Inflammatory Bowel Disease (IBD)
Inflammatory bowel disease, also called IBD, is an umbrella term for a group of conditions that cause swelling and inflammation of the tissues in the digestive tract.
The most common types of IBD include:
- Ulcerative colitis. This condition involves inflammation and sores, called ulcers, along the lining of the colon and rectum.
- Crohn’s disease. In this type of IBD, the lining of the digestive tract is inflamed. The condition often involves the deeper layers of the digestive tract. Crohn’s disease most commonly affects the small intestine. However, it also can affect the large intestine and, uncommonly, the upper gastrointestinal tract.
Symptoms of both ulcerative colitis and Crohn’s disease usually include belly pain, diarrhea, rectal bleeding, extreme tiredness and weight loss.
For some people, IBD is only a mild illness. But for others, it’s a condition that causes disability and can lead to life-threatening complications.
Inflammatory bowel disease symptoms vary depending on how bad the inflammation is and where it occurs. Symptoms may range from mild to severe. A person with IBD is likely to have periods of active illness followed by periods of remission.
Symptoms that are common to both Crohn’s disease and ulcerative colitis include:
- Diarrhea.
- Belly pain and cramping.
- Blood in the stool.
- Loss of appetite.
- Losing weight without trying.
- Feeling extremely tired.
When to see a doctor
See a healthcare professional if you experience a lasting change in your bowel habits or if you have any of the symptoms of inflammatory bowel disease. Although inflammatory bowel disease usually isn’t fatal, it’s a serious disease that, in some people, may cause life-threatening complications.
The exact cause of inflammatory bowel disease remains unknown. Previously, diet and stress were suspected, but now, healthcare professionals know that these factors may aggravate IBD but aren’t the cause of it. Several factors likely play a role in its development.
- Immune system. One possible cause is change in the function of the immune system. When the immune system tries to fight off an invading virus or bacterium, an immune response that is not typical causes the immune system to attack the cells in the digestive tract too.
- Genes. Several genetic markers have been associated with IBD. Traits passed down in families also seem to play a role in that IBD is more common in people who have family members with the disease. However, most people with IBD don’t have this family history.
- Environmental triggers. Researchers believe environmental factors may play a role in getting IBD, especially factors that affect the gut microbiome. These may include:
- Being raised in a sterile environment as a child, with limited exposure to germs.
- Having a gastrointestinal infection early in life.
- Taking antibiotics during the first year of life.
- Being mostly bottle-fed.
Risk factors for inflammatory bowel disease include:
- Age. Most people who get IBD are diagnosed before they’re 30 years old. But some people don’t get the disease until their 50s or 60s.
- Race or ethnicity. IBD is more common in white people, but it can occur in anyone. The number of people with IBD also is increasing in other races and ethnicities.
- Family history. You’re at higher risk if you have a blood relative — such as a parent, sibling or child — with the disease.
Cigarette smoking. Cigarette smoking is the most important controllable risk factor for getting Crohn’s disease.
Smoking may help prevent ulcerative colitis. However, its harm to overall health outweighs any benefit, and quitting smoking can improve the general health of your digestive tract as well as provide many other health benefits.
- Nonsteroidal anti-inflammatory medicines. These include ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve), diclofenac sodium and others. These medicines may increase the risk of getting IBD or worsen the disease in people who have IBD.
Ulcerative colitis and Crohn’s disease have some complications in common and others that are specific to each condition. Complications found in both conditions may include:
- Colon cancer. Having ulcerative colitis or Crohn’s disease that affects most of your colon can increase your risk of colon cancer. Screening for cancer with a colonoscopy at regular intervals begins usually about 8 to 10 years after the diagnosis is made. Ask a healthcare professional when and how often you need to have this test done.
- Skin, eye and joint inflammation. Certain conditions, including arthritis, skin lesions and eye inflammation, called uveitis, may occur during IBD flare-ups.
