IBD and the Gut-Brain Connection: a patient and carer's guide to taming Crohn's disease and ulcerative colitis

by Antonina Mikocka-Walus

Overview

As a health scientist and ‘expert patient’ who has spent more than 20 years researching IBD and whose work has changed the way IBD is managed in clinics worldwide, Dr Mikocka-Walnus is ideally placed to bring all the latest research findings and clinical experience together in a truly up-to-date, evidence-based guide for people with an IBD diagnosis and their families, friends and carers. As well as general considerations including what science tells us the condition is and how it is currently treated, she addresses issues in relation to age (there is an epidemic now among children and teenagers) and circumstances (sexuality and fertility). Most importantly she looks at the gut-brain connection and with it, mental health in IBD, the two-way relationship with stress, and the pros and cons of psychotherapy, hypnotherapy and antidepressants.

Product Details

ISBN-13:	9781781611418
Publisher:	Hammersmith Health Books
Publication date:	09/27/2018
Sold by:	Bookwire
Format:	eBook
Pages:	176
File size:	321 KB

About the Author

Antonina Mikocka-Walus is Senior Lecturer in Health Psychology at Deakin University, Australia; Visiting Associate Professor in Psychology at the University of Adelaide, Australia; and Visiting Senior Research Fellow at the University of York, York, UK. She completed her doctoral studies in medicine at the University of Adelaide and has since worked in several Australian and British universities. The main theme of her research has been the psychology of IBD. She has contributed to the international guidelines on IBD care. Her research has led to changes in how IBD services operate, with her recommendations for the use of an integrated model of care now being implemented in several clinics worldwide, including Australia, Europe and South America. She has published widely, with over 90 research papers, book chapters and books, and has received multiple research grants to fund her studies in IBD.

Read an Excerpt

CHAPTER 1

What is IBD?

The name 'inflammatory bowel disease' tells you that IBD is a disease of the intestines – that is, of the small and/or large bowel – and that some reddening and swelling must be involved, as these are the signs of inflammation. In IBD, our tummy (also called the abdomen) hurts mostly around and below the navel area where the intestines are located, though in some people upper tummy pain also occurs, and often diarrhoea, bleeding and nausea. However, explaining IBD as a condition is not as simple as this. Let's first focus on what healthy digestion is.

When we place food in our mouth we start the process of digestion, whereby food is changed into energy and nutrients to feed the body. The food passes down a long duct, our gastrointestinal tract, beginning in the mouth and leading through the oesophagus, into the stomach and then first to the small, and later to the large intestine (they are also called small and large bowel, respectively). The final portion of the large intestine is the rectum, which ends with the anus where the wastes of the digestive process (i.e. stool, popularly called poo) are discharged.

Each section of the gastrointestinal tract has its part to play in digestion. The small bowel absorbs 90% of nutrients from the food we have eaten. The large bowel absorbs water from what is left after digestion, and expels the solid wastes via the rectum and anus from the body. When inflammation and ulcers appear in the small or large bowel, the bowel stops working as it should – we no longer absorb all the necessary nutrients, minerals and water, and we notice unpleasant symptoms such as diarrhoea, bleeding and pain, which don't go away after a few days as they would if this was a simple bout of gastroenteritis. This is usually when we visit a doctor, and, after some investigations, we may learn that we have inflammatory bowel disease. But what exactly IBD is, is not yet fully understood. Let me briefly show you how the thinking on IBD has evolved throughout history and what is currently believed to cause it.

The history of IBD

IBD has been around for a long time. There are historical reviews indicating that the ancient Greeks and Chinese described cases of abdominal pain and diarrhoea that resembled IBD. IBD has two main subtypes: Crohn's disease (CD) and ulcerative colitis (UC). The term 'ulcerative colitis' was first used to describe the disorder by a British pathologist, Samuel Wilks, in 1859. Crohn's disease was not officially named until 1932, when Burrill Crohn wrote of the discovery of a new intestinal disease, 'terminal (regional) ileitis', in a letter to the American Gastroenterological Association. To honour the discoverer, surgeon Brian Brooke renamed the disease, and the term 'Crohn's disease' entered common use.

