Bowel cancer

Bowel (or colorectal) cancer is the second most common cancer in Australians and is particularly prevalent in those over 50 years of age. Symptoms of bowel cancer include a change in bowel habits, thin bowel movements, blood in the stools, abdominal or rectal pain, fatigue or weight loss. It is estimated that 16,682 new cases of bowel cancer will be diagnosed in Australia in 2017, accounting for 12.4% of all newly diagnosed cancer cases in Australia.

Incorrectly, many people believe that bowel cancer primarily affects men. However, it is also the second most common cancer amongst women, second only to breast cancer. A survey of 787 people by the Cancer Institute NSW found that whilst 69% of respondents recognised that bowel cancer commonly affects men, only 37% knew of its prevalence among women.

Bowel cancer develops from the inner lining of the bowel and is usually preceded by growths on the inner lining of the bowel that often protrude into the intestinal lumen. These growths are known as polyps and are caused by genetic changes or mutations. Although fairly common, polyps can become malignant (cancerous) and need to be monitored in order to recognise the signs that cancer may be developing.

There are various other factors that increase your risk of developing bowel cancer including a genetic vulnerability, inflammatory bowel disease (such as Crohn's disease or ulcerative colitis), being overweight or obese and environmental factors including high alcohol consumption, high red meat consumption (particularly processed meat) and smoking. By eating a healthy diet with plenty of fresh fruit and vegetables, maintaining a healthy body weight and not smoking the risk of developing bowel cancer can be reduced.

According to the Australian Institute of Health and Welfare, not only is bowel cancer the second most common form of cancer, it is also the second biggest killer after lung cancer. It is estimated that there will be 4,114 bowel cancer deaths in 2017, up from 4,071 deaths in 2014. Currently the five-year survival rate for Australians diagnosed with bowel cancer is 69%. Bowel cancer can be treated when diagnosed early, and the National Bowel Cancer Screening Program currently provides free screening kits that can be done at home for people over the age of 50. However, despite its importance, only 34.5% of those eligible for screening in NSW actually have completed these tests.

One of the biggest problems is the issue of stigma, with bowel cancer being seen as 'dirty or embarrassing', a view which is decreasing the rate of screening uptake. Although most people realise that early detection and diagnosis is essential in treating diseases such as bowel cancer, many are embarrassed to seek information and advice, or report concerns to their doctor. This embarrassment and stigma is costing lives and needs to be tackled to make people aware of the importance of screening to minimise their risk of bowel cancer.

Sources

The statistics presented above are summarised here and originally sourced from the Australian Institute of Health and Welfare.

Dietary advice for inflammatory bowel disease

Poor nutritional health and IBD

There is no evidence to support that diet or food allergies can cause, prevent or cure inflammatory bowel disease (IBD) such as Crohn's disease or ulcerative colitis. However, diet is an important consideration for individuals with IBD – especially those with Crohn's disease – as they are more at risk of poor nutritional health due to:

• Loss of appetite due to abdominal pain, nausea, fear of eating and worsening symptoms.
• Poor digestion and malabsorption due to the disease itself or medications.
• An increased need of nutrients for the body – chronic diseases such as Crohn's disease increase the energy needs of the body, particularly during flare ups.

Nutritional deficiencies are common in IBD, particularly Crohn's disease and can cause added complications such as anaemia, weight loss and impaired growth and development (in children). Therefore, in some cases nutritional supplements may be advised.

How IBD will affect my diet

Generally, most people with IBD should eat a varied, well-balanced diet, however it is advised that you consult with your GP or dietician to develop an individual diet plan based on:

• Which disease you have (Crohn's or ulcerative colitis).
• For Crohn's patients: Whether you have an intestinal stricture (narrowed section of the bowel).
• What part of your intestine is affected and to what severity.
• Whether your disease is active or inactive.

For inactive disease it is generally advised that you have a well-balanced, nutritious diet, however during active disease additional considerations may be required.

