Inflammatory bowel disease

Inflammatory bowel disease (IBD), the major example of which is Crohn's disease, involves inflammation of the intestine, especially the small intestine. Inflammation refers to swelling, redness, and loss of normal function. There is evidence that the inflammation is caused by various products of the immunesystem, which attack the body itself instead of helpfully attacking a foreigninvader (a virus or bacteria, for example). The inflammation of Crohn's disease most commonly affects the last part of the ileum (a section of the smallintestine), and often includes the large intestine (the colon). However, inflammation may also occur in other areas of the gastrointestinal tract, affecting the mouth, esophagus, or stomach. Crohn's disease differs from ulcerativecolitis, the other major type of IBD, in two important ways:

  • The inflammation of Crohn's disease may be discontinuous, meaning that areas of involvement in the intestine may be separated by normal, unaffected segments of intestine. The affected areas are called "regional enteritis," while the normalareas are called "skip areas."
  • The inflammation of Crohn's disease affects all the layers of the intestinal wall, while ulcerative colitis affects only the lining of the intestine.

Also, ulcerative colitis does not usually involve the small intestine; in rare cases it involves the terminal ileum (so-called "backwash" ileitis).

In addition to inflammation, Crohn's disease causes ulcerations, or irritatedpits in the intestinal wall. These pits occur because the inflammation has made areas of tissue shed.

Crohn's disease may be diagnosed at any age, although most diagnoses are madebetween the ages 15-35. About .02-.04% of the population suffers from this disorder, with men and women having an equal chance of being stricken. Whitesare more frequently affected than other racial groups, and people of Jewish origin are between three and six times more likely to suffer from IBD. IBD runs in families; an IBD patient has a 20% chance of having other relatives whoare fellow sufferers.

The cause of Crohn's disease is unknown. No infectious agent (virus, bacteria, or fungi) has been identified as the cause of Crohn's disease. Still, someresearchers have theorized that some type of infection may have originally been responsible for triggering the immune system, resulting in the continuing and out-of-control cycle of inflammation that occurs in Crohn's disease. Other evidence for a disorder of the immune system includes the high incidence of other immune disorders that may occur along with Crohn's disease.

The first symptoms of Crohn's disease include diarrhea, fever, abdominal pain, inability to eat, weight loss, and fatigue. Some patients have severe painthat mimics appendicitis. It is rare, however, for patients to notice blood in their bowel movements. Because Crohn's disease severely limits the abilityof the affected intestine to absorb the nutrients from food, a patient with Crohn's disease can have signs of malnutrition, depending on the amount of intestine affected and the duration of the disease.

The combination of severe inflammation, ulceration, and scarring that occursin Crohn's disease can result in serious complications, including obstruction, abscess formation, and fistula formation.

An obstruction is a blockage in the intestine. This obstruction prevents theintestinal contents from passing beyond the point of the blockage. The intestinal contents "back up," resulting in constipation, vomiting, and intense pain. Although rare in Crohn's disease (because of the increased thickness of the intestinal wall due to swelling and scarring), a severe bowel obstruction can result in an intestinal wall perforation (a hole in the intestine). Such ahole in the intestinal wall would allow the intestinal contents, usually containing bacteria, to enter the abdomen. This complication could result in a severe, life-threatening infection.

Abcess formation is the development of a walled-off pocket of infection. A patient with an abscess will have bouts of fever, increased abdominal pain, andmay have a lump or mass that can be felt through the wall of the abdomen.

Fistula formation is the formation of abnormal channels. These channels may connect one area of the intestine to another neighboring section of intestine.Fistuals may join an area of the intestine to the vagina or bladder, or theymay drain an area of the intestine through the skin. Abscesses and fistulascommonly affect the area around the anus and rectum (the very last portions of the colon allowing waste to leave the body). These abnormal connections allow the bacteria that normally live in the intestine to enter other areas of the body, causing potentially serious infections.

