Cram The Pance - S1E7 Ulcerative Colitis vs. Crohns Disease

Episode Date: January 19, 2021

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All right. So today we're going to be going over a couple pretty important topics for your pants, panor in EURs and exams. That's going to be ulcerative colitis and Crohn's disease. So these are two different forms of inflammatory bowel disease. And in a minute, we'll break down each individual disease and go through the specifics you need to know for each. But what I'd like to go over first is some of the things that they share in common, some of the risks and things like that. So let's first go over the race you'll see them in, the age and things like that. So this is going to be most common in Caucasian individuals. In particular, Ashkenazi Jewish individuals are, it's very common that you'll see both the ulcerative colitis and Crohn's disease. The age range that you're going to see are normally the teens like 15 to 16 to about 30 years old.

So this is seen in younger individuals. And as far as smoking, there's an interesting thing to note here. So in Crohn's disease, you're going to see an increased risk of Crohn's disease. But in ulcerative colitis, patients that have ulcerative colitis in smoke actually decrease the amount of flare. So it actually improves this disease. So if you have ulcerative colitis and you stop smoking, your flares will actually increase. And the thought process behind this is that nicotine suppresses the immune system, which normally isn't a good thing. But in an autoimmune process like this, it's actually helpful and can decrease the inflammation in the colon. And in addition,

the nicotine actually increases the mucus production in the colon, which has a protective barrier that it lays down with this extra mucus that's produced from the smoking. So that's something that's interesting to note about that. So there's some extra intestinal manifestations that you'll see in both ulcerative colitis and Crohn's, and these are things that you'll see outside of the bowel problems and other GI problems. So one thing that you'll see in both of these is something known as iritis or anterior uveitis. This is an inflammation of the eye. So remember, the inflammation could occur anywhere in the body. And that's one of the more common things that you'll see is this uveitis or iritis. Another thing that you'll see is B12 or iron deficiency. And this is due to the malabsorption more commonly that you'll see in Crohn's disease.

And then also you'll see some dermatological manifestations. In particular, erythymidodosum is something that you'll see most common in the anterior lower legs. And these are painful red nodules. And this is something known as pinoculitis, which is an inflammation of the subcutaneous fat. So again, another inflammation in a different part of the body. And then finally there's one other dermatological manifestation known as piodurituris. gangrenosum, which is this painful ulceration you'll see in the lower legs. And some other risk factors that are shared in both of these are patients who take an

increased amount of inseds, oral contraceptives. These are all things that can increase your risk of both ulcerative colitis and Crohn's disease. So let's start off with Crohn's disease. We'll go over the specifics for that. There's a lot of things that you need to know for Crohn's that will differentiate it from ulcerative colitis. And those are the things that you need to remember.

Those are the really important things. So let's start off with a useless fact. Crohn's disease was named or found by a GI doctor named Bill Crone in 1932. So useless fact, let's go into the important stuff. So Crohn's disease is an autoimmune inflammatory bowel disease with a relapsing, remitting course, meaning that there's periods where you'll have these flares, then there's periods where it does improve and get better. It's a transmural inflammation, very important.

Transmural, meaning it affects all the layers of the intestinal mucosa. and this is really important because ulcerative colitis is only mucosal and sub-mucosal, so more superficial. So Crohn's disease, transmural all the way through deep, all the way into all the intestinal mucosa that it affects. And then another important thing that differentiates it from ulcerative colitis is that it can affect any part of the GI tract. Anywhere from the mouth to the anus can be effective with Crohn's disease. And ulcerative colitis is going to be strictly just in the large bowel.

So that's another thing to differentiate here. And the most common area that will be affected in Crohn's disease is going to be the terminal ilium. So most common area for Crohn's disease that occur as the terminal ilium. So the way that I remember this, and hopefully this helps, I don't know the age range of the people listening to this podcast, but hopefully most of you know that there's a famous rapper named Ti. And TI, a famous rapper, like most rappers and other music musicians, make CDs, maybe not so much anymore, more Spotify. But anyways, for the sake of this, to mnemonic,

let's remember that TI is a wrapper and TI makes CDs. So, TI, Terminal Ilium, CD, Crohn's disease. That's how you can kind of remember that the terminal ilium is the most commonly affected area in Crohn's disease. I hope, hopefully that helps. It always helps me in PA school. I never forgot that. And then another important thing to note is that the rectum is often spared in

Crohn's disease compared with ulcerative colitis where it's almost always involved. So ulcerative colitis, the rectum is pretty much always involved, whereas in Crohn's disease, the rectum is often spared. So how is this patient going to present? Well, normally they're going to have right lower quadrant pain. Why are they having right lower quadrant pain? Well, just because of what we just went over, it's normally the terminal ilium that's affected and that's in the right lower quadrant.

