Inflammatory bowel disease

Definition

Inflammatory bowel disease (IBD) is the general name for ulcerative colitis and Crohn's disease. The disease is characterized by swelling, ulcerations, and loss of function of the intestines.

Description

The primary problem in IBD is inflammation, as the name suggests. Inflammation is a process that often occurs to fight off foreign invaders in the body, including viruses, bacteria, and fungi. In response to such organisms, the body's immune system begins to produce a variety of cells and chemicals intended to stop the invasion. These immune cells and chemicals, however, also have direct effects on the body's tissues, resulting in heat, redness, swelling, and loss of function. No one knows what starts the cycle of inflammation in IBD, but the result is a swollen, boggy intestine.

In ulcerative colitis, the inflammation affects the lining of the rectum and large intestine. It is thought that the inflammation typically begins in the last segment of large intestine, which empties into the rectum (sigmoid colon). This inflammation may spread through the entire large intestine, but only rarely affects the very last section of the small intestine (ileum). The rest of the small intestine remains normal.

Crohn's disease is a form of IBD that affects both the small and large intestines. The inflammation of ulcerative colitis occurs only in the lining of the intestine (unlike Crohn's disease which affects all of the layers of the intestinal wall). As the inflammation continues, the tissue of the intestine begins to slough off, leaving pits (ulcerations) that often become infected.

IBD can occur in all age groups, with the most common age of diagnosis being 15–35 years of age. Men and women are affected equally. Whites are more frequently affected than other racial groups, and people of Jewish origin have three to six times greater likelihood of suffering from IBD. IBD is familial; an IBD patient has a 20% chance of having other relatives who are fellow sufferers.

Causes & symptoms

No specific cause of IBD has been identified. Although no organism (virus, bacteria, or fungi) has been found to set off the cycle of inflammation, some researchers continue to suspect that an organism is responsible. Other researchers are concentrating on identifying some change in the cells of the colon that would make the body's immune system accidentally begin treating those cells as foreign. Additional evidence for a disorder of the immune system includes the high number of other immune disorders that frequently accompany IBD. The condition has also been linked to physical, mental, and emotional stress .

The first symptoms of IBD are abdominal cramping and pain , a sensation of urgent need to have a bowel movement (defecate), and blood and pus in the stools.

Some patients experience diarrhea, fever , and weight loss. If the diarrhea continues, signs of severe fluid loss (dehydration) begin to appear, including low blood pressure, fast heart rate, and dizziness .

Severe complications of IBD include perforation of the intestine, toxic dilation (enlargement) of the colon, and the development of colon cancer . Intestinal perforation occurs when long-standing inflammation and ulceration of the intestine weaken the wall to such an extent that a hole occurs. This is a life-threatening complication, because the contents of the intestine (which contain a large number of bacteria) spill into the abdomen. The presence of bacteria in the abdomen can result in a massive infection called peritonitis.

Toxic dilation of the colon is thought to occur because the intestinal inflammation interferes with the normal function of the muscles of the intestine. This allows the intestine to become lax, and its diameter begins to increase. The enlarged diameter thins the walls further, increasing the risk of perforation and peritonitis. When the diameter of the intestine is quite large and infection is present, the condition is referred to as "toxic megacolon."

Patients with IBD have a significant risk of developing colon cancer. This risk seems to begin around 10 years after diagnosis. The overall risk of developing cancer seems to be greatest for those patients with the largest extent of intestine involved. The risk becomes statistically greater every year:

• At 10 years, the risk of cancer is about 0.5–1%.
• At 15 years, the risk of cancer is about 12%.
• At 20 years, the risk of cancer is about 23%.
• At 24 years, the risk of cancer is about 42%.

Patients with IBD also have a high chance of experiencing other disorders, including inflammation of the joints (arthritis), inflammation of the vertebrae (spondylitis), ulcers in the mouth and on the skin, the development of painful, red bumps on the skin, inflammation of several areas of the eye, and various disorders of the liver and gallbladder.

Diagnosis

IBD is first suspected based on the symptoms that a patient is experiencing. Examination of the stool will usually reveal the presence of blood and pus (white blood cells). Blood tests may show an increase in the number of white blood cells, which is an indication of inflammation occurring somewhere in the body. The blood test may also reveal anemia , particularly when a great deal of blood has been lost in the stool.

