may try to compensate for painful lesions on the
oral mucosa.
As with Crohn’s lesions that impact other areas of the intestinal tract,
orofacial Crohn’s symptoms develop in a pattern of disease
exacerbation, or flares, followed by periods of remission for most
people. As a person enters a period of remission, the ulcerated tissue
in the mouth begins to heal. Depending on the extent of the lesions,
the tissue may heal completely or it may form a scar. If the time of
remission is relatively short, the ulcer may not have enough time to
heal completely before another disease flare begins.
During times of flares, the patient is usually very careful with what he
eats and drinks, as this is typically a natural response to mouth pain.
In addition to monitoring food and fluid intake, the individual should
use a soft toothbrush to gently clean the teeth without damaging gum
tissue. Because oral Crohn’s disease is associated with an increased
risk of dental caries and periodontal disease, it is important for the
affected patient to see a dentist on a routine basis for cleanings and to
inspect the oral tissue and the teeth for changes.
The treatment for orofacial Crohn’s disease often involves both
systemic and topical preparations. Systemic medications used for the
management of intestinal lesions to reduce inflammation and to
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control pain can be helpful in managing mouth inflammation as well.
Topical preparations are applied directly to the affected areas of the
mouth and may relieve some pain and inflammation on contact.
Corticosteroid mouthwashes have been shown to be effective in
relieving some pain and inflammation of oral Crohn’s lesions. The
patient rinses the mouth with the steroid solution to allow the fluid to
contact all surfaces of the mouth and gums before spitting it out.
Antibiotic mouthwashes may also be administered to reduce the risk of
mouth infections. There is a risk of infection in the mouth due to food
and fluid intake and it is important that the affected patient practice
regular oral hygiene to keep the tissues clean. However, the risk of
infection is still immediate and the individual may need antibacterial
mouth rinses to cleanse the mouth of excess microorganisms that
could cause complications such as abscesses in the teeth or gums.
Other medications may also be applied to soothe sensitive tissue and
to control pain. Some mouth rinses that contain lidocaine act as
anesthetics for short periods to numb the tissues and relieve some
pain. Oral pastes or gels can also be applied to affected areas to act as
anesthetics and control mouth pain.
Additional Types Of Inflammatory Bowel Disease
The majority of the literature focuses on inflammatory bowel disease
address Crohn’s disease and ulcerative colitis, as these two forms of
the disease make up the greater part of cases of IBD. However, there
are additional types of inflammatory bowel diseases that may have
similar manifestations and complications as Crohn’s and ulcerative
colitis, but that are technically different diseases, whether due to their
causes, influences, or manifestations. Additional types of IBD, while
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rare, can be just as serious as Crohn’s disease or ulcerative colitis and
because of their infrequency, they may be difficult to detect or may be
classified as being the same as the former diseases. It is therefore
important to understand some other types of inflammatory bowel
diseases that may be less common but that require their own forms of
treatment and management.
Microscopic Colitis
A less common form of inflammatory bowel disease, microscopic
colitis, is a condition in which there is inflammation of the
gastrointestinal tract. The inflammatory process of this disease may
not be fully apparent on visual inspection or examination.
The condition was observed for
decades but it was not until 1980
that researchers devised an
actual term for the illness.32 A
patient suffering from microscopic
colitis experiences pain and
diarrhea but there is no obvious
source during examination. The
condition only affects the large
intestine, the sigmoid colon, and
the rectum. This specific type of
inflammatory bowel disease most
commonly affects older adults,
with a higher percentage of older
females than males affected by
collagenous colitis, one of the subtypes of the disease.71
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Microscopic colitis is often classified as being one of two different
types: lymphocytic colitis and collagenous colitis.34 The two
classifications often appear very much the same but have differences
in histopathology. Lymphocytic colitis results in an increased number
of lymphocytes. The tissue usually appears normal but with more
lymphocytes than typical within the sample. Diagnosis of lymphocytic
colitis involves a tissue sample that is examined microscopically. The
tissue shows an increase in the number of lymphocytes in the tissue
and the epithelial layer of the mucosa in the affected area is damaged.
There is also inflammation or damage to the connective tissue layer of
the mucosa but not an increase in the amount of collagen present, as
is seen with collagenous colitis.33
Collagenous colitis occurs when areas of collagen under the epithelium
solidify and the tissue overall becomes concentrated and thick.
Collagen is normally present in the submucosal layer of the intestinal
tract, so evidence of collagen in a tissue sample for biopsy does not
necessarily isolate collagenous microscopic colitis. The condition is
considered to be the collagenous form of the disease when the
collagen has thickened and there is a greater than normal amount
present. It may be necessary to visualize several tissue samples to
make a comparison between the amounts of collagen present in
different areas of the intestinal tract. Upon histological examination,
collagenous colitis demonstrates a band of collagen underneath the
epithelial layer of at least 10 m; it also shows damage to the
epithelial cells of the intestinal tract, and damage to the lamina
propria, which is a layer of connective tissue that makes up part of the
mucosal layer of the intestinal tract.33 Collagenous microscopic colitis
may or may not involve increased numbers of lymphocytes within the
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tissue as well. The actual incidence of this subtype of microscopic
colitis is approximately 1.8 cases per 100,000 people.32
Microscopic colitis is diagnosed after a tissue sample has been
examined for microscopic evidence of inflammation and tissue
damage. During endoscopy used for diagnostic procedures, the
physician is usually not able to see any evidence of inflammation, even
though the patient complains of symptoms. The intestinal mucosa,
upon endoscopy, appears normal or almost normal. However, when
chronic diarrhea is present and the patient is experiencing colitis
symptoms, a biopsy should be performed to further examine the tissue
samples for evidence of microscopic inflammation.
The exact cause of microscopic colitis is unknown. As with Crohn’s
disease, ulcerative colitis, and other forms of IBD, microscopic colitis
development may be related to a combination of genetic factors and
environmental triggers; intestinal irritation due to chronic NSAID use,
autoimmune factors, or a combination thereof may also be possible
causes of this particular type of inflammation. Lymphocytic and
collagenous microcolitis cause the same kinds of symptoms, even
though they appear differently on a microscopic level and their disease
processes differ slightly. People with microscopic colitis typically have
frequent, watery diarrhea with or without abdominal pain and
cramping; patients may have 5 to 10 watery stools per day, but some
people have many more. The diarrhea is not caused by infection and
there are few other complications associated with the condition, unlike
some other forms of IBD. The stool output of microscopic colitis also
often differs from some other types of IBD in that stool is loose but
does not contain blood, pus, or mucus.
