Online Health Chat with David Liska, MD, and Nicole Palekar, MD
Friday, November 13, 2015
Inflammatory bowel disease (IBD) is a group of inflammatory conditions of the colon and small intestine. The major types of IBD are Crohn’s disease and ulcerative colitis. These are often grouped together because of their similar symptoms. Both can cause diarrhea, abdominal pain and vomiting, blood in the stool and weight loss.
Treatment of IBD includes either medication or surgery. Lifestyle changes are also important to alleviate symptoms that may be caused by diet or stress.
About the Speakers
David Liska, MD, earned his medical degree from Yale University School of Medicine in 2006. He completed his residency at New York Presbyterian Hospital Weill Cornell Medical Center and a fellowship in colorectal surgery at Cleveland Clinic.
Nicole Palekar, MD, earned her medical degree from University of Miami School of Medicine in 2000. She completed her residency and fellowship at Wilford Hall Medical Center in San Antonio, TX.
Let’s Chat About IBD
Defining the Disorders
singer: What is the difference between IBD and IBS?
Nicole_Palekar,_MD: IBS is a condition of GI symptoms of abdominal discomfort and a change in bowel movements. This can be constipation, diarrhea or an alternation of both. Unlike in IBD, IBS does not have any inflammation in the intestines and does not increase the risk of colon cancer. IBS treatment is aimed at minimizing symptoms. IBD treatment is aimed not only at minimizing symptoms, but at healing the intestinal mucosa and decreasing the risk of colon cancer.
lou: Does irritable bowel disease (IBD) affect a certain part of the colon or the entire bowel?
Nicole_Palekar,_MD: I believe the question is about inflammatory bowel disease (IBD). In ulcerative colitis, typically the colon is affected. Crohn's disease can affect anywhere in the GI tract, including the mouth, stomach, small bowel and colon.
solemon: Is IBD just related to the digestive system or can it affect the entire body?
Nicole_Palekar,_MD: IBD can affect not only the intestines, but multiple other organs. These are called extraintestinal manifestations. Patients with IBD may have skin lesions called erythema nodosum (EN) or pyoderma gangrenosum. The disease can affect the eyes with uveitis. It can be associated with kidney stones. It can also be associated with abnormalities in the liver, specifically the bile ducts, in a disease call primary sclerosing cholangitis.
Eman: Is there a specific test to diagnose Crohn’s or ulcerative colitis?
David_Liska,_MD: Both diseases are diagnosed with a combination of different modalities, including endoscopy, imaging (most commonly CT or MRI) and physical exam. Sometimes, the diagnosis is clear after a single endoscopic exam. In other cases, it can take multiple different methods to definitively diagnose. Crohn’s and UC can sometimes behave very similarly, especially if only the colon is affected. In those cases, we sometimes cannot tell the two diseases apart, and the diagnosis of indeterminate colitis is made.
Determining Your Diet
Bikeman: Can diet itself improve the disease? What diet is recommended for Crohn’s? What is the best method for weight gain?
David_Liska,_MD: IBD has a significant impact on the patient’s food tolerance, eating habits and nutritional status. As such, it is very important for patients with IBD to focus on their nutrition. That being said, we currently have no good evidence that supports any specific diet or food groups as a way to prevent or even induce remission in IBD. In patients with active disease, we advise avoidance of trigger foods, which are different from patient to patient. We also advise avoidance of high-fiber foods in patients with active disease or strictures. When considering surgery in patients with IBD, it is very important to optimize the nutritional status and avoid malnutrition prior to surgery to prevent post-surgical complications. This can sometimes be achieved with dietary supplements such as protein shakes; but in some cases, it even requires IV nutrition prior to surgery.
Nicole_Palekar,_MD: I would agree with Dr. Liska's response and would note that there is a high association of concomitant lactose intolerance in IBD patients. Up to 70 percent of patients may have lactose intolerance. Although lactose would not trigger disease activity, it may worsen symptoms of abdominal pain and diarrhea.
Nissa: Does the association of lactose intolerance also pertain to ulcerative colitis patients, and how does the individual determine if that is a possibility for them?
Nicole_Palekar,_MD: Yes, it does pertain to UC patients as well as CD patients. Although, there is a breath test for lactose intolerance that a GI doctor can perform, we typically try an elimination diet first, mainly because of its high prevalence.
Something About Surgery
fatima: What are the pros and cons for surgery for Crohn’s disease? Are there complications?
