Inflammatory Bowel Disease: Medical And Surgical Treatment · Inflammatory Bowel Disease: Medical...

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Inflammatory Bowel Disease:

Medical And Surgical

Treatment JASSIN M. JOURIA, MD DR. JASSIN M. JOURIA IS A MEDICAL DOCTOR, PROFESSOR OF ACADEMIC MEDICINE, AND MEDICAL AUTHOR. HE GRADUATED FROM ROSS UNIVERSITY SCHOOL OF MEDICINE AND HAS COMPLETED HIS CLINICAL CLERKSHIP TRAINING IN VARIOUS TEACHING HOSPITALS THROUGHOUT NEW YORK, INCLUDING KING’S COUNTY HOSPITAL CENTER AND BROOKDALE MEDICAL CENTER, AMONG OTHERS. DR. JOURIA HAS PASSED ALL USMLE

MEDICAL BOARD EXAMS, AND HAS SERVED AS A TEST PREP TUTOR AND INSTRUCTOR FOR KAPLAN. HE HAS DEVELOPED SEVERAL MEDICAL COURSES AND CURRICULA FOR A VARIETY OF EDUCATIONAL INSTITUTIONS. DR. JOURIA HAS ALSO SERVED ON MULTIPLE LEVELS IN THE ACADEMIC FIELD INCLUDING FACULTY MEMBER AND DEPARTMENT CHAIR. DR. JOURIA CONTINUES TO SERVES AS A SUBJECT MATTER EXPERT FOR SEVERAL CONTINUING EDUCATION ORGANIZATIONS COVERING MULTIPLE BASIC MEDICAL SCIENCES. HE HAS ALSO DEVELOPED SEVERAL CONTINUING MEDICAL EDUCATION COURSES COVERING VARIOUS TOPICS IN CLINICAL MEDICINE. RECENTLY, DR. JOURIA HAS BEEN CONTRACTED BY THE UNIVERSITY OF MIAMI/JACKSON MEMORIAL HOSPITAL’S DEPARTMENT OF SURGERY TO DEVELOP AN E-MODULE TRAINING SERIES FOR TRAUMA PATIENT MANAGEMENT. DR. JOURIA IS CURRENTLY AUTHORING AN ACADEMIC TEXTBOOK ON HUMAN ANATOMY & PHYSIOLOGY.

Abstract

Although there is no singular known cause for inflammatory bowel disease,

medical research is providing new treatments and reducing mortality rates

associated with the disease at a rapid pace. Inflammatory bowel disease is

the name given to a variety of gastrointestinal disorders that cause similar

symptoms and impact a patient's quality of life. There is no cure, but

symptomatic relief can be found with a variety of treatments, including

medical, surgical, and nutritional. As with many diseases, a multi-faceted

approach is commonly the best approach for successful treatment of

inflammatory bowel disease.


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requirements of the American Nurses Credentialing Center's Commission on

Accreditation for registered nurses. It is the policy of NurseCe4Less.com to

ensure objectivity, transparency, and best practice in clinical education for

all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 4 hours. Nurses may only claim credit

commensurate with the credit awarded for completion of this course activity.

Pharmacy content is 1 hour.

Statement of Learning Need

Health clinicians need to be able to differentiate between Ulcerative Colitis

and Crohn's Disease, as well as be able to describe the clinical

manifestations and potential effects of each on the gastrointestinal tract.

Understanding the common causes and symptoms of inflammatory bowel

disease, including the role that genetics may play and complications of the

disease is essential for a clear understanding of the four types of medical

and surgical techniques commonly used during treatment. Clinicians

supporting nutritional therapies and other health or group support resources

for patients and family members can be used during the treatment of



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Course Purpose

To provide health clinicians with knowledge of the potential causes of

inflammatory bowel disease to improve the chances that this illness can be

successfully treated or prevented.

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned

will be provided at the end of the course.


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1. The current, primary goal of medical therapies for treatment of inflammatory bowel disease is

a. to cure the disease without surgery. b. to maintain remission of symptoms for as long as possible. c. educating patient’s on how to live with their symptoms. d. finding herbal, non-pharmaceutical drugs to treat symptoms.

2. True or False: Olsalazine is more commonly used for ulcerative

colitis, even though diarrhea may be a cause side effect of the drug. a. True b. False

3. Patients who take __________________ for treatment of

inflammatory bowel disease should also take a folic acid supplement.

a. mesalamine b. sulfasalazine c. balsalazide d. olsalazine

4. Which of the following medications has been found to be

effective in treating inflammation associated with Crohn’s disease?

a. Balsalazide b. Mesalamine c. Olsalazine d. Sulfasalazine

5. Oral medications are beneficial because once a patient with IBD

receives a prescription drug for oral administration

a. the patient takes the drug without further instruction. b. the drug is easy for providers to monitor daily. c. the drug is easy for the patient to administer. d. the patient may take the drug only when symptomatic.


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Introduction

Inflammatory bowel disease cannot be cured completely through treatment.

There are various medical therapies available that can help with control of

symptoms and can reduce inflammation in the intestinal tract. Patients with

Crohn’s disease or ulcerative colitis often need more than one type of

medication and usually, the response to these drugs is beneficial in relieving

many of the discomforts of the disease. Medical therapies may be

administered as oral agents, through subcutaneous or intramuscular

injection, as rectal preparations or intravenously when necessary. The type

and route of administration varies with the kind of drug and the severity of

patient symptoms. When medical therapies are unsuccessful, the severity of

the disease has increased, or a patient has developed complications of IBD,

surgical intervention may be necessary to remove portions of the diseased

intestinal tract and to eliminate many of the problems that can occur. One of

the main goals of treatment for IBD is to help patients achieve this state of

remission and to maintain it for long periods to improve quality of life and to

prevent symptoms from returning.

Medical Therapies For Inflammatory Bowel Disease

The main purposes of using medical

therapies to treat IBD are to help

patients achieve states of remission in

which they are less likely to suffer from

negative symptoms and flares. Because

inflammatory bowel diseases are not

cured through medical therapies, goals

often consist of trying to maintain

periods of remission for as long as


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possible. Even when a patient has achieved a state of remission, he/she

often needs to continue seeing a health clinician for disease monitoring.

During remission, a patient may visit the clinician every few months for a

check up and to review medical therapies and ensure that they are working

properly. During times of disease flares, the affected patient often needs to

see a clinician much more often and may need to make prescription changes

to find the correct type and dose of medication to effectively treat

symptoms; medical treatments for IBD are reviewed here.1,15,16,19-25,30-36,73-84

For some people, medications provide freedom from symptoms and help to

induce remission. Additionally, there are many people with IBD who are

prescribed medication regimens that are successful but they do need to

continue taking their medications as prescribed in order to maintain a state

of remission. Sometimes, a disease flare can be triggered when an individual

stops taking medication or is not taking medication as prescribed. This may

occur because of a number of factors related to a patient’s specific situation.

For example, a patient may become so busy that he/she forgets to take a

medication dose for several consecutive days and, combined with increased

lifestyle stress, develops symptoms associated with a disease flare.

Medical therapies are successful enough for some people at maintaining

remission that they stop taking their medication over time because they

believe that the problem has been remedied and they do not understand

that stopping therapy will often cause symptom recurrence. The importance

of maintaining the prescribed regimen of medical therapy, including with

taking medications as prescribed and discussing medication changes first

with a health clinician, should be included as part of patient education to

prevent disease flares and to maintain remission as long as possible.


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Oral Medication

There are many different types of drugs available for management of IBD.

The difference in how they are delivered and the routes of administration

vary but administration is typically related to the formulation of the drugs,

how they are best absorbed and maintained. Another consideration is the

severity of a patient’s symptoms, which can indicate the type of drug

prescribed, and how well a patient responds to a medication. Oral

medications are beneficial in that once they are obtained through a

prescription, they are administered easily. A patient taking oral medications

often takes them independently while at home. A patient may need

instruction regarding the appropriate ways to take these drugs; for instance,

some oral preparations are better tolerated when taken with food. Some

patients may also need reminders if they must take their doses of these

drugs multiple times per day. Anyone who is given a prescription for oral

medications to use for IBD treatment should be educated about the side

effects of the drugs and the signs or symptoms that indicate they need to

call to a health clinician.

Aminosalicylates

One of the most commonly prescribed drugs for management of IBD is

aminosalicylates, which are sometimes known as 5-ASA. The primary mode

of action of 5-ASA is the control of inflammation, which is why they are often

prescribed for cases of inflammatory bowel disease, including during times

when extra-intestinal symptoms of inflammation are present, such as when

IBD causes symptoms of arthritis. Sulfasalazine is often the main drug

prescribed, which is a combination of aminosalicylate and sulfa antibiotics.

Aminosalicylate drugs, such as mesalamine, balsalazide, or olsalazine may

also be prescribed for some patients who do not tolerate sulfasalazine. These

drugs are more commonly used for treatment of ulcerative colitis and are


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less commonly used in Crohn’s disease; however, sulfasalazine has been

shown to be effective in treating inflammation associated with Crohn’s

disease.

Olsalazine is given orally in divided doses of up to 1 g per day, depending on

symptoms. It is more commonly used for ulcerative colitis, even though it

may cause side effects of diarrhea. Balsalazide, when given as an oral

capsule, is administered as 2.25 g daily in adults for up to 12 weeks.

Balsalazide may also be given in smaller doses when ulcerative colitis

develops in children and adolescents. Some mesalamine preparations are

coated so that they will be available as extended release. This delays the

absorption of the drug in the small intestine until it has a chance to reach

some of the distal areas of the small bowel. All of these medications are

considered to have almost the same effectiveness as sulfasalazine but they

are associated with fewer side effects.

Aminosalicylates or 5-ASA work to control inflammation in the intestinal tract

by inhibiting prostaglandins, which are lipid compounds that can affect the

inflammatory process, and leukotrienes, which are types of inflammatory

mediators; this action thereby inhibits part of the inflammatory cascade. 5-

ASA works very quickly and is absorbed rapidly in the lumen of the small

intestine. While it is usually given as an oral preparation, it must be

formulated as an extended release product to delay its absorption slightly

following intake.

Sulfasalazine was one of the earliest forms of aminosalicylate drugs; its

combination with sulfapyridine can help to fend off infection in the gut, if

present. When sulfasalazine is administered, the gut microbiota split the

aminosalicylic acid from the sulfapyridine. While it is frequently prescribed,


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there are many who do not tolerate sulfasalazine well because it is a sulfa

medication. For some, allergies to sulfa drugs prevent them from using this

medicine as a viable option for treatment of IBD. For others, the side effects

of sulfapyridine are strong enough that drug discontinuation and starting

again with another type of aminosalicylate that does not contain sulfa is

preferable. Some common side effects that have been seen specifically with

sulfasalazine include nausea, dyspepsia, and headache, as well as impaired

folate absorption and low sperm counts in men. Most people who begin

taking sulfasalazine must start at a lower dose and gradually increase the

amount until it reaches the therapeutic level.

Sulfasalazine is best tolerated when it is given with food. The American

College of Gastroenterology (ACG) recommends a dose of up to 4 to 6 g

initially for the management of ulcerative colitis. To improve tolerance, it

may be started at a low dose and gradually increased. Maintenance doses

for ulcerative colitis are 2 g sulfasalazine daily, given in divided doses as

long as the drug is tolerated. For treatment of Crohn’s disease, the

recommended dose of sulfasalazine ranges from 3 to 6 g daily, given orally

as tolerated. Sulfasalazine is associated with folate depletion, and can

potentially cause folate-deficiency anemia with regular use. Therefore,

patients who take sulfasalazine for treatment of IBD should also take a folic

acid supplement.

Other formulations of aminosalicylates that may be used instead of

sulfasalazine are available as extended-release forms when administered

orally. The delayed release factor allows the drug to move through the

gastrointestinal tract without being broken down and absorbed too quickly

so that it can reach the distal ileum. With an extended or delayed release

formulation drug, a patient may not need to take the drug as often, and


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these drugs may only be administered once or twice a day. Some side

effects that have been seen with aminosalicylate drugs include excess

diarrhea, gas, nausea, abdominal pain and cramping, and dizziness and

headache. Most of these side effects are contained with lower doses of the

drug, and serious side effects are rare.

Corticosteroids

Oral corticosteroids are designed to reduce inflammation and control pain

associated with various forms of inflammatory bowel disease. Corticosteroids

have been shown to be beneficial during severe flares and for short-term

use, but long-term use of these types of drugs may have more limited

effectiveness. As a result, corticosteroids are never prescribed as

maintenance medications for IBD; other drugs should be prescribed for long-

term or chronic use with use of corticosteroids relegated to acute disease

exacerbation. When used for acute flare up of symptoms, corticosteroids can

reduce inflammation and swelling, but they are often considered to be more

effective when combined with other drugs, such as immunosuppressive

agents.

Long-term use of corticosteroids also puts patients at risk of severe

complications, including osteoporosis and blood glucose abnormalities. Many

of these abnormalities, particularly reduction in bone mineral density, are

seen relatively quickly after starting corticosteroid therapy, often within the

first six months of use. Other adverse events that have been noted with

frequent corticosteroid use include an increased risk of infection.

Corticosteroid use may also cause overall growth retardation, particularly

when the drugs are used in pediatric patients. Use of the drug may lead to

hypertension, poor wound healing, and frequent relapses once the

medication has worn off. The drugs also must be tapered off when


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discontinuing, rather than stopping them abruptly. Additionally, use of these

types of drugs typically requires nutrient supplements, including those of

vitamin D and calcium, which are often depleted with corticosteroid

administration. The side effects associated with corticosteroids must be

considered when contemplating these types of drugs for management of


Prednisone is an oral preparation of corticosteroid that may be administered

with IBD symptom exacerbation. Another similar formulation is prednisolone,

which is also available orally. These drugs may be taken by a patient at

home and are prescribed for use for a specified period; they may be used

with mild to moderate symptoms of IBD. Patients must be instructed

carefully on use of corticosteroids to ensure that the prescribed dose is taken

at the suggested times and is not stopped suddenly. The full treatment of

the drug is given over a period of 1 to 4 weeks, depending on a patient’s

condition, the existing symptoms, the severity of the disease, and whether a

patient has had these drugs in the recent past.

