Ulcerative Colitis and Crohn's Disease

     Crohn’s disease and ulcerative colitis are chronic inflammatory bowel diseases. The cause is an inappropriate immune response in genetically susceptible individuals to microbial antigens of commensal microorganisms. Both diseases manifest themselves primarily in the gastrointestinal tract yet can affect all of the body's organ systems (Baumgart, 2009).

     In ulcerative colitis, ulceration of the mucosa extends proximally from the rectum into the colon. This disorder is prevalent in susceptible persons between 20 and 40 with a family history of disease or being Jewish. It is common in whites of Northern European descent (McCance & Huether, 2014).     On the other hand, Crohn's disease affects any part of the GI tract from the mouth to the anus. The most common sites affected are the distal small intestine and proximal large colon. Like in ulcerative colitis, the risk factors include family history, Jewish ethnicity, and age less than 40 years. Interestingly, ulcerative colitis is less common in smokers when compared to Chron's disease (McCance & Huether, 2014).

Pathophysiology

     In ulcerative colitis, the primary ulcerations are not transmural and continuous. There are no patchy lesions. The inflammation starts in the large intestine with infiltration and release of inflammatory cytokines. This inflammation damages the mucosal epithelial barrier by leaking fluids into the gut. It is most severe in the rectum and sigmoid colon. The mucosa of the colon may appear dark red and velvety in milder cases. In more severe cases, the mucosa is hemorrhagic, and small erosions can progress into ulcers. Abscess formation and necrosis may occur. In chronic disease, pseudopolyps develop in the colon (McCance & Huether, 2014).

    The inflammation in Chron's disease starts in the intestinal submucosa and progresses across the intestinal wall into mucosa and serosa in areas of the lymphoid tissue. Abscess form and crypt destruction happen in the process. The large and small intestines may be involved with skip ulcers with selective intestinal walls affected. Longitudinal and transverse fissures may be present with extended inflammation into lymphoid tissue. Fistulae may form and extend into the bladder. The typical presentations are granulomas with cobblestone projections of inflamed tissue surrounded by areas of ulceration (McCance & Huether, 2014).

Clinical manifestations

    Ulcerative colitis symptoms will depend on the inflammation's severity and location. The patient may present with diarrhea, often with blood or pus, passing a small amount of blood with stool, abdominal pain, cramping, rectal pain, the urgency to defecate, inability to defecate despite the urgency, weight loss, fatigue, and at times having fever. Most patients will have mild to moderate symptoms. The course of the disease may vary, with some people being asymptomatic for an extended period ( Mayo Clinic, 2022).

     Chron's Disease symptoms are similar to ulcerative colitis. Persons with this diagnosis may have no specific symptoms other than an “irritable bowel” for many years (McCance & Huether, p. 1443, 2014). Symptoms vary and may include abdominal pain, and diarrhea, the most common sign of more than five stools per day with blood and mucus. Inflammation in the ileum can cause tenderness in the lower right side of the abdomen (McCance & Huether, 2014).

Evaluation and Treatment 

    Medical history, clinical manifestations, imaging procedures, and histologic criteria are the most important in diagnosing ulcerative colitis. Infectious causes are ruled out by stool culture. The symptoms of ulcerative colitis are very similar to Crohn's disease. Therefore, serological markers can be helpful in the differential diagnosis (McCance & Huether, 2014).    Treatment depends on the severity and extent of mucosal damage. First-line therapy is 5-aminosalicylic acid. Corticosteroids and salicylates suppress the inflammatory response and help with the pain. Immunosuppressive agents, cyclosporine, tacrolimus, and infliximab, are used for chronic active disease. In severe cases, persons may need to be hospitalized for fluids and intravenous hyperalimentation. If the prior therapy is unsuccessful surgical resection of the colon or a colostomy placement might be the next step (McCance & Huether, 2014).

    Chron's disease diagnosis and treatment are similar to ulcerative colitis. Immunomodulatory agents and  TNF-α–blocking agents are used.  Surgery is performed to manage strictures, fistulae, abscesses, and perforation or to relieve the obstruction. Surgical resection of small intestinal segments can cause complications related to short bowel syndrome, including malabsorption, diarrhea, and nutritional deficiencies (McCance & Huether, 2014).

References 

Baumgart, D. C. (2009). The diagnosis and treatment of Crohn’s disease and ulcerative colitis.  Deutsches Ärzteblatt International,  106(8), 123.

McCance, K.L. & Huether, S.E. (Eds.). (2014). Pathophysiology: The biologic basis for disease in adults and children. (7th. ed.).Elsevier Mosby.

Mayo Clinic. (2022). Ulcerative Colitis. Mayo Foundation for Medical Education and Research.

Fibromyalgia is a disorder of musculoskeletal pain over the entire body along with problems with sleep, memory, tiredness, and mood.  It is believed fibromyalgia makes painful sensations bigger by changing the way the brain and spinal cord understand painful and nonpainful stimuli, known as central sensitization.  The symptoms will usually begin after serious psychological stress, surgery, trauma, or infection.  Sometimes fibromyalgia happens over time instead of something triggering it.  Women are primarily affected between the ages of 30-50, and they develop tension headaches, TMJ, anxiety, depression, and IBS.  Also, they may also have migraines, interstitial cystitis, postural tachycardia syndrome, or POTS.  There is no cure but medication, stress reduction, physical activity, and relaxation help (Mayo Clinic, 2021). 

