IBD: Evaluating Severity and Extent of Disease

Joseph Feuerstein, MD: As we know, inflammatory bowel disease is a chronic immune-mediated disease process that can be a progressive process and cause relapsing flares. Dr Ungaro, could you discuss the common clinical manifestations of ulcerative colitis based on disease location and severity? What objective ways do you assess the disease activity?

Ryan Ungaro, MD: In ulcerative colitis, the most prominent symptoms typically are rectal bleeding—blood in the stool, diarrhea, and increased frequency of bowel movements. It can range from just blood in the stool and a few increased bowel movements per day with patients who have a more mild disease, to patients who are very severe and going to the bathroom 10-plus times a day. They’re having abdominal pain. They’re having more systemic symptoms like fevers, chills, and fatigue. There are other symptoms that can be common, particularly in patients where there’s more limited disease or the rectum is very inflamed. If you have inflammation in just the lower part of the colon in the rectum, by which we refer to as proctitis, those patients can often manifest primarily with a lot of urgency, having to rush to the bathroom, or tenesmus, which is a sensation of incomplete evacuation. It can run the gamut, but typically all have bloody diarrhea, and it can range in the number of times a day they’re going. The more severe patients also have more systemic symptoms.

In terms of evaluating how severe the disease is, this is done on a combination of subjective and objective metrics. No. 1 is the patient symptoms where you have the number of times they’re going to the bathroom and whether they’re seeing blood. We want to pair that with objective assessments because sometimes the symptoms can be a little deceiving. With that we’re looking at not only blood-in-stool markers of inflammation like CRP [C-reactive protein], ESR [erythrocyte sedimentation rate], and fecal calprotectin, but we’re also leaning on the endoscopic appearance of the disease and doing a sigmoidoscopy or colonoscopy and grading the inflammation on endoscopy and how severe it is. If someone has milder disease and just some erythema, that’s very important to note vs a more severe case where they could have deep serpiginous or punched-out ulcerations.

Joseph Feuerstein, MD: Thank you. That was great. Dr Sands, if I could ask you the same question with regard to Crohn’s disease, how do you make that assessment?

Bruce E. Sands, MD: Patients with Crohn’s disease will generally have diarrhea or abdominal pain as the main symptomatic manifestations. They, too, can have a myriad of extraintestinal manifestations that can be very prominent. Fatigue is very common in Crohn’s disease and ulcerative colitis and doesn’t even necessarily improve with treatment. More typically, you’ll see arthralgias. You may see skin manifestations, the classic ones being erythema nodosum or pyoderma gangrenosum, inflammatory eye manifestations, and mouth sores. You may see all these symptoms. But because it’s a pen-and-care condition, the evaluation is a little different. Ileal colonoscopy is very helpful in evaluating the extent and severity of the disease. In addition, cross-sectional imaging takes on greater importance because there are many patients who have purely small bowel disease, so you need a more extensive way of evaluating. Video capsule endoscopy is another way that small-bowel disease can be evaluated. But you have to be careful because, as you heard earlier, some patients develop strictures, and there’s a rate of capsule retention behind strictures, so that’s never really a first modality of evaluation.

Joseph Feuerstein, MD: Thank you. Dr Hanauer, what are the most common extraintestinal manifestations of inflammatory bowel disease?

Stephen B. Hanauer, MD: As Dr Sands just mentioned, the most common extraintestinal manifestations of inflammatory bowel disease are joint involvement, skin involvement, and eye involvement. They can occur in up to 30% of patients who have either ulcerative colitis or Crohn’s disease. We tend to distinguish 2 types of extraintestinal manifestations. One, and most common, are those associated with active inflammation, including arthritis or arthralgias that typically involve the larger joints, which may precede or occur concomitantly with the intestinal inflammation and symptoms.

A second type of arthritic manifestation is known as central arthritis involving the spine. These include ankylosing spondylitis and sacroiliitis. In contrast with peripheral arthritis, these are associated with a genetic type of HLA B27 and more common in patients who are HLA B27–positive. These manifestations don’t necessarily correlate with the intestinal manifestation. Dr Sands already mentioned erythema nodosum and pyoderma gangrenosum, skin manifestations that likewise occur associated with active inflammation of the bowel. In the eye, iritis or uveitis is another HLA B27–associated inflammation. Scleritis can occur associated with active inflammation. They’re quite diverse, and we usually engage a rheumatologist, an ophthalmologist, or sometimes a dermatologist to help us with these distinctions.

Transcript edited for clarity.