Optimizing Treatment Strategies to Manage Inflammatory Bowel Disease - Episode 4

Diagnosing Patients With Inflammatory Bowel Disease

August 26, 2021
Remo Panaccione, MD, FRCPC

Jessica Allegretti, MD, MPH

Edward Loftus Jr., MD

William Sandborn, MD

Panel of gastroenterologists share their perspectives regarding the diagnostic work-up for patients who may have symptoms suggestive of IBD.

Remo Panaccione, MD, FRCPC: When you see somebody for the first time and they have symptoms suggestive of IBD [irritable bowel disease], what’s the diagnostic work-up that you start with? Why don’t we start with Jessica? What are you guys doing in Boston [at Brigham and Women’s Hospital]?

Jessica Allegretti, MD, MPH: There are 2 potential scenarios. There’s the person who’s presenting to you with new symptoms: bloody diarrhea, abdominal pain, and weight loss. You’re working them up for a potential diagnosis of IBD. In that situation, you’re ruling out other things first—making sure they don’t have an infection, getting adequate stool studies, ruling out C diff [Clostridioides difficile]. Typically, we’re doing a full endoscopy colonoscopy with TI [terminal ileal] intubation. You want to make sure you’re staging the whole area. I always pair with small-bowel imaging to make sure that once you rule out all those other things that I just mentioned and go down the path of an IBD diagnosis, that you get as much information as you can up front, before you start treatment and muddy the water. Typically, once we’ve ruled out infections and potential other IBD mimics, if you will. We perform a full colonoscopy with TI intubation, and we tend to use MR [magnetic resonance] enterography more than CT enterography just by institutional preference. That’s always part of making sure you get pathology, that you’re working with your pathologist and getting that critical information before you make therapy decisions. That’s generally how it starts.

Remo Panaccione, MD, FRCPC: Does someone want to come up with a comment on serology? We don’t use a lot of serology in Canada, but when I’m down in the United States, everyone is talking about the serological panels. Which of you uses serological panels up front when you’re diagnosing somebody and working them out?

Edward Loftus Jr., MD: I rarely get it. The most common time I might get serology panels done is when somebody comes to me who says they have IBD, but then we scope them or assess them and they’re in total remission. Perhaps that’s 1 little datum point, if it were positive, that would suggest they do have IBD. I don’t get them. I do think they can make things a bit more confusing, but let’s hear what Bill says.

William Sandborn, MD: I don’t routinely use them. First, to my knowledge, none of them is FDA approved. They are clear laboratory-developed tests. They have science information behind them, but for the most part the operating characteristics are best for separating Crohn disease—primarily involving the colon—from ulcerative colitis [UC]. They work best for separating small-bowel or ileocolonic Crohn disease from ulcerative colitis, but you’re not making a diagnosis. It’s only on a serology test. Once you’ve scoped them, you don’t need the test to tell you that.

In the case of indeterminate colitis, you’re trying to decide if this is more Crohn or UC. That’s where the data are for these things. If you screen for them—people looked at this in the treatment of IBS, and it was terrible—they’re not really designed to be a screening tool. They are an adjunctive diagnostic tool and can be useful when treating somebody who you know has IBD, someone for whom you’re trying to sort out which type they have. In this case, if you’ve done the work-up—as Jessica mentioned, with what I do, the roll ileocolonoscopy, biopsy, and MRI—it doesn’t add much. The emerging thing—which has more promise—is using them for prognosis. We have various tools that are coming along where serology and genetics are part of the prognosis measurement that predicts higher risk of surgery, a faster rate of progression, and more problems with structures. I can imagine that that would be useful.

It has been prospective—validated—that it predicts the course, but nobody has shown that predicting the course leads to interventions that change the course, which is the point of knowing the prognosis. A place where they could be interesting is when they’re incorporated into risk prediction tools. If you’re treating a patient with high risk for progression—you’d change your mind and, even more important, the patient’s mind, so that a newly diagnosed patient would agree to take a highly effective regimen early on. That might come with some toxicity risks, and then you could change the course and not need to earn your highly effective therapy; that can be good. In my way of thinking, that’s a hypothesis that’s not nailed down. I don’t know what Ed and Jessica are thinking about that.

Edward Loftus Jr., MD: I agree.

Jessica Allegretti, MD, MPH: I agree. I can’t even remember the last time I ordered a serology. The more likely scenario in which I am interacting with them is that they’ve been sent to us because the serology has come back positive. We’re doing the retroactive work-up to see if there’s any merit to that testing because nothing else has been done. Typically that’s the scenario I end up seeing, when I would be utilizing those serologies. I am rarely using them to make diagnoses. I’d rather get the primary data.

Remo Panaccione, MD, FRCPC: For diagnosis, I want to be clear for the audience or the people who are listening, so here’s the scenario. I’ll put in front of all of you. You start with a colonoscopy. Some people, as we know, may start with a flexible sigmoidoscopy if the patient is having bloody diarrhea. If it looks like UC either on a flex or a colon, do you always do a full colon scan? Do you always do small-bowel imaging? I’ll start with Ed. Just give a yes or no to both.

Edward Loftus Jr., MD: Yes to the scope. If it looks like a slam dunk—if I see clear-cut demarcation and no skip areas—I may not immediately go to small-bowel imaging.

Remo Panaccione, MD, FRCPC: Bill?

William Sandborn, MD: Yes, I do colon, and I generally do an MRI as well.

Remo Panaccione, MD, FRCPC: Jessica, that’s why I left you for last—because I wanted to clarify what we were saying. What do you do in Boston?

Jessica Allegretti, MD, MPH: Even if I’m treating a younger patient with bloody diarrhea, I’m still opting for the full colon and not the flexible sigmoidoscopy. If I’ve ruled everything else out—because once you start them on therapy, you’ve lost that opportunity—I want all the information I can get up front. I’m always doing at least the full colon with TI [terminal ileal] intubation. If the TI looks stone-cold normal and the path comes back fairly consistent—this occurs 80% of the time—I’m still going to get the MRI because I want that information up front. I don’t want to ever second-guess myself after the fact.

Remo Panaccione, MD, FRCPC: Thank you for watching this HCPLive® Peer Exchange. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your in-box. I’m sure you’ll see the folks in front of you on future programs. With that, thank you very much.

Transcript edited for clarity.