Inflammatory Bowel Disease

Inflammatory
Bowel Disease

Dousing the Fire in the Belly

The pain shoots across your belly, prodding you into action even before you've opened your eyes.

You lurch out of bed, steady yourself on the nightstand and stumble toward the bathroom. You know there's not much time, because seconds after the pain begins, your body is going to turn itself inside out with the morning's bout of diarrhea.

The only thing that alters each morning's routine is how long it lasts. If the diarrhea stops within two hours, you can get to the office. If it lasts longer, your limp body won't be able to do anything but crawl back into bed.

Living with inflammatory bowel disease (IBD) is tough, says Jacqueline L. Wolf, M.D., assistant professor of medicine at Harvard Medical School and co-director of the Inflammatory Bowel Disease Center at Brigham and Women's Hospital in Boston. It affects more than one million men and women across the country about equally, and although 10 to 25 percent of cases may have a genetic link, no one really knows what causes it.

The Two Faces of IBD

Dr. Wolf's theory is that IBD is caused by a three-step process. First a genetic predisposition somehow sets the stage. Then a virus or bacterium in the intestine penetrates the intestinal wall. Finally, the immune system goes on the attack, trying to rout the invader--and ends up decimating the intestine instead.

There are two types of inflammatory bowel disease, identified by where the inflammation occurs and how deeply it penetrates the intestinal wall.

When the inflammation starts along the lining of the rectum, moves upward into the large intestine, starts in pretty much the same place every time and sticks largely to the gut's surface, it's called ulcerative colitis.

This condition pops up out of nowhere, usually between the ages of 15 and 35. Sometimes a flare-up will scorch the surface of the intestine and cause seemingly endless bouts of nausea, diarrhea and pain. Surgically removing the affected area will usually eliminate the disease.

When the inflammation moves around the gut, involving the intestinal wall anywhere from the mouth to the anus, it's called Crohn's disease.

Crohn's can trigger waves of pain and diarrhea, sometimes with bleeding and, on rare occasions, nausea and vomiting. And sometimes the disease takes off on its own and sets fire to adjoining tissue. It can actually pass through the intestinal wall to other organs, triggering infection and leaving scar tissue that can lead to intestinal obstruction, fecal incontinence, infertility and perhaps even cancer. Surgery is not very helpful with Crohn's disease, because the problem will simply move to another section of the bowel.

Preventing Flare-Ups

Since inflammation is the common problem in both diseases, the strategies doctors have devised to prevent flare-ups are similar, says Dr. Wolf: a variety of drugs to smother or suppress inflammation and a healthy regimen of diet, exercise and stress control aimed at keeping the gut cool and calm. Here's how you can do it.

Eat well. "People feel better if they follow a good, healthy diet," says Dr. Wolf. Although the tendency may be to eat as little as possible, a well-rounded diet of fresh fruit, steamed fish and vegetables, lean meats and lots of carbohydrates--pasta, potatoes, breads and cereals--can all help prevent the malnutrition and weight loss that can potentially undermine the health of someone with IBD.

Watch for dietary land mines. You should also monitor how various foods affect your gut, says Dr. Wolf. "Some people have a specific food that causes them to flare. Other people can eat the same food and it causes no problem." For example, some patients find that they cannot eat red meat. Unfortunately, no specific diet has been found that will get the inflammation under control.

Use fiber cautiously. Check with your doctor about the amount of fiber you eat if you have Crohn's disease, cautions Dr. Wolf. Women with Crohn's disease frequently develop a narrowing somewhere along the intestine, and too much fiber--particularly in a bowel where walls are swollen--can cause obstructions.

Manage stress. You should also avoid stress where you can, says Dr. Wolf, since "there are reports that when people are under stress, the disease flares."

The best way to keep stress under wraps? Maintain a positive attitude, exercise every day and join a support group, says Dr. Wolf. There are support groups to help families cope with the stress caused by IBD.

Douse the fire. In ulcerative colitis, daily use of the prescription drugs sulfasalazine (Azulfidine) and 5-aminosalicylic acid components (Asacol) have been shown to prevent flare-ups, says Dr. Wolf--"not 100 percent, but they're pretty good." In Crohn's disease, daily use of Asacol can prevent a relapse.

