Inflammatory Bowel Disease

Inflammatory. Bowel. Disease. The name alone conjures up unpleasant and uncomfortable associations.  The disease it describes is a miserable.  Inflammatory Bowel Disease (“IBD”), is actually a group of three related conditions that affect the gastrointestinal tract:  Ulcerative Colitis, Crohn’s disease and less commonly, Pouchitis.    These conditions can really harm the quality of life of people who are afflicted with them.

IBD Conditions

Ulcerative Colitis

Ulcerative Colitis (“UC”) is a chronic disease of the lining of the colon (large intestine) that can affect people of any age but which is most commonly diagnosed in those who are in their mid-thirties.  Symptoms develop over time.  With the condition, the lining of the colon becomes inflamed and develops tiny open sores, or ulcers.  The ulcers produce mucous and pus and discomfort ensues.

According to the Mayo Clinic, the classifications of the types of UC are based on which particular symptoms the sufferer is experiencing. Symptoms may go and come over the course of the disease.

• Ulcerative proctitis. In this form of UC, inflammation is confined to the area right around the anus (rectum), and rectal bleeding may be its sole symptom. Other possible symptoms of this condition are: rectal pain, an urgent feeling of having to have a bowel movement or frequent, small bowel movements.
• Proctosigmoiditis. This form of UC affects the rectum and the lower end of the colon. Suffers often experience: bloody diarrhea, painful abdominal cramps, and an inability to move the bowels in spite of the feeling of needing to have a bowel movement.
• Left-sided colitis. In this form of UC, the area from the rectum through the sigmoid and descending colon (located in the upper left part of the abdomen) are inflamed. Symptoms of this condition include: bloody diarrhea, painful abdominal cramping of the left side of the abdomen and weight loss.
• Pancolitis. Often impacting up to the entire colon, this condition causes bouts of potentially serious bloody diarrhea, painful abdominal cramping, extreme tiredness and significant weight loss.
• Fulminant colitis. This is a rare, and potentially life threatening form of UC that affects the entire colon and causes extreme pain and voluminous diarrhea with the risk of resultant dehydration and shock.

In ulcerative colitis, the immune system mistakes friendly bacteria and food in the colon for dangerous invaders and attacks them.  In a normal colon, once the threat of the “foreign invader” is removed, the immune reaction stops.  But in UC, researchers are starting to believe the immune reaction continues and the resulting inflammation damages the colon and causes symptoms.

Crohn’s Disease

Crohn’s disease is a chronic inflammatory condition of the gastrointestinal tract.  Although it’s symptoms are similar to UC, the affected area is larger and it can impact the entire wall of the bowel, not just the innermost lining of the large intestine as in UC.  It may affect any part of the gastrointestinal tract, all the way from the mouth to the anus – but most commonly it affects the small intestine.  The most common symptoms of Crohn’s disease, which can range from mild to severe include:

• Diarrhea.  The inflammation causes cells in the diseased areas to discharge water and salt. As the colon can’t absorb it all, diarrhea ensues.
• Abdominal cramps and pain.  Over time, the inflammation and ulceration of the affected bowel walls start to swell and thicken with scar tissue. The scar tissue then can affect the normal movement of contents through the gastrointestinal tract, which can cause pain and cramping. In severe cases of Crohn’s, the extreme pain can even cause nausea.
• Rectal bleeding.  The blood may be bright red or darker and mixed with stool. Bleeding that is not noticeable (occult bleeding) is another possibility, and it can be detected in a stool sample.
• Urgent need to have a bowel movement
• Fecal incontinence
• Feeling that bowel movement was incomplete
• Sometimes constipation
• Ulcers. In addition to the ulcers within the gastrointestinal tract, ulcers throughout the body (including the mouth) are another potential symptom.

Pouchitis

This condition is a result of Ulcerative Colitis.  In those serious cases requiring surgical removal of the affected colon, the bowel is often surgically reconnected with a procedure known as an ileoanal anastomosis (IPAA).  In this procedure, surgeons create a small pouch from the small intestine that holds the waste before it is eliminated.

Pouchitis is the inflammation of the lining of this surgically created pouch and it occurs in about half of the patients who have undergone the IPAA.  Possible symptoms of Pouchitis include cramps, abdominal pain, increased frequency of bowel movement and urgent feeling of having to have a bowel movement.

Causes of IBD

Previously, IBD was blamed on stress and poor diet, but neither is now believed to be the cause (although certain foods may aggravate it).  Even after considerable research into IBD, doctors are not yet entirely certain what causes it. Currently there are two main theories.

