During this 20-25 minute pre-recorded lecture, Dr. Ryan Ungaro discusses the topic of epidemiology and diagnosis. This in-depth review will provide an update on this topic for your clinical practice as well as supplement your learning for the ABIM Gastroenterology and Hepatology boards.
Hello everyone. I'm Ryan Garrow, assistant professor of medicine at the Icahn School of Medicine at Mount Sinai and the division of gastroenterology and I'm going to be reviewing epidemiology and diagnosis of IBD using some board style review questions and highlighting some potential topics and fact toys that might be on your board exams. Okay, these are my disclosures. Our first question is a 32 year old woman who presents with three months of bloody diarrhea. She has 78 bloody Belgium is per day associated with urgency and mild abdominal cramping. Physical exam is notable for mild left lower quadrant tenderness, larger, notable for anemia and an elevated S. R. She undergoes a colonoscopy with biopsy which demonstrates ulceration. Is that areas of inflamed mucosa in the rectum and sigmoid. Which of the following statements is true. A ulceration within areas of normal mucosa are more common than you see. B. S. Are specific for a diagnosis of IBD. See, bleeding is more commonly seen in cd than in you see or d biopsy findings of abnormal architecture and basil plasma psychosis. Support diagnosis of IBD. The answer is d biopsy findings of abnormal architecture and basil plasma psychosis. Support a diagnosis of IBD ulceration within areas of normal appearing mucosa are more common in Crohn's disease as opposed to you see S. R. Is a non specific marker of systemic inflammation and cannot be used to diagnose. IBD rectal bleeding is a more common hallmark sign of you see and not Crohn's and abnormal architecture or crypt distortion. There will be a buzzword and basil plasma psychosis, which notes an increase in lymphocytes and plasma cells between the crypt bases can help distinguish IBD from other forms of colitis. This is a, the table that has some characteristics of U. C. Compared with Cd. Differentiating the two diagnoses you see is primarily mucosal, whereas Crohn's is trans mural you see tends to be contiguous from the rectum proximal, whereas Crohn's can skip anywhere from the mouth to the anus. Whereas you see tends to be almost exclusively in the colon, rectal involvement is almost uniform and you see. Whereas rectal involvement can be absent in Crohn's disease, particularly on index exam. Although in patients who are treated you can still have rectal sparing uh if you have you see and would not be indicative of Crohn's disease necessarily. So it's really the index exam where the rectal involvement can give you a hint if it's, you see your Crohn's little disease is common in Crohn's and occasionally you can have some backwash colitis and you see fistulas and periodontal disease are rare and you see but commonly seen or more commonly seen in Crohn's disease, granuloma is very unlikely to be seen almost unheard of. And you see. Whereas in crow's disease, you can see it up to a third of patients and biopsies uh that will have crew granulomas bleeding is a typical symptom of you see, but less common in Crohn's malnutrition unusual. You see more common in Crohn's and cancerous are similar between the two, although Crohn's disease also has a risk of small bowel cancer, although the absolute risk is very low. Tobacco use has this dual uh type of impact on you see, versus Crohn's, where tobacco use may be protective against, you see, um but harmful in Crohn's disease. Our next question, 16 year old man presents with two months of diarrhea and weight loss with occasional blood in the stool. Colonoscopy demonstrates moderate to severe pan colitis. With mild inflammation in the ilium biopsies demonstrate active chronic colitis with ulcer rations, crypt distortion and crypt abscesses, which of the following statements is false. A. And E. G. With gastric biopsy demonstrating h. Pylori negative gastritis may be consistent with either Crohn's or you see be a shallow anal fissure supports a diagnosis of Crohn's disease. See, a granuloma found adjacent to a ruptured script does not support a diagnosis of Crohn's disease. D sequel inflammation and left sided colitis does not strongly support a diagnosis of Crohn's disease. Yeah, the answer is B. A shallow anal fissure supports the diagnosis of Crohn's disease. This is false. So gastric inflammation may be seen in either Crohn's or you see uh particularly in younger patients have some mild gastritis is not uncommon in both. Diagnoses. Granulomas associated with a ruptured cyst does not count toward the Crohn's disease diagnosis and can be seen, and you see. So key is that ruptured um crypt or assist in the lining of the colonic epithelium, shallow midline fisher can be seen in you see but deeper, more eccentric fishers should increase the suspicion of Crohn's