Inflammatory Bowel Disease: Exploration of the Problem, Identification of the Causes and Approaches to Recovery; Part I of II

Inflammatory Bowel Disease: Exploration of the Problem, Identification of the Causes and Approaches to Recovery; Part I of II

This two-part series will explore the common problem of inflammatory bowel disease, a common affliction among the U.S. population and one which many chiropractic patients suffer from.

In this first part, the general syndrome is identified along with its epidemiology, current medical treatments and current medical theories as to etiological factors and important chiropractic relationships.

Part two of the series, which will follow in the September/October issue, will explore chiropractic ramifications of these disorders, some lesser known concepts as to etiology (cause) and how patients may find methods of recovery through identification of causes and application of chiropractic, nutritional and hygienic measures.

Few appreciate the extraordinary suffering people endure from chronic inflammation of the intestines/colon. Children and adults alike may suffer from these syndromes, which often result in a lifetime of pain, extreme inconvenience, extraintestinal symptoms and apparent hopelessness of inflammatory bowel disease.

Inflammatory bowel disease is a general term referring to inflammatory diseases of the intestines of (medically) unknown etiology. It includes the major syndromes of Crohn's disease and ulcerative colitis.

The medical diagnosis of inflammatory bowel disease is based upon internal visual examination of the intestines by sigmoidoscopy, colonoscopy and/or barium enema, symptoms (e.g., cramping pains and spasm), the presence of blood and/or mucus in the stool and by biopsy of intestinal tissue.

From these factors, an individual is labeled as having either Crohn's disease or ulcerative colitis, which are leading causes of hospitalization and disability.

The medical and scientific communities state that the etiology of both are unknown. Symptoms of both are similar, pathologic findings are often striking in their similarities, some of the epidemiologic characteristics of the two have much in common and the medical treatments nearly identical, yet much effort is often made at distinguishing one from the other.

The syndrome of ulcerative colitis is generally identified by frequent bloody diarrhea; intestinal cramps and a sense of urgency; anemia; and ulceration of the colon when viewed by direct examination.

The syndrome of Crohn's disease is generally identified by repeated bouts of fever and diarrhea accompanied by right lower quadrant pain; right lower quadrant tenderness; the presence of perianal disease with abscess and/or fistulas; and radiographic documentation of ulceration, strictures, etc., of the small intestine.

Patients with IBD present with a diversity of symptoms and, undoubtedly, have different factors contributing to their individual cases. This leads one to conclude that the attachment of a medical diagnosis of either Crohn's or ulcerative colitis to the symptoms is relatively unimportant. Of far greater importance is the search for the causes of the patients' problems.

EPIDEMIOLOGY

The epidemiologic consideration of ulcerative colitis and Crohn's disease share much in common. Both are seen most frequently in young people between the ages of 20 to 40, although no age is exempt.

In my practice, I have seen children of three and four years of age with IBD. Both sexes are equally afflicted. IBD is more common in whites than in blacks and Orientals, with a higher rate in Jews, as compared to non-Jews.

The incidence of Crohn's disease has been increasing over the past 30 years. It has generally been observed to occur less often in nonindustrialized nations, where traditional non-processed foods are consumed and a more primitive lifestyle is followed.

These same individuals, when moving to an industrialized area and adopting what dental epidemiologist Weston Price, D.D.S., called the "Diet of Commerce," soon begin to show the same levels of inflammatory bowel disorders, as seen in the urban populations they have moved into. These inflammatory bowel disorders, unrelated to infection or infestation, appear to represent chronic degenerative diseases of modern civilization.( 1)

There is some familial tendency toward IBD. It has been recorded that 2 to 5 percent of persons with IBD will have offspring also afflicted.( 2)

This argues in favor of either genetic or common environmental influences in the development of IBD. It would seem most likely that, while genetics plays some role, there is also a very strong environmental component.

Mortality rates for these two problems has decreased significantly, while the overall morbidity rates continue to climb. The death rates for whites are somewhat above those for non-whites, and are lower in rural than in urban counties.( 3)

The annual incidence of ulcerative colitis in the U.S. and Europe was 3 to 6 cases per 100,000, with a prevalence of 36 to 70 cases per 100,000 in the 1970s.( 4)

In the 1990s, the U.S. figure rose to approximately 6 to 8 cases per 100,000, and an estimated prevalence of 70 to 150 cases per 100,000.( 5)

The onset of IBD may be insidious, with the patient experiencing gradually increasing bowel irregularity with alternating constipation and diarrhea ("irritable bowel syndrome"). These symptoms may persist for many years, until one day the patient begins to have cramps, an urgent need to defecate and the release of blood and/or mucus from the bowel.

In other cases, the patient may have sudden onset with few preceding symptoms. It has been my experience that the majority of patients with this syndrome have had fatigue for a number of years, and other complaints such as allergies and vague muscle pains are commonly present.