David_Liska,_MD: This is probably one of the most important and difficult question to answer for each patient. There is no single answer for every patient as it depends on many factors. With the advances in the medical management of IBD, we are able to avoid surgery in more and more patients. That being said, it is important to recognize when the medications are not working. I see many patients who are so determined to avoid surgery at all costs that they are suffering for a long time before ultimately requiring surgery anyway. If they had considered surgery earlier, they would have not only gotten their quality of life back sooner, but also undergone surgery while healthier, which has big implications for the recovery from surgery. This is why it is really important for any patient with moderate to severe disease to discuss surgical options with their GI and a colorectal surgeon early on. The surgeon can then educate the patient about surgical options and have an ongoing discussion and follow-up with the patient and his/her gastroenterologist. The decision to ultimately perform surgery needs to be a team decision with the patient, the gastroenterologist and the colorectal surgeon all being on the same page, with the focus being on improving the quality of life of the patient. Avoiding surgery and preserving intestine in patients with IBD is very important, but not at the cost of prolonged suffering and complications.
Alison: Is surgery a "cure" or is there a risk of Crohn's coming back after surgery?
David_Liska,_MD: Unfortunately, there is currently no cure for Crohn’s disease. Neither medications nor surgery can cure Crohn’s disease. The goal of both medications and surgery is to prevent/treat complications of the disease and optimize the quality of life for the patient. Both medications and surgery can induce remission of the disease, but unfortunately it can and frequently does recur. After surgery, it is still important for patients to follow up with their GI and surgeon to monitor for recurrence so that it can be treated early on.
Meg: Would you discuss the history behind the surgical treatment for IBD? How was it initially treated? What has evolved and what does the future look like?
David_Liska,_MD: Not too long ago, patients with severe ulcerative colitis who required surgery had do come to terms with living with a permanent ostomy. While many patients with permanent ostomies have very full and active lives, this is a disease that affects young people who, in most cases, really want to avoid having a permanent stoma. In the 1980s, an English surgeon named Sir Alan Parks came up with the pelvic pouch procedure. The small bowel is used to create a reservoir (pouch) that is then attached to a small residual cuff of rectum or anus, which then allows the patients to again have bowel movements even after the entire colon and rectum are removed. This surgery has then been adapted by surgeons all over the world, and here at Cleveland Clinic, the technique has been modified and further refined and studied. We found that by leaving a small cuff of rectal mucosa and using a stapler, the postoperative function is better than when done in a hand-sewn fashion. The surgery has really revolutionized the quality of life for patients with UC and has become the gold standard treatment for patient who need their colon removed.
spel343: Are there any new surgical procedures to treat Crohn's disease, particularly perianal disease and fistulas?
David_Liska,_MD: Perianal Crohn’s disease is a tough problem and can be very complicated to treat. There are some new surgical procedures for the treatment of anal fistulae, but they don’t have a proven track record in Crohn’s disease specifically. In general, anal fistulae in CD are treated with adequate drainage using draining setons and medications such as Remicade. Aggressive surgery is usually avoided due to impaired healing. Sometimes, an ostomy is necessary for very complicated anal disease.
superior: Are there different medical treatments for ulcerative colitis as compared to Crohn's?
Nicole_Palekar,_MD: Most of the medical therapies we have available are used in the treatment of both UC and CD. There are mesalamine products, immune modulators and biologics. Choosing which medication to use in patients depends not only on whether they have UC or CD, but also, more importantly, on the extent of disease, severity of disease, extraintestinal manifestations of the disease and complications/sequela of the disease.
Charity: Does exercise help with symptoms and flare-ups of IBD?
David_Liska,_MD: As most patients with IBD know, the disease and its treatments not only affect the intestines, but also the entire body. While we don’t know yet if exercise has any direct effect on intestinal inflammation, exercise has many positive effects in patients with IBD. For example, IBD and its treatments can cause osteoporosis, which exercise is known to help prevent. Exercise can also help with joint disease that can commonly affect IBD patients. Being physically fit has a huge impact on recovery from surgery, with patients who are physically active before surgery usually recovering significantly faster.
2056: What can someone with IBD do to boost their immune system?
Nicole_Palekar,_MD: Although there is not one specific recommendation to "boost the immune system," we do have well-established health care maintenance guidelines that are aimed at keeping IBD patients healthy. We recommend annual labs to include checking blood counts, liver function and renal panel, thyroid function, iron levels, B12 and vitamin D levels. We also recommend certain immunizations in patients on high-dose immunosuppression or biologics; for example, hepatitis A/B, pneumovax every five years, flu shot annually and tetanus shot. Patients who have had cumulative exposure to steroids more than three months are recommended to have a bone density test. We also recommend an annual dermatology and eye exam in patients. These are some of the recommendations. There is emerging data regarding the role of vitamin D in inflammation and in the immune system. Although we are not ready to make specific recommendations based on current data, all patients should make sure they have their vitamin D levels checked and repleted if necessary.
Bikeman: What is the first-line treatment for a young adult with stomach and ileal ileocecal Crohn's disease?
