Advances in Inflammatory Bowel Disease
MADISON - If you're among the one to two million people in the United States with inflammatory bowel disease, you've probably heard it all.
Maybe you'd feel better if you weren't so stressed out… if you switched jobs… got more sleep… ate more sensibly.
And then there's the biggest misconception - It's all in your head.
In fact, Crohn's disease and ulcerative colitis - the two conditions that together are known as inflammatory bowel disease (IBD) - are systemic diseases, meaning that they can affect a person's entire body.
Characterized by chronic intestinal inflammation, or abnormality in the lining of the intestines, IBD is often confused with irritable bowel syndrome (IBS), which involves a constellation of bowel-related symptoms not caused by inflammation or tissue abnormalities.
At the seminar, UW Health gastroenterologists Mark Reichelderfer, MD
and Robert Judd, MD served on a panel of experts, along with University of Chicago School of Medicine associate professor of medicine Sunanda Kane, MD.
Addressing a group of IBD patients and their loved ones, Dr. Kane described some cases of IBS as the type of "butterflies in the stomach" that might cause an athlete to have diarrhea or nausea before a big game. But while IBS may be fleeting, inflammatory bowel disease is a chronic, lifelong disease for which there is no medical cure.
"That sounds pretty horrible, but you can say the same thing about diabetes, high blood pressure and asthma," says Dr. Kane. She added that though there's no known cure for Crohn's disease and ulcerative colitis, they are treatable conditions.
In fact, the outlook is improving for people with IBD. In the last decade, several medical and pharmaceutical advances have helped improve the quality of life for patients, and burgeoning research could lead to more breakthroughs. Several new drugs are on the cusp of FDA approval.
"There are many possibilities and options available today that were unheard of 25 years ago," said Jane Present, co-founder and executive director of the Foundation for Clinical Research in Inflammatory Bowel Disease.
Crohn's disease can affect any part of the digestive tract, from the mouth to the anus. It most frequently affects the lower part of the small intestine, called the ileum.
With Crohn's, the body mistakes normal bacteria in the intestines for foreign or invading substances, and the immune system launches an attack. The abnormal response causes symptoms that can dramatically change a Crohn's sufferer's life - from persistent diarrhea and abdominal cramps to fever and even rectal bleeding.
While Crohn's can strike anywhere in the digestive tract, ulcerative colitis only affects the colon. Symptoms differ depending on how much of the colon is inflamed, but may include urgency to evacuate and loss of appetite and weight. Because IBD is a systemic disease, symptoms may also include joint pain and swelling, eye inflammation and skin lesions.
The Spectrum of IBD Treatment
Crohn's disease and ulcerative colitis can broadly range in severity. Some patients may experience minimal symptoms every few years; others may have almost nonstop, severe symptoms.
Generally, the treatment approach is to start with mild medications to treat mild disease. With more severe disease cases, stronger medications are generally necessary, but they also tend to have more side effects.
Only a few types of medications were available prior to 1990 to treat Crohn's disease and ulcerative colitis. Since then, a dramatic increase both in the scope of research and medication development has opened up more treatment options than ever before for IBD patients.
With advances in both drug and surgical therapy, most people with IBD live normal, productive lives. But gastroenterology experts stress that it's important for patients to adhere to their drug therapies and maintenance medications, regardless of whether they believe their disease is in remission.
"You don't take insulin away from a diabetic just because their blood sugars are all under good control," says Dr. Kane. "It's the same thing for ulcerative colitis and Crohn's - if you're well, it's because you have been on medicine."
Treatment of inflammatory bowel disease involves a wide range of medications, as well as surgical options, nutrition therapy and emotional support. Goals include:
- Relieving symptoms; and achieving and maintaining remission (the absence of symptoms)
- Treating inflammation and complications
- Detecting cancer in early stages, including subtle "pre-cancer" warnings called dysplasia, which indicate that cancer is likely to develop
- Improving patients' daily functioning
- Replenishing nutritional deficits
IBD Drug Therapies
To achieve these goals, a range of drug therapies are available to treat IBD:
- Aminosalicylates:Sometimes called 5-ASAs, aminosalicylates are a group of medications that work against inflammation by releasing an anti-inflammatory medication inside the intestinal tract.
