Inflammatory Bowel Disease (IBD)
Gastro Health Cincinnati is an acknowledged local, regional, and national leader in treatment of patients with inflammatory bowel diseases (IBD). Annually we see hundreds of patients with Crohn’s Disease, Ulcerative Colitis, and Microscopic/Lymphocytic/Collagenous Colitis. Our extensive experience is the reason why many patients come to us for second opinion consultations and help. For decades, we have been actively involved in IBD clinical research, publishing innumerable journal articles, and participating in many national conferences. Our patients with IBD may chose to participate in clinical trials, giving them access to treatments not otherwise available. In Cincinnati, we helped found the local chapter of The Crohn’s & Colitis Foundation (CCF) and have remained very active in its organization, research, fundraising, and educational activities.
We strive to provide IBD patients the most effective and safe therapies available. We have had great success in reducing the use of steroids. We have a full-time IBD nursing staff who are responsible for administering and monitoring biologic medications. We utilize additional tools to track our patients’ progress and provide a personalized treatment plan.
IBD – ULCERATIVE COLITIS AND CROHN’S DISEASE INTRODUCTION
Inflammation can occur anywhere in the body. On the skin, it can cause redness or a sore, in the joints it leads to arthritis. In the digestive tract, inflammation can be an acute process, such as from an intestinal infection/flu or even a stomach ulcer caused by aspirin. Chronic intestinal inflammation is usually due to Crohn’s Disease or Ulcerative Colitis (UC), the two major Inflammatory Bowel Diseases (IBD).
Crohn’s Disease is an inflammatory process within the gastrointestinal tract that can occur anywhere from the mouth to the anus, but more typically affects sections of the large intestine (colon) and/or lower portions of the small intestine (ileum). The inflammation forms ulcers or sores that involve the entire thickness of the affected intestine. It can be patchy in its distribution, leaving normal areas in between inflamed ones.
In Ulcerative Colitis (UC), inflammation develops in the inner more superficial lining of only the colon (the colon is the same thing as the large intestine). Ulcerative colitis always involves the lower portions of the colon (the rectum) and from there can spread to involve other higher segments of the colon in a continuous fashion. If the rectum is the only area that is inflamed, the condition is referred to as ulcerative proctitis.
HOW COMMON IS IBD?
It is estimated that there are nearly 1,500,000 Americans with either ulcerative colitis or Crohn’s disease, roughly half of that number for each disease. These diseases are often diagnosed before age 30, although they can occur at any age. There is a greater incidence in Caucasians and in Jews.
WHAT IS THE CAUSE OF IBD?
The ultimate cause of IBD is unknown, but there seem to be several factors that play a role.
- Genetics: Up to 25% of patients with IBD have family members who also have been diagnosed with inflammatory bowel disease. The pattern of inheritance is indirect; rather than a parent, there may be a cousin, aunt, or uncle who have been diagnosed. There are many genes that have been shown to be associated with IBD, highlighting exciting ongoing genetic research. The overall risk for a child of a patient with IBD developing the disease is approximately 2-6%.
- Altered Immune Function: There are a number of abnormalities in the immune system that have been identified in the inflammatory process. There is extensive ongoing worldwide research in this area which has led to effective new medications targeted at the altered areas of the immune pathways.
- Infection/Environment: A specific bacterial or viral infection or environmental exposure is probably not the specific cause of IBD but may act as a triggering event to initiate the inflammation or a propagating factor stimulating ongoing inflammation. Possible offending agents could include infecting organisms or some of the myriad of bacteria that normally inhabit the GI tract.
- Stress, anxiety, and diet are often queried by patients with IBD but these factors do not cause IBD but may play an indirect role in accentuating flares of the disease.
Putting this all together, in a genetically susceptible person, a triggering event (infection or other) stimulates the body’s immune system to inappropriately cause inflammation in the digestive tract. Bacteria and some food in the gut also have a role in continued inflammation. The inflammation causes damage to the intestines, which is responsible for the symptoms of the disease.
SYMPTOMS OF IBD
Crohn’s Disease. The location of inflammation, the amount of intestine affected, and other complications such as scarring or narrowing of the bowel (stricture) and the presence of abnormal communication between two areas (fistula) determine the type of problems that a patient will experience. Active inflammation usually causes diarrhea, abdominal pain, bloody stools, low-grade fever, and weight loss. Areas of scarring or narrowing (stricture) usually lead to abdominal pain often with bloating, distention and sometimes nausea, vomiting and weight loss. Abdominal pain in patients with Crohn’s Disease can occur anywhere in the abdomen, but is commonly located around the belly button or the right lower abdomen. A fistula occurs when inflammation in a loop of bowel erodes into whatever is positioned next to it – creating a hole or a tunnel between these two structures. A fistula can occur between two loops of bowel or between the bowel and the bladder, the vagina, or the skin. Fistulas around the anal area are fairly common. These fistulas can lead to infection, bleeding, pain, and drainage.
