Ask a Doc: Inflammatory Bowel Disease

• By:  Emily Adamek
• Posted:  November 24, 2021
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Gursimran S. Kochhar, MD, brings energy and empathy to every aspect of helping people with inflammatory bowel disease. In addition to treating patients, he is a prolific researcher, publishing 15 peer-reviewed articles in 2020 alone. In 2021, he also took on administrative leadership responsibilities as an associate division chief and medical director of interventional endoscopy.

Inflammatory bowel disease (IBD) is sometimes conflated with irritable bowel syndrome (IBS), but Dr. Kochhar emphasizes that they are dramatically different. “IBD is an autoimmune disease that can be progressive and have bad outcomes, where IBS is not an autoimmune disease and doesn’t shorten your lifespan,” he explains. “IBD has no cure, but we do have treatments to help with symptoms and give people a better quality of life.”

In our interview, we discussed those treatments in depth, along with his research, the importance of the patient’s perspective and overall health, and more.

Inflammatory Bowel Disease: Background

Emily Adamek: What are the differences between Crohn’s disease and ulcerative colitis, the main conditions that fall under the IBD umbrella?

Dr. Gursimran S. Kochhar: The main difference is that ulcerative colitis (UC) mostly limits itself to the large intestine or colon, while Crohn’s can occur anywhere from mouth to anus. The second big difference is that the inflammation in Crohn’s is usually transmural, meaning it impacts all layers of the organ.

Someone with ulcerative colitis typically presents with diarrhea, lots of bowel movements, and blood in the stool. Blood scares everybody, so those people usually seek care and get diagnosed early. With Crohn’s, you might experience symptoms similar to those I described for UC or additional symptoms like belly discomfort, fatigue, or weight loss. Symptoms can sometimes be vague, making diagnosis of Crohn’s more difficult.

Emily Adamek: Many autoimmune diseases occur at a higher frequency in women than men. Does IBD have unique impacts on a woman’s life?

Dr. Gursimran S. Kochhar: Manifestations and complications of IBD are usually similar in men and women. However, due to female anatomy, some disease manifestations can have a significant impact on quality of life and can even influence very personal decisions like planning their family.

During my training years, I remember a young Crohn’s patient came in with a perianal fistula — an opening between two organs. She had a seton, which is like a ring placed to keep the fistula draining externally. She told us that she was getting married, and she didn’t want to have the seton during her honeymoon. At first, we thought that it is not medically advisable to remove a seton, but then we discussed her case with our surgical colleagues, and we were able to come up with a way to take it out right before her trip, give her antibiotics, and then replace it right after her honeymoon. That whole experience motivated me to pursue IBD, because I realized that this was the level of involvement I could have in patients’ lives. This experience also taught me how things which seem simple enough to us in the medical field can have significant social and personal implications for our patients.

Treatment options

Emily Adamek: What are the treatment options for someone living with IBD?

Dr. Gursimran S. Kochhar: IBD is unique in that each patient will require a customized treatment strategy. But broadly speaking, we divide treatment into three categories: medical, endoscopic, and surgical.

Under medical treatment, we’re looking at medications that can alter and suppress your immune system so it doesn’t attack itself, and that promote mucosal healing in the intestines. If we divide medications into broad groups, we have medications like aminosalicylates, corticosteroids, immuno-modulators (e.g., azathioprine, methotrexate), and a newer group called biologics and small molecules that block specific immune pathways and reduce inflammation. In the last few years, we’ve added at least three or four new meds, and the future of IBD medications looks very promising.

People often have an expectation that surgery is the last resort for a disease, but in IBD, that doesn’t necessarily apply. For instance, a patient with Crohn’s who has limited, mild to moderate inflammation is probably a candidate to undergo medical therapy first. But if you get a patient in the emergency room with a narrowing or blockage — a long, previously undetected stricture that doesn’t look inflammatory and is very fibrotic — they might benefit from surgery first.

Emily Adamek: What types of surgeries are involved with Crohn’s or ulcerative colitis?

