Inflammatory Bowel Disease - A Holistic Perspective
Environmental, immune and genetic susceptibilities have all been implicated in the pathogenesis of inflammatory bowel disease (IBD). The development of various experimental models (Table 1) has enabled researchers to study the development of inflammation in the intestine, under conditions where the underlying lesion is better understood.
Pregnant patients with inflammatory bowel disease are at increased risk for nutritional and metabolic abnormalities that may put the fetus at increased risk for intrauterine growth restriction. Pregnancy itself, however, seems to have little effect on inflammatory bowel disease. When an exacerbation does occur during pregnancy it most frequently happens in either the first trimester or the postpartum period. It is hypothesized that this is due to a correlation with levels of circulating corticosteroids during pregnancy. In general, the treatment of the pregnant patient with inflammatory bowel disease is the same as that of the nonpregnant patient. Antidiarrheal drugs including codeine, opium, paregoric, and Lomotil may also be used safely in pregnancy. While sulfasalazine and corticosteroids may be safely used in pregnancy, the possibility of the development of gestational diabetes must be considered in all patients on steroid therapy. Sulfa drugs are theoretically contraindicated in...
Hepatobiliary disease is common in patients with inflammatory bowel disease and includes pericholangitis, chronic active hepatitis, primary sclerosing cholangitis, and cholangiocarcinoma. Gallstones are detected in up to 33 percent of patients with Crohn's disease. Ihe incidence of acute and chronic pancreatitis is increased in patients with Crohn's disease and ulcerative colitis.
OTHER ETIOLOGIES Numerous other lesions may result in lower GI hemorrhage. Although carcinoma and hemorrhoids are relatively common causes of bleeding, massive hemorrhage is unusual. Similarly, inflammatory bowel disease, polyps, and infectious gastroenteritis rarely cause severe bleeding. Finally, Meckel diverticulum is an unusual but important etiology to keep in mind.
Russel M, Stockbrugger RW Epidemiology of inflammatory bowel disease An update. Scand J Gastroenterol 31 417, 1996. 2. Walker-Smith JA, Savage MO Effects of inflammatory bowel disease on growth Growth matters. Kabi Pharmacia 12 10, 1993. 3. Hebbar M, Wattel E, Mastrini S, et al Association between myelodysplastic syndromes and inflammatory bowel diseases Report of seven new cases and review of the literature. Leukemia 11 2188, 1997. 4. Freeman HJ Osteomyelitis and osteonecrosis in inflammatory bowel disease. Can J Gastroenterol 11 601, 1997. 8. Farraye FA, Peppercorn MA Inflammatory bowel disease Advances in the management of ulcerative colitis and Crohn's disease. Consultant 28 39, 46-7, 1988.
Resuscitation of the patient is the priority, with airway control and provision of oxygen plus large bore intravenous access. Blood should be taken for estimation of haemoglobin, urea, electrolytes, liver function and coagulation profile. Blood should be cross-matched and blood, and products given as required. Urinary and nasogastric catheters are helpful and arterial blood gas analysis will also help to guide the resuscitative effort. The history is important and evidence should be sought of previous GI bleeding, peptic ulcer or inflammatory bowel disease, liver disease, non-steroidal or warfarin usage. The abdomen and anorectum must be carefully examined and bedside examination of the anal canal and rectum are mandatory. If there is any suspicion of an upper GI source, this should be ruled out by upper GI endoscopy.
As IL-2 is required to maintain the growth and viability of T cells in vitro, one might expect disruption of the genes encoding IL-2 or any of the IL-2R subunits to significantly impair T cell development or expansion. However, mice lacking the IL-2, IL-2Ra or IL-2R(3 genes demonstrate apparently normal development of T, B and NK cells and, rather than showing reduced lymphocyte expansion, frequently demonstrate hyperproliferation of lymphocytes and development of T cell-dependent autoimmune disorders such as hemolytic anemia and inflammatory bowel disease. In contrast, yc- mice show severely impaired lymphocyte development, consistent with the involvement of yc in other cytokine receptor complexes. Indeed, the IL-7 receptor utilizes yc and has been shown to be essential for B cell and thymocyte development. Collectively, these results suggest that in the absence of IL-2 or a functional IL-2R, other yc-dependent cytokine receptors can mediate lymphocyte development and expansion in...
