Inflammatory bowel diseases and their treatment

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be "The Informed Patient," with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Today, I'm talking about inflammatory bowel disease with Dr. Idan Goren, who's an assistant professor of medicine specializing in gastroenterology at Upstate. He's an expert in managing inflammatory bowel diseases, such as Crohn's disease and ulcerative colitis. Welcome to "The Informed Patient," Dr. Goren.

[00:00:33] Idan Goren, MD: Thank you. Thank you so much for having me. I'm excited to be here.

[00:00:37] Host Amber Smith: Well, let's start with a description of what inflammatory bowel disease is.

[00:00:43] Idan Goren, MD: So inflammatory bowel disease is an umbrella term that includes two chronic conditions, both Crohn's disease and ulcerative colitis.

Both of them can affect the digestive system, but they can affect different parts of the intestines. So Crohn's can basically affect any part of the digestive tract. And ulcerative colitis affects only the colon, or the large intestine.

[00:01:11] Host Amber Smith: Well, we'll get into this a little more, but are the symptoms the same?

[00:01:15] Idan Goren, MD: First of all, I would like to state that this is pretty common nowadays. We have more than 3 million Americans living with these two conditions. And the most common symptoms for patients with IBD include abdominal pain, diarrhea, sometimes it can be even bloody diarrhea, fatigue, weight loss. In some cases fever is also one of the symptoms initially during a flare or first presentation of the disease.

Patient can also experience symptoms which are not inside their GI tract, but systemic symptoms such as joint pain, different skin problems, and eye inflammation.

There are certain differences between the presentation of these, of both diseases. Usually ulcerative colitis is associated with a bloody diarrhea, whereas in Crohn's disease, this is not really common.

[00:02:13] Host Amber Smith: I see. Do we know what causes Crohn's and ulcerative colitis?

[00:02:19] Idan Goren, MD: Yeah, so this is like the $1 million question, I would say, because we don't really fully understand what the exact cause is. But we do know that there are several risk factors that seems to play a role. And genetics is definitely one of them because we know that IBD can run in families, so if a parent or a sibling has it, you are at a high risk to develop it too. We also know that the environment plays a role.

We know that there are certain lifestyle factors such as high fat diet, living in urban areas, exposure to antibiotic, especially during the first year of life, put the patient at higher risk for developing inflammatory bowel diseases. Breastfeeding during the first year is considered one of the protective factors.

And then geography also plays a role. People in more developed countries, or people live in cities are, more likely to develop inflammatory bowel disease. And this is potentially related to the dietary pattern or lifestyle.

[00:03:27] Host Amber Smith: So if someone realizes that they're at high risk -- maybe they have family members that have had this -- is there anything they can do, actively, to help prevent the development of this?

[00:03:41] Idan Goren, MD: So I would say, first of all, eat well. So if you eat, your diet is rich in fiber, fruits, vegetables, that might be beneficial not only for inflammatory bowel disease prevention, generally, but we do know that healthier diet and higher in fibers is one of the potentially protective factors. Avoid smoking. So cigarette smoking is one of the major risk factors for Crohn's disease, and patients with Crohn's disease who continue smoking, they're at high risk to lose response to the therapy. So it, it is both risk factor to develop the disease, but it is also associated with a poor prognosis or worse outcomes in patients with preexisting diagnosis of Crohn's disease.

[00:04:32] Host Amber Smith: One general thing that I like to discuss with my patients: It's reducing stress. So chronic stress can worsen the symptoms and can also indirectly or directly cause a flare. These are conditions that flare up. So it's not always constant that you're having the symptoms. It comes and goes. Is that right?

[00:04:55] Idan Goren, MD: That's the case. So this is very unpredictable, and most patient experience periods of active inflammation and periods of remission. That's correct.

[00:05:07] Host Amber Smith: How is this treated, in general?

[00:05:10] Idan Goren, MD: So we have different ways to treat the inflammation. And the key here is medication.

So as I mentioned before, people that are dealing with inflammatory bowel disease have these flareups when the symptoms, like pain, diarrhea, fatigue, becomes really severe. And this is very unpredictable. So we do use different medication to treat the inflammation. And by doing so, we can put the disease into remission and help our patient feeling better.

[00:05:46] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with gastroenterologist Dr. Idan Goren from Upstate.

Can you tell us about the new IBD service that you've launched for Central and Upstate New Yorkers?

[00:06:03] Idan Goren, MD: Sure. So our new IBD service is focused on providing a more comprehensive care for people with inflammatory bowel disease.

I was privileged to do some of my training at the Cleveland Clinic, where I trained in advanced IBD care. And my goal here is to fill a gap in this community by offering both medical, surgical treatments for inflammatory bowel disease. And I do work closely with other specialties. So I have , a very good collaboration here with the surgeons, with rheumatology department, psychiatry, and also dermatology to make sure that we can cover all the aspects of inflammatory bowel disease management.

And hopefully in the future we'll also offer some support for diet to make sure that our patients have the care they need for their whole wellbeing, not just focusing on their inflammation, but treating them as a whole.

[00:07:06] Host Amber Smith: You mentioned psychiatry, rheumatology, dermatology. How do those specialties benefit patients with IBD?

[00:07:14] Idan Goren, MD: The main message here is that IBD is not just inflammation of the gut. It has many, many manifestations, both inside the gut and outside the gut. And this is basically a systemic inflammatory disease. Because it affects different parts of the body, it is important to have a team that can help with all the symptoms and all the manifestations, not just the digestive one. And unfortunately, over time, patients with Crohn's disease may develop bowel strictures and structural damage to their gut that may require surgery. So we do work very closely with our surgical colleagues. And in cases of poorly controlled colitis, we also may end up using surgery as a treatment for the disease. So know being followed in an academic center is a big advantage.

