Hello and welcome all to a new episode of the PACE Hospitals podcast. Today in this session we are here to discuss about the topic inflammatory bowel disease or IBD, it affects lots of people worldwide, yet it remains a widely misunderstood condition.
Joining us today, Dr. Govind Verma, Interventional Gastroentrologist, Transplant Hepatologist and Endosonologist having expertise in treating and managing inflammatory bowel disease. Today he would be compassionately helping to break down barriers, challenge misconceptions and foster a supportive space for those who are affected by IBD.
Dr. Govind Verma, thank you for joining us at PACE Hospitals, Hitech City.
Thank you for inviting me today. I will be discussing the most misunderstood condition inflammatory bowel disease which can lead to severe complications of the GI tract if not diagnosed and managed at right time.
Dr. Govind Verma, thank you for joining us. Let's start with the basics.
What is inflammatory bowel disease and its types?
So broadly as we know inflammatory bowel disease is divided into two types. One is ulcerative colitis second is Crohn's disease.
The big difference between the ulcerative colitis and the Crohn's disease is the involvement of the gut, so as far as ulcerative colitis is concerned it involves only colonic mucosa whereas Crohn's disease can involve any part of the gut from mouth to anus.
The other difference which between the ulcerative colitis and Crohn's disease is the extent of involvement. When it is Crohn's disease it involves the entire layers of the gut, so it is star's mural involvement we call and involvement is usually patchy or we call it as skip lesions whereas in ulcerative colitis it is continuous involvement. So, based on the extent of the disease the patient can have different presentations, severity and complications. Now, many a many times the people ask us sir why I have I am suffering from ulcerative why I am suffering from Crohn's disease.
What are the reasons for which the patients acquire this disease?
Most commonly there is a genetic predisposition. So, one of the strongest reason and documented is any genetic predisposition those people who are carrying the abnormal genes they are at risk of developing inflammatory bowel disease which is ulcerative or Crohn's disease.
The other mechanism which is proposed is immune dysregulation to the basically intestinal micro flora. Your own immunity reacts against your intestine or other organs and they create inflammatory response to this antigen and leading to immune dysregulation kind of presentation. So, if I summarize the etiology or the reasons for somebody to acquire inflammatory bowel disease one genetic predisposition second immune dysregulation to the intestinal microflora and third sometimes it is postulated that diet has a role, but it is not the reason it can be a factor for precipitation or you know it can trigger the recurrence of the disease.
What are the common symptoms of IBD and how do they differ between Crohn's disease and ulcerative colitis?
So, overall if you try to look at the different symptoms with which the patient come there are intestinal presentations there are extraintestinal presentation.
The patients who have inflammatory bowel disease if you split into two-one is ulcerative colitis the presentation is usually increased frequency of stool 6 to 8 times per day with blood or with mucus and pus, abdominal pain sometimes this patient can have a weakness, fatigue and then can have a weight loss.
Some patients can present with bloody diarrhoea and the patients who have a Crohn's disease they can present with little different symptoms like they can have abdominal pain as presentation symptom, distention of abdomen, night sweats, fever again increased frequency of loose tools, but without blood most of the times.
The patients who are having Crohn's disease they can present with a complication as I mentioned earlier which are fistula formation which are obstruction and sometimes they can present because of the stricture obstruction the patient can have omitting and then distention of abdomen.
Whereas the inflammatory bowel disease not only involves the intestine, it can involves other organ like liver so, they can have a primary sclerosis cholangitis so, they can also have hepatitis, they can also develop arthritis, eye infection or eye involvement in the form of Uveitis, episcleritis and joint involvement in the form of association with the ankylosing spondylitis, HLA-B27 positivity.
So, a patient who has inflammatory bowel disease can involve intestine, can involve other organs like extraintestinal organs like bones, joints, eye, liver and sometimes pancreas. So, a patient presented to you in the OPD can be because of any of these, they can have a fistula which can be perianal fistula, fistula-in-ano present to a doctor with symptoms of discharge perianal area, pain in perianal area or blood and mucus in that area and may not have any other symptoms for that matter. So, patient who has inflammatory bowel disease can present to a doctor with intestinal complaint, with extraintestinal complaints or complications of the existing inflammatory bowel disease which can be catastrophic sometimes.
