IBD & Colon Cancer -- July 9, 2012 -- Dr. Bill Harb, Dr. Howard - NewsChannel5.com | Nashville News, Weather & Sports

IBD & Colon Cancer -- July 9, 2012 -- Dr. Bill Harb, Dr. Howard Mertz

MEDICAL MONDAYS
Monday, July 9, 2012
TOPIC: IBD & Colon Cancer
Bill Harb, MD | colorectal surgeon | Baptist Hospital
Howard Mertz, MD | gastroenterologist | Saint Thomas Hospital

News notes via www.webmd.com

INFLAMMATORY BOWEL DISEASE

The term inflammatory bowel disease (IBD) describes a group of disorders in which the intestines become inflamed. What causes them to become red and swollen is not known. The most likely cause is an immune reaction the body has against its own intestinal tissue.

Two major types of IBD are ulcerative colitis and Crohn's disease. Ulcerative colitis is limited to the colon or large intestine. Crohn's disease, on the other hand, can involve any part of the gastrointestinal tract from the mouth to the anus. Most commonly, though, it affects the small intestine or the colon or both.

If you have an IBD, you know it usually runs a waxing and waning course. When there is severe inflammation, the disease is considered active and the person experiences a flare-up of symptoms. When there is less or no inflammation, the person usually is without symptoms and the disease is said to be in remission.

What Causes Inflammatory Bowel Disease?

IBD is an idiopathic disease -- a disease with an unknown cause. Some agent or a combination of agents triggers the body's immune system to produce an inflammatory reaction in the intestinal tract. It could be an infectious agent such as bacteria or viruses or an antigen such as a protein from cow milk. It could also be that the body's own tissue causes an autoimmune response. Whatever causes it, the reaction continues without control and damages the intestinal wall, leading to bloody diarrhea and abdominal pain.

What are the Symptoms of Inflammatory Bowel Disease?

IBD is chronic, which means it lasts a long time. As with other chronic diseases, a person with IBD will go through periods in which the disease flares up and causes symptoms followed by periods in which symptoms decrease or disappear and good health returns. Symptoms range from mild to severe and generally depend upon what part of the intestinal tract is involved. They include:

• abdominal cramps and pain
• bloody diarrhea
• severe urgency to have a bowel movement
• fever
• weight loss
• loss of appetite
• iron deficiency anemia due to blood loss

Are There Complications Associated With IBD?

IBD can lead to several serious complications in the intestines, including:

• profuse intestinal bleeding from the ulcers
• perforation, or rupture of the bowel
• narrowing – called a stricture -- and obstruction of the bowel
• fistulae (abnormal passages) and perianal disease, which is disease in the tissue around the anus
• toxic megacolon, which is an extreme dilation of the colon that is life-threatening

IBD also increases the risk of colon cancer and can involve organs other than the intestines. Someone with IBD may have arthritis, skin conditions, inflammation of the eye, liver and kidney disorders, or bone loss. Of all the complications outside the intestines, arthritis is the most common. Joint, eye, and skin complications often occur together.

How is IBD Diagnosed?

Your doctor makes the diagnosis of inflammatory bowel disease based on your symptoms and various exams and tests:

• Stool exam. You'll be asked for a stool sample that will be sent to a laboratory to rule out the possibility of bacterial, viral, or parasitic causes of diarrhea. In addition, the stool will be examined for traces of blood that cannot be seen with the naked eye.
• Complete blood count. A nurse or lab technician will draw blood, which will then be tested in the lab. An increase in the white blood cell count suggests the presence of inflammation. And if you have severe bleeding, the red blood cell count and hemoglobin level may decrease.
• Barium X-ray. To check the upper gastrointestinal (GI) tract, you will be given a chalky white solution containing barium to swallow. The barium will coat the inside of the intestinal tract so it will be visible on X-rays. If you have abnormalities caused by Crohn's disease in the upper GI tract, which includes your esophagus, stomach, and small intestine, they will show up. To check the lower GI tract, you will be given an enema containing barium and asked to hold it in while X-rays are taken of the rectum and colon. Abnormalities caused by either Crohn's or ulcerative colitis will show up in these X-rays.|
• Sigmoidoscopy. In this procedure, a doctor uses a sigmoidoscope, which is a narrow, flexible tube with a camera and light to visually examine the last one-third of your large intestine, which includes the rectum and the sigmoid colon. The sigmoidoscope is inserted through the anus and the intestinal wall is visually examined for ulcers, inflammation, and bleeding. The doctor may also take samples -- biopsies -- of the intestinal lining with an instrument inserted through the tube. These will then be examined in a laboratory under a microscope.
• Colonoscopy. A colonoscopy is similar to a sigmoidoscopy except that the doctor will use a colonoscope, which is a longer flexible tube, to examine the entire colon.
• Upper endoscopy. If you have upper GI symptoms such as nausea and vomiting, a doctor will use an endoscope -- a narrow, flexible tube with a camera and light that will be inserted through the mouth -- to examine your esophagus, stomach, and duodenum, which is the first part of your small intestine. Ulceration occurs in the stomach and duodenum in up to one out of every 10 people with Crohn's disease.

