Okay, and then I'll finalize with our large intestine IBD and IBS, and then I'm between the photo and the lunch, you know, after this, so let's get going here. So we'll concentrate on the large intestine. So inflammatory bowel disease, two main diseases, Crohn's disease and ulcerative colitis, that encompasses umbrella of inflammatory bowel disease. I will briefly talk about microscopic colitis as well. It is also under the umbrella, but these are the two main ones that has led and still leading to a lot of issues with quality of life for our patients. So you've seen, you know, how normal colon should look like or normal small bowel should look like, but in Crohn's disease, you can get inflammation of the entire, potentially the entire GI tract. Often it affects both the small intestine and the colon. In children or pediatric onset, it can tend to affect the upper GI tract, like the esophagus and stomach, but it's quite rare for that to affect that area in the adult onset disease. In Crohn's, you get transmural inflammation, meaning all layers of the bowel can get involved. Compared to an ulcerative colitis, you can get ulceration typically of the mucosa and the submucosal layer. You can get fat wrapping in both diseases of inflammation, the mesenteric fat, because of inflammation throughout the GI tract. And you'll see pictures of what cobalt sturning looks like and ulcerations as well. So symptoms of Crohn's, you can get pain, diarrhea, nausea, and vomiting, especially if they're having more stenosis or obstruction-type symptoms. You can have perianal disease, inflammation of the perianal area, rectum, fistulas, abscesses, can cause fevers just from inflammation, not necessarily from an infection. And of course, with significant absorption problems, you know, the small bowels is where most of our nutrients are absorbed. If that's disease, then you can actually get weight loss as well. And sometimes we can see either endoscopically or on imaging, not just inflammation, we can sometimes see stenosis where you're not able to get the scope through an area that's narrowed. Sometimes you can see fistulas, openings to another organ. So what typically happens or how fistulas develop is that if you look in someone who has from the small intestine to the colon, the ileocecal valve area, this is a very common area for Crohn's to affect. This can get so inflamed and narrowed that your body goes, well, I'm eating, I have contents, I can't get through this, let me just make another pathway and causes another opening to another part of the GI tract and can cause fistulas that way as well. And then of course, you can see that that can lead to diarrhea and all sorts of problems as well. So diagnosis is a combination of clinical imaging, endoscopy, and pathological findings. On imaging, this is just a small bowel follow-through. We rarely do this anymore, but you can actually see the contrast is unable or very hard to get through an area of narrowing right here. On colonoscopy, you can actually see ulcers. So this is cobblestoning, meaning this pink area is almost a normal tissue, but all of this white is the deep ulcerations in someone with Crohn's disease. We have MRI, CT, and torography protocols. We can look for wall thickness of the bowel. I was saying earlier, I was doing intestinal ultrasound in our office. We can actually see thickness of the bowel wall when there's active inflammation, and we can see Doppler flow, a lot of inflammatory activity of blood vessels to those areas as well. So we can pick those up on imaging. And of course, on biopsies, you'll see a lot of inflammatory cells under the microscope. And in Crohn's disease, more often, we'll see these granulomas form as well. So this is where the pathologist can tell us this looks more like Crohn's disease rather than ulcerative colitis, especially if someone's Crohn's is affecting only the colon, and sometimes it's difficult to assess which disease it is. Treatment. I mean, our ultimate goal is, of course, to improve the quality of life for our patients. And initially, we had thought, oh, if the patient's feeling well, that's great. That's OK. We've taken care of the disease. But we found over time that patients may feel well, but there may be still active inflammation going on. So our guidelines have changed to not just clinical remission, but we have to get our patients to endoscopic remission, meaning when we take a look doing a colonoscopy, we have to see all those ulcers that we saw as actually healed up and looks more like a normal colon. That's our ultimate goal right now. Now I guess that's our gold standard, but I like to call like our platinum standard maybe deeper remission where we have histological healing, where when the pathologist looks under the microscope, they no longer even see inflammatory cells. It looks like normal tissues even under the microscope. We're not there yet. It can be ideal if we can get our patients there, but we don't have enough medication or a remitterium to get there, but that would be one of our ideal goals. The ones that do get up to histological healing, they have a really great long-term prognosis for them as well. So lots of different medications. I won't go into all of them, but in general, we've been moving away from nonspecific general immunosuppressant to more specific biologics and small molecules that actually target the different inflammatory cytokines that cause inflammation. Of course, in some cases, patients have to get their bowels resected. It doesn't necessarily mean that it's last resort or, you know, often it can be a last resort, but sometimes it may be beneficial to go ahead and resect an area of stenotic bowel instead of putting them on more and more medical therapy because once scar tissue starts happening, we need to go in