Inflammatory bowel disease (IBD) is often misdiagnosed

Vishal Sharma

Mrs Bela T (47) had been having irregular episodes of bloody diarrhoea for 10 years and would often take antibiotics for it. Two years after the onset of symptoms, she was diagnosed with ulcerative colitis, but stopped treatment after her symptoms improved. When she experienced severe abdominal pain with bleeding, further evaluation showed the presence of disseminated colon cancer due to untreated ulcerative colitis, a subtype of inflammatory bowel disease or IBD.

At 15 lakh cases, India is believed to have the second largest patient base globally after the US. An autoimmune disease of the gut, its numbers are expected to increase in the coming years. While the causes are not entirely clear, it is believed that both genetic and environmental factors result in an autoimmune process that injures the gut and its barrier. Some studies attribute the rising numbers to westernisation of Indian lifestyles, increased intake of fat and carbohydrate-rich diet, reduction in fibre intake and rising use of ultra-processed foods.

Although lumped under a single term ‘IBD’, the disease is broadly recognised to have two sub-types — ulcerative colitis (largely affecting the large intestine) and Crohn’s disease (which may affect both large and small intestines). Besides the intestines, IBD may also have extra-intestinal manifestations resulting in many problems, including those related to joints, skin, liver and various other organs.

Non-specific symptoms

IBD’s symptoms are diverse and non-specific. Most patients experience bleeding in stools, long-standing diarrhoea, abdominal pain, intestinal obstruction, weight loss, etc. A diagnostic delay is well recognised due to the non-specificity of symptoms. Absence of specific clinical features, limited access to diagnostic facilities, confusion with other gastro-intestinal diseases that may mimic IBD, and lack of awareness about this condition remain major factors behind a delayed diagnosis.

In TB-endemic countries such as India, gastrointestinal tuberculosis closely mimics Crohn’s disease. Delay in diagnosis may cause complications like intestinal strictures, intestinal obstruction, massive bleeding or even colon cancer.

There is no permanent cure for IBD. The Hindi name ‘sangrahani’ aptly captures the disease’s chronic nature. IBD patients have to take medication throughout their life, making it an expensive affair. Many go through a cycle of denial, searching for a permanent cure, stopping standard therapy and trying alternative therapies, which often result in reactivation of the disease. These flare-ups usually result in increased cost of care, need for hospitalisation and emergency surgery. Managing IBD needs coordinated care between doctors and the patient.

Symptoms often take a toll on patients. Active disease is associated with fatigue, abdominal pain, bloody diarrhoea that may cause low BP, malnutrition, systemic toxicity, etc, endangering a patient’s life or necessitating surgery. As it is usually a prolonged problem, it may result in absenteeism from work, loss of job, low self-esteem, inability to do normal activities, travel, etc, as patients need access to clean toilets and hygienic food.

The disease has been recognised to impact the mental health of both patients and caregivers. However, if IBD remains under control, patients can live a near-normal life with routine activities and dietary precautions.

Standard therapy for IBD has been 5-aminosalicylates (routine IBD medication), steroids and immune-modulators. While steroids are cost-effective, have quick action and excellent response rates, their prolonged use is associated with significant adverse effects, including bone loss, risk of diabetes, cataract, deranged lipid profile, etc.

Recent research has identified some specific inflammatory mediators (chemical agents in the body) responsible for IBD. This has made feasible the possibility of targeted therapies that may have less immunosuppression and adverse effects. Unfortunately, some of these therapies are costly and not affordable for many IBD patients. However, advances, including introduction of biosimilars (drug similar to another biological medicine) and generic small molecules, and increasing insurance coverage through private and government insurance schemes, are likely to improve the access to advanced IBD therapies to a large number of patients.

Lifestyle measures for IBD patients

• Eat hygienic, well-cooked and balanced diet.
• Increase fibre intake. Many studies say fibre plays a significant role in reducing IBD due to its influence on healthy gut bacteria. However, in a subset of patients with narrowing in intestine (intestinal strictures), fibre may be detrimental.
• Reduce fried and fast food.
• Avoid eating out as hygiene may be a concern.
• Have more curd, buttermilk, fruits and vegetables.
• Opt for adult vaccinations for preventable diseases, as IBD and certain medications may reduce immunity and result in increased risk or adverse outcomes of infections.
• Avoid painkillers and antibiotics unless prescribed.
• Be compliant with treatment and regular with follow-up.

When to consult the doctor

• Blood in stools
• Long-standing or recurrent diarrhoea
• Urgency to pass stool and increased frequency of bowel movements
• Recurrent pain in abdomen
• Intestinal obstruction
• Unexplained weight loss or anaemia
• Non-healing or complex perianal fistula

— The writer is Additional Professor, Gastroenterology, PGIMER, Chandigarh