- Corticosteroids: These powerful and fast-acting anti-inflammatory drugs typically induce remission in Crohn's disease and ulcerative colitis patients, and they're generally viewed as a relatively inexpensive "quick fix" in this respect. However, corticosteroids offer no long-term benefits to IBD patients, so they're rarely used for maintenance therapy.
In addition, their toxicity can cause numerous undesirable side effects - from hypertension and diabetes to acne and depression. For these reasons, corticosteroids are usually given in the lowest possible dosage for the shortest amount of time, and much effort has been put into finding alternative therapies and educating patients and physicians about serious side effects associated with longer-term use.
- Antibiotics:Although helpful in treating mild symptoms of Crohn's disease, antibiotics generally are not considered useful for treating ulcerative colitis. Antibiotics tend to be used for longer periods, often several months at a time. The drugs may also be effective immediately after IBD-related surgery to decrease the risk of recurrence.
- Immunomodulators/immunosuppressants: These drugs act to suppress the excessive inflammatory characteristics of IBD. They can be highly effective in maintaining long-term remission in both Crohn's disease and ulcerative colitis patients, and they're often viewed as a "steroid-sparing" drug for both conditions. However, patients on immunomodulators must be monitored long-term, and side effects may include low white blood cell counts and kidney toxicity.
New IBD therapies have centered on a group of immunosuppressant drugs called biologics, which are proteins designed to reduce inflammation. Infliximab (Remicade®) is currently the most widely used biologic, but more drugs are being studied - including in clinical trials at UW.
Though Infliximab can be effective even when other therapies fail, it does carry risks - such as the potential development of rare infections, as well as antibodies which cause the patient to no longer respond to the drug.
"There's no question that being on these things long-term does carry some risks - weird infections can certainly result as a result of having your immune system suppressed," UW Health's Dr. Reichelderfer told patients at the IBD seminar. "But that also seems to be very uncommon."
"So, it's a constant, patient-by-patient balancing act," he adds. "If somebody has bad disease, and they're taking immunosuppressants to get their disease under control, then it's something that all of us feel fairly comfortable continuing long-term."
Advances in Surgical Therapy
Years ago, the only surgical option for ulcerative colitis patients was ileostomy, which involves removal of the entire colon and rectum. The surgeon would then create an opening on the abdomen through which wastes are emptied into a pouch attached to the skin with adhesives.
At UW Health, an IBD surgery group has been revolutionizing ulcerative colitis surgery since 1984. UW Health's Colon and Rectal Surgery Program offers a technique called Ileal Pouch Reconstruction
, which eliminates the need for a patient to wear a permanent external pouch. The procedure involves removing the colon, rectum and anal canal lining and using the end of the small bowel (ileum) to create a new rectum. When healing is complete, patients can go to the bathroom in a normal manner.
About 20 percent of people with ulcerative colitis will require surgery, which may also include colectomy (removal of the entire colon).
Crohn's disease can generate a number of problems that may require surgical treatment. Chronic inflammation can lead to scarring, which eventually leads to narrowing or "stricturing" of the intestine. No medication currently exists to reverse these strictures, but advances in Crohn's surgery are helping to conserve areas of obstructed small intestine that might otherwise be surgically removed.
Nutrition and IBD
Because IBD symptoms such as diarrhea can rob the body of essential nutrients, nutrition is often a concern for patients. Several patients at the "Advances in Inflammatory Bowel Disease" seminar posed questions about nutrition, but UW Health gastroenterologists Reichelderfer and Judd stressed that IBD patients generally don't need to greatly restrict their diets.
"I don't know of any foods that specifically make Crohn's disease or ulcerative colitis worse," says Dr. Judd. "Some people do seem to have more problems with some foods - it might be dairy products, it might be red meat. So I think if you have a specific problem with a food, you should just avoid that food."
If you know you have strictures or scar tissue, Dr. Judd says it makes sense to avoid high fibrous foods such as celery, popcorn, peanuts and leafy green vegetables.
"These are things that have a lot of fiber and might get stuck there," he explains. "But in general, I would encourage a broad range of foods and a generally nutritious diet."
And when patients experience IBD flare-ups, they should aim for a higher caloric intake than usual. "The more calories you can try and keep up with, the better," Dr. Judd says.
Though patients often take a host of supplements, Dr. Reichelderfer stresses that more clinical trials are necessary to determine their effectiveness.
"What we all agree on is multivitamins," he said, adding that ulcerative colitis patients should look for multivitamins containing folic acid.
Date Published: 01/10/2008