So right lower quadrant pain, diarrhea is very common, but important to note the diarrhea is normally non-bloody diarrhea. So ulcerative colitis, it's almost always bloody diarrhea. Crohn's disease is normally non-bloody. You may also have weight loss due to some malabsorption. These patients may also have B-12 and iron deficiency, again, due to some malabsorption in the small bowel. They may also present with fistulas. And this is because the inflammation like we talked about before is transmural. So it can actually burrow all the way through the lumen of the bowel or different areas. That's a and create these openings leading to abscesses and other types of infections. So how are you actually going to make the diagnosis of Crohn's disease?

So normally the first test that you'll do, you'll start off with the number GI series. And this is going to show a tapered off for this narrowed area of barium flow due to this inflammation or scar tissue. This is known as a string sign. And if you look this up online, it makes sense because you have this normal bowel, the areas that are unaffected. And again, remember, this isn't a continuous inflammation. It's discontinuous in these spared areas.

So you'll have this normal bowel that's not inflamed. And then you have this small tract where it's inflamed, their scar tissue, and the barium has to go through this narrowed lumen. And it literally looks like a string of barium flowing through these normal, thick areas where the actual lumen is normal and it's wide open and patent. And then you have these narrowed areas that looks like a string in between these normal bowel. So that's why in an upper GI series, you'll see something called a string sign. And that's very important to know for Crohn's disease. That's one of those, you know, those names that they'll bring up a lot. So string sign on an upper GI that narrowed lumen from this scar tissue and inflammation.

So what are some other tests that you're going to do for somebody who has Crohn's disease? Well, remember that this can be anywhere. So you're going to do not only a colonoscopy, but an endoscopy as well. And what are you going to see when you do an endoscopy? and a colonoscopy. But you're going to see something called skip lesions. And this is because the areas of inflammation in Crohn's disease are not continuous. There are these discontinuous areas. So you'll have a little bit of inflammation than normal bowel, a little bit of inflammation, then normal again. And sometimes it has an appearance of cobblestone appearance. So kind of these circular areas of

inflammation surrounded by normal areas. So those are two keywords you should know, skip lesions because it's skipping. Inflamed, normal, inflame, normal, and then cobblestone appearance because you have these circular areas of normal surrounded by these inflamed areas. So important because ulcerative colitis is this continuous inflammation. It doesn't spare any of these areas. It doesn't skip. It's continuous.

Whereas Crohn's disease has skip lesions, this areas of inflammation with normal areas as well. You also may see aptus ulcers because remember, mouth to A. so sometimes these people can have canker sores in the mouth that in other people may just be a normal finding but in these patients are actually due to the Crohn's disease. And then finally, there's a couple other things you can do. You can do biopsies and labs. Biopsies, you're going to see transmural inflammation. Remember, going all the way through. You may see something which is important because it's only seen in Crohn's disease and not ulcerative colitis is granulomas on the biopsy. And you're going to see these granulomas. And this is a

hallmark finding for Crohn's. It's not always found, but it is important when you do find it because it helps differentiate. And the reason you see these granulomas is because due to all the inflammation, macrophages respond and collect in this small area and form these granulomas due to all this chronic inflammation. So if you do see a granuloma on the biopsy, this is pretty much a hallmark finding of Crohn's disease. And then another thing that you may see, whether it's on an endoscopy, colonoscopy, is something called creeping fat. And this is very specific, again, to Crohn's. It's not really sure why you have this, but what this is, it's pathognomic for Crohn's.

It can cover up to 50% of the intestines, and it's this mesenteric fat that migrates to the bowel. And the reason they think this happens is a couple different theories. Again, nothing's really proven or they're not 100% sure, but they feel it may either, kind of patch up these fistulas that are seen in the bowel, or they also, there's also a theory that it may be bringing this beneficial bacterial flora to these areas to help heal it. So creeping fat seen on Crohn's disease, pathonomonic, remember that, not always seen, but it is important if you see it to think about Crohn's disease. On labs, you're going to see something called, I'm not going to say it because it's very

hard to pronounce, but it's known as ASCA, ASCA, anti-Scharomycese, forget it, ASCA, that's specific to Crohn's, remember that. And it's an immune protein that's found in Crohn's that you'll see in the labs. And then some of the other things you'll see in labs again, what we went over before, B-12, iron deficiency may be seen as well. But remember ASCA, ASCA. So treatment, there's really only a few things you're going to use. And if you think about it, it all makes sense.

So Crohn's is an autoimmune and an inflammatory disease. So first of all, what do we use in inflammatory processes? Well, there's a couple of things that we use. we can either use nseds or steroids. So, nseds and steroids are going to be really your first line. And then it's also an autoimmune process. So what do we use for that? Immunosuppressants.

