DigestiveTrac Digestive Diseases • FALL 2012 Issue 4
Inside this issue: An Overview of IBD: Crohn’s Disease and Ulcerative Colitis Accurate Diagnosis and Tracking are Important for Optimal Disease Management Long-term Remission is the Goal for Medical Management of IBD Minimally Invasive Surgical Approach to Inflammatory Bowel Disease Specialists Collaborate in the Care of IBD
Dear Colleagues, Inflammatory bowel disease is a relatively common diagnosis in our country. An estimated 1.4 million Americans – about one in 200 – suffer from chronic, inflammatory conditions of the digestive tract which fall into the categories of Crohn’s disease and ulcerative colitis. Symptoms are often very troublesome, and complications can be serious and even lifethreatening, including an increased risk of colorectal cancer. Barring surgery to remove the colon in the case of ulcerative colitis, these diseases are not curable; yet they are very manageable through a range of excellent medications as well as surgical options if needed. For these reasons, accurate diagnosis, the proper individualized treatment plan, and careful follow-up are important in order that patients can experience a higher quality of life. This issue of Digestive Trac is dedicated to inflammatory bowel disease, and the diagnostic and treatment journey of Crohn’s and UC patients. Avera Digestive Disease Institute gastroenterologists have the experience and expertise to guide patients on this journey and make treatment recommendations for the best outcomes. A range of diagnostic tools are available through Avera McKennan, including global studies such as CT enterography and MR enterography, endoscopy and colonoscopy with biopsy, video capsule endoscopy or the “pill cam,” and laboratory studies. These tools along with a full patient history help arrive at the correct diagnosis which will in turn lead to the best possible treatment plan. IBD is managed medically if possible. If surgery is needed, Avera surgeons offer the latest minimally-invasive procedures, so that patients experience a faster recovery and less pain. Avera offers the necessary consulting specialties including but not limited to rheumatology, dermatology, urogynecology, hepatology and oncology. We invite you to read about these specific aspects of our approach to IBD management in this issue. It is our continuing goal, as well as our privilege, to work closely with primary care physicians for our patients’ best interest and continuity of care. Please feel free to contact us at (605) 322-7797 with questions or for more information. Sincerely,
Scott L. Baker, MD, FACS Colorectal Surgery Surgical Institute of South Dakota Surgical Director of Avera Digestive Disease Institute
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Steven Condron, MD, MHES, FACP Gastroenterology and Hepatology Avera Medical Group Gastroenterology Medical Director of Avera Digestive Disease Institute
Ranked #1 Hospital in South Dakota.
www.Avera.org/number1
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An Overview of IBD: Crohn’s Disease and Ulcerative Colitis An estimated 1.4 million Americans – about one in 200 – suffer from inflammatory bowel disease – chronic, inflammatory conditions of the digestive tract. The two major categories are Crohn’s disease and ulcerative colitis, which have key similarities and differences. It’s important that patients are properly diagnosed, treated and followed so that they can continue to enjoy a high quality of life. “We have excellent medical management that makes these diseases very livable,” said Dr. Cristina Hill Jensen, gastroenterologist with Avera Medical Group Gastroenterology, who takes a special interest in the diagnosis, treatment and follow-up of IBD. These are chronic inflammatory conditions that most often require long-term follow-up and treatment. Both diseases happen for unclear reasons. Disease results from an abnormal immune response to harmless bacteria in the digestive tract. This immune response leads to chronic inflammation, thickening of the intestinal wall and ulceration. There’s thought to be a genetic component, as there are well over 120 genes which contribute to IBD. It’s believed that environmental factors set off these genes and cause active disease. Dr. Cristina Hill Jensen performing colonoscopy on a patient with Crohn’s disease
