This lecture is about Case Based Approach to CD

1. A Case-Based Approach
To A Patient With IBD
Prof. Mohamed-Naguib Wifi
Professor of Medicine and Hepatogastroenterology
Cairo University

2. Agenda
Case # 1

3. CASE # 1
Mona,
22 years

4. Mona: The Case Of A 22 Years Old Girl
 She came to you complaining of a 6
weeks H/O 4-5 non-bloody loose
motions/ day, partially stopped by
loperamide, along with recurrent
right lower quadrant abdominal
pains.
 She lost 8 kilograms without any
intention of weight loss.
 Mona is suffering from fatigue and
effortlessness.
 She also mentioned having bilateral
knee and ankle pains.

5. Complete the history….
 Not smoking
 Not drinking alcohol
 Not overusing NSAIDs
 No history of travelling abroad
 No history of prolonged hospital stay
 No history of previous major surgery
 No history of skin lesions, eye affection
 Normal menstrual history
 No history of similar condition in her family

6. On Examination
 BP: 100/70, HR: 100 bpm
 Temp.: 37.8oC
 Pallor
 Few aphthous oral ulcers
 Tender abdomen with
especially over her right
iliac fossa.
 No joint effusions.

7. What Do You Think Of?
 Gastroenteritis?
 Irritable Bowel Disease?
 Inflammatory Bowel Disease?
 Something else?
 Behcet’s Disease?
 Cancer?
 Appendicitis?
 Tuberculosis?
 Ovarian?
 ‫ممكن؟؟‬ ‫تانية‬ ‫حاجة‬

8. So What Will You Ask For?

9. 1st Visit Investigations
 CBC
 ESR, CRP
 Thyroid Profile
 Electrolytes
 FBS, A1c
 Kidney Functions
 Liver Functions
 Stool analysis + C&S

10. Results
 Hb: 10.1 gm/dL.
 Hct: 32
 ESR 1st Hr: 30
 CRP: 35
 Stool: RBCs 20-30/hpf, undigested food ++, C&S: free
 ALT: 22 Iu/ dL, AST: 19 Iu/dL, ALP 122 Iu/dL, S. Alb 4.5
gm/dL, Bil. T 0.9 mg/dL
 Urea: 20 mg/dL, Creat. 0.9 mg/dL.
 TSH 1.1 mU/l
 FBS 88 mg/dL, A1c 6.1
 Na 140 mEq/L, K 4.1 mmol/L, Calcium 8.8 mg/dL.

12. Other Investigations?
 Abdominal Imaging?
 US
 X-Ray
 CT or MRI
 Other specific Labs?
 Fecal Calprotectin/ Lactoferrin
 ANCA
 ASCA
 Others:
 Outer membrane porin protein C (OmpC) to Escherichia coli
 The nucleotide-binding oligomerization domain 2 (NOD2) gene

13. Or Go To Endoscopy?

15. Colonoscopy

17. Terminal Ileum

21. CDAI
 The Crohn's Disease Activity Index or CDAI is a
research tool used to quantify the symptoms of
patients with Crohn's disease.
 Useful to determine medications.
 Useful to define response or remission of disease.
 Determines quality of life, addressed by the
Inflammatory Bowel Disease Questionnaire (IBDQ)
and other indices of quality of life for patients with
Crohn's disease.

23. Complications*
One point (x20) each is added for each
set of complications:
 The presence of joint pains (arthralgia) or
frank arthritis
 Inflammation of the iris or uveitis
 Presence of erythema nodosum, pyoderma
gangrenosum, or aphthous ulcers
 Anal fissures, fistulae or abscesses
 Other fistulae
 Fever during the previous week

24. You can find it online:
https://www.mdcalc.com
/crohns-disease-activity-
index-cdai
Mona = 377 points, So??

25. Interpretation
 Remission of CD is defined as CDAI
< 150.
 Severe disease was defined as CDAI
> 450.
 Moderate-to-severe 230-400
 Most major research studies on
medications in CD define Response
as a fall of the CDAI of > 70 points.

26. Harvey-Bradshaw index
 The Harvey-Bradshaw index is a simpler version of
the CDAI for data collection purposes.
 It consists of only clinical parameters:
 General well-being (0 = very well, 1 = slightly below average, 2
= poor, 3 = very poor, 4 = terrible)
 Abdominal pain (0 = none, 1 = mild, 2 = moderate, 3 = severe)
 Number of liquid stools per day
 Abdominal mass (0 = none, 1 = dubious, 2 = definite, 3 =
tender)
 Complications, as CDAI, with one point for each.
Remission: HBI score <3 points.
Relapse: HBI score >7 points.

27. World Congress of Gastroenterology
Classification of CD

28. Revised Montreal (Disease Modifiers)
Mona = A2L1B1

29. What About The Specific Labs?
CRP
Fecal Calprotectin/ Lactoferrin
ASCA
ANCA
Other markers

30. CRP
 C-reactive protein appears to be an accurate marker
of CD activity.
 CRP level is increased in most patients with active
disease and may correlate with CDAI score.
 A low CRP level may be useful to predict inactive CD,
whereas a very high CRP level may predict
progression to fibrostenotic disease.
 However, up to 50% of patients with CD might not
have an elevated CRP level, despite documented
active inflammation.