Although there are plenty of diets advertised for especially managing IBD it is important to remember that the success rate of alleviating symptoms depends on the individual, there is no scientific evidence to support these diets. The best method to find a diet that works for you is to keep a food journal to track what you eat and your body's reaction and discuss this with your GP or dietician to develop a customised diet plan for you.

General dietary considerations for IBD

Certain aspects of your normal diet may not be tolerated well during IBD flare ups and may need altered following a discussion with your doctor/dietician.

Trigger foods

A benefit of a food journal is that you can keep track of which food act as triggers and worsen your symptoms as they will not be the same for all IBD sufferers. You may then be able to eliminate these certain foods from your diet, however it is essential this is done with the supervision of your doctor or dietician to ensure it doesn't result in nutritional deficiencies.

Fibre

For general health a high fibre diet is advised, however for many people with IBD may find that consuming fibre during active disease or if they have strictures may cause abdominal cramps, bloating and worsening diarrhoea. Insoluble fibre (doesn't dissolve in water) in particular is a harder, more coarse fibre that is more difficult to digest and can exacerbate IBD symptoms and even cause intestinal blockages in severe disease or when strictures are present. Soluble fibre (does dissolve in water) on the other hand absorbs water and makes food move more slowly through the intestine and can reduce diarrhoea. Most foods contain a combination of soluble and insoluble fibres.

Cooking, peeling and removing seeds from fruit and vegetables, and avoiding wholegrain carbohydrates are important ways for IBD patients to reduce their intake of insoluble fibre when required.

Lactose

Some people with IBD are also lactose-intolerant which can be diagnosed with a simple test. Some Crohn's disease patients may lack the enzyme 'lactase' found in the small intestine which breaks down lactose and therefore may need to avoid milk and other dairy products. Dairy products are an important source of calcium so supplements may need to be taken to avoid deficiencies.

High-fat foods

People with IBD may struggle with fat absorption and eating high-fat foods such as butter, margarine or cream may lead to increased diarrhoea or gas.

Fluids

It is essential to keep hydrated, and it is recommended that you drink 8-10 glasses of water a day. Fruit juices diluted in water can also be good to drink. Alcohol and drinks containing caffeine dehydrate the body and should be avoided.

In general, the dietary guidelines for managing IBD include:

• Eat smaller meals to reduce the load on the digestive tract.
• Eat more regularly to maintain calorie/energy needs.
• Avoid trigger foods.
• Eat more simply or blandly, avoiding spices.
• Limit foods containing insoluble fibre (seeds, nuts, beans, leafy vegetables, fruit).
• Reduce the amount of fried, greasy and high-fat foods.
• Keep hydrated and avoid alcohol and caffeine.

Examples of recommended foods and foods to avoid include:

Resources

The Crohn's and Colitis Foundation of America (CCFA) has a very useful booklet describing the impact of IBD on maintaining healthy nutrition, how diet can impact your disease, tips for managing IBD with a healthy diet, and other resources including sample meal plans, recipes and a food journal template and is available here.

Other useful websites include:

Crohn's and Colitis Foundation - I'll Be Determined
https://www.ibdetermined.org/ibd-information/ibd-diet.aspx

Guts4life
http://www.guts4life.com/living-with-ibd/lifestyle-matters/living-healthily

Ulcerative Colitis

What is Ulcerative colitis?

Ulcerative colitis (UC) is one of the two main types of inflammatory bowel disease (IBD) which are characterised by chronic intestinal inflammation. UC primarily affects the large intestine (colon) and rectum, with the inflammation tending to be continuous and only affecting the inner lining. In UC, small open sores (or ulcers) form on the surface of the lining which may bleed, and the colon produces a larger amount of intestinal mucus which may contain pus.

In severe cases of UC, where the inflammation has penetrated deeper into the intestinal wall, complications may arise and require immediate medical attention. These may include profuse bleeding from deep ulcers, perforation (rupture) of the colon and the shutdown of normal intestinal contractions.

It is estimated that approximately 33,000 Australians have UC (although numbers are expected to be higher), with women and men affected equally. UC can affect anyone of any age but usually first presents between 15 and 30 years of age.

