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Here we outline the significant aspects of IBD. It is important for patients to realize that each person is an individual and that many aspects discussed here may not apply to them. As in any chronic disease, it is valuable for patients to know as much as possible about their disease, whether some of the specifics apply to them or not. Patients are encouraged to discuss their particular situation with the healthcare professionals involved in their care.
Intestinal Anatomy
To better understand IBD, a basic explanation of the gastrointestinal (GI) tract is essential. The upper part of the GI tract includes the mouth, esophagus, stomach, and duodenum. Other vital components are the liver, pancreas, and spleen. The lower part of the digestive tract is the intestine, which is approximately 8 meters long and consists of two parts: the small bowel/intestine (about 6 meters in length), and the large bowel/intestine or colon. The small bowel is roughly divided into two parts. The upper portion is the jejunum and the lower is the ileum. The colon is divided into various segments, starting at the cecum and ending in the rectum at the anus.
The principal function of the small intestine is to digest and absorb all the dietary nutrients, including proteins, carbohydrates, fats, vitamins, and minerals. The colon serves mainly to absorb water. The small and large intestines work together in co-operation with the liver and the pancreas to break down complex foods and to extract the right amount of each nutrient.
The intestine has a thin inner lining, the mucosa, and beneath this is an area called the submucosa, where the blood vessels and lymph channels run. Surrounding this is a thick muscular wall, covered on the outside by a thin membrane called the serosa. The muscle of the bowel contracts to mix the food and also to propel the bowel contents and promote the passage of food. Although most individuals are aware of intestinal motility only through having bowel movements, motility occurs constantly and is particularly prominent after meals. Ordinarily a person is not aware of bowel contractions, and a meal passes through the digestive tract in 24 to 40 hours.
What is IBD?
IBD is a term that refers to two diseases of the intestines: Crohn's disease and ulcerative colitis. These diseases have a few similarities but are in fact significantly different. Both diseases are inflammations of the intestines. Inflammation does not mean infection. While bacteria, fungus, parasites, or even viruses may cause infection, inflammation may result from an infectious agent, but may also arise from trauma, burns, chemicals, and an array of known and unknown causes. The definitive cause or causes of inflammation in the bowel related to Crohn's and colitis are not currently known.
Ulcerative colitis only involves the large bowel and always starts at the anus. Crohn's disease usually involves the last part of the ileum (terminal ileum), but can involve the large bowel in about 30-50% of patients.
In ulcerative colitis, the inflammation usually involves only the inner mucosa; while in Crohn's disease the inflammation extends right through into the muscle and even into the serosa. The inflammatory process causes dilation of blood vessels with increased warmth, oozing of fluid into the tissue, infiltration with inflammatory cells, and ulceration of the mucosa.
Over the years, Crohn's disease has been given many names and may be referred to as regional enteritis, terminal ileitis, granulomatous colitis, or ileocolitis. These names are used interchangeably.
Ulcerative proctitis is a milder form of the condition of ulcerative colitis. When the inflammation of ulcerative colitis is confined to the rectum and when the upper limit of the inflammation is visible with the standard sigmoidoscope, the condition is referred to as "ulcerative proctitis". This means that the inflammation starts at the anus but extends up only about 20 centimetres or less. This variation of ulcerative colitis accounts for about 25 to 30% of all people with ulcerative colitis.
Symptoms of IBD
The most common symptom of inflammatory bowel disease is diarrhea. In ulcerative colitis, the normal function of water re-absorption is impaired, resulting in many liquid stools. Since the lining of the colon is also ulcerated, the diarrhea often contains blood. In the later stages of the disease the colon is often narrowed and shortened, with decreased absorption of water, rectal urgency and poor control of bowel function. Crohn's disease may prevent the proper absorption of food, resulting in diarrhea and the increased elimination of fat (steatorrhea) and other nutrients, leading to weight loss. Furthermore, the intestine may become narrowed and obstructed in Crohn's disease.
