SpA Sleuths: The Case of Undiagnosed IBD Save

As rheumatologists, we are medical detectives investigating complex and often elusive autoimmune and inflammatory conditions. Patients expect us to be the experts who understand their disease, give them confidence in their treatment plans, and to be on the lookout for additional comorbidities and possible complications. This has been particularly important in our spondyloarthritis patient population in which the spectrum of disease encompasses multiple domains and can evolve slowly over time. 

Abstract #0495 provides context to our continual search for better understanding of IBD in patients with AS, nr-AxSpA, and PsA. This Spanish study identified at total of 559 patients, 51% were men with the average age of 52 years. Patients had a mean age at diagnosis of 42 and time from symptom onset to diagnosis of 12 years. The primary evaluations, done by rheumatologists, checked a fecal calprotectin (FC) and all patients with a level greater than or equal to 80 micrograms/g underwent endoscopy. In patients with normal fecal calprotectin levels, endoscopic capsule study of MRI was completed. 

They found that nearly 50% of the PsA and AS patients had an elevated FC compared to 20% of nr-AxSpA.  In total, 10% of patients reported a positive IBD family history and 14% of patients had clinical symptoms of IBD (asthenia, abdominal pain, chronic diarrhea.) Of the total 189 colonoscopies, they found nearly 40% of the patients had IBD pathology, mainly in the terminal ileum with predominance for aphthous ulcers. In total, 23 patients received a formal IBD diagnosis, 95% of these were diagnosed as Crohn’s Disease. 

This study highlights the importance of continual follow up regarding additional systemic risks/co-morbidities with this vulnerable patient population. Pull out the magnifying glass, Sherlock! We need to be sleuths. Our review of systems needs to be robust. We must ask patients about symptoms that they may not be telling us and ensuring we understand the evolution of these symptoms in real time. Going beyond collaboration with our GI colleagues, this highlights our need to be first at bat through our histories, physicals, and with due consideration for adding fecal calprotectin levels to our repertoire.