Statement 5

Upper gastrointestinal endoscopy should be routinely done in all patients of Crohn’s

Disease

Why ?

• Disease Mapping ? • Does it help in patients with indeterminate

colitis ? • Any typical histological finding ?

Halme L, Karkkainen P, Rautelin H, et al. High frequency of Helicobacter pylori-negative gastritis in patients with Crohn’s disease. Gut 1996;38:379–83.Oberhuber G, Puspok A, Oesterreicher C, et al. Focally enhanced gastritis: A frequent type of gastritis in patients with Crohn’s disease. Gastroenterology 1997;112:698 –706.

Focally enhanced gastritiswas observed in 76% of H. pylori–negative patients with Crohn’s disease and in 0.8% of controls

Whether these focal inflammatory infiltrates are exclusive to CD ?

In H. pylori- negative patients, FEG was found in• 8 of 27 patients (29.6%) of CD patients• 6 of 27 (22.2%) patients with UC•2 of 9 (10.5%) of non-IBD control group (p=0.324)

Hung HC et al, Korean J Gastroenterol 2009;53:23-28

Morphologic Findings in Upper Gastrointestinal Biopsiesof Patients With Ulcerative ColitisA Controlled StudyJingmei Lin, MD, PhD, Barbara J. McKenna, MD, and Henry D. Appelman, MD(Am J Surg Pathol 2010;34:1672–1677)

CD involving the upper gastrointestinal tract is almost invariably accompanied by small or large bowel involvement

Rutgeerts P, Onette E, Vantrappen G, Geboes K, Broeckaert L,Talloen L. Crohn's disease of the stomach and duodenum: Aclinical study with emphasis on the value of endoscopy andendoscopic biopsies. Endoscopy 1980;12(6):288–94.Wagtmans MJ, van Hogezand RA, Griffioen G, Verspaget HW,Lamers CB. Crohn's disease of the upper gastrointestinal tract.Neth J Med 1997;50(2):S2–S7.Witte AM, Veenendaal RA, van Hogezand RA, Verspaget HW,Lamers CB. Crohn's disease of the upper gastrointestinal tract:the value of endoscopic examination. Scand J GastroenterolSuppl 1998;100-5:100–5.

Upper gastrointestinal tract involvement reportedly occurs in 5% to 70% of patients with CD

Korelitz BI, Waye JD, Kreuning J, et al. Crohn’s disease in endoscopic biopsies of the gastric antrum and duodenum. Am J Gastroenterol 1981;76:103–9.

Maki M, Vaajalahti P, Arajarvi P, et al. Upper gastrointestinal endoscopic findings in childhood Crohn’s disease. Acta Paediatr

Scand 1985;322(suppl):30.Kirschner BS. Gastroduodenal Crohn’s disease in childhood. J Pediatr Gastroenterol Nutr 1989;9:138–40.Cameron DJS. Upper and lower gastrointestinal endoscopy in children and adolescents with Crohn’s disease: A

prospective study. JGastroenterol Hepatol 1991;6:355–8.Lenaerts C, Roy CC, Vaillancourt M, et al. High incidence of upper gastrointestinal tract involvement in children

with Crohn’sdisease. Pediatrics 1989;83:777–81. Mashako MNL, Cezard JP, Navarro J, et al. Crohn’s disease lesions in the upper gastrointestinal tract:

Correlation between clinical,radiological, endoscopic, and histological features in adolescents and children. J Pediatr Gastroenterol Nutr

1989;8:442–6.Griffiths AM, Alemayehu E, Sherman P. Clinical features of gastroduodenal Crohn’s disease in adolescents. J

Pediatr GastroenterolNutr 1989;8:166–71.

The Role of Esophagogastroduodenoscopy in the InitialEvaluation of Childhood Inflammatory Bowel Disease:A 7-Year Study JPGN 39:257–261, 2004

Gastric biopsies may be useful in colitis unclassified, as focal active gastritis in the absence of ulceration may be a feature of CD

Histology of UGI tract biopsies mayconfirm diagnosis of CD that would be otherwise missed.

Granulomas, confirming the diagnosis of CD, werefound in the upper gastrointestinal tracts of 28% of our patientswith Crohn disease. In some cases, granulomas were foundsolely in the upper gastrointestinal tracts

Upper gastrointestinal inflammation was seen in 29 of 54 (22CD; 7 UC ).

Upper gastrointestinal tract endoscopy should bepart of the first-line investigation in all new cases suspected of IBD. Absence of specific upper gastrointestinal symptoms do not preclude presence of upper gastrointestinal inflammation.