Abdominal pain is another common symptom. Since the intestine has a muscular coat, it is subject to muscle spasm, just as in muscles anywhere in the body. Inflamed intestines are irritable and subject to spasm - the spasm applying pressure upon the extensive nerve endings in the bowel wall - explaining some types of pain in inflammatory bowel disease. Often, the pain due to intestinal spasm is cramping in nature. In Crohn's disease, pressure can build up behind the narrowed intestine and produce cramps. Occasionally, the narrowing is so severe that a blockage of the intestine occurs, requiring immediate medical, and less frequently surgical, attention. A sudden, short, severe type of pain at the opening of the rectum is called tenesmus and results from inflammation and spasm in the rectum.
Fever frequently accompanies inflammation of any type and is common in inflammatory bowel disease. Weight loss is common due to the bowel's inability to absorb sufficient nutrition. In children, a failure or delay in growth and maturity may result if the patient is not monitored closely and treated appropriately. A paediatric gastroenterologist, who is better trained to handle the special needs of children, should be consulted.
In Crohn's disease, the rectum and its opening may become a focal point for inflammation, with the formation of painful inflamed slits in the skin and superficial tissues, called anal fissures. Large pus pockets or abscesses may accumulate, producing severe pain and fever. An abnormal communication between the intestine and the skin may occur. When this communication is near the opening of the rectum, it is referred to as an anal fistula. Fistulae also may occur - only in Crohn's disease - between the intestine and the abdominal wall, particularly after surgery, or between loops of intestine within the abdomen.
Anemia, or low red blood count, frequently occurs from blood loss due to the ulcerations in the lining of the intestine. Occasionally, blood loss may be so severe as to require blood transfusions. Blood proteins may be depleted due to loss of blood serum into the bowel and also reflecting a general state of malnutrition secondary to the debilitating effects of the disease.
Arthritis, skin problems, liver disease, kidney stones, and eye inflammation are among the other manifestations of inflammatory bowel disease.
Diagnosis of IBD
Malfunction of the intestinal tract may occur from a wide variety of causes and the symptoms may be very similar - diarrhea, cramps, and weight loss. Many illnesses are short lasting but some require surgery. The accurate diagnosis of IBD is essential, as other diseases must be excluded.
A careful evaluation of the history of the illness is the first step to a correct diagnosis. How the disease began and subsequent problems are fitted into a meaningful record. The nature of the diarrhea, type of abdominal pain, as well as the characteristics and quantity of rectal bleeding are useful in arriving at a proper initial diagnosis.
In ulcerative colitis, the most useful diagnostic tool is the sigmoidoscope, a short rigid or flexible instrument that allows the inside of the lower bowel to be visualized and biopsies to be taken. Viewing the lining of the colon with this instrument, at regular intervals throughout the healing process, allows the doctor to monitor the disease.
The rest of the colon can be inspected by using a longer, flexible instrument called a colonoscope or by a barium enema x-ray. The last portion of the small intestine is a key location for the formation of Crohn's disease and can be seen either by working barium back into the terminal ileum during a barium enema, or by drinking barium and following it through the small intestine (small bowel follow through). Sometimes the terminal ileum can be visualized with the colonoscope. Biopsies can be taken during a colonoscopy examination but cannot be taken during a barium enema x-ray.
In addition, examination of the blood for its various constituents is necessary. The stool is examined for infectious agents and for hidden blood, by chemical testing.
Ultrasound and CT scan are helpful in looking for complications of IBD but are not useful in making the primary diagnosis.
Treatment of IBD
Unfortunately, when the cause of a disease is unknown, treatment is challenging. In the case of IBD, many treatments may control the disease or induce remission, which is a medical term meaning that the disease becomes inactive. While these are not cures, the disease could be subdued sufficiently to drastically reduce symptom intensity.
The pharmacological treatment of IBD divides into two areas: anti-inflammatory and symptomatic. Dietary and surgical treatments are also important.
Anti-Inflammatory Therapy
To reduce inflammation in IBD, 5-ASA (5-aminosalicylic acid) medication is used. Orally in the form of tablets and capsules, these medications include mesalamine (Asacol®, Mesasal®, Pentasa®, Salofalk®, Mezavant®) and olsalazine sodium (Dipentum®). Rectally, mesalamine (Pentasa®, Salofalk®) liquid enemas and suppositories are available. Your doctor will decide which form to prescribe for you, depending on the disease location.