How Is Inflammatory Bowel Disease Treated?

Treatment for IBD involves a combination of self-care and medical treatment.

Self-care| Diet is one tool you can use to help manage your symptoms. It's important to talk with your doctor about ways of modifying your diet while making sure you get the nutrients you need. For instance, depending on your symptoms, the doctor may suggest that you reduce the amount of fiber or dairy products that you consume.

One dietary intervention your doctor may recommend is a low-residue diet, a very restricted diet that reduces the amount of fiber and other undigested material that pass through your colon. Doing so can help relieve symptoms of diarrhea and abdominal pain. If you do go on a low-residue diet, be sure you understand how long you should stay on the diet since a low-residue diet doesn't let you get all the nutrients you need.

While diet can help manage symptoms for both ulcerative colitis and Crohn's disease, it has little effect on the inflammatory process in ulcerative colitis. But with Crohn's, diet can help control inflammation. If you have Crohn's disease, your doctor may recommend a special liquid diet or predigested formula to assist in reducing inflammation.

Another important aspect of self-care is to learn how to manage stress because being stressed can make your symptoms worse. One thing you might want to do is to make a list of things that cause you stress and then consider which ones you can eliminate from your daily routine. Also, when you feel stress coming on, it can help to take several deep breaths and release them slowly by blowing out. Learning to meditate, creating time for yourself, and regular exercise are all important tools for reducing the amount of stress in your life.

Taking part in a support group will let you meet and talk with others who know exactly the effect IBD has on your day-to-day life since they are going through the same things you are. They can offer support and tips on how to deal with symptoms and the effect they have on you.

Medical Treatment | The goal of medical treatment is to suppress the abnormal inflammatory response so intestinal tissue has a chance to heal. As it does, the symptoms of diarrhea and abdominal pain should be relieved. Then once the symptoms are under control, medical treatment will focus on decreasing the frequency of flare-ups and maintaining remission.

Doctors frequently take a stepwise approach to the use of medications for inflammatory bowel disease. With this approach, the least harmful drugs or drugs that are only taken for a short period of time are used first. If they fail to provide relief, drugs from a higher step are used.

Treatment typically begins with aminosalicylates, which are aspirin like anti-inflammatory drugs such as olsalazine(Dipentum), balasalazide ( Colazal), and mesalamine(Asacol,Lialda,Pentasa Apriso). These drugs can be taken orally or administered as a rectal suppository. Because they are anti-inflammatory, they are effective in both relieving symptoms of a flare-up and maintaining remission. The doctor may also prescribe anti diarrheal agents, antispasmodics, and acid suppressants for symptom relief.

If you have Crohn's disease, especially if it's accompanied by a complication such as perianal disease, the doctor may prescribe an antibiotic to be taken with your other medicines. Antibiotics are seldom used for ulcerative colitis because of the risk of an infectious type of colitis that they can cause.

If the first drugs don't provide the adequate relief, the doctor will likely prescribe a corticosteroid, which is rapid-acting anti-inflammatory agent. Corticosteroids tend to provide rapid relief of symptoms as well as a significant decrease in inflammation. However, because of side-effects associated with their long-term use, corticosteroids are used only to treat flare-ups and are not used for maintaining remission.

Immune modifying agents are the next drugs to be used if corticosteroids fail or are required for prolonged periods. These medications are not used in acute flare-ups because they may take as long as 2 to 3 months to take action. Examples of immunosuppressives are Azathioprine and 6-mercaptopurine.

