- [voiceover] inflammatory bowel disease is a chronic inflammatorydisease, as its name suggests. and both types of thedisease, both crohn's disease and ulcerative colitis, usuallylast throughout one's life after they're diagnosed. and if they're not properlymanaged, they can result in many serious or potentially even life-threatening complications. so, let's briefly talkabout the clinical course
of inflammatory boweldisease and how it relates to treating ibd. so let's create a timeline of the severity of inflammatory bowel disease. so, on the x axis, we have time, so this is going to be overa period of years to decades. and then, on the y axis, we'llhave the severity of disease. and we'll classify theseverity kind of in three categories here, withmild, moderate, and severe.
so, you'll notice that earlyon in the disease process, it starts out fairly mild. in fact, during this period,someone may not necessarily realize that they haveinflammatory bowel disease. but then, it's going to spike. and these spikes are knownas relapses or ibd flares. and it's during this firstinflammatory bowel disease flare typically when the disease is diagnosed. but then it's treated, andthe severity goes back down,
and it will go back downclose to, hopefully, close to their baseline severity. but what you'll notice is,over time, there'll be more and more of these flares and relapses. and occasionally, when therelapse resolves, the severity of the disease, the newbaseline, gets worse and worse over time. so, these peaks are knownas flares or relapses. and then these valleys,these baseline periods,
are known as remissions. so, this disease pattern isknown as relapsing-remitting. and it's very characteristic of both types but how does this allrelate to the treatment of inflammatory bowel disease? well, there are threegoals to the treatment of inflammatory boweldisease, and they have to do with these relapses and remissions. so, the first goal is to induce remission.
the second goal is to maintain remission, or you can think about itas preventing relapses. and the last goal is to preventand treat complications. now, to understand how wecan accomplish these goals, i think it's helpful tothink about the mechanism of inflammatory bowel diseaseas having three steps. and the first step is the immune response. and this is a drawing ofa macrophage, which is one of the main types of immune cells
in inflammatory bowel diseasethat causes the inflammation, which is the second step in the mechanism. then, it's the inflammation that results in the complications. now, we can use thesethree steps as a framework to develop a better understandingof how the different medications used to treatinflammatory bowel disease will achieve these three goals. now, it is important to notethat many of these treatments
are effective for both crohn's disease and ulcerative colitis. so i'm going to talk about them together. however, the efficacy ofsome of the medications may vary depending on the condition, whether it's ulcerativecolitis or crohn's disease, as well as it can vary fromindividual to individual. now, since inflammatorybowel disease most frequently presents from a medicalevaluation during this first
or second flare, let's startby discussing how to achieve this first goal of inducing remission. so, you can think of aninflammatory bowel disease flare as this immune response kindof getting out of control, and it results in a ton of inflammation. and it's this inflammationthat's causing all of the pain and discomfort for someone with inflammatory bowel disease. and because of this, theprimary mechanism by which
we can induce remissionis to directly treat this inflammation withanti-inflammatory medications. and the type of medicationthat's going to be used will likely depend on this severity here. so, for flares that are mildto moderate in severity, the primary anti-inflammatory medication that's going to be used toinduce remission is a group of medications known as aminosalicylates. then, for moderate to severeflares, the type of medication
that's primarily used is corticosteroids. now, corticosteroids arevery effective and powerful anti-inflammatories, butthe reason they're reserved for some of the moremoderate to severe cases of inflammatory bowel diseaseis because they can have many different side effects,and they shouldn't be taken for long periods of time. so, they're really onlyused when necessary. and there are some otherdrugs that can be used
as anti-inflammatory medications over the aminosalicylates,and corticosteroids are by far the most common anti-inflammatories. but this isn't the only type of medication that can be used to treat an acute flare. the other group of medications are known as immunomodulators. so, this immune responseis largely mediated by these signalingproteins that are released
by inflammatory cells such as macrophages. and one of these signalingproteins is a protein known as tumor necrosis factoralpha, which is abbreviated tnf alpha, and it is oneof the signaling proteins that's responsible for the inflammation. fortunately, we havemedications that can target tnf alpha and prevent its effect. so, one of the most commontypes of immunomodulators used to treat an acute flareof inflammatory bowel disease
are the tnf alpha inhibitors. now, once an acute flare has been overcome and the medications for inducing remission have been successful, thenext step is to maintain that remission. now, fortunately, themedications used to maintain remission are a lot of thesame medications that are used to induce remission. however, in the induction,the anti-inflammatories
are the primary focusbecause it's the inflammation that's causing all ofthe pain and discomfort. during the maintenance phase,it's the immunomodulators that are a little bit morestressed, but they're still taken at slightly less doses oftenthan they would be taken during the induction of remission. then, another treatmentcategory that's important to mention during thiskind of remission phase is lifestyle modifications.
