The term inflammatory bowel disease (IBD) includes ulcerative colitis. Ulcerative colitis is a chronic inflammatory disease that affects the lining of the large intestine. Although Crohn’s disease can affect all parts of the gastrointestinal tract from the mouth to the anus, it is mostly located in the last part of the small intestine (terminal ileum) and large intestine and, unlike ulcerative colitis, creates an inflammation that can involve all layers of the intestinal wall. In the periods when inflammation is active, the inner surface of the intestine is red and swollen, ulcerated and bleeding. In some cases, a clear distinction cannot be made between ulcerative colitis and Crohn’s disease, and in this case, indeterminate colitis is mentioned. and Crohn’s disease
What causes inflammatory bowel diseases?
The causes of inflammatory bowel disease are unknown, but there are many theories. According to one theory, the disease is of genetic origin. Such a relationship is found in 15-20% of patients. Studies investigating whether there is a group of genes that cause this disease are still ongoing. A number of changes have been seen in the body’s immune system in people with IBD. What causes these changes is still unknown. There are many studies done in this area. Although it has not been shown conclusively that stress causes this disease, stress increases the symptoms of the disease in IBD, as in many diseases.
IBD is most common in late adolescence (twenties) and young adulthood (thirties), but can occur in any age group. The disease is seen equally in men and women.
ULCERATIVE COLITIS
Ulcerative colitis (UC) is mostly seen between the ages of 15-40. Ulcerative colitis is a disease that affects only the large intestine and the inner surface of the intestine in the gastrointestinal tract. When it only affects the last part of the large intestine called the rectum, it is called proctitis. Inflammation in the large intestine prevents the absorption of water in the intestine, as well as causes water leakage into the intestine, causing diarrhea. Inflammation is often accompanied by the formation of sores and ulcers in the bowel, resulting in bloody diarrhea and abdominal pain.
What are the signs (symptoms) of ulcerative colitis?
The most common symptoms of UC are diarrhea, urgency to defecate, abdominal pain, and rectal bleeding with or without defecation (rectal bleeding = rectal bleeding). Some patients may feel anorexia, tired and may have lost weight. Although bleeding is usually mild, it can sometimes be severe and anemia may occur. Joint pain, swelling and redness of the eyes, and liver-related problems may occur. These problems may improve after the colitis resolves.
Ulcerative colitis is a disease that generally progresses with periods of recovery and relapse (periods of remission and relapse). Half of the patients have only mild symptoms, while others have fever, bloody diarrhea, nausea and abdominal pain. Patients with ulcerative colitis with severe signs (symptoms) may require hospitalization and, in some cases, surgical treatment. Bleeding is two major complications of toxic megacolon disease.
How do I know if I have ulcerative colitis? Should a patient with ulcerative colitis follow a special nutritional diet?
In periods when the disease is severe enough to require hospitalization, oral feeding may need to be discontinued for a while. Ulcerative colitis patients with moderately to mildly active disease or inactive disease do not have a special diet to follow. Since it is known that spicy and spicy foods can increase the symptoms of the disease, it is recommended not to consume such foods. Since bacterial or viral food poisoning can activate the disease, patients with ulcerative colitis should pay special attention to hygienic rules in food consumption. Antirheumatic drugs, aspirin, antibiotics and oral iron preparations should be used within the knowledge of the doctor. Patients using corticosteroids should reduce their salt use.
Patients with ulcerative colitis, whose diarrhea improves after treatment and on the contrary develop constipation, may be advised to eat a few dried apricots soaked in water or add 1-2 teaspoons of bran to their diet.
Does ulcerative colitis cause cancer?
Patients with ulcerative colitis, whose entire large intestine is affected by the disease, have a higher risk of colon cancer than the normal population. and also in patients who have been diagnosed with ulcerative colitis for 8-10 years, the risk is still high. The risk of developing cancer increases (10%), especially in those who have the disease for 20 years, and after 30 years, approximately 20% of the patients develop colon cancer. The risk of developing cancer is also increased in patients with ulcerative colitis who have a first-degree relative with colon cancer. People in this group should be consulted by doctors and periodically colonoscopy and biopsy should be performed.
CROHN’S DISEASE
Crohn’s disease is a chronic disease that progresses with the formation of inflammatory reaction, ulceration, stenosis and fistulas involving the deep layers of the intestinal wall and progresses with healing and relapses. The most affected areas are the last parts of the small intestine (terminal ileum) and the first part of the large intestine. This type of involvement is called ileocolitis. Crohn’s disease can sometimes affect other parts of the gastrointestinal tract. Aphthous ulcers in the mouth are common. These ulcers can also occur in the esophagus, stomach and duodenum. It is difficult to distinguish these ulcers from peptic ulcers without a biopsy.