- Medicine side effects. Certain medicines for IBD are associated with a risk of infections. Some carry a small risk of developing certain cancers. Corticosteroids can be associated with a risk of osteoporosis, high blood pressure and other conditions.
- Primary sclerosing cholangitis. In this uncommon condition seen in people with IBD, inflammation causes scarring within the bile ducts. This scarring eventually narrows the ducts, restricting bile flow. This can eventually cause liver damage.
- Blood clots. IBD increases the risk of blood clots in veins and arteries.
- Severe dehydration. Too much diarrhea can result in dehydration.
Complications of Crohn’s disease may include:
- Bowel obstruction. Crohn’s disease affects the full thickness of the bowel wall. Over time, parts of the bowel can thicken and narrow, which may block the flow of digestive contents. Surgery may be needed to remove the diseased part of the bowel. Rarely, bowel or colon obstruction may be seen in ulcerative colitis and could be a sign of colon cancer.
- Malnutrition. Diarrhea, belly pain and cramping may make it difficult for you to eat or for your intestine to absorb enough nutrients to keep you nourished. It’s also common to develop anemia due to low iron or vitamin B-12 caused by the disease.
- Fistulas. Sometimes inflammation can extend completely through the intestinal wall and create a fistula — a connection between different body parts that is not typical. Fistulas near or around the anal area are the most common kind. But fistulas also can occur internally or toward the wall of the abdominal area. In some cases, a fistula may become infected and form a pocket of pus known as an abscess.
- Anal fissure. This is a small tear in the tissue that lines the anus or in the skin around the anus where infections can occur. It’s often associated with painful passing of stool and may lead to a fistula around the anus.
Complications of ulcerative colitis may include:
- Toxic megacolon. Ulcerative colitis may cause the colon to rapidly widen and swell, a serious condition known as toxic megacolon.
- A hole in the colon, called perforated colon. A perforated colon most commonly is caused by toxic megacolon, but it also may occur on its own.
To help confirm a diagnosis of IBD, a healthcare professional generally recommends a combination of tests and procedures:
Lab tests
Blood tests. Blood tests can check for signs of infection or anemia — a condition in which there aren’t enough red blood cells to carry oxygen to the tissues.
These tests also may be used to check for levels of inflammation, liver function or the presence of infections that aren’t active, such as tuberculosis. Blood also may be screened for the presence of immunity against infections.
- Stool studies. A stool sample may be used to test for blood or organisms, such as infection-causing bacteria or, rarely, parasites, in the stool. These can be causes of diarrhea and symptoms. Sometimes looking for stool markers of inflammation, such as calprotectin, can be helpful.
Endoscopic procedures
- Colonoscopy. This exam allows a view of the entire colon and parts of the small intestine by using a thin, flexible, lighted tube with a camera at the end. During the procedure, a small sample of tissue called a biopsy may be taken for analysis. A biopsy is the way to make the diagnosis of IBD versus other forms of inflammation.
- Flexible sigmoidoscopy. This exam uses a slender, flexible, lighted tube to examine the rectum and sigmoid, the last portion of the colon. If the colon is badly inflamed, this test may be done instead of a full colonoscopy.
- Upper endoscopy. In this procedure, a slender, flexible, lighted tube is used to examine the esophagus, stomach and first part of the small intestine, called the duodenum. While it is rare for these areas to be involved with Crohn’s disease, this test may be recommended if you are having nausea and vomiting, difficulty eating, or upper abdominal pain.
- Capsule endoscopy. This test is sometimes used to help diagnose Crohn’s disease involving the small intestine. You swallow a capsule that has a camera in it. The images are transmitted to a recorder you wear on your belt, after which the capsule exits your body painlessly in your stool. You may still need an endoscopy with a biopsy to confirm a diagnosis of Crohn’s disease. Capsule endoscopy should not be done if a bowel obstruction is suspected.
- Balloon-assisted enteroscopy. For this test, a scope is used in conjunction with a device called an overtube. This lets the technician look further into the small bowel where standard endoscopes don’t reach. This technique is useful when results of a capsule endoscopy aren’t as expected but the diagnosis is still in question.
