Inflammatory Bowel Disease

Lars Haaland, FALUExecutive Director, Fac Exclusive SUP

Bonnie Rickert, FALUUnderwriting Consultant

September 2018

Did you know?

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Cynthia McFadden

ABC News Correspondent

Developed Crohn’s disease her sophomore year of college

Friends dubbed her disease as “George”- this was better than asking if she had 15 diarrhea attacks

1979 had 4 feet of her intestine removed after intestinal bleeding

Now works to raise awareness about the disease with the Crohn’s and Colitis Foundation of America

Images from www.health.com

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Frank FritzStar of History Channel’s American

Pickers

Battled Crohn’s for more than quarter of a century

“Crohn’s is like a Duck”. Ducks look calm, floating quietly on the surface of water, but underneath they are paddling like crazy. It takes hard work to keep it under control.

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John F. Kennedy

35th President of the United States

Developed abdominal pain as a teen and was diagnosed with colitis in 1934

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Amy Brenneman

Emmy-winning actress

Diagnosed with Ulcerative colitis during 2nd

pregnancy

Watched diet and used various medications, even trying acupuncture, herbs and supplements.

In 2010 she had surgery to remove her entire colon

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Agenda~ Inflammatory Bowel Disease• Overview:

• Crohn’s Disease• Ulcerative Colitis• Case Studies

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IBD:Definition:• Chronic inflammation of all or part of the

digestive tract

• Primarily includes:• Ulcerative Colitis

• Crohn’s

• Collageneous colitis and Lymphocytic colitis

• Indeterminate

Crohn’s Disease

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Crohn’s Disease

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What is Crohn’s Disease?

• Also known as granulomatous enteritis, regional enteritis, ileitis or terminal ileitis.

• Characterized by inflammation of all layers of the bowel wall

• More common in woman than in men

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Symptoms of Crohn’s Disease

• Unintended weight loss

• Diarrhea

• Fever and Fatigue

• Abdominal pain and cramping

• Blood in stool

• Reduced appetite

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Complications of Crohn’s Disease• Inflammation in all layers of the bowel

• Bowel Obstruction

• Ulcers

• Fistulas

• Anal Fissures

• Malnutrition/Anemia

• Colon Cancer

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Tests and Diagnosis

• Endoscopic procedures

• Blood Tests

• Imaging

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Mortality Factors for Crohn’s Disease• Younger age at onset, more likely to be recurrent disease

• Dermatological signs

• Ocular complications

• Arthralgia/Arthritis

• Sclerosing Cholangitis

• Active Hepatitis

• Cirrhosis

• Toxic Megacolon

• Anemia

• Thrombophlebitis

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Treating Crohn’s Disease

• Anti-inflammatory Drugs

• Immune System Suppressors

• Antibiotics

• Surgery (not curative)

• Other forms of treatment

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Underwriting Crohn’s Disease Treatment

• Concentrate on response to treatment rather than type of treatment• Side effects of medications

Hospitalizations

Compliance

Extraintestinal manifestations

Diet

Lab values

Ulcerative Colitis

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What is Ulcerative Colitis?

• Chronic relapsing and remitting inflammatory disorder that presents with sores/ulcers in the innermost lining of your large intestine (colon) and rectum.

• Indeterminate: Are cases in which there is difficulty distinguishing between UC and Crohn’s as they have overlapping symptoms and presentations. These make up about 10-15% of IBD cases.

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Types of Ulcerative Colitis:

Ulcerative Proctitis

Proctosigmoiditis

Left- Sided Colitis

Pancolitis

Acute severe ulcerative colitis

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Symptoms of Ulcerative Colitis

Unintended weight loss

Diarrhea

Fever and fatigue

Abdominal pain and cramping

Blood in Stool

Reduced appetite

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Complications of Ulcerative Colitis:

Severe bleeding

Perforated colon

Severe dehydration

Toxic Megacolon

Increased risk of colon cancer

Increased risk of blood clots

Osteoporosis

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Tests and Diagnosis Endoscopic procedures

Blood tests

Imaging

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Underwriting Ulcerative Colitis Current status of disease

• Path report• X-ray• Endoscopy

Complications

Relapses

Frequency and quality of cancer surveillance

Surgical treatment

Age at onset

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Screening with Crohn’s or Ulcerative Colitis Start 1-2 years after the first evidence of pancolitis

Start 12-15 years after evidence of colitis only in descending colon or rectum

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Screening After First Colonoscopy- with Polyps 1-2 polyps- repeat screen in FIVE years

3-10 polyps- repeat screen in THREE years

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Ulcerative Colitis vs. Crohn’s

Ulcerative Colitis Rectal bleeding common

Abdominal pain uncommon

Rectal involvement almost 100%

Fistula formation rare

Stricture and obstruction rare

Perirectal, perianal abscesses uncommon

Continuous involvement

Mucosa and submucosa involved

Small bowel not involved(*)

Risk of malignancy greatly increased

Crohn’s Occasional rectal bleeding

Abdominal pain common

Rectal involvement 50%

Fistula formation common

Structure and obstruction common

Perirectal, perianal abscesses common

Discontinuous involvement

Transmural

Small bowel often involved

Risk of malignancy increased

Extra-intestinal manifestations

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Disease Severity Weight

Number of stools per day

Flares

Treatment

Extent of disease

Activity Level

Extra-intestinal Manifestations

Case Studies

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Case study #1 45 year old female- Non-smoker applying for $1million