The deranged lymph flow in the initial stages may be radiologically demonstrated as edema in the wall of the bowel with mucosal thickening and luminal narrowing (Figs. 4-83 and 4-84). As the metastatic lymphatic edema increases, nodular tumor deposits occur that may be evident as thumbprinting in the colon and cob-blestoning of the small intestine (Fig. 4-85), changes mimicking inflammatory bowel disease.78 79 Radiologic demonstration of these findings indicates that extensive lymphatic permeation has occurred and that resection will not be curative.77 The process can also result in diversion of lymph flow into veins through direct lym-phaticovenous communications81 or through shared channels intrinsic to lymph nodes.82
Mucosal disorders, including inflammatory bowel disease, allergic diseases, and celiac disease, are additional examples of disorders causing protein malabsorption. Once intestinal inflammation is reduced with appropriate medical or nutritional therapy, absorption of protein is usually improved. In Shigella infections, some studies have demonstrated improved nutritional outcomes with a high-protein diet during recovery from the acute symptoms of diarrhea.
Jaundice that develops acutely with abdominal pain, vomiting, fever, and right upper quadrant tenderness is strongly suggestive of acute biliary obstruction from choledocholithiasis. A history of fatty food intolerance and typical biliary colic is supportive. Cholecystitis alone does not produce jaundice. Painless jaundice in an older patient, especially if accompanied by an epigastric mass and weight loss, strongly suggests biliary obstruction from a malignancy. A history of known gastrointestinal malignancy accompanied by a hard, nodular liver indicates metastatic disease as the cause of jaundice. A history of prior biliary tract surgery, pancreatitis, cholangitis, or inflammatory bowel disease should be elicited, since they may be associated with the development of biliary obstruction.
The incidence of diverticular disease in New Zealand concurs with postmortem findings in Australia, the UK and France (Debray et al., 1961 Parks, 1968 Hughes, 1969). Although large bowel disease such as cancer, polyps, inflammatory bowel disease and diverticular disease are noted to be
The indications for long-term nutrition support, specifically for home, include any patient who is unable to meet nutrient requirements by oral intake to avert the consequences of malnutrition. In the United States, cancer patients represent the most frequent use ( 40 ) of home parenteral and enteral nutrition support. Inflammatory bowel disease is the second most common reason for home parenteral
Either have the bolster removed endoscopically or the tube may be cut off and the bolster allowed to pass through the GI tract. 12 The latter technique is generally safe in adults however, its use in children has been associated with more frequent complications. 13 Endoscopic removal is advisable when there is suspected or potential obstructive disease of the GI tract, such as pyloric stenosis, intestinal pseudoobstruction, and intestinal stricture (e.g., due to radiation, ischemia, or inflammatory bowel disease). If the tube is cut, an abdominal radiograph should be obtained 1 week later to confirm passage of the internal component. Most reported complications from a retained internal bolster have occurred when the bolster did not pass within 1 to 2 weeks. 14
Patients with relative contraindications for external-beam radiotherapy may be more suitable for prostate brachytherapy. These include patients with bilateral hip replacements where CT-based treatment planning is technically difficult due to the substantial artifact created by the prostheses, which preclude adequate visualization of the target volume. Ultrasound-based seed implantation would be an appropriate alternative for such patients. In most cases, patients with hip prostheses are able to tolerate the extended dorsal lithotomy position for adequate perineal exposure during the procedure. Patients in whom the small bowel is in close proximity to the prostate volume are not ideal candidates for high-dose three-dimensional conformal radiotherapy (CRT) and are better suited for seed implantation due to the lower doses to the bowel expected with the latter treatment intervention. In addition, brachytherapy appears to be safe for patients with a history of inflammatory bowel disease...
