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.
When inflammation is present for a long time (chronic), it sometimes can
cause scarring (fibrosis). Scar tissue is typically not as flexible as healthy
tissue. Therefore, when fibrosis occurs in the intestines, the scarring may
narrow the width of the passageway (lumen) of the involved segments of the
bowel. These constricted areas are called strictures. The strictures may be mild
or severe, depending on how much they block the contents of the bowel from
passing through the narrowed area.
Crohn's disease is characterized by inflammation that
tends to involve the deeper layers of the intestines. Strictures, therefore, are
more commonly found in Crohn's disease than in ulcerative colitis. What is more, strictures in
Crohn's disease may be
found anywhere in the gut. Remember that the intestinal inflammation in
ulcerative colitis is
confined to the inner lining (mucosa) of the colon. Accordingly, in chronic
ulcerative colitis,
benign (meaning not malignant) strictures of the colon occur only rarely. In
fact, a narrowed segment of the colon in ulcerative colitis may well be caused by a colon cancer
rather than by a benign (non-cancerous), chronic inflammatory stricture.
What are symptoms of intestinal strictures, and how are they diagnosed
and treated?
Symptoms of internal strictures in IBD
Indviduals may not know that they have an intestinal stricture. The stricture may
not cause symptoms if it is not causing significant blockage (obstruction) of
the bowel. If a stricture is narrow enough to hinder the smooth passage of the
bowel contents, however, it may cause abdominal pain, cramps, and bloating
(distention). If the stricture causes an even more complete obstruction of the
bowel, patients may experience more severe pain, nausea, vomiting, and an
inability to pass stools.
An intestinal obstruction that is caused by a
stricture can also lead to perforation of the bowel. The bowel must increase the
strength of its contractions to push the intestinal contents through a narrowing
in the bowel. The contracting segment of the intestine above the stricture,
therefore, may experience an increased pressure. This pressure sometimes weakens
the bowel wall in that area, thereby causing the intestines to become abnormally
wide (dilated). If the pressure becomes too high, the bowel wall may then
rupture (perforate). This perforation can result in a severe infection of the
abdominal cavity (peritonitis), abscesses (collections of infection and pus),
and fistulas (tubular passageways originating from the bowel wall and connecting
to other organs or the skin). Strictures of the small bowel also can lead to
bacterial overgrowth, which is yet another intestinal complication of IBD.
Internal strictures diagnosis in IBD
Intestinal strictures of the small intestine may be diagnosed with a small bowel
follow-through (SBFT) X-ray. For this study, the patient swallows barium, which
outlines the inner lining of the small intestine. Thus, the X-ray can show the
width of the passageway, or lumen, of the intestine. Upper GI endoscopy (EGD)
and enteroscopy are also used for locating strictures in the small intestine.
For suspected strictures in the colon, barium can be inserted into the colon
(barium enema), followed by an
X-ray to locate the strictures. Colonoscopy is
another diagnostic option.
Treatment of strictures in IBD
Intestinal strictures may be composed of a combination of scar tissue
(fibrosis) and tissue that is inflamed and, therefore, swollen. A logical and
sometimes effective treatment for these strictures, therefore, is medication to
decrease the inflammation. Some medications for IBD, such as infliximab,
however, may make some strictures worse. The reason is that these medications
may actually promote the formation of scar tissue during the healing process. If
the stricture is predominantly scar tissue and is only causing a mild narrowing,
symptoms may be controlled simply by changes in the diet. For example, the
patient should avoid high fiber foods, such as raw carrots, celery, beans,
seeds, nuts, fiber, bran, and dried fruit.
If the stricture is more severe and
can be reached and examined with an endoscope, it may be treated by stretching
(dilation) during the endoscopy. In this procedure, special instruments are used
through the endoscope to stretch open the stricture. Typically, however, this
procedure does not produce long lasting results.
Surgery sometimes is needed to
treat intestinal strictures. The operation may involve cutting out (resecting)
the entire narrowed segment of bowel, especially if it is a long stricture. More
recently, a more limited operation, called stricturoplasty, has been done. In
this procedure, the surgeon simply cuts open the strictured segment lengthwise
and then sews the tissue closed crosswise so as to enlarge the width of the
bowel's passageway (lumen). After surgery in Crohn's disease patients, medication still
should be taken to prevent inflammation from recurring, especially at the site
of the stricture. The reason for this recommendation is that after abdominal
operations, recurrent intestinal inflammation is a common problem in Crohn's
disease.
Furthermore, the risk of post-operative intestinal fistulas and abscesses is
increased in Crohn's disease patients. Therefore, only abdominal surgery that is absolutely
necessary should be done in patients with Crohn's disease.
Abdominal pain is pain in the belly and can be acute or chronic. Causes include inflammation, distention of an organ, and loss of the blood supply to an organ. Abdominal pain can reflect a major problem with one of the organs in the abdomen such as the appendix, gallbladder, large and small intestine, pancreas, liver, colon, duodenum, and spleen.
Rectal bleeding (hematochezia) refers to the passage of bright red blood from the anus. Rectal bleeding may be moderate to severe and most bleeding comes from the colon, rectum, or anus. Common causes include anal fissures, hemorrhoids, diverticulitis, and more.
