Inflammatory Bowel Disease (IBD)

Inflammatory bowel disease (IBD) refers to a group of disorders that cause inflammation and swelling of the digestive tract tissues.

The most common types of IBD include:

• Ulcerative colitis: This condition involves inflammation and the formation of ulcers along the lining of the colon and rectum.
• Crohn’s disease: This type of IBD causes inflammation that affects deeper layers of the digestive tract. The small intestine is the most commonly affected area, although the condition can also involve the large intestine and, less frequently, the upper gastrointestinal tract.

Common symptoms of both ulcerative colitis and Crohn’s disease include abdominal pain, diarrhea, rectal bleeding, fatigue, and unintended weight loss.

For some individuals, IBD is relatively mild, while for others, it can lead to disability and cause potentially life-threatening complications.

Symptoms

The symptoms of IBD can differ based on the severity and location of the inflammation, and they can range from mild to severe. People with IBD typically experience active flare-ups followed by periods of remission.

Symptoms common to both Crohn’s disease and ulcerative colitis include:

• Diarrhea
• Abdominal pain and cramping
• Blood in the stool
• Loss of appetite
• Unexplained weight loss
• Extreme fatigue

When to Consult a Gastroenterologist

It is important to consult a gastroenterologist if there are significant changes in bowel habits or if any symptoms of IBD are present. While IBD is typically not fatal, it is a serious condition that can result in life-threatening complications in some individuals.

Causes

The exact cause of IBD remains unclear. While diet and stress were once thought to be primary causes, it is now understood that they may aggravate the condition but do not directly cause it. Various factors likely contribute to the development of IBD.

• Immune System: One possible cause is an abnormal immune response. When the immune system attempts to fight off an infection, it may mistakenly attack the cells of the digestive tract as well.
• Genetics: Certain genetic markers have been associated with IBD. The condition is more common in individuals with a family history of the disease, although many people with IBD do not have this family connection.
• Environmental Factors: Environmental factors, particularly those that affect the gut microbiome, may contribute to the development of IBD. These include:
  • Growing up in a sterile environment with minimal exposure to bacteria
  • Early gastrointestinal infections
  • Antibiotic use during infancy
  • Predominantly bottle-feeding during infancy

Risk Factors

Risk factors for developing IBD include:

• Age: IBD is most commonly diagnosed in individuals under 30 years old, although it can also occur in people in their 50s or 60s.
• Family History: The risk of developing IBD is higher for those with a close relative, such as a parent, sibling, or child, who has the condition.
• Cigarette Smoking: Smoking is a significant modifiable risk factor for Crohn’s disease. Although some studies have found that smoking may reduce the risk of ulcerative colitis, the overall health risks of smoking outweigh any potential benefit. Quitting smoking can improve digestive health and offer various other health benefits.
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Frequent use of medications like ibuprofen (Brufen) and diclofenac (Cataflam) may increase the risk of developing IBD or worsen the condition in those already affected.

Complications

Ulcerative colitis and Crohn’s disease share several complications, while others are specific to each condition. Common complications include:

• Colon Cancer: Those with extensive ulcerative colitis or Crohn’s disease affecting most of the colon have a heightened risk of colon cancer. Colonoscopies are recommended, usually starting 8 to 10 years after diagnosis, to monitor for cancer.
• Inflammation of the Skin, Eyes, and Joints: Conditions such as arthritis, skin lesions, and uveitis (eye inflammation) may occur during flare-ups.
• Medication Side Effects: Certain medications used to treat IBD can increase the risk of infections. Corticosteroids are associated with risks such as osteoporosis and high blood pressure.
• Primary Sclerosing Cholangitis: This rare condition, seen more frequently in individuals with IBD, causes scarring and narrowing of the bile ducts, which can lead to liver damage.
• Blood Clots: IBD increases the risk of developing blood clots in both veins and arteries.
• Severe Dehydration: Excessive diarrhea may lead to dehydration.

Specific complications of Crohn’s disease include:

• Bowel Obstruction: The chronic inflammation associated with Crohn’s disease can cause parts of the bowel to thicken and narrow, leading to blockages. Surgery may be required to remove the affected portion of the bowel.
• Malnutrition: Persistent diarrhea and abdominal pain may interfere with nutrient absorption, leading to malnutrition. Anemia, caused by low iron or vitamin B12 levels, is also common.
• Fistulas: Inflammation may create abnormal passages (fistulas) between different areas of the body. These can occur near the anus or within the abdominal cavity and may become infected, resulting in abscesses.
• Anal Fissures: Small tears in the tissue surrounding the anus can lead to infections and pain during bowel movements. In some cases, fissures may develop into fistulas.

Specific complications of ulcerative colitis include:

• Toxic Megacolon: This severe condition involves the rapid widening and swelling of the colon and can be life-threatening.
• Perforated Colon: This condition involves a hole in the colon, which can be caused by toxic megacolon or occur independently. Prompt treatment is required to avoid severe complications.

Diagnosis

To diagnose inflammatory bowel disease (IBD), a gastroenterologist typically recommends a combination of tests and procedures.

