Advances in the diagnosis and management of inflammatory bowel disease: challenges and uncertainties

Abstract

Over the past two decades, several advances have been made in the management of patients with inflammatory bowel disease (IBD) from both evaluative and therapeutic perspectives. This review discusses the medical advancements that have recently been made as the standard of care for managing patients with ulcerative colitis (UC) and Crohn's Disease (CD) and to identify the challenges associated with implementing their use in clinical practice. A comprehensive literature search of the major databases (PubMed and Embase) was conducted for all recent scientific papers (1990-2013) giving the recent updates on the management of IBD and the data were extracted. The reported advancements in managing IBD range from diagnostic and evaluative tools, such as genetic tests, biochemical surrogate markers of activity, endoscopic techniques, and radiological modalities, to therapeutic advances, which encompass medical, endoscopic, and surgical interventions. There are limited studies addressing the cost-effectiveness and the impact that these advances have had on medical practice. The majority of the advances developed for managing IBD, while considered instrumental by some IBD experts in improving patient care, have questionable applications due to constraints of cost, lack of availability, and most importantly, insufficient evidence that supports their role in improving important long-term health-related outcomes.

Figure 1

(a) Coronal gadolinium-based contrast material–enhanced fat-suppressed T1-weighted gradient-echo MR image shows luminal narrowing, mural thickening, and mildly increased vascularity of the terminal ileum (arrow). (Reproduced with permission from Leyendecker et al., MR enterography in the management of patients with Crohn disease. Radiographics, 2009. 29 (6): p. 1827-46.) (b) MRE demonstrating thickening and enhancement of the distal ileum associated with mesenteric fat creeping and engorgement of vasa recta in a 23-year-old female known to have Crohn's disease for 4 years

Figure 2

(a) Small bowel ultrasonographic images showing a lineal communication between two thickened small bowel loops which contains air (arrow), corresponding to an entero-enteric fistula. (b) Small bowel ultrasonographic images showing bowel wall thickening with moderate positive vascularity on Doppler. Surrounding peri-enteric fat has an increased echogenicity because of inflammatory changes. (Reproduced with permission from Panes et al., Systematic review: The use of ultrasonography, computed tomography and magnetic resonance imaging for the diagnosis, assessment of activity and abdominal complications of Crohn's disease. Aliment Pharmacol Ther, 2011. 34 (2): p. 125-45)

Figure 3

FICE images captured by video capsule endoscopy seen with (a) conventional imaging, (b) FICE setting 1 (red 595 nm; green 540 nm; blue 535 nm), (c) FICE setting 2 (red 420 nm; green 520 nm; blue 530 nm), and (d) FICE setting 3 (red 595 nm; green 570 nm; blue 415 nm) (FICE: Fujinon Intelligent Color Enhancement). (Permission obtained from Thieme Publishers©; reproduced with permission from Fisher LR and Hasler WL, New vision in video capsule endoscopy: Current status and future directions. Nat Rev Gastroenterol Hepatol, 2012. 9 (7): p. 392-405)

Figure 4

Chromoendoscopic images of (a) a dysplasia associated lesion or mass, (b) multiple pseudo polyps in ulcerative colitis

Figure 5

Confocal endomicroscopic imaging of epithelial cell shedding in the terminal ileum. (Reproduced with permission from Kiesslich et al., Local barrier dysfunction identified by confocal laser endomicroscopy predicts relapse in inflammatory bowel disease. Gut, 2012. 61 (8): p. 1146-53)

Figure 6

The metabolic pathway of thiopurines

Figure 7

An illustration of a surgically constructed ileal pouch