and although the effectof some of these lifestyle modifications can be kind ofsmall, they have been shown to decrease the rate of relapse. so, one of the lifestylemodifications is smoking cessation. and this is especiallyimportant in crohn's disease. and another one to mention is diet. now, there's no evidence thatcertain diets actually cause inflammatory bowel disease. however, some foods mayaggravate the symptoms
of inflammatory boweldisease and should be limited or avoided as much as possible. and these include thingslike dairy, high-fat foods, as well as high-fiber foods. and then, the last lifestyle modification is stress reduction, which can be achieved through meditation or routine exercise. all right. so, the last goal in treatinginflammatory bowel disease
is preventing and treating complications. so, let's start with the prevention. and there's two main areas we focus on, and that is infection and cancer. so, someone withinflammatory bowel disease during an acute flare ismuch more likely to develop a severe abdominal infection. so, sometimes, duringthese relapses or flares, prophylactic or preventativeantibiotics will be prescribed.
and the other is cancer,specifically colorectal cancer. so, inflammatory bowel diseaseis associated with a much higher risk of developingcolorectal cancer. now, it's higher for both crohn's disease and ulcerative colitis, butit's significantly higher much more so in ulcerative colitis. so, anyone with ulcerativecolitis is recommended to start having a routinecolorectal screening with a colonoscopystarting eight years after
they're diagnosed with ulcerative colitis or by the age of 40, whatever comes first. so, we'll start with abscesses. and what an abscess is isit's a localized walled-off pocket of infection. and on its own, an abscessisn't necessarily that bad of a complication, but ithas a risk of rupturing, and if it ruptures, it cancause a life-threatening infection of the abdominalcavity called peritonitis.
to prevent an abscess fromrupturing and to treat it, what happens is theindividual will be starting on iv antibiotics andthen the abscess is going to be drained. and drainage most commonly is accomplished by having a needle insertedthrough the abdominal wall into that pocket of inflammation,and this is typically done under x-ray guidancein order to make sure that the needle getsright into the right spot.
and then, the fluid isaspirated out of the abscess, and then it tends to heal down on its own. the next complicationis known as a fistula. so, a fistula is kindof like a tunnel between two structures that aren'tsupposed to be connected. so, imagine in this drawinghere, you have the bladder and it's kind of right up next to a loop of the small bowel. well, if that loop of thesmall bowel becomes inflamed
within inflammatory bowel disease lesions such as in crohn's disease,and that's right up next to the bladder, well,unfortunately, over time, that inflammation canextend through the wall of the bladder and formthis kind of tunnel into the bladder. so, the bladder isusually a sterile space, and so now it's exposedto all the bacteria and inflammation of the small intestine,
and you can get a prettybad bladder infection. so, fistulas are alsotreated with antibiotics because of this infectionrisk, and then also they typically will require surgery. now, there are a numberof other complications that can occur with crohn's disease but the abscesses and the fistulas are two of the most common. unfortunately, a lot of the complications
do require surgery. so, about one-third ofindividuals who have inflammatory bowel diseasewill eventually need surgery for the treatment ofsome sort of complication. and, unfortunately,surgery is not curative. so, if you think once againabout this three-step mechanism of inflammatory boweldisease, the surgery really only treats the complications. it doesn't really affect the inflammation
or this immune response. so, if you look at thisclinical course over time, unfortunately, surgery isn'tgoing to affect it that much because it doesn't focus onthe underlying mechanism. there is one exceptionto this, and that is with ulcerative colitis. so, because ulcerativecolitis never extends outside of the colon, someone who has inflammation of the entire colonknown as total colitis,
they can have a procedure known as a proctocolectomywhere their entire rectum and colon is removed. and this can actually becurative of ulcerative colitis because there's no longerthe large intestine to become inflamed. however, this is not somethingthat's typically done unless it absolutely needsto, because it is a very big surgery.
so, if you can remember, theinflammatory bowel disease is a relapsing, remitting disease. it's caused by thisinappropriate immune response resulting in inflammation throughout the gastrointestinal tract. you can remember that youcan use anti-inflammatory medications or theseimmunomodulators to treat