As chairman of the Department of Medicine at Mount Sinai Hospital, Dr. Mark Babyatsky is a gastroenterologist who has specialized in inflammatory bowel diseases since 1984. Seventy-five percent of his patients have Crohn's ­disease.

Who's at risk

"Crohn's disease is an inflammation of any part of the digestive tract," says Babyatsky. "It's most commonly located in the small intestine or the large intestine." More than 500,000 people in the U.S. are living with Crohn's disease. An even greater number have ulcerative colitis, a similar inflammatory bowel disease that strikes the colon.

"For reasons that we don't completely understand, these numbers are increasing and Crohn's is becoming more common," says Babyatsky.

Some groups are at higher risk of Crohn's disease than others. "Doctors have long recognized higher incidence of Crohn's in people of Scandinavian descent and the Ashkenazi Jewish population, which is Jews of Eastern European origin," says Babyatsky.

"Western European Jews have a lower incidence." Doctors have recently found other groups at risk, and now agree that any group can get Crohn's.

The biggest risk factor is genetics. "There's a genetic predisposition, but it's not strictly inherited," says Babyatsky. "If your parent or first-degree relative had the disease, your risk is 5% higher."

Doctors are also exploring environmental factors that contribute to the risks, stomach bacteria in particular.
"There's good and bad bacteria in terms of inflammation," says Babyatsky. "But we're not quite there in terms of understanding how that affects Crohn's."

The disease commonly shows up in young people. "The most common age of presentation is 15 to 30 years old," says Babyatsky. "Crohn's tends to be a young person's disease, and can appear even in childhood." There's a second peak of diagnosis from age 60-80.

Signs and symptoms

Crohn's diseases presents itself in different ways, depending on where the inflammation is in the gastro-intestinal tract.

"Abdominal pain, diarrhea and bloody bowel movements are three textbook symptoms," says Babyatsky. "Secondary symptoms can include weight loss, nausea and loss of appetite." In some patients, the disease causes abscesses or fistulas that can affect surrounding tissue or organs.

For most patients, Crohn's symptoms present as sporadic attacks. "These are symptoms that come and go," says Babyatsky. "Some people have one attack and then it doesn't come back, but most people have recurrences." Crohn's attacks are often triggered by factors like stress, smoking, certain foods (especially high-fiber foods and dairy) and nonsteroidal drugs, including aspirin and non-aspirin products.

One challenge of living with Crohn's disease is that it can be difficult to diagnose. "It takes a while to get the correct diagnosis, and Crohn's is often confused with irritable bowel syndrome," says Babyatsky. In milder cases, patients may think they are feeling the effects of a change in diet or bowel habits, or even an infection.

Crohn's is easy to diagnose once the doctor orders screening tests like a colonoscopy, X-ray or CT enterography. "These tests give images of the GI tract's lining," says Babyatsky. "The doctor can actually see abscesses, strictures or inflammation."

Traditional treatment

Doctors now have a powerful array of treatment options for Crohn's disease. "The traditional treatments include a novel class of anti-inflammatory medications, immunosuppressive agents at lower doses, and antibiotics," says Babyatsky. "Most of these drugs are taken orally."

In the past 15 years, a newer generation of drugs have dramatically improved quality of life for Crohn's patients.

"Starting in 1998, we've had anti-TNF (anti-Tumor Necrosis Factor) medicines like Remicade," says Babyatsky. "These drugs are antibodies against an inflammatory substance that is increased in Crohn's patients."

Doctors call these drugs biologic treatments because they're directed against the particular biology of the disease. "Now there's a family of anti-TNF medications and these are used extremely frequently and effectively for many forms of Crohn's," says Babyatsky, "especially for people with fistulas."

Surgery is an option of last resort for most patients because the disease is recurrent and the drugs are so effective.
"Nonetheless, for some people surgery can be a tremendous option," says Babyatsky. "The surgeon removes the inflamed part of the GI tract, strictures or the fistula."

Research breakthroughs

Doctors' understanding of Crohn's disease has increased radically in the past decade. "We've found that there are two major pathways in the disease: the first related to the bacteria in the gut and their relationship to how the body handles them, including autophagy, a particular process of degeneration in the cells. The second is a specific pathway of the body's immune system.

Targets against these factors are being evaluated," says Babyatsky.

"The next step is to use this knowledge to develop the right strategies for treating diseases like Crohn's," he says. One hope is to use good bacteria, called probiotics, to counteract the bad bacteria that cause Crohn's.

Questions for your doctor

If you're diagnosed with Crohn's ask, "What are the triggers I can avoid?" For many patients the answers include nonsteroidal drugs, not smoking and certain foods. Another good question is, "What risk do my family members have of getting the disease?

The third question is, "Is this going to kill me?" Almost without exception, the answer is no.

Babyatsky counsels patients that Crohn's is now a manageable disease. "Under great care, patients have a normal life span and, in some cases, permanent remissions."

What you can do

Comply with medication.
Take your medications as prescribed and have a close working relationship with your doctor.

