lnflammatory Bowel & Colorectal Disease

Inflammatory bowel disease (IBD) involves chronic inflammation of all or part of your digestive tract. IBD primarily includes ulcerative colitis and Crohn's disease. Both usually involve severe diarrhea, pain, fatigue and weight loss. IBD can be debilitating and sometimes leads to life-threatening complications.

Ulcerative colitis (UL-sur-uh-tiv koe-LIE-tis) is an inflammatory bowel disease that causes long-lasting inflammation and sores (ulcers) in the innermost lining of your large intestine (colon) and rectum.

Crohn's disease is an IBD that cause inflammation of the lining of your digestive tract. In Crohn's disease, inflammation often spreads deep into affected tissues. The inflammation can involve different areas of the digestive tract — the large intestine, small intestine or both.

Collagenous (kuh-LAJ-uh-nus) colitis and lymphocytic colitis also are considered inflammatory bowel diseases but are usually regarded separately from classic inflammatory bowel disease.

Tests and diagnosis

Your doctor will likely diagnose inflammatory bowel disease only after ruling out other possible causes for your signs and symptoms, including ischemic colitis, infection, irritable bowel syndrome (IBS), diverticulitis and colon cancer. He or she will use a combination of tests. To help confirm a diagnosis of IBD, you may have one or more of the following tests and procedures:

Blood tests

  • Tests for anemia or infection. Your doctor may suggest blood tests to check for anemia — a condition in which there aren't enough red blood cells to carry adequate oxygen to your tissues — or to check for signs of infection from bacteria or viruses.
  • Fecal occult blood test.You may need to provide a stool sample so that your doctor can test for hidden blood in your stool.

Endoscopic procedures

  • Colonoscopy. This test allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis, which may help confirm a diagnosis. Clusters of inflammatory cells called granulomas, if present, help confirm a diagnosis of Crohn's disease.
  • Flexible sigmoidoscopy. In this procedure, your doctor uses a slender, flexible, lighted tube to examine the last section of your colon (sigmoid).
  • Upper endoscopy. In this procedure, your doctor uses a slender, flexible, lighted tube to examine the esophagus, stomach and first part of the small intestine (duodenum). While it is rare for these areas to be involved with Crohn's disease, this test may be recommended if you are having nausea and vomiting, difficulty eating or upper abdominal pain.
  • Capsule endoscopy. This test is used to help diagnose Crohn's disease. You swallow a capsule that has a camera in it. The images are transmitted to a computer you wear on your belt, after which the camera exits your body painlessly in your stool. You may still need endoscopy with biopsy to confirm a diagnosis of Crohn's disease.
  • Double-balloon endoscopy. For this test, a longer scope is used to look further into the small bowel where standard endoscopes don't reach. This technique is useful when capsule endoscopy shows abnormalities, but the exact diagnosis is still in question.

Imaging procedures

  • X-ray. If you have severe symptoms, your doctor may use a standard X-ray of your abdominal area to rule out serious complications, such as a perforated colon.
  • Computerized tomography (CT) scan. You may have a CT scan — a special X-ray technique that provides more detail than a standard X-ray does. This test looks at the entire bowel as well as at tissues outside the bowel. CT enterography is a special CT scan that provides better images of the small bowel. This test has replaced barium X-rays in many medical centers.
  • Magnetic resonance imaging (MRI). An MRI scanner uses a magnetic field and radio waves to create detailed images of organs and tissues. MRI is particularly useful for evaluating a fistula around the anal area (pelvic MRI) or the small intestine (MR enterography). Unlike CT, there is no radiation exposure with MRI.
  • Small bowel imaging. This test looks at the part of the small bowel that can't be seen by colonoscopy. After you drink a liquid containing barium, doctors take an X-ray of your small intestine. While this technique may still be used, it has largely been replaced by CT or MRI enterography.

Treatments and drugs

The goal of inflammatory bowel disease treatment is to reduce the inflammation that triggers your signs and symptoms. In the best cases, this may lead not only to symptom relief but also to long-term remission and reduced risks of complications. IBD treatment usually involves either drug therapy or surgery. There is no cure for IBD.

Doctors use one of two approaches to treatment: "step-up," which starts with milder drugs first, versus "top-down," which gives people stronger drugs earlier in the treatment process. Researchers are actively exploring new approaches to treatment for IBD, especially as new technology becomes available. Investigators suggest links between diet, the immune system and bacteria in the digestive tract (microbiome).

