Transcript Diagnosis Statement 5 - Asia Pacific Working Group in Inflammatory

Statement 5
Upper gastrointestinal endoscopy should be
routinely done in all patients of Crohn’s
Disease
Why ?
• Disease Mapping ?
• Does it help in patients with indeterminate
colitis ?
• Any typical histological finding ?
Halme L, Karkkainen P, Rautelin H, et al. High frequency of Helicobacter pylori-negative
gastritis in patients with Crohn’s disease. Gut 1996;38:379–83.
Oberhuber G, Puspok A, Oesterreicher C, et al. Focally enhanced gastritis: A frequent type
of gastritis in patients with Crohn’s disease. Gastroenterology 1997;112:698 –706.
Focally enhanced gastritis
was observed in 76% of H. pylori–negative patients with
Crohn’s disease and in 0.8% of controls
Whether these focal inflammatory infiltrates are
exclusive to CD ?
Hung HC et al, Korean J Gastroenterol 2009;53:23-28
In H. pylori- negative patients, FEG was
found in
• 8 of 27 patients (29.6%) of CD patients
• 6 of 27 (22.2%) patients with UC
•2 of 9 (10.5%) of non-IBD control group
(p=0.324)
Morphologic Findings in Upper Gastrointestinal Biopsies
of Patients With Ulcerative Colitis
A Controlled Study
Jingmei Lin, MD, PhD, Barbara J. McKenna, MD, and
Henry D. Appelman, MD
(Am J Surg Pathol 2010;34:1672–1677)
CD involving the upper gastrointestinal
tract is almost invariably accompanied by
small or large bowel involvement
Rutgeerts P, Onette E, Vantrappen G, Geboes K, Broeckaert L,
Talloen L. Crohn's disease of the stomach and duodenum: A
clinical study with emphasis on the value of endoscopy and
endoscopic biopsies. Endoscopy 1980;12(6):288–94.
Wagtmans MJ, van Hogezand RA, Griffioen G, Verspaget HW,
Lamers CB. Crohn's disease of the upper gastrointestinal tract.
Neth J Med 1997;50(2):S2–S7.
Witte AM, Veenendaal RA, van Hogezand RA, Verspaget HW,
Lamers CB. Crohn's disease of the upper gastrointestinal tract:
the value of endoscopic examination. Scand J Gastroenterol
Suppl 1998;100-5:100–5.
Upper gastrointestinal tract involvement reportedly
occurs in 5% to 70% of patients with CD
Korelitz BI, Waye JD, Kreuning J, et al. Crohn’s disease in endoscopic biopsies of the gastric antrum and
duodenum. Am J Gastroenterol 1981;76:103–9.
Maki M, Vaajalahti P, Arajarvi P, et al. Upper gastrointestinal endoscopic findings in childhood Crohn’s disease.
Acta Paediatr
Scand 1985;322(suppl):30.
Kirschner BS. Gastroduodenal Crohn’s disease in childhood. J Pediatr Gastroenterol Nutr 1989;9:138–40.
Cameron DJS. Upper and lower gastrointestinal endoscopy in children and adolescents with Crohn’s disease: A
prospective study. J
Gastroenterol Hepatol 1991;6:355–8.
Lenaerts C, Roy CC, Vaillancourt M, et al. High incidence of upper gastrointestinal tract involvement in children
with Crohn’s
disease. Pediatrics 1989;83:777–81.
Mashako MNL, Cezard JP, Navarro J, et al. Crohn’s disease lesions in the upper gastrointestinal tract:
Correlation between clinical,
radiological, endoscopic, and histological features in adolescents and children. J Pediatr Gastroenterol Nutr
1989;8:442–6.
Griffiths AM, Alemayehu E, Sherman P. Clinical features of gastroduodenal Crohn’s disease in adolescents. J
Pediatr Gastroenterol
Nutr 1989;8:166–71.
The Role of Esophagogastroduodenoscopy in the Initial
Evaluation of Childhood Inflammatory Bowel Disease:
A 7-Year Study JPGN 39:257–261, 2004
Histology of UGI tract biopsies may
confirm diagnosis of CD that would be
otherwise missed.
Granulomas, confirming the diagnosis of CD, were
found in the upper gastrointestinal tracts of 28% of our patients
with Crohn disease.
In some cases, granulomas were found
solely in the upper gastrointestinal tracts
Gastric biopsies may be useful in colitis unclassified, as focal
active gastritis in the absence of ulceration may be a feature of
CD
Diagnostic Role of Upper Gastrointestinal Endoscopy in
Pediatric Inflammatory Bowel Disease
JPGN 39:257–261, 2004.
Upper gastrointestinal inflammation was seen in 29 of 54 (22
CD; 7 UC ).
