Inflammatory Bowel Disease Treatments with Thomas Curran, M.D.

There are millions of Americans living with some form of Inflammatory Bowel Disease (IBD) — typically Crohn’s disease or ulcerative colitis. While there’s no cure for IBD, treatment often includes dietary adjustments and medication. However, some patients do require surgery. Dr. Thomas Curran, a colorectal surgeon at MUSC Health, discusses IBD surgery and possible treatment plans for this chronic condition.

“While IBD is a GI-focused disease, it really doesn’t stop there and it can impact patients’ lives in a number of ways. To that end, we have an IBD nutritionist, a behavioral health social worker, an IBD-focused tobacco cessation counselor, and an IBD pharmacist. These are all ways we look to treat the whole person and not just one aspect of their disease process.”

– Thomas Curran, M.D.

Topics Covered in This Show

• Inflammatory Bowel Disease (IBD) includes ulcerative colitis, which typically affects the colon and rectum, whereas Crohn’s disease can affect anywhere along the gastrointestinal tract, from the mouth to the anal canal, Curran says.
• Ulcerative colitis usually presents as diarrhea and blood in the stool as well as malnutrition, weight loss, and abdominal pain. Crohn’s disease is characterized by intestinal blockages, the formation of fistulas, and general inflammation along with changes in bowel habits.
• While these are both considered GI disorders, they can also present outside the GI tract, manifesting as inflammatory arthritis, skin manifestations, rashes and ulcers, and even liver problems.
• IBD is an autoimmune disease with a genetic component, though what causes it is still being researched, Curran says. Cumulative exposure to certain types of foods are likely an influence as are other environmental factors. IBD is also considered a disease of the industrialized world and can affect any age group.
• Symptoms can be nonspecific sometimes, so if you suspect something is wrong Curran says you should see a doctor. Procedures such as colonoscopies and upper endoscopies can provide diagnostic support to help identify the issue.
• IBD is often confused with IBS, or Irritable Bowel Syndrome, which is an entirely different condition. IBS is a diagnosis of exclusion after ruling out more serious conditions. IBS typicallypresents as either predominantly diarrhea or constipation with abdominal pain.
• The majority of patients with IBD can be cared for with medicine alone. If they do need surgery, it is usually because medical treatments are no longer sufficient or because of the development of precancerous or cancerous cells, for example.
• Crohn’s disease patients need surgery more often – historically up to 70% of patients, though this number has been decreasing in recent years. Most commonly, the last part of the small intestine – the terminal ileum – is what is removed.
• IBD can be devastating to quality of life, and while surgical solutions may seem daunting for many patients, such procedures can actually improve daily living. In the vast majority of cases, minimally invasive surgery is sufficient – for example, laparoscopic or robotic surgical procedures that make thumbnail-sized incisions.
• While IBD is not curable, patients can go into remission. For example, Crohn’s disease patients often start with a clean slate after surgery. For ulcerative colitis patients, remission is very possible with the use of medication as well as after surgical procedures.
• MUSC Health has established a patient-centered medical home for IBD, Curran says. While IBD is a GI disease, it can affect people’s lives along a broader spectrum. The program supports holistic health including nutrition, behavioral health, smoking cessation counseling, and more.

Read the Show Transcript Below

Erin Spain, MS [00:00:04] Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. There are millions of Americans living with some form of inflammatory bowel disease, typically Crohn's disease or ulcerative colitis. While there is no cure, treatment for inflammatory bowel disease often includes dietary adjustments and medication. However, some patients do require surgery. Here to discuss inflammatory bowel surgery and possible treatment plans for this chronic condition is Dr. Thomas Curran, a colorectal surgeon at MUSC Health. Welcome to the show.

Thomas Curran, M.D. [00:00:47] Hello, Erin. It's fantastic to be here.

Erin Spain, MS [00:00:50] Well, today we're going to talk about an area in which you are a specialist of inflammatory bowel disease or IBD. Now, this is an umbrella term and as I mentioned, it encompasses two diseases. Tell me about these disorders, how they're related, how they're different.

