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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.

• 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

If you have persistent symptoms such as diarrhea and abdominal pain or cramps, it could be Crohn’s disease. A chronic disorder, Crohn’s disease may cause you to have a wide-range of digestive symptoms that may be mild or severe and may flare up over time.

• What is Crohn’s disease?

  Crohn’s disease is when there is irritation in the intestines. This is a type of inflammatory bowel disease (IBD). It can affect anywhere from the mouth to the anus (end of the bowel).

  Crohn’s disease usually occurs in the last part of the small intestine and the beginning of the colon. Sometimes it can show up in patches anywhere in the intestines though. If the irritation goes on for too long it can cause damage. This damage can be scar which narrows the bowel. Also, the body can form a tunnel going from inside the bowel out to the surface. This is called a fistula and can attach the bowels to other body parts like the skin or bladder. When this happens other problems can occur.

• What is the outlook for people with Crohn’s disease?

  Since Crohn’s disease has no cure, medicines are need to keep it under control. Usually this works and people can go a long time without issues. But sometimes Crohn’s can still flare up even when on medicine. If that happens, different medicines can be tried. It is important to always take your medicine even when you feel good. If the irritation in gut comes back, you may not feel it. If irritation goes on for a long time, damage can happen that may need surgery to fix. The best way stop that is to look for signs of irritation and damage. Seeing your doctor for check-ups can do this and help you feel as good as possible.

  Women who have Crohn’s disease can get pregnant and everything be normal. If you have Crohn’s disease and want to get pregnant, you should talk with your Crohn’s doctor first. The best time to get pregnant is when you are feeling good. This will lower the chances of any problems with the pregnancy. If you do get pregnant when the irritation is bad, that can higher the chances of problems like losing the baby. This is why it’s important to keep the irritation under control after you get pregnant.

• What are the signs and symptoms of Crohn’s disease?

  Signs and symptoms can be mild or severe and can be different. It depends on the part of the digestive tract involved. Symptoms usually build over time but also can happen suddenly.

  The most common symptoms of Crohn’s disease are:

  • Diarrhea
  • Pain and cramping in the abdomen (belly)
  • Feeling tired
  • Feeling the need to have a bowel movement
  • Fever
  • Weight loss

  Other symptoms may include:

  • Blood in the stool
  • Drainage around the anus
  • Joint pain
  • Lack of hunger
  • Nausea and vomiting
  • Pain, redness, or swelling in the eyes
  • Rashes
• When should I see a doctor about Crohn’s disease?

  The signs and symptoms of Crohn’s disease can be like other conditions. If you have any symptoms, or changes in your bowel habits that don’t go away, see your doctor and get checked out.

• What causes Crohn’s disease?

  Doctors don’t know the exact causes of Crohn’s disease. They think certain factors could be involved, such as:

  • Genes: People who have a family member with Crohn’s disease are more likely to get it.
  • Immune system: Infection can start Crohn’s disease. This is by turning the immune system on to attack the bowels but it never turns back off.
• What are the risk factors for Crohn’s disease?

  Risk factors for Crohn’s disease can include:

  • Age: Most people get it are in their twenties, but it can happen at any age.
  • Family history: If you have one parent with Crohn’s disease, odds of getting it are 7 to 10 percent. If both parents have it, the odds go up to 35 percent.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs): While medicines such as aspirin, ibuprofen and naproxen do not cause Crohn’s disease, they can worsen inflammation and make the disease worse.
  • Race and ethnicity: White people and people of Eastern European Jewish (Ashkenazi Jewish) descent are at the highest risk.
  • Smoking: Tobacco use doubles the risk of Crohn’s disease. It also increases the chances of having a more severe form that needs surgery.
  • Location: People who live in more developed countries and cities are also at higher risk.
  • Antibiotics: These can change the healthy bacteria living in the colon. These play a part in how the immune system is working in the intestines.
• Who should be evaluated for Crohn’s disease?

  See your doctor if you have any of the signs, symptoms, or risk factors for Crohn’s disease. Your doctor will perform an exam and testing. This will see if you do have it or another condition instead.

• How is Crohn’s disease diagnosed?

