Inflammatory Bowel Disease (IBD)

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What is IBD?

IBD consists of two distinct conditions referred to as Crohn’s Disease (CD) and Ulcerative Colitis (UC). Both conditions arise spontaneously with no exact cause identified as yet. However, it is thought that abnormal inflammatory processes within the intestine as well as a genetic tendency play a role in the development of the disease.CD can affect any part of the entire length of the intestine (from the mouth to the anus), whereas  UC is limited to the rectum and large intestine only.CD is characterized by damage (inflammation) to the entire thickness of the intestinal wall and by having segments of normal appearing intestine interrupted by affected areas. Because it affects the full thickness of the intestinal wall it may lead to scar formation that can result in a narrowing of the affected area which can cause total or partial obstruction (blockage) of the intestine. UC on the other hand is characterised by episodes of damage (inflammation) to only the surface layer of the inside of the intestine and has no segments of undamaged areas within the affected area. The rectum is almost always involved with varying amounts of the colon being affected.

Who usually suffers from IBD?

Most cases of IBD are seen in North America and Northern Europe but research shows that these conditions are being seen more frequently in countries within Africa, Asia and South America. In South Africa very little information is available on the numbers within our population who suffer from IBD. This will hopefully change with increased research being conducted on the topic. Most patients are diagnosed with IBD between the ages of 15-30 years, although it can develop at any age. CD appears to be most rife amongst young adults aged between 20-29 years.Males and females appear to be equally affected in UC with CD occurring slightly more in females compared to males. IBD is more common in Jewish and white populations compared to non-Jewish, black and Hispanic populations. However, the rate of IBD rises in any race with urbanization indicating that environmental and lifestyle factors may be the actual cause of the ethnic and racial differences seen previously.

What are the risk factors for IBD?

Smoking – current smoking is a risk factor for CD but not for UC, however former smokers appear to be more at risk of developing UC.

Physical activity – increasing activity levels has been associated with a lowered risk of CD but not UC. In patients with established CD, physical activity also helps to improve the severity of the condition.

Diet – some studies suggest that certain foods may play a role in the risk of developing IBD. These include increased intake of fats and a lack of Vitamin D intake which increases the risk of IBD. High intake of fibre is associated with a decrease in the risk of CD but not UC.

Stress – no strong evidence exists to suggest that stress can cause IBD, but stress may have a role in worsening of symptoms in a patient who has been diagnosed with IBD.

Intestinal biome – abnormal populations of microorganisms in the intestine and/or an abnormal immune reaction to these microorganisms are thought to be associated with the development of IBD. Certain diets, genetic factors and environmental exposures may contribute to abnormal intestinal biome states.

What are the signs and symptoms of IBD?

It is important to understand the IBD is a chronic condition that usually occurs in cycles of flares (when the condition worsens and symptoms are present) followed by periods of remission (when the condition improves and the symptoms are absent). The disease can range from being mild to severe.

The signs and symptoms caused by CD and UC may overlap but in general the symptoms are:

  • Stomach cramps/pain
  • Diarrhoea (stool may contain mucus, blood or pus)
  • Constipation
  • Painful bowel movements
  • Regular urge to pass a stool
  • Intermittent rectal bleeding
  • Anal problems: pain, fissures (tears), fistulas (a tunnel between the intestine and other organs), infection, narrowing of the anus
  • Nausea and vomiting
  • Fever
  • Loss of appetite
  • Weight loss
  • General tiredness

Some people get other symptoms outside of the digestive system known as extraintestinal manifestations:

  • Joints: swelling and pain of the large joints such as hips and knees
  • Eyes: inflammation to various parts of one or both eyes
  • Skin: various skin rashes

What are the complications of IBD?

Patients can experience complications from long-term disease as well as from long-term use of the treatment for IBD. Some of these complications include:

  • Bleeding from intestinal ulcers
  • Perforation (tearing) of the intestinal wall
  • Abscess formation
  • Narrowing and/or obstruction of the intestine
  • Increased risk of certain cancers in the colon, small intestine and gall-bladder duct
  • Depression and anxiety
  • Anaemia
  • Osteoporosis

How is IBD diagnosed?

