#502 Inflammatory Bowel Disease with Dr. Aline Charabaty

October 20, 2025 | By Elena Gibson

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Video

Transcript available via YouTube

Update your approach to the evaluation and management of IBD with Dr. Aline Charabaty (@DCharabaty). Review updates in management options, imaging modalities and preventive health recommendations. 

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Show Segments

• Intro
• Case
• Initial presentation and evaluation 
• Imaging and endoscopic findings 
• Treatment options 
• Treatment goals
• Diet Recommendations
• Preventive Health
• Vitamin Deficiencies 
• Flare evaluation
• Inpatient care 

Disclosures

Dr. Charabaty reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

IBD Update Pearls

1. Inflammatory bowel disease is a group of chronic immune mediated diseases of inflammation in the gastrointestinal tract, primarily Crohn’s Disease and Ulcerative Colitis. 
2. Common symptoms of IBD include diarrhea, constipation, weight loss, anemia and abdominal pain. 
3. Advanced therapies for IBD include biologics such as TNF inhibitors, anti-integrins, and anti-IL12/23 therapies. 
4. Treat to target goals in IBD should include clinical and endoscopic remission. 
5. Endoscopic remission in IBD is important to prevent future complications such as strictures and colorectal cancer.  
6. Patients with a stricture or flare should avoid fibrous foods such as raw vegetables and fruits. 
7. Zoster vaccination is recommended for all patients with IBD 19 years or older starting immunosuppression. 
8. A DEXA scan to evaluate for osteopenia/osteoporosis is recommended in patients with IBD and history of 3 or more cumulative months of corticosteroid exposure or a BMI <20. 
9. Patients hospitalized with an IBD flare should receive chemical VTE prophylaxis even in the presence of bloody bowel movements.
10. Acute severe ulcerative colitis has specific clinical diagnostic criteria and clear management guidelines for inpatient care. 

Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a group of chronic immune mediated diseases of inflammation in the gastrointestinal tract, primarily Crohn’s Disease and ulcerative colitis (UC). Crohn’s disease can affect any portion of the GI tract while UC is limited to the colon and rectum. 

Initial Presentation and Evaluation 

Symptoms for Crohn’s and ulcerative colitis can vary widely. Diarrhea, constipation, abdominal pain, iron deficiency anemia, blood in the stool, bloating, and weight loss can all be seen with IBD. Diarrhea is common, but it is also important to consider constipation as a potential symptom of IBD. Patients with Crohn’s often present with constipation related to a stricture and associated obstruction. In ulcerative colitis scarring in the rectum can lead to changes in rectal compliance and inadequate contraction to produce a bowel movement. 

The initial lab evaluation for IBD should include CBC, CMP, CRP, ESR, and fecal calprotectin (Li, 2024). It is important to recognize that up to 50% of patients with an active IBD flare will not have an elevated CRP (Mosli 2015). An ESR is often more sensitive but not very specific. The fecal calprotectin is evidence of inflammation in the bowel, but it can be elevated in other forms of colitis or cancer. The fecal calprotectin is more likely to increase in patients with colonic inflammation. 

Endoscopy and Imaging 

After completion of labs and stool studies, endoscopic evaluation is the next step in further evaluation for IBD (ASGE, 2015). Endoscopic inflammation includes mucosal changes such as ulcerations, erythema and changes in vascularity. Typical findings include: 

• Crohn’s: deep ulcerations with areas of normal mucosa between areas of active inflammation (skip lesions). Strictures are often identified at the ileocecal valve.
• UC: continuous inflammation from the rectum to the extent of disease. Always includes the rectum. Mucosa appears granular and friable with erosions and more superficial ulcerations. 

Patients can have features of both UC and Crohn’s, but this is less typical. 

Pathology 

Pathology findings for both UC and Crohn’s are similar. Acute changes include neutrophilic infiltrate and crypt abscesses which can be seen in inflammation from other etiologies such as infection as well. Chronic inflammatory changes include crypt architecture distortion and panneth cell metaplasia. Granulomas are present in around 10-20% of patients with Crohn’s on routine colonoscopy biopsies, and are highly suggestive of Crohn’s (Turner 2014, Johnson 2018). 

Cross sectional Imaging 

A CT scan is not recommended in the typical evaluation of IBD, but if one is completed for other reasons findings typical for IBD include inflammation in the bowel such as  bowel wall thickening, bowel wall enhancement and stratification as well as inflammation around the bowel such as increased mesenteric vasculature and fat proliferation (Kim 2024). Comb’s sign is caused by engorged vasa recta. Chronic inflammation like IBD can lead to fibrofatty proliferation and sacculations (Kim 2024). 

Intestinal Ultrasound 

When following patients with IBD over time it is important to be mindful of minimizing radiation exposure.Intestinal ultrasound is recommended as a noninvasive, radiation-free imaging method to evaluate for increased bowel wall thickness and vascularity as markers of inflammation in patients with IBD. It is most often being completed in clinic by IBD specialists to evaluate response to treatment or look for evidence of active inflammation in the setting of a symptom change (Chavannes 2024,Lichtenstein 2025, Rubin 2025). 

Treatment Options 

The advanced therapy treatment options for Crohn’s and UC have expanded considerably in recent years (Lichtenstein 2025, Rubin 2025). There are two main categories of advanced therapies: biologics and small molecules. Infliximab was approved in 1998, and it still has an important role in IBD management given it is such an effective therapy. Vedolizumab, an anti-integrin, was approved next and works by blocking inflammatory cell migration from the blood vessel to the gut. Given its gut specificity it has an excellent safety profile. The anti-IL-12/23 therapies work by blocking the cytokines IL-12 and IL-23. These provide improved efficacy and safety. Sphingosine-1-phosphate (S1P) modulators work by blocking the migration of lymphocytes from the lymph nodes. JAK inhibitors block the JAK STAT pathway and are useful in treating associated rheumatologic conditions as well as extra intestinal IBD manifestations. The small molecules have the added benefit of being oral medications. 

