Measuring disease activity in Crohn's disease: what is currently available to the clinician

Abstract

Crohn’s disease (CD) is a chronic inflammatory bowel disease characterized by a relapsing-remitting clinical behavior and dominated by intestinal inflammation. Being a chronic disorder that with time develops into a disabling disease, it is important to monitor the severity of inflammation to assess the efficacy of medication, rule out complications, and prevent progression. This is particularly true now that the goals of treatment are mucosal healing and deep remission. Endoscopy has always been the gold standard for assessing mucosal activity in CD, but its use is limited by its invasiveness and its inability to examine the small intestine, proximal to the terminal ileum. Enteroscopy and the less invasive small bowel capsule endoscopy enable the small bowel to be thoroughly explored and scores are emerging for classifying small bowel disease activity. Cross-sectional imaging techniques (ultrasound, magnetic resonance, computed tomography) are emerging as valid tools for monitoring CD patients, assessing inflammatory activity in the mucosa and the transmucosal extent of the disease, and for excluding extra-intestinal complications. Neither endoscopy nor imaging are suitable for assessing patients frequently, however. Noninvasive markers such as C-reactive protein, and fecal biomarkers such as calprotectin and lactoferrin, are therefore useful to confirm the inflammatory burden of the disease and to identify patients requiring further investigations.

Evaluating inflammatory activity in Crohn’s disease by cross-sectional imaging techniques

“…Its diagnosis results from the analysis of clinical data (collected through anamnesis, complete physical examination, and complete proctological examination) and data from endoscopic, radiological, and histological studies, as well as from laboratory tests (1) , cross-sectional imaging methods, such as computed tomography (CT) and magnetic resonance imaging (MRI), being more and more widely used (2) . Barium contrast studies (e.g., barium swallow and barium enema), traditionally used in the It is known that Crohn's disease is marked by periods of remission and relapse, and it is important to monitor the intensity of inflammation, in order to assess the effectiveness of the treatment, rule out complications, and prevent its progression (3) . Although endoscopy has been considered the gold-standard method for the evaluation of inflammatory activity, it has the major limitation of not allowing the routine evaluation of the whole intestine or the diagnosis of some of the main complications of the disease-obstacles which are overcome by cross-sectional imaging methods.…”

Resource use and cost of care with biologicals in Crohn’s disease in South Africa: a retrospective analysis from a payer perspective

“…Endoscopy is mostly used to diagnose and investigate symptoms of Crohn's disease rather than monitor treatment outcomes [28]. The decrease in endoscopy observed from Year 1 before biologicals to Year 2 after in our study may be due to a decrease in symptoms experienced by patients who then feel they no longer require endoscopy follow-up.…”

“…The decrease in endoscopy observed from Year 1 before biologicals to Year 2 after in our study may be due to a decrease in symptoms experienced by patients who then feel they no longer require endoscopy follow-up. However, more recent literature suggests that regular measurement of disease activity and treatment outcomes should be based on objective endpoints such as endoscopy and validated patient-reported outcome measures [28,29]. Therefore scopes in the year before starting biologicals may also be used to provide a baseline measurement to monitor the effectiveness of the biological medicine in the ensuing years.…”

Diagnosis and management of functional symptoms in inflammatory bowel disease in remission

“…Authors conclude that remission cannot be determined solely on clinical indices, as their subjective components makes it impossible to separate functional from inflammatory symptoms [10,14] . According to all this, additional tools are needed to establish a reliable diagnosis of remission in IBD [15] : (1) Endoscopic examination of the intestinal mucosa is the gold standard to determine inflammatory activity and the most reliable test to define remission. However, endoscopy is invasive and uncomfortable, not devoid of side effects.…”