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The Crohn’s and Colitis Foundation of America (CCFA) states that there
may be a link between microscopic colitis and celiac disease, an
autoimmune condition in which damage develops in the intestinal tract
after ingestion of gluten, a protein found in wheat products. The
connection is considered because some people with celiac disease have
microscopic inflammation in the intestinal tract that appears similar to
that often seen with microscopic colitis.35 The symptoms between
microscopic colitis and celiac sprue are also similar in that they cause
chronic diarrhea and abdominal pain. When formulating a diagnosis for
the cause of intestinal pain and inflammation, celiac disease should be
ruled out as a possible cause of the inflammation of microscopic colitis
by performing a thorough histological exam to assess the affected
cells.
Microscopic colitis can often be managed with anti-diarrheal
medications to control stool bulk by slowing intestinal motility so that
more water can be absorbed in the large intestine. These products are
available by prescription or they can be purchased as over-the-counter
preparations. Patients with microscopic colitis may take these antidiarrheal medications to help control their symptoms of diarrhea and
abdominal pain, but patients should know that these drugs do not
actually treat the inflammation or cure the disease. Some types of
drugs that may be used include loperamide or diphenoxylate.
The treatments for inflammation associated with both types of
microscopic colitis are typically the same. To treat the inflammation
that occurs with microscopic colitis, the patient often needs some of
the same medical therapies as those used for management of other
types of IBD, including some anti-inflammatory medications or
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immunomodulators. Corticosteroids may also be used on a short-term
basis when symptoms are severe, but these drugs are not
recommended as part of long-term treatment for microscopic colitis.
Approximately 7 percent of patients with the collagenous form of
microscopic colitis also suffer from inflammatory arthritis that affects
one or more joints in the body.32 It is usually managed through antiinflammatory drugs administered for treatment of the colitis. Other
autoimmune diseases may also be associated with collagenous
microscopic colitis, which may indicate a potential connection between
this type of IBD and an autoimmune process. Common conditions that
are seen with collagenous colitis include Sjögren’s syndrome,
thyroiditis, and myasthenia gravis.
Unlike Crohn’s disease or ulcerative colitis, microscopic colitis has not
been shown to increase the risk of colon cancer. The disease, while
producing inflammation and some of the same symptoms as other
types of IBD, does not necessarily cause the same complications and
problems. While patients with microscopic colitis still often struggle
with its symptoms and it is a form of inflammatory bowel disease, the
condition often responds well to treatment and is rarely serious
enough to lead to some of the harmful outcomes that are sometimes
seen with other forms of IBD.
Diversion Colitis
Diversion colitis refers to inflammation of the mucosal lining of a part
of the intestinal tract that is not functional, often because of surgery
for the creation of a colostomy. With placement of a colostomy, the
feces are directed through a certain portion of the bowel so that they
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will be excreted through the stoma and into the colostomy bag. The
defunctioned colon is the portion of the intestinal tract that has been
diverted from the fecal stream because of a diverting colostomy. It is
this defunctioned portion of the colon that develops inflammation
associated with diversion colitis.
Diversion colitis develops in the large intestine and is usually
considered to be benign, although it can cause unpleasant symptoms
and some complications for affected patients. Patients with diversion
colitis develop lymphoid follicular hyperplasia, which is an increase in
the size of lymph node follicles due to increased numbers of white
blood cells. The condition also causes bleeding of mucosal tissue,
mucous plugs, edema, ulcerations, and erythema, and the tissue
overall becomes more fragile. While lymphoid follicular hyperplasia is a
very common element in patients who develop diversion colitis, there
is not one single identifying characteristic of the condition.
Unlike many other forms of IBD, diversion colitis is usually
asymptomatic or produces only mild symptoms. As a result, many
cases go undiagnosed or are misdiagnosed as another type of IBD or
as another gastrointestinal condition altogether, such as irritable bowel
syndrome. Of patients who do experience symptoms, the most
common manifestations include abdominal pain, pain in the pelvic or
rectal areas, tenesmus, low-grade fever, and blood and mucosal
discharge from the rectum.36 Symptoms can develop right away
following colostomy surgery or they may take several years to
manifest.
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The reason some people develop diversion colitis are not clear. Several
potential causes of the condition have been hypothesized, including
bacterial overgrowth, malnutrition, bowel ischemia, low levels of shortchain fatty acids, or the presence of certain toxins in the intestinal
tract.36 Diversion colitis may also be more likely to develop as a type
of immune response, however, further research is needed to
determine if this type of response is an actual factor in disease
development.
Patients who have undergone colostomy or ileostomy are those who
suffer from diversion colitis when it develops. Some patients have preexisting IBD, which is the reason for colostomy placement to begin
with. A review by Kabir, et al., in the International Journal of Surgery
found that of patients who developed diversion colitis who had
colostomies, 91% already had a diagnosis of inflammatory bowel
disease. Approximately 87 percent of patients with preexisting
ulcerative colitis and 33 percent of patients with Crohn’s disease suffer
from symptomatic diversion colitis;36 unfortunately, despite
undergoing surgical intervention as treatment for IBD, diversion colitis
may develop afterward. Although diversion colitis may not be as
significant in symptoms as other cases of ulcerative colitis or Crohn’s
disease, it remains a complication that warrants treatment following
surgical management and colostomy.
Once the bowel has been restored and reanastomosis has been
achieved, diversion colitis almost always resolves. In fact, following
reanastomosis and resolution of diversion colitis, many patients
develop symptoms that seem unrelated to typical IBD symptoms, such
as constipation, dyspepsia, and abdominal bloating.
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Some people with diversion colitis have been treated with enemas that
contain short-chain fatty acids. Normally, bacteria in the colon help to
ferment dietary fiber and produce short-chain fatty acids. These fatty
acids are responsible for upholding some of the structure and integrity
of the gastrointestinal tract. They are also absorbed in the large
intestine during the process of sodium and water absorption through
the colon. Once they are absorbed, they provide fuel for the epithelial
cells of the colon. They are thereby beneficial in maintaining a healthy
intestinal tract; however, those with diversion colitis have been shown
to have low levels of these short-chain fatty acids in the
gastrointestinal system. This is typically because of the colostomy
surgery. The fecal stream, which is the process of feces moving and
being routed through the intestinal tract, normally supplies short-chain
fatty acids to the cells of the colon; however, with a colostomy, the
cells in the diverted portion of the bowel do not receive as many shortchain fatty acids, which can affect their integrity and can lead to
symptoms of diversion colitis.37
An early study in the New England Journal of Medicine tested the
effects of enema administration of short-chain fatty acids in solution to
patients with diversion colitis and found that patients who received
enemas had diminished colitis symptoms and decreased intestinal
inflammation. The symptoms returned when the enemas were
discontinued. One patient maintained remission from diversion colitis
for 14 months by administering twice-daily enemas of short-chain fatty
acids.38 Despite these findings, there have been other studies that
have not resulted in the same outcomes and have found little evidence
of the success of short-chain fatty acid administration. Still, since
some patients have benefited from this type of therapy, it may be an
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option for treatment of diversion colitis, particularly in situations where
other measures do not seem successful.
