• Dr. Jim Waller

INFLAMMATORY BOWEL DISEASE

THE TERM INFLAMMATORY BOWEL DISEASE REFERS TO TWO DISEASES; ULCERATIVE COLITITIS AND CROHN'S DISEASE.THESE DISEASES CAUSE INFLAMMATION OF THE BOWEL. THE CAUSE OF EACH REMAINS UNKNOWN, THOUGH THERE IS INCREASING EVIDENCE THAT THEY MAY BE RELATED TO COMPLEX INTERACTIONS BETWEEN THE BACTERIA OF THE GUT WITH DIET, ANTIBIOTICS, AND OTHER INTERNAL OR EXTERNAL FACTORS. BOTH DISEASES CAUSE NON-SPECIFIC INFLAMMATION OF THE GI TRACK. THIS RESULTS IN SYMPTOMS WHICH ARE COMMON TO BOTH DISEASES.


ULCERATIVE COLITIS ( UC ) INVOLVES ONLY THE COLON WITH THE INFLAMMATION LIMITED TO THE MUCOSA ( INTERNAL LINING ) . THE DISEASE IS ALSO CONTINUOUS, BEGINNING IN THE LOWER RECTUM WITH EXTENSION ANYWHERE FROM ONLY A FEW INCHES TO INVOLVEMENT OF THE ENTIRE COLON. THERE ARE NO SKIP AREAS. CROHN'S DISEASE ( CD ), IN CONTRAST, CAN INVOLVE ANY PORTION OF THE GI TRACK FROM THE MOUTH TO THE ANUS, AND CAN CAUSE FULL THICKNESS INFLAMMATION OF THE BOWEL WALL. SKIP AREAS ARE ALSO COMMON. THIS DISEASE OFTEN PRESENTS WITH INVOLVEMENT OF THE LAST PORTION OF THE SMALL BOWEL ( TERMINAL ILEUM ) AND THE RIGHT SIDE OF THE COLON IN THE AREA OF THE APPENDIX.


THE SYMPTOMS ARE SIMILAR IN BOTH DISEASES AND CONSIST OF CHANGES IN BOWEL PATTERN WITH LOOSE STOOL, URGENCY TO HAVE A BOWEL MOVEMENT, CRAMPING, BLEEDING, ABDOMINAL TENDERNESS, AND ANORECTAL DISCOMFORT IN PATIENTS WITH WITH ABCESSES, FISTULAE AND FISSURES. IN LONGSTANDING CASES WITH PROLONGED SYMPTOMS AND LACK OF ADEQUATE DIETARY INTAKE PATIENTS CAN DEVELOP SEVERE WEIGHT LOSS AND BECOME MALNOURISHED.


EVALUATION OF PATIENTS BEGINS WITH A THOROUGH HISTORY AND PHYSICAL EXAM FOLLOWED BY TESTING WHICH CAN INCLUDE BLOOD WORK LOOKING FOR MARKERS FOUND WITH INFLAMMATORY BOWEL DISEASE. ALMOST ALL PATIENTS WILL REQUIRE EXAMINATION OF THE GI TRACT WITH DIRECT OBSERVATION AND BIOPSIES. THIS WILL INCLUDE COLONOSCOPY AND SOMETIMES UPPER ENDOSCOPY AND CAPSULE ENDOSCOPY. IT IS IMPORTANT TO DETERMINE THE EXTENT AND SEVERITY OF THE DISEASE TO GUIDE MEDICAL AND SURGICAL TREATMENT IN THOSE PATIENTS WHERE SURGERY IS NEEDED. IT IS ALSO IMPORTANT TO RULE OUT OTHER CAUSES OF INFLAMMATION SUCH AS INFECTIONS, IRRITABLE BOWEL, MEDICATION EFFECTS INCLUDING ANTIBIOTICS, AND TUMORS...BOTH BENIGN AND MALIGNANT.


IN ADDITION TO THE SYMPTOMS CAUSED BY THE INFLAMMATION, APPROXIMATELY 20% OF PATIENTS MAY EXPERIENCE WHAT ARE CALLED EXTRA-INTESTINAL PROBLEMS SUCH AS DERMATITIS, ARTHRITIS, AND INFLAMMATION IN OTHER PARTS OF THE BODY.


TREATMENT FALLS INTO TWO GENERAL CATEGORIES; MEDICAL AND SURGICAL. THE VAST MAJORITY OF PATIENTS ARE STARTED ON MEDICAL THERAPY AND CAN BE SUCCESSFULLY CONTROLLED WITH THE USE OF MEDICATIONS.


MEDICATIONS USED TO BRING THE SYMPTOMS UNDER CONTROL FALL INTO SEVERAL CATEGORIES;

1) STEROIDS

2) AMINOSALICYLATES ( ANTI-INFLAMMATORY ), WHICH CAN BE USED BOTH ORALLY AND RECTALLY.

3) IMMUNOSUPPRESANTS

4) MONOCLONAL ANTIBODY THERAPY ( INFLIXIMAB, ADALIMUMAB )

5) ANTIBIOTICS ( CIPRO, FLAGYL )


THESE MEDICATIONS WORK IN DIFFERENT WAYS TO DECREASE THE INFLAMMATION BEING CAUSED BY THE DISEASE, WITH ANTIBIOTICS SOMETIMES USED FOR TREATMENT OF ANORECTAL DISEASE.


WHEN MEDICAL THERAPY FAILS TO CONTROL THE DISEASE, WITH DEVELOPMENT OF COMPLICATIONS OR CHRONIC DEBILITATING SYMPTOMS, SURGICAL THERAPY IS INDICATED. THE SURGICAL THERAPY IS VERY DIFFERENT FOR THE TWO DISEASES. WITH UC, REMOVAL OF THE COLON IS CURATIVE. THIS CAN BE ACCOMPLISHED BY REMOVING THE ENTIRE COLON AND RECTUM WITH CREATION OF AN ILEOSTOMY, OR AS IS DONE MORE COMMONLY IN THE LAST 30 YEARS, REMOVAL OF THE ENTIRE COLON AND RECTUM WITH CREATION OF A 'J' POUCH FROM THE SMALL BOWEL TO SERVE AS AN ARTIFICIAL RECTUM.

CROHN'S DISEASE IN CONTRAST IS NOT CURATIVE BY SURGICAL REMOVAL, AS 40% OR MORE OF PATIENTS WILL EVENTUALLY DEVELOP RECURRENT DISEASE. FOR THIS REASON IN CROHN'S PATIENTS REQUIRING SURGERY, ONLY THE INVOLVED SEGMENTS OF SMALL BOWEL OR COLON ARE REMOVED. MOST PATIENTS ARE THEN CONTINUED ON LONG TERM MEDICAL THERAPY.


IN SUMMARY, INFLAMMATORY BOWEL DISEASE IS A CHRONIC INFLAMMATORY DISEASE OF THE BOWEL OF UNCERTAIN CAUSE. IN MOST PATIENTS IT CAN BE MANAGED BY MEDICAL THERAPY WITH SURGERY LIMITED TO THOSE WHO DEVELOP SURGICAL COMPLICATIONS OR INTRACTABLE DISEASE. SURGERY IS CURATIVE WITH ULCERATIVE COLITIS IN CONTRAST WITH CROHN'S DISEASE WHERE RECURRENCES ARE COMMON.





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