Inflammatory Bowel Disease, medical management and complementary therapies Part 1.
I’m the founder of Inessa, a nutritional therapist and ulcerative colitis patient. When I was first diagnosed, it was really hard to explain to friends and family what the condition is, and that it is very different from irritable bowel syndrome, which I also have the ‘joy’ of suffering from!
In clinic, when I used to see newly diagnosed patients, I found that they often felt confused and frightened by their diagnosis and I remember feeling the same. Being in a flare-up can feel very lonely, embarrassing, and isolating, but well-managed inflammatory bowel disease (often referred to as IBD) means having long periods of remission and with that an opportunity to enjoy a full and ‘normal’ life.
In this first post I’m covering a short general overview of what IBD is and how complementary therapies may help.
Let’s start by looking briefly at what IBD is.
So what is IBD?
IBD is an abbreviation for inflammatory bowel disease, a group of non-infectious illnesses characterised by chronic inflammation and subsequent injury of the bowel or digestive tract. The two most common forms of IBD are ulcerative colitis and Crohn’s disease. These are autoimmune diseases, which means that IBD is a chronic lifelong medical condition that is relapsing and remitting in nature. The aim of treatment - medical or otherwise - is to induce remission or get the disease to ‘hibernate’ as I like to call it, and keep it in that state for as long as possible. This means that they are incurable conditions, so anyone promising a cure through the use of some magic alternative therapy is misleading.
Although inflammatory bowel diseases are illnesses of the digestive tract, they have been spoken of as systemic disorders[1]. This is because many patients develop extraintestinal symptoms (symptoms outside the digestive tract, more on this below) which may impact pretty much any organ system with a potentially detrimental impact on the patient's quality of life.
However, the good thing is that Crohn’s and UC can - for many patients - be managed into remission for significant periods through the use of medications, diet and lifestyle interventions, as well as some specific and well-researched supplements[2345]. During times of remission, patients are likely to be able to live a full and normal life.
What is Ulcerative Colitis? / Ulcerative Colitis Symptoms
In ulcerative colitis, inflammation can manifest in the colon (large intestine) and rectum. The disease presents as many small ulcers which affect the integrity of the bowel lining. These may bleed and produce pus and mucus that may possibly be seen in the stool of a patient with active disease. People with extensive inflammation can experience a significant impact on their quality of life and relationships.
Diagnosis of the disease is generally confirmed by colonoscopy and biopsy, and patients may need to undergo a less invasive procedure called a sigmoidoscopy during a flare-up to monitor the health of the bowel.
Depending on which section of the colon inflammation is present, the patient will experience varying degrees of discomfort or pain and symptoms ranging from rectal bleeding, nausea, diarrhea (more rarely constipation), low-grade fever and extreme fatigue, to name a few.
UC patients may also experience extraintestinal inflammatory conditions (symptoms outside of the colon), with rheumatoid arthritis, ankylosing spondylitis, eye inflammation and inflammatory skin conditions being the most prevalent, though inflammation can occur anywhere in the body and affect any organ.
What is Crohn’s Disease? / Crohn’s Disease Symptoms
In Crohn’s disease, inflammation can occur anywhere throughout the digestive tract - including the mouth. Unlike in ulcerative colitis, inflammation doesn’t necessarily occur in one particular area as a continuous pattern. It can show up in patches anywhere along the digestive tract, so for example a patient could have injury to one part of the bowel as well as the oesophagus and the rest of the digestive tract may remain healthy.
Where inflammation in ulcerative colitis is usually confined to the surface lining of the bowel tissue (inner lining) and rectum, in Crohn’s, inflammation can occur anywhere within the tissue layers. Testing and monitoring in Crohn’s involves not just investigating the bowel through colonoscopy and / or sigmoidoscopy, but also checking the upper gastrointestinal tract through an endoscopy procedure.
