- Colitis vs. Irritable Bowel Syndrome
- IBD & IBS: Q & A
- What’s the difference between IBS and IBD?
- Syndrome vs. disease
- Risk factors
- Triggers and symptoms
- Associated health risks
- Ulcerative Colitis vs Crohn’s Disease
- Similarities and Differences
- How are Ulcerative Colitis and Crohn’s Disease Similar?
- Differences Between Ulcerative Colitis and Crohn’s Disease
- Indeterminate Colitis
- Irritable Bowel Syndrome-Like Symptoms in Ulcerative Colitis Patients in Clinical Remission: Association with Residual Colonic Inflammation
- Prevalence of IBS in General Population
- Prevalence of IBS-Like Symptoms in UC Patients in Remission
- Endoscopic Findings
- Fecal Calprotectin Level
- Histological Findings
- Relapse of UC with or without IBS-Like Symptoms
- Disclosure Statement
- Author Contacts
- Article / Publication Details
- Copyright / Drug Dosage / Disclaimer
Colitis vs. Irritable Bowel Syndrome
Q1. How can I tell the difference between colitis and irritable bowel syndrome? I have had various testing done and have been told that I only had some diverticulitis. But in the past few years, I have diarrhea every day. Most of the time it is uncontrollable, so I take a lot of Imodium — and then I have problems with constipation. I have had barium enemas and have never had anyone tell me what I can do to stop the diarrhea. Is there any other test I should ask to have done?
— Rosanna, Florida
The best way to differentiate between irritable bowel syndrome (IBS), ulcerative colitis, and microscopic colitis (inflammation of the colon) is to have a colonoscopy and extensive biopsies done so your doctor can closely look at your colon and the tissues inside it. Colonoscopy findings in people with irritable bowel syndrome are generally completely normal, and antispasmodic treatments, whether herbal or prescription, often help.
In ulcerative colitis, there are always visible ulcerations in the colon along with friability (easily broken tissue), scarring, and redness. Biopsies are taken to confirm that a diffuse inflammatory response is present. The initial treatment used for ulcerative colitis is one of the 5-aminosalicylic acid (5-ASA) agents, which are anti-inflammatory drugs used to calm disease activity.
Patients with microscopic colitis, either lymphocytic colitis or collagenous colitis, often have normal colonoscopies, but their biopsies show intense inflammation consisting of lymphocytes, a particular type of white blood cell. The best therapies for microscopic colitis are Entocort (budesonide) or bismuth subsalicylate (Pepto-Bismol).
Since you are still uncertain about what your particular problem is, I would be sure to see a qualified gastroenterologist who can perform these tests and help you receive a correct diagnosis.
Q2. I am a 45-year-old male. I have had colitis since 16. The last 8 feet of my small intestine were perforated, and I was on a daily regime of pills for years. I’m now in remission and have had a few flare-ups over the years. My bowel movements have never recovered to normal consistency. Is this excessive liquid in my tract for all these years going to cause me future problems? And what can I do to make improvements?
Your history is confusing to me. Firstly, patients with ulcerative colitis rarely have small bowel involvement – only the large bowel is involved. Next, a perforated small bowel is a life-threatening emergency that would have required immediate surgery.
Finally, if 8 feet of your small bowel were removed, then you would be suffering from short bowel syndrome and have quite a bit of diarrhea. So, your diarrhea could be due to active disease or to short bowel syndrome. Often, identifying the correct diagnosis will lead to the best therapy to help your problems.
Q3. Over the years, I have been told by doctors that I have colitis, then irritable bowel syndrome , then Crohn’s. There’s always pain in the abdomen, and sometimes in my back. Sometimes I have diarrhea and other times I am blocked. They recently ran the scope into the anus only to find internal hemorrhoids . I have also been told I had a bacterial infection when my colon was swollen so much it was a little bit outside. There was also some bleeding two times. Years ago when the problem started, there was diarrhea and the passing of little black dots.
Ulcerative colitis and irritable bowel syndrome (IBS) are very different diseases, although ulcerative colitis patients can have IBS-like symptoms. For the diagnosis of ulcerative colitis to be made, there should be consistent diarrhea and bleeding, with ulcerations seen on colonoscopy and negative stool cultures.