Anti-inflammatory drugs

Anti-inflammatory drugs are often the first step in the treatment of inflammatory bowel disease. They include:

  • Aminosalicylates. Sulfasalazine (Azulfidine) can be effective in reducing symptoms of ulcerative colitis and for some people with Crohn's disease confined to the colon, but it has a number of side effects, including digestive distress and headache. Certain 5-aminosalicylates — including mesalamine (Asacol, Lialda, Rowasa, Canasa, others), balsalazide (Colazal) and olsalazine (Dipentum) — are available in both oral and enema or suppository forms. Which form you take depends on the area of your colon that's affected. Rarely, these medications have been associated with kidney and pancreas problems.
  • Corticosteroids. These drugs, which include prednisone and hydrocortisone, are generally reserved for moderate to severe ulcerative colitis or Crohn's disease that doesn't respond to other treatments. They are given orally, intravenously, or by enema or suppository, depending on the part of the digestive tract affected.

Corticosteroids have numerous side effects, including a puffy face, excessive facial hair, night sweats, insomnia and hyperactivity. More-serious side effects include high blood pressure, diabetes, osteoporosis, bone fractures, cataracts, glaucoma and increased chance of infection. They are not usually given long term.

Immune system suppressors

These drugs also reduce inflammation, but they target your immune system rather than directly treating inflammation. Instead, they suppress the immune response that releases inflammation-inducing chemicals in the intestinal lining. For some people, a combination of these drugs works better than one drug alone. Immunosuppressant drugs include:

  • Azathioprine (Azasan, Imuran) and mercaptopurine (Purinethol, Purixan). These are the most widely used immunosuppressants for treatment of inflammatory bowel disease. Taking them requires that you follow up closely with your doctor and have your blood checked regularly to look for side effects, including effects on the liver and pancreas. Additional side effects include lowered resistance to infection and a rare chance of developing cancers such as lymphoma and skin cancers. A blood test to determine the ability of your body to break down the medication should be done before starting. This will help identify the risk of suppression of the bone marrow and help with dosing.
  • Cyclosporine (Gengraf, Neoral, Sandimmune). This drug is normally reserved for people who haven't responded well to other medications. Its use is generally confined to ulcerative colitis. Cyclosporine has the potential for serious side effects — such as kidney and liver damage, seizures and fatal infections — and is not for long-term use. There's also a small risk of cancer, so let your doctor know if you've previously had cancer. It is now used much less often because safer alternatives are available.
  • Infliximab (Remicade), adalimumab (Humira) and golimumab (Simponi). These drugs, called tumor necrosis factor (TNF)-alpha inhibitors, or "biologics," work by neutralizing a protein produced by your immune system. They are for people with moderate to severe Crohn's disease or ulcerative colitis who don't respond to or can't tolerate other treatments. Infliximab is given by intravenous injection and the others by subcutaneous injection. They may be combined with other immunosuppressant medications such as azathioprine or mercaptopurine.

People with certain conditions can't take TNF-alpha inhibitors. If you have a history of tuberculosis, fungal infections or hepatitis B, you may experience a reactivation of your disease while on therapy. Your doctor will test you for previous exposure to tuberculosis and hepatitis B and may test you for possible fungal infection as well.

These drugs also are associated with a rare risk of developing certain cancers such as lymphoma and skin cancers.

  • Methotrexate (Rheumatrex). This drug — which is used mainly to treat cancer, psoriasis and rheumatoid arthritis — is sometimes used for people with Crohn's disease who don't respond well to other medications. It is given by injection. Short-term side effects include nausea, fatigue and diarrhea, and rarely, it can cause potentially life-threatening pneumonia. Long-term use can lead to bone marrow suppression, scarring of the liver and sometimes cancer. You will need to be followed closely for side effects.
  • Natalizumab (Tysabri) and vedolizumab (Entyvio). These drugs work by stopping certain immune cell molecules — integrins — from binding to other cells in your intestinal lining. These drugs are approved for people with moderate to severe Crohn's disease and ulcerative colitis with evidence of inflammation who aren't responding well to any other medications.

Because natalizumab is associated with a rare but serious risk of progressive multifocal leukoencephalopathy — a brain infection that usually leads to death or severe disability — you must be enrolled in a special restricted distribution program to use it.

Vedolizumab recently was approved for Crohn's disease. It works like natalizumab but appears not to have a risk of brain infection.

  • Ustekinumab (Stelara). This drug is used to treat psoriasis. Studies have shown it's useful in treating Crohn's disease as well and may be used when other medical treatments fail.

Antibiotics

People with ulcerative colitis who run fevers will likely be given antibiotics to help prevent or control infection. Antibiotics can reduce the amount of drainage and sometimes heal fistulas and abscesses in people with Crohn's disease.

Researchers also believe antibiotics help reduce harmful intestinal bacteria and suppress the intestine's immune system. They may be used in addition to other medications or when infection is a concern — in cases of perianal Crohn's disease, for example. However, there's no strong evidence that antibiotics are effective for Crohn's disease.