For natural products, and studies showing encouraging results for probiotics. This has led to more drug-like properties being investigated, such as for the use of VSL 3 to ameliorate symptoms of inflammatory bowel disease 21 . With this comes a need to develop product standards higher than have been expected in the past. The FAO WHO Guidelines represent a major roadmap for reaching this standard. Just as a consumer wants to, and needs to, know how much antibiotic to take, how often and what to expect from its usage, so too, the same consumer needs to be reassured that the consumption of a daily milk-based probiotic will provide tangible benefits. This can only be achieved by defining the product contents clearly, ensuring that manufacturing, packaging and storage conditions are optimal for retention of the required viable counts, and then proving that the health outcomes are verifiable. A number of websites mention that strains adhere to cells or mucus in vitro, or inhibit pathogens...
The recent approval of intramuscular ceftriaxone may be of benefit when a child cannot take oral antibiotics due to emesis, when absorption of an oral antibiotic is in doubt (e.g., with malabsorption or inflammatory bowel disease), or when compliance is questionable. 1 1 and 13
Protein Modeling on the Internet A group of patients suffering from Crohn's disease (an inflammatory bowel disease) underwent biopsies of their intestinal mucosa in an attempt to identify the causative agent. A protein was identified that was expressed at higher levels in patients with Crohn's disease than in patients with an unrelated inflammatory bowel disease or in unaffected controls. The protein was isolated and the following partial amino acid sequence was obtained (reads left to right)
We are just beginning to understand the spatial topography and localization of commensal bacteria in the mammalian intestine. Studies of the GIT microbiota using PCR-based methods and colony counts are difficult and rarely provide consistent results. Fluorescent in situ hybridization (FISH) is providing fundamental insights and can overcome limitations of PCR-based methods and bacteriologic culture. Recent, informative intestinal FISH studies used Carnoy's fixative, which retains the structural integrity of the mucus layer, and yielded detailed images of microbial communities in intestines of healthy and diseased animals and humans. One study examined the location and composition of the GIT microbiota using healthy mice and murine colitis models (Swidsinski, 2005a). In this study, each segment of the intestine differed in the type and location (fecal mass, interlaced layer, mucosa, or in the crypts) of the bacteria. Commensal Gram-positive bacteria consistent with either Enterococcus...
The most striking observation made with IL-2 animals is the development of an autoimmune syndrome. The intensity of the disease is dependent both on environmental factors and the genetic background of the animals. Fifty per cent of IL-2_ mice in a 129 Ola X C57B16 genetic background die of autoimmune hemolytic anemia before 9 weeks of age. All animals that survive past 10 weeks of age develop an inflammatory bowel disease comparable to ulcerative colitis in humans. Mice kept in germ-free conditions do not develop the disease. The data obtained with IL-2_ mice as well as with IL-2Ra_ and IL-2R3 _ animals indicate that there may be a defect in cell apoptosis in these animals.
Surgical gastrostomy and jejunostomy In a patient undergoing complex abdominal or trauma surgery, thought should be given during surgery to the possible routes for subsequent nutritional support because laparotomy affords direct access to the stomach or small bowel. The only absolute contraindication to feeding jejunostomy is distal intestinal obstruction. Relative contraindications include severe edema of the intestinal wall, radiation enteritis, inflammatory bowel disease, ascites, severe immunodeficiency, and bowel ischemia. Needle catheter jejunostomies can also be used with a minimal learning curve. The drawback is usually related to clogging and knotting of the 6-Fr catheter.
