Ulcerative Colitis, Crohn’s Disease And Other Inflammatory ...Ulcerative Colitis, Crohn’s...

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Ulcerative Colitis,

Crohn’s Disease

And Other

Inflammatory Bowel

Diseases 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 no singular known cause for inflammatory bowel disease

exists, medical research has led to new treatments and a reduction in

mortality rates associated with the disease. Inflammatory bowel

disease includes 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

multifaceted approach is commonly the best for successful treatment

of inflammatory bowel disease.


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Policy Statement

This activity has been planned and implemented in accordance with

the policies of NurseCe4Less.com and the continuing nursing education

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.

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 inflammatory bowel disease.


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Course Purpose

To provide health clinicians with knowledge of the etiology, diagnosis

and treatment of inflammatory bowel disease.

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. Inflammatory bowel disease (IBD) is actually a group of disorders that a. similarly cause inflammation in the gastrointestinal tract. b. affect the same areas of the intestine. c. respond treatment in the same way. d. All of the above

2. True or False: All types of IBD develop along the

gastrointestinal tract in the areas of the small or large intestines. a. True b. False

3. Two of the most common types of inflammatory bowel

disease (IBD) are a. ulcerative proctitis and Crohn’s disease. b. ulcerative proctosigmoiditis and proctitis. c. ulcerative colitis and sclerosing cholangitis. d. ulcerative colitis and Crohn’s disease.

4. Sclerosing cholangitis causes inflammation and scarring

within the a. the cecum. b. bile ducts. c. descending colon. d. the ileum.

5. _________________ is a chronic condition that causes

inflammation of the intestinal tract with concomitant ulcerations of the intestinal mucosa. a. Ulcerative proctosigmoiditis b. Behcet’s disease c. Ulcerative colitis d. Sclerosing cholangitis


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Introduction

The chronic gastrointestinal condition of inflammatory bowel disease

(IBD) is a recurring disease characterized by inflammation, tissue

deterioration, and ulceration in different regions of the gastrointestinal

system. The most common types of IBD are ulcerative colitis and

Crohn’s disease. The different types of IBDs may develop anywhere

along the gastrointestinal tract from the mouth to the anus, although

most cases are confined to areas of the small or large intestines.

Inflammatory bowel disease causes periods of active illness in which

affected persons suffer from multiple symptoms that include pain and

diarrhea, followed by periods of remission, in which there are few to

no symptoms at all. The chronic nature of the disease has confounded

physicians who have researched its causes and the most appropriate

forms of treatment to be able to induce remission and alleviate some

of the debilitating symptoms.

Overview Of Inflammatory Bowel Disease

Inflammatory bowel disease is actually a group of disorders that all

cause similar effects of inflammation in the gastrointestinal tract. The

diseases that are classified as IBD often produce similar symptoms,

but they also have variations in their causes, the areas of the intestine

involved, and their response to treatments. Two of the most common

types of IBD are ulcerative colitis and Crohn’s disease. Although there

are varying conditions that fall under the classification of being

inflammatory bowel diseases, ulcerative colitis and Crohn’s are the

most well known conditions of IBD because they are the most

common. Both of these diseases cause intestinal inflammation, pain,

and tissue damage in the gastrointestinal tract. Ulcerative colitis

primarily affects the large intestine, while Crohn’s disease is most


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common in the small intestine, but can occur anywhere along the

digestive tract. Inflammatory bowel disease has been, at times,

confused with some other conditions that affect the gastrointestinal

tract, including irritable bowel syndrome and general colitis. While

these conditions may be disabling to those who suffer from them, they

are not the same as inflammatory bowel diseases, which require

extensive treatment and daily management when symptoms develop.

Inflammatory bowel disease is characterized by fluctuations in the

course of the disease that involve periods of acute symptoms followed

by periods of remission when few or no symptoms are present. During

a disease flare the symptoms reappear; a flare can be brief with

symptoms lasting for a few days, or the flare could last for months.1

There is greater risk of tissue damage, disease complications, or

possibly permanent harm to the patient, when a flare episode becomes

prolonged and symptoms persist.

The type and extent of the symptoms that occur during a flare vary

between people, as well as the inflammatory bowel disease type.

Some people experience debilitating symptoms that affect their ability

to live a normal life, while others exhibit mild symptoms that are

uncomfortable but that are short lived. Common symptoms that

develop during disease flares for people with IBD include diarrhea and

urgent bowel movements, rectal bleeding, abdominal pain and

cramping, fever, fatigue, nausea and vomiting, and weight loss. The

main goals of treatment for IBD symptoms are to induce periods of

remission (in which few of these symptoms are present), and to

maintain remission for as long as possible.


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Ulcerative Colitis

Ulcerative colitis, a chronic condition that causes inflammation of the

intestinal tract with concomitant ulcerations of the intestinal mucosa,

was first recognized approximately 150 years ago as a distinct disease.

Although clinicians have long recognized the existence of this

particular type of inflammatory bowel disease, the underlying causes

and the specific forms of treatment are areas where knowledge

continues to develop.

Ulcerative colitis typically only causes inflammation of the large

intestine and the rectum; alternatively, the small intestine remains

largely unaffected. The exact cause of ulcerative colitis and the

reasons why some people develop the condition are not known, but

research suggests potential environmental or genetic causes. People

who develop ulcerative colitis often have a family member with IBD;

up to 25 percent of people with ulcerative colitis have a first-degree

relative with some form of inflammatory bowel disease. The

combination of family history of the disease and environmental

triggers, such as infection or smoking cessation, can lead to

development of ulcerative colitis.2

An environmental trigger, such as a period of illness or stress, can lead

to a period of intense symptoms, further ulcer development and a flare

episode. Normally, the person with ulcerative colitis struggles with

painful symptoms during times of flares, but these are often on an

intermittent basis. The disease has periods of remission and

exacerbation when symptoms are present. A trigger that causes a flare

activates the immune system, causing an autoimmune response in

which the body attacks the lining of the large intestine and/or the


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rectum, leading to tissue breakdown and ulcer formation. As

discussed, there are various situations and substances that can lead to

disease flares.

Although stress is known to be a triggering factor for a disease flare,

uncontrolled stress is not the cause of ulcerative colitis or of any other

type of IBD. Some people who experience intense emotional stress

may suffer from digestive symptoms; the term stress ulcer has even

been used among some in the lay public to describe a stomach or

intestinal ulcer that develops as a result of stress. While stress and

intense emotions associated with difficult situations can be

overwhelming and can lead to health issues, it is important to

understand that IBD develops due to other causes related to the

gastrointestinal tract and inflammation, not solely because of stress.

Stress and tension can trigger disease flares and so stressors should

be managed to prevent symptom recurrence.

Ulcerative colitis most often occurs in adolescents, young adults, and

those of middle age. It is most commonly diagnosed between the ages

of 15 and 40 years, and again after age 60. It is less commonly

diagnosed for the first time in adults of middle age to older adulthood;

however, a diagnosis at a younger age, combined with the ongoing

need for the treatment of flares and active disease, may mean that the

condition in an affected patient will persist throughout adulthood.

Approximately 5 percent of first-time cases of ulcerative colitis are

diagnosed after age 60.3 The condition is also more likely to develop in

industrialized countries, particularly in the United States and Europe;

the increased incidences of ulcerative colitis found in these countries

are thought to be partially associated with diet.


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The inflammation that develops with ulcerative colitis affects the lining

of the colon, most often the layers closest to the intestinal lumen. This

inflammation can occur anywhere in the large intestine; it may only

develop in small patches or it could affect the entire colon. In some

cases, the rectum is involved as well, or the rectum may be the only

site involved at all. The inflammation causes tissue breakdown of the

colon’s mucosal layer, leading to sores and ulcers that may contain

pus, mucus, or blood. The inflammation and ulcerations are not

present at all times; in fact, they may be in various stages of healing,

depending on whether the person is in disease remission. During a

flare, the inflammation and tissue damage causes multiple symptoms

of abdominal pain, diarrhea and an increased need for a bowel

movement. The loose stools often contain pus and blood, and episodes

of diarrhea may occur many times in a day.

In addition to the classic symptoms associated with ulcerative colitis

(diarrhea, abdominal pain, weight loss, and rectal bleeding), the

affected patient may suffer from extra-intestinal symptoms that are

unrelated to the gastrointestinal tract. There are a number of

conditions affecting the liver and the gall bladder that may develop

with ulcerative colitis. These illnesses may be more likely to develop

because of the close proximity of these organs with the intestinal tract.

A small percentage of patients develop sclerosing cholangitis, which

causes inflammation and scarring within the bile ducts. Other

complications commonly seen with these organs include fatty liver

disease, gallstones, chronic hepatitis, and pancreatitis.4 Extra-

intestinal manifestations that may be seen with ulcerative colitis that

are beyond those affecting the liver, gallbladder, or pancreas include

joint and muscle pain, septic arthritis, erythema nodosum (small, red


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bumps, swelling, and inflammation most commonly seen on the fronts

of the legs), irritation of the iris of the eye, kidney stones, and deep

vein thrombosis.5

Although symptoms can encumber those patients affected with

ulcerative colitis, their intensity and severity may fluctuate throughout

the course of the disease. When symptoms do develop, their effects

are related to the area of the intestinal tract most affected. In the case

of ulcerative colitis, because the disease affects the colon and/or the

rectum, the patient with the disease will most often suffer from the

effects that occur when the large intestine and the rectum are

damaged and are not working properly.

Large Intestine

Also known as the colon or the large bowel, the large intestine makes

up a significant portion of the final segment of the gastrointestinal

tract. The large intestine is the main site of fluid absorption from fecal

matter before it is expelled from the body. The large intestine consists

of several parts and connects with the small intestine at the cecum;

from that point, it is made up of the ascending colon, the transverse

colon, the descending colon, and the sigmoid colon, which precedes

the rectum and the anus. The large intestine is approximately 2½

inches in diameter and is roughly 7½ feet long.

When inflammation develops within the large intestine, it can impact

how well the various areas of the colon are able to perform their

routine duties. The inflammatory process is complex, designed as the

body’s response to exposure to certain antigens and as a form of

protection.


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It is well known that inflammation can develop as the body’s response

to its own cells in an autoimmune process or as a result of

dysregulation of the normal course of cell-mediated or humoral

immunity. When inflammation occurs with ulcerative colitis, it may be

the result of various factors. The initial triggering factor stimulates the

immune system to respond by sending certain substances to the site.

In the case of ulcerative colitis, this site is somewhere in the colon or

the rectum.


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Once activated, the immune system initially sends macrophages to the

area, which are designed to engulf and destroy antigens. The

activation of these macrophages stimulates the release of more

cytokines, leading to the inflammatory cascade, which is the continued

activation and release of cells of the immune system to protect the

body.

Cytokines are produced by the cells of the immune system, mainly the

B cells, T cells, NK cells, and macrophages. The T-helper cells are

responsible for producing many cytokines, therefore, inflammatory

processes associated with different types of IBD may be driven by

either T-helper 1 (Th1) cells or T-helper 2 (Th2) cells.6 In the case of

ulcerative colitis, the disease is said to have a Th2-like mediated

response, based on the types of cytokines released.3,6 There are a

number of different cytokines that may be released during the

inflammatory process, and each one plays a specific role. Some

cytokines are responsible for inducing inflammation and are considered

to be pro-inflammatory cytokines. Interleukin-1 (IL-1), for example,

stimulates various cells to initiate inflammation and stimulates the

hypothalamus to increase body temperature when inflammation is

developing. Tumor necrosis factor-alpha (TNF-α) also further induces

inflammation and promotes fever in the affected individual.24

Alternatively, some cytokines are designed to suppress the

inflammatory response once it occurs. Interleukin-4 promotes the

growth of B cells, while IL-10 inhibits some of the work of

macrophages, thereby restraining further inflammation. The role of

these cytokines is to initiate repair and healing of tissue when

inflammation has developed. One of the main reasons for the


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inflammatory response within the body is to increase blood flow to the

affected site, so areas that are inflamed become red and warm.

Nearby blood vessels dilate to increase blood flow, which can also

increase the risk of bleeding if the tissue becomes friable and breaks

down.

The inflammation that develops

with ulcerative colitis is

associated with a breakdown of

intestinal tissue that leads to

ulcers in the gastrointestinal

tract. The triggering event leads

to an inflammatory response,

leading to the release of

immune cells and inflammatory

mediators, which only prolongs

the inflammatory response. It is

thought that this derangement

of the inflammatory response

occurs as a result of the

patient’s immune system response and subsequent inflammation

development. It is also possible bacterial flora present in the intestinal

tract of the patient with ulcerative colitis plays a role in affecting the

integrity of the mucosal lining of the large intestine, which may make

it more prone to tissue breakdown and ulcer formation.3 As mentioned

above, a person with ulcerative colitis can develop inflammation and

ulcers in any part of the large intestine. The condition ranges in

severity from affecting only one portion of the large intestine to

causing inflammation and lesions throughout the entire colon.


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The lining of the intestinal tract consists of four main layers: the

mucosa, the submucosa, the muscularis layer, and the adventitious

layer. While most areas of the gastrointestinal tract consist of these

four layers, the cells of the large intestine contain some different

elements within its layers. In comparison to some other areas, the

cells of the mucosal layer in the large intestine are simple columnar

epithelial cells, which are densely packed. The intestinal lumen of the

large intestine does not contain villi; the intestinal villi are part of the

mucosa of the small intestine. The mucosal layer also contains many

goblet cells, which are responsible for secreting mucus into the

intestinal tract to keep the surface lubricated. The mucosal layer also

contains many crypts, which are chambers that extend down toward

the submucosal layer. Stem cells are located in the middle or at the

bottom of these crypts, and are responsible for creating new epithelial

cells.8

The submucosa contains connective tissue, as well as nerves and

blood vessels. These elements provide a supportive framework for the

other layers of the large intestine. The muscularis layer contains

smooth muscles that are responsible for the contractions of the colon

that move materials and feces along the intestinal tract.9 The outer

layer, which is the adventitious layer, is responsible for secreting

mucus to keep its surface lubricated so that it does not adhere to other

nearby organs.