One in every 20 people develop a kidney stone at some point in their life. A kidney stone is a hard mineral and crystalline material formed within the kidney or urinary tract. Kidney stones symptoms and signs are, blood in the urine and pain in the abdomen, flank (lower back), or groin. A number of different conditions can lead to kidney stones including: gout, hypercalciuria, people with inflammatory bowel disease, kidney disease, and hypoparathyroidism. Some medications also increase the risk of kidney stones.
Diarrhea is a change is the frequency and looseness of bowel movements. Cramping, abdominal pain, and the sensation of rectal urgency are all symptoms of diarrhea. Absorbents and anti-motility medications are used to treat diarrhea.
Pink eye, also called conjunctivitis, is redness or irritation of the conjunctivae, the membranes on the inner part of the eyelids and the membranes covering the whites of the eyes. These membranes react to a wide range of bacteria, viruses, allergy-provoking agents, irritants, and toxic agents.
Crohn's disease is a chronic inflammatory disease,
primarily involving the small and large intestine, but which can
affect other parts of the digestive system as well. Abdominal pain, diarrhea, vomiting, fever, and weight loss are
common symptoms.
Anemia is the condition of having less than the normal number of red blood cells or less than the normal quantity of hemoglobin in the blood. The oxygen-carrying capacity of the blood is, therefore, decreased.
Liver disease can be cause by a variety of things including infection (hepatitis), diseases such as gallstones, high cholesterol or triglycerides, blood flow obstruction to the liver, and toxins (medications and chemicals). Symptoms of liver disease depends upon the cause; however, common symptoms may include nausea, vomiting, upper right abdominal pain, and jaundice. Treatment depends upon the cause of the liver disease.
Colon cancer is a malignancy that arises from the inner lining of the colon. Most, if not all, of these cancers develop from colonic polyps. Removal of these precancerous polyps can prevent colon cancer.
Ulcerative colitis is a chronic inflammation of the colon. Symptoms include abdominal pain, diarrhea, and rectal bleeding. Ulcerative colitis is closely related to Crohn's disease, and together they are referred to as inflammatory bowel disease. Treatment depends upon the type of ulcerative colitis diagnosed.
Inflammation of the inner lining of the colon is referred to as colitis. Symptoms of the inflammation of the colon lining include diarrhea, pain, and blood in the stool. There are several causes of colitis including infection, ischemia of the colon, inflammatory bowel disease (Crohn's disease, Ulcerative colitis, or microscopic colitis). Treatment depends on the cause of the colitis.
Pernicious anemia is a blood disorder in which the body does not make enough red blood cells due to a lack of vitamin B12 in the blood. Pernicious anemia can develop from a lack of a protein that helps the body absorb vitamin B12, not getting enough B12 in the diet, and certain intestinal conditions that interfere with the absorption of vitamin B12 such as Crohn's disease, celiac sprue, or ulcerative colitis. There is no cure for pernicious anemia, thus treatment is life-long.
Corticosteroid drugs such as prednisone and prednisolone are commonly used to treat asthma, allergic reactions, RA, and IBD. Steroids such as these do have serious drawbacks such as steroid withdrawal symptoms such as: fatigue, weakness, decreased appetite, weight loss, nausea, vomiting, abdominal pain, and diarrhea. Speak with your healthcare provider prior to tapering off steroid medications.
Juvenile arthritis (juvenile rheumatoid arthritis or JRA) annually affects one child in every thousand. There are three types of JRA: pauciarticular (less than four joints affected), polyarticular (more than four joints affected), and systemic-onset (inflamed joints with high fevers and rash). Treatment of juvenile arthritis depends upon the type the child has and should focus on treating the symptoms that manifest.
Bronchiectasis is a condition in which the bronchial tubes of the lung become damaged. Inflammation from infection or other causes destroys the smooth muscles of the bronchial tubes. Bronchiectasis is a form of COPD (which includes emphysema and chronic bronchitis). There are three primary types of bronchiectasis: 1) cylindrical bronchiectasis; 2) saccular bronchiectasis; and 3) cystic bronchiectasis. Bronchiectasis may also be acquired or congenital. The most common symptoms of bronchiectasis are recurrent cough and sputum production. There is no cure for bronchiectasis. Treatment is often geared toward controlling the symptoms of bronchiectasis.
Brain lesions (lesions on the brain) are caused by trauma, inflammation, autoimmune diseases, cancers, other diseases, stroke, bleeding, pituitary adenomas, and cerebral palsy. Symptoms of brain lesions include headache, nausea, fever, neck pain and stiffness, affected vision and speech, weakness or paralysis to one side of the body. Diagnosis of brain lesions is generally with imaging studies like CT or MRI scans. Treatment and prognosis of brain lesions depends on the cause of the lesion.
Abdominal adhesions (scar tissue) bands of scar tissue that form between abdominal organs and tissues. Symptoms of abdominal adhesions are pelvic or abdominal pain. Abdominal adhesions on the intestines can cause bowel obstruction, which is a medical emergency. Treatment for abdominal adhesions is generally surgery to cut the adhesions away from the internal tissues and organs. There is no way to prevent abdominal adhesions.
Shigellosis is a disease caused by the Shigella bacteria. Bloody diarrhea, stomach cramps and fever are common symptoms. Mild infections usually resolve on their own. Antibiotics are used to treat more severe cases.
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