In the 1930s and 1940s, a view predominated that psychological problems played a central role in the development of ulcerative colitis. Sigmund Freud's work (on 'talk therapy') was influential at the time, so this wasn't surprising, and there were some documented cases of UC being successfully treated or managed with psychotherapy. In addition, the physiologists of this era – for example, Walter Cannon, famous for his research on stress – also believed that emotional calmness was important to normal digestion, hence the thinking that psychological distress equals poor digestion.

We now know that this view is not completely wrong – stress plays an important part in IBD as I will explain in Chapter 2 where I provide an overview of the gut-brain links and their implications for those living with IBD. However, the spread of research into physiology, immunity and genetics in the second half of the twentieth century meant that IBD started to be considered as a physiological condition rather than a psychological one (that is, to do with the functioning of the body rather than the mind). In 1969, colonoscopy – a procedure where a tube is inserted into the rectum and a little camera is passed up to observe the inside of the bowel – was introduced and it allowed doctors to see inflammatory changes in the bowel for the first time.

Modern theories on the causes of IBD

Later studies into immunity have proposed that IBD develops when our bodies struggle to tolerate the bacteria inhabiting our gut. Genetics has also contributed to our understanding of the disease. IBD occurs in people who are genetically predisposed to getting it – there are more than 100 distinct changes to the genes that are present in people living with IBD. There is also an increased risk of IBD among family members of patients with IBD (stronger for those with CD than UC) and particularly in siblings. The earlier the onset of IBD, the stronger the genetic link and the higher risk for the family members.

The environment has long been considered an important factor in IBD's causation. There is a well-known theory on how IBD came about, called the 'hygiene hypothesis'. It states that conditions such as IBD are common nowadays because we have little contact with bacteria during our childhood. The cleaner we become, the more sanitised our childhoods, the more prone we become to inflammatory conditions later in life. Studies on environmental factors show that IBD is more common in industrialised countries and in urban societies and in people with fewer siblings and generally smaller families.,

There are also other factors contributing to its incidence.

• Smoking, for example, makes one more likely to develop CD, though it doesn't have this effect on UC.

• Studies have also shown that some diets make IBD more likely. A high consumption of sugars and fats has been associated with an increased risk of developing IBD,, while high intake of dietary fibre, including fruit and vegetable consumption, may protect against IBD. It is important to note that this evidence doesn't tell us what we should eat when we have IBD. Instead, it simply says that people who were diagnosed with IBD could have been eating this diet before the diagnosis and it may have contributed (together with other factors) to their IBD coming about. I will tell you more about diet for IBD in Chapter 11.

• Prolonged use of the oral contraceptive pill is another factor which may make IBD more likely to occur. Hormones used in the pill have an impact on inflammatory processes in the body.

• A protective factor is the removal of your appendix (a tiny sac attached to the large bowel). Those without an appendix have a lower risk of developing UC. The relationship is, however, less clear for CD.

• Breastfeeding is a protective factor, with those breastfed in childhood less likely to develop IBD.

• On the other hand, taking repeated courses of antibiotics in early childhood is another risk factor for the development of IBD.

• Similarly, frequent use of nonsteroidal anti-inflammatory drugs, e.g. ibuprofen or aspirin, is a predisposing factor for IBD.

What do all these studies tell us about the causes of IBD? They tell us that IBD is a disease in which the immune system reacts in an exaggerated way to normal bacteria inhabiting the intestines, a response which may be triggered by environmental factors, or come about because someone has a genetic predisposition.

Types of IBD

The two main types of IBD are Crohn's disease and ulcerative colitis, but there is also a third type, indeterminate colitis (IC). This term is used when the disease resembles both CD and UC and neither can be clearly distinguished. A minority of patients (approximately 10%) fit into this category. In research studies, IC is often combined with UC because it resembles it more than the CD.

I am one of those few patients who have suffered from all three types of IBD. When I was diagnosed with IBD, it presented as Crohn's disease and it was CD for as long as I lived in Poland. My symptoms then included diarrhoea, weight loss, occasional tummy pain, fever and anaemia.

When I emigrated to Australia, something strange started happening to my body. First, the disease went completely quiet for a few years. I guessed this must have been due to the change in climate and diet. In Australia, I stopped eating as much meat as I had been used to in Poland and switched to seafood and vegetables. I also consumed less dairy. During the long hot summers my body craved a different kind of nourishment. But after a few years, IBD returned in a changed form. My symptoms shifted to rectal pain and bleeding. I no longer lost weight – in fact, I put on weight – but my diarrhoea remained the same. After a colonoscopy, I was given a new diagnosis of ulcerative colitis. My treatment changed as well, as the disease was now located much lower (in the rectum, so at the end of the large bowel) and enemas (a medication in a liquid form provided through the rectum) became more effective than steroids taken orally.

