As the number of Asian patients with inflammatory bowel disease (IBD) has increased recently, there is a growing need to improve IBD care in this region. This study is aimed at determining how Asian countries are currently dealing with their IBD patients in terms of diagnosis.
A questionnaire was designed by the organizing committee of Asian Organization for Crohn's and Colitis, for a multinational web-based survey conducted between March 2014 and May 2014.
A total of 353 Asian medical doctors treating IBD patients responded to the survey (114 in China, 88 in Japan, 116 in Korea, and 35 in other Asian countries). Most of the respondents were gastroenterologists working in an academic teaching hospital. While most of the doctors from China, Japan, and Korea use their own national guidelines for IBD diagnosis, those from other Asian countries most commonly adopt the European Crohn's Colitis Organisation's guideline. Japanese doctors seldom adopt the Montreal classification for IBD. The most commonly used activity scoring system for ulcerative colitis is the Mayo score in all countries except China, whereas that for Crohn's disease (CD) is the Crohn's Disease Activity Index. The most available tool for small-bowel evaluation in CD patients differs across countries. Many physicians administer empirical anti-tuberculous medications before the diagnosis of CD.
The results of this survey demonstrate that Asian medical doctors have different diagnostic approaches for IBD. This knowledge would be important in establishing guidelines for improving the care of IBD patients in this region.
Inflammatory bowel diseases (IBD), mainly including UC and CD, are characterized by chronic progressive inflammation of the bowel.
Growing evidence shows that the characteristics of IBD patients differ in epidemiology, phenotype, and genetic susceptibility according to geography.
As there is no single gold standard for the diagnosis of IBD, it is a great challenge for clinicians to correctly diagnose these diseases. In the Asian geographic area, it is even more difficult to make accurate diagnosis of IBD because of various infectious diseases that mimic IBD, which may delay the accurate assessment of the clinical characteristics of the disease, leading to failure of early detection and appropriate management. For instance, intestinal tuberculosis (TB), which is relatively prevalent in Asian countries, is very similar to CD in terms of clinical symptoms, disease location, endoscopic appearance of mucosal ulcerations, and pathologic feature. Thus, this study was focused on identifying how Asian physicians approach patients with suspected IBD for the correct diagnosis through a multinational survey in the region.
This survey was originally planned by the organizing committee of the AOCC and designed for one of the programs of the second annual meeting of AOCC, which was held in Seoul in June 2014. The questionnaire used in this study was made by members of the IBD study group of KASID. Then, it was revised several times after being reviewed by the staff officer members of KASID and their colleagues from Japan and China. It mainly consisted of four parts, including personal information (9 items), diagnosis of IBD (18 items), treatment of IBD (30 items), and quality of IBD care (36 items). For the diagnosis of IBD, questions were asked about the most commonly used diagnostic guidelines and disease activity assessment systems, whether or not to apply the Montreal classification, and the available tools for small-bowel or perianal disease evaluation for CD. The questionnaires are shown in the
Overall, 353 Asian medical doctors (male, 251 [71.1%]) who treat IBD patients responded to the survey. Most of them were working in academic teaching hospitals (336 [95.2%]). The respondents were from various Asian countries (Korea 116, China 114, Japan 88, Taiwan 17, Hong Kong 8, India 4, Singapore 3, Malaysia 1, the Philippines 1, and Indonesia 1).
The national diagnostic guideline for IBD is the most commonly used guideline among respondents from Korea, China, and Japan. Physicians from the other countries apply the European Crohn's Colitis Organisation's guideline most frequently (
For the index or scoring system for the clinical assessment of disease activity of UC, all respondents favor the Mayo score except those from China. The Truelove-Witts index is the most commonly used system for UC activity assessment by Chinese doctors (
Although most physicians (72%–88%) from all countries always use endoscopic examination for evaluating disease activity and extent at the time of diagnosis of UC (
More than 90% of respondents from all countries perform colonoscopy with terminal ileum evaluation to document the activity and extent of disease for suspected CD (
For suspected UC, more than half of doctors from China and Japan reported to always perform microbiological culture, whereas only 11.2% and 25.7% of doctors from Korea and the other countries do, respectively (
Many physicians in Asia administer empirical anti-TB medications before the diagnosis of CD. Approximately 44.7%, 8%, 19.8%, and 17.1% of respondents from China, Japan, Korea, and the other countries, respectively, reported that >20% of their patients with CD had been administered with anti-TB treatments before the diagnosis of CD (
The results of this survey demonstrate a diverse approach for the diagnosis of IBD among Asian physicians, especially in terms of the kind of guidelines, adoption of the Montreal classification, and modality of small-bowel and perianal evaluation of CD. This study, on the occasion of the second AOCC in 2014, was conducted with 353 physicians, the largest number of participants to date for the survey investigating the pattern of practice of IBD care.