  Your doctor will hear your symptoms, medical history and risk factors. They will also do an exam looking for any signs. No one test for Crohn’s disease exists, but a mixture of tests can rule out other problems and make the diagnosis.

  Tests that you may need:

  • Blood tests: Look for signs of infection, anemia (low blood count), low vitamin levels and abnormal liver tests.
  • Stool samples: Check for blood, inflammation or infections in the stool.
  • CT scans or MRI imaging: X-rays that see parts of the digestive tract in more detail. Can also see other parts of the body too.
  • Barium x-rays: Also an x-ray that shows how the bowel is shaped and looks. Can be done by drinking a liquid or having it put inside your bowel with an enema.

  Doctors may also use diagnostic procedures such as:

  • Colonoscopy or flexible sigmoidoscopy: Using a thin, flexible tube with a lighted camera, your doctor looks at the inside lining of the colon. They can possibly see the lower end of the small intestine as well.
  • Biopsy: Your doctor may perform this during a colonoscopy. A small tissue sample is taken and looked at under a microscope.
  • Upper endoscopy: Also called an esophagogastroduodenoscopy (EGD), this procedure examines the upper part of the digestive tract.
  • Capsule endoscopy: You swallow a pill containing a tiny camera. This takes pictures of the digestive tract. It then sends the pictures to a computer for your doctor to look at.
• What are the treatments for Crohn’s disease?

  Currently, there is no cure for Crohn’s disease. But treatments work differently in different people. There are many goals of treatment. They are to relieve symptoms and improve your quality of life. Also to heal the inflammation and prevent damage.

  Doctors usually start medicines to make symptoms go away. Then you can get medicines to keep it under control and prevent it from coming back.

  Medications

  Your doctor may use one or more medications such as:

  • Steroids: Some decrease inflammation throughout the body by suppressing the entire immune system. Others work just in the bowel and do not affect the immune system.
  • Immunosuppressant medications: These medications reduce the body’s immune response. This reduces inflammation and allows the intestine to heal.
  • Biologic therapies: These medications block the body’s immune response. Doctors typically use biologic therapies to treat moderate to severe Crohn’s disease.
  • Antibiotics: These medications are used if a pocket of pus (called an abscess) or a fistula are present. They may also be used to get rid of harmful bacteria in the intestines that could be making things worse.

  Nutrition therapy

  • In children, special liquid diets can help some in treating Crohn’s disease. But these can be hard to drink and so are usually given through a tube. This is hard to do for a long time for most people.
  • Some people may need fluid nutrition injected through an IV and to not eat or drink anything. This is used in more severe cases.

  Surgery

  If other treatments do not work or if a complication happens, then surgery can be done. This is just a short-term fix though. Surgery will not cure the Crohn’s disease. The surgeon just removes the damaged or abnormal part of the digestive tract and reconnects the healthy areas. About half of the people with Crohn’s disease need surgery over the course of their lifetime.

  Alternative medicine

  Complementary and alternative medicine (CAM) therapies, such as acupuncture, fish oil, or nutritional supplements, have not shown much benefit for treating Crohn’s disease.

• Am I at risk of developing other conditions?

  People with Crohn’s disease can develop problems due to the condition. Others may have side effects from medications. Some common issues include:

  • Anal fissures: A tear in the lining of the anus or in the skin around the anus. This can cause painful bowel movements, blood in the stool, or itching of the anus.
  • Ulcers: These open sores in the digestive tract, can also happen in the mouth, genital area or anus.
  • Fistulae: If ulcers go through the intestinal wall, an abnormal tunnel between different areas can form. Fistulas can lead to drainage, infections, and diversion of food. This can prevent you from getting enough nutrients.
  • Bowel obstruction: Long-term inflammation can cause scar tissue to form. This can thicken and narrow areas of the bowel, blocking the flow of digestive contents. Medications can reduce inflammation and open the narrowed areas. Others require surgery to remove the diseased portion of the bowel instead.
  • Malnutrition: Symptoms of Crohn’s disease may make eating difficult. Intestinal inflammation can prevent proper absorption of vital nutrients that are needed to stay healthy.
  • Colon cancer: Crohn’s disease that affects the colon increases the risk of developing colon cancer. People with Crohn’s disease should have colonoscopies more often than people without this risk factors. In certain situations, your doctor may want to spray a dye in the bowel (this is called “chromoendoscopy”) during your colonoscopy to see better.
• What are some recommendations for living with Crohn’s disease?

