Inflammatory Bowel Disease

Lars Haaland, FALU Executive Director, Fac Exclusive SUP Bonnie Rickert, FALU Underwriting Consultant

September 2018 Did you know? 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 attacks

. 1979 had 4 feet of her intestine removed after intestinal

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

Images from www.health.com 3 Frank Fritz

Star 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.

4 John F. Kennedy

35th President of the United States . Developed abdominal pain as a teen and was diagnosed with colitis in 1934

5 Amy Brenneman

Emmy-winning actress

. Diagnosed with 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

6 Agenda~ Inflammatory Bowel Disease • Overview: • Crohn’s Disease • Ulcerative Colitis • Case Studies

7 IBD: Definition:

• Chronic inflammation of all or part of the digestive tract

• Primarily includes: • Ulcerative Colitis • Crohn’s • Collageneous colitis and • Indeterminate

8 Crohn’s Disease Crohn’s Disease

10 What is Crohn’s Disease?

• Also known as granulomatous , regional enteritis, or terminal ileitis. • Characterized by inflammation of all layers of the bowel wall • More common in woman than in men

11 Symptoms of Crohn’s Disease

• Unintended weight loss • Diarrhea • Fever and • Abdominal pain and cramping • in stool • Reduced appetite

12 Complications of Crohn’s Disease

• Inflammation in all layers of the bowel

•

• Ulcers

•

• Anal Fissures

• Malnutrition/

• Colon Cancer

13 Tests and Diagnosis

• Endoscopic procedures • Blood Tests • Imaging

14 15 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

•

• Toxic

• Anemia

• Thrombophlebitis

16 Treating Crohn’s Disease

• Anti-inflammatory Drugs • Immune System Suppressors • • Surgery (not curative) • Other forms of treatment

17 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

18 Ulcerative Colitis What is Ulcerative Colitis?

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

• 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.

20 Types of Ulcerative Colitis:

. Ulcerative

. Proctosigmoiditis

. Left- Sided Colitis

. Pancolitis

. Acute severe ulcerative colitis

21 Symptoms of Ulcerative Colitis

. Unintended weight loss

. Diarrhea

. Fever and fatigue

. Abdominal pain and cramping

. Blood in Stool

. Reduced appetite

22 Complications of Ulcerative Colitis:

. Severe bleeding

. Perforated colon

. Severe dehydration

.

. Increased risk of colon cancer

. Increased risk of blood clots

. Osteoporosis

23 Tests and Diagnosis

. Endoscopic procedures

. Blood tests

. Imaging

24 25 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

26 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

27 Screening After First - with Polyps

. 1-2 polyps- repeat screen in FIVE years

. 3-10 polyps- repeat screen in THREE years

28 Ulcerative Colitis vs. Crohn’s

Ulcerative Colitis Crohn’s

. common . Occasional rectal bleeding

. Abdominal pain uncommon . Abdominal pain common

. Rectal involvement almost 100% . Rectal involvement 50%

. formation rare . Fistula formation common

. Stricture and obstruction rare . Structure and obstruction common

. Perirectal, perianal uncommon . Perirectal, perianal abscesses common

. Continuous involvement . Discontinuous involvement

. Mucosa and submucosa involved . Transmural

. Small bowel not involved(*) . Small bowel often involved

. Risk of malignancy greatly increased . Risk of malignancy increased

. Extra-intestinal manifestations 29 Disease Severity . Weight . Number of stools per day . Flares . Treatment . Extent of disease . Activity Level . Extra-intestinal Manifestations

30 Case Studies Case study #1 . 45 year old female- Non-smoker applying for $1million • Ulcerative Colitis o Diagnosed at age 25 o Current labs within normal limits o Build- 5’6” 145 lbs o Surgery completed 9 months prior to the application • Proctocolectomy with ileoanal anastomosis without complications or recurrence • Prior to surgery o ½ of colon involved o Approximately 4 flares per year o Occasional Pain o Mild Arthritis

32 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 burning o 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 movements o Rectal biopsy completed- diffuse active colitis- no evidence of dysplasia o Ileo-colonoscopy report- rectum shows severe inflammation until 18cm, loss of vascular markings, ulcerations and contact bleeding. Colon and are normal. Dx- active proctitis until 18 cm

33 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 positive for H. Pylori- advised to take H. Pylori kit for 10 days

34 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

35 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

36 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

37 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 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

38 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 - otherwise- WNL • Current medications- Mesacol and folic acid • Last office visit 12/2015- Blood and urine WNL.

39 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

40 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 41 Case Study #6 continued . February 19, 2015 • 2 stools per day- no blood and no • 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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