So that all makes sense. So what are you going to start off with first in your mild disease? You're going to use something called 5 ASA. One of the names of the medications in this class is misalamine. And what 5 ASA stands for is 5 ASA stands for acetyl cellic acid. Acetalic acid. Acetalicic acid is just aspirin. It just has this extra chain, so it's five acetylilic acid, five ASA, and really this is just an N-SED,

but the special thing about this five ASA class is they come in different forms to target different areas of the body. So if you take aspirin, it gets broken down, absorbed into the stomach, into the small bowel, but these specifically have different coatings so they can reach different areas of the body. So they have this delayed release. So there's a few different forms that they come in, depending on the area you want to target. Five ASAs come in an enema. If you're trying to reach up to the splenic flexure, you can use suppositories if you're

trying to target the rectal area. And then P.O. medications like the mesalamine comes in is going to be if you're trying to treat the small bowel on the right side of the colon. But really all these are are inseds and a special formulation to target specific areas of the GI track. So nothing complicated. It's really just aspirin specifically targeted for different. parts of the GI tract. So that's really going to be your first line. And then if it's a more severe case or

sometimes just like a moderate case, you can start using glucocorticoids. It's another option as well. And then in real severe or refractory cases, you'll reserve these immunosuppressants like methotrexate, your anti-TNF agents like influximab. That's going to be your more severe or refractory cases that you'll wait to use these. So initially, the five ASAs and the glucose corticoids or what you use. And then finally, surgery is an option, but remember, surgery is non-curative. It's only palliative in Crohn's disease. It's not going to cure it. Remember, this is the entire GI tract. So you cannot cure Crohn's disease with surgery, whereas ulcerative colitis, you can, because if you actually remove the large bowel, you cure the disease because it's only found in the large bowel.

But for Crohn's disease, it's only going to be palliative. It's not going to cure it. But it is an option in really symptomatic patients, maybe to treat some of the symptoms and help a little bit with the pain and other things going on. So those are your treatment options for Crohn's disease. It's basically your 5 ASAs, your glucose corticoids, and then a severe patient's, the immunosuppressants, and then surgery just for palliative treatment. Moving on to ulcerative colitis, this is another inflammatory bowel disease, and it's only going to be inflammation of the colonic mucosa. So it's only going to be in the large bowel that you're going to find ulcerative colitis. as far as the areas of the lumen that it affects, it only affects the mucosa and the submucosa.

And that's important because remember when we went over Crohn's, Crohn's was transmural, it went all the way through. Now, ulcerative colitis is only going to be the mucosa and submucosa. Another important differentiating factor is ulcerative colitis is going to be continuous inflammation. Unlike Crohn's disease that had skip lesions, little areas of inflammation, separated by normal, areas, ulcerative colitis is going to be continuous inflammation all the way through. I remember limited only to the column and rectum is almost always involved in ulcerative colitis. So that's important. The way that I remember these couple things about ulcerative colitis and that it's only

the large bowel and the rectum is always involved is I take the word ulcerative colitis and I take just the word ulcer. and ulcer, the letters stand for usually limited colon, so usually limited to colon, and the ER stands for especially rectum. So usually limited colon, especially rectum, helps me to remember this is just the colon and specifically the rectum. I know it's not hard to remember that because the word colitis literally means inflammation of the colon, but it just helps with the rectum part and, you know, helps to remember when you're thinking about a million other things on the exam. So how is this patient going to present? Well, they're going to have diarrhea like in Crohn's disease, but most of these

patients are going to have bloody diarrhea. Where in Crohn's disease, it was normally non-bloody. So ulcerative colitis, bloody diarrhea. They're going to have abdominal pain, but in this case, it's going to be more specific to the left lower quadrant. So instead of the right lower quadrant like in Crohn's, ulcerative colitis is going to be the left lower quadrant. And then finally, they're going to have something called tenesmus, which is this feeling that they need to move their bowels, even after they already had, it's something that this continuous sensation of needing to move their bowels that's seen in ulcerative colitis, mostly due to the inflammation and things like that. So in more severe cases, they may have signs of toxicity. They can develop toxic megacolon or they're going to have fever,

increased ESR, things like that. And some risks that you should know about with ulcerative colitis in addition to the risk of toxic megacolon is they have an increased risk of colon cancer, which is important. And this is due to the continual inflammation of the colon, which can actually lead to colon cancer. And then they also have an increased incidence of something called primary sclerosis colongitis, which is an autoimmune disorder of the intra hepatic small bile ducts. So if you see primary sclerosis and colitis, remember this kind of goes hand in hand with ulcerative colitis, and they can definitely be seen together.

