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Melanie Cole (Host): Welcome. Today we’re talking about Crohn’s Disease and colitis. My guests in this panel style discussion are Dr. Chad Burski. He’s a gastroenterologist and an Assistant Professor and Dr. Melanie Morris. She’s a colorectal surgeon and an Associate Professor and they are both at UAB Medicine. Doctors thank you so much for joining us today. Dr. Burski, I’d like to start with you. Please tell us about the current state of Crohn’s and colitis. What is the prevalence and what do you feel is different about what we know about these diseases now than say we knew 20 years ago.

Chad Burski, MD (Guest): Well thank you for asking me to be on and to talk about inflammatory bowel disease, both Crohn’s and ulcerative colitis. The prevalence of inflammatory bowel disease has probably increased over the past few years and that may attributed to people living longer but the prevalence at least for ulcerative colitis is about somewhere between 200 to 250 cases per 100,000 years. Person years that is and Crohn’s Disease is somewhere probably in the 175 to 200 cases per 100,000 person years.

Sometimes there is some graphical variation with that and over time like I said; those numbers have seemed to increase but that may be attributed to folks living longer with a longer life expectancy.

Host: Dr. Morris, I introduced you as a colorectal surgeon. Dr. Burski is a gastroenterologist. What kinds of physicians are treating IBDs these days?

Melanie Morris, MD (Guest): Yeah, thank you for that question. It’s really an honor to be here today and discuss these inflammatory bowel diseases. So, certainly gastroenterologists and surgeons, especially colorectal surgeons work very closely together in managing these patients. Usually patients first try medicines which would be managed under the gastroenterologists. And as you asked earlier, there have been really a lot of advances in the medications that the gastroenterologists have to treat these patients. Many patients can be successfully managed with medications alone and may not need surgery. However, when either complications arise from Crohn’s Disease or ulcerative colitis is not manageable with medications; then patients are referred to surgery. And colorectal surgeons really have expert special training in how to treat patients with inflammatory bowel disease.

Host: Dr. Burski, as a patient would come to you, which physical findings are related to the severity of their inflammatory bowel disease? What are you looking for?

Dr. Burski: Oh, that’s a fair question. So, it’s not a single entity or a single sign or symptom that we are sort of looking for. It’s the use of putting those signs and symptoms together. So, oftentimes depending on where their disease is located can manifest differently. For example, in somebody that has Crohn’s that only involves their terminal ileum; that may manifest as pain in their right lower quadrant. Whereas if somebody has ulcerative colitis that only involves the rectum; that may manifest more in urgency and rectal bleeding. So, to define severity that can take into a lot of accounts not just bowel habits but how they are doing systemically. How’s their weight doing? How’s their nutrition? How’s their energy level and sort of how they’re making it from a systemic standpoint whether fevers, maybe an elevated white count or signs of other active inflammatory markers or measures. So, not a single answer to that question. So, you are often looking for multiple different symptoms or signs to put together to try to define that severity.

Host: Dr. Burski, I’m going to stick with you for a second as we are talking about diagnostic criteria and diagnosis. Tell us about the role of lab testing and the role of imaging in the evaluation of inflammatory bowel diseases.

Dr. Burski: Yeah, so again, not a single lab that will diagnose Crohn’s or ulcerative colitis. There are some markers that may help you. Maybe that’s inflammatory markers, not just inflammatory markers that are specific for inflammation such as an estimated sedimentation rate or a CRP. But sometimes that could be markers of systemic inflammation such as a higher white count or a higher platelet count or markers like that. So, as far as labs go, there’s not a single lab that sort of diagnoses inflammatory bowel disease. And so you have to take those into consideration.

In regards to imaging; imaging can be very, very helpful for example, in folks with Crohn’s Disease that involves the small bowel; we often rely on imaging to try to help guide us with what the inflammation looks like and how much is involved compared to just doing endoscopy alone of the colon where we can only see the colon and not the small bowel.

Dr. Morris: And I would just like to add two things on that. One while there aren’t specific inflammatory markers that are 100% diagnostic; there is something called the Prometheus panel that I frequently find providers have not heard of that can help determine if the level of suspicion you have if a patient has Crohn’s Disease or ulcerative colitis. This can be especially helpful in patients where the diagnosis is unclear. We also use that to sort of decide – some patients we can’t tell if they have Crohn’s Disease or ulcerative colitis. They may have something we call indeterminate colitis. And the Prometheus panel maybe helpful.