  If you have Crohn’s disease, healthy lifestyle habits can help you maintain a good quality of life. Talk to your doctor about:

  • Healthy eating plan: Making some changes can help reduce symptoms. But diet alone cannot be used to treat your Crohn’s disease. Working with a dietician can be helpful to create a healthy eating plan and help you follow it. Dietary changes that help:
  • Eating nutritious foods (fruits, vegetables, whole grains)
  • Drinking plenty of liquids
  • Avoiding carbonated (fizzy) drinks
  • Avoiding a lot of high-fiber foods such as popcorn, vegetable skins, or nuts
  • Avoiding fatty, fried foods, or fast foods
  • Avoiding processed, sugary foods (junk food)
  • Taking vitamins (such as vitamin D or vitamin B12) or other nutritional supplements, if recommended by your doctor
  • Exercise: Make time for regular physical activity each day. Exercise can be as simple as walking for 10 to 20 minutes per day. It can help relieve stress and decrease symptoms.
  • Smoking cessation: Quitting smoking reduces your risk of health complications due to Crohn’s disease.

Ulcerative Colitis

• What is Ulcerative Colitis?

  Ulcerative colitis (UC) is when the lining of the large intestine gets inflamed. The large intestine is made up of the colon and the rectum. When this gets inflamed, symptoms of UC start.

  UC involves the rectum in everyone. But in some people, it can affect the whole colon. UC belongs to a group of diseases called inflammatory bowel diseases. The other main one being Crohn's disease (CD). Though it was once thought that UC and CD were different, as many as 10% of patients can have features of both. This is called IBD-U (IBD-Unclassified).

• What are the symptoms of UC?

  These depend on how bad the inflammation is and the amount of the colon that is involved.

  In mild to moderate inflammation, symptoms can include:

  • blood in the stool,
  • diarrhea,
  • mild abdominal cramps,
  • feeling the urge to go to have a bowel movement, and
  • tenesmus (the feeling that bowels have not emptied even after just going).

  If severe inflammation is present, patients can also get:

  • fever,
  • dehydration,
  • severe abdominal pain,
  • weight loss,
  • loss of appetite or
  • stunted growth (in children and adolescents with UC)
  • may lose control of bowels (have accidents)

  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 may suspect UC based on your symptoms. However, tests will need to be done to make the diagnosis.

  • Blood work is often checked to look for markers of inflammation or anemia (low blood counts). But these tests can be normal in patients with mild disease.
  • Stool samples: Check for blood, inflammation or infections in the stool.
  • Special x-rays and CT scans are usually not recommended but may be performed.
• What endoscopic tests are used to diagnose UC?

  All patients with symptoms of UC should have a colonoscopy or flexible sigmoidoscopy. This will confirm the diagnosis. During this procedure, your doctor will see the lining of your colon and rectum. This can see signs of irritation and small tissue samples (biopsies) can be taken. The samples are looked at under a microscope to see if it is UC.

• What causes UC?

  Why patients get UC is still poorly understood.

  Causes may include a variety of factors:

  • the unique genetic makeup of a person,
  • environmental factors, and
  • a patient's specific immune system
• What is known about risk factors for UC?
  • UC is not an infection that can be passed from person to person.
  • Men and women are affected the same.
  • UC is more common in people who have a first degree relative (sibling, parent, or child) with it. Up to 10% of patients have a family member with UC. Most patients with UC do not pass the disease to their children. But there is no way to predict those at higher risk.
  • Cases of UC have been seen around the world in certain groups. People who live in northern parts and those of Jewish descent, are at higher risk.
  • People having their appendix removed before the age of 20 appear to be at lower risk.
  • A particular infection has not been linked to UC. Diet, breast feeding, and medications have also been looked at, but none have been found to cause it.
  • Some patients develop UC after they quit smoking. It looks like smoking tobacco helps UC, since those who smoke have milder symptoms. This is the opposite of what we see in Crohn’s disease. However, it is not recommended to smoke to try and help UC. This is because smoking causes so many other illnesses and cancers that it is not worth it.
• What are the possible complications of UC?

