Gastroenterology

  • About Inflammatory Bowel Disease
    About Inflammatory Bowel Disease

    Gastroenterology
  • About Inflammatory Bowel Disease

    Ulcerative colitis (UC) and Crohn's disease (CD) both fall into the category of inflammatory bowel disease. They are chronic disorders causing the formation of areas of inflammation and ulceration in various sections of the digestive tract. This inflammation causes persistent and frequent diarrhoea (often blood stained and passed with urgency), abdominal pain, fever, tiredness and loss of weight.

    Inflammatory bowel disease (IBD) is mainly seen in industrialised parts of the world. They affect all races, though in some populations the incidence is lower. People who move from underdeveloped to developed parts of the world attain the same level of risk of developing IBD as the rest of the population after some time.

    There is generally a higher incidence in northern latitudes compared with southern latitudes and in urban areas over rural.

    Development of inflammatory bowel disease

    Ulcerative colitis and Crohn's disease affect all age groups and onset can occur at any age. The highest number of new cases occur in young people between 15 and 35.

    The course of UC and CD varies unpredictably in severity and usually cycles between periods of active inflammation (flare-ups) and periods of low activity or even remission when the patient feels well and is free from symptoms.

    In their early stages UC and CD may be difficult to diagnose. Their symptoms resemble that of each other and other conditions, such as infectious gastroenteritis and irritable bowel syndrome. It may take some time before a correct diagnosis is made.

    Diagnosis of inflammatory bowel disease1,2,3

    A GP will first ask about the patient’s symptoms, general health, diet, family history and medical history. There will also be a physical examination to check for signs of paleness (caused by anaemia) and tenderness in the tummy (caused by inflammation). The patient’s pulse and blood pressure may be checked, and their height, weight and temperature measured.

    A stool sample may be taken to be checked for blood and mucus, or for signs of infection. A faecal calprotectin test may be offered to adults who have recently developed symptoms such as abdominal pain, diarrhoea or constipation and are being considered for specialist treatment. This test helps the clinician to distinguish between irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). Blood tests (to check for anaemia, infections and levels of inflammation) may also be taken.

    You may be referred to a gastroenterologist (a specialist in conditions of the digestive system) who may carry out tests at a hospital. This could be an X-ray, endoscopy, MRE or CTE scan or a small bowel enema.

    Endoscopy

    An endoscopy is a procedure where the inside of your body is examined using a long, thin, flexible tube called an endoscope. There is a light and a camera on the end of the endoscope, which sends images to a television screen. The aim of the procedure is to show the level and extent of inflammation inside the bowel. A biopsy may also be taken in the process, where a small sample of tissue is taken to be tested. Different types of endoscopy may be done to examine your body:

    • Sigmoidoscopy: A sigmoidoscopy examines the rectum and lower part of the colon.

    • Colonoscopy: A colonoscopy uses a longer and more flexible tube to allow your entire colon to be examined. A colonoscopy requires the patient’s bowel to be completely empty in advance, so strong laxatives need to be taken beforehand.

    • Wireless capsule endoscopy: A small capsule is swallowed which transmits images to a recording device. The capsule is disposable and will pass out of the patient’s body a few days after the test.

    Small bowel enema (small bowel follow-through)

    A small bowel enema (SBE) or small bowel follow-through (SBFT) allows the whole of the small intestine to be examined, typically at the point where it meets the colon. During a colonoscopy, usually only the last 20cm of the small intestine can be viewed.

    A tube is passed through the patient’s nose and throat to the small intestine, and then a liquid called barium is passed down it. The barium coats the lining of the small intestine, allowing a series of clear X-ray images to be taken. These images can often highlight the areas of narrowing and inflammation caused by Crohn’s disease.

    MRE and CTE scans

    Magnetic resonance enterography/enteroclysis (MRE) or computerised tomography enterography/enteroclysis (CTE) scans can be used to examine the small intestine in patients with suspected Crohn’s disease.

    Contrast agents need to be taken before these scans to allow the small intestine to show up more clearly. In enterography, the patient is required to drink the contrast agent in the form of a harmless liquid and in enteroclysis, the contrast agent is placed through a tube in the patient’s nose that leads to the small intestine. MRE scans used magnetic fields and radio waves to produce the detailed images, whereas CTE scans use X-rays.

    These scans allow a more detailed examination of the small intestine than small bowel enema and MRE scans avoid any exposure to X-ray radiation.

