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Fiske HW, Ward C, Shah SA, Holubar SD, Al-Bawardy B, Barnes EL, Binion D, Bohm M, Brand M, Clarke K, Cohen BL, Cross RK, Dueker J, Engels M, Farraye FA, Fine S, Forster E, Gaidos J, Ginsburg P, Goyal A, Hanson J, Herfath H, Hull T, Kelly CR, Lazarev M, Levy LC, Melia J, Philpott J, Qazi T, Siegel CA, Watson A, Wexner SD, Williams ED, Regueiro M. Clinical Decision Making in Inflammatory Bowel Disease Mimics: Practice Management from Inflammatory Bowel Disease LIVE. Crohns Colitis 360 2024; 6:otae022. [PMID: 38720935 PMCID: PMC11078036 DOI: 10.1093/crocol/otae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Indexed: 05/12/2024] Open
Abstract
Background Since 2009, inflammatory bowel disease (IBD) specialists have utilized "IBD LIVE," a weekly live video conference with a global audience, to discuss the multidisciplinary management of their most challenging cases. While most cases presented were confirmed IBD, a substantial number were diseases that mimic IBD. We have categorized all IBD LIVE cases and identified "IBD-mimics" with consequent clinical management implications. Methods Cases have been recorded/archived since May 2018; we reviewed all 371 cases from May 2018-February 2023. IBD-mimics were analyzed/categorized according to their diagnostic and therapeutic workup. Results Confirmed IBD cases made up 82.5% (306/371; 193 Crohn's disease, 107 ulcerative colitis, and 6 IBD-unclassified). Sixty-five (17.5%) cases were found to be mimics, most commonly medication-induced (n = 8) or vasculitis (n = 7). The evaluations that ultimately resulted in correct diagnosis included additional endoscopic biopsies (n = 13, 21%), surgical exploration/pathology (n = 10, 16.5%), biopsies from outside the GI tract (n = 10, 16.5%), genetic/laboratory testing (n = 8, 13%), extensive review of patient history (n = 8, 13%), imaging (n = 5, 8%), balloon enteroscopy (n = 5, 8%), and capsule endoscopy (n = 2, 3%). Twenty-five patients (25/65, 38%) were treated with biologics for presumed IBD, 5 of whom subsequently experienced adverse events requiring discontinuation of the biologic. Many patients were prescribed steroids, azathioprine, mercaptopurine, or methotrexate, and 3 were trialed on tofacitinib. Conclusions The diverse presentation of IBD and IBD-mimics necessitates periodic consideration of the differential diagnosis, and reassessment of treatment in presumed IBD patients without appropriate clinical response. The substantial differences and often conflicting treatment approaches to IBD versus IBD-mimics directly impact the quality and cost of patient care.
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Affiliation(s)
- Hannah W Fiske
- Department of Internal Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Christopher Ward
- Division of Gastroenterology, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Samir A Shah
- Gastroenterology Associates Inc., The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Stefan D Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Badr Al-Bawardy
- Division of Gastroenterology, Yale School of Medicine, New Haven, CT, USA
- Division of Gastroenterology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - David Binion
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Matthew Bohm
- Division of Gastroenterology, Indiana University School of Medicine, Carmel, IN, USA
| | - Myron Brand
- Division of Gastroenterology, Yale School of Medicine, New Haven, CT, USA
| | - Kofi Clarke
- Division of Gastroenterology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Raymond K Cross
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jeffrey Dueker
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael Engels
- Division of Gastroenterology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Sean Fine
- Division of Gastroenterology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Erin Forster
- Division of Gastroenterology, Medical University of South Carolina, Charleston, SC, USA
| | - Jill Gaidos
- Division of Gastroenterology, Yale School of Medicine, New Haven, CT, USA
| | - Philip Ginsburg
- Division of Gastroenterology, Yale School of Medicine, New Haven, CT, USA
| | - Alka Goyal
- Department of Pediatric Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA
| | - John Hanson
- Division of Gastroenterology and Hepatology, Atrium Health, Charlotte, NC, USA
| | - Hans Herfath
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Tracy Hull
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Colleen R Kelly
- Division of Gastroenterology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Mark Lazarev
- Division of Gastroenterology, Johns Hopkins Medical Center, Baltimore, MD, USA
| | - L Campbell Levy
- Center for Digestive Health, Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Joanna Melia
- Division of Gastroenterology, Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Taha Qazi
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Corey A Siegel
- Center for Digestive Health, Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Andrew Watson
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Emmanuelle D Williams
- Division of Gastroenterology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA
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Reinisch W, Bressler B, Curtis R, Parikh A, Yang H, Rosario M, Røseth A, Danese S, Feagan B, Sands BE, Ginsburg P, Dassopoulos T, Lewis J, Xu J, Wyant T. Fecal Calprotectin Responses Following Induction Therapy With Vedolizumab in Moderate to Severe Ulcerative Colitis: A Post Hoc Analysis of GEMINI 1. Inflamm Bowel Dis 2019; 25:803-810. [PMID: 30295811 PMCID: PMC6416826 DOI: 10.1093/ibd/izy304] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND In patients with ulcerative colitis (UC), fecal calprotectin (FC) concentrations correlate with endoscopic inflammation evidence. This study investigated the effect of vedolizumab induction on FC concentrations and whether FC concentrations could be a reliable surrogate measure of disease status. METHODS Data from the placebo-controlled, phase 3 trial GEMINI 1 were used to evaluate week-6 relationships between outcomes (including clinical remission, mucosal healing [MH], and endoscopic remission) and both absolute FC concentration values and relative FC concentration changes from baseline (%FC0-6). Sensitivity and specificity were calculated by cross-tabulation; the value of week-6 FC concentration as surrogate biomarker was measured with Youden J statistic computed for various cut points. RESULTS GEMINI 1 induction phase enrolled 895 patients. Fecal calprotectin concentration decreases were deeper in patients with clinical remission, MH, and/or endoscopic remission than in patients without. The best week-6 indicator of clinical or endoscopic remission in this data set was absolute FC concentration ≤150 µg/g. The surrogate biomarker values (based on areas under the curve) for the best-performing cut points (FC0-6 reduction >90%, FC ≤150 µg/g) were fair (range, 0.70-0.77, total population). More patients met the ≤150 µg/g cut point with vedolizumab than with placebo. Baseline FC concentrations were not correlated with clinical outcomes. CONCLUSIONS Fecal calprotectin concentration reductions were greater with vedolizumab induction than with placebo. Week-6 FC concentrations had only fair surrogate biomarker value for endoscopic status. Our data suggest that, while FC may reflect inflammatory burden, FC concentration after vedolizumab induction may not be a robust biomarker of mucosal inflammation.
