THEME the gUTS of it

Graham Morrison Belinda Headon Peter Gibson

MBBCh, MRCP, is IBD Fellow, Department of is IBD nurse specialist, Department of MBBS, is Professor of Medicine and
Gastroenterology, Box Hill Hospital, Melbourne, Gastroenterology, Box Hill Hospital, Gastroenterology, Department of
Victoria. gmorrison2001@hotmail.com Melbourne, Victoria. Gastroenterology, Box Hill Hospital
and Department of Medicine, Monash
University, Melbourne, Victoria.

Update in inflammatory
bowel disease
Inflammatory bowel disease (IBD) refers to a group of
Background
conditions characterised by inflammation in the intestinal
Inflammatory bowel disease (IBD) is a common disease in
tract. Crohn disease (CD) and ulcerative colitis (UC) account for
Australia and frequently encountered in primary care. Major
the majority of these conditions. The aim of this article is to
developments in investigation and management have taken place.
review recent breakthroughs in IBD investigation and
Objective management. Several other comprehensive reviews and
This article aims to review some recent breakthroughs in IBD position statements are also available.1–4
investigation and management.
Discussion How common is IBD?
Diagnosis involves a changing combination of enhanced Inflammatory bowel disease is common and increasing in prevalence.
traditional techniques with new diagnostic tools, typically blood Recent population studies indicate it is as common in Australia and
and stool testing with improved endoscopy and new radiological New Zealand as other parts the world5,6 and prevalence is increasing
tests. Management has seen the introduction of new powerful
in Asia.7 What this means to general practice is that IBD is more
biologic therapies, greater understanding in the way we use
common than epilepsy or road traffic accidents, and as common as
older therapies, and a focus on preventing complications such
type 1 diabetes or schizophrenia. It is a major workload burden for the
as malignancy or infection. Treatment philosophy now attempts
to alter the natural history of the disease and prevent long health care system and a global economic burden.8
term complications. The importance of associated, previously The changing face of investigation
overlooked factors is being increasingly recognised. Only by
taking a long term, patient centred multidisciplinary approach A combination of noninvasive testing with endoscopy and/or
will an optimal outlook for the majority of patients with IBD be imaging is usually required and how these tests are being performed
achieved. is changing.

Noninvasive tests
Blood tests provide clues but are not specific for IBD. Many new or
not so new serological tests, such as anti-saccharomyces cerevisiae
antibody (ASCA) and atypical perinuclear antineutrophil cytoplasmic
antibodies (p-ANCA) are being used. 9 However, they cannot
differentiate UC from CD alone and can be considered at best as
‘supportive evidence’ when the diagnosis is uncertain.
A good marker of inflammation is needed. C-reactive protein
(CRP) levels have been shown to correlate with clinical, endoscopic
and histologic disease activity and persistent elevation is associated
with a higher relapse rate and better response to infliximab. 10
However, some patients will not mount a CRP response to intestinal

956 Reprinted from Australian Family Physician Vol. 38, No. 12, December 2009
inflammation11 so CRP is a useful marker if elevated, but care must be Techniques to endoscope the last frontier of the gut – the
taken in interpreting a normal value when clinical suspicion of active small intestine, have moved ahead considerably. Wireless capsule
inflammation exists. Calprotectin and lactoferrin (neutrophil derived endoscopy (WCE or ‘pillcam’), where patients swallow a capsule
proteins in the stool as a result of inflammation) are faecal markers that provides images as it passes through the small bowel, is now
that show promise as a way of excluding intestinal inflammation.9 available and experience in interpreting findings is growing. Double
balloon enteroscopy offers the possibility of complete diagnostic and
Endoscopy – keeps getting better
therapeutic access to the entire small bowel. Currently, the availability
Ileocolonoscopy and biopsy remain the gold standard for diagnosis of both these techniques is limited by high costs.
of colonic and terminal ileal disease, and will usually confirm the
Imaging – what’s in and what’s out
diagnosis. The instruments themselves have considerably improved
over recent years, both in their ease of use and ability to provide good Barium imaging of the gut is now rarely used in IBD and has been
mucosal images. The vast majority of colonoscopies now include replaced by colonoscopy. Small bowel barium studies are too
visualisation of the terminal ileum, of key diagnostic importance if insensitive and unreliable and have been replaced by enterography
IBD is suspected and monitoring patients with known IBD. Further (where contrast is swallowed) or enteroclysis (where the contrast
improvements in the quality and diagnostic ability of the endoscopic is infused via a nasogastric tube) with imaging via computerised
image have been the subject of many technological developments tomography (CT) (Figure 1, 2) 13 or magnetic resonance (MRI). 14
(Table 1). In IBD, only chromoendoscopy has entered routine practice in Enteroclysis is probably superior, but many patients do not tolerate the
surveillance for preneoplastic lesions.12 nasogastric tube.13