The most important allopathic method of diagnosis is endoscopy, during which a doctor passes a flexible tube with a tiny fiberoptic camera device through the rectum and into the colon. The doctor can then examine the lining of the intestine for signs of inflammation and ulceration. A tiny sample (biopsy) of the intestine will be removed through the endoscope, which will be examined under a microscope for evidence of IBD. X-ray examination is helpful to determine the amount of affected intestine. However, x-ray examinations requiring the use of barium should be delayed until treatment has begun. Barium is a chalky solution that the patient drinks or is given through the rectum and into the intestine (enema). The presence of barium in the intestine allows more detail to be seen on x ray films.

Treatment

Treatment for IBD targets the underlying inflammation, as well as the problems occurring due to continued diarrhea and blood loss. The use of alternative medicines in the treatment of IBD is common. IBD sufferers have used a variety of treatments; however, few controlled studies of their effectiveness have been performed.

Chamomile tea is used to treat IBD. Chamomile is known to have anti-inflammatory, antispasmodic, and antibacterial properties. The patient should steep dried flowers for 10 to 15 minutes and drink three to four cups daily. Chamomile can cause allergic reactions in those who are allergic to other daisies. Other antispasmodics include valerian , wild yam, and cramp bark .

There is some preliminary evidence that alteration of the kinds of bacteria in the intestine prevents or controls colitis. Intestinal bacteria can be manipulated through use of probiotics or prebiotics. Probiotics refers to treatment with beneficial microbes either by ingestion or through a suppository. Prebiotics refers to dietary changes that favor the overgrowth of beneficial microbes. Preliminary animal and human studies have shown that Lactobacilli and related bacteria can control colitis and prolong remission. Ingestion of the nondigestable carbohydrates inulin or lactulose as prebiotics stimulates growth of these beneficial bacteria.

In a related treatment, preliminary evidence suggests that ingestion of parasitic worm eggs eases the symptoms of IBD. Within two to three weeks, five out of the six IBD patients who ingested the eggs went into complete remission which lasted one month. The tiny, harmless worms cannot reproduce in humans and are passed out within a few months.

Ingestion of enteric coated fish oil capsules may reduce the IBD relapse rate. A small study found that patients taking fish oil supplements had a lower relapse rate (59%) than those on placebo (90%).

Seventy-two percent of ulcerative colitis patients taking a Kui Jie Qing enema (alum, Halloysite, Calamine, Indigo naturalis, and plum-blossom tongue-pointing pills) daily were considered cured, as compared with 5% of those who were taking anti-inflammatory drugs. Fifty-three percent of ulcerative colitis patients taking Jian Pi Ling tablet and root of Sophorae flavescentis plus the flower of sophora enema were considered cured, as compared with 28% of those taking sulfasalazine and dexamethasone and 19% of those taking a placebo tablet and the enema. There are many other Chinese herbs that are useful in treating diarrhea and mucus in the bowel. Sometimes these are effective when drugs are not.

Forty-five percent of ulcerative colitis patients on an enzyme-potentiated hyposensitization protocol (B-glucuronidase enzyme and 1,3-cyclohexanediol with egg, milk, wheat, potato, and yeast) were improved, as compared with 6% of those on placebo.

Nutritionists often recommend changes in the diet for patients with inflammatory bowel disease. Food allergies and certain kinds of food are linked with the increased incidence of the disease. Eliminating diary and wheat products, common allergens, often alleviates symptoms. The incidence of Crohn's disease is increasing in areas where people consume a diet high in refined sugars and carbohydrates and saturated fats and low in dietary fiber. Elimination diets or those restricted in refined foods have sometimes proved successful in the alleviation of inflammatory bowel disease.

Dietary supplements are generally beneficial in the treatment of digestive disorders. Some typical recommendations include:

• vitamin C: 4000 mg daily
• vitamin B₆: 250 mg daily
• magnesium (aspartate): 400 mg daily
• vitamin E: 800 IU daily
• glutamine: 3000 mg daily, taken between meals
• garlic, deodorized: 2000 mg daily
• deglycyrrhizinated licorice : chew as needed.

Other treatments for IBD include acupuncture , macrobiotics, cat's claw (Uncaria tomentosa ), slippery elm, acupressure, biofeedback, relaxation techniques, and hypnotherapy .

Allopathic treatment

Inflammation is often treated with an immune-suppressive drug called sulfasalazine. Because of poor absorption, sulfasalazine stays primarily within the intestine, where it is broken down into its two components: an antibiotic and an anti-inflammatory. It is believed to be primarily the anti-inflammatory component, salicylic acid, that is active in treating IBD. For patients who do not respond to sulfasalazine, steroid medications (such as prednisone) are the next choice.