“IBD is a life-changing diagnosis, especially with young patients,” Dr. Hill Jensen said. “While the disease can be a very big part of their life, it’s not something that needs to take over their life with a proper individualized treatment plan.” The two diseases are more common in industrialized countries, pointing to a possible association with development of the immune system. “No one causes it to happen by worrying too much, or because they didn’t eat right. It’s a chronic condition that people develop, like diabetes or high blood pressure, and once it develops it must be treated,” added Dr. Christopher Hurley, gastroenterologist with Avera Medical Group Gastroenterology. Classic presenting symptoms between the two diseases are the same: chronic diarrhea, bloody stools, abdominal pain and cramping. There may also be more vague constitutional symptoms, such as fever, fatigue, loss of appetite, weight loss and general malaise. Crohn’s can also present in arthritic conditions and skin manifestations. Or, disease can burrow into other structures, such as the vagina or bladder. IBD can affect people of all ages, from children to the elderly. The first peak of incidence happens in the late teen years to early 30s, with a second peak of incidence among people in their 50s and 60s. The two diseases differ in patterns of inflammation and location of that inflammation. Crohn’s disease is named after Dr. Burrill B. Crohn, who first described the disease in 1932 along with colleagues Drs. Leon Ginzburg and
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Gordon D. Oppenheimer. Crohn’s can affect any part of the digestive tract, from the mouth to the anus. One-third of Crohn’s patients are affected only in the small bowel; one-third are affected only in the colon; and the remaining third are affected in both the small intestine and colon.
Dr. Chris Hurley performing colonoscopy on a patient with Crohn’s disease
In comparison, ulcerative colitis affects only the colon, and the most superficial layer of the colon – the mucosa. Ulcerative colitis ulcerations are shallow and continuous, whereas Crohn’s is transmural, affecting the entire thickness of the intestinal wall with patchy, deep ulcerations as well as fistulas that may affect other structures. Ulcerative colitis usually starts at the rectum and progresses proximally; Crohn’s typically has skipped involvement. In more severe cases, Crohn’s can lead to tears or fissures in the lining of the anus, which may cause pain and bleeding. Inflammation may also cause a fistula to develop between one loop of the intestine to another, or between the intestine and the bladder, vagina or skin. Diagnosing Crohn’s and UC begins with a good patient history. “The diagnosis can be a challenge, so it’s important for us to work with the referring physician and patient in putting together the entire story,” Dr. Hurley said. Patients often do research on their symptoms, and come in already suspecting that they have IBD – although some patients confuse IBD with irritable bowel syndrome (IBS) which is a functional problem of the bowels without physical signs of inflammation. Diagnosis often includes blood work, stool studies, colonoscopy and radiology/imaging studies. Video capsule endoscopy – the pill cam – is a great tool for imaging the small intestine to look for ulcerations and narrowing consistent with Crohn’s disease. Biopsies taken in colonoscopy can check for dysplasia or help confirm a Crohn’s or UC diagnosis. Computed tomographic enterography (CTE) and magnetic resonance enterography (MRE) provide an overall evaluation of the entire abdomen. This provides a more global view, for example, if fistulas are occurring and if so, where. Putting all this information together with symptoms can help specialists accurately diagnose and follow IBD. Yet proper diagnosis can be challenging, because there is no single blood test or imaging scan which can confirm a Crohn’s or ulcerative colitis diagnosis 100 percent. For
example, infections can mimic IBD from symptoms to ulcerations in the bowel. Antibiotics may be a first-line treatment to try to rule out infection. After definitive diagnosis, an individualized medical management program is recommended first, and surgical intervention is the next resort if necessary. Crohn’s and UC cases can be mild or moderate to life-threatening, depending on the severity, extent and presence of complications. In severe cases, patients may present to hospital requiring surgery for a perforation or an obstruction caused by inflammation. In most cases, symptoms are severe and prolonged enough that patients seek medical care rather than living with the condition long term. Crohn’s and UC patients have a higher risk of colon cancer. If a patient has had extensive disease for seven to 10 years, close surveillance of the colon through colonoscopy is recommended every one to two years. “IBD is a life-changing diagnosis, especially with young patients,” Dr. Hill Jensen said. “While the disease can be a very big part of their life, it’s not something that needs to take over their life with a proper individualized treatment plan.”
