Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is an umbrella term used to describe disorders that involve chronic inflammation of your digestive tract.

Types of IBD include:

• Ulcerative colitis. This condition causes long-lasting inflammation and sores (ulcers) in the innermost lining of the large intestine (colon) and rectum.
• Crohn's disease. This type of IBD is characterized by inflammation in any part of the gastrointestinal tract from the mouth to the anus of the lining of the digestive tract, which often spreads deep into affected tissues. Most commonly, though, it affects the last part of the small intestine or the colon or both.

Both ulcerative colitis and Crohn's disease usually involve severe diarrhea, abdominal pain, fatigue and weight loss.

IBD can be debilitating and sometimes leads to life-threatening complications.

Symptoms

Inflammatory bowel disease symptoms vary, depending on the severity of inflammation and where it occurs.

• Symptoms may range from mild to severe. You are likely to have periods of active illness followed by periods of remission.
• Signs and symptoms that are common to both Crohn's disease and ulcerative colitis include:
  • Diarrhea
  • Fever and fatigue
  • Abdominal pain and cramping
  • Blood in your stool
  • Reduced appetite
  • Unintended weight loss
• If you have an IBD, you know it usually runs a waxing and waning course. When there is severe inflammation, the disease is considered active and the person experiences a flare-up of symptoms. When there is less or no inflammation, the person usually is without symptoms and the disease is said to be in remission.

Causes

• The exact cause of inflammatory bowel disease remains unknown. Previously, diet and stress were suspected, but now doctors know that these factors may aggravate but don't cause IBD.
• One possible cause is an immune system malfunction (autoimmune disease). When your immune system tries to fight off an invading virus or bacterium, an abnormal immune response causes the immune system to attack the cells in the digestive tract, resulting in an inflammation that leads to bowel injury. However, most people with IBD don't have this family history.
• Heredity also seems to play a role in that IBD is more common in people who have family members with the disease.

Risk factors

• Age. Most people who develop IBD are diagnosed before they're 30 years old. But some people don't develop the disease until their 50s or 60s.
• Race or ethnicity. Although whites have the highest risk of the disease, it can occur in any race. If you're of Ashkenazi Jewish descent, your risk is even higher.
• Family history. You're at higher risk if you have a close relative — such as a parent, sibling or child — with the disease.
• Cigarette smoking. Cigarette smoking is the most important controllable risk factor for developing Crohn's disease. Although smoking may provide some protection against ulcerative colitis, the overall health benefits of not smoking make it important to try to quit.
• Nonsteroidal anti-inflammatory medications. These include ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve), diclofenac sodium (Voltaren) and others. These medications may increase the risk of developing IBD or worsen disease in people who have IBD.
• Where you live. If you live in an industrialized country, you're more likely to develop IBD. Therefore, it may be that environmental factors, including a diet high in fat or refined foods, play a role. People living in northern climates also seem to be at greater risk.

Complications

Ulcerative colitis and Crohn's disease have some complications in common and others that are specific to each condition. Complications found in both conditions may include:

• Colon cancer. Having IBD increases your risk of colon cancer. General colon cancer screening guidelines for people without IBD call for a colonoscopy every 10 years beginning at age 50. Ask your doctor whether you need to have this test done sooner and more frequently.
• Skin, eye and joint inflammation. Certain disorders, including arthritis, skin lesions and eye inflammation (uveitis), may occur during IBD flare-ups.
• Medication side effects. Certain medications for IBD are associated with a small risk of developing certain cancers. Corticosteroids can be associated with a risk of osteoporosis, high blood pressure and other conditions.
• Primary sclerosing cholangitis. In this condition, inflammation causes scars within the bile ducts, eventually making them narrow and gradually causing liver damage.
• Blood clots. IBD increases the risk of blood clots in veins and arteries.

Complications of Crohn's disease may include:

• Bowel obstruction. Crohn's disease affects the full thickness of the intestinal wall. Over time, parts of the bowel can thicken and narrow, which may block the flow of digestive contents. You may require surgery to remove the diseased portion of your bowel.
• Malnutrition. Diarrhea, abdominal pain and cramping may make it difficult for you to eat or for your intestine to absorb enough nutrients to keep you nourished. It's also common to develop anemia due to low iron or vitamin B12 caused by the disease.
• Ulcers. Chronic inflammation can lead to open sores (ulcers) anywhere in your digestive tract, including your mouth and anus, and in the genital area (perineum).
• Fistulas. Sometimes ulcers can extend completely through the intestinal wall, creating a fistula — an abnormal connection between different body parts. Fistulas near or around the anal area (perianal) are the most common kind. In some cases, a fistula may become infected and form an abscess.
• Anal fissure. This is a small tear in the tissue that lines the anus or in the skin around the anus where infections can occur. It's often associated with painful bowel movements and may lead to a perianal fistula.

Complications of Ulcerative colitis may include:

• Toxic megacolon. Ulcerative colitis may cause the colon to rapidly widen and swell, a serious condition known as toxic megacolon.
• A hole in the colon (perforated colon). A perforated colon most commonly is caused by toxic megacolon, but it may also occur on its own.
• Severe dehydration. Excessive diarrhea can result in dehydration.

