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Video Transcript: Inflammatory Bowel Disease

Ellen Beth Levitt: Welcome to "Maryland Health Today." I'm Ellen Beth Levitt. Inflammatory Bowel Disease, which includes Crohn's and Ulcerative Colitis, affects more than one million people in the United States. On the show today, we'll talk about the symptoms and latest treatments for these disorders. My guest for the first half of the show is Dr. Raymond Cross. He's the director of the Inflammatory Bowel Disease Program at the University of Maryland Medical Center. Dr. Cross is also an associate professor of Medicine at the University of Maryland School of Medicine. Welcome to the show.

Raymond Cross, M.D.: Thank you for having me.

Ellen Beth Levitt: First of all, what is Inflammatory Bowel Disease? How is it defined?

Raymond Cross, M.D.: Inflammatory Bowel Disease is a chronic inflammatory condition of the intestines that's characterized by your, basically, your body's own immune system attacking the intestines. This can result in ulcerations in the small and large bowel, which can cause symptoms such as diarrhea, abdominal pain and sometimes passage of blood.

Ellen Beth Levitt: Are certain people more at risk of developing Inflammatory Bowel Disease than others?

Raymond Cross, M.D.: Inflammatory bowel disease was thought to be primarily a Caucasian, especially groups like Ashkenazi Jews and...

Ellen Beth Levitt: Do we know why that is?

Raymond Cross, M.D.: We don't know why that is.

Ellen Beth Levitt: Are there differences between men and women? Are men more commonly having Inflammatory Bowel Disease or women?

Raymond Cross, M.D.: Not really. It is primarily a one to one ratio. So men and women are equally affected by IBD.

Ellen Beth Levitt: Can it develop when someone is a child, or does it usually come about later on in life?

Raymond Cross, M.D.: It sure can. About 15 percent of patients have onset of disease under the age of 18.

Ellen Beth Levitt: Really? So it does affect children?

Raymond Cross, M.D.: Absolutely.

Ellen Beth Levitt: What causes Inflammatory Bowel in general?

Raymond Cross, M.D.: So we don't really know exactly the cause of the disease, but clearly you have to have several factors. One is you have to have a genetically susceptible host. You have to inherit the right genes from mom and dad to be able to get Inflammatory Bowel. Also, there is something in the environment that is very important. For example, in certain countries like Africa, you see very little Inflammatory Bowel, but in countries that are developed like the United States - in Europe - you see higher rates, so there is something about the environment whether that's the foods that we eat, certain pollutants in the environment, industrialized nations, there is something about the environment we live in that put us at risk. And, more recently, there is thought to be problems with bacterial populations in your intestines, so people with Inflammatory Bowel recognize bacteria that are normally in our intestines as a pathogen, and they attack those bacteria, causing the inflammatory response.

Ellen Beth Levitt: So they go after the substances as if they are foreign - like a foreign invader - like infection, when they are actually healthy?

Raymond Cross, M.D.: Exactly.

Ellen Beth Levitt: Microbes that belong in the intestine? We don't know what triggers that?

Raymond Cross, M.D.: Exactly.

Ellen Beth Levitt: Well, what are the three main types of Inflammatory Bowel Disease?

Raymond Cross, M.D.: So, Inflammatory Bowel Disease is primarily made up of two diseases: Crohn's and Ulcerative Colitis, which are fairly easy to distinguish in most cases. But, in about 15 percent of circumstances, we're not able to figure out if it is Crohn's or Ulcerative, and so that's Indeterminate Colitis.

Ellen Beth Levitt: There are two different types, but the third is you don't know exactly which it is?

Raymond Cross, M.D.: It is a little debatable. I think most people think that that indeterminate class is a separate disease state, that they act somewhat differently than the other two.

Ellen Beth Levitt: Does Inflammatory Bowel Disease ever get confused with Irritable Bowel Syndrome?

Raymond Cross, M.D.: Yes, it is very common in young women for there to be a delay in diagnosis because they are thought to have Irritable Bowel Syndrome, which is different than Inflammatory Bowel Disease, so that can lead to a delay in diagnosis.

