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
What are fissures and how are they treated?
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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.)
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.
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