Inflammatory bowel disease : Why do I have these symptoms ?

W II ETIIFR A l'ATIEN1 IIA:~YMPtoms of inflammatory h(>Wcl Jiscasc (I RL)) is dependent on the acti v i I y anJ I he extent of involvement. Patient, in qu1escc111 states may h ave no ,ymptom~ at all, while, during exacerbation,, they may he severely ill. Most people wllh rnn, irrespeCll \'l' whcther the} ,uffer from C rohn\ disease or ulcerat 1ve colius, cxpcriem:e three major symptoms: Jiarrhea, abdtinunal pa111 and fever. These arc u~uall } as,oc iateJ with weight loss and anemia. The nature of the diarrhea nfren helps the phy,ician 11, locali:e the area of the bowel involved hy 1he 1nflamm,1tury process. T he l ypc of.ihdommal pain may also vary depending on the severity and the locm inn nf bowel inflammat ion. Sometime, pa111 baggravateJ hy eating. Thb may le.1J to decrease intake of food and weight lms. In children, growth may he delayed o r rcrnrded . (,row1 h spuns may be stnnulatcd hy 111creasing the dai ly caloric intake. Fever 1s always an 11npnrrant sign of active disease. It may he intermi11e111 or persistent, ranging frnm 38.5'' to 40"C, and may he accompanied by shaking S LEMIRE, MD, FACG


Inflammatory bowel disease: Why do I have these symptoms?
W II ETIIFR A l'ATIEN1 IIA:-~YMP- to ms of inflammatory h(>Wcl Jiscasc (I RL)) is dependent on the acti v i I y anJ I he extent of invol vement.Patient, in qu1escc111 states may h ave no ,ymp-tom~ at all, while, during exacerbati on,, they may he severel y ill.
T he l ypc of.ihdommalpain may also vary depending on the severit y and the locm inn nf bowel inflammat ion.Som etime, pa111 baggravateJ hy eating.Thb may le.1J to decrease intake of food and weight lms.In children, growth may he delayed o r rcrnrded .(,row1 h spuns may be stnnulatcd hy 111creasing the dai ly caloric intake.
Fever 1s always an 11npnrrant sign of active disease.It may he intermi11e111 or persistent, ranging frnm 38.5'' to 40"C, and may he accompanied by shaking S LEMIRE, MD, FACG chills.Night sweats strongly suggest the presence of an ahscess or arc a significant c lue to the seriousncs~ of the illness.
The causes of anem ia in [8[) vary from mm deficiency to c hronic hlooJ loss, to anemia of c hronic disease.Generally speak.mg,chron ic disease depresses the bone marrow and inn.:rfcres with reJ hlnnJ cell production.Vi Lam in 812 and folic acid deficiency result either from 1naJcyuate intake or malahsorpt ion and wil l lead to megalo blas ti c anemia.

C ROHN'S DISEASE
Crnhn's disease is characterized by ulcers rhat can involve the whole thickne •s of the bowel and, on healing, this may result in fibrosis.The disease can affect any portion of the digestive tract from the mouth w the anus.Hence, symptoms wi ll depend on the location of the 111flammatory process.
Ulceratiom of the mouth can occur and may be painless.S ize o f these ulcers rnry.If there is infl,,nHnation in the esophagus, there may he pa in with swa llnwmg o r heartburn.The stomach may also he affected; the principal sym ptom s a rc nausea, vnmiung ,rnd upper ,ihdominal pain.In the du~iJenum, tht syrnproms may he s imilar t,> rhrn,e ol peptic ulcer: hurnmi_: or gn,1wing abdom inal pa111, naw,ea .mdvomiting The la tter cwo ,ymptrnm .iredue to rht impaired passage ot food, secnndar) tu inflammation that lau,cs narniwmg 111 the gut adjacent t11 l he ,tumach.
More typically, Crohn\ J1se,hc ,II fccts segme nts nf the sm.1 11 or the largt howel.If parts of l he ,mall buwcl art affected, luwer abdomina l pa m may he associated ,, 11 h Lramp, ,mJ hlnm1110 after cat ing, since food stimulates bowd acti vity.lnflammat ion , a, stated before, ma1 result in narrowing 1,f che hllwcl and this may cause partial nhstruction.Thl pain is mostly due en strong C.llntr,K tions and ~cverc spa,m~ tlf the 111testmt to overcome the hloc.kage.
When these bacteria arc present in excessive ,1mount.s,rhcy may cause malabso11~tinn offats, si nce they dccnnjugate bile acids.This will lead 10 111creased diarrhea.They may als11 compete wnh the absorption llf nut rimcnts, such as sugar, starc h es and vitamms, in particular vitam in B12.
The terminal ileum is the most frequently 11wolved pan nf the intestinal tract, occunng 111 50'\, of pauents.I( the J1sense b located at the tenninal ileum, a u~ndcr mass in the right lower quaJrnnt of the ahdomen may he present.This mas, 1s o ft en due tn inflamed howel loops that hecnmc thick and adherent, or w swellmg of sum,unding ussues such as the mt'scntcry.Terminal ilea! disease results 111 seve re diarrhea for twn reasons: • the inflamed il eum 1s capahlc of secreting excessive amnunh nf water and elect nilytes • bile sa lt, found normally 111 the sma ll intestine arc reahsorbcJ 111 this area.I( the hmvel 1s inflamed, hile salts \\'111 not be ahsorbed and they will reach the cnhm in large quantities.Rile salts arc known w tncrease rhe ~ecrc-t1on of water and electrolytes by the colo n .This wi ll lead ro diarrhca.T he elcctn1lytcs lost arc mmt ly pl)tassium, snd ium, chlo rides and bicmbonatcs.
Vitamin 81 2 1s ;1hsorbcd dt rhc terminal ileum.When this part of the bowel is diseased, R12 is not absorbed normally and its blood level 1s Jl'creascd.This v i1 am 1n is essential for the fo rmati on ofhlood cel b .A c hronic Jeficiency will produce anemia.
C rohn\ disease may involve the colon.This occurs in 20% of patients.

ULCERATIVE COLITIS
In ulcerative colitis, intlammatil)ll llCCurs only in the uilon and m,1y he limited to the distal part of the colon, the rectum.The latter is called ulccra-ti\'L' proctit1s.S111cc inllammat1nn 1s 1111 the surface 1111111g the howcl, the fiN symplnms a rc hlecd111g and diarrhea.
Severity of symptoms relates tu the extent of bowel 11w,1lvemcnt by 111tlam-111at ion.
When 1mly the rectum i, 11wnl\'ed hy the inflammatnry process, \\'h1ch occu rs in 2 5 to 30% of the u lcerative cnlius populatiun, p.1ssage of blood nr mucu~ alone may llC<..ur several times during the J,1y or nighr, withour any stool.In le,, severe cases, howcl movements, cnated hy l:,lnod or mucus, arc accompanied hy for med stools.Mucus is a clear secret inn of the digestive tract that may act as a defence mechani~m and a lubrican t lif rhe intestine.When inflammation uccurs, mucus is produced in excessi\'C amount.
Early diagno,1, of I RD may he difficult because symptoms o m be mild in th e first stages.Pain, diarrhea, tenesmus, hlondy stools, faugue and weight loss arc often present early in the dbease.With any of these symptoms, nnc must seriously con~ider the diagnosis of IBD.
ACKNOWLEDGEMENTS: The author expresses appreciation w S uzan ne Bilodeau for assisrnnce in preparing the manuscript.