Melanie Cole, MS (Host): Welcome to AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole, and joining me today to highlight endoscopic management of IBD complications is Dr. Gursimran Kochhar. He's the Chief in the Allegheny Health Network Division of Gastroenterology, Hepatology and Nutrition.

Dr. Kochhar, it's a pleasure to have you join us today as we get into this topic. Can you tell us a little bit about inflammatory bowel disease today, the prevalence, what you've been seeing in the trends, really what's the scope of the issue we're talking about here today?

Dr Gursimran Kochhar: Thank you so much for having me and discussing this important topic. So, inflammatory bowel disease basically encompasses two main disease categories that we commonly hear about. One is called Crohn's disease. One is called ulcerative colitis. The approximate 3.1 million adults, about 1.3 percent of the U.S. population currently is suffering from IBD. And in recent years, what we are seeing is a global increase in incidence of IBD across all age groups, especially the elderly population.

Melanie Cole, MS: If it's going global, as they say, are there some risk factors, Dr. Kochhar, that you can point to? Is there a strong genetic component? Do you have any theories on why the trend is rising?

Dr Gursimran Kochhar: So, it's a very complex answer. There's a lot of research that's going on. There are certainly some subset of genes that have been associated with stricturing Crohn's disease, like NOD2 mutations. This disease was very prevalent in Jewish population, especially pre-World War II era. But what we are now recently seeing is that it is affecting people from all ethnic backgrounds, including Asians, African Americans, young people, old people. although a lot of research is undergoing, but what we understand is there is a complex interaction of a person's environment, gut microbiome, with their genetic makeup. So, I think, there are a lot of hypotheses being proposed as to why this is increasing, but mainly it is coming back down to our daily lifestyle, our diet patterns, and the food that we are eating, along with the physical activity levels that we think that these complex interactions are playing a part along with the stress level that people function these days at, that people are having more and more, not just IBD, but in general, more autoimmune diseases, IBD being definitely a big part of that.

Melanie Cole, MS: It is certainly an interesting field of study right now. And as you say, gut microbiome and autoimmune diseases on the rise, and lifestyle. I mean, there are so many factors, it's very complex now. It's so interesting to me, we're talking about Interventional IBD and how this field has evolved. Tell us a little bit about what we mean by Interventional IBD.

Dr Gursimran Kochhar: Yes, it's a very new term. It starte floating around in the last seven, eight years. Basically, we always had a component of Gastroenterology, which was Interventional Endoscopy. It was a field where the gastroenterologists were doing cutting-edge advanced endoscopic procedures to manage various sorts of diseases. So, the term has been adopted from our Interventional Endoscopy colleagues into Interventional IBD.

Basically, in a nutshell, what it means is that we are using various endoscopic interventions to treat patients with IBD to manage complications that result from IBD, thereby either necessitating a delay in the surgeries that patients need, or even in certain cases, avoiding surgeries if possible.

I want to say here that surgery remains a very integral and important part in management of IBD, so it is something that we know that it can help patients, but there are certain subset of patients that can really benefit from maybe delaying those surgeries or, you know, not having those surgeries. And that's where Interventional IBD bridges that gap between the medical management and the surgical management.

Melanie Cole, MS: When you're talking about medical management and surgical management, and we're going to get into this endoscopy and how it's being used for IBD management. But when you're looking at the options for treatment, and there are so many tools in your toolbox today, Dr. Kochhar, when we talk about diagnoses and an accurate diagnosis of inflammatory bowel disease, the differentiation between ulcerative colitis and Crohn's can be made in most patients. But is it sometimes an overlap and does that affect treatment modality and management decisions?

Dr Gursimran Kochhar: Most of the times, yes, we have certain telltale signs that we say, "Okay, this is ulcerative colitis and Crohn's disease," but there are definitely an overlap of patients in which we are not able to differentiate exactly is this purely Crohn's disease or purely ulcerative colitis. And actually, there was a term that was being used for these patients that said indeterminate colitis, meaning we could not say either they're Crohn's or they're UC. But these patients, from management standpoint, we practically end up managing these patients as Crohn's disease itself, but there is a subset of patients that we still call them indeterminate colitis, and we treat them as such, like we treat patients with Crohn's disease.

Melanie Cole, MS: Then speak about endoscopy and how it's being used for IBD management. Provide a bit of an overview of the scope of the interventional techniques that are available for managing these diseases.

Dr Gursimran Kochhar: Yes, I think endoscopy plays a very integral role. We'll start from the basics, like endoscopy is a very important tool in basically diagnosing the disease. We need to have endoscopic biopsies performed that the pathologists review at the time of your index diagnosis of IBD. And subsequently, endoscopy is now being used as a very important tool in assessing disease severity and also achieving our medical management endpoints, which is endoscopic remission or mucosal healing. The third important role that endoscopy plays, both patients with ulcerative colitis and Crohn's colitis, they are at a higher risk of getting colon cancer than the general population, especially as they have had disease for longer duration. And endoscopy plays a very integral part in the disease surveillance in these patients and overall picking up early signs of cancer.

