Inflammatory Bowel Disease
What is Inflammatory Bowel Disease?
Inflammatory Bowel Disease (IBD) is a group of disorders that present with chronic inflammation of part, or all of the lining the gastrointestinal tract. IBD is generally sub-divided into two conditions
- Ulcerative colitis is an inflammatory bowel disease that presents with ulcers, typically found in the large intestine (colon) and rectum.
- Crohn’s disease is an inflammatory bowel disease that can occur throughout the digestive tract.
Collagenous and lymphocytic colitis are also considered inflammatory bowel diseases but are typically described as separate entities.
Causes and Symptoms
The exact cause of Inflammatory Bowel Disease (IBD) is not known, but experts believe that there may be many factors, including autoimmune reaction, genetics, bacteria, and environmental factors, or a combination of these factors.
Risk factors for IBD include:
- Age: The disease can occur at any age but is most likely to develop in people 20-29
- Genetics: Risk increases if a sibling or parent has IBD
- Smoking: Tobacco smokers are twice as likely to develop IBD as nonsmokers
- Ethnicity: IBD can affect any ethnic group but Caucasian and people of Eastern European Jewish descent tend to have the highest risk
- NSAIDs: Use of nonsteroidal anti-inflammatory medications (NSAIDs), such as ibuprofen, naproxen sodium, diclofenac sodium and others will not cause IBD, but they can lead to and exacerbate inflammation of the bowel.
Symptoms of IBD vary but some of the most common include:
- Persistent Diarrhea
- Blood in stool
- Urgent need for a bowel movement
- Abdominal pain and cramping
- Sensation of incomplete evacuation
- Mouth sores
- Loss of appetite and weight loss
- Night sweats
- Irregular menstrual cycle
There are a number procedures that can be used to diagnose Inflammatory Bowel Disease (IBD), starting with family history. Once a family history is recorded the physician may use the following diagnostic tools or procedures.
- Physical exam: The physician will check for abdominal distension, or swelling, listen to sounds within the abdomen through a stethoscope, check for tenderness and pain and establish if the liver or spleen is abnormal or enlarged.
- Lab tests: Blood tests will show changes in white and red blood cell counts. Stool samples may also be analyzed.
- Upper GI Series: Barium is swallowed and an x-ray and/or fluoroscope can be used to diagnose problems with organs in the gastrointestinal tract.
- CT Scan: Computer imaging can diagnose IBD and identify any complications of the disease.
- Endoscopy: Endoscopy uses a small, flexible tube with a light and camera on the end, which directly visualizes the lining of the upper GI tract. It is the most accurate method to diagnose IBD and the best way to rule out other possible conditions, such as ulcerative colitis, diverticular disease, or cancer. Biopsies may be gathered during the procedure.
- Colonoscopy: This procedure uses a long, flexible, narrow tube with a light and camera on one end to explore the entire colon. It shows inflamed and swollen tissue, ulcers, and abnormal growths such as polyps. If IBD is suspected, biopsies can be taken during the procedure.
Established Crohn’s disease is not often cured but is instead characterized by intermittent flare ups and remissions. With careful management and medical therapy or, in serious cases, surgical therapy, most people with Inflammatory Bowel Disease IBD adapt and live normal lives. While the disease can lead to GI cancer, including cancer of the colon and small bowel, disease-related mortality is low.
While living with Inflammatory Bowel Disease can be challenging, adjustments to diet and lifestyle may help control symptoms and lengthen the time between flare-ups. Recommended changes include:
While persons suffering from IBD report strong associations between diet and their disease, studies where dietary alterations are used have mixed results.
The most popular dietary changes are the following:
- Specific Carbohydrate Diet
- FODMAP (fermentable oligosaccharides, disaccharides, and monosaccharides) diet
- Paleolithic diet (Paleo)
- Vegetarian Diet
The symptoms of IBD (diarrhea, weight loss, abdominal pain) lend themselves to the suggestion that dietary pattern may be root cause. And, indeed, there is a strong association of IBD and Western diets.
While the FODMAP diet, Specific Carbohydrate Diet, and Paleo diet are lacking quality clinical studies, they share a common framework suggesting carbohydrate consumption leading to bacterial overgrowth (or dysbiosis) as a possible causative factor. The FODMAP diet is the best studied of these diets, but even it has contradictory results., This approach is complicated by other research suggesting high protein diets are associated with increased symptoms, and vegetarian/semi-vegetarian diets (which include an abundance of carbohydrates) have also shown some improvement. 
- Dairy products: any find that limiting or eliminating dairy products improves symptoms of IBD including diarrhea, abdominal pain and gas
- Fatty foods: it may be difficult to digest or absorb fat normally and fat may pass through the intestine causing diarrhea
- Fiber: foods high-fiber foods, especially fresh fruits and raw vegetables and whole grains, may help as well as exacerbate symptoms. Steaming, baking, or stewing vegetables may help.
