Question:
What is ulcerative enterocolitis? Does it affect the lining of the small and the large intestine (which portions?) Is it considered ulcerative colitis? Is it a rare form of ulcerative colitis?

Dr. Siegel:
Enterocolitis refers to inflammation of the intestinal lining, which involves both the small and large intestine. This term is typically used to describe a process that is occurring, as opposed to referring to a disease entity itself (like ulcerative colitis or Crohn's disease). Therefore, the term ulcerative enterocolitis is not really considered a form of ulcerative colitis, but a degree of inflammation that occurs in the bowel that can be caused by a number of things (such as infection, medications, possibly inflammatory bowel disease, or other).

Question:
My sixteen year old daughter is suspected of having Crohn's Disease because a thickened ileum was seen on colonoscopy. Her only symptom is mid-abdominal pain (since November 2011). How do we know if this is a bacterial infection or Crohn's? I want to be sure we are getting an accurate diagnosis.

Dr. Siegel:
Sometimes it is more difficult than others to make an accurate diagnosis of Crohn's, so you are asking a good question! We can see subtle abnormalities on imaging tests (CT scan, MRI or barium studies) and colonoscopy that can look like Crohn's, but may not be. A diagnosis of Crohn's needs to be made based on a combination of things including colonoscopy, imaging tests, x-rays, biopsies, symptoms, and sometime how things progress over time. Not one thing can make the diagnosis. Therefore, the "thickened ileum" you ask about on colonoscopy could be Crohn's, but this alone is not enough to make this diagnosis. Infection should always be considered, and can in fact be confused with Crohn's.

Question:
Can you explain why most doctors prefer the TNF blockers and other biological instead of prednisone? My son, who has had the disease for 15 years, refuses the biologicals and would rather have cortisone. His Crohn's is severe.

Dr. Siegel:
Prednisone does make people feel better quickly, but has two very big problems. First, prednisone has significant side effects. Some of the side effects that occur frequently in the short term include acne, weight gain, a "moon face", and mood changes. Over a longer period of time, prednisone can cause osteoporosis (weakening of the bones), cataracts in the eye, diabetes, significant damage to the hips, amongst others. The second problem is that prednisone does not lead to healing of Crohn's and therefore does not prevent complications of Crohn's from occurring (such as fistulas, strictures and the need for surgery). In fact, some believe that prednisone might lead to MORE complications developing from Crohn's. The biologic medications (including anti-TNF drugs) and immune modulator drugs (such as 6-mercaptopurine and azathioprine) can improve symptoms of Crohn's, prevent complications from developing and keep patients off of steroids (we call this "steroid-sparing"). Although there are some side effects to consider with these medications as well, they are FAR less frequent then the problems with prednisone, and in fact, I consider prednisone our most dangerous drug!

Question:
I was diagnosed with Crohn's Disease a few months ago. MY GI doctor prescribed Asacol 1600 mg. three times a day. I have never had to take any medication on a regular basis before, but this seems like an excessive amount. Is this the normal dosage for Asacol?

Dr. Siegel:
Asacol is typically dosed at either 2400mg daily, or 4800mg daily. Therefore, you are at the higher dose, which may be appropriate for you. We have learned that Asacol (and medications like Asacol called 5-aminosalicylate drugs) as less effective for Crohn's than we used to think – so it is worth talking to your doctor to make sure that this is indeed the right medication for you.

Question:
My husband has a severe case of ulcerative colitis. He is 36, very active, and otherwise a healthy person. He is on Remicade and Imuran as well as prednisone. His current flare up has been extremely severe with major weight loss, foliculitis, mouth sores, and an inflamed uvula. He seems to be improving. Our gastroenterologist has told us that surgery is most likely. Given his age and activities (snowboarding, mountain biking, a colostomy bag would devastate him. What advances in surgery are coming down the road? We've heard that the "j" pouch, while not requiring a bag, can have a lot of complications and still leave you sick.

Dr. Siegel:
You are asking this question at a good time, before he definitely needs surgery. I believe it is very important to have time to plan and ask questions. First, even very active people have done great with an ostomy (a bag on your side to collect stool). In fact, there have been professional hockey and football players who have had them! With that said, many young, active people prefer to have the J pouch surgery. Most of the recent advancement in surgery has been in continually improving this operation so that many of the complications that used to be problems in the past are now very infrequently an issue. There are other types of surgeries that have been done (one example is a Koch pouch, which is a different kind of internal pouch), but very few places do these because they have a higher rate of complications than a J pouch. Most people who have a J pouch do very well, and lead normal, active lives.

Question:
I have had Crohn's for 20 years, 17 years of those I managed with diet. I am allergic to prednisone, pentasa, and sulfasalazine. I am looking to start Humira. I am currently on Entocort, but it stopped working after three months. Would this be a smart way to go in treatment?

Dr. Siegel:
t is not unusual for Entocort to work for a few months, but then to lose some benefit. At this point, it sounds like your options include either an anti-TNF drug (Humira, Remicade or Cimzia) or an immune modulator drug (6-mercaptopurine or azathioprine). All of these medications can be effective for Crohn's disease. A choice between them could be made by reviewing the benefits and risks of these medications with your doctor and discussing your preferences of taking pills versus shots versus an intravenous infusion.