Because diversion colitis is only seen among patients who have had
colostomy or ileostomy surgery to divert a portion of the intestine, the
condition is not as frequently seen as other types of IBD. However, it
is a very real complication for those who have undergone surgery and
who develop its symptoms. Any patient who is preparing for ostomy
surgery as treatment of IBD should be educated about the potential
for diversion colitis as a possible complication. Although it is relatively
uncommon, education about the condition can still prepare surgical
patients for the possibility of needing to handle this outcome.
Behcet’s Disease
Behcet’s disease is a form of IBD that is more common in Middle
Eastern countries and in Asia when compared to the United States.
Behcet’s disease is an inflammatory condition that causes ulcers in the
mouth and on the genitalia, as well as inflammation in the
gastrointestinal tract, blood vessels, the eye, the brain, and the spinal
cord. A Turkish physician, Dr. Hulusi Behçet, first discovered the
disease in the 1930s.39
Behcet’s disease most commonly develops in young adults, but it has
been seen in people of all ages. As with other types of IBD, the
inflammation that occurs with Behcet’s often develops as a result of a
triggering event in susceptible people. Those who have a family history
of inflammatory bowel conditions or autoimmune disease are more
likely to develop Behcet’s disease and when an environmental trigger
happens, inflammation and ulcers develop. Behcet’s is thought to be
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an autoimmune process in that the associated inflammation occurs
when the body attacks its gastrointestinal and vascular systems. Other
studies have found that people with Behcet’s are more likely to have a
specific type of human leukocyte antigen in the blood but the exact
mechanisms for why these individuals then develop Behcet’s disease is
not entirely clear.40
In addition to being classified as a type of inflammatory bowel disease,
Behcet’s is also a musculoskeletal disorder because it is a type of
vasculitis that causes inflammation of the blood vessels. In fact, most
of the symptoms that develop with Behcet’s disease are from the
effects of inflammation of the blood vessels in the affected individual.
The majority of people with Behcet’s develop aphthous stomatitis:
inflammation and ulcerations in the mouth that are similar in
appearance to canker sores. These ulcers are painful and can make
eating very difficult. The ulcers are usually round with erythematous
borders and they may be shallow or they can be deep enough to
impact more than one layer of tissue. Often, ulcers develop as single
lesions but they can form clusters as well. They occur during flares of
Behcet’s disease and then heal during periods of remission, usually
without causing permanent scarring.40
Approximately half of all patients with Behcet’s disease also suffer
from ulcers on the genitalia.39 These areas of inflammation and
ulceration are most prominently found on the scrotum in men and on
the vulva in women and are similar in appearance to the ulcers and
sores that develop in the mouth. However, unlike the mouth sores
associated with the condition, the ulcers that develop on the genitalia
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with Behcet’s are often deeper and tend to leave scars after they have
healed.40
There are various other symptoms seen with Behcet’s disease that do
not necessarily affect the gastrointestinal tract, including sores on the
skin, which appear as red, pus-filled lesions. There may be
inflammation of the eye, most commonly the iris and the uvea,
although the retina may also become inflamed and the patient may
have vision loss, excess tear production, and photophobia. Severe
cases of eye inflammation may lead to complete blindness. Because
the disease tends to affect persons of Middle Eastern and Asian
descent more commonly than in Europe or the United States, cases of
eye inflammation are much more common in impacted countries.
Behcet’s disease eye involvement is the leading cause of blindness in
Japan.40
Central nervous system involvement leads to meningitis or
meningoenchephalitis, and the affected patient may develop severe
headaches, problems with walking or coordination, and seizures. The
disease affects the vascular system, causing thrombophlebitis, which
leads to pain, swelling, and inflammation associated with small blood
clots in the peripheral vascular system. Approximately 50 percent of
patients with Behcet’s disease develop arthritis in one or several joints
in the body, causing pain, swelling, and difficulties with joint
movement.40 The joint inflammation is more severe during times of
flares.
Behcet’s disease also affects the gastrointestinal tract when ulcers
develop along the intestinal lining. The ulcers are similar to the
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aphthous stomatitis found in the mouth with this condition. The ulcers
cause symptoms of abdominal pain and diarrhea. When the ulcers
bleed, the patient also demonstrates blood in the stool. Often, the
ulcerations and their accompanying symptoms are similar to and
sometimes mistaken for Crohn’s disease or ulcerative colitis. It is
therefore important to understand the signs and symptoms that are
common to Behcet’s but that are not present with ulcerative colitis or
Crohn’s disease.
According to the International Study Group for Behcet’s Disease, a
diagnosis of Behcet’s disease can occur when the patient has had
mouth sores at least three times in the past 12 months. In addition,
other common symptoms of Behcet’s include eye inflammation with
loss of vision, recurring genital sores, skin lesions, or a positive
pathergy test, in which a reaction develops following a small skin
prick.39,41
The gastrointestinal manifestations associated with Behcet’s can lead
to significant disability and increased mortality for affected patients.
The oral ulcers that develop with Behcet’s are early signs of the
disease, while gastrointestinal involvement tends to develop between
4 and 6 years after initial onset of symptoms. The gastrointestinal
ulcers of Behcet’s disease can develop at any point along the
gastrointestinal tract, including within the large and small intestines;
however, the most common location of ulcer development is near the
ileocecal valve. The ulcers can also develop on other organs of the
gastrointestinal system, such as the stomach and the pancreas.41
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According to Skef, et al., in the World Journal of Gastroenterology, the
gastrointestinal effects of Behcet’s disease are classified according to
two different types: neutrophilic phlebitis and large vessel disease. It
is the neutrophilic phlebitis that causes inflammation and ulcer
development. In contrast, those with large vessel disease suffer from
inflammation of the blood vessels that support the gastrointestinal
tract, mainly the mesenteric arteries, which leads to blood vessel
occlusion and resulting ischemia and infarct.41
Because ulcers can develop anywhere along the gastrointestinal tract
with Behcet’s the symptoms the patient experiences may be specific to
the region of the area involved. For example, while rare, esophageal
ulcers can develop in some people with Behcet’s disease, which can
cause symptoms of dysphagia, odynophagia, and chest pain behind
the sternum, and the patient may experience symptoms consistent
with relaxation of the lower esophageal sphincter. Persons with ulcers
affecting the stomach and duodenum may suffer from symptoms
similar to those of pyloric stenosis or from gastroparesis.