• Ulcerative Colitiso Diagnosed at age 25o Current labs within normal limitso Build- 5’6” 145 lbso Surgery completed 9 months prior to the application

• Proctocolectomy with ileoanal anastomosis without complications or recurrence

• Prior to surgeryo ½ of colon involvedo Approximately 4 flares per yearo Occasional Paino Mild Arthritis

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Case Study #2 47 year old male- Non-smoker applying $100k (10/2016)

• Ulcerative Colitis diagnosed August 2013 with complaints of rectal bleeding, weight loss and epigastric burningo Ileo-colonoscopy completed 8/2013 with UC in the rectum and patchy areas of erythema in the

sigmoid and distal transverse colon. Biopsy from the right colon was negative. Biopsy from transverse colon, sigmoid colon and rectum with active US- no evidence of dysplasia or malignancy

o Advised to start on 40 mg of oral steroid per day. Only took steroids for 2 weeks, then started Herbal(ayurvedic) treatment for 1.5 years and relapsed 1/2015

• January 2015 Follow up:o Mild relapse with cramping and abdominal pain and increased bowel movementso Rectal biopsy completed- diffuse active colitis- no evidence of dysplasiao Ileo-colonoscopy report- rectum shows severe inflammation until 18cm, loss of vascular

markings, ulcerations and contact bleeding. Colon and ileum are normal. Dx- active proctitisuntil 18 cm

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Case Study #2 continued: March 2015 Follow up:

• 3-4 stools per day with rare to no bleeding per rectum• Current medications- Vegaz OD(mesalamine) and Mesalo foam (mesalamine topical)• CBC- normal and LFT’s normal• Diagnosis of UC with proctitis until 18 cm- now better

June 2015 Follow up:• Left sided UC continues to be in remission continue Vegas and Cap. Lumia• 3-4 stools per day, no diarrhea, no bleeding• Stool exam- negative for occult blood• CBC- normal and LFT’s normal• EGD with patchy gastritis positive for H. Pylori- advised to take H. Pylori kit for 10 days

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Case Study #2 Continued: October 2015 Follow up

• UC continues in remission• Complaint of pain in left knee• Continue oral mesalamine and multivitamin with Vit D• CBC, urine, stool reports all normal• X-ray completed of both knees with early osteoarthritis and question of extra-intestinal

manifestation of UC

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Case Study #3

29 year old female, non-smoker, applying 6M (February, 2018)

History of Crohn’s disease, diagnosed 2007• Recent flare 9/2017• Colonoscopy 12/2017 without dysplasia• CBC completed 12/2017 H/H -14.1/41.4• Current meds- humira• October 2017 office visit for lesion on the left upper back- stable and mild in severity. No

history of melanoma, no history of atypical nevi, SCC or prior skin cancer

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Case Study #4 25 year old male, non-smoker. Applying $4 Mil

Diagnosed with Crohn’s disease “many years ago”

Insurance labs all normal

Limited medical records received• April 2017- moderate-severe ileitis with 1 stool per day. 5’7” 130lbs. Current meds

humira and anusol• May 2016 ileium chronic active enteritis

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Case Study # 5 51 year old female, non-smoker. Applying $100k

No admitted medical history

Labs-• AST 1.75 x nl• ALT 1.68 x nl• GGT 3.51 x nl

APS from PCP was received:• 9/22/16- noted history of Crohn’s disease of the small intestine with fistula and a need

for a c-scope in 2020. • 2015 CT scan of the abdomen was completed and noted a 7 mm soft tissue structure in

the gall bladder and U/S follow up needed. No follow up completed• No prior LFT’s in the APS for comparison

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Case Study #6 44 year old male, non-smoker, applying #300k (August 2016)

Medical history-• diagnosed with TB in 2001 and successfully treated• Diagnosed with left-sided UC in 2007- last flare 11-12/2014• Sigmoidoscopy completed 12/2014- internal hemorrhoids- otherwise- WNL• Current medications- Mesacol and folic acid• Last office visit 12/2015- Blood and urine WNL.

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Case Study #6 continued March 21, 2013 follow up

• 1-2 stools per day, no urgency• Mesacol 800 mg- three times per day. Started on oral steroid 40 mg for 6 days then

tapered until 10 mg. Folic acid and multivitamins

February 3, 2014 follow up• Flare up reported with increased stool frequency, urgency and tenesmus- clinically nml• Mesacol 2.4 g per day, folic acid and multivitamins

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Case Study #6 continued February 27, 2014

• Flare up continues- 3-4stools per day and bleeding per rectum• Mesacol 2.4 g per day, folic acid and multivitamins• Advised oral steroids 30 mg per day for 5 days

November 19, 2014• Overall doing well in remission• Trace blood in stools, 2 stools per day• Weight 76 kg, no weight loss• Mesacol, folic acid, multivitamins, no oral steroids

December 10/2014• Sigmoidoscopy completed with 2nd degree internal hemorrhoids, chronic UC and severe

left sided colitis• Advised to take oral steroids 30 mg for 5 days

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Case Study #6 continued February 19, 2015

• 2 stools per day- no blood and no mucus• Complaint of bloating, flatulence and pain in upper left abdomen• Advised with some antacid and continues on mesacol and folic acid

January 23, 2015• Complaint of bloating, flatulence, cramping in L sided abdomen• 2-3 stools per day without blood or mucus• Body weight 75 kg

December 29, 2015• Body weight 71 kg• 2 stools per day• Stable in remission on mesacol and folic acid

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