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