When I moved to the UK, the disease went silent as it had for a few years after my first emigration to Australia, though not completely this time. I had to use the enemas regularly, every few weeks, whereas in the past I had enjoyed long periods of remission. I was never completely free of symptoms, but on the other hand they were never unbearable. After another series of investigations, I was told I now had indeterminate colitis. The treatment remained the same as for UC.

I am now back in Australia and watch my body with interest. Which of the old friends will it be this time?

Typical symptoms of IBD

What is common for all three types of IBD is that some people have severe symptoms while others only suffer occasionally. The cycles of remission (quiescent disease when people are symptomfree or have limited symptoms only) and flares (active disease, with the full spectrum of symptoms) also vary. Some people can be free of symptoms (in remission) for years while others may have just days or weeks of freedom and very lengthy flares.

Crohn's disease

CD is characterised by inflammation anywhere in the digestive system (from the mouth to the anus), but most commonly in the last section of the small intestine or in the colon (i.e. the large intestine).

In CD, the typical symptoms are: recurring diarrhoea; abdominal pain and cramping (worse after meals); fatigue (i.e. extreme tiredness); weight loss; and mucus (and sometimes also blood) in stools. Less commonly, people report a high temperature (of over 38C); nausea; vomiting; and so-called 'extra- intestinal' (outside the intestine) symptoms, such as: joint pain and swelling; uveitis (inflammation of an eye); inflammation of the skin, presenting as painful, red and swollen patches, most typically on the legs; and mouth ulcers also called 'aphthae'.

Ulcerative colitis

In UC, the colon and rectum become inflamed. When you observe the bowel through a camera during a colonoscopy, small ulcers may be noticed which bleed and produce pus.

The symptoms of UC include recurring diarrhoea which may contain blood, mucus or pus; abdominal pain; and urgency (feeling that you need to empty your bowel immediately). Fatigue is also present, though its levels are slightly lower than in CD. Loss of appetite and weight loss do occur in some people as do the extra-intestinal symptoms described above for CD. In severe cases, with many bowel movements a day, shortness of breath; a fast or irregular heartbeat; fever; and blood in stools becoming more pronounced can also happen.

Indeterminate colitis

IC, as mentioned above, may have overlapping symptoms of both CD and UC and is usually treated similarly to UC. You can ask why it matters that we know whether we have UC or IC if the treatment for both is the same. The answer is, there are important differences if surgery such as colectomy (removal of the bowel) is required. Patients with UC usually respond better to it than those with IC who, on the other hand, respond better than those with CD. Thus, in the case of planned surgery, it's important to be sure which disease type you have.

How common is IBD?

When IBD was first described and named, it was a rare disease which few people had heard about. It owes its wider recognition to American President Dwight Eisenhower who suffered bowel symptoms for years but was only diagnosed with CD in his sixties. He had to undergo emergency surgery for CD and spoke about it openly, thus promoting understanding of IBD among the general public.

IBD occurrence increased in the developed countries in the second half of the twentieth century, and it is now increasing in developing countries. According to recent studies, between 300 and 480 people per 100,000 are affected by IBD in western countries.

Over 5 million people now live with IBD around the world. There are currently 2.5–3 million people with the condition in Europe, 1.4 million people in the US, 233,000 in Canada, and over 75,000 in Australia. In the developed countries, CD is more common than UC, whereas the trend is reversed in Asia. There is quite a significant geographic difference in IBD's incidence between eastern, western, northern and southern countries. The overall annual IBD occurrence in western Europe is roughly twice as high as the rates in eastern Europe. Similarly, the frequency of UC is 40% and CD 80% higher in the north of Europe as compared with the south.

IBD affects both males and females, but it's slightly more common in males (the rate for males is 56% as compared with 44% in females). It is most common in the 20–29 years age group, in populations with high socio- economic status, and those of Jewish ancestry, and uncommon in indigenous populations (those who have lived in a place for centuries before modern times and live in distinct traditional ways).