Ellen Beth Levitt: Well, let's talk first about Crohn's Disease. What specifically is that? Does it affect just a certain part of the digestive system?

Raymond Cross, M.D.: As I said, Crohn's and Ulcerative Colitis can affect any part of the GI tract. Mouth to anus can be involved in Crohn's Disease. In addition, the inflammation in Crohn's tends to be more patchy, so you can see skin lesions. The ulcerations tend to be deeper in patients with Crohn's Disease, you can develop complications such as strictures or fistulas, either internal or fistulas around the backside. Fistulas are tunnels from the bowel to either the skin surface or another loop of bowel or other organs, and there are certain biopsy-type changes that we can see in patients with Crohn's that are pathonumotic - it means diagnostic of Crohn's Disease. If you see a granuloma on a biopsy, in general, that signifies Crohn's as opposed to Ulcerative Colitis.

Ellen Beth Levitt: What are the symptoms of Crohn's?

Raymond Cross, M.D.: I group them into three main categories. Patients who have what we call Inflammatory Crohn's, they primarily present with non-bloody diarrhea, crampy abdomenal pain, and you can often see symptoms we call systemic symptoms, such as fever, fatigue, also loss of appetite and weight loss. In patients with Stricturing Crohn's, they present with blockages, so it is essentially like having a blocked pipe. They'll present with pain after eating, abdominal bouts, oftentimes nausea. They can have vomiting, weight loss can be fairly severe, and sometimes they'll have diarrhea at the end of an episode of blockage, which will signify the end of that episode. And the last group is patients with what we call Penetrating or Perforating Disease, and those patients are fistulas, usually internal fistulas from the skin to another loop of bowel to another organ, which can present with usually pain, fever, pretty rapid weight loss.

Ellen Beth Levitt: But you would think that those would be the last symptoms after the disease has progressed quite a while, right?

Raymond Cross, M.D.: That's exactly right. So, there is pretty good evidence that this is a fairly dynamic process; that patients start out with primarily inflammatory disease and, over time, these complications develop such as blockages and fistulas.

Ellen Beth Levitt: So it sounds as though if people are having some of the early symptoms, they should go to a specialist to be evaluated and so forth.

Raymond Cross, M.D.: No question. So, patients who have diarrhea that doesn't resolve after a few days absolutely should be evaluated, because it is thought that treatment early on is much more effective than when you get complications of disease.

Ellen Beth Levitt: Do the symptoms come and go, or are they fairly constant once they begin?

Raymond Cross, M.D.: Well, most patients have symptoms for weeks to months before coming to diagnosis, so it tends to be a chronic problem, and once you get a flare under control, the disease goes into what we call remission. Over time, you can expect periodic flares, followed by periods of time with remission, and the goals of therapy are to decrease the amount of time that you're flaring or decrease the amount of flares, and keep you in remission long term.

Ellen Beth Levitt: Do people who have Crohn's Disease need to worry about not getting enough nutrition?

Raymond Cross, M.D.: Sure, so patients with fairly extensive small bowel Crohn's Disease can have trouble with absorption of nutrients, vitamins and minerals. Just developing symptoms of diarrhea and pain after eating can decrease the amount of calories that they are taking in, which can make the weight loss worse. Also, if you have a lot of diarrhea, it can result in dehydration, so those types of problems are very common.

Ellen Beth Levitt: Let me ask you about Ulcerative Colitis. How is that different from Crohn's?

Raymond Cross, M.D.: It is primarily present with bloody diarrhea, and it very typically occurs in a former smoker or smoker where Crohn's tends to be a disease of smokers, so the smoking history I have is very critical in differentiating the two diseases. Also, when we do endoscopies or X-ray testing, only the colon is involved in Ulcerative Colitis, where any part of the intestines could be in Crohn's.

Ellen Beth Levitt: Are the symptoms similar to Crohn's if people have Ulcerative Colitis?

Raymond Cross, M.D.: They are different. Ulcerative colitis is diarrhea with blood, so that it is fairly simple in how it presents. It is much easier, in many aspects, than Crohn's as far as diagnosis.

