Welcome

Methodology• Voting was conducted anonymously at all times.

• The first vote was conducted by the entire Consensus Group electronically by email.• Relevant literature was then made available on a secured web site• for review by all voters. Modification of first round votes after• access to the literature, if required, constituted the second round of• voting.

• A face-to-face meeting of the entire Consensus Group was• then held to discuss any suggested modifications to the wording of• the statements and to discuss openly the evidence for and against• each specific statement. A third vote was held thereafter.

• Statements that could not reach consensus were discussed and modified• or rejected. Each statement was graded to indicate the level of• evidence available and the strength of recommendation by using• the Canadian Task Force on the Periodic Health Examination

Invited countries

• Australia• Hong Kong• India• Japan• Malaysia• New Zealand• Philippines• Singapore

• Sri Lanka• Taiwan• Thailand• Vietnam• South Korea

Definition and Diagnosis

CJ Ooi

Muhammad Radzi

Vineet Ahuja

Statement 1

• The diagnosis of Crohn’s disease is based on a combination of clinical, endoscopic and histological features and the exclusion of an infectious etiology

Statement 1The issue remains that no gold standard test exists for the diagnosis of IBD.

Until such time as highly specific and sensitive diagnostic tests for IBD are devised, distinguishing among various forms of intestinal inflammation of idiopathic and identifiable causes will remain a test of clinical acumen, drawing on relevant history, attentive physical examination, judicious laboratory testing, and detailed review

Sands BE. From symptom to diagnosis: clinical distinctions among various forms of intestinal inflammation. Gastroenterology 2004;126(6):1518–32

Statement 1As there is no single way to diagnose CD, many have defined macroscopic and microscopic criteria to establish the diagnosis.

The macroscopic diagnostic tools include physical examination,endoscopy, radiology, and examination of an operativespecimen.

Microscopic features can be only partly assessedon mucosal biopsy, but completely assessed on an operativespecimen. The diagnosis depends on the finding of discontinuousand often granulomatous intestinal inflammation.

Lennard-Jones JE, Shivananda S. Clinical uniformity of inflammatorybowel disease a presentation and during the first yearof disease in the north and south of Europe. EC-IBD StudyGroup. Eur J Gastroenterol Hepatol 1997;9(4):353–9.

Statement 1

CD is a heterogeneous entity comprising a variety ofcomplex phenotypes in terms of age of onset, diseaselocation and disease behaviour.

Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN,Brant SR, et al. Toward an integrated clinical, molecular andserological classification of inflammatory bowel disease:Report of a Working Party of the 2005 Montreal World Congressof Gastroenterology. Can J Gastroenterol 2005;19(Suppl A):5–36.

Statement 1

The current view is that the diagnosis is established by a nonstrictly defined combination of clinical presentation, endoscopic appearance, radiology, histology, surgical findingsand, more recently, serology

ECCO Guidelines 2010

Voting from Round 2

Comments

• May not need all if the evidence is obvious• Because not only infectious enteritis, but also lymphoma,

Behcet disease and other vasculitis should be excluded.• Add "Radiological" (in addition to clinical, endoscopic

and histological). • Yes accepted as there is no other gold standard

available• exclusion of infection is very relevant in some countries

in this region• Exclusion of infectious etiology not always alone in

Australia• What about radiological, especially when dealing with

small bowel?

Proposed amendment (if any)

• The diagnosis of Crohn’s disease is based on a combination of clinical, endoscopic, radiological and histological features and, where appropriate, the exclusion of an infectious etiology

Statement 1

Level of agreement: a- %b- %c- %d- %e- %

Quality of evidence: III

Classification of recommendation: C

Statement 2

• Ileo-colonoscopy should be done routinely in all cases. During ileo-colonosopy, multiple biopsies from five sites in the colon and terminal ileum should be taken

Statement 2

Colonoscopy with multiple biopsy specimens is wellestablished as the first line procedure for diagnosingcolitis.

Coremans G, Rutgeerts P, Geboes K, Van den Oord J, Ponette E,Vantrappen G. The value of ileoscopy with biopsy in thediagnosis of intestinal Crohn's disease. Gastrointest Endosc1984;30(3):167–72.

Statement 2Ileoscopy with biopsy can be achieved with practicein at least 85% of colonoscopies and increases the diagnostic yield of CD in patients presenting with symptoms of IBD.

Coremans G, Rutgeerts P, Geboes K, Van den Oord J, Ponette E,Vantrappen G. The value of ileoscopy with biopsy in thediagnosis of intestinal Crohn's disease. Gastrointest Endosc1984;30(3):167–72.

Geboes K, Ectors N, D'Haens G, Rutgeerts P. Is ileoscopy withbiopsy worthwhile in patients presenting with symptoms ofinflammatory bowel disease? Am J Gastroenterol 1998;93(2):201–6.

Cherian S, Singh P. Is routine ileoscopy useful? An observationalstudy of procedure times, diagnostic yield, and learning curve.Am J Gastroenterol 2004;99(12):2324–9

Allez M, Lemann M, Bonnet J, Cattan P, Jian R, Modigliani R.Long term outcome of patients with active Crohn's disease exhibiting extensive and deep ulcerations at colonoscopy. AmJ Gastroenterol 2002;97(4):947–53.

