Inflammatory Bowel Disease – Causes, Symptoms, Treatments

What is Inflammatory Bowel Disease?

Inflammatory bowel disease (IBD) is a term for a group of disorders that cause chronic inflammation of the gastrointestinal (GI) tract, also known as the digestive system. The two main forms of IBD are ulcerative colitis and Crohn’s disease.

Inflammatory bowel disease (IBD) is actually fairly prevalent, particularly in developed countries. Globally, estimates suggest roughly 4.9 million cases of IBD worldwide in 2019. The United States has also been shown to have one of the highest rates globally. Studies suggest 1.3% of adults (around 3.1 million people) have been diagnosed with IBD according to the Centres for Disease Control [CDC]. IBD can occur at any age and approximately 25% of patients with IBD will present symptoms before 20 years of age. The peak incidence of IBD in childhood is during adolescence, however approximately 20% of children with IBD will present before 10 years of age, and approximately 5% will present before 5 years of age.

IBD’s Impact on Quality of Life

Inflammatory bowel disease (IBD) can significantly impact a person’s quality of life due to its chronic, unpredictable nature, and potential complications. 

• Chronic symptoms: IBD is a lifelong condition, meaning individuals must manage ongoing symptoms like fatigue, abdominal pain, and diarrhea. This constant physical discomfort can disrupt daily routines, work, and social activities.
• Unpredictable flare-ups: The unpredictable nature of flare-ups, periods when symptoms worsen, adds another layer of stress. The fear of an unexpected flare-up in public places or during important events can lead to anxiety and social isolation.
• Impact on mental health: The chronic nature of the disease and the constant management can take a toll on mental well-being. Depression, anxiety, and even social stigma associated with bowel issues are common.
• Dietary limitations: Certain foods can trigger symptoms, leading to dietary restrictions. This can make social eating difficult and limit enjoyment of food.
• Work and education: Frequent bathroom breaks, fatigue, and unpredictable flare-ups can affect work or school attendance and performance. Individuals might  have trouble keeping up with deadlines or miss classes due to illness.
• Intimacy and relationships: The fear of incontinence or unpleasant bathroom odors can affect intimacy and relationships. Open communication and partner support become crucial.
• Complications: Potential complications like bowel obstructions, surgeries, and the need for an ostomy (creation of an external opening for waste elimination) can further disrupt daily life and add physical and emotional burdens.

Main Types of IBD

Inflammatory bowel disease (IBD) encompasses two main chronic conditions: Crohn’s disease and ulcerative colitis. While both cause inflammation in the digestive tract, they differ in their characteristics and the specific areas they affect.

Ulcerative colitis targets the inner lining of the large intestine, also known as the colon. The inflammation is continuous, meaning it affects the entire colon in a uniform way. This condition often leads to frequent, bloody diarrhea, urgency to have a bowel movement, and rectal bleeding.

Crohn’s disease, on the other hand, can involve any part of the digestive tract, from the mouth all the way down to the anus. However, it most commonly affects the small intestine, particularly the lower part called the ileum. Unlike ulcerative colitis, Crohn’s inflammation can be patchy, meaning there can be inflamed sections interspersed with healthy areas. This can lead to a wider range of symptoms beyond diarrhea, including abdominal pain, cramping, and even malnutrition due to difficulty absorbing nutrients.

Another key difference is that Crohn’s disease often affects deeper layers of the bowel wall, which can sometimes lead to complications like bowel narrowing (strictures) and fistulas (tunnels connecting abnormal bowel segments). Ulcerative colitis typically causes inflammation limited to the inner lining.

While the exact triggers differ, both Crohn’s disease and ulcerative colitis involve an abnormal autoimmune response. Normally, the immune system protects the body from invading pathogens like bacteria and viruses. In IBD, however, the immune system mistakenly identifies gut bacteria or other components in the digestive tract as harmful and launches an inflammatory attack. This chronic inflammation damages the lining of the digestive tract, leading to the symptoms commonly associated with IBD, such as diarrhea, cramping, and abdominal pain.

Symptoms of IBD

Inflammatory bowel disease (IBD) presents a range of symptoms that can vary in severity and duration depending on the individual and the stage of the disease (flare-up or remission). 

