So what we're going to do is we're just going to talk about these two diseases, and then we're going to talk a little bit about IBS. I think it's really important to talk about these two diseases. They may not be the most common diseases that you'll ever see, but they are one of the most costly to the United States of America. These patients get diagnosed young. There's no cure for these diseases. They require, in contrast to other autoimmune diseases, like in rheumatology or neurology, they require lots of imaging, lots of endoscopy, which you've heard about today, and lots of lab work and follow-up. In addition to that, it is one of the highest areas of research and new therapeutic modalities that are coming out. So it's a really, really hot topic in the world of GI. One thing that you'll notice is that a lot of our drugs overlap with rheumatology, neurology, dermatology, and a lot of our drugs overlap with the two diseases in and of themselves. But there are some drugs that you'll only find in one that's not found in the other, and that's because they're different diseases. Sometimes people will ask me, well, isn't Crohn's disease just ulcerative colitis that's progressed? And it's not. They're just two different diseases that fall under the umbrella. So we're going to learn two really important lessons today that you guys can bring back out into the community. Number one lesson, it is I-B-D, D, not S. Sometimes I don't even like to use these three letters anymore. IBS is irritable bowel syndrome, irritable bowel syndrome, whereas I-B-D is inflammatory bowel disease. I know, it was our fault. We were not smart when we put these letters together, and we just confused everybody. I cannot tell you how often at a soccer game a mom comes up to me and says, I heard you're the IBS specialist. And then I have to very nicely say, I'm not. I'm not. But if we go out there, so usually in the community, we say inflammatory bowel disease, I'll just say Crohn's or ulcerative colitis. Or you could go to my kids who just call me poopy doctor. All work. Ulcerative colitis, by definition, is going to start over here in the rectum, and then it's going to go up in some continuous manner. It does that sometimes just right here. Sometimes it'll just do the left side. Sometimes it'll be pancolitis. But it really doesn't go up into the small bowel. There's some nuances of that statement, whereas Crohn's disease can do whatever it wants. Remember I talked to you before about mouth to anus? So we're showing here just the GI tract. But it can occur in the mouth. It can occur up here in the stomach, esophagus. It's rare. It can also skip. So you can have one area involved, and then another area not involved. We used to call Crohn's disease transmural and ulcerative colitis mucosal. We don't really do that anymore. Ulcerative colitis can also be transmural. We know that because of pathology specimens and watching the disease really traverse all layers of the intestines. But Crohn's disease is transmural in the sense that it'll fistulize. It'll go to other parts of the body. For any of you guys who don't know, a fistula is a connection to something else. Remember I told you, it's not the smartest organ system. So when stool can't get through this way, it's going to find another place to go, whether or not that's the bladder, the vagina, the perianal region, the skin. It'll do whatever it wants. Usually don't see that in ulcerative colitis unless there's an overt obstruction there. So in Crohn's disease, you see all of these other manifestations within the mesentery. We call that fat wrapping or creeping fat is the other word that we sometimes use. Inside of the mucosa can have a cobblestone appearance, whereas you can see over here with this picture of ulcerative colitis, it really thins out the mucosa. Perforations are sometimes commonplace in both diseases, but the more that this thing ulcerates, and sometimes when you are doing an endoscopy on a UC patient, they're super easy. Though you'll end up in the cecum in 2.5 seconds, but you can perforate these really, really without making too much movement or sometimes just blowing in some CO2. And if you've ever talked to a surgeon about doing a UC surgery, sometimes the colon just shreds as soon as they open up the intestine because it gets so incredibly thin here. The opposite can occur in Crohn's disease, but again, the thing to remember, the other take-home message, Crohn's disease is the great mimicker. It does whatever it wants. It does not abide by any specific rules. We show here it in a thickened state, but I promise you it can look just like this. Crohn's disease can also have whatever types of symptoms you wanna think of. Things that spike my attention are gonna be nocturnal stooling, weight loss, things that a patient really can't, you know, that can't be assigned to something else. But the other things that you sometimes see on here like nausea and vomiting, abdominal pain, can be related to obstruction. Fever is because of