Question:
I have had ulcerative colitis for 20 years, and had a colon resection 10 years ago. When active I have severe bleeding, pain and diarrhea. I now have severe cramps, less blood and less diarrhea. Currently I am taking only medication to relax the colon and take fiber supplements. The pain is much more severe than ever before and now interferes with my daily routine.

Dr. Siegel:
When pain or new GI symptoms occur after surgery to remove the colon I think of a few things. First, scar tissue can develop (adhesions) and lead to bowel blockages and pain. Second, we always need to consider the possibility that it was not ulcerative colitis but Crohn's disease, and perhaps bowel inflammation is causing a problem. Third, irritable bowel syndrome can be a problem – and typically treated as you mention (with fiber and medications to relax the bowel). If you have not had a scope to look into your remaining bowel or any imaging test (CT scan or MRI) this would be a first step to help figure out if there is some inflammation that needs to be treated.

Question:
I have ulcerative colitis for the past three years. I've had C-difficile three times and have had so many narcotics, it has resulted in narcotic bowel syndrome. I have high amounts of pain that stop me from my daily activities. I need pain relief, and I am very depressed.

Dr. Siegel:
Unfortunately, pain and depression can occur when Crohn's disease and ulcerative colitis are not well controlled. I would strongly encourage seeking the help of both a pain specialist to help get you off of narcotics and on to other medications to treat your pain, and either your gastroenterologist, primary care provider or a psychiatrist to help treat depression. Pain and depression are both serious conditions, and need to be treated just as much as your ulcerative colitis.

Question:
My son was diagnosed with indeterminate colitis five weeks ago after severe diarrhea, bleeding and rectal pain which lasted for three weeks. During that time he lost 20 pounds and was hospitalized for four days, where he was give IV steroids. He is currently taking prednisone and asacol. He was tapering down from the prednisone, and was at a dose of 20mg once a day (down from 60mg). The asacol dose was two tablets, three times day. Three days ago he began having diarrhea, cramping and bleeding. The doctor increased his Asacol to three tablets, three times a day and prednisone to 20mg twice a day for three days and start to taper again. How long does it usually take for the Asacol to start working? Could the reason for the relapse be that the Asacol had not fully begun to work?

Dr. Siegel:
Asacol can take up to 4-6 weeks to work fully, and the maximum daily dose is 4.8 grams per day. When someone has had severe disease, it can take longer for the bowel to heal and symptoms go away completely. I typically would not start to taper the prednisone until symptoms are pretty much gone completely, and then slowly come down on the dose, dropping the dose by about 10mg every 2 weeks. If he is not getting better with the higher dose of prednisone, then it is important to look for signs of infection, specifically C. difficile or cytomegalovirus (CMV) infection. Rarely, Asacol itself can cause more diarrhea, so keep this in mind if it seems like the medication is hurting him more than helping him.

Question:
I am a radiologist and a Crohn's patient. I was diagnosed 17 years ago and surgery was performed 15 years ago with resection of 50cm from the terminal ileum and cecum. I am suffering from the same symptoms of diarrhea and abscesses again and in addition a new symptom of colicky obstruction pain. I did an MRI enterography and it revealed three active segments, 2 in the terminal ileum measuring about 25 and 18 cm and the third one involving the sigmoid. I started on prednisone 40mg, yet no response was achieved. I heard about Entocort, but it is not available in Egypt. I will try to bring it in, but should it be the oral or the enema, or can I use both medications to control the ileal and sigmoid activity?

Dr. Siegel:
It is important to know if the segments on the MRI that you mention show active inflammation, or fibrosis (scarring). If there is active inflammation, then the Crohn's may be treatable by medications. But, if it is all scar tissue (causing narrowing/stricturing) then medications are unlikely to help and you may need another surgery. Also, if there are currently abscesses these may need to be drained by either a surgeon or a radiologist. At the very least, antibiotics are needed for the abscesses. Entocort is probably not the right drug for you. It is a good treatment because it acts like a low-dose of prednisone, but without prednisone side effects. However, if even a full dose of prednisone did not help, Entocort will not help either. I would encourage being evaluated to see if you need surgery, and if not, to consider an anti-TNF agent with or without an immune modulator drug.

Question:
I was diagnosed with UC one month ago. I am on Colazal, three pills, three times a day and mesalamine enemas every night. Before I was diagnosed I could not even touch my stomach because my intestines were so sore. That is gone. What makes you go into remission and have normal stool, and still have diarrhea? Will the foods you eat that will help you go into remission?

Dr. Siegel:
It is terrific that the discomfort has improved, as this probably means that the inflammation is quieting down. If you are still having diarrhea this may be because there is still some inflammation that needs a longer time to heal. Other reasons why you can still have diarrhea include possible infection, or irritable bowel syndrome (IBS) than can occur after having inflammation (called post-inflammatory IBS). There are no specific foods that will help you get into remission faster, but some foods can make you feel worse, particularly dairy, during a flare. Many patients can tell us what foods are right or wrong for them, as this is very individual.