Crohn’s disease & Colitis
Callan Emery spoke to Dr Simon
Travis, Consultant Gastroenterologist,
Professor of Gastroenterology &
President of ECCO 2012-2014 (the
European Crohn’s and Colitis
Organisation), about Immune-
Mediated Inflammatory Disorders,
while he was in Dubai for the 3rd
Annual Abbott IMID Summit earlier
Callan Emery: What are Immune-
Mediated Inflammatory Disorders are?
Dr Simon Travis: Immune-Mediated
Inflammatory Disorders (IMID) are a
group of diseases that involve an immune
response that is inappropriate or excessive.
They have complex causes. The ‘aetiology
and pathogenesis’ are generally unknown.
CE: How do people get these disorders?
ST: People get these disorders as consequence
of dysregulation of the body’s
normal immune system, especially with
regard to cell signalling molecules called
cytokines and interleukins.
CE: Can you give some examples?
ST: IMID include Psoriasis, Crohn’s
Disease, Ulcerative Colitis and Rheumatic
Diseases such as rheumatoid arthritis and
CE: Is it the case that new IMID are
continuing to be identified?
ST: Crohn’s disease and Ulcerative Colitis
are chronic, inflammatory bowel diseases
(IBD) that causes inflammation of the
digestive tract, also known as the gastrointestinal
Other conditions where there is an
immune inflammatory component include
multiple sclerosis and systemic lupus erythematosus,
although not commonly included
in the IMID category. New conditions,
especially overlap syndromes (such as psoriatic
arthropathy), continue to be identified.
A characteristic feature of the conditions is
that they focus on one organ system
(skin/joints/gut), but have systemic features
as well; for instance there is a condition
called Sweet’s syndrome associated with
Crohn’s and ulcerative colitis, especially in
women, that affects the skin, joints and gut.
All the conditions relapse and remit, but
continue – at present – for life, unless or
until a cause is found
CE: Looking at your specialty –
gastroenterology – what advice can you
give doctors to help them identify these
disorders in patients?
ST: Any adolescent or adult of any age
who has diarrhoea for more than 3 weeks’
duration, should have IBD (Irritable Bowel
Syndrome) excluded; this will usually
involve simple blood tests and a
colonoscopy (examination of the large
bowel with a flexible camera under sedation).
This is particularly important if
there is bleeding with the diarrhoea: the
cardinal features of ulcerative colitis are
bloody diarrhoea. Ulcerative colitis is
much more common in the Middle East,
Africa and India than Crohn’s disease,
which is characterised by diarrhoea,
abdominal pain and weight loss. The
important conditions including infection
(especially TB) need to be excluded.
CE: What treatments are available?
ST: Conventional therapy includes steroids and azathioprine to modify the
For more severe cases, adalimumab
(Humira) is an injection that can be used
to treat Crohn’s disease or ulcerative
colitis. Humira is a prescription medicine
used to reduce signs and symptoms, and to
achieve and maintain clinical remission in
adults with moderate to severe Crohn’s
disease who have not responded well to
There are many other drugs that have
been used to treat ulcerative colitis and Crohn’s, but remarkably dietary therapy
has little role in most patients.
Surgery is needed in some – about 12%
with ulcerative colitis, but 60% with Crohn’s. It is hoped that timely medical
therapy will reduce the need for surgery.
CE: What progress is being made in
optimizing the management for IMID?
ST: Well, the fact that experts from the
Middle East, South Africa, Central and
Eastern Europe come together for the IMID Summit every year is a beneficial
way to help develop new treatments for
these disorders. It is a great opportunity for
those sharing an interest in therapeutics
targeting molecular and cellular immune
targets of common relevance across disease
phenotypes to promote interactive discussion,
new collaborations and creative
approaches to clinical best practice in the
A key concept at IMID was ‘treating to
target’ (T2T), where doctors agree treatment
goals with patients and treat beyond
symptom control to achievable goals such
as healing of the gut mucosa, since this
may prevent later complications.
Other important concepts are ‘adherence’ – where the person with the condition
takes the treatment prescribed!
Medicines don’t work in the box! Nonadherence
is unfortunately commonplace
– and then the drugs are unreasonably
blamed for lack of effect.
Another important concept is ‘communication’.
This is more than stating the
obvious, because the views of patients and
physicians may differ and appropriate goals
of treatment need to be agreed
CE: Do you have information on the
incidence of IMID in the Middle East
ST: It is estimated that 35,000 per million
people suffer from IMID diseases and
approximately 1,500 people specifically
suffer from Crohn’s Disease, while the prevalence
of ulcerative colitis may be 7,500. It
seems likely that these are underestimates,
but statistics are difficult to acquire, because
there has not been much systematic study
and the population is cosmopolitan, with
many temporary residents.
CE: I see you have authored a number
of disease guidelines – can you explain
briefly what these are?
ST: The international management guidelines
from ECCO (the European Crohn’s
and Colitis Organisation) are based on all
the published evidence from research and clinical trials of treatment, which is
appraised in a systematic manner, to avoid
prejudice and dependence on opinion.
There are, of course, questions that can’t
yet be answered from research, so expert
opinion from many specialists (about 60
specialists from 20 countries combined to
produce the ECCO guidelines) is quantified
and a consensus view is reached.
These guidelines set the standard of
care, but it is all too easy for such documents,
which run to 90 odd pages, to stay
on the shelf or on the computer hard drive. ECCO therefore runs workshops (such as
one in Dubai in 2011) which illustrate case
management based on the guidelines and
are an important educational tool.
Much of the opinion expressed at IMID
on specialist management of IBD was
based on these ECCO guidelines.
CE: Can you suggest further reading
on the subject?
ST: Absolutely. I am the author of over
140 papers and 6 books that delve deeply
into Gastroenterology with a great focus
on inflammatory bowel disease.
- Case studies in Gastroenterology.
Walsh A, Buchel OC, Collier J, Travis
SPL. Oxford University Press 2010
(353pp; reviewed by James Lindsay Gut
- Ulcerative colitis. Travis SPL, Mortensen NJMcC. In: Anorectal and
Colonic Diseases: A practical guide to
their management (3rd Edition). Givel JC,
Mortensen NJ, Roche B Eds. Springer
- Anorectal and colonic Crohn’s disease.
Travis SPL, Mortensen NJMcC. In:
Anorectal and Colonic Diseases: A practical
guide to their management (3rd
Edition). Givel J-C, Mortensen NJ, Roche
B Eds. Springer 2010; pp501-512.
- Therapeutic approaches to managing Crohn’s disease. Travis SPL. In:
Inflammatory bowel disease: translating
basic science into clinical practice. Targan
S, Shanahan F, Karp L Eds. Wiley-
Blackwell 2010; pp469-80.
- Conventional treatment of inflammatory
bowel disease. Burger DC, Travis SPL
- The second European evidence-based
Consensus on the diagnosis and management
of Crohn's disease: Current management.
Dignass A, Van Assche G. Lindsay
JO, Lémann M, Söderholm J, Colombel JF,
Danese S, D'Hoore A, Gassull M,
Gomollón F, Hommes DW, Michetti P,
O’Morain C, Öresland T, Windsor A,
Stange EF and Travis SPL, for the
European Crohn's and Colitis
Organisation (ECCO). J Crohn’s & Colitis 2010;4:28-62.
of upload: 20th Jun 2012