What is Inflammatory Bowel Disease (IBD)?
Inflammatory Bowel Disease (IBD) is characterized by long-term, repetitive episodes of inflammation in the digestive tract tissues caused by an abnormal immune response.
Roughly 10 million people worldwide live with IBD, and cases are growing. Researchers believe this may be associated with the spread of the Western diet and lifestyle across the globe.
What are the types of IBD?
IBD generally refers to two conditions, Crohn’s Disease (CD) and ulcerative colitis (UC), although there are a number of subtypes. Crohn’s disease and UC are differentiated by the location and depth of inflammation in the intestinal wall.
Crohn’s disease (CD) can affect any part of the gut (from the mouth to the rectum), although it usually develops in the ileum (the last segment of the small intestine).
In Crohn’s disease, the areas of inflammation are often patchy “skip lesions”, leaving sections unharmed. However, all layers of the intestinal wall can be inflamed. This is called transmural inflammation.
Crohn’s can cause strictures, which means the bowel walls have thickened or have been scarred to the point that the gut lumen has narrowed. Crohn’s may also lead to fistulas, which are small tunnels that can develop between the bowel and other organs.
Common symptoms of Crohn’s disease include diarrhea, abdominal pain, vomiting, and weight loss.
Ulcerative colitis (UC) can affect the entire colon (large intestine), however, the inflammation commonly starts developing in the rectum and lower colon.
Unlike Crohn’s disease, inflammation in UC has a continuous pattern and impacts the inner lining of the intestine (the mucosal lining), but does not reach the deeper layers or spread to other parts of the gastrointestinal tract. UC can cause ulcers (tiny open sores) in the intestinal lining.
The most obvious symptom of ulcerative colitis will be bloody stools and diarrhea.
Other Types of IBD
In roughly 2-3% of patients, IBD affecting the colon shares features of both UC and Crohn’s, making it hard to determine if it’s one or the other. Such patients are classified as having indeterminate or unclassified colitis but are generally treated similarly to those with UC.
Subtypes of Colitis
Colitis literally means ‘inflammation of the colon’ and can be caused by other disorders than IBD, such as:
- Infectious colitis
- Ischemic colitis
- Diversion colitis
- Lymphocytic colitis
- Collagenous colitis
Another type of inflammation in the intestines which is commonly confused with IBD is a condition called diverticulitis. This condition involves inflammation of the diverticula (an anatomic socket in the wall of the intestine). Although diverticulitis is an inflammatory condition of the gut and can become chronic, it is actually not a sub-type of IBD.
What Causes IBD?
Although no single, universal cause of IBD has been confirmed, certain factors are heavily implicated in the development of IBD.
The leading theory is that IBD may be caused or triggered by environmental factors (such as diet) in genetically susceptible individuals with a dysregulated immune response and/or gut dysbiosis (an imbalance of gut bacteria).
The Role of Diet in the Development of IBD
Researchers have noted an increase in IBD in developing countries as they become more Westernized and industrialized. This has heavily implicated the Western diet as a driving factor in IBD.
Studies show an increase in intestinal inflammation, impaired gut function, and impaired gut-barrier function after the consumption of cholesterol, saturated fats, and food additives. However, researchers now believe that the risk of IBD is linked less to specific foods, and more to regular dietary habits.
A prospective population cohort study observed participants’ diets in the Netherlands, with a 14-year follow-up. A ‘Western’ dietary pattern was linked with higher rates of Crohn’s disease. This pattern included the high consumption of snacks, prepackaged meals, refined grains, sugars, red and processed meat, animal protein, and high-fat dairy products, with a low intake of fruit and vegetables.
The study found that UC development was linked to a dietary pattern high in red meat, poultry, and processed meat, as well as a high intake of alcohol and coffee. It appears the high intake of protein and fat in meat can lead to disturbances in the gut microbiota, which can lead to intestinal mucosal permeability. This further exacerbates intestinal inflammation.
Environmental Factors in the Development of IBD
Recent research suggests that environmental factors do play role in the development of IBD.
A 2021 meta-analysis found that children who grew up with more siblings had a lower risk of developing IBD, and those who were raised on farms or with pets had a reduced risk of developing Crohn’s disease.
Lower rates of IBD development in these cases are likely due to more exposure to germs and bacteria, strengthening gut health and calming immune over-activation. The same study also found an increased risk of IBD in Western populations from large amounts of antibiotics taken during childhood.
