IBD and the Gut-Brain Connection

a patient and carer's guide to taming Crohn's disease and ulcerative colitis

Antonina Mikocka-Walus

• Publisher: Hammersmith Health Books
• Year: 2018
• Print ISBN: 9781781611401
• eBook ISBN: 9781781611418
• Topic: Medicine
• Subtopic: Diseases & Allergies

As a health scientist and 'expert patient' who has spent more than 20 years researching IBD and whose work has changed the way IBD is managed in clinics worldwide, Dr Mikocka-Walnus is ideally placed to bring all the latest research findings and clinical experience together in a truly up-to-date, evidence-based guide for people with an IBD diagnosis and their families, friends and carers. As well as general considerations including what science tells us the condition is and how it is currently treated, she addresses issues in relation to age (there is an epidemic now among children and teenagers) and circumstances (sexuality and fertility). Most importantly she looks at the gut-brain connection and with it, mental health in IBD, the two-way relationship with stress, and the pros and cons of psychotherapy, hypnotherapy and antidepressants.

Part I

Understanding IBD

Chapter 1

What is IBD?

The name ‘inflammatory bowel disease’ tells you that IBD is a disease of the intestines – that is, of the small and/or large bowel – and that some reddening and swelling must be involved, as these are the signs of inflammation. In IBD, our tummy (also called the abdomen) hurts mostly around and below the navel area where the intestines are located, though in some people upper tummy pain also occurs, and often diarrhoea, bleeding and nausea. However, explaining IBD as a condition is not as simple as this. Let’s first focus on what healthy digestion is.

When we place food in our mouth we start the process of digestion, whereby food is changed into energy and nutrients to feed the body. The food passes down a long duct, our gastrointestinal tract, beginning in the mouth and leading through the oesophagus, into the stomach and then first to the small, and later to the large intestine (they are also called small and large bowel, respectively). The final portion of the large intestine is the rectum, which ends with the anus where the wastes of the digestive process (i.e. stool, popularly called poo) are discharged.

Each section of the gastrointestinal tract has its part to play in digestion. The small bowel absorbs 90% of nutrients from the food we have eaten. The large bowel absorbs water from what is left after digestion, and expels the solid wastes via the rectum and anus from the body. When inflammation and ulcers appear in the small or large bowel, the bowel stops working as it should – we no longer absorb all the necessary nutrients, minerals and water, and we notice unpleasant symptoms such as diarrhoea, bleeding and pain, which don’t go away after a few days as they would if this was a simple bout of gastroenteritis. This is usually when we visit a doctor, and, after some investigations, we may learn that we have inflammatory bowel disease. But what exactly IBD is, is not yet fully understood. Let me briefly show you how the thinking on IBD has evolved throughout history and what is currently believed to cause it.

The history of IBD

IBD has been around for a long time. There are historical reviews indicating that the ancient Greeks and Chinese described cases of abdominal pain and diarrhoea that resembled IBD.1 IBD has two main subtypes: Crohn’s disease (CD) and ulcerative colitis (UC). The term ‘ulcerative colitis’ was first used to describe the disorder by a British pathologist, Samuel Wilks, in 1859.2 Crohn’s disease was not officially named until 1932, when Burrill Crohn wrote of the discovery of a new intestinal disease, ‘terminal (regional) ileitis’, in a letter to the American Gastroenterological Association. To honour the discoverer, surgeon Brian Brooke renamed the disease, and the term ‘Crohn’s disease’ entered common use.

In the 1930s and 1940s, a view predominated that psychological problems played a central role in the development of ulcerative colitis. Sigmund Freud’s work (on ‘talk therapy’) was influential at the time, so this wasn’t surprising, and there were some documented cases of UC being successfully treated or managed with psychotherapy. In addition, the physiologists of this era – for example, Walter Cannon, famous for his research on stress – also believed that emotional calmness was important to normal digestion, hence the thinking that psychological distress equals poor digestion.

We now know that this view is not completely wrong – stress plays an important part in IBD as I will explain in Chapter 2 where I provide an overview of the gut-brain links and their implications for those living with IBD. However, the spread of research into physiology, immunity and genetics in the second half of the twentieth century meant that IBD started to be considered as a physiological condition rather than a psychological one (that is, to do with the functioning of the body rather than the mind). In 1969, colonoscopy – a procedure where a tube is inserted into the rectum and a little camera is passed up to observe the inside of the bowel – was introduced and it allowed doctors to see inflammatory changes in the bowel for the first time.

Modern theories on the causes of IBD

Later studies into immunity have proposed that IBD develops when our bodies struggle to tolerate the bacteria inhabiting our gut.3 Genetics has also contributed to our understanding of the disease. IBD occurs in people who are genetically predisposed to getting it – there are more than 100 distinct changes to the genes that are present in people living with IBD.4 There is also an increased risk of IBD among family members of patients with IBD (stronger for those with CD than UC) and particularly in siblings. The earlier the onset of IBD, the stronger the genetic link and the higher risk for the family members.

