Inflammatory Bowel Diseases (IBD)

Inflammatory Bowel Diseases (IBD) develop due to chronic inflammation of GIT (the intestines more often).

Crohn's disease and ulcerative colitis are the two major disorders included under IBD, Both the disorders are characterised by periods of exacerbations and remissions of varying severity

The cause of IBD is still not clear, however, it is assumed to be the result of a genetic autoimmune state activated by an infection. The intestinal mucosa is made up of immune cells which on stimulation releases inflammatory mediators (e.g. histamine prostaglandins, leukotrienes, and cytokines).

The function and neural activity of the secretory and smooth muscle cells in the GIT are influenced by inflammatory mediators Also an imbalance in fluid, electrolyte, and pH occurs. IBD may cause intense pain, weaken the patient, and may be fatal.

Crohn's Disease

A condition in which any part of the GIT (the proximal portion of colon more commonly and the terminal ileum less commonly) becomes inflamed and the inflammation then extends to all the layers of intestinal wall is termed as Crohn's disease (or regional enteritis or granulomatous colitis).

The regional lymph nodes and mesentery may also get affected by this disease. The adults aged between 20-40 years are at more risk to Crohn's disease.

Etiology

The cause of Crohn's disease is not clear; however lymphatic obstruction, allergies, immune disorders, infection, and genetic predisposition are the causative conditions.

Pathogenesis

The inflammation caused by Crohn's disease spreads gradually at a progressive rate. The lymph nodes become enlarged and block the lymph flow in sub-mucosa.

This lymphatic obstruction results in oedema, mucosal fissures, abscesses, granulomas, and mucosal ulcerations (called skipping lesions since they are discontinuous).

Peyer's patches (oval and elevated patches of closely packed lymph follicles) line the small intestine.

As a result, fibrosis occurs which lines the bowel walls, making them. thick, causing stenosis, and narrowing the lumen

Consequently, serositis occurs in which the serous membrane becomes inflamed. The inflamed bowel loops adhere to other diseased or normal loops, and diseased bowel segments intermix with the healthy ones.

In the final stage, the diseased parts of the bowel become thicker, narrower, and shorter.

Signs and Symptoms

Crohn's disease develops the following signs and symptoms, depending on the affected bowel part and its severity:

1. Chronic diarthoca coften bloody and containing mucus or pus
2. Loss in weight,
3. Fever,
4. Pain and tenderness in abdomen,
5. Feeling of a mass or fullness in abdomen,
6. Rectal bleeding.

Apart from these some other symptoms may develop, depending on the complications disease.

For example, an individual having a fistula Cabnormal passageway formed between urious organs or tissues) in rectal area suffer from pain and discharge around the rectum.

Blockage in various parts of GIT due to inflammation and scarring lead to other fatal problems like bowel perforation, abdomminal distension (swelling), severe pain, and fever.

Complications

Crohn's disease when becomes severe lead to the following complications:

1. Bawel Obstruction: Crohn's disease alters the intestinal wall's thickness. In the final stages, the affected parts of bowel become scarred and narrower, thus obstricting the flow of digestive contents.
2. Ulcers: Severe inflammation results in ulceration of the digestive tract (including the mouth and anas) and the genital area (perineum).
3. Fistulas: When the ulcers completely extend through the intestinal wall, a fistula develops.
4. Anal Fissure: A small tear occurs either in the tissue lining the anus or in the skin around the anus. This area becomes prone to infections causing painful bowel movements and a perianal fistula.
5. Malnutrition: The affected individual may become malnourished as eating becomes difficult due to diarrhoea, abdominal pain, and cramping. The intestine also fails to absorb sufficient amount of nutrients.
6. Colon Cancer: If the affected part is colon, the patient becomes more vulnerable towards colon cancer.
7. Other Health Problems: Anaemia, skin disorders, osteoporosis, arthritis, and gall bladder or liver diseases are the other problems associated to Crohn's disease.

Diagnosis

Crohn's disease can be diagnosed as follows:

1) Blood Tests: These include:
i) Tests for Anaemia or Infection: Blood tests are performed to check for signs of anaemia or other infections.
ii) Fracal Occult Blood Tests: The patient's stool sample is checked for hidden (occult) blood in the stool.