  The complications of UC can be split into those that affect the colon or other parts of the body.

• What are the complications of UC within the colon?

  Within the colon, UC can rarely lead to colon cancer or toxic megacolon (a rare but potentially deadly widening of the large intestine). 

• What is the risk of Colon Cancer in UC?

  UC is known to increase the risk of colon cancer. Patients with UC symptoms for 8 or more years and those with more of the colon affected are at higher risk. Overall, the risk of colon cancer increases 0.5 percent every year after ten years of disease. Therefore, a colonoscopy is needed every one or two years starting 8 years after symptoms begin.

  Patients with inflammation of the bile ducts, called primary sclerosing cholangitis (PSC), are at highest risk for colon cancer and need a colonoscopy every year as soon as PSC is found.

  Luckily colon cancer is rare in UC. It may not happen if the inflammation of the colon is kept under control. By doing careful colonoscopy exams, biopsies can look for pre-cancerous changes called dysplasia under the microscope. If these are seen, further things can be done to remove it and prevent cancer from forming.

• What are the risks outside of the colon in UC patients?

  Patients with UC are also at risk for extra-intestinal manifestations of UC (complications outside of the colon). These complications often involve the liver, skin, eyes, mouth, and joints.

• What are the complications within the liver in UC patients?

  In the liver, patients may get primary sclerosing cholangitis. This occurs in about 3% of patients with UC. PSC can progress even if UC is not active. It is often detected by increases in liver blood tests. A special MRI scan such as a Magnetic Resonance Cholangiopancreatography (MRCP) can see it. Other times a procedure called an Endoscopic Retrograde Cholangiopancreatography (ERCP) is done.

• What rashes can appear UC patients?

  Patients with UC can develop sores in the mouth or rashes on the skin. These usually appear when UC symptoms are active. The most common rashes that are seen in UC are erythema nodosum (EN) and pyoderma gangrenosum (PG).

  • EN are red, raised, painful areas usually on the legs. If they show up, its usually during flares of UC.
  • PG can also look like raised lesions on the skin. Again, most commonly on the legs. These are different than EN for a few reasons. One is trauma to the skin like a cut can cause them. Also, they can grow into ulcers on the skin. Last, they may or may not be seen during flares of UC.
  • The eyes can become red and painful (uveitis) and vision problems should be reported to your doctor.
• How does UC affect the joints in UC patients?

  Arthritis is commonly associated with UC. It can involve small joints (such as the fingers/toes) or large joints (often the knee). When smaller joints are hurting, they may be going on at the same time as a UC flare. The joints of the spine can be affected as well, but this is less common than it is in Crohn's disease.

• What are mood problems that may impact UC patients?

  Anxiety and depression can be common. This is the same in any chronic condition. UC can be irregular and the need to take daily medicines can be frustrating. Even though these feelings are normal, bad anxiety or depression should be discussed with your doctor. There are many support groups for trouble coping with UC (see the final section).

• What is the clinical course of UC?

  UC can present in different ways. UC is often a chronic, life-long condition. It is often diagnosed between the ages of 11 and 30. Although it can be diagnosed at any age. Early symptoms can be mild and may be confused with other conditions such as Irritable Bowel Syndrome. Other times they are very severe and require a hospital stay and surgery. Usually, symptoms vary over time. There can be times where symptoms are constant. Other times symptoms are fully gone. Rarely though will someone just have a single flare.

  People with a severe first attack or those whose entire colon is affected usually have a more aggressive course. This means more frequent flares and shorter periods of being symptom-free. The good news is that patients are still able to function well. Also, life expectancy is the same as those without UC.

• How is UC treated?

  Medical treatment of UC has two separate goals:

  • the induction of remission (making a sick person feel well), and
  • the maintenance of remission (keeping them well and preventing flare-ups).

  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
  • biologics

  Aminosalicylates are a group of anti-inflammatory medications. Examples include sulfasalazine, mesalamine, olsalazine, and balsalazide. These are used to get rid of inflammation and keep it gone. They are used in mild to moderate UC. They come in both pill and rectal forms (suppositories and enemas). They 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 forms of mesalamine are used more often if UC is just the end of their colon.