The original drug used to reduce inflammation in IBD was sulfasalazine (Salazopyrin®, S.A.S.®). This combination of 5-ASA and sulfa antibiotic is available both orally and rectally.
5-ASA medication - both alone and in combination - is very safe and well tolerated for long-term use.
To reduce inflammation in more serious cases of ulcerative colitis and Crohn's disease, the following are some of the corticosteroids prescribed: budesonide (Entocort®) and prednisone, taken orally; hydrocortisone (Solu-Cortef®) and methylprednisolone (Solu-Medrol®), given intravenously; and budesonide (Entocort®), and hydrocortisone (Betnesol®, Cortenema®, Cortifoam™, Proctofoam™-HC), administered rectally (via enemas, foam, and suppositories).
Budesonide is similar to prednisone but has low systemic activity, meaning that its side effects are substantially less than those of prednisone. It comes in both oral (capsule) formats for individuals with Crohn's located at the terminal ileum and rectal suspension (enema) ideal for people who have inflammation in the large bowel.
Studies indicate antibiotics may help initiate remission in some patients, particularly when combined with other treatment. Specific antibiotics most widely prescribed include metronidazole (Flagyl®) and ciprofloxacin (Cipro®). Your physician may prescribe other, broad-spectrum antibiotics, which are important in treating secondary manifestations of the disease such as peri-anal abscess and fistulae.
Immunosuppressive agents are frequently used for steroid-dependent or steroid-resistant patients and it may take up to six months or more of therapy to see results. They are often effective in combination with low dose prednisone, to treat both ileal and colonic Crohn's and to reduce dependence on steroids. However, once treatment with this medication ends the symptom relapse rate is high. These agents include azathioprine (Imuran®), cyclosporine, 6-mercaptopurine (Purinethol®), and methotrexate sodium (Rheumatrex™).
A class of medications called monoclonal antibodies, or biologics, are now being used for treating IBD patients when the older medications fail to relieve symptoms. These treatments inhibit a substance called tumour necrosis factor alpha (TNF-a), a protein made by the immune system that plays a central role in inflammation associated with IBD. The first in this class is infliximab (Remicade®), which has been in use since 2001 for moderate to severe Crohn's disease and fistulizing Crohn's disease. It was approved in 2006 in Canada for treating patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy by reducing signs and symptoms, inducing clinical remission, inducing mucosal healing (in the innermost lining of the intestine), and reducing or eliminating corticosteroid use. Infliximab is administered by regular intravenous infusion, about every eight weeks, after a more frequent initial induction regimen takes place. Infliximab is a chimeric molecule, meaning that it contains DNA from two different organisms, in this case, human and mouse.
A newer, fully human anti TNF-a molecule, approved in Canada in 2008, called adalimumab (Humira®) offers a different delivery mode, in that the patient can self-administer the medication without attending an infusion centre. At this time, Humira® is indicated for reducing signs and symptoms, and inducing and maintaining clinical remission, of moderately to severely active Crohn's disease in adult patients who have had an inadequate response to conventional therapy, including corticosteroids and/or immunosuppressants, and for those patients who have also lost response to, or are intolerant to, infliximab.
Symptomatic Control
The symptoms of IBD are the most distressing components of the disease and direct treatment of these symptoms, particularly pain and diarrhea, will improve quality of life for the patient. For painful symptoms not controlled by other drugs, analgesics can be helpful, with acetaminophen being the preferred choice.
A number of treatments exist to address diarrhea. Dietary adjustment may be beneficial and anti-diarrheal medications have a major role to play. It is easier to understand anti-diarrheal treatments that are directed at preventing cramps and controlling defecation, by splitting them into two groups.
Group 1 alter muscle activity of the intestine, slowing down content transit. These include: non-narcotic loperamide (Imodium®); narcotic agents diphenoxylate (Lomotil®), codeine, opium tincture and paregoric (camphor/opium); and anti-spasmodic agents hyoscyamine sulfate (Levsin®), dicyclomine (Bentylol®), propantheline (Pro-Banthine®), and hyoscine butylbromide (Buscopan®).
