Chapter 1: THE INFLAMMATORY BOWEL DISEASE
WHAT IS INFLAMMATORY BOWEL DISEASE
Inflammatory bowel disease (IBD) means chronic inflammation of all or part of your digestive tract. IBD can be classified into two, which is, ulcerative colitis and Crohn’s disease. IBD is very painful and debilitating, and can sometimes lead to life-threatening complications. The IBD is called an autoimmune disease because the body’s immune system attacks the digestive system. The disease is so severe that it may cause abdominal pain, bloody diarrhea, cramps and fever.
This is however different from Irritable Bowel Syndrome (IBS).
DIFFERENCE BETWEEN INFLAMMATORY BOWEL DISEASE (IBD) AND INLAMMATORY BOWEL SYNDROME (IBS)
The difference between the IBS and the IBD is that IBD is structural, but IBS is not. If the gut is examined by x-ray, endoscopy, biopsy or surgery, structural damage to the gut can be seen. In IBD, the damage is caused by the inflammation and may require heavy duty medication, or even surgery. Whereas in IBS, the examination of the gut of a person having IBS would help detect nothing. It can only be detected by gut symptoms. These may include abdominal cramps or pain, harder or looser bowel movements than average, excess gas, diarrhea and constipation – or alternating between the two.
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Both of these affect people of all ages but young people are mostly affected. Females have more chances of having IBS. IBD has no gender preference but is mostly found in Jews and people from Northern Europe. IBS is a worldwide disorder, while IBD is prominent in the planet’s temperate zones.
In IBD, the gut is damaged by chronic inflammation. The damage is fought by the defense mechanism of the body resulting in fever and malaise. The intestines are disrupted, they may bleed and anemia is common too. There is inability to eat during attacks, inflammation is caused which results in wasting of energy, ultimately resulting in weight loss and malnutrition.
IBS cannot be identified by findings of physical examination. However, the structural damage caused by IBD is also capable of producing striking physical findings like a mass in the abdomen, or the symptoms such as that of weight loss and anemia. Other differences include the need for surgery in IBD, which is not required in IBS. IBS does not induce complications in the gut, skin, joints and eyes, but IBD does.
CROHN’S DISEASE This is the type of IBD that may involve any part(s) of the gastrointestinal tract, ranging from mouth to anus. Listed below are a few characteristic features:
- Inflammation usually occurs in patches.
- The pain is usually experienced in the lower right abdomen.
- The colon may turn thick and might appear to be rocky.
- Ulcers in and along the digestive tract are very deep, sometimes extending into every layer of the bowel wall.
- During bowel movement, rectal bleeding is not common.
Ulcerative colitis is the second type of IBD, which is taken up in the subsequent chapters.
Chapter 2: ULCERATIVE COLITIS
Defining Ulcerative colitis
“Colitis” means the inflammation of the colon, or more largely, inflammation of the large intestine ( that comprises of colon, caecum and rectum). Ulcerative colitis is a disease of the colon, which is the largest part of the large intestine, characterized by ulcers (open sores). These ulcers are painful wounds, they may bleed and also produce mucus and pus. The mucosa (inner lining) of the intestine becomes red and swollen. The rectal area is most severely affected. If the lining of the colon is damaged, it may cause bloody diarrhea.
Where Crohn’s disease can affect almost any part of the digestive tract, Ulcerative colitis only affects the large intestine. Crohn’s disease can be treated by removing the affected parts and reconnecting the healthy ones. Whereas to treat ulcerative colitis, one may have to remove the large intestine completely (called colectomy). It can occur at highly irregular intervals, at times, with symptoms extremely severe, and sometimes, no symptoms at all.
Ulcerative Colitis- An autoimmune condition
In autoimmunity, an organism fails to recognize its own constituent parts as “self, and thus leads to an immune response against its own tissues and cells. Such diseases are termed as autoimmune diseases.