In your case, a normal colonoscopy – except for internal hemorrhoids – mostly excludes ulcerative colitis as a diagnosis. Your bleeding is likely due to the hemorrhoids. IBS is diagnosed with symptoms of diarrhea and/or constipation, abdominal pain, and a normal intestinal evaluation. Your problems appear to be consistent with IBS.
Q4. What are the symptoms of IBS and colitis? Are they related in any way?
Both irritable bowel syndrome (IBS) patients and ulcerative colitis patients have abnormal bowel habits, usually severe diarrhea and abdominal pain. One distinguishing clinical feature is that patients with ulcerative colitis also have rectal bleeding. Also, colonoscopy results are different: IBS patients will have a normal examination, while patients with ulcerative colitis will show lesions or sores on the lining of the intestine.
Of course, the treatments are very different also. IBS patients frequently respond to fiber supplements and anti-spasmodic agents, like Bentyl (dicyclomine) and Levsin (hyoscyamine), while ulcerative colitis patients usually respond to drugs that block inflammation, such as 5-aminosalicylic acid drugs or steroids.
IBD & IBS: Q & A
What is the difference between irritable bowel syndrome and inflammatory bowel disease? How would I know if I have either one of these?
Irritable bowel syndrome (IBS) is a common though uncomfortable disorder of the colon or rectum. While the basic cause of IBS is unknown, researchers have found that the colon muscle in people with IBS contracts more readily than in people without IBS. A number of factors can “trigger” IBS, including certain foods, medicines, and emotional stress. IBS is not a life-threatening condition and does not make a person more likely to develop other colon conditions, such as colitis, Crohn’s disease, or colon cancer.
Symptoms of IBS include:
- Abdominal pains or cramps (usually in the lower half of the abdomen)
- Excess gas
- Harder or looser bowel movements than average
- Diarrhea, constipation, or alternating between the two
Symptoms of IBS DO NOT include bleeding or black stools.
Inflammatory bowel disease (IBD) most often refers to Crohn’s disease and ulcerative colitis, but also might be referred to as colitis, enteritis, ileitis, and proctitis. Both Crohn’s disease and ulcerative colitis cause inflammation of the bowel.
Crohn’s disease is a chronic illness in which the intestine (bowel) becomes inflamed and ulcerated (marked with sores). Crohn’s disease typically begins in the lower part of the small intestine (ileum), although it can occur in any part of the large or small intestine, stomach, or esophagus. Crohn’s disease affects the entire thickness of the walls of the bowel, explaining why patients with Crohn’s disease are prone to developing fistulas and abscesses. In addition, sections of diseased bowel can be interrupted by sections of healthy bowel.
The symptoms of Crohn’s disease depend on where the disease occurs in the bowel and its severity. In general, symptoms include:
- Chronic diarrhea
- Weight loss
- Abdominal pain and tenderness (often on the right side of the lower abdomen)
- Feeling of a mass or fullness in the lower, right abdomen
Ulcerative colitis occurs only in the large intestine and typically follows an unbroken pattern. Ulcerative colitis affects only the large intestine. It does not affect the esophagus, stomach, or small intestine. It affects only the inner layer of the colon (mucosa), and does so in a continuous pattern. The inflammation begins in the rectum and then spreads to other segments of the colon.
The main symptom of ulcerative colitis is diarrhea, which subsequently becomes bloody. Occasionally the symptoms of ulcerative colitis include severe bloody diarrhea, abdominal pain, and fever.
If you suspect you have IBS or IBD, it is important to see your health care provider. Your provider should review your medical history and perform a physical examination. To diagnose IBD, one or more of the following tests might be ordered:
- Blood tests
- Stool samples
- Endoscopic examination of the colon with biopsies
- CT scanning
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What’s the difference between IBS and IBD?
Confused by Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD)? Don’t worry, we’ve got you covered with this handy guide.
These two very similar acronyms stand for two very different conditions that affect the digestive tract. And it doesn’t help that both are popular with the media, so they probably pop up frequently in your news feed.
This article will teach you how to distinguish IBS from IBD, reviewing risk factors, symptoms and even how the gut microbiome is affected.
Syndrome vs. disease
In IBS, -S stands for syndrome. In medical terminology, a syndrome is a collection of symptoms occurring together that characterise a particular condition. Often, there is no identifiable cause and this is the case for irritable bowel syndrome.