The ulceration associated with ulcerative colitis often begins with

stimulation of the inflammatory process and the progresses to tissue

breakdown. White blood cells and other inflammatory cells travel to

the base of the crypts to form abscesses. The small abscesses that


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have formed within the crypts spread and connect with other nearby

abscesses until there is a large area of swollen and damaged tissue.

The overlying material then starts to break down and the topmost

layers of tissue are shed into the lumen. The ulceration associated with

ulcerative colitis often only affects the mucosal and submucosal layers

of the intestinal tract, but typically does not extend down into the

muscularis layer.3 The disease process associated with ulcerative

colitis differs from Crohn’s disease; with Crohn’s disease, ulcerations

can extend through all layers of the intestinal tract.

As the inflammation persists and the layers of the colon continue to

sustain damage, the mucosal and submucosal intestinal layers become

even more swollen and inflamed. There may be pseudopolyps, which

have the appearance of polyps, but are actually collections of scar

tissue that develop when ulcers are healing. Pseudopolyps are not

associated with an increased risk of colon cancer and they are typically

not removed unless they cause a blockage in the intestinal tract. The

ulcers that develop may be sporadic along the intestinal tract, but

more commonly, enough ulcerations form close together and are

eventually connected, leading to large areas of ulcerated tissue. The

disease may cover one or more segments of the large intestine,

depending on severity. In some cases, all areas of the colon are

involved. Ulcerative colitis that affects the entire large intestine,

including the ascending, transverse, descending, and sigmoid portions

is sometimes called pan-colitis.

The inflammation and ulcerations eventually spread through the

submucosa of the large intestine. Small fissures and cracks form in the

submucosa, which contribute to tissue breakdown. The tissue bleeds


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and becomes necrotic, leading to sloughing of cell debris into the

colonic lumen. Over time, scar tissue can develop and the affected

portions of the mucosa become thickened and scarred. Many times,

only partial healing occurs before the next disease flare, so the patient

has areas of ulcers in limited stages of healing alternating with fibrous,

thickened tissue.

Increased vascularity to the ulcerated portions of the intestinal tract

increases the risk of bleeding. The portions of the colon affected no

longer work properly because the tissue has become fibrous and

dense, increasing the risks of gastrointestinal complications. The

patient often develops frequent and severe diarrhea, dehydration from

a loss of fluid through the stool, and sodium imbalances from an

inability to reabsorb salt and water in the colon. Ulcerative colitis is

also associated with occasional severe complications that require

additional treatment and hospitalization.

Because ulcerative colitis primarily affects the large intestine, the

patient with this illness is at risk of several complications that are

associated with colonic damage, whether due to the physiological

breakdown of the intestinal wall and the protective mucosa, or

because of the colon’s inability to perform its normal functions due to

sustained damage from the disease. A person with ulcerative colitis is

at risk of toxic megacolon, a severe complication that can be life-

threatening if it is not contained. Toxic megacolon develops when the

lumen of the large intestine widens and dilates. Consequently,

undigested material and fecal matter cannot be moved through the

large intestine. Air and gas also build up within the colon and the

patient is at risk of colonic rupture.10 This condition causes severe


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abdominal pain and distention and the patient should seek emergency

care for help since toxic megacolon requires prompt treatment to

prevent further consequences. Prompt treatment often includes

emergency surgery. If toxic megacolon is left untreated it may be

fatal.

Bowel perforation is another potential complication that is associated

with severe cases of ulcerative colitis. When ulcers are large and deep

and inflammation is widespread, the wall of the colon can become

weakened to the point that it ruptures, spilling its contents into the

abdominal cavity. This can quickly lead to severe infection and can

become life threatening if not treated immediately. Bowel perforation

is more commonly associated with cases of toxic megacolon. When a

patient presents with possible bowel perforation, there are few medical

therapies administered once the condition is diagnosed. Instead,

emergency surgery is almost always required to remove the damaged

areas of the colon.

Ulcerative colitis and other forms of IBD that affect the large intestine

increase the risk of Clostridium difficile infection in the gastrointestinal

tract. C. difficile infection tends to cause severe diarrhea, which may

make it difficult to establish IBD versus C. difficile as the cause of

diarrhea. This infection is often a healthcare-associated infection, in

which patients contract it while in the hospital or healthcare

environment. The infection is also more common among patients who

are taking immunosuppressant medications as part of treatment for

IBD.11


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In addition to the potential complications described above, ulcerative

colitis symptoms during times of disease flares can range in severity

from mild to overwhelming. As discussed, ulcerative colitis is

characterized by ongoing periods of active symptoms followed by

periods of remission. During flares, damage from inflammation and

ulcers lead to rectal bleeding, bloody diarrhea, and destruction of the

mucosa of the large intestine. Once the flare subsides and symptoms

abate, partial healing occurs until the next flare. This partial healing of

the affected areas is what is usually involved in the next flare. The

affected portions of the large intestine are never quite free from

ulceration and diseased tissue, even if the patient is not having active

symptoms. Over time, because of the ongoing damage to the intestinal

tract, the patient with ulcerative colitis suffers from disrupted bowel

function and the large intestine no longer operates in a normal

manner.

The damage to the large intestine leaves the affected patient at risk of

fluid depletion due to abnormal absorption of water and electrolytes in

the colon. There may be subsequent electrolyte imbalances, which can

cause a variety of abnormal symptoms as well. During flares, the

patient often experiences abdominal pain and when symptoms are

worse after eating, he may choose to eat less food in order to avoid

symptom development; ultimately, this can lead to weight loss and

loss of muscle mass. Ultimately, when large areas of the colon are

affected and the patient is experiencing severe symptoms that are

significantly impacting quality of life, surgery to remove some of the

diseased portions of the bowel may be necessary as part of therapy.


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Rectum

The inflammation and tissue destruction of the large intestine seen

with ulcerative colitis can also affect the rectum; rectal involvement of

ulcerative colitis may be in addition to colonic involvement or it may

develop on its own. Approximately 46 percent of patients with

ulcerative colitis have rectal involvement, called ulcerative proctitis

when it affects only the rectum, and ulcerative proctosigmoiditis when

the sigmoid colon is also involved.12

The rectum describes the last six inches of the large intestine; it

begins just after the sigmoid colon. As stool passes through the large

intestine, it is mostly stored in the descending colon, just before

reaching the sigmoid colon. Once the descending colon is full, stool is

then passed into the rectum where it is stored until defecation. When

the stool enters the rectum, the individual typically feels the urge to

have a bowel movement. The end of the rectum terminates in the

anus, which is the opening through which stool passes with defecation.

Ulcerative proctitis occurs when the inflammation and lesions

associated with ulcerative colitis affect this area of the intestinal tract.

Burakoff, et al., in the book Medical Therapy of Ulcerative Colitis,

defines ulcerative proctitis as the inflammation and ulcerations of the

disease that is limited to the rectum or the first 15 to 20 cm from the

anal verge. In contrast, the patient with ulcerative proctosigmoiditis

has disease involvement of the rectum but that also extends into the

large intestine.13 A portion or all of the sigmoid colon may be involved.

The sigmoid colon is approximately 40 cm in length from where it

adjoins the rectum. Ulcerative proctitis typically causes uncomfortable

symptoms similar to those seen with ulcerative colitis affecting other


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areas. The affected patient most often experiences frequent diarrhea

and bloody stools; however, some symptoms are more pronounced

because of the effects of the disease on the rectum. Tenesmus may be

a common symptom with proctitis, which is the sudden and persistent

urge to have a bowel movement. Tenesmus may occur even if no stool

is present in the rectum and defecation is not imminent. In addition to

blood in the stool or diarrhea, the affected patient may have a mucous

discharge from the rectum that is not associated with a bowel

movement. Damage to the anal sphincter, which normally holds stool

in the body until an appropriate time for defecation, may cause

leakage of stool from the rectum when diarrhea is present.14

In contrast to the rectum, the sigmoid colon is the lower portion of the

large intestine that is situated between the descending colon and the

rectum. The sigmoid colon is the narrowest portion of the large

intestine. It appears to be S-shaped because of how it curves as it

advances toward the rectum. Ulcerative colitis rarely affects only the

sigmoid colon; the clinical manifestations of the disease usually also

include either the rectum, the left side of the large intestine, or both.

Ulcerative inflammation in the sigmoid colon may also be part of pan-

colitis when ulcerative colitis affects the entire large intestine.

The symptoms of ulcerative proctosigmoiditis are very similar to those

of proctitis. The affected individual often has frequent urges to have a

bowel movement and suffers from tenesmus whether stool has passed

into the rectum or not. Diarrhea, bloody stools, and mucous drainage

from the rectum are also present with proctosigmoiditis. Stool

incontinence can occur with leakage of diarrhea, which is often

embarrassing for the affected patient; the person with ulcerative colitis


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that leads to stool incontinence may avoid social activities and events

to avoid the humiliation of an accidental loss of stool.

The treatments for proctitis and proctosigmoiditis are similar to those

of ulcerative colitis that affects other portions of the colon. The patient

may benefit from systemic medications that control pain and

inflammation and that suppress the immune response. Because of the

location of the inflammation, proctitis and proctosigmoiditis are also

often managed successfully with medications that are administered

rectally, including rectal suppositories and enemas. The direct contact

of the medication with the affected tissue may result in greater pain

relief and resolution of inflammation with fewer systemic side effects

of the drugs.

Crohn’s Disease

One of the most common forms of inflammatory bowel disease is

Crohn’s disease, which affects approximately 700,000 people in the

United States. Crohn’s is a chronic disease that causes inflammation in

the intestinal tract, with periods of disease exacerbations (flares)

followed by periods of remission. However, for some people, Crohn’s

disease causes continuous symptoms that do not abate without

treatment. The disease is thought to affect men and women equally

and it most often develops during adolescence and young adulthood,

between the ages of 15 and 35 years.15 Crohn’s disease is also

sometimes referred to as regional enteritis.

There are many similarities between Crohn’s disease and ulcerative

colitis, such that the two conditions are sometimes confused. Although

Crohn’s disease affects other portions of the gastrointestinal tract


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beyond those impacted by ulcerative colitis, many of the pathological

manifestations of these two conditions are so similar that in

approximately 10 percent of patients, the actual diagnosis cannot be

determined between the two.3

As with other forms of IBD, Crohn’s disease is thought to develop due

to a combination of genetic factors and environmental triggers that

lead to disease flares. Genetic factors are thought to be more

prominent in the development of Crohn’s when compared to some

other types of inflammatory bowel diseases.16 Up to 20 percent of

people with Crohn’s disease have a relative afflicted with some type of

inflammatory bowel disease.15 The environmental triggers that lead to

disease flares can occur from any number of events, including severe

stress or infection.

Crohn’s disease is more commonly seen in industrialized countries,

including the United States and Europe, as opposed to its presence in

developing nations. Because of this, certain factors that appear within

industrialized countries, including lifestyle factors, pollution, and diet

may all play a role in acting as triggers for flares of the disease. Some

particular population groups are also at greater risk of developing

Crohn’s disease. For example, the condition targets people of

Ashkenazi Jewish descent: this population is almost 5 times at higher

risk of developing Crohn’s when compared to the general population.16

Crohn’s disease is also more commonly seen in people who are

Caucasian and is less common in those of Hispanic or Asian ethnicities.


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Unlike ulcerative colitis and some

other forms of IBD, Crohn’s disease

can cause inflammation along any

part of the gastrointestinal tract

and is not limited to specific areas.

The symptoms that each person

manifests often vary, depending on

the main area of the intestinal tract

affected. For example, an individual

with Crohn’s disease affecting the

proximal end of the small intestine

in the duodenum and jejunum may

suffer from anemia and

malnutrition due to poor nutrient

absorption because of damage to the intestinal wall. Alternatively,

someone with Crohn’s disease that impacts the majority of the

gastrointestinal tract, including the large intestine, may have lower

abdominal pain and frequent, bloody diarrhea.

In contrast to ulcerative colitis, the inflammation and ulceration that

occurs with Crohn’s disease can affect all layers of the gastrointestinal

tract. This is often described as being transmural, in which the lesions

cause full-thickness ulcerations. When the disease affects all intestinal

layers, there may be a greater risk of strictures and narrowing of the

intestinal lumen, as full-thickness lesions may be more likely to

produce scarring.

The transmural nature of the disease also increases the risk of other

gastrointestinal complications, such as intestinal abscesses and


24

fistulas, which are more commonly seen with Crohn’s when compared

to some other types of IBD. The surface of the intestinal lining often

appears rough with a “cobblestone” appearance that is characteristic

of Crohn’s disease. The areas of ulceration may or may not be

consistent and close together. Some affected areas of tissue may

contain large patches of ulcerations of varying thickness, while in some

other areas, lesions are not connected and there is healthy tissue in

between. These ulcers are often referred to as skip lesions and they

are more commonly seen with Crohn’s disease, but are less often seen

with some other forms of IBD.

