About Inflammatory Bowel Diseases
About Inflammatory Bowel DiseasesGastroenterology
About Inflammatory Bowel Diseases - managing and treating IBD
About Inflammatory Bowel Diseases - managing and treating IBDGastroenterology
- Control the symptoms of the flare-up as rapidly as possible
- Correct any disturbances to the body's nutritional, water, vitamin and mineral levels
- Prevent serious complications developing
- And finally, minimise risk of future flare-ups by choosing an effective maintenance therapy
About Inflammatory Bowel Diseases - summary of IBD
About Inflammatory Bowel Diseases - summary of IBDGastroenterology
About Inflammatory Bowel Diseases - links
About Inflammatory Bowel Diseases - linksGastroenterology
About Bleeding Oesophageal Varices
About Bleeding Oesophageal VaricesGastroenterology
About Bleeding Oesophageal Varices - managing and treating BOV
About Bleeding Oesophageal Varices - managing and treating BOVGastroenterology
About Bleeding Oesophageal Varices - links
About Bleeding Oesophageal Varices - linksGastroenterology
Gastroenterology is the study of the gastrointestinal (GI) or digestive system, including its problems and diseases. The digestive or GI tract (also known as the alimentary canal) is the main component of the digestive system and consists of an irregular 'tube' eight to nine metres long incorporating the mouth, oesophagus, stomach, duodenum, small bowel, large bowel, rectum and ending with the anus.
Inflammatory bowel diseases
Inflammatory bowel diseases (IBD) are a group of chronic conditions associated with many distressing and serious complications, but for all but the most severe cases, they are not generally considered fatal illnesses. IBD includes two main conditions, ulcerative colitis (UC) and Crohn's disease (CD).
Most patients with ulcerative colitis or Crohn's disease are diagnosed when they are relatively young, often after many months of symptoms such as stomach cramps, bloody diarrhoea etc. The diseases may influence their 'quality of life' and the manner in which they are able to live their lives.
Medical procedure preparation
Some endoscopy, surgery and radiological procedures require the patient's bowel to be cleaned in advance. Ferring offers a dual-action laxative medication that makes preparation for the procedure easier for the patient.
Bleeding oesophageal varices
There are many medical complications associated with cirrhosis of the liver, the hardening of the liver tissue that often follows long term excessive alcohol exposure or after infection of the liver e.g. through hepatitis.
For such a condition the development of oesophageal varices is one complication that can become a life-threatening, emergency situation if the varices rupture. The varices protrude from the inner surface of the oesophagus and often can without other, or previous, symptoms start to bleed.
Oesophageal varices can rupture suddenly and without warning necessitating hospitalisation and prompt action by the medical team.
What are inflammatory bowel diseases?
Ulcerative colitis (UC) and Crohn's disease (CD) are both relatively rare diseases. They are chronic disorders causing the formation of areas of inflammation and ulceration in various sections of the digestive tract. This inflammation causes persistent and frequent diarrhoea (often blood stained and passed with urgency), abdominal pain, fever, tiredness and loss of weight.
Inflammatory bowel diseases (IBD) are mainly seen in the industrialised parts of the world. They affect all races, though in some populations the incidence is lower. People who move from underdeveloped to developed parts of the world attain the same level of risk of developing IBD as the rest of the population after some time.
There is generally a higher incidence in northern latitudes compared with southern latitudes and in urban areas over rural.
Development of inflammatory bowel diseases
Ulcerative colitis and Crohn's disease affect all age groups and can start at any age, but the highest number of new cases occurs in young people.
The course of UC and CD varies unpredictably in severity and usually cycles between periods of active inflammation (flare-ups) and periods of low activity or even remission when the patient feels well and is free from symptoms.
In their early stages UC and CD may be difficult to diagnose. Their symptoms resemble that of each other and other conditions, such as infectious gastroenteritis and irritable bowel syndrome. It may sometimes take years before a correct diagnosis is made and a treatment used which is compatible with the patients and their way of life.
Causes of inflammatory bowel diseases
Much work is being undertaken worldwide into the possible causes of IBD, but despite many theories the cause and the exact changes occurring in the body remain poorly understood.
There seems to be a genetic and environmental impact behind IBD, causing an imbalance in the inflammatory processes of the gut. It is thought that viruses, bacteria, a highly refined diet, stress and smoking may contribute.
The inflammation in ulcerative colitis exclusively affects the superficial layer (the mucosa) of the large intestine. It almost always involves the rectum and spreads in a continuous manner from there. In a small percentage of patients, the whole of the large bowel is involved. The most common age group for UC to be diagnosed is within the 15 to 35 year-olds, with a second peak being seen in 55 to 70 year-olds. Up to 400 people per 100,000 inhabitants suffer from ulcerative colitis worldwide.
