IBD- Identifying the symptoms and when to refer
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Hi, my name is Dr Moschen
and I am joined by Professor
McGonagle and Dr Merola
to discuss inflammatory
bowel disease
from our 3 different perspectives:
gastroenterology, rheumatology,
and dermatology.
IBD is a chronic, relapsing-remitting
immune-mediated disorder,
characterized by inflammation
in the gastrointestinal tract.
Two major forms of IBD
include ulcerative colitis,
affecting only the colon,
and Crohn’s disease,
which may affect
the whole of the intestinal tract,
but typically
in discontinuous regions.
Research shows that
there is a lot of overlap
in terms of genetic susceptibility
between Crohn’s disease,
ulcerative colitis, and other
immune-mediated diseases.
We need to keep
this relationship in mind
and ask our patients with
immune-mediated diseases
about IBD, and vice versa.
If we look at the epidemiology of IBD,
a comparable prevalence
rate is observed
in North America and
Europe, with approximately
300 to 500 cases
per 100,000 inhabitants.
By comparison,
the incidence rate in patients
with immune-mediated
disorders is marginally higher.
In Rheumatology, we will ask
the patients who we suspect
might have spondyloarthritis
about abdominal symptoms
and ask about
a family history of IBD.
Beyond that, we run
routine blood investigations
including inflammatory markers
and looking for evidence of anemia,
and we may also
check fecal calprotectin.
And based on these findings
we may then refer the patient
to our gastroenterologist
to further evaluate for IBD.
From a dermatologist perspective,
I certainly consider it crucial to
obtain the patient’s personal history,
in terms of symptoms
that might be relevant to IBD
as well as family history.
I look for red flags
such as bleeding,
mucus in the stool, fever,
and I typically
will ask about fatigue,
and maybe number of bowel
movements throughout the day.
I would also look for signs
in their blood work,
such as hypoalbuminemia, anemia,
elevated white blood count,
as well as considering
fecal calprotectin.
I would recommend
asking two simple questions:
the first one is have
you ever experienced
any gastrointestinal symptoms,
namely, diarrhea, blood in stool,
mucus, abdominal pain
that have lasted
longer than 4 weeks?
And secondly, does anyone
in the family suffer from IBD?
If the patient has
a positive family history
or is reporting
persistent GI symptoms,
my recommendation would be
to run a test for fecal calprotectin.
Fecal calprotectin
is the most important parameter
to distinguish between inflammatory
and functional
gastrointestinal diseases
and the results are similar
to a traffic light system;
if the test is negative
it might be not really be necessary
to do any further testing,
and it’s likely IBS.
The first question to ask is:
“How long have you
had these symptoms?"
The duration of symptoms
is very important.
IBD is a form of chronic diarrhea
and is defined as having symptoms
for more than 4 weeks.
In a patient with an
immune-mediated disease,
I would recommend
referral to a gastroenterologist
if the patient has GI symptoms
for longer than 2 weeks.
Secondly if the onset
of symptoms occurs very rapidly.
It’s likely that
the problem is not IBD,
then it’s more likely
an acute gastroenteritis
caused by a virus or
bacteria or by food poisoning.
From a rheumatology perspective
if a patient’s been on an IL-17
inhibitor for psoriatic arthritis
or ankylosing spondylitis
for several months
and they develop
abdominal symptoms
but the absence
of bloody diarrhea and mucus
and weight loss
and clearly overt colitis,
and they simply have pains
which simply may be
linked to irritable bowel,
we wouldn’t jump in
and stop treatment.
I’d say from the
dermatology perspective,
abdominal complaints, diarrhea,
and GI symptoms are pretty common
so I wouldn’t be in a rush
to switch treatment,
particularly effective treatment
unless I really saw
those true red flags.
So, I fully agree.
So simple questions
are really useful tools to begin
differentiating idiopathic
gastrointestinal symptoms
from real IBD.
I think it’s important to understand
the signs and symptoms
and how to manage your patients
and when to refer
to a gastroenterologist.
Thank you very much.