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Accurate Diagnosis and Tracking are Important for Optimal Disease Management In the case of Crohn’s disease and ulcerative colitis, accurate diagnostic imaging is vital to the most effective treatment and prevention of complications. The Avera Digestive Disease Institute provides all diagnostic tools required for effective management, from endoscopy and colonoscopy, to video capsule endoscopy to global imaging studies. Colonoscopy and upper endoscopy are “gold standard” tests for Crohn’s and ulcerative colitis. Using these tests, physicians can visualize inflammation and take diagnostic biopsies if needed. Yet one-third of Crohn’s cases affect the small intestine only in sections which may not be accessible through endoscopy. What’s more, Crohn’s affects the entire bowel wall – not just the mucosal lining, and it can affect other organs and structures, for example, the liver, vagina or bladder. Video capsule endoscopy, commonly known as the “pill cam,” has been introduced in the past decade. “It is a wonderful diagnostic tool for visualizing portions of the small bowel non-invasively that we wouldn’t otherwise be able to see except through exploratory surgery,” said Dr. Cristina Hill Jensen, gastroenterologist with Avera Medical Group Gastroenterology. The test involves a capsulized microcamera, the size of a multivitamin, that the patient swallows. It takes 60,000 pictures over eight hours, which are transmitted to a computer pack worn by the patient.
Computed tomographic enterography (CTE) and magnetic resonance enterography (MRE) are imaging tools developed in recent years which can be used either independently, or to complement other diagnostic tests. Before CT came into its own, the main option for diagnosing IBD in the small intestine was a combination of colonoscopy and small-bowel follow-through (SBFT). However, this had limitations, for example, contrast tended to either flow too slowly through the intestines due to blockages, or too quickly. In addition, sections of the bowel would overlap, making it difficult to get an accurate diagnosis. Small-bowel enteroclysis is more accurate than SBFT at detecting lesions, but it requires a tube inserted through the nose, which is unpleasant for the patient. Both methods provide only limited information in regard to the state of the bowel wall and extraluminal extension of disease. CT proved to provide a superior snapshot picture of the bowel without the unpleasantness or frustration of the previous tests. Plus, it provides information about any disease in process beyond the bowel lining. Even today, CT provides a good baseline screen for patients, for example, those who have abdominal pain of unknown cause.
CT entero¬graphic of a patient with active Crohn disease
Source: Khaled M. Elsayes, MD, CT Enterography: Principles, Trends, and Interpretation of Findings, 2010
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Dr. Sabina Choudhry reading a CTE
in a delayed phase reveal whether blood dissipates or accumulates. The MRE test takes longer – from 30 to 45 minutes – yet new and emerging MRI equipment is faster than ever. The Avera McKennan Imaging Center will have a new, faster MRI machine late in 2012. Because MRI images are captured over time and the bowel is a mobile organ, a medication must be given to paralyze the bowel during the test. When a solution for this issue is perfected, Dr. Choudhry believes MRE will ultimately be found to surpass CTE in accuracy. “It is a more dynamic study,” she said. Not only are CTE and MRE easier on the patient, they are more accurate than past methodology. CTE and MRE have an accuracy rate of 85-90 percent.