The most common areas of ulcer development in gastrointestinal cases
of Behcet’s are in the ileum of the small intestine, the cecum, and the
junction between the small and large intestines at the ileocecal valve.
The entire large and/or small intestine may also be affected; however,
ulcer development in the rectum is very rare, accounting for
approximately 1 percent of patients. The patient with inflammation
and ulcers from Behcet’s is at risk of numerous complications,
including stenosis and strictures in the intestinal tract, fistulas, abscess
formation, and intestinal perforation.
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The treatment of Behcet’s disease is often similar to that used for
Crohn’s disease and ulcerative colitis and may consist of systemic
corticosteroids, immunomodulator drugs, and biologic agents to
control inflammation. These drugs are not only helpful in reducing
inflammation in the gastrointestinal tract but they often manage the
inflammation of other body systems that are prominent with this
particular disease. In addition to these therapies, various medications
may be used to treat specific problems associated with Behcet’s, such
as eye drops to prevent corneal or retinal damage, mouthwash that
controls pain and inflammation in the mouth and throat, and topical
ointment for genital ulcerations.
Although Behcet’s disease has many similarities to Crohn’s and
ulcerative colitis, it is fortunately a rare type of autoimmune disorder.
A patient who develops this particular disease may be able to manage
its symptoms and prevent complications through standard therapy
used for other forms of inflammatory bowel disease.
Indeterminate Colitis
There are times when it is difficult to determine the actual type of
inflammatory bowel disease as symptoms may overlap with one
another. When it is not clear whether a patient’s symptoms are caused
by Crohn’s disease or ulcerative colitis, the patient is diagnosed with
indeterminate colitis. Approximately 15 percent of people with IBD
have indeterminate colitis.42
People with indeterminate colitis typically have symptoms only
affecting the large intestine. This means that the condition could be
ulcerative colitis or Crohn’s disease affecting only the colon.
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A diagnosis of Crohn’s disease or ulcerative colitis obviously requires
extensive diagnostic testing that includes a review of the patient’s
symptoms, a physical examination, laboratory testing, a complete
medical and family history, endoscopic procedures to visualize the
intestinal tract, and often a biopsy to test tissue histology. Despite the
extensive nature of diagnostic testing available for these specific
diseases, there are times when it is still unclear which type of IBD is
present. Both ulcerative colitis and Crohn’s disease have diagnostic
criteria that must be present to make a formal diagnosis.
Indeterminate colitis may be a diagnosis given when symptoms affect
the large intestine and the patient does not have enough diagnostic
criteria to completely fulfill a diagnosis of either Crohn’s disease or
ulcerative colitis.43
According to an article in the Journal of Gastroenterology and
Hepatology Research, indeterminate colitis is considered to be a
temporary diagnosis, given to initiate treatment for the affected
patient and put in place until further testing or changes in the
pathophysiology of the disease reveals which type of IBD is present.43
Although the term is somewhat controversial for use, indeterminate
colitis is included as part of the International Classification of Diseases,
Tenth Revision (ICD-10). Some clinicians prefer to call the condition
Inflammatory Bowel Disease, Unclassified.
Indeterminate colitis typically possesses many of the same
physiological manifestations in the colon as seen with Crohn’s disease
and ulcerative colitis, although the severity and intensity of the
condition varies between patients. The disease causes areas of
inflammation in the large intestine that may lead to tissue breakdown
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and necrosis of ulcers. The ulcerations may affect one or more layers
of the intestinal tract, often leaving no indication as to whether the
condition is actually Crohn’s disease, which often causes transmural
ulcerations, or ulcerative colitis, which typically only affects the first
two layers of the colon.
The inflammation and ulcerations associated with indeterminate colitis
are often seen throughout the entire large intestine but rarely in the
rectum. Often, the right and transverse sections of the colon are
affected more frequently than the left side.43 There may be
intermittent alterations in tissue areas that give the appearance of skip
lesions associated with Crohn’s disease. Some areas of the bowel may
be dilated slightly and fissures can be present. The fissures that are
seen with this type of colitis often differ from those noted with Crohn’s
disease. Fissures associated with indeterminate colitis are described as
“knife-like” because of their appearance and depth.43 They may also
appear V-shaped, with wider openings on the mucosal surface and
becoming narrower with greater depth.
Patients with indeterminate colitis also suffer from a variety of
symptoms that are similar or even the same as those seen with other
forms of IBD, including frequent diarrhea, abdominal pain, rectal
bleeding, and abdominal cramping. The symptoms may be
exacerbated during times of disease flares and may then dissipate
when the patient enters remission.
The treatment for indeterminate colitis is often similar to that given for
ulcerative colitis. Many patients with this type of disease have
benefitted from administration of anti-inflammatory agents,
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immunosuppressants, corticosteroids, and biologic therapies. In many
cases, surgery to remove the diseased portions of the colon is often
necessary when symptoms are severe and complications have
developed. Unfortunately, because indeterminate colitis may be used
as an interim diagnosis, the patient who is suffering from symptoms of
this particular type of IBD may need to continue to undergo testing
and assessment for changes for a longer period when compared to
someone else with more straightforward symptoms. The condition may
change over time, which could allow the diagnosing clinician to
definitively diagnose indeterminate colitis as either Crohn’s disease or
ulcerative colitis.
Unless the symptoms and the pathophysiology of the disease actually
reveals which type of IBD is present, the patient will often benefit from
medical therapies and prescribed remedies. The term itself may be
controversial, but because indeterminate colitis seems to respond well
to the same types of therapy administered for other kinds of IBD and
it can be surgically corrected when needed, the patient with
indeterminate colitis can still benefit from standard forms of medical
therapies used for management of inflammation.
Summary
The chronic gastrointestinal condition of inflammatory bowel disease is
a recurring disease characterized by inflammation, tissue
deterioration, and ulceration in different regions of the gastrointestinal
system. The most common types of IBD are ulcerative colitis and
Crohn’s disease. The different types of IBDs may develop anywhere
along the gastrointestinal tract from the mouth to the anus, although
most cases are confined to areas of the small or large intestines.
