Prof. Dr. med. Robert Ehehalt is a renowned specialist in gastroenterology and head of the gastroenterology practice in Heidelberg. His specialization includes the diagnosis and treatment of gastrointestinal diseases, in particular chronic inflammatory bowel disease (IBD), as well as colorectal cancer screening and nutritional medicine. Thanks to his extensive expertise and many years of experience, he is a recognized authority in this field and enjoys the trust of numerous patients.
As an adjunct professor of internal medicine at the University of Heidelberg, Prof. Dr. Ehehalt passes on his specialist knowledge to medical students and also regularly gives lectures to specialist colleagues. Through his membership of the American Gastroenterological Association, he has an international network and is always up to date with the latest scientific developments. A particular focus of his practice is modern endoscopy. With the help of innovative procedures, including capsule endoscopy and the intelligent endoscopy module GI Genius™, he enables precise and gentle examination of the entire gastrointestinal tract. The early detection of bowel cancer through colonoscopies and the immediate removal of polyps make a decisive contribution to the prevention of serious diseases.
As head of the study center for IBD, Prof. Dr. Ehehalt is involved in researching new treatment options and has access to innovative medications that can help many patients even before they are launched on the market. In addition to medical treatment, he places particular emphasis on nutritional medicine, which often plays a decisive role as a complementary therapy. The gastroenterology practice in Heidelberg is certified as a specialist practice for chronic inflammatory bowel diseases and enjoys an excellent reputation nationwide. Patients not only appreciate Prof. Dr. Ehehalt's high level of professional expertise, but also his human and empathetic manner, which consistently earns him top marks in independent reviews.
There is a new cortisone-free therapy for chronic inflammatory bowel disease - the editors of the Leading Medicine Guide were able to talk to Prof. Dr. Ehehalt about this.
Chronic inflammatory bowel diseases (IBD) are long-term, usually intermittent diseases of the gastrointestinal tract that are associated with inflammation of the intestinal mucosa. The two most common forms are Crohn's disease and ulcerative colitis, which differ in their spread and symptoms. While Crohn's disease can affect the entire digestive tract, ulcerative colitis is limited to the large intestine. Typical symptoms such as diarrhea, abdominal pain and weight loss significantly impair the quality of life of those affected. Despite intensive research, the exact causes are not fully understood, but genetic factors, the immune system and environmental factors play a central role. Thanks to modern diagnostics and new drug therapies, IBD can be treated more and more effectively, enabling many patients to lead an almost normal life.
Chronic inflammatory bowel diseases (IBD) such as Crohn's disease and ulcerative colitis manifest themselves through a variety of symptoms that can have a major impact on the daily lives of those affected.
“The inflammation of a chronic inflammatory bowel disease does not usually go away on its own. The disease is caused by polygenetic components and additional environmental components, which ultimately trigger the whole thing. Depending on the disease, the entire gastrointestinal tract can be affected, in Crohn's disease from the oral cavity to the anus, and in ulcerative colitis, the other form of IBD, only the large intestine is affected. The symptoms experienced by those affected depend on the location in the intestine. If the inflammation is in the colon, they often have diarrhoea, bloody stools, abdominal cramps and/or symptoms of urge to defecate,” explains Prof. Dr. Ehehalt.
Many patients also complain of extreme tiredness and exhaustion, known as fatigue, which further reduces their quality of life. Weight loss and malnutrition are also common side effects, as the inflammation in the gut makes it difficult to absorb nutrients. Some patients also experience additional symptoms such as joint pain, skin changes or eye inflammation, which indicate the systemic nature of the disease. The course of the disease varies from patient to patient, with most experiencing a relapsing-remitting course. This means that the symptoms occur in phases - during active phases of the disease, also known as relapses, the symptoms are often very pronounced, while in remission phases (resting phases) they decrease significantly or even disappear completely. However, there are also patients for whom the symptoms persist continuously, which can significantly impair their quality of life.