inflammation in and of itself. And you make the diagnosis via a variety of things, including ultrasound, which we talked about earlier, but our gold standard is not granulomas on pathology, but chronic inflammation on pathology. You can also see granulomas there. But you can also do things like see an ileal stricture, especially if it's in the small bowel and you don't have colonic Crohn's. And as you can see here, it has a little bit of a different appearance. This is cobblestoning with some ulcerations, and it isn't continuous in the same way that an ulcerative colitis one is. Treatment in our disease is revolved around several things, and this is what we take out into the community. It's to get those patients into remission, treat them early and aggressively so we prevent a lot of those quality of life abnormalities, and then maintaining it for them. Histologic remission may be a goal in the future, but it's not right now. And my field is such a constant change. I will tell you our first drug came out in 1998. So the whole real history of medication in this field really revolves around the last 25-ish years. And it is very, very immunological, especially in the way that we treat it. You can see here some of the different medications that we use, and then sometimes these patients require surgery. Surgery is not curative in this disease. Ulcerative colitis, you heard me already talk about, it's continuous and it's refined to the colon, hence the colitis part of it. Same idea as being relapsing and remitting, and usually almost always involves a rectum, and I say usually almost always because there's caveats to every rule in this field. Bloody diarrhea and diarrhea are a little bit more commonplace in ulcerative colitis, and the blood is usually red because, again, you've got that rectal involvement, whereas in Crohn's you might have just a little bit of blood from up in the ilium, and then by the time it reaches the rectum it doesn't look red anymore. So here's some of the things that we typically look for. This is more of what we can be expecting. One thing that's easy about ulcerative colitis as a gastroenterologist, you're gonna know from the second you put a scope in whether or not their disease is active or under control, because typically you're gonna look right in the rectum and then it's gonna go on continuously from there. But you can see over here, this looks strikingly similar to that Crohn's disease picture I just showed you. That's why I said they can be very difficult endoscopically to determine. So what you may hear a patient or a community provider tell you is that it was ulcerative colitis, but then they changed it to Crohn's. I like to call myself the weatherman. It's because I can always change my mind. And you don't change your mind because you got it wrong. You change your mind because this disease is typically very difficult to treat. And you have to set these expectations out there for a patient. And they are very, very high maintenance. And it's one of the reasons why it's such a hard thing to treat. Back in the day we had what we called step-up therapy. I wouldn't think of anything in a step-up manner. You can treat mild disease and moderate disease with some of the targets up here. It's very dependent. But I will say that really the way, the goals of therapy are to try to get this disease under control early and aggressively much more than they were in the past. Surgery can be a part of the paradigm. Certainly you want to avoid it if possible as a medicine, as a gastroenterologist. But you also don't want to not offer it to a patient when it's something that may be beneficial to them. You hear a lot of this biologics, biologics, biologics, but then we don't like to say that anymore because now we've got small molecules in the game. Small molecules are not a biologic mechanism. So what we use now is the term advanced therapies. So you'll hear a lot about advanced therapies. So it combines both biologics and small molecules together. And then you'll see immunosuppressants, which are typically our thiopurine analogs or methotrexate, things like that. And then steroids, unfortunately, unfortunately are still a part of our field and they always will be. I say this a lot, they're one of the few medications that you can prescribe for a patient and they can get the same day, which is one of the limitations of inflammatory bowel disease. Complications in ulcerative colitis can be pretty severe. So this is why you want to get it under control. So toxic megacolon or megacolon is something that you can see, again, the disease is like a tornado. And so when it gets so far beyond itself, you can't bring it back in. The colon will stop moving, the contractility is lost. Patients will have pretty significant abdominal pain, rebound guarding, and you want to get them into the hospital as soon as possible. We talked earlier about some of the things that sort of overlap in this field. A lot of times microscopic colitis is brought into the equation of inflammatory