Question:
My son had resection surgery a month ago for Crohn's disease. He is currently taking 6MP. His doctor will then scope him in two months to see if the disease shows any signs of returning. Have you seen success and remission on 6MP alone? If he has to return to Remicade it will after a two year lapse. What are the chances he will develop antibodies to it?

Dr. Rosh:

6MP has been shown to have efficacy in preventing post-operative recurrence of Crohn’s disease and the need for another resection. Therefore, your son’s physician has developed a good plan to keep him well after surgery. Metronidazole is an antibiotic and a three month course of metronidazole after surgery has also been shown to be helpful and can also be considered for use in this setting.

Repeating the colonoscopy to see if there is a recurrence is also reasonable as long as there is a plan to be proactive and change therapy based upon the findings. If such a plan would be to move to biologic therapy, you are correct, it is highly likely that after a two year hiatus, there would be immunity (allergy) against Remicade precluding its use. Continuous use of 6MP may help prevent this from occurring, but it is still likely. If that is the case, there are now two other FDA approved agents (adalimumab = Humira and certolizumab = Cimzia) which work via the same mechanism and, since they are different medications, can be used in patients who have developed allergy against Remicade (infliximab).

Question:
My daughter is 14 years old. She was diagnosed when she was 2 years old with ulcerative colitis. She has been on all kinds of medications over the years. Her flare-ups have never been that severe until recently. After a severe flare-up and hospitalization in 2006 she was put on Imuran along with Dipentum and prednisone, Now she is on Remicade and the infusions are 4 weeks apart because they don't seem to work for 6 weeks. What other medications would you suggest that I ask her GI doctor about next?

Dr. Rosh:
If your daughter responded well at one point to Remicade (infliximab) and now is losing response to the agent, there are two other available agents (adalimumab = Humira and certolizumab = Cimzia) which work via the same mechanism. Since these two are different medications, they can be used in patients who have developed allergy against Remicade (infliximab). Neither is officially approved in pediatric patients (less than 18 years of age) nor for ulcerative colitis so your insurance company may deem their use “experimental” making it difficult to obtain payment in this setting. It sometimes requires a phone call by your physician to the insurance company’s medical director to obtain special approval.

If your child is still on Dipentum (olsalazine), it may be worth seeing what happens when you stop the agent. A very small percentage of adolescents (maybe about 5%) can develop intolerance to that class of medications leading to symptoms that will simulate their colitis. I should emphasize that this is rare, but worth a try before considering other options.

It would be helpful to know what happens when your daughter “breaks through” her Remicade therapy. Assuming that this is a mild degree of symptoms, medicated enemas and/or suppositories could be very helpful. If this is severe bloody diarrhea and leads to problems such as the need for blood transfusions or a significant impairment in her quality of life, you would be left to consider truly experimental medical therapies, or surgery. Bear in mind that ulcerative colitis is a condition that can be treated both medically and surgically and that 25% of pediatric and adolescent patients with ulcerative colitis do ultimately have their colon surgically removed (colectomy). The surgical approach to this disease has undergone marked advancement with interior hook-ups allowing patients to live without a permanent stoma (“bag”).

Question:
My 11 year old daughter has indeterminate colitis. She has been on azathiaprine for the last 7 months with no effect. We started Pentasa 2 months ago. She is finally starting to get better. Can it actually take azathiaprine 7 months to take effect? Or is it the Pentasa? At this point I can't tell. Can it take Pentasa 2 months to take effect? Her dose is 175mg of azathioprine and 3 gm of Pentasa.

Dr. Rosh:
Yes, to all of your questions! It can take a few months to see full effect from immunomodulators such as azathioprine. Pentasa (mesalamine) does have a direct anti-inflammatory effect on the bowel. Additionally, mesalamine containing medications have been shown to elevate blood levels of the active breakdown products from azathioprine. Therefore, the addition of Pentasa may have helped your daughter in more than one way--by acting as an anti-inflammatory and by increasing the effectiveness of the 6MP.

