Inflammatory Bowel Disease

IBD Podcasts Offer Expert Insight

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ACG experts answer questions on topics of most concern to IBD patients, their caregivers and loved ones. With an emphasis on helping patients live well despite their IBD, the podcasts address reproduction and fertility; diet and nutrition; new and emerging therapies; the importance of clinical trials; and pediatric IBD. Listen Now


What You Should Know

colon-img-smallUlcerative colitis (UC) is a disease marked by inflammation of the lining of the colon and rectum, together known as the large intestine. Learn more

dr-patient-consultCrohn's disease (CD) is a chronic disease that can cause inflammation anywhere from the mouth to the anus anywhere along the lining of the digestive tract. It most commonly affects the small intestine and the colon. Learn more

Audio Podcasts: ACG Experts Answer Common IBD Questions

Dr. Sunanda V. Kane

Insight on Fertility, Reproduction; Diet and Nutrition

Diet, nutrition, fertility and pregnancy issues are a concern for IBD patients and their loved ones. Dr. Sunanda V. Kane offers insight and tips on issues related to IBD and reproduction; as well on diet and nutrition. Listen Now

Dr. William J. Sandborn

New and Emerging Therapies for IBD

Dr. William J. Sandborn offers insight on new and emerging IBD therapies, the importance of clinical trials and the outlook for individualized therapies. Listen Now

Dr. Marla C. Dubinsky

Challenges Facing Children and Teens with IBD

Children and teens with IBD face unique challenges. Dr. Marla C. Dubinsky sheds light on these challenges, including the psychological aspects and offers tips for parents. Listen Now

Physician Resources

ACG IBD Physician Resources

IBD Overview

  • What is the difference between Ulcerative Colitis and Crohn's Disease?

    Ulcerative colitis and Crohn's disease are two types of Inflammatory Bowel Disease (IBD). The large intestine (colon) is inflamed in ulcerative colitis, and this involves the inner lining of the colon. In Crohn's disease the inflammation extends deeper into the intestinal wall. Crohn's disease can also involve the small intestine (ileitis), or can involve both the small and large intestine (ileocolitis).

  • How is IBD different from Irritable Bowel Syndrome?

    IBD develops due to inflammation in the intestine which can result in bleeding, fever, elevation of the white blood cell count, as well as diarrhea and cramping abdominal pain. The abnormalities in IBD can usually be visualized by cross-sectional imaging (for instance a CT scan) or colonoscopy. Irritable Bowel Syndrome (IBS) is a set of symptoms resulting from disordered sensation or abnormal function of the small and large bowel. Irritable Bowel Syndrome is characterized by crampy abdominal pain, diarrhea, and/or constipation, but is not accompanied by fever, bleeding or an elevated white blood cell count. Examination by colonoscopy or barium x-ray reveals no abnormal findings.

  • What is the cause of IBD?

    There is no single explanation for the development of IBD. A prevailing theory holds that a process, possibly viral, bacterial, or allergic, initially inflames the small or large intestine and, depending on genetic predisposition, results in the development of antibodies which chronically "attack" the intestine, leading to inflammation. Approximately 10 percent of patients with IBD have a close family member (parent, sibling or child) with the disease, which lends support to a genetic predisposition in some patients.

  • Is IBD caused by stress?

    Emotional stress due to family, job or social pressures may result in worsening of the Irritable Bowel Syndrome but there is little evidence to suggest that stress is a major cause for ulcerative colitis or Crohn's disease. Although IBD is not caused by stress recent studies show that there may be a relationship between the two--stressful periods in life may lead to a flare of disease activity in persons with the underlying diagnosis of IBD.

  • How is IBD diagnosed?

    There is no single test that can make the diagnosis of IBD or completely rule out its existence reliably. Colonoscopy, cross-sectional imaging studies of the colon or the upper GI tract, along with newer blood tests that detect markers that are commonly associated with IBD, along with a patient's history and physical exam, can all be useful in helping your doctor establish a diagnosis of IBD.

  • What are the complications of IBD?

    Ulcerative colitis and Crohn's disease can lead to diarrhea, bleeding, anemia, weight loss, fevers, malnutrition and fistulae. IBD can also have extra-intestinal manifestations where areas other than your gastrointestinal system such as your skeletal system, your skin or your eyes may be involved.

  • What medical treatments are available for IBD?

    Various formulations of 5-ASA, a drug which has been used to treat IBD for over 50 years, are available as oral preparations, suppositories and enemas. These are often one of the first drugs used to treat IBD.

    Corticosteroid therapies, such as prednisone or hydrocortisone, are given when the 5-ASA products are insufficient to control inflammation. These drugs can be given orally, rectally as suppositories or enemas, or intravenously.
    Drugs which suppress the body's immune response in IBD (known as immunomodulators) are used. Azathioprine and 6-mercaptopurine (6-MP) are the two most commonly used immunomodulators for anti-immune therapy.

