Question:
I have microscopic colitis. How common is this form of IBD? I also have one sister with UC and another one with Crohn’s. Is this common? Can my microscopic colitis affect all of my bowel? What is the best treatment? I have been on steroids off and on for the last three years.

Dr. Sninsky:
Microscopic colitis is not a true form of inflammatory bowel disease (IBD). IBD consists of Crohn’s disease and ulcerative colitis, both of which have changes noted by colonoscopy, x-rays and/or abdominal/pelvic CT scan. The changes in the intestinal mucosa seen with IBD include erythema (redness), loss of vascular pattern from edema, erosions, and ulcers. In contrast, microscopic colitis, as its name implies, has a normal appearing colonic mucosa by all of the above tests except there is inflammation microscopically on the biopsy and the changes are limited to the colon. Patients with microscopic colitis experience non-bloody diarrhea. Traditionally, microscopic colitis responds to stopping NSAIDs (non-steroidal anti-inflammatory drugs like ibuprofen) and treatment with one of the following: bismuth, mesalamine (ex. Asacol, Pentasa, etc) or budesonide (Entocort), a form of steroid. Microscopic colitis does not run in families whereas 20% of patients with IBD have a family history of the disease. However, it should also be noted that some patients with IBD in remission have a normal appearing mucosa but it is inflamed on biopsy. The type of inflammation in IBD can be distinguished from that seen in microscopic colitis. In certain circumstances, specialized blood tests (Prometheus IBD Serology 7) can identify markers that are more common to IBD but there are no specific markers for microscopic colitis. You should make your physician aware of your family history of IBD and you may need additional examinations (for example, small bowel follow-thru, CT enterography (specialized CT scan of small intestine), blood tests for IBD or capsule endoscopy if you have only had colonoscopy.

Question:
My doctor has tried all of the standard treatments for my Indeterminate colitis; azathioprine, 6MP, etc. They all make my condition worse. He won’t prescribe Remicade because he is worried about the possible risk of tuberculosis. Is this risk significant enough to suffer the flare-ups, versus having to have my colon removed with all of the life-long problems of an ileostomy?

Dr. Sninsky:
The term Indeterminant Colitis is typically used when inflammation with mucosal intestinal lining changes is limited to the colon but can’t be categorized as either ulcerative colitis or Crohn’s colitis. In certain circumstances, specialized blood tests (Prometheus IBD Serology 7) may distinguish ulcerative colitis from Crohn’s colitis. I am hesitant when patients say, all standard treatments were tried because certain medications may have been omitted. With that in mind, allow me to address your specific question about Remicade. Remicade, infliximab, is a complicated engineered antibody (75% human and 25% mouse) administered as an intravenous infusion over 2 hours. Carefully designed studies approved by the FDA demonstrate a significant clinical improvement in about 70% of patients and 30-40% of these patients have total resolution of symptoms caused by Crohn’s disease or ulcerative colitis. Remicade is effective in the induction and maintenance of remission when given at 0, 2 and 6 wks; then every 8 weeks. Remicade is not a cure for IBD. There are risks associated with Remicade and your physician and reliable sources can go into the details. Any time a physician and patient choose a medication, they weigh the potential benefits and risks with regard to their particular medical condition.

Specifically, Remicade may cause activation of latent or dormant tuberculosis (TB). Before Remicade is administered, guidelines require skin testing for TB (PPD skin test), careful questioning to determine any previous exposure, and frequently, a chest x-ray. There is a new highly sensitive blood test for patients who have been previously exposed to TB. In addition, patients who spent a considerable amount of time around the Ohio River Valley may have been exposed to a bacteria, histoplasmosis, that is similar to TB. Histoplasmosis may also be reactivated by Remicade. If the above tests are negative, you have an exceedingly low risk for TB activation. However, your physician may have other reasons not to use Remicade in your particular condition. I am sure your physician will be glad to discuss the above with you. With the above having being said, ileostomy is an acceptable option that improves quality of life in certain patients with poorly controlled indeterminate colitis.

