Understanding Ulcerative Colitis with Dr Jeremy Lipman
Understanding Ulcerative Colitis with Dr Jeremy Lipman
Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Welcome to another episode of Butts and Guts, I'm your host Scott Steele, Chairman of colorectal surgery here in beautiful Cleveland, Ohio. And I am very pleased to have Dr. Jeremy Lipman with me, one of the members of my staff. Jeremy is an associate professor of surgery at Cleveland Clinic Lerner College of Medicine. Jeremy also has been the program director for general surgery residency here at Cleveland Clinic since 2016. Jeremy, welcome to Butts and Guts.
Jeremy Lipman: Thanks, thanks a lot for having me. Thanks for including me.
Scott Steele: I like to start out these, tell us where are you from? How did it come to the point that you wound up here at Cleveland Clinic?
Jeremy Lipman: Grew up in Pittsburgh and Cleveland was always an athletic rival, but you know, stay true to the Steelers, no offense. Went to medical school in Philadelphia, and afterwards did my residency at Case Western here in Cleveland and really fell in love with the city. And when the opportunity arose to come over here and work, I jumped on it. It’s a great place to be, as you know.
Scott Steele: That's awesome and we're very, very lucky to have you here. Today we're going to talk a little bit about something called ulcerative colitis – falls under the umbrella of inflammatory bowel disease and, obviously, that along with Crohn's disease and indeterminate colitis are kind of a trifecta under that umbrella. But we're going to focus specifically on ulcerative colitis. So first thing right off the bat, what is ulcerative colitis?
Jeremy Lipman: Yeah good question. Ulcerative colitis is one of the inflammatory bowel diseases, so it's a disease that causes inflammation in your colon. Usually it is limited to the colon, whereas some of the other things you mentioned, like Crohn's disease, can involve really any part of the gastrointestinal tract – anything from your mouth all the way down to your bottom. Ulcerative colitis tends to really be focused just in the colon, and that's one of the things that makes it different and it's why it's called colitis for the colon.
Scott Steele: Where does it come from? Is it something that I that I eat and I get? What’s the origin of it?
Jeremy Lipman: There's probably a genetic component that tends to run in families. We know that people that have identical twins or also have it in other members of their family tend to be at higher risk. There is a lot of it that we don't understand yet. There are elements probably related to the environment, where you grow up, but it's nothing that you did or didn't do that led you to get it. It's bad luck, bad genes, but fortunately there are things we can do to help to get people better with it.
Scott Steele: Ok so let's take a step back, and let's say I'm a patient I got some GI symptoms, what are some of the more common symptoms that people would experience that may raise a red flag to say I might have ulcerative colitis?
Jeremy Lipman: Any change in how your bowel movements are going and how your bowels are feeling should prompt a visit to see your doctor, probably. With ulcerative colitis, specifically, people tend to get crampy abdominal pain, diarrhea, sometimes they see blood in their stool. They may notice that they have weight loss, loss of energy, just not feeling well. And so any of those things should probably get them a trip to the doctor to see what's going on to try to sort it out.
Scott Steele: How common is ulcerative colitis? If you ever notice a little bit of blood in your stool or you occasionally get diarrhea, or something like that, should you be worried that you have ulcerative colitis?
Jeremy Lipman: No, ulcerative colitis is not common. We see it a lot here because that's what we do. But it's not a very common disease, so most people who have diarrhea ate some bad food or just something that didn't agree with them. It’s when this goes on for weeks and weeks and months, that's when it's time to get something checked out. A little bit of blood when you wipe, it's probably worth getting a visit to the doctor to make sure nothing bad is going on. But it’s when you're seeing it over and over again and it becomes a chronic problem that you need to worry about something like this.
Scott Steele: Do you have to worry at all about the age that you are? If you're somebody out there, let's say, that’s listening to the podcast and they're 15 vs. somebody else who's 86. I mean is there a certain kind of patient that epitomizes ulcerative colitis? What does that patient look like?
Jeremy Lipman: Patients can get ulcerative colitis basically throughout their life. It's really uncommon in young kids less than 10 years old. But the typical person is going to be in their 20s or 30s or maybe in their 60s, not typically very young people or very, very old people.
Scott Steele: You mentioned a couple of things that I then kind of want to go back on. So patients might have crampy abdominal pain, they have the diarrhea and occasionally they get some blood in their stools. Are there any other manifestations, or is it just diarrhea or just the abdominal pain that could tip people off? Does it affect any other organs in the body?