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Inflammatory bowel disease causes periods of active illness in which
affected persons suffer from multiple symptoms that include pain and
diarrhea, followed by periods of remission, in which there are few to
no symptoms at all. The chronic nature of the disease has confounded
clinicians and medical scientists who have researched its causes and
the most appropriate forms of treatment to be able to induce
remission and alleviate some of the debilitating symptoms.
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1.
Inflammatory bowel disease (IBD) is actually a group of
disorders that
a.
b.
c.
d.
2.
similarly cause inflammation in the gastrointestinal tract.
affect the same areas of the intestine.
respond treatment in the same way.
All of the above
True or False: All types of IBD develop along the
gastrointestinal tract in the areas of the small or large
intestines.
a. True
b. False
3.
Two of the most common types of inflammatory bowel
disease (IBD) are
a.
b.
c.
d.
4.
Sclerosing cholangitis causes inflammation and scarring
within the
a.
b.
c.
d.
5.
ulcerative proctitis and Crohn’s disease.
Behcet’s disease and proctitis.
ulcerative colitis and sclerosing cholangitis.
ulcerative colitis and Crohn’s disease.
the cecum.
bile ducts.
descending colon.
the ileum.
_________________ is a chronic condition that causes
inflammation of the intestinal tract with concomitant
ulcerations of the intestinal mucosa.
a.
b.
c.
d.
Ulcerative proctosigmoiditis
Behcet’s disease
Ulcerative colitis
Sclerosing cholangitis
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6.
Behcet’s disease is an inflammatory condition that causes
ulcers
a.
b.
c.
d.
7.
The ulceration associated with ulcerative colitis often will
only affect _____________________ of the intestinal
tract.
a.
b.
c.
d.
8.
the muscularis layer
submucosal layer
muscularis and submucosal layers
the mucosal and submucosal layers
Ulcerative colitis differs from Crohn’s disease because with
Crohn’s disease, ulcerations typically
a.
b.
c.
d.
9.
in the mouth and on the genitalia.
inflammation in the gastrointestinal tract.
the eye, the brain, and the spinal cord.
All of the above
cause Clostridium difficile infection.
extend through all layers of the intestinal tract.
are limited to the colon and rectum.
does not develop in the ileum.
True or False: Inflammatory bowel disease (IBD) may be
caused solely by uncontrolled stress.
a. True
b. False
10. ______________ is an infection that is often contracted by
a patient while in a hospital or healthcare environment.
a.
b.
c.
d.
Microscopic colitis
Celiac disease
Clostridium difficile
H. pylori
11. True or False: True or False: Approximately 15 percent of
people with IBD have indeterminate colitis.
a. True
b. False
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12. _____________________ can cause inflammation along
any part of the gastrointestinal tract and is not limited to
specific areas.
a.
b.
c.
d.
Crohn’s disease
Pan-colitis
Ulcerative colitis
Sclerosing cholangitis
13. With _________________ the surface of the intestinal
lining often appears rough with a “cobblestone”
appearance that is characteristic of that disease.
a.
b.
c.
d.
vasculitis
indeterminate colitis
Crohn’s disease
sclerosing cholangitis
14. Ulcerative colitis that affects the entire large intestine,
including the ascending, transverse, descending, and
sigmoid portions is sometimes called
a.
b.
c.
d.
pan-colitis.
Behcet’s disease.
indeterminate colitis.
sclerosing cholangitis.
15. True or False: Smoking tobacco is a factor that has been
associated with increased incidences of disease flares
among those with Crohn’s disease.
a. True
b. False
16. Ulcerative colitis and other IBDs that affect the large
intestine may be difficult to distinguish from a Clostridium
difficile infection because they share the same
a.
b.
c.
d.
“cobblestone” appearance.
symptom, severe diarrhea.
symptomatic inflammation in the mouth and throat.
symptomatic psoriasis.
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17. Inflammation from Crohn’s disease most often develops in
the distal portion of the small intestine known as
___________ and the ileocecal region.
a.
b.
c.
d.
the
the
the
the
bile ducts
cecum
duodenum
ileum
18. _________________ is an autoimmune condition in which
damage develops in the intestinal tract after ingestion of
gluten, a protein found in wheat products.
a.
b.
c.
d.
H. pylori
Gastroparesis
Pyloric stenosis
Celiac disease
19. The Crohn’s and Colitis Foundation of America (CCFA)
states that there may be a link between microscopic colitis
and
a.
b.
c.
d.
celiac disease.
musculoskeletal disorder.
H. pylori.
gastroparesis.
20. True or False: Ileocolitis is considered the most common
form of Crohn’s disease.
a. True
b. False
21. Behcet’s disease is a type of inflammatory bowel disease
and a _____________________ because it is a type of
vasculitis that causes inflammation of the blood vessels.
a.
b.
c.
d.
autoimmune disorder
gastrointestinal disorder
musculoskeletal disorder
gluten disorder
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22. The administration of an enema of short-chain fatty acids
in solution to patients with _________________
decreased intestinal inflammation but the symptoms
usually returned when the enemas were discontinued.
a.
b.
c.
d.
diminished colitis
indeterminate colitis
microscopic colitis
diversion colitis
23. Collagenous colitis occurs when areas of collagen under
the epithelium solidify and the tissue overall becomes
a.
b.
c.
d.
diffused and thins out.
impaired and thins out.
perforated and takes on a “cobblestone” texture.
concentrated and thick.
24. With __________________ there may be inflammation of
the eye, and severe cases of eye inflammation may lead to
complete blindness.
a.
b.
c.
d.
celiac disease
Sjögren’s syndrome
Behcet’s disease
pan-colitis
25. True or False: Microscopic colitis has been shown to
increase the risk of colon cancer.
a. True
b. False
26. When it is not clear whether a patient’s inflammatory
bowel symptoms are caused by Crohn’s disease or
ulcerative colitis, the patient is diagnosed with
a.
b.
c.
d.
a Clostridium difficile infection.
pan-colitis.
Behcet’s disease
indeterminate colitis.
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27. Common autoimmune diseases that are seen with
collagenous colitis include
a.
b.
c.
d.
myasthenia gravis.
gastroparesis.
Clostridium difficile.
vasculitis.
28. Patients with microscopic colitis typically have frequent,
watery diarrhea
a.
b.
c.
d.
caused by infection.
with or without abdominal pain and cramping.
associated with all the other IBD symptoms.