Symptoms

UC presents with a number of symptoms which can range from mild to severe including:

• Diarrhoea (which is often bloody)
• Abdominal pain
• Vomiting
• Rectal Bleeding
• Loss of appetite
• Weight loss
• Anaemia
• Weakness and fatigue

People affected by UC may go through periods of remission where they experience no, or very mild, symptoms. However, they can then also relapse, where symptoms flare up once more. UC patients may also experience additional complications with their joints, skin, eyes, kidneys, liver and bones.

What causes Ulcerative colitis?

Despite extensive research the exact cause of UC remains unknown, but it is thought to involve a complex combination of interacting factors including genetics, the immune system, microbial factors and environmental factors.

Genetics
Genetics do have a role in UC, and a family history of IBD is associated with an increased risk of an individual developing the disease. Numerous genes have been linked to increased UC risk with research being heavily focused on why mutations in these genes may predispose an individual to UC.

Immunological factors
An abnormal immune response to normal substances and bacteria found in the intestine is characteristic of UC and causes the inflammatory injury in the bowel. What triggers this inappropriate immune reaction currently remains unknown.

Microbial factors
The normal balance of healthy gut bacteria is disrupted in UC and the role of the gut microbiota (population of microbes/bacteria that live in our intestines) in IBD has become a hot topic over recent years. There has also been a lot of research into specific bacterial infections including Fusobacterium varium contributing to UC development however research is still ongoing.

Environmental factors
Surprisingly, unlike for Crohn's disease (the other major IBD), smoking has been suggested to decrease the risk of UC. Diet is also thought to play an important role in the development of UC, and living in a Western society is also associated with increased prevalence of the disease.

Diagnosis

UC can be difficult to diagnose due to its similarities to other gastrointestinal disorders such as Crohn's disease. There is no single test for UC and a number of investigations may be required to determine a correct diagnosis including:

• Medical history
• Physical examination
• Blood tests
• X-rays
• Examination of stools
• Colonoscopy (direct visualisation of the bowel using a miniature camera attached to a long flexible tube that is inserted inside the anus)
• Biopsy

Treatment

UC treatment depends on disease location, severity, complications and response to previous treatment. There is no cure for UC and current treatments focus on controlling inflammation, relieving symptoms and correcting nutritional deficiencies. Common treatments include:

Anti-inflammatory agents
Aminosalicylates (5-ASA) are used to treat mild to moderate inflammation in UC by controlling inflammation, inducing and maintaining remission of disease. Corticosteroids may be used in moderate to severe cases but due to potential side effects, are only recommended as a short-term treatment.

Immunosuppressive agents
Immunosuppressive agents suppress the immune system to control inflammation by suppressing the release of inflammation-inducing chemicals.
Antibiotic agents
Research suggests that certain bacterial infections may contribute to the development and persistence of UC, and targeting these pathogens may initiate remission of the disease.

Nutritional supplementation
As UC can lead to nutritional deficiencies, supplements may be recommended, particularly for children with impeded growth and development.

Surgery
People with severe UC may at some point require a surgical procedure such as a resection (removal of the colon). Generally this involves removing the colon and creating a pouch from the end of the small intestine and joining it directly to the anus, or alternatively to an opening (stoma) on the surface of the abdomen to which a bag can be attached to collect faecal matter. Surgery is generally a very successful treatment for UC.

Resources

Crohn's and Colitis Australia 
https://www.crohnsandcolitis.com.au/about-crohns-colitis/

IBD support Australia 
http://www.ibdsupport.org.au/

Gastroenterological Society of Australia 
http://www.gesa.org.au/resources/patients/inflammatory-bowel-disease/

Centre for Digestive Diseases 
http://www.cdd.com.au/pages/disease_info/ulcerative_colitis.html

Crohn's Disease

What is Crohn's disease?
Crohn's disease is one of the two main types of inflammatory bowel disease (IBD) which are characterised by chronic intestinal inflammation. Crohn's can affect any part of the digestive tract from the mouth to anus but most commonly affects the lower small intestine (ileum) and the large intestine (colon). The inflammation tends to be patchy rather than continuous and extends throughout the thickness of the bowel wall.