    Causes of inflammatory bowel disease

    Much work is being undertaken worldwide into the possible causes of IBD, but despite many theories the cause and the exact changes occurring in the body remain poorly understood.

    There seems to be a genetic and environmental impact behind IBD, causing the normal functions of the gut to be disrupted. It is thought that viruses, bacteria, a highly refined diet, stress and smoking may contribute.

    Ulcerative colitis 

    The inflammation in ulcerative colitis exclusively affects the superficial layer (the mucosa) of the large bowel. It almost always involves the rectum and spreads in a continuous manner from there. In a small percentage of patients, the whole of the large bowel is involved.

    The most common age group for UC to be diagnosed is within the 15 to 35 year-olds, with a second peak being seen in 55 to 70 year-olds. Approximately 240 people per 100,000 inhabitants suffer from ulcerative colitis in the UK, around 146,000.

    Crohn's disease

    Unlike ulcerative colitis, Crohn's disease can affect any part of the gastrointestinal tract. In Crohn's, the disease most commonly affects just the small intestine (40%), though it can often affect both the small and large bowel (colon) (30%) and in other cases just the colon (30%).

    Crohn's disease affects approximately 180 people per 100,000, around 115,000 inhabitants in the UK, and is most commonly diagnosed in the 15 to 25 year-old age groups. Recent statistics appear to indicate a rise in the number of new cases, but it is not clear why this may be.

    About 15 to 20 per cent of people with Crohn's Disease have a close relative with some form of IBD, suggesting any genetic predisposition in these patients.

    References

    1. NHS Choices. Ulcerative colitis – Diagnosis [Internet]. [Updated March 2014; cited July 2015]. Available from: http://www.nhs.uk/Conditions/Ulcerative-colitis/Pages/Diagnosis.aspx

    2. NHS Choices. Endoscopy [Internet]. [Updated July 2014; cited July 2015]. Available from: http://www.nhs.uk/conditions/Endoscopy/Pages/Introduction.aspx

    3. NHS Choices. Crohn’s disease – Diagnosis [Internet]. [Updated April 2015; cited July 2015]. Available from: http://www.nhs.uk/Conditions/Crohns-disease/Pages/Diagnosis.aspx

    All information on this site is intended for UK audiences only.

    GO/1003/2015/UKb                                                   Date of preparation: August 2015

  • About Inflammatory Bowel Disease - managing and treating IBD
    About Inflammatory Bowel Disease - managing and treating IBD

    Gastroenterology
  • Managing and treating Inflammatory Bowel Disease

    Most people diagnosed with either ulcerative colitis or Crohn's disease receive a range of medications designed to control or reduce the inflammation and symptoms, and suppress the body's immune response.

    When inflammatory bowel disease (IBD) is active, the doctor's main aim is to:

      • Control the symptoms of the flare-up as rapidly as possible
      • Correct any disturbances to the body's nutritional, water, vitamin and mineral levels
      • Prevent serious complications developing
      • And finally, minimise risk of future flare-ups by choosing an effective maintenance therapy

    Maintenance therapy for long term control of IBD 

    Long term control of inflammatory bowel disease requires regular medication, known as maintenance therapy, to keep flare-ups at bay and reduce the risk of more serious complications developing.

    The aminosalicylate (mesalazine) group of medications is commonly prescribed as maintenance therapy for UC patients. More severe inflammation may need a number of different therapies to achieve long-term control. Usually the medication initially required to control the patient's flare-up will be continued as part of maintenance therapy.

    Prevention of serious long-term complications

    Individuals feeling quite well and free of symptoms between flare-ups may be less careful about complying with their doctors' recommendations for taking maintenance medication and attending the gastroenterology clinic for check-ups.

    Research suggests that long-term health benefits and reduction in the risk of developing cancer of the colon and/or rectum can be achieved if patients continue to take their medication as recommended by their doctor.

    Diet in controlling IBD

    The long-term management of IBD to reduce relapses also needs to address the role of stress and diet. Stress reduction and an adequate diet containing fibre (except in case of strictures) with vitamin and mineral supplements, is usually recommended by doctors.

    A well-balanced, high carbohydrate, high protein diet minimises the possibility of nutritional deficiency due to chronic diarrhoea. Crohn's disease appears to respond well to special diets and some patients respond to milk or wheat-free diets (lactose and gluten-free).