Table 1. Endoscopic image enhancing techniques used in IBD colonoscopic surveillance

Technology Principle Indication Advantages Disadvantages
Chromoendoscopy Application of dye (eg. indigo Highlight dysplastic Evidence supporting • Time consuming
carmine) during endoscopy tissue dysplasia pick up • Preparation of dye
Narrow band imaging Reflected light of varying Highlight dysplastic • Noninvasive • Conflicting evidence
wavelength used (via optical tissue • No dye to date
filter) to visualise structure and • Ease of use (‘push • Expense of new
vasculature within mucosa button on endoscope’) equipment
FICE®/iScan® Similar to NBI but no filter Highlight dysplastic • Noninvasive • Limited evidence
required tissue • No dye • Expense
• Ease of use • New technique
Confocal laser Imaging microscope in tip of ‘Real time’ histology Immediate histologic • Limited evidence
endoscopy scope or via working channel – a ‘virtual biopsy’ assessment • Expense
(An Australian • Additional training
invention) • Only able to visualise
small areas at once

Figure 1. Coronal CT enteroclysis showing small bowel thickening and Figure 2. Sagittal CT enteroclysis showing inflamed distal small bowel
Crohn stricture and Crohn stricture

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 theme Update in inflammatory bowel disease

Medical management – the old and the new Immunomodulators

The main immunomodulators in use in IBD patients are thiopurines
Old drugs used better (azathioprine, 6-mercaptopurine) and methotrexate. They are the
Aminosalicylates mainstay of treatment in maintenance therapy for patients with more
5-amino salicylic acid drugs (Table 2) are the standard treatment for than mild CD and for chronically active or frequently relapsing UC
induction and maintenance of remission in mild to moderate UC.1,3 where 5-ASA drugs have failed.4 The slow escalation of therapeutic
Their place in the management of intestinal inflammation in CD is effects of the drugs (at least 3 months for each) is an essential factor
controversial.15 They are well tolerated by most people with a low in decision making, and optimal use should be ensured before moving
rate of adverse events. Comparative trials have not clearly defined to new expensive therapies.
which preparation should be used in specific situations
and choice largely comes down to clinician experience or
Figure 3. Thiopurine metabolite reference ranges and interpretation
patient preference.
Rectally administered 5-ASA is more effective than Thiopurine metabolite measurement
rectal corticosteroid or oral 5-ASA for proctitis and left
sided UC.16 When used orally, it is generally believed Metabolite Reference range
there is a dose dependent response for 5-ASA drugs, (units: pmol/8 x 108 RBCs)
particularly for active disease. However, the evidence 6-thioguanine nucleotide (6-TGN) 235–450
base for this is small and involves preparations not 6-methylmercaptopurine (6-MMP) <5700
marketed in Australia. Nevertheless, higher oral doses
are anecdotally effective when efficacy is inadequate on
standard doses. Thiopurine metabolite result interpretation
The drugs certainly work better if actually taken;
studies show 5-ASA drugs (especially in maintenance) Metabolite Very low/absent Low 6-TGN Low 6-TGN Therapeutic
have a relatively low compliance rate.17 Recent trials result 6-TGN Low 6-MMP High 6-MMP 6-TGN
have clearly demonstrated that, for UC, once daily Very low/absent Therapeutic
delivery is as effective as twice daily, which may 6-MMP 6-MMP
improve compliance. 18–20 An additional reason for using Interpretation Noncompliance Under Thiopurine Thiopurine
5-ASA drugs is the concept of chemoprevention of dosing resistance refractory
colorectal cancer.21

