Prof. Dr. med. Robert Ehehalt is an experienced gastroenterologist and the right specialist when it comes to diseases of the stomach and intestines. At his gastroenterology practice in Heidelberg, he offers a comprehensive range of services, from cancer screening to the treatment of even the most complex conditions. Prof. Dr. Ehehalt’s patients consistently give him top ratings and particularly value his extensive experience.
As a specialist in internal medicine and gastroenterology, with additional certifications in diabetology, emergency medicine, and infectious diseases, Prof. Dr. Ehehalt is a proven expert in the field of gastroenterology. This field deals with all diseases of the esophagus, stomach, small and large intestines, as well as the pancreas and liver. He also shares his extensive knowledge as an adjunct professor of internal medicine at Heidelberg University, where he helps train future physicians.
The gastroenterology practice in Heidelberg is certified by the Professional Association of Practicing Gastroenterologists in Germany as a specialty practice in the field of inflammatory bowel disease (IBD). In 2016, an independent physician comparison portal recognized Prof. Dr. Ehehalt as a recommended specialist in the fields of gastroenterology and IBD. As director of the Study Center for Chronic Inflammatory Bowel Diseases, Prof. Dr. Ehehalt has access to novel medications that are still in development and can benefit many patients.
Another focus of his practice is nutritional medicine and counseling, which optimally complements medical treatment and often enables further improvement in therapy. The editorial team of the Leading Medicine Guide was able to speak with Prof. Dr. Ehehalt specifically on the topic of “chronic inflammatory bowel diseases.”
Chronic inflammatory bowel diseases (IBD), which include Crohn’s disease and ulcerative colitis, are complex and often lifelong health conditions that affect millions of people worldwide. These conditions are characterized by persistent inflammation in the gastrointestinal tract, which can lead to a variety of symptoms such as abdominal pain, diarrhea, fatigue, and weight loss. Despite extensive research, the exact causes of IBD remain largely unknown, making the development of effective treatment strategies challenging. Modern approaches to the treatment and care of patients with IBD rely on a combination of innovative drug therapies, surgical interventions, nutritional counseling, and psychosocial support to sustainably improve the quality of life for those affected.
Crohn’s disease and ulcerative colitis are characterized by persistent inflammation of the gastrointestinal tract, the causes of which are not yet fully understood despite intensive research.
“Chronic inflammatory bowel diseases are a group of conditions characterized by persistent inflammation (lasting more than 4–12 weeks) in the digestive tract. They are divided into two main groups: ulcerative colitis and Crohn’s disease. Colitis (from the Greek “colon,” meaning large intestine, and “itis,” meaning inflammation) is primarily localized in the large intestine, is very superficial, and typically begins at the anus and progresses continuously upward. It can affect part of the intestine, but it can also affect the entire intestine—in which case it is referred to as pancolitis. Crohn’s disease is a condition that primarily affects the large and small intestines but can involve the entire intestine, from the mouth to the anus. This condition typically affects the entire intestinal wall, with inflammation occurring throughout the entire gastrointestinal tract. There is also another group: colitis indeterminata, which affects patients in whom it is unclear whether they have Crohn’s disease or ulcerative colitis because the inflammation cannot be clearly classified. According to the literature, this affects approximately 10–15% of patients. These are the three typical groups of inflammatory bowel disease. One could also mention microscopic colitis, because it is also an inflammatory bowel disease, but it can only be detected under a microscope. It can cause diarrhea but does not result in bloody stools. For this reason, it is not fully classified as part of the group of chronic inflammatory bowel diseases,” explains Prof. Dr. Ehehalt, adding a comment on the prevalence of these bowel diseases: “Currently, we estimate that approximately 600,000 people in Germany suffer from one of the two main types, and the trend is rising sharply. According to some estimates, we can assume that by 2030, roughly twice as many patients will be affected—that would be 1% of the population, which is quite a lot.”
The causes of IBD are not fully understood, but it is believed that they result from a combination of genetic, environmental, and immunological factors.