Statement 2

• Number of biopsies

• Areas of biopsies – involved and uninvolved

Voting

Comments• Agree that ileocolonoscopy should be performed in all cases but disagree

with 5 sites being required.• Definitely ileoscopy should be done but number of biopsies is subjected to

debate• Ileocolonoscopy is the preferred investigation. Why 5 sites? • It depends on the location of the CD• "Five" need evidence.• "Ileocolonoscopy is important, however the evidence of necessity of multiple

biopsies from 5 sites is insufficient.• Often, granuloma is negative, but we can diagnose CD by typical

endoscopic findings, other modalities, and clinical manifestations. "• In case of normal colon is it still essential to take biopsies from 5

segments ? That issue needs to be resolved • Endoscopy cannot perform in all CD patients. Endoscopy is suitable for non-

stricture type CD patients. Furthermore, the targeted biopsy from active mucosal lesions is preferable.

• Why limit to five and should able that even in patients with normal endoscopy

Proposed amendment (if any)

• Ileo-colonoscopy is the preferred diagnostic investigation. During ileo-colonosopy, multiple biopsies from at least five sites in the colon and terminal ileum should be taken and include endoscopically normal and abnormal areas.

Statement 2

Level of agreement: a- %b- %c- %d- %e- %

Quality of evidence: III

Classification of recommendation: C

Statement 3

• Biopsies for mycobacterial studies should be taken from patients living in TB endemic countries

Statement 3

Microbiological features n (%)

CharacteristicsCD GITB

P value

(n = 26)

(n = 26)

AFB smear/culture positivity

0 (0)6 (23.1)

S

TB PCR positivity 0 (0)17 (65.4)

S

Amarapurkar DN, Patel ND, Rane PS. Diagnosis of Crohn's disease in Indiawhere tuberculosis is widely prevalent. World J Gastroenterol. 2008 Feb7;14(5):741-6

Interpreted as IBD by pathologist 10 (38.4) 3(11.5) S

Interpreted as TB by pathologist 0 (0) 13 (50) S

Voting

Comments• I am unsure how useful these studies are - would like to know

sensitivity and specificity• May add PCR study if needed in a very high suspicion• what type of tests, TB PCR, TB Culture, TB spot • Mycobacterial study should be specified.• However if only PCR for MTB is positive , that is not by itself a stand

alone diagnostic test for Intestinal tuberculosis• Typical TB enterocolitis can be diagnosed by endoscopic findings,

and PPD and TB-interferon gamma test should be done in such patients.

• Best practice. evidence found.• Cultures are impractical; PCR may not be always available and non-

specific

Proposed amendment (if any)

• Biopsies for Mycobacterium tuberculosis should be taken from patients living in TB endemic countries

Statement 3

Level of agreement: a- %b- %c- %d- %e- %

Quality of evidence: III

Classification of recommendation:C

Statement 4

• In Crohn’s disease, CT or MR enterocyclis is the preferred investigation of choice in evaluating small bowel disease. It should be done routinely in all patients undergoing workup for Crohn’s disease

Statement 4

CT and MR techniques can establish diseaseextension and activity based on wall thickness and increasedintravenous contrast enhancement. The magnitude of thesechanges, along with presence of edema and ulcerations allowcategorization of disease severity. These are the current standards for assessing the small intestine.

Koh DM, Miao Y, Chinn RJ, Amin Z, Zeegen R, Westaby D, et al.MR imaging evaluation of the activity of Crohn's disease. AJRAm J Roentgenol 2001;177(6):1325–32

Wold PB, Fletcher JG, Johnson CD, Sandborn WJ. Assessment ofsmall bowel Crohn disease: noninvasive peroral CT enterographycompared with other imaging methods and endoscopy–feasibility study. Radiology 2003;229(1):275–81

Statement 4

CT and MR have a similar diagnostic accuracy for thedetection of small intestine inflammatory lesions.

Horsthuis K, Bipat S, Bennink RJ, Stoker J. Inflammatory boweldisease diagnosed with US, MR, scintigraphy, and CT: metaanalysisof prospective studies. Radiology 2008;247(1):64–79

Schmidt S, Lepori D, Meuwly JY, Duvoisin B, Meuli R, Michetti P,et al. Prospective comparison of MR enteroclysis with multidetectorspiral-CT enteroclysis: interobserver agreement andsensitivity by means of "sign-by-sign" correlation. Eur Radiol2003;13(6):1303–11

Statement 4

CT is more readily available and less time-consuming than MR. However, the radiation burden from CT is appreciable.

Brenner DJ, Hall EJ. Computed tomography–an increasingsource of radiation exposure. N Engl J Med 2007;357(22):2277–84.

Voting

Comments• CT and MRI are not required in all patients. there are good data showing that small

bowel disease is seldom found in those without symptoms. Diagnostic medial radiation should be minimised so no to ct. Capsule endosopy can also be performed here and is probably more sensitive

• Patient who have a NEGATIVE ileocolonoscopy should undergo either balloon assisted enteroscopy or capsule endoscopy. CT/MRI enteroclysis may not pick up early lesions and cannot provide histology. On other hand, CT/MRI has the the advantage of identifying fistulas and ruling out coexisting abscesses.

• Cost effectiveness in each individual country may be different• Unnecessary in most cases. Exposure to radiation is not healthy and most sites would

not have easy MRI access. • Comparison between CT/MR?• Small intestinal series (enteroclysis or Barium X-ray) by experts is also useful as well as

CT or MRI.• These tools are useful, but their use should be combined with endoscopic examinations.

• not routinely done, only in patients with suggestive symptoms of small bowel

involvement• 2nd part not done in all patients• Should we mention availability. "should be routinely done, if available, in all patients"?

And, what about if not available, should we mention an alternative such as small bowel barium studies (Barium Enteroclysis).

Proposed amendment (if any)

• Evaluation for small bowel disease should be considered in patients with CD.

• CT or MR enterography/enterocylsis is the preferred investigation.

Statement 4

Level of agreement: a- %b- %c- %d- %e- %

Quality of evidence: II-2

Classification of recommendation: B