Inflammatory bowel disease

Inflammatory bowel disease

Although lumped together under the umbrella term, inflam matory bowel disease (IBD), ulcerative colitis and Crohn’s disease are two distinct disorders. Their differing locations and pathology produce different symptoms and require different treatment, but both can be difficult and frustrating to live with. Crohn’s disease can attack any part of the digestive tract from mouth to anus, but most often affects the small intestine. Ulcerative colitis is confined to the colon (large intestine). Inflammatory bowel disease can arise at any age, even during infancy, but usually appears between the ages of 15 and 25. A second incidence peak occurs in people aged 50 to 80. IBD affects males and females equally. Today, some 200,000 Canadians live with inflammatory bowel disease, which is mot common in North America and Western Europe than in Asia, Africa and South America.

The symptoms of inflammatory bowel disease

Despite significant differences between Crohn’s disease and ulcerative colitis, both share certain features: unpredictable flare-ups and inflammation of the intestinal tissues ranging from mild and easily manageable to severe and debilitating.

Symptoms include:

* severe diarrhea * waning appetite

* abdominal cramps * weight loss

Of the many possible complications of IBD, the most usual are nutritional problems (resulting in weight loss, weakness and fatigue), anemia, kidney stones, arthritic complaints, rash, eye disorders, growth retardation and delayed sexual maturation (in children). Some of these conditions arise directly from the disease itself (nutrient deprivation), others, such as arthritis, are related to mechanisms not yet fully understood. Neither surgery nor drugs can cure Crohn ‘s, but removal of the colon can permanently eliminate ulcer derived colitis.

Causes of inflammatory bowel disease still elusive

While the reasons for IBD remain unclear, there are some theories about possible triggers:

* Infections. As the symptoms of IBD resemble those of several bacterial or parasitic infections, IBD was often confused with bowel infections. Researchers still look for bacterial or viral triggers.

* Altered immunologic responses. An immune response mounted against the body’s own cells or disruption of the normal response is now considered largely responsible for IBD.

* Dietary causes. Recent studies created a stir by proposing that people who develop Crohn’s disease tend to eat a lot of refined sugar. However, these studies did not take into account the possibility that people with Crohn’s are often malnourished and their higher-than-average sugar intake reflects an attempt to get energy – as a consequence rather than a cause of the disease. Furthermore, populations that eat large amounts of sugar (such as Moroccans and Saudi Arabians) have a low incidence of Crohn’s disease. Another study correlated Crohn’s disease with the intake of corn flakes – again invalidated. Lack of fibre has long been a suspected cause of IBD because African populations that consume high fibre diets tend to have less IBD than Westerners. But this idea has not been confirmed.

* Genetic-family background. Between 20 and 40 per cent of people with IBD have one or more relatives with the disease.

* Psychiatric disorders. It was once believed that psychological problems might trigger IBD – a theory now abandoned. Earlier studies intimating that stress provokes IBD haven’t been confirmed. It is certainly hard to understand how stress could cause the widespread tissue damage seen in IBD, although its symptoms may be exacerbated by stress. People ill from IBD may experience a sense of hopelessness which might lead to depression as a consequence rather than a cause of IBD.

Great strides in the management of IBD

* Corticosteroid drugs reduce bowel inflammation in moderate to severe ulcerative colitis and Crohn’s flare-ups. Besides relieving symptoms, corticosteroids increase appetite and help people to regain lost weight. But adverse side effects offset steroid therapy – headaches, face flushing, puffiness (moonface), increased body fat especially around the trunk and fluid retention (particularly around the ankles). More serious side effects include osteoporosis, vascular hip damage, blood pressure elevation and reduced immune resistance. New corticosteroid preparations, now in clinical trials show promise – for example, budesonide, with fewer side effects for Crohn’s disease, and for ulcerative colitis, steroid enemas (e.g., tixocortol).

* Sulfasalazine – a mixture of sulfapyridine (an antibacterial) and 5-aminosalicylate (5-ASA), a relative of aspirin – is widely used to prevent flare-ups and alleviate mild to moderate ulcerative colitis, also for Crohn’s where disease is confined to the colon. Drug side effects are common in the first few weeks of use (headaches, nausea, loss of appetite), minimized by taking the medication on a full stomach or as coated pills. Some people are allergic to sulfasalazine (developing a rash or hives). Other possible side effects include: infertility in men (reversible when the drug is stopped) and orange coloured urine (harmless).

