Episode Summary Dr. Eric Acker is joined by Drs. Amulya, Michael Bass, and Nicole Ebalo to discuss Inflammatory Bowel Disease (IBD). The team reviews presentation, diagnosis, imaging, pathology, and management from mild to fulminant disease.

Key Discussion Points

1. Presentation & Epidemiology Typical symptoms: diarrhea, abdominal pain, weight loss, fatigue.

• UC: Bloody diarrhea, urgency, tenesmus.
• Crohn’s: Non-bloody diarrhea, crampy pain; may have constipation
• Extraintestinal: Arthritis, erythema nodosum, uveitis, primary sclerosing cholangitis.
• Epidemiology: Bimodal (15–30 & 50–80 yrs); Crohn’s—slight female predominance, UC—slight male predominance.

2. Diagnostic Evaluation Initial workup: CBC, ESR, CRP, stool cultures (Salmonella, Shigella, Campylobacter, C. difficile) and fecal calprotectin.

• Colonoscopy: Diagnostic gold standard.
  • UC: Continuous mucosal inflammation from rectum.
  • Crohn’s: “Skip lesions,” transmural inflammation, often terminal ileum.
• Histology:
  • UC—mucosal/submucosal inflammation.
  • Crohn’s—non-caseating granulomas, transmural inflammation.
• Imaging: CT or MR enterography for strictures, fistulas, abscesses.

3. Treatment Approach Mild–Moderate:

• UC: 5-ASA (mesalamine) ± topical therapy.
• Crohn’s: Budesonide (if colonic involvement).

Moderate–Severe:

• UC: Corticosteroids → immunomodulators (6-MP, azathioprine, methotrexate) ± biologics (infliximab, vedolizumab).
• Crohn’s: Corticosteroids → biologics (infliximab, adalimumab) ± immunosuppressants.

Severe/Fulminant:

• UC: IV steroids (methylpred 60 mg/day or hydrocortisone 100 mg TID); add infliximab or cyclosporine if refractory.
• Crohn’s: IV steroids;

Notes:

• Screen for TB and hepatitis before anti-TNF therapy.
• Key complications: toxic megacolon (UC), short gut syndrome (post-surgery).
• Maintenance: Continue lowest effective biologic/immunosuppressive dose.
• Surveillance: Colonoscopy every 1–5 years

4. Lifestyle & Long-Term Care

• Smoking cessation: Improves Crohn’s outcomes; mixed data in UC but overall beneficial.
• Diet: GI soft, hydration, monitor B12, folate, micronutrients.
• Pregnancy: Adjust biologics/immunosuppressants before conception

💡 Clinical Pearls

• Fecal calprotectin is more specific for IBD activity than CRP/ESR.
• Crohn’s: Transmural, skip lesions → fistulas/strictures.
• UC: Continuous mucosal disease → toxic megacolon risk.
• Immunosuppressives: Used for maintenance, not induction.
• Multidisciplinary management GI, surgery, nutrition, primary care

References:

• The Washington Manual of Medical Therapeutics
• ECCO Guidelines on Pregnancy and IBD.
• UpToDate