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Inflammatory bowel disease (IBD)

Inflammatory bowel disease (IBD) involves chronic inflammation of all or part of your digestive tract. IBD primarily includes ulcerative colitis and Crohn’s disease. IBD can be painful and debilitating, and sometimes leads to life-threatening complications.

Ulcerative colitis (UL-sur-uh-tiv koe-LIE-tis) is an inflammatory bowel disease that causes long-lasting inflammation in part of your digestive tract. Symptoms usually develop over time, rather than suddenly. Ulcerative colitis usually affects only the innermost lining of your large intestine (colon) and rectum. It occurs only through continuous stretches of your colon.

Crohn’s disease is an inflammatory bowel disease that causes inflammation anywhere along the lining of your digestive tract, and often spreads deep into affected tissues. This can lead to abdominal pain, severe diarrhea and even malnutrition. The inflammation caused by Crohn’s disease can involve different areas of the digestive tract in different people.

Collagenous colitis (kuh-LAJ-uh-nus) and lymphocytic colitis also are considered inflammatory bowel diseases, but are usually regarded separately from classic inflammatory bowel disease.

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

Ulcerative colitis symptoms

Ulcerative colitis is classified according to its signs and symptoms:

  • Ulcerative proctitis. In this form of ulcerative colitis, inflammation is confined to the area closest to the anus (rectum), and for some people, rectal bleeding may be the only sign of the disease. Others may have rectal pain, a feeling of urgency or have frequent, small bowel movements. This form of ulcerative colitis tends to be the mildest.
  • Proctosigmoiditis. This form involves the rectum and the lower end of the colon, known as the sigmoid colon. Bloody diarrhea, abdominal cramps and pain, and an inability to move the bowels in spite of the urge to do so (tenesmus) are common problems associated with this form of the disease.
  • Left-sided colitis. As the name suggests, inflammation extends from the rectum up through the sigmoid and descending colon, which are located in the upper left part of the abdomen. Signs and symptoms include bloody diarrhea, abdominal cramping and pain on the left side, and unintended weight loss.
  • Pancolitis. Affecting more than the left colon and often the entire colon, pancolitis causes bouts of bloody diarrhea that may be severe, abdominal cramps and pain, fatigue, and significant weight loss.
  • Fulminant colitis. This rare, life-threatening form of colitis affects the entire colon and causes severe pain, profuse diarrhea and, sometimes, dehydration and shock. People with fulminant colitis are at risk of serious complications, including colon rupture and toxic megacolon, a condition that causes the colon to rapidly expand.

The course of ulcerative colitis varies, with periods of acute illness often alternating with periods of remission. Most people with a milder condition, such as ulcerative proctitis, won’t go on to develop more-severe signs and symptoms.

Crohn’s disease symptoms

Inflammation of Crohn’s disease may involve different parts of the digestive tract in different people. The most common areas affected by Crohn’s disease are the last part of the small intestine called the ileum and the colon. Inflammation may be confined to the bowel wall, which can lead to scarring (stenosis), or inflammation may spread through the bowel wall (fistula).

Signs and symptoms of Crohn’s disease can range from mild to severe and may develop gradually or come on suddenly, without warning. Signs and symptoms may include:

  • Diarrhea. The inflammation that occurs in Crohn’s disease causes cells in the affected areas of your intestine to secrete large amounts of water and salt. Because the colon can’t completely absorb this excess fluid, you develop diarrhea. Intensified intestinal cramping also can contribute to loose stools. Diarrhea is a common problem for people with Crohn’s.
  • Abdominal pain and cramping. Inflammation and ulceration may cause the walls of portions of your bowel to swell and eventually thicken with scar tissue. This affects the normal movement of contents through your digestive tract and may lead to pain and cramping. Mild Crohn’s disease usually causes slight to moderate intestinal discomfort, but in more-serious cases, the pain may be severe and include nausea and vomiting.
  • Blood in your stool. Food moving through your digestive tract may cause inflamed tissue to bleed, or your bowel may also bleed on its own. You might notice bright red blood in the toilet bowl or darker blood mixed with your stool. You can also have bleeding you don’t see (occult blood).
  • Ulcers. Crohn’s disease and ulcerative colitis can cause small sores on the surface of the intestine that eventually become large ulcers that penetrate deep into — and sometimes through — the intestinal walls. You may also have ulcers elsewhere, including in your mouth similar to canker sores.
  • Reduced appetite and weight loss. Abdominal pain and cramping and inflammation of your bowel wall can affect both your appetite and your ability to digest and absorb food.

