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July 21, 2015

Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) involves chronic inflammation of all or part of your digestive tract. IBD primarily includes ulcerative colitis and Crohn's disease. Both can cause mild symptoms in many, but may also cause severe diarrhea, pain, bleeding, fatigue and weight loss in others. IBD can sometimes become debilitating and may lead to life-threatening complications.

Ulcerative colitis (UL-sur-uh-tiv koe-LIE-tis) is an IBD that causes long-lasting inflammation and sores (ulcers) in the innermost lining of your large intestine (colon) and rectum. Crohn’s disease is an IBD that cause inflammation of the lining of your digestive tract. The inflammation can involve different areas of the digestive tract — the large intestine, small intestine or both.

In Crohn’s disease, inflammation often spreads deeper into affected tissues. Collagenous (kuh-LAJ-uh-nus) colitis and lymphocytic colitis also are considered inflammatory bowel diseases but are usually regarded separately from classic inflammatory bowel disease. These diseases must be considered lifelong diseases, even though remissions sometimes last many years or relapses sometimes never occur.

Causes

The exact cause of inflammatory bowel disease remains unknown. Previously, diet and stress were suspected, but now doctors know that these factors may aggravate but do not cause IBD. One apparent cause is an immune system malfunction. When your immune system tries to fight off an invading virus or bacterium, an abnormal immune response causes the immune system to attack the cells in the digestive tract, too. Heredity also seems to play a role in that IBD is more common in people who have family members with the disease. However, most people with IBD do not have this family history.

Risk Factors

Some Risk factors for IBD are as follows:

  • Age: Most people who develop IBD are diagnosed before the age of 30 years old.
  • Race or Ethnicity: Caucasians have the highest risk of the disease, yet it can occur in any race. Those of Ashkenazi-Jewish descent are at an even higher risk.
  • Family History: Those who have a close relative diagnosed with IBD — such as a parent, sibling or child — are at higher risk for developing the disease.
  • Cigarette smoking: Cigarette smoking is the most important controllable risk factor for developing Crohn's disease.
  • Where you live: If you live in an urban area or in an industrialized country, you are more likely to develop IBD.

Signs & Symptoms

Inflammatory bowel disease symptoms vary, depending on the severity of inflammation and where it occurs within the body. Symptoms may range from mild to severe. You are likely to have acute episodes (flares) followed by periods of remission. Signs and symptoms that are common to both Crohn's disease and ulcerative colitis include:

  • Diarrhea
  • Fever and Fatigue
  • Blood in Stool
  • Abdominal Pain and Cramping
  • Reduced Appetite
  • Unintended Weight Loss
  • Sometimes mouth sores, eye inflammation, joint pain or other symptoms lead to diagnosis.

Screenings & Diagnostic Tests

Your doctor will likely diagnose inflammatory bowel disease only after ruling out other possible causes for your signs and symptoms, including ischemic colitis, infection, irritable bowel syndrome (IBS), diverticulitis and colon cancer. He or she will use a combination of tests. To help confirm a diagnosis of IBD, you may have one or more of the following tests and procedures:

Blood Tests

  • Tests for anemia or infection: Your doctor may suggest blood tests to check for anemia — a condition in which there are not enough red blood cells to carry adequate oxygen to your tissues — or to check for signs of infection from bacteria or viruses.
  • Tests for degree of inflammation: Tests called “sed rate” (sedimentation rate) and CRP can indicate general degree of inflammatory activity within your body.
  • Fecal occult blood test: You may need to provide a stool sample so that your doctor can test for hidden blood in your stool.
  • Fecal calprotectin: a newer stool sample test that can indicate whether bowel inflammation is present, and if present, how severe it is.

Endoscopic Procedures

  • Colonoscopy: This test allows your doctor to view your entire colon using a thin, flexible, lighted tube that is a video camera. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis, which may help confirm a diagnosis. Clusters of inflammatory cells called granulomas, if present, help confirm a diagnosis of Crohn's disease.
  • Flexible Sigmoidoscopy: In this procedure, your doctor uses a slender, flexible, lighted tube to examine the last section of your colon (sigmoid).
  • Upper Endoscopy: In this procedure, your doctor uses a slender, flexible, lighted tube to examine the esophagus, stomach and first part of the small intestine (duodenum). While it is rare for these areas to be involved with Crohn's disease, this test may be recommended if you are having nausea and vomiting, difficulty eating or upper abdominal pain.
  • Capsule endoscopy: This test is used to help diagnose Crohn's disease. You swallow a capsule that has a video camera in it. The images are transmitted to a computer you wear on a vest, after which the camera exits your body painlessly in your stool. You may still need endoscopy with biopsy to confirm a diagnosis of Crohn's disease.
  • Double-Balloon Endoscopy: For this test, a longer scope is used to look further into the small bowel where standard endoscopes do not reach. This technique is useful when capsule endoscopy shows abnormalities, but the exact diagnosis is still in question.