Symptoms of Crohn’s disease vary wildly from one patient to another depending on the location and severity of inflammation. Commonly reported symptoms include but are not restricted to pain, frequent and recurring diarrhea, weight loss, loss of appetite, abdominal pain and cramping, persistent fatigue and a lack of energy, passing blood in the stool and low grade fever. As in Ulcerative Colitis, Crohn’s patients may also experience extraintestinal inflammatory conditions (symptoms outside of the colon), with inflammation in the mouth, skin, joints and eyes being common. Extraintestinal inflammation can occur anywhere in the body, including the gallbladder, kidneys, liver and pancreas.
About Extraintestinal Symptoms
It is now known that the health of our gut can impact other organs in the body, with inflammation in the digestive tract potentially triggering inflammation virtually anywhere in the body - though not every patient suffers extraintestinal symptoms.
Common extraintestinal symptoms include skin inflammation commonly manifesting as acne or eczema, joint inflammation causing pain and swollen joints, or eye inflammation.
Whilst extraintestinal inflammation and associated conditions often resolve during periods of disease remission, in patients affected by ankylosing spondylitis - a condition affecting the spine - or inflammation of the middle layer of the eye known as uvetis, these can occur independently and may not improve when a patient’s Crohn’s or UC does[6].
Extraintestinal complications are different from extraintestinal symptoms - these are other health complications which arise from a person having a prolonged period of inadequate nourishment through malabsoption (common in IBD) or as a result of treatment with certain medications. These include micronutrient deficiencies, osteoporosis or loss of bone density, kidney stones, gallstones, peripheral neuropathies and drug-related side effects[7].
Who gets Ulcerative Colitis and Crohn’s Disease and how common is it?
Ulcerative colitis and Crohn’s seem to be on the rise. Interestingly IBD is most prevalent in developed countries, and in more urban environments than rural ones leading to some speculation that diet and excessive hygiene[8] may have a contributing role. In addition, we are starting to see more people diagnosed in developing nations, further fueling this hypothesis.
Ulcerative Colitis and Crohn’s causes
There is no definitive answer as to exactly what causes Crohn’s and UC. Researchers have established that there is a genetic component, with approximately 20% of sufferers (figures vary depending on source) having a close family member with some form of IBD. The risk of a mother passing on UC to her child is estimated to be only 2-5% with the risk increasing to about 30% if both parents have the disease. Interestingly, those descended from Ashkenazi Jewish communities are known to be at increased risk of developing UC or Crohn’s and incidence is rarer in Asian populations, though the reason for this is yet unclear.
Other hypotheses of the origin of disease include diet and stress, a viral trigger, and an inappropriate immune response to gut microbiota (bacteria, viruses and fungi that naturally reside in the digestive tract). In UC particularly - though it applies to Crohn’s as well - current research is focusing on the latter as a possibility for a new generation of treatments, particularly since the inflammation in ulcerative colitis is limited to the colon rather than the whole of the gastrointestinal tract as seen in Crohn’s disease. This theory has further been fuelled by encouraging results in patients who have undergone faecal transplants (yes, you read that right - more on that in my next post!).
Smokers are estimated to be twice as likely to be diagnosed with Crohn’s than those who don’t, though interestingly smoking has been shown to be protective against ulcerative colitis. Obviously smoking is not healthy, so if you’re thinking of starting as a way to induce remission in UC - please don’t! There have been some studies on UC patients using nicotine patches, with mixed results, which may be because other chemicals in cigarette smoke could be a contributing factor. In Crohn’s, in addition to increasing disease risk, studies suggest that smoking could worsen symptoms.
Ulcerative colitis affects approximately 1 in 420 people in the UK and 700,000 people in the US and affects men and women equally. Crohn’s disease is a little less common than UC, and is thought to affect 1 in every 650[9] people in the UK. In the US, the CDC reported that in 2015 around 3 million people were diagnosed with IBD[10] which was a large increase from 1999 when approximately 2 million adults were diagnosed[11]. Globally, UC is slightly more commonly diagnosed in women.
