Inflammatory Bowel Disease: Intestinal Problems (cont.)
What are fissures and how are they treated?
Fissures are tears in the lining of the anus. They may be superficial or
deep. Fissures are especially common in Crohn's disease. They differ from fistulas in that
fissures are confined to the anus and do not connect to other parts of the
bowel, other internal organs, or the skin. Still, fissures can cause mild to
severe rectal pain and bleeding, especially with bowel movements. The most
common treatment for anal fissures is periodic sitz baths or topical creams that
relax the muscle (sphincter) around the anus. Injections of tiny amounts of
botulinum toxin into the muscles around the anus have been reported to be
helpful in relaxing the sphincter, thereby allowing the fissures to heal. The
benefit of this type of therapy, however, is still controversial. Sometimes,
surgery is needed to relieve the persistent pain or bleeding of an anal fissure.
For example, the surgeon may cut out (excise) the fissure. Alternatively, the
muscle around the anus can be cut (sphincterotomy) to relax the sphincter so
that the fissure can heal. However, as is the cases with any surgery in patients
with Crohn's disease, post-operative intestinal complications can occur frequently.
What is small intestinal bacterial overgrowth (SIBO)?
Small intestinal bacterial overgrowth (SIBO) can occur as a complication of
Crohn's disease but not of ulcerative colitis since the small intestine is not involved in
ulcerative colitis. SIBO can
result when a partially obstructing small bowel stricture is present or when the
natural barrier between the large and small intestines (ileocecal valve) has
been surgically removed in Crohn's disease. Normally, the small bowel contains only few
bacteria, while the colon has a tremendous number of resident bacteria. If a
stricture is present or the ileocecal valve has been removed, bacteria from the
colon gain access to the small bowel and multiply there. With SIBO, the bacteria
in the small bowel begin to break down (digest) food higher up than normal in
the GI tract. This digestion produces gas and other products that cause
abdominal pain, bloating, and diarrhea. In addition, the bacteria chemically
alter the bile salts in the intestine. This alteration impairs the ability of
the bile salts to transport fat. The resulting malabsorption of fat is another
cause of diarrhea in Crohn's disease. (As previously mentioned, inflammation of the
intestinal lining is the most common cause of diarrhea in patients with IBD.)
How is SIBO diagnosed and treated?
SIBO can be diagnosed with a hydrogen breath test (HBT). In this test, the
patient swallows a specified amount of glucose or another sugar called lactulose.
If bacteria have reproduced in the small bowel, the glucose or lactulose is
metabolized by these bacteria, which causes the release of hydrogen in the
breath. The amount of hydrogen in the breath is measured at specific time
intervals after the ingestion of the sugar. In a patient with SIBO, the hydrogen
is eliminated into the breath sooner than the hydrogen that is produced by the
normal bacteria in the colon. Accordingly, the detection of large amounts of
hydrogen at an early interval in the testing indicates the possibility of SIBO.
Another test, which may be more specific, uses a sugar called xylose. In this
test, the swallowed xylose is tagged with a very small amount of radioactive
carbon 14 (C14). The C14 is measured in the breath and interpreted by applying
the same principles as used for hydrogen in the HBT.
The best treatment for
bacterial overgrowth is antibiotics for approximately 10 days using, for
example, neomycin, metronidazole, or ciprofloxacin. After this treatment, the
breath test may be repeated to confirm that the bacterial overgrowth has been
eliminated. SIBO may recur, however, if the stricture itself is not treated, or
if the bacterial overgrowth is due to the surgical removal of the ileocecal
valve.
Next: Does colon cancer occur in IBD? »
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