It has been recognized that there are various differences in phenotypes, epidemiologic features, and genetic backgrounds among CD patients from different countries, especially between the Western and Eastern geographic areas.
Interestingly, the results of the present survey show that the Montreal classification of IBD is less used by doctors from Japan than those from other Asian countries. In fact, the Vienna or Montreal classification is not stated in the Japanese guidelines,
For the system of UC activity index, the Mayo score is dominantly used by most doctors except those from China, who answered to mainly adopt the Truelove-Witts score. The simplicity of the Truelove-Witts score might be one of the explanations for the preference of Chinese doctors to this scoring system, as this system does not need endoscopy for the calculation of activity.
No endoscopic score system for UC has been widely used in daily routine practice. Although the Mayo endoscopic subscore has been extensively used in many trials,
It is notable that evaluation for
We found a significant range of variation in the evaluation of the small bowel for CD among countries. Korean and Chinese physicians favored CT enterography, whereas Japanese and those from other countries chose small-bowel follow-through as the first-line tool for assessing small-bowel lesions in CD patients. Notably, a considerable proportion of Japanese doctors (28.4%) use balloon-assisted enteroscopy, whereas no physicians in Korea prefer this modality (
One of the distinguished findings of the present study is the high rate of empirical anti-TB treatment before CD diagnosis in Asia, reflecting the difficulties in discriminating these two diseases. Although there have been several studies on the typical features of intestinal TB for differentiating it from CD,
In conclusion, the results of the present survey demonstrate that Asian doctors apply different approaches to their IBD patients, reflecting a unique situation in this region compared with Western countries. It would be important to establish Asian guidelines for improved care of IBD patients.
* Always (90-100%), Usually (70-90%), Sometimes (30-70%), Rarely (10-30%), Never (0-10%)
1. What diagnostic
1) ECCO consensus guideline (2012) 2) Guidelines of the American College of Gastroenterology (2010) 3) BSG (British Society of Gastroenterology) guidelines (2011) 4) Asia-Pacific consensus (2006) 5) National guidelines of your country (if any) 6) I do not use guidelines for UC diagnosis
2. Do you classify your UC patients according to the
1) Always 2) Usually 3) Sometimes 4) Rarely 5) Never
3. What index/scoring system do you use most commonly in your practice for
1) (Modified) Truelove-Witts' severity index 2) Mayo score 3) Seo index 4) St. Mark's index 5) Pediatric UCDAI 6) Others (please specify, ) 7) I do not use a scoring system
4. Do you perform
1) Always 2) Usually 3) Sometimes 4) Rarely 5) Never
5. Do you use a classification system of the
1) Always 2) Usually 3) Sometimes 4) Rarely 5) Never
6. How often do you perform
1) Always 2) Usually 3) Sometimes 4) Rarely 5) Never
7. How often do you perform
1) Always 2) Usually 3) Sometimes 4) Rarely 5) Never
8. How often do you perform
1) Always 2) Usually 3) Sometimes 4) Rarely 5) Never
9. How often do you perform
1) Always 2) Usually 3) Sometimes 4) Rarely 5) Never
1. What
1) ECCO guideline 2) Guidelines of the American College of Gastroenterology 3) Guidelines of the British Society of Gastroenterology 4) Asia-Pacific consensus 5) National guidelines of your country (if any) 6) I do not use guidelines for CD diagnosis.
2. Do you classify your CD patients according to the
1) Always 2) Usually 3) Sometimes 4) Rarely 5) Never
3. What index/scoring system do you use most commonly in your practice for
1) Crohn's disease activity index 2) Harvey Bradshaw Index 3) Pediatric CDAI 4) International Organization for the Study of Inflammatory Bowel Disease (IOIBD) score 5) Others (please specify, ) 6) I do not use a scoring system.
4. How often do you perform
1) Always 2) Usually 3) Sometimes 4) Rarely 5) Never
5. What kind of
1) Small bowel follow-through or enteroclysis 2) Abdominal ultrasonography 3) Conventional CT 4) CT enterography 5) MR enterography 6) Balloon-assisted enteroscopy 7) Capsule endoscopy 8) I do not perform small bowel imaging studies.
6. How often do you perform EGD to evaluate the
1) Always 2) Usually 3) Sometimes 4) Rarely 5) Never
7. Which of the following procedures do you perform most commonly in your practice to
1) Anorectal ultrasonography (including EUS) 2) Pelvic CT 3) Pelvic MRI 4) Consult surgeon 5) I do not perform any of these procedures
8. How often do you perform
1) Always 2) Usually 3) Sometimes 4) Rarely 5) Never
9. What percentage of your CD patients were administered empiric anti-tuberculous medications before the diagnosis of CD?
1) less than 20% 2) 20 – 40% 3) 40 – 60% 4) more than 60%