Imaging tests
- X-ray. If you have severe symptoms, your provider may use a standard X-ray of your abdominal area to rule out serious complications, such as toxic megacolon or a perforated colon.
- Computerized tomography, also called CT. You may have a CT scan — a special X-ray technique that provides more detail than a standard X-ray does. This test looks at the entire bowel as well as tissues outside the bowel. CT enterography is a special CT scan that provides better images of the small bowel. This test has replaced barium X-rays in most medical centers.
- Magnetic resonance imaging, also called MRI. An MRI scanner uses a magnetic field and radio waves to create detailed images of organs and tissues. An MRI is particularly useful for evaluating a fistula around the anal area or the small intestine, a test called MR enterography. Unlike with CT, there is no radiation exposure with MRI.
The goal of inflammatory bowel disease treatment is to reduce the inflammation that triggers symptoms. In the best cases, this may lead not only to symptom relief but also to long-term remission and reduced risk of complications. IBD treatment usually involves either medicines or surgery.
Anti-inflammatory medicines
Anti-inflammatory medicines are often the first step in the treatment of ulcerative colitis, typically for mild to moderate disease. Anti-inflammatories include aminosalicylates, such as mesalamine (Delzicol, Rowasa, others), balsalazide (Colazal) and olsalazine (Dipentum).
Time-limited courses of corticosteroids also are used to induce remission. In addition to being anti-inflammatory, steroids are immunosuppressing. The type of medicine recommended depends on the area of the colon that’s affected.
Immunomodulators
These drugs work in a variety of ways to suppress the immune response that releases inflammation-inducing chemicals into the body. When released, these chemicals can damage the lining of the digestive tract.
Some examples of immunosuppressant drugs include azathioprine (Azasan, Imuran), mercaptopurine (Purinethol, Purixan) and methotrexate (Trexall).
Small molecules
More recently, medicines given by mouth that are known as small molecules have become available for IBD treatment. Janus kinase inhibitors, also called JAK inhibitors, are a type of small molecule medicine that helps reduce inflammation by targeting parts of the immune system that cause inflammation in the intestines. Some JAK inhibitors for IBD include tofacitinib (Xeljanz) and upadacitinib (Rinvoq).
Ozanimod (Zeposia) is another type of small molecule medicine available for IBD. Ozanimod is a medicine known as a sphingosine-1-phosphate receptor modulator, also called an S1P receptor modulator.
The U.S. Food and Drug Administration, also called the FDA, recently issued a warning about tofacitinib, stating that preliminary studies show an increased risk of serious heart-related conditions and cancer from taking this medicine. If you’re taking tofacitinib for ulcerative colitis, don’t stop taking the medicine without first talking with a healthcare professional.
Biologics
Biologics are a newer category of therapy in which treatment is directed toward neutralizing proteins in the body that are causing inflammation. Some of these medicines are administered via intravenous, also called IV, infusions and others are injections you give yourself. Examples include infliximab (Remicade), adalimumab (Humira), golimumab (Simponi), certolizumab (Cimzia), vedolizumab (Entyvio), ustekinumab (Stelara) and risankizumab (Skyrizi).
Antibiotics
Antibiotics may be used with other medications or when infection is a concern — if there is perianal Crohn’s disease, for example. Often-prescribed antibiotics include ciprofloxacin (Cipro) and metronidazole (Flagyl).
Other medicines and supplements
In addition to managing inflammation, some medicines may help relieve symptoms. But always talk to a healthcare professional before taking any nonprescription medicines. Depending on how bad your IBD is, one or more of the following may be recommended:
Antidiarrheals. A fiber supplement — such as psyllium (Metamucil) or methylcellulose (Citrucel) — can help relieve mild to moderate diarrhea by adding bulk to the stool. For more-severe diarrhea, loperamide (Imodium A-D) may be effective.
These medicines and supplements could be harmful or not effective in some people with strictures or certain infections. Consult your healthcare team before starting these treatments.
