Inflammatory bowel disease (IBD, Crohn’s disease, ulcerative colitis, and indeterminate colitis) can affect more than the intestines. One of the potential complications is perianal disease, which affects the area around the anus (the bottom). This includes fissures (a tear in the anal canal) and fistulas (an abnormal connection between two organs or an organ and the skin).
To find out how these are managed and what treatments are being developed, the IBDMoms talk to David A. Schwartz, MD, who is a Professor of Medicine in the Division of Gastroenterology, Hepatology, and Nutrition at Vanderbilt University and the founder and Director of the Inflammatory Bowel Disease Center at Vanderbilt University Medical Center in Nashville. Plus: hosts Brooke and Amber talk about why they are exhausted with the internet challenges that are part of today’s teen culture.
Episode sponsored by:
Find David A. Schwartz, MD on Twitter: @ibddoc09
Find Vanderbilt IBD Center on:
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- Private Facebook Group: @groups/IBDMoms
Mix and sound design is by Mac Cooney. Find him on:
- Facebook: @michaelandrewcooney
- Instagram: @maccooneycomposer
- YouTube: @CooneyStudio
- Bandcamp: @maccooney
- The web: cooneystudio.com
Theme music, ”It Started With a Hashtag,” is from ©Cooney Studio.
[MUSIC: It Started With a Hashtag]
Brooke Abbott 0:04
I’m Brooke Abbott
Amber Tresca 0:05
And I’m Amber Tresca. And we’re the co founders of IBDMoms We’re moms and inflammatory bowel disease patients and we’ve created a safe space for other moms with Crohn’s disease or ulcerative colitis to share their journeys with one another.
Brooke Abbott 0:18
The IBDMoms Podcast will focus on topics such as body dysmorphia, sex and intimacy, how to parent through flare up and transitioning kids from pediatric care to adult care.
Amber Tresca 0:31
Thanks for being with us. We’re here to help moms on the challenges they face on their journey through motherhood and chronic illness.
Brooke Abbott 0:43
Amber Tresca 0:44
Brooke Abbott 0:45
So today we’ll be talking about fissures and fistulas. I’m super excited about this topic, actually. Because even though I’ve never had an experience with fistulas, I have had a fissure or two in my life. What about you?
Amber Tresca 0:58
Yeah, no, I Well, I had a kid that had a fissure and that was a whole thing. But thankfully, I really haven’t had any periodontal complications and so not having any personal experience. Of course, we did what we always do, we found an expert and we found one in David A Schwartz, who is a professor of medicine and the Division of gastroenterology, hepatology and nutrition at Vanderbilt University in Nashville. He founded and is currently the director of the amazing Inflammatory Bowel Disease Center at Vanderbilt University Medical Center, which he told us all about.
Brooke Abbott 1:35
I’m super excited about this episode. I think a lot of people are gonna get some good info. So stay tuned.
Amber Tresca 1:41
Coming up next, Dr. David A. Schwartz.
Amber Tresca 1:49
Dr. Schwartz, thank you so much for joining us on the IBDMoms podcast. We’re so excited to speak with you.
Dr David A. Schwartz 1:55
Thanks, Amber. Thanks, Brooke. I’m really glad to be here with you today.
Brooke Abbott 1:59
Dr. Schwartz, could you just take a moment and tell us a little bit about your background and your interest in inflammatory bowel disease?
Dr David A. Schwartz 2:06
Sure, I did my training at the Mayo Clinic a long, long time ago now 21 years ago. And I really like just completely fell in love with taking care of IBD patients, it was probably the one thing in medicine where we have medicines that really actually work. And because this disease process affects younger people, we can have a tremendous impact on a patient’s life.
Dr David A. Schwartz 2:30
And I’ve now been doing this long enough that not only have I taken care of patients, but I’ve seen them have kids, and I’ve also now taking care of their kids. So it’s sort of a nice merger of kind of primary care and specialty care and really let you get to know patients and really have a significant impact on their life.
Amber Tresca 2:47
So our topic today is fistulizing disease. So I want to jump right into that because you’re the expert. And we often talk about IBD and how it affects the digestive system. But I think some patients might not realize that it can also affect the Perry anal area, which is that area around the anus or the booty hole. So would you tell us Dr. Schwartz, what are the kinds of perianal complications that go along with IBD?