Diagnostic Role of Upper Gastrointestinal Endoscopy inPediatric Inflammatory Bowel DiseaseJPGN 39:257–261, 2004.

ESPGHAN’s Porto working group has recommendedroutine upper endoscopy at initial presentation to aid in the diagnosis of pediatric IBD

Inflammatory Bowel Disease Working Group of ESPGHAN.Inflammatory bowel disease in children and adolescents:recommendations for diagnosis–the Porto criteria. J Pediatr Gastroenterol Nutr 2005; 41:1–7

ESPGHAN’s Porto working group has recommendedroutine upper endoscopy at initial presentation to aid in the diagnosis of pediatric IBD

Why ?

• Disease Mapping ? Yes• Does it help in patients with indeterminate

colitis ? Probably Yes• Any typical histological finding ?Probably Yes• Does it help in investigating for celiac ? Yes• Is it more useful in a particular age group ? Yes

•Upper Gastrointestinal endoscopy should be routinely done in all patients of Crohn’s Disease

Comments:•There is no indication for upper gi endoscopy in all Crohn's patients•With suspected upper GI involvement •Only in paediatrics•If patients present with upper gastrointestinal manifestations, upper GI endoscopy should be indicated. •Upper GI involvement uncommon to warrent rountine int.•As a baseline test it should be done and need not be repeated •indicated for patients with UGI symptoms•"Pediatrics yes.•Adults-not as well validated "•Should be limited to patients with upper GI symptoms. •I will do it when symptom suggest upper GI involvement

Statement 5

Upper gastrointestinal endoscopy is advisable in subgroups of Crohn’s disease : a) pediatric age

group b) indeterminate colitis

Statement 6

Wireless capsule endoscopy is not indicated in all patients with Crohn’s disease. It is

indicated if suspicion of Crohn’s Disease still remains despite a negative ileocolonoscopy

and CT or MR enteroclysis

Capsule Endoscopy Has a Significantly HigherDiagnostic Yield in Patients With Suspected and Established Small-Bowel Crohn ’ s Disease: A Meta-Analysis Am J Gastroenterol 2010; 105:1240–1248

The yield of capsule endoscopy is superior to small-bowel radiography, computed tomography enterography, and colonoscopy with ileoscopy in the diagnosis of suspected small-bowel Crohn ’ s disease.

CE is also a more effective diagnostic tool in established CD patients compared with SBR, CTE, and PE.

Am J Gastroenterol 2010; 105:1240–1248

Impact of Capsule Endoscopy on Management of Inflammatory Bowel Disease: A Single Tertiary Care Center Experience(Inflamm Bowel Dis 2011;17:1855–1862)

Patients with CD61.6% : Change in medication in the 3 months after the CE 39.5% : initiating a new IBD medication12.8% : underwent surgery Severe findings on CE in patients with CD, as compared to no/minimal findings, resulted in significant differences in medication changes (73.2% versus 51.1%)addition of medications (58.5% versus 22.2%, P < 0.01), and surgeries (21.9% versus 4.4%, P=0.01).

Impact of Capsule Endoscopy on Management of Inflammatory Bowel Disease: A Single Tertiary Care Center Experience(Inflamm Bowel Dis 2011;17:1855–1862)

CE results in management changes in the majority of cases of symptomatic IBD

J Crohns Colitis. 2011 Apr;5(2):139-47.Small bowel capsule endoscopy vs conventional techniques in patients with symptoms highly compatible with Crohn's disease

30 cases SBCE may detect lesions compatible with small bowel CD in almost one third of patients with symptoms highly compatible with CD and no conclusive diagnosis by using conventional techniques ( Barium studies, Ileocolonoscopy, contrast USG)

•Wireless capsule endoscopy in not indicated in all patients with Crohn’s disease. •It is indicated if the suspicion of Crohn’s disease still remains despite a negative ileocolonoscopy and CT or MR enteroclysis.

Comments:•Agree with first sentence. CT should not be encouraged due to DMR. •Enteroclysis is not necessary with CT or MRI in most patients and is often poorly tolerated.• MR enterography is as good as mr enteroclysis (same for CT) when performed by specialist radiologists•What about strictures causing retained capsule? •Cautious with retained capsule•CT/MR enterography•and in patients without stricture lesions.•Reined sound statement

A normal SBCEexamination has a very high negative predictive value,essentially ruling out small bowel CD. However, the use ofSBCE in cases of suspicion of small bowel CD is limited by alack of specificity. CD associated lesions described by SBCEneed more precise definition. Over 10% of healthysubjects demonstrate mucosal breaks and erosions in theirSB. Thus, SBCE findings of mucosal lesions of the small bowelare not alone sufficient to establish a diagnosis of CD.

