Inflammatory bowel disease; procedures for diagnosis, appendicectomy and risk, and intestinal ultrasound

For August we return to a blog focussed on inflammatory bowel disease. Within the last month there have been a couple of excellent articles published, focusing on how IBD is being diagnosed in Denmark and the risks (or protection) associated with appendicectomy for the detection or develop of IBD in a Canadian population-based cohort. We also take a look at the potential of intestinal ultrasound in adult practice through a recent report in Frontline Gastroenterology. This technique more widely practiced in paediatrics, is an excellent tool for potin-of-care assessment of suspected IBD and for monitoring of disease activity and has the potential to improve care and save money. As always, there are a fantastic range of articles published in BMJOG within the last month and these can all be accessed free-of-charge on the website.

The exact process for diagnosis of IBD varies from patient to patient, despite international guidelines on the required tests being present. Rasmussen et al looked at the clinical procedures used to diagnose inflammatory bowel disease in Denmark through a nationwide population-based cohort. Utilising personal-level data and national health databases the team linked demographic and procedural data at the initial hospital visit for patients diagnosed with IBD. Of the 12871 patients with IBD, 84% underwent endoscopy with the same number having biopsies. Imaging was performed in 44% of patients. Strangely 7.5% of patients, 6% for Crohn’s disease and 8% for ulcerative colitis, managed to get a ‘diagnosis of IBD without undergoing any formal diagnostic procedures. Patients with Crohn’s disease, who were adults at the time of diagnosis and were male were more likely to have undergone a diagnostic procedure. The authors acknowledge some of these findings may be related to shortcomings of the database but they do raise further awareness of the importance of a structured diagnostic process.

The role of the appendix, and appendicectomy, in IBD is a hot-topic. In their paper, Fantodji and colleagues look at the risk of appendicectomy in diagnosis of IBD and determine the impact of age and time-post appendicectomy. A total of 400 520 subjects born in the province of Québec, Canada in 1970–1974 were followed until 2014. From this cohort 2545 Crohn’s disease and 1134 UC cases were identified. Appendicectomy increased the risk of Crohn’s disease with a HR of 2.02, especially when performed in the 18-29 age group and during the 2 years after appendicectomy. Conversely, appendicectomy was protective against UC, with a HR of 0.39. The authors hypothesise that appendicectomy in younger adults may result in detection of Crohn’s disease and confirm the previous findings of a protective effect of appendicectomy in future development of UC.

Finally, we switch to Frontline Gastroenterology for an original look at the role intestinal ultrasound (IUS). Luber and colleagues reviewed the use of IUS as a potential replacement for endoscopy and MRE, using predefined criteria for IUS use in patients with IBD. From the procedures reviewed, 73 of 260 lower GI endoscopies (28.1%) and 58 of 105 MREs (55.2%) met the criteria for IUS suitability. They determined from these cases no significant pathology would have been missed had IUS been performed in preference to the actual procedure. They also determined that if these criteria for IUS had been performed there would have been a saving of over £0.5m over the year. The authors conclude that IUS has a significant role and is a safe and cost-effective tool in IBD management.

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