2) Colonoscopy: In this test, the entire colon and terminal ileum are observed via thin, lighted tube having an attached camera. While observing, the doctor can even small samples of tissue (biopsy) to check for granulomas (clusters of inflammatory cells): the presence of which confirms the diagnosis.

3) CT Scan: The patient's entire bowel and the outer tissues are observed via CT scan Small bowel can be viewed via CT enterography (a special CT scan).

4) Magnetic Resonance Imaging (MRD): Whether or not the patient has developed a fistula around the anal area or in the small intestine is observed via pelvic MRI or MR enterography, respectively.

5) Capsule Endoscopy: The patient is made to swallow a capsule with an attached camera for taking pictures of the small intestine: the pictures are then transmitted to a recorder fitted on the patient's belt; the images are downloaded to a computer, presented on a monitor, and observed for signs of Crohn's disease.

The camera comes out of the body painlessly via facces. However, an endoscopy and biopsy is still required to confirm the diagnosis.
6) Balloon-Assisted Enteroscopy: The small bowelschenot be observed using standard endoscopes, thus a scope along with an over-tube is used. This technique is suggested when capsule endoscopy does not give appropriate results, but the diagnosis is still not confirmed.

Plan of Treatment

The treatment of Crohn's diseases focuses on the reduction of inflammation inducing symptoms, and also improving the long-term prognosis by limiting complications. This eases the symptoms and also the long-term remission. Crohn's disease can be treated as follows:

1) Medicines: Corticosteroids (hydrocortisone, beclomethasone, and budesonide) are effective for a short-term treatment only, because weight gain, diabetes, and osteoporosis are some of its side effects.

Immunosuppressants (azathioprine, mercaptopurine, and methotrexate) are used for suppressing the immune system. Antibiotics are used for reducing the infection risk.
2) Diet: The patients should have a healthy, balanced diet. If some foods worsen the symptoms, they should be removed from the patient's diet. During a flare-up, a liquid diet rich in simple proteins, carbohydrates, and fats help to cease the symptoms.

3) Surgery: When medications fail to control the symptoms, surgery is required in which the damaged portion of the GIT is removed and the healthy sections are reconnected.

 Surgery is also done for closing fistulas and draining abscesses. Surgery however provides only temporary benefits to the patients as the disease may persist near the reconnected tissue. Thus, medications to minimise the risk of relapse should be continued post-surgery.

Ulcerative Colitis

A chronic (long-term) condition in which the large intestine becomes inflamed is termed ulcerative colitis. This disease is a form of IBD and is somewhat similar to Crohn's disease.

The nutrients from undigested food are removed by the colon or large intestine, and they remove the waste products via faeces. In ulcerative colitis, the colon becomes inflamed and ulcers develop on the lining of the colon (in severe cases). These ulcers bleed and produce pus and mucus.

Types

Ulcerative colitis is classified into the following depending on its location:

1) Ulcerative Proctitis: This type is the mildest form of ulcerative colitis. In this type. the rectum becomes inflamed and rectal bleeding is the only sign.

2 Proctosigmoiditis: In this type, the rectum and sigmoid colon (lower end of the colon) becomes inflamed. Bloody diarrhoea, abdominal cramps, and tenesmus (the urge to empty the bowels frequently) are the common sign

3) Left-Sided Colitis: In this type, the rectum, sigmoid and descending colon becomes inflamed. Bloody diarrhoca, abdominal cramps on the left side, and weight loss are the common signs.
4) Pancolitis: In this type, the entire colon becomes inflamed. Fits of bloody diarthoca. abdominal cramps, fatigue, and significant weight loss are the common signs. 5) Acute Severe Ulcerative Colitis: In this rare type of ulcerative colitis, the entire colon becomes inflamed. Severe pain, profuse diarrhoea, bleeding, fever, and inability to eat are the common signs.

Etiology

The exact cause of ulcerative colitis is still not clear. Earlier, diet and stress were assumed to be the major causative factors; but at the present time it is believed that these factors can only worsen ulcerative colitis

Immune system malfunction can be a possible cause. In this condition, when the imune system tries to fight against an invading virus or bacterium, an abnormal immune response develops under the effect of which the immune system starts attacking the cells of GIT.

