Ernesto Drelichman, MD
Assistant Professor of Surgery
Department of Surgery- Gen Surg Gastrointestinal Section

Charles Elson, MD
Professor of Medicine
Department of Medicine, Division of Gastroenterology

The University of Alabama at Birmingham
Birmingham, Alabama

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IBD Symptoms

IBD affects both sexes equally and is generally diagnosed using clinical, endoscopic, and histologic criteria. However, no single finding is absolutely diagnostic for one disease, and 10% of patients may have symptoms that fall between both conditions, according to the Crohn’s and Colitis Foundation of America.

Symptoms of ulcerative colitis typically begin between ages 15 to 30 years and less frequently in people aged 50 to 70 years. Primarily involving the mucosa, the inflammation of ulcerative colitis always begins in the rectum and extends proximally to a variable extent. Symptoms typically begin with a progressive loosening of stool, which is generally bloody and may be associated with abdominal pain and urgency. Periods of remission may span years, but without treatment, symptoms eventually return.

Crohn disease often occurs in young adults during their most productive time of life, notably during childbearing years for women. Diarrhea is present in 85% of patients, and other symptoms include abdominal pain, hematochezia, fever, weight loss, malaise, nausea, and arthralgias, which lead to decreased quality of life as well as a difficult psychological burden (Am Fam Physician. 2003;68:707-714). Medical therapies and surgery relieve symptoms, but no current approaches are curative, and relapses are common.

Crohn disease involves all layers of the bowel wall and usually occurs in the small intestine and colon, although it may affect the mouth, esophagus, stomach, duodenum, appendix, and anus. Unlike ulcerative colitis, Crohn disease is discontinuous, with “skip areas” between involved sections that eventually develop a cobblestone appearance of ulcerations interspersed with areas of normal tissue.

Most patients with Crohn disease have involvement in the ileum and cecum; other common patterns include disease confined to the small intestine or colon. Associated anal fistulas and abscesses are painful and tend to recur.

“Our clinic evaluates complex patients who may not be responding favorably to conventional therapy,” Elson says. “The IBD Center reevaluates diagnoses for every referred patient. If someone is not responding to current therapy, a review of their symptoms may reveal they suffer from conditions other than IBD, and we can adjust treatment accordingly.”

Initial therapy for IBD includes 5-aminosalicylic acid preparations, including sulfasalazine, mesalamine, olsalazine, or balsalazide to control inflammation. They are effective in maintaining clinical response in mild-to-moderate IBD. Side effects are few but include nausea, vomiting, heartburn, diarrhea, and headache.

Systemic steroids may be indicated for rapid relief of moderate-to-severe Crohn disease, but prolonged use increases the risk of dependency and adverse effects. When used alone, steroids rarely sustain remission. A relatively new topical steroid, budesonide (Entocort), releases the drug in the distal ileum and proximal colon and has fewer side effects than traditional steroids.

“Patients who have failed standard therapy may require immunomodulators to control their symptoms,” Elson says. “These include azathioprine, 6-mercatopurine, and methotrexate, which have beneficial effects in multiple inflammatory disorders and are usually well tolerated. Often, simply adjusting the dose improves response rates. In fact, for patients on methotrexate, we work with their local physician to administer weekly low-dose pulse therapy, which studies show is effective in controlling long-term Crohn disease.”

Biologic agents introduced in the last decade have shown promise for treating IBD, because of their potential to alter disease course as well as relieve symptoms. Medical treatment for Crohn disease is now aimed at complete and persistent healing of bowel mucosa; avoiding disease complications, such as stenoses, abscesses, and fistulae; and reducing costly hospitalizations and surgeries.

Infliximab, the tumor necrosis factor-alpha blocker first approved for Crohn disease in 1998, was approved in 2005 for ulcerative colitis to reduce signs and symptoms; achieve clinical remission and healing of intestinal mucosa; and eliminate corticosteroids in patients with moderate-to-severe active colitis who are refractory to conventional therapy.

“Infliximab produces dramatic effects in certain patients who have not responded to other medical therapies. Currently, we give an induction course of infliximab at 0, 2, and 6 weeks, then maintain doses indefinitely at 8-week intervals for patients who continue to respond favorably,” Elson says. He prefers patients take an immune modulator prior to initiating infliximab, because some immune modulators alone resolve IBD symptoms and decrease the likelihood patients will develop antibodies to infliximab.

“When we first began prescribing infliximab, we used the drug as needed to treat flares,” he says. “However, recent studies show this strategy results in many patients developing antibodies to the agent, reducing its benefit. Regular maintenance doses help reduce antibody formation and are effective in controlling IBD symptoms in selected patients.”

Antibody responses to microbial antigens have been identified in groups of Crohn disease patients. One theory proposes that chronic intestinal inflammation is the result of a unique immunologic response to enteric bacteria. Although a specific bacterium has not been well established as an etiologic factor, clinical trials of antibiotics and probiotics have shown they help in some patients with Crohn disease. Metronidazole, ampicillin, and ciprofloxacin are often used for patients with Crohn disease who have an inflammatory mass or perianal complications.

“Two recent UAB studies have shown bacterial flagellin is a dominant antigen in Crohn disease, and serum antibodies to enteric bacterial flagellin identify a subset of patients with complicated disease,” Elson says. Large placebo-controlled trials available through UAB’s IBD Center will further research and help establish the safety and efficacy of newer therapies.

Technological improvements and specialized expertise of gastrointestinal surgeons allow UAB’s IBD Center to provide the newest laparoscopic procedures.

