Inflammatory Bowel Disease

What is Crohn’s Disease?

Crohn’s disease is a specific type of inflammatory bowel disease.  It can cause inflammation of any part of the gastrointestinal tract from the mouth to the anus.  It also has other organs involved including the skin, eyes and joints.  It is likely caused by a combination of genetics, auto-immune and environmental factors.

Incidence

Crohn’s disease is uncommon, affecting 5 in 100 000 people.  People usually have family members affected.  It can develop at any age but commonly presents at around 25 and 65 years of age.

How Does Crohn’s Disease Affect The Bowel

Crohn’s disease causes full thickness inflammation of the gastrointestinal tract causing ulceration and narrowing of the bowel.  This causes diarrhoea and bleeding in the bowel as well as abdominal pain and occasionally weight loss and malabsorption.  Complications may include abscesses, bowel obstruction, bowel perforation and fistulae.

Symptoms

When the inflammation is active, several symptoms may occur including abdominal pain, diarrhoea, weight loss, bleeding in the stools, general feeling of unwell and fatigue.  Other organ systems can also be involved.

Diagnosis

After taking a medical history and general examination, several investigations can be performed.  However the definitive diagnosis is made following biopsies taken during a colonoscopy and gastroscopy. Small bowel Crohn’s disease requires a small bowel barium x-ray series for diagnosis.

Treatment

Crohn’s disease is a chronic condition with no cure, however can be managed.  Medical therapy is the main course of therapy which includes steroids in the active stages and steroid sparing agents such as salazopyrine and immunosuppressants such as azathioprine as maintenance therapy.  Anti-diarrhoeals and anti-spasmodics, iron and nutritional supplements are occasionally required.

Failing medical therapy, occasionally surgery is required to remove affected areas of bowel particularly if there are strictures of the bowel or bowel perforations.  In general, the likelihood of surgery being required is high.

What Operation Might I Have?

If a short segment of bowel is involved and not improving with medical therapy, the section of bowel may need to be removed and the bowel joined immediately or after a short period with a stoma (bag).

A strictuoplasty may be carried out to widen a narrow area of bowel.

Abscesses are may need drainage.

All patients should have regular colonoscopies to monitor disease activity and to monitor for the development of pre-cancerous or cancerous changes.

Is More Than One Operation Likely?

Yes, more than 50% of patients require an additional operation, often years later.

What About The Future?

Most people with Crohn’s disease live a productive life with minimal effect from the disease.  Pregnancy is not contraindicated but should be discussed with an obstetrician to optimise your health prior to pregnancy.  All patients should have regular colonoscopies to monitor disease activity and to monitor for the development of pre-cancerous or cancerous changes.

 

What is Ulcerative Colitis?

Ulcerative colitis is an inflammatory condition of the inner layers of the large bowel.  It involves the rectum (distal part of the large bowel) and can advance to involve the proximal colon (caecum, start of the large bowel). The area of inflammation is continuous and involves ulceration of the bowel lining and abscess formation. Chronic inflammation of the bowel increases the risk of colorectal cancer.  Other organ systems can be involved including the eyes, liver, skin and joints.

What is the cause of ulcerative colitis?

The cause is unknown, but many theories exist. It may involve genetic/familial, environmental and autoimmune factors.

What are the symptoms of ulcerative colitis?

Symptoms of ulcerative colitis may be continuous or intermittent and range from mild to life threatening requiring hospitalisation.

Intestinal features include:

• Passage of blood and mucous in the faeces
• Abdominal pain
• Diarrhoea and faecal urgency

Extra-intestinal features include:

• Inflammation of the eyes (iritis, episcleritis)
• Skin changes lesions (pyoderma gangrenosum)
• Joint pain (arthritis)
• Liver disease (sclerosing cholangitis)

How is it diagnosed?

A thorough history will be taken by the doctor.  If ulcerative colitis is suspected a colonoscopy is recommended to visualise the bowel lining and take biopsies (tissue samples) of the bowel and any other concerning features including potential cancerous changes.  The pathologist examines the samples, confirming ulcerative colitis. Whilst some blood tests and imaging may show inflammation, they are not diagnostic.  Due to the risk of colorectal cancer, regular colonoscopies should be performed as per guidelines.

How is ulcerative colitis treated?

Ulcerative colitis is medically managed initially with steroids to induce remission and then maintenance therapy in continued with steroid sparing agents including oral 5-ASA agents (sulfasalazine/mesalazine) or thiopurines (azathioprine) depending on the location and severity of the disease.  Immunosuppressant’s including infliximab is used for severe disease.  If this fails then surgery may be required.

When is surgery needed?

Colonoscopies are required as part of regular surveillance for detection of pre-malignant or malignant change as well as response to medical therapy.

Surgery is required which involves removing the large bowel with either a permanent ileostomy (bag) or rejoining the bowel with a ‘pouch’ operation when:

• Medical treatment no longer controls the symptoms which are severely affecting quality of life.
• Pre-malignant or malignant changes detected on colonoscopy biopsies.
• Complications occur including bleeding, severe inflammation, bowel perforation and cancer.

What can I expect after surgery?

Following removal of the large bowel, ulcerative colitis is essentially cured and no further medication should be required.  You should continue to follow up with your surgeon, particularly if your bowel was joined in a ‘pouch’ operation as the end of the large bowel will need to be monitored via endoscopy.  You will have several loose but usually continent bowel motions a day as the large bowel was where most of the fluid was absorbed from the faecal content prior to surgery.  Otherwise you can expect a return to your regular activities and normal life expectancy.