Dr. Gursimran S. Kochhar: If you have ulcerative colitis and your disease is medically refractory or stubborn, or perhaps you had a medical emergency, then the surgery of choice may be to remove the entire colon. After that, if the patient desires to have continuity, and doesn’t wish to have an ostomy bag, we can do what’s called an ileal pouch anal anastomosis or j-pouch surgery. If the patient can’t have that, they could get an ostomy bag.

Examples of surgeries for Crohn’s disease in addition to the j-pouch surgery are segmental resections (the diseased area is clipped and then reconnected) and strictureplasty (not resecting tissue but incising it open enough that things can move through). If you present with a fistula, there are surgeries to take care of that as well.

Emily Adamek: I understand that AHN offers some treatments and procedures that are not available at most places?

Dr. Gursimran S. Kochhar: We excel in endotherapy or endoscopic management. We do endoscopic procedures that aren’t routinely done anywhere else. For example, we do a procedure called an endoscopic stricturotomy. Normally, when you have a stricture, if it’s not inflammatory, surgeons will go in, resect the segment, and put it back together. Sometimes, to space out surgeries, we use balloon dilation. In endoscopic stricturotomy, we instead reach the site of narrowing with an endoscope and then take an electro-incision knife and cut out the stricture or the scar tissue internally. We ultimately feel that this gives longer lasting results. Plus, with balloons, there can be complications like perforations, which would require surgery. The risk of perforation with endoscopic stricturotomy is low, but the risk of bleeding is higher. At AHN, based on various factors, we offer both treatments to our patients.

Endoscopic fistulotomy, repairing certain fistulas endoscopically, is another procedure we do that is not routinely done in other places. We also use advanced endoscopic resection techniques. With IBD patients, the immediate challenge is inflammation, but longer term, the challenge is cancer prevention. People with IBD are at a higher risk of getting colon cancer than the rest of the population. In the past, if you were to get one area showing dysplasia, you might be required to get the full colon removed, especially if you have UC. Now, we’ve developed techniques like endoscopic submucosal dissection and endoscopic full thickness resection where, if you have one area that looks abnormal, we can remove just that area and ensure negative margins, and put you on a close surveillance program.

In regard to other innovations beside endotherapy, we offer some of our patients with IBD a newer medical therapy, hyperbaric oxygen — we’ve published our experience with it and will be participating in a large NIH-based multi-center trial that uses this therapy for patients with UC who are admitted to the hospital.

Emily Adamek: Are non-pharmacological options also important?

Dr. Gursimran S. Kochhar: With all chronic diseases, non-pharmacological treatment can be a valuable supplement. I “prescribe” certain things in conjunction with other treatments, starting with a healthy diet. There’s a lot of research about the best diet for IBD patients. We don’t have enough evidence to recommend one diet over another, but in general, learning from our cardiology and endocrinology colleagues, we believe the Mediterranean Diet can reduce inflammatory burden. I also believe that a diet high in plant-based fiber is good, because it’s good for gut bacteria and can help with inflammation in the long run.

Another non-pharmacological intervention is exercise. We encourage IBD patients to have some sort of physical activity five days a week. Good data shows that physically active IBD patients do much better than non-active patients.

Behavioral therapy can also be important. If a patient has depression or anxiety, I would want them to see a behavioral psychologist.

There’s some data, albeit not much, on things like acupuncture, reiki therapy, cupping therapy, and yoga as ways to reduce inflammation. Whether they are effective therapeutically or not, if they make someone feel relaxed, I encourage it.

Mental health and the patient’s perspective

Emily Adamek: Can you talk more about the connection between IBD and mental health?

Dr. Gursimran Kochhar: Yes, patients with IBD are more prone to depression, anxiety, stress, and other mental health issues. Mental stress and physical stress from inflammation kind of go hand-in-hand. If you’re depressed and anxious, you’re less likely to take your IBD medication, and some studies suggest that people with mental health issues on top of IBD tend to have more surgeries. From the other direction, needing to have one or more surgeries can weigh a person down.

Some IBD patients are required to have stomas or bags. Some may have fistulas. All of this adds the pressure of body stigma, which can cause deeper body issues and impact relationships.