Question:
My son was recently diagnosed with ulcerative colitis. I am confused because he is not losing weight, and has no diarrhea but he does have painless recta; bleeding. His eosinophils are 13.3. Is this the right diagnosis?

Dr. Rosh:
It is not possible in this forum to confirm or change a diagnosis. I can say that ulcerative colitis results in an inflammation of the large intestine. The main symptom would be blood in the stool. As the inflammation increases in degree, so does the number of bowel movements and with it, abdominal cramps and pain. So, mild ulcerative colitis could fit your description. If you remain uncomfortable, you never lose by getting an additional opinion from a physician with expertise in IBD. Such a gastroenterologist would work with a pathologist who is a physician trained to interpret biopsies. The pathologist could review your son’s biopsies and help confirm the diagnosis.

Question:
I have a 5 year old son with Crohn's disease. He is on an imunosuppresant. When he gets a cold and has a fever, are NSAIDS recommended for him?

Dr. Rosh:
Non-steroidal anti-inflammatory agents (NSAIDs) can cause breaks or cracks in the lining of the intestine. Such a change in the lining could lead to an increased level of activity of Crohn’s disease. As a result, it is recommended that Crohn’s patients avoid NSAIDs and use acetaminophen (eg. Tylenol) for fever control.

Approximately 75% of pediatric patients with Crohn’s disease are on an immunosuppressant within two years of diagnosis. As a class, these are the most commonly used medications for pediatric Crohn’s disease. Therefore, there is a vast amount of clinical experience with these agents. I can reassure you that it is not likely that the immunosuppressant is causing the fevers and the colds.

Question:
My daughter is 19 years old, and has had UC since the age of 14. She has been given Remicade for three years now but it seems not to be working as well. She is considering an ileo-anal pouch. Is it time for this surgery?

Dr. Rosh:
This is a very personal decision that is best made by the patient themselves. We know that 25% of pediatric and adolescent patients with ulcerative colitis do ultimately have their colons surgically removed (colectomy). The surgical approach to this disease has undergone marked advancement with internal hook-ups allowing patients to live without a permanent stoma (“bag”). Your daughter can meet with an experienced IBD surgeon and discuss the surgical options. There are other medical options including going to a new medication that works through the same mechanism as the Remicade (infliximab). Alternatively, a surgical approach could also be considered.

Question:
My son is 15 years old and for the past year he has been suffering with severe stomach pain. He cannot eat in the morning and has constant bowel movements. He has stopped eating to avoid the pain. He had an upper and lower endoscopy this year, which was negative for celiac sprue, peptic ulcers and colitis or Crohn's. Within the terminal ileum there was a patchy area of mucosal erythema and what appeared to be nodular hyperplasia of the mucosa, plus in the sigmoid portion there was a loss of haustral marking and a lead pipe appearance of the colon. The doctor gave him Align probiotic, Zantac, Xifaxan but nothing works. What should I do for him now?

Dr. Rosh:
The most important piece of information to gather is whether your son's doctor took biopsies from the areas of the bowel that you describe as having some changes present (especially terminal ileum and sigmoid colon). It would have also been helpful to obtain biopsies from other more normal appearing areas.

Assuming such biopsies were done and were normal, an additional test called a video capsule endoscopy (VCE) could be considered. This test involves the swallowing of a capsule that is actually a wireless video camera that contains an eight hour battery. As the capsule moves through the small intestine, it takes an 8 hour movie of the small intestine (about 20 feet) that exists between the areas that were investigated by the upper endoscopy and colonoscopy. There are cases of conditions such as Crohn's disease that can only be found in this region of the bowel.

Assuming that all such tests are normal and that your son's symptoms are not due to an inflammation of the bowel, he would meet the definition of irritable bowel syndrome (IBS). This is a functional gastrointestinal disorder--meaning his symptoms are due to the way his intestines function. There are biological (such as trigger foods including lactose intolerance), psychological (such as stress and anxiety) and social factors that affect bowel function. A plan of treatment can be made based upon all three types of influences. Dietary changes, stress reduction and cognitive therapies including relaxation therapies have all been shown to be effective for treating IBS. There are also medications that can help control symptoms.