... Stressed out - what happens in the intestine ?

My dear patients,

stress remains at the top of the  list when it comes to answering the question: What modifies the course of inflammatory bowel disease Crohn`s disease or ulcerative colitis ? What is causing a flare ?

And one could certainly enter the discussion with the following approach:

“WELL … stress… – is actually nothing concrete. And that`s why it can not be counted among the reasons that are affecting the course of inflammatory bowel disease, Crohn`s disease and ulcerative colitis. These diseases are foremost multifactotally conditioned (which means: they have many factors that influence their progression). The immune cells and the excessive reaction of the immune system in the intestine is an important aspect. Dysbiosis (which means: the microbiome is not “in balance” anymore) plays an important role  as well as the impaired mucosal barrier. And finally  there is a basic genetic aspect…

And as a matter of fact all these aspects (except genetics. –  unless  … when thinking and discussing it in the context of epigenetics things would be different again … but that would surely go to far here) describe processes within the body and the intestine, which are all (all. Without exemption.) influenced by stress.

I would definetly aggree with anyone who considers stress  as one of the most important factors in the course of disease in case of inflammatory bowel disease, Crohn`s disease or ulcerative colitis. At least from my everyday clinical experience.

 And that`s why it is worth having a closer look on how stress affects the body and especially the inestine.  

And one thing to clarify at the beginning to avoid misconception: stress can certainly affect the course of inflammatory bowel disease, Crohn`s disease and ulcerative colitis. Yet it is not the root cause for the disaese. Stress is rather the occasion  for more disease actvity but not the fundamental cause.

... more than a "feeling" !

Stress is nothing inconcrete. It is not just  a “mood” or a “feeling”. Stress always has its equivalent on the physical level.

And the factors which have been investigated on behalf of the correlation of stress and it`s effects on  inflammatory bowel disease, Crohn`s disease and ulcerative colitis are pretty much the same as the ones mentioned above:

Changes in the immune response and in the activity of the intestinal immune cells, changes in mucosal barrier, changes of the microbiome and changes in nerval and hormonal signals (affecting the immune response). 

Stress anyway…

The term stress was defined not that long ago in a medical context as follows:

Stress is a physiological response of the body to internal or external, psychological or physical, real or imagined threat.  In case of threat the body shows an physiological und behavioural adaption via the central and peripheral nervous system. In case of stress vital functions can impair and acute and chronicall ilnesses can develop.”

Period. Simple as that. Hits the nail on the head.

Today we experience stress often as mental stress and psychosocial stress. Which is a kind of stress, that doesn`t result from a wild and dangerous animal visiting the entrace to our cave neither from the confrontation with a wounded (and understandable bad tempered) mammut during the hunt, in which we are most likely to lose out.

In “civilised” society stress mostly takes place on another level. Stress in our modern world is more often related to  prolonged demanding situations than to an acute “crisis”, which makes it even more difficult, because the observed effects are prolonged, or in terms of diseases: chronic as well.

The kind of stress that affects  health and by that affects the inflammatory bowel disease, Crohn`s disease and ulcerative colitis is often  related to situations like:

stressfull situations in professional or private life. The fear of not meeting the standarts, not belonging anymore and there as well in the professional or in the privat enviroment. Ongoing insecurity concerning the financial, private, social future are issues that especially people with chronical illnesses are concerned about. 

a matter of nerves ...!

The reactions of animals and humans to stress are similar in some ways. A lot of the research I refer to in this article is from animal studies. Some mechanisms have been approved for humans as well. Anyway the results are often pointing in the same direction.

Stress always affects the nervous system (or better : nervous systems). Or to put it differently: acute as well as chronic stress situations  results in changes in nerval signals or in changes in the intensity of nerval signals.

The intestine has it`s own nervous system which is called the enteric nervous system. You can imagine it as a nerve plexus (many nerve fibres) in different layers of the intestinal wall

By this the bowel movement is controlled. The secretion, meaning how much fluid or mucus is secreted in the intestinal lumen, and the blood flow is regulated over these nerves as well. Distension of the intestine is sensed by the enteric nervous system and information on things like movement, filling level of the intestine are processed.

And these information is transfered to the central nervous system via other nervous systems. The connection between the intestine and the brain is called gut – brain – axis. Some of you might have heard the term, it has made its way pretty far into the popular science literature. 

The gut and the nerveous system (the brain) are in constant exchange and there is a constant communication which runs in both directions. This is very important on how stress affects the gut. 

In case of acute or chronic stress situations a certain hormone called CRF is released. (CRF stands for corticotropin releasing factor, Not to memorize, not even memorize the abbreviation, but I did not want to write “a certain hormone” for the next passage).

CRF sets in motion the mechanisms that finally lead to secretion of cortisol from the adrenal glands (and cortisol secretion is “pure stress“) and activates the sympathetic nervous system (… I will write below what that is about).

For the gut`s reaction to stress it is important, that CRF also has a direct affect on the intestine. In case of stress CRF doesn`t just have an impact via the indirect route, but is able to dock right on the corresponding receptors in the intestine. Which leads to changes in the peristaltsis  (movement of the bowel), the secretion (ammount of fluid and mucus that is given into the lumen) and (ACHTUNG!:) the mucosal barrier, which is diminished by CRF (key word: leaky gut). And especially the increased mucosal permeability  is key for the CRF transmitted stressreaction as it is one of the basic mechanisms for inflammatory bowel disease, Crohn`s disease or ulcerative colitis. The immunsystem and the immune cells get in contact with the intestinal contents and the mikrobiome, which leads to inflammation. And with inflammation we are right in the middle of more acitivty of the IBD. 

