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FYI on the GI - 07/29/2009

In his early 20s, Adam Clark thought he was immune from health concerns. A gut feeling told him otherwise. It started in high school with periodic stomachaches. Then the diarrhea and vomiting began. “Being young, you think you’re invincible,” says Clark, who initially brushed off symptoms. Then at age 24, he lost 60 pounds within a year and was always tired. “I wasn’t eating at all,” Clark says. “Every time I ate, I had strong pains and I ended up throwing up. That’s how low it got.” Ironically, Clark, a metal machinist, couldn’t wait for lunchtime. He used the break to nap in his car. He soon learned from Hospital of Central Connecticut (HCC) gastroenterologist Mark Versland, M.D., that his fatigue came from the anemia he developed as part of Crohn’s disease, an immune system disorder that causes inflammation in the intestines. After two surgeries at HCC and ongoing medical care, Clark, now 38, is feeling well, even indulging, periodically, in once-forbidden popcorn. His Crohn’s disease is one of several gastrointestinal (GI) conditions the hospital tests for and treats.

A bit about belly tubing
“GI” problems include a range of lower gastrointestinal ills troubling millions of men, women, and children. Besides Crohn’s disease, these include ulcerative colitis, irritable bowel syndrome, diverticulitis and colorectal cancer. Each GI problem affects one or more sections of the digestive tract, which works like this: After digestion starts in the stomach, it continues with nutrient absorption in the nearly 20-feet of small intestine wrapped within the belly. Waste then moves to nearly five feet of muscular colon, the large intestine, where water is absorbed and stool formed. From the lower end of the colon, waste enters the rectum where it’s stored until passing through the anus. Depending on the GI condition, medicine may be all the treatment needed. Sometimes surgery is necessary, and in many cases at HCC, it’s minimally invasive. This means several smaller incisions vs. a large one, which helps reduce post-operative pain and speeds recovery.

An immune system gone haywire
Crohn’s disease, like ulcerative colitis, is a chronic inflammatory bowel disease (IBD).With IBD, the body’s cells that normally produce inflammation, as part
of the immune system, are out of control. For example, inflammatory cells typically work to treat an infection, and then turn off when the threat is gone. With IBD, the inflammatory cells don’t turn off and continually attack the intestines, explains Versland, who heads HCC’s Gastroenterology division. “In some cases, it’s difficult to separate Crohn’s and ulcerative colitis,” he adds, since symptoms are similar. These may include diarrhea, bleeding in the stool, weight loss, skin rashes and sores, low back pain, abdominal cramping, fever, mouth sores, and red, painful eyes. What distinguishes the conditions is the body parts affected. Ulcerative colitis affects only the large colon and rectum, but Crohn’s disease can affect the colon, small intestine, stomach and/or rectum. IBD affects over 1.4 million Americans, according to the Crohn’s and Colitis Foundation of America. Both conditions most commonly start in the teens through early 30s. Colonoscopy, a test that visualizes the colon, can help diagnose either disease, says HCC gastroenterologist Barry Kemler, M.D. The diseases have no known cause, tend to run in families and increase colon cancer risk, prompting the need for earlier colonoscopy screenings. Medical care aims to control GI tract inflammation and curb flareups or attacks, says Kemler, adding that a patient may be on more than one medication to reduce inflammation, suppress the immune system, and/or treat bacterial infection. Clark started on prednisone to reduce inflammation, and 6-mercaptopurine, an immune system suppressor. He also changed his diet, removing all roughage — broccoli, cauliflower, lettuce. Within months, he regained weight, but had periodic flare-ups, sending the Bristol resident to HCC’s Emergency Department about 25 times since diagnosis. “The pain was unbelievable,” he recalls of each attack. “I knew exactly what it was. I knew when I could take care of it and when I had to come into the ER.” Clark has had two surgeries within the past five years to treat complications that included a fistula, a pathway from the bowel to another organ into which stool may leak; and stricture, an intestinal narrowing. These days, Clark is feeling good. “I can eat pretty much anything I want to, in moderation. I can even eat popcorn.”

While Crohn’s disease has no cure, surgery can help patients, like Clark, whose symptoms continue despite other medical treatment. Surgery typically removes the part of the bowel most affected by disease. General Surgeon Michael Posner, M.D., says other IBD complications include a perforation, or hole, in the bowel; abscess, an infection, which can both cause stool or bacteria to move outside the bowel; and bowel obstruction that blocks stool passage. “You try and avoid surgery for Crohn’s disease whenever you can,” says Posner. “If you can control it medically, you’re better off.” Surgery can cure ulcerative colitis, explains colorectal surgeon Christine Bartus, M.D. With surgery, the small intestine assumes the role of the large intestine, and a small bowel “pouch” is made to take over the job of the rectum. This allows patients to avoid ostomy, which secures the small intestine to the abdominal wall and makes an opening for waste release into a small bag.

