So I'm going to talk to you guys about IBD and IBS. I like to say inflammatory bowel disease and irritable bowel. Oftentimes you may get them or you'll hear them confused, meaning because they use abbreviations some people may mean, they'll say IBS but really mean IBD. So inflammatory bowel disease and irritable bowel, two very different entities that we'll talk about. Okay, so inflammatory bowel disease is a chronic inflammation of the GI tract. For Crohn's disease it can affect any part from the mouth to the anus and for ulcerative colitis affects the colon. You're going to hear there are other what we say extra intestinal manifestations that can be associated with the GI luminal gut disease, meaning some eye issues, joint issues, liver issues that are associated. This picture shows what we call the mucosa involvement, so again we talked about the layers of the intestine. So the left showing what the normal intestine looks like. For Crohn's disease it is what we say a transmural inflammation, so it can affect all the layers of the intestine. And because of that we can see certain features such as cobble stoning, so the areas of inflammation or ulceration can be sort of depressed and then sort of normal mucosa can be sort of popped up so you get this cobblestone appearance. In addition you can get, you'll hear the surgeons talk about fat wrapping around the intestine when they do the surgeries. For ulcerative colitis it's again a mucosal disease, so again the very top layer is going to be inflamed where you see inflammation, ulcerations. And pseudopolyps occur usually in patients with more severe inflammation. The way I describe it is again when the colon has been inflamed it can heal and look for some patients totally back to normal, but for some patients you will see the scarring and sometimes the mucosa does not heal back to normal flat. You'll see what these pseudopolyps, so there are lumps and bumps in the colon that look like polyps but they're not really true sort of precancerous polyps. In terms of symptoms of Crohn's it really depends actually where your inflammation is. So some patients will present with abdominal pain. Symptoms you can see are abdominal pain, diarrhea, nausea, vomiting, fever and weight loss. It can affect the very end or the anal area so you can get what we call perianal disease. That can be severe pain because there is an abscess or pocket of infection and you can form fistula. So fistula can occur anywhere actually in the body. In Crohn's we commonly seen it to the anus to the outside of the skin. Other complications besides just inflammation related to the disease is when the inflammation especially in Crohn's disease as we're going to see this, because it's a transmural process, the lining gets fibrotic and also adenovirus where the stool or food can't pass through. So in the small intestine and the ileum is where you'll commonly see sort of strictures but it can also happen in the colon due to a chronic inflammatory process. In terms of diagnosis, so just remember diagnosis of Crohn's and ulcerative colitis is still sort of what we say clinical diagnosis, meaning we use a lot of tools to help diagnosis, meaning you have to have the clinical history. In addition we'll do scopes, histology, so again we're taking samples of the tissue, radiology images, blood tests, again we're using all these things to make the diagnosis of Crohn's or ulcerative colitis. The picture you see here is one of the common places where Crohn's is involved is in the ileum, again with that chronic inflammation we'll see stricture on a small bowel follow-through, which is just a radiology study where a patient drinks some contrast and it's an active exam, meaning the radiologist will actually follow and look and see how that liquid passes through and can see areas where it's more narrowed or constricted. The middle picture is what we talked about, about the cobblestoning appearance in Crohn's disease and then in Crohn's disease not all patients, about 20% or so patients, you'll see what we call these granulomas, which aren't 100% specific for Crohn's, you'll see them in other conditions but is associated with Crohn's. In terms of treatments, so remember the most important thing to the patient with any condition is right, they want to be back to normal, like not even knowing, right, or doing their day-to-day activities without even feeling like they have a condition or need to worry about it. So that's the number one goal for all patients is to get back to normal life without worrying about anything. The other goals we like to see, again besides achieving a clinical remission, is in IBD, our inflammatory bowel disease, we like to see endoscopic remission and what that means is when we look at the mucosa, it looks back to normal. Like say for some patients that can happen, you're like I wouldn't be able to tell that you actually have this condition, but for some patients that's not possible. Besides achieving remission is