Inflammatory Bowel Disease Overview

Ulcerative colitis and Crohn’s disease are types of inflammatory bowel disease (IBD), which affect an estimated 1.6 million Americans and involve chronic inflammation of the digestive tract.

Ulcerative colitis affects the inner lining of the colon (large intestine), while Crohn’s disease can affect any part of the gastrointestinal tract from the mouth to the anus. While the exact cause of these conditions is not known, both diseases can run in families.

“Both are chronic conditions, which means there is no cure, but they can be managed effectively with medications, with long-lasting periods of remission,” says Darrell S. Pardi, MD, a gastroenterologist at the Mayo Clinic in Rochester, Minnesota. “There is a lot of research going on in the area of IBD treatment, and we hope to see new treatment options in the next several years.”

Ulcerative Colitis

This disease affects only the colon. “For the most part it’s restricted to the inner lining of the colon, and it’s not as painful as Crohn’s disease,” Dr. Pardi explains. About half of all patients with ulcerative colitis have mild symptoms, and those symptoms may come and go. With current medical treatment, many people with ulcerative colitis have long periods in which they do not experience symptoms.

Common symptoms include:

  • Bowel movements become looser and more urgent
  • Persistent diarrhea accompanied by abdominal pain and blood in the stool
  • Abdominal cramps
  • Weight loss due to loss of appetite
  • Feeling of low energy and fatigue
  • Sensation of needing to move bowels even after going to the bathroom

Crohn’s Disease

Some symptoms of Crohn's disease overlap with ulcerative colitis but Crohn's is typically more painful and may also affect other organs including the liver, eyes, skin, and joints. “Crohn’s may affect the deeper layers of the bowel,” Dr. Pardi says. “Crohn’s is more likely to cause complications like bowel blockage or perforation of the bowel or an abscess.” A person with Crohn’s who feels severe pain should be evaluated by a doctor quickly, he notes.

Common symptoms of Crohn’s include:

  • Persistent diarrhea
  • Rectal bleeding
  • Urgent need to move bowels
  • Abdominal cramps and pain
  • Sensation of needing to move bowels even after going to the bathroom
  • Weight loss and fatigue

Diagnosis

While IBD can occur at any age, many people are diagnosed between the ages of 15 and 35.

A colonoscopy is used to diagnose both ulcerative colitis and Crohn’s. A colonoscopy involves inserting a flexible tube through the opening of the anus to examine the colon. For Crohn’s, the doctor may also order a CT, MRI, or a capsule endoscopy, which involves swallowing a camera pill to obtain pictures of the small intestine.

Treatment

Treating pain for IBD can be tricky, Dr. Pardi says. Non-steroidal anti-inflammatory medications, such as aspirin, ibuprofen or naproxen, can make both conditions worse. Opioid pain medications can worsen outcomes in Crohn’s disease, and probably ulcerative colitis as well. “Opioids are associated with serious infections and even death in people with Crohn’s,” Dr. Pardi says. “If a person has an immediate complication from either condition, the doctor may prescribe short-term use of pain medication, but we try to avoid chronic use. The risks far outweigh the benefits.”

The best way to control pain from ulcerative colitis or Crohn’s is to treat the condition itself. The doctor will choose the best medication based on the patient’s age, how long they have had the disease, how severe it is, which part of the bowel is affected and what other conditions the patient has. In some cases, the doctor may recommend a combination of drugs.

Medications

Medications can control and suppress symptoms, and decrease the frequency of symptom flare-ups. They may include:

  • Aminosalicylates (5-ASA). These drugs decrease inflammation in the lining of the gastrointestinal tract, and are used for more moderate cases of colitis. Brand names include Asacol, Pentasa and Salofalk.
  • Corticosteroids.These drugs, such as budesonide (Entocort, Uceris) and prednisone, suppress the immune system and are used to treat moderate to severe disease. Because these drugs may have significant side effects and are generally not effective for more than a few months, they should not be used long-term.
  • Immunomodulators. These drugs suppress the immune response so it cannot cause ongoing inflammation. These drugs include azathioprine (Imuran, Azasan), 6-mercaptopurine (6-MP, Purinethol) and methotrexate.
  • Biologic Therapies.These medications also suppress the immune response so it cannot cause ongoing inflammation. One biologic medicine, vedolizumab (Entyvio), is  less likely to cause side effects because it is more precisely targeted to particular proteins that are involved in IBD. In contrast, other IBD treatments such as corticosteroids, immunomodulators, and some biologics affect the entire body. In addition to Entyvio, other biologic drugs used to treat moderate to severe ulcerative colitis and Crohn’s include, ustekinumab (Stelara) and infliximab (Remicade), adalimumab (Humira). Dr. Pardi calls these therapies “a major advance” in the treatment of IBD.

Surgery, a Last Resort

For patients with certain complications and those whose disease is not controlled with medication, surgery is an option.

For ulcerative colitis, the colon is removed. After the surgery, the disease will not recur. With Crohn’s, surgery to remove the diseased segment of the bowel may be necessary if a person’s symptoms do not respond to medication, or if they develop an intestinal blockage, or a fistula—an ulcer that tunnels through the intestine and into the surrounding tissue, often around the anus and rectum. Other complications that may require surgery include excessive bleeding in the intestine or perforation of the bowel. The surgery does not cure Crohn’s but it can reduce symptoms and address complications that are not amenable to medical therapy.

If surgery is required for ulcerative colitis, the standard surgical procedure is removal of the colon and rectum, called proctocolectomy. In the past, patients who underwent this procedure had to wear a bag over a small hole in the abdomen to collect stool. Today, many patients undergo variations to the procedure that do not require wearing a permanent external bag.

Many patients with Crohn’s have surgery on their small bowel.  urgery for Crohn’s removes the area that is most involved, leaving behind as much bowel as possible. In many cases, the surgeon removes the end of the small bowel and beginning of the colon (which is where Crohn’s is most commonly located) and reconnects those areas.

If the rectum is affected and must be removed along with the colon, the patient will need to wear an external ostomy bag to collect stool.

Lifestyle changes, including quitting smoking, getting enough sleep and eating a healthy diet, are recommended for any type of IBD. Dr. Pardi notes that many restrictive diets are touted online as treatments for IBD. “Specific diets have not been definitively shown to help either ulcerative colitis or Crohn’s,” he says. “Don’t start any diet purported to treat these conditions without first speaking with your healthcare provider. They could end up contributing to malnutrition.”

One diet advertised specifically for managing ulcerative colitis and Crohn’s is the Specific Carbohydrate Diet, which eliminates many of the foods in a typical American diet, including all simple sugars, grains, starches and most dairy. According to the Crohn’s and Colitis Foundation of America, there has been no scientific evidence supporting these diets. The group notes the diet is very restrictive and difficult to follow.

Updated on: 10/16/17
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