IBS affects nearly one in five British adults. Women are more significantly susceptible to it than men when you break down the numbers: IBS affects 23% of British women, compared to just 11% of British men. 1 in 5 UK adults have IBS
However, it has been suggested that rates may be higher in men, but they are simply less likely to consult a doctor about it.
In IBD, -D stand for disease. A disease is a condition that prevents the body, or part of it, from functioning normally, and is usually distinguished by a collection of symptoms and signs. There are two subtypes of inflammatory bowel disease: Crohn’s Disease and ulcerative colitis.
They don’t affect the digestive tract in the same way, but they have many similarities and that’s why they are members of the same disease group. 1 in 420 Brits have ulcerative colitis
About 1 in every 420 people in the UK is affected by ulcerative colitis. That’s about 146,000 British people living with it, compared to about 115,000 living with Crohn’s.
☝️TIP☝️ The Atlas Biomed DNA Test checks for genes associated with ulcerative colitis and Crohn’s. We combine these data with your personalised Health Survey to estimate your risk level for IBD.
IBS usually occurs in people from adolescence to their 40’s. Gastrointestinal infections, emotional trauma, antibiotics and some other drugs are also considered risk factors. It’s more common in women who are, incidentally, more susceptible to stress.
Photo by Kinga Cichewicz / Unsplash
IBD has several risk factors, including genetic predisposition and abnormal immune system reactions. Many health professionals suggest that these risk factors may be triggered by environmental and lifestyle factors, including previous gastrointestinal infections and the Western diet.
Ulcerative colitis risk factors
|AGE||People usually get diagnosed with ulcerative colitis around 30 years old, but it can emerge later, even after age 60 in some cases.|
|ETHNICITY||Most common in people of Ashkenazi Jewish heritage, followed by white populations of European descent.|
|FAMILY HISTORY||Higher risk for people with direct relatives (child, sibling, patient) suffering from ulcerative colitis|
Crohn’s risk factors
|AGE||People usually get Crohn’s when they’re young, and most diagnoses happen around 30 years old.|
|ETHNICITY||Most common in people of Ashkenazi Jewish heritage, followed by white populations of European descent, but also on the rise in black populations of North America and the UK.|
|FAMILY HISTORY||Higher risk for people with direct relatives (child, sibling, patient) suffering from Crohn’s. Up to 1 in 5 patients have a family member with the disease.|
|TOBACCO||Smoking is a significant risk factor, and considered the greatest manageable risk for Crohn’s. It is also linked to more severe onset and higher risk of surgery.|
|NSAIDs||Nonsteroidal anti-inflammatory medications include common off-the-shelf painkillers, like ibuprofen. They can cause inflammation of the gut lining that can worsen the condition.|
|EXTERNAL||Living in an urban area or industrialised country increases the risk of getting Crohn’s. Diets with highly-processed, refined and friend foods may play a role in getting this disease.|
Inflammation is a response by the body’s immune system to a detected threat. Nowadays, doctors and researchers like to distinguish two different ways inflammation can affect human health.
IBS: low-grade chronic inflammation
Not visible to the naked eye, but stimulated by factors like stress, poor diet and imbalanced gut microbial communities. Low-grade chronic inflammation is believed to play a role in many preventable diseases including obesity, diabetes type II and cardiovascular disease.
IBD: acute inflammation
Inflammatory bowel disease is now considered an autoimmune condition: the body’s immune system reacts abnormally to specific triggers (foods, stress episodes, smoking, alcohol, etc.).
This acute response takes the shape of inflammation that causes lesions to form on the affected organ. These lesions can evolve into open wounds, which is why bloody stools are considered a sign of IBD.
☝️STRESS☝️It’s not mental weakness. It is a physiological reaction to a perceived threat (conscious or subconscious) that activates the central stress response system in the body, called the hypothalamic-pituitary-adrenal axis (HPA axis for short).
Photo by Nik Shuliahin / Unsplash
☝️STRESS☝️ generates a cascade of chemical events, heightens the senses, redirects blood away from “non-essential” functions like reproductive and digestive organs, and modifies how sugar is managed when it reaches the bloodstream. It also triggers inflammation. That’s why it’s considered a risk factor for many chronic and preventable diseases in modern-day society.
Triggers and symptoms
A significant difference between these conditions is in the symptoms. Two patients with IBS can experience it very differently, whereas a patient with Crohn’s or ulcerative colitis will have one prescriptive set of symptoms.