    Finally, a newer class of medications called "biologics" is used for patients with moderate to severe disease. Biologics include medications like infliximab (Remicade®), a medication given thru an IV infusion, and adalimumab (Humira®) and certolizumab pegol (Cimzia®), medications given via subcutaneous injection.
  • Are there complications from the medical treatments?

    Sulfasalazine, a 5-ASA product first used to treat IBD in the 1940s, may cause nausea, indigestion or headache in about 15 percent of patients and worsening diarrhea in about 4 percent of patients. The newer drugs have fewer side effects. Chronic corticosteroid therapy can lead to fluid retention and high blood pressure, some rounding of the face and softening of the bones similar to osteoporosis. These complications usually prompt attempts to discontinue corticosteroid treatment as soon as possible. The anti-immune drugs require periodic monitoring of the blood count since some patients will develop a low white blood cell count. These drugs, however, are usually well-tolerated in many patients. Biologics can alter a patient's ability to respond to any stressors to their immune system and in some patients may make it harder for their body to fight off infections.

  • Is diet management important for patients with IBD?

    Physicians prefer to maintain good nutrition for those diagnosed with IBD. If you are responding well to medical management you can often eat a reasonably unrestricted diet. A low-roughage diet is often suggested for those prone to diarrhea after meals. If you appear to be milk sensitive (lactose intolerant), you are advised to either avoid milk products or use milk to which the enzyme lactase has been added.

  • How successful is medical therapy?

    With early and proper treatment the majority of patients with IBD lead healthy and productive lives. Some patients may require surgery for treatment of complications of IBD such as an abscess, bowel obstruction or inadequate response to treatment.

  • What are surgical options for IBD?

    Crohn's disease of the small or large intestine can be treated surgically for complications such as obstruction, abscess, fistula or failure to respond adequately to treatment. The disease may recur at some time after the operation.

    Ulcerative colitis is curable with removal of the entire colon. This may require creating an "ileostomy" (with attachment of the ileum to the external abdominal wall with an external application pouch) or may involve the direct attachment of the small intestine (ileum) to the anus. This type of surgery, known as "IPAA surgery," does not require an external application pouch

Crohn's Disease

  • What is Crohn's Disease?

    Crohn's disease (CD) belongs to a group of diseases collectively called Inflammatory Bowel Disease (IBD) which also includes Ulcerative Colitis (UC). It is a chronic disease that can cause inflammation anywhere from the mouth to the anus anywhere along the lining of the digestive tract. It most commonly affects the small intestine and the colon. The disease can show up along different parts of the digestive tract in a continuous or patchy distribution. It typically involves both the superficial and deep layers of the intestinal wall

  • What are the symptoms of CD?

    Symptoms of CD depend on the severity and location of the intestinal inflammation and can range from none or mild, to severe. Symptoms may develop gradually or come on suddenly, without warning. Abdominal pain and cramping, persistent diarrhea (loose, watery, numerous bowel movements), blood in the stool and fever are hallmark symptoms of CD. Ulcers of the mouth, a lack of appetite, fatigue, nausea and vomiting and unexplained weight loss may also develop. With severe diarrhea and the digestive tracks' inability to absorb nutrients, nutritional deficiencies may occur over time

  • What causes CD?

    We do not yet know an exact cause of CD. Similar to other chronic inflammatory disorders (e.g. asthma, rheumatoid arthritis, psoriasis, multiple sclerosis) there is a complex interaction between an individual's genetic make-up, their immune system and foreign substances in the environment (including dietary factors and microbes living in our gut) that are responsible for the chronic uncontrolled inflammation in CD. The impact of the various factors (genes, immune system and environment) are different for each individual accounting for the broad spectrum of how patients present with inflammation in different segments of the intestine and in various degrees of severity. Unfortunately, it appears as if once this inflammatory process is set in motion it cannot be regulated or reversed by the body itself

  • Who gets CD and how common is it?

    CD affects about 500,000 Americans. Men and women appear to be affected equally. Symptoms usually start between the ages of 15-35 but can develop at any time during one's lifetime. It used to be thought that CD predominantly affects Caucasians in North America and Western Europe, however, we now see individuals being diagnosed with CD in populations from South America, Africa and Asia where the disease was unheard of 20 years ago.

    CD can run in families and having a sibling or another first degree relative afflicted with the disease can increase the risk of developing the disease by ten to fifteen times as compared to the general population. Some important genetic mutations have been identified in this disease including the NOD2/CARD 15 genes. However, more than 80% of patients with CD do not have a recognized genetic disposition. Given the complex genetic makeup the disease it is not inherited in the classic sense.

    Smoking is an important controllable risk factor in CD. People who smoke with this disease tend to have more severe forms of the disease and are at higher risk of needing surgery. People who live in industrialized countries and urban areas are also at elevated risk of having the disease. Some other factors including the use of medications such as non-steroidal anti-inflammatory drugs (aspirin-like drugs) and particular infections have been theorized to exacerbate or cause the disease although none have been shown in a consistent fashion to be the cause

  • How is CD diagnosed?

