Transcription:

Melanie Cole (Host):  Welcome to UF Health Med Ed Cast with UF Health Shands Hospital. I'm Melanie Cole, and I invite you to listen as we discuss a multidisciplinary approach to pediatric inflammatory bowel disease. Joining me is Dr. Saleem Islam. He's a Professor and Chief of Pediatric Surgery at the University of Florida College of Medicine and Dr. Genie Beasley. She's an Associate Professor in Pediatric Gastroenterology at the University of Florida College of Medicine.

Doctors, thank you so much for joining us today. And Dr. Beasley, I'd like to start with you. Tell us a little bit about inflammatory bowel disease and explain how Crohn's and ulcerative colitis fit into this umbrella term. What's the differences between these two for other providers, please give a little differentiation.

Genie Beasley, MD (Guest): Sure. I'd be happy to. Well, this is a chronic lifelong condition, and it's always been my interest within the field of GI. It involves ulceration and bleeding from the gastrointestinal tract. And we see a lot of both in the pediatric GI world. I would say Crohn's has been more common in our practice. The difference between the two is that Crohn's involves inflammation anywhere in the gastrointestinal tract, anywhere from the mouth, small and large intestine out to the skin. And ulcerative colitis just involves inflammation of the colon. Really, one's not worse than the other, but sometimes the way we approach it, either with medication or surgical options can look different depending on what the diagnosis is.

And that's where our approach in our clinic is really important to kind of help flush out that diagnosis, to determine the next best step for each individual child. I would say that the disease can look really different from person to person. There's this wide range of how it can present from really mild disease to really severe and impairing disease. And I would say we see everything along the spectrum.

Host: Dr. Beasley, just expand a little bit, help us to appreciate and better understand the features and presentation for primary care providers and pediatricians that get these patients into their offices. This is a difficult diagnosis. It's not always easy to diagnose. So, tell us a little bit about red flags, things they might look for. And some serious complications. Parents are worried that it can stunt a child's growth. There are a lot of issues here with these particular conditions. So, speak about that a little bit.

Dr. Beasley: Sure that's a great point. Really inflammatory bowel disease can present in a number of different ways and usually it's the pediatrician that becomes suspicious of the diagnosis. So, it's really important that pediatricians and primary care doctors and emergency department doctors are aware of the different ways it can look. A quarter of people with inflammatory bowel disease present in pediatrics. So, it's actually quite common to present as a child or adolescent. It can look like anything from abdominal pain, diarrhea, and blood in the stool. So, those are the very apparent things that are easier to notice in which case those kinds of symptoms can be easily picked up and then referred to a gastroenterologist. But it can also be more insidious. Kids and teenagers can present with slowing down of their linear growth, that's their height or decrease or plateau of their weight gain.

It can also look like a delay in puberty. And so those kinds of things should be watched on growth charts at the pediatrician or primary care doctor's office. And so when we see slowdowns in that, that's a good reason to refer over to us in GI. It can also look like anemia and it can also look like more surgical problems, which I think we'll get into in just a little bit, such as abscesses around the bottom area. So, when a primary doctor or emergency department or urgent care doctor, sees things like anemia or stomach pain or diarrhea or height and weight problems, that that's where we need to be suspicious for this disease.

Host: Well, thank you for that. So, then Dr. Islam, create a framework for the standard and higher level of therapy for these children with inflammatory bowel diseases. And tell us the role of potential surgical management as we discuss this multidisciplinary team approach.

Saleem Islam, MD, MPH (Guest): Sure. I think that what Dr. Beasley has said is exactly right. It's a challenging disease to take care of. From a surgical perspective, when we look at these, we really divide them and the diagnosis is critical for us to ascertain what the best therapy will be. Now, ulcerative colitis allows us since it's really contained to the colon and the rectum, allows us to consider a potential quote unquote curative approach. And what we mean by that is that we can remove the colon and we can remove the rectum and then we can reinstill the continuity of the intestine so that the children can still have bowel movements through their normal anus by attaching the small intestine down there. That's called an ilial pouch anal anastamosis sometimes referred to as a J-pouch. So, for ulcerative colitis, we can really offer that as a potential curative approach with the understanding of course, that having a normal colon is way better than not having a colon.

For Crohn's disease, the surgical management is a bit more nuanced; 40 years ago, 50 years ago, we used to kind of really be aggressive surgically with Crohn's. And we hurt a lot of patients with that by removing so much intestine that they didn't have enough intestine to be able to absorb nutrients. So, we realized during the course of the last 40 years, or four decades that in fact aggressive surgical approach for Crohn's is the wrong thing. And we operate on children with Crohn's disease when they have a complication that requires to us do so. Dr. Beasley mentioned abscesses or fistulas. So, if those are there, we can certainly surgically manage those conditions. Then if there's a condition where there's a stricture, meaning that things have narrowed down to the point where they're causing a blockage, that's one where we need to operate. And then finally, there's perforation where there's a hole in the intestine. And so in those situations, we do require surgery for Crohn's. But again, it's very important for us to distinguish between Crohn's and ulcerative colitis.