Unlike ulcerative colitis, Crohn's disease can affect any part of the GI tract, although it mainly presents itself in the small bowel. In Crohn's, the disease most commonly affects just the small intestine (40%), though it can often affect both the small and large intestine (colon) (30%) and in other cases just the colon (30%).
Crohn's disease affects up to 150 people per 100,000 inhabitants, and is most commonly diagnosed in the 15 to 25 year-old age groups. Recent statistics appear to indicate a rise in the number of new cases, but it is not clear why this may be.
About 15 to 20 per cent of people with Crohn's Disease have a close relative with some form of IBD, suggesting any genetic predisposition in these patients.
Complications of inflammatory bowel diseases
In cases where diarrhoea is very frequent, or bloody and severe, water loss and poor absorption of nutrients may occur, leading to anaemia, dehydration and severe weight loss.
The inflammation in Crohn's disease may lead to strictures (narrowing) of the bowel which helps create abdominal pain. Severe cases may lead to life-threatening complications such as blockage or perforation of the bowel, and there has been a definite link between patients with colitis having an increased risk of developing colorectal cancer.
The risk of colorectal cancer increases with the extent and severity of the disease, the age it started and how long the patient has had the disease. For patients suffering from ulcerative colitis, recent trials have shown the risk of colorectal cancer at 10, 20 and 30 years after the diagnosis of the onset of their disease as being 2, 8 and 18 per cent higher (respectively) than the incidence seen in the general population.
Managing and treating inflammatory bowel diseases
Most people diagnosed with either ulcerative colitis or Crohn's disease receive a range of medications designed to control or reduce the inflammation and symptoms, and suppress the body's immune response.
When inflammatory bowel disease (IBD) is active, the doctor's main aim is to:
Maintenance therapy for long term control of IBD
Long term control of inflammatory bowel diseases requires regular medication, known as maintenance therapy, to keep flare-ups at bay and reduce the risk of more serious complications developing.
The aminosalicylate group of medications, such as Ferring's PENTASA® (mesalazine), is commonly prescribed as maintenance therapy for IBD patients.
Clinical evidence has shown that without mesalazine maintenance therapy up to 80 per cent of mild/moderate active Ulcerative Colitis patients relapse within a year giving way to further flare-up and symptoms. But the research has also shown that if patients take their maintenance therapy correctly, many of these relapses could be prevented.
More severe inflammation may need a number of different therapies to achieve long-term control. Usually the medication initially required to control the patient's flare-up should be continued as part of maintenance therapy.
Prevention of serious long-term complications
Individuals feeling quite well and free of symptoms between flare-ups may be less careful about complying with their doctors' recommendations for taking maintenance medication and attending the gastroenterology clinic for check-ups.
New findings suggest that long-term health benefits and reduction in the risk of developing cancer of the colon and/or rectum can be achieved if patients continue to take their medication as recommended by the doctor.
Diet in controlling IBD
The long-term management of inflammatory bowel diseases to reduce relapses also needs to address the role of stress and diet. Stress reduction (which may be difficult) and an adequate diet containing fibre (except in case of strictures) with vitamin and mineral supplements, is usually recommended by doctors.
A well-balanced, high carbohydrate, high protein diet minimises the possibility of nutritional deficiency due to chronic diarrhoea. Crohn's disease appears to respond well to special diets and some patients respond to milk- or wheat-free diets (lactose and gluten-free).
Summary of Inflammatory Bowel Diseases
Characteristics of inflammatory bowel diseases:
|Ulcerative colitis||Crohn's disease|
|Typical age range at diagnosis||Primary 15 to 35 years|
Secondary 55 to 70 years
|Primary 15 to 25 years Secondary over 70 years|
|Prevalence||Up to 400 in 100,000||Up to 150 in 100,000 (rising in some areas)|
|Disease location||Involves only rectum and colon. In case of progression the inflammation spreads upwards from the rectum in a continuous way.||Can involve any part of the gastro-intestinal tract, from the mouth to the anus - most commonly distal part of the small bowel and the beginning of the large bowel (colon). The inflammation of the gut are spread irregularly with normal gut appearance in many areas (so called skip lesions)|
|Acute symptoms||Bloody diarrhoea Fever Abdominal pain and discomfort||Abdominal pain and discomfort Bloody diarrhoea Sore tongue and lips|
|Chronic symptoms||Diarrhoea Abdominal pain Weight loss Weakness Anaemia||Diarrhoea Abdominal pain Weight loss Loss of appetite Lethargy and malaise Anaemia|
|Chronic complications||Reduced weight Tiredness Cancer of the colon and/or rectum||Fibroses/stenosis of the gut Reduced weight Tiredness|
|Genetic connection||Link between family members||15 to 20 per cent have blood relatives with some form of IBD|
|Symptoms not involving the gut (extraintestinal symptoms)||Joint pain, eye & skin problems||Joint pain, gall stone & renal stone formation|
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About Bleeding Oesophageal Varices
Oesophageal varices protrude from the inner surface of the oesophagus and are usually the result of chronic liver disease. The position of the varices on the surface of the distal part of the oesophagus, or at its junction with the stomach, means that they are unsupported by other tissues and are at risk of rupturing when the blood pressure in the varices exceeds a certain level.