Patients suffering from Crohn's disease also have a significant chance of experiencing other disorders. Some of these may relate specifically to the intestinal disease, and others appear to have some relationship to the imbalancedimmune system. The faulty absorption state of the bowel can result in gallstones and kidney stones. Inflamed areas in the abdomen may press on thetube that drains urine from the kidney to the bladder (the ureter). Ureter compression can make urine back up into the kidney, enlarge the ureter and kidney, and can potentially lead to kidney damage. Patients with Crohn's diseasealso frequently suffer from:

  • Arthritis (inflammation of the joints)
  • Spondylitis (inflammation of the vertebrae, the bones of the spine)
  • Ulcers of the mouth and skin
  • Painful, red bumps on the skin
  • Inflammation of several eye areas; and
  • Inflammation of the liver, gallbladder, and/or the channels (ducts) that carry bile between and withinthe liver, gallbladder, and intestine.

The chance of developing cancer of the intestine is greater than normal amongpatients with Crohn's disease, although this chance is not as high as amongthose patients with ulcerative colitis.

Diagnosis is first suspected based on a patient's symptoms. Blood tests may reveal an increase in certain types of white blood cells, an indication that some type of inflammation is occurring in the body. The blood tests may also reveal anemia and other signs of malnutrition due to malabsorption (low bloodprotein; variations in the amount of calcium, potassium, and magnesium present in the blood; changes in certain markers of liver function). Stool samplesmay be examined to make sure that no infectious agent is causing the diarrhea, and to see if the waste contains blood.

During an endoscopic exam, a doctor passes a flexible tube with a tiny, fiber-optic camera device through the rectum and into the colon. The doctor can then carefully examine the lining of the intestine for signs of inflammation and ulceration that might suggest Crohn's disease. A tiny sample (a biopsy) of the intestine can also be taken through the endoscope, and the tissuewill be examined under a microscope for evidence of Crohn's disease.

X rays can be helpful for diagnosis, and also for determining how much of theintestine is involved in the disease. For these x rays, the patient must either drink a chalky solution containing barium, or receive a barium enema (a solution that is administered through the rectum). Barium helps to "light up"the intestine, allowing more detail to be seen on the resulting x rays.

Treatments for Crohn's disease try to reduce the underlying inflammation, theresulting malabsorption/malnutrition, the uncomfortable symptoms of crampy abdominal pain and diarrhea, and the possible complications (obstructions, abscesses, and fistulas).

Inflammation can be treated with a drug called sulfasalazine. Sulfasalazine is made up of two parts. One part is related to the sulfa antibiotics; the other part is a form of the anti-inflammatory chemical, salicylic acid (relatedto aspirin). Sulfasalazine is not well-absorbed from the intestine, so it stays mostly within the intestine, where it is broken down into its components.It is believed that the salicylic acid component actively treats Crohn's disease by fighting inflammation. Some patients do not respond to sulfasalazine,and require steroid medications (such as prednisone). Steroids, however, mustbe used carefully to avoid the complications of these drugs, including increased risk of infection and weakening of bones (osteoporosis). Some very potent immunosuppressive drugs, which interfere with the products of the immune system and can hopefully decrease inflammation, may be used for those patientswho do not improve on steroids.

Serious cases of malabsorption/malnutrition may need to be treated by providing nutritional supplements. These supplements must be in a form that can be absorbed from the damaged, inflamed intestine. Some patients find that certainfoods are hard to digest, including milk, large quantities of fiber, and spicy foods. When patients are suffering from an obstruction, or during periodsof time when symptoms of the disease are at their worst, they may need to drink specially formulated, high-calorie liquid supplements. Those patients whoare severely ill may need to receive their nutrition through a needle inserted in a vein (intravenously), or even by a tiny tube (a catheter) inserted directly into a major vein in the chest.

A number of medications are available to help decrease the cramping and painassociated with Crohn's disease. These include loperamide, tincture of opium,and codeine. Some fiber preparations (methylcellulose or psyllium) may be helpful, although some patients do not tolerate them well.

Crohn's disease is a life-long illness. The severity of the disease can vary,and a patient can experience periods of time when the disease is not activeand he or she is symptom free. However, the complications and risks of Crohn's disease tend to increase over time. Well over 60% of all patients with Crohn's disease will require surgery, and about half of these patients will require more than one operation over time. About 5-10% of all Crohn's patients will die of their disease, primarily due to massive infection.

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