Although it can affect any part of the gastrointestinal tract, the

inflammation from Crohn’s most often develops in the distal portion of

the small intestine — the ileum — and the junction between the small

intestine and the cecum, known as the ileocecal region. The symptoms

of the disease and the amount of damage caused by the inflammation

may range in severity from being classified as mild with few bouts of

diarrhea or other symptoms and few complications, to severe, in which

the patient has significant symptoms that disrupt daily life and

requires extensive medical treatment.

Crohn’s disease not only causes inflammation, pain, and tissue

damage within the gastrointestinal tract, but persons diagnosed with

this condition also tend to suffer from other systemic problems that

are not necessarily related to the intestines at all. Crohn’s disease also

tends to cause liver and gallbladder diseases, including an elevated

risk for gallstones; patients are also at increased risk of blood clots

and their associated consequences, such as stroke and pulmonary

embolism. Arthralgia and arthritis are two common extra-intestinal


25

complaints; arthritis is said to affect up to 30 percent of people with

Crohn’s.17 Some people also develop skin nodules, skin ulcers that

appear similar to those seen in the intestinal tract, and psoriasis.

As with other types of IBD, research continues to uncover reasons why

some people develop Crohn’s disease, why it flares, and why the

symptoms arise. There are a number of factors that can contribute to

disease flares in susceptible people, but there are various theories as

to why some people are more susceptible to intestinal inflammation

than others.

Smoking tobacco is a factor that has been associated with increased

incidences of disease flares among those with Crohn’s disease. For

those with IBD who smoke, quitting increases the likelihood of

maintaining periods of remission. People diagnosed with Crohn’s

disease who have quit smoking have reported fewer disease flares,

while those who continue to smoke often report increased incidences

of flares, increased need for medications to control inflammation, and

a more frequent need for surgical intervention.1

Other potential factors that seem to be related to Crohn’s disease

development include alterations in specific genes in the body, which

can lead to problems with defense mechanisms that would normally

protect the intestinal lining. An abnormal response of the immune

system is another possible cause of Crohn’s development. As with

ulcerative colitis, when inflammation related to Crohn’s develops in the

intestinal tract, it is because the body is releasing certain cytokines as

part of its defense mechanisms. An alteration in the ability to release

cytokines, or a disruption in how the body recognizes certain factors as


26

being foreign antigens, can all affect disease development. The T-

helper cells also play a role in the inflammatory process associated

with Crohn’s disease. As described, ulcerative colitis is considered to

have a Th2-mediated response to inflammation, but Crohn’s disease

tends to exhibit a Th1 response.18 This classification is given in large

part to the types of cytokines produced by the T cells when

inflammation of Crohn’s progresses.

As discussed, Crohn’s differs from ulcerative colitis in that it can affect

any portion of the gastrointestinal tract. Although it is most commonly

seen in the ileum and at the junction of the small and large intestines,

Crohn’s disease has been seen in some patients at any area of the

gastrointestinal tract, from the anorectal area to the upper GI area of

the mouth and esophagus.

Perianal Crohn’s Disease

Perianal Crohn’s disease affects the anus and the surrounding tissues.

Perianal Crohn’s may occur as its own set of symptoms or the disease

may flare at the same time as other intestinal areas. This particular

type of Crohn’s disease is characterized by pain, inflammation,

swelling, and lesions around the anal opening, in the anal sphincter,

and on the perianal tissue. Approximately one-third of patients with

Crohn’s disease develop perianal Crohn’s symptoms.19

People with perianal Crohn’s disease often suffer from symptoms that

are similar to those that occur when the disease affects the rectum.

There may be a frequent urge to have a bowel movement, and

defecation is painful. The affected person may be incontinent of stool

from an inability to maintain normal function of the anal sphincter.


27

Additionally, the individual may have pain or itching around the anus

and may pass blood, pus, or mucus with stools. Anal sphincter stenosis

may also develop with significant damage from inflammation, in which

the tissue around the anus becomes stenotic and the sphincter does

not work properly; the opening of the anus decreases in size and there

may be difficulty with passing stool. However, for many patients with

Crohn’s affecting the anus, these strictures and stenosis develop

slowly and they may adjust to routinely passing stool even when the

opening has narrowed.20

There is often great discomfort with having perianal Crohn’s disease,

whether it is because of physical manifestations that affect the ability

to have a normal bowel movement or due to social implications of this

particular type of disease. The individual may suffer embarrassment

and social anxiety because of an inability to control defecation and fear

of stool odor on clothing or of soiling the clothes from stool

incontinence. Consequently, Crohn’s disease that affects the anus,

while often only impacting one area of the gastrointestinal tract, can

still significantly diminish quality of life among affected individuals.

When the tissue around the anus becomes severely inflamed and

ulcerated, abscesses can develop in the area. These have the

appearance of large sores or boils; the tissue is red and swollen and

the sore may be filled with pus. Abscesses are extremely painful for

the affected patient. Fistulas, which occur when an abnormal channel

forms between tissues, may also develop between the anal opening

and the rectum because of deep ulcers that have formed.16 Fistulas

may also occur between the rectum and the bladder, the vagina, or

the surrounding skin. When a fistula develops, the affected person will


28

often experience bleeding and mucus discharge near the opening of

the anus. Fistulas around the anus are also very painful for patients

when having a bowel movement and the fistula is likely to become

infected if not treated. These fistulas are most common in patients

with Crohn’s disease when compared to persons with other types of

inflammatory bowel diseases.

Anal fissures may also develop as a complication of Crohn’s disease

when ulcerated tissue causes skin breakdown at the anal opening. This

can cause deep grooves and cracks in the skin, which can be very

painful for the patient, particularly when having a bowel movement,

and they are more likely to develop as a result of frequent, heavy

bowel movements. The fissures can be superficial and only affect the

upper layers of skin, or they can be deep. The depth of the fissures is

related to the amount of pain it causes for the patient and its ability to

heal. Superficial fissures typically heal completely with medical

therapy.

Skin tags may appear as benign growths on the skin near or in the

anus. These are almost always non-malignant but they also remain

once they develop.20 A skin tag may appear during a disease flare but

even when symptoms have resolved, the skin tag often remains. The

skin tags are also unaffected by treatment and they typically remain,

even when other areas are healed because of treatment. Skin tags

may become irritated or inflamed, which can be uncomfortable for the

patient. Usually they are left alone because they are benign, but if

they grow large enough to affect defecation, they may need to be

removed.


29

The main forms of treatment for perianal Crohn’s involve medications,

diet and lifestyle changes, and in some cases, surgical intervention.

The main goals of treatment for this specific form of Crohn’s disease

are to improve symptoms of pain and stool incontinence, control

inflammation, prevent the spread of painful and debilitating

complications, and to improve patient quality of life.

Crohn’s Disease of the Large Intestine

Crohn’s disease may affect the large intestine. The disease may be

isolated entirely to the colon or it may affect the large intestine in

addition to other areas of the gastrointestinal tract. When the disease

develops in the large intestine, it can be limited to specific areas of the

colon or it may cause tissue damage along the entire length of the

large intestine. Crohn’s disease that affects only the ileum and the

large intestine is known as ileocolitis. Approximately 50 percent of

people with the disease have Crohn’s ileocolitis.21

Crohn’s that affects the large intestine causes the characteristic tissue

injury and inflammation as seen in other areas of the gastrointestinal

tract. There may be abscesses and pockets of infection at various

points along the intestinal tract. Because Crohn’s can potentially cause

transmural effects, there may be damage at all layers of the lining of

the colon, from the inner mucosal layer to the outer adventitious layer.

The effects of Crohn’s in the large intestine impair its ability to carry

out normal functioning of fluid and electrolyte absorption. Since the

majority of nutrient absorption takes place in the small intestine, the

large intestine receives the leftover, undigested material. At the point

when this material reaches the large intestine, it is in liquid form. The

colon then absorbs much of the water from this material as it passes


30

through. The material becomes feces by the time it reaches the

rectum, due in large part to the absorption of water and salts in the

colon and the work of the microbiota within the intestinal tract. When

damage affects the large intestine, the affected patient may suffer

from electrolyte imbalances and fluid loss.

The patient with Crohn’s disease that affects the large intestine is at

risk of several complications that impact this particular area of the

gastrointestinal tract, including intestinal blockage, abscesses, and bile

salt diarrhea. The ulcers and inflammation from Crohn’s disease can

cause scarring in the intestinal tract, leading to thickening of tissue

and potentially narrowing the lumen of the colon. The movement of

material through the colon slows, which can cause stool impaction.

Because Crohn’s disease affects all layers of the intestinal tract,

abscesses, which are pockets of infection that contain pus, can develop

in the intestinal wall and cause it to bulge.10 Abscesses are more

commonly seen in patients with Crohn’s disease when compared to

those with other types of IBD, although they can form in anyone with

an inflammatory bowel condition. Because the ileocecal region of the

intestinal tract is the main location of bile acid absorption, as well as

the most common location of ulcer development in Crohn’s disease,

bile salt diarrhea can develop in some patients. This occurs when bile

acids are not absorbed and excess fat remains in the gastrointestinal

tract. This condition leads to fat malabsorption and causes more bouts

of diarrhea.

Crohn’s that affects the large intestine is the type of the disease that

most often results in severe diarrhea, rectal bleeding, and anal


31

abscesses or fistulas. While other diseased areas of the

gastrointestinal tract also cause a number of painful symptoms and

potential complications, Crohn’s that primarily affects the colon seems

to cause the highest risk of problems. Patients with Crohn’s affecting

the colon are also more likely to suffer from extra-intestinal symptoms

of the disease, including joint pain and skin lesions.1

Crohn’s Disease of the Small Intestine

The small intestine is the longest portion of the gastrointestinal tract.

Its name refers to the diameter of the intestinal lumen rather than its

length. The average length of the small intestine is approximately 20

feet long in adults. It connects with the stomach at its proximal end

and consists of three main parts, each of which has various functions.

The duodenum receives food from the stomach, which is mixed with

secretions from the pancreas and liver to promote digestion. The

second segment is the jejunum, which starts just after the duodenal-

jejunal flexure of the small intestine. It is in the jejunum that the

majority of nutrients are absorbed into circulation to be used by the

body. The final segment of the small intestine, the ileum, receives the

remainder of the material passing through the intestinal tract. Some

nutrient absorption takes place in the ileum as well before the rest of

the undigested material is pushed into the large intestine.

Nutrient absorption is an essential activity of the small intestine, and

damage to this area of the intestinal tract can result in several

metabolic consequences, including malnutrition, weight loss, and

wasting. The small intestine digests and absorbs nutrients through a

specific process that is carried out by its design. As food enters the

small intestine, it is known as chyme, which is mixed and moved


32

through the smooth muscle

contractions of the intestine. The

luminal surface contains millions of

microscopic projections known as

microvilli, which greatly increase

the surface area of the small

intestine and which facilitate

nutrient absorption. The intestinal

wall also contains lymph channels,

which are responsible for

absorption of fats and fat-soluble

vitamins.

Patients with Crohn’s disease are

at risk of malnutrition when the inflammation and ulcers in the small

intestine disrupt absorptive processes. The majority of nutrient

absorption takes place in the duodenum and the jejunum of the small

intestine. After eating a meal, most fatty acids, amino acids from

proteins, vitamins, minerals, and glucose from carbohydrates are

absorbed in the proximal sections of the small intestine. The ileum is

primarily responsible for absorbing vitamin B12 as well as bile salts.

When ulcers and inflammation penetrate these areas of the small

intestine, the villi on the mucosal surface are damaged and can no

longer absorb nutrients properly. Likewise, fats and fat-soluble

vitamins are unable to be absorbed by the corresponding lymph

channels. The patient instead passes the nutrients along through the

rest of the digestive tract where they are eventually excreted from the

body. Malnutrition due to malabsorption in the small intestine can lead


33

to a number of symptoms and problems, which can range from

electrolyte abnormalities when these nutrients are not absorbed

properly to severe weight loss and protein energy malnutrition from

loss of fat and protein. Larger sections of the small intestine affected

by Crohn’s disease result in a greater risk of malabsorption.

Additionally, some patients with severe disease have affected portions

of the small intestine surgically removed as part of treatment. This

surgical intervention, while often effective in disease management, can

contribute to malabsorption and malnutrition.

There are several subtypes of Crohn’s disease that are named based

on the area of the intestinal tract most affected. Jejunoileitis describes

Crohn’s disease that primarily affects the jejunum and the ileum of the

small intestine but few other locations. It is often confused with some

other diseases that may only impact only this portion of the intestinal

tract, such as celiac disease, irritation from use of NSAIDs, or

gastrointestinal infection. Crohn’s disease that is classified as

jejunoileitis is often much more aggressive compared to Crohn’s

disease in other locations of the gastrointestinal tract.22 The patient

with disease manifestations in this area may suffer more severe

symptoms, the disease may spread to other areas of the intestine, and

there is greater potential for complications. Ileitis describes Crohn’s

that affects only the ileum, and ileocolitis affects the ileum and the

colon. Ileocolitis is considered the most common form of Crohn’s

disease. Other subtypes describe Crohn’s that affects the stomach and

duodenum as well as the large intestine only.1

Patients with Crohn’s that primarily affects the small intestine will

usually suffer from abdominal pain, and they may also experience


34

nausea and vomiting. The symptoms that develop may depend on the

area of the small intestine affected. Crohn’s that impairs the

duodenum often leads to weight loss, malnutrition, anemia, and loss of

appetite. Jejunoileitis often causes severe abdominal cramps after

eating, as well as diarrhea and an increased risk of fistula formation.

