Download Definitions and Diagnosis

Welcome
Methodology
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Voting was conducted anonymously at all times.
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The first vote was conducted by the entire Consensus Group electronically by email.
Relevant literature was then made available on a secured web site
for review by all voters. Modification of first round votes after
access to the literature, if required, constituted the second round of
voting.
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A face-to-face meeting of the entire Consensus Group was
then held to discuss any suggested modifications to the wording of
the statements and to discuss openly the evidence for and against
each specific statement. A third vote was held thereafter.
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Statements that could not reach consensus were discussed and modified
or rejected. Each statement was graded to indicate the level of
evidence available and the strength of recommendation by using
the Canadian Task Force on the Periodic Health Examination
Invited countries
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Australia
Hong Kong
India
Japan
Malaysia
New Zealand
Philippines
Singapore
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Sri Lanka
Taiwan
Thailand
Vietnam
South Korea
Definition and Diagnosis
CJ Ooi
Muhammad Radzi
Vineet Ahuja
Statement 1
• The diagnosis of Crohn’s disease is based
on a combination of clinical, endoscopic
and histological features and the exclusion
of an infectious etiology
Statement 1
The issue remains that no gold standard test exists for the diagnosis of
IBD.
Until such time as highly specific and sensitive diagnostic tests for IBD
are devised, distinguishing among various forms of intestinal
inflammation of idiopathic and identifiable causes will remain a test of
clinical acumen, drawing on relevant history, attentive physical
examination, judicious laboratory testing, and detailed review
Sands BE. From symptom to diagnosis: clinical distinctions among various
forms of intestinal inflammation. Gastroenterology 2004;126(6):1518–32
Statement 1
As there is no single way to diagnose CD, many have defined
macroscopic and microscopic criteria to establish the diagnosis.
The macroscopic diagnostic tools include physical examination,
endoscopy, radiology, and examination of an operative
specimen.
Microscopic features can be only partly assessed
on mucosal biopsy, but completely assessed on an operative
specimen. The diagnosis depends on the finding of discontinuous
and often granulomatous intestinal inflammation.
Lennard-Jones JE, Shivananda S. Clinical uniformity of inflammatory
bowel disease a presentation and during the first year
of disease in the north and south of Europe. EC-IBD Study
Group. Eur J Gastroenterol Hepatol 1997;9(4):353–9.
Statement 1
CD is a heterogeneous entity comprising a variety of
complex phenotypes in terms of age of onset, disease
location and disease behaviour.
Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN,
Brant SR, et al. Toward an integrated clinical, molecular and
serological classification of inflammatory bowel disease:
Report of a Working Party of the 2005 Montreal World Congress
of Gastroenterology. Can J Gastroenterol 2005;19(Suppl A):
5–36.
Statement 1
The current view is that the diagnosis is
established by a nonstrictly defined combination of
clinical presentation, endoscopic appearance,
radiology, histology, surgical findings
and, more recently, serology
ECCO Guidelines 2010
Voting from Round 2
Comments
• May not need all if the evidence is obvious
• Because not only infectious enteritis, but also lymphoma,
Behcet disease and other vasculitis should be excluded.
• Add "Radiological" (in addition to clinical, endoscopic
and histological).
• Yes accepted as there is no other gold standard
available
• exclusion of infection is very relevant in some countries
in this region
• Exclusion of infectious etiology not always alone in
Australia
• What about radiological, especially when dealing with
small bowel?
Proposed amendment (if any)
• The diagnosis of Crohn’s disease is based
on a combination of clinical, endoscopic,
radiological and histological features and,
where appropriate, the exclusion of an
infectious etiology
Statement 1
Level of agreement:
abcde-
%
%
%
%
%
Quality of evidence: III
Classification of recommendation: C
Statement 2
• Ileo-colonoscopy should be done routinely
in all cases. During ileo-colonosopy,
multiple biopsies from five sites in the
colon and terminal ileum should be taken
Statement 2
Colonoscopy with multiple biopsy specimens is well
established as the first line procedure for diagnosing
colitis.
Coremans G, Rutgeerts P, Geboes K, Van den Oord J, Ponette E,
Vantrappen G. The value of ileoscopy with biopsy in the
diagnosis of intestinal Crohn's disease. Gastrointest Endosc
1984;30(3):167–72.
Statement 2
Ileoscopy with biopsy can be achieved with practice
in at least 85% of colonoscopies and increases the diagnostic yield of
CD in patients presenting with symptoms of IBD.
Coremans G, Rutgeerts P, Geboes K, Van den Oord J, Ponette E,
Vantrappen G. The value of ileoscopy with biopsy in the
diagnosis of intestinal Crohn's disease. Gastrointest Endosc
1984;30(3):167–72.
Geboes K, Ectors N, D'Haens G, Rutgeerts P. Is ileoscopy with
biopsy worthwhile in patients presenting with symptoms of
inflammatory bowel disease? Am J Gastroenterol 1998;93(2):
201–6.
Cherian S, Singh P. Is routine ileoscopy useful? An observational
study of procedure times, diagnostic yield, and learning curve.
Am J Gastroenterol 2004;99(12):2324–9
Allez M, Lemann M, Bonnet J, Cattan P, Jian R, Modigliani R.
Long term outcome of patients with active Crohn's disease exhibiting
extensive and deep ulcerations at colonoscopy. Am
J Gastroenterol 2002;97(4):947–53.
Statement 2
• Number of biopsies
• Areas of biopsies – involved and
uninvolved
Voting
Comments
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Agree that ileocolonoscopy should be performed in all cases but disagree
with 5 sites being required.
Definitely ileoscopy should be done but number of biopsies is subjected to
debate
Ileocolonoscopy is the preferred investigation. Why 5 sites?
It depends on the location of the CD
"Five" need evidence.
