My name is Dr. Mark Mattar, and I'm a gastroenterologist here at MedStar
Georgetown University Hospital. I mainly see patients with inflammatory
bowel disease, which is Crohn's, ulcerative colitis, but also see patients for
screening for colon cancer disease and also who have the disease itself.
Patients with inflammatory bowel disease, we definitely are seeing more and more
of them. Last year, there was about 1.4 million people with inflammatory bowel
disease in the U.S. Now,we're seeing up to 1.6 million people. So, it seems to be
every year, it keeps increasing. We see these diseases a lot in young
individuals. They can be diagnosed early even as young pediatrics or even in
the 20s and 30s most common the patients are diagnosed with these problems. But we
also see another group in the 50s and 60s, so we do see a good group of people.
Young professionals that come through here, college students even, with a lot of
these symptoms, so it tends to be pretty common. Our goal is to first diagnose and
see what the problem is, and at that point, come up with a good treatment plan
based on either endoscopy, coloscopy, your imaging or lab work. Patients
diagnosed with inflammatory bowel disease, we are able to get them back to
normal life. Usually with the right medications, lifestyle, diet, these
kinds of things usually about 50 to 60 percent of the time. I do try to take a
holistic approach to patient care. So, we do try to get patients if they need
to even some be evaluated by psychiatry that's the case, have exercise as a piece
of that. Also nutrition, we have them see nutritionists when applicable. And
we do try to also integrate probiotics or that kind of thing where they may be
of assistance. I think that's great seeing patients with a specific problem
and be able to treat them and have them come back from sort of a miserable life with
the symptoms of the colitis or the Crohn's and have them actually jump back
and being able to bepart of society again and
being able to participate in their families and just having their life back.
Inflammaotry bowel disease, or IBD, is a chronic inflammatory process which is
immune regulated in the bowel, anywhere from, and it can affect anywhere from
mouth to anus. So you have Crohn's disease and ulcerative colitis, those are
the two main types of inflammatroy bowel diseases. And the main symptoms of those
include abdominal pain, blood in the stool, sometimes patients can have fatigue
or sort of nonspecific symptoms. Or even younger patients can have sort of a
failure to thrive picture.
So inflammatory bowel disease is a sort of an umbrella term for Crohn's disease or
ulcerative colitis. There are some patients also have something called
indeterminate colitis. So these are diseases that are immune
regulated in the bowel. Crohn's disease can affect anywhere from mouth
to anus, along the small intestine or colon, versus ulcerative colitis could
only affect the colon or last part of the bowel. Crohn's disease, it can
affect the wall the bowel and go beyond the wall of the bowel versus also
colitis is more of a superficial inflammation. It doesn't cause a lot of
the potential complications that Crohn's disease can, such as fistula or abnormal
connection from the bowel to other loops of bowel or other infectious pockets
called abscess. And otherwise Crohn's disease can also cause narrowing or
strictures in the bowel. The ulcerative colitis usually does not. The treatment
for both of them are very similar.
Most of the things that we know about in terms of etiology of Crohn's and colitis
are related to either genetics. So about 20 to 30 percent of patients will have a
family member with with inflammatory bowel disease. But most patients do not
have that genetic predisposition so there potentially is a factor in the
diet, especially sort of westernized industrialized area with preservatives
and things like that that can potentially increase risk for Crohn's
disease and ulcerative colitis. So there may be some modifier risk factors but
for the most part it is very hard to try to prevent.
So in patients with mild Crohn's and ulcerative colitis, we usually start with an oral
anti-inflammatory medication. When patients progress to more moderate to
severe disease or have complications from the disease, then we
progress to medications called biologic agents which can be immunosuppressant
somewhat and the helps with the immune response that's abnormal in these
patients with Crohn's and colitis.
In patients with ulcerative colitis, this has been looked at more closely than
Crohn's disease. So we know that some probiotics are adding good bacteria back
into your diet in a capsule form or through a powder can be beneficial in
helping with this. The main one is called VSL number three and that has been shown
to decrease the signs and symptoms of mild ulcerative colitis. We also know that the
diet may be a factor, so increasing omega-3 types of fatty acids can be
beneficial versus some omega-6 fatty acids which is seen in some some of the
cooking oils that we use. We try to avoid some of those oils.
So because inflammatory bowel disease does affect the whole body, other things like
exercise or appropriate nutrition can be beneficial in patients with Chron's
or colitis. So we do recommend regular exercise just like we would with most
other chronic diseases, regular exercise and good dietary or nutrition balance.
So some of our patients do require surgery, either an ulcerative colitis to
have the colon removed that's one option. But other patient just for really
refractory or really disease that not responding to medications, they may need
other surgeries to remove parts of their bowel, and we work closely with our
colorectal surgeons for the specific types of surgeries. At times, we're
trying to avoid surgery or patients have already had surgery and sort of need
another type of medications, we don't have clinical trials available so we can
try newer medications on these patients that have maybe better side effect
profiles than our current medications or maybe are more efficacious.
