Inflammatory Bowel Disease: Intestinal Problems (cont.)
Lori Kam, MD
Leslie J. Schoenfield, MD, PhD
Leslie J. Schoenfield, MD, PhD
Dr. Schoenfield served as associate professor of medicine and consultant in gastroenterology on the faculty of the Mayo Clinic for seven years. He became a professor of medicine in residence at UCLA from 1972 to 1999 (now emeritus). He was the director of gastroenterology at Cedars-Sinai Medical Center in Los Angeles for 25 years, where he received the chief resident's teaching award, the president's award, and the pioneer of medicine award.
In this Article
Do intestinal ulcers occur in IBD?
When the inflammation in the inner lining of the intestine becomes severe, it can break through the inner lining to form ulcers. The ulcers associated with ulcerative colitis are located in the colon, whereas ulcers in Crohn's disease may be found anywhere in the gut from the mouth (aphthous ulcers) to the anus. Ulcerative colitis ulcers are typically shallow and more numerous, while Crohn's disease ulcers are usually deeper and with more distinct borders.
What are the symptoms of intestinal ulcers?
The symptoms caused by intestinal ulcers are predominantly abdominal pain, cramps, and bleeding. Sometimes, however, ulcers may be present in IBD but are not associated with any symptoms (asymptomatic).
In Crohn's disease, the inflammation and accompanying ulcers occur most commonly in the ileum, jejunum, and colon, but can occasionally occur in the duodenum. Note, however, that these ulcers are entirely different from the far more common acid-related peptic ulcers in the duodenum.
How are ulcers in IBD diagnosed and treated?
Ulcers in IBD diagnosis
Intestinal ulcers can be diagnosed by directly viewing the lining of the intestines. Various procedures, utilizing viewing instruments called endoscopes, are available. Endoscopes are flexible, thin, tubular instruments that are inserted into the gastrointestinal (GI) tract through either the mouth or rectum, depending on the procedure. Which procedure is done depends on the part of the GI tract that is being examined. Endoscopy can be done for either the upper or lower GI tracts. The endoscope is inserted through the mouth for upper endoscopy or through the rectum for lower endoscopy. The colon is examined either by sigmoidoscopy (using sigmoidoscopes) for the lower (sigmoid) part of the colon or by colonoscopy (using a colonoscope) for the entire colon.
The upper GI tract is examined by a procedure called esophago-gastro-duodenoscopy (EGD). An upper GI endoscope is used for this procedure. EGD is useful in detecting Crohn's disease ulcers in the esophagus, stomach, and the duodenum.
Crohn's disease ulcers in the small intestine may be seen by a procedure called enteroscopy, in which a special endoscope (called an enteroscope) is used. But enteroscopies need special equipments and are not widely available. Ulcers in the small intestine, however, are more often diagnosed with an X-ray study called a "small bowel follow-through" (SBFT). In this test, the patient swallows a few cups of barium, which coats the lining of the small intestine. On the X-ray, the barium may show the presence of ulcers. However, SBFT may not be accurate, and may not detect small ulcers in the small bowel. In patients suspected of having small bowel Crohn's disease ulcers and yet have normal SBFT studies, CT (computerized tomography) of the small bowel and capsule enteroscopy may be helpful in diagnosis.
Capsule enteroscopy is a procedure where a patient swallows a small camera the size of a pill. The pill camera takes multiple images of the inside of the small bowel and transmits these images wirelessly onto a recorder worn around the patient's waist. The recorded images are later reviewd by a doctor. Both CT of the small bowel and capsule enteroscopy in some studies have been found to be more accurate than the traditional SBFT in diagnosing Crohn's disease of the small bowel.
Ulcers in IBD treatment
The treatment of ulcers in IBD is aimed at decreasing the underlying inflammation with various medications. These medications include mesalamine (Asacol, Pentasa, or Rowasa), corticosteroids, antibiotics, or immunosuppressives such as 6-MP (6-mercaptopurine, Purinethol) or azathioprine (Imuran). In some cases, ulcers can be very resistant to these treatments and the use of stronger drugs may be required. These drugs include an immunosuppressive medication, cyclosporine (Neoral or Sandimmune), or the new drug, infliximab (Remicade), which is an antibody to one of the body's inflammation-inducing chemicals called tumor necrosis factor (TNFa). Occasionally, medical therapy fails to heal IBD ulcers and surgical treatment is needed.
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