Crohn’s disease and ulcerative colitis are chronic inflammatory bowel diseases (IBD – from Inflammatory Bowel Disease) characterized by alternating periods of flare-ups and periods of remission
Their incidence is gradually increasing, and a multidisciplinary approach is essential in managing them.
What are the causes of chronic inflammatory bowel disease?
The underlying reasons for these diseases are not yet well understood: a number of concomitant causes have been identified, from a broad genetic predisposition of the individual to a number of environmental factors.
These would intervene, at some point in the life of a predisposed person, in changing the intestinal bacterial flora, which would then result in an aberrant immune response in the intestines.
This is the biological beginning of the disease: subsequent flare-ups and remissions then lead to intestinal damage, ulcers, and then the symptomatology that leads to the doctor.
For this reason there can often be a diagnostic delay.
Chronic inflammatory bowel diseases: who they affect and how widespread they are
There is no epidemiologic registry of chronic inflammatory bowel disease in Italy, but we do have prevalence estimates that have been generated from regional epidemiologic studies and extrapolation of administrative databases: there are an estimated 250,000 people in Italy with chronic inflammatory bowel disease, of whom about 60 percent have ulcerative colitis and the remaining 40 percent have Crohn’s disease.
The peaks of incidence are in youth, late adolescence and young adulthood, then between 15-20 and 35-40 years of age; about 20% of patients are diagnosed in pediatric age.
The incidence of these diseases has been gradually increasing for about 30-40 years, in Italy as in other Western countries; an interesting finding, from the point of view of pathogenesis, is that the greatest increase in incidence is in countries that have had greater development from an economic and industrial point of view, such as China, India, and Brazil: this is probably related to changes in lifestyle and diet and other environmental factors.
There are several hypotheses from this point of view: other factors that could trigger the mechanism behind these diseases are improved hygienic conditions, cold chain food storage, and pollution, which trigger the immune response in the gut, in the case of these diseases, but also in other organs, in the case of other immune-mediated diseases such as rheumatoid arthritis or psoriasis.
Chronic inflammatory bowel diseases and the impact on quality of life
Emerging at a young-adult age, these diseases affect people when they are in the prime of their productive, working, and family lives.
Characteristic of these diseases is that the risk of death is not increased compared to the general population, but the impact on the individual’s adjusted quality of life is very heavy.
The burden of these diseases is considerable in terms of direct costs, so everything related to the management of the disease and any associated extraintestinal manifestations, visits, medications, sometimes surgery, because up to 40 percent of patients with Crohn’s disease may go through bowel resection within 10 years and up to 20 percent of patients with ulcerative colitis may go through colectomy within 10 years.
But even with regard to indirect costs, which are estimated to be even higher than the direct costs, such as productivity at work, disability pensions, absenteeism, presenteeism, everything that falls on the patient’s life and is often not calculable still constitutes a cost.
The multidisciplinary approach in chronic diseases
In more than 40% of cases of chronic inflammatory bowel disease there is the presence of associated extraintestinal immune-mediated manifestations.
Up to 30% of patients may have arthritis, 10% may have immune-mediated skin manifestations, 2-3% eye inflammation, and 5-6% biliary tract and liver inflammation.
When these extraintestinal manifestations are found, the impact on quality of life is even worse, of course, and multidisciplinary management becomes very important in these cases.
In modern chronic disease management, a multidisciplinary approach cannot be ignored: the presence of a team of specialists brings, for example, better outcomes in identifying possible comorbidities (some studies estimate 25% more diagnoses that would have been made with a shared outpatient clinic) but also in managing them.
Prolonged remission over time: a key goal
Prolonged remission over time is the goal that physicians and patients would like to achieve.
The main wishes reported by the patient with ulcerative colitis when offered treatment are that the treatment works quickly, lasts as long as possible, and has an acceptable safety profile.
Unfortunately, prolonged remission over time cannot always be achieved, and therefore, not only new therapeutic solutions are desirable, but also new treatment strategies that can allow a patient to remain asymptomatic for years in terms of both patient-reported symptoms and the anatomy of the disease, which is taken into great consideration today: thus restoration of normal intestinal mucosal integrity, without diarrhea and without bleeding, which are characteristic symptoms of ulcerative colitis and which significantly impair the patient’s quality of life.