Question:
I developed drug-induced lupus after my 5th Remicade treatment. Will I have lupus for the rest of my life? Will I be able to take the newer drugs or are they in the same family? They are now trying methotrexate. Is this approach going backwards in treatment?

Dr. Sninsky:
Drug-induced lupus is only seen in about 2% of patients treated with Remicade. The lupus associated with Remicade involves only the skin and generally resolves spontaneously when the Remicade is stopped. No further treatment for this form of lupus is required. Remicade is in the family of monoclonal antibodies that binds an inflammatory protein called TNF, tumor necrosis factor. Humira, another one of these monoclonal antibodies that was just recently approved for Crohn’s disease, is different enough that it may be used despite your history of Remicade-induced lupus.

Methotrexate is very effective in Crohn’s disease. Methotrexate is effective at inducing and maintaining remission in Crohn’s disease. One should take a daily folic acid supplement because methotrexate interferes with folic acid metabolism. Methotrexate is generally well tolerated but may cause lung and liver abnormalities so regular blood tests are needed during treatment. Methotrexate and Humira can be given at the same time to treat Crohn’s disease.

Question:
I have had colitis since 1980. During the past few years I have had very few flare-ups. In June I had a colonoscopy which was normal. Then after the exam my colon flared up until the point I had to go on cortisone again. It is now March and I am still having trouble, am taking 20 mg of prednisone a day, 12 Asacol and Nexium, but nothing is helping. I have some formed stools, less blood, but the minute I put food in my mouth I have to go to the restroom, day and night. My doctor says to go on higher doses of steroids.. I cannot get a handle on this.

Dr. Sninsky:
Ulcerative colitis and Crohn’s disease are chronic diseases characterized by periods of remission and relapse. At times, the disease may flare and be difficult to control. When patients flare their symptoms, the physician usually excludes other complicating factors like concurrent infection or factors that are known to induce a flare of ulcerative colitis. These factors include NSAIDs, non-steroidal anti-inflammatory drugs(ex. aspirin and ibuprofen) or a change in their smoking status. In ulcerative colitis, smoking cessation may cause a flare of the disease. In contrast, smoking worsens Crohn’s disease. Prednisone is effective in ulcerative colitis but many patients may need 40 to 60mg per day followed by a tapering dose. Immunomodulators (Imuran or Purinthol) are effective at allowing one to taper and discontinue steroids while maintaining remission. Remicade and Cyclosporin are effective in as many as 70% of patients with refractory ulcerative colitis.

As many as 20% of patients requiring steroids may need surgery to remove their colon (colectomy) to cure their ulcerative colitis. This is especially important in patients with greater than 10 years of disease. There is an increased incidence of colon cancer in patients with IBD. The incidence of colon cancer begins to increase after about 8 yrs of IBD and is estimated to increase 1% per year. Please speak to your physician about the above options to control your disease and improve your quality of life.

Question:
I was diagnosed with Crohn’s in November 2006. I have read that fish oil can be beneficial. Is this true? I am currently on Pentasa.

Dr. Sninsky:
Patients with different types of Crohn’s disease (fistulizing, stricturing or ulcerating) and involving different parts of the intestinal tract respond differently to specific medications. A special enteric-coated fish-oil preparation (omega-3 fatty acids) that limits unpleasant taste and gastrointestinal side effects(diarrhea) was reported to reduce the frequency of Crohn’s relapses in a small study from Italy. Certain types of fish oil may cause diarrhea. To date, no study has confirmed those earlier results so its role in treatment of Crohn’s disease remains unclear. The mesalamines (Pentasa, Asacol etc) are effective in Crohn’s disease but their benefit may only be seen in about 40-50% of patients. It is estimated that 60% of patients never need steroids to control their disease but 70% may require surgery over their lifetime.

Question:
I was diagnosed with Crohn’s in 2000. I have been feeling great for about six month and was feeling pretty good for a year before that. My husband and I want to get pregnant and I am trying to wrap my head around the risk I might be taking of being pregnant while on Immuran. I would love to have your thoughts.

