WebMD Live Events Transcript
Are you among the 2 million Americans with IBD? IBD (inflammatory bowel disease) is a group of disorders that causes chronic inflammation of the intestines. There are two major types of IBD: ulcerative colitis and Crohn's disease. Aaron Brzezinski, MD, joined us from The Cleveland Clinic on May 19, 2005 to answer your questions about IBD.
The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Welcome to WebMD Live, Dr. Brzezinski. Thank you for joining us today.
I believe this is a very important issue, because even amongst many physicians the terms can be misunderstood.
It is not uncommon for patients to tell you they have colitis when what they really have is irritable bowel syndrome. The main difference is IBS is a functional disease; it's a problem with how the bowel contracts and relaxes, but there isn't a significant inflammatory component to it. Inflammatory bowel disease has two main groups -- Crohn's disease and ulcerative colitis -- and is characterized by inflammation.
Irritable bowel syndrome is very common. It is usually manifested by intermittent episodes of diarrhea, constipation and abdominal bloating, but patients do not have what we call red flags. A red flag is something that tells us that there's something else going that needs attention. Red flags include bleeding with bowel movements, weight loss, fever, palpable abdominal mass, bowel movements at night when patients actually wake up to have a bowel movement, and anemia.
In inflammatory bowel disease, the symptoms depend on which type of illness the patient has. The main symptom in ulcerative colitis is bloody diarrhea and depending on the extent of the disease, patients may have other symptoms. If the disease is only in the rectum, patients have urgency to have a bowel movement and they have very frequent trips to the toilet, but they pass only very small amounts of mucus or blood. When the disease is extensive, involving the entire colon, patients have larger bowel movements that are still bloody. They may also have diffuse abdominal pain, weight loss, fever, and other systemic symptoms like dehydration or rapid heart rate.
Crohn's disease, on the other hand, can involve any segment of the gastrointestinal system. The symptoms are determined by which parts of the gastrointestinal system are involved. The most common site of involvement is the small bowel. In the small bowel it's particularly the terminal ilium, which is the most distal part of the small intestine, essentially where the small intestine joins with the large intestine with the colon. Patients that have disease in the terminal ilium usually have abdominal pain in the right lower quadrant, they have weight loss, diarrhea, poor appetite, abdominal bloating or distention, especially after meals, and on exam, they may have a palpable mass in the right lower quadrant of the abdomen. The next most common site of involvement is having both the small bowel and the colon, and these patients usually have a combination of symptoms that include the same symptoms of terminal ilium, but they may have more diarrhea and they can also have disease around the rectal area, where they may develop fistulas or abscesses. Patients who only have involvement of the large intestine primarily have diarrhea (which is usually nonbloody), abdominal pain, and weight loss. Patients with Crohn's disease can also have involvement of the esophagus (which is the swallowing pipe), the stomach, or the more proximal small intestine.
An important different association between inflammatory bowel disease and irritable bowel syndrome is that patients with inflammatory bowel disease also have what are called extraintestinal manifestations which are symptoms that occur outside the bowel. These extraintestinal manifestations can include inflammation of the eyes, mouth ulcers, joint pain or swelling, skin lesions, liver disease, and really can involve almost any organ in the body.
|"There are some other conditions that are very important to rule out in a patient in whom IBD is suspected, including gastrointestinal infections. We always check for infections because this can mimic Crohn's disease or ulcerative colitis."|
The first thing is to assess the history and see if any of the red flags are present. Once the disease is suspected, it depends a lot on whether it's a child, adolescent or adult. One can start by doing some blood tests looking to see if a patient has anemia, an elevation of the white blood cell count or platelet count that occur in inflammatory diseases. We would also check what's called C-reactive protein, usually referred to at CRP, or sedimentation rate; these are known specific markers of inflammation. If they are elevated, it means there is an inflammatory process. Other tests that are also useful include checking for protein because patients with IBD can have low protein.