In other words, our body’s defense mechanism goes wrong and attacks its own healthy tissue. There are harmless bacteria present inside the colon, which are mistaken to be harmful by the defense mechanism, and are attacked, leading to inflammation.
Classifying Ulcerative Colitis
- Ulcerative Proctitis
This is Ulcerative colitis in its mildest form. There is inflammation only within the rectal area. The various signs and symptoms are as follows:
- Rectal pain
- Rectal bleeding
- There is an urge to move the bowels but inability to do so.
This involves the lower end of the colon, that is, the sigmoid colon and the rectum. The signs and symptoms are as follows:
- Abdominal pain
- Bloody diarrhea
- Abdominal cramps
- Constant urge to go to the toilet
- Left sided colitis
There in inflammation in the rectum, up on the left side along the sigmoid colon and the descending colon. The signs and symptoms are:
- Abdominal cramping on the left side
- Bloody diarrhea
- Weight loss
- Pancolitis (Universal colitis)
This involves and affects the whole colon. The signs and symptoms are:
- Bloody diarrhea (there may be severe bouts)
- Abdominal pain
- Abdominal cramps
- Weight loss
- Fulminant Colitis
This is the most rare form of colitis and it can be life threatening. It affects the whole colon. Patients suffering from fulminant colitis are at a constant risk of toxic megacolon (the colon becomes swollen, or bloated, or distended) and colon rupture. The signs and symptoms are as follows:
- Severe diarrhea, that can lead to shock and dehydration
- Severe pain
SYMPTOMS OF ULCERATIVE COLITIS
The Gastrointestinal symptoms include:
Diarrhea with blood and mucus. This implies the gradual onset of the disease which may persist for an extended period, maybe weeks. If rectal examination is conducted, blood may be found. The patients also suffer from drastic weight loss. Due to the inflammation and extreme loss of blood from the gastrointestinal tract, anaemia may occur. There may be mild abdominal pain, or painful bowel movements accompanied with painful abdominal cramping. One may even experience fatigue and loss of appetite.
One may experience very mild or almost no symptoms, called “remission”, which may be followed by symptoms that are troublesome, called “flare-ups” or “relapses”. These may be triggered by stress. Flare-ups may be very troublesome, in which patients may have to empty their bowels about six times or more each day. Heartbeat may be fast or irregular, accompanied by shortness of breath and high fever.
Severity of the disease
- Mild disease
This means less than four stools each day. Blood may be present or absent. Patient may experience mild cramping and abdominal pain. The patient may feel constipated, with a continuous feeling of needing to empty the bowel, with cramping or pain and little or almost no fecal output.
- Moderate disease
This means more than four stools each day. Patient also displays signs of anemia, fever around 100 to 102 degrees Fahrenheit.
- Severe Disease
This means around six stools with blood each day, implying observable bowel movement, toxicity demonstrated in the form of fever, anaemia and tachycardia.
- Fulminant Disease
This means more than or equal to ten bowel movements each day, accompanied by continuous bleeding, abdominal tenderness, toxicity, colonic dilation and blood transfusion is often required. Patients may have toxic megacolon as the inflammation extends beyond the mucosal layer. At times, the serous membrane also gets involved causing colonic perforation. If not treated, fulminant disease may lead to death.
As ulcerative colitis is an autoimmune disease, patients may develop symptoms as well as complications outside the colon. These include:
- Ulcers in the mouth.
- Opthalmic: Irritated and red eyes, or inflammation o iris called iritis.
- Musculoskeletal: Swollen joints (arthritis). These may be large joints, or small joints of hands or feet. Or joints of the spine.
- Cutaneous: Inflammation of the subcutaneous tissue.
- Painful and ulcerating lesion of the skin.
- A deformity of the ends of the fingers (Clubbing).
- Inflammation of the bile ducts (Primary Sclerosing Cholangitis).