- Pain relievers. For mild pain, acetaminophen (Tylenol, others) may be recommended. However, medicines called nonsteroidal anti-inflammatory drugs, which include ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve) and diclofenac sodium, likely will make symptoms worse and can make the disease worse as well.
- Vitamins and supplements. If you’re not absorbing enough nutrients, vitamins and nutritional supplements may be recommended.
Nutritional support
If weight loss is significant, a healthcare professional may recommend a special diet given via a feeding tube, called enteral nutrition, or nutrients injected into a vein, called parenteral nutrition. Nutritional support can improve your overall nutrition and allow the bowel to rest. Bowel rest can reduce inflammation in the short term.
If you have stenosis or stricture in the bowel, your care team may recommend a low-residue diet. This diet can help minimize the chance that undigested food will get stuck in the narrowed part of the bowel and lead to a blockage.
Surgery
If diet and lifestyle changes, drug therapy, or other treatments don’t relieve your IBD symptoms, surgery may be recommended.
Surgery for ulcerative colitis. Surgery involves removal of the entire colon and rectum. An internal pouch is then made and attached to the anus. This allows the passing of stool without having a bag for stool on the outside of the body.
In some people, creating an internal pouch is not possible. Instead, surgeons create a permanent opening in the abdomen, called an ileal stoma, through which stool passes for collection in an attached bag.
Surgery for Crohn’s disease. Up to two-thirds of people with Crohn’s disease require at least one surgery in their lifetimes. However, surgery does not cure Crohn’s disease.
During surgery, the surgeon removes a damaged part of the digestive tract and then reconnects the healthy sections. Surgery also may be used to close fistulas and drain abscesses.
The benefits of surgery for Crohn’s disease are usually temporary. The disease recurs in many people, often near the reconnected tissue. The best approach is to follow surgery with medicine to lessen the risk of recurrence.
References
- Kellerman RD, et al. Inflammatory bowel disease: Crohn disease and ulcerative colitis. In: Conn’s Current Therapy 2024. Elsevier; 2024. https://www.clinicalkey.com. Accessed July 24, 2024.
- Goldman L, et al., eds. Inflammatory bowel disease. In: Goldman-Cecil Medicine. 27th ed. Elsevier; 2024. https://www.clinicalkey.com. Accessed July 24, 2024.
- Inflammatory bowel disease (IBD) basics. Centers for Disease Control and Prevention. Accessed July 24, 2024.
- Feldman M, et al., eds. Epidemiology, pathogenesis, and diagnosis of inflammatory bowel diseases. In: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 11th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed July 24, 2024.
- Crohn’s disease and ulcerative colitis: A guide for parents. Crohn’s and Colitis Foundation. https://www.crohnscolitisfoundation.org/patientandcaregivers/youth-parent-resources/kids/importance-of-planning. Accessed July 24, 2024.
- Kliegman RM, et al. Inflammatory bowel disease. In: Nelson Textbook of Pediatrics. 22nd ed. Elsevier; 2025. https://www.clinicalkey.com. Accessed July 24, 2024.
- Yao D, et al. New progress of small-molecule drugs in the treatment of inflammatory bowel disease. Chinese Medical Journal. 2024; doi:10.1097/CM9.0000000000003026.
- Xeljanz, Xeljanz XR (tofacitinib): Drug safety communication — Initial safety trial results find increased risk of serious heart-related problems and cancer with arthritis and ulcerative colitis medicine. U.S. Food and Drug Administration. https://www.fda.gov/safety/medical-product-safety-information/xeljanz-xeljanz-xr-tofacitinib-drug-safety-communication-initial-safety-trial-results-find-increased?utm_medium=email&utm_source=govdelivery. Accessed July 24, 2024.
- Crohn’s disease. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/crohns-disease. Accessed July 24, 2024.
- Nimmagadda R. Allscripts EPSi. Mayo Clinic. May 10, 2024.
- Medical review (expert opinion). Mayo Clinic. Oct. 9, 2024.
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