Dr David A. Schwartz 3:12
Yeah, there are several. So the most common one is probably perianal fistula is and kind of the best way to describe this as sort of a tunnel that connects the rectum to the the outside or to another organ that results from just the severe inflammatory process, causing a defect in the wall that then extends over time.
Dr David A. Schwartz 3:32
Although some patients will also get perianal fissures. I like to describe this as sort of a paper cut or tear in the anal canal. It can be very painful, and then also no alterations. So there’s a number of different periodo complications that go along with periodontal Crohn’s disease, probably about 40% of patients will have one of those or multiple ones of those during the course of their their lifetime.
Brooke Abbott 3:56
So how would someone know if they’re actually developing a fissure? Or a fistula? And in addition to that, how could they start that conversation with their doctor because that seems kind of odd to say, you know, it feels like something’s tearing down there.
Dr David A. Schwartz 4:13
Usually, the most common thing patients will will recognize what will be periodontal pain. So pain is the sort of the first presentation with an anal fissure, maybe it’ll have a little bit of bleeding associated with it.
Dr David A. Schwartz 4:26
With fistulas you also will get drainage of either purulent material pus or stool. And sometimes patients will not know if that’s just some little bit of incontinence or actually drainage through the track. And if they examine their bottom, they might see a little divot or opening that has a little bit of pus coming from it.
Dr David A. Schwartz 4:43
And sometimes doctors who don’t take care of a lot of patients with Crohn’s disease will not know exactly what this is. So it’s really important that you go to someone that is very familiar with Crohn’s and the different manifestations because we treat it very differently if it were from me because you can get an anal fissure without Crohn’s disease, you can get a fistula without Crohn’s disease. And we treat that very differently in a patient that does not have Crohn’s disease.
Brooke Abbott 5:07
I’m actually so glad that you mentioned checking, because I feel like a lot of patients don’t check in that area at all. And it’s so important because you really should know, you know, what’s going on down there.
Dr David A. Schwartz 5:20
And I think it’s an important when you first meet a patient, that’s having any of these manifestations to kind of talk them through what, what to expect, because the other thing I didn’t mention is a lot of times patients with perianal disease will get skin tags and and that can cause a lot of distress and sometimes pain.
Dr David A. Schwartz 5:39
And also, you know, a lot of doctors, again, aren’t familiar with that. And we’ll call that a hemorrhoid, which is not. And so it’s really important that the patient knows their own bottom and can recognize changes and report that back to their doctor.
Amber Tresca 5:51
I’ve heard from so many patients who are misdiagnosed with a hemorrhoid First off, because maybe they’re unable to look or nobody actually does look like even their healthcare provider isn’t isn’t looking. Do you have any sort of tricks for somebody? Like do you reckon like a mirror? Did you get that granular with your patients?
Dr David A. Schwartz 6:12
Yeah, yeah, no, actually, we do. So a mirror is a great option, if someone is doesn’t have a significant other, that can help them. But a lot of times, I just ask them to get their partner to take a look. And if they’re comfortable with that, and get a baseline, and then they can kind of follow things over time. That’s particularly important.
Dr David A. Schwartz 6:30
When we’ll get into this, I think probably a bit later when a patient has a surgical treatment for this and has a seat on place. And that’s something we want them to track over time. So it’s really important to know your own bottom, have you or your partner know your bottom and kind of monitor things.
Amber Tresca 6:44
I love that. My husband always knows what I’m like, I come to him. And I’m like, Okay, I’m really sorry, but I have to ask you to do something gross.
Brooke Abbott 6:52
That’s marriage. Right? That’s marriage.
Amber Tresca 6:54
That is marriage. My partner knows my bottom. So you mentioned treatments. Briefly, you mentioned a Seton. What are some of the treatments that are now available for fistula? And, you know, I think a lot of people also want to know, is there stuff that’s coming up in the future new treatments.
Dr David A. Schwartz 7:09
So the first thing I’ll say is, it’s really important to go somewhere where they have a multidisciplinary approach to this because 20 years ago, when I was first kind of learning about this stuff and training, the concept of working closely, gastroenterologist in a surgeon was really was really very foreign. And we just didn’t do it. And we weren’t getting really the optimal outcomes.
