Inflammatory Bowel Disease: Clinical Diagnosis and Surgical Treatment-Overview

Abstract

This article is an overview of guidelines for the clinical diagnosis and surgical treatment of predominantly colonic inflammatory bowel diseases (IBD). This overview describes the systematically and comprehensively multidisciplinary recommendations based on the updated principles of evidence-based literature to promote the adoption of best surgical practices and research as well as patient and specialized healthcare provider education. Colonic IBD represents idiopathic, chronic, inflammatory disorders encompassing Crohn's colitis (CC) and ulcerative colitis (UC), the two unsolved medical subtypes of this condition, which present similarity in their clinical and histopathological characteristics. The standard state-of-the-art classification diagnostic steps are disease evaluation and assessment according to the Montreal classification to enable explicit communication with professionals. The signs and symptoms on first presentation are mainly connected with the anatomical localization and severity of the disease and less with the resulting diagnosis "CC" or "UC". This can clinically and histologically be non-definitive to interpret to establish criteria and is classified as indeterminate colitis (IC). Conservative surgical intervention varies depending on the disease phenotype and accessible avenues. The World Gastroenterology Organizations has, for this reason, recommended guidelines for clinical diagnosis and management. Surgical intervention is indicated when conservative treatment is ineffective (refractory), during intractable gastrointestinal hemorrhage, in obstructive gastrointestinal luminal stenosis (due to fibrotic scar tissue), or in the case of abscesses, peritonitis, or complicated fistula formation. The risk of colitis-associated colorectal cancer is realizable in IBD patients before and after restorative proctocolectomy with ileal pouch-anal anastomosis. Therefore, endoscopic surveillance strategies, aimed at the early detection of dysplasia, are recommended. During the COVID-19 pandemic, IBD patients continued to be admitted for IBD-related surgical interventions. Virtual and phone call follow-ups reinforcing the continuity of care are recommended. There is a need for special guidelines that explore solutions to the groundwork gap in terms of access limitations to IBD care in developing countries, and the irregular representation of socioeconomic stratification needs a strategic plan for how to address this serious emerging challenge in the global pandemic.

Keywords: Crohn’s colitis; IBD care during COVID-19 pandemic; clinical diagnosis guideline; colitis-associated colorectal cancer; diagnostic challenges; indeterminate colitis; inflammatory bowel disease; molecular diagnostics advances; surgical treatment guidelines; ulcerative colitis; uneven representation of socioeconomic strata.

Figure 1

Restorative proctocolectomy with ileal pouch-anal anastomosis. (A) J-stapled double staples anastomosis and (B) handsewn anastomosis with mucosectomy. Reprinted/adapted with permission from M’Koma et al. [12]. Copyright © 2007, Springer-Verlag. (C) Columnar cuff: cuff inflammation is a common complication of RPC-IPAA, especially when a towed anastomosis has been used without mucosectomy. Reprinted/adapted with permission from Ref. [89], Copyrights © 2003 by the American Gastroenterological Association and © 2010 byThieme Medical Publishers, Inc. from Ref. [90].

Figure 2

Management of patients with IBD during the COVID-19 pandemic. 5-ASA, 5-aminosalicylic acid medication; CRP, C-reactive protein; mAb, monoclonal antibodies. * Symptoms and consequences of COVID-19: fever (83–99%); cough (59–82%); fatigue (44–70%); anorexia (40–84%); shortness of breath (31–40%); sputum production (28–33%); myalgias (11–35%); headache, confusion, rhinorrhea, sore throat, hemoptysis, vomiting, and diarrhea (<10%); lymphopenia (83%); computed tomography chest: bilateral, peripheral, ground-glass opacities [103]. ** Clearance of SARS-CoV-2 may enable the resumption of IBD therapy; the role of serologic antibody testing is unclear at the current time. *** Indicating new a sentence. Viral clearance testing may or may not be possible or appropriate, given local testing capabilities and health system-approved epidemiological testing strategies during the COIVD-19 pandemic. Treatments for COVID-19 are under investigation, considering therapies that have safety and efficacy in IBD. Reprint /Doneadapted with permission from Rubin et al. Ref. [10].