Patient Education: Inflammatory Bowel Disease

Inflammatory Bowel Disease (IBD) is a broader term for a group of chronic diseases that cause inflammation of the digestive tract.  The most common types of IBD are Crohn’s Disease and Ulcerative Colitis, which affect approximately 1.4 million Americans.  It is estimated that 7 out of 100,000 people in the U.S. develop Crohn’s disease, and 10 to 15 people out of 100,000 develop Ulcerative Colitis.  As many as 4 million people worldwide suffer from IBD.  There are still many unanswered questions about IBD, which is why the Northwestern IBD Center is dedicated to laboratory and clinical research studies into the causes and treatments of Crohn’s and Ulcerative Colitis. 

What causes IBD?

The exact causes of IBD are unknown.  The most recent research suggests that IBD may be caused by a problem with the body’s immune system which causes it to attack parts of the digestive tract as it would a virus or bacteria.  It also appears that there is a genetic component to IBD and that certain environmental factors may increase a person’s risk for developing Crohn’s or Ulcerative Colitis.  It’s likely that a combination of genetics and environmental triggers is what causes the immune system to malfunction in IBD.

How is IBD diagnosed?

Many times the diagnosis of IBD is difficult and time-consuming.  Making an accurate diagnosis is crucial so that a person can receive the most effective treatments.  A variety of tests are used to diagnose IBD.  These include colonoscopy, flexible sigmoidoscopy, barium x-rays, capsule endoscopy, and blood tests.  

A colonoscopy is the most definitive way to diagnose IBD.  This test is conducted at our GI Laboratory.  During this test, your doctor inserts a thin, flexible tube through the rectum to examine the tissue lining the colon.  The tube is long enough to view your entire colon, from the anus to the last part of the small intestines.  Colonoscopy allows your doctor to see any inflammation, ulcers, or other problems that may indicate IBD.  During this procedure, your doctor may also take tissue biopsies from inside the colon to test in the laboratory for certain types of cells called granulomas.  Granulomas are present in Crohn’s Disease but not Ulcerative Colitis.  This is an important way for your doctor to distinguish which form of IBD is present.

A flexible sigmoidoscopy is similar to a colonoscopy, except your doctor only views the last 2 feet of your colon and can be done in our clinic versus the GI Laboratory.  This procedure is useful for diagnosing disease in the lowest portion of the colon but does not allow your doctor to see any problems that may be higher in the colon or small intestine. 

X-rays used to diagnose IBD include a barium enema and small bowel follow-through.  These tests use barium, which is a safe dye that gives clearer x-ray images of the digestive tract.  During a barium enema, barium is placed in the colon which coats the lining and creates a silhouette of the entire large intestine.  A small bowel follow-through, or barium swallow, involves drinking a glass of barium which coats the stomach and small intestine so that parts of the digestive tract that cannot be viewed with a barium enema can be examined for any abnormalities.

Capsule Endoscopy is a newer technique used to examine the small intestines.  For this procedure, you swallow a small camera enclosed in a pill-like casing.  During the day, you wear a belt with a receiver that will capture pictures from the camera as it passes through your digestive tract.  The capsule endoscopy produces thousands of pictures that your gastroenterologist can review for ulcers, inflammation, or other abnormalities that would indicate that Crohn’s Disease is present.

Several blood tests may be used to help with diagnosing IBD.  These include checking for anemia, elevations in white blood cell counts, and changes in inflammatory markers in the body such as C-Reactive Protein (CRP) and Sedimentation Rate (ESR).  There are also specific blood tests for IBD, which look for certain antibodies in the blood that are specific to Crohn’s Disease or Ulcerative Colitis.  These tests are helpful but are not 100% accurate in diagnosing IBD.

Crohn’s Disease

Crohn’s Disease (CD) can affect anywhere from the mouth to the anus but most commonly affects the small intestine and/or colon.  It causes inflammation, deep ulcers, and scarring to the wall of the intestine and often occurs in patches.  The main symptoms are pain in the abdomen, urgent diarrhea, general tiredness, and loss of weight.  Crohn’s is sometimes associated with other inflammatory conditions affecting the joints, skin, and eyes.

The severity of symptoms fluctuates unpredictably over time.  Patients are likely to experience flare-ups in between intervals of remission or reduced symptoms.  The cause or causes of Crohn’s Disease have not yet been identified, but both genetic factors and environmental triggers are likely to be involved.

Ulcerative Colitis

Ulcerative Colitis (UC) affects the rectum and sometimes the colon (large intestine).  Inflammation and many tiny ulcers develop on the inside lining of the colon resulting in urgent and bloody diarrhea, pain, and continual tiredness.  The condition varies as to how much of the colon is affected.  In addition, Ulcerative Colitis can cause inflammation in the eyes, skin, and joints.  If the inflammation is only in the rectum, it is known as proctitis.

Like Crohn’s disease, the severity of symptoms fluctuates unpredictably over time.  Patients are likely to experience flare-ups in between intervals of remission or reduced symptoms.  The cause or causes of Crohn’s Disease have not yet been identified, but both genetic factors and environmental triggers are likely to be involved.

Microscopic Colitis

Microscopic colitis (MC) is the third type of IBD.  There are two types of microscopic colitis: collagenous colitis and lymphocytic colitis, both of which can be treated with medications. Common symptoms of MC are abdominal pain and diarrhea, but visualization of the colon via colonoscopy shows no abnormal changes or inflammation.  The physician takes biopsies of the colon, which are used to make the diagnosis of microscopic colitis.   It is thought that MC may be associated with Celiac Sprue (gluten-sensitive enteropathy).

