Updates in Inflammatory Bowel Disease (IBD) Treatment

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Hi again, everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in be beautiful Cleveland, Ohio. And today, for me, it's a huge treat to have my Vice Chair here on with us, Dr. Tracy Hull. Been at the Cleveland Clinic for a long time. Ex-President of our National Society, Board Chair. You name it, she's done it in the world of colorectal surgery. Dr. Hull, thanks so much for joining us on Butts and Guts.

Dr. Tracy Hull: Well, thank you for having me.

Dr. Scott Steele: So, in addition to everything that you do, you are one of the world's renowned surgeons, especially as it deals with inflammatory bowel disease. And we're going to talk a little bit about advancements in the treatment for patients with IBD. But before we go there, what I'd like to ask you is tell us a little bit about yourself. Where are you from, where did you train, and how did it come to the point that you came here and stayed here at the Cleveland Clinic?

Dr. Tracy Hull: So, I'm from Fremont, Ohio, which is two hours west of Cleveland. And I went to Ohio State for medical school. And then I went to Syracuse, New York for my surgery training. I then was lucky enough to come here for fellowship under Fazio, Lavery, Church, Milsom, Oakley, and I stayed on, and have been here ever since.

Dr. Scott Steele: Well, that's fantastic and we're so glad that you're here. I'm personally very glad you're here. And today, we're going to talk a little bit about inflammatory bowel disease, as well as the recent advancements in IBD treatment. So, to start, for those who haven't heard our past podcast on this, can you share with us a little overview of what IBD is to our listeners?

Dr. Tracy Hull: So, inflammatory bowel disease, the cause is really unknown. It is inflammation in the bowel, and there's basically two types: Crohn's disease and ulcerative colitis.

So, let's take each one separately. Ulcerative colitis only affects the colon of the bowel. You could still get things like arthritis problems, or eye problems, but primarily it affects the colon. And you can cure it by taking out the colon, versus Crohn's disease, which can affect anywhere from the mouth to the anus.

Both of them cause inflammation in the lining of the bowels felt to be probably from an environmental trigger that is set up from probably something in your genetic makeup that gives you a predisposition for it. So, it's basically inflammation in your bowel.

Dr. Scott Steele: So, terms that often get confused are IBD and IBS. Can you tell us a little bit about the difference between the two?

Dr. Tracy Hull: So, and it's very hard sometimes to make the diagnosis of inflammatory bowel disease, and it can be mistaken for an irritable bowel syndrome, IBS. IBS is usually characterized by pain and bloating. Pain is a main component of it; you have to have pain to have IBS. And you can have bowel disruption, diarrhea or constipation. And the diagnosis of that is based on symptoms. It's not true inflammation where you see a study, and you say that's inflamed. Now, there's probably, when we learn more about IBS, something that has to do with irritation that comes through the gut that leads to alterations in the function into pain. But it doesn't lead to inflammation, and that inflammatory problem that you see with inflammatory bowel disease. So, inflammation is one of the basic differences.

Dr. Scott Steele: So, when is the right time to seek IBD treatment? Or is there a wrong time to seek IBD treatment?

Dr. Tracy Hull: So, I think making the diagnosis is the most important thing. And it can be very challenging, as I said before, because if you have problems and you have abdominal pain, or fevers, or weight loss, or diarrhea, or a change in your bowels, it's always important to have that evaluated. It could be many different things, and one of them is inflammatory bowel disease. But particularly, if you have known inflammatory bowel disease and you develop things like weight loss, a change in your bowels, excessive diarrhea, fevers, just failure to have enough energy, that's a time when, for sure, you should see your medical caregiver.

Dr. Scott Steele: And truth or myth: IBD most commonly occurs between the ages of 15 and 30?

Dr. Tracy Hull: So, most commonly, yes, that's probably true. But we know the prevalence in Medicare beneficiaries has been increasing quite rapidly from 2001 to 2018. When they surveyed people in 2015, we found that 1.3 percent of adults in the US, and that's like 3 million people, have inflammatory bowel disease. And a large percentage of them are older. So, it's not only a disease of teenagers and early adults.

Dr. Scott Steele: And so, what are recent IBD treatment advances that have been made over the past few years?