Varices can be detected by endoscopy but are often only diagnosed when they start to bleed. The amount of bleeding can range from a gentle oozing of blood to haemorrhaging that is difficult to control and can be life-threatening.
Causes of oesophageal varices
Oesophageal varices generally form as the direct result of damage to the liver, which leads to an increase in blood pressure in the 'portal vein', which carries the main supply of blood from the bowel and spleen to the liver on its way back to the heart.
The rise in blood pressure in the portal vein is generally due to scarring and hardening of the liver tissue by cirrhosis, making it more difficult for the blood to flow through. This increased resistance causes the blood to find alternative routes to reach the heart, and new blood vessels open up to bypass the blockage.
These new routes involve veins that are not designed to carry this amount of blood. They are not very robust or elastic and become increasingly fragile as they continually enlarge and their walls become thinner in a bid to cope with the extra blood.
The original cause of restricted blood flow is not always obvious. Liver damage can be the result of a number of different factors including chronic alcohol abuse, infections, toxins, congestive heart failure and autoimmune disease.
In the West, alcohol is the most common cause of liver damage, though worldwide viral hepatitis and larval forms of parasitic schistosome worms, particularly common in the Middle East and South America, are responsible for 200 million cases.
Urgent need to treat bleeding oesophageal varices
Bleeding oesophageal varices (BOV) require urgent medical attention to prevent serious blood loss and complications. Not everyone with liver damage develops varices and not everyone with varices will bleed. In general, small varices rarely bleed, bigger ones may bleed, but over time, small ones generally develop into bigger ones.
Approximately 90 per cent of patients with cirrhosis of the liver will develop gastro-oesophageal varices over a period of about 10 years. In the West, oesophageal varices account for 5-10 per cent of all medical admissions with gastrointestinal bleeding.
Risk of death from bleeding oesophageal varices
The risk of death for those whose varices bleed for the first time has previously been put between 30 and 50 per cent. With recent therapies this risk has decreased to approximately 20 per cent. In some areas, the number of patients surviving one year after a bleed may be as low as 30-35 per cent, though this depends upon any associated liver damage as well as other complicating diseases.
Following an initial episode of BOV, the risk of it happening again is 60 to 80 per cent over a two year period with an approximate death rate of 20 per cent at each bleeding episode.
Managing and treating bleeding oesophageal varices
Emergency treatment of bleeding oesophageal varices
Bleeding should always be treated as an emergency and it is vital that blood pressure in the portal vein is reduced as quickly as possible to reduce the bleeding and minimise the risk of liver and kidney failure. The faster the treatment is started, the greater its chance of success.
Several drugs have been tried in the treatment of bleeding varices. Vasoactive drugs, such as Ferring's GLYPRESSIN® (terlipressin), decrease the blood pressure in the portal vein. It is consequently for many physicians a treatment of choice for this life-threatening condition.
GLYPRESSIN works by causing a vasoconstriction, or narrowing, of the blood vessels within the body's internal organs. This reduces the amount of blood reaching the portal vein relieving the pressure on the bleeding varices.
Medical support of bleeding oesophageal varices
A variety of supportive methods are also used, including transfusions of whole blood and plasma proteins (albumin) to replace lost fluid, maintaining blood volume and pressure to ensure that the kidneys and liver carry on working.
It is sometimes necessary to use additional techniques to help control serious bleeding. One technique, which is rarely used today, involves the insertion of a 'balloon' device into the stomach and oesophagus via a tube and commonly a Sengstaken-Blakemore tube), which when inflated, applies pressure to the bleeding varices reducing the blood loss.
Occasionally, a surgical procedure called TIPS (transjugular intrahepatic portal-systemic stent shunt) is required. This is a minimally invasive technique that involves the insertion of a metal tube known as a stent into the liver, bypassing some of the blood flow from the liver to another venous system (the cava system).
This procedure relieves excess blood pressure in the liver and restores blood flow. This is analogous to the technique used in the narrowed arteries of the heart affected by coronary heart disease.
TIPS is effective in relieving the excess blood pressure in the portal vein but it takes many hours to perform and carries its own risk of complications. In extreme cases of liver cirrhosis, liver transplantation may be the only effective treatment.
Prevention of oesophageal bleeding
For those with varices at risk of bleeding, regular drug treatment can sometimes reduce the risk and the severity should it occur. Preventative treatment usually consists of taking regular beta-blocker medication that helps to reduce the increased pressure in the portal vein and thus the pressure in the varices.