disease. And skip lesions on index colonoscopy could be support a diagnosis of Crohn's, but a single patch can be seen in left sided. You see just a few exceptions to the rules for differentiating crayons. And you see, you see after oral learned about therapy can be patchy pre treatment presentation of UC. And Children can actually have some rectal sparing so it could look like cruz. But that necessarily does not necessarily mean particularly younger patient population that it is Kroons. If you have uh if you have rectal sparing, sequel inflammation and left sided colitis where you have sparing of the colonic mucosa in between can still be consistent with. You see, a pencil inflammation in patients with sub total or left sided colitis was similar to the idea of a sequel patch. Fomented, you see cases can have that deep punched out some pigeons type of alterations that look like Crohn's. But in very severe cases it's still uh as you see, crows like at this ulcers can be seen. And you see Ellie itis in U. C. L. E. Itis and you see tends to be more of this backwash where you have pan colitis and it's a very mild colitis but you can't have some myelitis and you see upper tract involvement can happen to you see as you mentioned in the other question where you can have some mild gastritis, crows disease involving the mucosa, you see like pattern with minimal or no sub mucosal inflammation is rare but may happen. And Crohn's with continuous disease involving the entire colon where you just have colitis. Uh this is oftentimes referred to as IBD you, where you can't make a clear distinction between Crohn's and you say. But it is possible to have crews. Just the colon and anal fissures can be seen in you see, although as noted before tend to be more superficial. Next question. 20 year old man was recently diagnosed with chronic disease affecting his ilium. He is married and has a two year old son, his spouse does not have IBD. He is interested in knowing more about the heritability of crows disease. What is the chance that this patient's son develops crone's disease? There's a man with Crohn's, what's the chance that his son could develop it? A 2%. B 8%. C 15%. D 30% or E 50%. The answer is B 8%. So family members with I. B. D. Um Already, family members of patients with IBD Alright, increased risk of developing the disease. However, gen x are only one component of risk. In addition to immune response. Dis regulation environmental factors which likely play a larger role of eugenics. If one parent has Crohn's, the risk for a child developing Crohn's disease is in the 7-9% range, hence the answer here being 8%. And if both parents have Crohn's disease, the risk is actually markedly higher with the risk in the 30-40% range. And in general the genetic contribution genetic risk is thought to be hiring Crohn's than in you see Next question a 35 year old woman presents to your office with longstanding loose stools associated with abdominal pain. She has a family history of Crohn's and lab work up including inflammatory markers is concerning for inflammation. Colonoscopy confirms a little crow's disease. She has to have quote unquote diagnostic markers for Crohn's disease checked in advising the patient about the utility of checking serological markers. Which statement is true. A anti neutrophils, cytoplasmic antibodies or P ANCA is more likely to be present than anti sacrifices surveys antibody or ASPCA ask A. Is more commonly present in Crohn's disease than all sort of colitis. C. P. ECA is more commonly present in patients with a penetrating alien Crohn's disease prototype or D ask A is both highly sensitive and specific for Cruz disease. The answer is B. Ask A. Is more commonly President Crone's disease than all sort of colitis. This is a true statement. So this slide just gives a brief overview of the serological markers or antibody tests for IBD that are commonly available. First to know things to note are that ask a our president, 55% of Crohn's patients, but less than 10% of you see patients and the presence of I. G. R. I. G. A. Makes a diagnosis of chronic disease more likely. But it is neither sensitive nor specific as a single marker. PE enka is less commonly associated with Kroons and more likely to be seen in all sort of colitis where it can be seen up to two thirds of patients and crows these patients expressing panic are more likely to have Crohn's colitis and in the table below or some results from an analysis where just showing that there's low sensitivity of these markers from making a diagnosis of IBD and therefore or not something to be used as a diagnostic. Although their specificity is is reasonable. Next question an 18 year old man who was a smoker has just been diagnosed with polio colonic Crohn's disease. After a colonoscopy demonstrated illegal and sickle ulcers with granulomas. On biopsy. He has also failed to have a paralegal fistula. The family brings in IBD blood