Crohn's and Colitis. Dr. Hillary Steinhart

bone density.

      The treatment of low bone density in children and adolescents with IBD is somewhat different than in adults. The period during adolescence and early adult life is critical in determining the health of the skeleton and bones in later life. People reach their maximum bone density in early adulthood. However, adolescents with IBD may not be able to reach their potential maximum bone density because of poor nutritional intake, because of the underlying IBD, or because of medications. Special attention needs to be paid to adequately treating the IBD, to maintaining good nutrition, and to minimizing use of steroids during these critical years.

       Bone Density Tests

      Most IBD patients, particularly those with Crohn’s disease, should have their bone density measured and, if it is lower than normal, it should be checked periodically (every 1 to 2 years). Bone density is measured using a safe and easy test called a DEXA (dual energy X-ray absorptiometry), which doesn’t require any injections.

       Cancer

      While people with IBD have an increased risk of cancer, this should not be a cause for undue concern.

      Cancer is a common disease that can occur in many forms and degrees of seriousness. The increased risk of cancer in IBD patients appears to be limited to one or — at most — a handful of cancer types. Risk of colorectal cancer (cancer of the rectum or large intestine) appears to be most increased in individuals with IBD.

      Some recent research has suggested that patients with more inflammation occurring over a period of many years are at increased risk, but colorectal cancers can also be found in people who have had a very mild IBD course.

      While not everyone with IBD is at increased risk of developing colorectal cancer, it is important to be aware of the factors that do seem to increase the risk. For many years, only individuals with ulcerative colitis were considered to have an increased risk of colorectal cancer, but it now appears that people with Crohn’s disease, where the large intestine is extensively affected, are also at increased risk. However, in those individuals with ulcerative colitis, where the disease is limited to the rectum and the last part of the colon, there is no significant increase in the risk of cancer. Patients diagnosed before 20 years of age, with more than an 8-year history of IBD or with associated primary sclerosing cholangitis, are at increased risk of colorectal cancer. The risk appears to increase further the longer one has had the disease. Patients with a family history of colorectal cancer involving a parent, brother, or sister are likely also at increased risk. Whether or not the severity of the IBD affects the cancer risk is not entirely known.

       Risk Factors for Colorectal Cancer

      •Extensive inflammation of the colon (ulcerative colitis or Crohn’s colitis)

      •Early age of diagnosis (less than 20 years of age)

      •Long duration of disease (more than 8 years)

      •Active disease symptoms

      •Family history of colorectal cancer

      •Primary sclerosing cholangitis (PSC)

What can I do to reduce my risk of developing colorectal cancer now that I have IBD?

The first thing to do is to determine your degree of risk. This should be done in consultation with your doctor. If it is determined that you are at increased risk, by virtue of the risk factors, then it is possible that your doctor will recommend that you should enter into a screening program. Even if screening is not recommended, regular follow-up with your doctor is important.You may have heard of colorectal cancer screening for individuals who do not have IBD. This is different from the screening that an IBD patient would require. Some of the methods of screening used for non-IBD individuals, such as testing the stool for microscopic traces of blood, are not effective for screening IBD patients. Monitoring for symptoms of cancer is not effective because the symptoms of colorectal cancer may be very similar to those of IBD. The screening that is carried out in IBD patients involves conducting a colonoscopy in order to take numerous random biopsy samples of the colonic lining. Although this type of screening program does appear to reduce cancer rates and result in cancers being detected earlier at curable stages, it is still not a perfect method.In recent years, efforts have been made to detect precancerous changes by using newer colonoscopy technologies so that the areas of potential concern are made visible to the naked eye, allowing biopsies specifically targeted to those areas rather than the random biopsies that have been traditionally performed.

       Dysplasia

      Biopsies are carefully examined by a pathologist looking for precancerous changes, called dysplasia. If these changes are found, they indicate a higher possibility (10% to 20%) that the patient may already have cancer or, if cancer isn’t already present, the patient has a substantial chance of developing cancer over the subsequent few years. When dysplasia is found and confirmed, surgery to remove the colon is usually recommended.

       Colorectal Cancer Risk

      It has been estimated that people with ulcerative colitis have a 10% to 15% risk of developing colorectal cancer during their lifetime.

       Prevention and Treatment

      Because we cannot yet predict with certainty who will suffer from inflammatory bowel disease and because the causes of this disease have not yet been determined conclusively, it is difficult to recommend effective prevention strategies. The best strategy for now is to learn how to recognize the symptoms of the disease and bring them to the attention of your doctor for immediate assessment, diagnosis, and treatment. In the next chapter, we present a discussion of the symptoms of inflammatory bowel disease and the tests used by doctors to diagnose this condition.

      CHAPTER 2

       How Do I Know I Have IBD?

       CASE STUDY Jonathan

      Jonathan is a 33-year-old police officer who has had several episodes of belly pain every 6 to 9 months during the past 5 years. Each time, these last between 2 and 6 weeks. Usually, the pain is crampy and tends to occur anywhere from 30 to 90 minutes after he eats. He feels bloated and uncomfortable. Jonathan also experiences watery diarrhea up to eight times a day during the pain episodes. The episodes subside on their own.

      When the episodes occur, Jonathan’s appetite is poor, and he can lose up to 10 pounds (5 kg). In between the episodes, he has no pain and regains most of the weight that he lost. However, during the past 2 years, he has felt more tired than usual.

      Jonathan doesn’t think much of these episodes. His wife has irritable bowel syndrome, a condition she has been told is related to diet and stress, and he figures that he has something similar. However, this year, Jonathan happens to have had his annual physical examination shortly after an episode of pain and diarrhea, and he mentions it in passing to his doctor.

      After further questioning, his doctor is concerned that Jonathan may be suffering from something more serious than irritable bowel syndrome. He is concerned about the weight loss that occurs during the episodes and the fact that Jonathan wakes up from his sleep with pain and diarrhea. In addition, the doctor is able to feel a tender area of swelling in the lower right area of Jonathan’s abdomen.

      Based on these findings, the doctor is concerned that Jonathan may have Crohn’s disease in the ileum (the last part of the small intestine). He decides to order tests to investigate further…

       (continued)

Recognizing Symptoms

      Sometimes, people, particularly young people, delay seeking medical attention for inflammatory bowel disease because they believe that they will remain