    Ileostomy1

    In severe cases of IBD, some patients undergo surgery called an ileostomy where the colon is removed and the small intestine is diverted through an opening (stoma) in the abdomen. In England, over 9,000 ileostomies are carried out each year.

    A similar procedure sometimes carried out is the surgical creation of an ileo-anal pouch, which is a constructed internal reservoir. The purpose of the ileo-anal pouch is to retain or restore functionality of the anus with stools passed under voluntary control of the patient.

    References

    1. NHS Choices. Ileostomy [Internet]. [Updated February 2014; cited July 2015]. Available from: http://www.nhs.uk/conditions/ileostomy/pages/introduction.aspx

    All information on this site is intended for UK audiences only.

    GO/1003/2015/UKb                                                   Date of preparation: August 2015

  • About Inflammatory Bowel Disease - complications of IBD
    About Inflammatory Bowel Disease - complications of IBD

    Gastroenterology
  • Complications of Inflammatory Bowel Disease

    In cases where diarrhoea is very frequent, or bloody and severe, water loss and poor absorption of nutrients may occur, leading to anaemia, dehydration and weight loss.

    Patients with IBD have an increased risk of bowel cancer, which includes cancer of the colon, rectum or bowel. The initial symptoms of bowel cancer are similar to that of IBD. Regular colonoscopies from about 10 years after first symptoms will check for signs of bowel cancer. The risk of colorectal cancer increases with the extent and severity of the disease, the age it started and how long the patient has had the disease. For patients suffering from ulcerative colitis, recent trials have shown the risk of colorectal cancer at 10, 20 and 30 years after the diagnosis as being 2, 8 and 18 per cent higher (respectively) than the occurrence seen in the general population.1,5

    Complications of ulcerative colitis1

    Osteoporosis, a condition when bones become weak and are more likely to fracture, can develop as a side effect of the prolonged use of systemic corticosteroid medication, which is a treatment often used to treat active IBD. If a patient is thought to be at risk, their bone health will be monitored and they may be advised to take supplement of vitamin D and calcium. Osteoporosis affects around three million people in the UK, including those without UC.2

    Poor growth and development can occur in children and young people with IBD, as such they have regular height and body weight checks.

    Primary sclerosing cholangitis (PSC) is where bile ducts (small tubes used to transport bile out of the liver and into the digestive system) become progressively inflamed over time. Symptoms include fatigue, diarrhoea, itchy skin, weight loss, chills and fever. In severe cases, a liver transplant may be required. Up to 10% of people with UC also have PSC.3

    Toxic megacolon happens when inflammation in the colon causes gas to become trapped, which results in the colon becoming swollen. The body may be sent into shock, the colon could rupture or an infection in the blood could be caused (septicaemia). Toxic megacolon is treated with fluids, antibiotics and steroids, but a colectomy (removal of the colon) may be required in severe cases. The lifetime risk of toxic megacolon in UC has been estimated to be 1%-2.5%.4

    Complications of Crohn’s disease5

    The inflammation in Crohn's disease may lead to scar tissue formation, which in turn creates intestinal strictures (narrowing) of the bowel. Severe cases may lead to life-threatening complications such as bowel obstruction, which may cause the bowel to split if left untreated. The affected section of the bowel is widened, possibly through surgery.

    Ulcers can develop in Crohn’s disease due to the digestive system becoming scarred as a result of excessive inflammation. Over time, these ulcers may develop into fistulas. Fistulas are tunnels that connect one part of the patient’s digestive system to another, or to the bladder, vagina, anus or skin. Large fistulas can become infected and cause pain, fever, blood or pus in stools and leakage. They are usually treated with medication, or surgery if the medication isn’t effective.

    Complications of ileostomies6

    Having an ileostomy can lead to various complications such as:

    • Bowel obstruction, which may cause the bowel to rupture

    • Dehydration due to the large intestine not being able to absorb water

    • Rectal discharge

    • Vitamin B12 deficiency, which plays an important role in keeping the brain and nervous system healthy

    • Phantom rectum, where patients continue to feel the need to use the toilet

    • Various stoma problem such as;

      • Irritation and inflammation

      • Narrowing or widening

      • Parastomal hernia, where an internal body part pushes on a weakness in the muscle or surrounding tissue wall

      • Stoma retraction, where the stoma sinks below skin level after the initial swelling goes down