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Affiliation(s)
- Walter Reinisch
- Medical University of Vienna, Vienna, Austria,Address correspondence to: Walter Reinisch, MD, Department of Gastroenterology and Hepatology, Medical University of Vienna, Währinger Gürtel 18–20, 1090 Vienna, Austria. E-mail:
| | | | | | - Asit Parikh
- Takeda Pharmaceuticals, Cambridge, Massachusetts, USA
| | - Huyuan Yang
- Takeda Pharmaceuticals, Cambridge, Massachusetts, USA
| | - Maria Rosario
- Takeda Pharmaceuticals, Cambridge, Massachusetts, USA
| | | | | | - Brian Feagan
- Robarts Clinical Trials, Robarts Research Institute, and the University of Western Ontario, London, Ontario, Canada
| | - Bruce E Sands
- Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Philip Ginsburg
- Frank H Netter MD School of Medicine, Quinnipiac University, Hamden, Connecticut, USA
| | | | - James Lewis
- Center for Clinical Epidemiology and Biostatistics Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jing Xu
- Takeda Pharmaceuticals, Cambridge, Massachusetts, USA
| | - Tim Wyant
- Curis, Inc., Lexington, Massachusetts, USA
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Jacene HA, Ginsburg P, Kwon J, Nguyen GC, Montgomery EA, Bayless TM, Wahl RL. Prediction of the need for surgical intervention in obstructive Crohn's disease by 18F-FDG PET/CT. J Nucl Med 2009; 50:1751-9. [PMID: 19837758 DOI: 10.2967/jnumed.109.065466] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
UNLABELLED We preoperatively determined the accuracy of (18)F-FDG PET/CT for differentiating fixed muscle hypertrophy and fibrotic stenoses from acute transmural inflammatory stenoses in patients with Crohn's disease (CD) scheduled to undergo surgical resection for obstructive symptoms. METHODS Seventeen patients with known CD prospectively underwent (18)F-FDG PET/CT before already-planned surgery for obstructive symptoms. Image interpretation was by consensus of 2 readers with knowledge of patient participation in the study but not of other clinical history. Lesions were qualitatively graded on a 5-point scale for the presence of increased (18)F-FDG uptake consistent with active inflammation. Maximum lean standardized uptake value (SUL(max)) was determined for lesions scored 1 or more. Imaging results were compared with the pathologic grading of inflammation and predominant histopathologic subtype for each patient's surgical specimen, whether mainly inflammation, fibrosis, or muscle hypertrophy. RESULTS Thirteen of the 17 patients underwent surgery (median, 28 d after PET/CT; range, 2-148 d), and 12 of these 13 had histopathologic correlation. Despite the predominant histopathologic subtype (inflammation, 5; fibrosis, 4; and muscle hypertrophy, 3), acute and chronic inflammation, fibrosis (median, 50%; range, 40%-90%), and muscle hypertrophy (median, 20-fold thickening; range, 9- to 40-fold thickening) were found in all patients. SUL(max) was significantly higher in severe than in mild-to-moderate chronic inflammation (8.2 +/- 2.8 vs. 4.7 +/- 2.5, P = 0.04). No patient with predominantly fibrosis or muscle hypertrophy (n = 7) had an SUL(max) greater than 8. Visually, 10 of 12 patients on PET/CT were considered to have active inflammation of the bowel. CONCLUSION Patients with CD who undergo surgery for obstructive symptoms have histopathologically mixed findings of inflammation, fibrosis, and muscle hypertrophy. Qualitative PET interpretations were quite sensitive, but additional semiquantitative analyses using SUL(max) helped identify patients with active inflammation. This information may be beneficial for referring gastroenterologists considering medical therapy versus surgery for patients with CD who present with obstructive symptoms.
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Affiliation(s)
- Heather A Jacene
- Division of Nuclear Medicine, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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