IBS symptoms can vary from patient to patient. Usually, a doctor should recommend specific diagnostic assessments to rule out other potential causes, and the patient must experience symptoms for at least 1 day per week for 3 months before a diagnosis of IBS can be made.
People with IBS are divided into 3 subcategories, depending on whether they get diarrhoea, constipation or both (mixed type).
It is not uncommon for patients with IBS to feel like their symptoms are brushed off lightly by doctors, but they can be serious enough to cause significant physical and emotional distress.
Crohn’s and ulcerative colitis symptoms have a lot in common, but they’re not identical.
|SHARED SYMPTOMS||Abdominal pain/cramping|
Crohn disease can affect any part of the digestive tract and lesions can appear anywhere from the mouth to the rectum. However, it is most commonly found in the small intestine.
|CROHN’S SYMPTOMS||Mouth sores|
|Loss of appetite|
|Pain or leakage near anus (perianal fistula)|
This is a problem because the small intestine is responsible for absorbing the nutrients in your meals. Flares cause inflammation, and this is what prevents the small intestine from doing its job, putting patients at risk of deficiencies. In addition, the lesions can cause scar tissue that can have a long-term consequences for digestive health.
Ulcerative colitis only affects the colon (large intestine), home to your gut microbes, and also the location where your body forms poop – and poop is an important indicator of how well you are digesting food.
|ULCERATIVE COLITIS SYMPTOMS||Blood/pus in diarrhoea|
|Urgent need to defecate|
|Inability to defecate despite urgency|
|Failure to thrive (in children)|
Several liters of water are flushed through a normal human colon every day. In fact, this process allows fibre in your stool to absorb hormones and toxins so they can be removed from the body. However, during an ulcerative colitis flare up, inflammation can prevent water from entering and exiting the colon normally, leading to loose watery stools.
Thanks to DNA sequencing technology, scientists are now able to study the gut microbiome, a large and essential ecosystem of mostly bacteria that reside in our gut. There is growing evidence that the composition of our gut bacteria influences health and disease, including IBS and IBD.
Research into the gut microbiome indicates that specific bacteria may contribute to IBS-Constipation type. For example, Methanobrevibacter Smithii, can produce methane, a gas known to slow intestinal motility (the transit of stool through your gut).
Interestingly, people with IBS-Diarrhoea or IBS-Mixed types may have lower levels of methane-producing bacteria in their gut. Research also indicates that they may have depleted populations of microbes that produce butyrate.
Butyrate is a very important short-chain fatty acid for the human gut, because it provides up to 90% of fuel for the cells of the gut lining. It also helps maintain the integrity of the gut lining and prevent inflammation.
A lot of research has been conducted into the relationship between gut bacteria, ulcerative colitis and Crohn’s. It has identified a number of factors, including the elevated presence of pathogenic microbes like E. coli, as well as previous gastrointestinal infections as a precursor.
Researchers have also noted that patients experiencing a flare tend to have lower levels of probiotic and beneficial bacteria. It has also been suggested that specific patterns of dysbiosis (negative alterations in the composition of the gut microbiome) may participate in triggering inflammatory bowel disease.
In fact, there’s so much evidence and research into this topic that we actually wrote a whole article about it. If you’re interested, just click on the link to your right.
Associated health risks
An important differentiation between IBS and IBD are the associated health risks. Both IBS and IBD can cause anxiety, depression and significantly reduce a person’s quality of life.
However, IBD is linked to serious complications and health risks including weak joints and bones, ulcers, Parkinson’s and colon cancer.
That is why it’s important to consult your doctor if you experience persistent digestive symptoms, especially if they include weight loss or bleeding. We know, it’s awkward talking about such topics because the gut is such a taboo organ, but that’s what doctors are for!
1. IBD leaves visible lesions in the gastrointestinal tract.
2. IBS is a collection of symptoms with no obvious cause.
3. Lifestyle factors and diet are involved in both these conditions.
4. Research links negative changes in the gut microbiome to IBS and IBD.
5. Anxiety and depression are common in people with these conditions.
6. IBD significantly increases serious disease risks, but IBS does not.
Ulcerative Colitis vs Crohn’s Disease
Similarities and Differences
Ulcerative colitis and Crohn’s disease are the two main forms of inflammatory bowel diseases. They are both conditions characterized by chronic inflammation of the digestive tract. Although they share many similarities, there are key differences between the two diseases.