Chapter 3: Causes of Ulcerative Colitis
The causes of Ulcerative Colitis are still not known. Yet, the possible causes are listed below:
The disease can be inherited if one has a close relative suffering from the disease. Hence it can be found in the family. The regions of the genome that can be linked to this disease are the chromosome number 1, 3, 5, 6, 12, 14, 16, 19. Since none of these have been faulty continuously, it has led to a conclusion that the disease occurs due to a combination of various genes. One of the regions, for example, has been linked to ulcerative colitis is chromosome band 1p36.
- ENVIRONMENTAL FACTORS
Inflammation may be encouraged by diet. For example, if there is a large intake of vitamin b6 and unsaturated fat affect the development of ulcerative colitis. There are many other discovered dietary factors which may lead to the relapse or development of the disease, like meat protein and alcoholic beverages. Vitamin D deficiency is also a leading cause of the disease. Breastfeeding may also lead to the development of the disease.
The role of Sulphur in Ulcerative Colitis
Sulphur is found in many foods and substances like milk, eggs, cheese, mayonnaise. It is also used as a food preservative because it stabilizes protein structures. It also prevents microbial growth during fermentation of wine and beer.
Bacteria that are present in the bowel convert the sulphur present in the food to hydrogen sulphide, which is called fermentation. This substance is harmful as it can cause abdominal pain and urgent and frequent bowel movements. Because of the already existing inflammation of the bowel lining, patients suffering from ulcerative colitis find it difficult to break down the gas as they produce more hydrogen sulphide than normal. This toxic substance, in high amounts, reduces the protective unction of the cells that are lining the bowel. It can also cause cell death and induce ulceration in the superficial mucosa of the intestine. Hence the cells lining the colon are harmed.
- IMMUNE SYSTEM
Theories suggest that a virus or a bacterium also may trigger ulcerative colitis as the digestive tract may become inflamed when the immune system tries to get rid of the invading microorganism (pathogen). This inflammation is caused due to the release of white blood cells to destroy the present pathogen. This may lead to an autoimmune reaction/condition in which the body produces an immune response even during the absence of the pathogen. This happens because the body tries to eliminate pathogens which are either gut friendly, or non-existent.
The factors that raise the risk of developing Ulcerative colitis are as follows:
- Age: Though it may affect people at any and every age, it is more commonly found in people aged 15 to 30.
- Genetics: If someone has a close relative with the Crohn’s disease or ulcerative colitis, they are at a high risk of development of the disease.
- Isotretinoin: The treatment of cystic acne is often done with the help of this medicine. It can cure other kinds of acne too, but it increases the risk of this disease. The medicine is also called Accutane. Amnesteem, Sotret and Claravis (These are the various other brand names).
- Appendectomy: The removal of the appendix may lead to the reduction of the risk of developing ulcerative colitis but an increased risk of Crohn’s disease.
Chapter 4: DIAGNOSIS
Ulcerative colitis is diagnosed only when the possible signs and symptoms of infection, Crohn’s disease, irritable bowel syndrome (IBS) and colon cancer have been ruled out. The following tests are carried out:
They help to check anaemia, and also help to diagnose the name of the bowel disease the patient has.
If there are white blood cells present in the stool, it implies that the patient is suffering from an inflammatory disease, possibly ulcerative colitis. It also helps rule out other diseases, like those caused by bacteria, viruses and parasites. Clostridium difficile usually causes diarrhea but also common amongst people suffering from ulcerative colitis. Bowel infection can also be checked this way.
The entire colon can be viewed using a flexible, thin and lighted tube which has a camera attached to it. Small tissue samples are also taken (called biopsy) so that a laboratory analysis can be conducted and ulcerative colitis may be diagnosed.
This test is done if the colon is inflamed severely. A thin, lighted and flexible tube is used to examine the last portion of the colon, the sigmoid. But the drawback of this procedure is that the problems occurring higher up the colon may be missed and a full picture of the affected colon is not achieved.
