The inflammatory bowel diseases (IBDs) have been regarded traditionally as diseases of westernised nations. However, their epidemiology is changing throughout the world: Also in newly industrialised countries in Africa, Asia, and South America annual percentage changes of up to 18% for Crohn’s Disease (CD) and 15% for Ulcerative Colitis (UC) were found. A similar trend was shown for pediatric-onset IBD (PIBD) with annual incidences as high as 11.4/100,000 person-years in Asia, the Middle East and Oceania (vs. 15.2/100,000 in North America), indicating that PIBD too has become a global disease. This highlights the need not only for research into its prevention but also for innovations in health-care systems: Even in high-income countries (HICs) the quality of PIBD management may differ, as documented regarding significant diagnostic delay due to lack of referral centres or widespread variation in treatment and disease monitoring at geographic levels. Still, these observations contrast sharply with many low and middle-income countries (LMICs), where there is general lack of resources and structured health-care and insurance systems as well as formally trained (P)IBD experts and training programs. Importantly, current guidelines usually target an audience with a sub-specialist level of training, often assisted by cutting-edge diagnostic and treatment facilities. A modification of recent international guidelines on PIBD diagnostics and treatment is thus needed: It should be based on an analysis for their potential to be adjusted to practicalities and real-life scenarios, first focusing on middle-income countries (MICs) with limited resources, but a somewhat structured health-care system and documented increase in PIBD.
Accurate diagnosis of PIBD should be based on a combination of non-invasive (e.g. history, physical examination, specific laboratory tests) and invasive diagnostics (e.g. gastrointestinal endoscopy with histopathology). In this context, and for any objective evaluation of IBD phenotypes and activity, imaging is a must. Nonetheless, some techniques are not always available in LMICs: For example, to correctly differentiate CD and UC at diagnosis, small bowel evaluation should always be performed (with few exceptions). Particularly in patients whose ileum could not be intubated, imaging is needed to reach correct diagnosis and monitor disease. The choice of which test to perform depends on phenotypes and endoscopic data, local availability and expertise: It includes preferably magnetic resonance enterography (MRE), intestinal ultrasound (IUS) or capsule endoscopy, but, when unavailable, possibly computed tomography enterography (CTE) and small bowel follow-through (SBFT). MRE is the preferred imaging modality at diagnosis and during follow-up, allowing an evaluation of e.g. the degree of transmural inflammation or perianal CD, with no radiation exposure. In many LMICs, MR scanners are currently not (widely) accessible. Also, the radiologist’s expertise is another possible limitation of this technique, as no simple score systems for use in routine clinical practice have been developed so far. While SBFT is an alternative method to evaluate small bowel disease activity, it is limited by the high radiation exposure and the lack of assessment of peri-intestinal abnormalities. To date therefore, IUS, which allows a dynamic real-time bowel assessment, is the most valuable alternative to MRE, even if its performance is strictly related to the operator’s extensive training and experience. Published data report good performance of IUS, e.g. both for CD diagnosis (79.7% sensitivity, 96.7% specificity) and evaluation of already known disease (89% sensitivity, 94.3% specificity). Based on such findings and considering its wide availability, low costs and non-invasiveness for patients, IUS is the primary imaging modality when suspecting PIBD or for disease monitoring. If available, small intestinal contrast ultrasonography (SICUS) is also an interesting alternative to MRE, due to its good cost-efficacy and because it is also well-tolerated by patients. Because in CD, the performance of capsule endoscopy, MRE and IUS was shown to be comparable, monitoring could indeed be performed by IUS. In addition, SBFT and CTE, even if available, should not be repeated routinely for monitoring PIBD patients, due to high radiation exposure.

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References

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