Risk factors for both Crohn’s disease and ulcerative colitis include:
- Being of Ashkenazi Jewish descent
- Living in Westernized areas and urban environments
- Having a family history of IBD
- Alteration of the gut microbiome following antibiotic use
Inflammatory Bowel Disease Symptoms
Although each condition can cause slightly different symptoms, there is a considerable overlap of intestinal symptoms in Crohn’s disease and ulcerative colitis.
IBD can also cause non-intestinal symptoms due to the impact of chronic inflammation. This may manifest as anemia due to a lack of nutrient absorption and/or bleeding and loss of iron in the stool, and skin problems which may be partly due to the connection between the gut and skin microbiome.
Joint inflammation and pain is another common non-intestinal symptom.
Intestinal Symptoms IBD
- Rectal bleeding/bloody stools
- Mucus in stool
- Abdominal pain
- Tenesmus (feeling incomplete stool evacuation and need for repeat evacuation)
- Severe Urgency
- Gas and bloating
- Loss of appetite or unexplained weight loss
- Nausea and vomiting (more common in CD)
Extraintestinal Symptoms of IBD
- Mouth sores
- Itchy, red, painful eyes
- Joint pain or arthritis
- Skin rashes and sores
- Vision problems
- Liver conditions
Possible Complications of IBD
If you’ve been diagnosed with IBD, you should be aware of several potential complications that may need to be managed.
- Skin and eye inflammation
- Joint inflammation
- Blood clots
- Severe dehydration
- Medication side effects, including the risk of certain cancers, the risk of osteoporosis, and high blood pressure
- Primary sclerosing cholangitis driven by inflammation that scars and narrows the bile (this can lead to liver damage)
- Changes to the menstrual cycle
IBD involving the colon is also associated with a raised risk of colon cancer. Regular screenings are therefore recommended 8-10 years after diagnosis. Regular colonoscopies are also highly recommended, as they may help identify precancerous tissue.
How is IBD Diagnosed?
IBD is diagnosed through a physical examination, as well as various blood and stool lab tests, endoscopic procedures, and imaging procedures. CTs and MRIs are sometimes used in cases with severe symptoms to rule out serious complications or to define the extent of the disease, and these are increasingly complemented by intestinal ultrasound and sometimes by capsule endoscopy.
Additionally, your doctor may take stool samples to test for hidden (occult) blood or parasites, and test for anemia and for calprotectin (an indicator of inflammation).
Endoscopic Procedures for IBD
Colonoscopy: This procedure allows a view of your entire colon using a thin, lighted fiberoptic tube with a camera attached to the end. During the procedure, your doctor may perform a biopsy, removing small tissue samples for laboratory analysis.
Flexible Sigmoidoscopy: If your colon is severely inflamed, your doctor may perform a flexible sigmoidoscopy instead, which only examines the rectum and parts of the left colon but not the entire colon.
Upper Endoscopy: If your symptoms include nausea, vomiting, difficulty eating, or upper abdominal pain, your doctor may use a thin, lighted tube to examine your esophagus and the first part of your intestine.
Capsule endoscopy: This procedure involves swallowing a capsule with a tiny camera in it. Images are transmitted to a recorder worn by the patient like a belt until the capsule exits painlessly during stool evacuation. This is sometimes used to diagnose Crohn’s disease affecting the small intestine.
Balloon-assisted enteroscopy: This procedure uses a scope with an overtube, allowing a view into deeper sections of the small bowel which regular endoscopes can’t reach.
IBD is managed with a range of medications to mediate inflammation, as well as natural treatments or complementary and alternative medicine.
Due to the risk of malnourishment, lack of nutrient absorption, and anemia in IBD, it’s recommended to consult with a registered dietitian or nutritionist to address your individual needs.
5-Aminosalicylic Acid (5-ASA) is the first line of treatment for mild-to-moderate UC. 5-ASA is primarily effective for ulcerative colitis but is sometimes also prescribed for Crohn’s disease of the colon, although the evidence for its benefit in such patients is controversial. 5-ASA can be taken orally, as an enema, or as a suppository.
Corticosteroids are potent anti-inflammatory agents meant to be taken only for short-term relief of symptoms because of their harmful side effects if taken for prolonged periods. Corticosteroids can be taken orally, as an enema, or through IV infusions.
Immunomodulators are usually prescribed after a course of corticosteroids, once symptoms are under control. They work to regulate the immune system, alleviate symptoms, and decrease inflammation with the aim to achieve a state of remission and prevent repeated flares. They can be taken orally or by injection.