- Other: Spicy foods, alcohol, and caffeine
Keeping a food diary can help track which foods or drinks aggravate symptoms and instigate flare-ups. Eating smaller meals throughout the day instead of two or three larger ones can keep energy levels high while reducing digestion problems. It’s also important to drink plenty of water during the day to aid with digestion.
Certain lifestyle changes seem to help:
- Stop Smoking: Smoking increases the risk of developing IBD. Quitting smoking can improve the overall health of the digestive system.
- Reduce Stress: While stress isn’t a cause of IBD, it can increase symptoms and may trigger flare-ups. Managing stress by learning relaxation techniques like meditation or breathing exercises can help keep the digestive tract relaxed and functioning efficiently.
- Exercise: Because regular exercise helps reduce stress, relieve depression, and normalize bowel function, it’s highly recommended for those with IBD. Exercise has been shown to be protective against IBD. 
- Weight loss: long thought to be inert, fat cells (adipocytes) are now known to secrete chemical mediators (known as adipokines) that have impacts the rest of the body. The adipokines are known to increase inflammation, which may be a factor in the development of IBD. , Muscles, it appears, secrete chemical mediators (known as myokines), which are postulated to reduce inflammation in the body.
Pre-clinical trials of Aloe report that it produces a dose-dependent reduction of reactive oxygen metabolites, prostaglandins (E2), and interleukins (IL-8), but no effect on thromboxane. In a clinical study of 44 patients with colitis, half were given 100 mL aloe for 28 days, the others were given placebo. The study reported clinical remission in 30 % of those in the aloe group, along with another 37% showing some improvement. Significant histological improvements were also reported in the aloe group.
Preclinical studies have investigated the use of Boswellia in experimental models of ulcerative colitis and have shown reductions in lipid peroxidation, nitric oxide, and improvement to tissue injury. A small clinical trial where Boswellia (N = 44) was tested against standard treatment (N = 39), showed Boswellia to be equally as effectiveness as mesalamine.  Another clinical study comparing Boswellia against placebo showed no improvement.
Plant fiber (Plantago ovata- Psyllium) has been shown in a small clinical trial (N=105) patients to be equal to mesalamine to maintain remission of ulcerative colitis following 12 months of therapy.
Pre-clinical studies using licorice, or an extract of licorice (glabridin and 18 beta-glycyrrhetinic), have shown a reduction in inflammatory and oxidative measurements (NO, Prostaglandins (E2), interleukins (IL-8) and TNF-alpha). , To date, licorice lacks clinical studies to support its use.
Since nutrient deficiencies are common in people with IBD, multivitamins are commonly recommended. Serum vitamin status has been assessed in a small study (N=126) of people with IBD and found inadequate nutrition and markers of vitamin status: hemoglobin (40%), ferritin (39.2%), vitamin B(6) (29%), carotene (23.4%), vitamin B(12) (18.4%), vitamin D (17.6%), albumin (17.6%), and zinc (15.2%). They also reported that dietary intake (from food diary report) had no correlation with serum levels. The Crohn’s & Colitis Foundation of America suggest the use of multivitamins for those with IBD.
Omega 3 fatty acids (EPA/DHA) have long been used as anti-inflammatories for a variety of conditions. A 2011 review of omega-3 for both Crohn’s and ulcerative colitis found moderate relative risk reduction -0.14 (95% CI: -0.25 to -0.02) when compared to placebo, but doubted the effect was clinically significant.  A 2014 Cochrane review found six studies (N=1039) reported 39% relapse with omega-3 group compared to 47% in placebo group, but when studies with potential bias or poor methodology were removed, there was no effect. The review concluded marginal or no benefit for maintenance of remission with omega-3.
The interplay between colonic inflammation and the colonic microbiota is a growing area of research. The microbiota performs diverse physiological functions including inhibiting growth of pathogenic/opportunistic microorganisms, digestion of food material liberating nutritive compounds which may aid the health of colonic cells. IBD is often associated with qualitative and quantitative alterations of the microbiota (dysbiosis) which may play a role in the disease as seen by low incidence of IBD in Non-western countries (as well as a low levels of dysbiosis). This dysbiosis is thought to lead mucosal degradation and to activation of gut associated lymphoid tissue, which, in turn leads to chronic inflammation. , , While a strong theoretical and casual relationship exist between the IBD and dysbiosis, and probiotics, clinical trials are lacking.
Vitamin D deficiency is one of the commonly diagnosed deficiencies present in IBD. IBD has a strong geographical distribution, with less disease in sunnier climates. Vitamin D is now understood as a regulator of the immune system and possesses anti-inflammatory effects. Low serum levels are associated with disease severity. Both pre-clinical and clinical studies support a therapeutic role for vitamin D, but further clinical trials are needed to understand its role. ,
Other Professional Resources
 Gearry RB, Irving PM, Barrett JS, Nathan DM, Shepherd SJ, Gibson PR. Reduction of dietary poorly absorbed short-chain carbohydrates (FODMAPs) improves abdominal symptoms in patients with inflammatory bowel disease-a pilot study. J Crohns Colitis. 2009 Feb;3(1):8-14. PMID: 21172242.