endoscopically, start dilating or resecting because medications won't affect scar tissue. And of course, we work really closely with the co-actual surgeons on making sure any abscesses that form can be drained. Cetons are placed that especially have the fistula and the perianal area, and cetons are these little, the patients like to call it, they're like rubber bands, but not really rubber bands. They're not made out of rubber. Kind of plastic areas to kind of keep a fistula open so it can drain and heal from the inside out rather than close up quickly and cause an abscess. So we work closely with their surgical colleagues for them as well. Now with ulcerative colitis, again, affects only the mucosal and submucosal layer, but it's affecting only the colon. Some patients can have just proctitis or rectal inflammation. Some can have inflammation on the left side. Some can have what we call pan or universal colitis where the entire colon is affected. And some patients can start with rectal or proctitis and then over time progress to pan colitis as well. So obviously, the more areas of inflammation, the more symptoms they could potentially have as well. Symptoms, bloody diarrhea, most common. We can have mucus, pus in the stools, pain, anemia, weight loss, fever. Tinnismus is this concept of a patient saying, okay, I need to go to the bathroom. Either I get there and I can't go, or I get there and only a little bit comes out. And often this happens when the rectum isn't inflamed. You think, oh, there's inflammation. They should really be going to the bathroom very frequently. But when the rectum is inflamed, you heard from Dr. Mathur that we had the internal and external sphincters. And sometimes when it's so inflamed, the rectum goes, uh-uh, I don't want to work here. I'm too inflamed. And so then it keeps that stool in the rectum for too long. The patient has a sense to go, but they can't really evacuate because of the inflammation as well. So sometimes, again, opposite effect. Complaining of constipation ends up really being tinnismus. Diagnosis colonoscopy. You see ulcerations, pseudopolyps, just red, friable mucosa. And sometimes when it's really severe, we have to stop and not proceed further because there's a high risk of perforation when we're doing that colonoscopy. So to make that clinical judgment of, okay, when is it appropriate to keep going and when is it appropriate to stop our endoscopy, stop and take biopsies, and come out as well. Treatment. Lots of different medications out there. In general, it depends on how the patient presents. If they have mild disease, we'll do more topical, milder agents. But if they present with moderate to severe disease, we're starting them off on biologics and small molecules right away. Of course, complications can occur, especially if these diseases go untreated or even undertreated. Patients can get toxic megacolon, which is almost a medical emergency in the sense that these patients have the highest risk of bowel perforation and they need to get their colon out. So one of the most common, or not common, unfortunately, it's uncommon, pretty rare. But if this happens, then we're calling up pro-colectal surgeons right away saying, hey, get your OR ready. This person's colon needs to come out. Now, I mentioned briefly, there's an entity called microscopic colitis where there's inflammation of the colon, but endoscopically can actually look normal. And this often happens in the elderly patients, NSAIDs and PPIs have been contributing to this risk as well. The patient has chronic watery diarrhea. You do a scope, it looks completely normal. However, you'll miss the diagnosis if you don't take biopsies. So anytime a patient has diarrhea and we're doing a colonoscopy, we're always taking biopsies regardless of the colon looks normal. Because under the microscope, the pathologist actually sees lots of inflammatory cells. And we can see there's two types of entities in microscopic colitis. The simple entity, I should say, is lymphocytic colitis, where you see a lot of lymphocytes under the microscope in the colonic mucosa. Now there's another entity called collagenous colitis, where you actually see a collagen band. It's this very thick band under this layer, along with a lot of the lymphocytes as well. This is a bit harder to treat. But again, we treat with medications to reduce inflammation. And diagnosis, again, colonoscopy with biopsies. And treatment for that, antidiarrheals, five ASAs typically have not worked well for microscopic colitis. Budesonide and steroids have. But sometimes we even use biologics in patients who have really been refractory to the standard therapies for microscopic colitis. Now moving on to irritable bowel syndrome. Now this is, OK, so if you can't remember anything from my talk, just remember inflammatory bowel disease, IBD. And IBS is irritable bowel syndrome. Often I see too many times, often from patients though, they say, oh, I have inflammatory bowel syndrome. Or I have irritable bowel disease. It's like, no, no, no, no. So if you have inflammatory bowel, which is a disease, an irritable bowel is a syndrome. Think about the bowel just being irritated. It's going to mad at you. It's a functional GI disorder. It's not a disease. It's a syndrome or disorder. It's still a chronic condition, though, typically at the lower GI tract. And you get pain or discomfort in the abdomen, along with some change in bowel habits. That's a hallmark symptom. Now epidemiology of this, IBS affects one in seven Americans. Very common. That's 1% of the US population. Women are twice as likely than men to have IBS. However, there could be a little confounding factor that most often we've seen that women actually end up going to see a physician for their symptoms than males. Sorry for the males out