Very rare, but serious complications include liver inflammation and bone marrow shutdown (signalled by unusual bruising).

* Use of 5-ASA in a variety offi,’ms is a big advance in the drug treatment of ulcerative colitis. Since most side effects of sulfasalazine stem from the sulfa component, use of 5-ASA on its own. without sulfapyridine, taken either as daily enemas, suppositories or by mouth, may avoid problems in those intolerant to sulfasalazine. Various coated tablets can deliver the medication right to the affected part of the intestine. Enemas of 5-ASA can achieve remission in 80-90 per cent of ulcerative colitis (confined to the left side of the colon), although to maintain remission, sufferers may need to take 5-ASA tablets (e.g. Asacol, Pentasa, Salofalk, Mesasal, Dipentum) or continue with thrice weekly enemas.

* Metronidazole, an antibiotic, is increasingly tried for Crohn’s sufferers, especially to alleviate anal complications. Possible side effects include nausea, vomiting, constipation and a metallic taste in the mouth. Those on it need monitoring as therapy may occasionally produce foot numbness (reversible on discontinuing the drug). Another antibiotic, ceprofloxacin, used together with metronidazole is a recent advance that helps some serious Crohn’s sufferers.

* Immunosuppressants (6-mercaptopurine and azathioprine) may be helpful for Crohn’s disease by reducing the required dosage of corticosteroids and healing fistulas, or for cases that don’t respond to corticosteroids. Possible side effects include leukopenia (reduced white blood cell count) and pancreas inflammation. Cyclosporine – used in transplant operations – is also being tried experimentally for IBD.

* The new pelvic pouch surgery, used only for ulcerative colitis (not Crohn’s), has the great advantage of avoiding the need for an external stool collecting bag. The operation removes the colon and rectum, leaving intact the muscles of the anus, connecting the small intestine to them. A “pouch” made out of the small intestine serves as a surrogate colon. Although it doesn’t permit completely normal bowel movements, the operation reduces the inconvenience of frequent defecation and doesn’t interfere with daily life.

Dietary treatment of IBD

Nutrition is crucial in IBD but the exact role of diet is controversial. Experts have tried low sugar, high carbohydrate diets, exclusion diets or low fibre diets with inconclusive results. Special feeding methods often achieve remission in Crohns sufferers without a need for medication or surgery. The response of IBD sufferers to food varies widely. Ulcerative colitis sufferers are often lactose intolerant and must avoid milk products. Some with bowel stricture (narrowing) do best by avoiding bulky high fibre foods. One study on Crohn’s patients who had undergone surgery found that the most troublesome foods were: corn, nuts, fizzy drinks, raw fruits, shellfish, lettuce, pickles, alcohol, tomatoes. Least likely to cause problems were: chicken, white bread, rice and potatoes. Each sufferer must identify the foods that aggravate symptoms and avoid them. Regular, well balanced meals are essential for good nutrition. One recent approach being investigated by a University of Toronto team is an “elemental diet” of nutrients in their basic format, fed through a tube, used without any medications, which helps many Crohn’s sufferers. Pioneered as a diet for space travellers, it contains pre-mixed amino acids, fats, carbohydrates and other essential nutrients, producing minimal digestive activity and little stool formation.

In conclusion:

Despite advances in therapy, coping with IBD ultimately means coming to terms and living with it. As one researcher puts it, “chronic diseases can bring out the best or the worst in people.” With determination, optimism and a refusal to embrace the “sick role,” most IBD sufferers can lead normal lives – work, participate in sport, have an active sex life, bear and raise children. As role models, IBD sufferers might take heart from Crohn’s sufferers such as General Dwight D. Eisenhower, 34th president of the United States, who had persistent Crohn’s disease, or Peter Nielson, the body builder (known as “Mr. Intemational Universe”), Kevin Dineen (the Hartford Whalers hockey player) and football player, Roll Benirschke. Anyone interested can obtain a detailed chart comparing Ulcerative colitis and Crohns disease from the Health News office: (416) 978-5411

For more information, contact: the Canadian Foundation for Ileitis and Colitis, 21 St. Clair Ave. E., Toronto, Ont. M4T IL9: (416) 920-5035.

COPYRIGHT 1992 Strategic Inc. Communications Ltd.

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