Mar 12, 2019
Ulcerative colitis affects nearly 700,000 Americans and causes symptoms ranging from diarrhea to arthritis to skin rash. Thankfully, medication options and surgery can significantly reduce symptoms and even bring about long-term remission for patients.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: Thanks for joining us today. We’re speaking with Dr. Nidhi Malhotra, a gastroenterologist and Assistant Professor of Medicine at MedStar Washington Hospital Center. Today we’re discussing ulcerative colitis, which is an inflammatory bowel disease that causes long-lasting inflammation and ulcers, or sores, in the digestive tract. Welcome, Dr. Malhotra.
Dr. Nidhi Malhotra: Thank you for having me.
Host: Could you tell us what causes ulcerative colitis?
Dr. Malhotra: So, ulcerative colitis is thought to be an auto-inflammatory condition in a genetically susceptible individual. Let me simplify that. So, someone with a genetic predisposition, meaning that they have genes that make them more susceptible to acquire this disease, and then there is an inciting event that triggers the inflammation. The inciting event could be an infection. It could additives or preservatives in our diet which have directly implicated in IBD. It could be chemicals. Or, it could be antibiotics. Or really, sometimes, a completely unrecognized reason as a triggering factor. But once triggered, the inflammation causes damage to the colon, and patients will start having symptoms.
Host: What are some of the common symptoms of ulcerative colitis?
Dr. Malhotra: So, I usually divide up the symptoms into GI and non-GI related symptoms, because the inflammation can actually affect really any part of your body. So, GI-wise, patients may present with abdominal pain, diarrhea, bloody diarrhea, nocturnal diarrhea - meaning they are waking up at night to have a bowel movement, tenesmus - meaning they have feelings of incomplete evacuation and have to keep going back to the bathroom constantly, and severe urgency. And then the non-GI symptoms may be related to inflammation of other body parts. They could have severe arthritis - which is inflammation of the joints. They could have uveitis or episcleritis - which is inflammation of the eye. They could have skin rashes. So, a whole slew of symptoms.
Host: Can ulcerative colitis be serious or life threatening?
Dr. Malhotra: Yes. So, let’s talk about short term. Untreated disease, first of all, is a huge burden on the patient. They can have debilitating symptoms and therefore, it’s not just a burden on their workforce where they are forced to miss work due to their symptoms but also, you know, people miss out on their social and family life. So there is the personal, social and financial impact. But then there’s untreated or complicated disease that can certainly become bad enough to require urgent or emergent surgery and hospitalization. So we always try to avoid a situation where an emergency surgery may be needed. Patients may need emergency surgery for refractory bleeding where their colon is bleeding so much that they may be exsanguinating. They can get a toxic megacolon where the colon swells up and does not function and can cause life threatening infection if not taken out emergently. So those are sort of the short term serious, life threatening implications. Long term, the risk of untreated ulcerative colitis is a huge risk of cancers. So, untreated disease puts patients at risk of colon cancer almost 8-fold compared to someone without ulcerative colitis. And non-colon related patients are at risk for developing something called PSC, which is primary sclerosing cholangitis. It’s inflammation and scarring of the bile ducts and it puts them at risk for a bile duct cancer called cholangiocarcinoma as well as gallbladder cancers. So really, long term and short term implications on their health.
Host: Could you tell us a little bit about your patient population for ulcerative colitis?
Dr. Malhotra: Sure, ulcerative colitis has a bimodal peak of incidence, so patients may present in their mid to late teens all the way up to early thirties. And then there’s a second peak with patients in their 50s to early 60s
Host: So often ulcerative colitis begins gradually and then gets worse. How is it diagnosed?
Dr. Malhotra: So actually, about a third of patients may present with mild disease and continue to have mild disease throughout the course of the disease. A third of patients may present with mild disease and at some point gradually or sometimes all of a sudden worsen to have severe disease. And about a third of patients may present with severe or even what we call fulminant disease, where they need emergent hospitalization, aggressive therapy and sometimes even surgery immediately. So, diagnosis is based upon endoscopy and biopsy. So, most patients will need a colonoscopy. Sometimes we just do a flexible sigmoidoscopy if the colon is really inflamed and not go the entire length of the colon. And it’s really important to make sure that the patients, at the time of diagnosis and really at any point when their disease is worsening, don’t have a concurrent infection with clostridium difficile, which is C. diff. C. diff is a bacteria that’s increasing in the community in general, but it’s present in patients with colitis in a significant more proportion than patients without colitis. And, the presence of C. diff makes ulcerative colitis more difficult to treat. It increases the risk of getting hospitalization and the risk of getting an urgent colectomy.
Host: What medical treatments are available for ulcerative colitis?