The environment has long been considered an important factor in IBD’s causation. There is a well-known theory on how IBD came about, called the ‘hygiene hypothesis’. It states that conditions such as IBD are common nowadays because we have little contact with bacteria during our childhood.5 The cleaner we become, the more sanitised our childhoods, the more prone we become to inflammatory conditions later in life. Studies on environmental factors show that IBD is more common in industrialised countries and in urban societies and in people with fewer siblings and generally smaller families.6,7

There are also other factors contributing to its incidence.

• Smoking, for example, makes one more likely to develop CD,⁶ though it doesn’t have this effect on UC.
• Studies have also shown that some diets make IBD more likely. A high consumption of sugars and fats has been associated with an increased risk of developing IBD,8,9 while high intake of dietary fibre, including fruit and vegetable consumption, may protect against IBD.⁶ It is important to note that this evidence doesn’t tell us what we should eat when we have IBD. Instead, it simply says that people who were diagnosed with IBD could have been eating this diet before the diagnosis and it may have contributed (together with other factors) to their IBD coming about. I will tell you more about diet for IBD in Chapter 11.
• Prolonged use of the oral contraceptive pill is another factor which may make IBD more likely to occur. Hormones used in the pill have an impact on inflammatory processes in the body.⁶
• A protective factor is the removal of your appendix (a tiny sac attached to the large bowel). Those without an appendix have a lower risk of developing UC. The relationship is, however, less clear for CD.⁶
• Breastfeeding is a protective factor, with those breastfed in childhood less likely to develop IBD.⁶
• On the other hand, taking repeated courses of antibiotics in early childhood is another risk factor for the development of IBD.⁵
• Similarly, frequent use of nonsteroidal anti-inflammatory drugs, e.g. ibuprofen or aspirin, is a predisposing factor for IBD.⁶

What do all these studies tell us about the causes of IBD? They tell us that IBD is a disease in which the immune system reacts in an exaggerated way to normal bacteria inhabiting the intestines, a response which may be triggered by environmental factors, or come about because someone has a genetic predisposition.

Types of IBD

The two main types of IBD are Crohn’s disease and ulcerative colitis, but there is also a third type, indeterminate colitis (IC). This term is used when the disease resembles both CD and UC and neither can be clearly distinguished. A minority of patients (approximately 10%) fit into this category. In research studies, IC is often combined with UC because it resembles it more than the CD.

I am one of those few patients who have suffered from all three types of IBD. When I was diagnosed with IBD, it presented as Crohn’s disease and it was CD for as long as I lived in Poland. My symptoms then included diarrhoea, weight loss, occasional tummy pain, fever and anaemia.

When I emigrated to Australia, something strange started happening to my body. First, the disease went completely quiet for a few years. I guessed this must have been due to the change in climate and diet. In Australia, I stopped eating as much meat as I had been used to in Poland and switched to seafood and vegetables. I also consumed less dairy. During the long hot summers my body craved a different kind of nourishment. But after a few years, IBD returned in a changed form. My symptoms shifted to rectal pain and bleeding. I no longer lost weight – in fact, I put on weight – but my diarrhoea remained the same. After a colonoscopy, I was given a new diagnosis of ulcerative colitis. My treatment changed as well, as the disease was now located much lower (in the rectum, so at the end of the large bowel) and enemas (a medication in a liquid form provided through the rectum) became more effective than steroids taken orally.

When I moved to the UK, the disease went silent as it had for a few years after my first emigration to Australia, though not completely this time. I had to use the enemas regularly, every few weeks, whereas in the past I had enjoyed long periods of remission. I was never completely free of symptoms, but on the other hand they were never unbearable. After another series of investigations, I was told I now had indeterminate colitis. The treatment remained the same as for UC.

I am now back in Australia and watch my body with interest. Which of the old friends will it be this time?

Typical symptoms of IBD

What is common for all three types of IBD is that some people have severe symptoms while others only suffer occasionally. The cycles of remission (quiescent disease when people are symptomfree or have limited symptoms only) and flares (active disease, with the full spectrum of symptoms) also vary. Some people can be free of symptoms (in remission) for years while others may have just days or weeks of freedom and very lengthy flares.

Crohn’s disease

CD is characterised by inflammation anywhere in the digestive system (from the mouth to the anus), but most commonly in the last section of the small intestine or in the colon (i.e. the large intestine).

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Table of contents

• Cover
• Praise
• Title Page
• Dedication
• Contents
• Foreword
• Acknowledgements
• Preface
• Part I: Understanding IBD
• Part II: Living with IBD
• Part III: Treating IBD
• Conclusion
• Self-help resources
• Index
• About the author
• Copyright
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