maintaining it, right. So these conditions, Crohn's and ulcerative colitis, is a lifelong disease. So once we get into remission, the other key point is maintaining that remission. Histological healing has a question mark, so that would be an ideal goal. Even endoscopic remission is an ideal goal, but we know it's not attainable in 100% of our patients. So histological healing would be an ideal goal, but we're not there yet. In terms of treatments, we have lots of therapies, as you have heard, we've had an explosion of new therapies. On the left there, you'll see all the medical therapies from antibiotics, immunosolicial steroids, immunomodulators, a whole host of biologics, and then in our space we've had the small molecules. Sometimes medicines don't work or if you have a stricture, it just needs to be cut out because our medicines are used to treat active inflammation and when it's already scarred down, our medicines don't work. So a patient may need resection of that part of the bowel or actually their whole colon may need to come out because all our therapies are not effective in treating ulcerative colitis. A fistulactomy, again, if a patient has an abscess or fistula, sometimes that fistula tract needs to be opened up because otherwise they'll keep developing a recurrent abscess. In that fistula tract, sometimes the surgeons will place a seton to actually keep it open so they don't develop that infection pocket and then they can develop an abscess anywhere in the belly or around the anal area that needs to be drained and opened. For ulcerative colitis, again, inflammatory bowel disease we think of as a spectrum, meaning one end is Crohn's disease, the other end is ulcerative colitis. There are patients in the middle where we call sort of indeterminate colitis where they may have sort of features of both that's not clear cut right at that time. If it's a pure Crohn's or a pure UC. So we talked a little bit more about Crohn's in the beginning and now we'll flip to ulcerative colitis. Important things to remember about this condition is, again, it's an inflammatory condition but restricted to the colon only. It's an interesting condition, meaning it usually starts always at the very bottom and ascends in a continuous fashion. It can just be in the rectum and we call that proctitis. It can just be in the rectum and the sigmoid we call proctosigmoiditis. It can go all the way up to the splenic flexure, left side colitis, or the whole colon can be involved. So it's interesting when you do the scopes where you're like, what is the difference between the normal mucosa above that versus inflamed because it usually is a sharp sort of demarcation. So I think it's just very interesting to see that when you do the scopes. In terms of ulcerative colitis, again, where you have your inflammation really drives symptoms too. So we have patients who just have inflammation in the rectum or we call the proctitis where they may have still form stool, not diarrhea, but they may just pass blood and mucus. Some patients may even call themselves constipated. So really from the physician's standpoint, you have to really ask them what they mean when a patient tells you any symptoms. Just with proctitis, people feel like they have to go but nothing comes out so people think they're constipated but really they're not. It's just inflamed. So symptoms can be bloody diarrhea, again, that mucus and pus, abdominal pain, low blood counts, weight loss, fever, and testenosis, it's mainly feeling like you have to go but nothing much comes out, maybe some gas. I would say the picture on the left is probably an extreme of what we call severe ulcerative colitis. So it's amazing when you look at a patient on the outside, they can look fine. But on the inside, this is what you see and you're like, oh my gosh, how have you been living and surviving? But we do see that. So you're seeing ulcerations and then again, you see all just this lumps, bumps, those are pseudopolyps. The other appearance here, this is probably more of a moderate but you're seeing diffuse red friable so it's very – you touch it and it bleeds and you lose the normal sort of vascular or normally you can see the blood vessels in the lining. This is sort of a rough treatment algorithm in terms of mild disease, steroids or aminosalicylates. And then when we're talking about moderate to severe disease is when we're using biologics, steroids, small molecules or even surgery. Complications of ulcerative colitis include toxic megacolon and that means the colon is dilated. When it becomes so dilated, it's sort of like a balloon, it can pop or we call perforation. When we see this, it typically requires surgery to remove that colon because the colon just doesn't work and it's at risk for perforation. Microscopic colitis is another entity. So when we look at the colon, it actually looks normal. Patients can experience chronic water or diarrhea and then when we do biopsies, so any patient who has diarrhea and if