Ulcerative Colitis and Crohn’s Disease treatment
Typically, aminosalicylates or mesalazines are the ‘first line’ drug therapy, which may be administered in a variety of ways depending on where the inflammation presents in the digestive tract.
These are effective in around only 50% of cases, and where they fail, immunosuppressants such as corticosteroids or azathioprine may be used to dampen down the activity of the immune system.
A newer class of drugs called biologics act by targeting particular chemicals or cells involved in the body's immune system response, though these are often used as a last port of call due to potential side effects, particularly when taken long term.
Your gastroenterologist may choose to use a combination of drugs, particularly in complicated cases.
Where drug therapies fail, surgery may be required. In UC, surgical removal of the colon may be necessary, and in Crohn’s patients, it’s estimated that up to 60-75% of people with Crohn's disease will need surgery to repair damage to their digestive system and manage complications[12].
Ulcerative Colitis and Crohn’s natural treatment and lifestyle changes
I know from personal experience both as a patient and a practitioner that when medication doesn’t work or is causing debilitating side effects that it pays to look at complementary therapies as an adjunct treatment. Many interventions have been shown to prolong remission periods as effectively as some drug therapies. Some have been shown to boost conventional treatment outcomes by increasing the length of remission periods and/or reducing the time taken to induce remission, so I’m an advocate of using evidence-based natural therapies as well as lifestyle interventions for all IBD patients, something I’ll be discussing in detail in my next post.
I don’t advise anyone to come off their medication in favour of natural alternatives without the advice of their gastroenterologist. IBD can get out of control quickly and if you choose not to take medication this should be agreed with your physician.
Complementary therapies should be just that - they should be used as a complement to medical treatment or surveillance to help reduce inflammation and modulate the immune system.
Managing Ulcerative Colitis and Crohn’s flare ups
Working with your gastroenterologist or IBD nurse should be your first port of call if you are experiencing a flare-up. They can help to monitor your disease activity and recommend drugs that may be effective for you. Alongside your drug therapy, making some dietary and lifestyle changes can go some way to improving symptoms and have been shown to improve treatment outcomes - that is, induce remission quicker and maintain longer periods of remission[13].
Personally, I currently use a few select supplements as maintenance for decreasing inflammation and maintaining a healthy balance of gut bacteria[1415], and tend to use a ‘blanket’ strategy involving a lot of supplements and a much stricter diet when I’m in a flare. It may seem extreme to use so many products, but it works for me. The herbs and supplements I use have studies to demonstrate efficacy, and I will be writing about those in my next post. I will also be sharing a post on lifestyle interventions which may also be beneficial. I hope that you find them useful, and if you have anything to share that has worked for you, please do share your own experiences with me via Instagram @aliza_marogy or @inessa_wellness .
Inflammatory bowel disease can be highly unpredictable. The symptoms can vary dramatically from one flare-up to the next and from individual to individual. This also applies for complementary therapies and dietary interventions - even if a study shows that a certain supplement or diet helps to relieve symptoms it may not work for you, so it can mean a process of trial and elimination before you may find something that works for you and identify potential food triggers.
To conclude
All of the above sounds pretty depressing, and I know from personal experience how debilitating and isolating a bad flare up can be, however, when well-managed, IBD doesn’t have to dominate our lives.
Sadly, there will be a percentage of patients for whom all options fail and surgery is necessary. If drug therapies work for you without causing too many side-effects, then that is absolutely wonderful! But if, like me, you aren’t that lucky, it is worth exploring evidence-based dietary and lifestyle interventions, and supplements (or nutraceuticals as they are also known) in addition to your medical treatment to see what works for you and to give the best chance of a healthy life.
If you enjoyed reading this article, you might like Health benefits of Lactobacillus Rhamnosus GG.