    There is no single test to confirm the diagnosis of CD. Instead, multiple tests are usually used in combination to help arrive at the diagnosis depending on the symptoms that lead individuals to seek care. Ultimately, a colonoscopy or flexible sigmoidoscopy must be performed to directly visualize the intestine internally and to obtain small tissue samples (biopsies) for evaluation under the microscope. Other imagines studies can be used in conjunction with a colonoscopy to help in the evaluation including a barium enema, upper gastrointestinal series (UGI series) with small bowel follow through, computerized tomography scans (CT scans or 'cat scans'), magnetic resonance imaging (MRI) or a pill camera study (capsule endoscopy) but are not mandated. Blood tests which look for antibodies and markers of inflammation along with stool specimen tests for hidden blood and infection may also be used to help confirm or exclude the diagnosis of CD

  • What complications should I watch out for in CD?

    CD may cause symptoms outside the digestive tract including: inflammation of the eye (conjunctivitis, episcleritis, uveitis, iritis), inflammation of joints (arthritis), weakening of bones (osteoporosis), skin rashes (erythema nodosum, pyoderma gangrenosum), inflammation of the liver or bile ducts (primary sclerosing cholangitis), kidney stones, gallstones and in children, delayed growth or sexual development due to the use of steroids, malnutrition and malabsorption. Crohn's disease may also lead to several complications over time which may be related to the disease or due to the effects of medications used to treat the disease. Listed below are some of the common complications:

    1. Anal fissure. A crack, or cleft, in or around the skin of the anus which lead to painful bowel movements, blood in the stool and sometimes drainage around the anal canal.
    2. Ulcers. Chronic inflammation can lead to open sores (ulcers) anywhere in the digestive tract, including the mouth, genital area (perineum) and anus.
    3. Fistulas. Sometimes ulcers can extend completely through the intestinal wall, creating a fistula — an abnormal tunnel between different parts of the intestine, between the intestine and skin or other organs, such as the bladder or vagina. These abnormal connections affect up to a third of patients with CD. Internal connections lead to diversion of food contents while external connections can lead to drainage and infections. When a course of medical therapy fails, surgery may be necessary to fix these abnormal connections.
    4. Bowel obstruction. Due to inflammation over time, parts of the bowel could form scar tissue resulting in a thickening and narrowing of the bowel, which may block the flow of digestive contents through the affected part of the intestine. Medications may be of help in decreasing the inflammation and opening up the narrowed areas but some cases require surgery to remove the disesed portion of the bowel.
    5. Malnutrition. Symptoms of diarrhea, pain and cramping may make it difficult to eat. In addition, inflammation of the intestine can decrease absorption of vital nutrients needed to maintain nourishment. Deficiencies of proteins, calories and vitamins may occur over a prolonged period of time. Vitamin B-12 and iron deficiency frequently lead to anemia in patients with malnutrition.
    6. Colon cancer. Patients with Crohn's disease that involves the colon do have an increased risk of colon cancer depending upon the amount of the colon that is affected and the duration of disease. Less than 5% of patients develop colon cancer although this is higher than the general population. Therefore, after approximately 8 years from the start of symptoms a colonoscopy is performed every 1 to 2 years to look for precancerous changes called dysplasia. Identifying dysplasia allows the potential to remove dysplastic growths (polyps) prior to the development of cancer.
  • What are different types of treatment for CD?

    Currently, there is no cure for CD and the goal of treatment is to alleviate symptoms, prevent complications and improve quality of life. This can be achieved through suppression of the body's immune response which is paramount to allow the intestinal tissue to heal and retain its normal function. Initially, the goal is to induce remission, which is to bring the symptoms under control. Once this step is achieved, medical therapy is used to maintain remission with the goal of decreasing the frequency of disease flares. Several groups of drugs are used to treat Crohn's disease and are listed below:

    1. Aminosalicylates (5-ASA): This class of anti-inflammatory drugs is often used to treat mild to moderate symptoms in the colon and includes oral formulations of sulfasalazine and mesalamine (Apriso®, Asacol®, Colazal®, Dipentum®, Pentasa®, or Lialda®) and drugs that may be administered rectally (Canasa® or Rowasa®).
    2. Corticosteroids: This class of medications has a general, nonspecific effect of suppressing the entire immune system and is used to treat moderate to severe forms of the disease. Prednisone, budesonide and methylprednisolone are most commonly used. These are drugs that are best utilized short-term to alleviate major flares of the disease and due to side effects, these should not be used for maintenance therapy. Owing to a significantly increased risk of osteoporosis with the use of corticosteroids, a baseline DEXA scan should be performed at the initiation of therapy. Supplementation of calcium and vitamin D, and consideration of a bisphosphonate are also warranted.
    3. Immune modifiers: Azathioprine (Imuran®), 6-MP (Purinethol®), cyclosporine A and methotrexate alter the immune system and are also referred to as immunomodulators, used to help decrease exposure to corticosteroids, maintain disease remission and to help heal fistulas.
    4. Antibiotics: These are classically used to treat perianal disease, abscesses and sometimes acute flares of the disease. Metronidazole and ciprofloxacin are the most commonly used.
    5. Biologic therapies. This newer group of medications was first approved in 1998 for moderate to severe CD that did not respond to conventional therapy or to treat fistulae. These medications work by blocking specific chemical messages between immune cells. Infliximab (Remicade®) was the first biologic therapy to treat inflammatory bowel disease and since 2007, adalimumab (Humira®), Natalizumab (Tysabri®) and Certolizumab pegol (Cimzia®) have all been approved by the FDA to treat patients with CD. These medications primarily differ in their composition and schedule of administration. They are all given through infusion or injection therapy. These medications are more costly than conventional agents and also suppress the immune system leading to a small, but significant increased risk of infections and, rarely, to lymphomas.
  • Is there a role for surgery in CD?