How are Ulcerative Colitis and Crohn’s Disease Similar?
- Both diseases often develop in teenagers and young adults although the disease can occur at any age
- Ulcerative colitis and Crohn’s disease affect men and women equally
- The symptoms of ulcerative colitis and Crohn’s disease are very similar
The causes of both UC and Crohn’s disease are not known and both diseases have similar types of contributing factors such as environmental, genetic and an inappropriate response by the body’s immune system
Differences Between Ulcerative Colitis and Crohn’s Disease
The differences between ulcerative colitis and Crohn’s disease are:
- Ulcerative colitis is limited to the colon while Crohn’s disease can occur anywhere between the mouth and the anus
- In Crohn’s disease, there are healthy parts of the intestine mixed in between inflamed areas. Ulcerative colitis, on the other hand, is continuous inflammation of the colon
- Ulcerative colitis only affects the inner most lining of the colon while Crohn’s disease can occur in all the layers of the bowel walls
Approximately 10% of cases of inflammatory bowel diseases exhibit the features of both Crohn’s disease and ulcerative colitis. These are typically known as indeterminate colitis.
Irritable Bowel Syndrome-Like Symptoms in Ulcerative Colitis Patients in Clinical Remission: Association with Residual Colonic Inflammation
Ulcerative colitis (UC) patients in clinical remission often experience irritable bowel syndrome (IBS)-like symptoms. The prevalence rate of UC patients meeting the definition of IBS, such as shown by the Rome criteria, is significantly higher in those without ongoing clinical activity as compared to healthy controls. Several studies have investigated residual low-grade inflammation found in colonic mucosa of quiescent UC patients and its association with development of IBS-like symptoms. In these patients, residual colonic inflammation was evaluated using endoscopy and histology findings, as well as fecal calprotectin level and shown to not be simply associated with the presence of IBS-like symptoms in UC patients in clinical remission. However, these results are limited by the low number of related investigations conducted. Additional appropriately designed studies are necessary to confirm the relationship of low-grade colonic inflammation with IBS-like symptoms associated with UC.
© 2018 S. Karger AG, Basel
Irritable bowel syndrome (IBS), a functional disorder of the intestines, is characterized by abdominal pain and discomfort, along with alterations of bowel habits . On the contrary, ulcerative colitis (UC), a major form of inflammatory bowel disease (IBD), is a chronic immune- and inflammation-mediated intestinal disorder characterized by clinical symptoms, including bloody stool, diarrhea, and fever. Organic intestinal lesions are not usually found in IBS patients, thus the IBS disease entity is recognized to be fundamentally different from IBD. However, recent studies have revealed that etiological factors, such as genetic background, history of infectious gastroenteritis, impaired gut barrier function, and psychological stress, overlap between IBS and IBD . Moreover, overlaps have also been observed between these diseases with regard to clinical symptoms . Notably, IBS-like symptoms are often found in UC patients who have no evidence of the ongoing clinical disease activity . Numerous studies have demonstrated possible mechanisms related to the development of IBS-like symptoms in quiescent UC patients . In this review article, we focus on the degree of residual low-grade colonic inflammation in UC patients in clinical remission who were evaluated by endoscopy and histological findings, as well as fecal calprotectin (FC) level and discuss their association with the development of IBS-like symptoms.
Prevalence of IBS in General Population
A number of epidemiological studies have reported the prevalence of IBS in a variety of populations in various countries . In an evaluation presented by Manning, prevalence based on Rome I or Rome II criteria ranged from 2.3 to 22% . Furthermore, we recently reported that the prevalence of IBS in subjects who underwent general medical check-ups was 4.8% (Rome III criteria) . On the contrary, a Japanese study conducted by Miwa revealed that the prevalence of IBS was 13.1% (Rome III criteria). Although such heterogeneity may be dependent on the enrolled population, as well as sample size and the criteria used for diagnosis, the prevalence of IBS in the general population based on numerous previous studies is estimated to be approximately 10%.
Prevalence of IBS-Like Symptoms in UC Patients in Remission
Successful treatment of UC patients with anti-inflammatory and immunomodulatory drugs leads to the induction of remission. However, even after remission has been induced, as assessed by validated clinical scores, some patients have frequent abdominal symptoms, such as pain and discomfort with altered bowel habits, which are widely recognized as “IBS-like symptoms.”