  Steroids (prednisone or budesonide) work well to get rid of inflammation. They come in oral, rectal, and intravenous (IV) forms. They can be used in more moderate to severe cases. Some steroids are absorbed into the blood and have a number of side effects. That’s why they are not a good option for long-term use. Side effects include cataracts, osteoporosis (thinning of the bones), mood effects, and increased chance of infections. Others are high blood pressure, high blood sugar and weight gain. Some steroids are less absorbed and work mainly in the colon with less side effects.

  Immunomodulators include medications such as 6-mercaptopurine and azathioprine (thiopurines). These are taken in pill form and absorbed into the bloodstream. They work to just keep inflammation gone but are slow to work. They can take up to two to three months to really help.  Because of this, these are usually combined with other medications (such as steroids). Typically, in those with moderate to severe disease. Frequent blood tests are needed though. That is because these can injure the liver or decrease blood cells. If either happen, they go away after stopping the drug. Other side effects include nausea, rash, inflammation of the pancreas, and, rarely, lymphoma.

  Biologic agents are medications given by IV or a shot, that are used to treat moderate to severe UC. There are several different types.

  • First is anti-TNF drugs. These target an inflammatory protein called “TNF”. They can work for both the induction and maintenance of remission of UC. These include infliximab (Remicade®, Inflectra® and Renflexis®), adalimumab (Humira®) and golimumab (Simponi®). The side effects of these medicines may include an allergic reaction called a "hypersensitivity reaction." There are also rare risks of serious infections with these. Lymphoma is another rare risk. But more recent scientific studies say that this may not be from these medications, but instead due to the thiopurine immune drugs (see above.)
  • The second class is a drug that blocks the body’s ability to send white blood cells (part of your immune system) to the bowel. By doing this it can decrease inflammation. There is currently one therapy that is in this class (vedolizumab (Entyvio®). It can both induce and maintain remission of UC.
  • A third biologic is one that blocks two proteins called interleukins that also cause inflammation in the colon. There is just one therapy in this class (ustekinumab (Stelara ®). Again, it has been shown to induce and maintain remission of UC.

  Tofacitinib is a newer oral drug (not a biological therapy). It too can induce and maintain remission of UC. Tofacitinib (Xeljanz®) works by blocking an enzyme that is needed to turn on inflammation. This drug can work quickly. However, it may increase cholesterol levels. It also may increase the risk of getting the shingles infection (related to chicken pox). This risk can be decreased by getting the shingles vaccine.

  The most recent oral drug that’s not a biologic is called ozanimod. Ozanimod (Zeposia ®) works to block the blood cells that cause inflammation from ever leaving the lymph nodes. This has been shown to help in both moderate and severe UC but can decrease the heart rate or cause swelling of the eye. An electrocardiogram (ECG) should be done before starting. Also, if you have a history of conditions affecting the eye, such as uveitis, you may not be able to use this drug.

  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 drugs are sometimes used in those rare cases of severe UC that don’t respond to anything else. Side effects can include infections and kidney problems. These are only offered at a limited number of hospitals and are usually used for a short period of time. If used, the goal is to get you better long enough to get onto other drugs for long-term.

  Taking Medication for UC as Prescribed: No matter which medication you and your doctor decide on, it is very important to take it as directed. No medical therapy can work if it is not taken. Missing doses can lead to treatments that may have been avoided if not mentioned to your doctor. Plus, uncontrolled inflammation is what causes many of the complications. By taking your medicine, the chances of these happening are decreased.

• What is the role of surgery?

  Surgery in UC is performed for a number of reasons. It is generally considered to cure UC if the entire large intestine is removed. Some common reasons to need the colon removed are:

  • No response to medications
  • Severe side effects of medications
  • No longer able to safely take medications
  • Develop an enlarged colon called toxic megacolon
  • Have many areas of dysplasia (pre-cancerous lesions)
  • Develop cancer of the colon
  • Children who are not growing due to their UC

  Several different surgeries are performed for UC. The choice of surgery depends on what the patient wants and the experience of the surgeon. The most common surgery is total proctocolectomy with ileal pouch anal anastomosis. This is when the whole colon and rectum are removed. Then the small intestine is used to make a new area to hold stool. This new area is called a “J pouch.” This operation usually requires two separate surgeries to complete although it may require three stages in really sick patients.