Thomas Curran, M.D. [00:01:05] Absolutely. So you really hit the nail on the head. Ulcerative colitis and Crohn's disease are the primary diseases that fall under that umbrella term of inflammatory bowel disease, and they have a number of similarities and differences. From the anatomic point of view, ulcerative colitis generally is confined to the colon and rectum, whereas Crohn's disease can impact anywhere along the gastrointestinal tract from the mouth all the way down to the anal canal. With that, they have somewhat different manifestations. Ulcerative colitis tends to be demonstrate itself as diarrhea, blood in the stool — which is can be quite severe —and then often a number of things that come along with that: Malnutrition, weight loss, abdominal pain. From the Crohn's disease point of view., Crohn's can have a number of different behaviors, and so some of those can cause intestinal blockages. Others can cause something called fistulation or fistulas, where the bowel adheres or develops communications to other parts of the body that it shouldn't, and other general inflammation that can have some overlap with ulcerative colitis of having changes in their bowel pattern, blood in the stool, things of that nature. Importantly, while these are most primarily considered as GI disorders, they can have symptoms that are outside the GI tract, so they can have inflammatory arthritis type of symptoms, skin manifestations, rashes and ulcers, things of that nature, and even liver problems. So they can be quite broad-based, even though the major manifestations are intestinal.

Erin Spain, MS [00:02:44] Now, this is an autoimmune condition. Tell me about that. And why do some people develop this?

Thomas Curran, M.D. [00:02:51] That's a fantastic question and one that there are a lot of people working on better understanding of who gets inflammatory bowel disease and why. We know that it is some combination of a genetic predisposition and likely the cumulative exposure that we have over a lifetime. Those things can include the things we eat, the environment around us. Most of the the evidence we have to this end is somewhat circumstantial. So we know that in general, inflammatory bowel disease are diseases of the industrialized world. They tend to affect people more so in places that live similarly to the way we do here in the U.S. We really are working to better understand that.

Erin Spain, MS [00:03:34] So people who live and westernized cultures, is there any other groups of people who seem to be more at risk?

Thomas Curran, M.D. [00:03:41] That also is a really insightful question. Historically, this has been a disease of northern Europeans, the United States. But as we learn more about it and as as our world changes itself, more and more people are affected. So, for example, in recent years, we're having a growing understanding of how IBD affects patients of color, patients of different ethnic backgrounds, that that this was not previously thought to be impacting as significantly. And especially here in South Carolina, we see those things day to day. In terms of groups that are specifically at high risk there are northern Europeans. Ashkenazi Jewish populations tend to be at increased risk, but really can be affect really just about anyone.

Erin Spain, MS [00:04:29] Is there certain age groups? Can it appear in childhood, for example?

Thomas Curran, M.D. [00:04:34] Absolutely. So the most common ages tend to be in early adulthood and then can really demonstrate itself later in life as well, though there are juvenile onset instances of both Crohn's and ulcerative colitis and those tend to have a particularly aggressive course. Or they can. But usually it it affects adults and can really come on at at any point along the lifespan.

Erin Spain, MS [00:05:00] Is it pretty obvious to someone these symptoms. I mean, you mentioned some of the symptoms, but are there people out there who are undiagnosed? How do they know when to come in and get diagnosed and treated?

Thomas Curran, M.D. [00:05:11] That's a really important question. I think that knowing what to look for can really help people to seek help when they need it. From that point of view, the symptoms can be somewhat nonspecific at times, and so seeking help is is really critical. The things that we look out for, changes in bowel pattern, whether that's things that may suggest blockages or bloating, nausea, vomiting on the other end of the spectrum, diarrhea, particularly bloody diarrhea. Those are things that we would look out for. And often this can be brought to the attention of someone's primary care doctor and that who can then kind of help them navigate to their appropriate specialist, which is most commonly a gastroenterologist at the outset.

Erin Spain, MS [00:05:51] So maybe someone is having these symptoms, they come in for a colonoscopy or something like that, and then they get referred over for IBD.

Thomas Curran, M.D. [00:05:58] Absolutely. That's one of the tools that we have to confirm the diagnosis to look with the either colonoscopy for Crohn's disease, sometimes upper endoscopy can can help us to understand that once we have those pieces of information that can help us to guide folks in the right direction.