All of the above
29. People with indeterminate colitis typically have symptoms
only affecting
a.
b.
c.
d.
the
the
the
the
large intestine.
mouth and esophagus.
small intestine.
ileum.
30. The treatment for ____________________ includes the
administration of anti-inflammatory agents,
immunosuppressants, corticosteroids, and biologic
therapies.
a.
b.
c.
d.
celiac disease
indeterminate colitis
aphthous stomatitis
diversion colitis
31. True or False: The majority of people with Behcet’s develop
aphthous stomatitis.
a. True
b. False
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32. The small intestine is
a.
b.
c.
d.
named “small” because of its length.
approximately 8 feet long in adults.
the longest portion of the gastrointestinal tract.
All of the above
33. Patients with _________________ develop lymphoid
follicular hyperplasia, which is an increase in the size of
lymph node follicles due to increased numbers of white
blood cells.
a.
b.
c.
d.
celiac disease
Sjögren’s syndrome
Behcet’s disease
diversion colitis
34. True or False: Because of the controversy associated with
classifying indeterminate colitis as an IBD, it is NOT
included as part of the International Classification of
Diseases, Tenth Revision (ICD-10).
a. True
b. False
35. The group most likely to suffer from microscopic colitis is
a.
b.
c.
d.
males of all ages.
older females.
young males.
adolescent females.
36. The areas of the gastrointestinal tract that may be affected
by microscopic colitis include
a.
b.
c.
d.
the large intestine.
the small intestine.
the stomach.
All of the above
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37. The major difference between Crohn’s disease in the
mouth and orofacial granulomatosis is that the patient with
Crohn’s disease also have
a.
b.
c.
d.
overgrowths of granulation tissue.
inflammation and scarring within the bile ducts.
gastrointestinal tract lesions and inflammation.
aphthous stomatitis (similar to canker sores) in the mouth.
38. According to an article in the Journal of Gastroenterology
and Hepatology Research, indeterminate colitis is
considered to be _________________ given to initiate
treatment for the affected patient.
a.
b.
c.
d.
a
a
a
a
final diagnosis
non-IBD diagnosis
temporary diagnosis
pre-diagnosis classification
39. __________________ is a form of ulcerative colitis that
includes rectal involvement of the rectum only and NOT
other areas of the colon.
a.
b.
c.
d.
diversion colitis
indeterminate colitis
proctosigmoiditis
ulcerative proctitis
40. True or False: Diversion colitis develops in the large
intestine and usually develops into colon cancer.
a. True
b. False
41. True or False. The exact cause of microscopic colitis has
been well identified.
a. True.
b. False.
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CORRECT ANSWERS:
1.
Inflammatory bowel disease (IBD) is actually a group of
disorders that
a. similarly cause inflammation in the gastrointestinal tract.
p. 5: “Inflammatory bowel disease is actually a group of
disorders that all cause similar effects of inflammation in the
gastrointestinal tract.”
2.
True or False: All types of IBD develop along the
gastrointestinal tract in the areas of the small or large
intestines.
b. False
pp. 5-6: “Both of these diseases cause intestinal
inflammation, pain, and tissue damage in the gastrointestinal
tract. Ulcerative colitis primarily affects the large intestine,
while Crohn’s disease is most common in the small intestine,
but can occur anywhere along the digestive tract.”
3.
Two of the most common types of inflammatory bowel
disease (IBD) are
d. ulcerative colitis and Crohn’s disease.
p. 5: “Two of the most common types of IBD are ulcerative
colitis and Crohn’s disease.”
4.
Sclerosing cholangitis causes inflammation and scarring
within the
b. bile ducts.
p. 9: “A small percentage of patients develop sclerosing
cholangitis, which causes inflammation and scarring within
the bile ducts.”
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5.
_________________ is a chronic condition that causes
inflammation of the intestinal tract with concomitant
ulcerations of the intestinal mucosa.
c. Ulcerative colitis
p. 7: “Ulcerative colitis [is] a chronic condition that causes
inflammation of the intestinal tract with concomitant
ulcerations of the intestinal mucosa….”
6.
Behcet’s disease is an inflammatory condition that causes
ulcers
a.
b.
c.
d.
in the mouth and on the genitalia.
inflammation in the gastrointestinal tract.
the eye, the brain, and the spinal cord.
All of the above
p. 54: “Behcet’s disease is an inflammatory condition that
causes ulcers in the mouth and on the genitalia, as well as
inflammation in the gastrointestinal tract, blood vessels, the
eye, the brain, and the spinal cord.”
7.
The ulceration associated with ulcerative colitis often will
only affect _____________________ of the intestinal
tract.
d. the mucosal and submucosal layers
p. 15: “The ulceration associated with ulcerative colitis often
only affects the mucosal and submucosal layers of the
intestinal tract, but typically does not extend down into the
muscularis layer.”
8.
Ulcerative colitis differs from Crohn’s disease because with
Crohn’s disease, ulcerations typically
b. extend through all layers of the intestinal tract.
p. 15: “The disease process associated with ulcerative colitis
differs from Crohn’s disease: with Crohn’s disease, ulcerations
can extend through all layers of the intestinal tract.”
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9.
True or False: Inflammatory bowel disease (IBD) may be
caused solely by uncontrolled stress.
b. False
p. 8: “Although stress is known to be a triggering factor for a
disease flare, uncontrolled stress is not the cause of ulcerative
colitis or of any other type of IBD.”
10. ______________ is an infection that is often contracted by
a patient while in a hospital or healthcare environment.
c. Clostridium difficile
p. 17: “[C. difficile] is often a healthcare-associated infection,
in which patients contract it while in the hospital or healthcare
environment.”
11. True or False: Approximately 15 percent of people with IBD
have indeterminate colitis.
a. True
p. 59: “Approximately 15 percent of people with IBD have
indeterminate colitis.”
12. _____________________ can cause inflammation along
any part of the gastrointestinal tract and is not limited to
specific areas.
a. Crohn’s disease
p. 23: “Unlike ulcerative colitis and some other forms of IBD,
Crohn’s disease can cause inflammation along any part of the
gastrointestinal tract and is not limited to specific areas.”
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13. With _________________ the surface of the intestinal
lining often appears rough with a “cobblestone”
appearance that is characteristic of that disease.
c. Crohn’s disease
p. 24: “The surface of the intestinal lining often appears
rough with a “cobblestone” appearance that is characteristic
of Crohn’s disease.”