panel results. The patient's mother has many questions about his prognosis which of the following statements is true. A the greater the number and higher the tighter of serological markers of crows disease that are present. The more likely the patient is to experience complicated disease behavior such as a stricture or fistula, be the presence of parental fistulas and need for treatment with cortical steroids earlier in the course of the disease indicates an average risk for disabling disease. See smoking is only relevant as a prognostic factor in the postoperative scenario. Or d the presence of granulomas on colonic biopsy indicates a 1.8 fold greater risk of complicated disease behavior. Which of the following statements is true. The answer is a the greater number and higher the tighter of serological markers of crows is that our president, the more likely the patient is to experience complicated disease behavior, including strictures or fistula, prognostic factors and Cruz disease. Uh Here in this question is noted that the serology ease, although are not widely used, do have some prognostic capability that the greater the number of positive serology or higher, the tighter patients are more likely to have complicated disease behavior. Period of fistula and early use of cortical steroids are associated with the disabling course of Crohn's disease. So these are poor prognostic signs, smoking is associated with the worst disease course and a worse prognosis and and cruz disease and granulomas. Although they have been associated with a poor prognosis In some studies, this evidence is weak and the effect size is small. So this this question was getting at the idea of risk factors for more complicated disease in Crohn's disease. Uh And and in all sort of colitis. And I think it's important to just note that the high risk for complications patients are considered. These are data from recommendations from the AJ care pathways patients presenting at a young age having extensive an atomic involvement, having peri anal or severe rectal disease having deep ulcers on your colonoscopy, Having a history of surgery or prior complications. Including structures are penetrating disease behavior are high risk features and suggest the patient that is more likely to have a complicated disease course for crows days and similarly for you see the A. J. Published a set of recommendations about which factors should be considered high risk for collective me or high risk for more aggressive disease. And you see E three patients or extensive colitis deep ulcers similar to crones the younger age. HSM 40 very high sierra periods are steroid requiring disease histories of hospitalization or C. Diff infection or CMV infection. Also considered high risk features for patients with you see. And patients in the high risk groups should be considered for more targeted advanced therapies such as biologics. Next question. 34 year old woman with a history of chronic colitis imperial disease. Currently in remission, Anti TNF is seeing you for preconception counseling visit and wants more information on the impact of her disease, on fertility and pregnancy. She has no history of surgery and imperial disease has been quiescent, which of the following statements is false. So which of these is not true false. A Women with IBD who have not had surgery have no increase in voluntary childlessness. Be if she has a flair of her disease. While pregnant, it is most likely to occur in the third trimester. See patients in remission going into pregnancy are more likely to stay in remission. D patients with active period. Disease should be recommended to have a C. Section no matter what. E IBD patients having a baby are at increased risk of preterm birth and low birth rate, particularly if disease is active. So which of the following statements is false. Be if she has a flair of her disease, it is most likely to occur in the third trimester. This is false flares of disease. In pregnant IBD patients are most likely to occur in the first trimester or the postpartum period, not in the third trimester. Women with IBD and no history of surgery do not appear to have a lower rate of involuntary childlessness. So do the actual fertility for comedy issues, as opposed to choosing to not have a child, but rates of voluntary childlessness, as I just mentioned, are higher patients in remission prior to pregnancy are more likely to stay in remission. So going into pregnancy, intermission is the most important thing for the mom and baby to stay well active. Periodontal disease is a indication for C section and I ve patients are at higher risk for preterm birth or low birth rate, but the risk appears primarily driven by disease activity. Next question. 