IBD: Clinical Manifestations and an Accurate Diagnosis

Stephen Hanauer, MD: We certainly jumped right into the complexities of the evolution, particularly in the young kids. But I think your emphasis is that IBD [inflammatory bowel disease], whether it’s ulcerative colitis [UC] or Crohn disease, is a systemic disease. It’s not limited to the gut. In adults or at any age, it can also affect the joints with inflammation. There are numerous skin manifestations that could be complications; ocular inflammation, either related or unrelated to the underlying inflammatory process; liver disease, and sclerosing cholangitis as a potential complication. Then there are a lot of uncommon manifestations. There can be lung manifestations, kidney manifestations that tend to be rare. We really see these diseases as not just involving the gut but also having systemic aspects. But that also makes it challenging to assess severity. For instance in kids, as you mentioned, growth is a significant component of severity. How do we assess patients to designate where we want to insert therapies?

Marla Dubinsky, MD: As you were talking, and I was thinking about disease location and how it presents differently depending on age, I also began to think, should we be thinking about therapies based on which drugs work better in small bowel inflammation vs which drugs work better in large bowel inflammation? The whole construct of Crohn disease vs UC is probably archaic because we have a whole UC-like Crohn concept. When we started studying some of the serologies, we figured out that there was some overlap. And even when you look at the genetic overlap, for a lot of genes, they overlap between Crohn disease and UC. So even that construct, it’s difficult to separate them into 2 buckets when we know there’s a spectrum of biology. I did want to state that. I start thinking about which therapies fit based on disease location. 

Stephen Hanauer, MD: You don’t get hung up with the classification of ulcerative colitis versus Crohn disease.

Marla Dubinsky, MD: No, I’m focused on disease location. Which drugs do I know have better mucosal healing properties? And we’ll get into the targets in just a minute. I’m sure you’re going to ask me which target I go after. But I think about how these therapies fit much better, and the data we have on mucosal outcomes is better here vs there. Disease location, for me, dominates my choice. Disease severity dominates my choice. My fellows will laugh because they’ll come out of the room and they know, they’ll say, this person “earned infliximab,” for example. I have my categories, the bubble in my head saying, “Does this patient earn infliximab?” And if the answer is yes, we go in and we discuss how we’re going to optimize it, and that’s usually based on severity and speed. That’s my concept that goes into choice. Now I say infliximab is always on the table, but if they’re not earning it, then I’ve got a lot of options to talk about.

Transcript Edited for Clarity