they have a normal colon, we will always do biopsies because on the microscopic level, we can see inflammation. On the left is one subtype called collagenous colitis because you see a collagen band, that sort of light pink band at the top. Or we can see lymphocytes in the mucosa, so that's called lymphocytic colitis. So again, the difference when you do your scope, it looks normal but when we do the biopsies, we're seeing inflammation. These are just pictures of the colon. The bottom is just the ileocecal valve but what you're seeing is just normal colon. So again, in a normal colon, you're seeing those normal blood vessels run through there and you're seeing the nice sort of hostile folds. And then in microscopic colitis, again, you're seeing inflammation like on the microscopic level that we can't see with our eye. Treatment for microscopic colitis is a whole host of things. It can just be antidiarrheals, 5-aminosalicylates, some steroids, either budesonides or if a gut localized or prednisone. There's no FDA-approved biologic necessary for microscopic colitis. We use some other therapies sometimes. I would say that would be sort of the exceptional cases to calm down the inflammation. Moving to the other spectrum, so we talked about inflammatory bowel disease or IBD. Now we're talking about sort of IBS or irritable bowel syndrome. So we call this sort of a functional GI disorder. But it's a chronic condition of the lower GI tract and hallmarks are pain. So with the diagnosis, you have pain and a change of bowel habits. It's pretty common. It's probably the most common thing we see in the GI world. It affects about one in seven Americans and women are two times more likely to have IBS than men. In terms of subtypes, we have what we see, IBSD, which is a diarrhea-predominant bowel pattern versus IBSC, which is more common, a constipation-predominant or a mixed. Again, the patient has pain in addition to diarrhea and constipation. We diagnosed it using the Rome criteria. You have to have pain as your symptom and it has to have at least occur one or more days of the week in the last three months. And then two of the following, again, pain related to defecation, meaning usually it improves after defecation. And then a change in the stool frequency, again, it's either constipation or diarrhea and also the form. In terms of what causes an irritable bowel, so again, even with inflammatory bowel, multiple things that we think are involved. Psychosocial factors, meaning there's common sort of coincidence of depression and anxiety with it. You may have also heard the entity of a post-infectious IBS. So if a patient gets like neurovirus or like an E. coli, after that, they still have some alteration of their bowel habits in addition as well as pain. And their patients are not feeling normal. We look, we don't really see anything. And that can last up to two years after a patient has had an infection with the bacterial virus in their gut. In addition, there's probably some component of visceral hypersensitivity. The way I explain it to my patients is, you know, everyone has a different sensitivity to their skin. That probably holds true with the gut too in terms of distension and things moving through. Some people feel it more than others. In addition, some patients have altered bowel motility, meaning too fast, too slow. And then there's probably an imbalance in the gut neurotransmitters. In terms of a diagnosis, again, another clinical diagnosis, there's not one thing that says, yes, this is irritable bowel. We do, when we're taking the history, look for these alarm symptoms, meaning the alarm symptoms are things that are worrisome for other things going on, like cancer. If you're over 50 and all of a sudden you have these new bowel habits, weight loss, anemia, or GI bleeding, again, we're doing a full sort of workup just to make sure we're not missing anything else. In terms of treatment of irritable bowel, like with many things that start sort of with diet lifestyle modifications, you know, if they're constipated, again, maybe they're just not getting enough fiber. So we add fiber supplementation. We talk about their diet because there's a lot of room for improvement for many people. In addition to just psychological evaluation, meaning depression, anxiety, I mean, that can, again, we see it commonly with irritable bowel, but even managing or helping with that can improve their bowel symptoms. For symptom-specific treatments, you see listed, in addition, particular drugs that have been FDA-approved to treat irritable bowel. And then what we call alternative sort of therapies, in Northwestern, we do have a group of GI behavioral health psychologists who do all these things like hypnotherapy, cognitive behavioral therapy, which are really important as, again, treating the patient as a whole or as an overall in a holistic way. And that's it.

Inflammatory Bowel Disease

Crohn's disease

ulcerative colitis

Irritable Bowel Syndrome

treatment