People with severe Crohn’s disease may also experience:

  • Fever
  • Fatigue
  • Arthritis
  • Eye inflammation
  • Skin disorders
  • Inflammation of the liver or bile ducts
  • Delayed growth or sexual development, in children

When to see a doctor

See your doctor if you experience a persistent change in your bowel habits or if you have any of the signs and symptoms of inflammatory bowel disease. Although inflammatory bowel disease usually isn’t fatal, it’s a serious disease that, in some cases, may cause life-threatening complications.

No one is quite sure what triggers inflammatory bowel disease, but there’s a consensus as to what doesn’t. Researchers no longer believe that diet and stress are main causes, although stress can often aggravate symptoms. Instead, current thinking focuses on the:

  • Immune system. Some scientists think a virus or bacterium may trigger IBD. The digestive tract becomes inflamed when your immune system tries to fight off the invading microorganism (pathogen). It’s also possible that inflammation may stem from an autoimmune reaction in which your body mounts an immune response even though no pathogen is present.
  • Heredity. Because you’re more likely to develop IBD if you have a parent or sibling with the disease, scientists suspect that genetic makeup may play a role. However, most people who have IBD don’t have a family history of the disorder.
Inflammatory bowel disease affects about the same number of women and men. Risk factors may include:

  • Age. Inflammatory bowel disease usually begins before the age of 30. But, it can occur at any age, and some people may not develop the disease until their 50s or 60s.
  • Ethnicity. Although whites have the highest risk of the disease, it can occur in any ethnic group. 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.
  • Isotretinoin use. Isotretinoin is a medication sometimes used to treat scarring cystic acne or acne that doesn’t respond to other treatments. It used to be sold under the brand name Accutane, but that brand has been discontinued, and it’s now sold under the brand names Amnesteem, Claravis and Sotret.There is conflicting information as to whether isotretinoin use can increase the risk of inflammatory bowel disease. Some studies have suggested a possible link, while other studies have found no such evidence. The question of whether or not there is a link is further complicated by research that suggests a possible connection between the use of tetracycline class antibiotics and the development of IBD. Many people who have been treated with isotretinoin for acne also have received tetracyclines as part of their acne therapy. Studies that have examined the possible link between isotretinoin and IBD have not addressed the question of whether antibiotics used for acne may have played a role in increasing risk.
  • Cigarette smoking. Cigarette smoking is the most important controllable risk factor for developing Crohn’s disease. It leads to more-severe symptoms and higher risk of complications. If you smoke, stop. Discuss this with your doctor and get help. There are many smoking cessation programs available if you are unable to quit on your own.
  • Some pain relievers. These medications include ibuprofen (Advil, Motrin, others), naproxen (Aleve) and aspirin. These medications have been shown to cause gastrointestinal ulceration and may make existing IBD worse. Acetaminophen (Tylenol, others) does not have this effect. Discuss the use of any pain medication with your doctor.
  • Where you live. If you live in an urban area or in an industrialized country, you’re more likely to develop IBD. Because Crohn’s disease occurs more often among people living in cities and industrial nations, it may be that environmental factors, including a diet high in fat or refined foods, play a role in IBD. People living in northern climates also seem to have a greater risk of the disease.
Inflammatory bowel disease may lead to one or more of the following complications:

