Inflammatory bowel disease (IBD) is the general name for ulcerative colitis and Crohn's disease. The disease is characterized by swelling, ulcerations, and loss of function of the intestines.
Description
The primary problem in IBD is inflammation, as the name suggests. Inflammation is a process that often occurs to fight off foreign invaders in the body, including viruses, bacteria, and fungi. In response to such organisms, the body's immune system begins to produce a variety of cells and chemicals intended to stop the invasion. These immune cells and chemicals, however, also have direct effects on the body's tissues, resulting in heat, redness, swelling, and loss of function. No one knows what starts the cycle of inflammation in IBD, but the result is a swollen, boggy intestine.
In ulcerative colitis, the inflammation affects the lining of the rectum and large intestine. It is thought that the inflammation typically begins in the last segment of large intestine, which empties into the rectum (sigmoid colon). This inflammation may spread through the entire large intestine, but only rarely affects the very last section of the small intestine (ileum). The rest of the small intestine remains normal.
Crohn's disease is a form of IBD that affects both the small and large intestines. The inflammation of ulcerative colitis occurs only in the lining of the intestine (unlike Crohn's disease which affects all of the layers of the intestinal wall). As the inflammation continues, the tissue of the intestine begins to slough off, leaving pits (ulcerations) that often become infected.
IBD can occur in all age groups, with the most common age of diagnosis being 15–35 years of age. Men and women are affected equally. Whites are more frequently affected than other racial groups, and people of Jewish origin have three to six times greater likelihood of suffering from IBD. IBD is familial; an IBD patient has a 20% chance of having other relatives who are fellow sufferers.
Causes & symptoms
No specific cause of IBD has been identified. Although no organism (virus, bacteria, or fungi) has been found to set off the cycle of inflammation, some researchers continue to suspect that an organism is responsible. Other researchers are concentrating on identifying some change in the cells of the colon that would make the body's immune system accidentally begin treating those cells as foreign. Additional evidence for a disorder of the immune system includes the high number of other immune disorders that frequently accompany IBD. The condition has also been linked to physical, mental, and emotional stress.
The first symptoms of IBD are abdominal cramping and pain, a sensation of urgent need to have a bowel movement (defecate), and blood and pus in the stools.
Some patients experience diarrhea, fever, and weight loss. If the diarrhea continues, signs of severe fluid loss (dehydration) begin to appear, including low blood pressure, fast heart rate, and dizziness.
Severe complications of IBD include perforation of the intestine, toxic dilation (enlargement) of the colon, and the development of colon cancer. Intestinal perforation occurs when long-standing inflammation and ulceration of the intestine weaken the wall to such an extent that a hole occurs. This is a life-threatening complication, because the contents of the intestine (which contain a large number of bacteria) spill into the abdomen. The presence of bacteria in the abdomen can result in a massive infection called peritonitis.
Toxic dilation of the colon is thought to occur because the intestinal inflammation interferes with the normal function of the muscles of the intestine. This allows the intestine to become lax, and its diameter begins to increase. The enlarged diameter thins the walls further, increasing the risk of perforation and peritonitis. When the diameter of the intestine is quite large and infection is present, the condition is referred to as "toxic megacolon."
Patients with IBD have a significant risk of developing colon cancer. This risk seems to begin around 10 years after diagnosis. The overall risk of developing cancer seems to be greatest for those patients with the largest extent of intestine involved. The risk becomes statistically greater every year:
At 10 years, the risk of cancer is about 0.5–1%.
At 15 years, the risk of cancer is about 12%.
At 20 years, the risk of cancer is about 23%.
At 24 years, the risk of cancer is about 42%.
Patients with IBD also have a high chance of experiencing other disorders, including inflammation of the joints (arthritis), inflammation of the vertebrae (spondylitis), ulcers in the mouth and on the skin, the development of painful, red bumps on the skin, inflammation of several areas of the eye, and various disorders of the liver and gallbladder.
Diagnosis
IBD is first suspected based on the symptoms that a patient is experiencing. Examination of the stool will usually reveal the presence of blood and pus (white blood cells). Blood tests may show an increase in the number of white blood cells, which is an indication of inflammation occurring somewhere in the body. The blood test may also reveal anemia, particularly when a great deal of blood has been lost in the stool.
The most important allopathic method of diagnosis is endoscopy, during which a doctor passes a flexible tube with a tiny fiberoptic camera device through the rectum and into the colon. The doctor can then examine the lining of the intestine for signs of inflammation and ulceration. A tiny sample (biopsy) of the intestine will be removed through the endoscope, which will be examined under a microscope for evidence of IBD. X-ray examination is helpful to determine the amount of affected intestine. However, x-ray examinations requiring the use of barium should be delayed until treatment has begun. Barium is a chalky solution that the patient drinks or is given through the rectum and into the intestine (enema). The presence of barium in the intestine allows more detail to be seen on x ray films.
Treatment
Treatment for IBD targets the underlying inflammation, as well as the problems occurring due to continued diarrhea and blood loss. The use of alternative medicines in the treatment of IBD is common. IBD sufferers have used a variety of treatments; however, few controlled studies of their effectiveness have been performed.
Chamomile tea is used to treat IBD. Chamomile is known to have anti-inflammatory, antispasmodic, and antibacterial properties. The patient should steep dried flowers for 10 to 15 minutes and drink three to four cups daily. Chamomile can cause allergic reactions in those who are allergic to other daisies. Other antispasmodics include valerian, wild yam, and cramp bark.
