Management of Co-Existing Disorders That Make IBD Worse S. Kane, M.D., W. Tremaine, M.D. Rochester, MN, test

Sunanda Kane, M.D.

Case 1 29 yr old woman with history of Crohn’s disease of terminal ileum, colon Presents to office with several months of worsening lower abdominal pain Has episodic diarrhea and bleeding Currently on adalimumab + azathioprine On physical exam tender in periumbilical area, no rebound guarding or mass

Case 1 continued Labs including CBC, CRP normal Fecal calprotectin level normal Empiric trial of anti-spasmodic no help, she returns a month later with same sx CT performed

CT Scan

Case 1 continued Endometriosis can present with cyclical symptoms that patients will describe as “intermittent” or “unpredictable” Can present with diarrhea, bleeding that correlates with menses or just pelvic pain Jess T. Gut 2012; 61(9):1279-83.

Case 2 28 year old Crohn’s ileocolitis for 9 years Previous 12 cm ileal plus cecal resection Maintenance treatment: Adalimumab 40 mg weekly. Blood levels therapeutic. Current symptoms: Abdominal pain, bloating, distension. Loose stools, 0-5 daily.

Case 2 continued Physical exam Looks well No abdominal mass, mild direct tenderness Rectal. No lesions. No perineal descent with valsalva Colonoscopy Patchy erythema and granularity in the colon, no ulcers, normal TI

Rectal Balloon Expulsion Test Lying Measurement Weight Normal < 200 gm The rectal balloon expulsion test can be performed in the left later decubitus or in the seated position. In the left lateral position, the patients are asked to expel a balloon filled with 50 cc of warm water and connected over a pulley to a series of weights. Normally, patients can expel this balloon spontaneously or aided at maximum by up to 200 gm of external traction. On the other hand, patients with a defecatory disorder required increased external traction to expel the balloon. Alternatively, the test can be done in the seated position. Normal subjects can generally expel the balloon in three to five minutes where as patients with a defecatory disorder require more time to do so. The balloon expulsion test is very sensitive and specific for identifying a defecatory disorder. Moreover, and abnormal balloon expulsion test predicts the response to biofeedback therapy. This also guides management. Because biofeedback, we now have at least two randomized trials demonstrating that biofeedback therapy is superior to laxatives for patients with defecatory disorders. Bharucha A et al. Gastro 2013. 144: 218-38

Faubion SS et al. Mayo Clinic Proceedings 2012; 87: 187-93

Results: Symptoms UC Crohn’s 16 46 25 39 57% 57% Number of patients N-R PFD pt. have Diarrhea 16 46 25 39 20% of N-R PFD pt. have constipation 57% 57%

Pelvic Floor Retraining 1:1 training with a physical therapist Three times daily for 5 days then 2 times daily sessions for 5 days Initially with rectal sensor and EMG monitoring; subsequently rectal balloon expulsion

Results: Pelvic Floor Retraining. n=19 Improvement No Improvement Total Female 4 6 10 Male 3 9 Ulcerative colitis Crohn’s Disease Ileal J-pouch Pouchitis No-Pouchitis 8 2 10/19 (53%) improved

Case 3 41 yr old male with Crohn’s ileocolitis presents with intermittent abdominal pain No weight loss, diarrhea, bleeding More stress at work with big project due Physical exam unremarkable Labs including CBC, CRP, chemistries nl Trial of amitriptyline initiated

Case 3 continued Pt returns 2 months later with worse RLQ pain, still intermittent though Not related to food CT scan performed

Case 3

Case 3 continued Midgut carcinoid causes pain No diarrhea if no liver mets Surgical resection is treatment

Case 4 38 year old 3 jejuno-ileal resections totaling 160cm, 7 strictureplasties 280 cm of small bowel from ligament of Treitz to ileocecal valve Certolizumab plus methotrexate maintenance therapy

Case 4 continued Abdominal bloating, cramping, 3-8 loose to liquid stools daily 3 kg weight loss in the past 9 months Exam Mild dehydration No abdominal masses Normal rectal exam and pelvic descent

Case 4 continued Glucose hydrogen breath test Negative Upper GI endoscopy Normal, including duodenal biopsies Duodenal aspirates Multiple bacteria with >105 CFU/ml

SIBO in IBS: Aspirates vs Breath Tests Uttar Pradesh, India 80 pt with IBS, Rome 3 UGI endoscopy with small duodenal aspirates Glucose hydrogen breath test Lactulose hydrogen breath test % Ghoshal UC et al. Eur J Gastro Hep 2014; 26: 753-60

Meta-analysis: antibiotics for SIBO Biancone 2000 Pimentel 2003 Collins 2011 Chang 2011 2.55 Overall (95% CI 0.1 10 Shah SC et al. Aliment Pharm Ther 2013; 38(8)

SIBO Treatment Trials Antibiotic Test Rifaxamin vs placebo LHBT Rifaxamin vs Metronidazole GHBT Metronidazole vs Cipro Neomycin vs placebo Shah SC et al. Aliment Pharm Ther 2013; 38(8)

SIBO in Inactive Crohn’s Disease Valencia Spain 107 pt with CD in remission Immune suppressants: 57% Biologics: 20% GHBT Positive 16.8% SIBO: YES vs NO P value Immune suppressants NS Biologics Dual Rx PPI Sánchez-Montes C et al. World J Gastro 2014; 20: 13999-14003

Case 5 32 yr old with history of Crohn’s ileocolitis presents with abdominal pain, bloating Patient trying to lose weight secondary to steroid course Some nausea but no vomiting, rectal bleeding or diarrhea Physical exam reveals some tympany to percussion but soft and non-tender

Case 5 continued Labs including CBC, CRP and chemistries all normal CT scan shows stable inactive disease Trial of amitriptyline unsuccessful Now what?

Case 5 continued Next visit significant other comes along Complains that “special diet” is expensive and disruptive to household Patient has researched “IBD diets” and is on a regimen that is supposed to boost the immune system and “cleanse the body as well as the soul” Contains nothing but high residue and high FODMAP ingredients

Case 6 39 year old. Crohn’s since age 14. Two ileal resections totaling 73 cm. Last surgery 5 y ago. No recurrence seen at Colonoscopy, MRE each twice in past 3 years. Negative WCE one year ago. Normal CRP, Vitamin D, A, E, Ferritin. On B12 shots. Watery stools, 8-10 daily. Abdominal pain. Stable weight No improvement with colesevelam tablets. Hydromorphone 8 mg each 4 hours

Case 6 continued Working diagnoses BAM bile acid malabsorption BAD bile acid diarrhea Narcotic Bowel Syndrome

BAM: frequency in chronic diarrhea Sheffield, UK 92 consecutive pt with chronic diarrhea Full work-up Endoscopies Capsule CT GHBT, LHBT SEHCAT Scan Diagnosis % * IBD, Functional 79 IBD 9 BAD 6 Lactose intolerance 4 Celiac disease 3 Lymphocytic colitis 2 Pancreatic insufficiency 1 SIBO * Some had 2 diagnoses Kurien M et al. Alimen Pharm & Ther 2014; 40: 215

Bile Acid Malabsorption Type 1: Post-ileal resection Type 2: Primary, idiopathic Type 3: Other causes cholecystectomy gastric surgery radiation

BAM: diagnosis SeHCAT Scan 7 alphaC4 blood test 24 hr stool collection for bile acids

BAD: treatment Treatment Dose Colesevelam 3.75-4.375 g/d Colestyramine 4-36 g/day Colestipol 5-30 g/day Loperamide, Diphenoxylate /atropine