Crohn’s Disease: Treatment of Crohn’s Disease
Guest: Dr. Mark DeLegge – Gastroenterology and Hepatology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am talking today with Dr. Mark DeLegge who is the director of the MUSC Digestive Disease Center. Dr. DeLegge, let’s talk now about the treatment of Crohn’s disease. I would imagine there are a number of approaches. What are some of the main approaches?
Dr. Mark DeLegge: There are a lot of approaches. They would include diet changes, as one, lifestyle changes, medications and then, ultimately, in some patients, not the majority, but a small number, actual surgery, to remove a piece of bowel or small intestine that seems to be really giving them a problem.
Dr. Linda Austin: So, let’s take those one by one and start with diet. What are some of the dietary recommendations you make to Crohn’s patients?
Dr. Mark DeLegge: Yes, that is a very interesting question. The reason I say that is because when we look at the data with diet and what we call exclusion diets, meaning this week you stop eating turkey and next week you stop eating mashed potatoes, and then the following week you stop eating green leafy vegetables, to see if you can locate what it is that seems to make you worse or get your Crohn’s disease unhappy. We have not been able to come up with a specific food group. In Europe, what they will do is, especially with children, when they get Crohn’s disease, they will put them on a specialized tube feeding, or commercial brand tube feeding. Sometimes they will drink, or sometimes they will actually feed through a tube. Essentially, they have the opportunity to rest their intestines from regular food while they are getting this specialized concoction. By this method, they have had some good results, in Europe.
Dr. Linda Austin: Do you anticipate that we might start doing that here?
Dr. Mark DeLegge: I do not. The reason I say that is, the studies that have been done here in the U.S. have not been able to show those same good results. So, when you start to get into the dietary management of Crohn’s disease, what I can tell you is that I cannot sit here today and say to you there is a definite dietary change which is going to make your Crohn’s disease better. What I can say is there are probably food groups that you know, when you eat them, make your symptoms worse and you should avoid those.
Dr. Linda Austin: And, so, it starts with self-observation and monitoring, I would imagine?
Dr. Mark DeLegge: Absolutely.
Dr. Linda Austin: And, maybe, even reading labels to see what hidden ingredients there might be that could set if off. Do you ever see cases where dietary changes alone can have a dramatic impact?
Dr. Mark DeLegge: I do. It is unusual, but I do. Sometimes we will see this specifically in patients who are lactose intolerant on top of their Crohn’s disease. Lactose intolerant means they are intolerant to sugar that is in milk or milk products. Simply by changing that, some of their loose stools, abdominal swelling and abdominal pain will get better. Some people, too, who are on a high fiber diet, I have seen that be a problem with regards to bulky food and stool going through the colon. Somebody who has a swollen and ulcer-like colon, meaning that the inside is beaten up, I often tell patients that it looks like somebody took a baseball bat to the inside of the colon; it is really red and beefy, and swollen. You can imagine high fiber foods going through that may cause some difficulties. Sometimes putting patients on a low fiber diet, which normally we would not recommend, can be helpful.
Dr. Linda Austin: Now, the second thing you mentioned was lifestyle changes. What sorts of lifestyle changes?
Dr. Mark DeLegge: We generally recommend a couple of things. One is, we know that if patients get off their normal sleep-wake cycle, perhaps they are studying for exams or they work a swing shift or, for whatever reason, they are stressed and cannot sleep, that seems to make their symptoms worse. We also know that stress in general, where you are having mental stress over something, can also make symptoms worse. So, when we talk about lifestyle changes, we generally talk about trying to make sure that you are in a regimented lifestyle, you eat three meals a day, you get enough sleep and you drink plenty of fluids. We also try to minimize the stress that is out there, or perhaps even get you to a psychologist, or psychiatrist, to help you deal with some of those issues.
Dr. Linda Austin: I have become more and more convinced that just those simple basics of regular sleep, the kinds of things our mothers taught us to do, three good meals, exercise, are so essential for good health. Now, the third approach that you mentioned is medications. Who would be a candidate for medications and which ones, which meds do you use?
