Scott Webb (Host): Crohn's disease is an inflammatory bowel disease that causes chronic inflammation of the GI tract. And if left undiagnosed and treated, the consequences can be life-threatening. And joining me today to tell us more about Crohn's disease and the treatment options is Dr. Scott Dolejs. He's a Board Certified Colon and Rectal Surgeon at Franciscan Health.

This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctor, thanks so much for your time today. I realized this morning that I've never actually hosted a podcast on Crohn's disease. I've done maybe a thousand of these, but never on Crohn's. So great to have you and your expertise today. And let's just start there. What is Crohn's Disease?

Scott Dolejs, MD: So Crohn's disease is an inflammatory bowel disease. So this is a condition where the body starts attacking the gastrointestinal tract, resulting in inflammation. It was actually named after Dr. Burrell Crohn, who first described the disease in 1932. And it can happen anywhere along the gut from the mouth, all the way to the anus.

However, the most common location patients have problems with is the last part of the small intestine where the small intestine enters into the colon or large intestine. This area is called the terminal ileum. The next most common location is actually around the anus, and patients can get abscesses or other sores around their anus.

The other inflammatory bowel disease you may have heard of is ulcerative colitis. This has some similarities, but always starts in the rectum. And then stays confined to the colon, and we'll discuss some of those differences in treatment later. It's important to realize that our gut tract was designed to deal with bacteria, and there are a ton of immune cells around our gastrointestinal tract. So if this immune system gets overstimulated and cannot turn itself off appropriately, that's when we get inflammation and Crohn's disease can develop.

Host: So, who's most likely to develop Crohn's Disease?

Scott Dolejs, MD: Yeah, so unfortunately it'd be great if we could say, Hey, this is the exact cause of Crohn's disease, but we don't know that. What we do know is nearly one in a hundred Americans are diagnosed with Crohn's disease or ulcerative colitis. And then also, unfortunately, the rate of Crohn's disease seems to be increasing.

It most commonly is first diagnosed in patients between the ages of 15 to 30, although it can occur at any age. There is some genetic or familial component to Crohn's disease that we're still figuring out. If someone in your family has Crohn's disease, you have at least a three times higher chance of having Crohn's disease, and it might be as high as a 25 times higher chance.

Other risk factors for Crohn's disease include things like smoking, less physical activity, some dietary factors such as diets poor in fiber and poor sleep habits. There are some medicines like NSAIDs, an example of this would be ibuprofen that may also slightly increase the risk of Crohn's disease.

Unfortunately, even people who do not smoke, exercise regularly and have an excellent diet with good fiber can and do still get Crohn's disease. So those are factors. None of them actually cause the disease itself.

Host: Yeah, I see what you mean. I assumed that there was some family history, genetic component to it, and of course we can't outrun that, unfortunately. So you're saying it can sort of happen anywhere along that tract. What are the symptoms of Crohn's?

Scott Dolejs, MD: Yeah, so symptoms from Crohn's are based on the part of the gastrointestinal tract impacted. So the most common symptoms include things like diarrhea, abdominal pain, rectal bleeding, feeling tired, weight loss, and fever. Some people develop painful abscesses or sores around their anus, and people can also get mouth sores, joint pain, eye redness, irritation, and skin rashes.

But really kind of the diarrhea, abdominal pain, rectal bleeding are the three things that really trigger us into thinking, Hey, is this Crohn's disease or not?

Host: Yeah, I definitely don't envy doctors when it comes to diagnosis because so many of the things you're describing there could be Crohn's of course, and could be many other things. I mentioned IBS earlier, and you talked about colitis. Maybe you can just take us through that just a little bit, you know, the are there similarities, differences between Crohn's and IBS and you know, because I think for us laypeople, like I said, they all sort of seem bundled together, but I'm guessing there are some at least subtle differences.

Scott Dolejs, MD: Yeah, absolutely. You know, and it's confusing and a lot of the symptoms may be the same. And sometimes we as doctors will use the phrase when we're describing someone who we're worried about having Crohn's disease or ulcerative colitis as inflammatory bowel disease, which of course sounds very, very similar to irritable bowel syndrome.