Fibromyalgia is characterized by joint and muscle pain, as well as sensitivity to touch or tender points.  There is a lack of localized or systemic inflammation, and nonrestorative sleep involved.  It is due to central nervous system dysfunction.  ACR classification includes soft tissue pain throughout the body for at least 3 months, identifying 11-18 tender points by palpating the patient’s soft tissue.  The etiology is unknown.  It is most likely caused by more than one thing.  The factors that lead to fibromyalgia are the flu, chronic fatigue syndrome, HIV, Lyme disease, and steroid withdrawal.  Rheumatic diseases like rheumatoid arthritis and lupus can be co-occurring with it.  It may occur at the same time as myofascial pain syndromes (McCance & Huether, 2014).  Genetic mutations are suspected because it tends to run in families.  Some researchers think repeated nerve stimulation alters the brain and spinal cord in these patients.  The alteration leads to more of certain brain chemicals that signal pain.  The pain receptors in the brain remember the pain and are then sensitized to pain and overactivity of the pain signals becomes normal (Mayo Clinic, 2021).

Pathophysiology:  Fibromyalgia is a pain syndrome that lasts a long time when there are subjective symptoms.  The circadian activity of various neuroendocrine axes is changed.  There are other conditions that go with fibromyalgia like mood disorders and changes in neuroendocrine and stress response contribute.  Genetic studies have shown that changes in the genes responsible for serotonin, catecholamines, and dopamine contribute to stress response and sensory processing.  PET scans and functional MRIs show activity in different parts of the brain of a person with fibromyalgia than someone without it.  This is evidence that fibromyalgia is not imagined.  Those with fibromyalgia may have lower mechanical and thermal pain thresholds, rate pain of provoking stimuli as high, and changed temporal summation of pain stimuli.  There are hypothalamic-pituitary-adrenal axis changes that show uncommon responses to pain.  Cytokines may be responsible for the development of fibromyalgia which demonstrates that this disorder is not in someone’s head.  The corticotropin-releasing hormone (CRH) and locus ceruleus-norepinephrine (LC/NE), with their effectors on the side and the HPA axis, make up the stress system.  The HPA axis and LC/NE system are linked to fibromyalgia (McCance & Huether, 2014).

Clinical manifestations:  The main symptoms are far-reaching pain throughout the body.  It is like a persistent dull ache (Mayo Clinic, 2021).  Nine sets of tender points are identified for diagnosis.  A history of far-reaching pain as well as pain in 11 of the 18 tender points is necessary for diagnosis.  The tender points need to be on both sides of the spine as well as the upper and lower body.  The American College of Rheumatology (ACR) includes pain in the axial, left- and right-sided as well as upper and lower segment areas.  Usually, someone will start with pain in one area and in time it will become generalized.  Pain and tiredness consume 80-90% of the mostly women who suffer from fibromyalgia. Tiredness is greatest when waking up and in the afternoons.  They may also have sleep apnea or restless leg syndrome (Mayo Clinic, 2021).  Headaches, IBS, and cold sensitivity are experienced by 50% of those with fibromyalgia.  They also have a mental fog they suffer from (Mayo Clinic, 2021).  Around 25% get psychological help for depression.  Many tender points are the general diagnostic criteria (McCance & Huether, 2014).

Evaluation and treatment:  Rheumatic disorders should also be ruled out.  No single medication has been found to be effective in fibromyalgia.  Sleep medications and vitamin D may help.  CNS-active medications, particularly pregabalin (Lyrica) showed more effect than a placebo.  The best treatment is a combination of medication, physical activity, education, and cognitive-behavioral therapy (McCance & Huether, 2014). 

The current diagnosis does not use the 18 tender points and instead uses widespread pain throughout the body for three months.  Medications used are pain medications like Tylenol and Advil is helpful for dealing with pain.  The antidepressants Cymbalta and Savella have been helpful for the pain and tiredness linked to fibromyalgia.  Gabapentin is helpful with the symptoms and pain also.  Physical and occupational therapies can also augment the medications to help with life and the body.  Acupuncture, massage therapy, yoga, and tai chi are alternative treatments that are useful (Mayo Clinic, 2021).

References

Mayo Clinic.  (2021, October 26).  Fibromyalgia:  Diagnosis and treatment.  https://www.mayoclinic.org/diseases-conditions/fibromyalgia/diagnosis-treatment/drc-20354785

Mayo Clinic.  (2021, October 26).  Fibromyalgia:  Symptoms and causes.    https://www.mayoclinic.org/diseases-conditions/fibromyalgia/symptoms-causes/syc-20354780 

McCance, K.L. & Huether, S.E. (Eds.). (2014). Pathophysiology: The biologic basis for disease in adults and children. (7th. ed.).  Elsevier Mosby.