Diagnostic Work-up for a Patient With Symptoms of IBD

Joseph Feuerstein, MD: We’d like to start with a patient case presentation. We have a 24-year-old woman who presents with 6 months of abdominal pain, a 20-pound weight loss, and an increase in bowel movements. She’s having 7 nonbloody bowel movements during the day, and she often wakes up at night with urgency in having to run to the bathroom again. She has occasional nausea and vomiting. Fasting seems to improve her symptoms.

We’d like to poll the audience with some questions about this case. What is this patient suffering from? A) cancer; B) irritable bowel syndrome; C) anorexia nervosa; D) celiac disease; E) Crohn’s disease; or F) ulcerative colitis?

What would be your test of choice? A) CT scan; B) MRI; C) colonoscopy; or D) sigmoidoscopy? Dr Hanauer, with this interesting presentation of this patient who’s having increased bowel movements, abdominal pain, and some systemic symptoms, how would you initially work this patient up?

Stephen B. Hanauer, MD: As I mentioned earlier, we’re looking for red-flag symptoms or aspects that would be associated with inflammation, and she certainly has these. She has progressive symptoms associated with weight loss and nocturnal bowel movements, which would be very uncommon in patients who have irritable bowel syndrome. Likewise, the abdominal pain is less likely going to be present in patients who have celiac disease, who are more commonly going to present with diarrhea. The fact that she’s not having bloody bowel movements despite these pretty severe symptoms makes me think against ulcerative colitis and more likely the setting of Crohn’s disease. That would lead to additional diagnostic testing.

Joseph Feuerstein, MD: Thank you. Dr Ungaro, when thinking about this patient, what initial tests would you consider doing? What would be your final test of choice in working this patient up?

Ryan Ungaro, MD: As we alluded to before, in all these cases, you want to rule out infection. Although in this case, she’s beyond just a regular enteric infection. But it’s always important to have that initial set of stool studies. Because we’re highly suspicious that there’s some inflammatory condition of the bowel, possibly IBD [inflammatory bowel disease], whether it’s Crohn’s or ulcerative colitis, I’d go for a colonoscopy and cross-sectional imaging. I’d probably do MR [magnetic resonance] enterography or CT enterography plus a colonoscopy to get a diagnosis of the tissue biopsy and also get a full evaluation of the true extent of the disease and evaluate for any potential complications.

When patients are having lots of weight loss and other systemic symptoms, you want to make sure there are no strictures, fistulas, or potential abscesses if they’re having fevers in addition to their other symptoms. A full evaluation would require both the colonoscopy and the MRI. Although for the purposes of the multiple-choice question here, I’d probably want to go for colonoscopy, where you’re also going to get tissue to cinch that diagnosis.

Joseph Feuerstein, MD: That’s great. Thank you. Dr Sands, when thinking about this patient, what factors would be most important to consider when choosing a therapeutic agent?

Bruce E. Sands, MD: This patient is fairly sick. Assuming that the diagnosis is indeed Crohn’s disease, you have a number of options. The things you’ll end up considering are of course the efficacy and safety, the convenience to the patient, and access to the treatment. Hopefully most patients will be insured, because many of the treatments we use are of considerable cost. All those factors play a role.

Fortunately, we have many agents—many more than we had even 20 years ago—that are effective, work quickly, and can work in more severe disease, such as this patient has based on her weight loss and remarkable symptoms. These include broad categories of biologic agents such as anti–TNF [tumor necrosis factor] antibodies; other newer biologic agents, such as vedolizumab and ustekinumab; and also older agents such as methotrexate, which has a steroid-sparing role, and mercaptopurine and azathioprine, which are immune modulators in the class of thiopurines. Although we’ve tended to move away from those because they don’t have wonderful safety profiles, they’re adequate safety profiles, and we used them for many years. But the biologic agents prove to be probably safer.

Transcript edited for clarity.