 Croagh C, Shepherd SJ, Berryman M, Muir JG, Gibson PR. Pilot study on the effect of reducing dietary FODMAP intake on bowel function in patients without a colon. Inflamm Bowel Dis. 2007 Dec;13(12):1522-8. PMID: 17828776.
 Jantchou P, Morois S, Clavel-Chapelon F, Boutron-Ruault MC, Carbonnel F. Animal protein intake and risk of inflammatory bowel disease: The E3N prospective study. Am J Gastroenterol. 2010 Oct;105(10):2195-201. PMID: 20461067.
 Chiba M, Abe T, Tsuda H, Sugawara T, Tsuda S, Tozawa H, Fujiwara K, Imai H. Lifestyle-related disease in Crohn’s disease: relapse prevention by a semi-vegetarian diet. World J Gastroenterol. 2010 May 28;16(20):2484-95. PMID: 20503448.
 Karmiris K, Koutroubakis IE, Kouroumalis EA. The emerging role of adipocytokines as inflammatory mediators in inflammatory bowel disease. Inflamm Bowel Dis. 2005 Sep;11(9):847-55. PMID: 16116320.
 Bilski J, Mazur-Bialy AI, Wierdak M, Brzozowski T. The impact of physical activity and nutrition on inflammatory bowel disease: the potential role of crosstalk between adipose tissue and skeletal muscle. J Physiol Pharmacol. 2013 Apr;64(2):143-55. PMID: 23756389.
 Langmead L, Feakins RM, Goldthorpe S, et al. Randomized, double-blind, placebo-controlled trial of oral aloe vera gel for active ulcerative colitis. Aliment Pharmacol Ther. 2004 Apr 1;19(7):739-47. PMID: 15043514.
 Hartmann RM, Fillmann HS, Martins MI, Meurer L, Marroni NP. Boswellia serrata has beneficial anti-inflammatory and antioxidant properties in a model of experimental colitis. Phytother Res. 2014 Sep;28(9):1392-8. PMID: 24619538.
 Holtmeier W, Zeuzem S, Preiss J, et al. Randomized, placebo-controlled, double-blind trial of Boswellia serrata in maintaining remission of Crohn’s disease: good safety profile but lack of efficacy. Inflamm Bowel Dis. 2011 Feb;17(2):573-82. PMID: 20848527.
 Fernández-Bañares F, Hinojosa J, Sánchez-Lombraña JL, Navarro E, Martínez-Salmerón JF, García-Pugés A, González-Huix F, et al. Randomized clinical trial of Plantago ovata seeds (dietary fiber) as compared with mesalamine in maintaining remission in ulcerative colitis. Spanish Group for the Study of Crohn’s Disease and Ulcerative Colitis (GETECCU). Am J Gastroenterol. 1999 Feb;94(2):427-33. PMID: 10022641.
 Kwon HS, Oh SM, Kim JK. Glabridin, a functional compound of liquorice, attenuates colonic inflammation in mice with dextran sulphate sodium-induced colitis. Clin Exp Immunol. 2008 Jan;151(1):165-73. PMID: 18005263.
 Kang OH, Kim JA, Choi YA, et al. Inhibition of interleukin-8 production in the human colonic epithelial cell line HT-29 by 18 beta-glycyrrhetinic acid. Int J Mol Med. 2005 Jun;15(6):981-5. PMID: 15870903.
 Turner D, Shah PS, Steinhart AH, Zlotkin S, Griffiths AM. Maintenance of remission in inflammatory bowel disease using omega-3 fatty acids (fish oil): a systematic review and meta-analyses. Inflamm Bowel Dis. 2011 Jan;17(1):336-45. PMID: 20564531.
 Kanai T, Matsuoka K, Naganuma M, Hayashi A, Hisamatsu T. Diet, microbiota, and inflammatory bowel disease: lessons from Japanese foods. Korean J Intern Med. 2014 Jul;29(4):409-15. PMID: 25045286.
 Tomasello G, Tralongo P, Damiani P, et al. Dismicrobism in inflammatory bowel disease and colorectal cancer: changes in response of colocytes. World J Gastroenterol. 2014 Dec 28;20(48):18121-30. PMID: 25561781.
 Tomasello G, Bellavia M, Palumbo VD, Gioviale MC, Damiani P, Lo Monte AI. From gut microflora imbalance to mycobacteria infection: is there a relationship with chronic intestinal inflammatory diseases? Ann Ital Chir. 2011 Sep-Oct;82(5):361-8. PMID: 21988043.
 Reich KM, Fedorak RN, Madsen K, Kroeker KI. Vitamin D improves inflammatory bowel disease outcomes: basic science and clinical review. World J Gastroenterol. 2014 May 7;20(17):4934-47. PMID: 24803805.