here. But it could be that there could be a bias in diagnosis because females are actually going to see someone for their problem and getting diagnosed with it. So it could be a potential for underdiagnosing the males. But that's what we have in our data. Now there are three different subtypes of IBS. So there's a diarrhea predominant, a constipation predominant, or a mixed of both. And our official definitions based on this Rome 4 criteria, they have to have at minimum two or more of the following. The main thing is they have to have recurrent abdominal pain for one or more days per week in the last three months on average. Now you can't just say, oh, I have IBS after you ate something weird and had pain for a day or had diarrhea and then it went away and never happened again. You don't want to overdiagnose people either. So that's why it has to be more chronic and have to, even if it's intermittent symptoms, to have this recurrent pain. Now typically it can be related defecation, either it improves or reduces with after defecation. It's typically associated with changes in stool frequency or in the form of the stools as well. You just have to have the pain with one of the other components here to make the diagnosis. Now what are the causes of irritable bowel syndrome? Well, multiple things that you see here, psychosocial factors, huge, anxiety, depression, big component of IBS. There's that, and we talk about that mind-gut connection. This is a classic syndrome of the mind affecting the gut essentially. We've seen a lot of patients who end up having a gut infection, C. diff, E. coli, whatever it may be, and the infection clears up, but their gut and their symptoms are still there. We still see patients coming in to talk to us saying, hey, I had this. I'm still not better. I need more antibiotics. I'm like, no, no, no, your C. diff is cleared now, but now your guts, because the microbiome has changed or motility has changed from this recent infection, it hasn't come back to normal. We often see this, what we call post-infectious irritable bowel syndrome. That might last forever or it may take a few weeks or months for them to recover, but we've seen that as well. Often there's an alteration in their bowel motility. It's either moving too slow or too fast. It either causes constipation or diarrhea respectively. Often these patients have higher visceral hypersensitivity in that any minor things affect their sensation in the gut. We have this enteric nervous system, which I like to say our gut is actually smarter than the brain. Our enteric nervous system takes up more room than the neurons in our brain, in a sense, and that's that reason of the mind-gut connection and, of course, imbalance of some gut neurotransmitters that affect motility and sensation as well. Diagnosis, there is no magic test or lab work or endoscopy to make this diagnosis. It's a clinical diagnosis. So labs are normal, endoscopy is normal, biopsies are normal. It's like, again, we call this a disorder, but what we don't want to do is assume someone has IBS and then they get underdiagnosed or misdiagnosed of another actual disease condition like IBD or macroscopic colitis. So we have to evaluate for these alarm symptoms. If a patient comes in saying, oh, I have abdominal pain, it gets better with stool, but I haven't, you know, that said, well, it could be IBS, but we want to make sure that they don't have cancer or Crohn's or ulcerative colitis or microscopic colitis or whatnot. So if someone who's having weight loss or they're anemic on their lab work or they're complaining there's bleeding going on when they have their bowel movements or they're older in age, you want to go ahead and assess them. You don't want to assume it's just IBS. They need to get lab work or endoscopic workup or imaging based on our clinical diagnosis for these patients. So treatment for IBS, lifestyle modifications, number one. We tell them to make sure they get adequate fiber so they can regulate their stools. And fiber is great for both constipation and diarrhea. It can kind of help regulate it to more normal stools. Changing their diet. Sometimes these patients are just eating terrible foods or taking in foods that have a lot of additives in there that can affect, you know, cause bloating, distension, pain, and affect all their, you know, their motility as well. So we kind of, it's good to have a dietician with us to be able to, or refer them to them to review their diet and adjust that as well. And we have different things like low FODMAP diets and different things depending on what the patient needs. And of course, if they have high anxiety or depression, then it's always good to have them be seen by a psychiatrist or psychologist because if we can reduce their anxiety, help their mind, it can actually help their gut. And we've seen this over and over again. And of course, if they have specific symptoms, we'll treat according to that. They have lots of constipation, we'll do medications like laxative. They have diarrhea, we'll treat them with antidiarrheals, antidepressants, anxiolytics to help with them. And there's a whole slew of medications here depending on what they have, more constipation predominant or diarrhea predominant. And alternative therapies are great, including hypnotherapy. We referred some patients with more severe disorder to clinical hypnotherapists to help reduce their anxiety and reduce their pain sensation in their gut. Of course, having ruled out anything else that could be a specific disease for them. So stress management, holistic medications. So that was it on all of your training for today. Questions on the IBD and IBS for the didactic portion.

inflammatory bowel disease

irritable bowel syndrome

Crohn's disease

ulcerative colitis

symptoms and complications