What are the signs (symptoms) of Crohn’s disease?
The most common symptoms of Crohn’s disease are abdominal pain, especially in the right lower quadrant, diarrhea and weight loss. There may also be rectal bleeding and fever. Chronic occult or overt bleeding can cause anemia. Growth and developmental retardation is common in children with advanced Crohn’s disease. Joint pain, swelling and redness of the eyes, and liver-related problems may occur.
How do I know if I have Crohn’s disease?
When you have complaints similar to the symptoms of Crohn’s disease, your doctor will ask you for some blood and stool tests after listening to your disease history and doing your physical examination. Other tests that will be requested are the same as those described in the ulcerative colitis section; In addition to colonoscopy and barium radiography (enema opaque), barium radiography of the small intestine (enterochilysis or conventional small bowel radiography) is usually requested. What are the complications of Crohn’s disease? intestinal obstruction. Fistulas are another important complication of Crohn’s disease. Fistulas occur as a result of the ulcer perforating the intestinal wall and making a tunnel-like formation between the adjacent organs (surrounding tissues such as urinary bladder, vagina or skin) and the intestine. Fistulas that open to the skin are often formed around the anus. Fistulas can become infected and form abscesses. Sometimes surgical treatment may be required. Another long-term complication of the disease is reductions in bone density, which we call bone osteoporosis. HOW ARE ULCERATIVE COLITIS AND CROHN’S DISEASE TREATED?
Although ulcerative colitis and Crohn’s disease are chronic diseases with recovery and activation periods, most patients can lead a normal and good quality life. Your doctor will discuss a treatment program with you, including:
There may be different treatment approaches that your doctor will tell you about. The mechanism of action of different drugs to be used and their places of action in the intestines are also different. You should follow all your doctor’s recommendations and not stop your treatment until the planned treatment is finished or your doctor tells you to. While 5-ASA preparations (Salofalk, Asacol, etc.) to be taken in sufficient doses are sufficient in ulcerative colitis cases with mild disease, corticosteroids should generally be used in cases with moderate and severe active disease. In resistant cases, stronger drugs (Azathiopurin, Infliximab, cyclosporine, etc.) that suppress the immune system may need to be used. These drugs should only be used under the supervision of a doctor and patients should be followed up at regular intervals due to possible side effects.
What should be the diet in IBD?
Since a part of the digestive system is sick in IBD, both the absorption of nutrients and their loss are increased. In addition, food consumption has decreased due to the fact that patients have the thought of fasting due to their diseases. In periods when the disease is severe enough to require hospitalization, although rare, it may be necessary to stop oral feeding for a while and the patient to be fed with intravenous fluids, but there is no special diet that patients with moderate or mildly active disease or in inactive disease should follow. It is recommended not to consume such foods as spicy and spicy foods, very fatty foods, acidic fruit juices to be taken in large quantities can increase the symptoms of the disease. There is no evidence that alcohol and cola drinks worsen the disease, they can be consumed in moderate amounts if they do not touch it. Since bacterial or viral food poisoning can activate the disease or its symptoms, patients with inflammatory bowel disease should pay particular attention to hygienic rules in food consumption. If milk and dairy products do not touch and do not cause complaints, it is okay to consume, on the contrary, it is recommended as an important source of protein and calcium.
The aim of the diet program for IBD is to provide appropriate nutrient intake and to provide calcium, iron, vitamins, protein, etc. is to prevent the development of deficiencies of substances. While evaluating your diet, your doctor also evaluates whether you are getting enough calories, vitamins and minerals. If your diet is not sufficient, your doctor may recommend the use of some additional nutritional formulations. It is recommended that patients with Crohn’s disease who have developed severe stenosis and signs of intestinal obstruction should not consume pulpy foods such as shell fruits, dried fruits and vegetables and should be fed with liquid foods. Consumption of such foods by patients with intestinal stenosis causes an increase in their complaints.
Patients with ulcerative colitis and Crohn’s disease, whose diarrhea improves after treatment and who, on the contrary, develop constipation and do not develop stenosis in their intestines, may be advised to eat a few dried apricots soaked in water or add 1-2 teaspoons of bran to their diet. In diarrheal periods, fluid intake should be increased.
Antirheumatic drugs, aspirin, antibiotics and oral iron preparations are recommended to be used within the knowledge of the doctor. Patients using corticosteroids should reduce their salt use.
When is surgical treatment needed?
