Dr. Michael Smith (Host): This is Meaningful Medicine, a Novant Health Podcast. I'm your host, Dr. Mike, and with me is Dr. Robert Czuprynski, and today we'll be discussing Crohn's and ulcerative colitis. Dr. Czuprynski, welcome to the show today.

Dr. Robert Czuprynski: Thanks for having me. Great to meet you.

Host: Let's start with some basics, right? Describe for us and the audience, the main differences between Crohn's and ulcerative colitis. How do they differ?

Dr. Robert Czuprynski: Yeah, that's a great question. It really just comes down to a couple things. They're both inflammatory bowel diseases that affect the GI tract. The differences are really the location, maybe the symptoms. And the different biopsy results. So Crohn's typically anywhere from the mouth, all the way to the anus. Anywhere in the GI tract it can be located. Typically it, it skips. So you can have an area of small bowel that's very healthy, and then have a very active Crohn's disease location. It's typically like a full thickness. The entire bowel wall is involved and there's different ways it presents. Some patients have stricturing Crohn's where it's narrowed and it causes bowel blockages or some constipation or bloating. Some patients have perforating Crohn's that causes abscesses or bad infections. Some people have Crohn's that have fistulas that connect to other organs or even have some anorectal fistulas that cause infections in that region. It's very typical presentation of abdominal pain, weight loss and whatnot.

Whereas ulcerative colitis is really just located only in the rectum and the colon. It's not in the small bowel, not in the stomach, not in the orifice or anything like that. It's just located really there in the rectum and colon.

And similarly can present with rectal bleeding, bowel habit changes, you know, loose stools, some weight loss, lack of appetite. But very different is, it's not, it doesn't skip, it's really contiguous throughout the entire rectum and colon, endoscopically and on imaging. It's only in the very top layer, the mucosal layer of the inner lining of the colon.

There are some patients that can have Crohn's in the colon though, so there are some indeterminate colitis that are hard to fully differentiate. But typically with endoscopic biopsies, pathologic evaluation under the microscope and just clinical assessment, we can really best estimate what a person has, whether it be ulcerative colitis or Crohn's.

Host: What about in terms of gender, male versus female, age of presentation? How do they differ there?

Dr. Robert Czuprynski: So typically it's kind of bimodal. We see younger population 15 to 30. Sometimes in kinda the preteen years is the earliest presentation for Crohn's. And then there is a later time between 50 and eighties is a second kind of peak in incidence of IBD. As far as sex, it's a little more correlative as far as females with Crohn's. But there really is, not a direct correlation of this age will be the diagnosis or this exact exposure. It's just more kind of the studies we found. But in general we do see kind of a bimodal distribution, a younger population that maybe a little bit older too.

Host: What about the risk of colon cancer? Is one or the other increasing that risk?

Dr. Robert Czuprynski: Yeah, there are definitely some correlation with ulcerative colitis especially because it is in the colon primarily. There's some chronic inflammation there. So we do see a little bit higher incidence with UC which does require more interval screening colonoscopies, and that's really the key in general, is to come back sooner than the typical 10 years, you know, for standard screening, but to come back every several years.

Number one, just to survey. Take biopsies and look for early changes of precancer or even cancerous lesions. In that case, if someone has a precancerous or a cancerous lesion of the colon with ulcerative colitis, we recommend typically surgery. And that case would usually require a pretty significant colectomy to remove the entire colon to prevent another colon cancer from developing.

Host: When patients present the first time, they don't know Crohn's, colitis. They have no idea. They're just presenting with symptoms. So, as a patient, what are the symptoms I should be paying attention to? And when should I go it's time for me to see my doctor?

Dr. Robert Czuprynski: You know, definitely nowadays you can go online and read all the articles and all the Google docs that tell you what you have, and it can be a little intimidating and scaring. But I think really the key is to just look out for your symptoms, right? Look out for exposure. Where you traveling, where you exposed to any food that could have caused this issue.

If anybody's sick around you, because there are some things that can pass, right? If someone has a week of looser stools or maybe some bowel habit changes, but it's, it resolves quickly, we sometimes think those are things related to diet. Maybe it's a viral or bacterial infection, but obviously persistent changes like bloody stool is very concerning, right?

If someone has bloody stool, we never tell them to ignore that finding. If you have some looser stool, or maybe you're going way more than you're used to, or you're having a lot of abdominal discomfort or cramping, that doesn't go away after several weeks. If you're noticing you have a lack of appetite or you just don't have much interest in eating or you're losing some weight, or any other kind of symptom like that, it's really concerning that you should be seen by a doctor for that.

