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The Patient with Inflammatory Bowel Disease
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The Case: A 26-year-old woman had been in good health until 3 months ago, when, after returning from vacation in France, she began experiencing abdominal pain and diarrhea. She reports a 7-lb weight loss over the last few months. She is experiencing 4 to 6 loose stools daily. Her physical exam reveals right lower quadrant tenderness with no mass. Iliopsoas and obturator tests are negative. Rectal exam reveals hemoccult positive stool with no tenderness in the area of the appendix. Pelvic exam is non-remarkable. CBC reveals microcytic, hypochromic anemia with a hemoglobin of 10.8 g/dL, WBC of 8,100 cells/µL, CRP: 4.5 mg/dL, Albumin: 3.4 g/dL. She is not currently taking any medications. Upper GI and small bowel follow-up shows mild bowel wall thickening with slight narrowing in terminal ileum only. Colonoscopy shows numerous aphthous ulcerations in the terminal ileum and cecum.
Key Supporting Information
Ulcerative colitis (UC) and Crohn’s disease (CD) are the most common forms of inflammatory bowel disease (IBD); as many as 1.4 million Americans are estimated to suffer from these chronic diseases. While the underlying pathophysiological mechanisms are similar for UC and CD, their spatial presentation and degree of mucosal damage differ, necessitating specific diagnostic, therapeutic and management approaches.
Although treatment for IBD has improved over the past decade, previous and ongoing therapies have been only moderately successful. A cure for CD and UC does not currently exist, and patients often require a lifetime of care, which places substantial burden on the patient health care system and society. Improved classification criteria, the availability of biologic agents, new strategies for combining treatments and therapeutic sequencing, and new and emerging diagnostic and prognostic indicators that can help personalize patient care have raised the bar of treatment goals toward sustained disease remission and mucosal healing. Despite these advances, optimal patient care continues to elude physicians who treat this patient population.
The two most common types of IBD, CD and UC are characterized by a variety of immunologic changes that lead to mucosal damage of varying depth and intensity along the entire gastrointestinal tract. While the underlying pathophysiological mechanisms are similar, their spatial presentation and degree of mucosal damage differ, necessitating specific diagnostic, therapeutic and management approaches. Symptoms and pattern of disease presentation may overlap, making differential diagnosis challenging. Accurate assessment of the prevalence of CD and UC has been limited by the inherent problem of disease misclassification, the lack of gold standard criteria for diagnosis, and inconsistent case ascertainment. However, according to the CDC, as many as 1.4 million Americans are estimated to suffer from IBD, and while the diseases can occur at any age, the peak age of onset is 15 to 30 years and approximately 10% of cases occur in individuals younger than 18 years old.
Despite the publication of several guidelines that clearly present evidence-based recommendations for UC and CD diagnosis and treatment, several areas of uncertainty remain in everyday clinical management. The risks of disease misclassification and misdiagnosis can occur at all levels of the patient encounter. Regarding clinician accuracy in initial patient evaluation, a survey of 432 primary care physicians found wide variations in the definition, laboratory testing and diagnosis of IBD, with only 26% correctly identifying symptoms suggestive of chronic disease, as per standard definitions. Even among specialists, gaps exist: a survey of 192 gastroenterologists found wide variation in decision making between community gastroenterologists and those considered to be experts. Compared with community gastroenterologists, UC experts were more likely to diagnose correctly, endorse colectomy for both unifocal and multifocal low-grade dysplasia, use narrow band imaging and chromoendoscopy for surveillance colonoscopy, use high-dose mesalamine for inducing remission, use long-term mesalamine for cancer chemoprevention, order computed tomography enterography to evaluate for CD, and have a lower threshold to call for surgery consultation in steroid refractory UC. There was little agreement, even among the experts, regarding the optimal frequency of surveillance colonoscopy.
When IBD is suboptimally managed, patients experience substantial negative impacts on their quality-of-life, frequent symptomatic disease relapses, and increased risk for dysplasia and colorectal cancer. Therefore, it is critical that physicians are knowledgeable and able to manage IBD optimally. Gastroenterologists must also remain current about the latest advances and be able to assess their utility and placement in future treatment paradigms to achieve sustained remission and mucosal healing.
Several classification criteria have been developed for UC and CD over the years, with only subtle differences between them, creating confusion and challenges regarding the accurate differential diagnosis of these diseases. Failure to use the accepted classification criteria correctly can result in inconsistent and inaccurate diagnosis.
From the clinician’s perspective, accurate classification and subclassification of IBD offers several benefits, including effective patient counseling, assessment of disease prognosis, and the ability to choose the most appropriate therapy for each disease subtype. Historically, the definitions of CD and UC have varied in the literature, leading to potential confusion and necessitating a unified system of classification. The initial classification of IBD developed by the Vienna Working Party in 1998 was updated in 2005 by the Montreal Working Party, providing the currently accepted classification for differential diagnosis of CD and UC. Using the classification criteria, accurate diagnosis of IBD and differentiation between UC and CD is based on composite findings from endoscopic, radiographic and pathological assessments, together with a determination of IBD phenotype, disease extension and distribution, behavior, severity and drug responsiveness.
References:
Carter MJ, et al. Gut. 2004;53 Suppl 5:V1-16.
Centers for Disease Control and Prevention. Inflammatory Bowel Disease (IBD). Page last updated: September 4, 2014. Available at: http://www.cdc.gov/ibd/#aboutUlcer. Accessed March 19, 2015.
Cohen RD, et al. Aliment Pharmacol Ther. 2010;31:693-707.
Kornbluth A, et al. Am J Gastroenterol. 2010;105:501-523.
Lichtenstein GL, et al. Management of Crohn’s Disease in Adults. Available at: http://s3.gi.org/physicians/guidelines/CrohnsDiseaseinAdults2009.pdf.
National Institute for Health and Clinical Excellence (NICE). Crohn’s disease: management in adults, children and young people. London (UK): National Institute for Health and Clinical Excellence (NICE); 2012 Oct. 34 p. (NICE clinical guideline; no. 152). Available at: http://guideline.gov/content.aspx?id=38574&search=crohn%27s+disease. Accessed March 19, 2015.
North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition, et al. J Pediatr Gastroenterol Nutr. 2007;44:653-674.
Saha S, et al. Med Health R I. 2012;95:4-8.
Satsangi J, et al. Gut. 2006;55:749-753.
Silverberg MS, et al. Can J Gastroenterol. 2005;19 Suppl A:5-36.
Spiegel BM, et al. Clin Gastroenterol Hepatol. 2009;7:168-174.
Terdiman JP, et al. Gastroenterology. 2013;145:1459-1463.
Click here to see this Education Lab Activity.
Learning Objectives:
Upon successful completion of this educational activity, participants should be better able to assess and manage patients with inflammatory bowel disease.
Overview
Author(s)/Faculty: Ronald A. Codario, MD, FACP, FNLA, RPVI, CCMEP
Source: Healio Gastroenterology Education Lab
Type: Monograph
Articles/Items: 4
Release Date: 5/15/2015
Expiration Date: 5/15/2016
Credit Type: CME
Number of Credits: 0.25
Cost: Free
Provider: Vindico Medical Education
CME Information
Provider Statement: This continuing medical education activity is provided by Vindico Medical Education.
Support Statement: No commercial support for this activity.
Target Audience: The target audience for this activity is gastroenterologists and other health care professionals with an interest in the treatment of patients with gastroenterological disorders.