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Fiske HW, Ward C, Shah SA, Holubar SD, Al-Bawardy B, Barnes EL, Binion D, Bohm M, Brand M, Clarke K, Cohen BL, Cross RK, Dueker J, Engels M, Farraye FA, Fine S, Forster E, Gaidos J, Ginsburg P, Goyal A, Hanson J, Herfath H, Hull T, Kelly CR, Lazarev M, Levy LC, Melia J, Philpott J, Qazi T, Siegel CA, Watson A, Wexner SD, Williams ED, Regueiro M. Clinical Decision Making in Inflammatory Bowel Disease Mimics: Practice Management from Inflammatory Bowel Disease LIVE. CROHN'S & COLITIS 360 2024; 6:otae022. [PMID: 38720935 PMCID: PMC11078036 DOI: 10.1093/crocol/otae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Indexed: 05/12/2024] Open
Abstract
Background Since 2009, inflammatory bowel disease (IBD) specialists have utilized "IBD LIVE," a weekly live video conference with a global audience, to discuss the multidisciplinary management of their most challenging cases. While most cases presented were confirmed IBD, a substantial number were diseases that mimic IBD. We have categorized all IBD LIVE cases and identified "IBD-mimics" with consequent clinical management implications. Methods Cases have been recorded/archived since May 2018; we reviewed all 371 cases from May 2018-February 2023. IBD-mimics were analyzed/categorized according to their diagnostic and therapeutic workup. Results Confirmed IBD cases made up 82.5% (306/371; 193 Crohn's disease, 107 ulcerative colitis, and 6 IBD-unclassified). Sixty-five (17.5%) cases were found to be mimics, most commonly medication-induced (n = 8) or vasculitis (n = 7). The evaluations that ultimately resulted in correct diagnosis included additional endoscopic biopsies (n = 13, 21%), surgical exploration/pathology (n = 10, 16.5%), biopsies from outside the GI tract (n = 10, 16.5%), genetic/laboratory testing (n = 8, 13%), extensive review of patient history (n = 8, 13%), imaging (n = 5, 8%), balloon enteroscopy (n = 5, 8%), and capsule endoscopy (n = 2, 3%). Twenty-five patients (25/65, 38%) were treated with biologics for presumed IBD, 5 of whom subsequently experienced adverse events requiring discontinuation of the biologic. Many patients were prescribed steroids, azathioprine, mercaptopurine, or methotrexate, and 3 were trialed on tofacitinib. Conclusions The diverse presentation of IBD and IBD-mimics necessitates periodic consideration of the differential diagnosis, and reassessment of treatment in presumed IBD patients without appropriate clinical response. The substantial differences and often conflicting treatment approaches to IBD versus IBD-mimics directly impact the quality and cost of patient care.
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Affiliation(s)
- Hannah W Fiske
- Department of Internal Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Christopher Ward
- Division of Gastroenterology, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Samir A Shah
- Gastroenterology Associates Inc., The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Stefan D Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Badr Al-Bawardy
- Division of Gastroenterology, Yale School of Medicine, New Haven, CT, USA
- Division of Gastroenterology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - David Binion
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Matthew Bohm
- Division of Gastroenterology, Indiana University School of Medicine, Carmel, IN, USA
| | - Myron Brand
- Division of Gastroenterology, Yale School of Medicine, New Haven, CT, USA
| | - Kofi Clarke
- Division of Gastroenterology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Raymond K Cross
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jeffrey Dueker
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael Engels
- Division of Gastroenterology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Sean Fine
- Division of Gastroenterology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Erin Forster
- Division of Gastroenterology, Medical University of South Carolina, Charleston, SC, USA
| | - Jill Gaidos
- Division of Gastroenterology, Yale School of Medicine, New Haven, CT, USA
| | - Philip Ginsburg
- Division of Gastroenterology, Yale School of Medicine, New Haven, CT, USA
| | - Alka Goyal
- Department of Pediatric Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA
| | - John Hanson
- Division of Gastroenterology and Hepatology, Atrium Health, Charlotte, NC, USA
| | - Hans Herfath
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Tracy Hull
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Colleen R Kelly
- Division of Gastroenterology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Mark Lazarev
- Division of Gastroenterology, Johns Hopkins Medical Center, Baltimore, MD, USA
| | - L Campbell Levy
- Center for Digestive Health, Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Joanna Melia
- Division of Gastroenterology, Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Taha Qazi
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Corey A Siegel
- Center for Digestive Health, Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Andrew Watson
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Emmanuelle D Williams
- Division of Gastroenterology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA
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Hallock KK, Mizerak MR, Dempsey A, Maczuga S, Kirby JS. Differences Between Children and Adults With Hidradenitis Suppurativa. JAMA Dermatol 2021; 157:1095-1101. [PMID: 34379074 DOI: 10.1001/jamadermatol.2021.2865] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Up to 50% of patients may have hidradenitis suppurativa (HS) onset between age 10 and 21 years. To our knowledge, little is known about how adolescents with HS utilize health care during their journey to receiving a diagnosis. Objective To assess the clinical characteristics and health care utilization patterns of pediatric vs adult patients with HS. Design, Setting, and Participants This retrospective cohort study included adult and pediatric patients with HS claims from the MarketScan medical claims database during the study period, January 1, 2012, to December 31, 2016. The data were analyzed between March 1 and March 31, 2021. Exposures Clinical characteristics and health care utilization patterns of pediatric vs adult patients with HS. Main Outcomes and Measures Health care utilization patterns were examined and included concurrent diagnoses, outpatient care by discipline, and emergency/urgent care and inpatient claims. Results This study included 8727 members, comprising 1094 pediatric (155 male [14.2%] and 939 female patients [85.8%]; mean [SD] age, 14.3 [2.47] years) and 7633 adult patients (1748 men [22.9%] and 5885 women [77.1%]; mean [SD] age, 37.2 [12.99] years). Pediatric patients were likely to see pediatricians, dermatologists, emergency department (ED) staff, and family physicians before diagnosis and commonly received diagnoses of folliculitis and comedones. Pediatric patients with HS had high rates of comorbid skin and general medical conditions, including acne vulgaris (558 [51.0%]), acne conglobata (503 [45.9%]), obesity (369 [33.7%]), and anxiety disorders (367 [33.6%]). A higher percentage of pediatric than adult patients had HS-specific claims for services rendered by emergency and urgent care physicians (35.6% vs 28.2%; P < .001; and 18.1% vs 13.4%; P < .001; respectively). However, adult patients were more likely to have inpatient stays (2.38% vs 4.22%; P = .002). Pediatric patients had 2.24 ED claims per person, while adults had 3.5 claims per person. The mean cost per ED claim was similar between groups ($413.27 vs $682.54; P = .18). The largest component of the total 5-year disease-specific cost was the cost of inpatient visits for pediatric and adult patients with HS. Conclusions and Relevance This cohort study suggests that pediatric patients utilize high-cost ED care when HS can often be treated as an outpatient. These data suggest that there are opportunities to improve recognition of HS in pediatric patients by nondermatologists and dermatologists.
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Affiliation(s)
- Katherine K Hallock
- Department of Dermatology, Penn State Hershey Medical Center, Penn State University, Hershey, Pennsylvania
| | | | - Alison Dempsey
- Department of Internal Medicine, NYU Langone Health, Brooklyn, New York
| | - Steven Maczuga
- Department of Dermatology, Penn State Hershey Medical Center, Penn State University, Hershey, Pennsylvania
| | - Joslyn S Kirby
- Department of Dermatology, Penn State Hershey Medical Center, Penn State University, Hershey, Pennsylvania
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