Group 2 includes heterogeneous bulk formers that reduce stool looseness and frequency by binding (soaking up) water in the bowel in the form of fibre derivatives (e.g. Metamucil® or Prodiem®), and bile salt binders such as cholestyramine resin (Questran®).
If extra-intestinal signs of IBD such as arthritis or inflamed eyes occur, your physician will address these conditions individually. A program of stress management may be valuable and occasionally anti-anxiety medications may be useful in cases where anxiety and stress are major factors in a patient's life.
Patients with IBD may be anemic from a combination of factors such as chronic blood loss, malabsorption of certain vitamins and minerals, and other factors. Altering the diet and/or adding dietary supplements could help improve this condition. In the case of severe anemia, some patients might require blood transfusions.
Dietary Therapy
As in the management of inflammation anywhere in the body, there are certain basic principles that help to reduce inflammation and these are rest and nutrition.
Avoiding or eliminating repeated stress is critical for healing to occur, so resting of the very inflamed bowel must occur. A low residue diet can allow for mild rest, an elemental diet (an easily absorbed synthetic diet) for moderate rest, and for complete bowel rest, total fasting must take place.
Maintaining nutrition is also key. Healing requires protein and nutrients, and healing is often inefficient for those patients who are underweight or losing weight. If the patient is fasting to provide complete bowel rest, then intravenous feeding with special proteins, carbohydrates, and fats, a technique referred to as Total Parenteral Nutrition (TPN), is required.
Surgical Therapy
Patients often ask about the role of surgery. Since ulcerative colitis only involves the large bowel, removing this organ will remove the disease. Typically, such a patient would have an ostomy - where the small intestine is brought to a new surgical opening through the abdominal wall and a removable appliance is worn to collect the bowel contents. In recent years, new techniques have arisen whereby surgeons can preserve the anal muscle and create an internal pouch, or reservoir, from the remaining intestine. Emptying pouch contents via the anus more closely resembles the normal anatomical route, although the bowel movements are more frequent and liquid, so even after surgery patients could still face gastrointestinal symptoms. This treatment does not cure ulcerative colitis but it does remove the diseased colon. Sometimes, pouchitis occurs, which is inflammation of the surgically created pouch.
Experience has shown that Crohn's disease has a tendency to recur, perhaps in as many as 75% of patients, even with surgical removal of all apparently involved disease. Inflammation could recur months or years later, and be present elsewhere in the body. Because of this, and since the small bowel is often inflamed, it is not possible to simply remove the large bowel. Physicians thus reserve surgery in Crohn's disease for complications or instances where there is a total inability to control the disease in any medicinal way.
The Future of IBD
The future lies in education and research. Education of both the public and the medical profession is required, to emphasize the importance of inflammatory bowel disease research.
Research is the only hope for the determination of the cause and then the cure of inflammatory bowel disease. Many of the following areas need investigation:
the chemistry of the normal, as well as diseased intestine;
further study of tissue changes that occur in inflammation;
the relative incidence of the diseases, as determined by accurate population surveys;
emotional and psychiatric implications;
the possible role of infectious agents;
the study of the nature of inflammatory response; and
clinical trials of new forms of therapy.
A partnership between doctors and scientists interested in the study of these diseases, along with patients, their families, and their friends, is the best assurance towards finding the cause or causes and the cure(s) of Inflammatory Bowel Disease.
Are you taking prescription medication for any of the following stomach problems/symptoms:
Stomach pain or discomfort
Heartburn
Sour taste in mouth/acid regurgitation
Excessive burping/belching
Increased abdominal bloating
Nausea
Early satiety
If you answer yes to any one of the symptoms listed above then take this test to see if your current medication is adequately controlling your stomach symptoms.
The PASS Test
PPI* Acid Symptom Suppression Test
*PPI is short for proton pump inhibitor, a class of medication used to suppress the acid in your stomach. These include Losec®, Nexium®, Pantoloc®, Pariet™, and Prevacid®.