    Surgery does not cure CD but is currently required at some point in the course of a majority of patients (up to 80%) with CD over their lifetime. Common indications for surgery include presence of an intestinal obstruction, formation of an abscess or fistula. Surgery also becomes necessary in CD when medications can no longer control the symptoms. Usually, the severely affected part of the intestine is removed and the two ends are reconnected. If there is extensive disease of the colon in CD, the entire colon may be removed and an end-ileostomy (end of the small intestine attached to the skin with an external bag to collect the contents) may be performed. The overall goal of surgery in CD is to conserve bowel and maintain the best possible quality of life. Most patients who require surgery will have marked improvements in their symptoms, reduction in their medications and an improvement in their quality of life

  • What is the clinical course and prognosis in CD?

    Most people with CD with the proper medical care tend to live healthy, productive lives with a normal life span. Maintenance of remission and surveillance for complications are the major goals which lead to maintaining quality of life in patients with CD. Regular visits with a gastroenterologist and developing a longstanding relationship are vital to managing this disease

  • Can women with CD have children?

    A healthy pregnancy, childbirth and baby are possible in women with CD. Well controlled CD does not increase the risk of miscarriages, stillbirths or congenital abnormalities. The goal during pregnancy is to prevent and treat flares aggressively to decrease any increased risk to the fetus during a flare

  • What can I do to improve my health in CD?

    Diet, nutrition, stress and lifestyle modifications can all lead to improved quality of life in patients with CD. Unfortunately, there is no single diet that is appropriate for all patients with CD and dietary advice will depend upon the location of intestinal inflammation and the associated symptoms. There is no factor in the diet that we know causes inflammation, but dietary components can certainly cause or worsen symptoms. Healthy diets (avoiding fatty and fried foods), and adequate intake of protein improve symptoms and maintain nutrition. Some patients will not tolerate milk products (containing the milk sugar – lactose) or other concentrated sugars such as fructose (corn syrup). Taking multivitamins and speaking to a dietician also can be of great benefit. Exercise and stress management can decrease flares and help moderate the disease. Smoking should be stopped by all who have CD or are at increased risk of developing CD. A group of medications, known as NSAIDS (aspirin, ibuprofen, naproxen), should also be avoided as they can worsen CD in some patients

  • What are the chances my child will have CD if I do?

    Children who have one parent with CD have approximately a 7-10% lifetime risk of developing this disease. If both parents have the disease then the lifetime risk increases to 35%

  • Do complementary and alternative therapies work in CD?

    Many alternative therapies have been tried in CD due to either the lack of effectiveness of primary medical therapies or side effects of common therapies. Acupuncture, hypnosis, herbal supplements, fish oil, probiotics and other home remedies have been reported. Unfortunately, most of these remedies have shown no significant benefit, have never been rigorously studied and are not regulated by the FDA

  • Where can I get more information on CD?

    Many organizations exist which provide support and information for patients with CD. The ACG Web site has additional information. The Crohn's and Colitis Foundation of America (www.ccfa.org) has extensive patient information along with links to various different social, financial, and medical support groups. Other sources of information include the individual drug company Web sites, and, most importantly, a personal physician.

Ulcerative Colitis

  • What is Ulcerative Colitis?

    Ulcerative colitis (UC) is a disease marked by inflammation of the lining of the colon and rectum, together known as the large intestine. This inflammation causes irritation in the lining of the large intestine which leads to the symptoms of UC. Though UC always affects the lowest part of the large intestine (the rectum), in some patients it can be present throughout the entire colon. UC belongs to a group of diseases called inflammatory bowel diseases which also includes Crohn's disease (CD). Though it was once thought that UC and CD were two different diseases, as many as 10% of patients may have features of both diseases and this is called indeterminate colitis. It is important to note that inflammatory bowel disease (IBD) is different from irritable bowel syndrome (IBS).

  • What are the symptoms of UC?

