Clinical Decision Making in Inflammatory Bowel Disease Mimics: Practice Management from Inflammatory Bowel Disease LIVE

Hannah W Fiske; Christopher Ward; Samir A Shah; Stefan D Holubar; Badr Al-Bawardy; Edward L Barnes; David Binion; Matthew Bohm; Myron Brand; Kofi Clarke; Benjamin L Cohen; Raymond K Cross; Jeffrey Dueker; Michael Engels; Francis A Farraye; Sean Fine; Erin Forster; Jill Gaidos; Philip Ginsburg; Alka Goyal; John Hanson; Hans Herfath; Tracy Hull; Colleen R Kelly; Mark Lazarev; L Campbell Levy; Joanna Melia; Jessica Philpott; Taha Qazi; Corey A Siegel; Andrew Watson; Steven D Wexner; Emmanuelle D Williams; Miguel Regueiro

doi:10.1093/crocol/otae022

Clinical Decision Making in Inflammatory Bowel Disease Mimics: Practice Management from Inflammatory Bowel Disease LIVE

Crohns Colitis 360. 2024 Apr 11;6(2):otae022. doi: 10.1093/crocol/otae022. eCollection 2024 Apr.

Authors

Hannah W Fiske¹, Christopher Ward², Samir A Shah³, Stefan D Holubar⁴, Badr Al-Bawardy^{5

6}, Edward L Barnes⁷, David Binion⁸, Matthew Bohm⁹, Myron Brand⁵, Kofi Clarke¹⁰, Benjamin L Cohen¹¹, Raymond K Cross¹², Jeffrey Dueker⁸, Michael Engels¹³, Francis A Farraye¹⁴, Sean Fine¹⁵, Erin Forster¹⁶, Jill Gaidos⁵, Philip Ginsburg⁵, Alka Goyal¹⁷, John Hanson¹⁸, Hans Herfath⁷, Tracy Hull⁴, Colleen R Kelly¹⁹, Mark Lazarev²⁰, L Campbell Levy²¹, Joanna Melia²⁰, Jessica Philpott¹¹, Taha Qazi¹¹, Corey A Siegel²¹, Andrew Watson²², Steven D Wexner²³, Emmanuelle D Williams¹⁰, Miguel Regueiro¹¹

Affiliations

¹ Department of Internal Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
² Division of Gastroenterology, Lahey Hospital and Medical Center, Burlington, MA, USA.
³ Gastroenterology Associates Inc., The Warren Alpert Medical School of Brown University, Providence, RI, USA.
⁴ Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA.
⁵ Division of Gastroenterology, Yale School of Medicine, New Haven, CT, USA.
⁶ Division of Gastroenterology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
⁷ Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
⁸ Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
⁹ Division of Gastroenterology, Indiana University School of Medicine, Carmel, IN, USA.
¹⁰ Division of Gastroenterology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA.
¹¹ Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA.
¹² Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA.
¹³ Division of Gastroenterology, Lehigh Valley Health Network, Allentown, PA, USA.
¹⁴ Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA.
¹⁵ Division of Gastroenterology, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
¹⁶ Division of Gastroenterology, Medical University of South Carolina, Charleston, SC, USA.
¹⁷ Department of Pediatric Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA.
¹⁸ Division of Gastroenterology and Hepatology, Atrium Health, Charlotte, NC, USA.
¹⁹ Division of Gastroenterology, Brigham and Women's Hospital, Boston, MA, USA.
²⁰ Division of Gastroenterology, Johns Hopkins Medical Center, Baltimore, MD, USA.
²¹ Center for Digestive Health, Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
²² Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
²³ Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA.

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.

Keywords: Crohn’s disease; IBD mimics (IBD-M); clinical decision-making; inflammatory bowel disease (IBD); ulcerative colitis.