Table 2. 5-ASA drug preparations available via the PBS in Australia

Generic name Brand name Formulation Oral/rectal Strength Daily dose Site of delivery Authority
Sulfasalazine Salazopyrin® Tablet Oral 500 mg 2–4 g Colon No
Balsalazide Colazide® Capsule Oral 750 mg 4.0–6.75 g Colon Streamlined
Olsalazine Dipentum® • Capsule Oral 250 mg 1–3 g Colon Streamlined
• Tablet Oral 500 mg
Mesalazine Mesasal® Tablet Oral 250 mg 1.5–3.0 g Ileum and colon Streamlined
Pentasa® • Granules 1g Duodenum, Streamlined
• Granules Oral 2g 2–4 g jejunum, ileum
• Tablet 500 mg and colon
• Enema Rectal 1g 1g Recto-sigmoid Streamlined
• Suppository Rectal 1g 1g Rectal No
Salofalk® • Granules 500 mg
• Granules Oral 1g 1.5–3.0 g Ileum and colon Streamlined
• Granules 1.5 g
• Tablet 500 mg
• Enema 2g 2g
• Enema Rectal 4g 4g Recto-sigmoid Streamlined
• Foam 1g 1g

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 Update in inflammatory bowel disease THEME

Table 3. TNFα antagonists used in inflammatory bowel disease

Drug Brand name Class Administration Dose Induction Maintenance
Infliximab Remicade® Anti-TNF Intravenous infusion 5 mg/kg 0, 2 and 6 weeks Every 8 weeks
(chimeric)
Adalimumab Humira® Anti-TNF Subcutaneous injection See induction Week 0, 160 mg 40 mg fortnightly
(fully humanised) and maintenance Week 2, 80 mg from week 4
Certolizumab Cimzia® Anti-TNF Subcutaneous injection 400 mg 0, 2 and 4 weeks Every 4 weeks
(not available in (pegylated
Australia) humanised)

Getting the dose right is key to optimal efficacy. Traditionally, with several serious complications in the short and long term.26 Yet, in
weight based dosing with regular checks on toxicity (neutrophil CD, it has been ‘traditional’ to use steroids as monotherapy and observe
count and liver function tests) has been used to guide dosage. the behaviour of the individual’s disease. After 2–3 relapses (treated
Measuring thiopurine metabolites (Figure 3) has enabled the with steroids) immunomodulators would be introduced, the ‘step up’
heterogeneity in the metabolism of these drugs across individuals to approach (Figure 4). The outcome of this approach was to have a high
be taken into account and has improved the fine tuning of dosage to proportion of patients dependent on, or unable to stop taking, steroids
achieve better efficacy and safety.22 at 12 months. This led to the concept of using immunomodulators
Methotrexate is now being increasingly used in patients with as ‘steroid sparing agents’. It is now known that the disease is more
IBD. Its efficacy in CD has been demonstrated.4 In UC however, the responsive to therapy early in its time course and relative resistance to
appropriate randomised controlled trials have yet to be done and therapies increases with time. This has led to ‘top down’ therapy – the
evidence for efficacy is based upon observational studies only. 23 initiation of efficacious long term strategies from a diagnosis of CD.27
Because absorption after oral dosing is highly variable, the preferred The idea is that controlling the disease process early (when it is more
route of administration is subcutaneous, usually commencing with amenable to treatment) prevents resistance to therapy and subsequent
25 mg/week, adjusted accordingly.23 escalation, complications, and the need for surgery. Such an approach
will alter the natural history of the disease and reduce the need for
New drugs – the biologic therapies
steroids (and their adverse effects). There is short term evidence that
Biologic therapies are drugs directed against specific molecules in such strategies are successful.28,29
the inflammatory pathways involved in IBD. While many are under However, more aggressive therapy introduces risk from the
development, two are available via the Pharmaceutical Benefits drugs used (especially infection and malignancy), and this must be
Scheme (PBS) for Crohn disease (Table 3). Both bind tumour necrosis considered in balance with the risk from ongoing disease activity
factor alpha (TNF) and have efficacy for luminal, perianal and
fistulising CD.4 Infliximab has efficacy in UC24 but is not funded by Figure 4. Top down versus step up strategies in IBD management
the PBS. In general, they are used for induction (to get disease under
control) and long term maintenance of moderate to severely active Biologic molecules
disease which has not responded to conventional treatment. Current
controversies in their use evolve around the need for concurrent Step up Immunomodulators Top down
immunomodulatory therapy which, on the one hand, increases the risk
of serious infection (though still uncommon), but on the other, improves
5-ASA drugs
efficacy and the likelihood of durable response. Decisions rest with
each patient’s circumstances, but most clinicians continue concurrent
What the ‘top’ of the top down approach should be is still under debate
immunomodulators for the first 6 months of therapy. but usually implies use of biological molecules from the outset. This means
starting biologics on first presentation in an attempt to change the history
Treatment philosophy and keeping it safe of the disease and ensure healing. It is not currently in widespread practice
Planning treatment for patients with IBD now looks toward long and most patients are managed by starting at the bottom of the treatment
pathway (step up) and moving to stronger therapy based on poor symptom
term outcomes not just acute care. This implies changing the natural
control and/or evidence of active disease. The main use of top down is in the
history of the disease by preventing disease progression and avoiding first presentation of acute severe disease where biologic therapy can be used
treatment complications.4,25 For example, steroid use has changed as a ‘bridge’ to maintenance therapy (usually an immunomodulator)
dramatically. Steroids are rapidly effective for inducing remission Rapid escalation of therapy to gain effective disease control should be the
in IBD, and are cheap and readily available. However, they are not strategy from the point of diagnosis
effective or recommended for maintenance therapy and are associated

