On the surface, our bodies may seem fine. Inside the gut however, there is a continuous war between invaders and our immune system’s defenses. Attackers (bacteria, viruses and toxins) keep arriving in our food and drink. White blood cells in the gut are on constant alert to fight off these attackers.
At the same time, the immune system of the intestine must carefully regulate itself so that it can fight emerging threats without causing injury to the intestine itself.
In some people, however, the intestinal defense systems overreact. The white blood cells of the gut react not only against harmful organisms, but also against organisms that normally live in the intestine and in fact help the intestine be healthy. The white blood cells release inflammatory substances in excessive amounts, thereby causing inflammation and damage to the intestine. The result is inflammatory bowel disease (IBD). IBD is a chronic inflammatory condition of the gastrointestinal tract that produces tissue damage, in the same way that rheumatoid arthritis is an inflammatory condition that injures joints.
Crohn’s and Colitis
There are two main types of IBD: Crohn’s disease and Ulcerative colitis. Crohn’s disease can affect any part of the gastrointestinal tract, from the mouth to the anus. The most common symptoms are abdominal pain, watery diarrhea, weight loss and fever.
Ulcerative colitis, as the name implies, is marked by ulcers, or sores in the colon. People with ulcerative colitis develop bloody diarrhea, abdominal pain and ‘false alarms,’ in which they feel the urge to go to the bathroom but they do not produce a lot of stool.
Inflammatory bowel disease affects up to 1.3 million Americans, according to the Centers for Disease Control and Prevention (CDC). Although they may appear at any time in life, they are diagnosed most frequently in their 20s and 30s, says the CDC.
Culprits in the Genes?
Studies have discovered genes that predispose people to have trouble resisting bacteria. Studies have also shown that patients with IBD have different populations of bacteria in their intestines than people without these diseases.
Recent research has begun to uncover the mechanisms behind IBD. The main mechanism is an abnormal interaction between gut bacteria and the immune system of the gut. Studies have discovered genes that predispose people to have trouble resisting bacteria. Research has also shown that patients with IBD have different populations of bacteria in their intestines than people without these diseases. These are the current leads, but now we have to figure out exactly how the immune system is interacting with these bacteria.
Identifying the most important steps in the disease process will allow researchers to find new ways to attack the problem. The goal is to restore the normal balance between the immune system of the intestine and the bacteria that live within these walls.
Currently, medications are used to regulate the immune system, with the goal of dampening the hyperactivity of white blood cells against bacteria that live inside the gut. In the future, physicians hope to personalize therapy, based on a person’s genes and bacteria.
In the meantime, several IBD triggers are clear. There is emerging agreement that our Western diet, which is high in red meat, animal fats and processed foods, is one of the causes of IBD. Another trigger is antibiotic use during critical periods of life when the immune system is developing and the gut is being colonized with bacteria.
Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) can weaken the intestinal mucosal barrier, which is the wall that protects us from the outside world. Overuse of aspirin and NSAIDs can damage this barrier, allowing harmful agents to enter the trigger inflammation.
In addition, smoking is extremely harmful in patients with Crohn’s disease. Compared to nonsmokers, a smoker with Crohn’s disease can develop severe inflammation and require surgery more frequently.
IBD has many causes, including more than 200 genes, the Western diet, bacteria imbalance, certain medications and cigarette smoking. The “recipe” for the disease differs from person to person, so that every patient should be thought of as having their own unique type of IBD. This means treatment plans need to be individualized. At the Baylor Center for Inflammatory Bowel Diseases, the multidisciplinary treatment team includes a wide range of experts specializing in IBD, including gastroenterologists, pathologists, radiologists, and surgeons on the Baylor University Medical Center medical staff, along with dedicated IBD nurses and nutritionists.
A major advance in IBD treatment came with the anti-TNF drugs, which are also used to treat other inflammatory diseases, including rheumatoid arthritis and psoriasis. These drugs target a central player in the inflammation in the gut called TNF, or tumor necrosis factor.
About 50 percent of patients with Crohn’s disease will require surgery.
About 50 percent of patients with Crohn’s disease will require surgery to remove sections of bowel that have become diseased. Although the patients feel better, the disease often returns. Following surgery, patients have several treatment options to prevent the disease from coming back. It is important to halt this progression because the small intestine is the organ that absorbs nutrients essential to life.
Our team of colon and rectal surgeons on the medical staff at Baylor University Medical Center at Dallas are very experienced in removing as little of the small intestine as possible. The surgeons also specialize in managing other aspects of Crohn’s disease, including perianal disease, that is fistulas and boils around the anus. Perianal disease is especially difficult to manage; failure to manage it successfully necessitates a colostomy. This is why having access to expert gastroenterologist and surgeons is critical.
About 10 percent of patients with ulcerative colitis will require surgery to remove the colon, and their quality of life improves dramatically afterwards.
About 10 percent of patients with ulcerative colitis will require surgery to remove the colon, and their quality of life improves dramatically afterward. The colorectal surgeons on the medical staff at Baylor University Medical Center specialize in a procedure called an ileal pouch anal anastomosis, in which they create a reservoir (or pouch) out of the small intestine and connect it to the anus, thus preserving the natural route of defecation. The pouch serves the same role as the rectum — it stores stool until one decides to have a bowel movement.
Despite advances in treatments, the best approach to IBD is to prevent the disease in the first place. Adopting a Mediterranean-type diet makes good sense, as it promotes overall health and probably prevents the development of IBD. Other preventative steps are to stop smoking, avoid aspirin and other NSAIDs, and manage stress (which increases inflammation in many patients). Once the disease develops, an individualized management plan needs to be put in place that takes into consideration the specific characteristics of the disease in each patient and patient preferences. An excellent rapport between patient and the healthcare team, and patient support and education are critical in order to achieve the goal of restoring health.
The future is hopeful. There are very effective medications to control IBD, and scientists are making discoveries every day. Nowadays, the vast majority of patients with IBD lead normal lives. A cure for IBD is not too far away in the horizon.
Visit our website to learn more information about treatment options for inflammatory bowel diseases.
About the author
Themistocles Dassopoulos, MD, is the medical director of the Baylor Center for Inflammatory Bowel Diseases and a physician on the medical staff at Baylor University Medical Center at Dallas.