    The symptoms of ulcerative colitis depend on the severity of inflammation and the amount of the colon that is affected by the disease. In patients with mild to moderate inflammation, symptoms can include rectal bleeding, diarrhea, mild abdominal cramping, stool urgency, and tenesmus (discomfort and the feeling that you have not completely emptied your rectum after a bowel movement). When more severe inflammation is present, patients often develop fever, dehydration, severe abdominal pain, weight loss, loss of appetite or growth retardation (in children and adolescents with UC). Individuals with moderate or severe inflammation may also have to wake up at night to have bowel movements and may lose control of bowel movements. Some of the symptoms of UC may be non-specific and could be caused by other diseases such as Crohn's disease, irritable bowel syndrome, or infection. Your doctor can help determine the cause of your symptoms and should be consulted should you experience a significant change in your symptoms.

  • How is UC diagnosed?

    Your doctor will usually suspect the diagnosis of ulcerative colitis based on your symptoms, but confirmation of the diagnosis requires testing. Blood work is often checked to look for markers of inflammation or anemia (low blood counts), though these tests can be normal in patients with mild disease. Tests of your stool to look for evidence of an intestinal infection are often obtained. Radiologic images including x-rays and CT scans are usually not recommended but may be performed. All patients with symptoms consistent with UC should have a colonoscopy or flexible sigmoidoscopy to confirm the diagnosis assuming that they are healthy enough to undergo the procedure. During this procedure, your gastroenterologist will be able to directly examine the lining of your colon and rectum to look for evidence of inflammation and take small biopsies to be examined under a microscope to look for the cause of the inflammation.

  • What causes UC?

    The way in which patients get ulcerative colitis is still poorly understood. There seems to be an interaction between the unique genetic makeup of an individual, environmental factors, and a patient's specific immune system that triggers the disease. UC is not an infection that can be passed from person to person. Men and women are equally affected by UC.

    UC is more common in first degree relatives (siblings, parents, and children) of patients affected by UC and up to 20% of patients will have an affected family member. Despite the influence of genetics, the majority of patients with UC do not pass the disease to their children. There is no way to predict those at higher risk. Cases of ulcerative colitis have been identified throughout the world though certain populations, including those living in Northern climates and those of Jewish descent, are at higher risk of developing UC.

    Individuals having their appendix removed prior to the age of 20 appear to be at lower risk of developing UC. No specific infectious agent has been linked to UC and diet, breast feeding, and various medications have also been examined but none have been found to cause UC.

    It has been observed that smokers have lower rates of UC than non-smokers. Furthermore, those who smoke and have UC tend to have a milder course of UC than those who do not smoke (note that this is the exact opposite effect that smoking has on Crohn's disease). Despite the protective role smoking appears to have on the development and natural history of UC, it is not recommended that patients start smoking to prevent UC due to the fact that there are so many other illnesses and cancers in which smoking is a definite risk factor.

    UC is an immune-mediated disease in which there is loss of control of the normal bowel immune activity and the ongoing activity results in damage to the bowel wall.

  • What are the possible complications of UC?

    The complications of ulcerative colitis can be divided into those affecting the colon and those occurring outside of the colon. Within the colon, UC can rarely lead to toxic megacolon or colon cancer.

    Toxic megacolon describes a severe disease flare with a high risk of infection and colonic perforation (holes in the colon). Patients may occasionally present with toxic megacolon as their initial presentation of UC and this complication requires hospitalization and may lead to surgery to remove the colon (colectomy).

    UC is known to increase the risk of colon cancer. Those patients who have had UC for a long time and those with a longer length of the colon affected are at higher risk of developing colon cancer. In general, patients begin to have an increased risk of colorectal cancer 10 years after the onset of disease symptoms and should have colonoscopy every one or two years starting at this time. Colon cancer is a rare complication and it is thought that it may be preventable based on control of inflammation of the colon and careful colonoscopy examinations that look for any pre-cancerous changes called dysplasia. Overall, the risk of colon cancer increases 0.5% yearly after 10 years of disease though patients with inflammation throughout their colon may be at higher risk. Those patients with primary sclerosing cholangitis (PSC) are at greatest risk for colon cancer and need to start screening upon diagnosis.

    Patients with UC are also at risk for extra-intestinal manifestations of UC (complications outside of the colon). These complications most frequently involve the liver, skin, eyes, mouth, and joints. Within the liver, patients with UC may develop primary sclerosing cholangitis. This occurs in about 3% of patients with UC. PSC can progress even if UC is not active and it is often detected by elevations in liver blood tests and confirmed by the use of MRI scans such as Magnetic Resonance Cholangiopancreatography (MRCP) or endoscopic procedures such as Endoscopic Retrograde Cholangiopancreatography (ERCP).

    Patients with UC can develop sores in the mouth or rashes on the skin that generally only appear when UC colon symptoms are active. The most common rashes that are seen in UC are erythema nodosum (EN) and pyoderma gangrenosum (PG). EN usually presents as a red, raised, painful area most commonly on the legs and is most often seen during flares of UC. PG also presents as raised lesions on the skin (most frequently on the legs) that often develops after trauma to the skin and can lead to the formation of ulcers. Unlike in EN, the appearance of skin lesions in PG may or may not mirror the activity of bowel symptoms. The eyes can become red and painful (uveitis) and vision problems should be reported to your doctor.

