Inflammatory bowel disease (IBD) is a term used to describe more than one
conditions but the main ones are Ulcerative colitis and Crohn's disease.

They are relatively common conditions in western societies while they are rather
more rare in the developing world. The number of people suffering with IBD in
the West appears to be rising.

What is the cause?

Many contributing causative factors have been identified. This always means
that the true cause is unknown! In all cases the main problem is inflammation
of the bowel, which appears to be suffering a "self-harming" attack from its own
immune cells and antibodies. This is what we call "auto-immune" disease.

Genetics play a role: if you have a 1st degree relative in your family with
Crohn's disease then your risk of developing it is 10 times higher than the rest
of the population. No need to panic however, the general population risk is 1 in
1500 which means that family history brings the risk to less than 1% - this is still
very low. Ulcerative Colitis is slightly more common but again the risk should be
less than 5% with a positive family history.
There is a genetic link with other conditions such as ankylosing spondilitis,
sclerosing cholangitis, arthritis etc.

The issue of smoking causes confusion to patients with IBD. Although Crohn's
patients get worse if they smoke and get better when they quit, the exact
opposite occurs in UC, when sometimes attacks are triggered by abandoning
smoking. The preceis reasons for that are unknown but smoking intereferes
with the immune system in many ways and it has a predominantly detrimental
effect -this is also true in the case of diverticular disease of the colon.

Viruses and bacteria have been implicated although we do not have hard
evidence. The measles virus and the mycobacterium paratuberculosis have
been studied without conclusive evidence. Interestengly, in some cases Crohn's
and even UC respond to long term treatment with antibiotics.

Clinical Symptoms of Ulcerative Colitis

UC affects exclusively the colon and more commonly the rectum and left colon.
The main symptom is diarrhoea. The stools may contain mucous and blood.
The number of bowel motions can be from 3- more than 20 daily. Abdominal
discomfort or pain can be present. The patient may feel tired and
systemically unwell. There can be weight loss and dehydration.

Crohn's disease can affect any part of the gastrointestinal tract, from the
mouth to the anus. Therefore the symptoms can vary and depend on the site of
the disease. The more common symptoms are abdominal pain, diarrhoea,
anaemia, weight loss and the presence of a palpable mass in the right iliac
fossa (right lower abdomen).

In both diseases there can be extra-intestinal manifestations, such as skin
rash, arthritis, psoriasis, eye inflammation, liver damage, deep vein thrombosis,
mouth ulcers etc. In Crohn's of the anus there can be an abscess or fistula with
all the typical symptoms described elsewhere. In some cases can mimic the
presentation of acute appendicitis and be diagnosed only at the time of surgery.

Investigations in IBD

For UC the main investigation is colonoscopy which puts easily the diagnosis
with biopsies. For Crohn's the diagnosis can be more complicated depending
on the site of presentation. Most cases of Crohn's start from the last part of the
small bowel which is called the terminal ileum (this is why the other name of the
condition is "terminal ileitis"). In those cases if the lesion cannot be seen on
clonosocpy, a small bowel contrast study may show inflammation or
strictures.  Wireless capsule enteroscopy is a recent method which requires
the patient to swallow a microscopic camera in a capsule form. The capsule
runs through the whole small bowel taking hundreds of images which are
re-constructed afte the capsule exits the body in the natural way.

Complications

Ulcerative colitis non responding to treatment may give rise to a condition called
"toxic megacolon". The large bowel is grossly distended and very inflammed.
The patient becomes very unwell and, if untreated, a perforation can occur.
Peritonits and death follow. The treatment is emergency surgery with total
colectomy. An ileostomy has to be performed usually at that stage, although
an ileo-anal pouch may be created at a later stage.

Crohn's disease can lead to formation of strictures and obstruction of the
bowel. Also abscess of the bowel and fistulas (abnormal communications)
between bowel loops or bowel and other organs can occur. Perforation of large
or small bowel can occur. Emergency surgery may sometimes be required.