    Pouchitis is a condition where the internal pouch becomes inflamed. Symptoms include diarrhoea (sometimes bloody), urgency or difficulty in passing stools, abdominal pains, stomach cramps and fever. Approximately 50% of patients who undergo pouch surgery for UC will develop at least one episode of pouchitis.7

    References

    1. NHS Choices. Ulcerative colitis – Complications [Internet]. [Updated March 2014; cited July 2015]. Available from: http://www.nhs.uk/Conditions/Ulcerative-colitis/Pages/Complications.aspx

    2. NHS Choices. Osteoporosis [Internet]. [Updated April 2014; cited August 2015]. Available from: http://www.nhs.uk/conditions/Osteoporosis/Pages/Introduction.aspx

    3. NHS Choices. Bile duct cancer (Cholangiocarcinoma) – Causes [Internet]. [Updated October 2014; cited August 2015]. Available from: http://www.nhs.uk/Conditions/Cancer-of-the-bile-duct/Pages/Causes.aspx

    4. Devuni D et al. Medscape. Toxic Megacolon – Epidemiology [Internet]. [Updated October 2014; cited July 2015]. Available from: http://emedicine.medscape.com/article/181054-overview#a5

    5. NHS Choices. Crohn’s disease – Complications [Internet]. [Updated April 2015; cited July 2015]. Available from: http://www.nhs.uk/Conditions/Crohns-disease/Pages/Complications.aspx

    6. NHS Choices. Ileostomy – Complications [Internet]. [Updated February 2014; cited July 2015]. Available from: http://www.nhs.uk/Conditions/Ileostomy/Pages/Complications.aspx

    7. Shen B, Lashner BA. Gastroenterol Hepatol 2008; 4(5):355-361

    All information on this site is intended for UK audiences only.

    GO/1003/2015/UKb                                                   Date of preparation: August 2015

  • About Inflammatory Bowel Disease - summary of IBD
    About Inflammatory Bowel Disease - summary of IBD

    Gastroenterology
  • Summary of Inflammatory Bowel Disease

    Characteristics of inflammatory bowel disease:

     

    Ulcerative colitis

    Crohn’s disease

    Typical age range at diagnosis

    Primary 15 to 35 years

    Secondary 55 to 75 years

    Primary 15 to 25 years

    Secondary over 70 years

    Incidence

    6-10 per 100,000

    2-6 per 100,000

    Prevalence

    Approximately 240 per 100,000

    Up to 150 per 100,000

    Disease location

    Involves only rectum and colon. In case of progression the inflammation spreads upwards from the rectum in a continuous way

    Can involve any part of the gastrointestinal tract, from the mouth to the anus – most commonly the lower part of the small bowel and the beginning of the large bowel (colon). The inflammation of the gut are spread irregularly with normal gut appearances in many areas (so called skip lesions)

    Acute symptoms

    Bloody diarrhoea, fever, abdominal pain and discomfort

    Bloody diarrhoea, sore tongue and lips, abdominal pain and discomfort

    Chronic symptoms

    Diarrhoea, weight loss, weakness, anaemia

    Diarrhoea, weight loss, loss of appetite, anaemia, lethargy and malaise

    Chronic complications

    Reduced weight, tiredness, cancer of the colon and/or rectum

    Fibroses/stenosis of the gut, reduced weight, tiredness, cancer of the colon and/or rectum

    Genetic connection

    Link between family members

    15 to 20 percent have blood relatives with some form of IBD

    Symptoms not involving the gut (extraintestinal symptoms)

    Joint pain, eye and skin problems

    Joint pain, gall stone and renal stone formation

    All information on this site is intended for UK audiences only.

    GO/1003/2015/UKb                                                   Date of preparation: August 2015

  • About Inflammatory Bowel Disease - links
    About Inflammatory Bowel Disease - links

    Gastroenterology
  • Links

    For more information we recommend you to visit the following website:

    www.crohnsandcolitis.org.uk

    Please note that Ferring UK cannot accept liability for the content on the above link, since it is not managed or controlled by Ferring UK.

    All information on this site is intended for UK audiences only.

    GO/1003/2015/UKb                                                   Date of preparation: August 2015

  • About Bleeding Oesophageal Varices
    About Bleeding Oesophageal Varices

    Gastroenterology
  • About Bleeding Oesophageal Varices

    Oesophageal varices are dilated (widened) veins which protrude from the inner surface of the oesophagus (food pipe) and are usually the result of chronic liver disease. The position of the varices on the surface of the lower part of the oesophagus, or at its junction with the stomach, means that they are unsupported by other tissues and are at risk of rupturing when the blood pressure in the varices exceeds a certain level.