Most people with IBD can lead a comfortable life with a treatment program that includes medication and a diet plan. 40% of patients with Crohn’s disease require surgical treatment in the first 10 years after the onset of the disease, and 80% in the first 20 years, and almost half of these surgical interventions are performed under emergency conditions. Surgical treatment may be necessary when the following conditions occur in IBD. Your doctor will decide to perform surgical treatment in the presence of certain conditions;
– Excessive bleeding
– Presence of long-term and severe disease
– Development of toxic megacolon (A severe form of ulcerative colitis) and perforation of the intestinal wall
– Inability to control the disease with drug therapy
– Severe stenosis or obstruction in the intestine
– Growth retardation in children and young people
There are many surgical treatment techniques . The advantages and disadvantages of each will be explained to you by your doctor and the surgeon who will perform your surgery, and the best method will be tried to be applied for you. Removal of the large intestine in ulcerative colitis means that the diseased organ will be completely removed. In Crohn’s disease, the parts of the intestines that participate in the disease are usually removed, and since there is always the possibility of new disease in the remaining intestine, a permanent recovery cannot be achieved.
INFLAMMATORY BOTTOM DISEASES AND PREGNANCY
Advances in treatment have enabled women with IBD to conceive and have an uneventful pregnancy. Women with inactive Crohn’s disease (CH) and ulcerative colitis (UC) have the same chance of conceiving (fertility) as the general population. UC does not affect fertility whether active or in remission. Primary and secondary amenorrhea (absence of menstruation) is more common in women with CD. Active CH can lead to pelvic scarring and loss of Fallopian tube function. CH can cause painful sexual intercourse (dyspareunia) by forming an abscess or fistula around the vagina. In addition, nutritional deficiency (malnutrition) that may occur in the course of active IBD may have a negative effect on fertility. Sulfasalazine and Mtx, used in the treatment of IBD in men. Drugs such as oligospermia and decrease in sperm motility (movement) may affect fertility. Putting inactive
IBD into remission before pregnancy and maintaining the remission state during pregnancy is the optimal treatment approach. There is no indication to start medical treatment before pregnancy in pregnant women who are in remission despite not using medication before pregnancy. In patients who were in remission with medical treatment before pregnancy, maintenance therapy should be continued at the lowest dose necessary to maintain remission during pregnancy. Before getting pregnant, the pregnant patient should be told that the disease should be in the inactive period (put into remission). Ideally, the patient should remain in remission for a period of 3-6 months before conception.
In 1/3 of pregnant women with UC whose disease is in remission (recovered) during conception (conception), the disease is activated during pregnancy or after delivery, and this activation rate is not different from that of non-pregnant women followed for the same period. Disease activation is slightly more common in the 1st trimester (first 3 months of pregnancy). Disease activity increases in 45% of pregnant women with UC who have active disease during conception, decreases in 25% and does not change in 30%. In 25% of pregnant women with CD who have an inactive disease at the time of conception, the disease is activated during pregnancy, and this rate is not different from women who are not pregnant and are followed for the same period. In 1/3 of pregnant women with active CD at conception, the disease goes into remission during pregnancy, becomes active in 1/3 and does not change in 1/3, and these rates are not different from non-pregnant women followed for the same period.
In other words, active disease continues during pregnancy in 66% of pregnant women with active CD during conception and in 75% of pregnant women with active UC. While 80% of Crohn’s patients with inactive disease at the time of conception can deliver without complications, this rate drops to 50% in those with active disease at the time of conception. It is recommended to maintain maintenance therapy during pregnancy and to apply intensive therapy during exacerbations in pregnant women with active disease before and during conception.
5-ASA treatment is generally well tolerated during pregnancy and there is no risk of fetal anomaly. Since the need for folate may increase during this treatment, additional folate should be given to pregnant women. 5-ASA treatment should be continued during pregnancy at the dose used before pregnancy. The drug has been shown to be safe even at doses of 3.2g and above per day. Ampicillin can be used safely when antibiotic use is required. Cephalosporins and metronidazole can only be used in the second and third trimesters (2nd and 3rd trimesters of pregnancy). Ciprofloxacin has been shown to cause cartilage anomalies in animal experiments and therefore it is not recommended to be used during pregnancy. Most authors agree that Azathiopurine is safe and effective during pregnancy. However, azathioprine is among the D group drugs in the FDA (Food and Drug Administration) classification, which means that the drug may cause fetal anomalies. It has been observed that the pregnancy continues in a healthy way in 80-90% of the pregnant women who received azathioprine treatment and underwent renal transplantation. It has been shown that the frequency of prematurity (premature birth), abortion (miscarriage), congenital anomalies, infections in infancy and neoplasia do not increase in azathioprine treatment. There is a retrospective study showing that the use of azothiopurine by the father with IBD before conception increases the risk of congenital anomaly. For this reason, men should be advised to discontinue azathioprine treatment at least 3 months before sexual intercourse for the purpose of conception.
