Question:
I seem to have flare-ups after upper respiratory infections. Is this common? Can you tell me what causes flare-ups of ulcerative colitis?

Dr. Marion:
I often hear from patients that their ulcerative colitis flare followed some other, seemingly unrelated, infection or event. Since we don’t yet understand the essential nature of ulcerative colitis we can't yet explain all of the triggers or the mechanisms by which ulcerative colitis flares. Interestingly, antibiotics or anti-inflammatory (NSAID) medications, which may be used to treat viral or bacterial infections, may provoke a flare in some patients. Another theory holds that any stimulation of the immune system by an infection may provoke the immune system to provoke the colon as well. Finally, ulcerative colitis can be seasonal in some patients. Upper respiratory infections may occur more frequently in some patients during certain times of the year as well. However, the link in some patients, therefore, may be coincidental.

Question:
My 10 year old child has colitis. Are the same medicines equally effective in pediatric patients compared to adult patients?

Dr. Marion:
One of our biggest challenges in treating IBD is the relative lack of clinical data for treating IBD in children. Young children are not simply “little adults” in terms of their disease behavior, complications, response to medications and the safety issues of medications. For example, the use of corticosteroids can be particularly toxic to a growing child. A child's developing immune system may respond differently to long-term immunosuppressive therapy. A qualified pediatric gastroenterologist who is familiar with the clinical presentations of IBD, the available medical treatments and the long-term safety issues of the medications should evaluate any child with IBD.

Question:
I have Crohn’s disease in the last portion of my ileum. My doctor wants to give me Budesonide (Entocort). Is this a steroid? It is as effective as prednisone and what are the side effects?

Dr. Marion:
Budesonide is a corticosteroid, though not as potent as prednisone but with fewer side effects. The Entocort formulation releases budesonide in the distal small bowel and right colon, where it is absorbed and then rapidly broken down by the liver. The drug has an FDA indication for treatment of acute and aintenance therapy for Crohn’s disease. It is important to remember that many of the side effects of Budesonide are identical to those of prednisone (acne, weight gain, sleep disturbance, and if used long-term may cause diabetes and osteoporosis) Budesonide has not been tested on and should therefore not be used for patients with Crohn’s disease with fistula.

Question:
Some doctors prescribe “symptomatic” medications. What are these drugs and will they quiet my bowel inflammation?

Dr. Marion:
Symptomatic medications can really make the difference for many patients with IBD. Anti-diarrheals (lomotil, immodium) or anti-spasmodics (Hyoscamine, Levsin) are a useful adjunct for patients with IBD who are waiting for a medication to take effect or for those who have had a partial response but need to get back to living their lives. All of the symptomatic medications must be used under the supervision of a physician and none should be used as a substitute for effective medical therapy. Serious complications can happen if anti-diarrheal drugs are used in the setting of severe colitis.

Question:
Is it true that if I start smoking it can help my ulcerative colitis? I have never smoked. Will nicotine patches help? Will second hand smoke help? Does smoking help Crohn’s disease too?

Dr. Marion:
Physicians have long noticed a link between smoking cessation and ulcerative colitis. Former smokers are more likely to develop ulcerative colitis than smokers. The mechanism of this action is not clear but nicotine has been tested for these patients with a patch and even in an enema form. The clinical response to nicotine in these studies was modest at best so many of us think that there is more to it than the nicotine that impacts ulcerative colitis (and Crohn’s colitis too). People who have never smoked should not start since it will have no impact on their colitis. If former smokers choose to resume smoking to treat their colitis they may see a response but the side effect profile of smoking tobacco often remains unacceptable (addiction, emphysema, heart disease, lung cancer, etc.).

Crohn’s of the small bowel is made worse with tobacco and smoking increases the likelihood of needing surgery, with earlier recurrence after surgery.

Question:
I have Crohn’s disease and my doctor says my X-ray studies show internal fistula. What does this mean? Are there any special medicines that can heal these fistulas?

Dr. Marion:
A fistula is a small hole that can form when Crohn’s disease inflammation burrows through the bowel wall. Fistulizing Crohn’s disease can present with fistula to the bowel, internal organs and even to the skin. People with Crohn’s disease and fistula can be at risk of developing infections or abscesses related to their Crohn’s disease. Fistula can present with pain, fever or an abdominal mass or swelling. Commonly, fistula occur around the rectum and can be quite painful. Medications such as 5-ASA drugs are not helpful for fistula. Corticosteroids may make the fistula worse and promote abscess formation. Medications currently useful for fistula are antibiotics such as metronidazole (Flagyl) or ciprofloxacin. Immunosuppressive drugs such as 6-mercaptopurine/ azathioprine can help close fistula.

Medications such as infliximab have also been used to effectively treat fistula. Finally, surgery can also be used in the treatment of Crohn’s fistula. Before embarking on any therapy for fistula in Crohn’s you must carefully review the options, risks and benefits with your doctor.