The family medical practitioner will usually refer such patients to a gastroenterologist. Current medical protocol calls for patients to undergo a "colonscopy," a procedure in which the physician inserts a flexible optical instrument up through the rectum and entire colon doing a visual examination. The colonoscopy, a costly procedure, allows the physician to identify the presence of organic pathology, including the extent of inflammatory changes and/or the presence of tumors, cancer, polyps, etc.

A biopsy is commonly taken for the pathologist, so that a disease entity can be named. There is a risk involved from the puncturing the intenstine in order to perform this procedure.

Colonoscopy is for gross examination of organic pathology, and does not identify etiologic factors. It will identify the extent of damage, but not why the damage occurred.

The patient is assigned a name for their disease -- "ulcerative colitis" or "Crohn's disease." Both are (medically) etiology unknown.

The disability for the patient with ulcerative colitis or Crohn's disease can be severe. The extent of disease differs significantly one patient to another, but the eventual discomfort for most is profound.

Urgent, frequent trips to the toilet with cramping and spasms plague the sufferer at the most inconvenient times. On the toilet, there is frequent and severe discomfort with gripping spasms/tenesmus, only to result in the release of bloody diarrhea and mucus.

Rising from the toilet, the patient often has to return immediately, as another round of spasms and cramping pain sets in.

SURGICAL INTERVENTION

Surgical intervention is the ultimate action taken in many cases. Nearly one-third of all patients with extensive ulcerative colitis undergo surgery.( 6)

The operation commonly involves the removal of a portion of the small intestine, ranging from a few feet to many feet, and/or parts of or the entire colon. There is clear medical acknowlegement that this is not a satisfactory solution and that the problem continues:

"The inflammation tends to return in areas of the intestine next to the area that has been removed. Many Crohn's disease patients require surgery, either to relieve chronic symptoms of active disease that does not respond to medical therapy, or to correct complications such as intestinal blockage, perforation, abscess, or bleeding. Drainage of abscesses or resection (removal of a section of bowel) due to blockage are common surgical procedures."( 7)

We should not be surprised to hear that patients continue to have problems, not only from complications of the surgery itself, but also from the disease which has not been addressed as to its cause(s).

Removal of the colon, due to increased risk of cancer from ongoing inflammation of the colon, has become well enough accepted practice among much of the medical world that one dietetic text, written by a registered dietitian, refers to removal of the colon as an almost normal consequence of having the disease, stating that "an increased risk of cancer exists if the colon is not removed," and that "in many cases the colon must be removed."( 8)

In fact, as will be discussed in part two of this series, colon removal should rarely, if ever, be necessitated if proper, natural hygienic steps are taken.

CURRENT MEDICAL THERAPY FOR IBD

Traditional medical therapy for IBD includes corticosteroids and sulfasalazine and its derivatives. Corticosteroids are given both orally and sometimes through enemas into the bowel.

The most common form is prednisone. Immunosuppressive agents, including methotrexate (formerly, due to its toxicity, reserved for cancer patients), are also sometimes employed.( 9)

Other immunosuppressants used include Azathioprine, 6-mercaptopurine and Cyclosporine.( 10, 11) To add to this list of highly toxic drugs, nicotine, a drug long known for its general toxic effects on the body, has now been employed, although with questionable results, even within the medical community.( 12)

THE MEDICAL SEARCH FOR CAUSAL (ETIOLOGICAL) FACTORS

Medical investigation as to the causes of IBD have not proven fruitful. The major areas that have been investigated include genetic, infectious, immunologic and psychological factors.

Genetics: A search for genetic marker(s) that might identify those individuals more susceptible to the problem has not found any single marker.

Infection: The chronic inflammatory nature of IBD has led to an ongoing look for infectious agents, yet no single infectious agent has been found that can be widely implicated.

Immune Mechanism: The notion that an immune mechanism may be involved is logical, in light of the inflammatory nature of IBD, plus the many extraintestinal manifestations, including arthritis, uvelitis, sacroilleitis, etc.

Studies looking at associated abnormalities of cell mediated immunity, including diminished responsiveness to various mitogenic stimuli, decreases in the number of T cells, etc., all seem to revert to normal, when the disease is in a quiet state, thus suggesting that they are part of a secondary phenomenon and not part of the etiological foundation of IBD.

Psychological Factors: Psychological features of patients with IBD have been looked at extensively. It is common to find that the beginning of significant symptoms often follows a major emotional stress of some type. This, however, is true of many health problems and most likely reflects a triggering of the problem, rather than the initial cause in most cases.

Certainly patients who have suffered with IBD exhibit anger, anxiety, depression and frustration. It does not follow, however, that there is a personality flaw that causes the disease, rather it is more likely to assume that these emotions are to be expected in most people who have been afflicted (often in the prime of their lives) with an ailment that causes so much pain, inconvenience, disability, fatigue and uncertainty.

THE CHIROPRACTIC OFFICE

Patients with IBD are frequently seen in the chiropractic office. A chief reason for this is the relationship between inflammatory conditions of the gastrointestinal tract and the rest of the body, particularly the spine and the rest of the musculoskeletal system.