CTE technology made CT testing even more specific to IBD with the use of oral and IV contrast to distend the small bowel, and create more detailed images. “Scanning at certain phases helps physicians look for inflammation, abscesses and fistulas, and whether disease is active or quiescent,” said Dr. Sabina Choudhry, radiologist with Avera Medical Group Radiology. CTE uses the same CT scanner, yet with a different patient preparation, namely the oral and IV contrast. While CTE offers accurate testing for IBD patients, it does expose patients to ionizing radiation. IBD patients are often young, and repeated scans expose them to a high cumulative dose of radiation. Magnetic resonance enterography (MRE), in wide use only since 2010 in the United States, came to be identified as a safer alternative. MRE involves MRI equipment, with a similar patient preparation involving oral and IV contrast. A Mayo Clinic study found that the two tests are comparable and interchangeable in terms of accuracy, yet MRE exposes patients to no radiation. For this reason, MRE is now used almost exclusively, except in the case of emergency or when a GI bleed is suspected. Because it is faster, CTE is often used in emergent cases. CTE is also the “gold standard” in finding a GI bleed. It provides that rapid snapshot needed in making these diagnoses. For example, images of the arterial phase capture the blood escaping, and images
For both MRE and CTE, patients do not have to undergo bowel prep, as with colonoscopy. They are required to fast at least four hours. Patients must drink 1.5 liters of oral low-density barium contrast. Drinking this volume of fluid in a short time frame is the most difficult part of the test for most patients. Contraindications include renal disease – the kidneys must function well to flush out the contrast from the blood. Pregnant women cannot have contrast or the CT scan. A modified MRI scan without contrast may provide enough information on the disease process during the pregnancy. Patients with an implanted defibrillator or pacemaker cannot have MRE, as well as patients with a cochlear implant, and some types of clips, coils or stents that may be on or within blood vessels. Patients do not have to undergo anesthesia or sedation, unless they are claustrophobic or have anxiety about the test, so there is no recovery time or side effects. Some MRE patients have mild nausea or abdominal cramping due to medication to paralyze the bowel. These effects are transient. It’s not unusual for some patients to have multiple tests in a year, and the choice of MRE and CTE and other testing options at Avera McKennan offer GI specialists the diagnostic tools they need to accurately care for and track IBD patients.
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Long-term Remission is the Goal for Medical Management of IBD The chronic nature of Crohn’s disease and ulcerative colitis make medical management the front-line strategy for gastroenterologists when a patient is diagnosed with inflammatory bowel disease. “IBD is much more manageable than 20 years ago,” said Dr. Christopher Hurley, gastroenterologist with Avera Medical Group Gastroenterology. “Generally speaking, patients enjoy excellent quality of life. The disease is very manageable with the medications we have, unless in a rare case when the disease doesn’t behave the way it’s expected to.” It’s not unusual for patients to remain in complete remission for years if not decades, with the preservation of bowel function. An individualized plan of care is important, as there are many options available, and the same medications or dosage that works for one patient does not work for another, even between siblings or a parent and child who both have the disease. “Specialists follow either a step-up or top-down therapy in treating IBD medically,” said Dr. Steven Condron,
gastroenterologist with Avera Medical Group Gastroenterology. The step-up approach means starting with less potent medications and then going to the next step, and the top-down approach is hitting the inflammation hard up front, and stepping back on medications as inflammation improves. This may depend on the patient’s situation. For example, if the disease is in a severe, uncontrolled state when the patient presents, treatment may be more aggressive up front. The mainstay, long-term medication for most patients falls into the category of aminosalicylates, for example, mesalamine. These medications work to reduce inflammation, and are useful as a maintenance treatment in preventing relapses of the disease. Corticosteroids are available orally and rectally. Corticosteroids nonspecifically suppress the immune system and are used to treat moderate to severe disease. These drugs have significant short- and long-term side effects, so they are not used as a maintenance medication.