Upper gastrointestinal tract endoscopy should be
part of the first-line investigation in all new cases suspected of
IBD.
Absence of specific upper gastrointestinal symptoms do not
preclude presence of upper gastrointestinal inflammation.
ESPGHAN’s Porto working group has recommended
routine upper endoscopy at initial presentation to
aid in the diagnosis of pediatric IBD
Inflammatory Bowel Disease Working Group of
ESPGHAN.Inflammatory bowel disease in children and
adolescents:recommendations for diagnosis–the Porto
criteria. J Pediatr Gastroenterol Nutr 2005; 41:1–7
ESPGHAN’s Porto working group has recommended
routine upper endoscopy at initial presentation to
aid in the diagnosis of pediatric IBD
Why ?
• Disease Mapping ? Yes
• Does it help in patients with indeterminate
colitis ? Probably Yes
• Any typical histological finding ?Probably Yes
• Does it help in investigating for celiac ? Yes
• Is it more useful in a particular age group ? Yes
•Upper Gastrointestinal endoscopy should be routinely done in all patients of Crohn’s Disease
Comments:
•There is no indication for upper gi endoscopy in all Crohn's patients
•With suspected upper GI involvement
•Only in paediatrics
•If patients present with upper gastrointestinal manifestations, upper GI endoscopy should be indicated.
•Upper GI involvement uncommon to warrent rountine int.
•As a baseline test it should be done and need not be repeated
•indicated for patients with UGI symptoms
•"Pediatrics yes.
•Adults-not as well validated "
•Should be limited to patients with upper GI symptoms.
•I will do it when symptom suggest upper GI involvement
Statement 5
Upper gastrointestinal endoscopy is advisable in
subgroups of Crohn’s disease : a) pediatric age
group b) indeterminate colitis
Statement 6
Wireless capsule endoscopy is not indicated in
all patients with Crohn’s disease. It is indicated
if suspicion of Crohn’s Disease still remains
despite a negative ileocolonoscopy and CT or
MR enteroclysis
Capsule Endoscopy Has a Significantly Higher
Diagnostic Yield in Patients With Suspected and Established SmallBowel Crohn ’ s Disease: A Meta-Analysis
Am J Gastroenterol 2010; 105:1240–1248
The yield of capsule endoscopy is superior to smallbowel radiography, computed tomography
enterography, and colonoscopy with ileoscopy in the
diagnosis of suspected small-bowel Crohn ’ s disease.
CE is also a more effective diagnostic tool in
established CD patients compared with SBR, CTE, and
PE.
Am J Gastroenterol 2010; 105:1240–1248
Impact of Capsule Endoscopy on Management of
Inflammatory Bowel Disease: A Single Tertiary Care
Center Experience
(Inflamm Bowel Dis 2011;17:1855–1862)
Patients with CD
61.6% : Change in medication in the 3 months after the CE
39.5% : initiating a new IBD medication
12.8% : underwent surgery
Severe findings on CE in patients with CD, as compared to
no/minimal findings, resulted in significant differences in
medication changes (73.2% versus 51.1%)
addition of medications (58.5% versus 22.2%, P < 0.01), and
surgeries (21.9% versus 4.4%, P=0.01).
Impact of Capsule Endoscopy on Management of
Inflammatory Bowel Disease: A Single Tertiary Care
Center Experience
(Inflamm Bowel Dis 2011;17:1855–1862)
CE results in management changes in the
majority of cases of symptomatic IBD
J Crohns Colitis. 2011 Apr;5(2):139-47.
Small bowel capsule endoscopy vs conventional techniques in
patients with symptoms highly compatible with Crohn's disease
30 cases
SBCE may detect lesions compatible with small bowel CD in
almost one third of patients with symptoms highly
compatible with CD and no conclusive diagnosis by using
conventional techniques ( Barium studies, Ileocolonoscopy,
contrast USG)
•Wireless capsule endoscopy in not indicated in all patients with Crohn’s disease.
•It is indicated if the suspicion of Crohn’s disease still remains despite a negative ileocolonoscopy and CT or MR enteroclysis.
Comments:
•Agree with first sentence. CT should not be encouraged due to DMR.
•Enteroclysis is not necessary with CT or MRI in most patients and is often poorly tolerated.
• MR enterography is as good as mr enteroclysis (same for CT) when performed by specialist radiologists
•What about strictures causing retained capsule?
•Cautious with retained capsule
•CT/MR enterography
•and in patients without stricture lesions.
•Reined sound statement
A normal SBCE
examination has a very high negative predictive value,
essentially ruling out small bowel CD. However, the use of
SBCE in cases of suspicion of small bowel CD is limited by a
lack of specificity.
CD associated lesions described by SBCE
need more precise definition. Over 10% of healthy
subjects demonstrate mucosal breaks and erosions in their
SB. Thus, SBCE findings of mucosal lesions of the small bowel
are not alone sufficient to establish a diagnosis of CD.