Infliximab(Remicade) is a drug approved by the FDA to be used in persons with moderate to severe Crohn's disease when standard medications have been ineffective. It belongs to a class of drugs known as anti-TNF agents. TNF (tumor necrosis factor) is produced by white blood cells and is believed to be responsible for promoting the tissue damage that occurs with Crohn's disease. Other anti TNF agents approved for Crohns disease are Humira (adalumimab) and Cimzia (certolizumab). Remicade is the only anti-TNF agent currently approved by the FDA for ulcerative colitis.

If you are not responding to the drugs recommended for IBD, talk with your doctor about enrolling in a clinical trial. Clinical trials are the way new treatments for a disease are tested to see how effective they are and how patients respond to them. You can find out about clinical trials at the Crohn's& Colitis Foundation of America web site.

Is Surgery Ever Used To Treat Inflammatory Bowel Disease?

Surgical treatment for IBD depends upon the disease. Ulcerative colitis, for instance, can be cured with surgery because the disease is limited to the colon. Once the colon is removed, the disease doesn't come back. However, surgery will not cure Crohn's disease. It may be used for special treatments, but excessive surgery in persons with Crohn's disease can actually lead to more problems.

There are several surgical options available for people with ulcerative colitis. Which one is right for you depends on several factors:

• the extent of your disease
• your age
• your overall health

The first option is called a proctocolectomy. It involves the removal of the entire colon and rectum. The surgeon then makes an opening on the abdomen called an ileostomy that goes into part of the small intestine. This opening provides a new path for feces to be emptied into a pouch that's attached to the skin with an adhesive.

Another commonly used surgery is called ileoanal anastomosis. The surgeon removes the colon and then creates an internal pouch that connects the small intestine to the anal canal. This allows feces to still exit through the anus.

Even though surgery will not cure Crohn's disease, approximately 75% of people with Crohn's require surgery at some point. If you have Crohn's disease and require surgery, your doctor will discuss your options with you. Be sure you ask questions and understand:

• what the surgery is supposed to do
• what will happen if you don't have surgery
• what the risks are
• what the benefits are

Then you will be able to make an informed decision about the surgery.

When you have an IBD, the symptoms will come and go over a period of many years. But that doesn't your helpless to do anything about them. Working closely with your healthcare team is your best chance for being able to manage your condition.

Colorectal Polyps and Cancer

Colorectal cancer is the third leading cause of cancer deaths among American men and women. These cancers arise from the inner lining of the large intestine, also known as the colon. Tumors may also arise from the inner lining of the very last part of the digestive tract, called the rectum.

Unfortunately, most colorectal cancers are "silent" tumors. They grow slowly and often do not produce symptoms until they reach a large size. Fortunately, colorectal cancer is preventable, and curable, if detected early.

How Does Colorectal Cancer Develop?

Colorectal cancer usually begins as a polyp. The word "polyp" is a nonspecific term to describe a growth on the inner surface of the colon. Polyps are often non-cancerous growths but some can develop into cancer.

The two most common types of polyps found in the colon and rectum include:

• Hyperplastic and inflammatory polyps. Usually these polyps do not carry a risk of developing into cancer. However, large hyperplastic polyps, especially on the right side of the colon, are of concern and should be completely removed.
• Adenomas or adenomatous polyps. Polyps, which, if left alone, could turn into colon cancer. These are considered pre-cancerous.

Although most colorectal polyps do not become cancer, virtually all colon and rectal cancers start from these growths. People may inherit diseases in which the risk of colon polyps and cancer is very high.

Colorectal cancer may also develop from areas of abnormal cells in the lining of the colon or rectum. This area of abnormal cells is called dysplasia and is more commonly seen in people with certain inflammatory diseases of the bowel such as Crohn's disease or ulcerative colitis.

What Are the Risk Factors for Colorectal Cancer?

While anyone can get colorectal cancer, it is most common among people over the age of 50. Risk factors for colorectal cancer include:

• A personal or family history of colorectal cancer or polyps.
• A diet high in red meats and processed meats.
• Inflammatory bowel disease (Crohn's disease or ulcerative colitis).
• Inherited conditions such as familial adenomatous polyposis and hereditary non-polyposis colon cancer
• Obesity.
• Smoking.
• Physical inactivity
• Heavy alcohol use
• Type 2 diabetes

What Are the Symptoms of Colorectal Cancer?

Unfortunately, colorectal cancer may strike without symptoms. For this reason, it is very important to be screened regularly by your doctor for colorectal cancer, even if you have no symptoms.

