Inflammatory Bowel Disease

DESCRIPTION

Inflammatory bowel disease (IBD) is a general term for a group of chronic inflammatory disorders of the intestines characterized by recurrent inflammation in specific parts of the intestines. The two main types of IBD are Crohn’s disease and ulcerative colitis.

In Crohn’s disease, the ileum (the final part of the small intestine) is the primary area affected, although the inflammatory reaction may also involve the mucosa of the mouth, oesophagus, stomach, duodenum (the first part of the small intestine), jejunum (the middle portion of the small intestine), colon (the large intestine), the mesentery (outside covering of the intestines), or the lymph nodes in the abdominal region. In ulcerative colitis, the lining of the colon is the area affected.

IBD may occur at any age, but initial appearance is typically between the ages of 15 and 35 years, and women are affected slightly more often than men. Caucasians develop IBD two to five times more often than people of African or Asian descent, and individuals of Jewish descent have a three to six times higher incidence compared with other Caucasians. Ulcerative colitis is more common than Crohn’s disease, averaging between 70 and 150 cases per 100,000 people. The average incidence of Crohn’s disease is 20–40 cases per 100,000; however, the rate of Crohn’s disease is increasing in the West, possibly due to excessive antibiotic use and the Western diet (discussed below).

FREQUENT SIGNS AND SYMPTOMS

Crohn’s disease

• Cramping abdominal pain, especially after eating
• Pain may be in the right lower abdomen, mimicking appendicitis
• Nausea and
• Fever, generally ill feeling
• Loss of appetite and weight
• Tender abdomen, often with a palpable abdominal mass
• Bloody stools (sometimes)
• Growth retardation in children

Ulcerative colitis

• Pain in the left side of the abdomen (the location of the colon) that improves after bowel movements
• Attacks of bloody with mucus, alternating with symptom-free intervals
• Up to 10–20 bowel movements a day
• Dehydration
• Sweating, nausea
• Severe cramps and pain around the rectum
• Bloated abdomen
• Fever as high as 104?F (40?C)
• Loss of appetite and weight

Complications of IBD

• Malnutrition: unhealthy weight loss and malnutrition are prevalent in 65–75% of IBD patients.

Contributing factors include:

• Decreased food intake (most common cause)
• Diarrhoea-induced nutrient loss (especially electrolytes, minerals and trace mineral loss)
• Malabsorption in patients with extensive small intestine involvement or who have had surgical resection of the small intestine resulting in decreased absorptive surface and/or bile salt deficiency
• Overgrowth of unfriendly bacteria in the small intestine
• Fat malabsorption, which results in significant loss of calories and fat-soluble vitamins (vitamins E, A, D, K), and all minerals, including calcium, magnesium, potassium, and trace minerals is common
• Protein loss due to increased turnover and shedding of intestinal cells:
• A significant loss of blood proteins across the damaged and inflamed intestinal mucosa occurs that may exceed the ability of the liver to replace, even with a high protein intake. Chronic loss of blood often leads to iron depletion and anaemia.
• Common drugs – the corticosteroids – used in treatment of IBD significantly contribute to malnutrition:
• Corticosteroids (e.g., prednisone [prednisolone]) stimulate protein breakdown (catabolism); depress protein synthesis; decrease absorption of calcium and phosphorus; increase urinary excretion of vitamin C, calcium, potassium and zinc; increase levels of blood glucose, serum triglycerides, and serum cholesterol; increase requirements for vitamin B6, vitamin C, folate, and vitamin D; decrease bone formation; and impair wound healing.
• Rheumatoid arthritis: occurs in about 25% of IBD patients, typically affecting the knees, ankles, and wrists. Severity of symptoms is usually proportional to disease activity.
• Rheumatoid arthritis of the spine: this is similar to ankylosing spondylitis but is infrequent:
• symptoms are low back pain and stiffness with eventual limitation of motion.
• My precede bowel symptoms by several years.
• Skin lesions: occur in about 15% of patients, can be severe (gangrene or painful red lumps), but more typically are annoying, like canker sores. Canker sores occur in 10% of patients with IBD.
• Serious liver disease: affects 3–7% of people with IBD, can be severe (e.g., sclerosing cholangitis, chronic active hepatitis, cirrhosis):
• If liver abnormalities are present, patients should take Silybum marianum (see Botanical medicines below).
• Disease associations: inflammation of blood vessels, impaired blood flow to fingers or toes, inflammatory eye conditions (episcleritis, iritis, uveitis), kidney stones, gallstones, and in children, failure to grow, thrive and mature normally.

