Jaime Lewis (Host): Maybe you're familiar with the term irritable bowel syndrome, but have you ever heard of inflammatory bowel disease? Unless you've experienced IBD firsthand, chances are good you've never heard of it, but it affects 1.6 million Americans.

Today, we're talking about IBD with Dr. Roger Perez, a board-certified gastroenterologist with over 20 years of expertise in providing treatment for a wide variety of difficult GI disorders. He'll share information about the signs and symptoms of inflammatory bowel disease, how it can impact other body systems, and options for how to treat it. This is BayCare HealthChat, a podcast from BayCare Health System. I'm your host, Jaime Lewis.

Dr. Perez, I want to start with signs and symptoms of inflammatory bowel disease. What should I look for if I suspect I might have IBD?

Roger Perez, MD: Thanks for having me. This is a great question. I think it really segues well from your introduction, because the symptoms of inflammatory bowel disease and irritable bowel syndrome can overlap quite a bit, and they can be somewhat indistinguishable. In fact, I think people frequently have heard IBS, as you said, and so people say, "I have IBS." But as I like to explain to patients, IBS is a diagnosis of exclusion, meaning you've excluded other diseases. And when you have this final diagnosis, we call it irritable bowel syndrome. And the reason I say that is because patients can have undiagnosed inflammatory bowel disease, and IBD is inflammatory bowel disease, as opposed to irritable bowel syndrome, which is IBS.

So, one is irritable bowel syndrome and one is inflammatory. But the symptoms can overlap. So, not uncommon that people will have diarrhea with inflammatory bowel disease or IBD, but they can have diarrhea as well from IBS as well. In inflammatory bowel disease, constipation is uncommon. It would really be primarily diarrhea that people would have with IBD, or inflammatory bowel disease. Abdominal pain, of course, and that could be cramping abdominal pain, where people are getting pretty severe abdominal cramps, usually more so in the lower abdomen. But it can be anywhere from the belly button down. People will also get sometimes bloating or abdominal distension that can be pretty severe. It can be associated with other symptoms of nausea, bloating, diarrhea. Inflammatory bowel disease is an inflammatory process, it has systemic effects and so when you have systemic inflammation, it can have symptoms like anything else. If somebody just will feel tired, they'll be weak, they might have low-grade fevers, they might have night sweats. They kind of feel like they almost have the flu, but really their only symptom is gastrointestinal symptoms. So, it's like having almost like an inflammatory process or a flu-like symptom, but really it's because it's all driven from your gastrointestinal tract.

Host: Okay. So, let's say you've diagnosed me with IBD and we need to talk treatment. What kinds of medications and treatment options are available to me?

Roger Perez, MD: I try to tell patients it's really an exciting time, because the whole field of gastrointestinal diseases, and in particular, inflammatory bowel disease, has really kind of mushroomed quite a bit in the last several years. The options have really increased significantly. And I bring that up specifically because I think some people, either if they have family members or friends that have inflammatory bowel disease, in the "old days", and the old days just being, 20 years ago, we really had limited options. Definitely 25 years ago, we had limited options in medications and people were either on a medication called mesalamine or they were on steroids, oral steroids, prednisone. And unfortunately, prednisone, it can help, but it does cause a lot of side effects and symptoms. And the reason I bring that up is because it's not uncommon for me to see people who really have stories of being on steroids for prolonged periods of time and having a lot of the side effects from steroids from long-term steroid use. And really, medicine and gastroenterology has changed quite a bit, because we try to avoid steroid use if possible and try to minimize the dosage of the medication, the length of time that we have people on the medication, and use other medications that really have less side effects, but really are even more effective than the steroids.

So, I try to tell people, we think of it as almost a pyramid. At the bottom of the pyramid is mesalamine medications, which I use the term kind of loosely and I tell patients this too, they're anti-inflammatory medications. So, I try to explain they're not really anti-inflammatory in the sense of like an anti-inflammatory that you would take like for Advil or Aleve or ibuprofen. Those are anti-inflammatories, those are completely different. But they're anti-inflammatory, they can actually decrease the inflammation in the gastrointestinal tract, whether it's in the colon or the small intestine, or even in the stomach. The medication is almost like a topical medication. So, mesalamine is one category.

And previously, as I was alluding to before, 20, 25 years ago, we only had one or two mesalamines. We really only had two. And now, we literally have like 10 different mesalamines to use. So, mesalamine is one category and it has very little side effects. It's not absorbed. Only maybe 5-10% of the medication is absorbed. It's safe during pregnancy. It's safe in children. So, it's quite safe and it's good for what we consider a mild to moderate disease. So if somebody has mild disease, it's really quite effective. For moderate disease, it can help, but it may not be as effective. Mesalamine would be one category.

