This article delves into the complexities of Inflammatory Bowel Disease (IBD), a condition marked by prolonged digestive tract inflammation, heightening the risk of colorectal cancer. We get the expert recommendation of Dr Chok Aik Yong, Medical Director at Aelius Surgical Centre, Mount Elizabeth Orchard, Singapore.
What is Inflammatory Bowel Disease
Inflammatory bowel disease (IBD) is characterised by chronic inflammation of the digestive tract, resulting in damage to the digestive tract, impairing its function, and potentially leading to further complications. For instance, patients who have had IBD for many years are 5 to 17% (13%) more likely to develop colorectal cancer [1], with the risk increasing with age and duration of inflammation.
The two common types of IBD are Crohn’s disease and ulcerative colitis. Crohn’s disease can affect anywhere along the digestive tract from the mouth to the anus [2], with commonly affected areas being (i) the ileocaecal region- the last part of the small intestine leading to the colon, and (ii) the perianal region- the area around the anus. Inflammation seen in Crohn’s disease involves all layers of the bowel, occasionally leading to complications such as perforation and stricture formation, causing symptoms such as abdominal pain, vomiting and fever. Ulcerative colitis predominantly affects the rectum and colon. In some cases, the entire colon may be affected by chronic inflammation, causing ulcers to develop along the inner lining of the colon [2].
While the incidence and prevalence of IBD in Asia have been relatively lower compared to Western countries, the number of cases has been rising in the last decade [3]. The National University Hospital in Singapore (NUHS) reports a striking eight-fold increase in IBD patients, from below 50 in 2013 to close to 400 cases in 2018 [4]. The incidence of ulcerative colitis has also risen in the past 10 to 20 years, possibly contributed by changing diets [4].
Understanding the risk factors
IBD is most frequently diagnosed at two age peaks; between 20 to 30 years old, and in the 50s and 60s [5, 6].
IBD patients often experience adverse effects on food digestion and nutrient absorption due to chronic inflammation and complications, leading to malabsorption and malnutrition. The balance of good and bad bacteria in the colon may impact the course of the disease, and diet also plays a vital role in maintaining the balance of microorganisms in the gut. A diet high in protein has been linked to a 3.3-fold increase in risk of developing IBD [7].
IBD is also more commonly diagnosed in males, especially among Asians and smokers [5]. Familial predisposition is a risk factor as well; those who have a family member who has had IBD have an increased risk of developing the disease [8].
Recognising the symptoms
Symptoms of the disease depend on the part of the digestive tract affected and the severity of the inflammation. Patients who have very mild inflammation of the colon can report little to no abdominal pain and may have occasional diarrhoea, or a small amount of blood seen in their stools. If the inflammation is severe, patients experience more intense and persistent abdominal pain, often accompanied by fever, as well as frequent diarrhoea. As the inflammatory process is chronic, the symptoms may fluctuate over time [2].
The most common symptoms of IBD are fever, anaemia, and growth retardation in young adults [9]. Patients with Crohn’s disease commonly experience abdominal pain, diarrhoea, general exhaustion or fatigue, and weight loss. Bloody diarrhoea, abdominal pain, and prolonged/ ongoing fatigue are common symptoms of ulcerative colitis.
Some patients manifest symptoms in other areas of the body apart from the intestine, also called extra-intestinal manifestations. These include red and tender bumps on the skin, joint diseases such as arthritis, and eye inflammation. IBD has also been known to be associated with complications in other organs, such as gallstones (gallbladder) and primary sclerosing cholangitis (liver) [10].
Managing and treating IBD
Due to the complex nature of the disease, we usually recommend a multidisciplinary approach to manage the disease, involving gastroenterologists, colorectal surgeons, pharmacists, specialised stoma nurses, nutritionists, and dietitians.
During acute flare-ups of IBD, doctors usually recommend bowel rest. In some cases, doctors may recommend Total Parenteral Nutrition (TPN), where they administer nutrition intravenously to meet the body’s caloric requirements. Refined and processed carbohydrates, as well as sweetened beverages, can worsen the inflammation. In contrast, high-fibre complex carbohydrates, as seen in fruit and vegetables, have been shown to have a positive impact on IBD [7].
Newer medications, especially biologic therapy, can be effective in treating IBD. Additionally, if complications like bowel perforation or obstruction arise in emergencies, or if patients have persistent inflammation that doesn’t respond to medical therapy, they might need surgery.
Where possible, laparoscopic or keyhole surgery can be performed, enabling the patient to recover faster with other benefits, including significantly less bleeding and pain [11].
Be proactive with your gut
Chronic bowel diseases not only cause pain and discomfort. Additionally, they can also negatively impact a patient’s finances and social life, regardless of his or her age.
I attended to a 26-year-old male patient with Crohn’s disease who was not responding to medical therapy, with the disease already affecting the entire colon. Because of the extensive damage, his entire colon, including his anus, had to be removed, creating a permanent ileostomy.
I would advise all adults, regardless of age, to be proactive about their gut health and keep track of their bowel movements. Generally, anyone experiencing stool frequency more than three times daily or fewer than three times weekly over a period of more than three weeks, should see a medical or specialist consultation. Also, you should visit a specialist if you have blood in the stools.
If you fall in the high-risk group for IBD or other colorectal diseases, including cancer, you should undergo regular gastroscopy and colonoscopy. According to the American College of Gastroenterology recommendations (2023), the age to start screening for colorectal cancer among all average-risk adults is now 45 years [12]. Previously, doctors recommended people aged 50 years or older to undergo a colonoscopy, even if they didn’t show any symptoms.
Conclusion
Increasing evidence indicates that qualitative and quantitative disorders of the otherwise balanced intestinal microorganisms (dysbiosis of microbial flora) during IBD favour the production of specific toxins and metabolites associated with the formation of cancer cells (carcinogenesis). The disequilibrium in gut microflora composition also induces dysregulation of the immune response, which promotes and sustains inflammation in IBD, leading to carcinogenesis [13].
Chronic inflammation due to IBD, particularly among patients who have had the disease for over 10 years, increases their risk of developing colorectal cancer, despite the relatively young age at diagnosis. Diagnosing and treating colorectal diseases like IBD and colorectal cancer sooner improves the overall outcomes for the patient.
This article is a guest article written by Dr Chok Aik Yong. Dr Chok Ai Yong is the Medical Director at Aelius Surgical Centre, Mount Elizabeth Orchard, Singapore. As a Consultant Surgeon, he specialises in colorectal diseases such as haemorrhoids, anal fistula and fissures, bowel incontinence, inflammatory bowel disease (IBD) and colorectal cancer and minimally-invasive surgical procedures such as advanced endoscopy, laparoscopy and robotic surgery.