CAUSES

No definitive agreement exists as to the causes of IBD.

 
Theories include the following.

• Genetic predisposition: no specific genetic marker has been found, but genetic predisposition is likely since IBD is two to four times more common in Caucasians than non-Caucasians, and four times more common in individuals of Jewish descent than non-Jews. Also, in 15–40% of cases, multiple family members have IBD.
• Infectious agent or agents: numerous microorganisms could potentially cause IBD. Favoured candidates include mycobacteria and viruses such as rotavirus, Epstein–Barr virus, and cytomegalovirus. Other candidates include pseudomonas-like organisms, Chlamydia, and Yersinia enterocolitica.
• Antibiotic exposure: prior to the 1950s, when penicillin and tetracycline became available in oral form, Crohn’s disease was found only in isolated groups and had a strong genetic component. Since then, the number of Crohn’s disease cases has risen rapidly in developed countries, especially the US, and in countries that had virtually no reported cases:
• The annual increase in prescriptions for antibiotics parallels the annual increase in incidence of Crohn’s disease.
• Comparative statistics show that wherever antibiotics are used early and in large quantities, the incidence of Crohn’s disease escalates.
• One possible explanation is that Crohn’s disease is caused by an infectious agent that is a normally innocuous resident in the intestines, but when subjected to sublethal doses of antibiotics, increases its production of toxins and becomes invasive:
• Such behavior is typical of microbes. When not given a lethal dose of antibiotics, their usual response is to adapt, become more aggressive and multiply.
• Immune system abnormality: although immune disturbances are evident in IBD, they are most likely a result rather than a cause of the disease process.
• Dietary factors: several lines of evidence strongly support dietary factors as the most important causative factor:
• Incidence of Crohn’s disease is increasing in countries where people consume the Western diet (high in saturated fats, refined carbohydrates and sugars), while it is virtually nonexistent where a more “primitive” diet (high fiber, whole foods) is consumed.
• Food is the major factor in determining the intestinal environment.
• When the pre-illness diets of people who develop Crohn’s disease are analyzed, they habitually eat more refined sugar and less raw fruit, vegetables, and dietary fiber than healthy people.
• Patients with ulcerative colitis, however, do not show an increased consumption of refined carbohydrates compared with controls. In these patients, food allergy may be the most important causative factor.
• Emotional factors: while not an initiating cause, psychological factors can significantly affect the course of the disease.

 

RISK INCREASES WITH

• History: family history of IBD.
• Antibiotics: early and/or frequent use of antibiotics.
• Disease-promoting Western diet: a diet based on animal products and processed foods, with little consumption of fresh vegetables, legumes, fruits, nuts and seeds, and whole grains is low in fiber and protective factors such as antioxidants and essential fatty acids, and high in factors associated with IBD, specifically Crohn’s disease – sugar and refined carbohydrates, and saturated and trans fats (also called partially hydrogenated oils).
• Food allergies: numerous studies have demonstrated that common allergens, especially wheat and dairy products, are significant contributing factors in IBD.

PREVENTIVE MEASURES

• Minimize consumption of sugars and refined foods.
• A health-promoting diet: after identifying and removing any allergenic foods from the diet, choose a balanced diet composed of whole, unprocessed, preferably organic foods, especially plant foods (fruits, vegetables, whole grains, beans, nuts [especially walnuts], and seeds), and cold-water fish.
• A high-potency multiple vitamin and mineral supplement: this should include 400 ?g of folic acid, 400 ?g of vitamin B12, and 50–100 mg of vitamin B6. (Folic acid supplementation should always be accompanied by vitamin B12 supplementation to prevent folic acid from masking a vitamin B12 deficiency.) A daily multiple providing all of the known vitamins and minerals serves as a foundation upon which to build an individualized health-promotion program.
• Antibiotics: use antibiotics only when truly necessary.
• Regular exercise: among its many mental and physical benefits, regular exercise tones muscles, improving bowel function.

 

Expected outcomes

Crohn’s disease

Significant improvement in nutritional status and reduced frequency of acute attacks. Complete remission is quite possible. In several controlled studies of Crohn’s disease, a significant percentage of patients (approximately 20% at 1 year and 12% at 2 years) who were given a placebo experienced spontaneous remission. The rate of spontaneous remission was dramatically higher in patients who had no previous history of steroid therapy: 41% achieved remission after 17 weeks, and 23% of this group continued in remission after 2 years, compared to only 4% of the group with a prior history of steroid use. Once remission is achieved, the majority of patients can maintain their health using natural, non-drug therapy.