  • Bowel obstruction.Crohn’s disease affects the entire thickness of the intestinal wall. Over time, parts of the bowel can thicken and narrow, which may block the flow of digestive contents through the affected part of your intestine. Some cases require surgery to remove the diseased portion of your bowel.
  • 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) and anus. Bleeding may result.
  • Fistulas. Sometimes ulcers can extend completely through the intestinal wall, creating a fistula. A fistula is an abnormal connection between different parts of your intestine, between your intestine and skin, or between your intestine and another organ, such as the bladder or vagina. When internal fistulas develop, food may bypass areas of the bowel that are necessary for absorption. An external fistula can cause continuous drainage of bowel contents to your skin, and in some cases, a fistula may become infected and form an abscess, a problem that can be life-threatening if left untreated. Fistulas around the anal area (perianal) are the most common kind of fistula.
  • Anal fissure. This is a crack, or cleft, in the anus or in the skin around the anus where infections can occur. It’s often associated with painful bowel movements. This may lead to a perianal fistula.
  • 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. Additionally, anemia is common in people with IBD.
  • Colon cancer. Having IBD disease that affects your colon increases your risk of colon cancer.
  • Other health problems. In addition to inflammation and ulcers in the digestive tract, IBD can cause problems in other parts of the body, such as arthritis, inflammation of the eyes or skin, clubbing of the fingernails, kidney stones, gallstones, and, occasionally, inflammation of the bile ducts. People with long-standing IBD also may develop osteoporosis, a condition that causes weak, brittle bones.
Your doctor will likely diagnose inflammatory bowel disease only after ruling out other possible causes for your signs and symptoms, including ischemic colitis, infection, irritable bowel syndrome (IBS), diverticulitis and colon cancer. To help confirm a diagnosis of IBD, you may have one or more of the following tests and procedures:

  • Blood tests. Your doctor may suggest blood tests to check for anemia or infection. Tests that look for the presence of certain antibodies can sometimes help diagnose which type of inflammatory bowel disease you have, but these tests can’t definitely make the diagnosis.
  • Stool sample. The presence of white blood cells in your stool indicates an inflammatory disease, possibly IBD. A stool sample can also help rule out other disorders, such as those caused by bacteria, viruses and parasites. Your doctor can also check for a bowel infection, which is more likely to occur in people with IBD.
  • Colonoscopy. This exam allows your doctor to view the inside of 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. In this procedure, your doctor uses a slender, flexible, lighted tube to examine the last portion of your colon (sigmoid colon). The test may miss problems higher up in your colon, and it doesn’t give a full picture of how much of the colon has been affected. But if your colon is severely inflamed, your doctor may perform this test instead of a full colonoscopy.
  • Barium enema. This diagnostic test allows your doctor to evaluate your entire large intestine with an X-ray. Barium, a contrast solution, is placed into your bowel using an enema. Sometimes, air is added as well. The barium coats the bowel lining, creating a silhouette image of your rectum, colon and a portion of your small intestine. This test is rarely used anymore, and it can be dangerous because the pressure required to inflate and coat the colon can lead to rupture of the colon.
  • X-ray. A standard X-ray of your abdominal area may be done to rule out toxic megacolon or a perforation of the colon if these conditions are suspected because of severe symptoms.
  • Computerized tomography (CT) scan. A CT scan of your abdomen or pelvis may be performed if your doctor suspects a complication from ulcerative colitis or inflammation of the small intestine that might suggest Crohn’s disease. A CT scan may also reveal how much of the colon is inflamed.
  • Magnetic resonance imaging (MRI). An MRI scanner uses a magnetic field and radio waves to create detailed images of organs and tissues. Most MRI machines are large, tube-shaped magnets. During the test, you lie on a movable table inside the MRI machine. This test is very helpful in diagnosing and managing Crohn’s disease. It’s biggest advantage is that there is no radiation exposure. It’s particularly useful for evaluating a fistula around the anal area (pelvic MRI) or the small intestine (MRI enterography).
  • Capsule endoscopy. If you have signs and symptoms that suggest Crohn’s disease but other diagnostic tests are negative, your doctor may perform capsule endoscopy. For this test you swallow a capsule that has a tiny camera in it. The camera takes pictures as it moves through your digestive tract, and the images are transmitted to a computer that you wear on your belt. Your doctor later downloads the images, which are then displayed on a monitor and checked for signs of Crohn’s disease. Once it’s made the trip through your digestive system, the camera exits your body painlessly in your stool.
  • Double-balloon endoscopy. For this test, a longer scope is used to look further into the small bowel where standard endoscopes don’t reach. This technique is useful when capsule endoscopy shows abnormalities but the diagnosis is still in question. It allows for biopsy of the abnormal area. It’s usually performed in specialized endoscopy centers.
  • Small bowel imaging. This test looks at the part of the small bowel that can’t be seen by colonoscopy. You drink a solution containing barium, then X-ray, CT or MRI images are taken of your small intestine. The test can help locate areas of narrowing or inflammation in the small bowel that are seen in Crohn’s disease. The test can also help your doctor determine which type of inflammatory bowel disease you have.
The goal of inflammatory bowel disease treatment is to reduce the inflammation that triggers your signs and symptoms. In the best cases, this may lead not only to symptom relief but also to long-term remission. IBD treatment usually involves either drug therapy or surgery.