Complications which may develop in Crohn's disease include malabsorption and malnutrition, strictures (narrowing of bowel wall or intestinal obstruction), fistulae (abnormal channels connecting loops of intestine to itself or other body organs) and fissures (tears in the anal lining).

It is estimated that approximately 28,000 Australians have Crohn's disease (although numbers are expected to be higher), with women slightly more likely to be affected than men. Crohn's can affect anyone of any age but usually first presents between 15 and 30 years of age.

Symptoms

Crohn's disease presents with a number of symptoms which can range from mild to severe including:

• Diarrhoea (which may be bloody)
• Abdominal pain
• Vomiting
• Rectal Bleeding
• Loss of appetite
• Weight loss
• Anaemia
• Weakness and fatigue

People affected by Crohn's disease may go through periods of remission where they experience no, or very mild, symptoms. However, they can then also relapse, where symptoms flare up once more. Crohn's disease patients may also experience additional complications with their joints, skin, eyes, kidneys and liver.

What causes Crohn's disease?

Despite extensive research the exact cause of Crohn's disease remains unknown, but it is thought to involve a complex combination of interacting factors including genetics, the immune system, microbial factors and environmental factors.

Genetics
Genetics do have a role in Crohn's disease, and a family history of IBD is associated with an increased risk of an individual developing the disease. Numerous genes have been linked to increased Crohn's disease risk with research being heavily focused on why mutations in these genes may predispose an individual to Crohn's disease.

Immunological factors
An abnormal immune response to normal substances and bacteria found in the intestine is characteristic of Crohn's disease and causes the inflammatory injury in the bowel. What triggers this inappropriate immune reaction currently remains unknown.

Microbial factors
The normal balance of healthy gut bacteria is disrupted in Crohn's disease and the role of the gut microbiota in IBD has become a hot topic over recent years. There has also been a lot of research into specific bacterial infections including mycobacterium paratuberculoisis (MAP) contributing to Crohn's disease development however there is no conclusive evidence to suggest this is the case.

Environmental factors
Smoking has been well-established as contributing to the development (being associated with a 3-4 times increased risk) and the exacerbation of Crohn's disease, and patients are strongly advised to quit. Diet is also thought to play an important role, and living in a Western society is also associated with increased prevalence of the disease.

Diagnosis

Crohn's disease can be difficult to diagnose due to its similarities to other gastrointestinal disorders such as ulcerative colitis. There is no single test for Crohn's disease and a number of investigations may be required to determine a correct diagnosis including:

• Medical history
• Physical examination
• Blood tests
• X-rays
• Examination of stools
• Colonoscopy (direct visualisation of the bowel using a miniature camera attached to a long flexible tube that is inserted inside the anus)
• Biopsy

Treatment

Crohn's disease treatment depends on disease location, severity, complications and response to previous treatment. There is no cure for Crohn's disease and current treatments focus on controlling inflammation, relieving symptoms and correcting nutritional deficiencies. Common treatments include:

Anti-inflammatory agents
Aminosalicylates (5-ASA) are used to treat mild to moderate inflammation in Crohn's disease by controlling inflammation, inducing and maintaining remission of disease. Corticosteroids may be used in moderate to severe cases but due to potential side effects, are only recommended as a short-term treatment.

Immunosuppressive agents
Immunosuppressive agents suppress the immune system to control inflammation by suppressing the release of inflammation-inducing chemicals.

Antibiotic agents
Antibiotics may be useful in preventing and controlling bacterial infections, and reduce harmful intestinal bacteria. They may also be used in healing fistulae or abscesses in people with Crohn's disease.

Nutritional supplementation
As Crohn's can lead to nutritional deficiencies, supplements may be recommended, particularly for children with impeded growth and development.