CRF also has an affect on certain cells (mastocytes) in the mucosa, that again lead to an secretion of certain cytokines, which keep the stressreaction in the gut running. And there is evidence, that these cells and their products influence hormonal secretion in the bowel as well, which of course also has an effect on the intestinal function. 

So CRF does quite something to mediate stressreactions in the intestine. And that a direct link between CRF and IBD activity was found in research more than one time doesn`t surprise anyone here by now, I suppose.

... all about nerves

The enetric nervous system is also linked to another nervous system – the autonomic nervous system.

The autonomic nerveous system regulates and adapts the processes in the body to wether we are relaxed or stressed.

That is another important mechanism how stress affects the intestine in general but especially in case of  inflammatory bowel disease Crohn`s disease and ulcerative colitis

The autonomic nervous system has a sympathetic part (which I mentioned above, which is activated by CRF) with sympathic nervefibres. And the parasympathetic part with parasympathetik fibres.

It is the sympathetic nervous system that mediates stressreactions, while the parasympathetic part is active when we are relaxing. (that is very loosly speaking). So stress relates to the sympathetic nervous system and it`s activity.

The sympathetic nervous fibers stand in contact with and affect the immune system and the immune cells of the intestine. As a matter of fact the sympathetic nerveous system can enhance inflammation as well as it can inhibit it. But there is strong evidence that in case of IBD there is a clear proinflammatory (wich means inflammation is enhanced) effect in the intestine. (which I suppose doesn`t surpprise anyone who reads this either)

The parasympathetic nerveous system relates to relaxation and by that it is also linked to the immune system and has a clearly inhibting effect on the immune system. 

That is important. That is important and I will get back on that , when I write the article on how to prevent or better deal with stress.

Stress affects the immune system...

So when we are stressed or in a stressfull situation for a certain time, different things in the body change and so far I just mentioned two important mechanisms of that change: the effect of CRF

 

and the effect of the sympathetic nerveous system

And yet there are other mechanisms that can lead for example to more motility and secretion in the gut, that activate the immune system and by that can lead to more inflammation.

We know that the transmitters which are released at the endings of the nerve fibres (which are important for transmitting signals from one nerveous fibre to another) can influence the immune cells and the intestinal nerveous system (that is Neuroimunology, in case some of you might have heard that term in connection with IBD: neurons having an effect on the immune system)

And you have recognized by now: it always is about the immune system. When talking about stress we are in the center of the main IBD issue: immune reactions. And when that runs out of controll that does lead to uncontrolled inflammation

What is the use of it ?

Puh.

(or: … “what ?!”)

Probably quite confusing in some parts, isn`t it ?

Alright. And yes, I could have written the sentence: In case of stress the activation of different nerval systems, the secretion of certain transmitters and hormons in the intestine and the brain leads to changes in the intestinal function and to a direct activation of the immune system and by that can affect the activity of  inflammatory bowel disease, Crohn`s disease or ulcerative colitis.

But that probably would not have made the point that clear.

Hopefully you have an idea now, that stress can literaly change everything in the intestine.That it does change things.

Forget what you have read here so far. I `m serious. Forget it. Forget enteric nervous system, forget gut-brain-axis, forget CRF, forget sympathical nerves, forget mastcells, forget neuroimmunology, forget about peristalsis or secretion. Forget it.  

But from today on have and keep in mind very clearly: Stress is not a feeling. We do feel it, but it has a correlation in the body and the intestine. And that`s why it can affect IBD significantly. And yes, it even can cause more disease activity.

And why am I writing this ? What is your benefit from this information ?

Here on I.M. INFORMATION MATTERS I am always looking for a solution orientated aproach. I want to provide you with information that help you deal with the disease.

Stress changes something, in your body, in you gut, especially in case of inflammatory bowel disease, Crohn`s disease or ulcerative colitis. Stress is real, nothing you just fancy or what occurs because you are not cool enough or make a fuss about something.

And since you now can imagine how stress does affect your intestine, I strongly recommend: figure out, what puts stress on you. Recognize, what certain situations change in your condition regarding your IBD. That is the first step, admit that certain situations have an effect, do find out which these are.

And the second step (and there will definetly be an extra article on that): think about how you can deal with these situations in a better way. And with that I do not necessarily mean avoid or even quit stressfull situations completely. That`s not what it is about and everybody knows that some things or situations or circumstances, which put stress on us  should and sometimes even have to be changed. But a good part of the things that stress us belong to our life. It`s about how you deal with stress or the things that put stress on you. .

I will write more about that, but until than try Google: “stressreuction techniques“. Today in this moment 203.000.000 hits. 

Try “stressreduction breathing parasympathic nerve system”. 5.800.000 hits.

The year 2021 is a good year to approach that issue of active relaxation practice and I do encourage you to do so.  

It will not be possible to “heal” your IBD naturally, 100% not. The same as you won`t be able to heal it with physical exercise / sports or nutrition only.

But you will learn something from all these aspects and at best include it in your everyday life. And that will help you to feel and to be less powerless more empowered to actively change your disease for the better. 

Requires that you take it seriously and persue the issue. To read 3 article for 1 day isn`t enough. You are allowed to change and include things in your everyday life. It is about awareness, everyday “rituals” (both terms stereotyped times 10, I know…) breathing exercises, meditation etc.. That is challenging, much more challenging than injecting the Humira Pen or any other pen or to keep an appointment for a medical infusion. And it is not instead of medication but additional to it. 

It decisively influences the course of the disease, when you as a patient take care of the things you can take care of. Only you can take care of.

And with that once again take care, 

best regards !

Yours sicerely 

Dr. med. Susanne Weyrauch

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