You know, the first two letters are almost the same, so that just makes things even more confusing. But Crohn's disease, ulcerative colitis, are very different from irritable bowel syndrome. The key difference is that in irritable bowel syndrome, there's no inflammation of the gastrointestinal tract and biopsies that we take are normal. Irritable bowel syndrome is considered a functional gastrointestinal disorder, which just means that we do not have a particular test or finding when we look at tissue under the microscope that says, yep, you have irritable bowel syndrome or not. In comparison, Crohn's disease patients will usually have characteristic findings on biopsies and other imaging studies, which kind of gets us to, Hey, how is Crohn's disease diagnosed?

So laboratory studies, imaging studies, like a CT scan, can help us determine the severity of Crohn's disease and likelihood of having Crohn's disease. Usually we really like getting the diagnosis and, making a solid diagnosis with a colonoscopy, with biopsies or an upper endoscopy with biopsies.

So getting some kind of tissue that, that we can say, yep, there's some inflammation there, really helps us solidifying the diagnosis of Crohn's disease.

Host: Yeah. Are there times just popped into my head, Doctor, are there times when folks are there for their, you know, regular colonoscopies and then come to find out, oh, and by the way, you also have Crohn's disease. Is it one of those things that can sometimes be discovered and diagnosed, accidentally or incidentally?

Scott Dolejs, MD: Yeah, it's a great question. It's pretty uncommon because most people will have some symptoms, you know, before that diagnosis. So, it's not uncommon for somebody, for example, in my world as a surgeon, to see someone who's had kind of recurrent abscesses that have popped up around their anus and you know, they're wondering, Hey, why does this keep coming back? And we make a diagnosis that way when it was a little bit unexpected. But usually when we're trying to diagnose Crohn's disease and doing a colonoscopy for that, we have an idea that we think, Hmm, this may be, and in today's age, when CT scans and imaging are so widespread, we usually will have some imaging findings that makes us think, you know, I wonder if this person has Crohn's disease.

Host: Yeah, I see what you mean. So then you mentioned earlier, you teased a little bit, but let's talk about the treatment options, whether it's Crohn's or colitis specifically. What do folks do? How do they find some relief?

Scott Dolejs, MD: The first thing is treatment is really variable based on the severity of Crohn's disease and where it's located. So, I'm a surgeon, which tells you that a lot of patients with Crohn's disease eventually need surgery. But really treatment for Crohn's disease should happen in a multidisciplinary team. Because in general, we first try to treat patients with medicines to help decrease the inflammation. These medications also can suppress the immune system so they can have some side effects. These can range from pills to more powerful infusions and injections. And it's common to have to try a few medications before finding one that will work.

There are new medicines that are being released almost every year as we understand more and more about Crohn's disease and how it develops. Sometimes the medicines are not working well enough or other complications develop and surgery is needed. There's been some estimates that after about 10 years of having Crohn's disease, half of patients will require surgery to remove some of the inflammed intestine.

However, that proportion of patients who require surgery seems to be decreasing as we're getting new and better medication and more recent data show that 20% of patients have required surgery at five years. Sometimes patients may not want to be on medicines because of that immune side effects and some of the other side effects and may opt to have the part of the intestine that's inflamed, removed during surgery.

However, it is very important to remember that surgery does not cure Crohn's disease. It can help patients feel better, return to normal activities, and may help keep Crohn's disease in check. But because Crohn's disease can happen anywhere along the length of the gastrointestinal tract, it is not a cure by itself.

Also, about 30 to 50% of patients who have had a surgery for Crohn's disease will need another at some point during their life. And this is an important contrast between Crohn's disease and ulcerative colitis, the other inflammatory bowel disease. Ulcerative colitis can be cured by the removal of the entire colon and rectum because that disease is confined to that area.

And again, because patients need a combination of medical treatment, lifestyle changes, such as dietary changes and smoking cessation and potentially surgery; taking care of patients with Crohn's disease requires a team. This will usually include gastroenterologists, colorectal surgeons like myself, nutritionists, primary care providers, support groups, and at times psychiatrists or psychologists.

Host: Yeah, it's interesting. What are the complications Doctor, of sort of not treating Crohn's or not treating it or managing it as long as patients and doctors should.

