Inflammatory Bowel Disease Information

Inflammatory Bowel Disease

What Is Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) involves chronic inflammation of all or part of the digestive tract. The two main disorders within the umbrella term of IBD are Ulcerative colitis and Crohn’s disease. Patients with IBD can experience severe symptoms such as gastrointestinal tract (GI) tract inflammation, abdominal pain and cramping, and irregular bowel movements among other symptoms. It is estimated that 1 million Americans suffer from IBD.

To learn more about Crohn’s disease, visit the Crohn’s disease condition center, or check out our slideshow about Crohn’s and the microbiome.

To learn more about ulcerative colitis, visit the ulcerative colitis condition center.

What Causes Inflammatory Bowel Disease

Crohn’s Disease

Though there is not yet a definitive cause of Crohn’s disease, recent research suggests that it is caused by an immune response to the body’s natural digestive bacteria, which may be triggered by a combination of environmental factors and genetic disposition.

A healthy gastrointestinal (GI) tract is lined with a mucosal membrane filled with bacteria that assist in digestion and absorption. It is believed that in individuals with Crohn’s disease, there is an abnormal immune response against the gut bacteria, interfering with their ability to aid in digestion and compromising the integrity of the protective mucus membrane in which they exist. The immune response attracts immune cells to the affected area in the gastrointestinal tract, causing chronic inflammation and potentially permanent damage to the tissue of the affected areas. Research has shown that this may be caused by a genetic mutation that decreases the natural defense mechanisms of the bacteria or by a genetic pre – disposition to auto – immune diseases. Crohn’s can occur anywhere in the digestive tract.

Ulcerative Colitis

In ulcerative colitis, sores known as ulcers develop on the innermost lining of the colon, interfering with its ability to absorb liquid. This can cause diarrhea, and, as the ulcers worsen, bleeding, pus production, abdominal discomfort, and complete destruction of the inner lining of the colon. Medical experts are unsure of the exact cause of the ulcers and colon inflammation, but they are focusing on these factors:

Immune system. Some scientists think that ulcerative colitis may be an autoimmune disease. If this is true, this would mean that the inflammation and ulcers in the colon seen in ulcerative colitis would be a result of the immune system attacking the body’s natural digestive bacteria that line the innermost wall of the colon.
Exposure to a virus or bacterium. Some believe inflammation in the colon is caused by an immune response against a specific virus or bacterium, not against the body’s own bacteria.
Heredity. Scientists suspect genetic makeup may play a contributing role in ulcerative colitis, because a person is more likely to get UC if a parent or sibling has the disease. Most people who have UC don’t have a family history of the disease, however certain genes have been identified as being common among those that have UC.

UC is not caused by emotional distress, but the stress of living with UC may worsen symptoms. In addition, while sensitivity to certain foods or food products does not cause UC, it may trigger symptoms in some people. UC usually occurs in the large intestines.

Risk Factors For Inflammatory Bowel Disease

Crohn’s Disease

There are several risk factors known to contribute to the likelihood of developing Crohn’s disease. These include:

Age. Crohn’s can occur at any age, but most people are diagnosed between the ages of 15 and 30.
Ethnicity. The risk is higher for Caucasians, specifically those of Eastern European (Ashkenazi) Jewish descent.
Family history. You’re at higher risk if you have a close relative with the disease. About 20% of Crohn’s disease patients have a parent, sibling or child with the disease.
Smoking. Cigarette smoking is the most important controllable risk factor for developing Crohn’s disease. While smoking is not the cause of Crohn’s disease, it does increase your chances of severe flare-ups if you do develop the disease. Studies have shown that non-smokers or quitters are 65% less likely to have flare ups than smokers.
Geography. For unknown reasons, if you live in an urban area or in an industrialized country, you’re more likely to develop Crohn’s disease. People living in northern climates also appear to have a greater risk.
Genetics. Studies have shown that mutations in the NOD2/CARD15 gene and the ATG16L1 genes are associated with Crohn’s disease. Both genes are involved in the functioning of bodily defense mechanisms.

