Transcription:
Latest Treatments for Inflammatory Bowel Disease: Crohn’s Disease and Ulcerative Colitis

Melanie Cole (Host): Many people are confused when it comes to the differences between inflammatory bowel disease, Crohn’s disease, and ulcerative colitis. Here to clear up some of that confusion is Dr. J. Pruthi. He’s a gastroenterologist and a member of the medical staff at Palmdale Regional Medical Center. Welcome to the show, Dr. Pruthi. Please explain a little bit about what inflammatory bowel disease is and how Crohn’s and ulcerative colitis sort of fit under this umbrella term?

J. Pruthi, MD, FACG, CPI (Guest): Thank you, Melanie, for inviting me to the show. It’s always a pleasure. Today we’re going to talk about inflammatory bowel disease, which means, as the term conveys, the bowel is inflamed. There’s an inflammation in the GI tract system. Now, it can happen from anywhere from mouth to anus, from smaller cells in the mouth, inflammation in the esophagus, stomach, small intestine, and colon, or even fistulas in the anal area, and we can differentiate between these areas, and if the inflammation is prominently in the colon, and the characteristics of inflammation are different, then we classify this as ulcerative colitis. But if the inflammation is all over it or it’s in one segment of the small intestines, and it is full thickness inflammation, the characteristics are different then we classify it as Crohn’s disease. But some patients may fall in between these two categories, and it can be indeterminate or, you know, colitis, or indeterminate inflammatory bowel disease that has not yet been classified, and as the disease progresses, it will manifest either Crohn’s or ulcerative colitis. So, it’s a very disabling disease process where the intestinal system is inflamed, and people have a lot of symptoms.

Melanie: Are these considered autoimmune diseases, and do we know what causes them? Is there a genetic component to these? Tell us a little bit about the cause of these.

Dr. Pruthi: The cause is currently unknown. There is definitely a genetic component, you know. In 10-20% of patients of Crohn’s disease or ulcerative colitis, they have at least a family member or a blood relative with inflammatory bowel disease. So, there is definitely a genetic component. Some genes have been identified like NOD, NOD2 genes and other genes, and these are considered as autoimmune processes where the body’s immune system sort of attacks the intestinal lining and the wall and the inflammation sets in. The white blood cells move into the intestinal lining and cause the inflammation and alteration, formation, and really lots of abnormalities. So, the current cause is unknown.

Melanie: So, are there some symptoms, as Crohn’s disease can even start in children or teenagers or people in their 20’s, and if there’s this genetic component, what do you want people to watch out for or to be on the lookout, Dr. Pruthi? What red flags in symptoms would show up that would say, you know what? You need to get a GI find out if this is Crohn’s?

Dr. Pruthi: Yes. There are symptoms which will, you know, indicate that just that patient may be suffering from inflammatory bowel disease, and it can happen in the age groups from, you know, young adults, adolescents and young adults, and children and then later on in the 50’s to 70’s. So, there are two peaks in, you know, the distribution. One is early adolescence, 15 to 30 years of age. Then, the other peak of ordinary incidence of inflammatory bowel disease comes at age 50 to 70 to 75.
Now, the symptoms are non-specific. People may come with abdominal pain, chronic diarrhea, and particularly in children there will be a delayed development or stunted growth and then you have fever, rectal bleeding, blood in the stool, weight loss, and sometimes they may have a feeling of a burning mass, and a mass in the lower abdomen. These are the intestinal symptoms. But in order to say an inflammatory process, and it affects the rest of the body, also. So, some people may develop arthritis, joint pain. They can have inflammation in the eye or mouth. They can then develop kidney stones. They can develop abdominal pain from gallbladder stones. They can have inflammation in the liver. They develop liver test abnormalities, or they can develop skin rash or skin ulcers, even. So, if you have, you know, these symptoms, obviously, don’t delay. Go to the doctor because, you know, the data shows that, you know, the delay in the diagnosis for Crohn’s disease is at least one year from the time of onset of symptoms. Because symptoms are non-specific, you know, people tend to take various pains and you know, try to delay, but the more delay we have in making a diagnosis, more of this could be done, we’re getting into complications. So, if you have any symptoms, just go for it. See your doctor and determine whether this is inflammatory bowel disease or something else going on because, you know, a lot of people have irritable bowel syndrome, also. They will have diarrhea, abdominal pain, too, but they will not have rectal bleeding generally. They will not lose weight. That diarrhea in inflammatory bowel disease is different. It can have, you know, blood in it, and It may wake you up during the night. It may wake you up during your sleep so that you, you know—it’s real inflammation going on. But on the other hand, in irritable bowel syndrome when there is no significant inflammation, there is no inflammatory bowel disease, no Crohn’s disease, no ulcerative colitis, bad diarrhea is only daytime and does not wake you up at nighttime. People do not lose weight. It does not cause any fever. It does not cause severe sickness. So, if the diarrhea is not going away, you’re having bleeding; you’re losing weight; you should go to the doctor.

Melanie: So, since we know that there’s no right out cure for these, let’s talk about the medical treatment and what those goals would be to achieve remission or maintain remission or improve the quality of life because the quality of life, Dr. Pruthi, is so important for these types of patients—what they can eat, where they can go out to eat, all kinds of, you know, aspects of that quality of life come into play here. So, speak about intervention, medications for treatments, and what you do for these people to help increase their quality of life.