Dr. Beasley: And I would add Dr. Islam that I think we do a great job working together. We've been doing our multidisciplinary clinic for eight years now. And when we have cases where the medical management that I'm trying to do in my clinic, looks like it's not working so well. We see the patients and the families in the room together as a group. And so that's where we start those really patient specific conversations about where we should go next and how surgery can play a role or how, you know, further changes to the medication management might be more important to do first. So, I think that team approach is really the best way to do this.

Dr. Islam: I agree with exactly what Dr. Beasley has said. I'd like to add that, in fact, we've really made it a multidisciplinary approach to managing these patients who are very complicated by including our specialists from radiology, pathology, psychology, nutrition, and other specialties as well in a truly multidisciplinary clinic, which allows us to help our patients in the most broad way possible.

Host: Well, thank you both for that and for telling us about this multidisciplinary approach for these increasingly complex treatment algorithms. And Dr. Beasley, you mentioned just briefly about medicational intervention. And that is the first line that you would try before this approach where Dr. Islam would consider surgical interventions. Speak just a little bit for other providers about some of the exciting medicational interventions for inflammatory bowel diseases that are out there today.

Dr. Beasley: Sure. And it looks like that list is growing. Probably our most common medicines we will use in the treatment of either Crohn's disease or ulcerative colitis are going to be Remicade, which is an infusion. And we have a pediatric infusion center where our patients go to get that under observation. And another similar medication is called Humira, which is a subcutaneous injection that families can administer at home. But outside of that, we have some of our newer medicines such as Stelara, which is an injectable medicine and Intivio, which is a newer infusion medication. And we combine that sometimes with different older oral medications. And sometimes we also combine that with special dietary treatments. The exciting news is that there's additional infusions and shots on the way. It seems like the last decade has been some good years for development of new medicines. So, as soon as new medicines are out on the market, we're pretty quick to get those available for our families.

Host: I'd like to give you each a chance for a final thought for other providers about this complex condition we're discussing today, the inflammatory bowel diseases. So, Dr. Islam, why don't you start? What would you like other providers to know about the multidisciplinary clinic at UF Health Shands Hospital? And really how you all approach this. Tell us a little bit about who's in charge of guiding patients' care and how this introduction of multimodality therapy and the involvement of multiple sub-specialists is really such a great way to work with these patients.

Dr. Islam: Absolutely. Like, Dr. Beasley mentioned, these are really complicated patients and in fact are getting more complicated as time goes on, which behooves us to really include all these specialists so that we can come up with a really well thought out and agreed on plan so that the care is not as siloed if you will. And our multidisciplinary clinic, allows us to do that by getting everybody's opinion and putting it all together and then getting agreement from everybody about what the treatment plan is going to be going forward. This allows us to really, when we tell the family the plan, they can feel comfortable in that all the specialists have weighed in and they all agree what's the best plan moving forward for these children.

And I think that Dr. Beasley should be really congratulated for leading this. She's the one who leads the team and arranges all these meetings and helps us come up with these plans. In the increasingly complex world of more powerful medications and biologics and newer algorithms that have been coming up, that's been really helpful for us. And our goal is the same. Our goal is to provide high-class care to these children who are really complex.

Dr. Beasley: lines, because this is a very unique kind of a set up in clinic. And I think something else that makes it unique is how we involve the patients and the families in the decision making. So, when Dr. Islam and I are talking together or talking with the rheumatologist with the family involved, you know, they hear the entire conversation. So, they're part of us talking out the option and they're part of the decision making process, which I think is important and unique to this disease too.

Host: And Dr. Beasley, as we finish up, what would you like other providers to know about when you feel it's important that they refer to this multidisciplinary clinic at UF Health Shands Hospital?

Dr. Beasley: Sure. I think, if any primary care provider just is suspicious about the diagnosis, sending them to us, we'll help us flush that out and look for it. The disease is progressive. Ulcerative colitis can involve more and more colon over time and Crohn's disease can progress to more surgical problems that Dr. Islam mentioned. So, if this suspicion is there, I think it's fair to perhaps do some basic blood tests, but really just to send to us because a lot of times a colonoscopy is what's needed. It's also good for providers out there to know that we're here to see complex second and third opinions if needed. So, we're always happy to weigh in. Sometimes the family wants to keep their hometown GI doctor, but just come here just to get our thoughts and recommendations. And we're happy to do that. And we enjoy working with other GI providers in the state as well.

Host: Thank you both so much for joining us today. What an interesting and informative episode this was.  To learn more about our Pediatric Inflammatory Bowel Disease Program, call 352-273-9350 or visit UFHealth.org.  That concludes today's episode of UF Health Med Ed Cast with UF Health Shands Hospital. Please remember to download, subscribe, rate, and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.