Ulcerative colitis occurs commonly in individuals having family members with the disease, thus heredity is also assumed to play a role in it. However, most of the scerative colitis patients do not have this family history.

Pathogenesis

The exact cause of ulcerative colitis is still not clear. Autoimmunity is thought to be involved since antibodies to epithelial cells in the colon are found in some patients. Ulcerative colitis originates from the distal region of the rectum and extends up to the descending colon. The inflammation occurs in a continuous manner on the mucosal surface (i.e.. it covers the entire colon).

Inflammation reaches the superficial mucosa and causes friability, thus the tissues bleed casily. This makes the mucosa erythematous (red) and granular. Lesions in the crypts of Lieberkuhn develop into abscesses. Exudate matter and ulcerations occur in the early stages. As time passes, the mucosal epithelial cells undergo atrophy and metaplasia. Patients having a long-term ulcerative colitis become more vulnerable towards colorectal cancer, obstruction, perforation, and massive haemorrhage.

Signs and Symptoms

The very first symptom is diarrhoea which either begins slowly or suddenly. The affected area of colon and the inflammation decides the level of symptoms.

The commonly occurring symptoms are:

1. Pain in abdomen,
2. Fatigue,
3. Anaemia.
4. Dehydration,
5. Bloody diarrhoea with mucus,
6. Appetite and weight loss,
7. Fever,
8. Tenesmus.

The symptoms worsen in early mornings. Some patients either suffer from very mild Symptoms or no symptoms at all for months or years. But if left untreated the symptoms ventually return.

Complications

Ulcerative colitis may develop the following complications:

1) Severe bleeding.

2) Perforated colon.

3) Severe dehydration,

4) Liver disease (rare).

5) Osteoporosis,

6) Inflammation of skin, joints, and eyes,

7) An increased risk of colon cancer,

8) Toxic megacolon (a rapid swelling of colon), and

9) Increased risk of blood clots in veins and arteries.

Diagnosis

The diagnosis of ulcerative colitis is confirmed by the following tests :

1) Blood Tests: These tests check for anaemia or signs of other infections.

2) Stool Sample: Samples of stool collected from the patient are checked for the presence of WBC's (indicate ulcerative colitis). Other disorders (bacterial, viral, and parasitic infections) can also be determined by this test.

3) Colonoscopy: In this exam. the entire colon is viewed using a thin, flexible, lighted tube with an attached camera. During colonoscopy, the doctor also collects small tissue samples (biopsy) for confirming the diagnosis.

4) Flexible Sigmoidoscopy: In this exam, a slender, flexible, lighted tube is used for examining the rectum and sigmoid (last portion of colon).

5) X-Ray: In case of severe symptoms, a standard X-ray of the abdominal area is performed to check for serious complications (such as a perforated colon).

6) CT Scan: A CT scan of the abdomen or pelvic area is done if the doctor suspects a complication from ulcerative colitis. The amount of inflammation in colon can be observed through a CT scan.

7) CT Enterography and Magnetic Resonance Enterography: These non-invasive tests are performed to check for inflammation in the small intestine.

Plan of Treatment

Ulcerative colitis can be treated by including the following in the patient's diet:

1) A high fibre, high caloric, high protein diet.

2) Oral nutritional supplements.

3) Multivitamin supplements, and

4) Total Parenteral Nutrition (TPN) as the disease progresses.

The following medications should be used for treating ulcerative colitis:

1) Anti-diarrhoeal agents,

2) Antispasmodics.

3) Anticholinergic agents.

4) Amino salicylates (5-ASAs, to treat mild to moderate inflammation),

5) Glucocorticoids (to treat moderate to severe inflammation),

6) Immune modulators (to suppress inflammatory response).

7) Biologic agents,

8) Analgesics, and

9) Antibiotics (if infection is present).

Proctocolectomy is performed to remove the entire colon rectum. In most cases, ileal pouch anal anastomosis is carried out in which wearing a bag to collect stool is not required.

The surgeon constructs a pouch from the end of the small intestine, which is then attached directly to the anus. This enables the patient to expel waste normally.

Stress management (e.g.. exercise, meditation, deep breathing, biofeedback, and acupuncture)

and support (e.g., group involvement and counseling) are some other management efforts.