The first is that IBD is an immune disorder triggered by a pathogen (either bacteria or virus) and the immune system then tries to fight it off.  Some doctors believe that the immune response may even be triggered in the absence of any pathogen but that the body mounts an immune attack against a pathogen that does not actually exist – a type of auto-immune disorder.  In both of these cases, it is the body’s abnormal immune response that creates the condition.

The second theory is that IBD is hereditary because there is some evidence that it runs in families.  However, this theory is undermined by the fact that the majority of IBD sufferers do not have close family members with the disease.

Research to date is more supportive of the abnormal immune response theory of the disease, but there seems to be an underlying genetic susceptibility to it as well.

Risk Factors for IBD

Typically IBD is diagnosed before age 30, but can be diagnosed as late as in one’s 60’s.  People of ethnicity can develop IBD, but it is more prevalent in Caucasians and Ashkenazi Jews.  Those living in northern or urban areas or in industrialized countries are also more likely to develop IBD than those who do not.

The most important, controllable risk factor for IBD is cigarette smoking.  Patients with IBD should strongly consider quitting smoking as it can exacerbate the disease.

Patients suffering from IBD are significantly more likely than the average person to have gut dysbiosis – an alteration of the number of friendly or unfriendly bacteria normally found living in the gut.  A study of 1500 Crohn’s disease patients found that they had a lower diversity of overall gut bacteria than did people unaffected by Crohn’s.   A study published in 2014 in the journal of Cell, Host and Microbe, and reported in NPR looked at the mix of gut bacteria in 447 Crohn’s disease patients versus 221 healthy people.  Researchers found that the Crohn’s sufferers had a greater number of gut bacteria that tend to excite the immune system and a lower percentage of bacteria that have calming effects on the immune system than were found in the healthy patients.

There are several short-term studies showing that probiotics can provide some benefit in IBD, although further study is required to determine which specific strains are most helpful.  Many patients report that taking probiotics or drinking kefir (a fermented milk food containing high numbers of beneficial yeasts and bacteria) has provided them with relief from IBD.

Complications of IBD

Having IBD can lead to some unpleasant and dangerous complications in addition to inflammation and ulcers of the digestive tract.

• Bowel obstruction. In Crohn’s disease parts of the bowel can thicken and narrow, which may block the flow of contents through the diseased portion of the digestive tract. Surgery to remove the diseased portion of the bowel may be required in severe cases.
• Fistulas. Sometimes ulcers can extend completely through the intestinal wall, creating a hole in the wall called a fistula. With an internal fistula, food may bypass areas of the bowel that digest or absorb nutrition from food. Externally, a fistula can cause drainage of bowel contents to your skin. If a fistula becomes infected it may form an abscess, which is very serious.
• Malnutrition and Anemia. Some symptoms of IBD (diarrhea, abdominal pain and cramping) may affect appetite or make it difficult for your body to absorb sufficient nutrients to keep you healthy.
• Colon cancer. IBD that affects the colon increases the risk of colon cancer.
• Other potential complications: arthritis, eye, skin or bile duct inflammation, kidney stones and gallstones. Osteoporosis may arise in patients with long-standing IBD.

Traditional Treatment

Much of the traditional medical management of the disease is aimed at regulating the immune reaction.  Traditional treatments include medications to reduce inflammation, drugs to suppress the immune system and a restricted diet to avoid particular foods that aggravate the IBD.

Antibiotics may be prescribed to heal any fistulas or abscess that have arisen or in an attempt to reduce any pathogenic bacteria that might be triggering the immune response.  Antibiotic treatment, however, can increase the gut dysbiosis (mix of healthy versus harmful bacteria) in Crohn’s disease, at least in children that were studied in a study published in 20141. Gut dysbiosis may further irritate the IBD or lead to other health problems.

Steroids may be prescribed to Crohn’s patients, to reduce inflammation.  The powerful steroids that are used can have significant side effects, however.

As appetite is reduced with this condition and nutrients are lost through diarrhea, it is important to ensure a nutritious and well-balanced diet.

In extreme cases where none of the treatment options have been successful, surgical removal of the entire colon is a last-resort option for UC.  For Crohn’s disease, surgery may be necessary to remove diseased portions of the gastrointestinal tract, or to close fistulas or drain abscesses.

People who have or have had IBD must be monitored on an ongoing basis for colon cancer due to the increased risk.

Probiotics

Probiotic supplementation may be helpful for people suffering from IBD.  As mentioned earlier, many of people with IBD have been shown to have dysbiosis – an alteration to the normal, healthy mix of gut bacteria.  Medical researchers who have looked at this issue are starting to think that antibiotics should be avoided, if possible, in patients with IBD, due to the fact that they can increase this gut dysbiosis.  Probiotic-containing foods (such as kefir and other fermented foods) or good-quality probiotic supplements can alter and improve the gut microbiome (mix of microbes in the gut).