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 theme Update in inflammatory bowel disease

for each patient. There has been a major push to upgrade the efforts • screening for tuberculosis and hepatitis B infection before initiating
by clinicians to prevent infection in patients on immunomodulating therapy
drugs. This was prompted by poor outcomes (including death) from • checking immunisation/past infection status of relevant viruses (eg.
reactivation of serious infections, particularly tuberculosis, and varicella zoster)
opportunistic infections in patients on anti-TNF drugs.30,31 Patients • ensuring vaccination for influenza and pneumococcus, and
and health care staff must be aware of the need for prompt medical • advice regarding travel (eg. avoid travelling to areas where
attention and investigation if the suspicion of infection arises while tuberculosis is endemic if taking an anti-TNF agent).
on biologic therapy. Combination drug therapy, particularly where Emerging evidence suggests women with IBD on immunosuppression
steroids are used in moderate or high doses, carries the greatest risk have a higher risk of an abnormal Pap smear associated with
of severe infection.30 human papillomavirus (HPV) infection. 32 Vaccination should be
Given the risks of infection, vaccination and screening have offered to suitable patients and consideration given to screening
become important issues in IBD (Table 4). This includes: immunocompromised individuals with yearly Pap tests.33

Table 4. Infection prevention and screening strategies for IBD patients on immunomodulating drugs
Infection Prevention and screening strategy
Tuberculosis Screen with chest X-ray and QuantiFERON gold before therapy
Avoid travel to TB endemic areas
Active TB – anti-TNF contraindicated
Latent TB – assess need for therapy. May proceed if concomitant prophylactic TB treatment given
(seek specialist advice)
Hepatitis Check hepatitis B and C serology and immunise against hepatitis B if seronegative (some suggest all IBD
patients should be immunised)
Influenza Annual flu vaccination
Herpes zoster virus Check VZV serology before therapy and vaccinate if negative
Pneumococcus Pneumococcal vaccine every 5 years
Cytomegalovirus No action required
Herpes simplex virus No action required
Epstein-Barr virus No action required
Human papillomavirus Regular Pap smears
HPV vaccination should be offered
Note: Live attenuated vaccines should not be given to IBD patients on immunomodulator therapy. These include MMR, live typhoid vaccine, live attenuated
influenza, varicella, oral polio and bacille calmette-guerin (BCG)

Table 5. The overlooked issues in IBD patient care

Issue Comment
Employment The ACCESS report8 revealed over three-quarters of patients noticed a change in work life as a result of IBD. This included
time off, restriction of duties, travel restriction and loss of income
Education Similar findings to above, as well as a lack of understanding or not being believed about their illness8
Quality of life Many studies have shown a lower quality of life in IBD patients and this has been associated with disease activity34
Anaemia Common in IBD and often multifactorial. Iron deficiency is common and responds poorly to oral iron.35 Intravenous iron is
particularly useful in this situation
Psychological health Stress, depression and poor psychological health are associated with chronic disease and increased disease activity.34 Many
new psychological therapies may help, although evidence on the use of antidepressants is conflicting
Sexual dysfunction The potential for incontinence and wind, and a resistance to discuss sexual health concerns makes these issues common and
challenging8
Functional GI symptoms Common in IBD and require careful assessment. Dietary interventions (via a specialist dietician) have proven useful36
Smoking Strongly associated with negative disease outcomes in CD.37 Cessation should be actively encouraged and awareness of
available help and resources given
Nutrition and development Key priorities in all patients, but should be particularly focused on children, adolescents and young adults38