After a patient has taken the full dose for the prescribed period, the patient

must taper the dose by taking a lower dose each day over a period of

several weeks until the drug can be discontinued. Even when a patient has

tapered the dose of the drug to the point of being ready to discontinue its

use, the patient should continue to use another type of medication, such as

5-ASA, to help manage symptoms once corticosteroids are no longer being

taken. This process, in addition to avoiding some severe side effects that can

occur with abrupt discontinuation of corticosteroids, can also prevent some

patients from becoming dependent on these drugs. Patients should be

educated about the common side effects of corticosteroid drugs when using

them outside of the healthcare environment. They should also be taught


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about what signs or symptoms to look for that would warrant an immediate

call to a health clinician, such as sudden episodes of psychosis or

hyperactivity, problems with sleeping and insomnia, and hyperglycemia.

Budesonide is another type of corticosteroid that may be used for some

people with IBD. It is administered orally and is said to have high first-pass

liver metabolism, meaning that its concentration is greatly reduced first by

the liver before it reaches systemic circulation. Because of this rapid

metabolism, it may have fewer side effects when compared to other types of

corticosteroids. When compared to prednisolone, budesonide has fewer side

effects, but its effects are also not as rapid as prednisolone. Because of

these results, budesonide is often reserved for treatment of mild to

moderate forms of IBD. Budesonide is administered as a short-term drug

and is given once per day during active disease. Orally, it is approved for

use to treat Crohn’s disease of the small intestine or as an enteric-coated

preparation to manage ulcerative colitis in the large intestine.

Immunomodulator Drugs

Immunomodulator drugs are those that are administered to weaken some of

the effects of the immune system. When the immune system is altered

through these drug preparations, the inflammatory response is weakened,

leading to less inflammation that typically develops with IBD. Because

symptoms of IBD may develop in relation to excessive inflammation caused

by overactivity of the immune system, immunomodulators work to control

this response. They may also be administered in conjunction with

corticosteroids during times when steroid use is high and a patient needs to

taper a dose.


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Immunomodulators are an option for treatment for patients with IBD who do

not normally respond to 5-ASA or for those who have experienced severe

side effects of other drugs. They can be quite powerful in their activity and

have been shown to help minimize inflammation in the gastrointestinal tract

that often causes debilitating symptoms of inflammatory bowel disease.

When given for IBD, immunomodulators are helpful in suppressing

inflammation; they may also be administered when a person exhibits extra-

intestinal symptoms of IBD, including arthritis symptoms, as they control the

inflammation associated with many autoimmune conditions as well. A

disadvantage of regular use of these types of drugs is their potential to

suppress the immune system to the point that persons taking the drug are

at risk of infection with opportunistic diseases. There is an increased risk of

developing certain types of cancer with these drugs as well, including

lymphoma, and non-melanoma skin cancer. The most commonly

administered drugs in this class, when used for treatment of IBD, are 6-

mercaptopurine, azathioprine, and methotrexate.

Azathioprine, one of the most commonly prescribed immunomodulators for

inflammatory bowel disease, is often prescribed for inflammation associated

with severe rheumatoid arthritis, as well as several other autoimmune

diseases, including lupus and vasculitis. The drug works by suppressing

inflammation that develops because of an autoimmune response in the

body. Azathioprine is classified as a disease-modifying anti-rheumatic drug

(DMARD); it is composed of two main compounds, 6-mercaptopurine and 6-

thioinosinic acid, which is considered the active components of the drug.

These metabolites of azathioprine work by inhibiting T-cell function during

the inflammatory response.


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The doses of azathioprine differ among patients, depending on the extent of

the inflammatory bowel disease, the severity of symptoms, and whether

extra-intestinal symptoms are also present. A typical dose of azathioprine is

2.5 to 3 mg/kg orally per day. 6-mercaptopurine, a derivative of

azathioprine, may also be given. Dosage of 6-mercaptopurine for

management of inflammatory bowel disease is approximately 1 to 1.5 mg/kg

per day, given orally. Because 6-mercaptopurine is a derivative of

azathioprine, 6-mercaptopurine and azathioprine have similar rates of

effectiveness and are structurally similar. They also tend to produce

comparable side effects, including headache, nausea, and vomiting, as well

as canker sores in the mouth, fever, joint pain, bone marrow suppression,

and liver inflammation. Patients who take these drugs should have routine

laboratory testing to monitor liver function tests and white blood cell counts.

Azathioprine and 6-mercaptopurine have been shown to be beneficial in

helping patients who take concomitant steroids to wean off of the

corticosteroids. They may be administered at the same time as the steroid

preparations and given simultaneously for a period – approximately a

month, depending on the amount prescribed — while the corticosteroids are

tapered off. Another benefit of these types of immunomodulators is that,

while they do take approximately 3 to 6 months to achieve their full effects,

they can be used for long periods and are ideal for prescription management

of chronic inflammatory bowel disease.

Some studies have shown that certain immunomodulators, including

azathioprine combined with TNF-α blockers are just as successful as use of

corticosteroids in reducing the need for surgical intervention. A study by The

Canadian Society of Intestinal Research compared patients in Denmark who

received treatment for IBD between 1979 and 2011 and found that an


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increased use of combination azathioprine and TNF-α blockers was

consistent with a decrease in the use of 5-ASA and local corticosteroids, as

well as a parallel decrease in the need for surgical intervention, particularly

among patients with Crohn’s disease. Some of the long-term effects of

immunomodulator drugs still remain to be seen, but historically they have

been beneficial for many patients with inflammatory bowel disease:

immunomodulator drugs are viable treatment options and to avoid the need

for multiple treatment modality requirements for IBD symptoms.

Methotrexate is another type of immunomodulator, which has historically

been used for the treatment of rheumatoid arthritis and lupus. It is also used

as an anti-cancer agent in that it prevents the formation of specific elements

of DNA within tumors to counteract their growth. The drug inhibits a specific

enzyme that transforms folic acid from an inactive to an active form, which

is necessary for DNA and cell replication. Its use in the control of

inflammation is more complicated, and several studies have suggested

different mechanisms of action for how the medication suppresses the

inflammatory response. Methotrexate works faster than some other

immunomodulators, including azathioprine and 6-mercaptopurine, making it

a better choice of drug in some cases.

Methotrexate may be administered orally or as subcutaneous injection, at

doses of 15 to 25 mg. Some clinicians are reluctant to use methotrexate as

a first choice for management of IBD, even though positive effects have

been shown in controlling this particular form of inflammation. Their

hesitancy could be related to the fact that its exact mechanisms of action in

suppressing inflammation are unknown, or they may choose to try therapy

with other medications first. Methotrexate has been shown to be beneficial in

managing symptoms of Crohn’s disease that is otherwise unresponsive to


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azathioprine or 6-mercaptopurine. It may also be used successfully to treat

IBD in cases where a patient is unresponsive to corticosteroid therapy or in

someone who is dependent on corticosteroids to suppress inflammation and

who needs to wean off of the drugs.

Use of methotrexate has been associated with some severe side effects, and

continued use requires frequent monitoring of laboratory values to assess for

changes. The patient taking methotrexate should have a routine complete

blood count to assess for changes in white blood cell levels, as a decreased

white blood cell count is associated with its use. Some of the other mild side

effects most commonly seen with methotrexate include nausea, vomiting,

and abnormal liver function tests. Patients who take methotrexate may need

to have routine liver function testing to ensure that the drug is not causing

further liver damage.

Methotrexate also has the potential to cause birth defects, so women who

may become pregnant must use a reliable form of birth control, and women

who are pregnant and who have IBD may not use methotrexate. Severe side

effects sometimes seen with methotrexate include nephrotoxicity and

myelosuppression, which is a decrease in bone marrow activity.

A disadvantage of the frequent use of immunomodulators is the increased

susceptibility to certain infections. Approximately 10 percent of patients who

use immunomodulators for treatment of IBD develop some form of infection,

associated with a decreased immune response. TNF-α blockers may increase

the risk of some types of opportunistic infections, such as tuberculosis or

cytomegalovirus, and may increase the overall risk of sepsis. Some patients

with diabetes may also be at particular risk of infection when

immunomodulators are used for IBD.


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A study in the journal Alimentary Pharmacology and Therapeutics looked at

the risk of infection among patients using immunomodulator therapy and

who had co-existing diabetes. The study found that there was a nearly 2-fold

risk of increased infections among patients with IBD and diabetes who had

started immunomodulator therapy of azathioprine, 6-mercaptopurine, or

methotrexate within the previous 12 months of conducting the study.

Therefore, patients who have IBD and who also suffer from other extra-

intestinal symptoms or who have another chronic illness should be carefully

monitored while using immunosuppressive therapy to prevent additional

complications while treating inflammatory bowel disease.

There is further evidence of the increased risk of developing certain types of

cancer and lymphoproliferative disease, which describes a condition in which

a person has a significant increase in lymphocyte white blood cells and which

are often seen among those with immunosuppression. A review published in

the American Journal of Gastroenterology indicated that studies have shown

that patients taking immunomodulators azathioprine and 6-mercaptopurine

were at increased risk of lymphoproliferative malignancies; examples of such

types of cancer include lymphoma, multiple myeloma, and chronic

lymphocytic leukemia. The review also noted another study in which the risk

of a lymphoproliferative disorder was 5 times higher among those who were

given thiopurines (azathioprine and 6-mercaptopurine) for management of

IBD when compared to those who had never used these drugs. Specific

types of immunomodulators are not necessarily associated with particular

conditions, but these and many other studies indicate that their use must be

continued with caution to assess both short- and long-term effects of these

drugs.


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Biologic Therapies

Biologic therapies describe drugs that have developed from organisms and

that are prescribed for the treatment of certain diseases. As with

immunomodulator drugs, biologic therapies also work by suppressing the

inflammatory response of the immune system; they have been used

successfully for the treatment of some types of inflammatory bowel disease

and several specific kinds of biologic therapies have been approved for use

with indications given through the U.S. Food and Drug Administration (FDA).

Biologic therapies work by interfering with the body’s inflammatory response

by targeting certain immune factors that are involved with promoting

inflammation. Anti-tumor necrosis factor (TNF) drugs are classified as

biologic therapies that may be considered for some patients with IBD.

Remember that TNF is a type of cytokine excreted during the immune

response with the development of inflammation. Administration of biologic

drugs that inhibit tumor necrosis factor may further inhibit inflammation and

subsequent symptoms of IBD. There are various biologic agents that may be

administered as oral preparations for control of IBD symptoms, including

infliximab, certolizumab pegol, golimumab, and adalimumab. These drugs

are not usually administered orally and are given through injection or via

intravenous administration.

Biologic therapies work more rapidly when compared to some

immunomodulator drugs; their effects can be seen within days to weeks,

while it may take months for some people to achieve the full effectiveness of

immunomodulators. A downside of using these biologic therapies is that

when the immune system is suppressed and the body is unable to create

inflammation, the patient can be at risk of infection with other organisms.

The individual experiences immunosuppression and risk of illness because


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the body not only does not create inflammation related to IBD, but it also

does not respond to other potentially harmful antigens that could cause

other types of disease.

Antibiotics

Because inflammatory bowel disease is thought to develop in part due to

alterations in the gut microbiota, many patients with the disease benefit

from administration of antibiotics during times of disease flares. The changes

in gut microbiota often contribute to the increase in inflammation present

with IBD; consequently, antibiotics may eliminate excess harmful bacteria

and may resolve some inflammatory symptoms.

Research is ongoing about the effects of substances on the gut microbiota

and the ensuing effects on inflammation related to IBD. Prebiotics and

probiotics, found in many foods and available as supplements, have

continually been studied to determine their effects, if any, on improving

numbers of microorganisms in the gastrointestinal tract and ultimately

subduing levels of inflammation. Although research in these areas has not

found anything definite yet, the debate continues.

Alternatively, treatment with antibiotics has been shown to help some

people with IBD by altering levels of gut microbiota, treating active infection,

and managing some complications, including fissures. Antibiotics work by

decreasing concentrations of bacteria in the gastrointestinal tract. It should

be emphasized that antibiotics have been found to be more successful in

cases of Crohn’s disease, but less likely to be efficacious among those with

ulcerative colitis, except in cases of active infection or abscesses, or in cases

of sepsis or further disease complications. They can manage the overgrowth

of certain types of bacterial species that contribute to inflammation, such as


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E. coli or mycobacterium. According to Nitzan, et al., in the World Journal of

Gastroenterology, mycobacterial infection with the species Mycobacterium

avium has been thought to contribute to the development of Crohn’s

disease. Anti-tuberculosis drugs, such as isoniazid, may be given to control

levels of mycobacterium in the gut, thereby potentially reducing its

contribution to inflammation.

Antibiotics have also been shown to be useful in treating certain

complications of inflammatory bowel disease, and so may only be

administered when problems develop or during active periods of disease

symptoms. Fistulas that form when there is tunneling between the intestinal

tract and nearby organs can cause pain, inflammation, and infection, which

can be managed with antibiotics but may also require surgery. Fistulas can

occur anywhere along the gastrointestinal tract but they are most common

around the anal area. Abscesses are another complication that may be more

likely to develop with Crohn’s disease; these pockets of pus and infection

can be treated with antibiotics before they cause further damage to the

intestinal tract. Anal fissures can be particularly painful and are often red,

swollen, and inflamed, with the potential for infection, particularly with

continued exposure to fecal matter. Antibiotics may be administered to some

patients with IBD who have developed fissures to avoid infection in these

areas.

Antibiotics are also used in the treatment of pouchitis, which is inflammation

and infection that develops in the ileal pouch created during ostomy surgery.

Although antibiotics may or may not be used for management of other types

of IBD, either alone or in combination with other medications, they are a

mainstay of treatment of pouchitis. Pouchitis is thought to develop due to

various factors, most prominently because of an abnormal response of the


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immune system to intestinal bacteria. There may also be a shift in the

numbers of normal bacteria in the gut from those of the small intestine to

those of the colon, potentially leading to pouch infection due to differences in

commensal microorganisms. Pouchitis may be classified as acute or chronic

infection.

Alternatively, there are some negative consequences of antibiotic use.