bowel disease. It isn't inflammation, it's microscopic because that's what the colon looks like, completely salmon colored and healthy. But under the microscope, you're going to see either a collagen band or a lymphocytic predominance. And sometimes this is self-limited. Sometimes it's early Crohn's or ulcerative colitis. There's a lot of information out there. Sometimes it's just its own chronic disease in and of itself. But I would say the majority of the time you can treat microscopic colitis and get it under control. May have some sort of a microbiologic aspect or component to it. We do tend to see it a little bit more frequently in middle-aged women. Colonoscopy, again, we talked about how you want to diagnose microscopic colitis because you're going to want to get something that can go under the microscope. And here's some of the treatment you could see. There's an overlap here with some of these inflammatory conditions. 5-Aminosalicylates, Budesonide, steroids, even advancing therapies into some of the biologics and small molecules can be done in microscopic colitis when you don't get it under control. And then I just want to pivot to IBS, which is not, not what I am. Lots of people have IBS. IBS is irritable bowel syndrome. And about 15% of the population is going to have IBS. IBS consists of either a constipation-predominant subtype, a diarrhea-predominant subtype, or both. Women are a little bit more likely to get it, but that does not mean that men can't get it. And IBS is typically a diagnosis of exclusion because there's not anything that you're going to see. I mean, they're going to have symptoms, but there's not physically anything that you're going to see to make this diagnosis. So you really want to make sure that you've ruled out other things and that you're not telling a patient that they just have IBS. We've heard many stories today, even in the colorectal cancer. You can see this with celiac. You can see it with inflammatory bowel disease, where people, we automatically tell a patient, oh, it's just IBS, move on. So we just want to be very cognizant of making sure we're not missing something else. We use what's called the Rome criteria to make this. And so typically these patients have had these symptoms for three months. It's related to defecation. So defecation tends to improve the symptoms. And again, there's some sort of a change in the stool frequency or their stool appearance or form. So those are the things that the patients will come to you. But I will tell you, and this is what makes the Rome criteria really hard. You can see this with lots of other GI diseases that you've heard us talk about. So these are not specific to IBS. I think what happens is that we see people come in with these things and we forget to maybe take the time to look for other things. But you want to do this all in the right setting, right? If the patient's not having weight loss, it's okay to start the process of maybe treating for an IBS and then seeing what happens or fever or some of those other worrisome changes. There's one of many different reasons why an individual can get IBS. Or I think there is a genetic component that we need to talk about that we see this run in families. I think there is a psychological or psychosocial component to it. Visceral hypersensitivity is this idea that patient's tolerance of pain is different, right? And you may have somebody who is in excruciating pain and they tell you that they're fine. And somebody that doesn't have any pain in your world that is not able to get by and get through their daily life. It can also be related to motility, infections in the microbiome, and imbalance of neurotransmitters. And so you just want to be aware of not missing alarm symptoms. Weight loss, gastrointestinal bleeding, anemia, fever, nocturnal stooling, those are what I would call symptoms that would make me think maybe I shouldn't be making sure there's nothing else. But certainly in an over 50, and I would caution you over 40, over 45, with weight loss, anemia, or gastrointestinal bleeding, don't just assume it's IBS. Lots of different treatments for this, lots of different drugs, and lots of different drugs that are gonna be available. And many of you in industry are our colleagues in this. Numbers needed to treat are sometimes really high to have success, but numbers needed to harm are pretty low with the majority of these drugs, so that's a good thing. Lifestyle modifications are really important. Cognitive behavioral therapy, biofeedback, dietary modification, FODMAP diets, and fiber supplementation, which is a prebiotic. There's all types of things with hypnotherapy and stress management that may be available in your area. And so I know that was a little bit of a rapid IBS and IBD, and I'm happy to take any questions, or we could do it later. I know you guys are hungry, but anything that you guys have for me right now.

inflammatory bowel disease

irritable bowel syndrome

Crohn's disease

ulcerative colitis

Rome criteria