Welcome

1. Welcome

2. 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

3. Australia Hong Kong India Japan Malaysia New Zealand Philippines Singapore Sri Lanka Taiwan Thailand Vietnam South Korea Invited countries

4. Definition and Diagnosis CJ Ooi Muhammad Radzi Vineet Ahuja

5. 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

6. Statement 1 The 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

7. Statement 1 As 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 operative specimen. Microscopic features can be only partly assessed on mucosal biopsy, but completely assessed on an operative specimen. The diagnosis depends on the finding of discontinuous and often granulomatous intestinal inflammation. Lennard-Jones JE, Shivananda S. Clinical uniformity of inflammatory bowel disease a presentation and during the first year of disease in the north and south of Europe. EC-IBD Study Group. Eur J Gastroenterol Hepatol 1997;9(4):353–9.

8. Statement 1 CD is a heterogeneous entity comprising a variety of complex phenotypes in terms of age of onset, disease location and disease behaviour. Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR, et al. Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: Report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Can J Gastroenterol 2005;19(Suppl A): 5–36.

9. Statement 1 The current view is that the diagnosis is established by a nonstrictly defined combination of clinical presentation, endoscopic appearance, radiology, histology, surgical findings and, more recently, serology ECCO Guidelines 2010

10. Voting from Round 2

11. 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?

12. 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

13. Statement 1 Level of agreement: a- % b- % c- % d- % e- % Quality of evidence: III Classification of recommendation: C

14. 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

15. Statement 2 Colonoscopy with multiple biopsy specimens is well established as the first line procedure for diagnosing colitis. Coremans G, Rutgeerts P, Geboes K, Van den Oord J, Ponette E, Vantrappen G. The value of ileoscopy with biopsy in the diagnosis of intestinal Crohn's disease. Gastrointest Endosc 1984;30(3):167–72.

16. Statement 2 Ileoscopy with biopsy can be achieved with practice in 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 the diagnosis of intestinal Crohn's disease. Gastrointest Endosc 1984;30(3):167–72. Geboes K, Ectors N, D'Haens G, Rutgeerts P. Is ileoscopy with biopsy worthwhile in patients presenting with symptoms of inflammatory bowel disease? Am J Gastroenterol 1998;93(2): 201–6. Cherian S, Singh P. Is routine ileoscopy useful? An observational study 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. Am J Gastroenterol 2002;97(4):947–53.

17. Statement 2 • Number of biopsies • Areas of biopsies – involved and uninvolved

18. Voting

19. 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

20. 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.

21. Statement 2 Level of agreement: a- % b- % c- % d- % e- % Quality of evidence: III Classification of recommendation: C

22. Statement 3 • Biopsies for mycobacterial studies should be taken from patients living in TB endemic countries

23. Statement 3 Microbiological features n (%) Interpreted as IBD by pathologist 10 (38.4) 3(11.5) S Interpreted as TB by pathologist 0 (0) 13 (50) 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

24. Voting

25. 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

26. Proposed amendment (if any) • Biopsies for Mycobacterium tuberculosis should be taken from patients living in TB endemic countries

27. Statement 3 Level of agreement: a- % b- % c- % d- % e- % Quality of evidence: III Classification of recommendation:C

28. 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

29. Statement 4 CT and MR techniques can establish disease extension and activity based on wall thickness and increased intravenous contrast enhancement. The magnitude of these changes, along with presence of edema and ulcerations allow categorization 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. AJR Am J Roentgenol 2001;177(6):1325–32 Wold PB, Fletcher JG, Johnson CD, Sandborn WJ. Assessment of small bowel Crohn disease: noninvasive peroral CT enterography compared with other imaging methods and endoscopy– feasibility study. Radiology 2003;229(1):275–81

30. Statement 4 CT and MR have a similar diagnostic accuracy for the detection of small intestine inflammatory lesions. Horsthuis K, Bipat S, Bennink RJ, Stoker J. Inflammatory bowel disease diagnosed with US, MR, scintigraphy, and CT: metaanalysis of 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 multidetector spiral-CT enteroclysis: interobserver agreement and sensitivity by means of "sign-by-sign" correlation. Eur Radiol 2003;13(6):1303–11

31. 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 increasing source of radiation exposure. N Engl J Med 2007;357(22): 2277–84.

32. Voting

33. 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).

34. 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.

35. Statement 4 Level of agreement: a- % b- % c- % d- % e- % Quality of evidence: II-2 Classification of recommendation: B