The Medicine Grand Rounders
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The Medicine Grand Rounders
IBD essentials with Dr. Bret Lashner
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In this episode of Medicine Grand Rounders, we're joined by Dr. Bret Lashner, director of the Center for Inflammatory Bowel Disease (IBD), who explores the fundamentals of IBD, including diagnostic nuances and treatment strategies. Moderated by: Anthony Gallo.
CCF IMRP Grand Rounders Podcast Episode 21: Inflammatory Bowel Disease
Dr Brateanu:
Welcome to the Medicine Grand Rounders Podcast, a platform dedicated to exploring key topics in internal medicine. Highly relevant to the medical community. This podcast is made possible through the generous support of a grant from the Cleveland Clinic Education Institute. However, the views and opinions expressed here are those of the speakers and do not necessarily reflect the the official position of the Cleveland Clinic. Each episode brings together world class experts and distinguished physicians from Cleveland Clinic to share their knowledge, experience and perspectives on issues that impact healthcare professionals and patient care. Our discussions aim to promote learning, advance professional development and inspire meaningful conversations with the medical community. Today's episode is hosted by Dr. Nitu Kataria, Internal Medicine Physician at the Cleveland Clinic, and me, Dr. Andrei Brateanu also in Internal medicine. We invite you to join us as we delve into today's thought-provoking topic.
Anthony:
Welcome to the medicine grand Rounders podcast. My name is Anthony Gallo, and our topic today is inflammatory bowel disease. Currently, I am one of the chief residents in the Cleveland Clinic, internal medicine residency program, VA track, VA center of outstanding education. Our clinical expert today is Dr Brett Lashner. Dr Lashner is the former director for the Center of inflammatory bowel disease here at the Cleveland Clinic. Dr Lashner, welcome to the program.
Dr. Lashner:
Thank you, Anthony for having me here. I appreciate the opportunity.
Anthony:
To start off, can you define inflammatory bowel disease, or IBD, as we'll be referring to it?
Dr. Lasher:
Yes, so inflammatory bowel disease, simply put, is an inflammation in the intestine. There are two main types of inflammatory bowel disease, Crohn's disease and ulcerative colitis. These diseases are not limited to the intestine; they affect multiple organs throughout the body.
Anthony:
Thank you. So let's use a fictional case maybe to help improve our learning and enhance the experience. A 25-year-old white male presents to the emergency department with severe right lower quadrant abdominal pain, abdominal bloating and distension. He notes mild intermittent diarrhea for the past eight to 10 months associated with abdominal pain and low-grade fevers to 101 Fahrenheit. During those times, he has asymptomatic periods between these episodes, they range from a few weeks to a few months upon a deeper history taking he reports that in high school, he remembers being diagnosed with some sort of GI condition. However, he has not seen a doctor since moving away for college about seven or eight years ago. So, Dr. Lashner, IBD is on the differential for this patient. Would you be able to give us a diagnostic framework to better approach our care for this patient?
Dr. Lashner:
Yes, thank you, Anthony. First thing you need to do is review the old records, physical examination and look at his testing results from the past. What we're specifically looking for is the type of inflammatory bowel disease, Crohn's or ulcerative colitis, as well as the behavior of inflammatory bowel disease. For Crohn's disease, the three behaviors are inflammatory, where people present with diarrhea and abdominal pain, obstructive, where people present with diarrhea and fistulizing disease, where people present with abnormal communications between different pieces of bowel.
Anthony:
Unfortunately, let's say that many of those records have been lost to time, or we're not able to get them, as the patient in front of us is here. Are there any tests we should order? Whether lab tests? Are there any physical exam pearls that you could think of that could help better guide our management?
Dr. Lashner:
A full history is very important, as well as a complete physical exam. You're specifically looking for inflammatory masses in examination of the abdomen. You're looking for perianal disease for Crohn's disease. There are lots of clues to the diagnosis that you can get from a history and physical. There are some diagnostic tests that you can order, but they may take some time to come back.
Anthony:
Can you give us some insight what diagnostic tests? Certainly, I think a CBC or a metabolic panel would be appropriate. Any other ones that we should think of?
Dr. Lashner:
Yes, routine labs include a stool exam for infection or blood and a CT Enterography, which will outline the degree of inflammation that might be in the bowel. It'll outline any fistulas or strictures that might be present.