Then, the next step up would be potentially the steroids that we use that have what we call a first-pass effect, which would be something that it gets cleared from your system, and it doesn't have as much systemic side effects. Under this category, for example, would be budesonide, which is a steroid, which gets cleared from your system. As mentioned, it doesn't have as many of the systemic side effects. Right above that in the pyramid would be prednisone or Solu-Medrol or prednisolone. Those are steroids. These are all oral medications, the mesalamine, the budesonide, and the steroids are all oral medications. The prednisone is very effective. It really does help decrease inflammation. It helps frequently decrease the diarrhea. It helps decrease abdominal pain. But it's not a good long-term medication. So, we prefer other medications. In the short term, it's good at helping get people into remission. That's why I try to explain to patients that we use it sometimes for short periods of time, two weeks, four weeks, six weeks, trying to get people under better control symptomatically and just get the inflammation under control, and then transition to some other medication and not use that as a long-term medication.

Then, the next in the pyramid would be what we call biologic agents, which would be now there's so much advertisement on television. We see things like Humira, Remicade. These are all medications that are biologic agents in the sense that they're proteins that are made. And they're a protein that's an antibody against something in your immune system to kind of block the immune system, because inflammatory bowel disease, or IBD, is an inflammatory process driven by the immune system. And in the simplistic way of thinking about it, there's a disbalance in the immune system. And so, it's almost overactive. But unfortunately, that overactivity of the immune system is attacking our own bodies. So, it's nothing that the person's eating or drinking or doing, but it's inflammation that your body's producing. And we try to block that inflammatory process or immunologic process, so we use these biologic agents and Humira, Remicade, those things are against what we call anti-TNF medications. And those are intravenous medications that we give as injections or as an injection under the skin. Those became popular or first came out around the late 1990s, early 2000, and they're really kind of considered now the mainstay of treatment.

But over the last several years, we've had a lot of other new medications that have less side effects than those and are as effective or even more effective. And consequently, they're safer. So, we have new medications as well. Now, we have some other injection medications that are more specific to the GI tract that block white blood cells from getting into different parts of the GI tract. So, something called Entyvio, for example, it blocks white blood cells from getting in.

Another medication we have, which is exciting, are new medications, which we call small molecules. It's actually oral medications. So instead of having to go on an injection medicine or an intravenous medication, we have some oral medications that are once a day, are very well tolerated, and really have been shown to decrease inflammation. These small molecules have really ballooned in the last two years or so, two to less than three years. So, there's quite a few options for inflammatory bowel disease now. And it's an exciting time right now.

Host: This being a disease of the GI tract, it stands to reason that what we eat is a factor with IBD. Can you talk a little bit about that?

Roger Perez, MD: Absolutely. It's a good question. I think that it's a question that a lot of patients ask. And frankly, I think even myself, I've changed kind of my, I don't know, I don't want to say tune, but I think how we viewed things before. It's true, it seems like it's common sense that your diet is going to affect your stomach, your intestine, your colon. The general teaching before was that, and it's still to some extent, that if you eat certain foods that causes you symptoms, it might cause you abdominal cramps, might cause you some diarrhea, but by itself is not the cause of the inflammation. So if you ended up going out and eating a burrito somewhere and it gave you diarrhea, it's happened to all of us, but that didn't cause inflammation. It didn't cause the inflammatory process. It may have caused you to have some symptoms of diarrhea or maybe some cramps and maybe discomfort, but it didn't trigger inflammatory bowel disease. And so, we, and myself included, would say, you know, it's not necessarily that the food that you're having that's causing your flareup of your disease, so meaning if you can't give up certain foods and hopefully the disease will just abate and improve and go away.

We do know now, and there's been a lot of studies just lately in the last several years, showing that people are trying to study it more rigorously. Unfortunately, sometimes we all tend to think, "Well, okay, I should just eat less meat. I should eat more vegetables. I should have more fiber," different things like that. But we've actually, as gastroenterologists and doctors, have really tried to study that more vigorously and really decide if that really is the case or not. So recently, studies have shown that patients that eat ultra-processed foods, so we abbreviate UPF, ultra-processed foods, are at higher risk of developing inflammatory bowel disease. And now, there's definition, medical definitions, that we consider ultra-processed foods. You know, unfortunately, there's quick snacks that you take that are chips and different cheeses and even different ice creams and snacks and a lot of sweets and things like that and candies and things like that. They have been shown now to have a higher rate of inflammatory bowel disease if you eat those things. So, ultra-processed foods, we really would try to recommend that people avoid those things.

There are studies now looking at whether a high meat diet, having red meats, actually worsens the disease or if it contributes. And so far, no one's shown that having meat in your diet is actually worsening the disease itself. However, other meals, for example, having the opposite of ultra-processed, which is having vegetables and fruits and veggies that are not processed, whether they're frozen, have been shown to actually help decrease the inflammation to some extent, not decrease the inflammation, but not promote the inflammation, I guess would be a better way of putting it. Other foods, for example, people have looked at the Mediterranean diet. So, there's some data to suggest that the Mediterranean diet might have some anti-inflammatory effects. Again, probably not enough that it's going to completely reverse the disease, but I like to tell people, you know, a lot of diseases are multifactorial. It's your diet, it's your exposure to environmental things, and also obviously, the medications.