• Diarrhea: This is a hallmark symptom of IBD, often occurring frequently and urgently. The severity can range from loose stools to watery diarrhea. During flare-ups, diarrhea might be more frequent and severe.
• Abdominal pain and cramping: Pain can be a constant dull ache or sharp cramps, often located in the lower right abdomen for Crohn’s disease and throughout the colon for ulcerative colitis. Pain intensity can fluctuate, worsening during flare-ups.
• Rectal bleeding: This can range from passing bright red blood to having blood mixed in with stool. The severity of bleeding can vary and might be worse during flares.
• Urgency to have a bowel movement: The frequent and sudden urge to use the bathroom is a common symptom, especially during flare-ups.
• Fatigue: Constant inflammation can lead to extreme tiredness and fatigue, impacting daily activities.
• Weight loss: Due to inflammation and potential difficulty absorbing nutrients, unintentional weight loss can occur, especially during flares.
• Loss of appetite: Inflammation and pain can make eating uncomfortable, leading to decreased appetite and potential weight loss.
• Mucus in stool: The inflamed intestines might produce excess mucus, which can be seen mixed in with stool.
• Fever: Although not as common, some individuals might experience low-grade fevers, particularly during flare-ups.

Complications of IDB

Inflammatory bowel disease (IBD) can lead to various complications due to chronic inflammation and its impact on the digestive system. Chronic inflammation can create thickened bowel walls, causing strictures or narrowings that impede the passage of stool. Symptoms include cramping, abdominal pain, constipation, and bloating. Treatment might involve medications, balloon dilation, or surgery.

Inflammation can sometimes burrow through the bowel wall, creating abnormal tunnels (fistulas) connecting the bowel to other organs like the bladder or vagina. This can cause pain, drainage, and infection. Treatment typically involves medications or surgery to close the fistula.

Inflammation and damage to the digestive tract can hinder the absorption of essential nutrients. This can lead to malnutrition, manifesting as weight loss, fatigue, and deficiencies in vitamins and minerals. Dietary changes, nutritional supplements, and medication adjustments might be necessary to address malnutrition.

Chronic inflammation can also disrupt calcium absorption and bone metabolism, increasing the risk of osteoporosis, a condition that weakens bones and makes them more prone to fractures. Maintaining a calcium and vitamin D rich diet, considering bone density scans, and potentially using medications can help manage osteoporosis risk.

Individuals with long-standing IBD, particularly ulcerative colitis, have an increased risk of developing colorectal cancer. Regular screening colonoscopies are crucial for early detection and prevention.

Possible Risk Factors for IDB

The exact cause of inflammatory bowel disease (IBD) remains a mystery, but researchers believe it’s a complex interplay of several factors. 

• Genetics: Having a close relative (parent, sibling, or child) with IBD is the single biggest risk factor. Genes likely play a role in how the immune system responds to gut bacteria and environmental triggers.
• Immune system dysfunction: In IBD, the immune system mistakenly attacks healthy tissues in the digestive tract. The reasons for this malfunction are not fully understood, but certain genes might make someone more susceptible.
• Gut microbiome: The trillions of bacteria residing in our gut (microbiome) play a crucial role in digestion and immune function. An imbalance in gut bacteria composition might contribute to IBD development.
• Environmental factors: While the exact link is unclear, certain environmental factors like early childhood exposure to antibiotics, diet high in processed foods and low in fiber, and smoking are thought to be potential risk factors.
• Age: IBD can develop at any age, but diagnoses are most common between 15 and 35 years old.

It’s important to remember that these factors likely act together, and having one risk factor doesn’t guarantee developing IBD.

How is IDB Diagnosed?

Inflammatory bowel disease (IBD) is a complex condition with no single definitive test for diagnosis. Doctors rely on a multi-step approach, gathering evidence through various methods to reach an accurate diagnosis.

The initial phase involves a detailed medical history review. Your doctor will inquire about your symptoms, including their severity and duration. They’ll also be interested in your family history of IBD and any current medications you’re taking. A physical examination will assess for signs of inflammation, like abdominal tenderness or masses.

Stool tests come next. These analyze fecal samples for occult blood, hidden blood not visible in the stool, that might indicate bleeding in the digestive tract. Additionally, they can check for infections caused by bacteria or parasites, and inflammatory markers.

Blood tests play a role in evaluating for anemia, a condition common in IBD due to blood loss.  They can also assess inflammation markers and rule out autoimmune conditions that can mimic IBD symptoms. It’s important to note that some blood tests may look for specific antibodies associated with IBD, but these aren’t always conclusive for diagnosis.

Imaging studies provide valuable visuals of the digestive tract. They can help identify abnormalities like blockages or inflammation. Some commonly used imaging techniques include X-rays, CT scans, and MRIs.

• X-rays offer a basic view and might reveal blockages or inflammation in the bowel.
• CT scans provide detailed cross-sectional images of the abdomen and pelvis, which can be helpful in identifying inflammation, strictures (narrowing of the bowel passage), or fistulas (tunnels connecting abnormal bowel segments).
• MRI scans offer a clearer picture of soft tissues and are particularly useful in detecting fistulas or complications.