Dr David A. Schwartz 7:30
What we do is very complementary to what the surgeon does, we help each other out and really maximize treatment options. So for sort of the surgical approach, what we’re really asking a surgeon to do is sort of clean up all the infection that’s there. If there’s an abscess, for instance, they drain it, or they put in tube to help it drain.
Dr David A. Schwartz 7:48
And for the fistulas, we often put in what’s called a seton. And a seton is a string or tube that goes through the fistula track if you can picture it in a circle. So it goes through the official track and then comes back around through the anal canal. So it freely rotates in a circle. And the idea is to keep the internal opening, open and the external opening open so all that purulent material can come out and the medicines can work most effectively.
Dr David A. Schwartz 8:13
For medical therapy, we’ve we’ve gotten a lot better in our options. When the the introduction of anti TNF antibodies like infliximab, or Remicade came out that really helped improve the care of patients with with fistulas. The problem is that even under the best care, only about 30 to 40% of patients will have long term greater than a year healing with those medicines. We definitely need adjuvant options or better options that can help really get the majority of patients better, not just the minority.
Dr David A. Schwartz 8:44
And I’m very hopeful because in Europe, they have this this treatment, which uses allogenic, adipose stem cells, so fat stem cells that other people have donated, and they’ve cultured and expanded, and they inject them into the fistula tracks and in patients that have failed medicines like Remicade, they were able to get over half of them better by using this new treatment option.
Dr David A. Schwartz 9:09
We’re in the middle of doing actually, we just completed the study in the US that hopefully will lead to its approval in the US but they because of how long that whole process takes. We’re probably looking at a year and a half before that comes to market here in the US.
Brooke Abbott 9:23
I mean, dare I say that’s exciting to hear just all the things that are coming down the pipeline for people that have so many options. That’s amazing.
Dr David A. Schwartz 9:32
Yeah, I a lot of my patients who have been struggling with this for a long time, I will tell them you know there’s a light at the end of the tunnel. Just hang in there when this becomes available. You know, we’ll roll it out to the to everybody and hopefully, we’ll really improve the patient’s quality of life went home again.
Brooke Abbott 9:50
So I’ve never had a fistula I’ve I’ve had a fissure while living with a toddler which was baby that was what a time Uh, you know, emotionally physically trying to just take care of the house take care of yourself. But living with a fistula, I know can be even more difficult and even more emotionally draining and physically draining. What are some of your suggestions for women who are coping with some of the ways that a fistula could complicate their quality of life, you know, such as intimacy, being physical and active in their in their own lives?
Dr David A. Schwartz 10:29
Yeah, it’s, it can be very difficult. We know that, that women and men actually who have significant perianal disease, it really negatively impacts their their sexual quality of life. Some studies even suggest that up to 97%, and almost everybody essentially with this have a significant negative impact on their their sexual health.
Dr David A. Schwartz 10:51
So it really requires just open discussion, if the person’s in a long term relationship involving the partner to help explain what’s going on and a lot of planning as well. There are things as I mentioned, that we can do to help with the pain, help with the drainage, and really slow down or eliminate the drainage completely, to help improve the quality of life and really being at a center that has psychosocial care, and can involve the patient not only the patient, but the partner in that kind of counseling really helps go a long way to improving that.
[Music: IBDMoms Transition]
Amber Tresca 11:49
So we know that IBD patients who are educated about their disease do better. So I’m wondering, Where do you send your patients so that they’re not going off and finding something that is very scary or not very helpful? They’re living with a fissure, they’re living with a fistula…What do you recommend so that they can learn more either on their own or maybe with some direction.
Dr David A. Schwartz 12:12
You know, there is not a lot of information on on fistulas or fissures online, unfortunately, the ones that are perhaps the best, or there’s a nice infographic on the CCF web page, about perianal fistulas, that I find very helpful from like a once to get a one sort of snapshot as to what to expect and how prevalent it is, and the treatment options. WebMD and up to date, have good patient related resources.
Dr David A. Schwartz 12:40
But there really needs to be more and one of the things I’m very excited, obviously about this new treatment option becoming available in the US. But with that, I think there’ll be a lot more attention to this problem and more resources for patients when when that gets closer to being available.