Biologics

1. Anti-TNF: infliximab, adalimumab, certolizumab, golimumab 
2. Anti-integrin: vedolizumab 
3. Anti-IL-12/23: ustekinumab, risankizumab, miriukizumab, guselkumab

Small Molecules  

1. JAK inhibitors: upadacitinib (JAK 1), tofacitinib (JAK 1/3) 
2. S1P modulators: ozanimod, etrasimod  

How to Choose 

The decision about which advanced therapy is individualized to each patient based on their clinical history, preferences and comorbidities. For example TNF-inhibitors and JAK inhibitors have the best evidence in treating fistulizing or perianal Crohn’s as well as extraintestinal manifestations of IBD (Lichtenstein 2025). 

Treatment Monitoring and Goals 

IBD treatment goals include clinical and endoscopic remission. Guidelines recommend a “treat to target” approach with short-term goals of symptomatic relief and normalization of inflammatory markers and long-term goals include endoscopic remission. Endoscopic remission is important because clinical symptoms often improve despite ongoing inflammation in the bowel which can increase the risk for future complications such as strictures, fistulas or colorectal cancer. It is important to keep an individual patient’s goals in mind and aim to restore quality of life based on these (Biroulet 2015).

Diet Recommendations 

Dr. Charabaty recommends a healthy diet including being rich in fiber and avoiding added sugar, fried food, processed and ultra processed foods, for example the Mediterranean diet is recommended by some for IBD (Hashash 2024). She recommends patients eat foods that are recognizable in their original form. During a flare and in the setting of a stricture, patients with IBD should avoid fibrous foods such as raw vegetables and fruits. Epidemiological studies have identified a higher risk of Crohn’s and UC in individuals with diets poor in fiber, fruits and vegetables and high in red meat and processed foods (Babaei 2024, Narula 2023). 

Preventive Health 

It is very important for patients with IBD to receive age appropriate vaccinations, but patients on immunosuppression should not receive live vaccines (Caldara 2025). These include 

• Yearly influenza vaccine (high dose for patients on anti-TNF) 
• Age 19-64: initial pneumococcal vaccine
• Age 19+ on or with plans to initiate immunosuppression: zoster vaccination 
• Age 60 years+: RSV vaccine
• HPV and HBV vaccinations 

The zoster vaccination series is particularly important in patients being started on a JAK inhibitor given the increased risk of shingles with JAK inhibitors.  Patients with risk factors for osteopenia and osteoporosis including BMI <20, > 3 cumulative months of steroids, or active smoking should receive a DEXA scan. All patients with IBD should be screened for depression and anxiety annually (Caldara 2025). 

An annual skin exam is recommended in patients with IBD on immunomodulators, anti-TNF biologic agents and small molecules. Thiopurines are associated with the highest risk of non-melanoma skin cancer, and patients with any history of thiopurine use should continue annual skin exams even once the medication is discontinued (Caldara 2025). 

Evaluation of a Flare

Evaluation of an IBD flare includes a clinical assessment, labs and stool studies, and imaging or endoscopy if indicated. The clinical assessment should include assessment for number of daily bowel movements, frequency of bloody bowel movements, and urgency. Dr. Charabaty emphasizes the importance of urgency as it is an important marker for severity and is typically very important to the patient’s quality of life. To evaluate for potential triggers of a flare, ask about medication compliance, recent antibiotics or travel and any recent NSAID use. 

Lab evaluation- stool studies including C. difficile testing, stool culture, fecal calprotectin. C. difficile is one of the most common precipitating factors for an IBD flare. Additional labs include CBC, BMP, CRP, and ESR. If the flare is severe and you expect the potential need for starting a biologic such as an anti-TNF, check a T-SPOT or quantiferon gold and hepatitis B serologies. 

Inpatient Care

Clinical judgement is essential to determining which patients with an IBD flare require hospitalization, but factors that should prompt considering hospitalization include severe disease, lack of improvement to outpatient therapy, systemic illness, infectious complications and high-risk patients. Acute severe ulcerative colitis (ASUC) requires hospitalization. Criteria for ASUC is having greater than 6 bowel movements per day with a systemic sign of toxicity including anemia (hgb < 10.5 g/dL), elevated inflammatory markers, and tachycardia. Given the risk of complications and progression there are specific recommendations for the management of patients hospitalized with ASUC (Rubin 2025). Patients should receive intravenous corticosteroids, and Dr. Charabaty recommends early surgical consultation as the disease can worsen quickly. All patients hospitalized with an IBD flare should be started on chemical VTE prophylaxis given an increased risk of VTE during hospitalization, and prophylaxis should not be held for bloody bowel movements alone (Dawwas 2024). 

Links

1. Scrubs and Heels 

Goal

Listeners will identify and review the initial steps in the evaluation and management of Inflammatory Bowel Disease (IBD). 

Learning objectives

After listening to this episode listeners will…  

1. Define terms related to inflammatory bowel disease: Crohns, ulcerative colitis
2. Recognize signs and symptoms related to IBD 
3. Determine the best initial diagnostic steps in the evaluation of IBD 
4. Identify a differential for IBD
5. Review preventive care for patients with IBD 
6. Identify treatment options for IBD 
7. Determine how to best evaluate a flare in a patient with IBD 

Citation

Gibson EG, Charabaty A,  Williams PN, Watto MF. “502 Inflammatory Bowel Disease with Dr. Aline Charabaty”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast October 20, 2025.