00:00
Let's move to our next case.
00:03
A 33 year old man is seen in clinic for a 10-week history
of diarrhea and worsening abdominal crampy pain.
00:10
He has 6 to 8 bowel movements a
day, including a few at night.
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His stools are loose with streaks of blood and
he has poor appetite and nausea but no fever.
00:20
He does not take
any medications.
00:23
On exam, he is afebrile with a heart
rate of 100 and blood pressure of 95/50.
00:30
His abdomen is soft with moderate
diffuse tenderness in the lower quadrants
with no rebound or guarding.
00:37
Colonoscopy shows patchy colitis with
deep ulcers in a cobblestoning appearance
and there is no involvement of the rectum.
00:46
So, what is the most likely diagnosis here?
Let's look at some clues in this case.
00:52
So he has chronic diarrhea.
00:56
The presence of blood in the stools indicates
that he may have an inflammatory diarrhea.
01:01
On his physical exam, he is
tachycardic and mildly hypotensive
which indicates probably,
signs of mild hypovolemia.
01:09
And there is some keywords on his colonoscopy
report such as cobblestoning and rectal sparing.
01:17
So, we put this altogether, he
has chronic, bloody diarrhea
which should automatically raise your
suspicion for an Inflammatory Bowel Disease.
01:26
In addition, his colonoscopy report with patchy
colitis and cobblestoning with rectal sparing
should prompt you to think
about Crohn's disease.
01:36
So, let's talk a bit more about IBD.
01:40
There are 2 types of IBD, they are
Crohn's disease and ulcerative colitis.
01:45
They have very common clinical features and
that they can both present with hematochezia,
abdominal pain and fever, weight loss,
a sense of fecal urgency or tenesmus.
01:57
They can both also present with
symptoms outside of the GI tract.
02:02
So things like jaundice, uveitis,
arthritis and lesions on the skin.
02:09
For the diagnosis, you first want to rule out any
infection that could be contributing to their symptoms.
02:15
So, you would check a stool culture, a
C. difficile toxin and a stool ova and parasites.
02:22
You may next also look for signs
of inflammation in the stool.
02:26
So, a C-reactive protein or CRP and
an elevated sedimentation rate or ESR
can be helpful to look
for systemic inflammation.
02:35
A fecal calprotectin can also be helpful because
this is an inflammatory marker inside the stool
that can help you track
progression of the disease.
02:45
Lastly, you may do a colonoscopy to look
for the specific features of each disease.
02:51
The treatment depends on the type.
02:54
So let's go into
specifically Crohn's disease.
02:58
Crohn's disease is a transmural inflammation
that can affect really any part of the GI tract.
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So, the symptoms or clinical
features you may encounter
are diarrhea, abdominal pain, basically
any symptoms involving the intestine.
03:13
You may have rectal bleeding, in the
stomach, they may have vomiting,
and it can also affect the liver and
bile duct leading to inflammation.
03:22
Outside of the GI tract, patients may
have inflammation or uveitis of the eyes.
03:29
They may develop skin ulcers and sores,
One typical rash that we see
often is erythema nodosum.
03:36
They may also have systemic signs of fever,
weight loss and anorexia or decreased appetite.
03:42
They may also have ulcers in the mouth.
03:46
These patients tend to have frequent
flares and remissions of their disease.
03:50
And because of the transmural inflammation, so that's
inflammation extending through the wall of the bowel,
there are common complications such
as fistulae and bowel obstructions.
04:03
Treatment is done with
corticosteroids for flares
and for maintenance therapy, we give
immunomodulators such as methotrexate
or more advanced biologic agents that target
the anti-TNF pathway such as infliximab.
04:21
Most patients, because of their relapsing and
remitting disease will eventually require surgery.
04:28
Now let's talk about ulcerative colitis.
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So, unlike Crohn's disease
which is a patchy inflammation
involving any part of
the GI tract shown here,
ulcerative colitis is a continuous inflammation that
involves the colon and the rectum as shown here.
04:47
It usually does not involve the small bowel
and it is associated with diagnoses like
primary sclerosing cholangitis, cholangiocarcinoma
and higher rates of colorectal cancer.
05:01
The treatment as with Crohn's is with
first, corticosteroids for flares.
05:07
For maintenance therapy, we also give
5-aminosalicylic agents like mesalamine.
05:13
and we also have immunomodulators
and biologics for severe disease.
05:17
So you might be thinking at this point that a Crohn's
disease and ulcerative colitis have a lot in common.
05:23
So how do we tell them apart clinically?
These are some clues that can
help you make the diagnosis.
05:29
So Crohn's disease, again involves inflammation of
the entire bowel wall, so transmural inflammation.
05:37
Also, patients tend to have skip lesions, so
patchy involvement and a cobblestoning appearance.
05:45
They often have spared areas on colonoscopy.
05:48
On the other hand, ulcerative colitis involves
inflammation limited to the mucosa and the submucosa only.
05:56
and inflammation tends to be continuous,
so there are no skip lesions.
06:03
The location also differs.
06:04
With Crohn's disease, this can
involve any part of the GI tract.
06:08
It typically, however, spares the rectum.
06:11
And the terminal ileum
is the most common site.
06:14
With ulcerative colitis, only the
rectum and the colon are involved.
06:20
The last thing to distinguish between
the two are the common complications.
06:25
So if you remember that Crohn's disease
involves transmural inflammation
then you'll remember that fistulae and
abscesses are more common with this disease.
06:35
With ulcerative colitis, associated complications
are a higher risk of colorectal cancer
and the association with the diagnosis
of primary sclerosing cholangitis.