Inflammatory bowel disease
- Q. Does stress cause inflammatory bowel disease?
No. IBD (inflammatory bowel disease) is an inflammation of unknown cause but the majority of evidence does not point to stress as a cause.
Occasionally people with ulcerative colitis can link relapses to episodes of stress but mostly over time the general trend seems to be that most relapses occur without any obvious precipitating factor
Some possible triggers are a gastroenteritis infection and recent antbiotic use
- Q. If hospital admission is not required for a flare of colitis what changes to oral treatment will be effective??
Increasing the dose of 5-ASA medication (Pentasa or Asacol) is only of modest benefit.
This change alone is not usually be enough to resolve a relapse.
However any benefit of higher doses is achieved with only minimal risk of side-effects.
The usual maintenance dose can be increased from 4 to 6 tablets daily (for both Pentasa and Asacol). 8 tablets per day occasionally used.
If Salazaopyrin is the current treatment this can be increased from 4 to 6 tablets daily.
Even this dose increase will often result in headaches or gastrointestinal side-effects.
Most people can not tolerate 8 tabs per day because of some side-effects.
Most relapses will require a course of oral Prednisone.
The starting dose should be 40mg daily. Lower doses (10-20mg daily) are often not enough to induce remission. The dose should be decreased only when improvement is seen. This may take 2-3 weeks. Once symptoms have resolved there should then be a gradual reduction in dose. Total duration will usually be 4 - 8 weeks but depends on severity of relapse.
- Q. Is Crohn’s disease a more sever disease than ulcerative colitis??
Yes and No!
No. Both conditions have a highly variable course.
There is more uncertainty and perhaps fear of Crohn’s disease but the majority of patients with Crohn’s disease do achieve an excellent quality of life with a combination of medical and surgical treatment.
Yes. There is the potential for more complicated disease with Crohn’s disease.
The complications are more diverse and severe (compared to ulcerative colitis) because of the nature of the inflammation (intestinal obstruction, perforation and fistulae).
o Diffuse small bowel disease may have prominent abdominal pain, weight loss and nutritional deficiencies.
o Perianal disease may lead to abscess and fistulae leading to troublesome peri-anal pain and discharge. (see Crohn's disease).
- Q. Is proctitis different from colitis?
Proctitis is chronic inflammation (of the ulcerative colitis type) confined to the rectum.
That is, only the last few inches of the bowel are involved. Diarrhoea is generally not the problem. The main symptoms are bleeding, frequency and urgency of bowel motions and a feeling of incomplete emptying.
The treatment should concentrate on medication given through the anus. There are a variety of formulations available. The easiest (and most acceptable) method of delivering drug to the affected area is by suppositories (e.g. Asacol suppositories). Colifoam enemas are also convenient to use (foam in a pressurized container). Many people with proctitis alternate between these two types of medication or, by trial and error, find that one is better for them.
Taking tablets as well as per "rectal treatment" does have an additive benefit.
Usually this means a 5-ASA tablet like Asacol or Pentasa.
- Q. Should surgery for Crohn’s disease be delayed as long as possible??
Many people feel in retrospect that they waited too long before embarking on surgery.
If the symptoms due to a "blockage" then surgery is required - tablets will not work..
Surgery involves a resection of bowel but trying to maintain as much functional bowel as possible. Another option in some patients with short segments of diseased bowel is stricturoplasty. This is a refashioning process without removal of any bowel.
The chance of needing surgery in Crohn’s disease increases with time.
The risk is approximately 25% at 7 years and 50% at 15 years.
A symptomatic recurrence after the first operation occurs in 35 - 50% of patients after 5 years. Overall 20% will require a second operation (long-term follow-up information).
These figures are decreasing as medical treatment improves.
Recurrent disease can be observed well before symptoms arise if there is inspection of the bowel by colonoscopy and this can help plan further treatment with the hope of preventing further surgery.
Stopping smoking is crucial.
- Q. What drugs for IBD are safe in pregnancy?
What medications can be used during pregnancy?
Giving good advice to a pregnant patient with IBD involves balancing the risk of treatment with the risk of untreated disease. There is a large amount of data to support the continued use of 5-ASA and steroids (if required) during pregnancy. Azathioprine treatment can be continued during pregnancy if required to maintain remission. There is a large collective experience from mothers with renal transplants. Azathioprine does not cause birth defects. There is no increased risk of abortion and no decrease in fertility. There was some concern regarding fathers taking azathioprine. This came from one small study but other data is reassuring. Continuation of medication during pregnancy is usually the safest approach because of the greater risk to the fetus of uncontrolled disease activity.
- Q. What is the appropriate treatment for an acute flare of ulcerative colitis??
The immediate question to be resolved is the need for hospital admission.
This decision depends on severity of the colitis. This can easily be underestimated by both patient and Dr. Specialist assessment may be required.
A severe attack is suggested by the following features;
6 bowel motions /day and needing to get up at night to pass a bowel motion.
Abnormal blood tests.
Any significant abdominal pain or tenderness.
Hospital admission will usually be required with 2 or more of these features.
- Q. What is the role of diet??
The role of diet is surprisingly limited but nutritional deficiencies need to identified and treated. There are usually several factors leading to weight loss and nutritional deficiencies. Inadequate oral intake is often more important than failure of absorption.
Supplemental oral feeding with liquid diet (Ensure, Fortisip) may be helpful, particularly to enhance growth in children.
Some patients feel better with some dietary exclusions. e.g wheat-free or dairy-free diet or exclusion of specific vegetables/fruits - this is a non-specific effect.
An exclusion diet, similar to dietary advice given for irritable bowel, has been advocated by some doctors. For a well-motivated person keen to explore all natural options this has some value and some successes. Some of the benefit is because of an overlap between irritable bowel and inflammatory disease. This overlap is simply because irritable bowel is a common problem.