Inflammatory Bowel Disease

Introduction

You are an active adult busy with your career and life. Unexpectedly, you start experiencing stomach cramps and diarrhea. Then you notice blood in your stool. Alarmed, you go to the doctor and are told that you might be suffering from inflammatory bowel disease (IBD).

What is it?

IBD is a general term used to describe chronic inflammatory disorders of unknown cause that involve the gastrointestinal (GI) tract. IBD includes two major inflammatory disorders, ulcerative colitis and Crohn's disease. The differences between ulcerative colitis and Crohn's disease are detailed in the chart below.

IBD: Differences Between Ulcerative Colitis and Crohn's Disease

Although IBD primarily involves the GI tract, it can also affect other parts of the body. Complications associated with IBD may include arthritis, eye disease, liver disease, and skin disorders. How an individual experiences IBD varies from one person to the next. After the initial episode of the disease, most individuals continue to have occasions with some symptoms of the disease that alternate with symptom-free periods.

What causes it?

Currently, the exact cause of IBD is unknown, although a variety of theories are under investigation.

• Genetics: This theory includes the possibility that genetic defects may affect certain tissues in the body. Researchers recently discovered a specific gene that is linked to Crohn's disease. In addition, a family history of IBD may be a predictor in the development of this disease.

• Immune factors: Another theory is that an individual with IBD may be suffering from an immune disorder in which the body attacks itself. Specifically, researchers are looking at a cytokine called tumor necrosis factor (TNF). Cytokines are small proteins released from cells that have a very specific effect on the behavior of individual cells and on how one cell communicates and interacts with another cell. TNF, in increased amounts, could be responsible for causing the abnormal functioning of the intestine that results in IBD.

• Infections: Infections from viruses and bacteria (including chlamydia) are also under investigation as potential causes of IBD.

• Diet: Diets that are low in fiber and high in refined sugars could possibly contribute to the development of Crohn?s disease.

• Smoking: While smoking seems to reduce risk for ulcerative colitis, smoking has been associated with an increase in development of Crohn?s disease.

• Certain medications: Non-steroidal anti-inflammatory drugs (NSAIDs) are drugs that reduce pain, fever, and inflammation. Popular NSAIDs such as ibuprofen, aspirin, and naproxen (if used excessively) can help to tear down the mucus protective lining of the digestive tract thereby promoting IBD.

Who has it?

Overall, IBD affects approximately 1 million people in the United States; it is believed that 15,000 to 30,000 new cases develop each year. IBD can occur at any time in a person's life; however, it most frequently occurs in persons in their late teens and twenties and in persons between the ages of 50 and 80 years. Men and women are equally affected by IBD. Genetics research has indicated that IBD tends to run in families. Approximately 15 to 30 percent of patients with IBD have a relative with the disease.

What are the risk factors?

IBD tends to run in families and certain ethnic groups, although there is no clear-cut pattern. The occurrence of IBD is reported to be the highest in individuals of Jewish heritage followed by non-Jewish Caucasians, African Americans, Hispanics, and Asians. Also, IBD rate tends to be higher in people diagnosed with panic disorder or have a history of psychological trauma and abuse.

What are the symptoms?

Symptoms of IBD depend on whether a person has Crohn's disease or ulcerative colitis. Because some symptoms may occur in both conditions, differentiating between ulcerative colitis and Crohn's disease is sometimes difficult. The chart below lists symptoms of IBD and their unique association with either ulcerative colitis or Crohn's disease. Symptoms of IBD range from mild to severe and can include the following:

Symptoms of IBD

The following symptoms may occur with either ulcerative colitis or Crohn's disease:

• Diarrhea
• Loss of appetite
• Painful bowel movements
• Frequent bowel movements
• Weight loss
• Fatigue
• Sores on lower legs, ankles, calves, thighs, and arms
• Rheumatoid arthritis
• Irritation of the eye

How is it treated?

Because of the aggressive nature of IBD, successful treatment depends on individualizing treatment regimens to fit each person's needs. Treatment typically includes controlling the active inflammation of the disease and maintaining remission through medications. To learn more about the step-wise approach to how medications are used to treat Crohn's disease and ulcerative colitis, see "Treatment Approaches" below.

For some patients, medications may not adequately control inflammation and therefore surgical treatment will be needed. Surgery sometimes becomes necessary, either to relieve symptoms that do not respond to medical therapy or to correct complications such as blockage, perforation, abscess, or bleeding in the intestine. The approach to surgical treatment in IBD varies, depending on the location and severity of the disease. It must be emphasized that removal of the diseased part of the intestine can cure ulcerative colitis as long as the disease is limited to the colon. However, because Crohn's disease can involve any segment of the GI tract from the mouth to the anus, surgical resection typically does not provide a cure.

All people suffering from IBD need nutritional care and individually tailored diets. Controlling diet does not cure IBD, but it can keep patients well nourished and decrease some of the irritation experienced. Often individuals with this disease become malnourished because of poor absorption of nutrients from the GI tract. Furthermore, some foods can worsen the inflammation. Foods that worsen IBD may not be the same for every individual. For more information on foods that may exacerbate symptoms of IBD, see "Helping Yourself" above.