When Crohn’s affects the ileum, there is often severe diarrhea and

cramping, accompanied by significant weight loss and an increased

risk of fistula and abscess formation.23

Other significant complications can develop as well when Crohn’s

affects the small intestine. For some patients, bacterial overgrowth can

occur in the small intestine when the normal amounts of bacteria

present expand and multiply. Most people with this condition develop

abdominal pain, bloating, excess gas, and diarrhea. The symptoms

may or may not differ much from symptoms experienced during a

disease flare, which may make it difficult to diagnose based on

symptoms alone. Bacterial overgrowth typically requires treatment

with antibiotics to return the levels

of microorganisms back to normal.

Small bowel obstruction describes

a condition in which there is

narrowing or blockage of an area of

the small intestine leading to

slowed transit of food and chyme

through the digestive tract and

impaired nutrient absorption. The

patient with Crohn’s disease

affecting the small intestine is at


35

risk of small bowel obstruction due to damage in the intestinal lining

that causes strictures and tissue thickening. The inflammation of the

disease leads to fibrotic changes that eventually narrow the size of the

intestinal lumen.

Because the small intestine is so long and is centrally located along the

gastrointestinal tract, the ability to reach strictures and areas of tissue

damage through endoscopy may be limited. A report in the journal

Neurogastroenterology & Motility described small bowel strictures as

“unresponsive to medical management, necessitating surgical

intervention.”24 When strictures develop, small intestinal motility is

slowed significantly; this can be quite problematic for the affected

individual, as it can cause intestinal obstruction, malabsorption, and

malnutrition. As stated, the condition typically requires surgery to

correct because of its location within the intestinal tract.

Unfortunately, Crohn’s most commonly affects the small intestine,

meaning that patients are at risk of some very serious consequences.

The central location of the small intestine and its important work of

digestion and absorption indicate that disease development in this

area can be destructive to the affected patient’s overall health and

quality of life.

Gastroduodenal Crohn’s Disease

Gastroduodenal Crohn’s disease is a subtype of the condition in which

inflammation, ulcers, and scarring develop in the stomach and in the

duodenum of the small intestine. The antrum of the stomach, which is

the largest and lowest portion of the stomach that stores ingested

food, is the most common area involved with this type of Crohn’s,


36

along with the most proximal portion of the small intestine. The

manifestations of gastroduodenal Crohn’s disease are often non-

specific and may be mistaken for another condition, particularly if

Crohn’s has not been diagnosed elsewhere in the intestinal tract.

Gastroduodenal Crohn’s disease often has symptoms and

manifestations similar to H. pylori infection, peptic ulcer disease,

gastroenteritis, or Zollinger-Ellison syndrome, a condition in which

there is overproduction of gastric acid and peptic ulcers in the stomach

due to a pancreatic tumor.25

People who develop primarily gastroduodenal Crohn’s often have

difficulties with eating and may experience anorexia and nausea with

consequent weight loss.1 Scarred tissue in the duodenum may restrict

the passage of food as the stomach empties into the small intestine

and the patient may suffer from increased nausea and vomiting as a

result. Other symptoms commonly associated with Crohn’s disease in

this area include fatigue, early satiety, dyspepsia described as a

feeling of indigestion, and epigastric pain, particularly after eating.

Although Crohn’s disease most commonly affects the small and large

intestines, a number of patients have mild concomitant inflammation

in the stomach and duodenum. A report in the Video Journal and

Encyclopedia of GI Endoscopy stated that 20 to 60 percent of patients

with Crohn’s disease undergoing upper endoscopy manifest mild

inflammation and gastritis in the stomach and duodenum; however,

severe inflammation that causes symptoms of Crohn’s that affects this

area of the intestinal tract accounts for only 4 percent of cases.26 Most

people who develop Crohn’s disease in the stomach have inflammation

and Crohn’s ulcerations in other parts of the intestinal tract as well; if


37

the inflammation is only found in the stomach, it is often a precursor

to disease development in other areas.25

Gastroduodenal Crohn’s disease causes thickening in the folds of the

stomach as well as the characteristically bumpy, cobblestone

appearance associated with Crohn’s disease. The tissues in the

affected areas, often the antrum and the duodenum, become

thickened and digestion and food passage slows. There is inflammation

that worsens during time of disease flares, and tissue breakdown leads

to ulcerations forming within the stomach cavity and on the interior

lining of the duodenum. The affected areas of the stomach pouch

cannot distend with food intake because they are thickened. The tissue

is erythematous, friable, and easily prone to breakdown and bleeding,

and fissures or cracks may form, most often at the junction of the

head of the duodenum.25

Crohn’s disease that affects the stomach is treated with similar

medical therapies as those used for treatment of the disease in other

areas of the gastrointestinal tract, including systemic corticosteroids,

immunomodulator drugs, and biologic therapies. If H. pylori infection

is present, the patient may need antibiotics to control the spread of

the infection. Additionally, most patients with stomach manifestations

benefit from proton pump inhibitor medications to control stomach

acid secretion. These drugs are often effective in controlling excess

gastric acid secretion, but they do not reduce inflammation present

with the disease. Therefore, most patients have success in treating

gastroduodenal Crohn’s disease with a combination of therapies to

suppress gastric acid production and to reduce inflammation and pain.


38

Gastroduodenal Crohn’s disease increases the risk of gastric outlet

obstruction, which occurs as a blockage at the opening between the

stomach and the small intestine. The effects of Crohn’s can cause

stricture formation when inflammation and lesions affect the lower

portion of the stomach, the pyloric sphincter, or the duodenum. The

tissue is thickened and does not transport food in a normal manner

needed for digestion. The affected patient often suffers from

gastroesophageal reflux, frequent vomiting after meals, early satiety,

and pain in the area of the stomach.27 Consequently, the person can

suffer from significant weight loss and dehydration as well as

continued pain and symptoms of gastritis. The condition must be

corrected quickly to prevent further health deterioration.

When strictures develop to cause obstruction, endoscopic balloon

dilatation may be effective in widening the affected area and it reduces

the need for surgical intervention. If gastric outlet obstruction causes

enough problems with digestion and results in pain and malabsorption

that is ongoing despite attempts at dilatation, the patient may need

surgery to remove some of the diseased areas and to widen any

strictures that have developed. Approximately one-third of patients

with gastroduodenal Crohn’s disease eventually require surgery to

manage complications of this particular type of IBD.25

Crohn’s Disease of the Esophagus

Crohn’s disease that develops in the esophagus is a rare form of the

illness: of all the locations throughout the gastrointestinal system

where Crohn’s disease develops, the esophagus seems to be the area

least affected.28 The lesions and inflammation that occur in other parts

of the intestinal tract with Crohn’s disease can also develop in the


39

esophagus anywhere from the pharynx at the back of the throat to the

lower esophageal sphincter connecting the esophagus to the stomach.

Esophageal Crohn’s disease may sometimes be confused with other

inflammatory illnesses of the esophagus, most often gastroesophageal

reflux disease.

As with Crohn’s disease affecting the mouth, esophageal Crohn’s

disease is most often associated with inflammation and tissue changes

of the disease affecting other areas as well, including within the large

or small intestines. The esophageal lesions are rarely exhibited prior to

a formal Crohn’s diagnosis or as a precursor to intestinal

manifestations. In most cases, the individual with esophageal Crohn’s

has already been diagnosed with intestinal Crohn’s disease and is

managing the symptoms that develop with flares affecting that area of

the gastrointestinal tract.

Inflammation and lesions of esophageal Crohn’s are often patchy and

may be distributed throughout the esophagus, rather than being

localized to one distinct area. Many patients suffer from pain in the

back of the throat, non-cardiac chest pain, or epigastric pain,

depending on the areas of the esophagus most often affected. The

esophageal tissue is often inflamed and fragile and can bleed easily.

The affected patient may exhibit blood in the stool that has passed

through the digestive tract. Other noted manifestations are similar to

the disease in the intestinal tract and include cracks or fissures in the

esophagus, a cobblestone appearance to the tissue, thickened folds in

the tissue, and even tracheoesophageal fistula, in which tunneling

develops between the esophagus and the trachea.28


40

Pain and difficulty with swallowing

are two of the more common

symptoms of this particular type of

Crohn’s. A patient may have

difficulty swallowing various

textures of foods and the patient’s

diet may become limited only to

foods that he may tolerate.

Swallowing liquids can be

problematic and there may be an

increased risk of aspiration of fluids

into the lungs when swallowing is

impaired. A patient may have the

sensation of food or an object being stuck in his throat. To avoid

weight loss and malnutrition associated with poor food intake, the

patient may need a modified diet during times of disease flares to be

able to take in enough food.

When Crohn’s disease affects the esophagus, the disease flares and

periods of remission tend to be correlated with intestinal flares. In

other words, when the individual is experiencing severe symptoms

associated with a disease flare affecting the intestine, the esophageal

symptoms will most likely present themselves at the same time.

Alternatively, when the small bowel or colonic symptoms go into

remission, the esophageal symptoms also tend to abate at the same

time.

The tissue damage and scarring that develops when Crohn’s affects

the esophagus it can lead to tissue thickening and narrowing of the


41

esophagus. Strictures often develop in the esophagus when the

inflamed tissue partially heals before breaking down again. The lumen

of the esophagus eventually narrows, which can block the passage of

food and fluids into the stomach. The patient may experience difficulty

swallowing or may regurgitate food after eating. The condition is most

often treated by balloon dilatation, in which a tube is passed into the

esophagus and held at the narrowed area. The balloon is inflated at

the affected site, which stretches and opens the tissue.

Fistula formation can be a significant complication of esophageal

Crohn’s disease. According to Ji, et al. in the World Journal of

Gastroenterology, fistula formation occurs in approximately 33 percent

of patients with Crohn’s disease.29 Although the majority of fistulas

develop near the anus and the perineum, when Crohn’s affects the

esophagus, there is the potential for tunneling and connection between

the esophagus and nearby airway structures. This type of complication

can cause problems with eating and breathing normally and it requires

surgical correction to restore normal tissue. Also, a fistula may form

between the esophagus and the bronchus (esophagobronchial),

between the esophagus and the trachea (tracheoesophageal), or the

esophagus and the mediastinum (esophagomediastinal).

Fistula formation occurs when there is enough tissue damage from

ulceration or lesions that the tissue breaks down and is eroded away.

Diagnosis of an esophageal fistula requires prompt treatment to

prevent aspiration of food or saliva into the lungs. Normally, the

body’s reflexes close the epiglottis to prevent food from entering the

trachea when an individual eats or drinks, but the connection between

the esophagus and the airway can still lead to food aspiration if a


42

fistula develops, which almost always leads to airway infection and

pneumonia if not rapidly treated. The patient is often fed with a

feeding tube to avoid trying to swallow food and potentially aspirating

food or fluids into the lungs. Surgical intervention is needed to correct

the defect and to close the wall between the connecting structures.

The process often requires a time of healing in which the affected

patient will have pain and difficulty eating and drinking and may need

a feeding tube for an extended period until the complication has

resolved.

Esophageal Crohn’s disease, while rare, may be underdiagnosed as a

clinical entity. Because many of its symptoms are similar to those of

other esophageal conditions, it may be incorrectly treated as another

illness. It may then take months or even years to formulate the

correct diagnosis in this case and to allow for proper treatment and

healing of the affected area.

Orofacial Crohn’s Disease

Orofacial Crohn’s disease is a rare sub-type of Crohn’s in which the

affected patient develops inflammation and ulceration in the tissues of

the mouth in a manner similar to lesions in the intestinal tract. The

symptoms of orofacial Crohn’s may appear prior to a diagnosis of

intestinal Crohn’s disease or the lesions may develop around the same

time as the wounds in the intestinal tract. The individual with orofacial

Crohn’s disease almost always has inflammation and ulcers associated

with Crohn’s in other areas of the gastrointestinal tract, such as in the

small intestine or in the colon.30


43

Orofacial Crohn’s disease may be confused with other conditions that

affect the mouth; i.e., orofacial Crohn’s disease may be confused with

orofacial granulomatosis, which is a condition that causes overgrowth

of granulation tissue, primarily in the mouth. However, according to

Zbar, et al., in the Journal of Crohn’s and Colitis, the major difference

between Crohn’s disease in the mouth and orofacial granulomatosis is

that the patient with Crohn’s disease has concomitant lesions and

inflammation elsewhere in the gastrointestinal tract, while orofacial

granulomatosis typically only affects the mouth.31 Oral Crohn’s disease

rarely only affects the mouth. The patient may have mouth lesions as

an extension of intestinal Crohn’s manifestations, or the oral form of

the disease is a precursor to the development of the intestinal form.

The particular signs and symptoms of orofacial Crohn’s disease include

inflammation of the gums and buccal mucosa, swelling of the lips,

ulcerations in the folds between the inner cheek and gums, cracks and

fissures in the corners of the mouth or on the lips, mucosal tags,

periodontal disease and tooth caries, ulcerations on the hard and soft

palates, and the characteristic cobblestone appearance on the inner

lining of the cheeks.30 Often, affected patients tend to have more than

one symptom occurring at the same time.

Crohn’s disease that affects the mouth can be very painful. The

lesions, swelling, and fissures can impair food intake and cause

difficulties with other activities, including talking, drinking, or

swallowing. The patient’s sense of taste may be altered due to the

mouth sores, which can make adequate food intake difficult. The oral

lesions may make eating and swallowing painful. The patient may be

less likely to eat or drink because ingesting food or fluids and


44

swallowing may be too uncomfortable. Certain foods are often avoided

entirely because they only exacerbate the pain of the condition; many

people with mouth lesions avoid any food or liquids that are irritating

to the open tissue, such as citrus fruits or drinks, spicy foods, or those

that are very salty. Sores may also impact a person’s ability to speak

clearly, as the patient may try to compensate for painful lesions on the

oral mucosa.