Anthony:
In terms of some of these metabolic testings for a patient who is treatment naive, are there any other special considerations we should take before proceeding?
Dr. Lashner:
Well, I think it's important to get the proper diagnosis, to look at the extent and severity of disease, to take, like I said, a complete history and physical examination, diagnostic testing, and often the best initial therapy will be determined by all of that.
Anthony:
Let's say we perform a physical exam on this patient, and we notice an area of fluctuance near his anus. This exam was chaperoned appropriately, but we do not notice a draining opening. We took your advice and ordered CT Enterography. Ultimately, it demonstrated an area of thickening and narrowing near his ileum. There also appears to be a sinus tract extending from the ileum to near the anal canal. Does this affect your diagnosis and steps in management for him?
Dr. Lashner:
Yes, it does. So, I believe the CT Enterography confirms that he has Crohn's disease. The ileal thickening is seen very often in people with Crohn disease, and the fistula is a difficult complication that has to be dealt with. There's also probably an abscess in the area, meaning that any anti-inflammatory or immunosuppressive therapy could make that abscess worse. So as part of the initial treatment that has to be dealt with.
Anthony:
In terms of endoscopic evaluation, I know oftentimes some patients with Crohn's disease might have either an EGD, an upper endoscopy, or colonoscopy. If we were going to have that performed, are there any things that we should be looking for on endoscopy or on the endoscopy report? Likewise, if biopsies were taken during either of those procedures, are there any key pathology findings that might cue us into thinking that Crohn's is the appropriate diagnosis for this patient?
Dr. Lashner:
Yes, there are, but I would not do a routine upper endoscopy or colonoscopy yet on this patient. In those with active Crohn's disease, biopsies might show granulomas, inflammation, deep inflammation or transmural inflammation. What I would do for this patient is ask our colorectal surgeons to do an endoscopy under anesthesia, take them to the operating room, drain this abscess and see if a fistula is present and which needs to be controlled before you initiate any medical therapy.
Anthony:
Now let's say we see this patient in outpatient clinic. This patient ultimately their hospitalization resolves without issue. Colorectal surgery is not indicated. They see this patient and they do not feel surgery is indicated. He's treated with long term antibiotics and is set to follow up with GI in the coming months. You are now seeing him in clinic. Are there any special considerations that you were thinking about when approaching this patient, whether or not it's time to start any immunosuppressive therapies, any immunomodulating therapies? If you can give us some insight that would be appreciated.
Dr. Lashner:
Thank you. This patient should be started on anti-inflammatory therapies. Before 1998 our options were very limited. We didn't have anything more than steroids, mesalamine or azathioprine. Now we have a whole range of therapies, like biologics. So once this patient's abscess is drained, he needs anti-inflammatory therapies. I might give him steroids to cool things down but get him set up for biologic therapy when it's approved by his insurance.
Anthony:
In terms of biologic therapies, because this is a hot topic in the field. It seems as though every week or every year there's a new treatment or treatment option. Are there any key ones that we should be thinking about for a patient with Crohn's disease?
Dr. Lashner:
Yes, pretty much all of the biologic therapies that are approved for inflammatory bowel disease are approved for Crohn's disease. The prices differ and insurance companies sometimes dictate which ones we can use. For the most part, anti-tumor necrosis factor agents are used first and when that doesn't work, we can go to other biologic agents like IL-23 blockers, JAK inhibitors, or others that have a different mechanism of action and might pick up the slack for when people don't fully respond to the anti TNF agents.
Anthony:
Thank you, Dr Lashner, any other key points or takeaways for considerations when treating Crohn's disease?
Dr. Lashner:
Yes, it’s a good idea to get the colorectal surgeon involved early. Surgery and medicine people need to work together to give the best therapy possible. Almost certainly this patient will need the endoscopy under anesthesia and possibly an ileocolic resection of the thickened ileum, if it doesn't respond to medical therapy. But it's nice to have a team of experts working together to give people the best therapy they can.
Anthony:
I think that's an excellent insight, Dr Lashner. Oftentimes, when I'm learning in the GI clinics, a lot of these patients are seeing a multidisciplinary approach, between seeing the nutritionist, between seeing the psychologist, if necessary, the physician or other healthcare provider teams. I think these folks have often tend to do better when there's a multimodal approach in helping to manage their disease. Funny enough, Dr Lashner, as we were finishing this case, I received another page about a different fictional patient who's in the emergency department.