Ellen Beth Levitt: Are these attacks that you were talking about sometimes severe enough for people to have to be hospitalized?

Raymond Cross, M.D.: Absolutely. So, there is a significant percentage of patients who require hospitalization either at presentation or at some point during their illness, so the flares can be severe enough to require hospitalization for treatment.

Ellen Beth Levitt: Let's talk about treatment then. Are there some effective medications that can control the symptoms, and even quiet the disease? Is there a cure for example?

Raymond Cross, M.D.: So, we'll start with the bad news first, there is no cure right now for Ulcerative Colitis. There is no cure for Crohn's Disease. There is a cure for Ulcerative Colitis, which is surgery. As far as medical treatment, you can break it into two categories. There is supportive treatments, things that just make you feel better, such as pain medicine for abdominal pain, anti-diarrheal medicines, supplements to help with nutrition and so forth. Regarding specific medical treatments, it is typically still pyramid-based, so what we do is we basically slot patients into the pyramid based on how sick they are. For example, patients who have mild symptoms, those that are still going to work, not delaying social engagements, generally have mild symptoms, and will start with the less efficacious, but safer medications first.

Ellen Beth Levitt: So, some of the milder medications.

Raymond Cross, M.D.: Right, and the vast majority of patients in the community can be managed with mild medications, which have very few side effects. Those medications, once they are started, are often continued long term to prevent flares of disease, and, unfortunately, chronic medication use is needed to prevent flares. For those that are sicker, those with med rate disease, those that are starting to miss work, delay social engagements, for those patients we typically will use things like Prednisone and followed by immune suppressants to control the symptoms long term.

Ellen Beth Levitt: And those would have more side effects?

Raymond Cross, M.D.: They typically have more side effects associated with them, and for patients with more severe disease, we typically go to the top of the pyramid, which is our so-called biologic agents. Things like Remicade, Rumera, things that we typically reserve for sicker patients.

Ellen Beth Levitt: Are those given by pill or are those often infused as an IV?

Raymond Cross, M.D.: Those two are infused through an IV, whereas Humera and another are injectable drugs that can given true a subcutaneous injection into the skin.

Ellen Beth Levitt: Here, we have a patient having an infusion of one of these medications.

Raymond Cross, M.D.: Right. Typically with Remicade and drugs like that, they have been reserved for sicker patients. There is interest in the GI community to using these drugs earlier on to, you mentioned, preventing complications of disease. So, trying to prevent complications that were requiring surgery, so over the next few years, we're going to see these drugs being used earlier and earlier to try to get people under better control.

Ellen Beth Levitt: I was going to ask you if it is important to start with medications early, rather than waiting.

Raymond Cross, M.D.: If you can start these medications before complications develop, they can be very, very effective. And, there have been several studies showing that you can, that these drugs are more effective earlier in the disease course as opposed to later in a disease course.

Ellen Beth Levitt: What are some of the side effects of the medications, or some of the things that people need to avoid?

Raymond Cross, M.D.: So, with the medications, it is very - we spend a lot of time talking about risk and benefits of therapy because some of the medications can be quite scary to patients. Some of the things that we worry about are serious infections, opportunistic infections.

Ellen Beth Levitt: These suppress the immune system so the digestive system is not attacking itself.

Raymond Cross, M.D.: Yes, so we focus most of our medications on immune suppressing medications as opposed to immune stimulating medications, so they put you at risk for both serious common infections that anyone can get, as well as unusual infections, that a normal person who is not on immune suppressants wouldn't get, so-called opportunistic infections. The last concern with some of the medications is about certain types of cancer. Usually, the immune-driven type cancers, such as lymphomas, are the ones that we worry the most about. So, we try to go over a risk and benefit analysis of all of the MS before we start them, trying to highlight the fact that the worst thing that they could have is poorly treated Crohn's, as opposed to rare side effects of medications.

Ellen Beth Levitt: Right, but it sounds like there are a lot of different options, which is a very good thing for people who are coping with the Inflammatory Bowel Disease.

Raymond Cross, M.D.: Right. It is always bad to be a patient, but this is a good time to be a patient in the sense that there are a lot of medical options out there for you.