29 year old woman is seeing you for medically refractory, all sort of colitis. She's considering having a collective me she is married. It has a healthy daughter who was delivered vaginally and would like to have more Children. Which of the following statements is most accurate about pregnancy. After collecting me with creation of J pouch A she should not undergo J pouch surgery until she no longer is planning on having more Children. Be infertility is not an issue. If the J pouch surgery is done with laparoscopic technique, see she is at higher risk for infertility. Following a J. Pouch surgery. D. She is at higher risk of pouch itis since she has had a vaginal delivery. E she should not have a C. Section after J pouch surgery because of adhesions and altered anatomy. The answer is c. She is at higher risk for infertility. Following a J pouch surgery. J. Pouch surgery is associated with a higher risk of infertility estimates in the 3-4fold range if surgery is needed. However, we should not be delaying just based strictly on childbearing age. If someone is sick and he's their colon out, they should have their colon removed. Although laproscopic surgery might decrease the risk of infertility, it is not completely eliminated. There is no association between patch itis and mode of delivery and C. Section is not mandated after J pouch. However, according to toronto consensus, which is referenced below, it is suggested to have a C. Section in order to decrease the risk of sphincter dis motility or sphincter dysfunction and injury. Yeah. Next question. A 32 year old man is diagnosed with mild all sort of pan colitis after presenting with two months of intermittent dire bloody diarrhea. He has noted to have elevated alcohol and fast food taste but normal liver synthetic function. He undergoes an M. R. C. P. That is found to have beating and strictures of the intra and extra hepatic bile ducks. Which of the following statements is true. A. He should have a surveillance colonoscopy every 1-2 years after eight years of you see. B you should have a surveillance colonoscopy now and then every three years. See he should have a surveillance colonoscopy now that annually or D he should be counseled to have a prophylactic collectively. Now the correct answer is C he should have a surveillance colonoscopy now then annually. And this is sort of a two step question. We have to first make the diagnosis of you. CPSC driven by the finding on M. R. C. P. Of strictures and the intra extra padding bio ducks. And then asking about management related to the condition. So this question is getting at cold cancer risk and IBD. And it's important to know that PSC patients have nine times the risk of colorectal cancer compared to all you see patients. So if you have a patient with PSC and you see this is our highest risk group. An annual surveillance colonoscopies are recommended starting at the time of diagnosis of PSC and use. And you say The AG recommends surveillance beginning eight years after onset of disease for other cases of you see not associated with PSC Patients with left sided or pan colitis should be in a surveillance colonoscopy strategy, patients with prostatitis are not at increased risk of colorectal cancer. However, in surveillance colonoscopy should be done every 1-2 years. Should treat crows disease the same way as you see if at least a third of the colon has been involved has been inflamed in the past. But if it's less than a third of the colon, then crone's disease does not need the same. Uh as rigorous screening process or screening surveillance colonoscopy is going forward. Higher risk groups to be aware of. And you see are those with longer standing disease. Higher inflammatory burden, presence of pseudo polyps. Although that is becoming more controversial. Personal. Family history of colorectal cancer and as noted in this question, a history of PSC. Last question which of the following extra intestinal manifestations or symptoms of IBD is most likely to follow a course independent of bowel activity. So separate from the activity of the bowels. A oral app. This ulcers be ankle losing spotlight. This see erythema dose um D. EPI square itis or e peripheral arthritis. So which of these is most likely to follow a course independent of battle activity. Mhm. The answer is B ankle acing spondylitis, ankle losing spondylitis or actually throw up to these are most likely to follow course separate from the underlying IBD. The other items mentioned here oral app. This ulcers, erythema dose, um A piece claire itis poor for arthritis are more likely to parallel the intestinal IBD activity. So when a patient is in a flare of their G. I. Symptoms more likely to have the Z. I. M. S. Pilot aeruginosa, you ve itis and primary sclerosing cholangitis may or may not parallel bowel activity. And there's a little chart here that you can reference that has the listings of comedy I. M. S. On the left hand column and then noting which of these may or may not run separate or parallel course to the underlying IBD. Thank you very much for your time and attention and good luck. Good luck on your exams.
