Inflammatory Bowel Disease: Ulcerative Colitis and Crohn’s Disease

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You will see inflammatory bowel disease (IBD) in your community practice. About 1.3 million Americans are affected. IBD is a multifaceted group of chronic disorders that affect the gastrointestinal tract, consisting of two major conditions: Crohn’s disease and ulcerative colitis (UC). These conditions are characterized by recurrent inflammation and damage to the digestive system, causing a wide array of symptoms and complications. IBD is a complex and multifactorial condition, and it has become a significant health concern globally. IBD is no longer a rare disease. Over the past few decades, its prevalence has been steadily increasing worldwide. The burden of IBD varies geographically, with higher rates in North America and Europe. Although the exact reasons for this geographical distribution are not fully understood, it highlights the influence of genetic and environmental factors in IBD development.

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Many patients will have abdominal pain and alternating diarrhea and constipation, but diarrhea is the most troublesome.

IBD Environmental Factors

There are environmental factors that can increase the risk including diet, smoking, stress, and genetic factors. Environmental factors have been heavily implicated in the development of IBD. Factors such as smoking, diet, and exposure to pollutants can contribute to the risk of developing IBD. Additionally, the microbiome, the collection of microorganisms living in the gut, has been a subject of intense research. An imbalance in the gut microbiome, known as dysbiosis, has been linked to IBD.

IBD Genetics

One of the major contributors to IBD is genetics. A family history of IBD significantly increases the risk of developing the disease. Researchers have identified numerous genetic markers associated with IBD, but the precise interplay of these genes remains a subject of ongoing investigation. As I said, we don’t really know the cause, in terms of pointing to one thing that causes IBD in patients or in families. But we do believe that there is an autoimmune association and a genetic component.

 

Immune System Dysregulation in IBD

The immune system plays a pivotal role in IBD. It is believed that a dysregulated immune response mistakenly attacks the gut, causing inflammation. The exact triggers for this immune system dysfunction are not well-defined, but both genetic and environmental factors are believed to play a role.

Clinical Manifestations

IBD can manifest in a variety of ways, often making it a challenging condition to diagnose and manage. The symptoms vary between Crohn’s disease and Ulcerative Colitis but may include abdominal pain, diarrhea, weight loss, fatigue, and blood in the stool. Extraintestinal symptoms can also occur, affecting other organ systems and leading to complications like joint pain, skin issues, and eye problems. IBD generally presents around the age of 15 up to the age of 25. In UC, we see a second peak where it may present in individuals in their fifties or age 55 to 65. That’s not the case with Crohn’s. Crohn’s presents between ages 15 and 45 typically.

Diagnosis – Medical History and Physical Examination

A thorough medical history and physical examination are the initial steps in diagnosing IBD. Patients’ symptoms, family history, and a review of previous diagnostic tests are essential for the diagnostic process. Patients experience an increase in the number of stools per day and abdominal pain. You can imagine how that may affect mental health, relationships, daily activities, employment, etc. They may have bowel movements 10 to 20 times per day and skin breakdown. They can have severe anal irritation that is very painful. In Crohn’s Disease, 5 to 6 soft loose stools per day are usually non-bloody for the Crohn’s patient, but bloody in the patient with UC. Bleeding can be life-threatening.

Anatomy

Let’s look at the distribution in terms of the anatomy of the disease. In the Crohn’s patient, we see disease throughout the GI tract. UC has the disease throughout the colon including the anorectum.

Fistulas

Fistulas are common in patients with Crohn’s. It is something that sets the Crohn’s patient apart from the patient with UC. If in the vignette, you are presented with fistulas. You know that you’re talking about the Crohn’s patient.

Nutrition

Nutritional deficiencies are more common in Crohn’s patients. That makes sense because these patients have losses from the GI tract. In particular, we see hyponatremia, hyponatremia, hypocalcemia and severe bicarbonate losses.

Endoscopy

Endoscopy is a common procedure used to visualize the digestive tract. It allows for the direct examination of the mucosal lining, and biopsies can be taken to confirm the presence of inflammation and distinguish between Crohn’s disease and Ulcerative Colitis. Colonoscopy may reveal evidence of the disease, thickening of the wall of the colon. In Crohn’s, granulomatous, or skip patterns in the colon or cobble stoning, and skip lesions. In ulcerative colitis disease is continuous, so ulcerative colitis is often described as “continuous”, whereas Crohn’s is described as having “skip lesions.”