Ellen Beth Levitt: Do people, are people concerned about what they should eat, whether certain foods can provoke a flare up?

Raymond Cross, M.D.: It is probably our number one question in the clinic: what can I eat? What can't I eat? And, with the exception of patients with strictures who have a blockage - we do very restrictive diets for those patients - but in general, I tell patients to use a common sense approach. So something bothers you, you have to decide is it worth eating that food, or should I avoid it.

Ellen Beth Levitt: It is very individual.

Raymond Cross, M.D.: Absolutely, and there is also vitamins and minerals that we supplement With, things like Calcium, Vitamin D, B12, sometimes Zinc. Deficiency can occur, so we do supplements, but in general, we're pretty liberal with the diet.

Ellen Beth Levitt: Great, thank you so much for being on our show.

Raymond Cross, M.D.: Thanks for having me.

Ellen Beth Levitt: We have to the take break, but when we come back, we'll talk about the role of surgery treats in some complications of Inflammatory Bowel Disease, so stay with us. We'll be right back.

Part Two:

Ellen Beth Levitt: Welcome back to "Maryland Health Today." I'm Ellen Beth Levitt. On the show today, we're talking about the two major types of Inflammatory Bowel Disease: Crohn's and Ulcerative Colitis. My guest for this segment is Dr. Stephen Kavic, a general surgeon at the University of Maryland Medical Center who is part of the team of specialists who care for patients with Inflammatory Bowel Disease. Dr. Kavic is also an assistant professor of Surgery at the University of Maryland School of Medicine. What is the role of surgery in helping people who have Inflammatory Bowel Disease?

Stephen Kavic, M.D.: Well, often with surgery, we have to deal with not the Inflammatory Bowel Disease itself, but the complications of that disease, so sometimes we're confronted with patients that have difficulty taking medications, or who have complex disease that requires surgery or removal of a portion of their intestines in order to make them better.

Ellen Beth Levitt: I've heard that about 80 percent of people with Crohn's Disease need to have surgery at some point.

Stephen Kavic, M.D.: That's about right. It is estimated that about 3 out of 4 folks with Crohn's Disease will, at some point, need an operation during their lifetime.

Ellen Beth Levitt: But the percentage is lower for people who have Ulcerative.

Stephen Kavic, M.D.: About a third of those will need an operation at some point.

Ellen Beth Levitt: What are some of the reasons that surgery would be needed?

Stephen Kavic, M.D.: For some, we tend to intervene when there are complications of the disease process itself. That is to say, if there are different problems such as abscess or fistulas, or if the medications are a problem; the side effects may be not worth the benefit that you see, or if someone cannot or will not take the medications due to a variety of reasons.

Ellen Beth Levitt: So, what are some of the severe complications from Inflammatory Bowel Disease that would require the expertise of a surgeon such as yourself?

Stephen Kavic, M.D.: Unfortunately, there are a lot of different problems that can occur. Principally, there can be a hole in the bowel, or a perforation. This can occur on the surface of the bowel that leads into the abdominal cavity, what is known as a free perforation. Sometimes, that hole can occur against the side wall of the abdomen or another structure, which can lead to development of infection or an abscess. At other times, and perhaps more commonly, we see a stricture or a tightening of the intestine, which leads to obstruction or blockage. In addition, sometimes there can be bleeding or fistula formation.

Ellen Beth Levitt: What is a fistula?

Stephen Kavic, M.D.: A fistula is an abnormal connection between two surfaces that has aligning. And, in Crohn's Disease, we often see people that have problems in the perianal-perirectal region. Sometimes the fistulas can occur within the abdomen from one loop to another, and sometimes to the skin surface of the abdominal wall.

Ellen Beth Levitt: Does that mean that substances can pass from one area to another when they are not supposed to?

Stephen Kavic, M.D.: Absolutely. So, this is an abnormal opening that can allow for the passage of some of the normal GI contents into an unwelcome location.

Ellen Beth Levitt: So, a lot of these need to be repaired surgically?

Stephen Kavic, M.D.: That's correct. Now, what is even more effective than surgery alone is to combine it with medical therapies, which is why, at the University of Maryland, we're very happy to have a multi-disciplinary center to attack these problems from both the medical and surgical perspectives.

