Often confused with IBS, inflammatory bowel disease, or IBD is the umbrella term for two separate conditions which cause inflammation in the bowels and surrounding areas. We spoke to Professor James Lindsay, an expert gastroenterologist with over 25 years of experience, about these conditions and how they are treated.
Inflammatory bowel disease includes Crohn’s disease and ulcerative colitis which are two long term conditions that result in inflammation in the gut. The diseases occur when the immune cells that line the gut start reacting to the normal gut bacteria that they previously used to ignore.
The natural history of the condition is to have periods of disease activity (flares) with intervening periods during which the disease is well controlled (remission). During a disease flare, patients may experience loose stool, urgency to visit the toilet, bleeding when they pass stool, abdominal pain, and significant fatigue. The disease can also affect other areas the body resulting in inflammation of the eyes, joints, liver, and skin.
What causes IBD flare ups?
It is not entirely clear what precipitates a disease flare in all patients, the causes are likely to be different for individual patients over the course of their disease. There is evidence that a disease flare may be precipitated by an intercurrent gastrointestinal infection, taking nonsteroidal anti-inflammatory drugs such as ibuprofen or after a course of antibiotics.
There is also evidence that disease flares often follow a period of stress. Despite extensive research, there is no current evidence that modifying your diet can reduce the chance of a disease flare. Interestingly patients who smoke are more likely to flare if they have Crohn's disease, but seemed to be protected if they have ulcerative colitis.
How do you calm an IBD flare up?
Medication is the main strategy used to control a disease flare. Most medications aim to suppress the immune response to the gut bacteria. These include drugs that are used short term to reduce disease activity (induce remission) and drugs that are used over many years to prevent further disease flares once the disease has come under control (maintain remission). Some drugs are only used to induce remission (for example steroids), some only to maintain remission (such as azathioprine) whereas others including mesalamine and the biologic agents can be used both to induce and then maintain remission.
Drugs such as steroids and mesalamine can be given by mouth or via the rectum as enemas or suppositories depending on where the disease is most active. The immune supressing medications such as azathioprine methotrexate or tofacitinib are given by mouth and most biologics can be given as either injections or infusions.
What is the best medicine for IBD?
The exact choice of drug for an individual patient will depend very much on the type, location, and severity of their disease as well as how they have responded to previous treatments and what other illnesses or issues may be going on at the time. Treatment choices should always be made during a conversation between the patient and their IBD specialist. Specific diets may be used to reduce disease activity or to control non inflammatory symptoms in patients with inactive disease, but it is always worth discussing dietary modification with your IBD team before restricting what you eat.
There is no one drug that would be the best choice of drug for all patients all the time. Each treatment choice will have its benefits as well as its potential side effects. Some of the drugs that aim to suppress the immune system can have side effects including an increased risk of specific infections. Many of the newer, advanced therapies are very specific in how they target the gut immune reaction and therefore can focus their effect on reducing inflammation whilst minimising the risk of side effects. Excitingly there are many new classes of drugs currently in development to treat patients with inflammatory bowel disease.
Can IBD cause cancer?
The most recent data focusing on large populations of patients with inflammatory bowel disease has shown that their risk of developing bowel cancer is much lower than was previously thought. However, there are still some patients with IBD that do have a slightly higher risk than the general population. These include patients with extensive disease, or those in whom the gut lining remains inflamed for a long period of time, as well as those who also have the liver disease primary sclerosing cholangitis or a strong family history of colon cancer. All at risk patients would normally have surveillance using colonoscopy to prevent IBD associated colon cancer.
When should you see a doctor?
Most patients with inflammatory bowel disease should have their care coordinated by a consultant with a special interest in this condition. It may be that much of their care can be provided by their GP, but it is currently recommended that all patients see a specialist at least once a year. There will be patients with more severe or difficult to treat disease taking strong medication which requires monitoring in a specialist service every three to four months. Anyone who experiences a change in symptoms should seek urgent review by their IBD team.
At the London Digestive Centre, we have a complete inflammatory bowel disease multidisciplinary team. This includes world renowned IBD physicians and surgeons, radiologists, dietitian's and IBD nurses.
For consultation on IBD or any other problem related to the digestive system, visit Professor James Lindsay’s Top Doctors profile and request an appointment with him.