    Arthritis is commonly associated with UC and can affect either small (such as the fingers/toes) or large joints (often the knee), though involvement of the smaller joints may have a course that is not related to activity in the colon. The joints of the spine can be affected as well, though this is less common than it is in Crohn's disease.

    As in other chronic medical conditions, anxiety and depression are common in patients with UC. The unpredictability of UC and the need to take medications on a daily basis can lead to feelings of frustration or anger. Though occasional feelings of frustration can be normal, feelings of significant anxiety or depression should be brought to the attention of your physician. There are many support opportunities available for those having trouble coping with UC (see the final section).

  • What is the clinical course of UC?

    Ulcerative colitis can present in a variety of ways. UC is often a chronic, life-long condition. It most often is diagnosed in the 2nd and 3rd decades of life (ages 11-30), although it can be diagnosed at any age. The initial presentation can be mild and is sometimes confused with other conditions such as irritable bowel syndrome or it can be very severe and require hospitalization and surgery. For most patients, UC tends to follow a course marked by periods of disease activity followed by variable periods during which a patient is symptom free. Some patients may have continuous disease activity. Rarely, a patient will have only a single disease flare. In general, those people with a severe first attack of UC and those who have their entire colon affected by UC tend to have a more aggressive course with more frequent flares and shorter periods of remission. Despite the chronic nature of UC, most patients are able to function well and the life expectancy of a patient with UC is normal.

  • How is UC treated?

    Medical treatment of ulcerative colitis generally focuses on two separate goals: the induction of remission (making a sick person well) and the maintenance of remission (keeping a well person from getting sick again). Surgery is also a treatment option for UC and will be discussed separately. Medication choices can be grouped into four general categories: aminosalicylates, steroids, immunomodulators, and biologics.

    Aminosalicylates are a group of anti-inflammatory medications (sulfasalazine, mesalamine, olsalazine, and balsalazide) used for both the induction and maintenance of remission in mild to moderate UC. These medications are available in both oral and rectal formulations and work on the lining of the colon to decrease inflammation. They are generally well tolerated. The most common side effects include nausea and rash. Rectal formulations of mesalamine (enemas and suppositories) are generally used for those patients with disease at the end of their colon.

    Steroids (prednisone) are an effective medication for the induction of remission in moderate to severe UC and are available in oral, rectal, and intravenous (IV) forms. Steroids are absorbed into the bloodstream and have a number of severe side effects that make them unsuitable for chronic use to maintain remission. These side effects include cataracts, osteoporosis, mood effects, an increased susceptibility to infection, high blood pressure, weight gain, and an underactive adrenal gland.

    Immunomodulators include medications such as 6-mercaptopurine and azathioprine. These are taken in pill form and absorbed into the bloodstream. They are effective for maintenance of remission in moderate to severe ulcerative colitis, but are slow to work and can take up to 2-3 months to reach their peak effect. Because of this, these medications are often combined with other medications (such as steroids) in patients who are very ill. These medications require frequent blood work as they can cause liver test abnormalities and low white blood cell counts, both of which are reversible when the medication is stopped. Adverse reactions can include nausea, rash, liver and bone marrow toxicity, pancreatitis, and rarely lymphoma.

    Biologic agents are medications given by injection that are used to treat moderate to severe UC. At the current time, infliximab (Remicade®) is the only biologic agent approved for use in UC, but other biologics used for Crohn's disease under evaluation for the treatment of UC include adalimumab (Humira®), and certolizumab pegol (Cimzia®). Infliximab is effective in both the induction and maintenance of remission in UC. The side effects of this medicine may include an allergic reaction to the medication called an "infusion reaction" or "hypersensitivity reaction". There are also rare risks of serious infections with these medications. Lymphoma is a rare risk of these therapies as well. Combination therapy with azathioprine/6-mercaptopurine and biologics increases the risk of a particularly rare type of lymphoma called hepatosplenic T-cell lymphoma. As with all medications, you should discuss the risks and benefits with your doctor.

    Other medications used less frequently for UC include cyclosporine and tacrolimus. These agents are sometimes used in those rare cases of severe UC that are not responsive to steroids. Side effects of these agents include infections and kidney problems. These agents are offered at a limited number of hospitals and are usually used for a short period of time as a bridge to other maintenance therapies such as azathioprine or 6-mercaptopurine.

    No matter which medical therapy you and your doctor decide upon, adherence with the prescribed course is essential. No medical therapy can work if it is not taken and failure to take your medications can lead to unnecessary escalation of therapy if it is not brought to the attention of your doctor. Because many of the complications associated with UC are related to ongoing disease activity, good medication adherence may minimize these risks.

  • What is the role of surgery?