Treatment

A number of powerful medications are available today. Those are used
according to a strategy which suggests initial usage of milder drugs with few
side effects and reserves more drastic drugs for resistant forms of the
condition. Most drugs are used in both conditions so we will refer to them jointly.
Drugs can be given rectally (when symptoms originate from the anus/ rectum/
left colon), orally (when there is involvement of other parts of the intestines) or
intravenously (when the clinical condition is more severe).

a. 5-amino-salicylates (mesalazine, olsalasine, balsalazide etc.) are used in
suppositories, enemas or tablets. They are the first line treatment for milder
disease.
b. Steroids are used as  second line treatment in enemas and tablets.
Intra-venous steroids are more drastic and are used in acute phases of the
disease to prevent complications.
c. Immunosuppressants are the last line of treatment and are used only when
 other treatments fail. They include methotrexate, azathioprine, cyclosporine
and infliximab.
d. Antibiotics such as ciprofloxacin are sometimes effective in anal Crohn's
diseaseor as addition to other medications.
e. Diet: a number of dietary measures have been shown to have an effect. For
malnourished patients enteral feeding with enriched nutrients improves
Crohn's. On the other hand, bowel rest by fasting and parenteral nutrition
also can lead to remission of a Crohn's attack. Elemental diet is an artificial
liquid diet which replaces for a few weeks all food and has the same success
rate as steroids in acute Crohn's remission.
Although the temporary effect of those diet treatment is remarkable, it is not
unfortunately sustainable for more than a few months. Also diet treatments are
not easily applicable to all patients because they interfere with their lifestyle.

Surgery

Surgery is reserved in IBD for the cases where medical treatment fails or in
order to treat complications.

In Crohn's surgery should be as minimal as possible and aim to correct
problems which are the results of complications. The main indications for
surgery in Crohn's are the treatment of strictures, abscesses or
obstructions. Strictures are resected or soemtimes the bowel os subjected to
a widening of the stircture which is called "strictureplasty".

In UC surgery is performed in cases of toxic megacolon as an emergency. In
cases where the patient is not responding to medical treatment there is the
option of resection of the entire colon and rectum. This removes all
disease and is practically cure of UC. However the patient has the option of
a) Permanent ileostomy. Patients with ileostomy adpat easily and have good
quality of life. However t body image of some patients may be affected and it
may affect some patients psychologically. Personality factors are very important
but also social factors and factors of emplooyment.
b) Restorative procto-colectomy with ileo-anal pouch. This is a complex
operation which craetes a reservoir or pouch of small bowel which is connected
to the anus and replaces the rectum. The patient avoids the permanent
ileostomy. Bowel function is not entirely normal with an ileo-anal pouch because
there is always some degree of mild diarrhoea. Most patients will need to open
their bowels 3-6 times a day and the patient's satisfaction with the result will
depend on several factors. For example, a young housewife may value more
her body image and prefer the pouch over a permanent ileostomy. On the other
hand, a bus driver may not be able to continue working if he has to open his
bowels several times during his working day.
All those issues have to be considered very carefully with full information to the
patient. Counseling and support from a specialist nurse is necessary. Contact
of the patient with patient support groups and other sufferers is very valuable.

In general far more restorative procto-colectomies and pouches are performed
in the USA than in the UK when the gastroenterologists  treat patients with
immuno-suppressants for much longer. This is not only a matter of
disagreement between specialists but may also be a socio-economic issue: In
the USA the medical insurance system favours  a surgical "quick solution" to UC
which allows the patient to return to work. In the UK the social welfare system
protects more  patients who are often unwell and need frequent periods of time
off work.
In any case, the physician has to assess every case individually and the patient
has to have the final say on whether surgery might be a suitable option.

Prognosis and the risk of cancer

Most patients with IBD will have their condition under control for most of their
lives with the help of medication. In fact, many patients will have only one attack
and then be free of the condition for years , even decades. However some of
them may develop serious problems and need hospitalisation or surgery.
Patients with UC have an increased risk of getting colorectal cancer and in
order to prevent that regular follow-up colonoscopy is practiced by most.





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Papagrigoriadis.  All rights reserved.
Multiple strictures of
small bowel in Crohn's
disease (courtesy of
www.proctosite.com)
Inflammed colon
mucosa in ulcerative
colitis (courtesy of
www.proctosite.com)
Inflammatory Bowel Disease:
Ulcerative Colitis and Crohn's Disease