Recent studies have revealed that mutations in keratins expressed in simple epithelia may be involved in the pathogenesis of a number of gastrointestinal diseases. 20 Cryptogenic cirrhosis is a diagnosis of exclusion applicable to an individual with cirrhosis who does not carry a hepatitis B or C virus who does not test positive for serological markers associated with autoimmune hepatitis or primary biliary cirrhosis who has normal iron, ceruloplasmin, and aj-antitrypsin levels and who has no history of alcohol or toxin ingestion. Recurrent mutations in human K8 K18 genes have been shown to predispose individuals to cryptogenic cirrhosis, chronic pancreatitis, and inflammatory bowel disease. 20,34,35 How K8 K18 mutations cause liver disease is still a matter of debate. Animals deficient in K8 K18 are highly susceptible to proapoptotic signals, suggesting that keratins may play a cytoprotective role in the gastrointestinal tract. 20
Azathioprine (Immuran Wellcome) has been used as an immunosuppressive and immunomodulatory agent for the treatment of autoimmune skin diseases, polyarthritis and inflammatory bowel disease in the cat. Adverse reactions may include myelosuppression, hepatotoxicosis, vomiting, panniculitis, drug eruptions and alopecia. These reactions have limited the use of this drug in the cat. Azathioprine is a prodrug, being converted principally within the liver to the purine analogue 6-mercaptopurine (6-MP). The 6-MP is converted into cytotoxic thioguanine nucleotides, which suppress immune cell replication and response, while xanthine oxidase and thiopurine methyltrans-ferase (TPMT) catalyse the conversion of 6-MP to the inactive metabolites. The administration of azathioprine to cats at dosages of 1.1-2.2 mg kg body weight on alternate days has been associated with thrombocytopenia and leucopenia while treating pemphigus foliaceus. There are no clear indications for the use of this drug for...
Allan RN, Rhodes JM, Hanauer SB et al. eds. Inflammatory Bowel Diseases, 3rd edn New York Churchill Livingstone, 1997. Kirsner JB, Shorter RG, eds. Inflammatory Bowel Disease, 4th edn, Philadelphia Lea and Febiger, 1995. Targan SR, Shanahan F, Karp LC, eds. Inflammatory Bowel Disease. From bench to bedside, 2nd edn, Dordrecht Kluwer Academic Publishers, 2003. Rampton, DS, Shanahan, F. Fast facts Inflammatory Bowel Disease, 2nd edn, Health Press Ltd., Oxford, UK, 2006.
Irritable bowel syndrome There is a rationale for investigating the effect of probiotics in the treatment of this common disorder where intestinal motility and dysfunctions in the intestinal microflora are important factors to consider. In a recent study using L. plantarum 299v, a reduction of symptoms was reported. Enterococcus faecium preparations have also been evaluated for the treatment of patients with irritable bowel syndrome, and although patient-recorded symptoms did not show significant differences, the physician's subjective clinical evaluation revealed an improvement. Inflammatory bowel disease Inflammatory bowel disease (IBD) comprises a heterogeneous group of diseases of unknown etiology (Crohn's, ulcerative colitis, and pouchitis), but here also factors related to the intestinal microflora seem to be involved, providing a rationale for the application of probio-tics. From reviewing studies on the use of probiotics in IBD it can be concluded that, although there are some...
Sulfasalazine is used to treat ulcerative colitis and Crohn's disease. Folate deficiency often occurs in patients with inflammatory bowel disease, and risk may be worsened by treatment with sulfasalazine. This drug inhibits the intestinal absorption of folate, as well as enzymatic activity of dihydrofolate reductase, MTHFR, and serine hydroxymethylase (41). The drug is classified as pregnancy category B. Several case reports have suggested a terato-genic effect of the drug. A child with cleft lip and palate and hydrocephalus was born to a woman who had taken sulfasalazine prior to and throughout her pregnancy for treatment of ulcerative colitis (42). Stillborn twins were born to a woman with Crohn's disease who had taken the drug throughout her pregnancy one twin had a polycystic kidney on the left side and the other twin was missing both kidneys and ureters, had hypoplastic lungs and bladder, as well as undescended testes (43). A second case reported by these authors (43) described a...
