Whenever possible, his usual practice was to extend his assessment beyond the large intestine to the last section of the ileum, the posterior end of the small intestine. Most gastroenterologists limit their screening exams to the colon in healthy, asymptomatic patients. The ileum is not captured during a routine screening because it takes more time and there is little chance of finding anything significant. However, Chan had been trained by a doctor who specialized in inflammatory bowel diseases such as Crohn's disease and ulcerative colitis. A simple colonoscopy, if present, shows ulcerative colitis. But only half of people with Crohn's disease will have evidence of this in their colons. The likelihood of making this diagnosis increases significantly when the terminal ileum is included.
As Chan advanced his scope, he could see that the flap was distorted by scar tissue – so much so that the connection was too tight for his instrument to enter. As he brought his scope as close as possible to the opening, he saw that the tissue on the other side was angry red and ulcerated. You'd have to wait for the biopsies to come back, but Chan suspected Crohn's disease. That's impossible, replied the man. He didn't have a G.I. Symptoms at all. No pain, no diarrhea, no blood in his stool. How could he possibly have Crohns?
A hidden underlying disease
Crohn's disease is an autoimmune disease in which antibodies, the body's main line of defense against infection, mistakenly attack the digestive tract as if it were a foreign invader. Although the G.I. It is most commonly found in the terminal ileum anywhere in the tract. Most people with Crohn's disease experience pain and diarrhea – but not all. In studies of people with known Crohn's disease, one in six people has no symptoms at all.
The biopsy results were consistent with Crohn's. Likewise, blood tests to diagnose inflammatory bowel disease. But it wasn't the sick intestine that caused the pain in the man's buttocks. It was an associated disorder, a type of arthritis known as sacroiliitis – inflammation of the joint between the pelvic girdle and the sacrum, the triangular bone that connects the hips. Although the reason for this is not exactly known, it appears that some of the immune cells that have been misdirected to attack the gut can attack the joints as well. Up to 39 percent of people with inflammatory bowel disease will develop some form of arthritis. And up to 20 percent develop arthritis before they develop bowel disease. In this patient, it is difficult to know which came first because the bowel disease was discovered almost by accident.
Treat or not treat
Because Crohn's disease is usually painful and has complications such as bowel perforation, anemia, and malnutrition, patients are usually treated with medication to calm the immune system and reduce inflammation. These are powerful drugs that suppress the immune system. They are very effective in controlling pain and destruction, but can leave a patient open to infection. Because of this, it is less clear how patients with asymptomatic diseases should be treated. For those without pain and with no signs of inflammation, vigilant waiting is a common strategy.
The same type of medication is used to treat arthritis, which is associated with inflammatory bowel disease. The doctor wasn't sure if it made sense for him to use an immunosuppressive drug when seeing sick patients. His rheumatologist, who saw him put the pillow on his seat before gently lowering himself into the chair, was much less unsure. She gave these drugs to many people, she told him – some of them doctors. Most did well. He agreed to take it. The effect was immediate and amazing. His pain – a regular visitor for nearly a decade – is gone. Even at the end of the day, getting to and from his car is painless. Sometimes he still uses the pad; These bones are still a little tender. But the rest of him feels great.