The next tests look directly into the large intestine, into the colon. This is done with a colonoscopy and what's involved in a colonoscopy is that after preparing the colon, the patient receives intravenous medication to be sedated and a tube that has a camera and light source is inserted into the rectum and advanced through the large intestine and ideally reach the secum, which is where the large intestine begins, and enter into the small intestine, which is the terminal ilium. When this is done, if there is an area of inflammation, this can be visualized through the scope and also allows us to take tissue samples to send to the pathologist. Then the next step would be an X-ray, which is a barium X-ray to visualize the small bowel and determine if there are any lesions present in the small intestine.
This is somewhat different in children. There's a blood test that is used to tell us whether the child has a greater possibility of having inflammatory bowel disease. The reason why this is sometimes done in children is to avoid going through the process of doing a colonoscopy that would have to be done under anesthesia if all the examination and tests do not suggest IBD.
There are some other conditions that are very important to rule out in a patient in whom IBD is suspected, including gastrointestinal infections. We always check for infections because this can mimic Crohn's disease or ulcerative colitis. It is also important to make sure the patient is not taking anti-inflammatory medications, such as ibuprofen or aspirin, because this can also cause ulcers in the intestine that can look like IBD.
Yes. Patients that have IBD have an increased risk of colon cancer. The risk depends on the extent and duration of the disease as well as some other factors such as family history or the presence of a liver disease that is called primary sclerosing cholangitis, which is one of the extraintestinal manifestations of IBD.
Generally speaking, the risk of colon cancer in a patient who has extensive involvement increases after seven years of the onset of symptoms and it usually increases by about 0.5% per year until it reaches a risk between 15% and 30%. In patients who have disease limited to the left side of the colon, the risk begins after 10 to 15 years of the onset of symptoms.
Patients with Crohn's disease involving the colon also have an increased risk, and in Crohn's disease there is also an increased risk of small bowel cancer, which is very rare.
I think it's important to mention we don't like to see patients come in with colon cancer. So there are a few recommendations to decrease the risk of colon cancer. There's information that shows that supplementing folic acid may decrease the risk of colon cancer in these patients and in patients with IBD. Once they reach the state where there's an increased risk of colon cancer, we recommend they undergo a colonoscopy, numerous biopsies -- usually between 40 and 60 looking for early changes that are called dysplasia. If a patient has dysplasia in the colon, then we know the risk of colon cancer is so high that the recommendation is to remove the colon so the patient will not develop colon cancer and die from colon cancer. The analogy is the PAP smear. Using the results from the PAP smear, you look for change in the cervix early on rather than waiting until a patient has incurable cancer.
The frequency of screening needs to be individualized according to other factors a patient may have. For example, a patient with a strong family history for colon cancer or primary sclerosing cholangitis needs more aggressive surveillance.
|"The data to support a genetic basis for the disease is that 10% to 20% of patients with Crohn's disease have a first-degree relative with the disease, and importantly, there are some genes that have been identified in association with Crohn's disease."|
I have been diagnosed with ulcerative colitis and have been in remission for a year, but I don't understand what the cervix has to do with the colon.
That was the analogy. When you do a PAP smear you are looking for early changes that are called dysplasia to make a diagnosis. In the colon we also look for changes in the cells called dysplasia because if we find dysplasia, then we know that the risk of colon cancer is significantly increased. That was just an analogy of how we look for cellular markers in different organs to decrease the risk of cancer in that organ. By no means was I trying to imply an increased risk of cervical cancer associated with ulcerative colitis.
Yes, there is genetic basis for Crohn's disease. This is a disease that is still more common in Ashkenazi Jews, who are the Jews from central Europe, but there is a definite increase in the frequency of Crohn's disease worldwide, regardless of race or gender.
The data to support a genetic basis for the disease is that 10% to 20% of patients with Crohn's disease have a first-degree relative with the disease, and importantly, there are some genes that have been identified in association with Crohn's disease.