Diagnosis

One or more of the following tests and procedures may be necessary:

* Blood tests

• * Tests for anemia or infection. Your doctor may suggest blood tests to check for anemia — a condition in which there aren't enough red blood cells to carry adequate oxygen to your tissues — or to check for signs of infection from bacteria or viruses.
  • Fecal occult blood test. You may need to provide a stool sample so that your doctor can test for hidden blood in your stool.
• Endoscopic procedures
  • Colonoscopy. This exam allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis. Sometimes a tissue sample can help confirm a diagnosis.
  • Flexible sigmoidoscopy. Your doctor uses a slender, flexible, lighted tube to examine the rectum and sigmoid, the last portion of your colon. If your colon is severely inflamed, your doctor may perform this test instead of a full colonoscopy.
  • Upper endoscopy. In this procedure, your doctor uses a slender, flexible, lighted tube to examine the esophagus, stomach and first part of the small intestine (duodenum). While it is rare for these areas to be involved with Crohn's disease, this test may be recommended if you are having nausea and vomiting, difficulty eating or upper abdominal pain.
  • Capsule endoscopy. This test is sometimes used to help diagnose Crohn's disease involving your small intestine. You swallow a capsule that has a camera in it. The images are transmitted to a recorder you wear on your belt, after which the capsule exits your body painlessly in your stool. You may still need an endoscopy with a biopsy to confirm a diagnosis of Crohn's disease.
  • Balloon-assisted enteroscopy. For this test, a scope is used in conjunction with a device called an overtube. This enables the doctor to look further into the small bowel where standard endoscopes don't reach. This technique is useful when a capsule endoscopy shows abnormalities, but the diagnosis is still in question.
• Imaging procedures
  • X-ray. If you have severe symptoms, your doctor may use a standard X-ray of your abdominal area to rule out serious complications, such as a perforated colon.
  • Computerized tomography (CT) scan. You may have a CT scan — a special X-ray technique that provides more detail than a standard X-ray does. This test looks at the entire bowel as well as at tissues outside the bowel. CT enterography is a special CT scan that provides better images of the small bowel. This test has replaced barium X-rays in many medical centers.
  • Magnetic resonance imaging (MRI). An MRI scanner uses a magnetic field and radio waves to create detailed images of organs and tissues. An MRI is particularly useful for evaluating a fistula around the anal area (pelvic MRI) or the small intestine (MR enterography). Unlike a CT, there is no radiation exposure with an MRI.

Statistics & Mortality

• We included 16,550 IBD cases with 1047 deaths and 82,917 controls with 3758 deaths. The mortality rate was 17.1 per 1000 person-years overall for IBD cases and 12.3 for controls; this difference was greatest in the elderly. Conversion of these figures to hazard ratios by Cox regression gave hazard ratios of 1.54 (1.44-1.65) for all IBD, 1.44 (1.31-1.58) for ulcerative colitis (UC), and 1.73 (1.54-1.96) for Crohn's disease. The greatest hazard ratio for UC was among the 40-59-year age group (1.79 [1.42-2.27]%29 and for Crohn's disease among 20-39-year-olds (3.82 [2.17-6.75]). (From: NCBI - Mortality in inflammatory bowel disease: a population-based cohort study. Gastorenterology, 2003 Dec; 123(6): 1583-90. By: T Card, R Hubbard, RF Logan)
• The standardized mortality ratio for inflammatory bowel disease (IBD) ranges from approximately 1.4 times the general population (Sweden) to 5 times the general population (Spain). Most of this increase appears to be in the Crohn disease population; the ulcerative colitis population appears to have the same mortality rate as the general population. (From: Medscape – What is the mortality rate for inflammatory bowel disease (IBD)? By: William A Rowe, MD. Updated 17 Oct 2017)
• People with IBD do have a greater risk of death than the general population (people that do not have IBD). There are a great many reasons someone with IBD might die: complications from surgery, a reaction to the medication, developing a serious related condition (such as liver disease or toxic megacolon), or from a completely unrelated condition.
• Overall, the IBDs are not generally fatal conditions, but they are serious diseases. While death from IBD is uncommon, it is still important to seek treatment and develop an overall healthy lifestyle.
  • People living with Crohn's disease and ulcerative colitis are particularly susceptible to complications, and the first year of diagnosis and the year after surgery are vulnerable times.
• While the onset of inflammatory bowel disease (ulcerative colitis or Crohn's disease) in adulthood is tied to a higher mortality, the actual number of deaths has been falling, a Swedish study from Karolinska Institutet published in the journal Gut reports.

Resources & Additional Reading

• Mayo Clinic – Inflammatory bowel disease (IBD) – Overview
• Mayo Clinic – Inflammatory bowel disease (IBD) – Diagnosis & treatment
• WebMD – Inflammatory Bowel Disease
• Verywell Health – Can Inflammatory Bowel Disease Be Fatal? By: Amber J Tresca; Medically reviewed by Doru Paul, MD; Updated 15 Nov 2019
• MedicalXpress – Adult-onset IBD linked to higher mortality. By Karolinska Institutet. 17 May 2019