Ellen Beth Levitt: Tell us a little bit more about abscesses, and why surgery might be needed to treat an abscess?

Stephen Kavic, M.D.: When you have an abscess, or a collection of infections, often the best and most expeditious route to treatment is with a surgical drainage. Antibiotics alone work very effectively for infection, but when you have a collection, that gets drained much more quickly and better for the patient to have it drained surgically.

Ellen Beth Levitt: Also, there is something called a stricture and things called strictureplasty?

Stephen Kavic, M.D.: It is a tightening of a pipe, or blockage, and it is a step beyond the inflammation that can be controlled with...

Ellen Beth Levitt: ...with medicines?

Stephen Kavic, M.D.: That's right. So, after repeated bouts of inflammation, there can potentially be scarring of the bowel, which causes it to tighten, and we use the medical term stricture. There are specific surgical techniques we can use up to the small blockages without actually needing to remove those portions of intestines.

Ellen Beth Levitt: Now, I have also heard that some people need to have a portion of their bowel actually removed. Would that be most commonly for Crohn's as opposed to Ulcerative Colitis?

Stephen Kavic, M.D.: Probably we do more operations on Crohn's Disease than Ulcerative Colitis, that's true. When the bowel is in an unsalvageable state, when the stricture is so severe, or the bowel wall is so pliable or delicate that it tends to puncture and leak, at that point we should consider a resection or a removal rather than a repair.

Ellen Beth Levitt: Now, can these operations be done in a minimally invasive way?

Stephen Kavic, M.D.: Absolutely. So, the minimally invasive approach started with gallbladder surgery and has been extended to a variety of procedures, including Inflammatory Bowel. And so, the University of Maryland prides itself on applying the minimally invasive approach.

Ellen Beth Levitt: There has been a lot of leadership there, and all kinds of surgeries.

Stephen Kavic, M.D.: Absolutely.

Ellen Beth Levitt: Even heart bypass surgeries, and minimally invasive ones with a robot, but you're not using the robot for...

Stephen Kavic, M.D.: No.

Ellen Beth Levitt: ...Inflammatory Bowel surgery yet.

Stephen Kavic, M.D.: We tend not to use the robot, but we do apply laparoscopy, some of the small cameras and delicate instruments to enable us to do a lot of the same procedures through much smaller incisions.

Ellen Beth Levitt: How fast can somebody leave the hospital and recover from these types of operations?

Stephen Kavic, M.D.: It depends a lot on the operation. Most of the procedures that we do are inpatient procedures, where people should expect to come to the hospital, typically for around four or five days after a major resection.

Ellen Beth Levitt: Can surgery cure Inflammatory Bowel Disease?

Stephen Kavic, M.D.: As Dr. Cross mentioned, unfortunately, there is no cure for Crohn's Disease, so we can deal with some of the more severe complications only. It is our belief that when we remove the main focus of disease, that perhaps the medications have a greater effect on the remaining more normal bowel that's left behind.

Ellen Beth Levitt: What part of the intestine would normally have to be removed for people who need to have it done?

Stephen Kavic, M.D.: The most common bowel is the terminal ilium, or the end before it meets the colon, and that's where we see the bulk of the problems that need to be addressed surgically as well.

Ellen Beth Levitt: I hear that there is a technique with the creation of a "J-pouch," so that people would not need to have bowel material coming out into a bag that is hooked on to the outside of the body, could you explain that?

Stephen Kavic, M.D.: Certainly. So, for patients that have Ulcerative Colitis, we may need to remove the colon and the proper operation is removal of the entire colon, which serves to absorb water. We're left with the end of the small bowel, which in and of itself does not function very well at absorbing that water, so we can fold it on itself in the fashion of the letter J, and divide the common channel at the end of that pouch, which serves as a little reservoir that encourages absorption of excess water. From there, rather than putting it into a bag on the abdominal wall or a stoma, we can attach it to the anal canal directly, so that people do not need a bag long term.