Surgery
Many patients with Crohn's disease may require surgery to solve problems such as stricture, obstruction or fistulae or even require resectioning to remove diseased portions of the gastrointestinal tract. This may involve joining the remaining intestine directly to an opening (stoma) on the surface of the abdomen to which a bag can be attached to collect faecal matter.

Resources
Crohn's and Colitis Australia 
https://www.crohnsandcolitis.com.au/about-crohns-colitis/

IBD support Australia 
http://www.ibdsupport.org.au/

Gastroenterological Society of Australia 
http://www.gesa.org.au/resources/patients/inflammatory-bowel-disease/

Centre for Digestive Diseases 
http://www.cdd.com.au/pages/disease_info/crohns_disease.html

Inflammatory bowel disease

What is IBD?
The term Inflammatory Bowel Disease (IBD) covers a group of chronic diseases characterised by inflammation of the gastrointestinal tract, primarily the intestines. It is estimated that over 75,000 Australians have an IBD, although the number is likely higher, and it usually first presents in individuals aged 15-30 years, although all ages can be affected.

What causes IBD?
The cause of IBD remains unknown but it is believed to be a combination of genetic, environmental and immunological factors. The current hypothesis is that in genetically predisposed individuals, the immune system fails to 'switch off' it's normal defence mechanism (inflammation) following exposure to an environmental factor – possibly viruses or bacteria for example – and this prolonged inflammation damages the intestinal tract and causes the symptoms of IBD.

Symptoms of IBD
Symptoms of IBD include abdominal pain, diarrhoea and fatigue, and appear in cycles of remission – where the patient has no or very mild symptoms and feels generally well – and relapse – when symptoms flair up once more. There is currently no cure for IBD with current treatments focussed on managing symptoms and extending periods of remission. Symptoms can range in presence and severity between individuals and additional complications affecting joints, eyes, liver, kidney and skin may also arise.

Types of IBD
The two main types of IBD are Crohn's disease and ulcerative colitis. Diagnosis of either Crohn's disease or ulcerative colitis (or another bowel condition) can be delayed as they both present with similar symptoms and cycle through periods of relapse and remission. However there are some key differences between Crohn's disease and ulcerative colitis:

Differences between Crohn's disease and ulcerative colitis
Factor	Crohn's disease	Ulcerative colitis
Primarily affected region	Ileum (last part of small intestine) and colon	Colon (large intestine) and rectum
Pattern of inflammation	Patchy	Continuous
Depth of inflammation	Throughout entire bowel wall	Bowel wall lining only
Rectal bleeding?	Uncommon	Common
Strictures/fissures?	Common	Uncommon
Association with smoking	Strongly associated with smoking along with worse outcome	Associated with non-smokers or ex-smokers - smoking may protect against disease

Diagnosis and treatment of IBD

Diagnosis usually requires a number of medical investigations including:

• Medical history
• Physical examination
• Blood tests
• X-rays
• Examination of stools
• Colonoscopy (direct visualisation of the bowel using a miniature camera attached to a long flexible tube that is inserted inside the anus)
• Biopsy

Following a diagnosis, treatment of IBD may include a combination of:

• Anti-inflammatory agents – to control inflammation, and induce and maintain remission of disease.
• Immunosuppressive agents – to suppress the immune system to control inflammation.
• Antibiotic agents – to prevent and control bacterial infections.
• Nutritional supplementation – to combat nutritional deficiencies.
• Surgery – to solve additional complications.

Resources

Crohn's and colitis Australia
https://www.crohnsandcolitis.com.au/about-crohns-colitis/
https://www.crohnsandcolitis.com.au/site/wp-content/uploads/PwC-report-2013.pdf

Personal stories of those affected by IBD
https://www.crohnsandcolitis.com.au/about-crohns-colitis/member-stories/

Gastroenterological society of Australia
http://www.gesa.org.au/resources/patients/inflammatory-bowel-disease/

The Gutsy Group
http://www.thegutsygroup.com.au/crohns-colitis/what-are-crohns-colitis/