Having said this, 80% to 90% of patients do not have a first-degree relative, so the belief is that in a genetically susceptible individual there is an environmental trigger that leads to an abnormal response of the immune system of the gastrointestinal tract. Unfortunately, we haven't been able to identify which these are for the triggers of the disease.
What is causing the increase in this disease? Is it something in the environment? Or is our diet to blame?
Diet is part of the environment -- it's part of a person's lifestyle.
I don't believe we really know what it is. One interesting theory is that the gastrointestinal tract has a huge number of immune cells. In fact, it's the largest concentration of immune cells. And that is because we have billions of bacteria in the colon and less in the small bowel. If these bacteria could migrate into the blood, we would have infections all the time. So the way they are contained inside the lumen of the intestine is by an immune system that prevents them from going through.
Crohn's disease and ulcerative colitis are more frequent in industrialized countries and less in the third world. The rise in frequency of these diseases parallels industrialization that also has an improvement in hygiene. So, one of the theories is that children are no longer exposed to some bacteria or infectious agents in the environment during childhood and the immune system overreacts when it's stimulated later in life.
There are other theories, such as an infectious etiology, and there are some bacteria that may play a role, at least in some patients, but these are probably diseases that can be triggered by a variety of agents in the environment and these are still to be determined.
Currently the reality is there is no cure for Crohn's disease or ulcerative colitis. These are chronic diseases and the way these should be viewed is like diabetes and high blood pressure.
One of the common mistakes we see is that when a patient is in remission the medications are stopped even though these are recurrent diseases. The risk of recurrence is much greater in patients that are not on medication.
What I always remind patients of is that if somebody has high blood pressure and their blood pressure is controlled on medication, you don't stop the medication because the blood pressure will go up again.
|"There's also a clear association between having more aggressive Crohn's disease and cigarette smoking, so patients with Crohn's disease that smoke cigarettes should quit."|
My doctor says she wants me to stay on Imuran because she fears a flare-up. Do you agree?
Yes. The treatment of inflammatory bowel disease -- both Crohn's and ulcerative colitis -- is divided into induction of remission, which means bring the disease under control, and maintenance of remission, which means to keep the patient in remission under control.
The choice of medication depends on how severe was the disease and what medication was required to bring on remission. In general, it's believed that a patient that keeps taking medication to stay in remission has about a 10% risk of having an exacerbation every year, compared to 50% risk at six months in patients that are not taking medications.
That might be the reason why the physician is choosing Imuran, because it may be the disease was more severe. When you can bring on remission with medications that belong to a group that is called 5ASA, which are also known as mesalazine, then this is the medication of choice, given that it has a better safety profile. But when patients have severe disease, they require more potent medication, such as Imuran to maintain remission.
What diet changes are necessary if you have IBD? Are there any foods to be avoided? Are there any foods that help?
That's actually an excellent question. If we think of this as a disease of the gastrointestinal tract it would be intuitive that diet plays a major role. However, this has not been shown to be the case. So the changes in diet depend on the type of disease and the site of involvement. For example, if a patient has a stricture or narrow area in the small intestine, from Crohn's disease, then the recommendation is to be on a low-residue diet. So patients should avoid foods such as celery that has long fibers or peanuts, corn or popcorn, because this is what gives bulk to the stool. This would have to go through an area that is narrow and may cause a blockage.
Other changes depend on whether patients have had surgeries or not. With some surgeries patients lose their ability to digest fat, so if they eat a fatty, greasy meal they will have more diarrhea.
Now, even though we don't consider medications as food, patients with inflammatory bowel disease should not take any of the anti-inflammatory medications that are commonly used for headache or joint pain because this can worsen the disease.
There's also a clear association between having more aggressive Crohn's disease and cigarette smoking, so patients with Crohn's disease that smoke cigarettes should quit.
As far as foods that might be beneficial, diets that are high in fish or fish oils seem to decrease inflammation in these patients, and probiotics which are "good bacteria" such as lactobacillus that is present in yogurt, may have a beneficial effect.
