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Digestive Diseases

Treatment for Inflammatory Bowel Disease

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While there is no cure for inflammatory bowel disease (IBD), lifestyle changes, medications and surgery may help reduce the signs and symptoms of IBD and help bring about remission (a period of time when symptoms fade).

Diet and Lifestyle Changes to Treat Inflammatory Bowel Disease (IBD)

Diet. What you eat cannot cause IBD, but certain foods may worsen your symptoms. Our nutrition team, working in close collaboration with your gastroenterologists, can help you modify your diet to reduce symptoms of IBD and also make sure that you are eating and absorbing enough food to meet your nutritional needs.

Smoking cessation. Smoking may be a cause of IBD and may also worsen symptoms. Thus, it is important to try to quit smoking. Talk to your doctor about the various options available to help you stop smoking.

Stress relief. While stress is not a know cause of IBD, as with many chronic diseases, stress can worsen the symptoms of IBD or bring about a relapse. Thus, it may be helpful for people with IBD to use positive ways to reduce stress such as exercise, yoga, meditation, massage, breathing exercises, and biofeedback. Support groups and therapy may also help people cope with the physical and mental aspects of living with IBD.

Medications to Treat Inflammatory Bowel Disease (IBD)

A variety of medications are available to help manage the symptoms of IBD and try to keep the disease in remission. No single medication is right for each person, so it is important to work with your doctor to determine what is right for you. These medications include:

  • Antibiotics
  • Anti-inflammatory agents
  • Steroids
  • Immunologic agents
  • Biologic agents

Our physicians try to use the least toxic medication to get the best results. As shown in the treatment pyramid (Figure), treatment often starts with anti-inflammatory agents and may involve use of a combination of oral (by pill) and topical (by an enema) agents to get the best effect. If you have proctitis, which is an inflammation of the lining of the rectum at the very end of your gastrointestinal tract, the enema will not reach this area and your doctor may give you a suppository containing an anti-inflammatory agent. Another early step is to give antibiotics to patients with Crohn's disease.

If you have more severe IBD, corticosteroids may be necessary. Because of the side effects linked to corticosteroids (described below), these agents are only used for a short time – two to three months – to limit patients' exposure.

The next step is immunologic agents, which are used to suppress the overactive immune system in the gut and help lower the dose or keep patients off of steroids. These are used less often in Crohn's disease than in ulcerative colitis.

At the top of the pyramid are the biologic agents. In the past, biologics were used after a failure of response to corticosteroids or immunomodulators. Now researchers are beginning to evaluate use of these in select patients earlier, sometimes after a short course of steroids or instead of using steroids. Doctors are cautious in using biologics because of their side effects (described below), but in select patients with severe disease, biologics may limit or prevent the need for corticosteroids.

Surgery to Treat Inflammatory Bowel Disease (IBD)

Surgery should be looked at as a therapeutic option rather than as a failure of therapy. Indeed, the goal of surgery is to improve quality of life and help patients lead healthier, more active lifestyles. For example, if only a short segment of your small intestine is affected by Crohn's disease, you may benefit from surgery without the exposure to potentially harmful side effects of medications. Although the use of medications such as biologics or immunomodulators can be indispensable for many patients, their prolonged use in the setting of a poor response may delay surgery, and as a result, may increase the risk for complications. Optimal timing of surgery and early partnership with our surgical team insures the best quality of life. While surgery is not the first approach used to treat Crohn's disease or ulcerative colitis, it can greatly restore quality of life in people who are struggling to get better despite medical treatment.

Optimal timing of surgery is critical. A close collaboration between gastroenterologists and surgeons is key to the proper treatment of patients and is a benefit of care at NewYork-Presbyterian Hospital. Our colon and rectal surgeons are some of the world's leaders in laparoscopic surgery, and the majority of elective colon and rectal surgeries by this team are performed laparoscopically. Laparoscopic surgery is performed through a small incision rather than larger incisions made in traditional open surgery, which reduces healing time, pain, and hospital stay.

Surgery to Treat Crohn's Disease

Surgery for Crohn's disease is offered when medications are no longer effective or may even be harmful. For example, in a person with a long history of Crohn's disease, areas of inflammation in the bowel may develop a stricture (a narrowing of the intestines) that may block the passage of food. Since the stricture occurs as a result of scar tissue, it may not improve even with the strongest anti-inflammatory medications. In this case, surgery is the only way to restore intestinal flow. Surgery may also be needed to treat a symptomatic fistula (an abnormal connection between two organs) that is the result of severe inflammation. The fistula could be between two loops of intestines, or may even involve the bladder or vagina.