Biologics are a type of medication that targets certain immune system responses to reduce inflammation. Biologics are used for more severe cases that have not responded to other medications. They are taken through a syringe by injection under the skin or by IV infusion.
Although many benefit from conventional medication, drugs for IBD are somewhat limited in efficacy. Therefore, many seek additional natural treatment, or what is known as Complementary and Alternative Medicine (CAM).
This term encompasses a broad range of interventions including acupuncture, meditation, massage therapy, music therapy, vitamins, dietary interventions, and supplements. However, only a few have shown proven efficacy in well-performed clinical trials.
Acupuncture for IBD
Acupuncture has been used for over 3000 years in Traditional Chinese Medicine. The practice involves the careful insertion of fine needles into certain points on the outer layer of the skin. The needles are believed to stimulate nerves on those points, causing the nervous system to release beneficial chemicals into the rest of the body.
A 2022 study found that acupuncture can reduce disease activity in Crohn’s disease and improve the quality of life in patients with mild to moderate active disease. Although more research is needed, the studies so far suggest acupuncture may be beneficial to overall health and well-being.
Curcumin for IBD
Curcumin, the active compound extracted from the turmeric rhizome, has been shown in numerous trials to induce and maintain remission in patients with IBD.
Rich in anti-inflammatory and antioxidant properties, and safe to take long-term with most medications, the compound is an ideal maintenance therapy that contributes to mucosal healing and long-lasting relief from intestinal inflammation.
Qing Dai (QD) for IBD
Indigo, or Qing Dai (QD), is a potent anti-inflammatory compound extracted from the pigments of plants such as Indigofera tinctoria, Strobilanbthes cusia, O Kuntze, and Polygnonum tinctoium Lour.
The latest evidence from placebo-controlled studies shows that Qing Dai is an effective short-term induction treatment for UC patients, even those who do not respond to conventional therapy.
How to use herbal compounds for IBD
A recent, multi-center RCT found that the best use of curcumin and Qing Dai for IBD patients involves a careful combination of the two with varying ratios over time, under a regimen called the CurQD® protocol.
According to the study, higher concentrations of QD early on in the induction phase and higher concentrations of curcumin in the later stages leading to remission vastly improve patient outcomes without causing any side effects.
It should be noted that using Qing Dai from a non-standardized formulation and in an uncontrolled strategy was associated with the risk of side effects.
Diet for IBD
Due to the varying nature of IBD, dietary guidance should be provided by a registered dietician who can tailor a plan to meet your nutritional needs and target any potential deficiencies you may have.
That said, there is one golden rule for IBD: the less processed, the better. This means cooking from home as much as possible, purchasing bread from the bakery instead of the supermarket, and eliminating inflammatory foods such as processed meats, saturated fats, refined sugars, fried foods, and sodas.
For those in remission, following the Mediterranean diet can be hugely beneficial as it is rich in plant-based, anti-inflammatory, nutritional foods, and provides seasonal variety that promotes gut health via the gut microbiome.
General diet tips for IBD:
- Smaller, more frequent meals are preferable to 3 large meals a day
- Avoid identified trigger foods
- Stay hydrated with plenty of water and diluted fruit juice
- Avoid caffeine, alcohol, and energy drinks
- Limit your intake of red meat, and avoid processed meat altogether if possible
Addressing Nutritional Needs
IBD patients require extra nutritional support due to nutrient depletion from certain pharmaceuticals, as well as IBD itself, which may hinder nutrient absorption, or flush out the nutrients altogether. This is called malabsorption.
Common symptoms of malabsorption include:
- Ongoing diarrhea
- Weight loss
- Changes in your menstrual cycle
Iron Deficiency in IBD
Those with UC are more susceptible to iron deficiency anemia due to blood loss. As iron-deficiency anemia is difficult to treat with just diet and supplements, you may require intravenous (IV) iron.
Signs of iron deficiency anemia include:
- Fatigue and weakness
- Pale skin
- Cold hands and feet
- Brittle nails
- Fast heartbeat or shortness of breath
- Headaches, dizziness, or lightheadedness
- Craving for ice, clay, soil, or paper
If you feel experience any of the above symptoms, it’s recommended to alert your treating physician.
If you or a loved one has been diagnosed with IBD, it’s natural to feel overwhelmed. IBD is a complex condition that requires a certain degree of management. Still, many with IBD are able to live normal, healthy lives.
Connecting with other patients and learning more about your condition can help, as well as keeping up with the latest treatment options as there are novel therapies emerging that may be more suitable to your individual needs.