Ulcerative Colitis

Risk factors for ulcerative colitis include:

Age. Ulcerative colitis usually begins between the ages of 15 and 30 and between the ages of 60 and 80, but it can be triggered at any age.
Race or ethnicity. The risk is higher among those of Ashkenazi Jewish descent.
Family history. You’re at higher risk for ulcerative colitis if you have a close relative, such as a parent, sibling or child, with the disease. Additionally, certain genes have been identified as being common among ulcerative colitis patients.
Certain medications. This is a more controversial risk factor, as some studies suggest links between antibiotic use and ulcerative colitis and others do not. Isotretinoin (Accutane, Sotret, Claravis, Amnesteem), certain anti-inflammatory drugs, and tetracycline antibiotics have all been suspected to increase colon inflammation, which may lead to ulcerative colitis, though no definitive conclusion has been made.

Diagnosing Inflammatory Bowel Disease

Crohn’s Disease

There is no single test to diagnose Crohn’s disease. To make a diagnosis, doctors most commonly rely on a combination of diagnostic tests, including:

Physical examination. The doctor will check for pain in the abdominal area that may be a sign of Crohn’s disease and any other physical abnormalities that could point to other conditions.
Medical history. A medical history is important for the doctor to learn about the patient’s past and recent medical activity. Family history of GI disease, recent travel, and current or recent medication use are all crucial for the doctor to know during the diagnosis process
Blood tests. A complete blood count (CBC) can detect anemia (low red blood cell count) or a high white blood cell count (a sign of inflammation or infection). t
Stool tests. Stool tests will not necessarily signal Crohn’s disease, however they can rule out other causes of gastrointestinal (GI) symptoms, such as bacterial or parasitic infection.
Flexible sigmoidoscopy, colonoscopy, and endoscopy are useful to determine the location and severity of GI inflammation. In these procedures, doctors use a small camera mounted on a flexible tube inserted through the mouth or anus to see the inside surfaces of the GI.
Computerized tomography (CT) scan uses a combination of x-rays and computer technology to create three-dimensional (3-D) images of the digestive tract.
Capsule Endoscopy. New technology allows patients to swallow a pill with an embedded camera that takes footage throughout the digestive process, revealing any inflammation or abnormalities. This method of endoscopy is less favorable for patients with moderate to severe Crohn’s disease, as there is a greater risk that the pill will become lodged within the scar tissue of the intestine, requiring surgical removal.

Ulcerative Colitis

Ulcerative colitis (UC) can be difficult to diagnose because it has symptoms similar to those of other intestinal disorders, especially Crohn’s disease. The NDDIC says Crohn’s disease differs from UC in that Crohn’s disease causes inflammation deeper within the intestinal wall and can occur in other parts of the digestive system, including the small intestine, mouth, esophagus, and stomach, while ulcerative colitis affects only continuous stretches of the inner most colon lining.

Your doctor will make a diagnosis of ulcerative colitis based on the following:

Physical Examination. Your doctor will conduct a physical exam of your body and interview you to learn more about your general health, diet, family history, and environment.
Blood Tests. Blood test can reveal a high white blood cell (WBC) count, a sign of an immune response, as well as anemia, which may indicate bleeding in the colon or rectum. They can also rule out other causes of your gastrointestinal symptoms.
Stool specimen. Stool specimens are analyzed to eliminate the possibility of bacterial, viral, or parasitic causes of diarrhea. Several stool samples may need to be taken, as certain gastrointestinal illnesses may not show up with just a single stool sample.
Endoscopy. Done with a medical instrument, the doctor can visually examine the interior of your colon with a lighted tube that is inserted through the anus. Your doctor may recommend two types of endoscopic examinations: a sigmoidoscopy and a total colonoscopy.
- Sigmoidoscopy involves the insertion of a flexible instrument into the rectum and lower colon that allows the doctor to visualize the extent and degree of inflammation in these areas.
- Total colonoscopy is a similar exam, but it examines the entire colon.
During these procedures, your doctor may wish to obtain a sample of affected tissue, called a biopsy. Biopsied tissues are then sent to a laboratory to help confirm a diagnosis and to rule out other diseases such as colon cancer.
Computerized tomography (CT) scan. According to the NDDIC, the CT scan uses both x-rays and computer technology to create three-dimensional (3-D) images. A CT scan may include the injection of a dye called contrast medium in order for the images to be read more clearly. With a CT scan, a patient lies on a table that slides into a tunnel-like device where the images are captured. An x-ray technician performs the procedure and the images are interpreted by a radiologist – a doctor who specializes in medical imaging; anesthesia is not needed. Ct scans can spot abscesses or blockages in the colon that can be signs of UC, as well as rule out other causes for symptoms.
Barium enema x-ray. A barium enema x-ray involves the injection of contrast medium, called barium, into the colon to make the colon, rectum, and lower part of the small intestine more visible in x-ray images. Intestinal narrowing or scar tissue from continued intestinal inflammation (both signs of UC), are made visible with barium enema x – rays. The procedure is performed in a hospital or outpatient center by an x-ray technician, and the images are interpreted by a radiologist; anesthesia is not needed for this procedure.