Imaging Studies

Imaging studies, such as CT scans, are often employed to assess the extent and severity of inflammation and any complications that may have arisen due to IBD.

Treatment Approaches – Medications

Pharmaceutical interventions are commonly used to manage IBD. Anti-inflammatory drugs, immunosuppressants, and biologics are prescribed to control inflammation and alleviate symptoms. The choice of medication depends on the type and severity of the disease. While there is no cure for IBD, there are several medications available to manage symptoms, induce and maintain remission, and reduce inflammation. However, these medications come with a range of potential side effects, and a careful balance must be struck between the benefits and risks of treatment.

Aminosalicylates

Aminosalicylates, or 5-ASA drugs, are often the first-line treatment for mild to moderate IBD, particularly in cases of Ulcerative Colitis. They work by reducing inflammation in the gut lining.

Side Effects:

Corticosteroids

Corticosteroids like prednisone and budesonide are potent anti-inflammatory drugs used to control moderate to severe IBD flares and induce rapid symptom relief.

Side Effects:

Weight gain
Mood swings, anxiety, and depression
High blood pressure and increased risk of diabetes
Osteoporosis with long-term use
Increased susceptibility to infections

Immunomodulators

Immunomodulators, such as azathioprine, 6-mercaptopurine, and methotrexate, work by suppressing the immune system to reduce inflammation. They are used in cases where aminosalicylates and corticosteroids are ineffective or have too many side effects.

Side Effects:

Increased risk of infections, as the immune system is compromised

Biologics

Biologics are a newer class of medications that target specific proteins in the immune system to reduce inflammation. Examples include infliximab, adalimumab, and vedolizumab.

Side Effects:

Antibiotics

Antibiotics like metronidazole and ciprofloxacin are sometimes used to treat IBD, particularly for the management of abscesses and fistulas in Crohn’s disease.

Side Effects:

In severe recalcitrant disease, removing the colon is curative for these patients with UC. In Crohn’s disease, we actually try to limit surgical procedures in these patients because of the risk of strictures and intraabdominal adhesions. Surgery is considered when medical treatments fail or when complications such as strictures or fistulas develop. While surgery can provide relief, it may lead to a permanent ileostomy or colostomy, impacting the patient’s quality of life.

Staging

We stage IBD in terms of whether it’s mild, moderate, or severe.  We consider the frequency of stools or the number of stools per day – for mild disease more than 4 stools per day, moderate disease up to 10, and for severe more than 10 stools per day. You may see some systemic symptoms, including just generally feeling ill, fever, anemia, and malaise. The degree of anemia is often associated with the amount of blood that you see in the stool, so it can be mild. Patients have anorexia so patients often experience weight loss. Gross blood may be seen in the stool. These patients may require a blood transfusion. Dehydration from water losses will be observed.

Enteral nutrition

Enteral nutrition involves consuming specially formulated liquid diets as the primary source of nutrition, providing rest to the gut. This approach is often used in pediatric cases of IBD.

Side Effects:

Complications

What are some complications of IBD? We observe conjunctivitis, iritis, uveitis, oral ulcers, kidney stones, and osteoporosis, which is apparent earlier than you would expect in an individual of that age. Erythema nodosum and pyoderma gangrenosum, sacroiliitis, peripheral arthritis, ankylosing spondylitis, gallstone formation, liver disease, sclerosing cholangitis, and increased risk of thromboembolism are noted. Complications of their GI tract include strictures, bowel perforation, peritonitis, increased risk of colorectal cancer and toxic megacolon.

Balancing Relief and Risks

The choice of medication for IBD depends on the type, severity, and location of the disease, as well as the patient’s response to treatment and potential side effects. Healthcare providers and patients must work together to strike the right balance between symptom relief and the risks associated with each medication. It is crucial to carefully monitor and manage side effects, and regular follow-up appointments are necessary to ensure the chosen treatment plan remains effective and safe.

Conclusion

Medications play a vital role in managing Inflammatory Bowel Disease, offering relief from symptoms and promoting remission. However, it is essential to be aware of the potential side effects associated with these medications, as they can vary in severity and impact on a patient’s overall well-being. Patients should engage in open and ongoing discussions with their healthcare providers to make informed decisions about the most appropriate treatment plan for their specific condition, considering the potential risks and benefits of each medication. Additionally, research continues to advance, offering hope for more targeted and effective therapies with fewer side effects in the future.