The manifestations of benign belly discomfort are short-lived, with a full recovery in a few days. A more severe form of stomach discomfort may include two bowel maladies: irritable bowel syndrome and irritable bowel disease. Irritable bowel syndrome (IBS) is described in two categories: with constipation or with diarrhea. Irritable bowel disease is defined as ulcerative colitis or Crohn’s disease.
Irritable bowel syndrome with constipation (IBS-C) and irritable bowel syndrome with diarrhea (IBS-D) are functional disorders of the digestive system without causing physical damage or inflammation. IBS in North America is seen most commonly in middle-aged women. IBS risk factors are gastroenteritis due to norovirus, rotavirus, and stress. Acute gastroenteritis and stress are also triggers for IBS. Another trigger for IBS is short-chain carbohydrates, which include candy, baked goods, cereals, dairy products, honey, apples, bananas, dates, grapes, watermelon, onions, leeks, garlic, and beets. The symptoms of IBS include abdominal pain, bloating, gas, constipation, diarrhea, or both. The location of the abdominal pain is described as right, left, and central epigastric (top of the abdomen), umbilical (belly button), and hypogastric (lower abdominal) region pain. IBS causes are multifactorial, with changes in regular bowel movements, increased gut sensitivity, infectious processes, and stress.
First-line treatment for mild IBS-C (constipation) is a combination of medications that treat the patient’s constipation and abdominal pain. The osmotic laxative drug of choice is polyethylene glycol PEG) named Miralax. The mechanism of action of PEG is pulling water into the colon to soften the stool. Antispasmodic medications are administered for the relief of pain. Hyoscyamine relaxes smooth muscle in the bowel and relieves painful spasms. Side effects of hyoscyamine are drowsiness and unusual thoughts. There is a 48-hour wait before flying. Peppermint oil as a capsule or oil is also utilized for spasmodic pain. Peppermint oil is an over-the-counter medication. Second-line therapy for moderate IBS-C is a category of medications called secretagogues. Linaclotide (Linzess) softens the stool for a more effortless bowel movement. Side effects of Linzess are black, tarry stools and a high heart rate. The first-line therapy for mild IBS-D is loperamide (Imodium). Loperamide is an over-the-counter medication that increases the tone of the anal sphincter, thereby reducing the lack of control during diarrheal episodes. Side effects that may be observed with loperamide are a fast or slow heart rate, difficulty in passing urine, and constipation. Spasmodic pain seen in IBS-D can be controlled with hyoscyamine and peppermint oil. Second-line therapy for moderate IBS-D is a non-absorbable antibiotic called rifaximin. Gastroenterologists feel rifaximin inhibits bacterial overgrowth, which may be the cause of diarrhea in IBS-D patients.
Crohn’s disease (CD) and ulcerative colitis (UC) are chronic inflammatory conditions that can damage the lining of the intestines. The inflammation of the colon seen in UC patients is pervasive. Twenty percent of the patients will have extensive inflammation of the colon. Thirty to forty percent of UC patients will have left-sided colitis, and twenty percent will have inflammation of the rectal lining. CD has a very distinctive inflammatory pattern called skip lesions. The inflammation, as seen on colonoscopy, is found in multiple areas and is not continuous. Symptoms of both UC and CD are diarrhea, rectal bleeding, abdominal pain, fever, weight loss, vomiting, cramps, and muscle spasms. CD and UC are autoimmune diseases. Autoimmune diseases occur when the body’s immune system mistakenly attacks its healthy tissues. In the case of Crohn’s disease and ulcerative colitis, the immune system targets the gastrointestinal tract, leading to inflammation and other symptoms.
Medication treatment for mild to moderate UC is a group of anti-inflammatory medications called 5-ASAs. For those in the healthcare field who know the ASA abbreviation, yes, it stands for aminosalicylic acid (aspirin). 5-ASAs are very effective for inducing remission and inflammation and maintaining remission in inactive UC patients. Azulfidine and mesalamine are commonly prescribed anti-inflammatories in mild to moderate UC. Fever, nausea, and fatigue are a few of the side effects seen in patients who are prescribed 5-ASAs. The American Gastroenterologist Association (AGA) guideline-based recommendations for moderate to severe UC are a class of anti-inflammatory medications called biologicals. These medications, prescribed in moderate to severe UC, inhibit a specific inflammatory substance called tumor necrosis factor (TNF). Tumor necrosis factor plays a role in the inflammatory process in the colon. Inhibiting TNF in UC can induce and maintain remission. The most common TNF inhibitors prescribed are infliximab (Remicade), ustekinumab (Stelara), and vedolizumab (Entyvio).
The AGA medication treatment recommendations for CD are similar to those for UC treatment. Corticosteroids are first-line medications for mild to moderate CD patients. Corticosteroids are anti-inflammatory medications and play a role in remission rates and prevent flare-ups in inactive CD patients. The most commonly prescribed corticosteroids are budesonide (Entocort) and prednisone. The side effects of corticosteroids include hyperglycemia (high blood glucose), osteoporosis, cataracts, and mood swings. Basalazide is the only 5-ASA medication indicated in CD. Immune system suppressants are prescribed to decrease white blood cells that increase the inflammatory process in the bowel. Azathioprine (Imuran) is one of the immune suppressants prescribed to CD patients. The disadvantage of instituting Imuran is the side effect profile, which includes increased bowel pain, changes in hair texture, loss of appetite, and blood in the urine and stool. Biologicals are prescribed in moderate to severe CD as well. The first-line biological medication initiated is infliximab (Remicade). Two other TNF inhibitors recommended for CD are adalimumab (Humera) and certolizumab (Cimzia).
Crohn’s disease and ulcerative colitis patients have an increased risk of colorectal cancer. Patients with UC and CD involving the colon need to be especially vigilant about screenings for colorectal cancer. These patients are at higher risk for developing colorectal cancer than the general population.
In the summer of 1969, I started losing weight quickly after lettering in baseball at my high school. I lost my appetite and was having cramping and pain in the left lower quadrant of my abdomen. After each meal, I was vomiting. I was eventually admitted to the hospital, where I was diagnosed with CD. I was fortunate to have a complete remission of CD after medication therapy. Please be aware and report any abnormal weight loss, constant pain, blood in the stool, and diarrhea or constipation. IBS, CD, and UC are all treatable bowel diseases with good outcomes. Be vigilant. Be well and fly safe.