As with Crohn’s lesions that impact other areas of the intestinal tract,

orofacial Crohn’s symptoms develop in a pattern of disease

exacerbation, or flares, followed by periods of remission for most

people. As a person enters a period of remission, the ulcerated tissue

in the mouth begins to heal. Depending on the extent of the lesions,

the tissue may heal completely or it may form a scar. If the time of

remission is relatively short, the ulcer may not have enough time to

heal completely before another disease flare begins.

During times of flares, the patient is usually very careful with what he

eats and drinks, as this is typically a natural response to mouth pain.

In addition to monitoring food and fluid intake, the individual should

use a soft toothbrush to gently clean the teeth without damaging gum

tissue. Because oral Crohn’s disease is associated with an increased

risk of dental caries and periodontal disease, it is important for the

affected patient to see a dentist on a routine basis for cleanings and to

inspect the oral tissue and the teeth for changes.

The treatment for orofacial Crohn’s disease often involves both

systemic and topical preparations. Systemic medications used for the

management of intestinal lesions to reduce inflammation and to


45

control pain can be helpful in managing mouth inflammation as well.

Topical preparations are applied directly to the affected areas of the

mouth and may relieve some pain and inflammation on contact.

Corticosteroid mouthwashes have been shown to be effective in

relieving some pain and inflammation of oral Crohn’s lesions. The

patient rinses the mouth with the steroid solution to allow the fluid to

contact all surfaces of the mouth and gums before spitting it out.

Antibiotic mouthwashes may also be administered to reduce the risk of

mouth infections. There is a risk of infection in the mouth due to food

and fluid intake and it is important that the affected patient practice

regular oral hygiene to keep the tissues clean. However, the risk of

infection is still immediate and the individual may need antibacterial

mouth rinses to cleanse the mouth of excess microorganisms that

could cause complications such as abscesses in the teeth or gums.

Other medications may also be applied to soothe sensitive tissue and

to control pain. Some mouth rinses that contain lidocaine act as

anesthetics for short periods to numb the tissues and relieve some

pain. Oral pastes or gels can also be applied to affected areas to act as

anesthetics and control mouth pain.

Additional Types Of Inflammatory Bowel Disease

The majority of the literature focuses on inflammatory bowel disease

address Crohn’s disease and ulcerative colitis, as these two forms of

the disease make up the greater part of cases of IBD. However, there

are additional types of inflammatory bowel diseases that may have

similar manifestations and complications as Crohn’s and ulcerative

colitis, but that are technically different diseases, whether due to their

causes, influences, or manifestations. Additional types of IBD, while


46

rare, can be just as serious as Crohn’s disease or ulcerative colitis and

because of their infrequency, they may be difficult to detect or may be

classified as being the same as the former diseases. It is therefore

important to understand some other types of inflammatory bowel

diseases that may be less common but that require their own forms of

treatment and management.

Microscopic Colitis

A less common form of inflammatory bowel disease, microscopic

colitis, is a condition in which there is inflammation of the

gastrointestinal tract. The inflammatory process of this disease may

not be fully apparent on visual inspection or examination.

The condition was observed for

decades but it was not until 1980

that researchers devised an

actual term for the illness.32 A

patient suffering from microscopic

colitis experiences pain and

diarrhea but there is no obvious

source during examination. The

condition only affects the large

intestine, the sigmoid colon, and

the rectum. This specific type of

inflammatory bowel disease most

commonly affects older adults,

with a higher percentage of older

females than males affected by

collagenous colitis, one of the subtypes of the disease.71


47

Microscopic colitis is often classified as being one of two different

types: lymphocytic colitis and collagenous colitis.34 The two

classifications often appear very much the same but have differences

in histopathology. Lymphocytic colitis results in an increased number

of lymphocytes. The tissue usually appears normal but with more

lymphocytes than typical within the sample. Diagnosis of lymphocytic

colitis involves a tissue sample that is examined microscopically. The

tissue shows an increase in the number of lymphocytes in the tissue

and the epithelial layer of the mucosa in the affected area is damaged.

There is also inflammation or damage to the connective tissue layer of

the mucosa but not an increase in the amount of collagen present, as

is seen with collagenous colitis.33

Collagenous colitis occurs when areas of collagen under the epithelium

solidify and the tissue overall becomes concentrated and thick.

Collagen is normally present in the submucosal layer of the intestinal

tract, so evidence of collagen in a tissue sample for biopsy does not

necessarily isolate collagenous microscopic colitis. The condition is

considered to be the collagenous form of the disease when the

collagen has thickened and there is a greater than normal amount

present. It may be necessary to visualize several tissue samples to

make a comparison between the amounts of collagen present in

different areas of the intestinal tract. Upon histological examination,

collagenous colitis demonstrates a band of collagen underneath the

epithelial layer of at least 10 µm; it also shows damage to the

epithelial cells of the intestinal tract, and damage to the lamina

propria, which is a layer of connective tissue that makes up part of the

mucosal layer of the intestinal tract.33 Collagenous microscopic colitis

may or may not involve increased numbers of lymphocytes within the


48

tissue as well. The actual incidence of this subtype of microscopic

colitis is approximately 1.8 cases per 100,000 people.32

Microscopic colitis is diagnosed after a tissue sample has been

examined for microscopic evidence of inflammation and tissue

damage. During endoscopy used for diagnostic procedures, the

physician is usually not able to see any evidence of inflammation, even

though the patient complains of symptoms. The intestinal mucosa,

upon endoscopy, appears normal or almost normal. However, when

chronic diarrhea is present and the patient is experiencing colitis

symptoms, a biopsy should be performed to further examine the tissue

samples for evidence of microscopic inflammation.

The exact cause of microscopic colitis is unknown. As with Crohn’s

disease, ulcerative colitis, and other forms of IBD, microscopic colitis

development may be related to a combination of genetic factors and

environmental triggers; intestinal irritation due to chronic NSAID use,

autoimmune factors, or a combination thereof may also be possible

causes of this particular type of inflammation. Lymphocytic and

collagenous microcolitis cause the same kinds of symptoms, even

though they appear differently on a microscopic level and their disease

processes differ slightly. People with microscopic colitis typically have

frequent, watery diarrhea with or without abdominal pain and

cramping; patients may have 5 to 10 watery stools per day, but some

people have many more. The diarrhea is not caused by infection and

there are few other complications associated with the condition, unlike

some other forms of IBD. The stool output of microscopic colitis also

often differs from some other types of IBD in that stool is loose but

does not contain blood, pus, or mucus.


49

The Crohn’s and Colitis Foundation of America (CCFA) states that there

may be a link between microscopic colitis and celiac disease, an

autoimmune condition in which damage develops in the intestinal tract

after ingestion of gluten, a protein found in wheat products. The

connection is considered because some people with celiac disease have

microscopic inflammation in the intestinal tract that appears similar to

that often seen with microscopic colitis.35 The symptoms between

microscopic colitis and celiac sprue are also similar in that they cause

chronic diarrhea and abdominal pain. When formulating a diagnosis for

the cause of intestinal pain and inflammation, celiac disease should be

ruled out as a possible cause of the inflammation of microscopic colitis

by performing a thorough histological exam to assess the affected

cells.

Microscopic colitis can often be managed with anti-diarrheal

medications to control stool bulk by slowing intestinal motility so that

more water can be absorbed in the large intestine. These products are

available by prescription or they can be purchased as over-the-counter

preparations. Patients with microscopic colitis may take these anti-

diarrheal medications to help control their symptoms of diarrhea and

abdominal pain, but patients should know that these drugs do not

actually treat the inflammation or cure the disease. Some types of

drugs that may be used include loperamide or diphenoxylate.

The treatments for inflammation associated with both types of

microscopic colitis are typically the same. To treat the inflammation

that occurs with microscopic colitis, the patient often needs some of

the same medical therapies as those used for management of other

types of IBD, including some anti-inflammatory medications or


50

immunomodulators. Corticosteroids may also be used on a short-term

basis when symptoms are severe, but these drugs are not

recommended as part of long-term treatment for microscopic colitis.

Approximately 7 percent of patients with the collagenous form of

microscopic colitis also suffer from inflammatory arthritis that affects

one or more joints in the body.32 It is usually managed through anti-

inflammatory drugs administered for treatment of the colitis. Other

autoimmune diseases may also be associated with collagenous

microscopic colitis, which may indicate a potential connection between

this type of IBD and an autoimmune process. Common conditions that

are seen with collagenous colitis include Sjögren’s syndrome,

thyroiditis, and myasthenia gravis.

Unlike Crohn’s disease or ulcerative colitis, microscopic colitis has not

been shown to increase the risk of colon cancer. The disease, while

producing inflammation and some of the same symptoms as other

types of IBD, does not necessarily cause the same complications and

problems. While patients with microscopic colitis still often struggle

with its symptoms and it is a form of inflammatory bowel disease, the

condition often responds well to treatment and is rarely serious

enough to lead to some of the harmful outcomes that are sometimes

seen with other forms of IBD.

Diversion Colitis

Diversion colitis refers to inflammation of the mucosal lining of a part

of the intestinal tract that is not functional, often because of surgery

for the creation of a colostomy. With placement of a colostomy, the

feces are directed through a certain portion of the bowel so that they


51

will be excreted through the stoma and into the colostomy bag. The

defunctioned colon is the portion of the intestinal tract that has been

diverted from the fecal stream because of a diverting colostomy. It is

this defunctioned portion of the colon that develops inflammation

associated with diversion colitis.

Diversion colitis develops in the large intestine and is usually

considered to be benign, although it can cause unpleasant symptoms

and some complications for affected patients. Patients with diversion

colitis develop lymphoid follicular hyperplasia, which is an increase in

the size of lymph node follicles due to increased numbers of white

blood cells. The condition also causes bleeding of mucosal tissue,

mucous plugs, edema, ulcerations, and erythema, and the tissue

overall becomes more fragile. While lymphoid follicular hyperplasia is a

very common element in patients who develop diversion colitis, there

is not one single identifying characteristic of the condition.

Unlike many other forms of IBD, diversion colitis is usually

asymptomatic or produces only mild symptoms. As a result, many

cases go undiagnosed or are misdiagnosed as another type of IBD or

as another gastrointestinal condition altogether, such as irritable bowel

syndrome. Of patients who do experience symptoms, the most

common manifestations include abdominal pain, pain in the pelvic or

rectal areas, tenesmus, low-grade fever, and blood and mucosal

discharge from the rectum.36 Symptoms can develop right away

following colostomy surgery or they may take several years to

manifest.


52

The reason some people develop diversion colitis are not clear. Several

potential causes of the condition have been hypothesized, including

bacterial overgrowth, malnutrition, bowel ischemia, low levels of short-

chain fatty acids, or the presence of certain toxins in the intestinal

tract.36 Diversion colitis may also be more likely to develop as a type

of immune response, however, further research is needed to

determine if this type of response is an actual factor in disease

development.

Patients who have undergone colostomy or ileostomy are those who

suffer from diversion colitis when it develops. Some patients have pre-

existing IBD, which is the reason for colostomy placement to begin

with. A review by Kabir, et al., in the International Journal of Surgery

found that of patients who developed diversion colitis who had

colostomies, 91% already had a diagnosis of inflammatory bowel

disease. Approximately 87 percent of patients with preexisting

ulcerative colitis and 33 percent of patients with Crohn’s disease suffer

from symptomatic diversion colitis;36 unfortunately, despite

undergoing surgical intervention as treatment for IBD, diversion colitis

may develop afterward. Although diversion colitis may not be as

significant in symptoms as other cases of ulcerative colitis or Crohn’s

disease, it remains a complication that warrants treatment following

surgical management and colostomy.

Once the bowel has been restored and reanastomosis has been

achieved, diversion colitis almost always resolves. In fact, following

reanastomosis and resolution of diversion colitis, many patients

develop symptoms that seem unrelated to typical IBD symptoms, such

as constipation, dyspepsia, and abdominal bloating.


53

Some people with diversion colitis have been treated with enemas that

contain short-chain fatty acids. Normally, bacteria in the colon help to

ferment dietary fiber and produce short-chain fatty acids. These fatty

acids are responsible for upholding some of the structure and integrity

of the gastrointestinal tract. They are also absorbed in the large

intestine during the process of sodium and water absorption through

the colon. Once they are absorbed, they provide fuel for the epithelial

cells of the colon. They are thereby beneficial in maintaining a healthy

intestinal tract; however, those with diversion colitis have been shown

to have low levels of these short-chain fatty acids in the

gastrointestinal system. This is typically because of the colostomy

surgery. The fecal stream, which is the process of feces moving and

being routed through the intestinal tract, normally supplies short-chain

fatty acids to the cells of the colon; however, with a colostomy, the

cells in the diverted portion of the bowel do not receive as many short-

chain fatty acids, which can affect their integrity and can lead to

symptoms of diversion colitis.37

An early study in the New England Journal of Medicine tested the

effects of enema administration of short-chain fatty acids in solution to

patients with diversion colitis and found that patients who received

enemas had diminished colitis symptoms and decreased intestinal

inflammation. The symptoms returned when the enemas were

discontinued. One patient maintained remission from diversion colitis

for 14 months by administering twice-daily enemas of short-chain fatty

acids.38 Despite these findings, there have been other studies that

have not resulted in the same outcomes and have found little evidence

of the success of short-chain fatty acid administration. Still, since

some patients have benefited from this type of therapy, it may be an


54

option for treatment of diversion colitis, particularly in situations where

other measures do not seem successful.

