Crohn’s disease but no symptoms

DEAR DR. ROACH » I am a 77-year-old man in good health. I was diagnosed with Crohn’s disease about 15 years ago, but had no symptoms. Recently I had a colonoscopy after blood was found in my stool. A biopsy confirmed Crohn’s disease, and a follow-up CT scan showed a stricture in the terminal ileum. My doctor prescribed Humira, but I am concerned about the possible side effects. With no symptoms, I wonder whether I really need it.

DEAR READER » Management of Crohn’s disease is complicated, and there is no substitute for experienced clinical judgment, so I asked my colleague Dr. Sunanda Kane at the Mayo Clinic. She advised me that many people who say they have no symptoms “subconsciously changed their diet or other habits based on early satiety, bloating or a sense of fullness.”

Dr. Kane noted also that strictures can be due to inflammation or fibrosis. If the stricture they found was inflammatory, she says: “Humira is a good therapy and the risk is worth the benefits. If this is a fibrostenotic stricture then we recommend a low residue diet and monitoring for complications like anemia or vitamin deficiencies. A dedicated CT enterography can discern between an inflammatory and fibrostenotic stricture. Some people have an element of both, and Humira is good for the inflammation portion. In this era of COVID we try to stay away from steroids and absolutely want to treat active inflammation, as this appears to be a risk factor for contracting COVID and more complicated infection.”

DEAR DR. ROACH » Twentyfive years ago I had a gallstone stuck in my pancreas, causing me to have severe pancreatitis. My gallbladder was removed. I haven’t had another attack since. I was taking Pravachol at the time, but was taken off of it. At the age of 78, my triglycerides are borderline high. Is there a statin I could safely take that would not cause stones or affect my pancreas?

DEAR READER » Gallstones are made of a combination of cholesterol and bile salts. If one gets stuck in the bile duct, it may cause inflammation of the gallbladder (acute cholecystitis), but it may also get stuck in the common bile duct, causing cholecystitis and pancreatitis, since it will block the outflow of the pancreas as well.

Some drugs can predispose to getting gallstones, including the cholesterollowering class of drugs called fibrates. People who regularly take statin drugs like pravastatin (Pravachol) have a DECREASED risk of gallstones. The risk in a person taking a statin is roughly 1/3 less than a person not taking one: Not enough to protect all attacks, but certainly not a reason to stop taking a statin.

Borderline high triglycerides may not, by itself, be enough of a reason to start a statin, so it’s a good idea to discuss all the pros and cons of a statin with your doctor, but gallstone risk is likely to be helped, not worsened, by statin treatment.

DR. ROACH WRITES » A recent column on the MMR vaccine misstated the conclusions of a paper. The lead author of this paper noted that while the currently available COVID-19 vaccines offer the best protection right now, an MMR vaccine for people over 40 may provide some protection against COVID-19 at very low risk and cost. Further studies are ongoing to explore whether this strategy might reduce COVID-19 infections or severity, particularly since the specific COVID-19 vaccines may not be available to everyone for months or even years.

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