Inflammatory Bowel Disease: Diagnosing and Treatment
Inflammatory bowel disease is a term used to describe a group of disorders that cause varying degrees of inflammation and ulceration within the digestive tract. The two main types include ulcerative colitis and Crohn’s disease. Within each type, specific disorders are defined according to the extent of the inflammation or the specific areas affected.
Symptoms and Causes of Inflammatory Bowel Disease
Ulcerative colitis and Crohn’s disease are similar in many ways. They both cause inflammation, which in turn causes symptoms throughout the body, including fever, anemia, fatigue, cramping, diarrhea, weight loss and abdominal pain. However, constipation also can occur, either due to obstructions in the intestines or because chronic inflammation damages nerves in the gut so that they fail to produce an urge. Symptoms outside the digestive system can involve eye problems such as inflammation of the iris and conjunctivitis, skin rashes, canker sores and joint pain. Both, ulcerative colitis and Crohn’s disease tend to first appear in young people, though they can also peak in later years. Most patients have alternating periods of relapse and remission.
The exact cause of inflammatory bowel disease is not known, but recent evidence suggests that a malfunctioning and misdirected immune system, attacking and destroying intestinal tissue might be the culprit. A microorganism called Mycobacterium paratuberculosis is suspected as the instigator of this immune system malfunction, but there possibly are multiple variations of the disorders, with each of them having a different cause and course. Previously it was believed that stress, anxiety, tension and wrong diet were at fault, but there is no scientific evidence to support such theory. What we now know, however, is that these factors can aggravate the symptoms of inflammatory bowel disease but they do not cause it.
Despite many similarities, differences between the two disorders exist and they are quite significant. Some of the distinguishing characteristics include:
Ulcerative Colitis: Distinguishing Characteristics
- Ulcerative colitis is confined to the mucosa (inner lining) of the colon. Therefore, it can be cured by surgically removing the colon.
- The main feature of ulcerative colitis is profuse diarrhea caused by the mucosa’s failure to absorb enough water. It is usually combined with blood and pus from the tiny ulcers.
- Though location and characteristics of the inflammation may vary from person to person, it is typically most severe in the rectal area. Severity decreases further up the tract toward the cecum, where the colon and small intestine join.
- Cramps are common because the muscles of the bowel are affected by the disorder.
- Patients with long-standing ulcerative colitis are at higher risk for colorectal cancer.
Crohn’s Disease: Distinguishing Characteristics
- Crohn’s disease affects not only the inner lining of the colon but all parts and layers of the digestive tract. Surgery is seldom helpful.
- Diarrhea is often a symptom, just like in ulcerative colitis, but blood in the stool is less common among Crohn’s patients.
- The ulcers can be surrounded by relatively healthy mucosa while these normal portions of the digestive tract have to work harder in order to propel intestinal contents through the damaged sections. The rigorous contractions of the healthy sections of bowel lead to abdominal pain and cramping.
- Localized pain and tenderness may also occur.
- This disease usually affects the small intestine but sometimes it is found in the esophagus, stomach or colon.
- Although ulcerative colitis is most commonly found inside the rectum, Crohn’s disease seldom strikes there. Instead, it is more likely to affect the anus.
- Crohn’s disease is a more insidious disease than ulcerative colitis because the ulcers that form on the mucosa can merge and break through the bowel wall, form a deep fissure, and penetrate into adjacent organs.
- With the exception of Crohn’s colitis (Crohn’s disease that is only found in the colon), this disorder is not accompanied by increased risk for colorectal cancer.
Diagnosing Inflammatory Bowel Disease
The two disorders, ulcerative colitis and Crohn’s disease, are diagnosed in similar ways, using the same techniques. Your doctor will need to differentiate between the two disorders and distinguish them from some other diseases with similar symptoms. The most common disorders that get misdiagnosed as inflammatory bowel disease based on their symptoms include:
- Irritable bowel syndrome
- Ischemic colitis – inflammation and congestion of the colon due to poor blood circulation
- Abdominal angina – hardening of the arteries that supply the intestines, triggering pain
- Colon cancer – bleeding
- Large villous adenoma (benign tumor) of the rectum
- Angiodysplasia, an abnormality of the connection between the small veins and the small arteries in the gastrointestinal tract
Before ordering any tests, your doctor will ask you questions about your recent symptoms. After that, there will be a physical exam, laboratory tests and possibly imaging procedures and endoscopy. The physical exam involves testing the abdomen for tenderness and inspecting the anal area for hemorrhoids, skin tags, abscesses, anal fissures or sinus tracts (false openings in the area around the anus). A rectal exam can disclose ulceration of the lining, serious narrowing and crumbling of the tissue.
Laboratory tests will most likely include blood and stool analysis. Your blood will be tested for anemia and inflammation. Stool samples can reveal hidden blood in your stool and bacteria causing infectious colitis or the presence of parasites in those who have recently visited the tropics.