The entire large intestine can be examined using an X-Ray. A contrast solution of barium accompanied with some air is placed into the bowel with the help of an enema. Once the barium coats the entire lining of the colon, rectum and a part of the large intestine, it creates a silhouette. This is a dangerous test and hence rarely used because the pressure that is applied to inflate the colon and coat it may lead to its rupture.
An X-ray of the abdominal area can be done to rule out the possibility of toxic megacolon and perforation as these conditions may appear because of the severe symptoms.
This scan is carried out to check the extent of inflammation of the colon. The abdomen and pelvis are scanned if complications due to ulcerative colitis are observed or an inflamed small intestine that may be because of Crohn’s disease.
VIDEO CAPSULE ENDOSCOPY (VCE)
In this test, a patient swallows a capsule containing a camera which takes pictures of the intestine as it travels through it and sends them to a recorder wirelessly. The pictures can then be reviewed.
Chapter 5: TREATMENT
The treatment of ulcerative colitis is done on the basis of the severity of the disease. It mainly consists of changes in the diet and medication. If symptoms are found to be severe and long lasting, more medicines may be required or even surgery. But medicines cannot completely the disease. They can only minimize the risk of cancer, induce remissions and maintain them and improve the quality of life.
These are anti- inflammatory drugs that are used to induce and maintain remission. 5-aminosalicylic acid (5- ASA) produces the anti-inflammatory action. Examples of aminosalicylates are-
MESALAZINE: Also called Pentasa, Octasa and Asacol
SULFASALAZINE: This belongs to a class of antibiotics and it decomposed in the intestine to release 5-ASA.
Since this substance is not entirely absorbed by the intestine, it gives a topical relief.
These are often used with 5-ASA drugs to induce remission of ulcerative colitis. These work by the blocking the parts where leukocyte adhesion cascade occurs to induce inflammation. These have many side effects like the puffiness on the face, called “moon face”, and manic behavior. It may also cause bipolar disorder, inducing periods of elevated mood and depression.
Examples include Cortisone, Hydrocortisone, Prednisone.
- IMMUNOSUPPRESSIVE DRUGS
These inhibit the immune system. They stop cell division of white blood cells that occur as an immune response. Examples are: Mercaptopurine, Methotrexate, Azathioprine.
- DIET MODIFICATION
- Fresh fruit, carbonated drink and caffeine should be avoided by patients suffering from diarrhea and abdominal cramping.
- Some patients show lactose intolerance (they are not able to digest lactose) hence they can’t consume lactose. To supplement the bone loss, calcium is given to them.
- The gastrointestinal and auto-immune symptoms can be helped by using the Specific Carbohydrate Diet that allows only the use of monosaccharides and not the other carbohydrates.
- At times due to metabolic defects, Hydrogen Peroxide may build up underneath the membrane that usually protects the walls of the intestine from the bacteria that are present. To protect ourselves from these oxidants, a need to take antioxidants arises. These include vitamins A, E, C, Selenium and manganese.
While Kampo is a medicine that is used in Japan, Boswellia is and Ayurvedic medicine that can be used as an alternative to other drugs.
Medicinal cannabis can also be used as it helps reducing abdominal discomfort and abdominal irritability caused by ulcerative colitis.
Sometimes, parasites may help in the reduction of the immune response of the intestine. Whipworm may be used for this purpose. Reduction of immune response may help in the complete elimination of ulcerative colitis.
Colectomy is required to remove all or a part of the colon when it gets infected and begins to spread the infection to other parts.
It can be classified as follows:
TOTAL COLECTOMY: The entire colon is removed
PARTIAL COLECTOMY: The entire colon is not removed, but only a part of it is.
HEMICOLECTOMY: Removal of the left or right part of the colon
PROCTOCOLECTOMY: Removal of the colon as well as the rectum.
Once colectomy is performed, the remaining portions of the gastrointestinal tract are reattached in order to allow the waste to be eliminated from the body.