Populations and Risk Factors
- Most frequently diagnosed in young adults (ages 20-30), with a second smaller peak at ages 50-70
- Northern European and Ashkenazi Jewish descent have the highest prevalence
- Smoking increases Crohn disease risk but paradoxically appears to decrease ulcerative colitis risk
- Genetic susceptibility (NOD2/CARD15 mutations in Crohn disease)
- Family history (10-25% of IBD patients have a first-degree relative with the condition)
- Environmental triggers: Western diet, antibiotic exposure, urban living
- Appendectomy is protective against ulcerative colitis (epidemiological observation)
Causes and Pathophysiology
- Immune dysregulation: The exact cause is idiopathic but involves a combination of genetic susceptibility, intestinal barrier dysfunction, and abnormal immune responses to commensal gut bacteria. T-helper cell imbalance (Th1/Th17 in Crohn; Th2 in UC) drives chronic inflammation.
- Crohn disease: Affects any GI tract segment (most commonly terminal ileum and colon). All bowel wall layers are involved (transmural). Characterized by patchy "skip lesions" separated by normal bowel. Granuloma formation is characteristic. Transmural inflammation causes complications: fistulas (enterocutaneous, enteroenteric, perianal), strictures, abscesses, and malabsorption.
- Ulcerative colitis: Limited to the colon and rectum. Affects only the mucosal and submucosal layers. Inflammation is continuous starting from the rectum and extending proximally. Colectomy is curative. Major complication is toxic megacolon (acute colonic dilation — surgical emergency).
- Extraintestinal manifestations (both forms): Migratory peripheral arthritis (most common extraintestinal manifestation), ankylosing spondylitis and sacroiliitis, erythema nodosum skin lesions, pyoderma gangrenosum, episcleritis and uveitis, primary sclerosing cholangitis (UC), oral aphthous ulcers (Crohn)
Signs and Symptoms
- Persistent or recurrent diarrhea (often bloody in ulcerative colitis; watery in Crohn)
- Severe abdominal pain and cramping. Weight loss. Fever. Fatigue
- Lower right quadrant pain (common in Crohn — terminal ileum involvement)
- Fecal urgency, nocturnal diarrhea, blood or pus in stools
- Mouth ulcers (aphthae), erythema nodosum skin lesions, red and inflamed eyes
- Migratory arthritis or axial joint stiffness (ankylosing spondylitis association)
- Perianal disease: fistulas, fissures, abscesses (Crohn disease)
Red Flags
- Rebound tenderness or peritoneal signs: Indicates perforation or abscess — emergency referral
- Toxic megacolon (UC): Abdominal distension with systemic toxicity (high fever, tachycardia, dehydration) — surgical emergency; call 911
- Massive rectal hemorrhage: Requires emergency medical evaluation
- New fistula formation: Purulent drainage, new pain tract — urgent surgical evaluation
MT Considerations
- Stress management is a primary goal: Psychological stress is a known flare trigger. Establishing a parasympathetic state supports digestion and may reduce flare frequency
- Acute flares: Contraindicate vigorous circulatory massage and any abdominal work. During remission, gentle abdominal holding or reflexive techniques may be tolerated.
- Positioning: Side-lying or semi-reclined preferred. Prone is often intolerable for clients with colostomy bags, active abdominal discomfort, or perianal disease
- Medication awareness — immunosuppression: Corticosteroids reduce pain sensation, increasing overtreatment risk. Use conservative pressure. Biologic medications (infliximab/Remicade, adalimumab/Humira, vedolizumab/Entyvio) and JAK inhibitors (tofacitinib/Xeljanz) suppress the immune system — do not treat if the therapist has an active infection. Ask about injection or infusion sites and avoid direct pressure over recent sites.
- Corticosteroid effects: Long-term use causes skin thinning, easy bruising, and osteoporosis — adjust pressure accordingly
- Extraintestinal arthritis: Treat affected joints as inflammatory arthritis — respect active inflammation. Avoid deep pressure on inflamed joints
- Parasympathetic support: Relaxation techniques that reduce sympathetic tone are strongly indicated during remission
CMTO Exam Relevance
- Category: A7 Systemic Conditions (Gastrointestinal/Autoimmune)
- Differentiate Crohn disease (transmural, skip lesions, any GI segment, fistulas) from ulcerative colitis (mucosal, continuous, colon only, toxic megacolon)
- Rebound tenderness indicates peritoneal involvement — requires medical referral
- Arthritis is the most common extraintestinal manifestation
- Clients on corticosteroids have reduced pain sensation — overtreatment risk
- Biologic medication site awareness (injection/infusion sites)
- Colectomy is curative for ulcerative colitis but not for Crohn disease
Key Takeaways
- Acute flares contraindicate vigorous circulatory or locally intrusive massage. Abdominal work is limited to gentle holding even during remission
- Clients on corticosteroids or biologic medications require pressure modification and infection precautions
- Rebound tenderness indicates peritoneal involvement and requires medical referral
- Side-lying or semi-reclined positioning is preferred. Prone is often intolerable with colostomy bags or active discomfort
- Extraintestinal manifestations (arthritis, skin lesions, eye inflammation) are common and affect treatment planning
- Stress reduction through relaxation massage is a primary therapeutic contribution