Statement 7

Serum ASCA and ANCA have no role in diagnosing Crohn’s Disease

The prevalence and diagnostic value of p ANCA and ASCA in patients with inflammatory bowel disease in mainland China. Zhou F. Clinica Chimica Acta 411 (2010) 1461–1465

The prevalence and diagnostic value of p ANCA and ASCA in patients with inflammatory bowel disease in mainland China. Zhou F. Clinica Chimica Acta 411 (2010) 1461–1465

Detection of pANCA and ASCA is useful in confirming the diagnosis of IBD, but plays a limited role in the differentiation between UC and CD in a central Chinese population.

pANCA and ASCA are not specific in identification of UC and CD in Canadian patientsCan J Gastroenterol 2008

Low sensitivity Cannot replace existing diagnostic tools May be useful in indeterminate colitis

Clinical significance of anti-Saccharomyces cerevisiae antibody(ASCA) in Korean patients with Crohn’s disease and itsrelationship to the disease clinical courseKim et al, Digestive and Liver Disease 39 (2007) 610–616

A more severe clinical course andthus often required more aggressive medical treatment

Ghoshal UC, Ghoshal U, Singh H, Tiwari S. Anti-Saccharomyces cerevisiaeantibody is not useful to differentiate between Crohn's disease and intestinaltuberculosis in India. J Postgrad Med. 2007 Jul-Sep;53(3):166-70.

Makharia GK, Sachdev V, Gupta R, Lal S, Pandey RM. Anti-Saccharomycescerevisiae antibody does not differentiate between Crohn's disease and intestinal tuberculosis. Dig Dis Sci. 2007 Jan;52(1):33-9.

ITB vs CD

What Is the Role of Serological Markersin IBD? Pediatric and Adult DataMarla DubinskyPediatric IBD Center, Cedars-Sinai Medical Center, David Geffen School of Medicine, Los Angeles, Calif. , USADig Dis 2009;27:259–268

Newer antiglycan antibodies

The search for novel diagnostic approaches that accurately distinguishes a group of patients with IBD from those unaffected by the disease has become a focus in IBD research.

•Serum ASCA and ANCA antibodies have no role in diagnosing Crohn’s disease.

Comments:•May be for research benchmark•"May in occasions, help differentiate Crohn's disease from ulcerative colitis" •"There are some reports against this statement.•Such as Zhou F et al. Clin Chim Acta 2010, Oct 9, 416 (19-20)"•Can be helpful in differentiating UC from CD•In cases of indeterrminate colitis , the serological tests may help in distinguishing Crogn's disease from Ulcerative colitis •These are sometimes useful for differential diagnosis. •more data are necessary to confirm its accuracy•Its not curcil for diagnosis but helps in differentiation of difficult cases of Crohn's and UC•In the west, in CD 2/3 are ASCA+, 1/3 ANCA+. ASCA+ and ANCA- combination may help differentaing CD from UC.• Can we use another word rather than "no role" such as "limited role".

Statement 7

Serum ASCA and ANCA have a limited role in diagnosing Crohn’s Disease , particularly in differentiating indeterminate colitis

Statement 8

Genetic testing is not routinely recommended for work up of Crohn’s Disease patients

•Genetic testing is not routinely recommended for work up of Crohn’s disease patients

Comments:•"For Diagnosis of Crohn's Disease"•In future, the development in genomic test may change in scenario.

Statement 14

Starting concomitant therapy for CD while the patient is on anti TB therapy should be

discouraged in patients that are indeterminate for ITB and CD

Timer Period –Response CD (n=109)N(%)

ITB(n=25)N(%)

P value

At 1 month(n=109)Complete response 1 (0.9) p<0.001Partial response 9 (8.3) 21 (84)No response 99 (90.8) 4 (16)At 2 months( n=109)Complete response 3 (2.8) 4 (16) p<0.001Partial response 14 (12.8) 20 (80)No response 90 (82.6) 1 (4)Worsened 2 (1.8)At 3 months(n=109)Complete response 5 (4.6) 17 (68) p<0.001Partial response 38 (34.9) 8 (32)No response 63 (57.8)Worsened/relapsed 3 (2.7)At 6 months(n=87)Complete response 15 (17.4) 23 (92) p<0.001Partial response 29 (33.7) 2 (8)No response 35 (39.6)Worsened/relapsed 8 (9.3)

Case Scenarios

• A patient has completed 5 months of ATT and then shows lack of response

• ? Drug resistant tuberculosis