NPR reports that Dr. Ramni Xavier, the lead researcher on the 2014 study on gut bacteria in Crohn’s patients, field believe drugs that mimic properties of probiotics are where future research needs to focus. Several studies have shown the benefits of a variety of probiotics for IBD, particularly for Pouchitis and UC. Unfortunately, the current findings for Crohn’s disease and probiotics have yet to show results that are as promising.

IBD is a disease of inflammation.  Probiotics have the ability to reduce inflammation in the body as a whole and to reduce the inflammatory response in the lining of the gut in particular. They can improve the barrier function of the lining of the gut.  The barrier function of the gut is what keeps the contents in the gastrointestinal tract separate from the rest of the body. Should any of the contents of the gut enter the body, they could trigger or exacerbate an inflammatory condition elsewhere in the body. The ability of certain types of probiotics to reduce gastrointestinal inflammation and to strengthen the lining of the gut suggests that they should be extensively studied as a potential treatment for IBD.

Ulcerative Colitis (UC)

A systematic review of the controlled trials performed on UC and probiotics has shown that Escherichia coli, Saccharomyces boulardii2, and Lactobacillus reuterii (administered by enema)3 have been effective at maintaining remission in UC and in treating mild to moderate disease.

Pouchitis

Lactobacilli and bifidobacteria (two very common, beneficial bacteria that are typically found in the gut) are present in lower percentages in pouchitis patients than they are in patients without the disorder. Double blind, placebo controlled studies have verified that probiotics are effective at preventing and significantly controlling Pouchitis.  The probiotic studied was VSL#3, which is a medical food that requires a prescription to buy and, according to its manufacturer, should be taken only under medical supervision, given the large numbers of active bacteria that it contains.

Crohn’s Disease

The current medical theory behind the disease is that it is bacterial imbalances, in genetically susceptible people, that cause the inflammation that is characteristic of Crohn’s. As mentioned above, patients with Crohn’s often have too many bacteria in their guts that excite the immune system and too few that calm it.

Studies to date with probiotics and Crohn’s have been underwhelming.  The bulk of them did not show significant improvement with the probiotics.  However, one small study that examined five UC patients and 15 Crohn’s patients and twenty control subjects was encouraging.  Each was given yogurt containing Lactobacillus rhamnosus GR-1 and L. reuteri RC-14 daily.  The patients had significantly decreased inflammation at the end of the study.

Unfortunately, in the few studies that have been done do date with Crohn’s, it does not seem like the research community has identified the particular bacteria or mix of bacteria that can be helpful in calming the inflammation and crowding out the bad bacteria that are triggering the condition.    Nonetheless, Crohn’s disease specialist Dr. Xavier suggests that a sort of “super probiotic” may be discovered that could have beneficial effects in Crohn’s disease (and by extension with the other conditions of IBD).  There are some large, controlled studies that are currently underway to further research this issue.

The research that has been done seems to indicate that the beneficial effects of probiotics on each of the IBD conditions appear to be strain specific i.e. only particular subspecies of bacteria will provide benefit for the particular type of IBD is being treated.  As there are literally thousands of types of friendly bacteria that may reside within the gut, this means that the many more studies may need to be done before the medical community knows precisely which probiotic strains, if any, can provide the most benefit to the particular IBD condition that is trying to be improved.

1. Dirk Gevers, Subra Kugathasan, Lee A. Denson, Yoshiki Vázquez-Baeza, Will Van Treuren, Boyu Ren, Emma Schwager, Dan Knights, Se Jin Song, Moran Yassour, Xochitl C. Morgan, Aleksandar D. Kostic, Chengwei Luo, Antonio González, Daniel McDonald, Yael Haberman, Thomas Walters, Susan Baker, Joel Rosh, Michael Stephens, Melvin Heyman, James Markowitz, Robert Baldassano, Anne Griffiths, Francisco Sylvester, David Mack, Sandra Kim, Wallace Crandall, Jeffrey Hyams, Curtis Huttenhower, Rob Knight, Ramnik J. Xavier. The treatment-naive microbiome in new onset Crohn’s Disease. Cell Host & Microbe, March 2014 DOI: 10.1016/j.chom.2014.02.005 [↩]
2. Jonkers D, Penders J, Masclee A, Pierik M. Probiotics in the management of inflammatory bowel disease: a systematic review of intervention studies in adult patients. Drugs. 2012;72:803-23. [↩]
3. Oliva S, Di Nardo G, Ferrari F et al., Randomised clinical trial: the effectiveness of Lactobacillus reuteri ATCC 55730 rectal enema in children with active distal ulcerative colitis. Aliment Pharmacol Ther. 2012;35:327-34 [↩]