Finally, endoscopy and colonoscopy procedures allow for direct visualization of the digestive tract’s inner lining. A thin, flexible tube equipped with a camera is inserted to examine the different sections.

• Endoscopy focuses on the upper digestive tract, including the esophagus, stomach, and duodenum.
• Colonoscopy specifically inspects the entire large intestine (colon and rectum).

During these procedures, doctors can collect tissue samples (biopsies) for microscopic examination by a pathologist. Biopsy is a crucial step, as it confirms the presence and type of inflammation and helps differentiate between Crohn’s disease and ulcerative colitis, the two main forms of IBD.

How is IDB Treated?

There are two main goals in treating inflammatory bowel disease (IBD):

• Inducing and maintaining remission: This means controlling the inflammation and reducing symptoms to the point where you experience minimal to no discomfort and can function normally.
• Preventing future flare-ups: Once remission is achieved, treatment aims to prevent the disease from relapsing and causing flare-ups, periods when symptoms worsen.

Doctors employ a variety of treatment modalities depending on the severity of your condition, the specific type of IBD (Crohn’s disease or ulcerative colitis), and your individual response to medications. Here’s a breakdown of the common treatment approaches:

1. Medications:

• Anti-inflammatory drugs: These medications, like aminosalicylates (sulfasalazine, mesalamine),  help reduce inflammation in the gut. They are commonly used to induce and maintain remission, especially for mild to moderate cases of ulcerative colitis.
• Immune system suppressors: These medications, like azathioprine, mercaptopurine, and methotrexate, work by dampening the overactive immune response that contributes to inflammation. They are often used in combination with other medications, particularly for Crohn’s disease and more severe cases of ulcerative colitis.
• Biologics: These are relatively new and targeted medications that block specific proteins involved in the inflammatory process. Some examples include adalimumab, infliximab, and vedolizumab. Biologics can be highly effective for inducing and maintaining remission in moderate to severe IBD cases.
• Antibiotics: While not a primary treatment, antibiotics can be helpful in certain situations. They might be used to treat infections that can worsen IBD symptoms or for fistulas (tunnels connecting abnormal bowel segments) caused by bacteria.

2. Surgery:

In some severe cases, surgery might be necessary to manage complications or improve quality of life. The type of surgery will depend on the specific situation. Here are some possibilities:

• Bowel resection: This surgery removes a damaged portion of the intestine.
• Strictureplasty: This procedure widens a narrowed section of the bowel.
• Ostomy creation: In some cases, an ostomy might be necessary. This involves creating an opening on the abdomen to divert stool flow into a collection pouch.

3. Dietary modifications:

While there’s no specific diet proven to cure IBD, some dietary changes can help manage symptoms and improve overall well-being. A healthcare professional or registered dietitian can help create a personalized plan that works for you.

4. Lifestyle changes:

Managing stress, getting enough sleep, and quitting smoking can all contribute to a better quality of life with IBD.

Which Medications are Most Often Prescribed for IBD?

The most commonly prescribed medications for IBD depend on the specific type and severity of the disease. 

• 5-Aminosalicylates (5-ASAs): These medications are generally first-line therapy for mild to moderate ulcerative colitis and can also help maintain remission. They work by reducing inflammation in the gut.  Examples of 5-ASAs include sulfasalazine, mesalamine (Asacol, Ipocol, Octasa, Pentasa, Salofalk), and olsalazine (Dipentum).
• Immunomodulators: These medications suppress the overall activity of the immune system, aiming to prevent the immune system from attacking healthy tissues in the digestive tract. They are often used in combination with other medications, particularly for Crohn’s disease and more severe cases of ulcerative colitis. Examples of immunomodulators include azathioprine, mercaptopurine, and methotrexate.
• Corticosteroids: These medications act as powerful anti-inflammatory drugs, providing rapid relief for moderate to severe flare-ups of both Crohn’s disease and ulcerative colitis. However, corticosteroids are typically used for short-term relief due to potential side effects with long-term use. Examples of corticosteroids include prednisone and budesonide.
• Biologics: These are newer and targeted medications that block specific proteins involved in the inflammatory process. Biologics can be highly effective for inducing and maintaining remission in moderate to severe IBD cases. Some commonly used biologics include adalimumab, infliximab, and vedolizumab.
• Antibiotics: While not a primary treatment, antibiotics can be helpful in certain situations. They might be used to treat infections that can worsen IBD symptoms or for fistulas (tunnels connecting abnormal bowel segments) caused by bacteria.