I tell patients if you're having pretty substantial bleeding, go to the ER, get immediate labs. If you're having some chronic symptoms that are more manageable, it's best to let your primary doctor know and check up with them. They can do an exam, get some labs, and maybe even send you to gastroenterology or get imaging for this.

Host: Let's talk a little bit about treatment for both of these. How has that changed over, say, the past decade? You especially kind of with the rise of number one, biologics, right? And number two more of a personalized medicine approach.

Dr. Robert Czuprynski: Yeah, it's really amazing the pharmaceutical development we've seen over the last 20, 30 years. When you look at the drugs we had in the seventies, eighties, it was very minimal. And many patients required repetitive steroid infusions, come to the hospital to get steroids. They had multiple operations sometimes because they just couldn't find the right medical therapy.

We had a lot of medications metabolic medications like mesalamine or ASA that worked okay. But they just didn't work that great for especially Crohn's patients. So we kind of had the first infusion of medications like remicade, Humira in like the nineties and early two thousands, which had really been successful.

I don't really promote any of the medication necessarily. It's more just, what really works best for patients. But we really had a really big increase in medication in the last 10, 15 years, you've probably heard of medications on commercials nowadays, the pharmaceuticals like Entyvio and Stelara and Rinvoq, and even there's off-label uses now. Some medications we use for psoriasis or even dermatologic conditions that are immune related have had some crossover into even IBD care. And so, really I think the benefit of that is patients have more options, right? I mean, back in eighties, nineties you had one medication. If it failed, you were in some trouble.

Because some patients do develop antibodies to medications. Some patients have side effects or allergies. And as we all know, over time your body can adjust to medications and you may need a different one to help treat this. And so I think the perk now is that we have a lot of options for patients to choose from and it's really great to have informed discussion with your gastroenterologist to go over the risks and benefits of each medication.

Make sure you know what comes with that. Patients do need to have close immunologic surveillance. Make sure they don't have any liver disease or any kind of immune concern because those medications do affect the immune system. But they're really well tolerated, a lot of options. And I think the nice thing now is there's many ways of administering this, whether it be oral or infusion or different ways that you can give yourself the medication.

So it really allows patients to choose what's best for them in their life. And as you said, personalized medicine is great because patients have different lifestyles, they have different wants and needs, they have quality of life, work, travel, family. And so really that's the key is to find what works best for them, what they're going to administer closely, and have good surveillance long, long term.

Because we do know that patients that don't follow up, that do not take their medications, have more problems. And so really if they can find the right treatment for them, it really helps their long-term care. And I think the future hopefully holds that we'll have more information on genomics and genetic studies and potentially even better understand what a person has as far as mutations that may have caused this IBD. Is there a certain medication that better treats that and may reduce the amount of recycling of medications or even delay in treatment and get them on the right medication quicker.

Host: Yeah. It is fascinating, right? You know, I think that's kind of the next step in personalized medicine is recognizing that given one disease state, it can act differently in different people based on genetics. I find that fascinating. I want to go back to biologics real quick.

Very common commercials, as you said all over the place. How do you describe what a biologic is and what it's doing to your patient like in very simple terms.

Dr. Robert Czuprynski: That's a great question because I do sometimes use more scientific terms and it's important to know how to portray that to different people of course. But biologics really are just immune medications that help to suppress the immune response, right? IBD is an inflammation of your GI tract that's immune responsive, right?

So really our job is, these medications is to slow down that immune response on your own cells. And so there's different ways these work. There's multiple pathways that these attack. So interleukin is a type of protein that is immune responder that can be suppressed by these medications.

There's different inhibitors along these pathways that affect the immune response basically, prevent them from being overactive. And so this really just helps to reduce that inflammation, that chronic scarring that occurs from IBD. And again, there's really many options, right?

Which is the perk. There's not just one type anymore. We have multiple ways to approach this. So some patients will not benefit from certain medications, but others will see benefit in different medications. And even, for instance, we noticed that some people with fistulas or connections from bowel to other bowel or to the anus, there's fistulas. These can be treated with certain kind of medications. They work better for that versus perforating Crohn's or affecting Crohn's. So it's really great to have these options for patients based on their again, presentation and their type of Crohn's they have.

Host: Inflammatory bowel disease, that's what we're talking about here, Crohn's, ulcerative colitis. I know, when you're taking care of these patients, it's not just the physical side of the disease, the symptoms, treatments, there's a lot of emotional aspects to this. How do you guys approach this when you are creating a treatment plan?

