Inflammatory Bowel Disease

Dear Dr. B: I was recently diagnosed with inflammatory bowel disease (IBD). I have been advised to stay on medication for IBD for the rest of my life. Why do I have to do that? What happens if I take it only when I have a relapse?

Answer: First, we need to clarify what is IBD. IBD covers two forms of intestinal inflammation: ulcerative colitis and Crohn’s disease. It has nothing to do with irritable bowel syndrome (IBS).

Ulcerative colitis is inflammation of the colon and rectum only. It does not affect other parts of the gastro-intestinal tract. Crohn’s disease can occur anywhere in the gastro-intestinal tract, from mouth to anus. The most common sites being the terminal ileum and the colon.

Exact cause of IBD is not known. IBD is associated with wide variety of complications which may affect the bowel or other parts of the body. There is no medical treatment to cure IBD. Therefore bringing the disease under control and maintaining remission is very important to prevent complications. But attaining and maintaining remission is a big challenge.

After appropriate investigations, in 80 to 90 per cent of the cases of IBD your doctor should be able to tell you whether you have ulcerative colitis or Crohn’s disease. Sometimes it is hard to differentiate between the two.

Most common medications used in the management of ulcerative colitis are: 5-ASA (aminosalicylates) and corticosteroids. Patients who do not respond to these medications are then managed by azathioprine, 6-mercapturine, methotrexate, cyclosporine or infliximab.

5-ASA is the first line of treatment. Episodes of remission and relapse are very common in ulcerative colitis. Studies have shown that those who take their medications on regular basis are fivefold more likely to remain in remission than those who are not compliant.

There are many advantages to maintaining remission in ulcerative colitis. Abdominal cramps, diarrhea and blood loss are not pleasant symptoms to have every few weeks or months. It may also reduce the risk of colon cancer by half in compliant patients. It is important to remember ulcerative colitis is a pre-malignant condition. Corticosteroids are good for short term use but should not be used for long term remission because it has many side-effects.

Ulcerative colitis can be cured by surgically removing the whole colon and rectum and having an ileostomy for faecal passage. Surgical option is entertained only if there is a risk of cancer, if cancer is found in the colon, if the disease is not responding to medical treatment or patients develop complications. Overall, in ulcerative colitis, very few patients need surgery.

Drugs used to induce remission in Crohn’s disease are the same ones as used in ulcerative colitis. First line of treatment is 5-ASA but it is not as effective in Crohn’s as it is in ulcerative colitis. Most patients end up getting corticosteroids. But corticosteroids have many side-effects so it should be used only for short term purposes.

If the patient has recurrent episodes of flare-ups then azathioprine or methotrexate is effective in maintaining remission. There is no consensus as to how long these medications should be continued as they can be associated with side-effects. The next line of treatment to maintain remission is infusion of infliximab every eight weeks.

There is no simple way to keep Crohn’s in remission. Eighty per cent of the patients with Crohn’s will eventually require surgery as they become resistant to medical therapy or develop complications. Surgery does not cure the disease. It only removes the diseased segment of the bowel. There is high rate of recurrence of the disease after surgery. Within 15 years, more than 70 per cent of patients will require a second operation.

Unfortunately, in IBD, taking pills is a life long commitment without any guarantee of cure or episodes of relapse.

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