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Inflammatory Bowel Disease

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Inflammatory bowel disease (IBD) includes a group of chronic disorders that cause inflammation or ulceration in the small and large intestines. Most often IBD is classified as one of two conditions:

  • Ulcerative colitis causes ulceration and inflammation of the superficial layers of the inner lining of
    the colon or rectum (or both) that is usually diffuse and uniform. The inflammation typically begins in the rectum and lower (sigmoid) intestine and spreads upward to the entire colon. It rarely affects any but the lowest section of the small colon.
  • Crohn's disease is an inflammation extending into the deeper layers of the intestinal wall, normally concentrated in certain areas, primarily the small intestine, typically the lower part called the ileum. The condition is also sometimes referred to as ileitis or enteritis. It can affect areas anywhere in digestive tract, including the mouth, esophagus, stomach, duodenum, appendix, colon, rectum, or anus.

In IBD, the immune system (in and as it affects the GI system) is abnormally and chronically activated for unknown reasons. If the disease progresses, small erosions in the intestinal track can turn to ulcers severe enough to cause scarring and stiffness in the bowel, and eventually a narrowed, obstructed, or punctured bowel. Perforations and fistulas can create urgent medical conditions. The course of IBD is different for every person. Some individuals with IBD may progress to these complications; some may not. Patients with widespread ulcerative colitis are greater risk of colon cancer.


Causes/risk factors

Adolescence or young adulthood are the most common periods for IBD to begin, although it can also occur in childhood or later in life. The condition affects males and females equally. It can sometimes run in families. For example, about 20 percent of people with Crohn's disease have a blood relative with some form of inflammatory bowel disease.

The cause of IBD is not known for certain. Researchers investigating this condition have been looking at infectious organisms, such as viruses or bacteria that may affect the body's immune system and trigger an inflammatory reaction in the intestinal wall. One theory suggests that, as a result of overly sanitary environments in modern life, persons who develop IBD may not have had fully normal GI exposure to these germs at a young age and therefore experience an immune overreaction to them in the digestive tract at some later point of exposure. However, although a lot of evidence indicates that patients with this disease have abnormalities of the immune system, it is not known conclusively whether the immune problems are a cause or a result of the disease.

 

Signs & symptoms

Ulcerative colitis and Crohn's disease cause similar symptoms that often resemble other conditions, such as irritable bowel syndrome. These conditions may sometimes go into remission (a period when the symptoms go away) for months or even years, but normally the symptoms will return. Most patients experience recurrence at various times over a lifetime. IBD manifests itself differently in different people, depending in part on the location and severity of the inflammation, but the primary symptoms are:

  • abdominal pain;
  • diarrhea (sometimes bloody);
  • weight loss;
  • fatigue;
  • loss of appetite;
  • rectal bleeding;
  • loss body fluids and nutrients;
  • night sweats;
  • fever;
  • and anemia due to bleeding.

There is no way to predict when a remission may occur or when symptoms will return.


Diagnosis

In addition to taking a medical history and performing a physical examination, physicians may request the following diagnostic procedures in order to diagnose IBD:

  • blood tests to determine if there is anemia resulting from blood loss, or if there is an increased number of white blood cells, suggesting an inflammatory process;
  • stool culture;
  • barium, upper-GI x-ray (upper GI series or barium swallow);
  • upper endoscopy;
  • biopsy;
  • barium, lower-GI x-ray (lower GI series or barium enema);
  • colonscopy;
  • CT scan
  • or video capsule endoscopy (PillCAM).


Treatment

At this time there is no cure for these diseases, however, several methods are helpful in controlling them. Ulcerative colitis and Crohn's disease generally require long-term medical care. The goals of treatment are to get patients into remission and keep them there with minimal side effects and to improve their quality of life by:

  • correcting nutritional deficiencies;
  • controlling inflammation;
  • relieving abdominal pain, diarrhea, and rectal bleeding.

Treatment may include:

  • medication. Different types of medications can help to relieve symptoms by decreasing inflammation, and a variety of new or improved drugs for this purpose offer a wide choice of medications. These include 5-ASA compounds, corticosteroids, antibiotics, or immuno-modulator medications (which more directly affect the body's immune function). Drugs to control diarrhea and intestinal spasms can sometimes help relieve cramps and diarrhea.  Infusion with the monoclonal-antibody drug infliximab can help patients who have not gotten adequate response from other therapies.
  • diet. No special diet has been proven effective for preventing or treating Crohn's disease. Certain symptoms are sometimes made worse by milk, alcohol, hot spices, or fiber, but this may not be true for everyone. Some patients benefit from low-fiber, or softer or liquid diets.
  • supplements. Nutritional supplements or special high-calorie liquid formulas may sometimes be suggested, especially for children with delayed growth. Large doses of vitamins are useless and may even cause harmful side effects.
  • feeding through a vein. A small number of patients, who temporarily need extra nutrition, may need periods of feeding by vein (intravenously).
  • surgery. Most patients with IBD will not require surgery, a treatment typically reserved for those for whom drug therapy and other treatments have not been successful. When patients medically treated still experience severe bleeding, debilitating illness, perforation of the colon, or high risk of cancer, operations to remove the most diseased section of the intestine can be beneficial. Surgery for IBD, though will not cure the disease. The inflammation tends to return to the areas of the intestine next to the area that has been removed. Types of surgery include drainage of abscesses or removal of a section of bowel. Among the latter type of operations for IBD are:
    - ileostomy. This entails removal of the entire colon and rectum with creation of a small opening (or stoma) in the abdominal wall where the tip of the lower small intestine, the ileum, is brought to the skin's surface to allow drainage of waste.
    - colostomy. The rectum is removed and the colon is attached to the stoma. Sometimes, a temporary colostomy may be performed when part of the colon has been removed and the rest of the colon needs to heal.
    - ileoanal anastamosis. Also called a pull-through operation, this procedure avoids the use of an external pouch. The diseased portion of the colon is removed and the outer muscles of the rectum (anus) are preserved. The ileum is attached inside the rectum, forming a pouch, or reservoir, that holds the waste. This allows the patient to pass stool through the anus in a normal manner, although the bowel movements may be more frequent and watery than usual.

Surgery can significantly improve the quality of the patient's life; however, about half of patients treated in this way experience a return of the disease within a few years. Anti-inflammatory and immuno-modulator drugs can help to decrease the chance of recurrence.

At their Inflammatory Bowel Disease Clinic, the experienced staff of Aria's Division of Gastroenterology can review all treatment option and offer complete evaluation and care recommendations.  As needed, the team works closely with surgeons in Aria's Division of General Surgery and Section on Colorectal Surgery who are experts in providing surgery for IBD and for surgery of the small intestine.