Dr. Steven Condron performing an upper endoscopy to evaluate for remission of disease
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Immunomodulators modulate or suppress the body’s immune system response so it cannot cause ongoing inflammation. Immunomodulators generally are used if aminosalicylates and corticosteroids have not been effective, or have been only partially effective. Antibiotics may be used when infections or abscesses are present. They can also be helpful with fistulas around the anal canal and vagina. Biologic therapies, also known as anti-TNF agents, are the latest class of therapy used for people suffering from moderate-to-severe IBD. Tumor necrosis factor (TNF) is a chemical produced by the body to cause inflammation. Antibodies attach to these chemicals and
allow the body to destroy the chemical and reduce the inflammation. Biologic therapies are very expensive, and only used if disease is moderate to severe, or symptoms are debilitating. “Biologic therapy has revolutionized treatment and the ability to avoid surgery,” Dr. Condron said. Lifestyle changes, such as change in diet or stress reduction, do not have a great impact on IBD. While patients who have IBD or any chronic disease are encouraged to eat wisely, exercise and avoid stress, there’s no lifestyle plan that will cure IBD. Left untreated, patients often experience flare-ups, or cycles of active and non-active disease. Some patients
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Dr. Dany Shamoun performing surveillance colonoscopy for UC
notice increased flares of the disease if they take non-steroidal anti-inflammatory drugs (NSAIDs), so patients are advised to avoid them. Some patients report flare-ups when they eat dairy products. More flare-ups are also reported in the spring and the fall. The goal is sustained inactive disease, or remission. If patients respond to medications, follow-up evaluations are needed to determine if remission extends beyond relief of symptoms to clearing of inflammation. “It’s possible for people to go into clinical remission, in that their symptoms are gone, yet they still have inflammation. We need to be aggressive about quieting down the inflammation, because it can be a significant risk factor for colon cancer and other complications, such as strictures or perforations,” said Dr. Dany Shamoun, gastroenterologist with Avera Medical Group Gastroenterology.
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Once patients are in remission, they do not have to undergo regular endoscopy unless symptoms change. After they have had the disease for seven to 10 years, colonoscopies every one to two years are recommended with systematic biopsies to check for dysplasia and/or cancer. Depending on the medications prescribed and their particular side effects, blood testing is warranted to check on kidney and liver function or white blood cell count. Medical management has greatly improved, reducing the need for surgery. Five years ago, eight out of 10 Crohn’s patients would need surgery at some point in the disease process – today, that number is six out of 10. What’s more, prolific active research is taking place to further improve the treatment of IBD – including clinical trials available at Avera.
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Minimally Invasive Surgical Approach to Inflammatory Bowel Disease In those cases when Crohn’s or ulcerative colitis cannot be controlled medically, or when complications such as narrowing, obstructions, bleeding or perforation result from chronic ulceration, the latest surgical techniques can help resolve symptoms, repair a life-threatening condition, or return patients to a more normal lifestyle.
Dr. Scott Baker performing a single incision proctocolectomy
Scott Baker, MD, with Surgical Institute of South Dakota, who is fellowship trained in colorectal surgery, advises the most common surgical indications for Crohn’s include an area of narrowing which causes an obstruction, ongoing bleeding or perforation. Surgery may involve one of two approaches. One is to resect the affected portion of the bowel and put it back together. “We can do that minimally invasively with laparoscopy, so patients experience less pain and a faster recovery in comparison to the traditional open technique.” Stricturoplasty is another alternative to open a narrowed section of bowel. A cut is made longitudinally, which is then closed transversally, which serves to widen the stricture without removing any bowel. This prevents from having to remove section after section of small bowel, which is needed for absorption. This technique can also be performed minimally invasively.
“We are now more aggressive in treating with surgery. If patients are not responding to medication we’re quicker to say it’s time for surgery,” Dr. Baker added.
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A. Resection of colon and rectum
ileum
entire colon and rectum removed
anal sphincter preserved
C. Final surgical stage, removal of ileostomy
B. Creation of J-pouch
temporary ileostomy diverts flow (while ileoanal anastomosis heals)
J-pouch
D. J-pouch
prior ileostomy site ileal reservoir functions as “new” rectum
Patients suffering from ulcerative colitis may require surgical resection of the colon if medications are not effective, or if they develop dysplasia or colon cancer. This involves removal of the entire colon and rectum. Removing the entire structure essentially cures ulcerative colitis, because that’s the only portion of the digestive tract affected by UC. If patients are a candidate for the J-pouch procedure, a reservoir that functions like the rectum is created at the end of the small bowel, and attached to the anus.
