GastroEast Physicians, Louisville, KY

Crohn's Disease and Ulcerative Colitis are found under the heading of inflammatory bowel disease.
Crohn's Disease will be discussed first.

Crohn's Disease

Crohn's Disease (CD) is a disorder of the gastrointestinal (GI tract) in which inflammation, ulceration, and stricturing can occur. Its effects can be found anywhere form the mouth to the anus. It commonly affects the terminal ileum (the last part of the small intestine) or the colon. The inflammation of the GI tract can cause pain and diarrhea, two common complaints in people with Crohn's Disease.

Crohn's Disease affects the genders equally and seems to run in some families.The cause of Crohn's Disease is unknown, but certain theories such as a viral cause or an abnormality in the immune system exist. Symptoms include diarrhea, abdominal pain, weight loss, fever, and rectal bleeding causing anemia.

After visiting a doctor, giving a complete medical history, and undergoing a physical exam, blood work and diagnostic testing will likely need to be performed. A complete blood count will be done to check for anemia (low red blood cell count) and for a high white blood cell count (marker of inflammation).Stool may be tested for microscopic red blood cells or white blood cells. An upper GI series may also be done. Crohn's Disease frequently affects the small intestine causing stricturing or narrowing of the bowel. A series of XRAY tests may be performed as ingested barium travels through the small intestine. If stricturing is found on small bowel GI series, a diagnosis of Crohn's Disease likely exists.

A colonoscopy may also be performed to look at the lining of the colon and do biopsies if ulcers or mucosal alteration is seen. The colonoscopy also allows intubation of the small intestine at the end of the ileum where the small intestine meets the colon. Crohn's Disease has a high rate of attack in the terminal ileum causing ulcers, inflammation, and stricturing.

Rarely, Crohn's Disease may become so severe that blockage of the intestine may occur, necessitating admission to a hospital. Occasionally this disease causes fistulae to form. Fistulae are a result of ulcers and inflammation in the bowel wall. Because of damage to the bowel wall, a tunnel forms between the bowel and surrounding organs such as the bladder, skin, or vagina. Traditionally, fistulas are treated with antibiotics to speed healing, but surgical excision of fistulae often is needed. A new medication, called Remicade has become a novel tool to heal fistula and avoid surgery.

Complications from the disease
Complications of Crohn's Disease include nutritional and vitamin deficiencies, skin disease, arthritis, and mouth ulceration. Formation of gallstones and diseases of the bile ducts can occur also.

Treatment
Treatment includes healing of the inflammation and ulceration, repletion of lost nutrients, and relieving symptoms. Treatment may help symptoms, but does not cure. Crohn's Disease tends to be a relapsing and remitting condition, but at this time there is no cure.

Predicting when a remission may occur or when symptoms will return is not possible. Someone with Crohn's Disease may need medical care for a long time, with regular doctor visits to monitor the condition and to check symptoms and to change medication. When someone is first diagnosed with Crohn's Disease the 5-ASA agents are prescribed first. These include mesalamine also called Asacol or Pentasa. If these medications do not control symptoms, a steroid course may be started. A common steroid preparation is prednisone. A long tapered course is usually prescribed. This course may be up to 8 or 10 weeks long.

When steroids become necessary chronically to control symptoms, an immunomodulator medication will be started to allow discontinuation of the steroid. These medications, 6-mercaptopurine or imuran, take 3 months for their full effect to be achieved so a 2-3 month course of steroids will be continued while these medications are initiated. Not only do these drugs suppress the inflammation associated with Crohn's Disease, but they also suppress the immune system and increase the chance of infection in the patient.

A new drug class has been approved, infliximab (Remicade) and Humira, for the treatment of moderate to severe Crohn's Disease that does not respond to standard therapies described above and for the treatment of non-healing fistulas.

Diarrhea and abdominal pain are often relieved when the inflammation dissipates, but additional medication may also be necessary such as over the counter antidiarrheal like Imodium or Pepto Bismol.

Surgery may ultimately be necessary to remove a part of the GI tract that is causing bowel obstruction because of stricturing. Surgery may also be necessary to cure abscesses, fistula, or bleeding in the GI tract. This area may be in the colon or small intestine. Surgery is only entertained when medical management fails. Because Crohn's Disease is not cured with surgery, frequently patients will remain on many of the above medications after surgery is performed.