Data on the use of other immunomodulatory drugs during pregnancy are limited. According to the findings in the transplantation literature, the use of cyclosporine in the first trimester should be avoided. Due to its frequent toxic side effects and interaction with other drugs, it should not be used during pregnancy unless necessary. It has been reported that it increases the risk of preterm birth and low birth weight, but does not have a teratogenic effect. It can be used as an alternative to surgical treatment in severe cases. Treatment with TNF-alpha blockers (Infliximab, Remicade) may be required during exacerbations of the disease. According to the results of studies performed on pregnant women who were treated with infliximab during pregnancy, no teratogenic effect related to this drug was reported and the drug is not excreted in milk. However, since the available data are not sufficient, it is recommended not to be used during pregnancy unless necessary and to discontinue the treatment 6 months before conception. The use of MTX and thalidomide during pregnancy is contraindicated. Especially when taken in the first 6-8 weeks of pregnancy, its teratogenic effect is evident. In patients on MTX therapy, it should be recommended to discontinue therapy at least 6 months before conception.
In patients considered for surgical treatment, this procedure should be performed, if possible, before conception (preferably at least 1 year before). Surgery should be considered in pregnant women with IBD only when complications such as toxic megacolon, bleeding, obstruction, and perforation occur. When such a complication develops, surgical intervention should not be postponed because the mortality (risk of death) is around 50%. The 2nd trimester (2nd trimester of pregnancy) is considered the most suitable time for surgical intervention. Surgical intervention in the third trimester (the third trimester of pregnancy) increases the risk of premature birth. Proctocolectomy (surgical removal of the large intestine) to be applied together with ileal pouch-anal anastomosis in a pregnant woman with ulcerative colitis does not affect the course of pregnancy and does not increase the risk of preterm birth, but it may affect pregnancy in the later period. In cases where total colectomy was performed due to severe colitis or toxic megacolon, fetal (infant) mortality is around 50% and in such cases iv. cyclosporine or preterm delivery seem to be more appropriate treatment modalities.
Pregnant women with ulcerative colitis with ileostomy and ileoanal pouch anastomosis generally tolerate pregnancy well. The risk of stomal prolapse and obstruction is slightly increased. Pregnancy does not cause much change in pouch and stoma functions. An increase in the number of defecations and incontinence may be seen. These patients can deliver vaginally if there is no obstetric contraindication.
Many pregnant women with IBD can have a normal vaginal delivery (normal delivery). Cesarean delivery is recommended in pregnant women with active perianal disease such as rectovaginal fistula or abscess. Previous colectomy, ileostomy or ileoanal anastomosis etc. due to IBD. The majority of patients who have undergone surgical intervention such as can have a normal vaginal delivery and this chance should be given to them. It has been reported that some patients may develop new perianal disease (anus and surrounding area) after vaginal delivery (15-20%). When an episiotomy is performed, care should be taken that the incision does not pass through the fissure or fistula line. Vaginal delivery should not be recommended in patients with disease-related rigid perineum.
The effect of breastfeeding on IBD activity is unknown. 5-ASA appears to be safe during breastfeeding. Opinions on azathiopurine have not been finalized yet, and many authors recommend that these drugs be used only when necessary. Medicines called metronidazole and ciprofloxacin should not be used during breastfeeding. MTX (Methotrexate) and cyclosporine should not be used in breastfeeding mothers.
Pregnant women with the disease do not have an increased risk for miscarriage (abortion), premature birth or congenital anomaly formation. However, the presence of active IBD increases the risk of developing undesirable events such as premature birth, miscarriage and low birth weight baby birth that may occur during pregnancy. The risk of abortion and preterm birth is 2-3 times higher in pregnant women with active disease compared to the general population. Obstruction (stenosis- stricture) occurs as a result of thickening of the intestinal wall due to edema and scar tissue. The intestinal lumen narrows until it is completely closed, eventually resulting in complete intestinal obstruction.
When you have symptoms similar to ulcerative colitis, your doctor will ask you for some blood and stool tests after listening to your medical history and performing a physical examination. Other tests that may be requested may be: Flexible sigmoidoscopy or colonoscopy and biopsy Barium enema ( enema opaque)
This test is an X-ray imaging of the colon. Barium, a radiopaque substance, is introduced into the colon by enema. : Endoscope examination of your large intestine. A small bendable tube is inserted through the anus to examine the lining of your large intestine. If necessary, a tissue sample is taken. (see Colonoscopy). With endoscopic examination, it is possible to have information about the degree of inflammation (mild, moderate, and severe) and the level of involvement in the large intestine, which will help your doctor decide what kind of drug to treat you with.