Prof. Dr. Ehehalt explains: “The cause of the disease is not 100% clear. Genetics definitely play a role. We assume that these diseases are polygenic, meaning they are based on multiple genetic factors that, when they converge, lead to a susceptibility to chronic intestinal inflammation. Mechanistically, we assume a barrier dysfunction that then facilitates the progression to Crohn’s disease or ulcerative colitis. The disease itself is triggered by environmental factors, some of which are playing an increasingly significant role in today’s society. These include excessive stress, insufficient sleep, lack of sunlight (vitamin D deficiency), lack of exercise, possibly frequent use of medications such as antibiotics, infections, and a diet that is often of poor quality due to an excess of additives such as plasticizers and emulsifiers in food. “All of these factors influence our microbiome (the totality of all microorganisms, including bacteria, viruses, fungi, and other microbes that colonize the human body),” and describes the symptoms of the diseases:
“The symptoms of Crohn’s disease and ulcerative colitis can be similar and include chronic diarrhea, abdominal pain, blood in the stool, weight loss, fatigue, and fever. In Crohn’s disease, symptoms often depend on the affected region of the digestive tract and may also include perianal conditions such as abscesses and fistulas. If the disease is located in the large intestine, the patient experiences diarrhea and urgency (the feeling of needing to use the restroom immediately); if it is located in the small intestine, it primarily causes pain in the form of abdominal cramps, as well as bloating and nausea. Ulcerative colitis frequently leads to bloody diarrhea, as the inflammation and ulcers typically begin in the rectum and spread continuously upward. And because the bowel then works faster, it can become cramped. Urgent bowel movements may also occur in this case. “There are therefore no specific symptoms that indicate a chronic inflammatory bowel disease.”
Live an active and healthy life!
Everyone is encouraged to take active steps to look after themselves. Relaxation techniques such as meditation, yoga, and regular physical activity can help reduce stress and improve overall well-being. Regular exercise is also beneficial regardless of its stress-reducing effects, as it supports bowel motility and promotes overall physical health. Smoking has a negative impact on disease activity, particularly in Crohn’s disease, and should be avoided. Good sleep hygiene is another important factor. Adequate, high-quality sleep supports the immune system and can help reduce inflammation. Patients should try to establish regular sleep habits and minimize sleep disturbances.
“As far as nutrition is concerned, there is no specific diet that must be followed. However, there are certain basic principles to consider. For example, one should primarily consume unprocessed foods (no ready-made products), and the diet should be varied and include a healthy mix of foods. It’s important to consume sufficient micronutrients such as iron, vitamin D, folic acid, zinc, and vitamin B12, which can be supplemented if necessary in case of deficiency. If you have an acute or chronic inflammatory bowel disease, you should opt for a low-fiber diet to avoid putting additional strain on the intestines due to frequent bowel movements. Otherwise, a high-fiber diet is recommended. There are also anti-inflammatory foods, such as omega-3-rich foods like salmon or fish in general. Blueberries and turmeric should also be incorporated into your diet. “Every patient with a chronic inflammatory bowel disease should receive nutritional counseling, which is also covered by health insurance,” Prof. Dr. Ehehalt strongly recommends.
The gut is a complex ecosystem that harbors a multitude of microorganisms, collectively referred to as the gut microbiota. These microorganisms, primarily bacteria, colonize the gut in great numbers and with great diversity. They play a crucial role in the digestion of food by fermenting indigestible dietary fiber and thereby producing short-chain fatty acids and other beneficial substances.
Diagnosis is a multi-faceted puzzle.
“First, a detailed medical history must be taken. This is followed by a physical examination, which includes, for example, listening to the abdomen and feeling how it moves. Then laboratory tests are performed, including testing stool samples for markers of inflammation. And the gold standard is endoscopy, during which the mucosa is examined and samples are taken from it. The results of all these tests help determine whether a chronic inflammatory bowel disease is present. However, a completely definitive diagnosis is often only possible after a certain period of time and based on the patient’s response to treatment. Genetic testing is conducted only in a research setting. This is because it is a polygenic disease—there are more than 250 susceptibility genes that we currently know of, which is why it is difficult to say anything definitive about its genetics. This is because having genes from this pool does not necessarily mean that a person will develop a chronic inflammatory bowel disease. In the future, classification may be more feasible using AI (artificial intelligence). Once a chronic inflammatory bowel disease has been definitively diagnosed, it is a lifelong condition—though it does not necessarily remain active throughout one’s life. It can go into temporary remission, but it can also flare up again. Some patients receive immunosuppressants to keep the disease in check, while others need more medication to be able to lead a normal life. “The course of the disease varies greatly,” explains Prof. Dr. Ehehalt regarding the diagnosis.
Biologics have proven to be very effective in the long-term treatment of inflammatory bowel disease (IBD). These therapies offer several advantages over conventional medications, both in terms of efficacy and safety profile, particularly for patients who do not respond adequately to traditional treatments.
