Inflammatory bowel disease
- Q. Are there any new treatments in Crohn's disease?
Yes. The future is looking good. Two new monoclonals look very good - vedolizumab and ustekinumab. They are available in Australia and are under active consideration in NZ. Go to section on Crohn's / treatment
- Q. Can I get off Prednisone if this has been used for many years for Crohn's or colitis??
This can be a difficult task. The main objective will be to drugs that can replace the effect of steroids. Typically this will be azathioprine or adalimumab. It can be helpful to use Entocort a non-absorbed steroid for a few 6-12 months while slowly reducing Prednisone by 1mg per month. The critical period is reducing from Prednisone 5mg.
- Q. Does stress cause inflammatory bowel disease?
No. IBD (inflammatory bowel disease) is an inflammation of unknown cause but the majority of evidence does not point to stress as a cause.
Occasionally people with ulcerative colitis can link relapses to episodes of stress but mostly over time the general trend seems to be that most relapses occur without any obvious precipitating factor
Some possible triggers are a gastroenteritis infection and recent antbiotic use
- Q. If hospital admission is not required for a flare of colitis what changes to oral treatment will be effective??
Increasing the dose of 5-ASA medication (Pentasa or Asacol) is only of modest benefit.
This change alone is not usually be enough to resolve a relapse.
However any benefit of higher doses is achieved with only minimal risk of side-effects.
The usual maintenance dose can be increased from 4 to 6 tablets daily (for both Pentasa and Asacol). 8 tablets per day occasionally used.
If Salazaopyrin is the current treatment this can be increased from 4 to 6 tablets daily.
Even this dose increase will often result in headaches or gastrointestinal side-effects.
Most people can not tolerate 8 tabs per day because of some side-effects.
Most relapses will require a course of oral Prednisone.
The starting dose should be 40mg daily. Lower doses (10-20mg daily) are often not enough to induce remission. The dose should be decreased only when improvement is seen. This may take 2-3 weeks. Once symptoms have resolved there should then be a gradual reduction in dose. Total duration will usually be 4 - 8 weeks but depends on severity of relapse.
- Q. Is Crohn’s disease a more sever disease than ulcerative colitis??
Yes and No!
No. Both conditions have a highly variable course.
There is more uncertainty and perhaps fear of Crohn’s disease but the majority of patients with Crohn’s disease do achieve an excellent quality of life with a combination of medical and surgical treatment.
Yes. There is the potential for more complicated disease with Crohn’s disease.
The complications are more diverse and severe (compared to ulcerative colitis) because of the nature of the inflammation (intestinal obstruction, perforation and fistulae).
o Diffuse small bowel disease may have prominent abdominal pain, weight loss and nutritional deficiencies.
o Perianal disease may lead to abscess and fistulae leading to troublesome peri-anal pain and discharge. (see Crohn's disease).
- Q. Is proctitis different from colitis?
Proctitis is chronic inflammation (of the ulcerative colitis type) confined to the rectum.
That is, only the last few inches of the bowel are involved. Diarrhoea is generally not the problem. The main symptoms are bleeding, frequency and urgency of bowel motions and a feeling of incomplete emptying.
The treatment should concentrate on medication given through the anus. There are a variety of formulations available. The easiest (and most acceptable) method of delivering drug to the affected area is by suppositories (e.g. Asacol suppositories). Colifoam enemas are also convenient to use (foam in a pressurized container). Many people with proctitis alternate between these two types of medication or, by trial and error, find that one is better for them.
Taking tablets as well as per "rectal treatment" does have an additive benefit.
Usually this means a 5-ASA tablet like Asacol or Pentasa.
- Q. Should surgery for Crohn’s disease be delayed as long as possible??
Many people feel in retrospect that they waited too long before embarking on surgery.
If the symptoms due to a "blockage" then surgery is required - tablets will not work..
Surgery involves a resection of bowel but trying to maintain as much functional bowel as possible. Another option in some patients with short segments of diseased bowel is stricturoplasty. This is a refashioning process without removal of any bowel.
The chance of needing surgery in Crohn’s disease increases with time.
The risk is approximately 25% at 7 years and 50% at 15 years.
A symptomatic recurrence after the first operation occurs in 35 - 50% of patients after 5 years. Overall 20% will require a second operation (long-term follow-up information).
These figures are decreasing as medical treatment improves.
Recurrent disease can be observed well before symptoms arise if there is inspection of the bowel by colonoscopy and this can help plan further treatment with the hope of preventing further surgery.
Stopping smoking is crucial.
- Q. What are the risks of COVID-19 if I have inflammatory bowel disease (IBD) and are currently requiring treatment that is immunosuppressive??
There is no evidence that there is an increased risk of becoming infected with the virus because of your treatment. This includes azathioprine, methotrexate and infliximab / adalimumab. There may be risk of a worse outcome if your general health is poor - usually because of active disease. The biggest risk may be prolonged steroid treatment.
The current advice is to continue all current treatments but isolation precautions should be carried out to a high level. The situation is being actively monitored and advice could change as more information becomes available.
- Q. What drugs for IBD are safe in pregnancy?
What medications can be used during pregnancy?