How is IBD diagnosed and what diagnostic tools or tests are commonly used?
Now, coming to the diagnosis there are tools apart from the blood investigation which we do like complete blood picture, renal profile, liver profile and stool examination, feacal calprotectin which is a marker released by the leukocyte and we can do this test in the stool which is very specific and very sensitive for diagnosing inflammatory bowel disease and can also rule out irritable bowel syndrome.
So, feacal calprotectin more than 215 in a new case is almost significant and associated with the inflammatory bowel disease. It is not only inflammatory bowel disease in feacal calprotectin can also be elevated in other disorders like malignancy and tuberculosis, but the level of feacal calprotectin rise is more inflammatory bowel disease as compared to non -inflammatory bowel disease whereas in irritable bowel syndrome it is usually less than 250, usually it is in the range of 50 to 100.
So, very important marker faecal calprotectin. The other test which we do is in the blood test is seriacto protein we also do ESR to see elevated if it is elevated again, suggest a chronic disease. Apart from this what else we can do is P ANCA and ASCA because these are the blood test which gives you either it is ulcerative colitis or a Crohn's disease. Patient can have a co -existent other disorders like HLA-B27 association with inflammatory bowel are well known. We can also do a diagnostic test which is like colonoscopy most important gold standard test for diagnostic inflammatory bowel disease especially in ulcerative colitis.
In Crohn's disease we may have to do more test like endoscopy for involvement of food pipe stomach or a duodenum. Because as I mentioned earlier Crohn's disease can involve multiple places it can involve large bowel can involve small bowel in 30 -30 percent of the cases can have a mixed picture it can involve in some part of the stomach and then can present with the nodule and pain in abdomen.
Apart from this the other test which can be done is that we can take biopsies. So what we do essentially in colonoscopy is we use a flexible tube we pass it through the anal canal under sedation and we examine entire large intestine which involves rectum, sigmoid, descending colon, transverse colon, ascending colon and cecum and we enter into the small intestine called terminal ileum and when we examine all these areas for the features of inflammatory bowel disease which can show ulceration, which shows friability means on just touching also the patient may have bleeding there, then in that case if you find frank ulceration which are continuous the possibility of ulcerative is high.
But if the ulcerations are patchy then the possibility of Crohn's is high. Whatever the clinical and colonoscopy picture may be we take multiple biopsies to diagnose whether there is ulcerative colitis or Crohn's disease based on which we then decide further line of treatment because the treatment of ulcerative and Crohn's disease is completely different.
What are the risk factors that could aggravate the symptoms of inflammatory bowel disease and its reoccurrence?
There are few factors which I would like to mention here in the etiology of inflammatory bowel disease which actually aggravate the inflammatory bowel disease recurrence.
One of them is actually you know stress; second factor is your food or dietary habits. Food which is more chili or spicy, food which is fermented, food which is baked items are the people are at risk of developing the inflammatory bowel disease recurrence.
Patients who are taking painkillers for variety of reason can have a recurrence of inflammatory bowel disease. Those patients who are smokers can have a high risk of Crohn's disease. So, there is an association with the stress, with the painkiller, with the infection, a simple infection whether it is a bacterial or viral any infection of the gut can precipitate and can aggravate the patient from a silent ulcerative colitis or Crohn's disease to present clinically.
So, we see many patients who come to us they say that sir I was alright till this time and I had a loose motion for 6 days and along with the fever followed by that I have developed after 2 to 3 weeks blood in the stool.
So, what does it signifies that if the patient may be having a baseline ulcerative colitis or Crohn's disease which was silent and then after the infection the patient got a relapse of the disease and the patient presented with the symptoms which are classical of inflammatory bowel disease.
What are the available treatment options for managing IBD symptoms?
So, there are two terminologies which medical gastroenterologist or doctor use when they treat these patients one is the emission and other is the relapse. Now what do you mean by remission is that the patient does not have any active symptoms and also has control of the disease endoscopically, clinically, histopathologically on biopsy and biochemically.
So we call it as complete remission. So whenever we treat the patient, we focus on complete remission of the patient means complete disappearance of the disease from the patient. So that is only achieved when we prove all these five parameters.