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If patients undergo the procedure in more than one operation, they may have a temporary ileostomy, in which the end of the small intestine is emptied through a stoma in the skin into an exterior pouch worn by the patient.
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Patients who are not good candidates for the J-pouch may have a permanent ileostomy. Continence and good function of the sphincter are key deciding factors. After resection of the colon, patients will have liquid stool, with bowel movements from three to seven times per day, and they must have good control in order to live with this. Patients experience more urgency and frequency than people with normal bowel function, but for most it’s an improvement over the chronic diarrhea and pain of UC. Like many other surgical procedures, this procedure has evolved to be minimally invasive. “We used to make a big abdominal incision to do this. Now, we can perform the surgery laparoscopically through a single incision, which becomes the stoma, and when it’s all complete the only scar a patient has is the former temporary stoma,” Dr. Baker said. About 25 percent of UC patients require surgery at some point in their disease process. “We are now more aggressive in treating with surgery. If patients are not responding to medication we’re quicker to say it’s time for surgery,” Dr. Baker added.
Specialists Collaborate in the Care of IBD. After the referral of primary care physicians, the physicians who may be most involved in the care of patients with Crohn’s disease and ulcerative colitis are gastroenterologists, colorectal surgeons and radiologists. Other specialties that may be consulted include: •
Rhematology: Inflammatory bowel disease causes a whole range of inflammatory reactions in joints, sinews and vessels. Ulcerative colitis patients are more likely to experience arthritis in their peripheral joints whereas patients with Crohn’s disease are more likely to develop arthritis in knee and ankle joints.
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Dermatology: About 40 percent of Crohn’s patients experience dermatological manifestations, for example, fissures and abscesses around the perineal and perianal region. Lesions may also present as spots or plaques found on the trunk, arms and legs, or elsewhere.
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Urogynecology: Extraintestinal involvement of Crohn’s can affect structures such as the bladder or vagina with inflammation or the formation of fistulas.
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Hepatology: In sufferers of IBD, the liver may develop active inflammation, which usually subsides with appropriate treatment. Serious disease involving the liver affects only about 5 percent of people with IBD.
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Medical and/or radiation oncology: If IBD patients develop colon cancer, they may be referred for oncology treatment, if needed in addition to surgery.
Strictureplasty
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Multidisciplinary Team Includes the Following Areas of Specialty: Colorectal Surgery: Scott L. Baker, MD, FACS
Gastroenterology and Hepatology:
Steven Condron, MD, MHES, FACP Cristina Hill Jensen, MD Christopher Hurley, MD Larry W. Schafer, MD, FACP Dany Shamoun, MD
General Surgery:
Scott L. Baker, MD, FACS Michael Bauer, MD Wade E. Dosch, MD, FACS David Flanagan, MD Thomas E. Fullerton, MD Michael Person, MD David A. Strand, MD, FACS Bradley C. Thaemert, MD, FACS Donald J. Wingert, MD, FACS
Genetics:
Nicole Mattila, CGC, MS
Hepatology:
Hesham Elgouhari, MD, FACP Mumtaz Niazi, MD
Medical Oncology: David Elson, MD Mark R. Huber, MD Michael McHale, MD Heidi McKean, MD Addison R. Tolentino, MD
Pathology:
Steven P. Olson, MD Bruce R. Prouse, MD Raed A. Sulaiman, MD
Radiation Oncology: Barbara Schlager, MD Kathleen L. Schneekloth, MD James Simon, MD
Radiology:
Sabina Choudhry, MD Brad A. Paulson, MD
Research
(Cancer clinical trials)
Transplant Surgery:
Christopher Auvenshine, DO Tariq N. Khan, MD
Urogynecology:
Matthew A. Barker, MD, FACOG
If you have any questions or would like to make a referral to the Avera Digestive Disease Institute, call (605) 322-7797. 13
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