Giving good advice to a pregnant patient with IBD involves balancing the risk of treatment with the risk of untreated disease. There is a large amount of data to support the continued use of 5-ASA and steroids (if required) during pregnancy. Azathioprine treatment can be continued during pregnancy if required to maintain remission. There is a large collective experience from mothers with renal transplants. Azathioprine does not cause birth defects. There is no increased risk of abortion and no decrease in fertility. There was some concern regarding fathers taking azathioprine. This came from one small study but other data is reassuring. Continuation of medication during pregnancy is usually the safest approach because of the greater risk to the fetus of uncontrolled disease activity.
- Q. What is the appropriate treatment for an acute flare of ulcerative colitis??
The immediate question to be resolved is the need for hospital admission.
This decision depends on severity of the colitis. This can easily be underestimated by both patient and Dr. Specialist assessment may be required.
A severe attack is suggested by the following features;
6 bowel motions /day and needing to get up at night to pass a bowel motion.
Abnormal blood tests.
Any significant abdominal pain or tenderness.
Hospital admission will usually be required with 2 or more of these features.
- Q. What is the role of diet??
The role of diet is surprisingly limited but nutritional deficiencies need to identified and treated. There are usually several factors leading to weight loss and nutritional deficiencies. Inadequate oral intake is often more important than failure of absorption.
Supplemental oral feeding with liquid diet (Ensure, Fortisip) may be helpful, particularly to enhance growth in children.
Some patients feel better with some dietary exclusions. e.g wheat-free or dairy-free diet or exclusion of specific vegetables/fruits - this is a non-specific effect.
An exclusion diet, similar to dietary advice given for irritable bowel, has been advocated by some doctors. For a well-motivated person keen to explore all natural options this has some value and some successes. Some of the benefit is because of an overlap between irritable bowel and inflammatory disease. This overlap is simply because irritable bowel is a common problem.
Irritable bowel syndrome
- Q. Are there good natural treatments for irritable bowel??
Yes, natural treatments will always be the best approach (compared to medication) for a condition that may continue for some time
Probiotics are useful. I recommend Inner Health Plus or IBS Support (Ethical Nutrients).
Aloe vera juice is useful to relieve spasm pains and has a mild laxative effect
If there is constipation then kiwifruit concentrates such as Kiwi Crush may help
The best option is careful dietary exclusion. See page on Diet and IBS
- Q. Do I need to avoid pips, seeds or whole kernels if I have diverticular disease??
NO. There is no evidence that dietary restrictions of any sort will prevent progression of the disease or prevent complications such as infection or bleeding
- Q. Does aloe vera juice have a role in managing irritable bowel syndrome?
This natural product has a long history of use in treating bowel problems. There is some anti-spasmodic effect and a mild laxative effect. This can be useful for some people with IBS
- Q. How useful are breath tests for IBS??
There is some recent interest in breath tests to evaluate IBS. These are breath hydrogen tests after a meal of fructose, lactose and lactulose. Each sugar needs to be tested separately and the test takes 2-3 hours for each sugar. Often just the fructose test is performed. The concept is that response to a FODMAP diet can be predicted by a positive fructose breath test - i.e showing failure of normal absoprtion of fructose (malabsorption). In practice a positive test is very common and has minimal predictive value.
Positive breath tests for lactose may be found in 10-15% of people with IBS and 5% of the general population. Knowledge of a positive test can be helpful although a trial of diary exclusion for a month is perhaps more informative as symptoms from diary products may be due to factors other than the lactose.
Some groups have proposed that bacterial overgrowth in the small bowel causes many of the symptoms of IBS particularly bloating. Tests for this possible abnormality are difficult. A simple test is the lactulose breath test but this is difficult to interpret. There is a relatively high rate of positive tests making it difficult to know if this is a genuine finding. There is an antibiotic called rifaxamin that is claimed to treat this problem. This antibiotic is expensive and has limited availability and is not used in NZ for IBS. There may be some people who will benefit from this treatment if cheaper alternatives are available. it is not clear if repeated courses - perhaps every 3 months - will continue to maintain the improvement in symptoms.
Some tests also check for methane as well as H2 (hydrogen). About 40% of people are methane producers and this will give some extra information. Methane actually slows down the bowel - ? cause or effect. There is debate as to what to do with a positive test (as applies for hydrogen tests)
- Q. Is it safe to use Loperamide long-term for management of diarrhoea?
Yes. This is a very safe and highly effective treatment for diarrhoea but the cause of the diarrhoea should be investigated before starting long term treatment
The commonest indication is for diarrhoea-predominant irritable bowel syndrome where there is urgency of bowel habit and fear of incontinence. One or two capsules of loperamide daily can significantly improve quality of life. Sometimes in IBS there is sensitivity to the action of loperamide and only small doses are required. In this situation the tablet needs to be prescribed so that only half tablet can be taken daily
- Q. What are prebiotics and do they help IBS symptoms??
Prebiotics are currently being promoted for gut health and IBS. They are poorly absorbed carbohyrates - e.g short chains of fructose or resistant starch. They are fermented by colonic bacteria. The breakdown products result in substrate (food) for the colon and also encourage the growth of "good" bacteria such as Lactobacillus.
These beneficial effects have theoretical value but remain unproven in IBS. The major disadvantage is the increase in bloating and flatulence - often troublesome symptoms in IBS