In terms of how IBD behaves, we know it is a recurring condition, but how often does it recur? During a period of two years of observation, approximately 50% of UC patients are likely to be in remission but the chance of a flare in five years is high – approximately 80%.

In CD, 34% of people flare after one year of observation, 70% after five years, and 77% after 10 years of observation. While the majority of IBD patients experience both remissions and flares/relapses, 20–25% of patients have continuous symptoms, so they are never in remission. Note that these rates come from studies that may have started quite a long time ago when biologics (see Chapter 9) were not widely available, and thus the course of IBD over time may improve in the future as we get better treatment. For example, current hospitalisation rates in CD are quite high, with 50% of European CD patients needing a hospital stay within 10 years from diagnosis, but these rates are dropping. Moreover, although 30–50% of CD patients require surgery in the 10 years following diagnosis, these rates are also falling. In contrast, just 10% of UC patients presently require colectomy (major bowel surgery) within 10 years of their diagnosis. Extra-intestinal manifestations are present in up to 40% of CD patients and up to 20% of UC patients.

Conditions that coexist with IBD

I mentioned in the Preface to this book that IBD is associated with a greater likelihood of suffering from other inflammatory conditions, such as asthma or arthritis. What is, however, more common than these inflammatory 'comorbidities', is an overlap of IBD with irritable bowel syndrome (IBS). Another common issue is fatigue. Cancer is a fear often reported by those living with IBD, and although cancer is a less common comorbidity than IBS or fatigue, the risk needs to be addressed and understood.

Irritable bowel syndrome and IBD

IBS is commonly confused with IBD, as they have similar names and symptoms. But IBS differs from IBD. It does not cause ulcers or lesions and when a patient undergoes a colonoscopy, no clear signs of disease can be spotted in the bowel, though the patient reports aggravating symptoms of diarrhoea and/or constipation, pain, cramping and bloating. The pain or discomfort is generally relieved after a bowel movement.

In the case of IBD, IBS may appear during periods of remission. In such cases, patients continue to report diarrhoea and pain even though the common inflammation markers are within the normal range and colonoscopy shows that they are in remission. In fact, 40% of IBD patients report symptoms consistent with IBS and we are four times more likely to have IBS than the rest of the population. What is more, 50% of first-degree relatives of people who suffer IBD report symptoms of IBS, meaning the two can be genetically linked. Some current research suggests that IBS in IBD may be a product of inflammation which is not detected by the standard inflammation tests, but this needs to be further investigated.

Interestingly, patients with IBS in IBD have higher levels of anxiety and depression than other IBD patients. IBS is, in fact, a condition serving as a model for the importance of gut-brain interactions, with a recent study showing that people who have anxiety and depression and no bowel problems tend to develop gastrointestinal symptoms over time, while those with bowel problems and no anxiety or depression initially, over time are at a higher risk of developing these common mental disorders. It is therefore not surprising that psychological factors such as anxiety may contribute to having IBS in IBD and that counselling and psychotherapy are recommended in people having this comorbidity. Antidepressants and dietary interventions are other treatments commonly used. The latter often entails a low FODMAP diet (a diet restricting some carbohydrates – see page 112) or a diet addressing fructose malabsorption, which is common in CD. I discuss diet in IBD in Chapter 11.

(Continues…)

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Excerpted from "IBD and the Gut–Brain Connection"
by .
Copyright © 2018 Dr Antonina Mikocka-Walus.
Excerpted by permission of Hammersmith Books Limited.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

Title Page,
Dedication,
Foreword,
Acknowledgements,
Preface,
Part I Understanding IBD,
Chapter 1 What is IBD?,
Chapter 2 What causes IBD?,
Part II Living with IBD,
Chapter 3 The psychological impact of IBD,
Chapter 4 IBD in children and adolescents,
Chapter 5 Sexuality, fertility and pregnancy in IBD,
Chapter 6 IBD in the over 60s,
Part III Treating IBD,
Chapter 7 Healthcare models for IBD,
Chapter 8 Diagnosing IBD,
Chapter 9 Drug treatments for IBD,
Chapter 10 Surgery and IBD,
Chapter 11 The role of diet and exercise,
Chapter 12 Psychological treatments for IBD,
Chapter 13 Complementary and alternative therapies for IBD,
Conclusion,
Self-help resources,
Index,
About the author,
Copyright,