Dr. Malhotra: There actually many treatments available today. Mesalamine, which is a very old drug and we still use it in practice, is used for mild disease as first line therapy. Then there’s immunomodulators, such as Azathioprine or 6-mercaptopurine, which modulate, as their name suggests, modulate the immune system. So they decrease inflammation over time. We’re sort of steering away from those medications as first line as better and improved drugs are available on the market. And then there is biologics, which are medications that bring down inflammation and actually help heal the lining of the colon. And in reality, since the advent of these biologics, the face of colitis has changed. Less patients are getting surgery and more patients are achieving healing. The first biologic that was approved was infliximab. Now it’s been on the market for almost 18 years and it works very well in patients with colitis. And then there’s two other similar biologics - adalimumab and golimumab. There was another mechanism of drug that was approved in 2014 called vedolizumab which works completely different and, again, works really well in colitis. So, overall, we have a lot of medications. We are also anticipating approval of two new medications with different mechanism of action, hopefully this year - tofacitinib, which is a jak inhibitor and ustekinumab, which is actually approved in Crohn's disease and is hopefully going to be approved for ulcerative colitis as well.
Host: Is surgery an option to cure ulcerative colitis?
Dr. Malhotra: Yes. Removing the colon is actually curative of ulcerative colitis. We usually reserve a colectomy, a removing the colon, for patients who are not responding to our best medications or they’re extremely sick and their chances of responding to a medication is very low. But, I always tell my patients, getting surgery to remove colon is not failure of treatment - it’s just another modality of treatment. Surgery is done best when it’s planned. So, emergent surgery can sometimes be difficult as it can involve up to 3 procedures for the patient to complete the surgery and can even involve having a temporary ileostomy. But yes, in short, removing the colon is curative of ulcerative colitis. I do want the listeners to be aware that primary sclerosing cholangitis, which is inflammation of the bile ducts, can still happen or occur as a complication of ulcerative colitis, even years after their colon is taken out. So, even if they’ve had a colectomy, it’s important for them to follow up with their GI provider at least once a year to make sure that it’s not a complication they’re developing.
Host: When you have patients who you recommend surgery - what is their emotional state, what is their mental state, when you recommend that they have their colon removed?
Dr. Malhotra: You know, nobody wants to hear that they need emergency surgery or part of their organs removed. The good thing about the colon is we don’t really need the colon for any nutritional support. The colon’s there to absorb water. Now, that being said, of course we are finding more and more that the microbiome, which is the life of bacteria, fungi and viruses that live in our colon, have a lot to do with our overall health. So maybe there are some long term implications of getting your colon taken out that we don’t recognize to date. However, studies have actually been done in patients who did undergo a colectomy for their colitis, and most of those patients, in retrospect, were relieved after the surgery as they got their life back. They lived a better, fuller life. And most of the patients did respond saying that they wish they had gotten the surgery earlier.
Host: Could you share a story about a patient who had a poor prognosis and you were able to help them?
Dr. Malhotra: I saw a young lady, in her late 20s, single mom, she’d been battling with ulcerative colitis for many years, and because of social issues had very fragmented care and had been on steroids for many years. As we know, we’re really deviating away from using steroids. Steroids have long lasting implications on a person’s body and health overall. I saw her when she was first admitted to the hospital. She was anemic, losing weight, having 20 bowel movements a day and just very depressed, understandably so, from her disease. We actually had our surgeons also see her because we were worried she may need a colectomy, but we initiated infliximab. She did extremely well with two treatments, was able to be discharged from the hospital, four months later, I just recently saw her in clinic. She’s doing great. She’s off of steroids and she actually has a part-time job and was just out of her depression and it just felt really good to see her getting her life back.
Host: Are you conducting any research regarding ulcerative colitis that people in the community should know about?
Dr. Malhotra: Yes. We’re currently partnered with Georgetown University Hospital to bring trials to Washington Hospital Center. We just completed enrolling for a trial for ustekinumab for ulcerative colitis, which we have completed enrollment at this time. We currently have a trial looking at the new drug filgotinib, both for ulcerative colitis and Crohn's disease. We’re also just about to start a trial looking at stem cell treatment for Crohn's disease with perianal involvement. And we’re also looking at novel ways to treat colitis that’s being caused by immunotherapy. Immunotherapy-induced colitis appears very similar to ulcerative colitis and so we’re looking at novel ways to treat that colitis, as well.
Host: Why is MedStar Washington Hospital Center the best place for patients to seek care for ulcerative colitis?
Dr. Malhotra: For diseases such as ulcerative colitis, which fall under the umbrella of inflammatory bowel disease, these conditions require very specialized and patient-oriented and patient-centered approach. We have a team of highly trained gastroenterologists with advanced training in inflammatory bowel disease, as well as a group of highly trained colorectal surgeons. We work together in a multidisciplinary approach for these complicated patients.
Host: Thanks for joining us today.
Dr. Malhotra: Thank you.
Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.