Symptoms of Inflammatory Bowel Disease

Prognosis

Living With Inflammatory Bowel Disease

Screening

Prevention

Medication And Treatment

CROHN’S DISEASE:

Crohn’s disease cannot be cured, but appropriate treatment can help suppress the inflammatory response and manage symptoms. The risk of side effects for each medication is generally proportional to the degree of the disease’s severity. Drugs with relatively few side effects are used in the earliest stages of treatment, with the aim of not worsening a patient’s condition with medication-related side effects at the risk of a slightly less effective Crohn’s treatment. Stronger drugs with more risky side effects are used to treat later stages of the disease.

Nutritional Therapy.

Intestinal inflammation can interfere with the absorption of nutrients, causing various deficiencies. Because of this, nutritional therapy is often part of Crohn’s treatment, especially in pediatric cases where regular development depends on proper nutrition. The Crohn’s and Colitis Foundation of America (CCF) reports that supplements such as vitamins and minerals should only be used in addition to conventional medical treatment. Registered dietitians can assist you in building a proper supplement and diet regimen that ensures proper nutrition without worsening digestive symptoms. Vitamin and mineral deficiencies are among the most common nutritional deficits that Crohn’s patients suffer. The following supplements may be considered:

Vitamin B-12. If diet and oral vitamin supplements don’t correct this deficiency, a monthly intramuscular injection of vitamin B-12 or once weekly nasal spray may be required. Vitamin B-12 is essential to brain and nervous function, and can naturally be found in eggs, fish such as salmon, beef, shellfish, liver, and fortified soy and dairy products.
Vitamin D. Vitamin D deficiency is common in people with Crohn’s disease. Vitamin D is essential for good bone formation and for the metabolism of calcium.
Certain medications may also have an adverse effect on bone health, especially long-term use of steroids. Calcium can help to fortify bones and promote healthy muscle and nerve function.
Iron. An iron deficiency can result from blood loss following inflammation and ulceration of the intestines seen in Crohn’s disease. Iron is essential to protein production in the body and can naturally be found in beef, fish, poultry, pumpkin seeds, spinach, cooked beans, tofu, and wheat germ among many other foods.
Probiotic supplement. The inflammation of Crohn’s disease can decrease the population of what are considered to be healthy gut bacteria. Probiotics may help replenish healthy bacteria. Types of lactobacillus and bifid bacteria are typically found in most probiotic supplements.

In addition to recommending the proper supplements, your dietitian will be able to help you build a diet plan that avoids foods that exacerbate your Crohn’s symptoms. Typical inflammatory foods that you may want to avoid include:

Alcoholic beverages including mixed drinks, wine and beer
Foods high in fat such as butter, oil, mayonnaise, and fried foods
Caffeinated beverages (i.e. coffee and tea, energy drinks)
Chocolate
Spicy foods
Raw fruits and vegetables
Foods high in fiber such as whole grains and beans
Nuts, nut butters, and seeds

Nutritional therapy can be a critical part of treatment no matter what stage of your condition is in. Make sure that your doctor and dietitian are in communication about what supplements you are taking in order to avoid medication interference.

