Medicine / Rheumatology
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So you have been diagnosed with inflammatory bowel disease?

March 11, 2008

Frank Vasey, MD



Up front you should know, I am not a gastroenterologist and they are the experts regarding inflammatory bowel disease (IBD). I am a rheumatologist who believes the arthritis of IBD should shed some light on its course and treatment. By IBD, I mean Crohn's disease, ulcerative colitis, microscopic colitis, collagen colitis and indeterminate colitis. Indeterminate colitis is when it is impossible to distinguish if a patient has either Crohn's disease or ulcerative colitis.

About 10 to 20% of people with these conditions develop a unique arthritis which fits into the group of conditions rheumatologists call the spondyloarthropathies. These include ankylosing spondylitis, psoriatic arthritis, acne arthritis and reactive arthritis to food poisoning by bacterial not viral infections. The bacteria include salmonella, shigella, among others and three kinds of chlamydia, a topic further discussed in the rheumatology section of NYJSM.com.

The arthritis of IBD is effectively identical to that acquired after a salmonella infection as we can remember "Typhoid Mary", who became a chronic carrier of the organism. Based on the arthritis, IBD should have a specific bacterial cause, because all the spondyloarthropathies do. Also, colonoscopy studies from Belgium in asymptomatic (from the bowel perspective) people with psoriasis and ankylosing spondylitis show patchy inflammation in the colon typical of mild IBD. This has recently been recognized by gastroenterologists. The bacteria causing IBD is in the bowel. This is where agreement breaks down. Which organism is it? The bowel is full of millions of organisms, and while it may be unhealthy to get rid of all of them, it would also be impossible as we keep putting bacteria from food into our mouth and swallowing. Stomach acid kills some but not all of them.

I think the causative organism is enterococcus, formerly recognized as a Group D streptococcus. Here's why. If you study genetically identical twins with Crohn's disease, psoriasis and anklosing spondylitis you find identical results. In 60% of the twins both have the disease and in the other 40% only one twin has the disease. This means these conditions are not entirely caused by your genes because if this were the case all twins would have it. These conditions are partially caused by genes, but an environmental factor such as bowel bacteria is also critical. In other words, if you don't have enterococcus in your colon you don't have the disease.

Don't be turned away by the following math. If you add up the affected people in a hundred sets of identical twins it is 200 people. Looking at our example, 60 + 60 + 40 = 160. Trust me that's 80% of identical twins affected with either IBD or psoriasis or ankylosing spondylitis. That says you need an organism that is found in 80% of people. That's enterococcus. I can't deny there could be some other organism that is present in 80% of population, but it argues against E. coli which is present in everyone.

To date, this is as far as I've gone. It does suggest that everyone's choice of antibiotics Cipro and Flagyl in the management of IBD are likely not the best as enterococcus is "gram-positive" and "aerobic". Cipro is best against "gram-negative" organisms and Flagyl affects "anaerobic" organisms. Tell your doctor to check the New York Journal Style and Medicine and consider this advice or just stay tuned to the IBD Journal as our conclusions have been accepted for publication. (Click to see in IBD Journal)

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