Dr. Sninsky:
The issues surrounding pregnancy and IBD are complex because they deal with the impact of IBD on pregnancy, the impact of pregnancy on IBD, and the influence of specific medications used in IBD on pregnancy, the fetus and breast-feeding. Most women with IBD have normal uneventful pregnancies. The greatest risk to pregnancy is active Crohn’s disease because it decreases fertility and increases the frequency of premature deliveries. There is a system of classifying drugs according to their established risks for use during pregnancy. Category A: Controlled human studies have demonstrated no fetal risk. Category B: Animal studies indicate no fetal risk, but no human studies; or adverse effects in animals, but not in well-controlled human studies. Category C: No adequate human or animal studies; or adverse fetal effects in animal studies, but no available human data. Category D: Evidence of fetal risk, but benefits outweigh risks. Category X: Evidence of fetal risk. Risks outweigh any benefits. The mesalamines (Asacol, Pentasa etc) and prednisone are safe in pregnancy and breast feeding. Flagyl is similar to mesalamines in safety but fluoroquinolone antibiotics (Cipro and Levaquin) may interfere with cartlagenous development in the fetus in animals. Azathioprine, or 6MP, have a possible but not proven increased risk in pregnancy and breast feeding issues. However, the risk of stopping azathioprine or 6MP may be a greater risk to the pregnancy than continuing the drug. Remicade, with limited data, has thus far has been relatively safe in pregnancy. Methotrexate should never be used immediately before or during pregnancy because it may cause abortion.

Question:
I have the diagnosis of Celiac Sprue and "gluten free". We are told that IBS means "I be stumped" when given that diagnosis. What is the relationship of Celiac Sprue to IBS and/or IBD?

Dr. Sninsky:
Celiac sprue and irritable bowel syndrome (IBS) are not inflammatory bowel diseases. There is no relationship between celiac sprue and irritable bowel syndrome with IBD. Celiac sprue is a gluten(wheat containing foods) sensitive gastrointestinal disorder that causes diarrhea usually with weight loss and malabsorption of certain foods. Some patients with celiac sprue only have iron deficiency anemia. It is diagnosed by a blood test(celiac panel with a serum tissue transglutaminase(tTG) and biopsy of the small intestine. The patients symptoms resolve when a gluten free diet is followed.

Irritable bowel syndrome (IBS not IBD) is diagnosed in patients with diarrhea, constipation or alternating diarrhea and constipation in patients with abdominal pain relieved with bowel movement. Most patients also note a sensation of incomplete evacuation during 25% of bowel movements. There is no blood test or radiographic, endoscopic or pathologic features of IBS. Therefore, some patients get the impression that IBS is made after multiple tests to exclude other diseases. Hence the misconception that IBS means, "I am stumped." IBS can be diagnosed in the appropriate clinical setting when there are no "warning symptoms" (weight loss, rectal bleeding etc) that suggest more serious disease.

Question:
My mother died of Crohn’s in 1982. The doctors did not know how to treat her. What are the chances of me having it, or my two daughters?

Dr. Sninsky:
Patients with Crohn’s disease have a normal life expectancy. 20% of patients with Crohn’s disease have a family history of IBD. Patients with Crohn’s disease are more likely to have a family history of IBD than patients with ulcerative colitis however, both diseases can be seen in a single family. IBD is more common in Caucasians, especially patients who are Jewish, and less likely in Afro-Americans, Asians and Hispanics. If both parents have IBD then as many as 50% of their offspring may develop the disease. If only one parent has Crohn’s disease then it is estimated that less than 10% may develop the disease. If an identical twin develops Crohn’s disease, his sibling has a 50% chance of developing Crohn’s disease. In contrast, if an identical twin develops ulcerative colitis the sibling has about a 15% chance of developing the disease. Therefore, genetic factors are stronger in Crohn’s disease than in ulcerative colitis.