The way the fecal transplant works is pretty much taking healthy stool that
has the healthy bacteria from an individual without the disease and
instilling it to another individual with the disease and for some reason the
healthy bacteria kind of takes over and helps with the current infection.
Patients really are very excited when they have this done successfully because
they have had this disease the C. difficile infection for up to, I've had
patients even up to one to two years, that has been tried with antibiotics of
antibiotics. Sometimes patients need surgery for this to remove the colon so
for the C. difficile So patients are very relieved and excited and surprised that
this simple technique actually works.
The data for FMT and inflammatory bowel disease is not so clear yet. There's
probably about 18 studies that have been performed so far
internationally, mainly in ulcerative colitis but some in Crohn's disease. And the data
there still shows some improvement of symptoms with continuous stool
transplants usually usually via an enema. But these symptoms do not continue on
into remission and a lot of times the colonoscopy does not show improvement in
these patients. So they're still more that needs to be studied with FMT in
terms of ulcerative colitis and Crohn's.
So we see patients who have C. difficile infection that causes copious amounts of
diarrhea. Patients can't live their normal life. They come in, have this procedure
done we call fecal transplant. With that, we get a stool sample from a
company just to assure safety, and we deposit that sample into the beginning
of the colon using a sedated colonoscopy. And then, we come back out
and even by that evening some patients of mine have felt better with formed
stools that they have not had for months before. And then we recheck again for
C. diff, and it's cured.
So there is a website called openbiome.org that does have all the
practitioners that are performing FMT nationally, and we are performing a here
at MedStar Georgetown University Hospital. We are able to see new
patients with this at any moment.
So FMT for C. diff is only indicator in patients have what's
called recurrent or refractory C. difficile which means they've had the
disease, they tried antibiotics usually like vancomycin or metronidazole, didn't
get better, tried another course of antibiotics. With two courses of
antibiotics, if the C. diff is still there, the diarhea is still
there then you need to see me or you have a consultation for FMT.
So that takes us back to the microbiome, the bacterial makeup of the gut system.
And we know that many patients have C. diff bacteria sitting in their gut
not causing any problems. But once you start antibiotics for any other reason,
for sinusitis or bronchitis or what have you, then it's sort of unmasks the C.
difficile bacteria by removing or killing off the potentially healthy
bacteria also. So once the C. diff is unmasked that's when it could cause more
diarrhea. Now, we don't use the same antibiotic so where you would use for
say sinusitis, but it's a specific antibiotic that's targeted towards the C.
difficile that actually takes care of that infection.
So patients who do not have any symptoms over the age 50 or patients 45
years or older who are African-American should be screened for colon
cancer. There are other individuals who have higher risk, some genetic problems
or patients with inflammatory bowel disease do need earlier screening.
So that would be the patients who have increased risk for colon cancer, it's
just such like Crohn's disease, ulcerative colitis, whenever they have
involvement of more of their colon with inflammation. Otherwise some patients
have genetic predispositions to colon cancer or their family history of colon
cancer in a young individual.
So patients wuth a family history of colon cancer and someone say with their
parents with colon cancer, at age say they have the colon cancer at age 50,
then you would have the screening of that child at age 40, so 10 years before
the parents or the relative had their colon cancer themselves or at age 40
whichever comes first.
So that is a problem that we are seeing a little bit more common than we used
to see in the past. Colon cancer used to be a disease sort of older patients over
50 or 65 or so, but we are seeing some more younger patients with this. It's
hard to say what the reason is, but possibly related to diet. We know the
high fat, high preservative in the diet, high red meat consumption may increase
the risk for colon cancer. And we know the obesity rate in the U.S. is
escalating, so that is one factor, but at the same time we know there's some young
individuals who are very healthy and otherwise fit and eat the right things
that still succumb to colon cancer.
So patients who have any blood in the stool that's not improved with topical agents
for say hemorrhoids, patients with iron deficiency anemia or low blood count
that's not getting any better, or abdominal pain that seems to not being
improved, especially lower abdominal pain needs to be evaluated regardless of
their age. We are seeing more young patients with these symptoms. So even if
you are 20 years old and you have these symptoms, I would take it seriously.
So just like anything else in medicine, if you feel like your symptoms are being
dismissed, I would consider a second opinion. So for example, if you have blood
in the stool not quite getting better and the doctors aren't necessary taking it
seriously, I would consider either asking them to refer you to a
gastroenterologist or see if you get a second opinion to be further evaluated.
So a lot of times we think about colon disease for older patients and that
usually is the case. My young patients do still get the symptoms like blood in the
stool and/or change in bowel habits or that kind of thing that we do need to take
more seriously. So in those instances, we do need to be persistent with our
physicians to make sure you get the appropriate referrals for colonoscopy or
colon cancer evaluation and also to evaluate for other things like Crohn's
and colitis other things that could be going on that don't just go away with time or
topical therapies.