Right lower quadrant pain is a common complaint. It is also one of the most difficult areas of the abdomen to evaluate because the differential diagnosis is widely varied. The resulting workup is dependent on the age and sex of the patient, as well as the clinical picture. The differential diagnosis can include appendicitis, diverticulitis, inflammatory bowel disease, cecal volvulus, inguinal or femoral hernias, urinary tract infections, renal stones, and pyelonephritis. In females, organs of the female reproductive tract must be evaluated as a possible source of the pain, including evaluation for mittelschmerz, endo-metriosis, and ectopic pregnancy. In males in their 50s and 60s, other diseases should also be considered such as diverticulitis. In this population, as well as people with a history of inflammatory bowel disease, a CT scan should be used for further evaluation. Although this may lead to a slight delay in diagnosis, there is a much greater chance of having an incorrect...
The association of bifidobacteria with a healthy infant intestinal tract has promoted the addition of bifidobacteria to dairy products as probiotics. Probiotics are defined as 'live microorganisms which when administered in adequate amounts confer a health benefit on the host' (FAO WHO, 2002). Survival of the probiotic upon gastrointestinal transit, adhesion to the intestinal mucosa, and stability in the product are considered desirable properties for a probiotic, although not necessarily a good indicator for health-improving properties of the probiotic (Tannock, 2005). Ultimately, the efficacy of these probiotic strains in the products for a certain health benefit must be proven in clinical trials. The viability of the ingested probiotic as well as the effect on the autochthonous microbiota has been reported in numerous studies. The therapeutic efficacy of these probiotic strains (and combination species and strains) has been demonstrated in various clinical trials usually involving...
The most common cause of protein malabsorption is so-called protein-losing enteropathy. Etiologies include diffuse mucosal disease such as celiac disease or Crohn's disease, elevated right heart pressure with resultant dilatation of lymphatics and leakage of lymph into the lumen, and colitides such as Shigella or Salmonella infections. Since protein is a relatively minor component of dietary energy compared with carbohydrate and fat, symptoms of protein malabsorption can sometimes be minimal. However, infectious colitis or exacerbations of inflammatory bowel disease often present with frequent loose stools, which may be bloody. Rare, congenital etiologies of protein malabsorption include enterokinase and trypsinogen deficiencies (Table 1).
On the other hand, if the child is sick- or ill-appearing or shocklike or has petechiae, one must consider vascular malformation, Meckel's diverticulum, intestinal duplication, or sepsis. In adolescents, one must consider stress ulceration, peptic ulcer disease, and inflammatory bowel disease. Sepsis, severe gastroenteritis, HSP, and HUS should also be part of the differential diagnoses.
I have seen some strange cases where pelvic endometriosis causes seemingly unrelated symptoms. A patient had right-side pain at the level of her umbilicus (belly button) and multiple intestinal symptoms, such as nausea, constipation, and pain after eating. She had a previous diagnosis of irritable bowel syndrome (IBS) or some other inflammatory bowel disease, but when she didn't receive any relief from other
Conditions that cause excessive bleeding additionally compromise iron status. Approximately 1 mg of iron is lost in each 1 ml of packed red blood cells. Excessive losses of blood may occur from the gastrointestinal tract, urinary tract, and lung in a variety of clinical pathologies, including ulcers, malignancies, inflammatory bowel disease, hemorrhoids, hemoglobinuria, and idiopathic pulmonary hemosi-derosis. In developing countries, parasitic infestation with hookworm and schistosomiasis can contribute substantially to gastrointestinal blood loss and iron deficiency.
Some secondary forms of IgA nephropathy appear to be caused by either decreased clearance of IgA from the circulation (e.g., reduced hepatic clearance caused by cirrhosis) or increased entry of IgA complexes into the circulation (e.g., caused by increased synthesis and greater access to the circulation in inflammatory bowel disease).