"Ileocolonoscopy is important, however the evidence of necessity of multiple
biopsies from 5 sites is insufficient.
Often, granuloma is negative, but we can diagnose CD by typical
endoscopic findings, other modalities, and clinical manifestations. "
In case of normal colon is it still essential to take biopsies from 5 segments
? That issue needs to be resolved
Endoscopy cannot perform in all CD patients. Endoscopy is suitable for
non-stricture type CD patients. Furthermore, the targeted biopsy from
active mucosal lesions is preferable.
Why limit to five and should able that even in patients with normal
endoscopy
Proposed amendment (if any)
• Ileo-colonoscopy is the preferred
diagnostic investigation. During ileocolonosopy, multiple biopsies from at least
five sites in the colon and terminal ileum
should be taken and include
endoscopically normal and abnormal
areas.
Statement 2
Level of agreement:
abcde-
%
%
%
%
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Quality of evidence: III
Classification of recommendation: C
Statement 3
• Biopsies for mycobacterial studies should
be taken from patients living in TB
endemic countries
Statement 3
Microbiological features n (%)
P
value
CD
GITB
(n =
26)
(n =
26)
AFB smear/culture
positivity
0 (0)
6
(23.1)
S
TB PCR positivity
0 (0)
17
(65.4)
S
Characteristics
Interpreted as IBD by pathologist 10 (38.4) 3(11.5) S
Interpreted as TB by pathologist 0
(0)
13 (50) S
Amarapurkar DN, Patel ND, Rane PS. Diagnosis of Crohn's disease in
Indiawhere tuberculosis is widely prevalent. World J Gastroenterol. 2008
Feb7;14(5):741-6
Voting
Comments
• I am unsure how useful these studies are - would like to know
sensitivity and specificity
• May add PCR study if needed in a very high suspicion
• what type of tests, TB PCR, TB Culture, TB spot
• Mycobacterial study should be specified.
• However if only PCR for MTB is positive , that is not by itself a stand
alone diagnostic test for Intestinal tuberculosis
• Typical TB enterocolitis can be diagnosed by endoscopic findings,
and PPD and TB-interferon gamma test should be done in such
patients.
• Best practice. evidence found.
• Cultures are impractical; PCR may not be always available and nonspecific
Proposed amendment (if any)
• Biopsies for Mycobacterium tuberculosis
should be taken from patients living in TB
endemic countries
Statement 3
Level of agreement:
abcde-
%
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Quality of evidence: III
Classification of recommendation:C
Statement 4
• In Crohn’s disease, CT or MR enterocyclis
is the preferred investigation of choice in
evaluating small bowel disease. It should
be done routinely in all patients
undergoing workup for Crohn’s disease
Statement 4
CT and MR techniques can establish disease
extension and activity based on wall thickness and increased
intravenous contrast enhancement. The magnitude of these
changes, along with presence of edema and ulcerations allow
categorization of disease severity. These are the current
standards for assessing the small intestine.
Koh DM, Miao Y, Chinn RJ, Amin Z, Zeegen R, Westaby D, et al.
MR imaging evaluation of the activity of Crohn's disease. AJR
Am J Roentgenol 2001;177(6):1325–32
Wold PB, Fletcher JG, Johnson CD, Sandborn WJ. Assessment of
small bowel Crohn disease: noninvasive peroral CT enterography
compared with other imaging methods and endoscopy–
feasibility study. Radiology 2003;229(1):275–81
Statement 4
CT and MR have a similar diagnostic accuracy for the
detection of small intestine inflammatory lesions.
Horsthuis K, Bipat S, Bennink RJ, Stoker J. Inflammatory bowel
disease diagnosed with US, MR, scintigraphy, and CT: metaanalysis
of prospective studies. Radiology 2008;247(1):64–79
Schmidt S, Lepori D, Meuwly JY, Duvoisin B, Meuli R, Michetti P,
et al. Prospective comparison of MR enteroclysis with multidetector
spiral-CT enteroclysis: interobserver agreement and
sensitivity by means of "sign-by-sign" correlation. Eur Radiol
2003;13(6):1303–11
Statement 4
CT is more readily available and less time-consuming than
MR. However, the radiation burden from CT is appreciable.
Brenner DJ, Hall EJ. Computed tomography–an increasing
source of radiation exposure. N Engl J Med 2007;357(22):
2277–84.
Voting
Comments
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CT and MRI are not required in all patients. there are good data showing that small
bowel disease is seldom found in those without symptoms. Diagnostic medial
radiation should be minimised so no to ct. Capsule endosopy can also be performed
here and is probably more sensitive
Patient who have a NEGATIVE ileocolonoscopy should undergo either balloon
assisted enteroscopy or capsule endoscopy. CT/MRI enteroclysis may not pick up
early lesions and cannot provide histology. On other hand, CT/MRI has the the
advantage of identifying fistulas and ruling out coexisting abscesses.
Cost effectiveness in each individual country may be different
Unnecessary in most cases. Exposure to radiation is not healthy and most sites
would not have easy MRI access.
Comparison between CT/MR?
Small intestinal series (enteroclysis or Barium X-ray) by experts is also useful as well
as CT or MRI.
These tools are useful, but their use should be combined with endoscopic
examinations.
not routinely done, only in patients with suggestive symptoms of small bowel
involvement
2nd part not done in all patients
Should we mention availability. "should be routinely done, if available, in all patients"?
And, what about if not available, should we mention an alternative such as small
bowel barium studies (Barium Enteroclysis).
Proposed amendment (if any)
• Evaluation for small bowel disease should
be considered in patients with CD.
• CT or MR enterography/enterocylsis is the
preferred investigation.
Statement 4
Level of agreement:
abcde-
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Quality of evidence: II-2
Classification of recommendation: B