Anti-inflammatory drugs

Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. They include:

  • Sulfasalazine (Azulfidine).Sulfasalazine can be effective in reducing symptoms of ulcerative colitis, but it has a number of side effects, including nausea, vomiting, diarrhea, heartburn and headache. Don’t take this medication if you’re allergic to sulfa medications.
  • Mesalamine (Apriso, Asacol, Lialda, others), balsalazide (Colazal) and olsalazine (Dipentum). These medications are available in oral forms, and also in topical forms, such as enemas and suppositories. Which form you take depends on the area of your colon that’s affected. These medications tend to have fewer side effects than sulfasalazine, and are generally very well tolerated.
  • Corticosteroids. Corticosteroids can help reduce inflammation, but they have numerous side effects, including weight gain, excessive facial hair, mood swings, high blood pressure, type 2 diabetes, osteoporosis, bone fractures, cataracts, glaucoma and an increased susceptibility to infections. Doctors generally use corticosteroids only if you have moderate to severe inflammatory bowel disease that doesn’t respond to other treatments. Corticosteroids aren’t for long-term use and the dose is usually tapered down over two to three months.

Immune system suppressors

These drugs also reduce inflammation, but they target your immune system rather than treating inflammation itself. Because immune suppressors can be effective in treating ulcerative colitis, scientists theorize that damage to digestive tissues is caused by your body’s immune response to an invading virus or bacterium or even to your own tissue. By suppressing this response, inflammation is also reduced. Immune system suppressors are associated with a small risk of developing cancer, such as lymphoma. Immunosuppressant drugs include:

    • Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol). Because azathioprine and mercaptopurine act slowly — taking three months or longer to start working — they’re sometimes initially combined with a corticosteroid. With time, they seem to produce benefits on their own and the steroids may be tapered off.

Side effects can include allergic reactions, bone marrow suppression, infections, and inflammation of the liver and pancreas. There also is a small risk of development of cancer with these medications. If you’re taking either of these medications, you’ll need to follow up closely with your doctor and have your blood checked regularly to look for side effects. If you’ve had cancer, discuss this with your doctor before starting these medications.

    • Cyclosporine (Gengraf, Neoral, Sandimmune). This potent drug is normally reserved for people who don’t respond well to other medications or who face possible surgery because of severe ulcerative colitis. In some cases, cyclosporine may be used to delay surgery until you’re strong enough to undergo the procedure. It may also be used to control signs and symptoms until less toxic drugs start working. Cyclosporine begins working in one to two weeks, but because it has the potential for severe side effects, including kidney damage, seizures and fatal infections, talk to your doctor about the risks and benefits of treatment. There’s also a small risk of cancer with these medications, so let your doctor know if you’ve previously had cancer.
    • Infliximab (Remicade). This drug is specifically for those with moderate to severe ulcerative colitis who don’t respond to or can’t tolerate other treatments. It works quickly to bring on remission, especially for people who haven’t responded well to corticosteroids. It works by neutralizing a protein produced by your immune system known as tumor necrosis factor (TNF).