“Laparoscopic colon resections result in decreased postoperative pain, reduced narcotic requirements, shorter lengths of hospital stay, more rapid return to work and leisure activities, better cosmetic results, and fewer adhesions compared to open colectomy. Yet, only 5% of surgeons have the advanced skills necessary to perform laparoscopic colectomy, since dissection of the colon involves multiple steps, and the anastomosis must be performed safely,” says Drelichman, who trained in complex open and laparoscopic colon and rectal surgery at the Mayo Clinic.

For ulcerative colitis, ileostomy was long considered the only curative surgical option. Total proctocolectomy and ileal pouch-anal anastomosis have given patients an alternative to permanent ileostomy. “We remove the colon and rectum and rebuild the rectum from the distal small intestine,” Drelichman says. “The surgeon can employ either an open or laparoscopic technique for this multistage process. At UAB, we advocate a stepwise approach to laparoscopic colectomy, which is increasingly used for benign and malignant disease.” The laparoscopic technique simplifies the operation, significantly reduces procedure time, and leads to more uniform reproducible results with less morbidity.

Because Crohn disease can occur anywhere in the gastrointestinal tract, surgery is reserved for patients who have failed medical therapies or develop complications. “Patients who are refractory to medical therapy or have obstructions, perforations, abscesses, or fistulae often benefit from an operation,” Drelichman says. Other indications include intractability, perianal problems, or growth retardation due to nutritional deficiencies in children. Surgical resection provides relief from the debilitating symptoms of Crohn disease, reduces dependence on medication, and allows for rapid return to work and daily activities.

“Nearly 80% of Crohn disease patients will require surgery, and 50% of those individuals will require more than one operation. Laparoscopic approaches are ideal for treating complications from Crohn disease, because the repeat procedures are less painful and result in fewer adhesions,” he says.

IBD often strikes adults younger than 30 years at a time when they are starting careers and are socially active. The condition is painful and embarrassing, and although limited to the gastrointestinal tract, can lead to extracolonic complications that affect nearly every organ system. A recent Mayo Clinic study found 40% of IBD patients had one or more extraintestinal manifestation (Inflamm Bowel Dis. 2004;10:207-214).

Patients with IBD can experience arthralgias and arthritis, which tend to occur asymmetrically, but often resolve when gastrointestinal symptoms subside. Conversely, associated ankylosing spondylitis is usually chronic and progressive, running a course independent from IBD symptoms.

“Sclerosing cholangitis is the most common hepatobiliary disease observed in IBD, potentially leading to the need for liver transplantation,” Drelichman says. IBD patients may suffer from painful skin lesions, such as pyoderma gangrenosum and erythema nodosum. Increased propensity for blood clots is particularly common in ulcerative colitis patients. Uveitis occurs in about 1% of IBD patients and is associated with pain and redness of the eye, as well as decreased visual acuity. Dilating agents and topical corticosteroids may prevent scarring and reduce inflammation that occurs behind the lens and leads to blindness.

One of the primary goals of the IBD Center is to significantly streamline care for patients with IBD, who have traditionally had to visit multiple specialists on different occasions.

Because prolonged corticosteroid use increases the risk for osteoporosis and osteopenia and IBD results in loss of body fluids and nutrients, consultation with a nutritionist specializing in gastrointestinal disorders is key. Douglas C. Heimburger, MD, director of UAB Medical Nutrition Services, advises IBD patients about effective ways to maintain proper nutrition despite clinical manifestations that hinder eating and bowel habits. As director of UAB’s Clinical Nutrition Fellowship Program and the National Institutes of Health-funded Cancer Prevention and Control Training Program, he trains future clinicians to emphasize dietary methods for preventing malignancies in IBD patients, who face an elevated risk for colon cancer.

Increased risk for developing colon carcinoma and hepatobiliary carcinoma is similar in people living with Crohn disease and ulcerative colitis. However, patients with ulcerative colitis have an increased risk of rectal carcinoma, while those with Crohn disease face an increased risk of carcinoma of the small bowel. Overall, colon cancer occurs more frequently in IBD patients with a first-degree relative diagnosed with colon cancer before age 50 years (Cancer. 2001;91:854-862).

Drelichman advises anyone who has suffered symptoms of IBD for 10 years or more to begin annual colon cancer screenings. The IBD Center performs endoscopy at The Kirklin Clinic®. “For diagnosis, localization of disease, and postoperative surveillance, endoscopy serves as an extension of the physical exam for patients with IBD. For example, when flexible sigmoidoscopy is advised for a suspected diagnosis of proctitis or pouchitis, the condition can be confirmed the same day a patient is evaluated,” he says.

“Ideally, patients arrive in the morning for diagnostic testing, consult with IBD specialists, select the most effective individualized treatment options and, when warranted, return the following morning for surgery or endoscopy requiring anesthesia,” Drelichman says. Coordinating visits provides continuity of care and decreases the need for return appointments, which is particularly important for IBD patients with active symptoms who are traveling long distances.

“UAB’s IBD Center offers specialized expertise, core facilities, multidisciplinary collaboration, and single-site care unmatched in the region,” Drelichman concludes. “We are building on UAB’s reputation for IBD clinical research and care by expanding faculty expertise and, most importantly, strengthening and streamlining the diagnostic and treatment process for patients.”

For more information:

Dr. Ernesto Drelichman
Dr. Charles Elson
1-800-UAB-MIST
mist@uabmc.edu

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