Nicole_Palekar,_MD: Over the last several years, we have strayed away from the thinking of treatment as a just a pyramid (i.e. first line, second line, third line). Treatments for each patient are individualized and based more on the extent of disease, severity and features of disease in that patient that are considered higher risk for future complications or worse disease status. For example, perianal fistulizing disease in a young patient portrays a difficult to manage patient with high risk for future complications. This patient would likely receive biologics up front (along with likely seton placement by colorectal surgery). This is just an example of how treatments need to be individualized.
soloman: Do you recommend any alternative therapies for IBD?
David_Liska,_MD: I don’t think we know enough about the effects of alternative therapies to make well-informed recommendations about them. As long as these therapies are not interfering or replacing proven therapies, I have no problem with my patients pursuing them.
Nicole_Palekar,_MD: I agree with Dr. Liska's comments.
WallywnnaBe: Can IBD lead to more serious diseases like cancer?
David_Liska,_MD: Patients with IBD are at increased risk for colon and rectal cancer. The risk is related to the severity and duration of the disease and how much of the colon is affected by disease. Patients with mild disease limited to a small portion of the colon for less than eight years are at relatively lower risk, whereas patients with pancolitis (entire colon involved) for greater than eight years are at higher risk. Patient with UC who are also affected by PSC (disease of the bile ducts) are also at a higher risk to develop colorectal cancer. In patients at high risk, we generally recommend colonoscopies with multiple biopsies every one to two years, starting at eight years after being diagnosed with the disease.
Nissa: What is the probability of an 18-year-old UC patient placed on IV Remicade after a flare up requiring five transfusions needing to stay on that medication forever?
Nicole_Palekar,_MD: In patients who require biologics for severe disease, whether it be UC or CD, most patients will have to stay on that medication or another biologic indefinitely. The relapse rate after stopping the medication is about 70 percent. In practice, we don't typically tell patients they will be on that specific medication "forever," not because they may not need the medication, but because we know that over time they may lose response to that particular medication.
Harper: If you've had a traditional resection for Crohn's disease can you still be considered for laparoscopic surgery with future strictures/narrowing?
David_Liska,_MD: Previous open surgery can lead to scar tissue (adhesions) that can make subsequent laparoscopic surgery difficult. However, it is not a strict contraindication to attempting a laparoscopic approach.
johnson: What is a pelvic pouch, and are there different types?
David_Liska,_MD: A pelvic pouch is the treatment of choice for patients with ulcerative colitis who require surgery. In involves surgery usually done in stages, during which the entire colon and rectum are removed and a new stool reservoir is created from the small intestine. Thereby we can remove the entire diseased intestine without needing a permanent ostomy. The most commonly used pouch is a J-pouch, where the small bowel is configured in the shape of a J and then attached (stapled) to a small residual cuff of rectum. There are some other pouch configurations, but those are much less commonly used.
silverfox: How do patients feel about their quality of life after getting a pouch? What is the average number of bowel movements? What other pluses do patients notice?
David_Liska,_MD: Excellent questions. These questions have been extensively studied here at Cleveland Clinic. We have asked approximately 4000 patients who had their pouch surgery done at Cleveland Clinic to answer these important quality of life related questions. Ninety-five percent of patients had excellent outcomes following pouch surgery. After 10 years of having an ileal pouch, on average, patients rated their quality of life a 9 on a 1-10 scale with 10 being the best. Ten years after having had pouch surgery, 96 percent of our patients are happy with their decision to have had the surgery. On average, pouch patients move their bowels ~5-7 times per 24 hours. The symptoms of abdominal pain, cramping, nausea and bloody BMs are cured by removing the diseased colon and rectum. Most patients with an ileal pouch can defer having a BM for at least one to two hours, which is a huge improvement over the urgency our patients experience before surgery, when many are afraid to even leave the house due to the concern of not making it to the bathroom in time.
jsmidpn: Does pouch surgery affect fertility? Will I be able to have a baby?
David_Liska,_MD: This is an important question, since many patients with UC who are candidates for pouch surgery are young women of childbearing age. This is an issue that has been studied in our patients here at Cleveland Clinic and at other institutions. We know that patients with severe UC frequently have difficulties conceiving even before surgery. Pouch surgery, most likely due to scar tissue formation, does make conceiving naturally more difficult. However, it’s been shown that in patients with ileal pouches who are unable to conceive naturally, there is still a high success rate of becoming pregnant with modern infertility treatments.
That is all the time we have for questions today. Thank you, Dr. Liska and Dr. Palekar, for taking time to educate us about IBD.
On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at my.clevelandclinic.org.
To make an appointment with David Liska, MD, or any of the other colorectal surgeons in Cleveland Clinic’s Digestive Disease and Surgery Institute, please call toll-free at 866.320.4573 or visit us clevelandclinic.org/digestivedisease for more information.
To make an appointment with Nicole Palekar, MD, or any of the other gastroenterology specialists in Cleveland Clinic Florida’s Digestive Disease Center, please call toll free at 877.463.2010 or visit us online at clevelandclinicflorida.org for more information.
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