How do you diagnose ulcerative colitis? Start with your flexmoidoscopy. This is going to show that can. continuous ulceration, the uniform inflammation of the large bowel. Remember, continuous. It's not going to be skipped like in Crohn's. And then if you do a bariumenema, you're going to see something called a lead pipe or a stove pipe sign. So what exactly is this? So when you do a bariumenema, normally in a normal patient, you're going to see these kind of segmented areas, these pouches, these like outpouch areas, which is from the hostra, which is a normal part of the large bowel. So in patient,

with ulcerative colitis, this hostera kind of smoothed out and disappears. So in these patients with ulcerative colitis, you actually see these smooth and straight areas of bowel that kind of look like a pipe. That's where they got the name from. So instead of a normal patient where you have these kind of like puffy outpouched areas from the hostera, this area is gone in ulcerative colitis patients. You need to see the smooth, straight pipe-like structure of the baryum filling the bowel. So that's what you see on a baryminaum. And then labs, unlike in Crohn's disease, you know, where we had an ASCA positive lab. In these patients, you're going to have something called a P.

Anka positive lab. So Pianca for ulcerative colitis, ASCA for a Crohn's disease. As far as treatment, again, you're going to be using your 5 ASAs. These are usually first line. But compared to Crohn's disease where you could use P.O. meds and things like that, this is normally going to be your topical 5 ASAs, your foam suppositories and things like that. Because remember, you're only targeting the large. bowel. So you can actually use a suppository. You can use a foam. They actually come in a foam

to treat different parts of the large bowel. You can use PO in more severe cases, but more commonly it's going to be the topical five ASAs. And then also in more severe cases, you can introduce glucocorticoids, but five ASAs are almost always first line. So try that first. And then finally, you can do a surgical resection, essentially curing this, but you would have to remove the entire large bowel, but in some patients that are refractory or real severe cases or patients that have a real serious risk of colon cancer, that is the only option or the best option. And then immunosuppressants do have a role in ulcerative colitis, not as much as in Crohn's disease, but certain ones like cyclosporine and inflixomab may be used sometimes in ulcerative

colitis, but really just in an attempt to delay surgery. They don't have a very big role in ulcerative colitis like they did in Crohn's disease. So basically first line your five ASAs, you can use steroids and more severe cases, surgical resection and really severe refractory patients, maybe that have a high risk of colon cancer, and then some of your immunosuppressants really just to delay surgery, no other role besides that. One of the things that I wanted to mention that I think is an important way to remember Crohn's disease. So let's go back to Crohn's disease for one second. Remember, there was a few things that I felt like was really important for Crohn's disease to differentiate it from ulcerative colitis. And if you can remember these, it'll really help you in a vignette to kind of differentiate

the two. So there's a few things that you need to know about Crohn's disease that'll help differentiate from ulcerative colitis. One is that it's transmural. Another one is that it's very diverse. It can affect any part of the GI tract. Another one is that there's normally no blood in the stool. So normally the stool is, you know, non-bloody diarrhea. And also that the inflammation is this skip lesions. It's this discontinuous inflammation. So the way that I remember that is Crohn's disease. The initials are CD. So I take a bunch of different ways to say the other things with the initial CD. So Crohn's disease, CD. First one, completely deep. That's because it's transmural. It's completely deep all the way through the mucosal layers. So CD completely deep, transmural. Second one,

completely diverse. That's because it's diverse. Any segment of the GI tract. So so far, completely deep, transmural, completely diverse, any segment of the GI tract. Third one is completely dry. What does that mean? So that's the bowel, or I'm not sorry, not the bowel, the stool is dry. It's non-bloody, so non-bloody diarrhea. So the bowel is dry, so completely dry. And then the last one is completely discontinuous. That's because the inflammation is discontinuous. There's these skip lesions in the bowel that's non-continuous in fashion. So discontinuous, completely discontinuous. So remember those four things.

Crohn's disease, CD, completely deep, transmural, completely diverse, any segment of the GI-I tract, completely dry, non-bloody stool, and then completely discontinuous, skip lesions in the bowel. And that's the way I remember Crohn's disease. And I think that'll help you because if you can remember that, you can remember the opposite for ulcerative colitis. And then you got your easy way to remember Crohn's disease. I think that'll help a lot.

So, guys, thank you so much for listening to my podcast. I'm getting some positive feedback and it really helps me just know because there's really another line of communication for me to know how you guys if this is helping you guys or if you like it. So please let me know. Leave me a review. Tell me if there's something you want me to do differently or if you like what I'm doing, please just let me know. It really helps keep me motivated to keep these coming out. But I'm definitely going to be releasing some more, probably one or two a week. And thank you so much for listening. And good luck in school and your pants, your panery, your EORs.