Several previous studies enrolled patients without ongoing disease activity (clinical remission) and investigated the prevalence of symptoms meeting the criteria for IBS. Halpin and Ford presented results of a systematic review and meta-analysis regarding the prevalence of IBS-like symptoms in UC patients in remission. They examined 3,045 articles, and analyzed data obtained from 6 cross-sectional and 4 case-control studies selected from those that identified and reported IBS-like symptoms in examined patients, and reported a pooled prevalence of 31.0%, which was significantly higher than that of the control cases in those studies (7.5%). However, the remission criteria used in those studies varied, as some focused only on clinical symptoms as remission criteria , while others defined remission in their UC patients by evaluating both clinical and endoscopic findings . Since residual colonic inflammation is often found in UC patients with clinical evidence of remission, it is possible that achievement of endoscopic remission (mucosal healing; MH) in addition to the absence of ongoing clinical symptoms may reduce the development of IBS-like symptoms. Previous studies have reported that the prevalence of IBS-like symptoms is associated with the degree of MH assessed by endoscopic and histological examination findings, and FC level.
Isgar et al. and Simrén et al. included endoscopic findings in their criteria for determining remission of UC, though these definitions were not sufficiently validated. We found several studies including our own that discussed endoscopic findings in association with IBS-like symptoms in UC patients (Table 1). In these studies, Rome II or III criteria were used for the diagnosis of IBS-like symptoms, while endoscopic remission was defined by Mayo (MES ≤1) or Matts (Matts grade ≤2) endoscopic score. Ansari et al. used MES ≤1 to define endoscopic remission and found that the prevalence of IBS-like symptoms in such patients was 46%, which was relatively higher as compared to previous studies of UC patients in clinical remission. We previously investigated the influence of endoscopic remission (Matts grade ≤2) on prevalence of IBS-like symptoms in 172 UC patients in clinical remission (clinical activity index, CAI < 4) . However, the difference between clinical and endoscopic remission was not significant (26.7 vs. 25.6%). Furthermore, a more recent study revealed that the prevalence of IBS-like symptoms in UC patients in endoscopic remission (MES ≤1) was 26.6%, which was similar to that in previous studies of such patients .
Prevalence of IBS-like symptoms in UC patients in endoscopic remission
Although Matts grade ≤2 and MES ≤1 are widely recognized for defining endoscopic remission, mild mucosal activity remains in the colonic mucosa of patients diagnosed as Matts grade 2 or MES 1. In this regard, the prevalence of IBS-like symptoms may be decreased in patients with complete endoscopic remission, defined as Matts grade 1 and MES 0 . In our previous study, when endoscopic remission was strictly defined as Matts grade 1, the prevalence of IBS-like symptoms decreased from 25.6 to 15.4% (Table 1) . In contrast, a more recent study did not find a difference in regard to the prevalence of IBS-like symptoms between patients classified as MES 0 (25.4%) and MES ≤1 (26.6%; Table 1) . Therefore, it is unclear whether endoscopic evidence of remission is directly associated with the prevalence of IBS-like symptoms in UC patients in clinical remission. In fact, the number of studies of this issue is still quite limited and further investigations are necessary.
Fecal Calprotectin Level
Calprotectin is a calcium- and zinc-binding protein that is released mainly by neutrophils. Since infiltration of neutrophils during intestinal inflammation results in the release of calprotectin in stools, termed FC, its level is well correlated to mucosal activity in UC patients . In particular, FC level is considered to be an effective surrogate marker for evaluating mucosal healing in UC patients in clinical remission .
Several groups have investigated the correlation between the prevalence of IBS-like symptoms and FC level in UC patients in clinical remission (Table 2). In a previous study reported by Keohane et al. , IBS-like symptoms were detected in 38.6% of UC patients in remission (Rome II criteria) and were significantly associated with an increased level of FC. In a recent study reported by Jonefjäll et al. , who defined remission criteria based on endoscopic findings (MES ≤1) and FC level (< 200 μg/g), the prevalence of IBS-like symptoms was relatively low (18.2%) (Table 1). This latter finding suggests that a lower level of FC, in addition to endoscopic remission, may be associated with a reduced rate for the prevalence of IBS-like symptoms.