Because of the increasing rate of antibiotic resistance, many patients cannot

take these drugs for prolonged periods and they may only be relegated to

times when severe symptoms are present. Continued and prolonged use of

antibiotics may decrease the susceptibility of infectious microorganisms to

these drugs and they may become ineffective over time. Some patients with

IBD are at increased risk of developing infection with C. difficile, which

causes severe diarrhea and abdominal pain. Prolonged use of antibiotics has

been connected with an increased risk of C. difficile infection. Further,

stopping antibiotics after a period of use may also increase the risk of a

rebound effect in which the symptoms that abated with antibiotic use return.

Finally, the side effects of some types of antibiotics can be severe enough

that many people with inflammatory bowel disease do not want to continue

taking them, despite their benefits. Some of the more common side effects

seen with antibiotics include nausea, vomiting, headache, photosensitivity,

and thrush infection.

Despite potential side effects and complications with antibiotic use, these

drugs remain a valid part of treatment when active disease symptoms

develop. Common antibiotics prescribed for IBD include ciprofloxacin,

metronidazole, rifaximin, and clarithromycin. Some of these drugs may be

administered concomitantly for greater effectiveness. Ciprofloxacin is a

quinolone broad-spectrum antibiotic that is prescribed to manage a number


22

of different types of bacterial infections. It may also be prescribed for

treatment of disease-related flares in inflammatory bowel disease, as well as

when disease complications such as intestinal abscess have developed.

A study published in the journal Gut showed that combining ciprofloxacin

with adalimumab for treatment of perianal fistulas associated with Crohn’s

disease was more effective when compared to adalimumab monotherapy.

This research further supports the concept that combining antibiotic therapy

has greater benefits in disease management in many cases, rather than

attempting to control symptoms and complications with a single drug.

Studies indicating the effectiveness of ciprofloxacin for the specific treatment

of ulcerative colitis have shown mixed results.

Metronidazole may be more effective in treating inflammation that affects

the colon when compared to treatment of the small intestine. Metronidazole

used to be one of the most frequently prescribed drugs for management of

complications associated with inflammatory bowel disease, but it has been

largely replaced by ciprofloxacin. As with ciprofloxacin, studies showing

metronidazole to be effective in managing moderate-to-severe cases of

ulcerative colitis have been met with mixed results.

Rifamixin is a broad-spectrum antibiotic that has been shown to successfully

manage infections caused by both Gram-negative and Gram-positive

bacteria. In research studies, rifamixin has been shown to induce remission

in patients with active Crohn’s disease more quickly than placebo. An

effective dose of rifamixin is 800 mg, given orally over the course of 12

weeks. Similar to metronidazole, rifamixin is often more effective in treating

disease affecting the colon.


23

In addition to the systemic effects of oral medications, some people with IBD

need oral preparations that are designed as topical treatments for ulcers and

inflammation that develop in the mouth, such as in cases of orofacial Crohn’s

disease. Oral corticosteroid agents may be applied topically to mouth lesions

affecting the buccal mucosa and the lips in these cases. Additionally,

patients who suffer from Behcet’s disease and who have developed lesions in

the mouth often benefit from mouthwash rinses that can provide some pain

relief. These rinses typically contain small amounts of lidocaine to act as a

short-term anesthetic and may be particularly helpful in certain cases, such

as when mouth ulcers have caused such discomfort that the patient is

unable to eat normally.

Rectal Medication

Rectal medications, including those given as suppositories, rectal creams and

foams, or enemas are often administered for the management of rectal

bleeding and severe diarrhea. Rectal medications are most often

administered when a patient is suffering from disease that affects the lower

end of the large intestine, including the rectum, the sigmoid colon, and the

lower left side of the colon.

5-ASA is one type of medication that can be administered as a rectal

suppository or as an enema. 5-ASA is a type of aminosalicylate that is most

often administered as an oral preparation, but it must be given as an

extended-release tablet because it is otherwise too quickly absorbed in the

small intestine. When given via rectal suppository, 5-ASA has been shown to

be beneficial in managing inflammation of the rectum associated with

proctitis and in some cases where IBD impacts the sigmoid colon. Rectal

preparations of 5-ASA may be given to those patients who cannot tolerate

oral medications. They are also easy to administer and may be used for


24

acute treatment of disease flares or as long-term maintenance treatment of


Rectal administration of corticosteroids may be given through enemas or

foam suppositories. Hydrocortisone is available in a form that can be

administered rectally; the drug is often combined with an isotonic solution to

be able to retain the liquid within the bowel for longer periods. An enema is

often delivered once a day, preferably at night prior to a time when the

patient will be lying down for a long period. It is usually given each night for

2 to 4 weeks and then, because its use must be tapered down, given every

other night for another 1 to 2 weeks, and then gradually discontinued until

stopped.

Budesonide, as described, is also a corticosteroid but because it is

metabolized extensively in the liver upon first pass, it causes fewer side

effects than some other steroid preparations. Budesonide is available as a

foam enema that can be administered rectally to control symptoms

associated with proctitis, proctosigmoiditis, and areas affecting the lower

segment of the large intestine. Because of its foam substance, it is

associated with greater retention and less leakage. In two randomized trials

explained by Sandborn, et al.,32 in the journal Gastroenterology, budesonide

foam administered as an enema showed a significantly greater benefit with

use when compared to placebo, including among patients with proctitis and

proctosigmoiditis, and it was equally effective when used with or without

systemic mesalamine. The dose used during the studies was 2 mg given

twice daily for 2 weeks, followed by once daily administration for another 4

weeks.


25

While effective in most cases, rectal therapies also have some limitations in

that once administered, they may be difficult to retain. Administration of

suppositories, for example, is often necessary at night before the patient will

be lying down, as walking or sitting upright may cause some of the

medication to leak. Suppositories also tend to impact only the rectum and

the immediate area of use; the medication is usually not distributed into the

sigmoid colon or the large intestine. Despite some of these limitations, rectal

therapies are often very useful in managing inflammatory bowel disease that

specifically affects the rectum and sigmoid colon because they are able to be

administered directly into the site of inflammation, often providing

immediate contact with diseased areas.

At times, rectal medications may be combined with oral agents to improve

effectiveness of the medications and to control symptoms. The combination

of rectal medications and systemic drugs have been shown to improve

symptoms in patients who have concomitant disease in both the colon and

the rectum, so this may be another option for some patients who are

suffering from IBD that affects both areas.

Injection Medication

The administration of medications by injection involves inserting the

medication under the skin, either subcutaneously into the tissue directly

under the skin, or intramuscularly, in which the drug is administered into the

thicker portions of certain muscle groups. Most injectable medications given

for IBD are administered subcutaneously and may be given in the healthcare

environment or at home by the patient or a family member.

As described, biologic agents use living organisms as part of their

composition. They are comprised of antibodies that have been developed in


26

a laboratory setting. Because they are specifically created in this

environment, they focus on subduing specific cytokines as part of the

inflammatory process. Biologic agents can reduce inflammation associated

with ulcerative colitis or Crohn’s disease by suppressing the immune

response, often by blocking the action of the cytokine tumor necrosis factor.

They improve inflammation and its associated symptoms and they improve

the appearance of the tissue and promote healing in the intestinal tract.

Biologic agents usually require several injections initially, followed by routine

injections for maintenance. It can take up to 2 months for symptoms to fully

resolve with some of these drugs, but with maintenance therapy, patients

who use biologic agents often achieve and maintain remission for longer

periods.

One biologic agent, certolizumab, is administered via subcutaneous injection

for control of inflammation associated with inflammatory bowel disease and

certolizumab helps maintain remission. Certolizumab may be given when a

patient does not respond to other forms of treatment of inflammation. It is

administered as a subcutaneous injection, but does not necessarily need to

be given in a healthcare center, as the affected patient can learn to self-

inject the drug at home. Certolizumab is an anti-TNF biologic drug that can

help with controlling severe symptoms of Crohn’s disease, making it a good

choice for patients who are suffering from debilitating symptoms during

disease flares. It is administered at a dose of 400 mg subcutaneously. Initial

therapy involves administration of the injection once every 2 weeks until the

patient is ready for maintenance dosing, when it is given every 4 weeks.

Golimumab is also given via subcutaneous injection and the patient can

administer it after training while at home. The FDA has approved this


27

particular drug for treatment of moderate to severe ulcerative colitis. A

patient who takes golimumab initially administers starter injections 3 times

and can then change to a maintenance dose of the drug once every 4 weeks.

Golimumab has been shown to decrease inflammation and to improve the

appearance of the colon with use, as seen upon colonoscopy. Patients with

ulcerative colitis who take this drug are often able to achieve remission and

sustain it for longer periods when compared with some other types of

medical therapies. Golimumab is given as 50 mg subcutaneous injection,

although it may also be administered intravenously.

Adalimumab is another type of biologic agent administered as subcutaneous

injection. As with other types of these drugs, when given as an injection, the

patient may receive the first dose by a healthcare provider but can then

administer subsequent injections at home with appropriate education. The

initial loading dose is 160 mg, followed by 80 mg the second week, and then

40 mg every 2 weeks thereafter. Adalimumab is approved for use to treat

both moderate to severe Crohn’s disease and ulcerative colitis. It is often

given when patients with inflammatory bowel disease have not responded to

other forms of treatment, including other biologic therapies.

Methotrexate, as described, is an immunomodulator that is available as an

oral preparation, but it may also be given by subcutaneous injection. A

typical dose is similar to that given orally, and ranges from 15 to 25 mg.

Subcutaneous injection of methotrexate has been shown to improve some

symptoms of inflammation in people suffering from Crohn’s disease who

have otherwise not responded to corticosteroid therapy.

Biologic therapies and immunomodulators place patients at risk of certain

side effects. Side effects include an increased risk of infection, as mentioned,


28

which results from a diminished immune response from the action of the

drugs. Other side effects and adverse reactions that have been more

commonly seen with these agents include changes in liver function and

jaundice, joint pain similar to that of rheumatoid arthritis, nervous system

effects, including numbness and tingling of the extremities, weakness, or

visual disturbances, and skin and musculoskeletal reactions that are similar

in effects to lupus, including joint swelling, rash, muscle aches, and fever.

In addition to injectable medications, patients who suffer from extra-

intestinal symptoms of certain inflammatory bowel diseases often require

topical corticosteroids as part of treatment. As an example, a patient with

Behcet’s disease may have skin lesions and ulcers on the genitalia in

addition to ulcers and bleeding from the gastrointestinal tract. Skin and

genital ulcers associated with Behcet’s are often treated with topical

corticosteroids and topical anesthetics for pain control and reduction of

swelling and inflammation.

Along with the side effects associated with certain medications given for IBD,

there are some specific side effects associated with the injection route of

administration. Patients who receive routine injections, whether via

subcutaneous or intramuscular routes, often experience pain during the

injection, although the pain is usually brief. With intramuscular injections,

there may be ongoing muscle pain and tenderness at the injection site that

can last from several hours to a few days. Injections can also cause mild

swelling, redness, bruising, or itching at the injection site as well. While

these symptoms are typically mild and often do not negate the effects of the

medication, they must still be monitored to ensure that further complications

do not develop in the area.


29

Infusion Medication

Infusion of medications for

inflammatory bowel disease is usually

done in the healthcare environment

where the drug administration can be

well controlled and a healthcare

provider can monitor the infusion site.

While there are various drug

preparations that can be administered

via infusion, these types of treatments

for IBD are often reserved for cases in

which the patient is experiencing

severe symptoms that require

hospitalization or when the complications of the disease have caused

significant illness or problems that require more focused care as well as

intravenous medicine. Some of the drugs that are normally administered

orally can be given through infusion in larger or more concentrated doses.

Intravenous corticosteroids can be administered during the acute stages of

disease, particularly when symptoms are manifested during disease flares.

Because of the requirements for intravenous administration, corticosteroids

given through this method are often administered within a healthcare

facility, often when a patient is hospitalized because of symptom severity.

Hydrocortisone is one type of corticosteroid administered as an intravenous

infusion for symptom management of IBD. It may be given as a continuous

infusion or as a bolus dose when combined with intravenous fluids,

administered twice per day. Methylprednisolone may also be given in cases

of severe exacerbation of symptoms; like hydrocortisone, it is given

intravenously either as a bolus dose twice a day or as a continuous drip.


30

Because of the potential for complications associated with corticosteroids,

patients in a hospital who receive intravenous doses of these medications

often require continued monitoring for side effects, including regular checks

of blood glucose levels, changes in level of consciousness, and routine

laboratory checks of complete blood counts to assess for changes in white

blood cell levels.

Cyclosporine is an immunosuppressant agent that is sometimes prescribed

for the prevention of rejection after transplant surgery. Cyclosporine is a

type of immunomodulator therapy that blocks activation of lymphocytes to

suppress immunity. This drug is not commonly administered unless in very

severe cases of IBD, most often with Crohn’s disease, and when

complications such as fistulas have developed. It is administered

intravenously at doses of 2 to 4 mg/kg continuously. Patients who require

cyclosporine are often those who have not responded to other types of

medications or therapies and who have severe disease symptoms.

Cyclosporine is not intended for long-term use for inflammatory bowel

disease management and patients who receive the drug for short periods

and who respond well to its effects should be slowly tapered off the dose

while initializing another type of drug to take its place once it has been

discontinued. It should be used in combination with other anti-inflammatory

agents, such as azathioprine or 6-mercaptopurine. Because of its side

effects, the patient who requires initial cyclosporine therapy should be

tapered from its use as quickly as possible. It is associated with renal

toxicity, seizures, and severe hypertension. For many people who have

reached the point of needing cyclosporine, the only other option for

treatment is surgical intervention, since there has been little to no response

to other types of medical therapies.


31

Infliximab is an immunosuppressant that is often used for the treatment of

IBD, as well as many other inflammatory conditions, including rheumatoid

arthritis and psoriatic arthritis. It has been approved to maintain remission

of moderate to severe Crohn’s disease and ulcerative colitis. When patients

with IBD develop fistulas, infliximab may be administered to maintain tissue

patency after they have been closed, particularly when rectovaginal fistulas

develop as a result of the disease. The standard dose of infliximab, when

given for IBD, is 5 mg/kg, given once as an intravenous infusion. Further

intravenous administrations of infliximab may be repeated after the initial

dose, but several weeks often must pass in between. Infliximab is a

formulation similar to standard infliximab; it can be administered to both

children and adults with Crohn’s disease. As with infliximab, this drug is also

administered intravenously.