Frequently prescribed antibiotics include:

  • Metronidazole (Flagyl). At one time, metronidazole was the most commonly used antibiotic for Crohn's disease. It can cause serious side effects, including numbness and tingling in your hands and feet and, occasionally, muscle pain or weakness. If these effects occur, stop the medication and call your doctor. You should also not drink alcohol while taking this medication because of severe side effects — including nausea, vomiting and tremor — due to the interaction of the drug with alcohol.
  • Ciprofloxacin (Cipro). This drug, which improves symptoms in some people with Crohn's disease, is now generally preferred to metronidazole. A rare side effect is tendon rupture, which is an increased risk if you're also taking corticosteroids.

Other medications

In addition to controlling inflammation, some medications may help relieve your signs and symptoms, but always talk to your doctor before taking any over-the-counter medications. Depending on the severity of your Crohn's disease, your doctor may recommend one or more of the following:

  • Anti-diarrheal medications. A fiber supplement — such as psyllium powder (Metamucil) or methylcellulose (Citrucel) — can help relieve mild to moderate diarrhea by adding bulk to your stool. For more severe diarrhea, loperamide (Imodium) may be effective. Anti-diarrheal medications should only be used after discussion with your doctor.
  • Pain relievers. For mild pain, your doctor may recommend acetaminophen (Tylenol, others). However, ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve, Anaprox) and diclofenac sodium (Voltaren, Solaraze) likely will make your symptoms worse and can make your disease worse as well.
  • Iron supplements. If you have chronic intestinal bleeding, you may develop iron deficiency anemia and need to take iron supplements.
  • Vitamin B-12 shots. Crohn's disease can cause vitamin B-12 deficiency. Vitamin B-12 helps prevent anemia, promotes normal growth and development, and is essential for proper nerve function.
  • Calcium and vitamin D supplements. Crohn's disease and steroids used to treat it can increase your risk of osteoporosis, so you may need to take a calcium supplement with added vitamin D.
  • Nutrition. Your doctor may recommend a special diet given via a feeding tube (enteral nutrition) or nutrients injected into a vein (parenteral nutrition) to treat your Crohn's disease. This can improve your overall nutrition and allow the bowel to rest. Bowel rest can reduce inflammation in the short term. If you have a stenosis or stricture in the bowel, your doctor may recommend a low-residue diet. This will help to minimize the chance that undigested food will get stuck in the narrowed part of the bowel and lead to a blockage.

Surgery

If diet and lifestyle changes, drug therapy, or other treatments don't relieve your IBD signs and symptoms, your doctor may recommend surgery.

  • Surgery for ulcerative colitis. Surgery can often eliminate ulcerative colitis, but that usually means removing your entire colon and rectum (proctocolectomy). In most cases, this involves a procedure called ileoanal anastomosis that eliminates the need to wear a bag to collect stool. Your surgeon constructs a pouch from the end of your small intestine. The pouch is then attached directly to your anus, allowing you to expel waste relatively normally.

In some cases, a pouch is not possible. Instead, surgeons create a permanent opening in your abdomen (ileal stoma) through which stool is passed for collection in an attached bag.

  • Surgery for Crohn's disease. Up to one-half of people with Crohn's disease will require at least one surgery. However, surgery does not cure Crohn's disease.

During surgery, the doctor removes a damaged portion of your digestive tract and then reconnects the healthy sections. Surgery may also be used to close fistulas and drain abscesses. A common procedure for Crohn's disease is strictureplasty, which widens a segment of the intestine that has become too narrow.

The benefits of surgery for Crohn's disease are usually temporary. The disease often recurs, frequently near the reconnected tissue. The best approach is to follow surgery with medication to minimize the risk of recurrence. If you have had surgery on your colon or where your small intestine and colon meet, your doctor may recommend a repeat colonoscopy in six to 12 months to look for signs of disease and help with correct treatment

Colorectal, or Colon cancer is cancer of the large intestine (colon), the lower part of your digestive system. Rectal cancer is cancer of the last several inches of the colon. Together, they're often referred to as colorectal cancers.

Most cases of colon cancer begin as small, noncancerous (benign) clumps of cells called adenomatous polyps. Over time some of these polyps become colon cancers.

Polyps may be small and produce few, if any, symptoms. For this reason, doctors recommend regular screening tests to help prevent colon cancer by identifying polyps before they become colon cancer

Diagnosing colon cancer

If your signs and symptoms indicate that you could have colon cancer, your doctor may recommend one or more tests and procedures, including:

  • Using a scope to examine the inside of your colon.Colonoscopy uses a long, flexible and slender tube attached to a video camera and monitor to view your entire colon and rectum. If any suspicious areas are found, your doctor can pass surgical tools through the tube to take tissue samples (biopsies) for analysis.
  • Using multiple CT images to create a picture of your colon. CT colonography, also called virtual colonoscopy, combines multiple CT scan images to create a detailed picture of the inside of your colon. If you're unable to undergo colonoscopy, your doctor may recommend virtual colonoscopy.