31. Fecal Calprotectin/ Lactoferrin
 Fecal calprotectin and lactoferrin are markers of
inflammation that correlate with endoscopic remession
and disease activity (mild, moderate and severe).
 The cut-off level for fCal of 155 mcg/g appears to be ideal
for the noninvasive assessment of inflammatory activity
as it presents with good sensitivity (96%), a diagnostic
accuracy of endoscopic activity of (78%), and a significant
negative predictor value.
 Values above 1009 mcg/g and, specifically those over
1473 mcg/g, are indicative of intestinal inflammatory
activity in CD.
 The value of 1128 mcg / g correlates with moderate to
severe endoscopic activity

32. ASCA, ANCA, Others
 Antibodies against Saccharomyces cerevisiae (ASCA) are the
most thoroughly studied markers and have a sensitivity of
60% for CD, associated with severe disease and need for
surgery.
 Perinuclear antineutrophil cytoplasmic antibodies (pANCA)
have a sensitivity of 40–60% for ulcerative colitis.
 Outer membrane porin protein C (OmpC) to Escherichia coli
has a sensitivity of 20–40% for CD, usually associated with
fibrostenosis, perforating disease, and the need for small-
bowel surgery.
 The nucleotide-binding oligomerization domain 2 (NOD2)
gene has been associated with fibrostenosing CD.

34. Updated Management of CD
In September 2019, the British Society of
Gastroenterology (BSG) released consensus
guidelines on the management of inflammatory
bowel disease.

35. Updated Management of CD
In November 2019, the European Crohn's and
Colitis Organisation (ECCO) published separate
guidelines on the medical and surgical
management of Crohn disease.

36. BSG Recommendations
 For remission-induction treatment for mild-to-
moderate ileocecal CD, the recommended therapy is
ileal-release budesonide at 9 mg once daily for 8
weeks.
 For remission-induction treatment for mild-to-
moderate Crohn colitis, the recommended therapy is
an 8-week course of systemic corticosteroids.
 For moderate-to-severe uncomplicated luminal
ileocolonic Crohn disease, the recommended
treatment is systemic corticosteroids initially, but if
patients have extensive disease or other poor prognostic
features, consideration should be given to early
introduction of biological therapy.

37. BSG Recommendations
 The suggested surgical treatment for localized
ileocecal CD in patients:
 (1) in whom initial medical therapy failed
 (2) who relapsed after initial medical therapy
 (3) who prefer surgery over continued medical treatment is
laparoscopic resection.
 Avoid systemic or locally acting corticosteroids for
maintenance treatment in ileocolonic CD,
owing to toxicity and lack of efficacy.

38. BSG Recommendations
 For moderate-to-severe CD that is responsive to
prednisolone, consider early introduction of
maintenance therapy with thiopurines or
methotrexate in order to minimize the risk of
disease flare when prednisolone is withdrawn.
 Mesalazine is not recommended for induction
or maintenance of remission in CD.

39. BSG Recommendations
 Biologic therapy is recommended in patients
with disease refractory to immune-
modulator therapy despite dose optimization.
 Considerations in the drug choice (ie, anti–
tumor necrosis factor therapy, ustekinumab,
vedolizumab) include patient preference, cost,
likelihood of adherence, safety data, and
response speed to the drug.

40. ECCO Recommendations
 Induction of Remission
Mild-to-moderate disease
 Budesonide is recommended for the induction of
clinical remission in patients with active mild-to-
moderate CD limited to the ileum and/or ascending
colon (strong recommendation).
 ECCO suggests against using 5-aminosalicylic
acid (5-ASA) for induction of remission of CD (weak
recommendation).

41. ECCO Recommendations
 Induction of Remission
Moderate-to-severe disease
 In patients with active, moderate-to-severe CD, ECCO
suggests using systemic corticosteroids for the
induction of clinical response and remission (weak
recommendation).
 The use of Biologic Therapy e.g. tumor necrosis factor
(TNF) inhibitors [infliximab, adalimumab, and
certolizumab pegol] is recommended to induce
remission in patients with moderate-to-severe CD
refractory to conventional therapy (strong
recommendation).

42. ECCO Recommendations
 ECCO suggests against the use of thiopurines
as monotherapy for the induction of remission of
moderate-to-severe luminal (weak
recommendation).
 ECCO also suggests against the combination of
adalimumab and thiopurines over
adalimumab alone to achieve clinical remission
and response (weak recommendation).
 Combination therapy with a thiopurine is
recommended when starting infliximab to
induce remission in patients with moderate-to-
severe CD, who have had an inadequate response to
conventional therapy (strong recommendation).

43. ECCO Recommendations
 Ustekinumab or Vedolizumab is
recommended for induction of remission in
patients with moderate-to-severe CD with
inadequate response to conventional therapy
and/or to anti-TNF therapy (strong
recommendation).
 ECCO equally suggests the use of either
ustekinumab or vedolizumab for the treatment
of moderate-to-severe active luminal CD in
patients with previously failed anti-TNF
therapy (weak recommendation).

45. In A Capsule
 IBD is an everyday practice, Every story is unique and
treatment should be tailored after thorough steps of assessing
severity and extent of disease.
 Clinical, Laboratory, Endoscopic and sometimes imaging
techniques integrate to make the whole picture of the puzzle.
 Deep mucosal healing is preferred to the mere control of
symptoms to prevent complications and need for surgery.
 There are many treatment options and plenty of
recommendations according to different studies, scientific
societies and patients’ response to treatment.
 Biologic therapies are one available option, optimization and
their proper usage and monitoring is an art.

48. THANK YOU