Because diversion colitis is only seen among patients who have had

colostomy or ileostomy surgery to divert a portion of the intestine, the

condition is not as frequently seen as other types of IBD. However, it

is a very real complication for those who have undergone surgery and

who develop its symptoms. Any patient who is preparing for ostomy

surgery as treatment of IBD should be educated about the potential

for diversion colitis as a possible complication. Although it is relatively

uncommon, education about the condition can still prepare surgical

patients for the possibility of needing to handle this outcome.

Behcet’s Disease

Behcet’s disease is a form of IBD that is more common in Middle

Eastern countries and in Asia when compared to the United States.

Behcet’s disease is an inflammatory condition that causes ulcers in the

mouth and on the genitalia, as well as inflammation in the

gastrointestinal tract, blood vessels, the eye, the brain, and the spinal

cord. A Turkish physician, Dr. Hulusi Behçet, first discovered the

disease in the 1930s.39

Behcet’s disease most commonly develops in young adults, but it has

been seen in people of all ages. As with other types of IBD, the

inflammation that occurs with Behcet’s often develops as a result of a

triggering event in susceptible people. Those who have a family history

of inflammatory bowel conditions or autoimmune disease are more

likely to develop Behcet’s disease and when an environmental trigger

happens, inflammation and ulcers develop. Behcet’s is thought to be


55

an autoimmune process in that the associated inflammation occurs

when the body attacks its gastrointestinal and vascular systems. Other

studies have found that people with Behcet’s are more likely to have a

specific type of human leukocyte antigen in the blood but the exact

mechanisms for why these individuals then develop Behcet’s disease is

not entirely clear.40

In addition to being classified as a type of inflammatory bowel disease,

Behcet’s is also a musculoskeletal disorder because it is a type of

vasculitis that causes inflammation of the blood vessels. In fact, most

of the symptoms that develop with Behcet’s disease are from the

effects of inflammation of the blood vessels in the affected individual.

The majority of people with Behcet’s develop aphthous stomatitis:

inflammation and ulcerations in the mouth that are similar in

appearance to canker sores. These ulcers are painful and can make

eating very difficult. The ulcers are usually round with erythematous

borders and they may be shallow or they can be deep enough to

impact more than one layer of tissue. Often, ulcers develop as single

lesions but they can form clusters as well. They occur during flares of

Behcet’s disease and then heal during periods of remission, usually

without causing permanent scarring.40

Approximately half of all patients with Behcet’s disease also suffer

from ulcers on the genitalia.39 These areas of inflammation and

ulceration are most prominently found on the scrotum in men and on

the vulva in women and are similar in appearance to the ulcers and

sores that develop in the mouth. However, unlike the mouth sores

associated with the condition, the ulcers that develop on the genitalia


56

with Behcet’s are often deeper and tend to leave scars after they have

healed.40

There are various other symptoms seen with Behcet’s disease that do

not necessarily affect the gastrointestinal tract, including sores on the

skin, which appear as red, pus-filled lesions. There may be

inflammation of the eye, most commonly the iris and the uvea,

although the retina may also become inflamed and the patient may

have vision loss, excess tear production, and photophobia. Severe

cases of eye inflammation may lead to complete blindness. Because

the disease tends to affect persons of Middle Eastern and Asian

descent more commonly than in Europe or the United States, cases of

eye inflammation are much more common in impacted countries.

Behcet’s disease eye involvement is the leading cause of blindness in

Japan.40

Central nervous system involvement leads to meningitis or

meningoenchephalitis, and the affected patient may develop severe

headaches, problems with walking or coordination, and seizures. The

disease affects the vascular system, causing thrombophlebitis, which

leads to pain, swelling, and inflammation associated with small blood

clots in the peripheral vascular system. Approximately 50 percent of

patients with Behcet’s disease develop arthritis in one or several joints

in the body, causing pain, swelling, and difficulties with joint

movement.40 The joint inflammation is more severe during times of

flares.

Behcet’s disease also affects the gastrointestinal tract when ulcers

develop along the intestinal lining. The ulcers are similar to the


57

aphthous stomatitis found in the mouth with this condition. The ulcers

cause symptoms of abdominal pain and diarrhea. When the ulcers

bleed, the patient also demonstrates blood in the stool. Often, the

ulcerations and their accompanying symptoms are similar to and

sometimes mistaken for Crohn’s disease or ulcerative colitis. It is

therefore important to understand the signs and symptoms that are

common to Behcet’s but that are not present with ulcerative colitis or

Crohn’s disease.

According to the International Study Group for Behcet’s Disease, a

diagnosis of Behcet’s disease can occur when the patient has had

mouth sores at least three times in the past 12 months. In addition,

other common symptoms of Behcet’s include eye inflammation with

loss of vision, recurring genital sores, skin lesions, or a positive

pathergy test, in which a reaction develops following a small skin

prick.39,41

The gastrointestinal manifestations associated with Behcet’s can lead

to significant disability and increased mortality for affected patients.

The oral ulcers that develop with Behcet’s are early signs of the

disease, while gastrointestinal involvement tends to develop between

4 and 6 years after initial onset of symptoms. The gastrointestinal

ulcers of Behcet’s disease can develop at any point along the

gastrointestinal tract, including within the large and small intestines;

however, the most common location of ulcer development is near the

ileocecal valve. The ulcers can also develop on other organs of the

gastrointestinal system, such as the stomach and the pancreas.41


58

According to Skef, et al., in the World Journal of Gastroenterology, the

gastrointestinal effects of Behcet’s disease are classified according to

two different types: neutrophilic phlebitis and large vessel disease. It

is the neutrophilic phlebitis that causes inflammation and ulcer

development. In contrast, those with large vessel disease suffer from

inflammation of the blood vessels that support the gastrointestinal

tract, mainly the mesenteric arteries, which leads to blood vessel

occlusion and resulting ischemia and infarct.41

Because ulcers can develop anywhere along the gastrointestinal tract

with Behcet’s the symptoms the patient experiences may be specific to

the region of the area involved. For example, while rare, esophageal

ulcers can develop in some people with Behcet’s disease, which can

cause symptoms of dysphagia, odynophagia, and chest pain behind

the sternum, and the patient may experience symptoms consistent

with relaxation of the lower esophageal sphincter. Persons with ulcers

affecting the stomach and duodenum may suffer from symptoms

similar to those of pyloric stenosis or from gastroparesis.

The most common areas of ulcer development in gastrointestinal cases

of Behcet’s are in the ileum of the small intestine, the cecum, and the

junction between the small and large intestines at the ileocecal valve.

The entire large and/or small intestine may also be affected; however,

ulcer development in the rectum is very rare, accounting for

approximately 1 percent of patients. The patient with inflammation

and ulcers from Behcet’s is at risk of numerous complications,

including stenosis and strictures in the intestinal tract, fistulas, abscess

formation, and intestinal perforation.


59

The treatment of Behcet’s disease is often similar to that used for

Crohn’s disease and ulcerative colitis and may consist of systemic

corticosteroids, immunomodulator drugs, and biologic agents to

control inflammation. These drugs are not only helpful in reducing

inflammation in the gastrointestinal tract but they often manage the

inflammation of other body systems that are prominent with this

particular disease. In addition to these therapies, various medications

may be used to treat specific problems associated with Behcet’s, such

as eye drops to prevent corneal or retinal damage, mouthwash that

controls pain and inflammation in the mouth and throat, and topical

ointment for genital ulcerations.

Although Behcet’s disease has many similarities to Crohn’s and

ulcerative colitis, it is fortunately a rare type of autoimmune disorder.

A patient who develops this particular disease may be able to manage

its symptoms and prevent complications through standard therapy

used for other forms of inflammatory bowel disease.

Indeterminate Colitis

There are times when it is difficult to determine the actual type of

inflammatory bowel disease as symptoms may overlap with one

another. When it is not clear whether a patient’s symptoms are caused

by Crohn’s disease or ulcerative colitis, the patient is diagnosed with

indeterminate colitis. Approximately 15 percent of people with IBD

have indeterminate colitis.42

People with indeterminate colitis typically have symptoms only

affecting the large intestine. This means that the condition could be

ulcerative colitis or Crohn’s disease affecting only the colon.


60

A diagnosis of Crohn’s disease or ulcerative colitis obviously requires

extensive diagnostic testing that includes a review of the patient’s

symptoms, a physical examination, laboratory testing, a complete

medical and family history, endoscopic procedures to visualize the

intestinal tract, and often a biopsy to test tissue histology. Despite the

extensive nature of diagnostic testing available for these specific

diseases, there are times when it is still unclear which type of IBD is

present. Both ulcerative colitis and Crohn’s disease have diagnostic

criteria that must be present to make a formal diagnosis.

Indeterminate colitis may be a diagnosis given when symptoms affect

the large intestine and the patient does not have enough diagnostic

criteria to completely fulfill a diagnosis of either Crohn’s disease or

ulcerative colitis.43

According to an article in the Journal of Gastroenterology and

Hepatology Research, indeterminate colitis is considered to be a

temporary diagnosis, given to initiate treatment for the affected

patient and put in place until further testing or changes in the

pathophysiology of the disease reveals which type of IBD is present.43

Although the term is somewhat controversial for use, indeterminate

colitis is included as part of the International Classification of Diseases,

Tenth Revision (ICD-10). Some clinicians prefer to call the condition

Inflammatory Bowel Disease, Unclassified.

Indeterminate colitis typically possesses many of the same

physiological manifestations in the colon as seen with Crohn’s disease

and ulcerative colitis, although the severity and intensity of the

condition varies between patients. The disease causes areas of

inflammation in the large intestine that may lead to tissue breakdown


61

and necrosis of ulcers. The ulcerations may affect one or more layers

of the intestinal tract, often leaving no indication as to whether the

condition is actually Crohn’s disease, which often causes transmural

ulcerations, or ulcerative colitis, which typically only affects the first

two layers of the colon.

The inflammation and ulcerations associated with indeterminate colitis

are often seen throughout the entire large intestine but rarely in the

rectum. Often, the right and transverse sections of the colon are

affected more frequently than the left side.43 There may be

intermittent alterations in tissue areas that give the appearance of skip

lesions associated with Crohn’s disease. Some areas of the bowel may

be dilated slightly and fissures can be present. The fissures that are

seen with this type of colitis often differ from those noted with Crohn’s

disease. Fissures associated with indeterminate colitis are described as

“knife-like” because of their appearance and depth.43 They may also

appear V-shaped, with wider openings on the mucosal surface and

becoming narrower with greater depth.

Patients with indeterminate colitis also suffer from a variety of

symptoms that are similar or even the same as those seen with other

forms of IBD, including frequent diarrhea, abdominal pain, rectal

bleeding, and abdominal cramping. The symptoms may be

exacerbated during times of disease flares and may then dissipate

when the patient enters remission.

The treatment for indeterminate colitis is often similar to that given for

ulcerative colitis. Many patients with this type of disease have

benefitted from administration of anti-inflammatory agents,


62

immunosuppressants, corticosteroids, and biologic therapies. In many

cases, surgery to remove the diseased portions of the colon is often

necessary when symptoms are severe and complications have

developed. Unfortunately, because indeterminate colitis may be used

as an interim diagnosis, the patient who is suffering from symptoms of

this particular type of IBD may need to continue to undergo testing

and assessment for changes for a longer period when compared to

someone else with more straightforward symptoms. The condition may

change over time, which could allow the diagnosing clinician to

definitively diagnose indeterminate colitis as either Crohn’s disease or

ulcerative colitis.

Unless the symptoms and the pathophysiology of the disease actually

reveals which type of IBD is present, the patient will often benefit from

medical therapies and prescribed remedies. The term itself may be

controversial, but because indeterminate colitis seems to respond well

to the same types of therapy administered for other kinds of IBD and

it can be surgically corrected when needed, the patient with

indeterminate colitis can still benefit from standard forms of medical

therapies used for management of inflammation.

Summary The chronic gastrointestinal condition of inflammatory bowel disease is

a recurring disease characterized by inflammation, tissue

deterioration, and ulceration in different regions of the gastrointestinal

system. The most common types of IBD are ulcerative colitis and

Crohn’s disease. The different types of IBDs may develop anywhere

along the gastrointestinal tract from the mouth to the anus, although

most cases are confined to areas of the small or large intestines.


63

Inflammatory bowel disease causes periods of active illness in which

affected persons suffer from multiple symptoms that include pain and

diarrhea, followed by periods of remission, in which there are few to

no symptoms at all. The chronic nature of the disease has confounded

clinicians and medical scientists who have researched its causes and

the most appropriate forms of treatment to be able to induce

remission and alleviate some of the debilitating symptoms.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement.


64

1. Inflammatory bowel disease (IBD) is actually a group of disorders that a. similarly cause inflammation in the gastrointestinal tract. b. affect the same areas of the intestine. c. respond treatment in the same way. d. All of the above

2. True or False: All types of IBD develop along the gastrointestinal tract in the areas of the small or large intestines. a. True b. False


disease (IBD) are a. ulcerative proctitis and Crohn’s disease. b. Behcet’s disease and proctitis. c. ulcerative colitis and sclerosing cholangitis. d. ulcerative colitis and Crohn’s disease.

4. Sclerosing cholangitis causes inflammation and scarring

within the

a. the cecum. b. bile ducts. c. descending colon. d. the ileum.