If you take sulfasalazine, you should also take a daily one-milligram supplement of folic acid, a B vitamin, says Dr. Wolf. It will compensate for the way sulfasalazine upsets your body's ability to absorb the essential nutrient, and it may also help prevent colon cancer--a disease for which women with IBD are at increased risk.

Reconsider birth control pills. There is some question as to whether oral contraceptives trigger Crohn's disease in genetically susceptible women, scientists say. In a study of 303 women with IBD, for example, researchers from the University of North Carolina at Chapel Hill found that women who used oral contraceptives had a 50 percent greater risk of developing Crohn's disease than other women.

Overcoming Sexual Difficulties

Many women with IBD take their worries to bed with them, where their sex life may be affected by fear of soiling the sheets and pain during intercourse.

In a study of 50 women with Crohn's disease at Leicester General Hospital and the University Hospital of Wales in Cardiff, researchers found that even though 45 of these women were in stable, ongoing relationships, more than a quarter were abstaining from sex. Of those who did have sex, 60 percent reported it was painful and 22 percent reported difficulty conceiving.

Luckily, there are several things you can do to prevent these problems.

Move your bowels. "If there's stool in the rectum when you're going to have intercourse, have a bowel movement ahead of time," says Dr. Wolf. Then you won't have to worry about fecal material leaking out at the wrong moment.

Check for structural problems. Painful intercourse may be caused by pelvic nerves that are irritated when your partner pushes on the posterior wall of the vagina, says Dr. Wolf. Or it may be caused by a fissure or fistula--a hollow tube forged between two organs by the inflammatory process. If either a fissure or fistula opens into a vagina that's being stretched during intercourse, the result can be painful intercourse.

In any case, the best way to tackle the problem of painful intercourse is to first visit your doctor, says Dr. Wolf. If there's a fissure or fistula, she can correct it.

Smooth the way. Use lubrication before intercourse, make sure you have enough foreplay and suggest that your partner enter slowly and/or not go in quite all the way, says Dr. Wolf.

Preventing Problems in Pregnancy

Most women with IBD will not have any more difficulty getting pregnant than other women--as long as inflammation has not spread from the bowel to the ovaries and left scars that block the fallopian tubes.

What can be a problem, however, is the potential father's sperm if he has IBD and is being treated with sulfasalazine, says Dr. Wolf. The drug will reduce the number of sperm, slow them down and twist them into odd shapes that will have difficulty penetrating an egg. Within three months of stopping the drug, however, the sperm will resume their usual form.

"A lot of doctors tell women with IBD they shouldn't get pregnant," says Dr. Wolf. But a woman with IBD can carry a baby to term without exacerbating the disease or harming her baby.

Studies indicate that results of pregnancies among women with IBD are similar to those of women who do not have it. Among pregnant women with ulcerative colitis, 76 to 97 percent produce healthy babies, 1 to 13 percent miscarry, and up to 3 percent experience stillbirths or give birth to babies with congenital abnormalities.

Among pregnant women with Crohn's disease, studies show that 70 to 93 percent give birth to healthy babies, 1 to 4 percent miscarry, and up to 1 percent have stillbirths or give birth to babies with congenital abnormalities.

Here's how you can better the odds of a successful pregnancy.

Schedule the pregnancy. Get pregnant while IBD is in remission rather than during a flare-up, says Dr. Wolf. This is because when a woman is very ill--with IBD or any disease--the baby won't grow as well.

Stay on medication. You can continue taking the drugs prescribed by your doctor to suppress the inflammation, Dr. Wolf says--they're safe during pregnancy. You should, however, discuss your IBD history with your obstetrician and get her okay to continue your medication.

Avoid drugs that suppress immunity. Experimental studies indicate that prescription drugs that inhibit your immune system in order to prevent gut inflammation can cause low fetal birthweights and double the number of birth defects. Two such drugs are azathioprine (Imuran) and 6-mercaptopurine (Purinethal).

Some scientists are so uncomfortable with 6-mercaptopurine's potential for birth defects that they recommend discontinuing the drug three months prior to conception--no matter which partner is taking it.

Similar drugs that should be avoided during pregnancy are ciprofloxacin (Cipro) and metronidazole (Flagyl), says Dr. Wolf.

If you are pregnant, go over all your medications with your obstetrician and don't take anything without her blessing.