One is a clinical remission when the patient does not have symptoms. Second is a biochemical remission where the patient laboratory value improves, stool examination, feacal call protecting improves. Third is that patient’s colonoscopy finding shows a disappearance of ulcerations and other abnormal finding. Fourth is we take the biopsies of the patient and they also do not show the inflammatory cells inside and if these all are achieved then we call it as a patient is now having complete remission.
But if you only have a clinical symptoms, disappearance and other parameters are still not recovered then they have a potential to have a recurrence. Whereas when we call relapse, we call relapse to a terminology where patient who is already under medication and control disease has again developed the symptoms which are new onset of symptoms which are I mentioned earlier like blood in the stool, increased frequency of stool, pain in abdomen and all those.
So reappearance of the same symptoms after complete remission is called as relapse. Now the treatment part when you talk about the treatment part when it comes to ulcerative colitis or Crohn's disease the treatment is lifelong this is one. Two, apart from the dietary factors which we discussed that we usually ask patients to avoid milk because most of the patients have lactose intolerance. So we tell them do not take milk because that will confuse the doctor because of milk intolerance there is an increased frequency of stool the disease is recurring or the disease is recurring.
So, the other factor which we other thing which we take tail in diet is avoid chili spicy food because that increases the intestinal motility and again can cause reappearance of symptoms. As far as the medications are concerned, we give anti -inflammatory medications like aminosalicylic acid the most common we use is mesacol, pentacol.
These are all similar products which work on the large and small intestine specifically and helps in maintaining the remission. But as far as remission induction is concerned, we use steroids, we use immunomodulators like azothioprene, methotrexate and sometimes we may have to use biologicals like influximab and all.
When it comes to Crohn's disease, the treatment modality which we treat actually is that we usually give heat hard and then taper the dosage is what our regimen nowadays. Previously, we used to give amino salicylate, steroid and immunomodulators for Crohn's disease patient and then we used to start biologicals.
But with the recent literature and with the recent advances, we realized that when the patient has small bowel disease in Indian population, when the patient has fistula disease, when the patient has refractory response to the previous treatment, then at that time we start the biologicals which is influximab or adelizumab or other biological medications which we give every two weekly and then they have to take it for two years or lifelong whichever is earlier possible based on the patient's follow.
The patients do come to us with agony and pain and kind of depressive thoughts because this inflammatory bowel disease is actually a crippling disease when it comes to the symptoms and the suffering of a patient.
But nevertheless, now with the advent of science, there are treatments which are available which works at the molecular level and the patients are definitely getting benefited as the time goes on.
Is there any role for surgery in this kind of patients?
Yes, there is a role for patients. There is role of surgery in few patients, select patients for ulcerative and Crohn's disease. If the ulcerative colitis patient is not responding to any of the above treatment or they come with the complications like fulminant colitis not responding to the immunomodulators or the biologicals, in those subgroup of patients we can do total practical ectomy along with iloenol pouch anastomosis.
But those patients who have Crohn's disease, we treat based on their complications. If they come, if they have a stricture disease and they come with the obstruction, then we do a selective segmented resection an anastomosis.
If they have a disease which is aggressive and leading to other complication, we can do the colectomy and all. So, it all depends if the patient present with fistula anano, then we do fistula tome with satan placement.
So, it all depends what kind of disease patient has and the presentation we decide the mode of treatment. Nevertheless, this disease is to be fought back by means of the changes in the diet, decreasing the stress, taking regular medications and follow up with the doctor and most important is there are few patients, select patients who actually can get benefited by alternative relaxing techniques which are yoga or having diet which is less fermented and avoidance of self -rescription is also important fact to be remembered in patients with inflammatory bowel disease. Thank you.
Thank you Dr. Govind Verma for sharing crucial information related to topic inflammatory bowel disease to our listeners.
I hope this information helps listener for a better decision making in getting early diagnosis, cleaning and treatment at the right time.
If any of you have any further questions regarding IBD please don’t hesitate to consult a gastroenterologist and remember you are not alone, IBD is common, but it can be treatable. We will be back soon with another episode on PACE Hospitals podcast. Stay strong, stay informed, and remember that your health is a priority. Until then take care, Thank you.