Imaging procedures. In order to detect abnormalities in the gut, standard x-rays were usually taken at various angles after administering barium. However, this procedure has been in recent years largely replaced by more advanced imaging tests such as computerized tomography (CT) scanning, CT enterography and magnetic resonance imaging.
Endoscopy. Most physicians will probably opt for one of the two most common types of endoscopy procedures: colonoscopy or flexible sigmoidoscopy. Tissue samples can be taken during either of these two tests. Other endoscopy procedures such as capsule endoscopy, double-balloon endoscopy and sometimes upper endoscopy may also be used.
- Flexible sigmoidoscopy. This procedure can be used to examine the last section of the colon called sigmoid colon. Practically all cases of ulcerative colitis can be diagnosed through flexible sigmoidoscopy, and when Crohn’s disease lies in the lower colon, it can be detected as well.
- Colonoscopy. Resembling a sigmoidoscope, a colonoscope can view the entire length of the colon. The procedure is more painful than sigmoidoscopy. However, it can be useful in gathering tissue samples from various areas along the gut wall and in monitoring for early signs of cancer.
Treatment of Inflammatory Bowel Disease
Since there is no ultimate cure for either ulcerative colitis or Crohn’s disease, the focus of the treatment is to reduce the inflammation that triggers your symptoms. This goal can be achieved with drug therapy or surgery.
Aminosalicylates. A group of drugs known as aminosalicylates are used along with corticosteroids to reduce inflammation of affected tissues. Aminosalicylates cannot be used by patients allergic to aspirin. Once a key drug for treating inflammatory bowel disease, sulfasalazine (Azulfidine), though effective, can produce a number of side effects, including nausea, headache, heartburn, dizziness, anemia, digestive distress and skin rashes. Certain 5-aminosalicylates (5-ASAs), such as mesalamine, olsalazine and balsalazide, have now taken over sulfasalazine’s role as the mainstay of inflammatory bowel disease therapy. These medications are used to control first attacks and relapses and to maintain recovery. They include trade names such as Asacol, Canasa, Lialda, Pentasa and Rowasa (mesalamine), Dipentum (olsalazine) and Colazal (balsalazide). Reported side effects of 5-aminosalicylates are rare.
Corticosteroids. When 5-aminosalicylates fail to do bring relief, steroids including prednisolone (Prelone), prednisone (Deltasone) and hydrocortisone (Hydrocortone) are the next line of defence. Corticosteroids are potent anti-inflammatory drugs but their side effects can be severe. Potential adverse effects include increased facial hair growth, puffy face, night sweats, mood swings, increase in the size of fat pad on the back and neck, insomnia, acne, increased appetite and weight gain, thinning of the bones and bone fractures, osteoporosis, peptic ulcers, diabetes, high blood pressure, glaucoma, cataracts, and an increased susceptibility to infections.
Immunosuppressants. Drugs that suppress the wayward immune system can also be employed in the treatment of inflammatory bowel disease. The most commonly prescribed immunosuppressant drugs include Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol, Purixan). Another group of immunosuppressant drugs including infliximab (Remicade), adalimumab (Humira) and golimumab (Simponi) combat an immune chemical called TNG-alpha which results in neutralizing a protein produced by the immune system. In addition, cyclosporine (Gengraf, Neoral, Sandimmune), methotrexate (Rheumatrex) as well as a recently approved vedolizumab (Entyvio) can be given to patients who do not respond to corticosteroids or other available medications.
Antibiotics. Antibiotics, such as metronidazole (Flagyl) and ciprofloxacin (Cipro), are prescribed to patients with ulcerative colitis in order to fight infection. They can be used alongside other medications to support the treatment.
Other medications. In addition to controlling inflammation with the aforementioned drugs, certain other medications, such as anti-diarrheal agents and pain relievers, are used to relieve the symptoms of inflammatory bowel disease.
Vitamins and other nutrients. Scientists are relentlessly studying the effects of vitamins and dietary nutrients on inflammatory bowel disease. Antioxidants such as vitamins C and E, selenium, beta-carotene and methionine have been shown to help to keep inflammatory bowel disease in remission, whereas fish oil derivatives seem to show promise for preventing Crohn’s disease relapse. Folic acid (B9) and vitamin B12 can be depleted by bowel disease, whereas iron deficiency may develop due to chronic intestinal bleeding, hence, they may need to be supplemented. In some patients osteoporosis may develop as a result of corticosteroid treatment, so the patients are recommended to take vitamin D and calcium supplements to prevent this condition.
When All Else Fails
Surgery for ulcerative colitis. 80% of patients with ulcerative colitis find sufficient relief from medical therapy. For the remaining 20%, surgical removal of the colon will cure the disease and usually all related symptoms. Typically, a procedure called ileoanal anastomosis is used in order to eliminate the need to wear a bag to collect stool.
Surgery for Crohn’s disease. Unfortunately, prospects for Crohn’s disease victims are not as good. About 60% of patients eventually need surgery and even that may not be a cure as 60% of surgical patients suffer a relapse. The surgery usually involves a resection of the small intestine. But, if more than three feet are removed, malabsorption of nutrients may become a problem while healing is often poor.