This second patient: she's a 30-year-old woman who presented to the ED with complaints of mild abdominal discomfort and cramping over the last six weeks. It's also associated with diarrhea; however, it's bloody, mucous-y diarrhea. She reports that it's nocturnal or postprandial. She's not on her menstrual period presently. The emergency department performed a physical exam; her abdomen was non-tender without guarding. They also performed a rectal exam, taking your advice, and it demonstrated bright red blood grossly on her glove. They've also ordered a bunch of lab tests. They've sent many stool studies. Her CBC is unremarkable. Her C reactive protein, her CRP, is 12.4, this is significantly above the normal reference limit. Her ESR is 50. This is about two and a half times the upper limit of normal. And she has a fecal lactoferrin of 15, about double the limit of normal. So, Dr Lashner, what are you thinking about as far as your differential for this?
Dr. Lashner:
So, this is a patient with colitis. It could be ulcerative colitis. It could be an infectious colitis. So, part of the history should include travel, should include antibiotic use, and sick contacts and other things that might help you with the diagnosis. Also, both Ulcerative Colitis and Crohn's disease are not just limited to the GI tract. They are systemic diseases that have lots of extra-intestinal manifestations that involve the liver, the joints, the eyes, the skin, and that should be part of the initial history to see if there are any of those that would give you clues to the proper diagnosis.
Anthony:
Thank you. So, this patient was admitted to the hospital, onto the primary Medicine Service, in conjunction with our colorectal colleagues, she ended up having sigmoidoscopy performed. Biopsies were taken during that time, and the biopsies revealed continuous inflammation from the rectum and moving proximally upwards. Dr Lashner, does this confirm that this patient has ulcerative colitis? And if so, are there any special considerations that we should even look deeper into the report about?
Dr. Lashner:
It looks like the patient does have ulcerative colitis, but still, I cannot rule out an infectious colitis, and you cannot even rule out Crohn's Colitis. Most times, Crohn's Colitis does not affect the rectum. There's rectal sparing, but not all times, there are biopsies that are necessary, and there are clues on the biopsies to help you distinguish Crohn's disease. Patients have granulomas, skip lesions, discontinuous inflammation. Ulcerative Colitis have more superficial inflammation, no granulomas and a continuous inflammation from the rectum to points proximally.
Anthony:
Gotcha. In terms of my readings into this, I've learned of the mayo scoring system as maybe a way of helping to categorize the severity of ulcerative colitis. Are you able to give our listeners some insight into how the mayo score can help guide our treatment approach and our prognosis for this patient?
Dr. Lashner:
Yes, the mayo score looks at all the regions of the colon and grades them to mild, moderate and severe, add them up, and you have the mayo score. And yes, the high Mayo scores mean you got to treat the patients right away, possibly with steroids to sort of cool them off before you talk about long term therapy. But that is a universal score that is very useful to the clinician.
Anthony:
Thank you. You mentioned some treatment options. So steroids certainly could be on the table for short term discussion. Are there any considerations for treatment, both in the short term first and then possibly in the long term?
Dr. Lashner:
Yes, so short term, yes, is steroids. Long and short term are the mesalamine products. The products that we've had since the 1940s, 5 amino salicylic acid products. Many times, that will help with the inflammation, could be long term. So, a lot of advantages there, and even before they leave the hospital, they may be getting some biologic therapy to induce a rapid reduction in their inflammation.
Anthony:
Are there any special considerations for biologics? Biologics that have been demonstrated to work better for patients with ulcerative colitis?
Dr. Lashner:
Yes, all the anti TNF agents prove to be effective in ulcerative colitis. There are some the Jak inhibitors. One specific called tofacitinib, is also approved just for ulcerative colitis. There are options that go beyond those even, but those are the big ones.
Anthony:
In terms of surgical planning, I know that having a multidisciplinary team having colorectal surgery on board early in the course is better for patients. Are there any specific things that we should be discussing with our colorectal colleagues, from your experience, that might help guide when surgery is favored compared to when medical management is preferred?
