Chronic disorders of the intestine

The Baltimore Sun

About one in 300 people suffer from inflammatory bowel disease, a chronic disorder of the intestines that can cause a variety of symptoms and, in many cases, have a significant impact on a person's lifestyle, says Dr. Raymond K. Cross Jr., a gastroenterologist and director of the Inflammatory Bowel Disease Program at the University of Maryland Medical Center.

What is inflammatory bowel disease?

This is an umbrella term used to describe chronic disorders of the intestines - Crohn's disease and ulcerative colitis - in which your body's immune system essentially attacks the lining of your intestine, forming ulcers. The ulcers then can cause diarrhea, often bloody diarrhea; abdominal pain and intestinal fistulas. [A fistula occurs when the intestine ulcerates and forms a tunnel that can continue until it reaches the surface of a nearby organ or the skin.]

What causes inflammatory bowel disease or IBD?

Why people develop this is not well known. There is certainly a genetic component; 15 to 20 percent of patients have a family history of the disease. Obviously, there are some abnormalities in the immune system involved. And there are triggers that can set off IBD. These can include something that alters the bacteria in the intestine such as a course of antibiotics or other types of drugs, or the diet that we eat here in the West. But once it gets initiated, it doesn't shut off.

What is the difference between these two diseases?

Ulcerative colitis involves the large intestine and presents primarily with bloody diarrhea; it can be seen in patients who have never smoked and in former smokers.

Crohn's is much more complicated; it is more common in smokers. It can present with inflammation and nonbloody diarrhea. It can include the fistulas that we talked about earlier, and it can affect any segment of the intestine: large and small, the stomach or the esophagus.

What typically are the initial symptoms?

Although you can see it in any age group, IBD tends to hit when patients are in their 20s and 30s. They usually have gastrointestinal symptoms - gut symptoms - such as diarrhea, rectal bleeding and abdominal pain. Patients can also have extra-intestinal symptoms such as canker sores in their mouths, forms of arthritis, eye infections, loss of weight, fever, poor appetite.

How is IBD diagnosed?

We take a complete medical history and do an exam, blood work and stool studies. But primarily, we use a colonoscopy, or an upper endoscopy (that goes through the mouth and into the upper GI tract). Ninety-five percent of the time we can see lesions or ulcers and do a tissue biopsy.

What is the treatment?

Patients with mild symptoms (who are still going to work and who aren't delaying social engagements because of symptoms) are treated with antibiotics [and] designer steroids such as Entocort and 5-aminosalicylates. Those with moderate symptoms are treated with steroids such as Prednisone and immune suppressants (6-MP and Imuran).

Those who haven't responded to moderate treatments or who cannot stop taking the steroids or are very sick at presentation are given a different kind of anti-inflammatory medicine, TNF-Alpha inhibitors. These are administered either intravenously or by injection. ...

Medical treatment is ineffective in patients with Crohn's disease who have developed blockages or strictures. In this situation, surgery is required. About 75 percent of patients with Crohn's will need one surgery, 30 percent will need two and 25 percent will need three or more.

What do you typically tell patients when they are diagnosed with IBD?

If they smoke, I try to get them to stop smoking. There are a lot of fad diets out there for people with Crohn's, and I encourage them to use a common-sense diet. I tell them that patients with colitis are at higher risk for common cancers, so we talk about getting routine colonoscopies.

I tell them it is a chronic disease that they are going to have for life. They will have peaks and valleys, and my job is to minimize the valleys so they are more well than sick.

What else should someone coping with IBD know?

That it is important for us to have a team in place to care for them. And this [team approach] is something I think we will see more of in the future.

The team may include a surgeon, a gastrointestinal specialist, a nutritionist, a medical crisis counselor and a dedicated radiologist.

And I try to go over this with [doctors who are in training]: These patients can have many complaints and can take a lot of time. So I tell doctors to imagine that you are a 25-year-old man or woman and you have a perianal fistula or you are having 15 bowel movements a day and need to plan your day around your bowel movements. It can have a devastating effect with depression and maladaptive coping mechanisms.

So we screen for depression, evaluate coping methods and stressors and talk about what is important to the patient. That is why it is important to have a team in place.

Read more about inflammatory bowel disease at

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