Crohn's and Ulcerative Colitis

By Johnathon Markus M.D.

This brief summary of Inflammatory Bowel Disease is designed to help you understand the basics of Crohn’s and Ulcer­ative colitis and highlight key differences between the two and hopefully help you seek out a doctor if necessary.

Ulcerative colitis is an in­flammatory condition limited strictly to the large intestine (colon). The colon is the part of the GI tract that reab­sorbs water and where stool is creat­ed. The inflammation here is local­ized to the superficial layers of the colon. The most common symp­toms are diarrhea with mucus and/ or blood but the pain is typically less severe. During a colonoscopy, inflammation is typically continu­ous with a clear start and end with sparing of the anus. Removing the large intestine is curative.

Crohn’s is also an inflammatory disorder which can manifest any­where in the gastrointestinal tract. The inflammation here is transmu­ral, essentially meaning that it is deeper. Thus, inflammation, stric­tures, and fistulae can occur from the mouth to the anus. The most commonly affected area is the ter­minal ileum, the last part of the small intestine prior to transition­ing to the large intestine. The diar­rhea here is typically more “porridge like” and associated with significant pain. Crohn’s is also more com­monly associated with anal disor­ders including abscesses and fissures. On a colonoscopy the inflammation is occurs sporadically and at times impairs passage of the camera. Surgery is re­served for removing nar­rowed segments of bowel but unfortunately is not curative.

The diarrhea can be loose, watery, or bloody and occurs over several weeks. They can be as­sociated with urgency (feeling the need to go), frequency, pain, weight loss, fatigue, anemia, and the diarrhea can wake you up from sleep. Many patients at the time of diagnosis have over 20 bowel move­ments per day! These symptoms should prompt you to see a doctor as soon as possible. There is a sig­nificant overlap with irritable bowel syndrome which at times can delay the diagnosis as patients can have both occurring at the same time. It should be noted that waking up from sleep for a bowel movement is almost never considered normal.

Both of these conditions are considered autoimmune disorders where the immune system attacks the body for unknown and unclear reasons. There is a genetic and environmental component but the trigger has yet to be discovered and this is an active area of research. The disease can start at any age but typically manifests between 15- 35. Patient with one autoimmune disease are also at risk for another autoimmune disease.

The treatment for these condi­tions has progressed rapidly in the past 20 years after an initial slow start. In the 1950’s the only two treatments were corticosteroids and sulfasalazine. Corticosteroids work quickly and effectively but their long-term use has been asso­ciated with diabetes and osteoporo­sis. Sulfasalazine has been largely replaced by the aminosalicylates such as mesalamine. The 1960’s brought us Azathioprine (Imuran) and Methotraxate. As a side note, if you are a woman on methotrex­ate, you should NOT get pregnant as this medication is known to cause harm to the fetus.

The world of inflammatory bow­el disease changed in 1997 with ap­proval of the TNF-alpha inhibitors. This one of the first medications that was able to place patients in deep remission without pain or diar­rhea. However, these medications were not without flaws. Namely, many patient’s lost response either due to adaptation of the disease or creation of antibodies which deac­tivated the medication. There was also an increased risk of infections and lymphoma.

Two new medications have been approved for the treatment of in­flammatory bowel disease. Vedoli­zumab (Entyvio) was approved in May of 2014 for the treatment of both Crohn’s and Ulcerative coli­tis. This medication blocks white blood cells from entering the GI tract. Ustekinumab (Stelara) was approved for Crohn’s disease in September of 2016 and is now one of the most prescribed medications for moderate-severe Crohn’s. This works by inactivating proteins that stimulate inflammation. There is minimal cancer, infection, and an­tibody formation with both of these medications. Finally, Tofacitinib (Xeljanz) was approved to treat UC in May of 2018.

These conditions are life-long and require an intimate relation­ship between you and your gastro­enterologist. Goals of therapy have changed over the years with more emphasis on aggressively treat­ing any inflammation rather than symptoms. These conditions are associated with increased risks of cancer, vitamin deficiencies, and infections which further neces­sitate open and clear dialogue be­tween you and your doctor. It can be scary to think that these diseases are for life but there is a significant amount of hope for those afflicted with either of these diseases given the vast amount of ongoing re­search. With aggressive care and a close relationship with your gas­troenterologist many of the symp­toms and complications can now be avoided.

For further information visit the Crohn’s and Colitis Foundation: www.crohnscolitisfoundation.org