Ulcerative colitis

In most cases, significant clinical improvement and/or complete resolution are seen within the first 3 months following the protocol. Complete resolution of signs and symptoms are much more likely in this form of IBD compared to Crohn’s disease.

 

TREATMENT

Optimize diet and correct nutritional deficiencies.

Diet

• Identify and eliminate food allergens.
• Eliminate alcohol, caffeine, and sugar: all exacerbate inflammation.
• Drink at least 2 L (3 US pints) of clean water (filtered if your tap water has not been tested and found to be pure) daily to prevent dehydration.
• Reduce or eliminate consumption of meat and dairy products, while increasing consumption of cold-water fish (salmon, mackerel, herring, halibut):
• Meat and dairy products are the highest sources of arachidonic acid, a type of omega-6 essential fatty acid that the body uses to create inflammatory compounds called leukotrienes. Leukotrienes amplify the inflammatory process and cause intestinal cramping and pain.
• Cold-water fish are the best sources of the anti-inflammatory omega-3 essential fatty acids, EPA (eicosapentaenoic acid) and DHA (docosahexanoic acid).
• Avoid all foods containing carrageenan:
• Carrageenan, a compound extracted from red seaweeds, is used by researchers to experimentally induce ulcerative colitis in animals, including primates.
• Carrageenan compounds are widely used by the food industry as stabilizing and suspending agents in milk and chocolate milk products (ice cream, cottage cheese, milk chocolate, etc.) because of their ability to stabilize milk proteins.
• In healthy human subjects and animals whose intestines are germ-free, carrageenan does not cause ulcerative colitis.
• The bacterium Bacteroides vulgatus, an organism typically found in high concentrations (six times higher than normal) in the fecal cultures of patients with ulcerative colitis, appears to be responsible for facilitating carrageenan-induced damage in the intestines.
• Patients with IBD typically require as much as, or even more than, 25% more protein than the usual recommended dietary allowance (see Complications of IBD, Malnutrition above).
• An elemental diet is often an effective alternative to corticosteroids in IBD:
• An elemental diet contains all essential nutrients, with protein provided in the form of predigested or isolated amino acids.
• Improvement may be due to allergy elimination.
• Elimination (oligoantigenic) diets: these eliminate potentially offending foods:
• Most common offending foods in IBD are wheat and dairy products.
• See the ICIM Web Article on Food allergy for more information on elimination diets and various methods of determining food allergy or sensitivity.
• High-complex carbohydrate, high-fiber diet:
• A high-fiber diet has been shown to have beneficial effects in both Crohn’s disease and ulcerative colitis.
• Dietary fiber exerts numerous beneficial effects on the digestive tract:
• Provides food for health-promoting intestinal flora
• Soluble fiber slows transit time in individuals with diarrhoea
• Binds to and removes toxins via faeces.
• Foods rich in fiber (legumes, fruits, vegetables) and unrefined carbohydrates (starchy vegetables such as potatoes, corn, and whole grains such as rice, barley, millet, quinoa, spelt) should be emphasized.
• Best additional fiber choices are oat bran and flaxseed meal, both of which provide soluble fiber:
• Flaxseed meal also contains anti-inflammatory omega-3 essential fatty acids
• Wheat bran should not be consumed as it is too rough and irritating.
• Food allergens should be identified and avoided.