The other thing I wanted to add is that we tend to get CT scans on patients when they have abdominal pain, but we want to be cautious in these patients. Because many CT scans over time result in a lot of radiation to the patient. So, that’s when we think about things like MR enterography or other modalities. So, I just want providers to be conscious of those two things.

Host: Dr. Morris, in your opinion, if there is a rise in these diseases; to what do you attribute this? Do you feel that overuse of antibiotics or genetic predisposition or sanitization? There’s theories that abound. Do you have your own?

Dr. Morris: Wow, what a great question that is. I mean we all certainly wish we knew what caused Crohn’s Disease and ulcerative colitis. And there are a lot of theories out there as you’ve pointed out. It is probably some combination of some genetic predisposition, some environmental factors. I think the few things that we know may play a role that patients can help. We do know that patients who smoke and have Crohn’s Disease have worse outcomes. Their disease is harder to manage. They are more likely to have recurrences. So we certainly suggest smoking cessation in all of our patients with Crohn’s Disease.

There’s also a lot of interesting research going on with the microbiome. So, the bacteria that all live in our guts and play a role in health and wellness. We’re still learning what those bacteria mean. But you asked a question about antibiotics and so antibiotics certainly shift the bacteria that live in our colon and so I recommend that patients take probiotics. I don’t see any harm in that. While there’s no convincing evidence; it may sort of help.

The other thing we do know is that when patients are under more stress either physically or emotionally; their inflammatory bowel disease is worsened. So, I frequently talk to my patients too about trying to find healthy ways to manage stress.

Host: What a great answer and Dr. Burski, speak about the role of colonoscopy. We are going to start to speak about treatments now and so, while you’ve talked about diagnostic criteria; speak about things like colonoscopy that would be more in your purview in the treatment of inflammatory bowel diseases. What treatments do you look to first?

Dr. Burski: Yeah, that’s a great question. So, when I think about colonoscopy obviously, I think that colonoscopy is a very useful tool to try to help define patient’s disease process. Whether that be at the time of the original diagnosis or that be at the time to try to stage their response to therapy. But the role of colonoscopy can be invaluable to try to determine whether somebody has ulcerative colitis versus Crohn’s Disease. And we often will rely on colonoscopy to help guide us not just for that diagnosis but also to help us with severity of their disease process.

So, in regards to defining therapy and sort of helping guide therapy; those become very difficult to sort of make as a standard recommendation and each individual patient becomes somewhat tailored. But we often – originally, we would only have a couple drugs that would induce remission and those medications; the standard would have been steroids at the time. We now have the addition of our anti-TNF medications such as infliximab or adalimumab or certolizumab that we are able to use not just as induction medicines but also as maintenance therapy. And so we often turn to those either steroids or anti-TNF alpha medications depending on the severity to induce remission. And once we’re in a maintenance situation; we have a few more options where we can consider thiopurine, medication such as mercaptopurine or azathioprine or if we want to continue – if we started with an anti-TNF, we would just continue with that medication.

So, the medication answer is often tailored to that patient depending on their severity of disease and whether they have Crohn’s or ulcerative colitis and people that have ulcerative colitis we do have an extra sort of medication for induction with salicylate medications or 5-ASA medications that we can use for induction and maintenance and in people with mild to moderate disease; that would be the therapy normally of choice for the very mild to moderate UC patient that we think can get under control with topical 5-ASA medications.

Host: And that’s with the goal of maintaining that remission and improving the patient’s quality of life, yes, because that is a whole big part of this goal?

Dr. Burski: Yeah, that’s a – yes ma’am, that’s a fair sort of question but yeah, I think ultimately the goal of those medications is number one priority is to improve the patient’s symptoms and their overall global feeling of health but also, we look for other certain markers of that and that would be improving their inflammatory markers, improving their fatigue, improvement in their endoscopy as well as their pathological diagnosis. So, yeah, I think when we think about those medications; we want complete remission from symptoms and as well as inflammation.

Host: Dr. Morris, what is the role of surgical interventions and when does that role come into play for the patients? What would you like other providers to know if they are referring patients to you at UAB, when does that discussion take place in their process? Because this can be a very long disease, a lifelong process. When does some kind of an intervention come into play?

Dr. Morris: Great. Thanks for that question. I’d like to address it for both the main disease processes. So, for ulcerative colitis, it’s a little more clearly defined. So, we know that ulcerative colitis only affects the colon and rectum and that we can cure patients with surgery by taking out the colon and rectum. Sometimes gastroenterologists will refer to this as failing medical management. We in surgery, don’t see it as failing because we actually have the opportunity to cure the patient. In general, if patients have ulcerative colitis, they end up having surgery because they’ve either failed their medical management, so they’ve tried all appropriate medical options and their colitis is not under control. Or there is some contraindication for them taking further medications. Or they come in where they are very sick and they’ve had sort of a toxic colitis event to where they can not get better with any medications.

