Dive into Diagnostics and Master Monitoring

Clinicians treating inflammatory bowel disease should have a monitoring strategy in place for every patient, beginning with prediagnosis and pretreatment assessment and continuing through maintenance, said presenters Sarah Massey, MSN, APN, and David T. Rubin, MD, from the University of Chicago.

Massey provided a brief overview of Crohn’s disease (CD) and ulcerative colitis (UC), the differences between the conditions, and the most common symptoms. She further detailed the considerations in differential diagnosis of IBD​, including infection, malignancy, irritable bowel syndrome, and colitides induced by medications. 

Take clues from the patient’s history when arriving at a clinical diagnosis, Massey said. “How did the symptoms start? ​Was this an acute onset or were the symptoms insidious over time​?” Get a clear definition of symptoms, such as diarrhea, abdominal pain, and bleeding.

“We always want to be asking about red flag symptoms such as waking up in the middle of the night with the urge to have a bowel movement, weight loss of more than 5-10% of body weight and findings of anemia on labs warrant further investigation​,” she added. Also delve into any family history that may indicate a risk of IBD but be aware that most patients diagnosed with IBD do not have a family member with the disease.

The physical examination​ will also provide important clues, Massey noted. Pay attention to any fullness or mass on abdominal examination​; look for fissures, fistulas, and skin tags that indicate the presence of perianal disease​; and note symptoms that could be indicative of extraintestinal manifestations​, such as reddened eyes, aphthous ulcers, joint pain, and skin symptoms. These may precede GI symptoms​ among patients with IBD and provide clues about how to treat these patients.

Dr Rubin observed that in diagnosing IBD “we have to also carefully think about whether the person in front of you is at the right age for IBD.” He acknowledged that IBD can present at any age but is most commonly diagnosed among patients ​between the ages of 15 and 30. There is a growing population of older patients who present with IBD, either as an initial presentation or perhaps after having had mild IBD for many years that was never diagnosed and now has progressed.

“When you’re not sure, remember that time is on our side,” he said. Following up and repeating an evaluation in a number of months, including repeating endoscopy if necessary, can be important in clarifying the diagnosis of IBD. “This includes making sure the patient has findings by scope, but also very importantly, by biopsy,” which need to show chronicity—chronic changes under the microscope—to confirm the IBD diagnosis.

“It’s also important to make sure you trust and know that your pathologists are comfortable reading these biopsies,” Dr Rubin continued. CT enterography, MR enterography, intestinal ultrasound, and capsule endoscopy are also useful tool for helping to confirm a diagnosis.

For patients with perianal disease, “examination under anesthesia by a trained colorectal surgeon is a very important adjunct to diagnosis but also obviously provides some treatment options for a perianal abscess,” he said.

Dr Rubin went on to clarify that there are serologic markers associated with IBD, but these are not to be used for diagnosis. “We thought we should emphasize this point because these are still ordered, sometimes by primary care physicians. You should understand that the antibody to the yeast Saccharomyces can be associated with Crohn’s, but the presence of that antibody does not diagnose Crohn’s disease.” ACG Guidelines recommend against the use​ of these serologic markers for diagnosing or ruling out UC or CD, Dr Rubin stressed.

A confirmed diagnosis of IBD is based on the gold standard of clinical, radiographic, endoscopic, and histologic findings​, and “most importantly, chronicity on biopsies.”

A small number of patients will have an overlap that is called IBD-unclassified, because it’s unclear whether they have UC or CD. Dr Rubin noted that “we’re working on a new global classification of IBD to clarify further how we should think about all of this.”

Among patients with CD, those at moderate to high risk for complications include patients under the age of 30 at diagnosis and patients with extensive anatomical involvement, perianal or severe rectal disease, deep ulcers, structuring and/or penetrating disease, and patients with a history of surgical resection. In UC, patients at high risk for colectomy are generally those diagnosed under the age of 40, with extensive colitis, deep ulcers, high C-reactive protein and ESR, low serum albumin, and patients with a history of hospitalization, C difficile, CMV infection, and those who are dependent on steroids to control their disease.  

“There are some pearls to making sure that you’re clear on your diagnosis of IBD,” he continued. “The baseline assessment is most important. What does the scope look like when they’re being diagnosed?” Always examine the perianal area, he stressed. “Those big skin tags or perianal manifestations will give you a clue that this might be Crohn’s and you don’t want to miss that.” Do a full colonoscopy and get biopsies of normal and abnormal areas, he recommended.

Massey reviewed drug and disease monitoring and its importance in the management of IBD. “Disease monitoring is assessment of disease in different phases,” she explained, while drug monitoring is for the assessment of efficacy and safety of therapies.

Monitoring is essential in IBD because “IBD is chronic, and chronic diseases can drift away from control,” Massey stated. Further, symptoms and objective measures of disease control do not always correlate. Patients may feel well and have no obvious clinical symptoms, but careful monitoring via biomarkers and imaging may reveal active disease in up to 50% of patients.

“Delays and limitations in care delivery and management adjustments result in poor outcomes​, Massey observed. “Proactive disease monitoring allows for earlier assessment of response to therapy, earlier interventions for optimization of treatments, and prevention of clinical consequences​” including hospitalization and surgery.”

Dr Rubin stressed, “Proactive monitoring—that means keeping an eye on all the inflammatory markers and other ways we look at the disease—so that we know when someone’s inflamed before they develop a symptomatic relapse and certainly before they develop a complication. Increasingly we recognize that early treatment makes a big difference, and intervening with effective therapy is critical to disease control.”

“Treat-to-target is a systematic approach to achieve disease control and improve quality of life​,” Massey said. The process requires periodic assessment of disease activity and severity. In their practice, Massey said, she and Dr Rubin reassess patients at about 6 weeks to see if the objective measures are being met. ​If not, they adjust therapies accordingly.

Dr Rubin reviewed the treat to target algorithm, which begins with baseline assessment of disease activity and choice of therapy. After benchmarking biomarkers​ and undertaking shared decision-making​ and goal-setting with the patient, the targets are reassessed. “A lot of times it ends up that you just tweak the dose of the existing therapy or maybe add a second treatment. Then once you hit the target you continue to monitor but less often.”

Incompletely controlled disease can progress, Massey noted, so monitoring during the maintenance phase is critical because many factors may cause changes that can affect disease control. Changes in the patient’s weight, aging, and pregnancy can affect control.

“When patients are feeling better, they may stop their therapy and not tell us,” she said. Patients also may lose response to therapy for reasons that aren’t fully understood. With systematic disease monitoring, subclinical relapse can be detected before the patient becomes symptomatic.

“CRP and fecal calprotectin lead ​clinical relapse, Dr Rubin noted. “When you catch the marker going up, you can intervene.”