People with Crohn's Disease may feel well and be symptom free for extended periods of time when their disease is inactive. Despite the necessity to take medication for extended periods of time and infrequent hospitalizations, most people with Crohn's Disease are able to hold jobs, get married, raise children, and function successfully.

Diet changes are usually minimal. Most people avoid spicy, fatty food, eat lots of fiber-filled foods, avoid alcohol and avoid foods which worsen their symptoms. Most diet changes are done by trial and error.

Ulcerative Colitis
Ulcerative Colitis (UC) is a condition that causes ulcers in the large intestine or colon. Diarrhea, usually bloody diarrhea with pus and abdominal pain are the most common symptoms. The blood is from the ulcers which line the lining of the colon. This disease, unlike Crohn's Disease, affects the colon only, and does not exist from mouth to anus. UC is also different from CD in that UC usually affects the superficial layers of the bowel, while CD typically is transmural or affects all layers of the bowel wall including the deep, muscle layers.

Ulcerative Colitis can occur at any age, but most often it starts between ages 20 and 30, or less frequently between ages 50 and 70. Ulcerative Colitis affects genders equally and appears to be present in families. The cause of UC is not known definitively. Theories about a viral cause or an autoimmune response exist, but none have been proven.

Symptoms
The most common symptoms of Ulcerative Colitis are abdominal pain and bloody diarrhea. Other people have weight loss, anemia, fatigue, weakness. Many patients also have associated symptoms such as arthritis, biliary or liver disease, ocular inflammation, rashes on the skin, and thinning of the bone called osteoporosis.

After seeing a doctor and receiving a thorough physical exam, you will receive blood work and diagnostic testing. A complete blood count will be done to check for anemia (low red blood cell count) and for a high white blood cell count (marker of inflammation). Stool may be tested for microscopic red blood cells or white blood cells.

One should avoid any foods which trigger a flare of their UC. Avoid alcohol. Avoid spicy and fatty foods. Occasionally milk products trigger a flare. Each individual must tailor his or her diet in a fashion to avoid a flare. This is usually done by trial and error.

Treatment
Treatment includes healing of the inflammation and ulceration, repletion of lost nutrients, and relieving symptoms. Medical treatment may help symptoms, but does not cure. The only definitive cure is removal of the colon and this will be discussed below after medical treatments are discussed.

When someone is first diagnosed with UC the 5-ASA agents are prescribed. These include mesalamine also called Asacol or Pentasa. If these medications do not control symptoms, a steroid course may be started. A common steroid preparation is prednisone. A long tapered course is usually prescribed. This course may be up to 8 or 10 weeks long.

When steroids become necessary chronically to control symptoms, an immunomodulator medication will be started to allow discontinuation of the steroid. These medications, 6-mercaptopurine or imuran, take 3 months for their full effect to be achieved so a 2-3 month course of steroids will be continued while these medications are initiated. Not only do these drugs suppress the inflammation associated with UC, but they also suppress the immune system and increase the chance of infection in the patient.

The goal of therapy is to induce and maintain period of remission, and to improve the quality of life for people with UC.

Many people, about 30%, eventually have their colons removed for complete cure of their UC. The colon is removed because of worsening symptoms and failure to respond to medical therapy. As the colon is removed, the ileum or small intestine is attached to the anus, affording the patient to have normal bowel movements with anal continence.

Most people with UC will never need to have surgical removal of the colon. If surgery does become a necessity, the colitis is cured; and many people go on to live normal, healthy, active lives without incident.

The Risk of Colon Cancer in Ulcerative Colitis is Small
About 1-3% of people with UC develop colon cancer. This risk increases as the length of time with disease progresses. Therefore, if the whole colon is affected, colon cancer surveillance with colonoscopy will begin at the 8-year mark. If the UC only affects the end of the colon, this surveillance will begin at the 10-15 year mark after disease onset. This surveillance will involve full colonoscopy with random biopsies each time. These biopsies will be examined under the microscope and if changes consistent with a pre-cancerous state are found, the whole colon will be removed; this colon cancer surveillance will occur every one to two years for life or until the colon is removed. Once the colon is removed, the risk of colon cancer is obliterated.