Erin Spain, MS [00:06:17] So just to clarify something here, irritable bowel syndrome is a common condition that maybe can be confused with IBD. How do these two conditions differ from one another?

Thomas Curran, M.D. [00:06:28] Sure, that is something that comes up again and again in my conversations with patients that they all mention that they maybe have a family member or knows someone with irritable bowel syndrome or IBS. And we have to really kind of carefully explain that that's a different disease process than inflammatory bowel disease. Irritable bowel syndrome is really a diagnosis of exclusion. So if someone tends to have either constipation or diarrhea, predominant bowel pattern with abdominal pain, there are some kind of technical criteria they have to meet. But generally they go through an extensive workup. And if they rule out that there are other conditions such as inflammatory bowel disease that are ruled out, then that diagnosis of exclusion would be irritable bowel syndrome, and that tends to be managed medically under the supervision of a functional gastroenterologist.

Erin Spain, MS [00:07:16] So walk me through the steps. Someone comes in, they're diagnosed. What happens then?

Thomas Curran, M.D. [00:07:22] At their core, the majority of patients with inflammatory bowel disease can be managed medically, which is fantastic and I think really speaks to the multidisciplinary nature of caring for these diseases. Typically, someone on diagnosis would be put in touch with a IBD specialized gastroenterologist who then can really make an assessment of how severe the disease is. Because we try to calibrate the severity or the intensity of the treatment with the severity of the disease. There are a number of patients, many patients, in fact, who are living with inflammatory bowel disease, who would never meet me as a surgeon because they're doing very well with the medical treatments that are being provided them by their GI provider.

Erin Spain, MS [00:08:06] So by the time people come to see you, they need something stronger. They need a more permanent solution in some ways. Tell me about the surgical approach to treating IBD.

Thomas Curran, M.D. [00:08:16] I think that one of the really critical things is when that introduction to a surgeon is made. Ideally, it's something that you can establish a relationship with a patient early on when surgery is not needed as an emergency, but rather, you know, it's something where it could be a part of the necessary treatment down the road. And they can establish with the surgeon to learn more about what surgery for inflammatory bowel disease entails and what they can expect. Most commonly, patients who who come to surgery for inflammatory bowel disease, it will be for one of a few reasons. One may be that the medical treatments they've been pursuing have not been effective. Another might be that in the case of ulcerative colitis or Crohn's colitis, that their colon is demonstrating precancerous changes or even cancer itself. And then there are some other reasons why surgery may be required, but I think it's it's really important for there to be that multidisciplinary evaluation that the the GI doctor and the surgeon are working closely together to really weigh the pros and cons of different treatment options.

Erin Spain, MS [00:09:26] Tell me about the different types of surgeries that are available, especially for Crohn's disease, because about 70% of these folks do end up needing surgery over time. Isn't that right?

Thomas Curran, M.D. [00:09:37] That's historically the number that we used, and we're really excited that that number seems to be decreasing in recent years. So from the medical point of view, there have been a number of advances in treatment just as recently as, say, 25, 30 years ago, many patients required steroids for long term, prolonged periods of time. And there really have been tremendous advances in the medical management of Crohn's disease with with things in recent years. But from the surgery point of view, the most important thing is thinking about which portion of the GI tract is involved. Most commonly, it is the last part of the small intestine that we call the terminal ilium. That's one of the common sites that's affected. And in general, the principles of managing that surgically would be to remove all of the disease bearing area so that we can leave the patient with healthy and well functioning bowel and ideally put those to enter the ball back together and really do that with an eye toward maintaining and really helping their quality of life.

Erin Spain, MS [00:10:39] I want to talk about quality of life because that really does seem to impact patients with these chronic inflammatory conditions. Tell me about quality of life for patients that you see before they come in for surgery and then after surgery.

