Ulcerative Colitis Blog

Ileal pouch anal anastamosis (IPAA) is usuallythe procedure of choice for young, healthy patients with ulcerative requiring colectomy since it requires 2-3 significant surgeries. After completion of the ileal pouch, or neorectum, from multiple loops of small bowel a continuous intestine is re-established.

After surgery it is expected that there will be diarrhea 5-10 times per day, sometimes resulting in dehydration and requiring aggressive anti-diarrheal mediciations. Over the course of weeks to months the diarrhea tapers to an average of 4 soft bowel movements per day.

There is rarely an impact on bowel absorption after IPAA, but because the terminal ileum is used to construct the neorectum with some loss of normal function, there may be B12 deficiency requiring supplemental injections.

A majority of patients develop at least one episode acute pouchitis after IPAA. It results in inflammation of the pouch causing stool urgency and rectal pain. Acute pouchitis responds to short courses of antibiotic or corticosteroid therapy. In about 5% of patients the pouchitis is recurrent, or chronic, requiring frequent or even continuous antibiotics, corticosteroids, or probiotics. Rarely, chronic pouchitis requires pouch resection and creation of an end-ileostomy.

Finally, Crohn’s disease diagnosed after surgery for suspected ulcerative colitis occurs rarely, but more often in patients with indeterminate colitis. Surgical revision to end-ileostomy is usually required.

A common question among UC patients is whether their diet may have caused or contributed to colitis. Numerous researchers have investigated this topic and found no conclusive evidence that there are specific food items that cause or worsen the state of inflammation in the colon.

Certainly, there are some foods which are more likely to result in GI symptoms than others. For example, if a person eats a whole bag of prunes, he or she is likely to develop diarrhea regardless of whether the individual has IBD or not. The food does not necessarily make the colon more inflamed, but it can cause common symptoms in almost every individual.

As an analogy, think about a cut on the skin. If lemon juice is squeezed over the cut, the cut will burn and hurt. The cut skin is not necessarily worse in terms of inflammation nor will it take longer to heal, it just temporarily hurts more because of the lemon juice. The same is true of various food effects on the colon in UC. When the colon is inflamed, ingestion of gas producing foods containing lactose or high fiber products may result in abdominal cramping and discomfort. These foods, however, will not cause the lining of the colon to develop more ulcers or bleeding.

Along the same line, bowel rest and intravenous nutrition may decrease the number of bowel movements a person has, but it does not specifically translate into healing of the lining of the colon. Your doctor may decrease your food intake if you are hospitalized for a flare to help you feel better until medicines begin to heal the colon.

Future blogs will contain more information about diet advice and UC.

I am posting this blog from south Florida, site of the 2007 national meeting of the Crohn’s and Colitis Foundation. Several provocative presentations have been made, some of which I will summarize over the next several days.

Researchers from Johns Hopkins, the Mayo Clinic, and Kaiser Permanente (Hutfless S, et al) studied the risk of cervical cancer in patients with inflammatory bowel disease (IBD). Using a large database including 30% of the population in the San Francisco Bay area the authors identified eight cases of cervical cancer out of 1841 patients with IBD and a pap smear. The risk of cervical cancer in IBD patients was 1.7 times greater than in healthy controls, but this difference was not quite statistically significant. When the results were broken down by medication, there was no increased risk of cervical cancer in patients taking corticosteroids, immune modulators (methotrexate or azathioprine), or 5-aminosalicylates, while patients on infliximab had an eleven-fold increase in risk.

An even larger study would be required to better determine the risk of cervical cancer in various treatment groups. Fortunately, the pap smear is an effective screening test for cervical cancer and all IBD patients, especially those on infliximab should have appropriate and regular screening. Furthermore, girls and young women with IBD should receive the HPV vaccine to reduce their risk of cervical cancer.

Brenda wrote in to our blog regarding her daughter who was recently diagnosed with UC and is having difficulty with low potassium levels. Brenda's question was whether or not her daughter's recurrent symptoms of diarrhea could be a result of low potassium levels in the blood.

The medical term for low blood potassium is "hypokalemia". In general, there are 3 ways people can develop low potassium levels:
1) The potassium in the blood can move into cells in the body making the blood level low
2) Excessive potassium can be lost by the kidneys and excreted in the urine
3) Excessive potassium can be lost by the gastrointestinal tract through vomiting and/or
diarrhea.

In IBD patients, a common cause of low potassium levels is diarrhea. A considerable amount of potassium can be lost in stool which can disrupt electrolyte balances. As such, it is more likely that diarrhea would cause the low potassium levels as opposed to the other way around (ie; low potassium levels causing diarrhea). When bouts of diarrhea occur, it is important that individuals (both those with and without IBD) rehydrate themselves with drinks that contain glucose, sodium, and potassium. The glucose and sodium help the body retain more fluid and stay hydrated while the potassium makes up for losses in vomit and stool. Gatorade and Pedialyte are examples of drinks which contain these components.