Depending on the degree of blood loss, a patient with IBD may require blood transfusions and fluid replacement through a needle in the vein (intravenous or IV). Medications that can slow diarrhea must be used with great care, because they may actually cause the development of toxic megacolon.

A patient with toxic megacolon requires close monitoring and care in the hospital. He or she will usually be given steroid medications through an IV, and may be put on antibiotics. If these measures do not improve the situation, the patient will have to undergo surgery to remove the colon. This is done because the risk of death after perforation of toxic megacolon is greater than 50%.

A patient with proven cancer of the colon, or even a patient who shows certain precancerous signs, will need a colectomy (colon removal). When a colectomy is performed, a piece of the small intestine (ileum) is pulled through an opening in the abdomen and fashioned surgically to allow attachment of a special bag to catch the body's waste (feces). This opening, which will remain for the duration of the patient's life, is called an ileostomy.

Expected results

Remission refers to a disease becoming inactive for a period of time. The rate of remission of IBD (after a first attack) is nearly 90%. Those individuals whose colitis is confined primarily to the left side of the large intestine have the best prognosis. Those individuals with extensive colitis, involving most or all of the large intestine, have a much poorer prognosis. Recent studies show that about 10% of these patients have died within 10 years after diagnosis. About 20–25% of all IBD patients will require colectomy. Unlike the case for patients with Crohn's disease, however, such radical surgery results in a cure of the disease.

Resources

BOOKS

Glickman, Robert. "Inflammatory Bowel Disease: Ulcerative Colitis and Crohn's Disease." In Harrison's Principles of Internal Medicine, edited by Anthony S. Fauci, et al. New York: McGraw-Hill, 1998.

Long, James W. The Essential Guide to Chronic Illness. New York: HarperPerennial, 1997.

Saibil, Fred. Crohn's Disease and Ulcerative Colitis. Buffalo, NY: Firefly Books, 1997.

PERIODICALS

"Alternative Therapies Commonly Used by Patients with Inflammatory Bowel Disease." Nutrition Research Newsletter 18 (June 1999):13+.

Campieri, Massimo and Paolo Gionchetti. "Probiotics in Inflammatory Bowel Disease: New Insight to Pathogenesis or a Possible Therapeutic Alternative?" Gastroenterology 116 (1999):1246-1249.

Coghlan, Andy. "Wonderful Worms." New Scientist 163 (August 7, 1999):4.

Hilsden, Robert J. and Marja J. Verhoef. "Complementary and Alternative Medicine: Evaluating its Effectiveness in Inflammatory Bowel Disease." Inflammatory Bowel Diseases 4 (1998):318-323.

Martin, Frances L. "Ulcerative Colitis." American Journal of Nursing 97 (August 1997): 38+.

Peppercorn, Mark A., and Susannah K. Gordon. "Making Sense of a Mystery Ailment: Inflammatory Bowel Disease." Harvard Health Letter 22 (December 1996): 4+.

"Ulcerative Colitis: Manageable, With a Brighter Outlook." Mayo Clinic Health Letter 13 (December 1995): 1+.

ORGANIZATIONS

Crohn's and Colitis Foundation of America, Inc. 386 Park Avenue South, 17th Floor, New York, NY 10016-8804. (800) 932-2423.

Belinda Rowland

Inflammatory Bowel Disease

What Is Inflammatory Bowel Disease?

What Are the Different Types of IBD?

How Is IBD Diagnosed?

How Is IBD Treated?

Living with IBD

Resources

Inflammatory bowel disease (IBD) involves inflammation of the intestines and is a chronic (long-lasting) illness. The two major types of IBD are ulcerative colitis and Crohn’s disease. Ulcerative colitis affects the lining of the large intestine (colon) and/or the rectum. Crohn’s disease affects deeper layers of tissue and can occur in any part of the digestive system, although it occurs most commonly in the lower part of the small intestine (ileum).

KEYWORDS

for searching the Internet and other reference sources

Colitis

Digestive system

Enteritis

Gastroenterology

Gastrointestinal system

Ileitis

Inflammation

Proctitis

What Is Inflammatory Bowel Disease?

Inflammatory Bowel Disease (IBD) encompasses several diseases caused by inflammation* of the intestinal tract. The different types of IBD have many symptoms in common, including abdominal pain, frequent diarrhea (sometimes with blood and mucus), constipation, weight loss, fatigue, and fever.