Imaging Procedures

  • X-ray: If you have severe symptoms, your doctor may use a standard X-ray of your abdominal area to rule out serious complications, such as a perforated colon.
  • Computerized tomography (CT) scan: You may have a CT scan — a special X-ray technique that provides more detail than a standard X-ray does. This test looks at the entire bowel as well as at tissues outside the bowel. CT enterography is a special CT scan that provides better images of the small bowel. This test has replaced barium X-rays.
  • Magnetic resonance imaging (MRI): An MRI scanner uses a magnetic field and radio waves to create detailed images of organs and tissues. MRI is particularly useful for evaluating a fistula around the anal area (pelvic MRI) or the small intestine (MR enterography). Unlike CT, there is no radiation exposure with MRI.
  • Small bowel imaging. This test looks at the part of the small bowel that cannot be seen by colonoscopy. After you drink a liquid containing barium, doctors take an X-ray of your small intestine. While this technique may still be used, CT or MRI enterography has largely replaced it.

Treatment

The goal of inflammatory bowel disease treatment is to reduce the inflammation that triggers your signs and symptoms. In the best cases, this may lead not only to symptom relief but also to long-term remission and reduced risks of complications. IBD treatment usually involves either drug therapy or surgery. There is no cure for IBD. Doctors use one of two approaches to treatment: "step-up," which starts with milder drugs first, versus "top-down," which gives people stronger drugs earlier in the treatment process to stop the damage before it progresses. Medications most commonly prescribed for IBD patients fall into five basic categories:

Aminosalicylates include mesalamine, sulfasalazine, balsalazide and olsalazine. These drugs can be given orally or rectally and work to decrease inflammation at the inner wall of the intestine. It does not suppress the immune system and is effective in treating mild-to-moderate IBD.

Corticosteroids include prednisone, prednisolone, methylprednisolone and budesonide. These drugs also reduce inflammation, but they target your immune system rather than directly treating inflammation. Instead, they block the immune responses that release inflammatory chemicals in the intestinal lining. These can be administered orally, rectally or intravenously and are effective for short-term control of acute episodes (flares).

Immunomodulators include Azathioprine and 6-mercaptopurine (6-MP), methotrexate, and cyclosporine. These medications modify the body’s immune system and stops immune response. These drugs are typically prescribed to patients whose treatment with Aminosalicylates and Corticosteroids were ineffective, or along with biologic therapies to help them work more effectively.

Biologic Therapies are antibodies grown in the lab and work to target very specific molecules involved in the inflammatory process. These include TNF blockers (adalimumab, infliximab, golimumab, others); integrin blockers (vedolizumab) and IL12/IL23 blocker (ustekinumab).

If diet and lifestyle changes, drug therapy, or other treatments don't relieve your IBD signs and symptoms, your doctor may recommend surgery.

Lifestyle and Home Remedies

Sometimes you may feel helpless when facing inflammatory bowel disease. But changes in your diet and lifestyle may help control your symptoms and lengthen the time between flare-ups. Limit dairy intake, try low-fat foods, limit fiber intake, avoid problem foods, eat smaller portions and drink plenty of fluids. Specific approaches and medications to control symptoms can be discussed with your clinician. Diet changes are very individualized and restricting foods without discussing in detail can lead to imbalanced diets with serious health consequences. Handling stress in your life and the stress of having IBD is a very important aspect of ongoing treatment. Your clinician, and resources InSite can provide, are here to help.

Talk to your clinician about any herbs or supplements you're taking since some can be harmful to your liver.

References

Digestive Disease Organizations

Many organizations provide support to patients and medical professionals. View the full list of Digestive Disease Organizations

Crohn’s and Colitis Foundation: https://www.crohnsandcolitis.com/

You & IBD.com:http://www.youandibd.com/en/home.aspx

IBD Support Foundation: http://www.ibdsf.org/

Mayo CLinic