Ellen Beth Levitt: So, what would be the symptoms if people did not have this J-pouch? What kind of symptoms might they have if you were to connect the end to the rectum, where it would normally be connected?

Stephen Kavic, M.D.: We learned through bitter surgical experience many decades ago, that applying the small bowel directly to the anal canal leaves you with a lot of diarrhea, an unacceptable amount of watery discharge from the bottom, so that is really not an operation that can be performed anymore. If the whole colon needs to be removed, the options are a J-pouch internally, or a stoma or bag externally.

Ellen Beth Levitt: And I guess, the whole adjustment for someone to have to live after these kinds of surgeries...

Stephen Kavic, M.D.: It is a terrific psychological adjustment to change in bowel habits, and sometimes in eating habits, after an operation.

Ellen Beth Levitt: What kind of changes in eating habits do your patients have to be aware of?

Stephen Kavic, M.D.: For the people that come in with the blockage, often the diets can be liberalized. They no longer have to be stuck with just a liquid or limited amount of intake. Eating is one of the great pleasures in life, and it is always a delight to see some of our post operative patients who can eat some of the foods they were unable to enjoy before. But, then as Dr. Cross mentioned, they always have to be cognizant of the triggers that set off their own disease.

Ellen Beth Levitt: Is there an increased risk of colon cancer among people who have Inflammatory Bowel Disease?

Stephen Kavic, M.D.: Absolutely. Ulcerative Colitis is associated with a higher incidence of colon cancer. It has traditionally been felt to be a very high increase in the incidence of colon cancer, the jury is still out about the exact numbers, but, for certain, Ulcerative Colitis and Crohn's Colitis leads to an increased risk of pre-cancer, dysplasia and actual cancer.

Ellen Beth Levitt: People have to get colonoscopies more often?

Stephen Kavic, M.D.: We either have to do them more frequently, or be a little bit smarter about them in doing targeted colonoscopies.

Ellen Beth Levitt: We only have a couple of minutes left, but I wanted to ask you about the kinds of research that you might be involved in or the center might be involved in.

Stephen Kavic, M.D.: Sure. Important people with Inflammatory Bowel Disease, they say lot of research that's going on around Inflammatory Bowel Disease, we have a number of active protocols and, also importantly, we keep track of all of our patients in terms of a database, so that we can help to be part of the solution really, part of the process of developing new techniques, new protocols, so that we can give optimal care for all of our patients.

Ellen Beth Levitt: Is there one particular area of research that looks very promising or something that you're involved with?

Stephen Kavic, M.D.: Well, it is tough to narrow it down to just one, but we from the surgical side, the challenge is to look at the different techniques that we have, sort of the mechanical solutions to the disease process; whereas, Dr. Cross and the medical side focus in on some of the newer medications and their applications. So, I can't say there is only one protocol per se that is nearest and dearest to my heart, but I'm very proud of the work that we're able to do at our center.

Ellen Beth Levitt: Do people sometimes need more than one surgical intervention over the course of their life if they have Inflammatory Bowel Disease?

Stephen Kavic, M.D.: That would basically be the expectation is that, if there is more than one problem fistula or an abscess, it may require multiple stages in order to get you through the process.

Ellen Beth Levitt: And so, it would be interesting to still do more work on the causes and, maybe one day, there will be some really good ways to prevent Inflammatory Bowel Disease.

Stephen Kavic, M.D.: Absolutely, I would love to be out of business.

Ellen Beth Levitt: Well, thank you very much for being on the show. My guest has been Dr. Stephen Kavic, a general surgeon at the University of Maryland Medical Center. Dr. Kavic is also an assistant professor of Surgery at the University of Maryland School of Medicine. I'd also like to thank Dr. Raymond Cross, who was our guest in the first half of the show. If you have any comments or questions about this program, please contact me by e-mail at eblevitt@umm.edu. If you'd like to reach Dr. Cross, Dr. Kavic or any other University of Maryland physician, call 1-800-492-5538, or visit the web site, where you'll find a great amount of health information and be able to see other Maryland Health Today programs. The address is www.umm.edu. Take good care of yourself. We'll see you next time for "Maryland Health Today."

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This page was last updated on: August 25, 2009.

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