* inflammation

(in-fla-MAY-shun) is the body’s reaction to irritation, infection, or injury that often involves swelling, pain, redness, and warmth,

Why some people get IBD is not clear. What is known is that IBD is not passed from person to person. However, up to 25 percent of people with IBD have a relative with the disease, suggesting that genetic factors play a role in its development. Some researchers believe that IBD occurs because a virus or bacterium triggers an inappropriate response from the immune system in people who have a genetic tendency for the disease. This response causes the digestive tract to become inflamed.

What Are the Different Types of IBD?

The two major types of inflammatory bowel disease are ulcerative colitis and Crohn’s disease.

Ulcerative Colitis

Ulcerative colitis is sometimes referred to as colitis or proctitis. Ulcerative colitis is a disease that occurs when the lining of the large intestine and/or rectum become inflamed. Usually tiny open sores, or ulcers, develop on the intestine or rectum wall. These sores often result in bloody diarrhea. Substantial blood loss can occur. People with ulcerative colitis often have symptoms that affect other areas of the body. These may include inflammation of the joints (arthritis) or the eye, skin rashes and mouth ulcers, liver disease, osteoporosis*, and anemia* caused by blood loss.

* osteoporosis

(os-te-o-por-O-sis) is the loss of material from the bone. This makes the bones weak and brittle.

* anemia

(an-E-me-ah) is the condition of having too few red blood cells. People with anemia often feel tired and weak.

Most people who develop ulcerative colitis are between the ages of 15 and 40. The severity of the disease varies from person to person. Some people seldom have an attack of symptoms. Others have almost continuous attacks that interfere with their daily activities.

Experts agree that having ulcerative colitis increases the risk of getting colon cancer. The longer a person has ulcerative colitis and the larger the part of the digestive system involved, the greater the risk of developing colon cancer.

Crohn’s Disease

Crohn’s disease is sometimes referred to as ileitis or enteritis. Crohn’s disease is an inflammation that extends deep into the tissues of the digestive system. Although this inflammation can be found anywhere in the digestive tract, most often it is found in the lower end of the small intestine where the small intestine connects to the large intestine. Ulcers often appear in patches separated by stretches of normal tissue.

There are many conflicting theories about what causes Crohn’s disease. Men and women seem to get Crohn’s disease in equal numbers, and about 20 percent of people with the disease have a relative who also has it. Many people with Crohn’s disease have abnormalities in their immune system, but it is not known if these abnormalities are the cause of the disease or the result of it.

Crohn’s disease is a chronic condition that varies from person to person in severity. In severe cases, the disease can cause major loss of blood, and it can interfere with food intake and absorption of nutrients* from the intestine. Children with Crohn’s disease may develop slowly and not reach their full growth potential because their bodies do not get enough nourishment for normal growth. Adults also may have problems with getting adequate nutrition because of the disease.

* nutrients

are the components of food (protein, carbohydrate, fat, vitamins, and minerals) needed for growth and maintenance of the body.

The most common complication of Crohn’s disease is a blockage of the intestine. Crohn’s disease causes the intestinal walls to swell and thicken with scar tissue that may eventually prevent the movement of materials through the intestine. In some people, the ulcers expand into the tissues that surround the digestive system, creating a high risk of additional infection. As with ulcerative colitis, Crohn’s disease can affect other parts of the body with symptoms such as arthritis, skin rashes, mouth sores, eye problems, kidney stones, anemia, or liver diseases.

How Is IBD Diagnosed?

A medical history, physical examination, and diagnostic tests are problems required to diagnose IBD. Blood samples may be taken to look for evidence of anemia and infection. Examination of stool samples for the presence of blood also may help the doctor make a diagnosis.

Often the colon is examined through a procedure called a colonoscopy. An endoscope (a lighted flexible tube and camera attached to a television monitor) is inserted through the anus. This allows the doctor to see the inside lining of colon and rectum. Sometimes during the colonoscopy a tissue sample (called a biopsy) is taken from the intestine lining for further examination under a microscope.

Another diagnostic procedure a physician can use is a barium study. A person drinks a mixture of barium that is flavored with another liquid, and then the person is x-rayed. Because barium shows up on x-rays, the doctor can detect abnormalities as the mixture flows through the persons intestines. CT scans* may be useful in evaluating the progress of the disease once it has been diagnosed.