Brooke Abbott 12:55
Can we talk a little bit about the Vanderbilt IBD center, we know that this you know it takes a multidisciplinary patient centered approach, which we heard that you refer to as a medical home, which I actually I love that because when it comes to living with a chronic condition, you need some sort of base, and a place where you can go and get everything taken care of at one time because patient being a patient is hard enough being a mom is hard enough being both is it? You know, it’s a lot of work. Dr. Schwartz, will you talk to us a little bit more about the Vanderbilt IBD center and what they have available for patients.
Dr David A. Schwartz 13:44
Sure, um, you know, I’m proud to say that we were the first medical home for IBD in the country. And it kind of came from the realization that we were doing a pretty good job of treating the small intestine treating the colon, but we weren’t really treating the whole patient.
Dr David A. Schwartz 14:01
And both Crohn’s and Ulcerative Colitis affects so much more than just your GI tract. And unless you really address those other things that the disease impacts, you’re really not going to get optimal outcomes. And so I’ve put together a team that involves a psychologist, several social workers that do counseling, pharmacists, nurses, doctors, and MP and PAs, who are all trained in IBD.
Dr David A. Schwartz 14:27
And the whole the idea is when a new patient comes, we tell them they’re going to be there for three or four hours. But we’re going to make a very comprehensive evaluation, the patient sees one of our mental health providers first. Then they see one of our dietitians.
Dr David A. Schwartz 14:41
We have a brief team meeting to kind of discuss points that came up in the their visits and then we go in and meet the patient and talk about the medical side of things. If they have any ongoing issues like anxiety and depression, which we know about half of our patients do, they can continue to see one of our mental health providers in our clinic or now virtually, virtual care has become really very important in our what we offer.
Dr David A. Schwartz 15:04
So they don’t have that stigma of having to go to a separate mental health facility and and similarly with the dietician that can plug into our diet dietician resources to help them with some of their their dietary issues. Malnutrition is a big issue, particularly when people have active disease.
Dr David A. Schwartz 15:20
And a lot of time people have gotten just terrible advice on the internet or from page from a friends who are well meaning but really have actually made their symptoms worse. And so it’s a lot of undoing of bad advice and trying to set them on the right path.
Dr David A. Schwartz 15:33
And we’re also increasingly becoming interested in dietary therapies as adjuvants to our standard therapies and sorcerer and incorporate that into some of our treatment approaches. And I think that kind of that whole team approach is really, really important to getting the best outcomes when you’re taking care of patients.
Brooke Abbott 15:52
Wow. Okay, so I guess I’m moving.
Amber Tresca 15:58
Just sounds it sounds wonderful. And we’re so grateful that you have this available to your patients. Is there any social media that you can share with us where patients can find you can find the Vanderbilt IBD center so that we can direct them to you?
Dr David A. Schwartz 16:12
Sure. So my Twitter handle is @IBDdoc09. And we have a website for our clinic. It’s Vandy IBD, which is one word, dot com.
Amber Tresca 16:23
Dr. Schwartz, I want to know a little bit more about you. Do you have any favorite trips that you’ve taken that you could tell us about where’s your favorite place to sort of unplug and relax?
Dr David A. Schwartz 16:34
I absolutely fell in love with Spain. I just find the lifestyle. Fantastic. It’s the food is amazing. The people are amazing. Lots of history. And it’s beautiful. I we often joke my wife and I often joke that we might retire there. It’s just such an amazing place. So that’s that’s where I would go.
Amber Tresca 16:53
Why is it a joke, though? Couldn’t you do it?
Dr David A. Schwartz 16:57
I don’t know. It seems like I’m a very conservative person in general, it seems like a big kind of a risky thing. leaving the country but maybe you never know.
Amber Tresca 17:09
Well, we thank you so much for talking with us today for everything that you do for patients and for making yourself available online to discuss these issues and to bringing more treatments for Fisher and fistula. So thank you so much for joining us.
Dr David A. Schwartz 17:23
My pleasure. I really enjoyed this.
Brooke Abbott 17:24
Great, thank you.
[Music: IBDMoms Transition]
Hi, this is Jax. And you’re listening to my mom Brooke Abbott and my aunt Amber Tresca on the IBDMoms podcast. Just because I don’t listen to her doesn’t mean you shouldn’t.