In cases of very severe colitis, such as in fulminant ulcerative colitis, an

affected patient may need intravenous infusion of several medications. There

may be times when a patient’s initial presentation is for treatment of

fulminant colitis or another complication of inflammatory bowel disease,

such as toxic megacolon or severe bleeding, when IBD has never actually

been diagnosed. When this occurs, the patient often needs emergency

intervention to correct fluid and blood loss. This often includes fluid

resuscitation with administration of large amounts of crystalline fluids to

replace volume that may have been depleted through diarrhea, vomiting, or

bleeding. A patient often needs intravenous, high-dose corticosteroids to

manage the present inflammation, along with administration of electrolytes

to correct imbalances. Blood transfusions are often necessary in cases of

massive hemorrhage; antibiotics are typically administered intravenously to

manage infection. When the patient is in a life-threatening situation and

needs surgery, fluid administration is given according to preparatory


32

guidelines for care to ensure that the patient is prepared and ready for

surgery as quickly as possible.

Administration of medications through infusion has its own risks and

benefits. While patients with intravenous access can receive medication

quickly and the drugs often take action rapidly to start relieving symptoms,

there are some adverse effects associated with the use of intravenous lines

and central lines. Patients are at increased risk of infection with

administration of drugs through this route. When administering biologic

therapies and immunomodulators in particular, the risk is even higher

because of the effects of these drugs on the immune system. A patient may

be in danger of a bloodstream infection or sepsis if the infection enters the

body through the intravenous line and spreads through the bloodstream or

through lymph circulation. Some people also experience hypersensitivity

reactions or even anaphylactic reactions when receiving intravenous drugs.

Because these medications take effect quickly, they can just as quickly

cause adverse reactions that can sometimes be life threatening. Fortunately,

most intravenous preparations are administered in the healthcare

environment where the patient can be monitored for immediate side effects,

but this potential reaction should always be considered whenever giving any

intravenous preparations to patients for IBD treatment.

The health clinician should assess a patient’s medical history prior to

administering medications for IBD, which can disclose contraindications of

administration. A patient with a current infection should be monitored closely

and drug administration delayed, as bacterial infection is a contraindication

to receiving immunomodulator and biologic drugs. Potential patients should

also be screened for hepatitis or tuberculosis infection as well.


33

Despite the possible consequences associated with infusion of certain drugs,

these medications remain a common form of treatment of complicated cases

of IBD. Patients who do not respond to oral or injectable preparations may

respond to infused medications instead, providing another option for medical

treatment.

Surgical Approaches For Inflammatory Bowel Disease

At times, surgery is indicated for people

with inflammatory bowel disease who

have not responded to traditional forms

of treatment though medication. There

are a number of surgical procedures

that may be included as part of

treatment for Crohn’s disease or

ulcerative colitis. Although some forms

of IBD have overlapping symptoms, the

surgical treatments for these diseases

are not always the same. For some

people with ulcerative colitis, the

surgical interventions needed to control

the disease may actually be contraindicated in cases of Crohn’s disease. Still,

surgery is a viable option for controlling the symptoms that develop during

flares and to remove the diseased portions of the intestinal tract that are

most affected by inflammatory bowel disease.1-3,20,21,33-35,53,103-113

For some, surgery is done when medical therapies have been unable to

control symptoms of the disease and the patient’s quality of life is suffering.

Additionally, some patients with chronic, long-term forms of IBD eventually

take maximum doses of drugs and have few other options. Surgical


34

intervention often provides a means of controlling symptoms for the long

term and being able to decrease or even eliminate the use of some

medications.

Approximately 25 to 40 percent of people with ulcerative colitis eventually

have surgery as either a medical treatment for the disease or to manage a

complication. Additionally, up to 75 percent of people with Crohn’s disease

eventually require some form of surgery, either as an elective option or

because of severe consequences of the disease.

Surgery is often done to remove the diseased parts of the intestine that

cause the most symptoms. For some people, this means removing a

significant portion of the small or large intestine, which can lead to problems

with nutrient absorption and may necessitate a colostomy or ileostomy: a

stoma on the abdominal wall in which the body excretes stool into a bag.

Despite the complications and outcomes associated with this process, as well

as the reality of living without a portion of the intestinal tract, many people

with inflammatory bowel disease choose to undergo surgery because

removal of the portions of the intestine causing the problems will mean a

significant decrease in symptoms or possibly even permanent symptom

remission. The decision of whether to move forward with surgery to promote

remission of symptoms is one that is decided on an individual basis after

examining all of the factors involved.

Many patients with inflammatory bowel disease choose to undergo corrective

surgery at early points in the disease process, rather than wait to manage

the condition through medical therapies. Even though surgery is invasive

and has its risks, it may be an option for patients with IBD because it

ultimately offers them better outcomes. While at one time surgery was only


35

reserved for the most severe cases of IBD, many patients are electing to

undergo surgery to combat milder forms of these diseases, which can

prevent many complications that can develop when symptoms or the disease

process itself is not well managed. For many people, surgery provides the

chance for improved quality of life and living either disease-free or with

considerably fewer symptoms than their current conditions allow.

Proctocolectomy

Proctocolectomy describes surgery done to remove the colon, the rectum,

and the anus. The procedure is often considered to be the only absolute cure

for conditions such as ulcerative colitis, but it is so extensive and complex

that it is not always taken on as a method of treatment unless a patient has

not responded to other forms of treatment or when serious and life

threatening complications have developed.

The individual undergoing proctocolectomy requires a permanent ileostomy

after the surgery, in which the lower portion of the small intestine — the

ileum — is connected to a stoma where it can drain outside of the body.

When this type of surgery is done, it is known as total proctocolectomy with

permanent ileostomy. Because the rectum and anus have been removed,

the patient must have an area in which to contain and release stool. In some

cases, an internal pouch may be placed in the lower abdomen; this pouch

eliminates the need for an external ileostomy and its associated stoma and

bag. The pouch must be emptied through a tube to clear stool from the

body.

During surgery, the surgeon enters the abdominal cavity and removes the

colon, including the main body of the large intestine, as well as the sigmoid

colon and the rectum. The end of the ileum is then brought to an opening in


36

the abdominal wall to create a stoma for release of stool. If the anus is

removed during the surgery, the ileostomy will be permanent, but if the

anus is preserved, the ileostomy can be a temporary measure until the rest

of the bowel has healed. This is followed by a later surgery for anastomosis.

Although proctocolectomy involves the removal of a significant amount of

the large intestine in most cases, for some people, particularly those with

Crohn’s disease, only affected portions of the bowel and/or rectum are

removed. When this occurs, the surgeon identifies the diseased areas that

are most affected and removes them, leaving healthy tissue behind, when it

is present. When a total proctocolectomy is not required, the patient does

not need an ileostomy. This is more commonly performed in those with

Crohn’s disease; alternatively, people with ulcerative colitis more frequently

need to undergo total proctocolectomy. The CCFA states that up to 40

percent of people with ulcerative colitis will need to undergo

proctocolectomy.

Proctocolectomy is often performed as an open procedure, but it is

increasingly available as a laparoscopic procedure as well. Because many

patients with IBD use medications such as immunomodulators or biologic

agents that can depress the immune system, they may already be at

increased risk of infection or other complications following surgery. A

laparoscopic procedure can reduce some of the risks of infection associated

with an open procedure. A study in the journal Inflammatory Bowel Disease

found that laparoscopic total proctocolectomy (performed through

laparotomy) is a safe alternative to proctocolectomy and that patients with

laparoscopic-assisted procedures suffer fewer complications of infection and

reduced wound complications. This type of surgery may therefore be an

option for some patients with ulcerative colitis, as there is a decreased risk


37

of complications with an earlier return of bowel function and a shorter

hospital stay.

Pain medications administered after surgery can help to control some of the

discomfort that occurs but should be limited to those that do not irritate the

gastrointestinal lining. For example, non-steroidal anti-inflammatory agents

such as ibuprofen, while effectively controlling some inflammation and pain

associated with surgery, should be avoided once the patient is able to take

oral pain medications, as these drugs can irritate the stomach lining and

worsen symptoms of inflammatory bowel disease.

The risks associated with proctocolectomy are increased when the procedure

is performed in an emergent situation. However, even scheduled, elective

proctocolectomies are not without some risk, and are associated with an

approximate 20 percent overall morbidity. Some complications associated

with this type of surgery include hemorrhage, wound contamination, and

sepsis, as well as sexual and bladder dysfunction due to nerve damage.

Because patients with ulcerative colitis and Crohn’s disease are at increased

risk of colon cancer, colectomy may also be performed to remove cancerous

tissue if malignancy has developed. The removal of tissue is often necessary

when the cells demonstrate hyperplasia, which is an unnatural growth of

tissue that may occur because of cancerous cell proliferation. If a biopsy has

been performed already that has confirmed malignancy, surgical intervention

may have two outcomes: removal of the diseased portion of the intestinal

tract that is ulcerated and that is causing symptoms, and removal of the

cancerous tissue to prevent metastasis and further growth.


38

There are also some patients who undergo colectomy as a prophylaxis for

colon cancer. According to Bayless and Hanauer,59 authors of the book

Advanced Therapy of Inflammatory Bowel Disease, total proctocolectomy is

the most effective means of minimizing the risk of colorectal cancer in

patients with IBD. Despite the success of eliminating potential locations for

colorectal cancer development by removing the large intestine, the process,

when used as prophylaxis, it often met with mixed reviews. There currently

is a certain amount of controversy surrounding prophylactic surgery for

prevention of cancer, particularly when the surgery is performed in patients

who have mild forms of IBD and few symptoms. The risks associated with

surgery, along with the change in quality of life following the procedure, are

sometimes too extensive to promote a surgical procedure that may prevent

cancer. Alternatively, patients who have several risk factors and who also

struggle with symptoms of the disease may benefit from surgery, which can

help with disease management in addition to reducing cancer risk.

Ileostomy

Ileostomy surgery involves the

creation of a stoma, or opening of the

small intestine, outside of the body.

The body drains waste through the

stoma instead of passing it on to the

large intestine for excretion the anus.

This type of surgery is normally done

when there is disease of the colon

that affects a person’s ability to pass

fecal matter through the large

intestine for defecation. For patients

with inflammatory bowel disease, an


39

ileostomy is often created following surgery to remove the large intestine.

A patient with IBD who is undergoing an ileostomy may have had surgery

previously in an attempt to correct some of the effects of the disease. The

affected individual may have already had part of the gastrointestinal tract

removed, such as through colectomy, in which the large intestine has been

removed, or through surgical removal of a portion of the small intestine,

known as a small bowel resection. The placement of an ileostomy often

comes at a time when other measures for treatment of IBD have not been

successful.

An ileostomy may or may not be permanent for the affected patient. If part

of the large intestine or the rectum is still present, the patient may have the

ileostomy for a period of time and may then undergo reanastomosis to

connect the portion of the ileum that was previously the stoma with the

other end of the intestinal tract. A temporary ileostomy may be indicated in

cases where the patient needs to undergo a period of bowel rest so that the

large intestine can settle and heal. The patient who has a temporary

ileostomy must still have part of the rectum left to be able to use it again

after reanastomosis. If the patient has had the colon, rectum, and anus

surgically removed through another surgery, the ileostomy is then

permanent because it becomes the only method of defecation for the

patient.

During ileostomy surgery, the surgeon creates an opening in the abdominal

wall. This opening is usually on the lower right side of the patient’s

abdomen. The end of the small intestine at the level of the ileum is brought

up to the opening and connected there to create the stoma.


40

The most common type of ileostomy surgery is the Brooke ileostomy, often

considered a standard form of surgical treatment for management of

ulcerative colitis and Crohn’s disease. With this procedure, the surgeon

creates an opening in the abdominal wall and forms a stoma with the end of

the ileum. The edges of the intestine are pulled through the opening and

then turned back and connected to the skin so that there is a smooth

surface with the opening in the middle. Persons with this type of ileostomy

must wear a collection bag for stool at all times because they cannot control

stool output from the stoma and it will otherwise leak out of the opening of

the abdomen.

Although the Brooke ileostomy is one of the most common surgical

procedures used to create an ileostomy, it is often met with resistance from

patients and it is becoming less popular as a surgical alternative. In most

cases, creation of this type of ileostomy is permanent and the patient must

have a stoma and ileostomy bag. Depending on the patient’s age and

activity levels, this may be an unacceptable option. For example, a patient

who was diagnosed with Crohn’s disease at a young age may opt to have

surgery during young adulthood, but having an ileostomy with an external

pouch may cause embarrassment or could interfere with some activities.

A continent ileostomy, also called an abdominal pouch, can sometimes be

performed for patients with ulcerative colitis. This procedure involves the

creation of a pouch within the abdominal cavity when part of the ileum is

turned back onto itself and sewn into place. Wastes collect within this pouch,

rather than outside of the body, so that the patient does not need to wear

an ileostomy bag. A small port extends from the pouch through the

abdominal wall. To empty the pouch, the patient inserts a tube through the

port to drain the waste from the body.


41

The benefits of having a continent ileostomy are that the patient retains

much of his stool continence and is not dependent on an external ileostomy

bag to collect waste. Unfortunately, there are a number of complications

associated with this specific procedure, often because of the location of the

pouch and the port that extends outside of the body. Patients have been

seen with further inflammation of the gastrointestinal tract and/or the pouch

itself, malabsorption problems, and severe diarrhea following this procedure;

there is also a risk for fistula formation between the pouch and the skin.

Despite these drawbacks, this type of surgery is a viable option for many

patients, particularly those who have previously had an ileostomy and would

like to restore stool continence.

A third type of ileostomy procedure, which may also be used for

management of ulcerative colitis, is the ileo-anal reservoir, which is also

called a J-pouch or ileal pouch anal anastomosis (IPAA). The procedure is

done when the patient must have the entire colon and the rectum removed,

but the anus is preserved. Most patients with Crohn’s disease are not

candidates for this type of surgery and in order for it to be successful, the

patient must have a functioning anal sphincter to be able to control the

passage of waste. However, there are many surgeons who agree that this

type of surgery is a first-line option for management of ulcerative colitis.