Another cause of low potassium in IBD patients is steroids. The addition of steroids (which is necessary to decrease inflammation and treat the disease) can affect hormones that regulate steroid balance in the body. Potassium supplements may be needed to maintain a stable balance.

Although these are probably two of the more common reasons one would see low potassium levels in IBD, it should be noted that there are many causes of low potassium levels including other medications, hormone effects, and kidney conditions. Therefore, if you are suffering from low potassium levels it is important to inform your doctor of all the medications you are taking - both prescription and nonprescription - and all medical conditions for which you are being treated. By simultaneously analyzing potassium levels in the blood, urine, and stool, your doctor may be able determine where the loss is occuring and gain a better understanding of the cause.

Here are summaries of two important studies presented at the 2007 CCFA national conference.

ACT 1 and 2 are multi-center studies which tested the effect of infliximab in patients with moderate to severe ulcerative colitis. The initial study results showed that infliximab led to greater response and remission than placebo. A sub-analysis was performed on patients from the ACT 1 and 2 studies to assess the incidence of colectomy at 54 weeks. Patients treated with infliximab had a lower rate of colectomy (14.8% vs. 9.5) 54 weeks after their first infusion. In addition, overall surgeries and hospitalizations were lower in patients treated with infliximab than those receiving placebo.

Dr. Waljee working with Dr. Higgins at the University of Michigan used a novel computerized technique in order to predict optimization of azathioprine and 6-mercaptopurine dosing. The authors used machine learning, a computerized modeling technique, which places different weights on input variables in order to best predict an outcome. The authors found that their computerized algorithm predicted medication optimization better than the current approach of checking blood levels of 6-thioguanine (6-TG) and (6-MMP). Since the algorithm uses blood count and liver tests which are already drawn for routine safety monitoring the costs were lower than commercial metabolite testing. Further studies will be needed to validate the accuracy of this promising approach.

The concept that the origin of adulthood disease may be influenced by environmental factors early in life has become a topic of great interest. In utero events, pre-term birth, and low birthweight have been associated with the development of some chronic diseases later in life. In the November edition of the Inflammatory Bowel Diseases Journal, investigators from Germany performed a study to determine whether a variety of early life events may make people more likely to develop IBD. Over 1800 patients with IBD were compared with 900 healthy individuals regarding their gestational age at birth, mode of delivery (C-section vs. vaginal), birthweight, history of health problems during their mother's pregnancy, breastfeeding, and health problems in the first year of life. The researchers found that individuals with IBD were one and a half times more likely than healthy controls to have been born pre-term and have a maternal history of health problems while their mother was pregnant. Furthermore, people with IBD were twice as likely to have had a significant illness during the first year of life. No association was found between mode of delivery or history of breastfeeding and the development of IBD.

While the finding of an association between two factors does not prove a causal link, it does provide interesting fodder for thought. Pre-term birth and maternal complications during pregnancy are often a result of infections. It has been postulated that early exposure to pathogens may in some way program the immune system predisposing to inflammatory disease later in life. Pre-term birth and maternal complications may result in physiologic stress to a fetus, altering the hormonal or immunologic milieu with longstanding consequences. While the current research is speculative at best, it does open more avenues for possible investigation into the cause of IBD.

The human gastrointestinal tract is a unique environment home to millions of bacteria. There is a great deal of interest in understanding the role these bacteria play in the GI tract and how they can be modulated to treat disease.

Probiotics are living organisms in food and dietary supplements which when ingested, improve the health of the host beyond their inherent, basic nutrition. Similar to the living bacterial cultures in yogurt, probiotics are ingestible cultures of organisms believed to have health benefits. Examples of probiotics include: Lactobacillus GG (LGG), Lactobacillus acidophilus, Saccharomyces boulardii, Bifidobacterium, and E. coli Nissle 1917. Studies in ulcerative colitis have shown that probiotics do not differ significantly from 5-ASA medications for remission of UC with regard to efficacy or safety. Whether they add an additional health benefit when used in conjunction with conventional therapy is an area of active investigation

Probiotics have been shown to have a definitive benefit in the treatment of chronic pouchitis for UC patients who have undergone colectomy with creation of an ileal pouch. A study of the probiotic VSL#3 showed that 90% of patients taking the probiotic had remission of symptoms after a year, compared to only 60% of patients who took a placebo. Other studies suggest that VSL#3 may be useful in preventing pouchitis in patient who undergo colectomy. Studies of Lactobacillus GG in pouchitis, however, did not active the demonstrate the beneficial results as VSL#3.

It should be noted that because probiotics are not a "drug" type therapy, their manufacturing and use is not overseen by governmental body such as the FDA. As such, there is diversity among probiotics in terms of the number of active organisms contained in each and their potential efficacy. Patients considering the use of probiotics are advised to speak with their doctors regarding the efficacy and choice of a probiotic for their condition.