Emily Adamek: So those mental health aspects really need to be integrated into care and treatment?

Dr. Gursimran S. Kochhar: Absolutely. Here’s what I’ve learned: If you don’t ask about a patient’s mood, sleep patterns, and feelings of depression or anxiety, they probably won’t tell you. So, we emphasize the importance of asking. It’s sounds simple, but this can have a significant impact on a person’s quality of life and on the disease itself.

Emily Adamek: And AHN’s multidisciplinary, coordinated care approach would also be vital for someone with IBD?

Dr. Gursimran S. Kochhar: Yes, in numerous clinical scenarios, there is not just one right answer, so we never want to take a cookie-cutter approach. We have a monthly IBD group meeting with physicians, colorectal surgeons, pathologists, radiologists, and others where we bring cases forward that benefit from group input and developing consensus on the best strategy. The concept of highly personalized medicine for IBD has been discussed for years, but we’re really putting that into practice. The extra coordination can also help save a patient from needing to make extra trips to multiple physicians. I’ll add that this coordination and collaboration isn’t limited to the monthly meeting. We’re all closely connected and routinely call each other to talk about cases.

I also want to emphasize the importance of the patient’s perspective. Physicians can easily fall into a pattern of just dumping information without stopping to consider what the patient is thinking. For example, what is going through a person’s mind when we tell them a therapy has a 1 in 10,000 chance of leading to skin cancer? That’s why we asked a patient advocate to talk at this year’s AHN IBD Summit and help all the health care providers learn the patient’s perspective on various issues.

Inflammatory Bowel Disease research

Emily Adamek: Could you talk about the focus of your research with IBD and your motivations to participate in so much clinical research?

Dr. Gursimran S. Kochhar: Research is a very integral part of my clinical practice, and my research is mainly clinical. I do IBD medications research, outcomes research (looking at large data sets), and endoscopic procedural research. My research is diverse, but the connection is that it’s always been very patient-centric. If I don’t have a solution to the problem a person brings me, I go back and do research. Managing IBD patients in the clinic and doing advanced endoscopic procedures gives me a different perspective and often informs my approach to research.

My main motivation is that we don’t have a cure. Whatever we can do to advance the field or create stepping stones for future clinical trials is important. We practice evidence-based medicine, and it’s rewarding to be contributing to that evidence, which ultimately improves outcomes and quality of life for people.

Emily Adamek: You’ve also been involved in promoting ongoing clinician education and conferences, correct?

Dr. Gursimran S. Kochhar: Yes, one example is the AHN IBD Summit I started in 2019, an annual event where we get international speakers to talk about various aspects of IBD. We also have monthly speakers talk to our entire department about gastrointestinal topics.

We have so many medical journals and so much research published globally — it’s not possible for one person to know it all. You need conferences and ongoing education to help summarize recent advancements. If there’s a new technology or procedure being performed in Asia, but I’m not aware of it, that doesn’t help my patient.

Education also helps us understand what is missing in the field. When I hear someone present at a conference and they say they don’t have the data on a particular subject, that gives me my next research question.

Emily Adamek: What are you most excited about in IBD research — what are the most promising advances for IBD in the next decade?

Dr. Gursimran S. Kochhar: Endoscopic treatment for IBD is an avenue of research I really like. Again, it goes back to the patient. If I have a 33-year-old patient who had surgery three years ago and now has a stricture and is looking at a second surgery, I can potentially do an endoscopic procedure and push back that surgery to age 38 or 39. That’s a huge accomplishment — especially with Crohn’s where there is never really an endpoint to surgeries. Ten years ago, we didn’t have the technology that makes these procedures possible, and so looking toward the future, we know endoscopic and surgical techniques will continue to evolve. We’re moving away from the days of open surgery to minimally invasive procedures with better outcomes.

There’s also an important push to understand what we can do to prevent IBD.

Another exciting development is using big data to understand various IBD phenotypes and then translate that into better treatment. The influx of artificial intelligence will change many things, including helping to speed up clinical trials and reduce cost, allowing for more trials, and accelerating advances that will help people living with IBD.