During the process of creating an ileo-anal reservoir, after the colon and

rectum have been removed, the end of the ileum is looped back on itself to

form a J. This is the reservoir that is then connected to the anus. Waste

collects in the reservoir and the patient rids the waste from the body

through defecation using the anal sphincter muscles. The procedure is

typically done in at least 2 stages to remove the bowel and to create the

pouch; often, the entire process takes several months to complete, as there


42

must be at least 3 months between the time of the colectomy and the

creation of the reservoir. Often the patient requires a temporary ileostomy in

which stool empties through a stoma on the abdominal wall into an attached

bag. The ileostomy is usually required to allow the tissue of the ileo-anal

sphincter and the pouch to heal.

Despite its increasing popularity, there are some complications specifically

associated with this procedure. In the short-term period just following

surgery, the patient is at increased risk of pelvic infection due to leakage

from the anastomosis site. Chronic complications that have been seen with

this procedure include small bowel obstruction due to adhesions, infection or

poor healing of the pouch, and pouchitis, which describes inflammation

within the pouch tissue and is one of the most common complications of this

surgery. A small percentage of patients who have IPAA go on to develop

symptoms of Crohn’s disease in the remaining small intestine or the ileal

pouch.

The patient who undergoes ileostomy is at certain risks because of the

invasiveness of the procedure. As with any type of surgery, the patient is at

risk of infection, often at the surgical site, when microorganisms invade the

tissue and it becomes inflamed and infected. A surgical-site infection most

often occurs within 30 days after surgery. Other general complications

associated with surgery that must be considered include an increased risk of

blood clots and risk for pneumonia.

There are also risks involved with ileostomy that are specifically related to

the procedure. Patients who undergo ileostomy are at greater risk of

intestinal blockage if scar tissue develops in the area around the stoma or

within the nearby intestinal tract. The tissue may become inflamed and


43

fibrous, causing it to thicken, which can make passage of stool through the

intestinal tract and the stoma more difficult. Because the tissue has been

manipulated to create the stoma and the ileostomy, and the patient may

already have fragile intestinal tissue if IBD is present, there is an increased

risk of intestinal bleeding and blood loss from the stoma site. The intestinal

tissue and the mucosa of the stoma can break down and bleed; additionally,

the surgical area and suture line can break open and cause further bleeding.

The stool output from an ileostomy is much more watery and contains more

liquid when compared with stool that leaves the rectum. This is because the

feces do not pass through the colon, which is the main location where fluid

and salt are reabsorbed, causing feces to have more bulk and to be formed.

Without the routine uptake of fluid in the colon, the feces that exit the

ileostomy are often liquid and runny. As a result, patients with ileostomies

are at greater risk of dehydration and may need to increase fluid intake to

avoid serious consequences. Further, many people complain that the stool

output from an ileostomy has a strong odor and that there is more gas

emitted from the stoma. Avoiding certain foods that are more likely to cause

gas, such as broccoli or cabbage, can control this. These patients should

limit intake of carbonated beverages, which contribute more air to the

intestinal tract, and avoid drinking with a straw, which also introduces air

with swallowing.

Initially, the patient may need to avoid excess fiber in the diet, as too much

can lead to dehydration. Eventually, most patients with ileostomies are able

to follow regular diets without many restrictions, but during the first several

weeks after surgery, there are a few constraints needed. In addition to

avoiding extra fiber, patients must avoid foods that could obstruct the stoma


44

site, including items that contain seeds or husks, such as corn, celery, and

beans.

Because the stool empties into a bag, the patient must learn how to care for

the bag, emptying of stool, and the skin at the stoma site. The bag may

need to be emptied of stool several times per day, particularly if stool is

liquid. The patient is taught how to care for the colostomy bag, keep it clean

on the outside of the bag, and reapply a new bag when needed. Most

ileostomy bags can be emptied when using the bathroom, with the contents

of the bag emptied directly into the toilet. The bottom of the bag is kept

closed with a clip or with Velcro closure.

The skin around the stoma site may become irritated, particularly when it

remains in frequent contact with stool in the ileostomy bag. Skin irritation

also occurs more often when the bag is not well connected to the skin or

when the patient uses tape or some other form of adherent to try to keep

the bag connected to the skin. Changing the pouch too often or not often

enough can also result in skin irritation, so it is important for the patient to

follow all of the guidelines provided to keep the area as clean and healthy as

possible. Otherwise, the stoma site should be cleaned regularly, but the

patient should not apply emollients or creams to the site in an attempt to

keep it lubricated or moist. These products can impact how well the stoma

pouch stays connected to the skin, and in some cases they may cause

further irritation.

Bowel Resection

A bowel resection involves removal of the intestine; when the small intestine

is involved, it is called a small bowel resection and when the colon is

involved, it is called a large bowel resection or colectomy. The surgery may


45

involve removal of part of only part of the bowel or it may involve removal of

the entire bowel. The amount of the intestinal tract removed depends on the

extent of IBD present. The resection is done so that when the diseased part

of the intestine is removed, the patient should most likely be free of

symptoms of IBD. If cancer has been detected or if the patient has evidence

of tissue dysplasia, as seen with colonoscopy, colectomy involves removal of

the affected tissue as well, which reduces the chance that malignancy will

spread. In some cases, where cancer is confirmed, the patient may need to

have surrounding lymph nodes removed as well.

A bowel resection may be performed as an open procedure or it can be done

laparoscopically. Obviously, with a laparoscopic procedure, the process is

less invasive and often leads to a shorter recovery time and less pain for the

patient. There are few scars when compared to the larger, vertical scar

associated with open bowel resection; however, even for patients who

undergo a standard or open process, the recovery time in the hospital can

be fairly rapid if there are few complications.

As with proctocolectomy, patients with ulcerative colitis may undergo a

bowel resection when they have not responded to other traditional forms of

medical therapy. When symptoms recur as soon as medication is decreased

or discontinued or when disease flares become so debilitating that there are

no other options for treatment, surgery is usually discussed as the next step

of treatment. For patients with Crohn’s disease, a bowel resection is most

often necessary when complications have developed that must be treated

surgically, such as through severe disease symptoms, strictures, or abscess

development. Unfortunately for some people with Crohn’s disease, removal

of a portion of the intestinal tract through a bowel resection does not


46

entirely eliminate the disease, and Crohn’s inflammation and ulcerations can

recur in the portions of the intestinal tract that remain behind.

There are different types of bowel resection that may be performed,

depending on the amount of tissue involved and the patient’s disease

process. A sub-total colectomy describes a type of bowel resection in which

only part of the large intestine is removed. It may involve removal of most

or all of the large intestine, but leave behind the rectum and the anus. A

subtotal colectomy is often performed in cases where urgent surgery is

needed to prevent further complications that could be life threatening. It

may also be an option when a patient has disease that only affects one

portion of the bowel, which can be removed while keeping other areas of the

intestinal tract intact. Most people who undergo a sub-total colectomy still

need an ileostomy on a temporary basis to allow the intestinal tract to heal.

When Crohn’s disease affects the small intestine, a small bowel resection

may be needed to remove some diseased tissue. The most common type of

small bowel resection for Crohn’s disease is an ileocolic resection, because

the ileum is the area most often affected by the disease. During this

procedure, the surgeon removes the terminal ileum and part of the right side

of the colon. The remainder of the small intestine is connected directly to the

remaining portion of the large intestine. There may be times when a

temporary ostomy is needed following this surgery, but in most cases, the

patient can resume regular bowel function with time.

A large bowel resection may be necessary for some patients with Crohn’s

disease that affects the colon, although it is more common in patients with

ulcerative colitis. A large bowel resection can describe a sub-total colectomy,

total proctocolectomy, or ileal pouch anal anastomosis procedure. As with


47

any type of surgery, the patient is at risk of problems during the post-

operative period, including surgical site infections, poor wound healing, and

problems with digestion and absorption. Patients with IBD who have used

biologic agents and drugs that affect the immune system may be at risk of

infection following surgery as well. Many of the indications for bowel

resection are similar to those for proctocolectomy and ileostomy surgeries,

and the complications of this procedure are comparable as well.

Strictureplasty

Strictures, or the narrowing of the intestinal tract due to thickening of areas

of the bowel wall, can cause multiple complications and may need to be

surgically removed. As discussed, strictures develop when inflammation from

inflammatory bowel disease causes scarring and fibrosis in the intestinal

mucosa. The scar tissue is thicker than normal and does not function in the

same manner as healthy tissue. Eventually, the affected area narrows, and

the lumen of the intestinal tract become smaller. Strictures are more

commonly seen with Crohn’s disease and they can happen anywhere along

the intestinal tract.

Strictures have the potential to cause harm in that they can cause partial or

complete obstruction of the intestine, which causes the passage of intestinal

contents to slow or even stop altogether. The area distal to the obstruction

may also become dilated in response when the bowel attempts to

compensate by increasing the strength of contractions and areas of the

intestinal wall are weakened. Further complications associated with

strictures can then result in bowel perforation and intestinal abscesses.

Strictures are sometimes treated with balloon dilatation, in which a balloon-

tipped catheter is threaded to the stricture site and the balloon is expanded.


48

This action widens the sclerosed area by breaking up the tissue and

expanding the size of the lumen. Depending on the location of the strictures,

though, balloon dilatation may not be available, particularly if the balloon

catheter cannot reach the strictures.

Surgery through strictureplasty is necessary in cases where strictures have

caused complications with movement of food through the intestinal tract and

when other complications associated with intestinal obstruction have

developed. Surgery to correct strictures involves the surgical resection of an

area of the bowel where the strictures are present. It may mean removing a

significant portion of the intestinal tract if the strictures are large and

encompass a greater area.

Strictureplasty is a procedure that removes only the area affected by

resecting the actual strictures. During strictureplasty, the surgeon makes a

lengthwise incision along the stricture to release some of the thickened

tissue and to enlarge the size of the intestinal lumen. Once the lumen of the

intestinal tract has been widened, the tissue is sewn closed to maintain the

new size. Strictureplasty may be performed when strictures are affecting

several areas of the intestinal tract and removal of the portion of the

intestine affected would mean removing a significant area of the bowel. In

some cases, patients may have already had surgery for bowel resection and

may have strictures develop in the remaining intestine. Strictureplasty can

correct the size of the intestinal lumen in these cases when removal of more

of the bowel is not feasible.

One of the more common techniques of strictureplasty is the Heineke–

Mikulicz technique, in which an incision is made horizontally along the length

of the intestine. The incision is centered over the area where the stricture is


49

present and the ends of the incision extend past either end of the stricture

into healthy intestinal tissue. An article by Pocivavsek, et al.,111 in the

journal Inflammatory Bowel Disease noted that by extending the incision

into the healthy tissue on the proximal and distal ends of the stricture,

healthy tissue is drawn toward the stricture site to add to the intestinal

lumen circumference. The resection of the stricture tissue in this manner

then increases the diameter of the lumen and also improves the rate at

which the tissue is able to heal.

Colostomy

Similar to ileostomy, colostomy involves the formation of a stoma in the

abdominal wall through which stool output is released. The end of the stoma

is created by the large intestine and feces are excreted through this opening

instead of from the rectum and the anus. The intestinal tract beyond the site

of the stoma has been removed. The patient with a colostomy must wear a

bag attached to the skin and covering the stoma site to be able to collect

stool. A colostomy may be a temporary measure that a patient has for a

period of time following surgery and as part of treatment; alternatively, a

colostomy is a permanent method of stool excretion for many patients who

have had surgery to correct some complications of an inflammatory bowel.

Colostomy may be performed for people with ulcerative colitis or those with

Crohn’s disease affecting the large intestine. A colostomy differs from an

ileostomy in that because the large intestine is responsible for fluid

absorption, the absorption of most nutrients from food remains unaffected

because the small intestine is intact. Depending on the amount of the large

intestine that is removed, the appearance of stool can differ. The area that is

left must continue to absorb more fluid, but if there is little to no large bowel

remaining after surgery, there will be more liquid in the stool because the


50

body is unable to absorb remaining fluid from the feces. Alternatively, when

much of the large intestine remains after surgery, the stool output from the

colostomy is more formed.

There are different sub-categories of colostomies and the type of surgery

performed differs depending on an individual patient’s condition and the

severity of the disease. A transverse colostomy involves the transverse

segment of the colon, which is located just after the ascending colon. This

type of colostomy is performed in the middle or center of the abdomen or

toward the right side. A temporary colostomy may be performed with a

transverse colostomy to prevent stool from reaching a distal area of the

colon that has been resected or repaired. The stool is diverted through the

colostomy until the distal area heals and then the ends are reconnected

later.

Transverse colostomy consists of two different kinds: a loop colostomy and a

double-barrel colostomy. During a loop transverse colostomy, a loop of the

bowel creates the stoma and there are actually two small openings that look

like one stoma opening. One opening is for removal of wastes and stool and

the other inactive portion leads to the rectum. This second opening may

exude some mucus during bowel movements.

A double-barrel transverse colostomy involves complete division of the bowel

wall and both ends are brought to the surface of the abdomen to form two

stomas. One of the openings releases stool, while the other is inactive. The

inactive portion may be enclosed within the abdomen, in which it is

bypassed completely and non-functional. Because a transverse colostomy is

performed at the more proximal end of the large intestine, stool output is

often liquid and soft since it has spent less time in the colon. The patient is


51

at greater risk of skin irritation at the stoma site because the stool is more

acidic and can cause skin breakdown.

An ascending colostomy is performed on the right side of the abdomen,

removing the ascending portion of the large intestine. As with the transverse

colostomy, stool output from an ascending colostomy is mostly liquid

because it is done at the very beginning of the colon. Because of the high

levels of digestive enzymes present in the stool, the patient with a colostomy

in this area is also at greater risk of skin breakdown and irritation at the

stoma site.

Colostomies located in the lower portion of the large intestine are done when

the descending or sigmoid portions of the colon are removed. These result in

stoma sites that are lower on the left side of the abdomen. The stool output

is mostly formed and is similar in appearance and consistency to that of

stool from the rectum. These types of colostomies may also be double-barrel

colostomies or they may only have one end with a stoma.

People who have undergone colostomies must wear exterior bags attached

to the skin to collect feces. Because there are no muscles to control the

passage of stool from the stoma, the fecal contents spill out of the stoma to

collect in the bag. It is therefore important for the patient to always wear a

collection bag to prevent leakage of stool and soiling of clothing from stool

output. The patient may experience problems with odor and gas, which can

be remedied with diet. Dehydration is also a concern because of fluid loss

through the ostomy opening, particularly with ascending or transverse

colostomies. Many of the requirements needed to maintain the attached bag

and to clean the skin around the stoma are similar to ileostomies and have

been discussed.