960 Reprinted from Australian Family Physician Vol. 38, No. 12, December 2009
 Update in inflammatory bowel disease THEME

The other feared complication of immune modulating therapy is small bowel Crohn’s disease categories with medical response and surgical pathol-
ogy. World J Gastroenterol 2009;15:3367–75.
malignancy. This can be limited to an increased risk of skin cancer
15. Gearry RB, Ajlouni Y, Nandurkar S, Iser JH, Gibson PR. 5-aminosalicylic acid
(related to long term thiopurines) through to the development of nasty (mesalazine) use in Crohn’s disease: A survey of the opinions and practice of
hepatosplenic T-cell lymphoma (HSTCL).34 Fortunately the latter is rare. Australian gastroenterologists. Inflamm Bowel Dis 2007;13:1009–15.
16. James SL, Irving PM, Gearry RB, Gibson PR. Management of distal ulcerative colitis:
The risks lie with all immunomodulators (perhaps with the exception of
Frequently asked questions analysis. Intern Med J 2008;38:114–9.
methotrexate) and correlates to a 2–3 fold increased risk compared to 17. Kane SV. Systematic review: Adherence issues in the treatment of ulcerative colitis.
the non-IBD population.30,31,35 Aliment Pharmacol Ther 2006;23:577–85.
18. Kamm MA, Lichtenstein GR, Sandborn WJ, et al. Randomised trial of once- or
While investigation and management is important in treatment twice-daily MMX mesalazine for maintenance of remission in ulcerative colitis. Gut
decision making, many other issues are important to patients. These 2008;57:893–902.
are best managed by a multidisciplinary team (Table 5). 19. Kruis W, Kiudelis G, Racz I, et al. Once daily versus three times daily mesalazine
granules in active ulcerative colitis: A double-blind, double dummy, randomised non-
Conclusion 20.
inferiority trial. Gut 2009;58:233–40.
Lichtenstein GR, Kamm MA, Boddu P, et al. Effect of once- or twice-daily MMX
While our ability to diagnose, evaluate and manage patients with IBD mesalamine (SPD476) for the induction of remission of mild to moderately active
ulcerative colitis. Clin Gastroenterol Hepatol 2007;5:95–102.
continues to improve, it remains a challenging and complex disease. 21. Andrews JM, Travis SPL, Gibson PR, Gasche C. Systematic review: Concurrent
Treatment philosophy is moving toward altering the natural history of therapy with 5-ASA and immunomodulators in IBD. Aliment Pharmacol Ther
the disease while aiming for as normal a quality of life as possible. 2009;9:459–69.
22. Gearry RB, Barclay ML. Azathioprine and 6-mercaptopurine pharmacogenetics and
Inflammatory bowel disease is no longer an illness managed by metabolite monitoring in inflammatory bowel disease. J Gastroenterol Hepatol
the gastroenterologist. It requires a multidisciplinary approach with 2005;20:1149–57.
23. Nathan DM, Iser JH, Gibson PR. A single centre experience of methotrexate in the
many key players. Only by taking a long term approach in treatment
treatment of Crohn’s disease and ulcerative colitis: A case for subcutaneous admin-
decisions, delivering a patient centred multidisciplinary approach, and istration. J Gastroenterol Hepatol 2008;23:954–8.
adopting a chronic disease pathway to management will an optimal 24. Behm BW, Bickston SJ. Tumour necrosis factor-alpha antibody for maintenance of
remission in Crohn’s disease. Cochrane Database Syst Rev 2008;(1):CD006893.
outlook for the vast majority of patients with IBD be achieved.
25. Grimpen F, Pavli P. Advances in the management of inflammatory bowel disease. Int
Med J 2009; in press.
Conflict of interest: none declared. 26. Irving PM, Gearry RB, Sparrow MP, Gibson PR. Review article: Appropriate use of
corticosteroids in Crohn’s disease. Aliment Pharmacol Ther 2007;26:313–29.
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correspondence afp@racgp.org.au

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