Inflammatory bowel disease
Behind this name, usually shortened to IBD, sit two different illnesses: Crohn's disease and ulcerative colitis.
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Medicines commonly prescribed for Inflammatory bowel disease
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 500 mgActive substance: mesalazineManufacturer: Faes Farma S.A.Prescription requiredDosage form: INJECTABLE, 120 mg/mlActive substance: infliximabManufacturer: Celltrion Healthcare Hungary Kft.Prescription requiredDosage form: MODIFIED-RELEASE POWDER/GRANULATE, 500 mgActive substance: mesalazineManufacturer: Dr. Falk Pharma GmbhPrescription required
Behind this name, usually shortened to IBD, sit two different illnesses: Crohn's disease and ulcerative colitis. What they share is that the immune system, for reasons still not properly understood, starts inflaming the person's own bowel and keeps doing it for years, with flares alternating with quiet spells. IBD cannot yet be cured outright, but it is entirely possible to get the inflammation to settle, keep it settled, and live an ordinary life. The one thing that matters most is not delaying the start: the longer the bowel stays inflamed untreated, the more scarring it leaves behind and the fewer options remain.
Two diseases under one label
Crohn's disease can affect any stretch of the digestive tract from the mouth to the anus, most often the end of the small bowel. The inflammation comes in patches with healthy tissue in between, and it goes through the full thickness of the wall. Hence its particular consequences: narrowings that stop food passing, fistulas, meaning tracks between the bowel and a neighbouring organ or the skin, and abscesses. A separate and especially miserable form is disease around the anus, with fissures, fistulas and collections of pus.
Ulcerative colitis is confined to the large bowel. The inflammation begins at the rectum and spreads upwards in one continuous band, skipping nothing, and it involves only the lining. The picture is therefore different: blood in the stool, urgency, the feeling of never having finished, pain before opening the bowels and relief afterwards.
IBD is constantly mistaken for irritable bowel syndrome, and the confusion is expensive. Irritable bowel brings pain, diarrhoea and bloating, but it does not bring blood, weight loss, waking at night to open the bowels, or any change in inflammatory markers. In IBD all of that does appear, and those are the features that tell the two apart far more reliably than how it feels.
How it shows itself
The commonest complaints are diarrhoea lasting weeks, abdominal pain and a constant tiredness that rest does not touch. Alongside them come:
- blood or mucus in the stool;
- weight loss you were not trying for;
- getting up at night to open your bowels, which a healthy gut does not demand;
- a temperature with no cold to explain it, usually a low one;
- pallor, breathlessness on exertion and odd cravings such as ice or chalk, which point to iron deficiency;
- in children, poor growth and late puberty, sometimes the only visible sign at all.
It is worth knowing that IBD does not always stay inside the abdomen. In roughly one person in three the joints become inflamed, mainly the large ones and the spine; painful red lumps appear on the shins and ulcers in the mouth. The eyes deserve a separate mention: a red eye with pain and dislike of light is not tiredness and not conjunctivitis but inflammation inside the eye, which is assessed urgently because sight is at stake. Less often the bile ducts are affected, which is why liver blood tests are checked from time to time in ulcerative colitis.
When it cannot wait
See a doctor the same day if bloody diarrhoea has not settled over several days, if you are opening your bowels more than six times in twenty-four hours, if a temperature appears during a flare, or if you are losing weight fast. Waiting for it to “calm down on its own” is a poor bet: a severe flare is treated in hospital, and the earlier that treatment starts the less often it ends in surgery.
Call an ambulance, in Europe on the single number 112, for any of the following:
- severe abdominal pain that will not let up, especially with a hard, distended abdomen and no wind passing;
- heavy bleeding, with the toilet water turning red or large clots appearing;
- vomiting blood, or vomit that looks like coffee grounds;
- a high temperature together with a racing heart, weakness and an abdomen that keeps swelling: this is how dilatation of the colon presents, a rare but life-threatening complication of severe colitis;
- vomiting that will not stop, bloating and no stool or wind at all, which mean the bowel is blocked by a narrowing.
Do not drive in that state: ask someone to take you or call the ambulance. Bring your medication list, because the doctor needs to know whether you are on steroids or on drugs that suppress the immune system.