Jeremy Lipman: It's a strange disease because it really starts in the colon but can affect a lot of other things. People can get pain in their joints, like arthritis; they can get problems on their skin with either these little red bumps that can show up or sometimes even worse wounds that can show up on the skin, something called pyoderma gangrenosum. It sounds terrible; it is terrible, but not very common, fortunately. People can get problems with their eyes, or their eyes get red and burning and watery. Rarely people can get trouble with their back or trouble with their liver. So maybe another thing to raise some of the red flags is that if you're having these abdominal complaints and some of these other things going on. Maybe they do tie together and your doctor can help you sort that out.
Scott Steele: Ok, so I'm a patient out there and I'm listening to this podcast. I'm thinking to myself, “I experience some of those symptoms that Dr. Lipman is talking about.” Who should they go to and what can they expect during that office visit?
Jeremy Lipman: The first visit, in my opinion, should always be to the primary doctor. They know you best; they know your history; they know your family and can help direct you to the right person. And when you go in they'll talk to you and ask about all these symptoms and signs that we've been talking about. They'll examine you, do a head-to-toe exam, maybe do a rectal exam, not fun but important. And probably the next step will be to refer you for a colonoscopy with either a gastroenterologist or colorectal surgeon. Take a look inside; see what the lining of the colon looks like, because that's really where the rubber meets the road on this one. If the lining of the colon is inflamed and ulcerated, that's what we use to say that this is some type of colitis, probably ulcerative colitis.
Scott Steele: And can the patients expect to get a scope during that first office visit?
Jeremy Lipman: No, that first office visit will just be a conversation. Make some plans and then the colonoscopy will be scheduled at a later time so that it can be set up with some sedation and after a bowel prep where you drink that stuff and get all cleaned out.
Scott Steele: Now let's say I'm a patient out there that has had a recent colonoscopy. I’m 54 years old and I was told that that was normal. But I'm listening to this podcast and, more importantly, I’m experiencing some of these symptoms. Do I still need to have a colonoscopy?
Jeremy Lipman: Yeah it's time to go back and get it checked again because this could have developed in the interim. Like I said, very young people, sort of people in the middle of their lives, tend not to get it. But it may be that you didn't have it four years ago but now it's showing up, so it can it can sort of pop up out of the blue. Again, not anything you did or didn't do, just it was time and this is when it shows up.
Scott Steele: You mentioned the endoscopy and what the lining of the colon looks like. You also mentioned that it predominantly, in terms of the G.I. tract, affects just the colon and the rectum alone. Are there any other tests that the patient could expect to get in terms of their ulcerative colitis evaluation, or is it just the colonoscopy and just the biopsies?
Jeremy Lipman: One of the things that's important is making sure of the diagnosis. Like you were mentioning earlier, Crohn's disease is something that can look exactly like all ulcerative colitis. It can affect the colon very much the same way that ulcerative colitis does. But Crohn's disease can infect other parts of the GI tract, and so your doctor may do a camera down the mouth to look in the stomach. Sometimes they'll do a CAT scan, a special CAT scan, or an MRI test to look at the rest of the intestines that we can't reach with the scopes but need to make sure don't have inflammation. That would lead us more toward a diagnosis of Crohn's disease and not ulcerative colitis.
Scott Steele: So let's say that I'm a patient and now, unfortunately, I'm diagnosed with ulcerative colitis. Does everybody need surgery or what are the types of treatment options? And talk a little bit about that and then maybe some of the surgical options?
Jeremy Lipman: So there are a lot of good medical options, and they range in intensity and side effects from very mild pills that you take every day that can help to keep that inflammation down. As people don't do as well or don't respond, if their disease is more severe, sometimes they have to take medicines that depress the immune system -- something called 6-mercaptopurine is a thiopurine or Imuran. Those medications have a little more side effects. Your immune system helps you to fight off disease, helps you to fight off infection. And so if we push that down with these medications, you have a little higher risk of having problems like that. If those don't work, sometimes we have to use even stronger medicines to push the immune system down, like prednisone or other types of steroids, and those can be very effective but have a lot of side effects that can be problematic. So we try not to keep people on that long term. And then at the highest end there are medications that we call biologics. These are medications that really help to keep the immune system down and in some cases only working right on that area that's inflamed. These are usually given by injections and usually have a lot more side effects than some of those lesser medications. But we have a lot of really good options to try to get people better with medication.
Scott Steele: So how do the doctors sort all this out, in terms of what type of medication that I would need if I had this, or even come into the hospital?