Keep a dietary chart.
The triggers for Crohn's are different for everyone, and keeping a chart can help identify your pattern. High-fiber foods and dairy are two common triggers.

See a nutritionist.
No single diet fits all Crohn's patients, so working with a nutritionist is key. Most nutritionists will ask you to keep a food log, then design a diet tailored to your specific needs.

Get informed.
The Crohn's Colitis Foundation (ccfa.org) posts excellent, up-to-date information, including search engines for clinical trials and physicians who specialize in the disease.

Ask about colon cancer screening.

Patients with Crohn's in the large intestine can be at increased risk of colon cancer. Most doctors advise colon cancer screening eight-10 years after diagnosis with Crohn's, and repeating it every one to two years.

nydailynews.com

-->Read more...

The specialist: Dr. Scott Nguyen on diverticulitis.

A gastrointestinal surgeon specializing in laparoscopic surgery, Scott Nguyen performs 300 to 400 operations a year. Ten percent of his patients at Mount Sinai have diverticular disease.

Who's at risk

You may never have heard of diverticular disease, but there's a fair chance you have it if you're over 60. Thirty percent of those over 60 have diverticula — pouches in the lining of the large intestine or ­colon.

"The good news is that the pockets themselves only cause problems for 20% to 30% of patients," says Nguyen. "When the pockets cause complications like localized inflammation or infection, we call it diverticulitis."

Another form of diverticular disease is diverticular bleeding, when pockets erode into the blood vessels of the colon and cause bleeding.

As of now, there's no known genetic component to diverticular disease. The primary cause of the disorder is thought to be the modern diet.

"This is a disease of developed countries," says Nguyen. "A low-fiber, high-fat diet is the biggest risk factor, so the obese and people who eat a lot of red meat and other fats are at elevated risk."

Because of the links to fiber, diverticular disease is also possibly associated with constipation.
Your odds of developing diverticular disease increase as you age. Both men and women develop the disease, but often at different points in their lives.

"Most people who develop diverticular disease before age 40 are men, and after age 70 are women," says Nguyen.

Signs and symptoms

The symptoms of both diverticulitis and diverticular bleeding can be extremely disabling.

"The red flag is the acute onset of lower abdominal pain, usually persisting for several hours, up to several days," says Nguyen. "The pain is relatively severe and often associated with a fever,
because it's a type of infection."

If left untreated, the pain often spreads throughout the abdomen and the infection can worsen into a severe infection like sepsis. In some cases the inflammation is so severe that it forms an abscess, erodes into organs like the bladder or blocks the colon.

"Most people have an attack or two of diverticulitis and go to see their doctor for relief," says Nguyen.

Diverticular bleeding is even easier to diagnose, and patients usually head to the hospital immediately. "The sign of diverticular bleeding is the sudden onset of painless rectal bleeding," says Nguyen, "This is profuse bleeding that often leads people to call 911."

The blood tends to be a bright, fresh red, but can also be darker old blood. In some cases, the bleeding is severe enough to cause fainting.

Traditional treatment

The first course of action for preventing or treating diverticular disease is lifestyle modification.

"That means changing your diet, getting exercise, losing weight," says Nguyen. "Unfortunately, it's very hard to change these habits."

During an acute attack, doctors use antibiotics to calm the infection. "Many people respond really well to this," says Nguyen. "But the standard of care is that if you have two or more attacks, you need surgery to remove the diseased area of the colon."

Surgical intervention is called for because these patients are more likely to have a recurrence and to develop complications like abscesses or serious infection.

"For people who had multiple attacks, surgery is successful and prevents another attack about 90% of the time," says Nguyen.

"If we can do it as an elective operation, where we can cool people off with antibiotics, they are usually in and out of the hospital within a week." The results of emergency surgery are much less ideal: Patients usually spend weeks in the hospital for recovery and often need an ostomy bag afterward.

Diverticular bleeding usually calls for admission to the hospital for intravenous fluids and possibly blood transfusions until the bleeding stops. Sometimes a colonoscopy or a special radiologic procedure can be used to halt the bleeding.

"If the bleeding doesn't stop, then we do emergency surgery to remove that section of the colon," says Nguyen.

Research breakthroughs

Doctors are still figuring out how diverticulitis works. "In the past, the traditional school of thought was that diverticulitis in people under 50 was a more virulent form of the disease, so we advocated earlier surgery," says Nguyen. "But now evidence shows that diverticulitis acts the same in young and old — that's a big change in dogma."

Another improvement is in surgical technique. "Laparoscopic surgery is becoming the preferred method, because it has a shorter recovering time and fewer complications," says Nguyen.

Questions for your doctor

If you have an attack of diverticular disease, ask: "What can I do to prevent this from happening again?"

A better lifestyle can protect you against recurrence.

Another essential question is, "Should I get a colonoscopy?" This test will both evaluate the extent of your diverticular disease and check for co-existing cancers.

"Diverticular disease is a sign that it's time to change your life, and it's never too late," says Nguyen. "Even at 90, improving your diet will do its best to correct diverticular disease."

www.nydailynews.com

-->Read more...