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 this year.

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?
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?
IMID include Psoriasis, Crohn’s Disease, Ulcerative Colitis and Rheumatic Diseases such as rheumatoid arthritis and ankylosing spondylitis.

CE: Is it the case that new IMID are continuing to be identified?
Crohn’s disease and Ulcerative Colitis are chronic, inflammatory bowel diseases (IBD) that causes inflammation of the digestive tract, also known as the gastrointestinal (GI) tract.

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?
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?
Conventional therapy includes steroids and azathioprine to modify the immune response

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 conventional treatments.

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?
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 IMID arena.

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 region?
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?
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?
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 2010;59:1728)

- 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 2010; pp513-532.

- 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 Gastroenterology 2011;140:1827-37 (invited review)

- 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.

 Date of upload: 20th Jun 2012


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