Dr. Tracy Hull: So, medical therapy for IBD is one of the most rapidly changing avenues right now. In the '90s, we had so few medicines, and people came to surgery pretty quickly because we didn't have a lot of opportunities to treat them otherwise. So, I think the medicines and the medical care that are delaying or leading to people not needing surgery have really been amazing. And they continue to come up with more and more medications that are effective treatment for IBD. I mean, just look at the TV and all the different advertisements and marketing by the pharmaceutical companies. So, I think those are wonderful breakthroughs.

There are some surgery breakthroughs. We are doing more and more surgery laparoscopically and robotically with small incisions. And that's really very important because it allows patients to have less hernias, less wound infections, get back to work more quickly, especially when we're talking about young people.

Right now, one of the hot topics in Crohn's disease is the way we do the join in the bowel when we have to take out the last part of the small bowel. So how do we do the join from the small bowel of the colon. And there was a Japanese surgeon called Kono and he did this kind of very elaborate anastomosis and felt that it really delayed recurrence of Crohn's disease in the terminal ilium. And right now, there's a lot of studies looking at that to see does that really has a big difference? So those are kind of the most recent big changes.

Dr. Scott Steele: So, you mentioned a little bit about surgery, and understanding that it can be a lot of different manifestations, but when is surgical treatment necessary for IBD? And then, what's the recovery like?

Dr. Tracy Hull: So, obviously, it depends a lot on how healthy you are going into the surgery when you talk about recovery, and then the reason that you need the surgery. So, people that have cancer, pre-cancerous changes, those are people that we are very, very aggressive about encouraging surgery.

The rest of the surgery is more quality-of-life surgery. So, if you have something that narrows your bowel, one of the processes, and you can't eat, and you're losing weight, we are pretty aggressive at recommending surgery for that.

If you have bad colitis that's not responding to medical therapy, doing surgery on that, removing that part of your colon, that almost instantaneously makes people feel better. So, I think, it depends on how you are feeling and what is going on with your care as far as when you should have surgery. And it's usually a decision that you, and the surgeon, and your GI doctor make together, unless it's a cancer, or an obstruction that's relatively happening quickly, or you're really in the hospital failing to thrive, and you can't get out of the hospital. Otherwise, it's more of a shared decision making.

Dr. Scott Steele: So, when you talk a little bit about shared decision making, as you said, medical and surgery play a large role. So, do you coordinate care with the patient's gastroenterologist?

Dr. Tracy Hull: Sure. That's one of the wonderful things, I think, about being at the Cleveland Clinic, and that's kept me here all these years is we have always had a team spirit. It's a team caregiver attitude. So along with gastroenterologists, we have psychologists, nutritionists, the radiology doctors are very active in helping us make diagnoses and helping us decide different treatment options. So, it is really, truly a team-based approach.

Dr. Scott Steele: And does treatment for IBD differ between men and women?

Dr. Tracy Hull: I would say, no. What differs is when we talk about different issues with fertility and sexual function. When we're going to do surgery, particularly in the pelvis in either men or women, the risk in men of injury to the nerves that supply sexual function are real risks, particularly if there's abscesses, or a lot of inflammation. And we discussed that. And in women, the risks are a little bit more insidious because you can have risks to the tubes and ovaries that lead to problems with conceiving. So, those are kind of the things that surgery-wise that we really are concerned about. There are some medicines that seem to cause more problems in men than women, but I don't deal with those as much; those are more gastroenterology things. But, as far as surgery goes, we're talking about usually fertility when we're thinking about that.

Dr. Scott Steele: So, like most things maybe, especially in this case, it's your environments which you eat, lifestyle choices. Are there certain dietary and lifestyle changes that can help control IBD symptoms?

Dr. Tracy Hull: The most important thing is to quit smoking, if you're a smoker, particularly if you have Crohn's disease. There are very few things we really know with good data that affect the disease. And smoking is certainly one of them with Crohn's disease.

There's a lot of literature that eating smaller meals helps. There's this anti-inflammatory diet, you can look it up on the Internet. I have a lot of patients that feel that that has really helped them with some of their symptoms. I don't think it helps all patients, but some patients have had help.