14. Ulcerative colitis that affects the entire large intestine,
including the ascending, transverse, descending, and
sigmoid portions is sometimes called
a. pan-colitis.
p. 15: “Ulcerative colitis that affects the entire large intestine,
including the ascending, transverse, descending, and sigmoid
portions is sometimes called pan-colitis.”
15. True or False: Smoking tobacco is a factor that has been
associated with increased incidences of disease flares
among those with Crohn’s disease.
a. True
p. 25: “Smoking tobacco is a factor that has been associated
with increased incidences of disease flares among those with
Crohn’s disease.”
16. Ulcerative colitis and other IBDs that affect the large
intestine may be difficult to distinguish from a Clostridium
difficile infection because they share the same
b. symptom, severe diarrhea.
p. 17: “Ulcerative colitis and other forms of IBD that affect
the large intestine increase the risk of Clostridium difficile
infection in the gastrointestinal tract. C. difficile infection
tends to cause severe diarrhea, which may make it difficult to
establish IBD versus C. difficile as the cause of diarrhea.”
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17. Inflammation from Crohn’s disease most often develops in
the distal portion of the small intestine known as
___________ and the ileocecal region.
d. the ileum
p. 24: “Although it can affect any part of the gastrointestinal
tract, the inflammation from Crohn’s most often develops in
the distal portion of the small intestine—the ileum—and the
junction between the small intestine and the cecum, known
as the ileocecal region.”
18. _________________ is an autoimmune condition in which
damage develops in the intestinal tract after ingestion of
gluten, a protein found in wheat products.
d. Celiac disease
p. 49: “The Crohn’s and Colitis Foundation of America (CCFA)
states that there may be a link between microscopic colitis
and celiac disease, an autoimmune condition in which damage
develops in the intestinal tract after ingestion of gluten, a
protein found in wheat products.”
19. The Crohn’s and Colitis Foundation of America (CCFA)
states that there may be a link between microscopic colitis
and
a. celiac disease.
p. 49: “The Crohn’s and Colitis Foundation of America (CCFA)
states that there may be a link between microscopic colitis
and celiac disease, an autoimmune condition in which damage
develops in the intestinal tract after ingestion of gluten, a
protein found in wheat products.”
20. True or False: Ileocolitis is considered the most common
form of Crohn’s disease.
a. True
p. 33: “Ileocolitis is considered the most common form of
Crohn’s disease.”
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21. Behcet’s disease is a type of inflammatory bowel disease
and a _____________________ because it is a type of
vasculitis that causes inflammation of the blood vessels.
c. musculoskeletal disorder
p. 55: “In addition to being classified as a type of
inflammatory bowel disease, Behcet’s is also a
musculoskeletal disorder because it is a type of vasculitis that
causes inflammation of the blood vessels.”
22. The administration of an enema of short-chain fatty acids
in solution to patients with _________________
decreased intestinal inflammation but the symptoms
usually returned when the enemas were discontinued.
d. diversion colitis
p. 53: “An early study in the New England Journal of Medicine
tested the effects of enema administration of short-chain fatty
acids in solution to patients with diversion colitis and found
that patients who received enemas had diminished colitis
symptoms and decreased intestinal inflammation.”
23. Collagenous colitis occurs when areas of collagen under
the epithelium solidify and the tissue overall becomes
d. concentrated and thick.
p. 47: “Collagenous colitis occurs when areas of collagen
under the epithelium solidify and the tissue overall becomes
concentrated and thick.”
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24. With __________________ there may be inflammation of
the eye, and severe cases of eye inflammation may lead to
complete blindness.
c. Behcet’s disease
p. 56: “There are various other symptoms seen with Behcet’s
disease that do not necessarily affect the gastrointestinal
tract, including sores on the skin, which appear as red, pusfilled lesions. There may be inflammation of the eye, most
commonly the iris and the uvea, although the retina may also
become inflamed and the patient may have vision loss,
excess tear production, and photophobia. Severe cases of eye
inflammation may lead to complete blindness.”
25. True or False: Microscopic colitis has been shown to
increase the risk of colon cancer.
b. False
p. 50: “Unlike Crohn’s disease or ulcerative colitis,
microscopic colitis has not been shown to increase the risk of
colon cancer.”
26. When it is not clear whether a patient’s inflammatory
bowel symptoms are caused by Crohn’s disease or
ulcerative colitis, the patient is diagnosed with
d. indeterminate colitis.
p. 59: “When it is not clear whether a patient’s symptoms are
caused by Crohn’s disease or ulcerative colitis, the patient is
diagnosed with indeterminate colitis. Approximately 15
percent of people with IBD have indeterminate colitis.”
27. Common autoimmune diseases that are seen with
collagenous colitis include
a. myasthenia gravis.
p. 50: “Common conditions that are seen with collagenous
colitis include Sjögren’s syndrome, thyroiditis, and
myasthenia gravis.”
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28. Patients with microscopic colitis typically have frequent,
watery diarrhea
b. with or without abdominal pain and cramping.
p. 48: “People with microscopic colitis typically have frequent,
watery diarrhea with or without abdominal pain and
cramping;….”
29. People with indeterminate colitis typically have symptoms
only affecting
a. the large intestine.
p. 59: “People with indeterminate colitis typically have
symptoms only affecting the large intestine.”
30. The treatment for ____________________ includes the
administration of anti-inflammatory agents,
immunosuppressants, corticosteroids, and biologic
therapies.
b. indeterminate colitis
pp. 61-62: “The treatment for indeterminate colitis is often
similar to that given for ulcerative colitis. Many patients with
this type of disease have benefitted from administration of
anti-inflammatory agents, immunosuppressants,
corticosteroids, and biologic therapies.”
31. True or False: The majority of people with Behcet’s develop
aphthous stomatitis.
a. True
p. 55: “The majority of people with Behcet’s develop
aphthous stomatitis: inflammation and ulcerations in the
mouth that are similar in appearance to canker sores.”
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32. The small intestine is
c. the longest portion of the gastrointestinal tract.
p. 31: “The small intestine is the longest portion of the
gastrointestinal tract. Its name refers to the diameter of the
intestinal lumen rather than its length. The average length of
the small intestine is approximately 20 feet long in adults.”
33. Patients with _________________ develop lymphoid
follicular hyperplasia, which is an increase in the size of
lymph node follicles due to increased numbers of white
blood cells.
d. diversion colitis
p. 51: “Patients with diversion colitis develop lymphoid
follicular hyperplasia, which is an increase in the size of lymph
node follicles due to increased numbers of white blood cells.”
