Long term outcome of patients with active Crohn's disease exhibiting extensive and deep ulcerations at colonoscopy1

Background: While therapeutic strategies able to change the natural history of inflammatory bowel diseases (IBD) are being developed, factors predicting aggressive disease are needed to be able to choose the appropriate therapeutic strategy for the individual patient based on the risk/benefit ratio. The aim of this review is to focus on the tools assisting the clinician in routine practice regarding the prediction of disease evolution. Methods: A literature review was performed, which was mainly based on PubMed search, using the following terms: Crohn's disease, ulcerative colitis, inflammatory bowel disease, genetics, serology, biomarkers, endoscopy, C-reactive protein, faecal calprotectin, disease evolution and complications. Results: For the prediction of disease evolution, clinical characteristics, particularly disease location and behaviour, are probably currently the most useful. In addition, a series of biomarkers, including genetic, serological and inflammatory markers, as well as characteristics of endoscopic lesions may have an added value. Conclusions: Simple clinical, biological and endoscopic tools may help the clinician in predicting disease evolution in IBD. However, these tools are still insufficient, and prospective evaluation of new genetic and biological markers are needed.

Section: Prediction Of Disease Evolution In CDmentioning

confidence: 91%

Can We Predict the High-Risk Patient?

Benitez

Louis

2014

“…Two studies have supplied important information. The prediction study by Allez [5] showed that the presence of severe endoscopic lesions in the colon, defined as deep colonic ulcers, predicted colonic resection with a risk ratio of 5.43 (95% confidence interval = 2.64–11.18). The population-based Frøslie study (IBSEN cohort) [6] showed that in UC and CD healing of the (ileo-)colonic mucosa results in better disease control and a decreased requirement of surgery (significant for UC at 5 years and for CD at 10 years).…”

Section: Risk Assessment For Outcome In the Ibd Patientmentioning

confidence: 99%

How to Guide Therapeutic Decisions in a Patient-Tailored Approach to Treatment of IBD?

Rutgeerts

2012

Therapeutic decisions in the treatment of IBD involve the initial choice of therapy(ies) and designing a long-term strategy for the individual patient. Putting forward clear therapeutic aims is therefore critical in order to assess treatment success and to guide the sequential use of therapies. Although the ultimate goal of therapy is to achieve steroid-free remission and avoid complications and surgeries, the first therapeutic intervention will achieve these aims only in a minority of patients. Depending on the requirements and successes of each stage of therapy, interim goals are pursued which may be small steps towards the total control of the disease. A patient-tailored approach does not necessarily conflict with algorithm-based decision-making; indeed, they are complementary. The former allows the skipping of some steps in the algorithm, based on the individual patient characteristics. The latter supplies a basis for the rational sequential use of drugs. Many physicians use an accelerated step-up approach in the treatment of IBD, although it has not yet been established whether this is associated with a better outcome. Whether or not an endoscopic or (and) CT or MRI assessment is conducted, the therapeutic approach should be based on mucosal activity and the location and extent of the disease. Treatments that do not heal (or at least improve) ulcers are not to be continued if they have been given a reasonable time to work. Biomarkers like C-reactive protein and calprotectin can be useful surrogates in this setting.

“…The simplified endoscopic severity score of CD has been widely used to grade mucosal inflammation [46]. In one study of a large adult population with CD, the presence of severe endoscopic lesions (defined as extensive and deep ulcerations of at least 10% of the mucosal surface of one segment of the ileocolon) was found to be significantly associated with progression to penetration and the eventual need for surgery [47]. This finding has not been corroborated in children where no formal studies using centralized reading of endoscopic photographs or videos has been completed in this population.…”

Section: Endoscopic Severitymentioning

confidence: 99%

Standardized Recording of Parameters Related to the Natural History of Inflammatory Bowel Disease: From Montreal to Paris

Hyams¹

2014

Similar to adults, there is heterogeneous phenotypic expression of inflammatory bowel disease (IBD) in children. Thus, a classification system for disease characteristics is obligatory if one seeks to understand and eventually change the natural history of IBD. Extrapolation of adult clinical trial results to children also depends upon comparable classifications of disease. Features that can differentiate IBD in children from adults include more extensive and severe disease at presentation, frequent corticosteroid dependency, change in location and behavior over time, and the implications of disease for growth and sexual maturation. In contrast to the Montreal classification where all patients <17 years were grouped together, the Paris classification recognizes the different expression of pediatric IBD between those patients aged <10 years and those 10-17 years of age. The recent identification of monogenic disorders in very young children (<2 years) with severe IBD-like disease has further clouded the issue of where appropriate pediatric age guidelines should be drawn, though it is clear these infantile-onset cases should not be grouped with older children. The Paris classification recognizes the importance of upper tract disease on natural history by dividing it into L4a and L4b (proximal and distal to the ligament of Treitz, respectively), while the Montreal system groups all upper-tract patients together. Complicated disease behavior in the Montreal system mandated a single category preventing the concomitant designation as stricturing and penetrating, whereas the Paris classification recognizes that both stricturing and penetrating behavior may occur at the same or different times. Growth delay is recognized only in the Paris classification as a serious manifestation of IBD in children affecting therapeutic decisions. As our understanding of the basic molecular mechanisms of disease pathogenesis in IBD changes over time, it is likely that the IBD classification will change as well. A single classification system that reflects both pediatric and adult disease is needed.