There's literature on managing stress, which sometimes is very hard, getting enough sleep, avoiding foods that are triggers. If you're lactose intolerant, obviously avoid milk and milk products. So, really a lot of them are just common-sense things like enough sleep, for instance. But smoking is the most definite thing that people can do to help themselves.

Dr. Scott Steele: Is there anything else that you'd like us to share with our listeners who might be experiencing IBD, or know someone who is?

Dr. Tracy Hull: Yeah, there's a few things that come up that I think are misconceptions. So, one is if you're a manager, or a boss, I think, as caregivers we need to advocate for our patients to those folks because a lot of them don't understand IBD, and they are thinking that these patients when they have to go to the bathroom a lot, or have urgency, or some problem with their bowels, that they're faking it. And I think that understanding is really prime there. There's a lot of folks that tell me they lose their jobs because their bosses don't understand, and they have to have bathroom privileges.

I think the second thing is that IBD does not shorten your lifespan. There's a lot of discussion on some of the pages of the Internet that makes you have a shorter lifespan. I think that's probably not true.

A lot of people with inflammatory bowel disease have more problems with anxiety and depression just because of the uncertainty of the disease. I mean, if I wasn't sure when I was going to have a flare, if I could go on vacation, I think that would make me anxious and depressed, too. And get help for that. There's a lot of opportunities and avenues to get help.

And then lastly, if your doctor, or your surgeon says that you need a stoma, that isn't the end of your life. A bag on the outside, while I have to say I've never had one, but I've had family members with them. It isn't a picnic, but it does not mean it's going to be the end of your life. And so, don't look at it like, "I can't live. My life is going to stop." I've had young people play football with bags on the outside. People ride horses, go skydiving, which looked dangerous to me in and of itself, let alone who cares about the bag on the outside. So, I think trying to live your life, but having people to be understanding, particularly family members and people that are your managers, or your boss is the biggest message.

Dr. Scott Steele: So, now it's time for our quick hitters where we get a chance to know you a little bit better. So, first of all, what's your favorite food?

Dr. Tracy Hull: Lobster.

Dr. Scott Steele: What is your favorite sport to watch and/or to play?

Dr. Tracy Hull: Ohio State football to watch. To play, would be riding my horse.

Dr. Scott Steele: And as people may not know, Dr. Hull is actually a world champion horse rider. And that's just incredible to see that skillset there. And you've been to a lot of places and given a lot of lectures all over the world, Tracy, so what's a place to listeners that you would say, "Hey, you should go there if you get a chance?"

Dr. Tracy Hull: Poland. It is a truly incredible country with a lot of very, very interesting things to see. And the people embrace you coming, and really want to show you, their country. It's a little chaotic. I've been there since the war in Ukraine started, there's a lot of Ukrainian refugees that they have embraced and taken in, but it's really a wonderful country to visit.

Dr. Scott Steele: And then finally, obviously, you're from Fremont and you've spent a long time here, so what's one of the things that you like about living here in Northeast Ohio?

Dr. Tracy Hull: The change of the seasons. I have to say, in the dead of winter, I do like to go to Florida, and see paradise in Florida, or someplace like that. But I like to see the fall with the beautiful leaves that we have. And I like to see spring when the flowers are coming out. And the snow and the winter that only lasts so long, although we haven't had much this year. And then, how beautiful things are in the summer.

Dr. Scott Steele: That's great. And so, give us a final take home message, if you will, to our listeners regarding the advances in the treatment of IBD.

Dr. Tracy Hull: I think the best is yet to come. There's so much enthusiasm towards how to cure the disease. And I'm hoping that - it won't be in my lifetime because I'm getting older - but I'm hoping in the next generation's lifetime that we'll find a cure. We are operating on so many less folks, which I think is a good thing, and finding more ways to really control the disease. So, I think the best is yet to come.

Dr. Scott Steele: Well, that's fantastic. And to learn more about IBD treatment here at the Cleveland Clinic, please visit our website at clevelandclinic.org/ibd. That's clevelandclinic.org/ibd. You can also call us on 216-249-6470. That's 216-249-6470. Dr. Hull, thanks so much for joining us on Butts and Guts.

Dr. Tracy Hull: Thank you for having me. It's a pleasure.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.