Dr. Mark DeLegge: Sure. If I had somebody who we had change their diet and spoken to about stress and lifestyle and they continued to have symptoms, meaning abdominal pain, diarrhea, bleeding, fever, or maybe abdominal pain, to the point where they had to be admitted to the hospital, this is somebody who is going to need some medication. Another group would be in pediatrics. If you let Crohn’s disease go on for awhile in children with Crohn’s disease of the small intestine, they will have difficulties with food absorption. So, in fact, they will have lots of diarrhea. In addition to that, they can have retardation of their growth, they can stunt their growth. If it is in phase where they should be growing and they are not getting enough nutrients, those are patients that I would begin medications on.
Dr. Linda Austin: And, finally, surgery. That, I would imagine, is last a resort. Who needs surgery for Crohn’s?
Dr. Mark DeLegge: Surgery for Crohn’s disease is in a very small number of patients. It usually is for one of three reasons. One would be blockage. What I mean by that is the lining of your small intestine or colon becomes so swollen from the Crohn’s disease that it actually starts to form scar tissue and then we have a problem with food or stool moving through to the rectum. So, patients become obstructed. Those patients might need surgery.
One of the symptoms that I did not talk about, symptoms patients develop originally, is something called a fistula. A fistula is an opening between the bowel and some other organ, like the skin. So, you can actually have a hole that develops between your large intestine and your skin surface, where small amounts of stool will actually leak out onto your skin surface. That can happen from Crohn’s disease. Those patients can have surgery to remove a fistula and remove the most diseased portion of the bowel. Lastly, if you had somebody who, no matter what medications you gave them, their Crohn’s disease was so bad that they continued to have to be hospitalized with abdominal pain, fever, nausea and vomiting, you would try to isolate the Crohn’s disease to either the small intestine, or perhaps the large intestine, and remove as much of the Crohn’s disease infected bowel as you could.
Dr. Linda Austin: I am sure there are some folk listening to this who have just gotten a diagnosis of Crohn’s disease and want to know what the prognosis is. Can you try to address that? I am sure that is a complex question. It must be different for kids and grown ups. But, how do you talk to patients about prognosis?
Dr. Mark DeLegge: I would say, today, the prognosis for Crohn’s disease compared to even 10 years ago is much better. We have a new class of medications which actually attack the immune system, or, not really attack it but seem to modulate or calm down the immune system. We talked a little bit about how the immune system can be revved up and be a cause of Crohn’s disease. Well, there is this whole new class of medications, some of them given intravenously, some of them actually given in a shot underneath your skin, which can modulate or calm down your immune system. This has really had a tremendous impact on the disease. So, today, I would say, compared to even 10 years ago, the number of patients having to have surgery is much smaller than it used to be.
Dr. Linda Austin: Could you hazard a guess as to what percentage go on to surgery?
Dr. Mark DeLegge: I would say no more than three to four percent.
Dr. Linda Austin: How about pediatric Crohn’s, what kind of prognosis do those kids have?
Dr. Mark DeLegge: Now, with the new agents that we have talked about, just about as good as the adults. If the disease is caught early enough, depending upon where it is, the small intestine the colon, or both, there are medications that we can prescribe that are very effective for controlling the disease. My thought here is, say you are diagnosed at 10, once you get on the right medical regimen, you can continue on that medical regimen and have a normal life.
Dr. Linda Austin: Can it go away altogether?
Dr. Mark DeLegge: There are people who you will diagnose with Crohn’s disease, you will actually see it with your eye and biopsy it. Then, they will come back two or three years later and you will repeat, say, a colonoscopy, where you look in the colon, and everything has disappeared. The wonder there is if I have the right diagnosis to start with or was this, in fact, Crohn’s disease that went away. We do think there are patients who do get it and do lose it, although that is not the most common occurrence of Crohn’s disease.
Dr. Linda Austin: Dr. Mark DeLegge, thank you so much for talking with us today.
Dr. Mark DeLegge: You are welcome.
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