    Varices can be detected by endoscopy (a procedure used to look inside the body by using a lighted, flexible instrument) but are often only diagnosed when they start to bleed. The amount of bleeding can range from a gentle oozing of blood to haemorrhaging that is difficult to control and can be life-threatening.

    Causes of oesophageal varices

    Oesophageal varices generally form as the direct result of damage to the liver, which leads to an increase in blood pressure in the 'portal vein', which carries the main supply of blood from the bowel and spleen to the liver on its way back to the heart.

    The rise in blood pressure in the portal vein is generally due to scarring and hardening of the liver tissue, making it more difficult for the blood to flow through. This increased resistance causes the blood to find alternative routes to reach the heart, and new blood vessels open up to bypass the blockage.

    The original cause of restricted blood flow is not always obvious. Liver damage can be the result of a number of different factors including chronic alcohol abuse, infections, toxins, congestive heart failure and autoimmune disease.

    In the West, alcohol is the most common cause of liver damage, though worldwide viral hepatitis and larval forms of parasitic schistosome worms, particularly common in the Middle East and South America, are responsible for 200 million cases.

    Urgent need to treat bleeding oesophageal varices

    Bleeding oesophageal varices require urgent medical attention to prevent serious blood loss and complications. Not everyone with liver damage develops varices and not everyone with varices will bleed. In general, small varices rarely bleed, bigger ones may bleed, but over time, small ones generally develop into bigger ones.

    All information on this site is intended for UK audiences only.

    GO/1003/2015/UKc                                                   Date of preparation: August 2015

  • About Bleeding Oesophageal Varices - managing and treating BOV
    About Bleeding Oesophageal Varices - managing and treating BOV

    Gastroenterology
  • Managing and treating Bleeding Oesophageal Varices

    Emergency treatment of bleeding oesophageal varices

    Bleeding should always be treated as an emergency and it is vital that blood pressure in the portal vein is reduced as quickly as possible to reduce the bleeding and minimise the risk of liver and kidney failure. The faster the treatment is started, the greater its chance of success. 

    Several drugs have been tried in the treatment of bleeding varices. Vasoactive drugs decrease the blood pressure in the portal vein. They work by causing constriction, or narrowing, of the blood vessels within the body's internal organs. This reduces the amount of blood reaching the portal vein, relieving the pressure on the bleeding varices.

    Medical support of bleeding oesophageal varices

    A variety of supportive methods are also used, including transfusions of whole blood and plasma proteins (albumin) to replace lost fluid, maintaining blood volume and pressure to ensure that the kidneys and liver carry on working.

    It is sometimes necessary to use additional techniques to help control serious bleeding. One technique, which is rarely used today, involves the insertion of a 'balloon' device into the stomach and oesophagus via a tube (commonly a Sengstaken-Blakemore tube), which when inflated, applies pressure to the bleeding varices reducing the blood loss.

    Occasionally, a surgical procedure called TIPS (transjugular intrahepatic portal-systemic stent shunt) is required. This is a minimally invasive technique that involves the insertion of a metal tube known as a stent into the liver, bypassing some of the blood flow from the liver to another venous system (the cava system).

    This procedure relieves excess blood pressure in the liver and restores blood flow. This is similar to the technique used in the narrowed arteries of the heart affected by coronary heart disease.

    TIPS is effective in relieving the excess blood pressure in the portal vein but it takes many hours to perform and carries its own risk of complications. In extreme cases of liver cirrhosis, liver transplantation may be the only effective treatment.

    Prevention of oesophageal bleeding

    For those with varices at risk of bleeding, regular drug treatment can sometimes reduce the risk and the severity should it occur. Preventative treatment usually consists of taking regular beta-blocker medication that helps to reduce the increased pressure in the portal vein and thus the pressure in the varices.

    All information on this site is intended for UK audiences only.

    GO/1003/2015/UKc                                                   Date of preparation: August 2015

  • About Bleeding Oesophageal Varices - links
    About Bleeding Oesophageal Varices - links

    Gastroenterology
  • Links

    Please note that Ferring UK cannot accept liability for the content on the above links, since they are not managed or controlled by Ferring UK.

    All information on this site is intended for UK audiences only.

    GO/1003/2015/UKc                                                   Date of preparation: August 2015

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