Crohn's and Colitis. Dr. Hillary Steinhart

takes no more than 10 to 15 minutes and is typically not painful. In young children, it may be necessary to administer heavier sedation or general anesthetic in order to carry out the procedure.

       Colonoscopy

      Colonoscopy requires preparation of the bowel with a special diet (usually clear liquids) and a special laxative for one or more days prior to the procedure. This is important because the presence of feces can interfere with visibility and make the procedure almost useless. In some cases, the physician may not order a special laxative for the patient. Usually this is when the IBD is very active, but even in these instances, a smaller or more gentle preparation is probably still advisable and safe.

       Upper Gastrointestinal Endoscopy

       Colonoscopy

      The colonoscopy procedure itself is usually performed with a sedative and an analgesic (pain medication). It typically takes 15 to 45 minutes to complete. It is generally quite a safe procedure, with a very small risk of serious complications, but some degree of abdominal pain and cramping is not unusual at times during the procedure. In most cases, the medication given before the procedure helps to minimize the discomfort.

       Extremely Useful

      Colonoscopy is an extremely useful diagnostic test in IBD. It will always detect ulcerative colitis if it is present, and will detect Crohn’s disease in 80% to 90% of cases. In 10% to 20% of cases of Crohn’s disease, the procedure is not able to examine the areas of disease because of technical factors or because the disease is beyond the reach of the colonoscope.

       Wireless Capsule Endoscopy

      Standard gastroscopy and colonoscopy are not able to reach large segments of the small intestine that may be affected in Crohn’s disease. The imaging studies that can take pictures of those areas of the small intestine are improving, but do not always provide the detailed images required by the physician to make management recommendations. Wireless capsule endoscopy (WCE), or PillCam technology, was developed to provide the types of high-quality visual images of the inner lining of the small intestine that are provided by gastroscopy in the stomach and duodenum and by colonoscopy in the colon and ileum. In most cases, the procedure allows examination of the entire length of small intestine.

      A capsule — about the size of a large vitamin pill or capsule — that contains a battery, light source, and a tiny lens and camera chip is swallowed by the patient and begins taking two pictures every second during an 8-hour period. It is propelled through the esophagus, stomach, and small bowel by the normal muscular movements of the gastrointestinal tract in the same way food is passed down along the gastrointestinal tract. The patient wears a recording device, much like a cellular telephone, and can go about daily activities. Once the procedure is over, images are downloaded from the recorder to a computer. The physician can then look for signs of Crohn’s disease.

      Despite the fact that the WCE can provide excellent images of the entire small intestine, it is not commonly used in IBD diagnosis. In ulcerative colitis, the small intestine is not involved and does not require this type of detailed evaluation. In Crohn’s disease, care must be taken because the capsule could produce a blockage or bowel obstruction in any strictures of the intestine. Nevertheless, the capsule may be helpful in diagnosing subtle degrees of Crohn’s disease in the small intestine, where the other imaging techniques do not provide a full answer to the patient’s symptoms.

       Enteroscopy

      A number of innovations have been developed in the area of endoscopy to allow examination of areas of the small intestine that are beyond the reach of the standard gastroscope and colonoscope.

      •Push enteroscopy uses a longer-than-normal gastroscope to get farther into the small intestine, but the success of this procedure is limited because of the floppiness and many twists and turns of the small intestine.

      •Double balloon enteroscopy (DBE) generally allows more extensive examination of the small intestine through sequential inflation and deflation of two balloons near the tip of the instrument. This inflation and deflation helps to propel the tip of the instrument along the small intestine. The technique can be performed through the mouth, esophagus, and stomach into the first part of the small intestine, or it can be performed through the colon into the last part of the small intestine. It tends to be a longer procedure than standard endoscopy and typically requires general anesthetic or propofol for deep sedation. Using this technique, it is often possible to examine the entire length of small intestine that cannot be examined by gastroscopy or colonoscopy. Biopsies can be obtained of the inner lining of the small intestine, and the rate of progress through the small intestine is under the control of the physician, as opposed to the wireless capsule endoscopy, where the progress through the intestinal tract is largely determined by contractions of the small intestine.

       Biopsies

      Endoscopy also allows the operator to perform biopsies of the inner lining of the gastrointestinal tract. Small samples are taken with a tiny instrument with small jaws that can cut or pull off pieces of the inner lining. This part of the procedure is not painful; usually, the patient is not aware that it is happening. The biopsy process is very safe; complications, such as serious bleeding, are extremely uncommon.

      In some instances, biopsies are done to screen for precancerous changes. Some patients with IBD involving the large intestine for more than 8 to 10 years are at increased risk of colon cancer, and their physicians may recommend a surveillance program that involves regular colonoscopy with many biopsies taken throughout the colon.

       Rule Out Other Conditions

      Biopsies are usually taken to confirm the suspected diagnosis of IBD and to help rule out other conditions, such as infection. As surprising as it may seem, biopsies do not always provide 100% certainty about the diagnosis, particularly when distinguishing between Crohn’s disease and ulcerative colitis. Other information, such as the location of the inflammation or other associated features, provides more assistance in diagnosis.

Prognosis

      Once the diagnosis of IBD has been confirmed using one or more of the available investigations, some of that information can be used to help the physician determine the severity and prognosis of a patient’s particular IBD. However, even with the most complete diagnostic staging, the ultimate prognosis can be unpredictable, varying from person to person with the same disorder. Patients naturally have many pressing questions about the course of their disease, which are asked and answered in the next chapter.

      CHAPTER 3

       What Can I Expect Now That I Have IBD?

CASE STUDY Kelly

      After asking her doctor a host of questions about the symptoms and diagnosis of ulcerative colitis, Kelly was still upset because she knows of a boy who went to her high school who had ulcerative colitis. Her recollection of him was that he was sick for many days at a time. He finally had to take several weeks off school and have surgery. She is concerned that a similar fate awaits her and that she will fall behind in her university studies — or possibly even have to drop out. Even worse, she fears she may have to wear a bag to collect her stool. She has heard that people with colitis live shorter lives and are likely to develop colon cancer.

      From her doctor, Kelly wants to know if the disease will get worse. What are the chances of her getting better? Will she require surgery and need a bag to collect her stool? Will she be able to live a full, productive life — complete her studies, go to work, have a family? Can she expect to live a normal life? Can she travel? And most urgently, can she die from IBD?