* CT scans

or CAT scans are the shortened names for computerized axial tomography (to-MOG-ra-fee), which uses x-rays and computers to view structures inside the body.

Endoscopy

The word endoscopy means “peering within.” Endoscopes allow a physician to see inside the human body.

An endoscope is a long, flexible, viewing instrument that contains lenses and a light source. It is called a fiberoptic instrument because it contains thousands of thin glass fibers that carry light into body cavities and reflect an image back to the viewer by way of a video screen. This system makes it possible for the physician to examine the inside of the body in the area of interest.

Endoscopes also contain an opening through which the doctor can maneuver tiny surgical tools, such as scissors, forceps, and suction devices. This enables the doctor to do surgery or to take tissue samples without cutting through the wall of the abdomen or chest.

In 1957, at the University of Michigan, Dr. Basil Hirschowitz figured out how to light the interior of the body for examination using a fiberoptic tube. This was the first fiberoptic endoscope. Today, endoscopes are used routinely in examinations and surgical procedures.

How Is IBD Treated?

Medication and diet are the two primary approaches to controlling IBD. They do not cure the disease, but are effective in reducing symptoms in the majority of people. In severe cases of IBD, surgery may be necessary. Anti-inflammatory drugs often are used to help control the inflammation caused by the disease. In some cases, immunosuppressant drugs may be helpful in controlling symptoms that do not respond to antiinflammatory drugs. Antibiotics often are used to treat Crohn’s disease. In addition, several experimental drug therapies are under investigation.

Many of the drugs used to treat IBD are powerful and may have undesirable side effects. The physician must balance the undesirable side effects against the positive benefits of the drugs, sometimes trying several different drug combinations before a successful balance is reached.

Diet

In addition to drug therapy, a special diet may be prescribed by the physician. Since IBD interferes with the absorption of nutrients from the intestines, people with the disease often must increase the amount of calories, vitamins, and minerals they consume. Some individuals find that they must avoid specific foods that aggravate their symptoms. Other people find a bland, low-fiber diet offers some relief. Because there is no cure for IBD, people with any form of the disease should receive regular medical examinations that include a review of their treatment and diet.

Surgery

In severe cases of IBD, when damage has occurred to parts of the intestinal tract, a person may need surgery to remove damaged sections of the intestines. About 20 percent of people with ulcerative colitis require surgery at some point in their lives. If necessary, ulcerative colitis may be treated by surgery that removes the entire colon and rectum. After this procedure, normal bowel movements are not possible, so the small intestine is given a surgically created opening (ostomy) through the lower abdomen. This opening is covered with a bag that collects waste and must be emptied several times a day.

About 70 percent of people with Crohn’s disease eventually need to have damaged areas of the colon removed. Removing the damaged parts does not cure Crohn’s disease, because the inflammation may return in other places in the colon. Many people with Crohn’s disease need additional surgery because the symptoms reappear.

Living with IBD

There is no cure for inflammatory bowel disease, but people with IBD often go for substantial periods of time when they feel well and have few symptoms. During these times they are able to hold jobs, raise families, and participate in normal daily activities. Throughout the United States, there are support groups for people with IBD that help them learn to cope with their illness and maintain a normal, happy life.

See also

Anemia

Colitis

Colorectal Cancer

Constipation

Diarrhea

Diverticulitis/Diverticulosis

Irritable Bowel Syndrome

Resources

U.S. National Digestive Diseases Information Clearinghouse, 2 Information Way, Bethesda, MD 20892-3570. The National Digestive Diseases Information Clearinghouse is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). It publishes brochures and posts fact sheets about Crohn’s disease and ulcerative colitis at its website.

http://www.niddk.nih.gov/health/digest/pubs/colitis/colitis.htmhttp://www.niddk.nih.gov/health/digest/pubs/crohns/crohns.htm

Crohn’s and Colitis Foundation of America, 386 Park Avenue South, 17th floor, New York, NY 10016-8804. Telephone 800-932-2433 http://www.ccfa.org

Pediatric Crohn’s and Colitis Association, P.O. Box 188, Newton, MA 02468. Telephone 617-489-5854 http://pcca.hypermart.net

United Ostomy Association, 19772 MacArthur Boulevard, Irvine, CA 92612-2405. Telephone 800-826-0826 http://www.uoa.org

inflammatory bowel disease (IBD) n. any of a group of inflammatory conditions of the intestine that include (among others) ulcerative colitis and Crohn's disease.