[Music: IBDMoms Transition]
Amber Tresca 17:50
Brooke Abbott 17:51
Amber Tresca 17:51
Hey, I wonder if you would listen to my mommy meltdown for a minute.
Brooke Abbott 17:55
Girl, I got you.
Amber Tresca 17:56
I need something to happen to stop these Tik Tok challengers that are invading the kids and making them do crazy things. I feel like every week, I’m having to talk to my kids about some other dumb thing that’s going around the Tik Tok.
Brooke Abbott 18:18
Amber Tresca 18:19
Are you having the same experience?
Brooke Abbott 18:20
Oh, gosh, yeah. It’s annoying.
Amber Tresca 18:23
It’s annoying. And recently, there was this this one Chip Challenge situation where there is this I don’t want to call attention to like brand names and whatnot. But it’s this idea where there’s a chip that is dusted with like hot pepper. And to me, it kind of sounds like a like a Dorito chip or something like that.
Amber Tresca 18:45
And then you’re supposed to just like eat the chip. And it is so hot, spicy, that I’ve heard people eat them on podcasts, and they can’t like they can’t talk for like a minute like they have to deal. Like it reminded me…My kids were laughing at me. So I told them this, it reminded me of maybe like being in labor, and you get to a certain point with the contractions where you can’t…
Brooke Abbott 19:09
…You can’t…there’s no talking. There’s no thinking No, I literally just went there you describe that? I was like, Oh.
Amber Tresca 19:17
I really alright, I have not eaten one of these chips. I’m not doing any Tik Tok challenges. I’m talking to my kids at least once a week about some challenge that’s going around. Thankfully, like you know, the school is on it. And then I’m pretty clued in I listened to like a lot of new shows and stuff.
Amber Tresca 19:33
So but of course, I know these things are spreading before I’m ever hearing about them because I’m an old mom. But like, like, I’m just tired of trying to have to be out ahead of it.
Brooke Abbott 19:45
Amber Tresca 19:47
…and I would really just like it to stop. I would like this challenge culture. That’s what I’m gonna call it. I haven’t heard anyone else say that. I’m coining it right now. I would like this challenge culture to stop because I’m tired of spending so much time thinking about how I have to talk to my kids about it. Ask them if they know anything about it. Ask them if they know anybody who is doing it. Ask them if they think it’s a good idea because I just don’t go after them and go, don’t do this thing. Like, you know, I’m that kind of Mom where I like I have I make them have a conversation with me.
Brooke Abbott 20:23
Amber Tresca 20:25
And I’m just I’m tired of it. Like I’m exhausted with it.
Brooke Abbott 20:29
Also, because we have 10,000 other things to do. There’s only so much that we can do like we should all be working together to help raise children and raise the future and make sure that the future is safe, not you know, shoving Tide Pods down their throat and eating Nyquil chicken like and the stuff just sounds dumb. Like we’ve all done done dumb things. Granted, you and I never had them recorded.
Amber Tresca 20:59
I don’t know man. I just I’m like I just don’t I don’t know. I never did stuff like that. I never did. I was boring. I’m still boring.
Brooke Abbott 21:07
This is different than like dingdong ditching someone or prank calling someone.
Amber Tresca 21:14
You know, which neither of those things can be done any more, by the way.
Brooke Abbott 21:18
Amber Tresca 21:19
All right. I subscribed to a newsletter and in the newsletter, in my email came in a warning about don’t steam your vagina with magic mushrooms. I actually posted about it because it caught me off guard.
Brooke Abbott 21:32
Oh, my God.
Amber Tresca 21:35
And there was somebody who DMed me and they said, Do you remember when people used to talk about soaking a tampon in vodka or whatever and using it because that gets you drunk? And I’m like, Yeah, that was a thing. Look in my day. Yes, that was a thing. I’ve never known anyone who did that.
Brooke Abbott 21:55
Are you serious.
Amber Tresca 21:56
But I definitely know people who talked about it or knew of it, but I’ve never known anyone who did it.
Brooke Abbott 22:03
Wait, wait, wait. I never heard of this. And this is really tripping me up. I’ve never heard of this.