If a patient visits a doctor with symptoms that indicate a possible diagnosis of IBD the doctor will want to first of all obtain of full medical history to gain more information of current and previous problems that could provide clues and more information in general. A full physical exam will follow. In order to confirm the diagnosis further investigations will need to be performed. These may include blood tests, stool sample analysis, X-rays, ultrasounds and CT/MRI scans. In all likelihood a colonoscopy (insertion of a camera into the colon via the anus) will be needed in order to view the inside of your colon and during which tissue samples from your colon can also be taken for further analysis.Collectively these tests can assist with making the diagnosis of IBD, determining the severity of the IBD, identifying any complications as well as ensuring that other potential diseases similar to IBD are not present. Based on all the results and findings a distinction can be made between whether the diagnosis is CD or UC in the majority of cases. The severity, presence of complications and type of IBD will determine the treatment plan that will be followed.

What can mimic IBD?

There are other conditions or diseases that may cause signs and symptoms that are similar to those associated with IBD. In the South African setting intestinal TB may need to be ruled out before a diagnosis of IBD can be made. Other conditions to consider include:

  • Irritable bowel syndrome
  • Celiac disease
  • Gastrointestinal infections
  • Eating disorders
  • HIV/AIDS
  • Lactose intolerance
  • Colon cancer

What treatment options are available?

There is no cure available for IBD. In approximately 15% of UC cases, after an initial attack the condition clears and remains absent without medication possibly for the rest of the patient’s life. Unfortunately, the more common scenario is a chronic course of disease requiring long-term treatment. The first step in treating IBD is ensuring that the person with the diagnosis is well educated and informed on the condition and that supportive measures are put into place.The medical management consists of medication, surgery or a combination of the two.

When treating IBD there are 2 main goals:

  • End the current symptoms (i.e. achieve remission)
  • Prevent the symptoms from coming back (i.e. maintain remission)

The ideal medicine used to treat IBD will be selected based on age, which part of the intestine is involved, the severity of the disease and the presence of other medical conditions. Medication may include cortisone (potent anti-inflammatories that are usually used for a limited time period to get the inflammation under control and are then gradually stopped), aminosalicylates (a group of medicines that reduce inflammation in the intestines) and immunomodulators (a group of medicines that suppress the immune system).If the above medications are not affective another option available is a group of powerful medicines known as biologics. These medicines are very costly and are given either as an injection or through a vein. Many biologics are still in the development stage and currently being tested in clinical trials. If the goals of treatment are not being achieved with medication alone or the medication causes too many unbearable side effects the next step to consider is surgery. In CD patients 70-75% will eventually require some form of surgery, whereas the same is true for 25-30% of UC patients. Surgery will not cure IBD but can assist to improve symptoms and allow patients to carry out their normal activities. Usually medication will still be required to control symptoms over the long term. The most common surgeries performed are the partial or total removal of the colon and opening of any obstructions within the intestine.Other factors to consider when treating IBD is avoiding foods that worsen symptoms, avoiding medications that contain non-steroidal anti-inflammatories (e.g. brufen, voltaren) and regular use of multivitamin supplementation. Medications for pain and diarrhoea can be used as and when needed.It is of benefit to enquire whether there are any IBD support groups in area that could assist with coping and living with the condition on a daily basis.

Clinical research in IBD

New medicines are continually being developed for IBD that are currently being investigated in clinical trials. Patients with IBD are able to take part in these clinical trials if they are willing and fulfil the criteria to participate. Those interested are encouraged to discuss this with your health care provider or read more about clinical trials on the internet (www.clinicaltrials.gov/)

References

  1. World Gastroenterology Organisation Global Guideline. Inflammatory bowel disease: a global perspective. Munich, Germany: World Gastroenterology Organisation (WGO); 2009. Updated Aug 2015.
  2. Silverberg MS, Satsangi J, Ahmad T, et al. Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Can J Gastroenterol 2005; 19 Suppl A:5A.
  3. Satsangi J, Silverberg MS, Vermeire S, Colombel JF. The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. Gut 2006; 55:749.
  4. Karlinger K, Györke T, Makö E, et al. The epidemiology and the pathogenesis of inflammatory bowel disease. Eur J Radiol 2000; 35:154.
  5. Higuchi LM, Khalili H, Chan AT, et al. A prospective study of cigarette smoking and the risk of inflammatory bowel disease in women. Am J Gastroenterol 2012; 107:1399.

Inflammatory Bowel Disease (IBD)

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