Individuals with IBD should see their doctors on a regular basis for appropriate treatment and monitoring of the disease. Complications from IBD such as fistulas and strictures (narrowing or constriction of part of the GI tract) can be identified through frequent checkups.

After controlling the acute symptoms, IBD may improve, but most individuals will need to remain on medication for continued improvement and prevention of future symptoms. (This continuation of medications for prevention of future symptoms is called the "maintenance period.")

Once symptoms of the disease are controlled, a person may go into remission and not have symptoms of the disease. Length of remission varies from person to person. When attacks occur, it may be necessary to change the prescribed medications depending on whether or not the individual is in the maintenance period.

Treatment Approaches to Crohn's Disease

Treatment Approaches to Ulcerative Colitis

Helping Yourself

In some cases, IBD can dramatically affect a person's life and limit activities. However, with proper care, a person may be able to overcome those limits and maintain an active lifestyle. Medications help control and treat IBD. You can help yourself by talking with your doctor and learning how and when to use the available medications.

Other things you can do to help yourself include the following:

1. Monitor and track when your IBD symptoms occur, their degree of severity, and any side effects you have from medications. Discussing these with your doctor helps him or her better tailor a treatment regimen to your needs. Avoid substances that trigger IBD. These can include but are not limited to nicotine, lactose, and fiber. Avoid foods that trigger IBD. Because these vary from person to person, it is important to first identify those foods that trigger symptoms. Some individuals find lactose-containing foods difficult to tolerate. If this is true for you, avoiding dairy products may help you control IBD symptoms. If you need help, a registered dietitian can help you design a healthy diet that is low in lactose.

2. If you have Crohn's disease that specifically affects the small intestine, you may not be able to digest or absorb fat. Instead, fat passes through your intestine, making your diarrhea worse. Foods that may be especially troublesome to digest include butter, margarine, peanut butter, nuts, mayonnaise, avocados, cream, ice cream, fried foods, chocolate, and red meat. Some people find that too much fiber can also worsen symptoms. Experiment with different sources and amounts of fiber to find what works best for you. You may have more problems with foods in the cabbage family, such as broccoli and cauliflower, and with very crunchy foods, such as raw apples and carrots. There is some evidence that foods high in protein such as lean meats, chicken, fish, and eggs can help control the symptoms of IBD. Most people find that they can tolerate some foods better than others can, so experiment to find what works best for you.

3. Closely monitor your diet to ensure that you are getting all the nutrients and vitamins necessary to stay healthy. It is critical to maintain nutrition even in the face of acute flare-ups of IBD to prevent further complications. Discuss with your doctor different sources of water-soluble and fat-soluble vitamins, specifically vitamins B, C, A, D, E, and K. Minerals that we normally get from food include calcium, magnesium, phosphorous, sodium, potassium, chlorine, iron, zinc, copper, manganese, molybdenum, fluorine, iodine, cobalt, chromium, and selenium. Ask your doctor if you should supplement your diet with any of these substances if you have problems absorbing them from your diet.

What is on the horizon?

Research continues in the quest to more clearly identify the causes of IBD. Studies are underway that examine genetic and environmental factors that may have a role in the development of IBD. Once the exact causes of IBD are identified, new treatments and detection techniques can be developed. Researchers recently discovered a specific gene that has been linked to the development of Crohn's disease. The presence of this gene in a person is an accurate predictor of the chances for developing Crohn's disease.

Additionally, researchers are investigating a variety of new treatments for IBD. Preliminary studies of interleukin-11 have shown promising results in patients with ulcerative colitis and Crohn's disease. Other agents including growth hormone, nicotine patches, fish oil, budesonide (a corticosteroid), heparin, rosiglitazone (Avandia), tacrolimus, and mycophenolate mofetil (in combination with steroids) have shown some effect in IBD, but further study is warranted.

References

1. Brandt LJ, Steiner-Grossman P, eds. Treating IBD: A Patient's Guide to the Medical and Surgical Management of Inflammatory Bowel Disease. New York: Raven Press, 1989.

2. Dipiro JT, Schade RR. Inflammatory Bowel Disease. In: Dipiro JT, et al. Pharmacotherapy: A Pathophysiologic Approach. 6th ed., 649-664.

3. Wall G. Lower Gastrointestinal Disorders. In: Koda-Kimble MA, et al. Applied Therapeutics: The Clinical Use of Drugs. 8th ed., 28-1 to 28-23.

4. National Digestive Diseases Information Clearinghouse. Ulcerative Clearinghouse. Available at: http://digestive.niddk.nih.gov/ddiseases/pubs/colitis/index.htm#hope. Accessed Aug 2007.

5. http:// www.gastro.org/clinicalResearch/brochures/ibd.html. Accessed Aug 2007.

6. Sleisenger, Fordtran's Gastrointestinal and Liver Disease Pathophysiology/Diagnosis/Management. 6th ed. Philadelphia: Saunders, 1998:38-42.

7. http://www.niddk.nih.gov/federal/advances/2002/genetic-breakthroughs.pdf. Accessed Dec 2004.

8. Podolsky DK. Inflammatory Bowel Disease. New England Journal of Medicine. 2002(347): 417-429.

   Inflammatory Bowel Disease Health Condition Last Updated: August 2007

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   Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.

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