    Surgery in ulcerative colitis is performed for a number of reasons and is generally considered to be curative if the entire large intestine removed. Patients who do not respond to medications, are concerned about or have unacceptable side effects from medications, develop toxic megacolon, dysplasia (precancerous lesions) or cancer, or children who are not growing because of UC are often considered for surgery. Several different surgeries are performed for UC and the choice of surgery is dependent on patient preference and the experience of the surgeon. The most common surgery is total proctocolectomy with ileal pouch anal anastomosis (total removal of the colon and rectum with creation of a pseudo-rectum from a portion of the small intestine). This operation usually requires two separate surgeries to complete although it may require three stages in severely ill patients. Following this surgery, patients can expect 5-10 stools daily as they no longer have a colon to store stool. Patients usually feel better because their sense of stool urgency improves, they no longer have bleeding, and their medications can often be stopped. However, these patients are at risk for post-operative inflammation of the pouch known as pouchitis which is usually treated with antibiotics. Women who have this surgery may have decreased ability to get pregnant naturally.

    Another common surgical procedure involves a proctocolectomy with ileostomy (removal of the entire colon and rectum and connection of the small intestine to the abdominal wall so that stool empties into a bag). This procedure is often undertaken in elderly patients, obese patients or those with anal dysfunction. Should you need a surgical procedure for UC, your surgeon can help you decide which type of surgery best fits your needs.

  • Do complementary and alternative therapies work in UC?

    Outside of the standard medical therapies discussed for ulcerative colitis, many alternative therapies have been studied. No studies have suggested that diet can either cause or treat UC and there is no specific diet that patients with UC should follow though it is advisable to eat a balanced diet. Likewise, there is no convincing evidence that UC results from food allergies. Though vitamin and mineral deficiencies are more common in Crohn's disease, specific deficiencies can occur in UC patients. For this reason, a multivitamin and a calcium supplement are not unreasonable. Malnutrition can become a concern in severe UC.

    Probiotics are species of bacteria that are thought to have beneficial properties for the bowel. There are a number of scientific studies which have been performed to assess the role of probiotics in UC, and most of these have not shown benefit. There is some evidence, however, that a specific probiotic (VSL #3) may be helpful as an additive to other therapies for maintenance of remission.

    Various other herbal remedies and alternative therapies have been studied for use in patients with IBD such as curcumin (a derivative of the herb tumeric) and parasitic worms (helminths). Though limited studies have shown promise for a number of alternative therapies, these have not yet been shown to be safe and effective and are not currently recommended. Studies of homeopathic compounds are currently ongoing and will hopefully provide novel treatments for use in UC in the future.

  • What type of follow-up is required?

    As mentioned earlier, ulcerative colitis is a chronic disease and establishing a long term relationship with a gastroenterologist experienced in the treatment of UC is advisable. Many medications used in UC require regular blood work to ensure that they are not causing any serious side effects. Patients with UC have a higher risk of osteoporosis associated with both underlying disease activity and long term or frequent steroid use. Because of this risk, your doctor may recommend measurement of Vitamin D blood levels and a bone mineral density screening with a DEXA scan. Colorectal cancer screening is also important because of the higher risk of cancer in patients with UC as discussed earlier.

  • Where can you get more information?

    Many organizations provide support and information for patients with ulcerative colitis. The ACG Web site has additional information. The Crohn's and Colitis Foundation of America (www.ccfa.org) has extensive patient information along with links to various different social, financial, and medical support groups. Other sources of information include the individual drug company Web sites, and, most importantly, your personal physician.

Authors

Crohn's Disease:
Bhavik M. Bhandari, MD and Joyann A. Kroser, MD, FACG, Drexel University College of Medicine, Philadelphia, PA – Published March 2011.

Ulcerative Colitis:
Richard S. Bloomfeld, MD, FACG, and Sean P. Lynch, MD, Wake Forest University School of Medicine, Winston-Salem, NC – Published May 2010.

IBD FAQs

  • What is the difference between ulcerative colitis and Crohn's Disease?

    Ulcerative colitis and Crohn's disease are two types of Inflammatory Bowel Disease (IBD). The large intestine (colon) is inflamed in ulcerative colitis, and this involves the inner lining of the colon. In Crohn's disease the inflammation extends deeper into the intestinal wall. Crohn's disease can also involve the small intestine (ileitis), or can involve both the small and large intestine (ileocolitis).

  • How is IBD different from Irritable Bowel Syndrome?

    IBD develops due to inflammation in the intestine which can result in bleeding, fever, elevation of the white blood cell count, as well as diarrhea and cramping abdominal pain. The abnormalities in IBD can usually be visualized by cross-sectional imaging (for instance a CT scan) or colonoscopy. Irritable Bowel Syndrome (IBS) is a set of symptoms resulting from disordered sensation or abnormal function of the small and large bowel. Irritable Bowel Syndrome is characterized by crampy abdominal pain, diarrhea, and/or constipation, but is not accompanied by fever, bleeding or an elevated white blood cell count. Examination by colonoscopy or barium x-ray reveals no abnormal findings.