Jeremy Lipman: It really depends on how bad your disease is and everyone is going to be different. Some people can have ulcerative colitis and it's really mild, and with some of those lesser medications the gastroenterologist will start them on those and they get better, and they can stay on those and that's all they need. The doctors respond to your disease. So if you start on these lesser medications and things aren't getting better, then they'll ramp things up until they get to a level that will get you under control. Sometimes when they first get diagnosed, people have extremely severe disease and they do have to come into the hospital because they're having so much diarrhea, or they're so weak and malnourished that we have to give them nutrition and fluids in their I.V.. We have to give them steroids in their I.V. and really go at it very aggressively, starting with those biggest medications to try to keep them safe and get them healthy right away. It really depends on how bad your disease is, and you and your doctors will work together to find the right treatment option that works for you.
Scott Steele: If you haven't had surgery or haven't gone to the point where you needed that, are there any diet or lifestyle changes that can help any patients with ulcerative colitis out there do better?
Jeremy Lipman: Well definitely not smoking is important. Cigarettes are definitely out. Otherwise, just following a healthy diet is not really a great recommendation – that if you eat this then your disease will get better or stay under control. Patients will find that some foods aggravate their symptoms more than others, and obviously they should avoid those. But there is not one thing that I can tell someone or give them a brochure that says if you eat this you'll get better.
Scott Steele: What about probiotics? I hear probiotics are activated cultures in yogurts. Is there any role for those in patients with ulcerative colitis?
Jeremy Lipman: Probiotics are probably not harmful, and if you take one and it makes you feel better then fantastic, keep taking it. They can be expensive, though. And there is definitely not evidence that it's going to make anything better long term. So if it's not making you feel better, it's probably not worth it.
Scott Steele: You're a surgeon and you treat patients that have ulcerative colitis, so let's step on to surgery right now. First and foremost, what are some of the reasons that you, as a surgeon, would take a patient to the operating room for ulcerative colitis?
Jeremy Lipman: There are really two types of patients that are going to end up in surgery. One is that very sick patient we were talking about who could not function at home – so much diarrhea, malnourished, in bad shape in the hospital. And we do it as an emergency to get them better and get them safe from the severe inflammation that's going on in their colon. On the other side is going to be patients that just are not getting better with the medicines. And usually that's a long conversation between me as a surgeon their gastroenterologist and the patient about where they are, and should we keep going up on medications or have they reached the maximum dose of medication and there's nothing else to try? But they're still having bad symptoms and they can't get better. It comes down to their lifestyle. Rarely, people can get cancer from ulcerative colitis, and those people need to have surgery as well in order to treat the cancer, just as we do for other colon cancers.
Scott Steele: Let's start right there with the cancer thing. So is having ulcerative colitis mean that I have cancer?
Jeremy Lipman: No, ulcerative colitis is not cancer – it’s totally separate. But having that inflammation in your colon for a long time puts you at risk for getting cancer, and that risk goes up the longer you have it. After about 10 or 20 years that risk starts to get pretty significant if it's not well controlled.
Scott Steele: So are patients that have ulcerative colitis, short of having an operation, are there any surveillance guidelines or recommendations that patients with ulcerative colitis are going to make sure that they don't develop a cancer or to assess their disease?
Jeremy Lipman: Like we were talking about the patients that do well on the medications or their symptoms are controlled, they do still have that cancer risk. And one of the things in addition to how they feel that their gastroenterologist is going to want to use to make sure they're doing OK is a colonoscopy. Usually every year, every other year, if they're doing real well. And at that time they'll take some biopsies and make sure there's nothing in there that's leading toward cancer that may make us want to think about doing surgery earlier to prevent them from getting into trouble down the road.
Scott Steele: Let's circle back to surgery now. So now we have our patient, let’s say they don't have cancer but they're not responding well to medications. What are the operative procedures that are at your disposal as a surgeon that some of the patients with ulcerative colitis could undergo?
Jeremy Lipman: So the mainstay of surgery is removing the colon. That sounds crazy to a lot of people – your colon is a nice thing to have but you don't need it. Lots of people don't have their colon. We remove the colon, we leave behind the muscles, though, they give you control of your bowel movements, your sphincter muscles. We have a couple options – one is to just close everything up, be totally done and do a permanent ileostomy bag, where the small intestine is left behind; we don't remove any of the small intestine. Where that comes up through the skin and then the poop goes out into a bag for the rest of somebody's life. The plus side of that is they have no more ulcerative colitis. All of their symptoms go away. They come off the medications, they feel fantastic, and they never have to have another scope in their bottom ever again because it's all closed up and done. The other option now is to try to put the bowels back together we can make a new rectum out of the small intestine. We take this small intestine and fold it around and do some origami on it and then plug it back into the bottom. We call that a J pouch. People sometimes get confused about a bag or a pouch, and it all sounds sort of similar. When we talk about the bag, or the ostomy bag, that's the thing on the skin. The other alternative is to do the pouch, which is the small intestine folded to create a new rectum and then plugged into the bottom, and that can let people go back to having bowel movements the way they always have.
