ASGE Recognized Industry Associate (ARIA) Training Program OPEN | October 2024-Large Intestine (in Disease) IBD and IBS

Large Intestine (in Disease) IBD and IBS

Video Transcription

Okay, great, well, everyone has had a good session on endoscopy and had some coffee. This is, I promise, this is the last part of unilateral teaching, so I'll try to make  it as interesting as possible. Again, referring back to the diagram I started with, that was the gastrointestinal tract,  and we're going to be focusing on inflammatory bowel disease and then irritable bowel syndrome mostly, and then a couple other forms of colitis as well.  So inflammatory bowel disease, they're broadly classified into Crohn's and ulcerative colitis.  And you can see in ulcerative colitis, the red markings are limited to the colon, whereas in Crohn's, the red marking is sort of everywhere.  So that's the idea, that ulcerative colitis stays in the colon, and then the Crohn's is any part of the GI tract, so from mouth to anus, it can involve any part.  And then the other major difference is that ulcers are at the mucosal level in the ulcerative colitis, whereas in Crohn's disease, they don't just stay inside at the mucosal level,  they sort of go transmural, meaning across the thickness of the bowel, and then can involve  the bowel and then the surrounding tissue around it, and can cause strictures and adhesions that we're going to talk about.  So this is the normal colon, which is held by, you know, with the help of the mesentery, so holding it, and then there's the yellow thing that you're seeing is just the fat.  When there's Crohn's disease, it's kind of transmural, as I said, so involving the entire width of the wall.  And so you're seeing a lot of inflammation inside as well as outside, whereas in ulcerative colitis, it's just the sort of mucosa being eaten up with the inflammation.  So the lumen itself looks, you know, more bigger, and if anything, it becomes like a tubular structure, so it loses the convoluted nature that normally the colon has, versus  in the Crohn's, there is inflammation inside, outside, so it's really hard to navigate, and problems in terms of passage and obstruction start coming up in terms of presentation.  So when we have a patient presenting with Crohn's, they could have, you know, early kind of the beginning phase of the Crohn's, or they could already have developed complication,  which is usually the bad sign. So if you see the first picture is sort of showing you stenosis, where the continuity of the bowel is not able to maintain.  The second one is just showing that there is, you know, connection with the small pipe as a small intestine, and then this is the large intestine.  So there is continuity, but everything looks inflamed, and there are ulcers inside. And then the third picture is showing that ilium, which is the small intestine, should  ideally be connecting smoothly to the cecum, but there is stenosis in that area, and not  just that, sigmoid colon, which is lying somewhere in the, over here in the lower area, is having  a connection with the ilium inappropriately because of the ongoing inflammation, so that's called the fistula.  So patients often present with pain, diarrhea, nausea, vomiting, could have perianal disease, so they could have some drainage in around the anus area.  They could be febrile for a very long time, losing weight. So depending on the complication, usually the presentation may vary, but could be really severe.  Once we, you know, clinically see these patients in the clinic, or if, you know, unfortunately if they get admitted in the hospital, we need other ways to diagnose it as well.  So the diagnostic, you know, the absolute gold standard would be to look under a microscope and look at the pathology and say, this is Crohn's disease, and it kind of looks like  all these, you can see these kind of like the blue dots, which are, you know, just aggregation of a certain kind of inflammatory cells, and they're classically known as a granuloma.  So once my pathologist tells me that this is what it is, I know this patient definitely has an inflammatory bowel disease, but prior to that, we need to get that tissue.  So tissue is often, you know, procured by colonoscopy. So with that, in a colonoscopy, we're going to go in, try to see, and you can see these  ulcers, sort of serpentineous ulcers that we're seeing in the colon. We get biopsy of those, and then our pathologist reads the biopsy.  There is concern for complication, like a stricture of fistula. Something like an SPFT, which is a small bowel follow-through, can be done.  Again, small bowel being the most difficult part to examine or get biopsies from. This small bowel follow-through is a very old study, which is basically kind of pushing  some contrast in through your GI tract, and as it kind of goes through the small bowel, if there is any stricturing or narrowing in a certain area, that is picked up by the  small bowel follow-through. So a combination of things help us kind of make that diagnosis.  Obviously, it's a life-changing, life-altering diagnosis for patients, because Crohn's cannot be completely cured, but it can be managed.  So the treatment, you know, then we have to set sort of expectations with our patients. What are they trying to achieve? Are they just trying to get better?  What is the goal to make them better from the endoscopy standpoint or right at the level of the pathology standpoint?  And those endoscopy and pathology aspects are important, too, because Crohn's disease and ulcerative colitis are higher risk for colon cancer.  So these patients may feel better after some degree of therapy or treatment, but if you don't get them all the way to being better, like at the histological level, they still  would be having smoldering inflammation and can develop colon cancer. Management. There is, you know, in the last 20, 30 years, we've just seen a boom of the medications.  