Dr. Robert Czuprynski: Yeah. That's a great response there because it is important to know what a patient is enduring with this because it is a battle, right? It's physical, it's mental, it weighs on these patients. As a surgeon, we operate on the small bowel or the colon.

It's a pretty big operation. We do a smaller incisions nowadays for the most part, and it's a little bit faster recovery, but it still is a major abdominal surgery. And some of these patients do need assistance post-op. Of course, we provide that with nutritional support. They need that right for recovery to be able to maintain the nutrition and heal.

It's important to have physical therapy, occupational therapy to help them ambulate and get their strength back from surgery or even if they have a, a flare up that's pretty significant. Social workers, right? They are really a crucial part of our care to provide help for home as many patients need help with infusions or antibiotics or, medications.

And as you can imagine, the insurances with a lot of these biologics do take some approval and some, some help. So that's a really big part of it. And of course, nursing care is important. The communication between our staff and our patients is really key to have that open line of communication.

And then like you said, the mental part of it. I think these patients go through a lot. We know it's a painful thing sometimes having surgery or having these flareups. The mental weight of having recurrent flareups or having to go to the ER continuously for some people or having to go to the doctor more than they want to or missing out on some trips or missing work. It is a big weight on people. So I really encourage them to always bring up the concerns you have. I try to ask questions about their mental state, where they're at, and some patients do need help, right?

 We encourage that and it's expected. You might need a little bit of therapy, you might need some medication to help with some anxiety, depression. But I think nowadays with the treatment plans, we have a lot more tolerable, hopefully less ER visits, less admissions to the hospital, less disturbances in your life, which is a huge benefit to everyone's kind of mental health in that regard.

Host: What excites you about the future when it comes to IBD treatment?

Dr. Robert Czuprynski: Yeah, I think it's just all the data we're accruing, right? We have years and years of data aligning about the new medications and, and different approaches to treatment, and I think that we talked about it earlier, the genomics part of it and having more of a targeted-based therapy and not just throwing darts at a wall, right?

We're actually targeting the issue. There's a lot of look into microbiome which means, the gut flora, right? Because there is some thought that there are some viral pathogens or some kind of infectious etiology to Crohn's especially. So if we can target that, maybe intervene earlier, identify more resources of why this happens to patients and potentially screen earlier. Those are all things we can do to hopefully reduce the effects of the disease. And then I think a lot of hope in stem cell research. We all know that across the board in medicine. There are some ethical concerns of course, that have to be addressed with that. But even gene modulating or changing the genomics and trying to reduce the effect of that disease. It's always a thought. Again it's a long ways away. I think there's a lot of research that has to be done in that with stem cell research, but regenerating the cells that are destroyed by the disease or trying to correct that would be an amazing opportunity if we have it at some point.

Host: Well maybe with AI it's not so far away, right? You never know nowadays. So things are definitely changing fast. Just to end and summarize here, let's say you got somebody newly diagnosed with Crohn's or ulcerative colitis. What's the one thing you want them to know?

Dr. Robert Czuprynski: I think it's just important to understand that just looking out for yourself. Right. I think a lot of patients, it's easy in the beginning to take the diagnosis and think it's kind of curse or like a lifelong process.

But I think nowadays we have so many ways to approach this, that you can live a normal life, that you can have a job. You can maintain your job, you can exercise, you can eat mostly what you want, with moderation. You can travel still, have a family. And so I think really having that self-advocacy of hopefully people in your life that can help or looking for help to find the right doctor, find the right nursing staff. Because really, again, if you have a good follow-up, if you have that right relationship with your doctor and your and their staff, you're going to come back more. You're going to follow up more. You're going to have your medications and you're going to keep those flares hopefully at bay. And so I think that's really the key is to, maybe it's easy in the beginning, I think, to get caught up in the diagnosis.

I think we all would understand that. It would be pretty daunting to have that. But I think many patients I notice come in and have a normal life and have families and live life they want. And so I want to encourage them to seek the attention they need and always ask for help because we love helping people that have this condition because we know we can intervene and help their life.

Host: Fantastic. Great information. Thank you so much for coming on the show today.

Dr. Robert Czuprynski: Thank you. Great to meet you.

Host: For more information, please visit healthyheadlines.org and novanthealth.org. If you liked this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. This is Meaningful Medicine.

I'm Dr. Mike. Thanks for listening.