Spastic colon at work
Our bodies react to stress in different ways — sweaty palms, tension headaches, or frequent trips to the bathroom. Stress and anxiety can aggravate irritable bowel syndrome (IBS), also known as spastic colon, wherein the colon’s digestive process moves too fast or slow, causing pain and either diarrhea or constipation. Kemler says the pain occurs when the bowel is stretched. “It happens when the gas is redistributed in a smaller area, much like what happens if you squeeze an elongated balloon at both ends, causing the air to be forced into the middle of the balloon and stretching it out.” IBS, which doesn’t increase colorectal cancer likelihood, affects about 20 percent of men and almost 40 percent of women in the U.S., and is the most common reason patients see a gastroenterologist, says Versland. There is no definitive cause, but miscommunication between the brain and gut’s nervous system might activate IBS. Current research, says Kemler, shows a possible link between the intestines’ muscular response and altered stimuli from the bowel’s nerve endings. Versland recommends patients make lifestyle changes to avoid stress, get regular exercise and stay away from food triggers to IBS. These include coffee and other products with caffeine, carbonated beverages and gas-causing foods like cauliflower and broccoli. The probiotic bacterium in certain yogurts may help tame the belly. Medications to minimize symptoms might include a laxative, fiber, an antispasmodic, antidepressant or antibiotic.

Ironically, lack of fiber likely increases the GI condition diverticulosis. It affects the large colon’s lining, and is marked by small “outpouches” known as diverticuli, which extend outside the colon and usually present no symptoms but can cause constipation. “Once you’re over 50, the majority of people start to show outpouches,” says Kemler. “The basic treatment is to make sure the patient maintains a regular bowel pattern by having adequate fiber and fluid in the diet.” Infected pouches create a condition known as diverticulitis, which can lead to intestinal perforation. Diverticulosis is also the most common cause of significant bleeding from the colon, which can, at times, be life threatening. These conditions may require surgery, which can be performed with minimally invasive techniques, to remove the affected colon if medical treatment is not effective.

Aiming to find cancer early
Do you remember Katie Couric’s televised colonoscopy in 2000? She very publicly drove home the importance of colorectal cancer screening after losing her husband to the disease. Colorectal cancer, a catch phrase for colon and/or rectal cancer, is the third leading diagnosed cancer in the United States. In 2008, according to the American Cancer Society, nearly 149,000 newly diagnosed colorectal cancer cases were expected and almost 50,000 deaths anticipated from the disease. Colon cancer is nearly three times more common than rectal cancer. Despite increased publicity around colorectal cancer and the importance of colonoscopy screenings from famous and public figures, screenings remain well below target. On a national level, says Versland, only about 45 percent of people who need screenings get them. Screenings are critical because, unlike most other GI problems, colorectal cancer in its early stages typically has no symptoms. Advanced cancer symptoms include rectal bleeding, anemia, abdominal pain, constipation and colon blockage. “The most important thing that people need to know is prevention, which, for most people, means getting their colonoscopy at age 50,” says HCC hematologist/oncologist John Delmonte Jr., M.D. The hardest part of a colonoscopy, confirms Versland, is the patient’s prep work the day before, to cleanse the bowel. The screening, available at HCC, takes about 30 minutes during which a patient is sedated. A long tube with a camera passes through the rectum and into the colon to examine its lining for anomalies like polyps, usually removed at that time. These tissue growths, usually non-cancerous when small, can develop into cancer. In 2007, New Britain resident Dottie Walker, now 73, had a colonoscopy that revealed colon cancer. Luckily, it was at an early stage. At HCC, Bartus conducted a minimally invasive colectomy on Walker, which removed the cancer using only three small incisions. Since her cancer was at stage 1, she didn’t need chemotherapy. Chemotherapy is more typical with stages three and four, and sometimes two, says Delmonte. Walker says she felt fine within a week after the surgery. “I’m feeling great and have no effects from this.” Rectal cancer treatment can be more complicated because of the rectum’s location deep in the pelvis. Chemotherapy and radiation therapy might precede surgery to minimize long-term complications and reduce chances of cancer recurrence, Delmonte says. Both chemotherapy and radiation therapy are available at HCC. Surgery removes the tumor and reattaches the colon to the remaining rectum or anus, says Bartus. For this operation, an ostomy may be needed; it may be temporary and surgically removed weeks later. Like other cancer patients, Walker says she was upset with her cancer diagnosis but bolstered by faith and courage. Bartus acknowledges the emotional toll a cancer diagnosis and the prospect of surgery can take on patients. “We have an opportunity to help patients through a very difficult period, and then guide them on the path toward getting better.”