Tag: inflammatory bowel disease

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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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Colitis

Dear Dr. B: My doctor thinks I have “colitis”. What is colitis and how is it diagnosed and treated? Yours Miss C.

Dear Miss C: “Colitis” is a very loose term used by many people to indicate some sort of irregularity of bowel movements – especially diarrhoea. If you have diarrhoea or irregular bowel movements then you don’t have “colitis” until proven by biopsy of the lining of the colon or by some other investigation. Literally, colitis means inflammation of the colon.

There are many causes for the inflammation of the colon. One may get colitis from viral infection, bacterial infection, parasitic infection, or fungal infection. Radiation colitis occurs when the colon is “burnt” during radiation therapy to the prostate, cervix or other abdominal organs.

Certain medications can cause colitis. Use of antibiotics can kill good bugs in the colon and allow the bad bugs to thrive causing bloody diarrhoea. This is known as antibiotic associated colitis or pseudomembranous colitis.

Then there is microscopic colitis. Here there is no change in the bowel wall as seen through the naked eye but the changes are visible only microscopically. These patients have chronic diarrhoea without any blood in the stool.

Irritable bowel syndrome (IBS) is quite often called mucous colitis or spastic colitis. But there is no true inflammation of the bowel. It is basically a motility problem.

The term “colitis” is most frequently used for inflammatory bowel disease (IBD). IBD comprises of two conditions: ulcerative colitis and Crohn’s disease. Crohn’s disease can affect any part of the gastro-intestinal tract – from mouth to anus. But most common site is the small intestine where it joins the colon. Colon is the second most common site and it is called Crohn’s colitis. Crohn’s can be at more than one site.

Ulcerative colitis is disease of the colon only and does not affect the rest of the gastro-intestinal tract. It is associated with bloody diarrhoea. Crohn’s and ulcerative colitis can have systemic effects and can affect the joints (arthritis), eyes, skin, bile ducts etc. Ulcerative colitis is a pre-malignant condition. That means that it may turn into cancer. If ulcerative colitis is present for eight years then the risk of cancer increases and the colon needs to be checked on regular basis. If there is evidence to suggest that colitis is turning into cancer then the colon needs to be removed.

On the other hand, Crohn’s does not require same sort of surveillance but the incidence of cancer of the gastro-intestinal tract is increased in patients with Crohn’s. IBD can run in the families. In Crohn’s, there is diarrhoea, which may or may not be bloody. There may be lump in the abdomen. Abdominal pain is more severe than in ulcerative colitis. Sometimes it is difficult to differentiate from irritable bowel syndrome.

Diagnosis of “colitis” is based on history and physical findings. Stools are cultured for growth of bacteria or parasites. Colon is checked by way of barium enema and flexible sigmoidoscopy (a 60 cm. flexible instrument to check the distal colon and rectum), an office procedure or colonoscopy (a longer flexible instrument) under sedation in the hospital.

Treatment depends on the type of “colitis”. As far as IBD is concerned, the medical treatment for ulcerative colitis and Crohn’s disease is the same. But the surgical management varies. And there are many variables when it comes to surgical management of Crohn’s disease.

So we have to be careful before we use the term “colitis”. It is better to give it a proper name. Miss C, you should talk to your doctor and he will give you more details. I hope the information provided here will be of some help.

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Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD)

“Dr. B, what is the difference between irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD)?” asks Susan.

Irritable bowel syndrome is a condition where the symptoms are due to disturbance in the movement and sensation of the bowel. The person is otherwise well but presents with chronic or recurrent abdominal pain, change in bowel habit (constipation and/or diarrhea) and bloating.

Inflammatory bowel disease is a condition where symptoms are due to inflammation (redness, swelling, ulcers) of the lining of the bowel. This result in abdominal pain, bloody diarrhea, and loss of weight and feeling unwell.

The exact cause of either condition is not known. Sometimes the symptoms are such that it is difficult to differentiate between the two conditions.

“Dr. B, can you tell me more about irritable bowel syndrome (IBS)?”

IBS affects about 15 percent of the population. Only 30 percent of the people affected by the condition seek help from their family physicians.

Usually a diagnosis is made after extensive and uncomfortable investigations to rule out other conditions like inflammatory bowel disease and cancer. This is called diagnosis by exclusion!

Couple of years ago, internationally recognized experts in IBS held a consensus conference to develop recommendations on diagnosis, patient education, psychosocial management, dietary advice and treatment. This is to help physicians understand and manage the condition better.

For diagnosis without investigations, the most reliable symptoms criteria used are 1. Abdominal pain 2. Pain relieved by defecation 3. Pain relieved with looser stools 4. Pain associated with more frequent stools.

Bloating is more common in women.

Using these symptom criteria, the chances are that the physician’s diagnosis of IBS is correct in 60 to 80 percent of cases. Physical examination is usually normal. In some cases there may be some abdominal tenderness or palpable colon.

Investigations are required in patients who have weight loss, rectal bleeding, anemia, family history of inflammatory bowel disease or bowel cancer, new symptoms in patients over 50 or the physician is uncertain of diagnosis of IBS.

These patients should have complete blood count and colonoscopy (a day surgery procedure under sedation in a hospital). Instead of colonoscopy, one can have air-contrast barium enema and flexible sigmoidoscopy (a 60-cm version of a colonoscope done without sedation in a doctor’s office).

Management of this condition is not always easy. Patient needs education and reassurance. It is a chronic, relapsing but benign condition although in some it can cause significant psychosocial problems.

Advice on balanced diet, exercise, and “toilet training” is important.

Most patients do not need drug therapy. No single medication has been shown to be beneficial for IBS. Symptomatic treatment of constipation, diarrhea, abdominal pain, and bloating is required.

Associated conditions like depression and anxiety should be recognized and treated.

As you can see, lot more research is required to unlock the mystery and frustration of this condition. In the meantime, we have to deal with the problem with patience and perseverance.

Physicians and patients have to understand each other’s limitations and difficulties and work together to relieve pain, anxiety and discomfort.

“Thank you Dr. B., this will certainly help me understand my problem!” says Susan as she gets ready to leave.

This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.

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