VIENNA — New guidelines designed to streamline recommendations on inflammatory bowel disease (IBD) have been developed by the European Crohn's and Colitis Organisation (ECCO) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR).
Currently, "we have a huge number of excellent guidelines. It starts to get a bit tricky to find your way around diagnosing Crohn's disease and ulcerative colitis because you have to look at so many guidelines," said Christian Maaser, MD, from Hospital Lüneburg in Germany.
The goal was to make the guidelines comprehensive and user-friendly, Maaser explained here at the ECCO 2018 Congress. They focus on five areas: initial diagnosis; monitoring of therapy; complications; endoscopic and clinical scoring; and general principles and technical aspects of IBD.
For example, the guidelines state that conventional endoscopy is essential for the diagnosis and monitoring of IBD. However, they point out, the experiences of patients and their acceptance must be considered.
Upper gastrointestinal endoscopy is still recommended for people with Crohn's disease and upper GI symptoms. However, this technique is no longer recommended for asymptomatic, newly diagnosed patients, said Jaap Stoker, MD, from the Academisch Medisch Centrum Universiteit in Amsterdam, who presented the guidelines along with Maaser.
In terms of diagnostic techniques, the preferred method depends on local availability and expertise. "Capsule endoscopy has good sensitivity for early mucosal inflammation, but can only detect mucosal changes," Maaser explained. "MRI and intestinal ultrasound can describe the transmural inflammation and detect complications." In addition, MRI can detect fistulas, deep ulcerations, and a thickened small bowel wall, but ultrasound can be performed at the point of care by the treating gastroenterologist and is inexpensive.
"We hope this chapter will help to optimize the quality of endoscopy imaging at your center and will serve as a basis for discussion with local radiologists," Maaser said. And it is hoped that these guidelines will "improve the diagnosis of IBD."
When monitoring Crohn's disease, the guidelines state that clinical and biochemical responses to treatment should be determined in the 12-week period after the initiation of therapy. In addition, endoscopy or transmural responses to therapy should be evaluated in the 6 months after the start of therapy.
For patients with ulcerative colitis, mucosal healing should be determined endoscopically or using fecal calprotectin levels approximately 3 to 6 months after treatment initiation.
"So there is clear help for you to guide your treatment and monitoring of the patient," Maaser said.
Colonoscopy is the technique of choice to assess disease activity in patients with symptomatic colonic Crohn's disease or ulcerative colitis. Complementary cross-sectional imaging can be used to assess phenotype and as an alternative to evaluate disease activity.
The guidelines are designed to be practical over the typical course of disease. For example, they outline monitoring options after clinical remission, with normalization of calprotectin levels, and advise what to do when a patient in remission experiences a recurrence of symptoms.
The timeline for monitoring depends on risk factors. "We refer you to the full guidelines for more on this," Maaser said.
These and other guideline statements include a notation regarding the level of evidence in the literature. The guidelines also feature a table with recommendations for the surveillance of colorectal cancer.
Cross-sectional imaging should be used to detect strictures in the case of complications. And because of radiation associated with CT, the preferred methods are MRI and intestinal ultrasound, Stoker added. Cross-sectional imaging is also recommended for the detection of abscesses.
For the diagnosis of perianal Crohn's disease, clinical and endoscopic examination of the rectum plus MRI should be used. Ultrasonography in the absence of anal stenosis or transperineal ultrasonography can be used in the place of MRI.
Endoscopic and Clinical Scoring
There are a number of clinical scoring systems for Crohn's disease and ulcerative colitis, each with its own pros and cons, Maaser explained. The various scoring tools will be available for download from the guidelines appendix. Unfortunately, despite the importance of quality of life to the patient, "we realize there is no one score we can recommend for use in daily clinical practice, so there is definitely a need for more scientific work," he added.
The guidelines — drafted with the participation of expert working groups from many European countries — have been submitted for publication. It is expected that they will be available online in April or May. In the meantime, a new eCourse on the upcoming guidelines is available on the ECCO website. "You can go online and do some training," Stoker said.
These guidelines are important because there have been advances "in terms of different techniques available for diagnostic and monitoring purposes," said session comoderator Jonas Halfvarson, MD, from Örebro University in Sweden. "I think aspects of how we look at IBD today are different than they were a few years back," he told Medscape Medical News.
The consolidation of the various ECCO guidelines into one ECCO–ESSGAR set of recommendations "is highly appreciated," Halfvarson said.
Maaser, Stoker, and Halvarson have disclosed no relevant financial relationships.
European Crohn's and Colitis Organisation (ECCO) 2018 Congress: Presented February 16, 2018.
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Cite this: New IBD Guidelines Aim to Simplify Care - Medscape - Feb 20, 2018.