Dr. Pruthi: Sure. The treatment goals for inflammatory bowel disease, number one, we want to reduce the inflammation in the intestinal system. Then, number two, we want to control their signs and symptoms. They want to control the pain. We want to control the diarrhea, and we want to stop the bleeding. Then number three, we want to correct the nutritional deficiencies. You notice people who have inflammation in their digestive system, they may develop nutritional deficiencies. They may not absorb certain nutrients very well and then, you know, that causes another problem. Then, number four, we want to mobilize their life as much as possible. We want them to get back to their work and not, you know, get disabled from it. Now these goals—we try to make all these goals for everybody. How do we do it? First thing is to make a correct diagnosis. So, we want to have a correct diagnosis, whether it is Crohn’s or ulcerative colitis or indeterminate or whatever else is going on—if there’s any superimposed infection there. To make a diagnosis, we do endoscopy, take biopsies, look at the inflammatory patch in the intestinal system and do some blood tests. If the need be, we do CT scan or x-rays or MRI to look at the intestinal system and categorize the patient—establish a differential diagnosis. Then, we offer the treatment, medications.
Certain categories of medications, beginning with sulfasalazine is a very common drug that we use. Then, another derivative of sulfasalazine is 5-ASA compounds called mesalamine. Then, we can use suppositories, either the simple anti-inflammatory medications, which work in a topical manner. Like it is a fire retardant, we spread the fire retardant on the inflamed colon and control the inflammation. Many patients, it works good. Then, if that doesn’t help, the next category we go to are the steroids, corticosteroids, prednisone or IV solumedrol or IV prednisone. So that will control the inflammation and control and modify the immune system so that the immune system is not attacking the intestinal system, but there are side effects for the corticosteroids—so that’s why we don’t want to continue the corticosteroids for a long time. My goal generally is to, if I want to use corticosteroids in a patient, we want to use it for a limited period of time and in tapering doses, but we can get them off of steroids and control the disease process with another medication. Then the third category of medications are immunomodulators, which will modify the immune system, so that the immune system is not attacking the intestinal lining. So, those are azathioprine, mecatopurine, methotrexate, etcetera. Then, the newer drugs are biological drugs, which are anti-inflammatory, and they are called anti-TNF alpha, anti-tissue necrosis factor medication like infliximab, adalimumab. Remicade and Humira are their trade names, and then newer ones are alpha-4 integrin inhibitors like Entyvio or vedolizumab. Then, interleukin 12 and interleukin 23 inhibitors called Stelara or ustekinumab. So, these are the new medications which modify the disease process and modify the immune system so that, you know, we can control inflammation better. Then, finally, we have antibiotics that we use sometimes, ciprofloxacin, Flagyl, and metronidazole, tetracycline, sulfa medications. So, we tend to use all these medications whether, you know, by itself or in various combinations to control the disease process and bring the patients back to normal, like as much as possible.
Then Melanie talked about the nutrition. It’s very important. We want to check their, you know, levels of nutrients. Particularly, we want to make sure they have enough calcium in their system, folate, B12, vitamin D. So, those supplements are important in this patient population. Then, she mentioned diet. Diet is very important, too. Now, there is not a particular diet that everybody can, you know, just go for it. So, I recommend the food diary and see which items suit you and which don’t, and then modify the diet accordingly. And, stop smoking and avoid alcohol and take small frequent meals and keep regular exercising and a good lifestyle.

Melanie: Does stress play a role as a trigger, Dr. Pruthi, in Crohn’s disease and ulcerative colitis?

Dr. Pruthi: Very good question, Melanie. Stress can do a number on us. Per se, stress is not going to cause inflammatory bowel disease, but it can make the matter worse. It can make the symptoms worse, you know. It becomes a vicious cycle. When you have inflammatory bowel disease, you are stressed out and the stress makes the symptoms worse. So, you’ve got to get out of that vicious cycle by, you know, seeing your physician, controlling the disease process better and even relaxing, and if there need be, take some medications.

Melanie: So, wrap it up for us please, Dr. Pruthi, with your best advice about how patients that suffer from Crohn’s disease, inflammatory bowel disease, ulcerative colitis, any of these autoimmune disorders, what you would like them to know about treatments out there and living a normal life with these diseases and how they can live a normal life with some of the latest treatments.

Dr. Pruthi: Yes. inflammatory bowel disease to summarize is, you know, inflammation of the intestinal system. It can happen anywhere from mouth to anus. Symptoms are usually non-specific, but I would recommend, do not ignore the symptoms: abdominal pain, nausea, vomiting, weight loss, diarrhea, rectal bleeding, arthritis, skin rash. Just go to the physician early. Make the diagnosis. Get established the correct diagnosis and then start the treatment early so that we can prevent the complications. Then, all of the good lifestyle and if patients, you know, have long-term disease process and after 10 years of colitis, then, we get worried about colon cancer because after eight to ten years of ulcerative colitis, the risk for colon cancer goes very high, too. So, in those patients, we recommend they have a scanning colonoscopy every two years and take random biopsies from every 10 centimeter interval in the colon to check for any early signs of cancer, and after 15 years of chronic colitis, then colonoscopy every year, and just be compliant with the medications. Become a partner in your disease process and treatment process. Understand the disease process and be sure to take your medications on time and follow the recommendations.

Melanie: It's great information. Thank you so much, Dr. Pruthi. It’s always such a pleasure to have you on the show. You're listening to Palmdale Regional Radio with Palmdale Regional Medical Center. For more information, please visit palmdaleregional.com. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks so much for listening.