Chronic inflammatory diseases: what they are and what they involve

By Cristiano Antonino On Oct 11, 2022

More than 5 million people in Europe are living with chronic inflammatory diseases, conditions that share a chronic inflammatory condition associated with an abnormal immune reaction directed against the body

Chronic inflammatory diseases: what they are and what they lead to

Rheumatoid arthritis, chronic inflammatory bowel diseases, such as ulcerative colitis and Crohn’s disease, psoriasis, and psoriatic arthritis, result in daily management of painful or disabling symptoms, impair patients’ quality of life, are a risk factor for the development of comorbidities, such as cardiovascular disease and cancer, and weigh on the lives of families, with major socioeconomic repercussions.

In recent years, attention to these diseases has increased, while Research has made enormous progress in understanding the mechanisms underlying acute and chronic inflammation and has led to the development of therapeutic options that can intervene in the inflammatory process.

Inflammation underlying chronic inflammatory diseases

The underlying mechanism of these diseases is inflammation, which must be evaluated by considering both the causes, including environmental ones, and the consequences on the whole organism, according to an integrated and multidisciplinary approach that privileges the continuity and interrelationships among different chronic inflammatory diseases.

Inflammation is a nonspecific innate defense mechanism, which is a protective response of the organism to the action of a damage operated by a foreign agent to eliminate the initial cause of cellular or tissue damage and the initiation of the reparative process inflammatory cells peculiar to innate immunity, such as macrophages, neutrophils begin to produce cytokines in response to a stimulus that can be infectious, chemical, non-infectious.

When acute inflammation does not resolve, chronic inflammation takes over, which consists of a long-lasting inflammatory process in which active inflammation, tissue destruction, and attempts at repair coexist.

Among the determinants of inflammation, attention has grown in recent years to the role played by the microbiota, the diverse set of microorganisms that live in symbiosis with us, in the gut but also in all surfaces exposed to the external environment.

A variation in the gut microbiota can result in inflammation that tends to spread from the gut to other organs.

A recent study carried out by Humanitas and published in the journal Science shows that in cases of ulcerative colitis, in order to prevent the spread of severe intestinal inflammation, the brain closes a kind of gate located in the choroid plexus, resulting in states of anxiety-like state and depression.

Effects often seen in patients with chronic inflammatory bowel disease.

Chronic intestinal diseases: symptoms and complications

There are more than 250,000 people living with chronic inflammatory bowel diseases in Italy, of whom about 60 percent have ulcerative colitis and the remaining 40 percent have Crohn’s disease.

These diseases, which are rapidly increasing in countries with advanced economies, manifest themselves mainly with diarrhea, often accompanied by traces of blood, abdominal pain, vomiting, asthenia, fever, and are characterized by alternating periods of flare-ups and periods of remission.

Up to 40% of patients with Crohn’s disease may undergo bowel resection within 10 years, and up to 20% of patients with ulcerative colitis may undergo colectomy within 10 years.

The impact of these diseases goes beyond the intestinal district:

In more than 40% of cases, chronic inflammatory bowel disease is accompanied by associated extraintestinal immune-mediated manifestations.

Up to 30% of patients may have arthritis, 10% immune-mediated skin manifestations, and 5-6% biliary tract and liver inflammation.

Therefore, a multidisciplinary approach cannot be disregarded, leading to better outcomes in the detection of any associated extraintestinal manifestations, but also in their management.

The goal of therapy remains prolonged remission over time, which means absence of symptoms, both those directly reported by the patient and in terms of the anatomy of the disease, i.e., restoration of the normal integrity of the intestinal mucosa, without diarrhea and without bleeding.

The possibilities offered by surgery

One of the tools increasingly considered to induce remission is surgery, which for some patients with MICI is the best option.

By now, surgery is no longer considered as the only option, ‘the last resort’ after exhausting the available options, when the patient was completely defecated by disease symptoms and non-response and immunosuppressed by medical therapies, with inevitable bad results.

Today, thanks in part to the multidisciplinary approach to chronic inflammatory bowel disease, which brings together the expertise of gastroenterologists and surgeons, surgery, which is increasingly less invasive, is a weapon that can be used at any point in the treatment pathway, depending on the needs of the individual patient.

Joint deformities and pain: rheumatoid arthritis

Rheumatoid arthritis is characterized by its impact on quality of life: deformities and joint pain, if not adequately treated, can affect the patient’s ability to perform normal daily activities and limit work opportunities, even to the point of hindering the performance of household and family tasks.

The advent of new treatment options, however, has altered a course that until a few years ago seemed inescapable.

For patients diagnosed with rheumatoid arthritis today, there is a lot of good news: the most important element is that today the patients’ pathway does not lead to the deformities that can be seen on the web, thanks to biologic drugs and small molecules that are able to stop inflammation and thus disease progression and have collapsed the curve of surgeries to resolve these deformities.

But there are other positive notes as well: diagnoses are much earlier, thanks to increased knowledge and new diagnostic technologies; cortisone is used much less than in the past, sparing patients the medium- and long-term side effects; and patients of childbearing age can now plan a successful pregnancy by agreeing on the timing and synchronizing therapies so that they are not harmful to the fetus.

Chronic intestinal diseases: psoriasis and alterations in the microbiota

Inflammatory mechanisms, along with triggers such as infections, stress, and alterations in the microbiota, are at the root of immune-mediated skin diseases such as psoriasis, which affects about 2 million people in Italy, and psoriatic arthritis.

Psoriasis is a systemic disease in which the inflammatory process affects not only the skin, but also other districts and organs.

Especially at a young age, this disease is associated with an increased risk of acute cardiovascular events, and in 20-30% of cases patients with psoriasis may develop psoriatic arthritis.

In addition, subclinical intestinal inflammation can be found in patients with psoriasis, especially in the moderate-severe form, and 3% of patients with chronic inflammatory bowel disease also have psoriasis.

The link between intestinal and skin inflammatory processes is proven, and it is therefore essential that patients with immune-mediated diseases are evaluated from multiple perspectives and taken care of by a multidisciplinary team deputed to coordinate therapy and follow-up.

The professional medical figures who normally follow patients with psoriasis and psoriatic arthritis are the dermatologist and rheumatologist, but we also deal with the gastroenterologist, to significantly improve inflammation in the patient with Crohn’s disease and ulcerative colitis, thanks to combined therapies, which affect multiple areas by acting on a fundamental mechanism of pathogenic inflammation.

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