Ulcerative Colitis. The type and degree of symptoms depend on the amount of colon that is inflamed and the severity of the inflammation. Most patients experience bleeding with bowel movements. Bloody diarrhea is seen if the inflammation involves more that just the lower few inches of the colon/rectum. Passage of the bowel movements may be painful and often associated with a sensation of incomplete evacuation of feces. A sense of urgency to defecate is common. Constipation can be a symptom if just the rectum is involved (proctitis). In these patients, constipation with straining and blood on the stools mimics hemorrhoidal bleeding. Loss of appetite, weight loss and low-grade fever often indicate active inflammation.
Manifestations Outside the Digestive Tract. Symptoms due to the underlying inflammatory disorder can include weight loss, fever, and loss of appetite. In children, poor weight gain or a delayed growth pattern may be the initial manifestation of IBD. Effects of IBD outside of the gastrointestinal tract can occur causing certain skin rashes (pyoderma gangrenosum and erythema nodosum) and pink eye (conjunctivitis, uveitis), joint aches, back pain, arthritis, and certain liver conditions (sclerosing cholangitis). Anemia is common due to bleeding, malabsorption, and dietary factors. Patients with IBD are at risk for osteoporosis due to the affect of inflammation and of steroids on the bones.
TESTING FOR IBD
To evaluate the lower intestine, colonoscopy is usually the test of choice. Colonoscopy allows for comfortable direct inspection of the colon and the last portion of the small intestine (terminal ileum) using a fiberoptic scope in a sedated patient. Crohn’s Disease appears as redness, bleeding, ulcers or sores in a spotty distribution. Ulcerative colitis appears as confluent redness and bleeding. An x-ray examination of the small bowel (small bowel follow through or enteroclysis) evaluates the small intestine for active Crohn’s Disease or stricture (narrowing) or fistula. This is performed by drinking barium while taking abdominal x-rays as the barium flows down the intestinal tract. A CT Scan is an x-ray technique allowing for cross-sectional imaging of the abdominal structures. This can help to identify areas of bowel wall thickening/inflammation and also look for pockets of infection (abscess). MRI uses magnetic forces to image the body and does not involve radiation. Both CT and MRI can evaluate the small bowel (CT-enterography and MR-enterography). Endoscopic ultrasound utilizes an ultrasound probe placed under endoscopic control to carefully evaluate the area around the rectum for infection and inflammation, especially in Crohn’s disease. Blood work can evaluate for anemia (low blood count) and evaluate the liver and other parameters. Blood levels of inflammatory markers including the white blood cell count, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR or sed rate) can signify inflammation or infection. Blood testing for certain IBD-related markers can sometimes support a diagnosis in some patients.
WHAT CAUSES IBD FLARES?
Factors may include stopping or reducing medications, smoking (makes Crohn’s disease more refractory), use of antibiotics, use of NSAIDs (ibuprofen, naproxen and others), and gut infections. Please see our brochure “Staying Healthy with IBD” below.
TREATMENT OPTIONS FOR IBD
Crohn’s and ulcerative colitis often follow a pattern of flares (when the condition worsens) and remissions (when it improves). The pattern can be quite variable, ranging from rapid and continued remission to recurrent periods of symptoms to disabling symptoms. The goal is to drive active disease into remission and then maintain remission. Treatments can include drug therapy, lifestyle and diet modifications, and surgery. Many different medications are used to treat IBD. The choice of medications depends upon the severity of disease and the area of the digestive tract affected. In severe IBD cases, surgery may be recommended to remove damaged portions of the GI tract.
With the cause and the cure for IBD unknown, there are extensive research efforts underway. We have been active in IBD research for decades and have participated in clinical trials through the spectrum of IBD medications. Our research company, Gastro Health Research, has several ongoing clinical trials to advance the science of IBD and allow patients to participate in research and receive medications that would otherwise not be available to then.
THE CROHN’S AND COLITIS FOUNDATION (CCF)
The CCF is a national organization devoted to the interest of patients and significant others with Ulcerative Colitis and Crohn’s Disease. In Cincinnati, we have an active CCF chapter that offers educational brochures, seminars, support groups, and fund raising events that are planned with an eye toward fun and sociability. The CCF phone number is 513-772-3550. The CCF website is www.crohnscolitisfoundation.org.