Amber Tresca 22:13
Well, here’s the thing. You don’t you don’t steam your vagina or your vulva. By the way. The vulva is on the outside the vagina is on the inside. People get them confused all the time and they say your vagina or I can see your vagina. If you can see my vagina, then you are a lot more intimate than theirs…
Brooke Abbott 22:34
There’s a lot going on there.
Amber Tresca 22:35
Okay, so, all right, you may be able to see someone’s vulva, but you really gotta be between their legs if you want to see their vagina because the vagina is on the inside.
Amber Tresca 22:43
Okay, so when I had my first baby, I had a really funny nurse who came in and was giving my discharge instructions, and I had had a vaginal birth. And she said, All right, this has a lot of stuff on it. I’m just going to tell you one thing, don’t put anything in your vagina, not one thing for four weeks. And I was laughing. And she was like, I find that there’s too much misunderstanding. And if you tell people don’t put in a tampon, they’ll think that they can have penetrative sex, or like the reverse, you tell them not to have sex, but they think that they can use a tampon or something.
Amber Tresca 23:21
So she’s like, so now I’m just very clear. Don’t put anything in your vagina. And like, look, it’s a rule. Like don’t put stuff in your vagina that is not made to go in your vagina. Okay, so I don’t understand why we have to keep going over this, that it like, it was a thing in my day, that was going around soaking a tampon and whatever. Now there to I’ve heard like CBD, like all these things.
Amber Tresca 23:51
And I hope I’m not like giving people ideas. But like, don’t, don’t put stuff on a tampon and then put it in your vagina. Don’t eat really hot stuff on a dare. Like, that’s just dumb. Don’t put NyQuil on your chicken.
Amber Tresca 24:09
And I’m kind of like, I need the challenges to stop. I also have grave concerns. And this is like my being boring mom, again, I have grave concerns about people who think it’s okay to record pranks or record challenges. And some of these things are not real. They’re using camera tricks and things like that, or delayed recording or whatever they’re doing.
Amber Tresca 24:37
And then it is me that is having to tell the elders in my family or the children in my family that what they saw on video is not real and convince them because you know, I’m just a mother. I don’t know anything. So I have to convince them that it’s not real and make them believe me when they literally don’t believe me about anything. Even things that I am an expert in. So it’s really just wild. And I need that to stop.
Amber Tresca 25:05
And I’m also going to say, if people know of a way that moms are keeping themselves informed about these things, I would really like to know what it is because I need to be a step ahead of it. Because I’m tired. I’m exhausted by it.
Brooke Abbott 25:21
Ya know, I feel like that that would be great.
Amber Tresca 25:24
If they’re spying on the teem grapevine, like I need, I need this.
Brooke Abbott 25:28
Where’s the mom form?
Amber Tresca 25:31
Well, we do have the IBD moms Facebook group. So maybe we can use that to to backchannel and sort of warn each other about these odd things that are coming along. And so we can just head them off and have conversations with their kids about it. And help each other out a little bit.
Brooke Abbott 25:48
You can find it at facebook.com/groups/ibdmoms.
Amber Tresca 25:54
I love how you knew that. I couldn’t have said if you asked me I wouldn’t have been able to tell to you. Thank you, Brooke.
Brooke Abbott 26:00
Thank you Amber. On that. I’m gonna go make myself some fall coffee.
[Music: It Started With A Hashtag]
Brooke Abbott 26:10
Hey, y’all, we made it to episode three. I’m so glad y’all are still with us. Links to a written transcript. Everyone’s social media handles and more information on the topics we discussed is in the show notes and on the episode three page on IBDmoms.org.
Amber Tresca 26:26
You can follow us across all social media as IBDMoms
Brooke Abbott 26:30
The IBDMoms podcast is written, produced and directed by the IBDMoms: Amber Tresca and me, Brooke Abbott.
Amber Tresca 26:38
IBDMoms would like to thank Takeda Pharmaceuticals for their support of this program.
Amber Tresca 26:44
Mix and sound design is by Mac Cooney. The music is from Cooney Studio
Amber Tresca 26:54
And then a Clap. 3-2-1 Clap. 3-2-1 [clapping sounds]
Amber Tresca 27:01
Are you waiting for me?
Brooke Abbott 27:04
I don’t know. I was trying to be in sync. I’m not The Temptations, okay. I don’t know how to work in sync.