Some people with heart failure, people with multiple sclerosis, and people with cancer or a history of cancer can’t take infliximab. The drug has been linked to an increased risk of infection, especially tuberculosis and reactivation of viral hepatitis, and may increase your risk of blood problems and cancer. You’ll need to have a skin test for tuberculosis, a chest X-ray and a test for hepatitis B before taking infliximab.

    • Adalimumab (Humira).Adalimumab works similarly to infliximab by blocking TNF for people with moderate to severe Crohn’s disease. It can be used soon after you’re diagnosed if you have a fistula, or if you have more severe Crohn’s disease. It also may be used after other medications have failed to improve your symptoms. Adalimumab may be used instead of infliximab or certiluzimab, or it can be used if infliximab or certiluzimab stop working. Adalimumab may reduce the signs and symptoms of Crohn’s disease and may cause remission.

However, adalimumab, like infliximab, carries a small risk of complications, including tuberculosis and serious fungal infections. Your doctor will give you a skin test for tuberculosis, obtain a chest X-ray and test you for hepatitis before you begin adalimumab treatment. The most common side effects of adalimumab are skin irritation and pain at the injection site, nausea, runny nose and upper respiratory infection.

  • Certolizumab pegol (Cimzia). Approved by the Food and Drug Administration for the treatment of Crohn’s disease, certolizumab pegol works by inhibiting TNF. Certolizumab pegol is prescribed for people with moderate to severe Crohn’s disease. Certolizumab pegol may be used instead of infliximab, or it can be used if infliximab or adalimumab stop working. Common side effects include headache, upper respiratory infections, abdominal pain, nausea and reactions at the injection site. Because this drug affects your immune system, you’re also at risk of becoming seriously ill with certain infections, such as tuberculosis. Your doctor will give you a skin test for tuberculosis, obtain a chest X-ray and test you for hepatitis before you begin certiluzimab pegol.
  • Methotrexate (Rheumatrex)zThis drug, which is used to treat cancer, psoriasis and rheumatoid arthritis, is sometimes used for people with Crohn’s disease who don’t respond well to other medications. Short-term side effects include nausea, fatigue and diarrhea, and rarely, it can cause potentially life-threatening pneumonia. Long-term use can lead to scarring of the liver and sometimes to cancer. Avoid becoming pregnant while taking methotrexate. If you’re taking this medication, follow up closely with your doctor and have your blood checked regularly to look for side effects.
  • Natalizumab (Tysabri). This drug works by inhibiting certain immune cell molecules — integrins — from binding to other cells in your intestinal lining. Natalizumab is approved for people with moderate to severe Crohn’s disease with evidence of inflammation and who aren’t responding well to other conventional Crohn’s disease therapies. Because the drug is associated with a rare, but serious, risk of multifocal leukoencephalopathy — a brain infection that usually leads to death or severe disability — you must be enrolled in a special program to use it.

Antibiotics

Antibiotics can reduce the amount of drainage and sometimes heal fistulas and abscesses in people with Crohn’s disease. Researchers also believe antibiotics help reduce harmful intestinal bacteria and suppress the intestine’s immune system, which can trigger symptoms. However, there’s no strong evidence that antibiotics are effective for Crohn’s disease. Frequently prescribed antibiotics include:

  • Metronidazole (Flagyl). Once the most commonly used antibiotic for Crohn’s disease, metronidazole can cause serious side effects, including numbness and tingling in your hands and feet and, occasionally, muscle pain or weakness.
  • Ciprofloxacin (Cipro). This drug, which improves symptoms in some people with Crohn’s disease, is now generally preferred to metronidazole. A rare, but possible side effect of this medication is tendon rupture.

Other medications

In addition to controlling inflammation, some medications may help relieve your signs and symptoms. Depending on the severity of your inflammator