We have medical therapy and surgical therapies. So when we have problems like fistulas, stenosis, you know, abscess or perianal disease, those  we have to really work with the colorectal surgeons to kind of do certain procedures, whether they are resections or drainages.  In terms of the medical therapy, those kind of go hand-in-hand with the surgery. And then we, you know, historically it has been managed with steroids because it's an  inflammatory condition, but steroids have a lot of side effects. So then alternative therapies like biologics, which are basically targets of like an antibody  targeted to the inflammatory pathway, those are biologics given in form of injections or infusions.  And then there are small molecules, which also target the inflammatory pathway by inhibiting certain steps, but they are taken in form of oral therapy.  So there are a lot of these treatment options that are alternative to steroids that are  now available for these patients, which we use in form of sometimes solo, sometimes combination. The next, the other type of IBD is ulcerative colitis.  So as I said, this limits itself to the colon and depending on what part it involves, it could just involve the rectum or a little bit of the rectosigmoid.  So that's called proctitis, meaning rectal inflammation or proctosigmoiditis. So involving the sigmoid and then just left-sided or then, or pancolitis.  So usually it's a contiguous involvement. So if it starts from the rectum and then, you know, involves us to a certain level or  certain degree, and then at rest of the colon kind of looks normal, but the part that's inflamed is the reason why patients often develop symptoms.  So in contrast to the Crohn's disease, we do not see cyanosis or fistulas or, you know, strictures or perianal disease with ulcerative colitis.  Ulcerative colitis is just plain inflammation causing irritation to the patient. So diarrhea, blood in stool, fevers, weight loss, or running to the bathroom and accidents  are usually the presenting complaints. Again, for diagnosis, we need the tissue. So we take a look with a camera. So we do the colonoscopy.  You can see the ulcerations are kind of all over and we're seeing the entire mucosa being involved.  The tissue is very friable and then we get the biopsy for our patients, for the pathologist to look at.  The pathology is a little bit different, although we see a lot of inflammation. We don't see the classic granuloma in these, but it often is required for diagnosis.  Once these patients are diagnosed, then depending on how they're presented, how much part of  the colon is involved, we then sort of categorize them into whether they are mild, they are moderate, or in the severe category.  If they are mild disease, then just topical therapy in that local area, or if it is involving  a lot of colon, but not too much inflammation, then some oral therapy can be introduced. And then if the severity goes up, then we can require, we often require steroids for  a short period of time and then give similar treatments like we talked in Crohn's, which  are antibiotic, which are biologic, or inflammatory pathway inhibitors, small molecules can then  be introduced. Surgery is usually sort of the last resort, so if the patients require that, we do offer that too, but it's pretty end-stage or a bad severity sign.  In terms of complication, so even though we don't see any stenosis of fistulas and ulcerative  colitis, we do see a complication of the toxic megacolon, meaning that the inflammation has been going on for so long, like I was trying to tell you in the very beginning that the  colon is losing its convoluted nature, and then it's kind of becoming more tubular, and then it dilates to a certain point that you can see on that CT scan, and when it's so  dilated, it tends to perforate because of the ongoing inflammation. If the patients do present with that, then we don't really have much option but take them to surgery.  So that was the inflammatory colitis, or inflammatory bowel disease, IBD. Next is the microscopic colitis.  So this is also an inflammatory condition, however, the colon in this is normal, as you can see in the picture in between.  So the patient is symptomatic, and if I were to get biopsies of this colon, the pathology will show inflammation, but the colon itself is completely normal.  So this is a condition usually seen in more sort of elderly females, or middle-aged female, who come to us with diarrhea.  When we get the biopsies, we could see just those multiple blue dots. I don't know if you're able to see that.  But the blue dots are just the inflammation, you know, kind of scattered throughout, and then the pink, thick sort of the band that you're seeing is the collagen band, which  is a different kind of microscopic colitis called the collagenous colitis. So there could be more prominent inflammation or more prominent fibrosis that we might see,  but both of them are categorized as microscopic colitis. So this is just the colonoscopy with biopsy. These are all pictures of a normal colon. Again, everything normal here.  In terms of the treatment, what we do, we do offer initially sort of symptomatic management. Microscopic colitis does not increase the risk for colon cancer as opposed to IBD.  So the goal is to manage the symptoms mostly, so we do antidiarrheals. We do give them some anti-inflammatory agents like budesonide, which is also a steroid,  and sometimes we have to give them, you know, the corticosteroids, which is prednisone, which has a lot more side effect than budesonide.  There's also recently, we're trying to navigate to see whether the biologics that we are using for IBD can also be used as a treatment or as an adjunct for patients who remain to be  symptomatic even after receiving these therapies. So the last component is actually is IBS, which is different from IBD, and this one is irritable bowel syndrome.  