References
[1] Vavricka SR, Schoepfer A, Scharl M, Lakatos PL, Navarini A, Rogler G. Extraintestinal Manifestations of Inflammatory Bowel Disease. Inflamm Bowel Dis. 2015;21(8):1982–1992. doi:10.1097/MIB.0000000000000392
[2] Derikx LA, Dieleman LA, Hoentjen F. Probiotics and prebiotics in ulcerative colitis. Best Pract Res Clin Gastroenterol. 2016 Feb;30(1):55-71. doi: 10.1016/j.bpg.2016.02.005. Epub 2016 Feb 9. Review. PubMed PMID: 27048897.
[3] Damaskos, D., & Kolios, G. (2008). Probiotics and prebiotics in inflammatory bowel disease: microflora 'on the scope'. British journal of clinical pharmacology, 65(4), 453–467. doi:10.1111/j.1365-2125.2008.03096.x
[4] Ananthakrishnan A. N. (2013). Environmental triggers for inflammatory bowel disease. Current gastroenterology reports, 15(1), 302. doi:10.1007/s11894-012-0302-4
[5] Lewis JD, Abreu MT. Diet as a Trigger or Therapy for Inflammatory Bowel Diseases. Gastroenterology. 2017 Feb;152(2):398-414.e6. doi: 10.1053/j.gastro.2016.10.019. Epub 2016 Oct 25. PubMed PMID: 27793606.
[6] Vavricka SR, Schoepfer A, Scharl M, Lakatos PL, Navarini A, Rogler G. Extraintestinal Manifestations of Inflammatory Bowel Disease. Inflamm Bowel Dis. 2015;21(8):1982–1992. doi:10.1097/MIB.0000000000000392
[7] Vavricka SR, Schoepfer A, Scharl M, Lakatos PL, Navarini A, Rogler G. Extraintestinal Manifestations of Inflammatory Bowel Disease. Inflamm Bowel Dis. 2015;21(8):1982–1992. doi:10.1097/MIB.0000000000000392
[8] López-Serrano P, Pérez-Calle JL, Pérez-Fernández MT, Fernández-Font JM, Boixeda de Miguel D, Fernández-Rodríguez CM. Environmental risk factors in inflammatory bowel diseases. Investigating the hygiene hypothesis: a Spanish case-control study. Scand J Gastroenterol. 2010 Dec;45(12):1464-71. doi: 10.3109/00365521.2010.510575. Epub 2010 Aug 12. PubMed PMID: 20704469.
[9] https://www.crohnsandcolitis.org.uk/about-crohns-and-colitis/publications/crohns-disease
[10] Dahlhamer JM, Zammitti EP, Ward BW, Wheaton AG, Croft JB. Prevalence of inflammatory bowel disease among adults aged ≥18 years—United States, 2015. MMWR Morb Mortal Wkly Rep. 2016;65(42):1166–1169.
[11] Nguyen GC, Chong CA, Chong RY. National estimates of the burden of inflammatory bowel disease among racial and ethnic groups in the United States. J Crohns Colitis. 2014;8:288–295.
[12] https://www.nhs.uk/conditions/inflammatory-bowel-disease/
[13] Haskey, N., & Gibson, D. L. (2017). An Examination of Diet for the Maintenance of Remission in Inflammatory Bowel Disease. Nutrients, 9(3), 259. doi:10.3390/nu9030259
[14] Derikx LA, Dieleman LA, Hoentjen F. Probiotics and prebiotics in ulcerative colitis. Best Pract Res Clin Gastroenterol. 2016 Feb;30(1):55-71. doi: 10.1016/j.bpg.2016.02.005. Epub 2016 Feb 9. Review. PubMed PMID: 27048897.
[15] Damaskos, D., & Kolios, G. (2008). Probiotics and prebiotics in inflammatory bowel disease: microflora 'on the scope'. British journal of clinical pharmacology, 65(4), 453–467. doi:10.1111/j.1365-2125.2008.03096.x
