Silent Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic and incurable disorder caused by inflammation in the gastrointestinal (GI) tract. The two most noticeable symptoms that patients report during active flares are abdominal pain and change in bowel habits, including the increased urgency and frequency of stools. 

Contrastingly, individuals who suffer from what is known as “silent IBD” are often unaware of their disease due to either the lack of inflammatory symptoms or the minimization of mild symptoms by patients. The UPMC IBD Center research group pioneered this terminology with the first papers on “Silent Crohn’s disease” which were published in the journal Inflammatory Bowel Diseases in 2015 and 2016. Similar to the well-established concept of “silent cardiac ischemia,” where patients have little to no pain but are suffering from lack of oxygen to the heart (seen most commonly in individuals with diabetes mellitus), the researchers have identified a similar presentation in a subgroup of patients with established Crohn’s disease. These individuals with active disease but little to no symptoms are at risk for presenting later in the natural history of the disease, with more advanced problems often requiring surgical intervention. 

UPMC’s David G. Binion, MD, from the Division of Gastroenterology, Hepatology and Nutrition, and his colleague Matthew D. Coates, MD, PhD, from Penn State College of Medicine published a review of previous studies that further examines the epidemiology, potential contributors, and current diagnostic tools for silent IBD. They also offer recommendations for better recognizing this disease in patients in the future.

Since there is little existing knowledge about silent IBD and varying terminology is used by health care providers to describe this phenomenon, there is uncertainty as to how to accurately evaluate patients for silent IBD. While there are multiple screening approaches, experts have yet to establish the optimal set of diagnostic criteria that can conclusively identify and manage at-risk patients. 

Previous studies have demonstrated the importance of regularly evaluating patients using a multimodal approach that includes physical examination, serological and stool testing, imaging studies, and endoscopic evaluations. It is believed that combining the incidental findings from patient physical examinations with these objective measures of disease activity helps health care providers recognize silent IBD and its contributors more easily. 

However, it is believed that using novel endoscopic tools such as an optical chromoendoscopy and confocal laser endomicroscopy may provide a more accurate assessment of the presence of silent IBD moving forward. This research review also suggests that incorporating genomic and proteomic techniques to diagnostic assessment tools may help predict silent IBD recurrence and occurrence.
Dr. Binion and Dr. Coates suggest that individuals who have been diagnosed with Crohn’s disease, ulcerative colitis, or IBD-associated colitis by at least one health care provider will be determined to have silent IBD if they: 

(1) exhibit moderate-to-severe IBD-associated inflammation of the bowel, based upon direct gross (eg, surgical), endoscopic and/or histologic assessment(s) and

(2) are found to be in clinical remission based upon simultaneous, IBD-symptom assessment surveys. 

As a result of this work, Dr. Binion and Dr. Coates recommend identifying individuals with “silent” IBD, and following them with objective guidance (i.e. lab work, endoscopy, radiology, etc.) and not relying on symptoms, which may minimize their actual burden of inflammation.

Read the full review here.