How is IBD treated?

For both Crohn’s Disease and Ulcerative Colitis medication is the recommended form of treatment. Currently, there is no medication that can cure IBD.  The goal of medical treatment is to reduce the abnormal inflammatory response in the intestines and allow tissues to heal.  Once active symptoms such as diarrhea and pain are controlled, medications are used to reduce the frequency of flare-ups and maintain remission. In more advanced disease, surgery is often necessary. The type of operation performed and the prognosis are specific to each disease. 

The most commonly prescribed drugs for inflammatory bowel disease are:

  • Aminosalicylates (mesalamine, balsalazide, sufasalazine, osalazine). These are often used as first-line treatment in early disease.  These drugs work similarly to aspirin to reduce inflammation in the intestines. 
  • Corticosteroids (prednisone, methyloprednisone, and budesonide ). Steroids are powerful drugs that reduce inflammation in the intestines and can aid in the treatment of fistulas.  
  • Immunomodulators (6-mercaptopurine, azathiopri ne, methotrexate, tacrolimus, thalidomide). These drugs control the immune response and can help maintain remission and reduce the dose of corticosteroids.
  • Antibiotics (metronidazole and ciproflaxin). Antibiotics are helpful in patients with fissures or abscesses, particularly in disease involving the rectum or anus.
  • Anti-TNF Medication (infliximab, adalimumab).  Infliximab is a medication that suppresses a certain part of the immune system (Tumor Necrosis Factor-Alpha) and can help induce and maintain remission.  It can also aid in the treatment of fistulas.  Adalimumab is another anti-TNF medication currently being used for off-label treatment of Crohn’s Disease.

Depending on the form of IBD you are experiencing, another option is endoscopic treatment. Visit IES Medical Group to learn more about the kinds of conditions they treat and what procedures are available to you.

Other Ways to Manage IBD

Psychosocial Therapy

Patients with IBD often have psychosocial concerns directly or indirectly associated with their disease. Coping with a chronic, unpredictable disease can be extremely difficult for patients and their loved ones. People who are newly diagnosed with an IBD often feel overwhelmed with the treatment decisions they have to make and the effects the disease may have on their lifestyle. Patients who have had an IBD for a long period of time may continue to struggle with the impact the disease has on their relationships, employment, and educational goals. Addressing these issues with a health psychologist is often helpful.

Similarly, because the gastrointestinal system is highly susceptible to the consequences of stress, patients with IBD often have to be more proactive than the average person in adequately managing their day-to-day stress. Stress management techniques such as cognitive-behavioral therapy and hypnotherapy can be useful in disease management, potentially reducing one’s risk for relapse or reducing the need for certain medications.

Because we firmly believe in the importance of addressing psychosocial concerns as part of optimal IBD management, our Center employs a GI-health psychologist, Dr. Laurie Keefer, to assist with our patient’s educational & emotional needs.

Dietary Therapy

Diet and nutrition is an important aspect of living with IBD.  While it may be common to believe that the disease is either caused or cured by certain diets, data do not exist to support this idea.  It is likely, however, that diet affects symptoms and plays a small role in the underlying inflammatory process. 

IBD can interfere with digestion and the absorption of nutrients by the body, making proper nutrition important.  There is no single diet that will work for every person, so you should discuss an individual dietary plan with your physician who may recommend you see a licensed nutritionist.  A first step to identifying foods that may either help or worsen your symptoms is to keep a food diary.  A food diary can also help identify if you are receiving an adequate supply of nutrients from what you are eating.  This should include the proper intake of calories, proteins, vitamins, and other nutrients.  The most common vitamin deficiencies are vitamin B12, Folic Acid, Vitamin D, Vitamin A, Vitamin E, Vitamin K, and Calcium.  These may be affected by the disease itself or certain medications taken to treat IBD.

Nutrition is critical for IBD patients, who may become malnourished from loss of appetite, the bodily stress of chronic disease, and poor digestion of protein, fats, carbohydrates, water, and other vitamins and minerals.  Maintaining good nutrition is pivotal in the management of IBD.  Being well-nourished leads to better effects from medication and fewer growth problems, among other benefits.  Because cramping and pain may occur after eating during disease flares, there are some techniques you can use to reduce these effects:

  • Eat five small meals every 3 to 4 hours.
  • Limit your consumption of milk or dairy products if you are lactose intolerant.
  • Reduce the amount of greasy or fatty foods in your diet.
  • Reduce certain high fiber foods, such as nuts, seeds, popcorn, and some vegetables.
  • The CCFA website has a list of IBD friendly recipes that you may find helpful in planning your diet.

Some patients require nutritional support, known as enteral or total parenteral nutrition (TPN).  Enteral feedings are given via a nasogastric (NG) tube or gastrostomy tube (G-tube).  The nutrient-rich liquid formula is delivered directly into the stomach via these methods and is typically given at night while you sleep.  You are then free to eat normally if you can throughout the day knowing that the proper nutrition you require was already provided. 

TPN is used when the bowel needs to rest and not digest any food, even formula.  During TPN, a catheter is placed into a large blood vessel (usually in the chest).  TPN is more complex nutritional support than enteral nutrition and requires the supervision of a physician who is specially trained in this area.

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