Scott Steele: You mentioned the bag and the pouch, which is a really confusing to a lot of people, and I can understand that. Does this all happened at the same time? Did they just go in for an operation, and also the colon and the rectum are removed, and they wake up with a new rectum and there’s no bag? What's this all about?
Jeremy Lipman: Because the operations are big and, usually, the patients are very sick when we're going to surgery, we typically do it in two or three steps. Usually we can do the operations laparoscopically with small incisions, and we go in and the first step is to get the majority of the colon out. And with the colon out the disease pretty much goes away. People feel better. They come off the medications, they get healthy again, and they get back to their life. When they're ready, we can then go back and take out the bit of colon that we've left behind. It's called the rectum, the last bit down there right before it comes out the bottom, and we create the J-pouch. The J-pouch has a lot of places where the bowels are joined to each other, and there are a lot of things that can go wrong if it's not done just right. We want it to heal in perfectly. And to let that happen they keep the ileostomy bag while the J-pouch is healing. Then we go back in one last time for a much smaller operation to close up the ostomy bag and then they're good to go.
Scott Steele: What can patients that have their colon and rectum removed, and get this J-pouch, what kind of function can they expect to have?
Jeremy Lipman: Those people can expect to have about four to six bowel movements a day, sometimes one overnight, and usually with good control, meaning they get to the bathroom in time. And four to six might sound like a lot of bowel movements. But for someone with ulcerative colitis is going 10-15-20 times a day, it really is a blessing. They usually can hold their bowel movements, so if they feel like they got to go, they'll have time to get to the bathroom. So you can go on a car trip, you can go somewhere without having to know where every bathroom is. And a lot of ulcerative colitis patients, as their disease gets severe, we'll tell you exactly that they can't do those things, and as soon as they walk into a restaurant or a movie theater, the first thing they're doing is scoping out the bathrooms, and that can all go away. They also will have to have that scope into the pouch, usually once a year or every other year, to check and make sure things are healthy.
Scott Steele: Now the patients that have the pouch, or even have the ileostomy, do they still have to be on medications?
Jeremy Lipman: No. Almost always they are able to come off their medications and get back to feeling totally healthy or feeling good.
Scott Steele: I had a friend of mine who was originally diagnosed with ulcerative colitis, and they said he got Crohn’s later on in life. Do you catch Crohn’s, or what’s that all about?
Jeremy Lipman: The pouch can have problems down the road. And one of the problems you can get is where the pouch gets inflamed – something called pouchitis. Or sometimes what can happen is it can actually turn out that what looked very much like ulcerative colitis at the outset was actually Crohn's. Like I said a while ago, Crohn’s can look just like ulcerative colitis – it can affect only the colon. It cannot be in any other part of the intestine, and sometimes after the J-pouch is made down the road, Crohn’s changes start to show up in the pouch and can cause problems with the pouch. That only happens to about 10 or 15 percent of people. Most people don't have that problem.
Scott Steele: And just to clarify, you don't necessarily just have a pouch that Crohn’s can affect, or later a person could have an ileostomy and Crohn’s could kind of rear its head.
Jeremy Lipman: Sometimes they can look identical for a while, and then down the road that other finding can show up that makes us realize that it really was Crohn’s the whole time.
Scott Steele: Any other final thoughts or things that if you were going to give words of wisdom to patients with ulcerative colitis or symptoms of ulcerative colitis, what’s some take home messages?
Jeremy Lipman: I think it's really important to have a good relationship with your gastroenterologist, and you're going to help to drive the care that you get. Patients that get better with medications, fantastic. I'm a surgeon, I love operating, I love doing these operations but I'm much happier when people don't need it. But if you do, then there are options beyond the medications and you can come and see us and we’ll help to get you better.
Scott Steele: We like to wind up with some quick hitters. So real quick, favorite sport?
Jeremy Lipman: Hockey.
Scott Steele: Favorite meal?
Jeremy Lipman: Pizza.
Scott Steele: What's the last book that you've read?
Jeremy Lipman: Getting to Yes.
Scott Steele: And although you live in a lot of different places, tell the audience something that you like about Cleveland.
Jeremy Lipman: I love the restaurant scene here. It’s really fantastic.
Scott Steele: Jeremy, thanks to you so much for joining us here on Butts N’ Guts. To learn more please download our free ulcerative colitis treatment guide at clevelandclinic.org/IBD. To make an appointment with a Cleveland Clinic specialist please call 216.444.7000. Jeremy, thanks so much for joining us.
Jeremy Lipman: Thank you very much for having me.
Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts N’ Guts.