Depending on how the patient presents; we take out the entire colon and rectum and that maybe done in one stage or two stages and then depending on the specific patient; they may or may not be a candidate to have what’s called a J-pouch reconstruction where we create a new rectum and sew it down to their anus so that they can eventually poop out of their bottom again. Again, some patients will not be a candidate for that and would have a permanent ostomy.

Crohn’s disease is different. We know we cannot cure Crohn’s Disease with surgery. So, we need to be very careful only to operate when there are specific complications from Crohn’s Disease such as a fistula or an abscess or a strictured area or if a patient has a very small active inflammation strictured area we may consider operating on that. But again, patients who have surgery for Crohn’s Disease or more likely to need more surgery in the future and we need to be very cautious about preserving bowel length. So, any time we are talking about surgery for Crohn’s Disease; we need to make sure that the lesions that we see that are affected with Crohn’s Disease are consistent with the symptoms that the patient is having. So, just abdominal pain alone is not an indication for surgery. There just has to be something that we see that we can fix and make better with Crohn’s Disease.

Dr. Burski: What I’d like to add is I agree with Dr. Morris and that is a great response. I think from a gastroenterology or medicine side I think it’s very important to partner with our colorectal surgery colleagues quite frequently and I guess I would urge people to involve colorectal surgery early and often in the setting of trying to guide the right steps in therapy, not always are we asking colorectal surgery to operate, we are sort of asking to get their input and get knowledge and their expertise on the options that are available not just from a surgical standpoint but from a planning standpoint and I think that Dr. Morris and her group, we have a very strong working relationship and I think it’s important that people in the community if they have a colorectal surgeon that they can partner with, that becomes very important for the longevity of the patient and the choosing of the right timing for surgery.

Dr. Morris: Thanks Chad. And they can always send them here to us too. We are always happy to partner with anyone on these complicated patients.

Host: Dr. Burski, I’d like to start with you for this wrap up. Tell us some promising new therapies for medicational intervention. Where do you see this going on the horizon?

Dr. Burski: As far as new therapies that have come out that we use and have deployed here at UAB; I think the vedolizumab is new biological therapy that is sort of specific and was developed to target specifically the GI tract. We are continuing to get new biologics that become approved and as our experience grows; we will continue to work and help decide what medication works best for the patient on an individual basis.

So, I guess at UAB, where are we going to try to help define and work towards a better overall health for our inflammatory bowel patients. UAB is working to develop an inflammatory bowel center where we can partner with our inflammatory bowel specialists as well as our colorectal specialists to help patients navigate through this complicated disease and help to get them enrolled in trials if available at that time and to help manage their whole healthcare rather than only their inflammatory bowel disease.

Host: Dr. Morris, last word to you. What do you see happening in the world of inflammatory bowel diseases, new therapies, new interventions? Where do you see it going and what is your best advice for other providers that are looking for referral?

Dr. Morris: Yeah, thanks. I think certainly, as I mentioned earlier, the microbiome is very promising. And I would say everyone should look forward to see what we learn more about innovations in the microbiome and perhaps in the future we will be treating that instead of the inflammation. Maybe the microbiome is contributing to the inflammation. We don’t know yet. Too early to say.

I think a couple of things we’re doing here on the surgical side that we’re really excited about. One, we have an enhance recovery pathway for patients that we started in 2015. It helps patients recover more quickly after surgery. It has decreased our lengths of stay without increasing any readmissions or complications and patients are happier. Part of it involves pain control, part of it involves early mobilization. We are using – we are trying to use medicines that are not narcotics because we know that’s just contributing to our opioid epidemic. So, we use multimodal pain management therapies and strategies.

So, our patients are really getting good surgical care here. We also employ many minimally invasive techniques including laparoscopic or robotic surgery whenever it is possible to treat these diseases. So, I think minimizing the impact surgery can have on our patients lives in important as we are trying to get them back to health and wellness. So, we certainly wish we had cures for inflammatory bowel disease. We don’t yet. But I think at UAB, we’re ahead of all the most current treatment strategies and we do partner really well with our gastroenterology colleagues to think about a whole care plan for these patients.

Host: Thank you both so much for joining us today and sharing your expertise in this very prevalent topic. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician. I’m Melanie Cole. Thanks so much for joining us today.