5. _________________ is a chronic condition that causes

inflammation of the intestinal tract with concomitant ulcerations of the intestinal mucosa. a. Ulcerative proctosigmoiditis b. Behcet’s disease c. Ulcerative colitis d. Sclerosing cholangitis


65

6. Behcet’s disease is an inflammatory condition that causes ulcers a. in the mouth and on the genitalia. b. inflammation in the gastrointestinal tract. c. the eye, the brain, and the spinal cord. d. All of the above

7. The ulceration associated with ulcerative colitis often will

only affect _____________________ of the intestinal tract. a. the muscularis layer b. submucosal layer c. muscularis and submucosal layers d. the mucosal and submucosal layers

8. Ulcerative colitis differs from Crohn’s disease because with

Crohn’s disease, ulcerations typically a. cause Clostridium difficile infection. b. extend through all layers of the intestinal tract. c. are limited to the colon and rectum. d. does not develop in the ileum.

9. True or False: Inflammatory bowel disease (IBD) may be

caused solely by uncontrolled stress. a. True b. False

10. ______________ is an infection that is often contracted by

a patient while in a hospital or healthcare environment. a. Microscopic colitis b. Celiac disease c. Clostridium difficile d. H. pylori

11. True or False: True or False: Approximately 15 percent of

people with IBD have indeterminate colitis. a. True b. False


66

12. _____________________ can cause inflammation along any part of the gastrointestinal tract and is not limited to specific areas.

a. Crohn’s disease b. Pan-colitis c. Ulcerative colitis d. Sclerosing cholangitis

13. With _________________ the surface of the intestinal

lining often appears rough with a “cobblestone” appearance that is characteristic of that disease. a. vasculitis b. indeterminate colitis c. Crohn’s disease d. sclerosing cholangitis

14. Ulcerative colitis that affects the entire large intestine,

including the ascending, transverse, descending, and sigmoid portions is sometimes called

a. pan-colitis. b. Behcet’s disease. c. indeterminate colitis. d. sclerosing cholangitis.

15. True or False: Smoking tobacco is a factor that has been

associated with increased incidences of disease flares among those with Crohn’s disease. a. True b. False

16. Ulcerative colitis and other IBDs that affect the large

intestine may be difficult to distinguish from a Clostridium difficile infection because they share the same

a. “cobblestone” appearance. b. symptom, severe diarrhea. c. symptomatic inflammation in the mouth and throat. d. symptomatic psoriasis.


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17. Inflammation from Crohn’s disease most often develops in the distal portion of the small intestine known as ___________ and the ileocecal region.

a. the bile ducts b. the cecum c. the duodenum d. the ileum

18. _________________ is an autoimmune condition in which

damage develops in the intestinal tract after ingestion of gluten, a protein found in wheat products. a. H. pylori b. Gastroparesis c. Pyloric stenosis d. Celiac disease

19. The Crohn’s and Colitis Foundation of America (CCFA)

states that there may be a link between microscopic colitis and

a. celiac disease. b. musculoskeletal disorder. c. H. pylori. d. gastroparesis.

20. True or False: Ileocolitis is considered the most common

form of Crohn’s disease. a. True b. False

21. Behcet’s disease is a type of inflammatory bowel disease

and a _____________________ because it is a type of vasculitis that causes inflammation of the blood vessels.

a. autoimmune disorder b. gastrointestinal disorder c. musculoskeletal disorder d. gluten disorder


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22. The administration of an enema of short-chain fatty acids in solution to patients with _________________ decreased intestinal inflammation but the symptoms usually returned when the enemas were discontinued.

a. diminished colitis b. indeterminate colitis c. microscopic colitis d. diversion colitis

23. Collagenous colitis occurs when areas of collagen under

the epithelium solidify and the tissue overall becomes a. diffused and thins out. b. impaired and thins out. c. perforated and takes on a “cobblestone” texture. d. concentrated and thick.

24. With __________________ there may be inflammation of

the eye, and severe cases of eye inflammation may lead to complete blindness.

a. celiac disease b. Sjögren’s syndrome c. Behcet’s disease d. pan-colitis

25. True or False: Microscopic colitis has been shown to

increase the risk of colon cancer. a. True b. False

26. When it is not clear whether a patient’s inflammatory

bowel symptoms are caused by Crohn’s disease or ulcerative colitis, the patient is diagnosed with

a. a Clostridium difficile infection. b. pan-colitis. c. Behcet’s disease d. indeterminate colitis.


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27. Common autoimmune diseases that are seen with collagenous colitis include

a. myasthenia gravis. b. gastroparesis. c. Clostridium difficile. d. vasculitis.

28. Patients with microscopic colitis typically have frequent,

watery diarrhea

a. caused by infection. b. with or without abdominal pain and cramping. c. associated with all the other IBD symptoms. d. All of the above

29. People with indeterminate colitis typically have symptoms

only affecting a. the large intestine. b. the mouth and esophagus. c. the small intestine. d. the ileum.

30. The treatment for ____________________ includes the

administration of anti-inflammatory agents, immunosuppressants, corticosteroids, and biologic therapies.

a. celiac disease b. indeterminate colitis c. aphthous stomatitis d. diversion colitis

31. True or False: The majority of people with Behcet’s develop

aphthous stomatitis. a. True b. False


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32. The small intestine is a. named “small” because of its length. b. approximately 8 feet long in adults. c. the longest portion of the gastrointestinal tract. d. All of the above

33. Patients with _________________ develop lymphoid

follicular hyperplasia, which is an increase in the size of lymph node follicles due to increased numbers of white blood cells.

a. celiac disease b. Sjögren’s syndrome c. Behcet’s disease d. diversion colitis

34. True or False: Because of the controversy associated with

classifying indeterminate colitis as an IBD, it is NOT included as part of the International Classification of Diseases, Tenth Revision (ICD-10). a. True b. False

35. The group most likely to suffer from microscopic colitis is

a. males of all ages. b. older females. c. young males. d. adolescent females.

36. The areas of the gastrointestinal tract that may be affected

by microscopic colitis include

a. the large intestine. b. the small intestine. c. the stomach. d. All of the above


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37. The major difference between Crohn’s disease in the mouth and orofacial granulomatosis is that the patient with Crohn’s disease also have

a. overgrowths of granulation tissue. b. inflammation and scarring within the bile ducts. c. gastrointestinal tract lesions and inflammation. d. aphthous stomatitis (similar to canker sores) in the mouth.

38. According to an article in the Journal of Gastroenterology

and Hepatology Research, indeterminate colitis is considered to be _________________ given to initiate treatment for the affected patient. a. a final diagnosis b. a non-IBD diagnosis c. a temporary diagnosis d. a pre-diagnosis classification

39. __________________ is a form of ulcerative colitis that

includes rectal involvement of the rectum only and NOT other areas of the colon.

a. diversion colitis b. indeterminate colitis c. proctosigmoiditis d. ulcerative proctitis

40. True or False: Diversion colitis develops in the large

intestine and usually develops into colon cancer.

a. True b. False

41. True or False. The exact cause of microscopic colitis has

been well identified.

a. True. b. False.


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CORRECT ANSWERS: 1. Inflammatory bowel disease (IBD) is actually a group of

disorders that

a. similarly cause inflammation in the gastrointestinal tract. p. 5: “Inflammatory bowel disease is actually a group of disorders that all cause similar effects of inflammation in the gastrointestinal tract.”

2. True or False: All types of IBD develop along the

gastrointestinal tract in the areas of the small or large intestines.

b. False pp. 5-6: “Both of these diseases cause intestinal inflammation, pain, and tissue damage in the gastrointestinal tract. Ulcerative colitis primarily affects the large intestine, while Crohn’s disease is most common in the small intestine, but can occur anywhere along the digestive tract.”


disease (IBD) are

d. ulcerative colitis and Crohn’s disease. p. 5: “Two of the most common types of IBD are ulcerative colitis and Crohn’s disease.”

4. Sclerosing cholangitis causes inflammation and scarring within the

b. bile ducts. p. 9: “A small percentage of patients develop sclerosing cholangitis, which causes inflammation and scarring within the bile ducts.”


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5. _________________ is a chronic condition that causes inflammation of the intestinal tract with concomitant ulcerations of the intestinal mucosa.

c. Ulcerative colitis p. 7: “Ulcerative colitis [is] a chronic condition that causes inflammation of the intestinal tract with concomitant ulcerations of the intestinal mucosa….”

6. Behcet’s disease is an inflammatory condition that causes

ulcers

a. in the mouth and on the genitalia. b. inflammation in the gastrointestinal tract. c. the eye, the brain, and the spinal cord. d. All of the above

p. 54: “Behcet’s disease is an inflammatory condition that causes ulcers in the mouth and on the genitalia, as well as inflammation in the gastrointestinal tract, blood vessels, the eye, the brain, and the spinal cord.”

7. The ulceration associated with ulcerative colitis often will only affect _____________________ of the intestinal tract.

d. the mucosal and submucosal layers p. 15: “The ulceration associated with ulcerative colitis often only affects the mucosal and submucosal layers of the intestinal tract, but typically does not extend down into the muscularis layer.”

8. Ulcerative colitis differs from Crohn’s disease because with Crohn’s disease, ulcerations typically

b. extend through all layers of the intestinal tract. p. 15: “The disease process associated with ulcerative colitis differs from Crohn’s disease: with Crohn’s disease, ulcerations can extend through all layers of the intestinal tract.”


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9. True or False: Inflammatory bowel disease (IBD) may be caused solely by uncontrolled stress.

b. False p. 8: “Although stress is known to be a triggering factor for a disease flare, uncontrolled stress is not the cause of ulcerative colitis or of any other type of IBD.”

10. ______________ is an infection that is often contracted by

a patient while in a hospital or healthcare environment.

c. Clostridium difficile p. 17: “[C. difficile] is often a healthcare-associated infection, in which patients contract it while in the hospital or healthcare environment.”

11. True or False: Approximately 15 percent of people with IBD

have indeterminate colitis.

a. True p. 59: “Approximately 15 percent of people with IBD have indeterminate colitis.”

12. _____________________ can cause inflammation along any part of the gastrointestinal tract and is not limited to specific areas.

a. Crohn’s disease p. 23: “Unlike ulcerative colitis and some other forms of IBD, Crohn’s disease can cause inflammation along any part of the gastrointestinal tract and is not limited to specific areas.”


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13. With _________________ the surface of the intestinal lining often appears rough with a “cobblestone” appearance that is characteristic of that disease.

c. Crohn’s disease p. 24: “The surface of the intestinal lining often appears rough with a “cobblestone” appearance that is characteristic of Crohn’s disease.”

14. Ulcerative colitis that affects the entire large intestine, including the ascending, transverse, descending, and sigmoid portions is sometimes called

a. pan-colitis. p. 15: “Ulcerative colitis that affects the entire large intestine, including the ascending, transverse, descending, and sigmoid portions is sometimes called pan-colitis.”

15. True or False: Smoking tobacco is a factor that has been associated with increased incidences of disease flares among those with Crohn’s disease.

a. True p. 25: “Smoking tobacco is a factor that has been associated with increased incidences of disease flares among those with Crohn’s disease.”

16. Ulcerative colitis and other IBDs that affect the large intestine may be difficult to distinguish from a Clostridium difficile infection because they share the same

b. symptom, severe diarrhea. p. 17: “Ulcerative colitis and other forms of IBD that affect the large intestine increase the risk of Clostridium difficile infection in the gastrointestinal tract. C. difficile infection tends to cause severe diarrhea, which may make it difficult to establish IBD versus C. difficile as the cause of diarrhea.”


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17. Inflammation from Crohn’s disease most often develops in the distal portion of the small intestine known as ___________ and the ileocecal region.

d. the ileum p. 24: “Although it can affect any part of the gastrointestinal tract, the inflammation from Crohn’s most often develops in the distal portion of the small intestine—the ileum—and the junction between the small intestine and the cecum, known as the ileocecal region.”

18. _________________ is an autoimmune condition in which

damage develops in the intestinal tract after ingestion of gluten, a protein found in wheat products.

d. Celiac disease p. 49: “The Crohn’s and Colitis Foundation of America (CCFA) states that there may be a link between microscopic colitis and celiac disease, an autoimmune condition in which damage develops in the intestinal tract after ingestion of gluten, a protein found in wheat products.”

19. The Crohn’s and Colitis Foundation of America (CCFA) states that there may be a link between microscopic colitis and

a. celiac disease. p. 49: “The Crohn’s and Colitis Foundation of America (CCFA) states that there may be a link between microscopic colitis and celiac disease, an autoimmune condition in which damage develops in the intestinal tract after ingestion of gluten, a protein found in wheat products.”

20. True or False: Ileocolitis is considered the most common

form of Crohn’s disease.

a. True p. 33: “Ileocolitis is considered the most common form of Crohn’s disease.”


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21. Behcet’s disease is a type of inflammatory bowel disease and a _____________________ because it is a type of vasculitis that causes inflammation of the blood vessels.

c. musculoskeletal disorder p. 55: “In addition to being classified as a type of inflammatory bowel disease, Behcet’s is also a musculoskeletal disorder because it is a type of vasculitis that causes inflammation of the blood vessels.”

22. The administration of an enema of short-chain fatty acids

in solution to patients with _________________ decreased intestinal inflammation but the symptoms usually returned when the enemas were discontinued.

d. diversion colitis p. 53: “An early study in the New England Journal of Medicine tested the effects of enema administration of short-chain fatty acids in solution to patients with diversion colitis and found that patients who received enemas had diminished colitis symptoms and decreased intestinal inflammation.”

23. Collagenous colitis occurs when areas of collagen under

the epithelium solidify and the tissue overall becomes

d. concentrated and thick. p. 47: “Collagenous colitis occurs when areas of collagen under the epithelium solidify and the tissue overall becomes concentrated and thick.”