Now, Interventional Endoscopy, the various procedures can be divided into various categories, but we'll touch upon some important ones. Up to 25 percent patients with Crohn's disease at some point will have a stricture. And stricture is basically a luminal narrowing that they can get either from disease itself or sometimes in postoperative states. So, in Interventional Endoscopy, we can use three tools now to manage these complications. For so many years, we were only being able to use endoscopic balloon dilation, in which we use a hydrostatic balloon to dilate the strictures. Now, we have techniques like endoscopic stricturotomy, in which we can take a scope to the site of the stricture and using an electro-incision knife cut out the scar tissue internally. So instead of stretching the scar tissue, we are able to remove that scar tissue and thereby alleviating symptoms of obstruction, because now we have improved the stricture. One of the leading centers to do that, in fact, we were the second center in the region after Cleveland Clinic to provide this procedure to our patients. And since I joined, we have now done more than 140 cases for our patients with endoscopic stricturotomy.

The third avenue that is emerging, it is still being developed, is using enteral stents in patients with strictures. Stents traditionally have been used for patients with malignancy. And for some patients with benign diseases, IBD patients, they were not very popular. But now since our stent designs are being improved newer types of stents are coming, I think in next five, seven years, we might see potential use of more endoluminal stents to manage strictures.

Moving on, there are other complications like fistulas. We can now do endoscopic fistulotomies, basically opening up the fistula with the help of a scope, thereby avoiding a need of surgery in these patients. Again, these are very highly selected fistulas. Not every fistula can be endoscopically managed. But simple fistulas, straight track fistulas can be managed now endoscopically.

The third very important arm, and we briefly touched about this, was the cancer surveillance in IBD patients. So as part of cancer surveillance, when IBD patients do develop areas of dysplasia, especially areas of low-grade dysplasia or polyps, sometimes in the past we were not able to remove these, challenging polyps or challenging areas endoscopically because of the scar tissue. But now, our techniques have evolved with the development of endoscopic mucosal resection, endoscopic submucosal dissection. And the latest, as I say, kid on the block, is endoscopic full thickness resection. We can remove these areas without having to have patient undergo a surgery or a colectomy. So thereby, we can save the entire colon and still remove the dysplastic lesions. So, these three are the big top categories in Interventional Endoscopy I see. There are other areas also where we have used our interventional and endoscopic technique, such as use of endoscopic ultrasound, drainages of sinuses, and so on and so forth.

Melanie Cole, MS: That's absolutely fascinating. What an exciting time in your field, Dr. Kochhar. And as you're telling us how it's being used at AHN, what are the patient outcomes that you're seeing? How does it benefit the patients and what are they seeing?

Dr Gursimran Kochhar: So, we've seen some very good patient outcomes in this regard. want to say that, we are blessed at AHN to have great surgical colleagues, in terms of our colorectal surgical colleagues. And we manage these patients in conjunction with them. Once we do identify a patient that we think can benefit with endoscopic therapy, we then perform these on them. And our patients have had very good outcomes. We have been successful achieving technical success, meaning opening up the stricture in nearly all patients. So, the technical success is nearly 100%. And even so, the long-term outcomes, meaning how many patients required a need of surgery at the end of one year, we have actually outcomes more than 80% of the time where we did not have our patients requiring surgery at the end of one year who underwent this technique.

The other benefit of this technique is that we can repeat it if we have to, because it entails patient undergoing another endoscopic procedure. So, we've had some very good results. Patients have been very happy, because they've been able to delay the surgeries. And sometimes even delaying a surgery in IBD patient for a few years can be very useful. This way, they don't have to lose too much of their intestines. So, I think we've had a very good success rate here and we are happy to provide this technique to our patients.

Melanie Cole, MS: Dr. Kochhar, please speak about referral as we wrap up. I'd like you to offer providers your key takeaways from this interesting field of study for inflammatory bowel disease and who should be referred to interventional IBD and when do you think it's important.

Dr Gursimran Kochhar: Yes. I think there are two things very important and I hope our listeners can appreciate that the field of IBD has grown many fold. And day by day, it's becoming more complex, not just from the standpoint of disease, but also our management options. We have so many medications. However, the key in IBD patients is to identify which patients may not respond to medication and they may need surgery and/or endoscopic therapy.

So, my urge is always asking providers that if you have a patient that is more complex than an average IBD patient, it's never wrong to seek a second opinion. Now, if they do develop complications like strictures, fistulas, sinuses, abscesses, please do refer them to us. Our surgical colleagues and my medical colleagues, including myself, we comprehensively evaluate these patients and then come with a common plan, which we think will most benefit the patient.

Melanie Cole, MS: Thank you so much, Dr. Kochhar, for joining us today and sharing your incredible expertise. Thank you again. And to learn more or to refer a patient, please call 844-MDREFER or visit ahn.org. Thank you so much for listening to this edition of AHN MedTalks with the Allegheny Health Network. Please always remember to rate, subscribe, and review AHN Med Talks on Apple Podcasts, Spotify, iHeart, and Pandora. I'm Melanie Cole. Thanks so much for joining us today.