Staging colon cancer

Once you've been diagnosed with colon cancer, your doctor will order tests to determine the extent (stage) of your cancer. Staging helps determine what treatments are most appropriate for you.

Staging tests may include imaging procedures such as abdominal and chest CT scans. In many cases, the stage of your cancer may not be determined until after colon cancer surgery.

The stages of colon cancer are:

  • Stage I. Your cancer has grown through the superficial lining (mucosa) of the colon or rectum but hasn't spread beyond the colon wall or rectum.
  • Stage II. Your cancer has grown into or through the wall of the colon or rectum but hasn't spread to nearby lymph nodes.
  • Stage III. Your cancer has invaded nearby lymph nodes but isn't affecting other parts of your body yet.
  • Stage IV. Your cancer has spread to distant sites, such as other organs — for instance to your liver or lung.

The type of treatment your doctor recommends will depend largely on the stage of your cancer. The three primary treatment options are: surgery, chemotherapy and radiation.

Surgery for early-stage colon cancer

If your cancer is small, localized in a polyp and in a very early stage, your doctor may be able to remove it completely during a colonoscopy. Larger polyps may be removed using endoscopic mucosal resection. If the pathologist determines that it's likely that the cancer was completely removed, there may be no need for additional treatment.

Polyps that can't be removed during colonoscopy may be removed using laparoscopic surgery. In this procedure, your surgeon performs the operation through several small incisions in your abdominal wall, inserting instruments with attached cameras that display your colon on a video monitor. The surgeon may also take samples from lymph nodes in the area where the cancer is located.

Surgery for invasive colon cancer

If your colon cancer has grown into or through your colon, your surgeon may recommend a partial colectomy to remove the part of your colon that contains the cancer, along with a margin of normal tissue on either side of the cancer. Nearby lymph nodes are usually also removed and tested for cancer.

Your surgeon is often able to reconnect the healthy portions of your colon or rectum. But when that's not possible, for instance if the cancer is at the outlet of your rectum, you may need to have a permanent or temporary colostomy. This involves creating an opening in the wall of your abdomen from a portion of the remaining bowel for the elimination of body waste into a special bag. Sometimes the colostomy is only temporary, allowing your colon or rectum time to heal after surgery. In some cases, however, the colostomy may be permanent.

Surgery for advanced cancer

If your cancer is very advanced or your overall health very poor, your surgeon may recommend an operation to relieve a blockage of your colon or other conditions in order to improve your symptoms. This surgery isn't done to cure cancer, but instead to relieve signs and symptoms, such as bleeding and pain.

In specific cases where the cancer has spread only to the liver and if your overall health is otherwise good, your doctor may recommend surgery to remove the cancerous lesion from your liver. Chemotherapy may be used before or after this type of surgery. This treatment may improve your prognosis.

Chemotherapy

Chemotherapy uses drugs to destroy cancer cells. Chemotherapy for colon cancer is usually given after surgery if the cancer has spread to the lymph nodes. In this way, chemotherapy may help reduce the risk of cancer recurrence.

Chemotherapy can also be given to relieve symptoms of colon cancer that has spread to other areas of the body. Chemotherapy may be used before surgery to shrink the cancer before an operation. In people with rectal cancer, chemotherapy is typically used along with radiation therapy.

Radiation therapy

Radiation therapy uses powerful energy sources, such as X-rays, to kill cancer cells that might remain after surgery, to shrink large tumors before an operation so that they can be removed more easily, or to relieve symptoms of colon cancer and rectal cancer.

Radiation therapy is rarely used in early-stage colon cancer, but is a routine part of treating rectal cancer, especially if the cancer has penetrated through the wall of the rectum or traveled to nearby lymph nodes. Radiation therapy, usually combined with chemotherapy, may be used after surgery to reduce the risk that the cancer may recur in the area of the rectum where it began.

Targeted drug therapy

Drugs that target specific defects that allow cancer cells to grow are available to people with advanced colon cancer, including bevacizumab (Avastin), cetuximab (Erbitux), panitumumab (Vectibix) and regorafenib (Stivarga). Targeted drugs can be given along with chemotherapy or alone. Targeted drugs are typically reserved for people with advanced colon cancer.

Some people are helped by targeted drugs, while others are not. Researchers are working to determine who is most likely to benefit from targeted drugs. Until then, doctors carefully weigh the limited benefit of targeted drugs against the risk of side effects and the expensive cost when deciding whether to use these treatments.