Dr. Lashner:
Right, so there are some complications for ulcerative colitis that will require surgery sooner than later. The big one is toxic megacolon, when the colon dilates and basically cannot function anymore, there's no hope to treat it. Those people will need surgery right away to save their lives. So, it's always good to have a surgeon on board, not to be surprised, just to see if their services will be needed soon.
Anthony:
You mentioned earlier in the podcast about maybe more rare forms of colitis, Crohn's Colitis, indeterminate colitis. While these are more rare, are there any special considerations or clues that we should be thinking about when addressing a patient to see if they don't necessarily fit into the UC mold?
Dr. Lashner:
Correct, there's about 10% of all inflammatory bowel disease patients that are called indeterminate. We can't distinguish between Ulcerative Colitis and Crohn's disease. There's some epidemiologic parts of the history that may be of interest. For example, Crohn's disease patients tend to be smokers, and ulcerative colitis tend to be non-smokers. People who live in the northern tier of states or northern parts of Europe have inflammatory bowel disease more often than people in the more southern tier of states or Europe. A lot of the epidemiologic features we've learned over the years can be used to help to confirm the diagnosis.
Anthony:
Since a portion of our audience are primary care providers, residents on outpatient rotations, are there any special tips or considerations on things that we should be thinking about, tests that we should be ordering or following up on for patients who have IBD?
Dr. Lashner:
It's always good to do a stool culture for enteric pathogens and C difficile when they have diarrhea. For people with ulcerative colitis and some Crohn's disease patients, a colonoscopy with extensive biopsies is highly reasonable and helpful. A CT Enterography also can help look at the extent and severity of disease, as well as the complications patients might have, but get your gastroenterologist involved early to initiate therapy as soon as possible, so that the patient has the best chance of recovery.
Anthony:
In particular, cancer screening within the IBD population is an important consideration for primary care providers. Are there any special things for us to consider, any special cancers for us to be on the lookout for?
Dr. Lashner:
Well, the cancer we're talking about is colorectal cancer, mostly in ulcerative colitis patients, but also seen in Crohn's Colitis patients. For non-IBD patients, we start colorectal cancer screening at age 45 but for colitis patients, we start colorectal cancer screening much earlier, usually about five years after disease onset, and we do it every three years to look for the rapid changes that may occur and lead to cancer. The premalignant lesion we're looking for is called dysplasia, which can be categorized as low grade or high grade dysplasia.
Anthony:
In terms of other general health measures, certainly as a primary care provider, vaccinations are hot topic, and something, often, my patients will come to me wanting more information about are there any special considerations for vaccinations in immunosuppressed populations, especially?
Dr. Lashner:
Yes, people who are on these biologics agents are immunosuppressed and will have to have vaccinations offered to them. In our IBD home where you said, we have nutritionists and psychologists, we also have a pharmacist who reviews that, as well as the medicines they're on, and helps them with injecting themselves or just understanding how best to be safe in inflammatory bowel disease.
Anthony:
In terms of routine imaging follow up, I know that patients with IBD are more likely to develop osteoporosis. Are there any other special imaging considerations, other than starting DEXA screening early in these people?
Dr. Lashner:
Not that I'm aware of. You also have to be careful about primary sclerosing cholangitis. If there are abnormal liver function tests, it would be good to get a fiber scan to look for the degree of fibrosis that might be in the liver and refer them to liver if there is.
Anthony:
Can you give our listeners, especially for those in training, those in primary care, some key summary take home points from today's episode.
Dr. Lashner:
Inflammatory Bowel Disease is a systemic disease. It's not just the bowel that's affected, i's lots of other organs. The initial onset is between ages 10 and 19 years old, (it) is the disease of teenagers and lasts for life. You should think about this disease when people come in with symptoms that suggest it could be it, and make the diagnosis early, so that they have the best chance of getting the best therapy and having less disease activity during their lifetime.
Anthony:
On behalf of the team, thank you to our special guest, Dr. Lashner for joining us today. Special thank you to Dr. Arjun Chatterjee and Dr. Katie Faloon for helping to edit the script for this episode.
Dr. Kataria:
To our listeners, thank you for joining us on this deep dive into this important topic. We hope you found this episode both educational and engaging. On behalf of the team, thank you to our special guests who joined us today. Thank you also to the Cleveland Clinic Education Institute for the educational support of this project. Until next time, please enjoy this and future podcasts from the Cleveland Clinic Medicine Grand Rounders.