Bleeding may be a sign of GI inflammation, duplication, foreign-body infection, or systemic illness, or it may be nothing more than an anal fissure or milk allergy. GI bleeding in the newborn, either vomited or per rectum, may be the result of swallowed maternal blood. The laboratory can differentiate between maternal and fetal blood by the Kleihauer-Betke test or hemoglobin electrophoresis. Rarely, hemorrhagic states cause GI bleeding in the newborn. Small amounts of blood in the stool of an infant, if fresh, may be a manifestation of anal fissures, which are easily identified. In children 2 to 10 years of age, painless bleeding of small to moderate amounts of fresh blood usually mixed through the stool might be an indication of benign GI polyps, or bloody diarrhea may indicate a bacterial infection or inflammatory bowel disease.4
The important causative factors include sepsis, steroid and other immunosuppressant therapy, and inflammatory bowel disease. Obesity is an important risk factor both for the occurrence of the original incisional hernia and for the likelihood of recurrence of the hernia after repair. Less significant factors include age and sex, anaemia, malnutrition, hypopro-teinaemia, diabetes, type of incision, postoperative intestinal obstruction and postoperative chest infection.
Additionally, a standard upper gastrointestinal contrast series utilizing barium is required for assessment of anatomy of the gastrointestinal tract. Children with repetitive vomiting or abdominal pain require endoscopic evaluation, and many will also need colonoscopy to rule out the possibility of underlying inflammatory bowel disease. Some children will need cranial imaging, such as computed tomography or magnetic resonance imaging, to search for evidence of intracranial mass lesions, hydrocephaly, or posterior fossa anomalies such as the Chiari malformation. Fiberoptic endoscopic evaluation of swallowing (FEES) allows for direct visualization of the hypopharynx and larynx during swallowing by use of a flexible laryngoscope. This will allow evaluation of the valleculae and pyriform sinuses as well as the assessment of anatomy during swallowing and potential aspiration problems. This procedure, however, does not provide information on the oral phase of swallowing. FEES may also be...
The clinical signs of local inflammation have been described by Celsus (25 AD) 'Notae vero inflammationis sunt quattuor rubor et tumor cum calore et dolore', with Galen (AD 170) later adding 'Functio laesa' to the definition. If the injurious agent is removed or overcome by the local inflammatory response, the inflammation will subside with complete restitution of the original architecture and function of the injured tissue (resolution), or when tissue had been destroyed, with the formation of scar tissue. Persistence of injury will result in chronic inflammation with gradual destruction to tissues caused by the inflammatory process. Should the body mount an inadequate inflammatory response, poor wound healing and uncontrolled infection may result. Under certain conditions a normal or exaggerated local inflammatory process can become deleterious for example, intracranial inflammatory oedema after head injury, inflammatory bowel disease and laryngeal oedema in croup.
Non-steroidal anti-inflammatory medications like aspirin may reduce the numbers of polyps, particularly in families with FAP. Colonoscopy can identify polyps that may be premalignant and can facilitate polyp removal. It is recommended that all individuals have a colonoscopy at age fifty. High-risk patients, such as those with inflammatory bowel disease, FAP, or HNPCC, should have screening initiated at an earlier age and repeat exams at shorter time intervals. see also Apoptosis Breast Cancer Cancer Carcinogens Cell Cycle DNA Repair Genetic Testing Mutation Oncogenes Tumor Suppressor Genes.
Theories on the etiology of diarrhea in diabetics include (1) generalized autonomic neuropathy in poorly controlled type 1 diabetes (2) small bowel dysmotility and abnormal intraluminal pressures and (3) dysfunction of the a2-adrenergic receptors of the small and large intestine that are responsible for stimulating sodium absorption and bicarbonate secretion. Infection, inflammatory bowel disease, irritable bowel syndrome, bacterial overgrowth due to small bowel stasis, or pancreatic exocrine deficiency can mimic the diarrhea associated with diabetes. Chronic diarrhea of diabetes is defined as increased frequency or liquidity of bowel movements of greater than three weeks duration. Incompetence of the internal anal sphincter may also mimic diabetic diarrhea and asymptomatic sensorimotor deficit commonly exists in the anal canal of diabetic patients. Rectal examination is always necessary to exclude fecal impaction as a cause of diarrhea.