As a general rule, our surgeons aim to preserve as much of the bowel as possible (using bowel sparing surgery) when surgery is needed. Typically, for isolated disease that affects only a small area of the intestine, the initial operation used is called a resection. The surgeon will cut above and below the diseased area, remove a section of the intestine, and reconnect the two areas. This allows for the relief of symptoms such as bloating, nausea, pain, and vomiting.

Short areas of stricturing can be treated with a procedure called a strictureplasty. A strictureplasty does not remove the diseased segment of the bowel, but opens the narrowing in a way that restores flow of intestinal contents and allows nutrients to be absorbed. Sometimes, it is necessary to undergo multiple strictureplasties in a single operation if several areas of the small intestine are diseased.

When stricturing is more extensive (over a greater area) and patients have threatened short bowel syndrome, a side-to-side isoperistaltic strictureplasty may be needed. This technique was developed by Dr. Fabrizio Michelassi, the surgeon-in-chief at NewYork-Presbyterian/Weill Cornell, and alleviates symptoms while preserving as much intestine as possible.

More than half of people who are diagnosed with Crohn's disease will eventually need an operation during their lifetime. After an initial resection, many patients require additional surgery for inflammation in new areas of the bowel. Because of this chance for developing recurrent Crohn's disease after the first surgery, our gastroenterologists use early intervention including postoperative therapies to prevent recurrence, Often postoperative endoscopy is effective in identifying patients who are more likely to developed recurrent Crohn's disease and therefore are more likely to require aggressive postoperative therapy. The hope is that by identifying patients who are at risk for disease recurrence following surgery, we can prevent that recurrence from happening. Thus, the use of laparoscopic surgery at NewYork Presbyterian Hospital is helpful because it results in less scarring, making it easy to perform future operations laparoscopically. It also leads to faster recovery, less pain, and earlier discharge from the hospital.

Surgery to Treat Ulcerative Colitis

A proctocolectomy – removal of the entire colon and rectum – is the most common surgery for ulcerative colitis. Since ulcerative colitis involves only the large bowel, this operation is considered curative. The end of the small intestine, after it is disconnected from the large intestine, is then used to create an ileostomy, or used for an ileoanal reservoir. An ileostomy (or stoma) is a small opening surgically created in the abdominal wall through which the end of the small intestine, the ileum, is brought to the skin's surface to allow waste to drain into a bag attached to the opening. Patients have their health and quality of life restored, and this remains a great option for many. There are no activity restrictions with an ileostomy, and patients can work, play sports, and go out to eat (activities that were often difficult with active disease).

An ileoanal anastomosis, also called a pull-through operation or a J pouch, avoids the use of a permanent bag to drain waste. The surgeon removes the diseased colon and rectum, preserving the anal muscles necessary for bowel control. The ileum is used to create an internal reservoir (or pouch) that holds waste, and this is then surgically attached to the anal muscles. This enables the patient to pass waste (stool) via the anus. Bowel movements may be more frequent and watery than usual.

The main complications of the ileoanal anastamosis include pouchitis (inflammation of the J pouch), infection, and bowel obstruction. Some patients experience a mild amount of anal leakage as well, due to the liquid nature of the stool. Despite these complications, over 90% of patients who have undergone an ileoanal pouch consider their quality of life to be excellent, and would make the same decision to undergo the procedure again. Patients have a choice in whether to have a permanent ileostomy or an ileoanal anastomosis; both surgeries are effective and help restore quality of life equally.

Fertility and Inflammatory Bowel Disease (IBD)

Some studies suggest that fertility may be decreased after an ileoanal pouch procedure, but this by no means suggests that women who have undergone this procedure can't have children. Indeed, many woman of child-bearing age have spontaneously conceived and given birth successfully after this procedure. It is possible that pelvic scarring may be the cause of this decreased fertility, and therefore the current laparoscopic techniques used at NewYork-Presbyterian Hospital are attractive in that they reduce the amount of internal scarring.

Contact

Digestive and Liver Diseases, NewYork-Presbyterian/Columbia
Directions
(212) 305-1909
Gastroenterology and Hepatology, NewYork-Presbyterian/Weill Cornell
Directions
(646) 962-4463
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