Prevalence of IBS-like symptoms in association with fecal calprotectin levels
On the contrary, recently published studies that used Rome III criteria did not find a correlation between FC level and prevalence of IBS-like symptoms, though average or mean FC levels varied among them (Table 2) . In our recent study, we also did not find a significant increase in the level of FC in UC patients with IBS-like symptoms in clinical remission (data not shown). Thus far, the results of studies related to this issue remain controversial, and possibly dependent on the study population and sample size, as well as remission criteria used for defining UC and IBS-like symptoms.
Histological changes such as infiltration of various inflammatory cells without endoscopic evidence of inflammation have been found in certain populations of IBS patients. These findings have been primarily observed in patients with post-infectious IBS (PI-IBS), which is defined as a type of IBS that develops in previously asymptomatic individuals following an episode of acute gastroenteritis caused by bacterial or viral infection . PI-IBS is found in approximately 10–20% of patients diagnosed with IBS . Previous studies of affected patients have reported a variety of immune cells, including T cells (CD3+, CD4+, CD8+ cells), macrophages, B cells, and mast cells, infiltrating the mucosa of the small and large intestines without endoscopic inflammation. In addition, increased levels of interleukin-1β and interferon-γ have been found in rectal and colonic biopsy tissues in patients with PI-IBS . Taken together, these findings suggest that histological evidence of intestinal inflammation in the absence of endoscopic activity may have a relationship with the pathogenesis of IBS.
On the contrary, residual low-grade histological inflammation is often found in the colonic mucosa of UC patients even after they show clinical and endoscopic remission , which might be associated with the development of IBS-like symptoms. Recently, Henriksen et al. investigated the influence of histological inflammation on the prevalence of IBS-like symptoms in UC patients with endoscopic evidence of remission and lower FC levels. They did not find reduced frequency of IBS-like symptoms in these cases, even when histological inflammation was not revealed in colonic biopsy findings. The study was the first to report the influence of histological inflammation on IBS-like symptoms in UC patients in remission. In patients with PI-IBS, various factors related to systemic immune activation, in addition to histological inflammation, have been reported. In this regard, the pathogenesis of IBS symptoms in PI-IBS patient may differ from that in UC patients in remission, though low-grade histological inflammation is observed in association with both disease entities.
Relapse of UC with or without IBS-Like Symptoms
In a recent investigation, we reviewed the records of UC patients in clinical remission who had been enrolled in our previous study to determine the period without relapse in association with IBS-like symptoms. In the clinical remission group with IBS-like symptoms, the mean relapse-free period was shorter as compared to that of patients in the group without such symptoms, suggesting that the presence of IBS-like symptoms is predictive of UC relapse . However, endoscopic activity (Matts grade) was significantly higher in the group of patients with IBS-like symptoms. Therefore, we speculate that residual inflammation in colonic mucosa might have an influence on UC relapse. Nevertheless, this is the only study presented that investigated this issue and further investigations to confirm the influence of IBS-like symptoms on relapse of UC are needed.
Our findings indicate that the degree of residual low-grade colonic inflammation, as evaluated by endoscopy and histology findings, as well as FC level, is not correlated with the prevalence rate of IBS-like symptoms in all cases. Although IBS-like symptoms in certain patients may be predominantly affected by low-grade colonic inflammation, such a population has not been clearly shown, possibly because of the limited number of appropriate studies. On the contrary, apart from colonic inflammation, the pathogenesis of IBS has been reported to be associated with a variety of factors, including genetics, visceral hypersensitivity, increased gut permeability, microbiota dysbiosis, immune activation, and abnormal serotonin metabolism. Overlaps between colonic inflammation and those factors might have an influence on the presence of IBS-like symptoms in quiescent UC patients. Additional studies are necessary to more fully understand the pathogenesis of IBS-like symptoms in UC patients in remission, ultimately leading to the development of new therapeutic options.
The authors have no financial or other conflicts of interest to declare in relation to the contents of this article.
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Shunji Ishihara, MD, PhD
Department of Internal Medicine II, Inflammatory Bowel Disease Center
Shimane University Hospital, Shimane University Faculty of Medicine
89-1, Enya-cho, Izumo, Shimane (Japan)
E-Mail [email protected]
Article / Publication Details
Published online: December 14, 2018
Issue release date: December 2018
Number of Print Pages: 6
Number of Figures: 0
Number of Tables: 2
ISSN: 0012-2823 (Print)
eISSN: 1421-9867 (Online)
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