34. True or False: Because of the controversy associated with
classifying indeterminate colitis as an IBD, it is NOT
included as part of the International Classification of
Diseases, Tenth Revision (ICD-10).
b. False
p. 60: “Although the term is somewhat controversial for use,
indeterminate colitis is included as part of the International
Classification of Diseases, Tenth Revision (ICD-10). Some
clinicians prefer to call the condition Inflammatory Bowel
Disease, Unclassified.”
35. The group most likely to suffer from microscopic colitis is
b. older females.
p. 46: “This specific type of inflammatory bowel disease most
commonly affects older adults, with a higher percentage of
older females than males affected by collagenous colitis, one
of the subtypes of the disease.”
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36. The areas of the gastrointestinal tract that may be affected
by microscopic colitis include
a. the large intestine.
p. 46: “A patient suffering from microscopic colitis
experiences pain and diarrhea but there is no obvious source
during examination. The condition only affects the large
intestine, the sigmoid colon, and the rectum.”
37. The major difference between Crohn’s disease in the
mouth and orofacial granulomatosis is that the patient with
Crohn’s disease also have
c. gastrointestinal tract lesions and inflammation.
p. 43: “[A]ccording to Zbar, et al., in the Journal of Crohn’s
and Colitis, the major difference between Crohn’s disease in
the mouth and orofacial granulomatosis is that the patient
with Crohn’s disease has concomitant lesions and
inflammation elsewhere in the gastrointestinal tract, while
orofacial granulomatosis typically only affects the mouth.”
38. According to an article in the Journal of Gastroenterology
and Hepatology Research, indeterminate colitis is
considered to be _________________ given to initiate
treatment for the affected patient.
c. a temporary diagnosis
p. 60: “According to an article in the Journal of
Gastroenterology and Hepatology Research, indeterminate
colitis is considered to be a temporary diagnosis, given to
initiate treatment for the affected patient and put in place
until further testing or changes in the pathophysiology of the
disease reveals which type of IBD is present.”
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39. __________________ is a form of ulcerative colitis that
includes rectal involvement of the rectum only and NOT
other areas of the colon.
d. ulcerative proctitis
p. 19: “Approximately 46 percent of patients with ulcerative
colitis have rectal involvement, called ulcerative proctitis
when it affects only the rectum, and ulcerative
proctosigmoiditis when the sigmoid colon is also involved.”
40. True or False: Diversion colitis develops in the large
intestine and usually develops into colon cancer.
b. False
p. 51: “Diversion colitis develops in the large intestine and is
usually considered to be benign, ….”
41. True or False. The exact cause of microscopic colitis has
been well identified.
b. False.
p. 48. “The exact cause of microscopic colitis is unknown.”
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References
The References below include published works and in-text citations of
published works that are intended as helpful material for your further
reading.
1.
Crohn’s and Colitis Foundation of America (CCFA). (2009, Apr.).
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3. Parray, F., Wani, M., Malik, A., Wani, S., Bijli, A., Irshad, I., UlHassan, N. (2012, Nov.). Ulcerative colitis: A challenge to
surgeons. Int J Prev Med. 3(11): 749-763. Retrieved from
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manifestations of IBD? Retrieved from
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6. Strober, W., Fuss, I. (2011, May). Pro-inflammatory cytokines in
the pathogenesis of IBD. Gastroenterology 140(6): 1756-1767.
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8. Bowen, R. (2000, May). Gross and microscopic anatomy of the
large intestine. Retrieved from
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gut/anatomy.html
9. Taylor, T. (2016). Large intestine. Retrieved from
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10. Crohn’s and Colitis Foundation of America. (2015, Jan.). Intestinal
complications. Retrieved from
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11. Crohn’s and Colitis Foundation of America. (2012, Sep.).
Understanding your risk: C. diff. Retrieved from
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g.html
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12. Sandborn, W., et al. (2015, Apr.). Budesonide foam induces
remission in patients with mild to moderate ulcerative proctitis
and ulcerative proctosigmoiditis. Gastroenterology 148(4): 740750. Retrieved from http://www.gastrojournal.org/article/S00165085(15)00154-7/fulltext
13. Dewint, P., et al. (2014). Adalimumab combined with ciprofloxacin
is superior to adalimumab monotherapy in perianal fistula closure
in Crohn’s disease: a randomized, double-blind, placebo controlled
trial (ADAFI). Gut 2014; 63: 292-299.
14. Colon & Rectal Surgery Associates. (2016). What is ulcerative
proctitis? Retrieved from
http://www.colonrectal.org/services.cfm/sid:6694/ulcerative_proc
titis/index.html
15. Crohn’s & Colitis.com. (2016). Understanding Crohn’s disease.
Retrieved from https://www.crohnsandcolitis.com/crohns
16. University of Maryland Medical Center. (2012, Dec.). Crohn’s
disease. Retrieved from
http://umm.edu/health/medical/reports/articles/crohns-disease
17. Crohn’s and Colitis Foundation of America. (2015, Jan.). Arthritis
and joint pain. Retrieved from
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18. Lashner, B. (2013, Jan.). Crohn’s disease. Retrieved from
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gement/gastroenterology/crohns-disease/
19. IBD Relief. (2016). What is perianal Crohn’s disease? Retrieved
from https://www.ibdrelief.com/learn/what-is-ibd/what-is-crohnsdisease/perianal-crohns
20. De Zoeten, E., Pasternak, B., Mattei, P., Kramer, R., Kader, H.
(2013, Sep.). Diagnosis and treatment of perianal Crohn disease:
NASPGHAN clinical report and consensus statement. JPGN 57(3):
401-412.
21. IBD Relief. (2016). What is ileocolitis? Retrieved from
https://www.ibdrelief.com/learn/what-is-ibd/what-is-crohnsdisease/ileocolitis
22. Bayless, T., Hanauer, S. (2011). Advanced therapy of
inflammatory bowel disease (3rd ed.), Volume 2. Shelton, CT:
People’s Medical Publishing House USA
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disease and associated symptoms. Retrieved from
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Steckstor, M., Adam, B., Pech, O., Tannapfel, A., Riphaus, A.
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Dyall-Smith, D. (2016). Orofacial Crohn disease. Retrieved from
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Harig, J., Soergel, K., Komorowski, R., Wood, C. (1989, Jan.).
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IBD Relief. (2016). What is indeterminate colitis? Retrieved from
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Mahdi, B. (2012). A review of inflammatory bowel disease
unclassified – Indeterminate colitis. Journal of Gastroenterology
and Hepatology Research 1(10). Retrieved from
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