PN is often used when continued use of the gastrointestinal tract may not be advisable. PN may be selected for inflammatory bowel disease patients with severe acute exacerbations or for perioperative care. For patients with Crohn's disease, PN may aid the management of complications such as intestinal obstruction, fistula formation, short bowel syndrome, and severe diarrhea. Otherwise, enteral nutrition support is frequently used for nutrition support in inflammatory bowel disease with comparable efficacy. Perioperative support in severe malnutrition Inflammatory bowel disease and related complications Short bowel syndrome Severe acute pancreatitis
The irritable bowel syndrome (IBS) is a 'functional' disorder of the bowel, which is said to affect up to 15 of the population and is characterized by some, but not necessarily all, of a range of symptoms including abdominal pain relieved by constipation, alternating diarrhea and constipation, recurrent abdominal pain, and urgent or frequent defecation. An important part of management is the exclusion of other serious organic disease such as inflammatory bowel diseases. In IBS the gut is abnormally sensitive to distension, and symptoms may be related to or In inflammatory bowel disease (IBD) high fiber diets have no special part to play in the management of Crohn's disease where enteral feeding (with formula low-residue, low-fiber preparations) is especially beneficial where there is acute extensive small bowel disease. In ulcerative colitis specific dietary advice is usually unnecessary though fiber supplements may be of benefit in patients whose disease is limited to proctitis...
Figure 3 Mechanism of tissue injury in IBD. Inflammatory processes can be dramatically increased by a variety of mechanisms, including 1) direct activation of granulocytes or neutrophils by bacterial products, 2) priming of phagocytes directly by IgG, or 3) specific immunological effector events mediated by IgG activation of the complement cascade. After priming or activation of granulocytes and macrophages, a host of destructive inflammatory mediators and toxic oxygen radicals can lead to direct tissue damage by a variety of destructive mechanisms. The two primary agents used to treat IBD patients (steroids and 5-ASA products) are effective because of their ability to inhibit many of the pathways that lead to inflammation-induced injury. (Adapted with permission from Screiber S, Raedler A, Stenson WF and MacDermott HP (1992) The role of the mucosal immune system in inflammatory bowel disease. In MacDermott RP and Elson CO (eds) Gastroenterology Clinics of North America, 21 453....
Colonic risk of cancer from inflammatory bowel disease (Crohn's disease and ulcerative colitis) Bayless TM and Hanauer S (eds.) (2001) Advanced Therapy of Inflammatory Bowel Disease. Hamilton, Ontario, Canada BC Decker. Griffiths AM and Bueller HB (2000) Inflammatory bowel disease. In Waker WA, Durie P, Hamilton R, Watkins J, and Walker-Smith J (eds.) Pediatric Gastroenterology Pathophysiology, Diagnosis, Management, 3rd edn, pp. 28-38. Hamilton, Ontario, Canada BC Decker.
Continence depends on a number of factors, notably normal anatomy and function of the internal-external anal sphincters and of the pelvic floor muscles, and normal anal-rectal sensation. Other variables that play a part in preserving continence are stool volume and consistency, intestinal transit and normal mental function. A complete history, examination for inflammatory bowel disease, sphincter damage or faecal impaction, and correction of predisposing factors can lead to successful treatment in many patients.
Truth About Irritable Bowel Syndrome
Irritable Bowel Syndrome, also known as IBS, is a condition in which the bowel does not function as it should. If you are one that has been diagnosed with IBS, then there is a real need to find the help to relieve the symptoms you are facing.