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CLINICAL REVIEW: J R Fraser Cummings, Satish Keshav, and Simon P L Travis Medical management of Crohn’s disease BMJ 2008; 336: 1062-1066 [Full text]

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Non-invasive markers in Crohn’s

Mohammed A Butt, Sameer Mallick F1 general medicine   (13 May 2008)

Antibodies in inflammatory bowel disease

Mohammed A Butt, Mallick S F1 medicine, Ahammed SF F2 medicine, Donnelly A ST2 medicine   (13 May 2008)

Crohn's disease

GEORGE Y CALDWELL, SINGAPORE 259858   (14 May 2008)

Remember lymphogranuloma venereum

Kinesh P Patel, David Hawkins   (3 June 2008)

Non-invasive markers in Crohn’s 13 May 2008
Mohammed A Butt, ST2 general medicine Worthing Hospital, West Sussex BN11 2DH, Sameer Mallick F1 general medicine Send response to journal: Re: Non-invasive markers in Crohn’s	Cummings et al write an excellent review on the medical management of Crohn’s disease (1). However, the potential of non-invasive faecal markers in the diagnosis and monitoring of inflammatory bowel disease (IBD) in the future also warrants a special mention. Inflammation of the gut wall produces an acute phase response reflected through non-specific changes in white cell count, platelet count and erythrocyte sedimentation rate. Several neutrophil-granular proteins released by activated neutrophils and derived from faeces have been investigated as potential markers for this acute phase response in IBD. These include calprotectin, lactoferrin, polymorphonuclear neutrophil elastase (PMN-e) and S100A12. Langhorst et al compared faecal calprotectin, lactoferrin and PMN-e and found all were able to differentiate active from inactive IBD, and IBD from IBS (all p<0.05) (2). None of the investigated faecal markers had clear and consistent superiority in their ability to reflect endoscopic inflammation, but all three were superior to CRP in their diagnostic accuracy. Kaiser et al investigated the use of faecal S100A12 in IBD (3). They found that S100A12 could distinguish IBD from healthy controls and IBD from IBS with a high sensitivity and specificity. S100A12 was found to be more sensitive 86% versus 63%, and more specific 96% versus 86%, than faecal calprotectin (a complex of S100A8 and S100A9) when distinguishing active IBD from IBS. S100A12 levels in stool also reflected inflammatory activity of chronic IBD. To confirm intestinal inflammation, most procedures are too invasive or expensive for routine use, or they require some form of radiation exposure. Whereas most serological biomarkers are of limited use, increasing evidence is now showing that faecal markers of neutrophil activity can accurately indicate intestinal inflammation. These markers may revolutionise IBD management in the future. References: 1. Cummings JRF, Keshav S, Travis SPL. Medical management of Crohn’s disease. BMJ 2008; 336: 1062 - 1066. 2. Langhorst J, Elsenbruch S, Koelzer J, et al. Noninvasive Markers in the Assessment of Intestinal Inflammation in Inflammatory Bowel Diseases: Performance of Fecal Lactoferrin, Calprotectin, and PMN- Elastase, CRP, and Clinical Indices. Am J Gastroenterol 2008. Jan; 103(1): 162-9 3. Kaiser T, Langhorst J, Wittkowski H, et al. Faecal S100A12 as a non-invasive marker distinguishing inflammatory bowel disease from irritable bowel syndrome. Gut 2007; 56: 1706-1713 Competing interests: None declared
Antibodies in inflammatory bowel disease 13 May 2008
Mohammed A Butt, ST2 general medicine Worthing Hospital, West Sussex BN11 2DH, Mallick S F1 medicine, Ahammed SF F2 medicine, Donnelly A ST2 medicine Send response to journal: Re: Antibodies in inflammatory bowel disease	In their recent article, Cummings and colleagues comment on the vast differential diagnosis for Crohns disease (1). Coupling this with its relatively low incidence, diagnosis of Crohns is often delayed. They advise the primary care physician of tests that can be done in the community to aid in making the diagnosis, such as the full blood count, C- reactive protein (CRP) and stool culture. Sub-classifying inflammatory bowel disease (IBD) into either Crohn’s, ulcerative colitis (UC) or indeterminate colitis is sometimes challanging. It is estimated that using the current diagnostic criteria, almost 10% of patients will be misclassified (2). Anti-Saccharomyces cerevisiae antibodies (ASCA) have been described in patients with Crohn’s disease, whilst perinuclear anti-neutrophil cytoplasmic antibodies (pANCA) have been detected in patients with ulcerative colitis. Assays of these antibodies have been shown to be effective in diagnosing and sub-classifying IBD. Reese and colleagues (2) performed a meta-analysis of studies reporting on ASCA and pANCA in IBD. They found the presence of either pANCA or ASCA antibodies of any class was most sensitive for differentiating between IBD and non-IBD (sensitivity 62.6%, specificity 92.6%). The ASCA positive with pANCA negative test offered the best sensitivity (55%) and specificity (93%) for diagnosing Crohn’s disease. For UC a positive pANCA test in the absence of information regarding ASCA status had a sensitivity and specificity of 55% and 93% respectively. ASCA and pANCA are specific but not sensitive for diagnosing Crohn’s and UC. They can therefore play a key role when sub-classifying IBD. References 1. Cummings JRF, Keshav S, Travis SPL. Medical management of Crohn’s disease. BMJ 2008; 336: 1062 - 1066. 2. Reese GE, Constantinides VA, Simillis C, et al. Diagnostic Precision of Anti-Saccharomyces cerevisiae Antibodies and Perinuclear Antineutrophil Cytoplasmic Antibodies in Inflammatory Bowel Disease. Am J Gastroenterol 2006;101:2410–2422) Competing interests: None declared
Crohn's disease 14 May 2008
GEORGE Y CALDWELL, GENERAL PRACTITIONER 31 BALMORAL PARK #18-33,, SINGAPORE 259858 Send response to journal: Re: Crohn's disease	Itraconazole has been used in the past quite effectively in controlling untoward symptoms. Is it mentioned? Maybe add on a bacteriostatic Sulphonamide? Competing interests: None declared
Remember lymphogranuloma venereum 3 June 2008
Kinesh P Patel, ST2 GUM Chelsea & Westminster Hospital, London, SW10 9TH, David Hawkins Send response to journal: Re: Remember lymphogranuloma venereum	We were surprised that the review by Cummings et al did not mention rectal lymphogranuloma venereum (LGV) as a differential diagnosis of Crohn’s disease. It is well recognised that the severe exudative proctitis caused by LGV can be histopathologically indistinguishable from that of Crohn’s disease(1). Patients with LGV erroneously treated for Crohn’s disease have been reported in the literature (2). In light of the recent epidemic of LGV (3), physicians should consider the diagnosis of LGV in all cases of proctitis in men who have sex with men. 1) T C Quinn, S E Goodell, E Mkrtichian, M D Schuffler, S P Wang, W E Stamm, K K Holmes Chlamydia trachomatis proctitis. N Engl J Med. 1981 Jul 23;305 (4):195-200 7017409 2) Forrester B, Pawade J, Horner P. The potential role of serology in diagnosing chronic lymphogranuloma venereum (LGV): a case of LGV mimicking Crohn's disease. Sex Transm Infect. 2006 Apr;82(2):139-40; 3) Simms I, Macdonald N, Ison C, Alexander S, Lowndes CM, Fenton KA. Enhanced surveillance of lymphogranuloma venereum (LGV) begins in England. Euro Surveill. 2004;8(41):pii=2565. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=2565 Competing interests: None declared