52

While colostomy surgery is invasive and typically requires a significant life

change because of the ostomy and required bag, for many patients with

IBD, a colostomy is a step toward health and healing. For those who have

suffered from symptoms and complications of ulcerative colitis or ileocolitis,

surgery for colostomy means no longer managing these problems. Most

people, following colostomy, can live full and normal lives.

Nutritional Therapy For IBD Management

Nutritional therapy is a mainstay of treatment and management of

inflammatory bowel diseases. The use of nutritional therapy started when

these diseases were first being discovered, as clinicians recognized the

impact of chronic bowel inflammation on overall patient nutrition and sought

to prevent weight loss and malnutrition as consequences of inflammatory

bowel diseases. Further, the Western diet, which is high in fat, protein, and

sugar, as well as is often presented in very large portion sizes, contributes to

the obesity epidemic well known throughout many industrialized countries.

There is a correlation between the rising incidences of IBD and intake of

foods mainly found in Western diets. Many of the additives involved,

including emulsifying agents and complex carbohydrates have been shown

to have damaging effects on intestinal tissues. The role of nutrition therapy

in both the prevention and management of inflammatory bowel diseases

cannot be underestimated.10,14-18,89,93-95

Types of diets and supplements have varied over the years, with some

patients being told to eat or avoid certain substances based on available

research at the time. Research is ongoing in this area to determine what

types of foods and nutrients should be avoided or included in the diets of

people with IBD. For example, some healthcare providers recommend the

use of probiotics to increase intestinal bacteria and to possibly help with


53

controlling diarrhea. Probiotics are often

available by eating more yogurt or

sauerkraut or consuming foods containing

them. However, research has not confirmed

that probiotic use is entirely beneficial for

patients with IBD.

Inflammatory bowel disease increases the

risk of malnutrition due to problems with

nutrient absorption and an increase in fluid

loss through diarrhea and vomiting that

often accompanies the disease. People with

Crohn’s disease, in particular, often suffer from malnutrition because of

absorption problems. Dehydration is common with many patients with IBD

because of loss of fluid and electrolytes through frequent diarrhea. Because

of this, the person diagnosed with IBD should receive nutritional therapy and

counseling to determine the most appropriate diet, to calculate appropriate

fluid intake, and to prevent malnutrition, vitamin or mineral deficiencies, or

electrolyte imbalances.

It is therefore important to include nutritional therapy as part of treatment

for IBD. A well-balanced diet that includes regular intake of whole grains,

fruits, vegetables, and low-fat meat and dairy can ensure that the patient is

taking in enough vitamins and nutrients that he needs. There is not one

exact diet specifically for IBD. Some people suffer from more symptoms

after eating certain foods, so the exact types of foods and the amounts need

to be individualized according to patient needs. The affected patient may

need to discern which foods cause more gas and diarrhea and which foods

are safe to eat. Additionally, to reduce excess abdominal pain and diarrhea


54

from certain foods, the patient should avoid very spicy or greasy foods that

would be more likely to cause stomach upset, as well as avoid foods that are

considered to be empty-calorie foods: those that contain large amounts of

sugar or high-fructose corn syrup and therefore plenty of calories, but with

few nutrients.

Other foods that have been shown to cause problems in patients with

inflammatory bowel diseases include high-fiber foods, such as stringy fruits

and vegetables, citrus fruits that contain pith, or vegetables such as celery

or corn that have fibrous components and husks that are not broken down in

the intestinal tract. Fiber is still an important component of good health, and

people with IBD should not avoid all sources of fiber. Instead, choosing a

variety of fruits and vegetables that contain fiber will help to ensure

adequate fiber intake. Some people feel better by eating cooked fruits and

vegetables, rather than raw, cold ones. Cooking vegetables makes digestion

a little easier. All seeds found in fruits and vegetables should be removed

before eating. Although whole grains are often recommended as excellent

sources of fiber, whole-grain breads and pastas may cause problems during

disease flares for those with IBD. Most people with IBD can tolerate eating

white bread or pasta that has been enriched with iron and vitamins,

particularly during times of excessive disease symptoms.

While dairy products are beneficial for many people as excellent sources of

nutrients, some people with IBD do not tolerate dairy because of lactose

intolerance. When determining the most appropriate foods for the diet, each

individual patient with IBD will need to determine whether dairy products

cause more gas and diarrhea or if they are well tolerated. They should be

included in the diet if they do not cause problems but if they must be


55

avoided, affected patients should use lactase products and dietary

supplements.

Some other foods are known as trigger foods and should also be avoided in

cases where they cause problems. Again, not everyone with inflammatory

bowel diseases has the same trigger foods. For example, someone with

ulcerative colitis may be able to tolerate eating fast food while another

person with the same diagnosis may not tolerate the extra fat found in fast

foods. Trigger foods are individualized to each condition. Some types of

foods that are more likely to trigger disease flares in some people include

products that contain wheat gluten; sugar alcohols, including items that

contain sorbitol or mannitol; high-fat foods, including fast foods and full-fat

dairy products, and high-fructose corn syrup.

In addition to eating foods that contain plenty of nutrients and avoiding

foods that are more likely to cause symptoms, people with IBD can follow

certain eating guidelines to help prevent further problems. Eating smaller

meals throughout the day may help some people to be more comfortable,

rather than consuming three large meals a day. Eating in a relaxed setting

can also be beneficial; this helps the individual to lessen stress associated

with eating and prevents rapid food consumption, which can lead to in

increase of air intake. Increasing intake of fluids can also help to prevent

dehydration due to chronic diarrhea. The best fluids to choose are those that

do not add much sugar and that are caffeine free and contain no alcohol.

Examples include water, fruit juices that have been diluted with water, and

sugar-free sports drinks that contain some electrolytes.

As previously discussed, keeping a food diary may be helpful for some

people with inflammatory bowel disease. A food diary records the types and


56

amounts of foods the individual eats, as well as any specific responses to

certain foods, and the timing of disease flares. If any foods or fluids are

included that are not normally a part of the diet, these are noted in the diary

as well. The purpose of keeping a food diary is to find a correlation between

food consumption and symptoms. In some cases, the diary can help to

pinpoint what items exacerbate IBD symptoms and those that potentially

lead to disease flares. Even if the individual is unable to correlate certain

foods with actual disease symptoms, keeping a diary can sometimes identify

those substances that should be avoided in the diet because they worsen

symptoms. There is often no specific method or template to use when

keeping a food diary, but an affected patient may get ideas about how best

to record intake by working with a registered dietitian.

Some patients with IBD benefit from taking a multivitamin or iron

supplement to combat anemia or vitamin deficiencies they may have

developed because of the disease. Supplementation of specific nutrients is

often effective in controlling many symptoms associated with nutrient

shortages. For example, a patient who is taking corticosteroids is at risk of

loss in bone mineral density and osteoporosis with continued use and he

may have difficulties with taking in enough dairy products in his diet.

Supplementation with calcium and vitamin D in this case may help to

prevent further bone loss and could support and protect the patient’s bones

and teeth.

It is important to remember that, while vitamin and mineral supplements

can provide many of the nutrients that a patient may be missing,

supplements should not replace food. Further, some people are sensitive to

the effects of supplements in the gastrointestinal tract, such as when pills

are taken on an empty stomach. If a patient is unable to take in enough


57

food by eating and is starting to rely only on vitamin supplements to prevent

complications, further nutrition support is most likely necessary. However,

for some, the routine flares of inflammatory bowel diseases may cause such

nutritional imbalances that further nutrition support is necessary.

There are some patients that do no tolerate many foods because eating

leads to disease flares and excessive symptoms; they are also more likely to

lose weight and become dehydrated due to diarrhea and fluid loss. In these

patients, enteral nutrition support may be considered as an option to

improve nutrient intake. Some studies have shown that the use of enteral

nutrition is beneficial in helping patients with IBD achieve states of remission

for longer periods. In some cases, patients with IBD who have become

dependent on corticosteroids for management of symptoms have also

benefitted from enteral nutrition therapy in that the nutritional support

helped to reduce their need for the drugs and they were able to achieve

symptom relief.

The use of exclusive enteral nutrition

(EEN) has been used to improve

symptoms of IBD and to reduce

negative effects such as wasting and

poor nutrient tolerance. Exclusive

enteral nutrition describes the

process of providing enteral formula

to a patient through a feeding tube

as the exclusive form of nutrition,

without ingestion of any other oral

food, with the exception of some

water or small amounts of other


58

beverages. A review by Kansal, et al., in Gastroenterology Research and

Practice examined the use of EEN in controlling symptoms of Crohn’s disease

in some patients.16 The review showed that certain types of formula used

with EEN, in particular polymeric formulas, have induced states of remission

in patients with Crohn’s disease more quickly when compared to oral

nutrition therapy alone. In particular, the EEN was able to modify gut

microbiota and it had anti-inflammatory effects; it was shown to promote

mucosal healing and there was also some evidence that EEN lengthened

overall periods of remission.

In particular, EEN has been shown to be effective for children, adolescents,

and young adults living with Crohn’s disease. It is often a prescribed form of

treatment for this population because of the effects of the disease on growth

and development with these age groups. For example, malabsorption

associated with Crohn’s can lead to poor muscle and skeletal development

and use of corticosteroids for treatment of inflammation can increase the

risk of osteoporosis. Therefore, implementing EEN for this population can

reduce some of the harmful effects of the disease and its associated

therapeutic interventions.

Exclusive enteral nutrition is administered using a specific type of formula

that has been created for the affected patient, based on his nutritional

status. The formula is most often administered through a nasogastric tube

that is placed in the nose and threaded to the stomach; however, it may

also be consumed as an oral supplement. There are no other foods or

beverages, excluding water, that are consumed during the time of EEN. The

enteral nutrition is then administered exclusively over a given period of time,

often over eight weeks, for every meal of the day. It may be gradually


59

tapered off at the end of treatment while the patient starts to incorporate

regular foods into the diet again.

In very severe cases of inflammatory bowel diseases, total parenteral

therapy (TPN), which is administered through a central line, may be needed

to prevent muscle wasting and protein energy malnutrition. However, due to

the cost of TPN and the associated risks, including increased risks of

infection and hyperglycemia, as well as risks from the use of a central line

such as blood clots and hemorrhage, this line of treatment is often only used

when the patient needs bowel rest, has a condition such as short bowel

syndrome that has caused problems with malabsorption, or has not

responded to other forms of nutritional and medical therapy.

Nutrition therapy is almost always more effective in managing symptoms of

IBD when combined with medical therapy through medication. This is so

whether nutrition therapy is done through oral intake of specific foods, the

use of supplements and vitamin-mineral preparations, or enteral feedings.

Nutrition support can promote healing in some areas and it usually prevents

many of the problems of malnutrition, osteoporosis, and electrolyte balances

often seen with patients with IBD. Further, nutritional therapy can help to

relieve some of the uncomfortable symptoms that often occur with IBD,

including severe diarrhea or weight loss, thereby helping the patient to be

more comfortable.

Counseling with a registered dietitian may be needed to determine the

appropriate amount of protein and fat in the diet, which often exceeds that

of standard diets, in order to prevent weight loss and muscle wasting. When

a child or adolescent has been diagnosed with inflammatory bowel disease,

nutritional counseling is especially important to prevent delays in growth and


60

development. Children are measured on a growth curve to track their height

and weight and to ensure that they are progressively growing in proportion

to their age. However, because of the effects of IBD and poor absorption and

ensuing malnutrition, many children do not follow the growth chart in terms

of appropriate growth. They may also be behind in normal developmental

tasks and activities because of poor nutritional intake and due to missing

nutrients in the diet. A nutritionist can help the parents of a child or teen

with IBD to ensure that he gets enough food in his diet or that he is taking

in enough nutrients (through regular food intake or through enteral

feedings) to prevent weight loss and growth retardation. The exact amounts

of calories and nutrients often need to be carefully calculated through a

series of nutritional formulas to determine the most appropriate needs for

individual patients.

Inflammatory Bowel Disease Prognosis

Prognosis for inflammatory bowel diseases can vary considerably, depending

on the type of disease, the extent of inflammation and the amount of

damage that has occurred, and the length of time that the affected patient

has had the condition. For some, IBD may only cause a single episode of

inflammation and symptoms. Alternatively, some people struggle with

ongoing episodes of disease flares and they have severe symptoms that are

difficult to manage. It is not clear why there is such variety with disease

severity between the types of inflammatory bowel disease. This section

briefly discusses the prognosis of IBD and its sequelae.1-13

In cases of Crohn’s disease, almost 20 percent of patients have a chronic

form of the condition that results in long-term and continuous episodes of

flares and periods of remission. Most people diagnosed with Crohn’s disease

have normal life spans; Crohn’s disease, unless it causes severe


61

complications because of extensive damage from the disease, usually is not

life threatening. Alternatively, about 50 percent of people with ulcerative

colitis have mild symptoms and the remaining 50 percent go on to develop

severe forms of the disease.

People with inflammatory bowel disease, including ulcerative colitis and

Crohn’s disease that impacts the large intestine, are at an increased risk of

developing colorectal cancer. The risk is greater among those who already

have a family history of colon cancer. Additionally, people with Crohn’s

disease that affects the small intestine are at greater risk of developing

cancer in the small intestine, although the cancers that form in this portion

of the gastrointestinal tract are rare to begin with. Other factors that have

been shown to be related to increased risk of colorectal cancer in patients

with IBD include duration of the disease, as a longer disease duration

increases the cancer risk; the extent of the disease, as larger areas of the

intestinal tract affected by IBD increase risk; age of onset of IBD diagnosis,

as early age of onset (before 20 years) increases the chances of cancer

development; and the amount of inflammation present, as larger amounts of

inflammation contribute to increased risk. Additionally, some studies have

shown that people with inflammatory bowel disease and concomitant

primary sclerosing cholangitis, which describes scarring and narrowing of the

bile ducts, are also at increased risk of cancer.