Statement 7
Serum ASCA and ANCA have no role in
diagnosing Crohn’s Disease
The prevalence and diagnostic value of p ANCA and
ASCA in patients with inflammatory bowel disease in
mainland China. Zhou F.
Clinica Chimica Acta 411 (2010) 1461–1465
The prevalence and diagnostic value of p ANCA and
ASCA in patients with inflammatory bowel disease in
mainland China. Zhou F.
Clinica Chimica Acta 411 (2010) 1461–1465
Detection of pANCA and ASCA is useful in
confirming the diagnosis of IBD, but plays a
limited role in the differentiation between UC
and CD in a central Chinese population.
pANCA and ASCA are not specific in identification of
UC and CD in Canadian patients
Can J Gastroenterol 2008
Low sensitivity
Cannot replace existing diagnostic tools
May be useful in indeterminate colitis
Clinical significance of anti-Saccharomyces cerevisiae antibody
(ASCA) in Korean patients with Crohn’s disease and its
relationship to the disease clinical course
Kim et al, Digestive and Liver Disease 39 (2007) 610–616
A more severe clinical course and
thus often required more aggressive medical
treatment
ITB vs CD
Ghoshal UC, Ghoshal U, Singh H, Tiwari S. Anti-Saccharomyces cerevisiae
antibody is not useful to differentiate between Crohn's disease and intestinal
tuberculosis in India. J Postgrad Med. 2007 Jul-Sep;53(3):166-70.
Makharia GK, Sachdev V, Gupta R, Lal S, Pandey RM. Anti-Saccharomyces
cerevisiae antibody does not differentiate between Crohn's disease and
intestinal tuberculosis. Dig Dis Sci. 2007 Jan;52(1):33-9.
What Is the Role of Serological Markers
in IBD? Pediatric and Adult Data
Marla Dubinsky
Pediatric IBD Center, Cedars-Sinai Medical Center, David Geffen
School of Medicine, Los Angeles, Calif. , USA
Dig Dis 2009;27:259–268
Newer antiglycan antibodies
The search for novel diagnostic approaches that
accurately distinguishes a group of patients with
IBD from those unaffected by the disease has
become a focus in IBD research.
•Serum ASCA and ANCA antibodies have no role in diagnosing Crohn’s disease.
Comments:
•May be for research benchmark
•"May in occasions, help differentiate Crohn's disease from ulcerative colitis"
•"There are some reports against this statement.
•Such as Zhou F et al. Clin Chim Acta 2010, Oct 9, 416 (19-20)"
•Can be helpful in differentiating UC from CD
•In cases of indeterrminate colitis , the serological tests may help in distinguishing Crogn's disease from Ulcerative colitis
•These are sometimes useful for differential diagnosis.
•more data are necessary to confirm its accuracy
•Its not curcil for diagnosis but helps in differentiation of difficult cases of Crohn's and UC
•In the west, in CD 2/3 are ASCA+, 1/3 ANCA+. ASCA+ and ANCA- combination may help differentaing CD from UC.
• Can we use another word rather than "no role" such as "limited role".
Statement 7
Serum ASCA and ANCA have a limited role in
diagnosing Crohn’s Disease , particularly in
differentiating indeterminate colitis
Statement 8
Genetic testing is not routinely recommended
for work up of Crohn’s Disease patients
•Genetic testing is not routinely recommended for work up of Crohn’s disease patients
Comments:
•"For Diagnosis of Crohn's Disease"
•In future, the development in genomic test may change in scenario.
Statement 14
Starting concomitant therapy for CD while the
patient is on anti TB therapy should be
discouraged in patients that are indeterminate
for ITB and CD
Timer Period –Response
At 1 month(n=109)
Complete response
Partial response
No response
At 2 months( n=109)
Complete response
Partial response
No response
Worsened
At 3 months(n=109)
Complete response
Partial response
No response
Worsened/relapsed
At 6 months(n=87)
Complete response
Partial response
No response
Worsened/relapsed
CD
(n=109)N(%)
1 (0.9)
9 (8.3)
99 (90.8)
ITB(n=25)N(%
)
P value
p<0.001
21 (84)
4 (16)
3 (2.8)
14 (12.8)
90 (82.6)
2 (1.8)
4 (16)
20 (80)
1 (4)
p<0.001
5 (4.6)
38 (34.9)
63 (57.8)
3 (2.7)
17 (68)
8 (32)
p<0.001
15 (17.4)
29 (33.7)
35 (39.6)
8 (9.3)
23 (92)
2 (8)
p<0.001
Case Scenarios
• A patient has completed 5 months of ATT and
then shows lack of response
• ? Drug resistant tuberculosis