The following partial list includes some of the problems associated with IBD in patients, many representative of problems of the musculoskletal system:

- Chronic fatigue;

- Arthralgias;

- Allergies;

- Fistulas;

- Hemorrhoids;

- Low back pain;

- Sacroilleitis;

- Psoriatic arthritis;

- Ankylosing spondylitis;

- Neck pain;

- Shoulder pain;

- Bursitis;

- Hip pain;

- Knee pain;

- Ankle pains;

- Uveitis;

- Iriditis;

- Heart disease;

- Fibromyositis; and

- Generalized rheumatism.

Where bowel anatomy and/or physiology is altered, bacterial overgrowth can lead to the formation of immune complexes that may result in inflammation of the synovial membranes.( 13)

Where there is abnormal bowel permeability, as seen in many allergic conditions, the groundwork may be laid for rheumatological disease. Patients with arthritic problems are often observed to have GI problems. The linkage between the Gl tract and the musculoskletal system is now believed by many to be altered premeability.( 14)

Certainly, those with IBD are likely to have an altered state of gut permeability. Abnormal permeability has also been observed in cases of rheumatoid arthritis and other connective tissue diseases, such as ankylosing spondylitis.( 15)

It is of special interest that the Lancet reported that where patients undertook an elimination diet, or a partial fast, there was significant improvement in patients with rheumatoid arthritis, and this was felt to be consequence of the reduction in absorption of food or bacterial antigens and gut permeability.( 16)

Other journals have noted this relationship between the GI tract spinal problems and inflammatory joint diseases, yet standard gastroenterologists and rheumatologists do not make practical application of this information.( 6-8)

Factors that will be addressed in part two of this series are:

What considerations should be made of patients with recurrent subluxation complexes that have IBD?
What causal factors are most likely to be involved in the development and progression of IBD? How can these causal factors best be identified?
How does current medical treatment of IBD complicate and hinder effective chiropractic care and patient recovery?
What laboratory tests may be utilized in identification of causal factors and monitoring in an objective manner steps toward recovery?
What specific natural hygienic steps can patients take under supervision to assist in not merely managing the disease, but in actually reversing it?
Discussions of these questions, along with case histories illustrating the potential of assisting IBD patients to recover from what are considered medically incurable diseases, will be included in Part II of this article.

References
(1.) Price, W., Nutrition and Physical Degeneration, Price Pottenger Foundation.

(2.) Wilson, Braunwald, Isselbacher, Persdorf, Martin, Fauci, and Root, Harrison's Principles of Internal Medicine, 12th edition, p. 1269.

(3.) Memdeloff A., The Epidemiology of Idiopathic Inflammatory Bowel Disease, In: J.B. Kirsner and R.G. Shorter (eds.), Inflammatory Bowel Disease, Philadelphia; Lea and Febiger, 1975.

(4.) Ibid.

(5.) Wilson. Braunwald, Issenbacher, Persdorf, Martin, Fauci and Root, Loc. Cit.

(6.) The Merck Manual, 14th edition, 1982, p. 786.

(7.) Bonner, G.F., Current Medical Therapy for lnflammatory Bowel Disease, Southern Medical Assn.

(8.) Mahan, K.L., and Escott-Stump, S., Krause's Food. Nutrition and Diet Therapy.

(9.) Feagan, B.G., Rochon, J., Fedorak, R.N., et al., "Methotrexate for the Treatment of Crohn's Disease," N. Eng. J. Med., 332: 292-297, 1995.

(10.) Bonner, G.F, Current Medical Therapy for Inflammatory Bowel Disease, Southern Medical Assn.

(11.) Brandt, L.J., Steiner-Grossman, P., eds., Treating IBD: A Patient's Guide to the Medical and Surgical Management of Inflammatory Bowel Disease, New York: Raven Press, 1989.

(12.) Thomas, G.A.O., Rhodes, J., Mani, V., et al., "Transdermal Nicotine as Maintenance Therapy for Ulcerative Colitis," N. Engl. J. Med. 332: 988-992, 1995.

(13.) Inman, R., "Antigens: The Gastrointestinal Tract and Arthritis," Rheum. Dis. Clin. North Am., (U.S.), May, 1991, 17(2): 309-321.

(14.) Katz, K.D., and Hollander, D., "Intestinal Mucosal Permeability and Rheumatological Disease," Baillieres Clin. Rheumatol. (England), Aug., 1989, 3(2): 271-284.

(15.) Smith, M.D., Gibson, R.A., and Brooks, P.M., "Abnormal Bowel Permeability in Ankylosing Spondylitis and Rheumatoid Arthritis," J. Rheumatol. (Canada), April, 1985, 12(2): 299-305.

(16.) Darlington, L.G., and Ramsey, N.W, "Diets for Rheumatoid Arthritis," Lancet 1991, 338: 1209.

Life University.

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By Paul A. Goldberg

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