Biologics are medications produced by living organisms that specifically block certain components of the immune system that play a role in inflammation. The efficacy of biologics in the long-term treatment of IBD is well documented. “Drug therapy for IBD is based on several pillars. The first pillar consists of salicylates, anti-inflammatory substances; the second is the group of steroids; the third is that of immunosuppressants; and the fourth is that of biologics, which are antibodies that specifically intervene in the inflammatory cascade and can thereby promote intestinal healing. Biologics are used in cases of moderate to severe disease,” explains Prof. Dr. Ehehalt.
Compared to conventional medications such as corticosteroids and immunosuppressants, biologics offer several significant advantages. Corticosteroids are often suitable only for short-term use, as their long-term use is associated with serious side effects such as osteoporosis, high blood pressure, and diabetes. Immunosuppressants such as azathioprine and methotrexate can be effective but often require regular monitoring due to their potential for toxic effects and infections. Biologics, on the other hand, offer a more targeted therapy with a better side-effect profile for long-term use. They can modulate the immune system more specifically, resulting in fewer systemic side effects.
“Biologics are protein molecules that cannot be taken in tablet form. They must be injected under the skin or administered intravenously. In practice, this can be done as infusion therapy or at home via self-injection, similar to how people with diabetes administer insulin to themselves. Typically, treatment with biologics lasts several years, though it can also be paused to see if the disease has entered a new stage and whether medication may no longer be needed at all,” summarizes Prof. Dr. Ehehalt.
Surgical treatment for chronic inflammatory bowel diseases (IBD) such as Crohn’s disease and ulcerative colitis may be appropriate at any stage of the disease but is often only considered when drug therapies are no longer sufficient to control the symptoms or when complications arise.
Specific indications for surgical intervention include treatment-resistant disease progression, obstructive intestinal strictures, fistulas, abscesses, severe bleeding, toxic megacolon, and an increased risk of or the presence of colorectal cancer. “The surgeon is also an integral part of the treatment of inflammatory bowel disease. He or she does not necessarily have to be consulted only at the end, when medical therapies have been exhausted, but must also intervene at an earlier stage in cases of doubt—for example, if a fistula has formed or a narrowing has occurred. In such cases, for example, a specific segment of the intestine may need to be removed or a fistula divided. In the case of ulcerative colitis, the surgeon usually becomes involved when it becomes apparent that drug therapy is not effective or when there is an increased risk of cancer, especially in the colon. Here, precancerous lesions—known as dysplasias—or actual colorectal cancer can develop. Crohn’s disease also leads to an increased risk of cancer, so these patients are monitored regularly via endoscopy (every 1–4 years, depending on the stage of the disease),” explains Prof. Dr. Ehehalt.
Since Crohn’s disease can affect the entire digestive tract, the type of surgical procedure varies depending on the affected region. Common surgeries for Crohn’s disease include stricturoplasty, in which narrowed sections of the intestine are widened, and resection, in which severely damaged sections of the intestine are removed and the healthy ends are connected to one another (intestinal anastomosis). Sometimes a proctocolectomy is necessary, in which the entire colon and rectum are removed, often requiring the temporary creation of a stoma (artificial bowel opening). In ulcerative colitis, surgery is generally indicated when medical treatments are ineffective or when severe complications such as toxic megacolon or the presence of cancer or precancerous lesions occur. The most common surgical option in such cases is proctocolectomy with ileoanal pouch anastomosis (IPAA), in which the colon and rectum are removed and a pouch (pouch) is formed from the small intestine, which is then connected to the anus to maintain continence. In some cases, the creation of a permanent ileostomy is necessary, in which the small intestine is brought out through the abdominal wall.
Prof. Dr. Ehehalt recommends regular screening.
“As a general rule, it is recommended to undergo regular colorectal cancer screening! If someone has inflammation, it must be monitored regularly, and colorectal cancer screening plays an even greater role here due to the increased risk. Depending on the risk assessment, one should then undergo a colonoscopy every 1–4 years. It’s helpful for affected patients to have a gastroenterologist nearby whom they can see quickly if inflammation develops. If the gastroenterologist is too far away, close cooperation with the primary care physician is important and advisable. Fundamentally, good cooperation between patients and their treating physicians is essential for staying in control of the situation. There are also good support groups, such as DCCV e.V. (German Crohn’s Disease and Ulcerative Colitis Association), the largest support group in Germany, where patients can get advice from others with the condition and share experiences,” advises Prof. Dr. Ehehalt, and with that we conclude our conversation.
Thank you very much, Professor Dr. Ehehalt, for this extremely informative and engaging conversation!