Thomas Curran, M.D. [00:10:53] This is something that, for example, patients for whom medical therapy has been failing to control their symptoms, there can be a really successful transition to surgical treatment. And for ulcerative colitis, that can be a tremendous help to their quality of life. Because if someone is either that their symptoms are not well controlled or if that the treatment they're on, for example, if they're requiring high doses of steroids to control their symptoms, that may be something where the side effects of those treatments may be overwhelming. With that, the goals of surgery for ulcerative colitis are to remove the colon and rectum, and then it really is up to the patient as to how we proceed from there. Some patients will choose to have something called an ileostomy, where we show the small intestine to the skin and they would pass their bowel movements into the ileostomy. But many patients pursue restoring their intestinal continuity. They want to go to the bathroom from their bottom again. And so over a series of operations, usually two or three, we're able to remove the rectum and colon, create a new reservoir out of the small intestine, and hook that up down to their bottom. It does involve a temporary ileostomy, but at the end of that sequence of surgeries, they're able to use the bathroom normally.

Erin Spain, MS [00:12:14] Tell me about how you approach these surgeries. Are these really big surgeries or are there ways to be less invasive these days?

Thomas Curran, M.D. [00:12:21] There absolutely are. And that's something that we really look to do here at MUSC, provided, you know, within feasibility. And we want to make sure that the foremost priority as is the patient safety and having a successful operation. But in the vast majority of cases, we're able to approach these operations in a minimally invasive manner. So that may be laparoscopic or even robotic, where we'll make thumbnail sized incisions and the patient's abdomen and put in working tools and a camera to accomplish all those goals of the operation through those smaller incisions. And the benefit of that is really to help the patient recover faster and get back to their day to day life. These days, most of our patients are able to leave the hospital in just a few days and be back doing the things that they want to do, living their life, whether that's spending time with their family working in a few weeks time.

Erin Spain, MS [00:13:15] And it's important to know that while these surgeries can be pretty life changing for folks, these are curable diseases. Tell me about that. Patients typically can go into remission.

Thomas Curran, M.D. [00:13:25] That's correct. So that's something that really reflects that partnership between surgery and GI and managing these diseases. From the point of view of Crohn's disease after surgery, the patient is really starting with a clean slate. They have normal, healthy bowel in place and then in conjunction with their gastroenterologist, they can remain on medications to really have a durable and sustained remission, which can help their quality of life, their symptoms and hopefully prevent future surgery. From the point of view of ulcerative colitis. Remission is is very much possible with medications. But if the person comes to surgery and they have their colon and rectum removed, we do monitor things in terms of kind of the health of their small bowel, whether that's what we would call it, an pouch or even if they have an ileostomy. But many of them are able to be in remission from that.

Erin Spain, MS [00:14:18] Tell me about MUSC's Health approach to IBD. You mentioned there's this collaboration between the surgeons and the GI specialists. What else is offered that really sets the care apart at MUSC Health?

Thomas Curran, M.D. [00:14:31] This is something we're really excited about in the last recent months to year or two, we've been establishing something called a patient centered medical home for inflammatory bowel disease. The reason for this is that we have recognized, as have a number of other centers, that while IBD is a GI focused disease, it really doesn't stop there and it can really impact patients lives in a number of different ways. And so to that end, we have a number of services, certainly an IBD, specialized gastroenterologists, colorectal surgeons, but then other colleagues who help to kind of put those other pieces together. So we have a dedicated IBD nutritionist, for example. We have a behavioral health social worker who can help patients with the impact of IBD on their lives. We have a IBD focus tobacco cessation counselor and IBD specialized pharmacist, and these are all ways that we look to treat kind of the whole person, not just kind of one aspect of their disease process.

Erin Spain, MS [00:15:33] That must feel good for you as a surgeon to be able to give people their lives back.

Thomas Curran, M.D. [00:15:38] It really is such a rewarding job. It can be humbling at times, of course, but to see the difference that you can make is really a special thing.

Erin Spain, MS [00:15:47] Well, tell me, what do you do to optimize your health and live well?

Thomas Curran, M.D. [00:15:51] I think the number one thing is really spending time with my family. So I have two beautiful children and my lovely wife. My kids are three and almost two, so they keep me plenty busy. And it is absolutely the thing that I love doing the most outside of the hospital.

Erin Spain, MS [00:16:07] Well, thank you so much, Dr. Thomas Curran, for being on the show. For more information on this podcast, check out advance.muschealth.org.