There is some preliminary evidence that alteration of the kinds of bacteria in the intestine prevents or controls colitis. Intestinal bacteria can be manipulated through use of probiotics or prebiotics. Probiotics refers to treatment with beneficial microbes either by ingestion or through a suppository. Prebiotics refers to dietary changes that favor the overgrowth of beneficial microbes. Preliminary animal and human studies have shown that Lactobacilli and related bacteria can control colitis and prolong remission. Ingestion of the nondigestable carbohydrates inulin or lactulose as prebiotics stimulates growth of these beneficial bacteria.
In a related treatment, preliminary evidence suggests that ingestion of parasitic worm eggs eases the symptoms of IBD. Within two to three weeks, five out of the six IBD patients who ingested the eggs went into complete remission which lasted one month. The tiny, harmless worms cannot reproduce in humans and are passed out within a few months.
Ingestion of enteric coated fish oil capsules may reduce the IBD relapse rate. A small study found that patients taking fish oil supplements had a lower relapse rate (59%) than those on placebo (90%).
Seventy-two percent of ulcerative colitis patients taking a Kui Jie Qing enema (alum, Halloysite, Calamine, Indigo naturalis, and plum-blossom tongue-pointing pills) daily were considered cured, as compared with 5% of those who were taking anti-inflammatory drugs. Fifty-three percent of ulcerative colitis patients taking Jian Pi Ling tablet and root of Sophorae flavescentis plus the flower of sophora enema were considered cured, as compared with 28% of those taking sulfasalazine and dexamethasone and 19% of those taking a placebo tablet and the enema. There are many other Chinese herbs that are useful in treating diarrhea and mucus in the bowel. Sometimes these are effective when drugs are not.
Forty-five percent of ulcerative colitis patients on an enzyme-potentiated hyposensitization protocol (B-glucuronidase enzyme and 1,3-cyclohexanediol with egg, milk, wheat, potato, and yeast) were improved, as compared with 6% of those on placebo.
Nutritionists often recommend changes in the diet for patients with inflammatory bowel disease. Food allergies and certain kinds of food are linked with the increased incidence of the disease. Eliminating diary and wheat products, common allergens, often alleviates symptoms. The incidence of Crohn's disease is increasing in areas where people consume a diet high in refined sugars and carbohydrates and saturated fats and low in dietary fiber. Elimination diets or those restricted in refined foods have sometimes proved successful in the alleviation of inflammatory bowel disease.
Inflammation is often treated with an immune-suppressive drug called sulfasalazine. Because of poor absorption, sulfasalazine stays primarily within the intestine, where it is broken down into its two components: an antibiotic and an anti-inflammatory. It is believed to be primarily the anti-inflammatory component, salicylic acid, that is active in treating IBD. For patients who do not respond to sulfasalazine, steroid medications (such as prednisone) are the next choice.
Depending on the degree of blood loss, a patient with IBD may require blood transfusions and fluid replacement through a needle in the vein (intravenous or IV). Medications that can slow diarrhea must be used with great care, because they may actually cause the development of toxic megacolon.
A patient with toxic megacolon requires close monitoring and care in the hospital. He or she will usually be given steroid medications through an IV, and may be put on antibiotics. If these measures do not improve the situation, the patient will have to undergo surgery to remove the colon. This is done because the risk of death after perforation of toxic megacolon is greater than 50%.
A patient with proven cancer of the colon, or even a patient who shows certain precancerous signs, will need a colectomy (colon removal). When a colectomy is performed, a piece of the small intestine (ileum) is pulled through an opening in the abdomen and fashioned surgically to allow attachment of a special bag to catch the body's waste (feces). This opening, which will remain for the duration of the patient's life, is called an ileostomy.
Expected results
Remission refers to a disease becoming inactive for a period of time. The rate of remission of IBD (after a first attack) is nearly 90%. Those individuals whose colitis is confined primarily to the left side of the large intestine have the best prognosis. Those individuals with extensive colitis, involving most or all of the large intestine, have a much poorer prognosis. Recent studies show that about 10% of these patients have died within 10 years after diagnosis. About 20–25% of all IBD patients will require colectomy. Unlike the case for patients with Crohn's disease, however, such radical surgery results in a cure of the disease.
BOOKS
Glickman, Robert. "Inflammatory Bowel Disease: Ulcerative Colitis and Crohn's Disease." In Harrison's Principles of Internal Medicine, edited by Anthony S. Fauci, et al. New York: McGraw-Hill, 1998.
Long, James W. The Essential Guide to Chronic Illness. New York: HarperPerennial, 1997.
"Alternative Therapies Commonly Used by Patients with Inflammatory Bowel Disease." Nutrition Research Newsletter 18 (June 1999):13+.
Campieri, Massimo and Paolo Gionchetti. "Probiotics in Inflammatory Bowel Disease: New Insight to Pathogenesis or a Possible Therapeutic Alternative?" Gastroenterology 116 (1999):1246-1249.
Coghlan, Andy. "Wonderful Worms." New Scientist 163 (August 7, 1999):4.
Hilsden, Robert J. and Marja J. Verhoef. "Complementary and Alternative Medicine: Evaluating its Effectiveness in Inflammatory Bowel Disease." Inflammatory Bowel Diseases 4 (1998):318-323.
Martin, Frances L. "Ulcerative Colitis." American Journal of Nursing 97 (August 1997): 38+.
Peppercorn, Mark A., and Susannah K. Gordon. "Making Sense of a Mystery Ailment: Inflammatory Bowel Disease." Harvard Health Letter 22 (December 1996): 4+.
"Ulcerative Colitis: Manageable, With a Brighter Outlook." Mayo Clinic Health Letter 13 (December 1995): 1+.
ORGANIZATIONS
Crohn's and Colitis Foundation of America, Inc. 386 Park Avenue South, 17th Floor, New York, NY 10016-8804. (800) 932-2423.