I have ulcerative colitis and I just suffered a stroke. The doctor tells me it was caused by my colitis and an over-the-counter sinus medication. I am only 32 years old. How can this happen?
That's another excellent question. Some patients with inflammatory bowel disease have an increased risk of stroke because of abnormalities in their clotting system. The reasons why patients have an increased risk of forming blood clots include that during exacerbation of the disease, they have an elevated platelet count, they may be bedridden, they have some inflammatory proteins in their blood, and also there are some specific abnormalities in the clotting system that have an increased frequency in inflammatory bowel disease patients. Such an abnormality, for example, includes factor V Leidin deficiency, this is a factor that is normally present to prevent clotting and when you don't have this factor in your blood, you are prone to blood clots.
Young patients who have inflammatory bowel disease and form blood clots or older patients who form blood clots without a clear explanation should have a workup done by a hematologist with expertise in diseases of the clotting system to determine whether they will need blood thinners or not.
My doctor keeps checking to make sure my bloating remains soft. What can I do about the bloating?
I believe that what the doctor might be checking for is to see if there's any tenderness or any enlarged lymph nodes, or an enlarged liver or spleen. This is probably related to the use of Imuran. Patients on Imuran should be examined on at least a yearly basis, or twice a year if they're in remission and also have blood tests on a regular basis.
|"I think that biologics is an example of how bench research can be applied to medical practice. Biologics is a new class of medications that we use for the treatment of inflammatory bowel disease."|
I read an article on WebMD: "Parasitic Worms Ease IBD; May Reduce Overactive Immune Response Behind Crohn's Disease, Ulcerative Colitis". Can you comment? Worms?
Remember when I explained what could be the environmental factors? That is one of the environmental factors that play a role in the third world -- children have more gastrointestinal infections and some of those infections are caused by worms such as Ascaris. This type of infection might help the immune system in the bowel learn how to modulate the inflammatory response.
The study that you're referring to is what is called a pilot study, which was in a very small group of patients that were given the egg of a worm that is not pathogenic to humans (doesn't cause disease in humans) and they had decreased inflammation in the bowel. This really should be viewed as very preliminary data; there's a lot of research to be done.
What do you see in the future for treating IBD?
I think that what we'll learn in the future is that there isn't a single Crohn's disease or ulcerative colitis, but this is a term that includes different diseases. We'll be able to identify or stratify patients according to the basis of their disease and develop specific treatments for such patients. For example, one of the genes that has been identified in Crohn's disease increases the risk of having strictures or narrowing in the terminal ilium in the distal part of the small intestine. So in the future, we may be able to detect more abnormalities, or more genes, and be able to predict what type of disease the patient will develop and determine the best treatment for that patient.
I think that biologics is an example of how bench research can be applied to medical practice. Biologics is a new class of medications that we use for the treatment of inflammatory bowel disease. In short, there's a protein that was identified to be in excessive amounts in the blood and in the stool in patients with Crohn's disease. So a company with molecular biologic techniques designed a protein that blocks the action of this proinflammatory protein and neutralizes it. This medication really has probably been the most significant breakthrough in the treatment of Crohn's disease in the last 20 to 30 years. As we learn more about which are the proteins that are abnormal or where the problem lies, we can design better treatments and we'll have better medications with fewer side effects.
Dr. Brzezinski, we are almost out of time. Before we wrap things up for today, do you have any final words for us?
I think we should be hopeful. I think these are very exciting times in the understanding of IBD, and hopefully multicooperation between numerous centers doing research will be able to better understand and help our patients.
Our thanks to Aaron Brzezinski, MD, for joining us today. Members, thanks for all of your great questions. I'm sorry we couldn't get to all of them. For more discussion on this topic, be sure to visit the WebMD message boards to ask questions of our online health professionals and to share questions, comments, and support with other WebMD members.