In the course of the disease, serious complications can also occur without adequate treatment. These include intestinal constrictions, which make bowel movements difficult, and fistulas, which can form inflammatory connections between the intestine and other organs. The risk of developing bowel cancer also increases, particularly with long-term ulcerative colitis.
The causes of chronic inflammatory bowel diseases (IBD), such as Crohn's disease and ulcerative colitis, are complex and not yet fully understood. However, it is becoming increasingly clear that genetic, immunological and environmental factors play a decisive role in the development and progression of these diseases.
Genetic factors play a role in susceptibility to IBD. Researchers have identified several genes that are associated with an increased risk of these diseases. “In inflammatory bowel disease (IBD), more than 300 susceptibility genes have already been identified that influence disease risk, including NOD2, ATG16L1, IL23R and many more. These are genes that increase susceptibility to IBD, but do not trigger the disease on their own. They are therefore risk genes which, in combination with environmental factors, influence the likelihood of developing the disease. All of these genes are likely to have something to do with the maintenance of the intestinal barrier. IBD is not necessarily a disorder of acquired immunity, as is the case with an autoimmune disease, for example, but more likely a disorder of the intestinal barrier. To put it simply, the intestinal barrier is more permeable, which is why commensal bacteria can find their way into the intestinal wall and lead to chronic inflammation. In addition, environmental triggers such as stress, the frequent use of antibiotics, too little sleep, smoking and too little exercise contribute to the disease becoming manifest,” explains Prof. Dr. Ehehalt.
In healthy people, the immune system recognizes foreign invaders such as bacteria or viruses and fights them. In people with IBD, however, this immune response is impaired. The immune system reacts excessively to harmless substances in the intestine, which can trigger chronic inflammation. This defective immune response affects, among other things, the so-called T cells, which play a central role in the regulation of the immune response. This overreaction of the immune system leads to inflammation becoming chronic and damaging the intestinal mucosa.
The microbiome - the entire community of microorganisms that live in the human body, especially in the gut - plays a central role in the health of the gut and the entire body.
Prof. Dr. Ehehalt explains: “In the context of chronic inflammatory bowel diseases (IBD), such as Crohn's disease and ulcerative colitis, the microbiome is probably very important. A healthy microbiome contributes to a stable immune defense, supports digestion, helps to produce certain metabolites and protects against harmful germs. In IBD patients, the microbiome is often disturbed. A reduced diversity of beneficial microbes and an overgrowth of potentially less stabilizing bacteria can lead to inflammation and dysregulation of the immune system. Ultimately, however, every microbiome is like a fingerprint that is variable. A decline in the diversity of the microbiome is a problem that is being observed in industrialized nations. There are various theories here, one of which is the so-called hygiene hypothesis: In modern, more 'hygienic' societies, children may be exposed to a lower number of different microbes and fewer infections, which ultimately 'trains' the immune system less and can therefore lead to increased sensitivity. The microbiome can be influenced by a change in diet, for example by switching completely to a Mediterranean diet and no longer eating fast food. The Mediterranean diet is recommended. It is said to contribute to a particularly positive flora with a high diversity, while one-sided convenience or fast food products tend to have a negative effect. It is always better to eat fresh food and a wide variety of foods,” he adds:
“In Germany, there are now estimated to be around 600,000 people with IBD, and this is expected to increase to around 800,000 by 2030. Those affected are usually between 15 and 40 years old when they are first diagnosed, and today's lifestyle has certainly contributed to the rising number of sufferers. Cited are too little time spent in nature, possibly too little exposure to sunlight and therefore less vitamin D, too little exercise and possibly too much hygiene in some areas. There is a study that shows that people who had dogs in childhood, for example, are less likely to develop IBD than those who grew up without a dog/pet. There is evidence here - but how robust it is still needs to be discussed”.
Certain diets, such as the so-called elemental diet or special nutritional approaches such as the microbiome-targeted diet or the low-FODMAP diet, aim to influence the microbiome through targeted food intake, among other things. The elemental diet consists of easily digestible foods that can relieve the microbiome. The low FODMAP diet, on the other hand, aims to reduce fermentable carbohydrates in the intestine, which are associated with a disturbed microbiome flora. Dietary changes aimed at restoring a healthy microbiome composition can be an important complement to drug therapy.
FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols. These are certain short-chain carbohydrates and sugar alcohols that are poorly absorbed in the small intestine and therefore ferment in the large intestine.
In recent years, the treatment options for chronic inflammatory bowel disease (IBD) have developed considerably, and modern treatment concepts such as biologics, personalized medicine and innovative nutritional concepts have significantly improved patients' prospects.
“We talk about 'advanced therapy', i.e. an advanced therapy that we offer patients. This includes the approved drugs that have nothing to do with cortisone (anti-inflammatory drug), mesalazine (anti-inflammatory drug) or azathioprine (immunosuppressant). Advanced therapy' uses biologics and so-called 'small molecules' that target specific molecules of the immune system that influence the inflammatory processes in the gut. There are biologics that we have known about for 20 years, but we also have new biologics. Therapy with 'small molecules' is a tablet therapy with immunosuppressants, where patients usually only take one tablet a day to suppress the disease. These therapies are good on the one hand because the patient gets better quickly, and on the other hand they are also suitable for remission, as IBD is a recurring disease. This means that they are therapies that are usually carried out over several years,” says Prof. Dr. Ehehalt about the ‘modern’ forms of therapy.
TNF-alpha inhibitors in particular (such as infliximab, adalimumab, golimumab) revolutionized the treatment of Crohn's disease and ulcerative colitis over 15 years ago by effectively suppressing TN-alpha-mediated inflammatory reactions. However, newer biologics, such as integrin inhibitors (e.g. vedolizumab) and interleukin inhibitors (such as ustekinumab, guselkumab, mirikizumab and risankizumab), have also delivered promising results by specifically interfering with the immune response and inhibiting the inflammatory processes. These drugs are highly effective, even in patients who have been unable to achieve sufficient control of the disease with conventional forms of therapy. Particularly in severe forms of IBD, biologics have significantly improved the quality of life and well-being of patients and in many cases achieved a remission that was previously unthinkable.
The latest drug classes JAK-1 inhibitors, S1P receptor modulators and IL-23 inhibitors offer promising options for the treatment of chronic inflammatory bowel diseases (IBD) such as Crohn's disease and ulcerative colitis. These drugs represent a new generation of therapies that can specifically intervene in the immune process and positively influence the course of the disease.
“These therapies can be used in all patients, unless there is a contraindication. In certain medical situations, for example, modern drugs such as JAK inhibitors should not be used or should only be used with caution, for example if the patient has a cardiac arrhythmia or hypercholesterolemia (where the cholesterol level in the blood is too high). This means that the choice of therapy is very individual, because it is always necessary to look at the overall medical problems and which medication has already been taken. It is also important to discuss with the patient what he or she would like, so that the right treatment decision can be made together. There is no real cure for IBD. However, it is possible that the disease is in remission, i.e. the patient has no symptoms, which is what we are aiming for with the medication, but the disease remains for life,” explains Prof. Dr. Ehehalt.
Complications of chronic inflammatory bowel disease
“If the bowel is inflamed and the inflammation cannot be controlled, complications such as fistulas or stenoses can occur, and chronic inflammatory IBD can increase the risk of cancer. Chronic inflammatory diseases are often associated with each other, so a patient with IBD can also suffer more frequently from other inflammatory diseases such as psoriasis or rheumatism, and finally, someone who is chronically actively ill is naturally also exhausted more quickly and more susceptible to infections due to the persistent inflammation,” adds Prof. Dr. Ehehalt.
In conclusion, Prof. Dr. Ehehalt emphasizes: “Modern medicine today offers numerous innovative therapeutic approaches with which we can significantly improve the quality of life of patients with chronic inflammatory bowel disease. Early diagnosis, individually tailored treatment strategies and a comprehensive understanding of the disease are crucial. Together with our patients, we look for the best possible therapy to enable them to live as symptom-free a life as possible.”
Thank you, Professor Dr. Ehehalt, for the information on chronic inflammatory bowel disease!
