IBD- Identifying the symptoms and when to refer

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.