Scott Dolejs, MD: Unfortunately, there can be complications from Crohn's disease and myself as a surgeon, is usually the one who hops in when these complications develop. So because Crohn's disease can involve the whole thickness of the intestine, it means that Crohn's disease can cause the bowel to do things like perforate or form strictures or narrowing of the intestines.

And these strictures can result in blockages of the bowel. And because it can involve the whole thickness of the bowel, Crohn's disease can result in fistulas, which is that our fancy word for connections to other organs. So an example of this would be Crohn's disease can cause a small bowel to become connected to the bladder.

So contents from the bowel enter into the bladder and eventually in the urinary stream. Sometimes these complications can be treated with medicines, but often they do require surgery.

Host: Yeah.

Scott Dolejs, MD: Another thing that we need to keep in mind is a long-term complication of Crohn's disease is cancer. And that's because longstanding inflammation, really anywhere in the body, can result in changes to our cells that eventually result in cancers. And because of this, after having Crohn's disease for many years, your doctor will likely recommend more frequent colonoscopies.

Host: Yeah, and you mentioned some behavior and lifestyle changes. So are there some certain foods or activities or anything that either contributes to Crohn's and or would help us to, let's say manage it?

Scott Dolejs, MD: So the biggest thing a patient with Crohn's disease can do to help their disease is to not smoke. And if they are smoking, to quit, really, I, I can't stress enough. This is the number one factor that will impact a patient's disease course so strongly. So, so, so important. Patients with Crohn's disease should avoid medicines like NSAIDs.

So that would include things like ibuprofen and naproxen, which have been shown to trigger flares of Crohn's disease and some patients, dietary wise will have issues with different types of foods. For some that will be foods that are high in residue. So I give people the example of things that look the same, going in as they do going out, so you know, fruit with peels on it, corn, those kind of things.

You know, if you have a stricture or a narrowing, you can imagine, well, it could potentially plug that. Some patients have issues with fiber and some patients find that too much alcohol or caffeine may make their symptoms worse. Finding the right diet can be tricky, and it's different really for everyone. So working with a dietician can really help solidify and figure this out better.

Host: Yeah, and as you mentioned, it really is a team approach to treating and managing Crohn's. And, uh, this has been really educational as I thought it would be today. Doctor, as we wrap up here, final thoughts, takeaways, when we think about folks who I just feel, and again, just anecdotally, I feel like there's a lot of folks out there who haven't been diagnosed.

So how do we get them in the office? How do we get them diagnosed and how can you reassure them that there is treatment available, that there is relief available?

Scott Dolejs, MD: Yeah, absolutely. So, a lot of people want to know, Hey, is this ever going to go away? I don't want the diagnosis because what am I going to do with it? And, and the first thing to understand is that it certainly is tricky because the presentation of Crohn's disease can be so variable. In fact, about one in five patients, who gets treated for an initial flare of Crohn's disease, never have problems with it again.

So in those patients, pretty much it is gone. But that means that, you know, four and five or 80% of patients, do require ongoing treatment. But with treatment, patients can live normal and full lives. Many patients may have mild flares like you were suggesting, that come and go, but are very well controlled with medications.

Again, about half of people will need surgery at some point, but after surgery, people can go years without having any issues. Because it's so different for each patient, it's difficult to predict how an individual will do. In general, we say younger age at diagnosis, using tobacco, having that rectal or perianal involvement with abscesses and needing long-term steroids are risks for worse and progressive disease.

But we have new medications that are coming out every year. Better surgical techniques that have happened and been developed even, you know, in the last couple years. And, with all that, we can get patients back to their lives, get their lives on track and give patients a great future.

Host: Yeah. I mean, that's what we all want, right? Even with something, you know, like Crohn's, which can kind of hang around and nag at us for years. It's good to know that we have experts and teams of folks, especially at Franciscan Health that can help us. So Doctor, thanks so much for your time today. You stay well.

Scott Dolejs, MD: Thank you.

Host: And for more information, visit franciscanhealth.org and search Crohn's Disease. And if you found this podcast helpful, please share it on your social channels. And be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.