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24. With __________________ there may be inflammation of the eye, and severe cases of eye inflammation may lead to complete blindness.

c. Behcet’s disease p. 56: “There are various other symptoms seen with Behcet’s disease that do not necessarily affect the gastrointestinal tract, including sores on the skin, which appear as red, pus-filled lesions. There may be inflammation of the eye, most commonly the iris and the uvea, although the retina may also become inflamed and the patient may have vision loss, excess tear production, and photophobia. Severe cases of eye inflammation may lead to complete blindness.”

25. True or False: Microscopic colitis has been shown to

increase the risk of colon cancer.

b. False p. 50: “Unlike Crohn’s disease or ulcerative colitis, microscopic colitis has not been shown to increase the risk of colon cancer.”

26. When it is not clear whether a patient’s inflammatory

bowel symptoms are caused by Crohn’s disease or ulcerative colitis, the patient is diagnosed with

d. indeterminate colitis. p. 59: “When it is not clear whether a patient’s symptoms are caused by Crohn’s disease or ulcerative colitis, the patient is diagnosed with indeterminate colitis. Approximately 15 percent of people with IBD have indeterminate colitis.”

27. Common autoimmune diseases that are seen with

collagenous colitis include

a. myasthenia gravis. p. 50: “Common conditions that are seen with collagenous colitis include Sjögren’s syndrome, thyroiditis, and myasthenia gravis.”


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28. Patients with microscopic colitis typically have frequent, watery diarrhea

b. with or without abdominal pain and cramping. p. 48: “People with microscopic colitis typically have frequent, watery diarrhea with or without abdominal pain and cramping;….”

29. People with indeterminate colitis typically have symptoms

only affecting

a. the large intestine. p. 59: “People with indeterminate colitis typically have symptoms only affecting the large intestine.”

30. The treatment for ____________________ includes the

administration of anti-inflammatory agents, immunosuppressants, corticosteroids, and biologic therapies.

b. indeterminate colitis pp. 61-62: “The treatment for indeterminate colitis is often similar to that given for ulcerative colitis. Many patients with this type of disease have benefitted from administration of anti-inflammatory agents, immunosuppressants, corticosteroids, and biologic therapies.”

31. True or False: The majority of people with Behcet’s develop

aphthous stomatitis.

a. True p. 55: “The majority of people with Behcet’s develop aphthous stomatitis: inflammation and ulcerations in the mouth that are similar in appearance to canker sores.”


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32. The small intestine is

c. the longest portion of the gastrointestinal tract. p. 31: “The small intestine is the longest portion of the gastrointestinal tract. Its name refers to the diameter of the intestinal lumen rather than its length. The average length of the small intestine is approximately 20 feet long in adults.”

33. Patients with _________________ develop lymphoid

follicular hyperplasia, which is an increase in the size of lymph node follicles due to increased numbers of white blood cells.

d. diversion colitis p. 51: “Patients with diversion colitis develop lymphoid follicular hyperplasia, which is an increase in the size of lymph node follicles due to increased numbers of white blood cells.”

34. True or False: Because of the controversy associated with

classifying indeterminate colitis as an IBD, it is NOT included as part of the International Classification of Diseases, Tenth Revision (ICD-10).

b. False p. 60: “Although the term is somewhat controversial for use, indeterminate colitis is included as part of the International Classification of Diseases, Tenth Revision (ICD-10). Some clinicians prefer to call the condition Inflammatory Bowel Disease, Unclassified.”

35. The group most likely to suffer from microscopic colitis is

b. older females. p. 46: “This specific type of inflammatory bowel disease most commonly affects older adults, with a higher percentage of older females than males affected by collagenous colitis, one of the subtypes of the disease.”


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36. The areas of the gastrointestinal tract that may be affected by microscopic colitis include

a. the large intestine. p. 46: “A patient suffering from microscopic colitis experiences pain and diarrhea but there is no obvious source during examination. The condition only affects the large intestine, the sigmoid colon, and the rectum.”

37. The major difference between Crohn’s disease in the

mouth and orofacial granulomatosis is that the patient with Crohn’s disease also have

c. gastrointestinal tract lesions and inflammation.

p. 43: “[A]ccording to Zbar, et al., in the Journal of Crohn’s and Colitis, the major difference between Crohn’s disease in the mouth and orofacial granulomatosis is that the patient with Crohn’s disease has concomitant lesions and inflammation elsewhere in the gastrointestinal tract, while orofacial granulomatosis typically only affects the mouth.”

38. According to an article in the Journal of Gastroenterology

and Hepatology Research, indeterminate colitis is considered to be _________________ given to initiate treatment for the affected patient.

c. a temporary diagnosis p. 60: “According to an article in the Journal of Gastroenterology and Hepatology Research, indeterminate colitis is considered to be a temporary diagnosis, given to initiate treatment for the affected patient and put in place until further testing or changes in the pathophysiology of the disease reveals which type of IBD is present.”


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39. __________________ is a form of ulcerative colitis that includes rectal involvement of the rectum only and NOT other areas of the colon.

d. ulcerative proctitis p. 19: “Approximately 46 percent of patients with ulcerative colitis have rectal involvement, called ulcerative proctitis when it affects only the rectum, and ulcerative proctosigmoiditis when the sigmoid colon is also involved.”

40. True or False: Diversion colitis develops in the large

intestine and usually develops into colon cancer.

b. False p. 51: “Diversion colitis develops in the large intestine and is usually considered to be benign, ….”

41. True or False. The exact cause of microscopic colitis has been well identified. b. False.

p. 48. “The exact cause of microscopic colitis is unknown.”


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References

The References below include published works and in-text citations of published works that are intended as helpful material for your further reading.

1. Crohn’s and Colitis Foundation of America (CCFA). (2009, Apr.). Managing flares and other IBD symptoms. New York NY: CCFA

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. Crohn’s and Colitis Foundation of America. (2012, May). Liver disease and IBD. Retrieved from http://www.ccfa.org/resources/liver-disease-and-ibd.html?referrer=https://www.google.com/

5. University of Alberta IBD Clinic. (2016). What are extra-intestinal manifestations of IBD? Retrieved from http://www.ibdclinic.ca/what-is-ibd/complications/

6. Strober, W., Fuss, I. (2011, May). Pro-inflammatory cytokines in the pathogenesis of IBD. Gastroenterology 140(6): 1756-1767. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3773507/

7. Kennedy, A. (2015). The inflammatory response. Retrieved from http://primer.crohn.ie/the-inflammatory-response

8. Bowen, R. (2000, May). Gross and microscopic anatomy of the large intestine. Retrieved from http://arbl.cvmbs.colostate.edu/hbooks/pathphys/digestion/largegut/anatomy.html

9. Taylor, T. (2016). Large intestine. Retrieved from http://www.innerbody.com/anatomy/digestive/large-intestine

10. Crohn’s and Colitis Foundation of America. (2015, Jan.). Intestinal complications. Retrieved from http://www.ccfa.org/assets/pdfs/intestinalcomps.pdf

11. Crohn’s and Colitis Foundation of America. (2012, Sep.). Understanding your risk: C. diff. Retrieved from http://online.ccfa.org/site/PageNavigator/2012_09_enews_landing.html


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12. Sandborn, W., et al. (2015, Apr.). Budesonide foam induces remission in patients with mild to moderate ulcerative proctitis and ulcerative proctosigmoiditis. Gastroenterology 148(4): 740-750. Retrieved from http://www.gastrojournal.org/article/S0016-5085(15)00154-7/fulltext

13. Dewint, P., et al. (2014). Adalimumab combined with ciprofloxacin is superior to adalimumab monotherapy in perianal fistula closure in Crohn’s disease: a randomized, double-blind, placebo controlled trial (ADAFI). Gut 2014; 63: 292-299.

14. Colon & Rectal Surgery Associates. (2016). What is ulcerative proctitis? Retrieved from http://www.colonrectal.org/services.cfm/sid:6694/ulcerative_proctitis/index.html

15. Crohn’s & Colitis.com. (2016). Understanding Crohn’s disease. Retrieved from https://www.crohnsandcolitis.com/crohns

16. University of Maryland Medical Center. (2012, Dec.). Crohn’s disease. Retrieved from http://umm.edu/health/medical/reports/articles/crohns-disease

17. Crohn’s and Colitis Foundation of America. (2015, Jan.). Arthritis and joint pain. Retrieved from http://www.ccfa.org/assets/pdfs/arthritiscomplications.pdf

18. Lashner, B. (2013, Jan.). Crohn’s disease. Retrieved from http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastroenterology/crohns-disease/

19. IBD Relief. (2016). What is perianal Crohn’s disease? Retrieved from https://www.ibdrelief.com/learn/what-is-ibd/what-is-crohns-disease/perianal-crohns

20. De Zoeten, E., Pasternak, B., Mattei, P., Kramer, R., Kader, H. (2013, Sep.). Diagnosis and treatment of perianal Crohn disease: NASPGHAN clinical report and consensus statement. JPGN 57(3): 401-412.

21. IBD Relief. (2016). What is ileocolitis? Retrieved from https://www.ibdrelief.com/learn/what-is-ibd/what-is-crohns-disease/ileocolitis

22. Bayless, T., Hanauer, S. (2011). Advanced therapy of inflammatory bowel disease (3rd ed.), Volume 2. Shelton, CT: People’s Medical Publishing House USA

23. Crohn’s & Colitis Foundation of America. (2016). Types of Crohn’s disease and associated symptoms. Retrieved from http://www.ccfa.org/what-are-crohns-and-colitis/what-is-crohns-disease/types-of-crohns-disease.html?referrer=https://www.google.com/

24. Menys, A., et al. (2013, Dec.). Small bowel strictures in Crohn’s disease: a quantitative investigation of intestinal motility using MR


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enterography. Neurogastroenterology & Motility 25(12): 967-e775. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/nmo.12229/full

25. Bayless, T., Hanauer, S. (2011). Advanced therapy of inflammatory bowel disease (3rd ed.), Volume 2. Shelton, CT: People’s Medical Publishing House USA

26. Steckstor, M., Adam, B., Pech, O., Tannapfel, A., Riphaus, A. (2013, Jun.). Gastroduodenal Crohn’s disease. Video Journal and Encyclopedia of GI Endoscopy 1(1): 178-179.

27. Scheck, S., Ram, R., Loveday, B., Bhagvan, S., Beban, G. (2014, Dec.). Crohn’s disease presenting as gastric outlet obstruction. J Surg Case Rep. 2014(12): rju 128. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4255135/

28. Gore, R., Levine, M. (2015). Textbook of gastrointestinal radiology (4th ed.). Philadelphia, PA: Elsevier Saunders

29. Ji, X., Wang, L., Lu, D. (2014, Oct.). Pulmonary manifestations of inflammatory bowel disease. World Journal of Gastroenterology 20(37): 13501-13511. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4188901/

30. Dyall-Smith, D. (2016). Orofacial Crohn disease. Retrieved from http://www.dermnetnz.org/topics/orofacial-crohn-disease/

31. Zbar, A., Ben-Horin, S., Beer-Gabel, M., Eliakim, R. (2012, Mar.). Oral Crohn’s disease: Is it a separable disease from orofacial granulomatosis? A review. Journal of Crohn’s and Colitis 6(2): 135-142.

32. Hopkins Medicine. (2013). Collagenous and lymphocytic colitis: Introduction. Retrieved from http://www.hopkinsmedicine.org/gastroenterology_hepatology/_pdfs/small_large_intestine/collagenous_lymphocytic_colitis.pdf

33. Wickbom, A., Bohr, J., Eriksson, S., Udumyan, R., Phil, M., Nyhlin, N., Tysk, C. (2013, Oct.). Stable incidence of collagenous colitis and lymphocytic colitis in Orebro, Sweden, 1999-2008: A continuous epidemiologic study. Inflamm Bowel Dis. 19(11): 2387-2393.

34. National Institute of Diabetes and Digestive and Kidney Diseases. (2014, Jun.). Microscopic colitis. Retrieved from https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/microscopic-colitis/Pages/facts.aspx

35. Crohn’s & Colitis Foundation of America. (2012, Oct.). Microscopic colitis. Retrieved from http://www.ccfa.org/resources/microscopic-colitis.html?referrer=https://www.google.com/

36. Kabir, S., Kabir, S., Richards, R., Ahmed, J., MacFie, J. (2014, Aug.). Pathophysiology, clinical presentation and management of


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diversion colitis: A review of current literature. International Journal of Surgery. Retrieved from http://dx.doi.org/10.1016/j.ijsu.2014.08.350

37. Crohn’s Forum. (n.d.). Diversion colitis. Retrieved from http://www.crohnsforum.com/wiki/Diversion-Colitis

38. Harig, J., Soergel, K., Komorowski, R., Wood, C. (1989, Jan.). Treatment of diversion colitis with short-chain-fatty acid irrigation. N Engl J Med 1989; 320: 23-28.

39. 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

40. National Organization for Rare Disorders (NORD). (2015). Behçet’s syndrome. Retrieved from http://rarediseases.org/rare-diseases/behcets-syndrome/

41. Skef, W., Hamilton, M., Arayssi, T. (2015, Apr.). Gastrointestinal Behçet’s disease: A review. World J Gastroenterol. 21(13): 3801-3812

42. IBD Relief. (2016). What is indeterminate colitis? Retrieved from https://www.ibdrelief.com/learn/what-is-ibd/what-is-indeterminate-colitis

43. Mahdi, B. (2012). A review of inflammatory bowel disease unclassified – Indeterminate colitis. Journal of Gastroenterology and Hepatology Research 1(10). Retrieved from http://www.ghrnet.org/index.php/joghr/article/view/214/395

The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NurseCe4Less.com. The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare. The information provided in this course is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold NurseCe4Less.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication. The contents of this publication may not be reproduced without written permission from NurseCe4Less.com.

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