In addition to getting a medical history and physical exam, there are a number of tests your doctor can perform to help detect colorectal cancer and polyps early. Tests to help detect colorectal polyps and cancer include:

• Sigmoidoscopy. This is a procedure used to examine the rectum and very last part of the colon. This test can detect polyps, cancer, and other abnormalities in the sigmoid colon and rectum. During this exam, a biopsy (tissue sample) may also be removed and sent for testing.
• Colonoscopy. A colonoscopy examines the entire colon and rectum. During this procedure, polyps can be removed and sent for testing.
• Colon X-rays. Also known as a double-contrast barium enema or lower GI series, this test provides an outline of the lining to detect abnormalities in the colon and rectum.
• CT Colonography. This is a special X-ray test (also referred to as a virtual colonoscopy) done of the entire colon using a CT (computed tomography) scanner. This test takes less time and is less invasive than other tests. However, if a polyp is detected, a standard colonoscopy needs to be performed.

The earliest sign of colon cancer may be bleeding. Often tumors bleed only small amounts intermittently, and evidence of the blood is found only during chemical testing of the stool. This is called occult bleeding, meaning it is not always visible to the naked eye. When tumors have grown to a large size they may cause a change in the frequency or the caliber of the stool.

Symptoms of colorectal cancer include:

• A persistent change in bowel habits (such as constipation or diarrhea).
• Blood on or in the stool.
• Abdominal discomfort.
• Unexplained weight loss.
• Anemia.

What Happens If a Colorectal Polyp Is Found?

If colorectal polyps are found, they should be removed and sent to a laboratory for microscopic analysis. Once the microscopic type of polyp is determined, the follow-up interval for the next colonoscopy can be made.

How Is Colorectal Cancer Treated?

The majority of colorectal polyps can be removed during a routine colonoscopy and and examined under a microscope. Very large adenomas and cancers are removed with surgery. If the cancer is found in the early stages, surgery can cure the disease. Advanced colorectal cancers may be treated in a variety of ways, depending on their location. Treatments include surgery and radiation therapy and chemotherapy.

How Can I Prevent Colorectal Cancer?

Living a healthy lifestyle that includes no smoking, regular exercise, maintenance of a healthy weight, and a diet that is low in red meat and high in vegetables and fruit is probably your best start at general cancer prevention.

Some studies have shown that aspirin and other drugs known as non-steroidal anti-inflammatory drugs, or NSAIDs, may help prevent colon cancers but this is usually in patients with familial adenomatous polyps, a condition discussed below. NSAIDs also carry increased risks of serious complications, such as stomach bleeding and heart attacks, so they are not recommended as a general preventive measure for people at average risk for colorectal cancer.

Screening for cancer is another important step.

General Colorectal Cancer Screening Recommendations:

These recommendations are for people at average risk for colorectal cancer without symptoms or a personal or family history of colorectal polyps or cancer or inflammatory bowel disease. Screening should begin at the age of 50.

• Stool tests (fecal occult blood test or fecal immunochemical test) performed once a year. These are simple at-home tests that check for hidden blood in the stool from multiple samples. A newer stool test is a stool DNA test, which requires an entire stool specimen. The recommended interval for stool DNA testing has not been determined. A colonoscopy should be done if stool test results are abnormal. OR
• Flexible sigmoidoscopy performed every 5 years. This is an outpatient procedure for examining the inside of the lower portion of the large intestine, called the sigmoid colon, and also the rectum. This test can miss polyps, cancer, or other abnormalities that are beyond the reach of the scope. If abnormalities are detected then a colonoscopy needs to be done as well. OR
• Colonoscopy, performed once every 10 years. This is the preferred test. OR
• Air contrast barium enema performed every 5 years. During this procedure, a barium enema is given and then air is blown in to make the barium spread over the lining of the colon, producing an outline of the inner colon and rectum on X-ray. This test can miss small polyps or cancer. If any abnormalities are detected, a colonoscopy is needed.
• CT colongraphy (virtual colonoscopy) performed every 5 years. This can miss small polyps. If any abnormalities are detected, a colonoscopy is needed.

People at higher risk for colorectal cancer include those with a personal history of polyps on previous colonoscopy, colorectal cancer, and/or inflammatory bowel disease, strong family history of colorectal cancer or precancerous polyps, and a family history of a hereditary cancer syndrome. Screening guidelines for adults consist of screening with colonoscopy starting at a younger age however, the exact age to start screening and interval of testing vary depending on specific risk factors.