Approach to the Management of Recently Diagnosed Inflammatory Bowel Disease Patients: A User's Guide for Adult and Pediatric Gastroenterologists

Abstract

Inflammatory bowel diseases (IBDs), including Crohn's disease and ulcerative colitis, are chronic, progressive, immune-mediated diseases of adults and children that have no cure. IBD can cause significant morbidity and lead to complications such as strictures, fistulas, infections, and cancer. In children, IBD can also result in growth impairment and pubertal delays. IBD is highly heterogenous, with severity ranging from mild to severe and symptoms ranging from mild to debilitating. Delay in IBD diagnosis, especially in Crohn's disease, is common and associated with adverse outcomes. Early diagnosis and prompt institution of treatment are the cornerstones for improving outcomes and maximizing health. Early diagnosis requires a low threshold of suspicion and red flags to guide early specialist referral at the primary provider level. Although the armamentarium of IBD medications is growing, many patients will not respond to treatment, and the selection of first-line therapy is critical. Risk stratification of disease severity, based on clinical, demographic, and serologic markers, can help guide selection of first-line therapy. Clinical decision support tools, genomics, and other biomarkers of response to therapy and risk of adverse events are the future of personalized medicine. After starting appropriate therapy, it is important to confirm remission using objective end points (treat to target) with continued control of inflammation with adjustment of therapy using surrogate biomarkers (tight control). Lastly, IBD therapy extends far beyond medications, and other aspects of the overall health and wellbeing of the patient are critical. These include preventive health, nutrition, and psychobehavioral support addressing patients' concerns around complementary therapy and medication adherence, prevention of disability, and ensuring open communication.

Keywords: Adult; Crohn’s Disease; Early Diagnosis; Early Therapy; Inflammatory Bowel Disease; Pediatric; Personalized Therapy; Ulcerative Colitis.

Figure 1.

Inflammatory bowel disease severity vs disease activity variables. ASCA, anti-Saccharomyces cerevisiae antibodies; ANCA, anti-neutrophil cytoplasmic antibodies; GMCSF, granulocyte-macrophage colony-stimulating factor; TI, terminal ileum.

Figure 2.

Stratification of inflammatory bowel disease risk of progression based on disease severity and activity. BMI, body mass index; CDAI, Crohn’s Disease Activity Index; ESR, erythrocyte sedimentation rate; UCEIS, Ulcerative Colitis Endoscopic Index of Severity. *Refer to Figure 1. **From Torres et a1, adapted with permission. ***From Rubin et al, adapted with permission.

Figure 3.

Therapeutic strategies for the management of recently diagnosed CD. IMMs include thiopurines and methotrexate. CDED, Crohn’s disease exclusion diet; TI, terminal ileum.

Figure 4.

Therapeutic strategies for the management of recently-diagnosed ulcerative colitis. IMMs include thiopurines and methotrexate. 5-ASA, 5-amino salicylic acid; ASUC, acute severe ulcerative colitis; IPAA, ileal pouch anal anastomosis.

Figure 5.

360° care of the patient with IBD. Please see Supplementary Figure 1 for screening tool to identify patients who may need 360-degree care services. CBC, complete blood count; CMP, comprehensive metabolic panel; CRP, C-reactive protein; CTE, computed tomography enterography; DEXA, dual energy X-ray absorptiometry; EBV, Epstein-Barr virus; ESR, erythrocyte sedimentation rate; IgG, immunoglobulin G; MMA, methylmalonic acid; MRE, magnetic resonance enterography; PPD, purified protein derivative; PPSV23, pneumococcal polysaccharide vaccine 23; sAb, surface antibody; sAg, surface antigen; SB, small bowel; SBFT, small bowel follow through; SBUS, small bowel ultrasound.