Patients with IBD should have routine colonoscopies to monitor and detect

changes that could indicate cancer development. Rectal bleeding is often a

sign of colon cancer among those in the general population who do not have

IBD. Because rectal bleeding could indicate a symptom of inflammation

among persons with IBD, potential signs of colon cancer may not always be

so obvious. Colonoscopy is recommended once every 1 to 2 years starting


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approximately 8 to 10 years after a diagnosis of IBD to consistently monitor

the intestinal environment and to assess for signs of colon cancer.

There is no cure for ulcerative colitis or Crohn’s disease. Treatment focuses

on management of symptoms, preventing the disease from progressing, and

maintaining the patient’s quality of life. Control of inflammatory bowel

disease requires routine follow up with a healthcare provider to determine

the progression of the disease, whether the medications prescribed are

effective, and if the patient is experiencing complications. The patient must

also make lifestyle changes, such as by monitoring nutritional intake and

activity levels, to promote the highest quality of life while living with the

disease. With regular medical care and adherence to drug therapy, the

patient with IBD can live an active life.

In addition to nutritional counseling and support, the patient typically

requires psychological support and counseling. Treatment is often ongoing to

provide education and resources to patients who are undergoing therapeutic

procedures; for example, a patient preparing for surgery should receive

education and intervention so that the healthcare provider spends time

talking with the patient and discussing the procedure, explaining what to

expect during recovery, the long-term expected outcomes of the procedure,

and the patient’s expectations for the procedure.

Continued counseling and support is often necessary throughout the process

of treatment and follow-up is warranted to determine the patient’s

psychological response to the situation. Many patients diagnosed with

inflammatory bowel disease struggle with depression because of the chronic

nature of the disease. When IBD symptoms are severe, the affected patient

may struggle with feeling isolated when few people understand the


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condition. A patient may feel like a burden to others. Eating and socializing

with others is often challenging because of the effects of food and digestion

and the person may prefer to stay alone to avoid embarrassment, leading to

further isolation. Depression and anxiety about the condition can occur and

management with counseling or medication may be necessary.

Summary

Inflammatory bowel disease, consisting mainly of Crohn’s disease and

ulcerative colitis, does not have a specific cause, but research continues to

provide new treatments to reduce overall morbidity and mortality.

Inflammatory bowel disease can include a variety of gastrointestinal

disorders, all of which cause symptoms that can significantly impact a

patient's quality of life. There are a number of treatments available that can

be implemented to control disease symptoms, including medical therapies,

and surgical and nutritional interventions. While treatments may take many

forms and are often used in combination, patients with inflammatory bowel

disease have various options for management and control of this debilitating

disease.

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64


a. to cure the disease without surgery.

b. to maintain remission of symptoms for as long as possible. c. educating patient’s on how to live with their symptoms. d. finding herbal, non-pharmaceutical drugs to treat symptoms.


colitis, even though diarrhea may be a side effect of the drug. a. True b. False

3. Patients who take __________________ for treatment of

inflammatory bowel disease should also take a folic acid supplement.

a. mesalamine b. sulfasalazine c. balsalazide d. olsalazine



a. Balsalazide b. Mesalamine c. Olsalazine d. Sulfasalazine



a. the patient takes the drug without further instruction. b. the drug is easy for providers to monitor daily. c. the drug is easy for the patient to administer. d. the patient may take the drug only when symptomatic.


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6. The primary mode of action of 5-ASA in treating inflammatory bowel disease is

a. for treating extra-intestinal symptoms of inflammation only. b. the control of diarrhea. c. the control of inflammation. d. to control bleeding.

7. 5-ASA works to control inflammation in the intestinal tract by

inhibiting ___________________, which are lipid compounds that can affect the inflammatory process.

a. immunomodulators b. TNF-α blockers c. leukotrienes d. prostaglandins

8. In addition to taking the prescribed dose of corticosteroids, a

patient must be instructed that with corticosteroids,

a. the prescribed dose should not be stopped suddenly. b. they may be taken over time to control IBD symptoms. c. the risk of infection is reduced. d. they may be taken only when symptomatic.

9. Corticosteroids are prescribed

a. alone and should not be combined with other drugs. b. for acute flare up of IBD symptoms. c. as maintenance medications for IBD. d. All of the above

10. Long-term use of corticosteroids by a patient puts the patient at

risk of severe complications, including

a. bone marrow suppression, and liver inflammation. b. lymphoma, and non-melanoma skin cancer. c. lupus and vasculitis. d. osteoporosis and blood glucose abnormalities.


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11. True or False: Balsalazide may also be given in smaller doses when ulcerative colitis develops in children and adolescents. a. True b. False

12. Budesonide is a corticosteroid often reserved for treatment of

mild to moderate forms of IBD because

a. its concentration is greatly reduced first by the liver. b. it has more side effects than other corticosteroids. c. of its slow metabolism. d. its effects are more rapid than other corticosteroids.

13. Which of the following drugs increases the risk of developing

certain types of cancer, such as lymphoma, and non-melanoma skin cancer?

a. Corticosteroids b. Aminosalicylates c. Immunomodulator drugs d. Mesalamine

14. Patients who take _______________________ should have

routine laboratory testing to monitor liver function tests and white blood cell counts.

a. aminosalicylates b. corticosteroids c. mesalamine and sulfasalazine d. 6-mercaptopurine and azathioprine

15. True or False: When the immune system is altered through

immunomodulator drugs, the inflammatory response is weakened, leading to less inflammation that typically develops with IBD. a. True b. False


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16. A disadvantage of the frequent use of immunomodulators is the increased susceptibility

a. for diabetes. b. to skin cancer. c. to infection. d. for vasculitis.

17. Biologic therapies describe drugs that have been developed from

organisms and that

a. work slower than immunomodulator drugs. b. have been developed from organisms. c. have slow metabolism. d. work by exciting the immune system.

18. _________________ has the potential to cause birth defects, so

women who may become pregnant must use a reliable form of birth control, and women who are pregnant and who have IBD may not use it.

a. Budesonide b. Azathioprine c. Sulfasalazine d. Mesalamine

19. 6-mercaptopurine and azathioprine tend to produce similar side

effects, including headache, nausea and vomiting, fever, joint pain, and

a. canker sores in the mouth. b. liver inflammation. c. bone marrow suppression. d. All of the above

20. True or False: Immunomodulators such as azathioprine and 6-

mercaptopurine can be used for long periods and are ideal for prescription management of chronic inflammatory bowel disease.

a. True b. False


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21. A downside of using biologic therapies is that when the immune system is suppressed the body

a. may suffer from inflammation. b. may not feel the effects for months. c. will suffer acute flares but not long-term flares. d. does not respond to other harmful antigens.

22. Antibiotics are a mainstay of treatment for

a. ulcerative colitis. b. pouchitis. c. all types of IBD. d. its direct effect on inflammation.

23. The antibiotic _______________ may be more effective in

treating inflammation that affects the colon when compared to treatment of the small intestine.

a. ciprofloxacin b. rifamixin c. metronidazole d. mesalamine

24. Negative consequences associated with the use of antibiotics

include:

a. stopping antibiotics increase the risk of a rebound effect. b. infectious microorganisms become resistant to the antibiotic. c. an increased risk of developing infection with C. difficile. d. All of the above

25. True or False: Prebiotics and probiotics, found in many foods

and available as supplements, have been found to reduce levels of inflammation and are effective in treating the symptoms of IBD.

a. True b. False


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26. Patients who suffer from ________________ and who have developed lesions in the mouth often benefit from oral corticosteroid mouthwash rinses that can provide some pain relief.

a. C. difficile b. ulcerative colitis c. Behcet’s disease d. pouchitis

27. Patients with ulcerative colitis who take ________________ are

often able to achieve remission and sustain it for longer periods when compared with some other types of medical therapies.

a. certolizumab b. golimumab c. ciprofloxacin d. mesalamine

28. For patients who have reached the point of needing _________,

the only other option for treatment is surgical intervention, since there has been little to no response to other types of medical therapies.

a. cyclosporine b. ciprofloxacin c. certolizumab d. mesalamine

29. In cases of very severe colitis, such as in _______________, an

affected patient may need intravenous infusion of several medications.

a. Crohn’s disease b. Behcet’s disease c. pouchitis d. fulminant ulcerative colitis

30. True or False: Cyclosporine is an immunosuppressant agent that

is administered in moderate to mild cases of IBD, most often with Crohn’s disease.

a. True b. False


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31. Approximately _________________ of people with ulcerative colitis eventually have surgery as either a medical treatment for the disease or to manage a complication.

a. up to 75% b. half c. 10 percent d. 25 to 40 percent

32. A proctocolectomy with a permanent ileostomy describes

surgery done to remove

a. the colon, the rectum, and the anus. b. part of the colon. c. the ileum and the colon. d. the ileum.

33. If the anus is preserved during surgery, the ileostomy can be a

temporary measure until the rest of the bowel has healed, and this is followed by a later surgery

a. for an ileostomy. b. known as a laparotomy. c. known as an ileocolic resection. d. for anastomosis.

34. True or False: When considering immunomodulator and biologic

drugs for an IBD patient with a current infection, these drugs should be delayed because bacterial infection is a contraindication to receiving these drugs.

a. True b. False

35. What procedure involves the creation of a pouch within the

abdominal cavity where part of the ileum is turned back onto itself and sewn into place?

a. Colostomy b. Brooke ileostomy c. Continent ileostomy d. Ileostomy


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36. Another type of ileostomy procedure, which may also be used for management of ulcerative colitis, is the ileo-anal reservoir, which is also called

a. a J-pouch. b. an abdominal pouch. c. a proctocolectomy. d. an I-pouch (internal pouch).

37. A bowel resection involves removal of the intestine and when

the colon is involved, it is called

a. ileocolic resection. b. a large bowel resection. c. small bowel resection d. a reanastomosis.

38. The most common type of ileostomy surgery is the __________,

often considered a standard form of surgical treatment for management of ulcerative colitis and Crohn’s disease.

a. Crohn’s ileostomy b. Behcet’s ileostomy c. Brooke ileostomy d. fulminant ileostomy

39. True or False: Removing the large intestine as prophylactic for

prevention of cancer in patients who have mild forms of IBD and few symptoms is generally recommended to reduce cancer risk.

a. True b. False

40. During ileostomy surgery, the surgeon creates an opening in the

abdominal wall, usually on

a. the lower right side of the patient’s abdomen. b. the lower left side of the patient’s abdomen. c. the front of the abdomen. d. the patient’s left side.


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41. A patient who is taking corticosteroids is at risk of loss in bone mineral density and osteoporosis with continued use; the patient may supplement his diet with

a. complex carbohydrates b. emulsifying agents c. calcium and vitamin D d. iron

42. True or False: There is a correlation between the rising

incidences of IBD and intake of foods mainly found in Western diets.

a. True b. False

CORRECT ANSWERS:


b. to maintain remission of symptoms for as long as possible. pp. 5-6; ‘Because inflammatory bowel diseases are not cured through medical therapies, goals often consist of trying to maintain periods of remission for as long as possible.”


colitis, even though diarrhea may be a side effect of the drug.

a. True p. 8: “Olsalazine is given orally in divided doses of up to 1 g per day, depending on symptoms. It is more commonly used for ulcerative colitis, even though it may cause side effects of diarrhea.”


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3. Patients who take __________________ for treatment of inflammatory bowel disease should also take a folic acid supplement.

b. sulfasalazine p. 9: “Sulfasalazine is associated with folate depletion, and can potentially cause folate-deficiency anemia with regular use. Therefore, patients who take sulfasalazine for treatment of IBD should also take a folic acid supplement.”



d. Sulfasalazine pp. 7-8: “Aminosalicylate drugs, such as mesalamine, balsalazide, or olsalazine … are more commonly used for treatment of ulcerative colitis and are less commonly used in Crohn’s disease; however, sulfasalazine has been shown to be effective in treating inflammation associated with Crohn’s disease.”



c. the drug is easy for the patient to administer. p. 7: “Oral medications are beneficial in that once they are obtained through a prescription, they are administered easily. A patient taking oral medications often takes them independently while at home. A patient may need instruction regarding the appropriate ways to take these drugs; for instance, some oral preparations are better tolerated when taken with food. Some patients may also need reminders if they must take their doses of these drugs multiple times per day.”


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6. The primary mode of action of 5-ASA in treating inflammatory bowel disease is

c. the control of inflammation. p. 7: “The primary mode of action of 5-ASA is the control of inflammation, which is why they are often prescribed for cases of inflammatory bowel disease, including during times when extra-intestinal symptoms of inflammation are present, such as when IBD causes symptoms of arthritis.”

7. 5-ASA works to control inflammation in the intestinal tract by inhibiting ___________________, which are lipid compounds that can affect the inflammatory process.

d. prostaglandins p. 8: Aminosalicylates or 5-ASA work to control inflammation in the intestinal tract by inhibiting prostaglandins, which are lipid compounds that can affect the inflammatory process, and leukotrienes, which are types of inflammatory mediators; this action thereby inhibits part of the inflammatory cascade. 5-ASA works very quickly and is absorbed rapidly in the lumen of the small intestine.”

8. In addition to taking the prescribed dose of corticosteroids, a patient must be instructed that with corticosteroids,

a. the prescribed dose should not be stopped suddenly. pp. 10-11: “Other adverse events that have been noted with frequent corticosteroid use include an increased risk of infection…. Patients must be instructed carefully on use of corticosteroids to ensure that the prescribed dose is taken at the suggested times and is not stopped suddenly. The full treatment of the drug is given over a period of 1 to 4 weeks, depending on a patient’s condition, the existing symptoms, the severity of the disease, and whether a patient has had these drugs in the recent past.”


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9. Corticosteroids are prescribed

b. for acute flare up of IBD symptoms. p. 10: “Corticosteroids have been shown to be beneficial during severe flares and for short-term use, but long-term use of these types of drugs may have more limited effectiveness. As a result, corticosteroids are never prescribed as maintenance medications for IBD; …. When used for acute flare up of symptoms, corticosteroids can reduce inflammation and swelling, but they are often considered to be more effective when combined with other drugs, such as immunosuppressive agents.”

10. Long-term use of corticosteroids by a patient puts the patient at

risk of severe complications, including

d. osteoporosis and blood glucose abnormalities. p. 10: “Long-term use of corticosteroids also puts patients at risk of severe complications, including osteoporosis and blood glucose abnormalities.”