Medications.

Medications for mild to moderate Crohn’s:

There is some evidence suggesting that antibiotics like ciproflaxin and flagyll may be helpful in treating mild to moderate cases of Crohn’s disease; however this is not backed up by significant statistical data. Antibiotics are, however, known to be effective in treating Crohn’s related complications such as infections occurring as a result of extra-intestinal manifestations.
5-Aminosalicylates (5-ASAs). 5-ASAs are a class of anti-inflammatory drugs that are thought to work as a topical anti-inflammatory for the GI tract. They have few side effects but can have a burdensome pill count (anywhere from 4-12 each day). Patients taking 5-ASAs should have regular blood and liver tests to check for potential low cell count and liver complications. Side effects may include abdominal pain, headache, dizziness, and nausea.Common 5-ASAs include:
- Sulfasalazine (Azufadine), which is one of the longest running drugs on the market for treating irritable bowel disorders. Though it has been used for decades, about 1 in 3 people are unable to sustain sulfasalazine use long-term due to severe side effects. The majority of people who react to sulfasalazine can, however, tolerate the other 5-ASAs that are listed below:
Asacol
Asacol HD
Apriso
Lialda

Medications for moderate to severe Crohn’s:

Corticosteroids. Corticosteroids are anti-inflammatory and immunosuppressant, meaning that they reduce inflammation and work to suppress the immune system. Corticosteroids may be administered in pill form, by intravenous drip (IV), as an enema, or as a rectal suppository. Caution should be used in their prescription because of the risk of the body becoming steroid-dependent. When antibiotics and 5-ASAs fail to treat Crohn’s symptoms successfully, corticosteroids are the next-in-line drug. These include:
- Prednisone is one of the most commonly prescribed steroids, and is known to cause remissions in 70-80% of patients. It is not effective for long-term treatment and has high-risk side effects including osteoporosis, diabetes, depression, high blood pressure, and adrenal conditions.
- Budesonide is another corticosteroid that was created with the goal of having fewer side effects than prednisone and other corticosteroids. Instead of travelling throughout the whole body, budesonide is released only in the end of the small intestine and ascending colon, limiting its affects to those areas. This prevents more widespread side effects, but limits its use to only patients who have Crohn’s inflammation in those areas. Budesonide may cause headache, dizziness, and nausea.

Immunosuppressants, also called immunomodulators or immune modifiers. This class of drugs works to block actions in the immune system that are involved with the inflammatory response. Common immunosuppressants include:

Azathioprine (AZA). It may take 6 to 12 weeks for the full effects of AZA to be observed. AZA is taken orally, is successful in preventing Crohn’s flare-ups in 2 out of 3 patients, and has limited side effects (the most common being nausea). Few patients (2%) are allergic to AZA or develop pancreatitis (inflammation of the pancreas) as a result of treatment. It can also put patients at a higher risk of infection and lymphoma. Patients should receive regular blood testing while on this medication to detect any potentially serious side effects.
Methotrexate (MTX). Unlike the orally-taken AZA, MTX is administered via weekly injection. MTX may take around 6 weeks for its effects to be noticed, and like AZA is successful in preventing Crohn’s flare-ups in 2 out of 3 patients. Patients taking MTX should undergo regular blood testing to monitor potentially low cell counts and liver damage. Folic acid supplementation should be paired with MTX treatment due to the drug’s depletion of the essential fatty acid. MTX should NOT be taken by pregnant women or those looking to conceive.

Medications for severe or fulminate Crohn’s:

Anti-tumor necrosis factor-alpha (Anti-TNF-α). This type of drug works by using antibodies targeted at TNF-α, an inflammatory protein that has been found in high levels in Crohn’s disease patients. 2 out of 3 patients report symptom improvement within the first two doses, around 2-3 weeks. 30-50% of patients continue their success past the one year mark, and 30-50% will need to change their medication or anti-TNF-α dosage at some point during their therapy. Anti-TNF factors put patients at a slightly higher risk of serious heart disease, autoimmune conditions, and liver disease.The FDA approved Anti-TNF-α therapies are:
- Infliximab is used in cases where Crohn’s disease symptoms do not respond to any other therapies and in cases of severe Crohn’s extra-intestinal manifestations (i.e. fistulae). It has proven to be very effective, though it can lose its effectiveness over time in some patients. Infliximab is given via an intravenous drip (IV) during a two to three hour session. Follow up doses are given two and six weeks later. Following the initial 3 doses, the medication is administered every 8 weeks.
- Adalamumab (Humira). Adalamumab is used in cases where Crohn’s disease symptoms do not respond to other therapies, in cases of severe Crohn’s complications, or in cases where patients have lost responsiveness to Infliximab. Adalamumab is given in a single injection every other week following an initial four injections during the first week of treatment and two injections during week three. Patients may become unresponsive to adalamumab in time, a problem that can be addressed by upping the dosage to weekly injections or by switching medications.
- Certolizumab pegol (Cimzia). Certolizumab pegol is a prolonged effect anti TNF agent, and only needs to be administered once monthly either by an in-home nurse or at a medical facility.
Anti-adhesion molecules. Anti-adhesion molecules work by preventing the flow of immune cells within the body, lessening the effect of the immune response observed in Crohn’s disease. The most commonly prescribed anti-adhesion molecules is:
- Natalizumab (Tysabri). Natalizumab was developed as a treatment for multiple sclerosis but was approved as a treatment for Crohn’s disease in 2008 due to evidence showing that it was effective at inducing and retaining periods of Crohn’s disease remission. There is a higher risk of developing progressive multifocal leukoencephalopathy (PML), a potentially deadly brain infection. Medical experts are more able to control the risk of developing PML today than when the drug first came out on the market. The risk of developing PML remains at 1 in 1000.

Surgery.

70-80% of Crohn’s disease patients will eventually need some type of surgery. Surgical options are considered when symptoms have not responded to medications or when there is a physical obstruction to the digestive tract. Surgeries may be be helpful in relieving symptoms connected with intestinal blockages, bowel perforations, fistulas, and rectal bleeding.

70-80% of Crohn’s disease patients will eventually need some type of surgery. Surgical options are considered when symptoms have not responded to medications or when there is a physical obstruction to the digestive tract. Surgeries may be helpful in relieving symptoms connected with intestinal blockages, bowel perforation, fistulas, and rectal bleeding.

Common surgical procedures used to treat Crohn’s disease patients include:

Bowel Resection. This is the most common form of surgery for patients with Crohn’s disease. During the procedure, doctors remove the inflamed area of the intestine and reconnect the healthy portions. This is usually successful in reducing symptoms almost immediately, however 50% of patients see symptoms return within 5 years, and 20% will require additional surgeries within 10 years.
Proctocolectomy and Ostomy. In cases where Crohn’s disease affects the entire colon, a proctocolectomy, or total removal of the colon, may be necessary. After the colon is removed, surgeons redirect waste through the small intestine to a hole in the abdominal wall known as a stoma. Waste then collects in a bag outside of the body that needs to be emptied several times a day. This is shown to effectively eliminate all Crohn’s disease symptoms in cases where inflammation was limited to the colon.
Stricturoplasties are performed when there is an obstruction of the intestine that does not necessitate removal, and widen the intestine in order for waste to be able to pass through intestinal blockages.

ULCERATIVE COLITIS:

Even though there’s no known cure for UC, a combination of treatments including medications may be able to help you stay in control of the disease. These are the major classes of medication used to treat ulcerative colitis:

Aminosalicylates (5-ASA) work on the level of the lining of the GI tract to decrease inflammation. A medication known as sulfasalazine (Azulfidine), combines sulfapyridine and 5-ASA, the NDDIC says. The sulfapyridine component carries the anti-inflammatory 5-ASA to the intestine. However, experts caution that sulfapyridine may lead to side effects such as nausea, vomiting, heartburn, diarrhea, and headache. 5-Asa can also be combined with other complimentary agents, such as olsalazine (Dipentum), mesalamine (Asacol, Canasa, Lialda, Rowasa), and balsalazide (Colazal), which cause fewer side effects and can be used by people who cannot take sulfasalazine. Depending on which parts of the colon and rectum are affected by UC, 5-ASAs can be given orally; through a rectal suppository, a small plug of medication inserted in the rectum; or through an enema—liquid medication put into the rectum. Unless the UC symptoms are severe, aminosalicylates are usually the first line of treatment for UC sufferers. These medications are also used when symptoms return after a period of remission.
Corticosteroids suppress the immune system and are used to treat moderate to severely active UC. According to the Mayo Clinic, corticosteroids have a number of side effects, including weight gain, the growth of facial hair, mood swings, high blood pressure, type 2 diabetes, osteoporosis, bone fractures, glaucoma and a higher vulnerability to infections. These are usually prescribed only for patients with moderate to severe UC who haven’t responded to treatment, and aren’t for long-term use.
Immunomodulators modulate or suppress the body’s immune system response so it can no longer cause ongoing inflammation. Immunomodulators may take several months to start working. These drugs include Azathioprine (Azasan, Imuran); mercaptopurine (Purinethol); Cyclosporine (Gengraf, Neoral, Sandimmune); infliximab (Remicade) and Adalimumab (Humira).
Antibiotics may be used when infections such as abscesses occur.
Anti-diarrheals. The Mayo Clinic says that for severe diarrhea, loperamide (Imodium) may be effective. Use anti-diarrheal medications with great caution, however, because they increase the risk of toxic megacolon (a widening of the colon) that can cause septic shock and ultimately lead to perforation of the colon.
Pain relievers. For mild pain, your doctor may recommend acetaminophen (Tylenol, others). However, experts advise against using ibuprofen (Advil, Motrin, others), naproxen (Aleve) or aspirin, as all of these are likely to make symptoms worse.
Biologic therapies, such as anti-TNF agents, are the latest class of therapy. Anti-TNF agents are antibodies, proteins that attach to substances and mark it for destruction, against Tumor necrosis factor (TNF). Tumor necrosis factor is a chemical produced by our bodies to cause inflammation. When it is attacked by anti-TNF, it loses its ability to produce inflammation in the body, thus reducing inflammation in the colon.

About one-quarter to one-third of patients with UC are unresponsive to medical therapy or complications from treatment arise. Under these circumstances, surgery may be considered. This operation involves the removal of the colon (colectomy).

Complementary and Alternative Treatment

Care Guide

Though some of the disruptive symptoms of IBD can be out of your control, there are things you can do to try to minimize the severity and impact of the symptoms. These include:

While ulcerative colitis is not caused by the foods you eat, you may find that once you have the disease, particular foods can aggravate it. Try to maintain a healthy and soothing diet that helps reduce your symptoms. Many people with ulcerative colitis find that soft, bland foods cause less discomfort than spicy or high-fiber foods.
Drink liquids as directed. Adults should drink between 9 and 13 eight-ounce cups of liquid every day. Ask your doctor what amount is best for you. For most people, good liquids to drink are water, juice, and milk. Do not drink alcohol. This can make your symptoms worse.
Get plenty of exercise. Talk to your doctor about the best exercise plan for you. Exercise can help decrease your blood pressure, and improve your overall health and mood.
Manage stress. Stress may slow healing and contribute to a flare-up. Mind body techniques such as deep relaxation and breathing may be helpful.
Take your drugs as prescribed by your doctor. Discuss any side effects.
Know you’re not alone. The Crohn’s and Colitis Foundation of America (CCFA) offer an on-line community. [NOTE: hyperlink highlighted section to: //www.ccfacommunity.org/]
Work closely with your doctor to determine the types of treatment that are best for you.
Keep a food journal. You may find it helpful to avoid certain foods for a while. Depending on your condition, these may include caffeine (coffee, tea, and cola), spicy foods, milk products, and raw fruits and vegetables.
Try eating several small meals a day instead of 3 large ones.
Keep appointments for regular checkups even if you are not having symptoms.
Talk to your doctor about surgery for Crohn’s disease or ulcerative colitis. Surgery won’t cure Crohn’s disease, but it may help control the symptoms of IBD. Only you and your doctor can decide if this option is right for you.