Optimal Management of Biologics in Crohn’s Disease - Episode 2
Dr Anita Afzali and Dr Bincy P. Abraham review the diagnostic workup for Crohn’s disease and challenges in diagnosing the disease.
David P. Hudesman, MD: Dr. Afzali, when somebody does present to your office, what's the work up that you do to help get you to the diagnosis of Crohn's disease? And what are some pitfalls in that work up?
Anita Afzali, MD, MPH, MHCM, FACG, AGAF: As we already discussed, I want us to be very clear that everyone suffers from Crohn's disease in their own way, their presentation, their initial symptoms that ultimately leads the diagnosis is variable. But certainly, we recognize that there's different ways that we can make the final diagnosis. We are endoscopists as well as gastroenterologist, right? And the gold standard if you will, will include that colonoscopy. But even initially you listen for clinical symptoms, there are certain symptoms that we know are associated with Crohn's disease not just the diarrhea but the abdominal pain, the weight loss, anemia. And that's the clinical symptoms that has reported to us. Then, you obtain your baseline laboratories studies and tests, whether that's the inflammatory marker, CRP and ESR, fecal calprotectin. I'm sure my colleagues and all of us are using fecal calprotectin as a good inflammatory biomarker to evaluate for inflammation and for inflammatory bowel disease. And then, the colonoscopy to evaluate. An ileal colonoscopy to make sure you get into that terminal ileum and evaluate for involvement of the small bowel. I obtain an upper endoscopy based off the symptoms and on the right patient. And then, the cross-sectional imaging. I believe for patients who, again, may have only small bowel Crohn's disease, that's the only way we could evaluate that with cross sectional imaging. And I prefer an MRI over a CAT scan. Let's spare our patients the radiation exposure. Putting that altogether is being into having the opportunity to evaluate how severe, active is the disease. But the pitfalls to that, to your question, comes in the sense of recognizing that because of the distribution of the disease for someone who may just have small bowel involvement, if you limit that workup to just a colonoscopy, you might not capture that. You must be, bear in mind, what you're looking for and being able to properly evaluate that accordingly for each respected patient.
David P. Hudesman, MD: That's great. Dr Abraham, I know you do a lot of work with intestinal ultrasound. Maybe you can just comment on that?
Bincy P. Abraham, MD, MS, AGAF, FACG: That's a fabulous tool to be able to assess our patients. Of course, for diagnosis, it's good to have endoscopic evidence and histological evidence of chronic inflammation.
Anita Afzali, MD, MPH, MHCM, FACG, AGAF: Right.
Bincy P. Abraham, MD, MS, AGAF, FACG: But once you made that diagnosis, it's easy to follow these patients over time to look for some objective evidence of healing. And with intestinal ultrasound, this point of care testing, we can do it in the office when they come for their clinic visit. They don't necessarily have to be fasting for it, they don't have to take any bowel prep, they're not sedated and we're actually able to look at the entire abdomen, look at a small valve disease, look at colonic disease, and really show the patient if there's active inflammation, they're visually seeing this in real time. And it's been phenomenal. You can assess disease activity; you can actually look for improvement after starting therapy as well. They don't have to necessarily go through a colonoscopy to assess for healing essentially with that. And I think it's a fabulous tool.
David P. Hudesman, MD: Great. And the key here is when a patient is newly diagnosed or maybe one of us is seeing them in the office, we wanted to find the full extent and severity of the disease, as you're saying. And that could better help then decide what's the best treatment option.
Transcript edited for clarity