11. True or False: Balsalazide may also be given in smaller doses

when ulcerative colitis develops in children and adolescents.

a. True p. 8: “Balsalazide may also be given in smaller doses when ulcerative colitis develops in children and adolescents.”

12. Budesonide is a corticosteroid often reserved for treatment of mild to moderate forms of IBD because

a. its concentration is greatly reduced first by the liver. p. 12: “Budesonide is another type of corticosteroid that may be used for some people with IBD. It is administered orally and is said to have high first-pass liver metabolism, meaning that its concentration is greatly reduced first by the liver before it reaches systemic circulation.”


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13. Which of the following drugs increases the risk of developing certain types of cancer, such as lymphoma, and non-melanoma skin cancer?

c. Immunomodulator drugs p. 13: “When given for IBD, immunomodulators are helpful in suppressing inflammation; they may also be administered when a person exhibits extra-intestinal symptoms of IBD, including arthritis symptoms, as they control the inflammation associated with many autoimmune conditions as well. A disadvantage of regular use of these types of drugs is their potential to suppress the immune system to the point that persons taking the drug are at risk of infection with opportunistic diseases. There is an increased risk of developing certain types of cancer with these drugs as well, including lymphoma, and non-melanoma skin cancer.”

14. Patients who take _______________________ should have

routine laboratory testing to monitor liver function tests and white blood cell counts.

d. 6-mercaptopurine and azathioprine p. 14: “Because 6-mercaptopurine is a derivative of azathioprine, 6-mercaptopurine and azathioprine have similar rates of effectiveness and are structurally similar. They also tend to produce comparable side effects, including headache, nausea, and vomiting, as well as canker sores in the mouth, fever, joint pain, bone marrow suppression, and liver inflammation. Patients who take these drugs should have routine laboratory testing to monitor liver function tests and white blood cell counts.”

15. True or False: When the immune system is altered through

immunomodulator drugs, the inflammatory response is weakened, leading to less inflammation that typically develops with IBD.

a. True p. 12: “Immunomodulator drugs are those that are administered to weaken some of the effects of the immune system. When the immune system is altered through these drug preparations, the inflammatory response is weakened, leading to less inflammation that typically develops with IBD.”


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16. A disadvantage of the frequent use of immunomodulators is the increased susceptibility

c. to infection. p. 16: “A disadvantage of the frequent use of immunomodulators is the increased susceptibility to certain infections.”

17. Biologic therapies describe drugs that have been developed from

organisms and that

b. have been developed from organisms. p. 18: “Biologic therapies describe drugs that have developed from organisms and that are prescribed for the treatment of certain diseases.”

18. _________________ has the potential to cause birth defects, so

women who may become pregnant must use a reliable form of birth control, and women who are pregnant and who have IBD may not use it.

d. Mesalamine p. 16: “Methotrexate also has the potential to cause birth defects, so women who may become pregnant must use a reliable form of birth control, and women who are pregnant and who have IBD may not use methotrexate.”

19. 6-mercaptopurine and azathioprine tend to produce similar side

effects, including headache, nausea and vomiting, fever, joint pain, and

a. canker sores in the mouth. b. liver inflammation. c. bone marrow suppression. d. All of the above p. 14: “Because 6-mercaptopurine is a derivative of azathioprine, 6-mercaptopurine and azathioprine have similar rates of effectiveness and are structurally similar. They also tend to produce comparable side effects, including headache, nausea, and vomiting, as well as canker sores in the mouth, fever, joint pain, bone marrow suppression, and liver inflammation. Patients who take these drugs


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should have routine laboratory testing to monitor liver function tests and white blood cell counts.”

20. True or False: Immunomodulators such as azathioprine and 6-

mercaptopurine can be used for long periods and are ideal for prescription management of chronic inflammatory bowel disease.

a. True p. 14: “Azathioprine and 6-mercaptopurine have been shown to be beneficial in helping patients who take concomitant steroids to wean off of the corticosteroids. They may be administered at the same time as the steroid preparations and given simultaneously for a period – approximately a month, depending on the amount prescribed — while the corticosteroids are tapered off. Another benefit of these types of immunomodulators is that, while they do take approximately 3 to 6 months to achieve their full effects, they can be used for long periods and are ideal for prescription management of chronic IBD.”

21. A downside of using biologic therapies is that when the immune system is suppressed the body

d. does not respond to other harmful antigens. pp. 18-19: “A downside of using these biologic therapies is that when the immune system is suppressed and the body is unable to create inflammation, the patient can be at risk of infection with other organisms. The individual experiences immunosuppression and risk of illness because the body not only does not create inflammation related to IBD, but it also does not respond to other potentially harmful antigens that could cause other types of disease.”

22. Antibiotics are a mainstay of treatment for

b. pouchitis. p. 20: “Although antibiotics may or may not be used for management of other types of IBD, either alone or in combination with other medications, they are a mainstay of treatment of pouchitis.”


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23. The antibiotic _______________ may be more effective in treating inflammation that affects the colon when compared to treatment of the small intestine.

c. metronidazole p. 22: “Metronidazole may be more effective in treating inflammation that affects the colon when compared to treatment of the small intestine.”

24. Negative consequences associated with the use of antibiotics

include:

a. stopping antibiotics increase the risk of a rebound effect. b. infectious microorganisms become resistant to the antibiotic. c. an increased risk of developing infection with C. difficile. d. All of the above

p. 21: “Alternatively, there are some negative consequences of antibiotic use. Because of the increasing rate of antibiotic resistance, many patients cannot take these drugs for prolonged periods and they may only be relegated to times when severe symptoms are present. Continued and prolonged use of antibiotics may decrease the susceptibility of infectious microorganisms to these drugs and they may become ineffective over time. Some patients with IBD are at increased risk of developing infection with C. difficile, which causes severe diarrhea and abdominal pain. Prolonged use of antibiotics has been connected with an increased risk of C. difficile infection. Further, stopping antibiotics after a period of use may also increase the risk of a rebound effect in which the symptoms that abated with antibiotic use return.”

25. True or False: Prebiotics and probiotics, found in many foods

and available as supplements, have been found to reduce levels of inflammation and are effective in treating the symptoms of IBD.

b. False p. 19: “Research is ongoing about the effects of substances on the gut microbiota and the ensuing effects on inflammation related to IBD. Prebiotics and probiotics, found in many foods and available as supplements, have continually been studied to determine their effects, if any, on improving numbers of microorganisms in the


80

gastrointestinal tract and ultimately subduing levels of inflammation. Although research in these areas has not found anything definite yet, the debate continues.”

26. Patients who suffer from ________________ and who have

developed lesions in the mouth often benefit from oral corticosteroid mouthwash rinses that can provide some pain relief.

c. Behcet’s disease p. 26: “Oral corticosteroid agents may be applied topically to mouth lesions affecting the buccal mucosa and the lips in these cases. Additionally, patients who suffer from Behcet’s disease and who have developed lesions in the mouth often benefit from mouthwash rinses that can provide some pain relief.”

27. Patients with ulcerative colitis who take ________________ are

often able to achieve remission and sustain it for longer periods when compared with some other types of medical therapies.

b. golimumab p. 27: “Golimumab has been shown to decrease inflammation and to improve the appearance of the colon with use, as seen upon colonoscopy. Patients with ulcerative colitis who take this drug are often able to achieve remission and sustain it for longer periods when compared with some other types of medical therapies.”

28. For patients who have reached the point of needing _________,

the only other option for treatment is surgical intervention, since there has been little to no response to other types of medical therapies.

a. cyclosporine p. 30: “Because of its side effects, the patient who requires initial cyclosporine therapy should be tapered from its use as quickly as possible. It is associated with renal toxicity, seizures, and severe hypertension. For many people who have reached the point of needing cyclosporine, the only other option for treatment is surgical intervention, since there has been little to no response to other types of medical therapies.”


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29. In cases of very severe colitis, such as in _______________, an affected patient may need intravenous infusion of several medications.

d. fulminant ulcerative colitis p. 31: “In cases of very severe colitis, such as in fulminant ulcerative colitis, an affected patient may need intravenous infusion of several medications.”

30. True or False: Cyclosporine is an immunosuppressant agent that

is administered in moderate to mild cases of IBD, most often with Crohn’s disease.

d. False p. 30: “Cyclosporine is a type of immunomodulator therapy that blocks activation of lymphocytes to suppress immunity. This drug is not commonly administered unless in very severe cases of IBD, most often with Crohn’s disease, and when complications such as fistulas have developed.

31. Approximately _________________ of people with ulcerative

colitis eventually have surgery as either a medical treatment for the disease or to manage a complication.

d. 25 to 40 percent p. 34: “Approximately 25 to 40 percent of people with ulcerative colitis eventually have surgery as either a medical treatment for the disease or to manage a complication. Additionally, up to 75 percent of people with Crohn’s disease eventually require some form of surgery, either as an elective option or because of severe consequences of the disease.”

32. A proctocolectomy with a permanent ileostomy describes

surgery done to remove

a. the colon, the rectum, and the anus. “Proctocolectomy describes surgery done to remove the colon, the rectum, and the anus…. The individual undergoing proctocolectomy requires a permanent ileostomy after the surgery, in which the lower portion of the small intestine — the ileum — is connected to a


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stoma where it can drain outside of the body.”

33. If the anus is preserved during surgery, the ileostomy can be a temporary measure until the rest of the bowel has healed, and this is followed by a later surgery

d. for anastomosis. p. 36: “If the anus is removed during the surgery, the ileostomy will be permanent, but if the anus is preserved, the ileostomy can be a temporary measure until the rest of the bowel has healed. This is followed by a later surgery for anastomosis.”

34. True or False: When considering immunomodulator and biologic

drugs for an IBD patient with a current infection, these drugs should be delayed because bacterial infection is a contraindication to receiving these drugs.

a. True p. 32: “A patient with a current infection should be monitored closely and drug administration delayed, as bacterial infection is a contraindication to receiving immunomodulator and biologic drugs.”

35. What procedure involves the creation of a pouch within the abdominal cavity where part of the ileum is turned back onto itself and sewn into place?

c. Continent ileostomy p. 40: “A continent ileostomy, also called an abdominal pouch, can sometimes be performed for patients with ulcerative colitis. This procedure involves the creation of a pouch within the abdominal cavity when part of the ileum is turned back onto itself and sewn into place.”


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36. Another type of ileostomy procedure, which may also be used for management of ulcerative colitis, is the ileo-anal reservoir, which is also called

a. a J-pouch. p. 41: “A third type of ileostomy procedure, which may also be used for management of ulcerative colitis, is the ileo-anal reservoir, which is also called a J-pouch or ileal pouch anal anastomosis (IPAA).”

37. A bowel resection involves removal of the intestine and when the colon is involved, it is called

b. a large bowel resection. p. 44: “A bowel resection involves removal of the intestine; when the small intestine is involved, it is called a small bowel resection and when the colon is involved, it is called a large bowel resection or colectomy.”

38. The most common type of ileostomy surgery is the __________,

often considered a standard form of surgical treatment for management of ulcerative colitis and Crohn’s disease.

c. Brooke ileostomy p. 40: “The most common type of ileostomy surgery is the Brooke ileostomy, often considered a standard form of surgical treatment for management of ulcerative colitis and Crohn’s disease.”

39. True or False: Removing the large intestine as prophylactic for prevention of cancer in patients who have mild forms of IBD and few symptoms is generally recommended to reduce cancer risk.

b. False p. 38: “Despite the success of eliminating potential locations for colorectal cancer development by removing the large intestine, the process, when used as prophylaxis, it often met with mixed reviews. There currently is a certain amount of controversy surrounding prophylactic surgery for prevention of cancer, particularly when the surgery is performed in patients who have mild forms of IBD and few symptoms.”


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40. During ileostomy surgery, the surgeon creates an opening in the abdominal wall, usually on

a. the lower right side of the patient’s abdomen. p. 39: “During ileostomy surgery, the surgeon creates an opening in the abdominal wall. This opening is usually on the lower right side of the patient’s abdomen.”

41. A patient who is taking corticosteroids is at risk of loss in bone

mineral density and osteoporosis with continued use; the patient may supplement his diet with

c. calcium and vitamin D p. 56: “Some patients with IBD benefit from taking a multivitamin or iron supplement to combat anemia or vitamin deficiencies they may have developed because of the disease. Supplementation of specific nutrients is often effective in controlling many symptoms associated with nutrient shortages. For example, a patient who is taking corticosteroids is at risk of loss in bone mineral density and osteoporosis with continued use and he may have difficulties with taking in enough dairy products in his diet. Supplementation with calcium and vitamin D in this case may help to prevent further bone loss and could support and protect the patient’s bones and teeth.”

42. True or False: There is a correlation between the rising

incidences of IBD and intake of foods mainly found in Western diets.

a. True p. 52. “There is a correlation between the rising incidences of IBD and intake of foods mainly found in Western diets. Many of the additives involved, including emulsifying agents and complex carbohydrates have been shown to have damaging effects on intestinal tissues. The role of nutrition therapy in both the prevention and management of inflammatory bowel diseases cannot be underestimated.”


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References Section

The References below include published works and in-text citations of published works that are intended as helpful material for your further reading.

1. Nair, M., Peate, I. (2015). Pathophysiology for nurses at a glance. Malden, MA: John Wiley & Sons, Ltd.

2. Peppercorn, M., Kane, S. (2016, Sep.). Patient education: Ulcerative colitis (beyond the basics). Retrieved from http://www.uptodate.com/contents/ulcerative-colitis-beyond-the-basics

3. Parray, F., Wani, M., Malik, A., Wani, S., Bijli, A., Irshad, I., Ul-Hassan, N. (2012, Nov.). Ulcerative colitis: A challenge to surgeons. Int J Prev Med. 3(11): 749-763. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506086/

4. National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2015, Aug.). Questions and answers about Behçet’s disease. Retrieved from http://www.niams.nih.gov/health_info/Behcets_Disease/default.asp

5. National Organization for Rare Disorders (NORD). (2015). Behçet’s syndrome. Retrieved from http://rarediseases.org/rare-diseases/behcets-syndrome/

6. Skef, W., Hamilton, M., Arayssi, T. (2015, Apr.). Gastrointestinal Behçet’s disease: A review. World J Gastroenterol. 21(13): 3801-3812

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