Host: Can probiotics help in any way with IBD?

Roger Perez, MD: I think that's a great question. I think it's true. I think probiotics have become a pretty popular thing now and they're kind of "sexy" things to say, "I'm taking a probiotic." Unfortunately, as a common sense, you know, not all probiotics are equal. Just because it says it's a probiotic doesn't mean it's helpful necessarily. I frequently tell my patients, you know, you go to the pharmacy and literally, the aisle is 20 or 30 different probiotics. And how do you know which one is the right one to use and which one's going to help? Unfortunately, studies have shown people usually, they don't want to get the least expensive, but they don't want to get the most expensive, and they just try to stick to somewhere in the middle just because of the cost, but that doesn't necessarily mean it's the one that's most effective.

So, we have actually and, in fact, we think that part of the disease in and of itself of inflammatory bowel disease and even irritable bowel syndrome may be related to a dysbiosis or imbalance of good bacteria and bad bacteria in our GI tract. So, there may be an imbalance. And if we obviously can get that in a better balance where the good bacteria are outweighing the bad bacteria. And I tell people all the time, you know, our GI tract is full of good and bad bacteria, and there's almost a constant battle going on between the good bacteria and the bad bacteria. And what can set off some of those things? Certainly sometimes people think of antibiotics, but it's not always, it doesn't have to do necessarily with antibiotics. And it goes back to your question about diet.

Interestingly, we realize now that a lot of the diets can really change the bacteria in our GI tract. So, in fact, if you do eat foods that are high in certain carbohydrates, foods that are, as I mentioned, ultra-processed, those foods can promote certain bacteria to grow, and foods that don't have those things, that are more vegetables and grains and fruits don't promote the growth of some bacteria. So, that's a simple example. Even exercise, for example, studies now show that even in people that do different types of exercise, whether you're a runner, whether you do different types of exercise, it alters the bacteria in your GI tract. So in fact, interestingly, marathon runners, for example, their body will actually promote bacteria that help use lactic acid. And you produce lactic acid when you run, and now your body's producing more bacteria in your GI tract that help digest that lactic acid to allow you to exercise longer or a different type of exercise. So certainly, the probiotics are helpful. I think we're still trying to figure out which probiotics might be helpful and which aren't, but certainly probiotics can be helpful.

Host: Well, of course, our body systems aren't independent of one another. So tell me, how does IBD affect systems outside the intestine?

Roger Perez, MD: Interesting question. Patients and people can have symptoms outside of their GI tract and they don't realize that they're related or associated. So, I frequently like to tell people of the different symptoms that can be associated. For example, some patients will develop canker sores in their mouth, recurrent canker sores, sores or like little sores inside your gums or your lips or your tongue or the roof of your mouth. Those canker sores are not infrequently associated with Crohn's disease or ulcerative colitis. And so, some people, when they start having GI symptoms or gastrointestinal symptoms of diarrhea or cramps or things, they'll notice that they develop canker sores in their mouth. So, that's one thing I tell patients to keep an eye on. Do you get recurrent canker sores?

Another example is joint pains, very common with inflammatory bowel disease, whereas you don't get that with irritable bowel syndrome. In general, patients with irritable bowel syndrome don't have inflammation in their joints. But inflammatory bowel disease, it's an inflammatory process in your gastrointestinal system, and it leads to inflammation in other parts of your body, whether it's in your knees or your ankles or your elbows. People will get inflammation in their joints, and they can actually cause swelling of your joints and even redness and irritation. And in fact, some of the medications I mentioned, if you treat the inflammatory bowel disease, the joint pain improves. So, some people will have really bad joint pain. Sometimes their gastrointestinal symptoms aren't so bad, but their joints are terrible. And if we treat them for their inflammatory bowel disease, their joints get so much better. They can get up, they can move, they're not really in bad shape. Some patients have what we call axial inflammation, which is inflammation in the spine, and they'll get inflammation, and that can cause a lot of joint pains in your spine, in your lower back that can be associated with inflammatory bowel disease. So aphthous ulcers, like I said, the canker sores, joint pains, rashes as well. Some people will get certain types of rashes, usually in their lower extremity that can be associated with inflammatory bowel disease.

And then, lastly, one of the things that I tell people that's associated that they don't realize, that sometimes you can have problems with your eyes where you can have recurrent red eyes, itchy eyes. You feel like you have a foreign body in your eye and that can be associated with inflammatory bowel disease as well.

Host: Interesting. Well, thank you, Dr. Perez, for sharing your experience and your expertise with our listeners.

Roger Perez, MD: Thank you. Thanks for having me.

Host: That wraps up this episode of BayCare HealthChat. I'm your host, Jaime Lewis. Head to our website at BayCare.org for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all other BayCare podcasts. For more health tips and updates, follow us on your social channels. And if you found this podcast informative, please share on social media and be sure to check out all the other interesting podcasts in our library.