So the more we understand our gut, we're, you know, recognizing that there is brain-gut access, which is, you know, how people, what people experience in terms of mental health  is, you know, the GI tract reacts to all those feelings. So this is a functional gastrointestinal disorder, and usually patients come to us  with abdominal pain and refer to us for discomfort or change in bowel habits. While there's a criteria to diagnose this, this is almost like a diagnosis of exclusion.  So when patients are coming in with pain and diarrhea, then we rule out everything else  to make sure, you know, no infection or inflammation or anything else is not playing a role, and then we label them as irritable bowel syndrome.  But you often see patients being mislabeled or misdiagnosed, you know, just because they have been having symptoms for too long, and this actually leads to more clinical problems  because other pathological disease may not get diagnosed or may be missed if this is not evaluated.  So IBS affects one in seven Americans, and females are more likely to have IBS than men, so this is just the, you know, geographical distribution.  And then from the IBS subtype standpoint, there's IBS-D, which is diarrhea-predominant  symptom, constipation-predominant is IBS-C, and then mixed type, so they could have alternating diarrhea, constipation.  What needs to remain constant is that patients should complain of pain. So these criteria, this is called the Rome IV criteria.  Patients need to have two out of the following, meaning they could have some changes in the stool frequency, stool appearance, but the pain component is very important, so if they  are experiencing pain at least over one day in a span of a week, and then that pain continues to go on for over three months, that's one of the criteria.  If the pain is related to how they poop, so the poop resolves the pain or makes it worse when the patient is experiencing, you know, the pain gets worse when they're about to  defecate or after defecating, that's important, and then the stool frequency and consistency and appearance itself.  So when patients fit into these criteria, that is when they get diagnosed with IBS, and then again, we rule out other sort of other major causes that may present this way  prior to making this diagnosis. Because of the brain gut, more understanding of brain gut access, we now know that the  psychosocial factors, the visceral hypersensitivity component, you know, is an important reason for developing IBS, although there is some proposed, you know, literature to support  certain infections can cause that some altered bowel motility may be responsible or a combination of all of these factors may be responsible for IBS.  There's no definitive diagnostic findings, so we have to essentially look for any alarm symptoms.  Well, you know, alarm symptoms in general in GI tract, so if your patient comes to you and they're complaining, if they have any of these alarm symptoms, then they need to  be more aggressively evaluated. So if they're older, losing weight, anemia, or having GI bleed, then they need to be more  aggressively evaluated versus a patient who is, let's say, younger, overall doing well, blood work looks good, and there's not really much complaint other than, you know, them  fitting into the Rome IV criteria. Then we are, you know, we can make a diagnosis, but any of the alarm symptoms would make me  kind of look for other alternative explanation of those symptoms a little bit more aggressively. The management, it is really kind of, this is an unchartered area, so the management  guidelines tell us to kind of manage it in a certain way, but, you know, not every trick works for every patient, so we have to do a combination, sometimes, you know, cycling  through multiple medications or doing a combination of these. So we can start with some lifestyle modification, which is usually the first step for management,  so we do some fiber supplementation, dietary changes are really helpful, then psychological evaluation, we are really understanding more of the behavioral health component in GI,  you know, management, GI problems management, so this has been recently introduced. And then we have symptom-specific management of their diarrhea, their spasms, antispasmodic,  some use of the anxiolytics and the antidepressants in this population also helps a lot. And receptor drugs are certain channels that are making them have more diarrhea, so if,  you know, you block those channels, if you block those pathway, you know, the diarrhea could potentially stop, so that's the basis of using these receptor drugs.  And then there are alternative therapies used by our GI psychologists, like hypnotherapy, stress management, and holistic medicine.  And a combination of this, usually, you know, we try to improve the quality of life for these patients.  Yeah, that's pretty much it that I got for you. Any questions?

Video Summary

The session focuses on gastrointestinal issues, specifically inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS). IBD includes Crohn's disease and ulcerative colitis, characterized respectively by inflammation throughout the GI tract and limited to the colon. Crohn's involves the entire bowel wall, causing strictures and fistulas, while ulcerative colitis affects the mucosa, often leading to toxic megacolon. Diagnosis involves endoscopy and biopsy, with treatments ranging from steroids to biologics and surgery. Meanwhile, microscopic colitis shows normal colon appearance but microscopic inflammation, primarily affecting middle-aged women. It is managed with anti-inflammatory agents and antidiarrheals. IBS, characterized by abdominal pain and altered bowel habits, is a functional disorder influenced by brain-gut interaction. It is diagnosed by exclusion using the Rome IV criteria and managed through lifestyle changes, psychological approaches, and symptom-specific medications, enhancing patients' quality of life.

Asset Subtitle

Kajali Mishra, MD