How the diagnosis is reached
It starts with tests. Blood is checked for inflammatory markers, haemoglobin, iron stores and vitamin B12. In the stool, calprotectin is measured: it rises specifically when the bowel is inflamed and therefore separates IBD from irritable bowel rather well. Infection is always excluded with a stool culture and a test for clostridial infection, since that produces a similar picture and is treated in a completely different way.
The decisive investigation is colonoscopy with biopsy. Looking at the bowel is not enough; pieces of tissue are needed, because they are what shows which disease it is and how deep the inflammation goes. Where Crohn's disease is suspected, the small bowel is examined as well, by scan with contrast or by a swallowed capsule containing a camera.
What the treatment involves
Treatment splits into two jobs: putting out the current flare and holding the remission. These cannot be blurred together, and here is why that matters in practice.
- Steroids put out a flare quickly, but they cannot be taken long term: they do not hold remission, and they thin the bones, push up blood sugar and bring on cataracts and infections. If the flare returns as soon as they are withdrawn, the message is that a different drug is needed, not another course of steroids.
- Drugs based on 5-aminosalicylic acid are the backbone of treatment in ulcerative colitis, including as suppositories and enemas when only the rectum is inflamed. In Crohn's disease they are of little use.
- Medicines that damp down the overactive immune response are prescribed for the long haul and take weeks rather than days to work.
- Biological drugs are antibodies that block specific steps in the inflammation. They are used when the earlier rungs have failed to hold the disease, and they have changed the outlook in severe forms.
- Antibiotics do not treat the inflammation itself but its complications: abscesses and fistulas around the anus.
- Surgery. In Crohn's disease the narrowed or destroyed segment is removed, though the disease can come back above the join. In ulcerative colitis removing the large bowel ends the bowel disease for good, and it is chosen when drugs cannot cope or pre-cancerous changes are found.
In children with Crohn's disease a flare is often settled not with steroids but with a special diet: for several weeks the person takes nothing but a treatment formula. It works as well as steroids and does not hold back growth.
Life between flares
There is no universal IBD diet, and anyone promising to cure the bowel through food is not telling the truth. It is more useful to keep a short food diary and drop whatever repeatedly gives you symptoms; during a flare, food without coarse fibre is easier to tolerate. Cutting out whole food groups long term on your own is a bad idea, as it produces a deficiency more readily than a remission.
What genuinely changes the course of the illness:
- Smoking. In Crohn's disease it speeds up flares and raises the chance of surgery, so stopping is part of the treatment here, not general advice.
- Painkillers. Anti-inflammatory drugs of the ibuprofen type can trigger a flare; if you are in pain, discuss what to use instead.
- Vaccination. Best done before starting treatment that suppresses immunity: once it has begun, live vaccines are off the table, while protection against flu and pneumococcus becomes more important than usual.
- Deficiencies. Iron, vitamin B12 after removal of a length of small bowel, vitamin D and bone health are checked to a schedule rather than according to how you feel.
- Keeping an eye on the bowel. When inflammation persists for years over a wide stretch of the colon the risk of a tumour rises, so around eight to ten years from the start of the disease repeat colonoscopies begin. The doctor sets the interval according to what was seen last time.
A word on pregnancy. It is best planned during remission: quiet disease gives a normal pregnancy, active disease raises the risk of premature birth. Most drugs are continued, because a flare is more dangerous than the medication, but there is one exception: methotrexate is incompatible with pregnancy and is stopped months in advance, and that applies to the prospective father too. Do not stop anything yourself; go through the regimen before trying to conceive.
Online consultation
A great deal of what living with IBD actually consists of can be handled remotely. If there is no diagnosis yet, the doctor works through whether your picture looks more like inflammation or like an irritable bowel, and says which tests are worth doing before a colonoscopy. If the diagnosis is already made, an online appointment can sort out whether a flare is starting and how serious it is, go through recent blood tests, cover side effects and how long you have been on steroids, and plan vaccination and preparation for pregnancy. The signs on the emergency list are not dealt with remotely: for those, call an ambulance straight away.
This material is for information only and does not replace medical advice.
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