  Following this surgery, patients can expect five to ten stools a day. This is because they no longer have a colon to store stool. Patients usually feel better because their symptoms are gone, and their medications can be stopped. However, inflammation of the pouch known as pouchitis can still happen afterwards which is usually treated with antibiotics. Women who have this surgery may have a 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 done 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?

  Many alternative therapies have also been studied to treat UC. No studies have suggested that diet can either cause or treat UC. All that is advised is that people eat a well-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, some vitamin deficiencies can also happen in UC patients. For this reason, a multivitamin and a calcium supplement may be needed.

  Probiotics are species of bacteria that are proposed to help the bowel. There have been a number of scientific studies conducted to see how probiotics could help UC. Most of these have not been shown to help UC, so probiotics are usually not recommended.

  Other herbal remedies and alternative therapies have been studied for use in patients with IBD such as curcumin (comes from the herb turmeric) and parasitic worms (helminths). Though studies have shown promise for several alternative therapies, these have not yet been shown to be safe and effective. Therefore, they are currently not used.

• What type of follow-up is required?

  UC is a chronic disease so having a GI doctor with experience in seeing people with UC is best. Many of the medicines used need regular bloodwork. This is to make sure they are not causing any serious problems. Patients with UC have a higher risk of osteoporosis (thinning of the bones). This can be from the disease itself or from long term or frequent steroid use. Therefore, your doctor may recommend checking Vitamin D levels and a bone mineral density test called 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 UC. The ACG website has additional information. The Crohn's and Colitis Foundation has extensive patient information. They also have links to various other social, financial, and medical support groups. Other sources of information include the individual drug company websites, and, most importantly, your doctor.

Authors

Crohn's Disease:
Reviewed by Gary R. Lichtenstein, MD, FACG, University of Pennsylvania, Philadelphia, PA, and David T. Rubin, MD, FACG, University of Chicago, Chicago, IL – June 2019.
Joseph Feuerstein, MD, Beth Israel Deaconess, Boston, MA – Updated April 2021.
Justin A. Crocker, MD, FACG, Duke GI of Raleigh, Raleigh, NC – Updated April 2024.

Ulcerative Colitis:
Richard S. Bloomfeld, MD, FACG, and Sean P. Lynch, MD, Wake Forest University School of Medicine – Published May 2010.
Richard S. Bloomfeld, MD, FACG, Wake Forest University School of Medicine – Updated February 2016.
David T. Rubin, MD, FACG, University of Chicago – Updated June 2019.
Justin A. Crocker, MD, FACG, Duke GI of Raleigh, Raleigh, NC – Updated April 2024.

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 affect any part of the bowel from the mouth to the anus.

• How is Inflammatory Bowel Disease 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 diarrhea, crampy abdominal pain, 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.

	Diet, Nutrition, and IBD - Sunanda V. Kane, MD, MSPH, FACG Is there a special diet for IBD? Nutritional challenges for IBD patients Tips for Self-Management
	Fertility and Reproduction - Sunanda V. Kane, MD, MSPH, FACG Fertility and Reproduction Pregnancy
	New and Emerging Therapies - William J. Sandborn, MD, FACG New and emerging therapies for IBD Outlook for individualized therapies
	Pediatric IBD - Marla C. Dubinsky, MD Challenges Facing Children and Teens with IBD Does IBD Get Better or Worse as you Grow Up? Growth, Development and Body Image Concerns Psychological Aspects of IBD for Children and Teens Thriving with IBD Tips for Parents of a Child or Teen with IBD Will My Child Outgrow IBD?
	The Importance of Clinical Trials - William J. Sandborn, MD, FACG IBD and The Importance of Clinical Trials Patient Success With Trials
	Ulcerative Colitis - Stephen B. Hanauer, MD, MACG Ulcerative Colitis: A Guide for Patients

GastroGirl Podcast with Jacqueline Gaulin