Inflammatory Bowel Disease

by Dr. Tan Huck Joo

Inflammatory bowel disease (IBD) comprises a group of disorders characterised by inflammation in the digestive tract. When this happens over a period of time, the intestinal lining is damaged and develops ulcers, which may bleed or produce mucous.

The two main disorders under IBD are Crohn’s disease (CD) and ulcerative colitis (UC), which are characterised by recurrent episodes of abdominal pain, often with diarrhoea and rectal bleeding.

IBD is more prevalent in Western countries, but its incidence is on the rise in Asia. IBD generally affects the younger age group and it tends to run in families.

What Causes IBD?

It is a common misconception that IBD is caused by what we eat as IBD causes inflammation in the digestive tract. However, there is no evidence to suggest that our dietary habits cause or contribute to IBD.

Although the causes are not completely known, doctors believe that IBD occurs as a result of the body's immune system reacting against its own intestinal tissue. Other contributing factors include a family history of the disease, infections, immunologic (to do with the immune system) factors, and psychological factors. What triggers the body's immune system has yet to be identified. So far, many studies have shown that there is an association between smoking and the development of Crohn's disease.

CD and UC may have overlapping and shared symptoms, but they are treated very differently, medically and surgically.


The most common symptoms are abdominal pain and diarrhoea. Other symptoms include :

* Bloody diarrhoea
* Loss of appetite
* Weight loss
* Mucous from back passage (anus)
* Pain or rectal bleeding with bowel movement
* Severe urgency to have a bowel movement
* Bloating
* Fistula or perianal disease. This normally present as discharge around the anus and is mainly found in Crohn's disease
* Fever (during active inflammation)
* Tiredness (anaemia, general feeling of unwell)

During active flare ups or inflammation, patients with ulcerative colitis will experience rectal bleeding and frequent bowel motions. Patients with Crohn's disease in the small intestine tend to have abdominal pain.

Sufferers may develop toxic megacolon (an abnormal dilatation of the large intestine) if ulcerative colitis is not treated during an acute flare up. This is a medical emergency and the large bowel may rupture if not treated in time.


IBD can cause profuse bleeding from the ulcers (in ulcerative colitis) and a perforation (or rupture) of the bowel. Individuals with Crohn's disease may also be plagued by strictures (a partial obstruction or narrowing) in the intestines or a narrowing of the bowel from inflammation.

IBD may affect organs outside the digestive system, such as the joints, eyes, skin, and liver. Patients who frequently use steroids for active inflammation may develop diabetes, high blood pressure, and osteoporosis.

In longstanding IBD cases, the risk of colon cancer also increases. Patients in this group require regular monitoring in order to detect the early changes indicative of colon cancer.

Detecting IBD

Your doctor will assess your symptoms by:

* Taking a full medical history and physical examination.

* Blood tests are useful to look for anaemia (low blood count), a high white cell count indicating infection, and so on.

* Stool samples are occasionally useful to rule out causes of infection that may mimic the symptoms of IBD.

* Colonoscopy and tissue biopsy also allows your doctor to take small tissue samples to examine the insides of the colon, rectum, and the small intestine.

* A capsule endoscopy can be used to discover how far the disease has progressed, especially in Crohn's disease. This procedure involves the patient swallowing a capsule or pill that contains a video camera to examine the small intestine. The drawback of this technique, however, is that your doctor will not be able to take biopsies.

Treating IBD

As IBD is a chronic illness, it requires long term medication. The main purpose in treating IBD is to suppress the abnormal inflammatory response. Some medicines are used to treat acute inflammation to bring them under control. Others decrease the frequency of flare ups and help keep IBD in remission.

Steroids – Steroids are prescribed for active disease only and should only be used for a short period. Steroids provide rapid relief of symptoms but do not prevent the activation of IBD. Side effects, which are mainly related to high doses and long term use, includes acne, cataracts, osteoporosis (weakening of bones), and moon face (where the face swells up into a round shape).

Mesalazine – This group of drugs are useful to keep IBD in remission. Patients will need to take this medication long term. As it prevents recurrent inflammation, it reduces complications associated with IBD. Mesalazine is also useful in active inflammation.

Immunosuppression – Drugs that suppress the immune system (as IBD is a result of the body's immune reaction) are also used. Unfortunately, the time they take to act is relatively slow, but they are a useful addition to patients not completely controlled or partially controlled by a single agent such as mesalazine.

They also reduce the frequency of steroid use and have less long term side effects. However, patients will have a higher risk of developing infection and therefore require regular monitoring (blood tests).

Anti-TNF agents – Tumour necrosis factor (TNF) is produced by white blood cells and is responsible for tissue damage. Infliximab is an anti-TNF antibody approved for the treatment of moderate to severe Crohn's disease and severe ulcerative colitis. However, it is very expensive.

Antibiotics – Metronidazole and ciprofloxacin are the two commonest antibiotics used for IBD. They are useful for mild acute flare ups. However they are not useful for IBD in remission.

Surgery – Surgery can potentially cure ulcerative colitis, but not Crohn's disease. Surgery is recommended for patients who are intolerant to or do not respond to medications. Doctors will also conduct surgery on ulcerative colitis patients if there are pre-cancerous or cancerous changes in the colon.

For Crohn's disease, surgery is recommended for patients who suffer from complications of the disease or are not responding to medications.

Probiotics – There are studies suggesting that probiotics potentially is useful as an adjuvant therapy in maintaining remission and reducing active inflammation in mild to moderate ulcerative colitis.

10 Tips for People With IBD

The World Gastroenterology Organization offers these tips for IBD sufferers :

1. Learn about IBD and its sign and symptoms.

2. Remember that everyone with IBD is different, i.e. there's no typical case.

3. Find someone who you can talk to about your condition and who will provide a sympathetic ear.

4. Eat a well balanced diet.

5. Don't do more than you can physically manage.

6. Ask your healthcare provider what your medications are for, what side effects there might be, and how long you should expect to use them.

7. Once you have decided on a treatment, make sure that you follow through; if medications have been prescribed, take them regularly as prescribed.

8. Some medications need to be continued even when you are well.

9. Do not smoke – this worsens Crohn's disease.

10. Colonoscopy is required for patients with longstanding IBD to detect early changes of colon cancer.

Thanks to individually tailored medical and surgical therapy, many also find their disease in long-lasting remission. Sufferers of inflammatory bowel disease can also lead full and productive lives by taking steps towards limiting IBD and its impact on their everyday life.


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