Prioritise Gut Health

It is estimated that more than 1.1 million people in India have ulcerative colitis, and at least 300,000 more have Crohn’s disease. Neha Berry M.D., D.M. Consultant, Institute of Digestive and Liver diseases, BLK-Max Super Specialty Hospital, talks to BW Businessworld about inflammatory bowel disease and its management. 

What is inflammatory bowel disease (IBD)?

IBD is an idiopathic, relapsing immune-mediated disease triggered by an imbalance between the beneficial and commensal microflora in the human gastrointestinal (GI) system, leading to an aggravated inflammatory response involving the lining of the gut. In other words, in IBD, the patient's immune system itself attacks the intestines, causing inflammation and ulcerations. The two most common forms of IBD are ulcerative colitis (UC) and Crohn’s disease (CD).

While UC manifests as continuous ulcerations involving the large intestine, CD may involve the small or large intestine or both in a discontinuous pattern. IBD patients usually present with loose stools, blood in stools, pain in abdomen, weight loss, and occasionally fever. Not only the intestines, but IBD may have certain extra-intestinal manifestations with involvement of other parts, such as eyes, skin, and joints.

Have IBD cases increased over the last few years? What is the reason for this increase?

IBD was once recognised as a western disease, however, IBD in India is on the rise, as documented by the IBD survey in 2012. It is estimated that more than 1.1 million people in India have UC, and at least 300,000 more have CD.

Increased urbanisation, with dietary changes from a traditional high-fibre to a more westernised diet which is rich in fats, omega-6 fatty acids, red meat, and processed foods, changing socio-economic conditions, and stress from a high speed of living, have all contributed to an increased incidence of IBD. Nevertheless, a better ascertainment driven by increasing patient and physician awareness, improved diagnostic testing, and healthcare access, have also contributed to the rise in IBD. 

Can IBD be managed with lifestyle changes?

Lifestyle changes play an important role in controlling the symptoms of IBD. We usually advise our patients to have hygienic food with adequate calories, proteins, and fats, similar to a healthy individual, as common misconceptions can lead to undernutrition in IBD patients. Milk should not be restricted unless the patient has severe lactose intolerance.

Studies have shown that in up to 70 per cent of patients with UC, psychosocial stress may have caused a flare-up or worsened disease course. Hence, multi-component interventions including mind-body care, stress management strategies, exercise, and dietary counselling positively impact disease course and quality of life in IBD. However, compliance to prescribed medicines is to be reinforced at every step to maintain remission, as the commonest cause of flare-up in IBD is poor adherence to medications.

How does IBD impact fertility?

In patients with IBD whose disease is in remission and who have never had surgery, fertility rates are similar to the general population. Medical therapies for IBD, including mesalamine, steroids, azathioprine, methotrexate, and biological drugs, do not affect fertility. However, women who have had surgery like ileoanal pouch formation, rectal surgery, or stoma formations, have decreased fertility due to scarring of fallopian tubes.

Also, women with active disease are advised to consider conception after achieving remission. For women trying for assisted reproductive technology (ART), IBD medicines do not affect egg freezing or ART efficacy. A higher percentage of women with IBD are voluntarily childless mainly due to misconceptions about pregnancy in IBD which need to be clarified. 

What are the effects on pregnancy?

Normal pregnancies are observed in 85 per cent of women with IBD if they are in remission or have mild disease activity at the time of conception and throughout. As many as two-thirds of patients may relapse during pregnancy or in the post-partum period if conception occurs at the time of active disease. This underscores the importance of at least a 3 to 6 months period of remission before conception.

While the majority of patients with quiescent or mild disease have normal vaginal deliveries, caesarean section is recommended in patients with a perianal disease or active disease with rectal involvement. Foetal exposure to most IBD medicines is considered low risk to the child, except methotrexate. Both thiopurines and biologicals do not increase the risk of adverse pregnancy outcomes but are important to control disease activity and relapse, which itself can lead to preterm and low birth weight babies. 

How can these effects be managed?

Certain precautions and steps to be taken by patients with IBD and pregnancy are

•3 to 6 months remission before conception

•Optimising nutritional status – take iron, folic acid, and calcium supplements, try to achieve an ideal weight

•Prevent relapse during pregnancy – strictly adhere to medicines

•Mesalamine, short-duration steroids, thiopurines, and biologicals are considered low risk to the child during pregnancy and breastfeeding and should be continued

•Flexible sigmoidoscopy, if required, is safe throughout gestation

•Regular gastroenterologist visits throughout pregnancy, and let the doctor decide on the vaginal or caesarean mode of delivery

•Breastfeeding is not associated with risk of flare up or any risk to the child and may have a protective effect

•There should be strict adherence to medicines. 

Blurb 1: Increased urbanisation, with dietary changes from a traditional high-fibre to a more westernised diet which is rich in fats, omega-6 fatty acids, red meat, and processed foods, changing socio-economic conditions, and stress from a high speed of living, have all contributed to an increased incidence of IBD 

Blurb 2: Studies have shown that in up to 70 per cent of patients with ulcerative colitis, psychosocial stress may have caused a flare-up or worsened disease course