  • What is the cause of IBD?

    There is no single explanation for the development of IBD. A prevailing theory holds that a process, possibly viral, bacterial, or allergic, initially inflames the small or large intestine and, depending on genetic predisposition, results in the development of antibodies which chronically "attack" the intestine, leading to inflammation. Approximately 10 percent of patients with IBD have a close family member (parent, sibling or child) with the disease, which lends support to a genetic predisposition in some patients.

  • Is IBD caused by stress?

    Emotional stress due to family, job or social pressures may result in worsening of the Irritable Bowel Syndrome but there is little evidence to suggest that stress is a major cause for ulcerative colitis or Crohn's disease. Although IBD is not caused by stress recent studies show that there may be a relationship between the two--stressful periods in life may lead to a flare of disease activity in persons with the underlying diagnosis of IBD.

  • How is IBD diagnosed?

    There is no single test that can make the diagnosis of IBD or completely rule out its existence reliably. Colonoscopy, cross-sectional imaging studies of the colon or the upper GI tract, along with newer blood tests that detect markers that are commonly associated with IBD, along with a patient's history and physical exam, can all be useful in helping your doctor establish a diagnosis of IBD.

  • What are the complications of IBD?

    Ulcerative colitis and Crohn's disease can lead to diarrhea, bleeding, anemia, weight loss, fevers, malnutrition and fistulae. IBD can also have extra-intestinal manifestations where areas other than your gastrointestinal system such as your skeletal system, your skin or your eyes may be involved.

  • What medical treatments are available for IBD?

    Various formulations of 5-ASA, a drug which has been used to treat IBD for over 50 years, are available as oral preparations, suppositories and enemas. These are often one of the first drugs used to treat IBD.

    Corticosteroid therapies, such as prednisone or hydrocortisone, are given when the 5-ASA products are insufficient to control inflammation. These drugs can be given orally, rectally as suppositories or enemas, or intravenously.
    Drugs which suppress the body's immune response in IBD (known as immunomodulators) are used. Azathioprine and 6-mercaptopurine (6-MP) are the two most commonly used immunomodulators for anti-immune therapy.

    Finally, a newer class of medications called "biologics" is used for patients with moderate to severe disease. Biologics include medications like infliximab (Remicade®), a medication given thru an IV infusion, and adalimumab (Humira®) and certolizumab pegol (Cimzia®), medications given via subcutaneous injection.
  • Are there complications from the medical treatments?

    Sulfasalazine, a 5-ASA product first used to treat IBD in the 1940s, may cause nausea, indigestion or headache in about 15 percent of patients and worsening diarrhea in about 4 percent of patients. The newer drugs have fewer side effects. Chronic corticosteroid therapy can lead to fluid retention and high blood pressure, some rounding of the face and softening of the bones similar to osteoporosis. These complications usually prompt attempts to discontinue corticosteroid treatment as soon as possible. The anti-immune drugs require periodic monitoring of the blood count since some patients will develop a low white blood cell count. These drugs, however, are usually well-tolerated in many patients. Biologics can alter a patient's ability to respond to any stressors to their immune system and in some patients may make it harder for their body to fight off infections.

  • Is diet management important for patients with IBD?

    Physicians prefer to maintain good nutrition for those diagnosed with IBD. If you are responding well to medical management you can often eat a reasonably unrestricted diet. A low-roughage diet is often suggested for those prone to diarrhea after meals. If you appear to be milk sensitive (lactose intolerant), you are advised to either avoid milk products or use milk to which the enzyme lactase has been added.

  • How successful is medical therapy?

    With early and proper treatment the majority of patients with IBD lead healthy and productive lives. Some patients may require surgery for treatment of complications of IBD such as an abscess, bowel obstruction or inadequate response to treatment.

  • What are surgical options for IBD?

    Crohn's disease of the small or large intestine can be treated surgically for complications such as obstruction, abscess, fistula or failure to respond adequately to treatment. The disease may recur at some time after the operation.

    Ulcerative colitis is curable with removal of the entire colon. This may require creating an "ileostomy" (with attachment of the ileum to the external abdominal wall with an external application pouch) or may involve the direct attachment of the small intestine (ileum) to the anus. This type of surgery, known as "IPAA surgery," does not require an external application pouch

IBD Podcasts and Videos

ACG experts answer questions on topics of most concern to IBD patients, their caregivers and loved ones. With an emphasis on helping patients live well despite their IBD, the podcasts address reproduction and fertility; diet and nutrition; new and emerging therapies; the importance of clinical trials; and pediatric IBD.

Marla C. Dubinsky, MD

Fertility and Reproduction - Sunanda V. Kane, MD, MSPH, FACG

Marla C. Dubinsky, MD

New and Emerging Therapies - William J. Sandborn, MD, FACG

Marla C. Dubinsky, MD

The Importance of Clinical Trials - William J. Sandborn, MD, FACG