[00:08:09] Host Amber Smith: Does having an inflammatory bowel disease raise a person's risk for developing a colorectal cancer?

[00:08:15] Idan Goren, MD: Yes. So people with long-term inflammatory bowel disease, especially when the affected area is extensive part of their colon, or their large bowel, they are at high risk for colorectal cancer. And that's why we do need to screen them regularly. When I say screen, I mean doing more frequent colonoscopies on those patients.

[00:08:40] Host Amber Smith: OK. And is that the best way for them to reduce their risk? Or are there other things that they need to be doing actively?

[00:08:48] Idan Goren, MD: There are three waysto reduce the risk for colorectal cancer in patients with inflammatory bowel disease. The first is by treating the inflammation. The better we can treat the inflammation over time, we can prevent or reduce the risk for colorectal cancer in our patients.

Second is by doing surveillance. So surveillance colonoscopies starting at eight to 10 years after the IBD diagnosis is the way that we can identify earlier and treat earlier any lesions that may eventually end up developing into colorectal cancer. So the ideal cases that we can detect earlyany lesion, and then we do repeat more frequently the screening colonoscopies, meaning that after eight to 10 years, we tend to do more colonoscopies, usually every one to three years on average.

And the third thing is like any other person, just lifestyle. So don't smoke. Stay active. These are always beneficial to reduce the risk for colorectal cancer.

[00:09:58] Host Amber Smith: So what does natural aging do? If someone has inflammatory bowel disease in their 30s, what is it like in their 50s or 70s? Does it naturally get better or worse?

[00:10:10] Idan Goren, MD: That's a great question. So since this is a very unpredictable disease, I would say that in some patients, we do see decline in the inflammatory activity over the years, and when they get older, the disease become more.... I like to call it, like, "burned out" disease, or less active. But we do see that in certain individuals, the age does not really play a significant role. And we have patients in their 70s and now even 80s, showing up with very, very severe active disease, sometimes after years of remission. So I would say that this is really variable and unpredictable.

[00:10:54] Host Amber Smith: So it's a lifetime disease. There's not a treatment that cures it, then?

[00:10:58] Idan Goren, MD: So unfortunately we cannot cure it, but we can definitely treat it.

[00:11:04] Host Amber Smith: OK. Well, let me ask you about some of the latest advances in IBD treatment or what you see on the horizon.

[00:11:13] Idan Goren, MD: There have been some really exciting advances in the treatment of IBD in recent years, and I think that one of the most important developments is the advanced therapies.

And we do offer many, many new therapies, both biologic therapies, which are usually given in injections. But we also have some new oral small molecules, which are pills, that does not require going into infusion clinic anymore and really improve, our patient satisfaction.

These are really game changers, these medications, because many of our patients did not really respond to the older medications or the traditional treatments. And now we can help them getting into remission and improve their quality of life.

I think that one of the key advantages, of the way we treat IBD now is that we don't really wait too long until putting the patient on a good and effective treatment. So, in the early days of inflammatory bowel disease, there was a perception that delaying the care and keeping the best medication down the road when everything else failed is the right way to go. Now we know that this is the other way around. We should use our best tools upfront as soon as possible, and then we can prevent some of the damage or some of the irreversible damage of this lifelong disease.

[00:12:43] Host Amber Smith: I didn't ask you before, but how does a person become diagnosed with an inflammatory bowel disease?

[00:12:50] Idan Goren, MD: So as I mentioned, there are certain symptoms which are really typical for inflammatory bowel disease, and they include both abdominal pain, diarrhea, with and without blood, fatigue, weight loss, fever, and any of the extraintestinal manifestations such as joint pain, low back pain, new skin rashes or eye inflammation. Usually the combination of them.

Once the patient has these symptoms, they should get referred to IBD center or any GI provider who can further assess them. And there is not a single test to diagnose a patient with inflammatory bowel disease. There's a combination of endoscopy, which means colonoscopy and upper endoscopy, as well as some cross-sectional imaging like CT scan or MRI. And then when we do scope the patient, we take biopsies from areas that look inflamed and check them under the microscope to look for specific signs of chronic inflammation. And this combination altogether helps us to diagnose a patient with inflammatory bowel disease.

[00:14:05] Host Amber Smith: Now, can you tell me the difference between inflammatory bowel disease and something I've heard of, irritable bowel disease? They're not the same thing, right?

[00:14:13] Idan Goren, MD: Correct. So, irritable bowel disease is way more common than inflammatory bowel disease, thankfully. As opposed to inflammatory bowel diseases, which involves inflammation in your colon or any other area of your GI (gastrointestinal tract,) irritable bowel disease is a diagnosis of exclusion. It means that the patient does not have any inflammation or any disease that can be found in their system, but they still have a lot of symptoms such as abdominal pain, diarrhea, constipation, or the combination of them.

And one of the key features is abdominal pain. As opposed to inflammatory bowel disease, irritable bowel disease is a functional disorder. So our approach to the therapy of irritable bowel disease is completely different. When we treat patients with irritable bowel disease, the goal is to treat their symptoms. Whereas when we treat patients with inflammatory bowel disease, we should treat both the inflammation as well as their symptoms.

[00:15:19] Host Amber Smith: I see. Well, Dr. Goran, I want to thank you so much for making time for this interview.

[00:15:25] Idan Goren, MD: Thank you for having me.

[00:15:26] Host Amber Smith: My guest has been gastroenterologist, Dr. Idan Goren, an assistant professor of medicine at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen, too, and you can rate and review "The Informed Patient" podcast on Spotify, Apple Podcasts, YouTube or wherever you tune in. This is your host, Amber Smith, thanking you for listening.