Nutritional supplements

• Flaxseed oil.
• Flaxseed oil contains the omega-3 essential fatty acid ALA (alpha-linolenic acid), which the body converts to the anti-inflammatory fatty acid, EPA.
• Caution: flaxseed oil should always be refrigerated and should not be used in cooking as its essential fatty acids are very susceptible to oxidation/rancidity.
• Probiotics: friendly intestinal flora are needed to repopulate the intestines, both for their numerous beneficial effects on intestinal health and also because they compete with, and therefore lessen the effects of, less friendly bacteria whose cell components promote destruction of intestinal cells; viable Lactobacillus acidophilus and Bifidobacterium bifidum cells
• A high-potency multiple vitamin and mineral supplement (see Preventive Measures above) is essential.
• Additional antioxidants: vitamins C and E are the two primary antioxidants in the body. Vitamin C is found in all body compartments composed of water, while vitamin E is found in the fat-soluble compartments (all cell membranes, and fat-containing molecules such as cholesterol). Recommended dosages for patients with IBD (including the amount found in the multiple vitamin and mineral formula) are:
• Vitamin E (mixed tocopherols).
• Vitamin C.
• Zinc: zinc deficiency is a well-known complication in both Crohn’s disease and ulcerative colitis, occurring in approximately 45% of patients, as a result of low dietary intake, poor absorption, and excessive faecal loss:
• Many complications of IBD may be due to zinc deficiency, including poor healing of fissures and fistulas, skin lesions, decreased sexual development, growth retardation, retinal (eye) dysfunction, lowered immune function, and loss of appetite.
• Many patients appear to have a defect in tissue transport that prevents them from responding to oral or even intravenous zinc supplementation.
• Zinc picolinate, a form of zinc bound to a molecule secreted by the pancreas, appears to be best absorbed and utilized.
• Folic acid: deficiency is quite common in IBD, ranging from 25–64% of patients:
• The drug sulfasalazine is a frequent cause of folic acid deficiency.
• Folic acid deficiency results in abnormalities in the structure of the intestinal mucosal cells, thus promoting further malabsorption and diarrhoea. The turnover of intestinal mucosal cells for which a constant supply of folic acid is needed, is very rapid (1–4 days).
• Vitamin B12: B12 is absorbed in the portion of the intestine most commonly affected in Crohn’s disease (the terminal ileum):
• Abnormal B12 absorption is found in 48% of patients with Crohn’s disease
• Often the terminal ileum is surgically removed (resected) in Crohn’s disease patients. If the length removed is less than 60 cm, or the extent of the inflammatory lesion is less than 60 cm, adequate absorption of B12 may occur. Otherwise, monthly B12 injections (1,000 mg IM) are necessary.
• Vegetarians should also supplement with a sublingual form of B12.
• Pancreatic extracts: pancreatic enzymes can reduce the inflammation of IBD and help with digestion;

Botanical medicines

IBD

• Robert’s Formula: a naturopathic remedy with a long history of effectiveness in treating IBD, Robert’s Formula may be purchased in health food stores. It is composed of:
  ¦ Althea officinalis (marshmallow root): a soothing demulcent
  ¦ Baptista tinctora (wild indigo): used for gastrointestinal infections
  ¦ Echinacea angustifolia (purple coneflower): antibacterial, used to support immune function
  ¦ Geranium maculatum (geranium): astringent action helps heal ulcerations
  ¦ Hydrastis canadensis (goldenseal): inhibits the growth of many disease-causing bacteria
  ¦ Ulmus fulva (slippery elm): soothing demulcent.

Ulcerative colitis

• Demulcent herbs such as deglycyrrhizinated licorice (DGL), marshmallow root, and slippery elm:
  ¦ demulcent herbs contain glycoproteins (proteins with sugar molecules attached) called mucins that are largely responsible for the viscous and elastic character of secreted mucus. ¦ mucin abnormalities are typical in ulcerative colitis patients (but not in Crohn’s disease) and are a major factor in their increased risk of colon cancer.
  ¦ in ulcerative colitis, the mucus content of the intestinal goblet (mucus-producing) cells dramatically decreases, as does the production of sulphur containing mucin.
  ¦ demulcent herbs soothe irritated mucous membranes and promote mucus secretion.

IBD with liver disease

• Silybum marianum (milk thistle): milk thistle contains silymarin, a mixture of flavonoids that is one of the most potent liver-protecting substances known. Silymarin is dramatically effective in reversing liver damage and in treating both acute and chronic hepatitis.
• Silymarin inhibits liver damage by:
  ¦ acting as a direct antioxidant and free radical scavenger
  ¦ increasing intracellular levels of glutathione and superoxide dismutase, two critically important liver antioxidants and detoxifying agents
  ¦ inhibiting the formation of leukotrienes (agents that promote inflammation and free radical generation)
  ¦ increasing bile flow
  ¦ stimulating liver cell regeneration
  ¦ dosage: best results are achieved at higher doses –
  ¦ Silymarin phytosome: research indicates that this new form of silymarin, which is bound to phosphatidylcholine, is better absorbed and produces better and more rapid clinical results than unbound silymarin.

Drug–herb interaction cautions

None.

ICIM Medics Approach

If you feel that this article relates to you and you suspect that Inflammatory Bowel Disease may be present, then please make an appointment for your Digestive Assessment http://icimmedics.com/medical-assessments/digestive-assessment/

The results from the assessment can be used by one of our Natural Medical Practitioners who will help you with your individualised treatment plan. This may include dietary, nutritional and/or botanical advice.

This article is not meant to be used for treatment but for information purposes only. If you feel that this approach is appropriate for you please contact ICIM Medics on 045 844 819 or www.icim.ie e-mail : info@icim.ie Both appointments can be arranged for you.

Tags: Crohn’s Disease, IBD, Inflammatory Bowel Disease, Ulcerative Colitis.