Lab Tests

• Blood Tests: These tests can detect signs of infection or anemia, a condition in which there are insufficient red blood cells to carry oxygen to the tissues. Blood tests also assess inflammation levels, liver function, or the presence of inactive infections, such as tuberculosis. Blood may also be screened for immune responses to infections.
• Stool Studies: A stool sample is often tested for blood or organisms, such as bacteria or, on rare occasions, parasites, which could contribute to symptoms like diarrhea. Sometimes, stool markers for inflammation may be examined to provide more insight.

Endoscopic Procedures

• Colonoscopy: A colonoscopy allows for the examination of the entire colon and parts of the small intestine using a flexible, lighted tube with a camera. A biopsy, which involves taking a small tissue sample for analysis, is commonly performed during this procedure to help differentiate IBD from other forms of intestinal inflammation.
• Flexible Sigmoidoscopy: This procedure uses a slim, flexible tube with a light to examine the rectum and sigmoid colon. If the colon is severely inflamed, this test may be used instead of a full colonoscopy.
• Upper Endoscopy: An upper endoscopy uses a flexible tube with a camera to assess the esophagus, stomach, and the first part of the small intestine (duodenum). Although the upper gastrointestinal tract is rarely involved in Crohn’s disease, this test may be recommended if symptoms like nausea, vomiting, eating difficulties, or upper abdominal pain are present.
• Capsule Endoscopy: This test is occasionally used for diagnosing Crohn’s disease in the small intestine. A patient swallows a capsule with a camera inside. The images it captures are transmitted to a recorder worn by the patient. The capsule exits the body naturally through stool. A follow-up endoscopy with biopsy may still be needed for confirmation. Capsule endoscopy should not be used if a bowel obstruction is suspected.
• Balloon-Assisted Enteroscopy: This test employs a scope along with an overtube to explore the small intestine, especially areas that standard endoscopes cannot reach. It is useful when capsule endoscopy results are unclear, and a diagnosis is still uncertain.

Imaging Tests

• X-Ray: In cases with severe symptoms, a standard X-ray of the abdomen may be used to rule out serious complications such as toxic megacolon or perforated colon.
• Computerized Tomography (CT): CT scans, a more detailed X-ray technique, are used to assess the entire bowel and surrounding tissues. CT enterography provides clearer images of the small bowel and has largely replaced barium X-rays in most medical settings.
• Magnetic Resonance Imaging (MRI): MRI scans use a magnetic field and radio waves to produce detailed images of organs and tissues. An MRI is particularly useful for evaluating fistulas around the anus or small intestine (MR enterography), and it has the advantage of not exposing the patient to radiation.

Treatment

The primary goal of IBD treatment is to reduce inflammation and alleviate symptoms. Successful treatment may lead to long-term remission and a decreased risk of complications. The treatment plan typically involves medication or surgery.

Anti-Inflammatory Medications

Anti-inflammatory drugs are often the first treatment step for ulcerative colitis, especially in mild to moderate cases. These include aminosalicylates, which help control inflammation in the intestines.

Short-term corticosteroids are also used to induce remission. These steroids are immunosuppressive in addition to being anti-inflammatory, and the type prescribed depends on which area of the colon is affected.

Immunomodulators

Immunosuppressant drugs work by targeting the immune response that triggers the release of chemicals causing inflammation in the digestive tract.

Small Molecules

Recently, small molecule drugs have been introduced for treating IBD. These medications help reduce inflammation by targeting immune system components responsible for causing inflammation in the intestines.

Biologics

Biologics are a newer class of treatment targeting proteins that promote inflammation. Some biologics are administered via intravenous infusions, while others are self-injected.

Antibiotics

Antibiotics are often used alongside other treatments, particularly if there is concern about infection, such as with perianal Crohn’s disease.

Other Medications and Supplements

To manage symptoms, additional medications may be prescribed. Always consult a gastroenterologist before taking non-prescription treatments. Options may include:

• Antidiarrheals: Fiber supplements can relieve mild to moderate diarrhea by adding bulk to the stool. For severe diarrhea, medications that slow down bowel movements may be helpful.
• Pain Relievers: For mild pain, acetaminophen is often recommended. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided, as they can worsen IBD symptoms.
• Vitamins and Nutritional Supplements: If absorption issues occur, vitamins and supplements may be suggested.

Nutritional Support

If weight loss is severe, a gastroenterologist may recommend a specialized diet delivered through a feeding tube (enteral nutrition) or intravenous nutrients (parenteral nutrition). These options help improve overall nutrition while giving the bowel time to rest, potentially reducing inflammation. For patients with stenosis or strictures, a low-residue diet may be advised to prevent blockages in the narrowed parts of the bowel.

Surgery

If other treatments do not relieve symptoms, surgery may be considered. Surgery for IBD is typically performed by a general surgeon after a referral from a gastroenterologist.

• Surgery for Ulcerative Colitis: This involves removing the entire colon and rectum, followed by the creation of an internal pouch connected to the anus, allowing for stool passage without an external bag. In cases where an internal pouch is not feasible, an ileal stoma is created, and stool passes into a bag outside the body.
• Surgery for Crohn’s Disease: Up to two-thirds of individuals with Crohn’s disease will need surgery at some point, although surgery does not cure the disease. During surgery, damaged parts of the digestive tract are removed and the healthy sections are reconnected. Surgery may also address fistulas and abscesses. However, the disease often recurs, particularly near the reconnected areas, so post-surgical treatment with medication is recommended to reduce recurrence risks.