Content uploaded by Shiu Kum Lam
Author content
All content in this area was uploaded by Shiu Kum Lam on Oct 10, 2018
Content may be subject to copyright.
SPECIAL REPORT
Management consensus of inflammatory bowel disease for
the Asia–Pacific region
Qin Ouyang,* Rakesh Tandon,†K L Goh,‡Guo-Zong Pan,§K M Fock,¶Claudio Fiocchi,†† S K Lam‡‡
and Shu-Dong Xiao§§
*Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, §Department of Gastroenterology, Peking Union Medical
College Hospital, Beijing, §§Shanghai Institute of Digestive Disease, Shanghai Renji Hospital, Shanghai Second Medical University, Shanghai,
China, †Department of Gastroenterology, Pushpawati Singhania Research Institute for Liver, Renal and Digestive Diseases, New Delhi, India,
‡Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia, ¶Department of Gastroenterology, Changi General
Hospital, Singapore, ††Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA and ‡‡Faculty of
Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
Abstract
At the present there are no large-scale epidemiologic data on inflammatory bowel disease
(IBD) in the Asia–Pacific region, but several studies have shown an increased incidence and
prevalence of IBD in this region. Compared to the West, there appears to exist a time lag
phenomenon. With regard to the two main forms of IBD, ulcerative colitis (UC) is more
prevalent than Crohn’s disease (CD). In addition to geographic differences, ethnic differ-
ences have been observed in the multiracial Asian countries. Moreover, the genetic back-
grounds are different in the Asian compared to Western patients. For instance, NOD2/
CARD15 variants have not been found in Asian CD patients. In general, the clinical course
of IBD seems to be less severe in the Asia–Pacific region than in Western countries.
Diagnosis of IBD in this region poses special problems. The lack of a gold standard for the
diagnosis of IBD, and the existence of a variety of infectious enterocolitis with similar
manifestations to those of IBD make the differential diagnosis particularly difficult. So far,
Western diagnostic criteria have been introduced for the diagnosis of IBD. A stepwise
approach to exclude non-IBD enterocolitis also must be introduced, and a definite diagnosis
must include typical histological features. In some patients, follow up and therapeutic trials
might be necessary to obtain a definitive diagnosis. A better understanding of the patho-
genesis of IBD will allow the development of better diagnostic markers. The management
of IBD also poses some special problems in the Asia–Pacific Region. There is often a delay
in using proper medications for IBD, and alternative local remedies are still widely used.
With a combination of Western guidelines and regional experiences, similar principles can
be used for induction and maintenance of remission. A stepwise selection of medications is
advocated depending on the extent, activity and severity of the disease. Comprehensive and
individualized approaches are suggested for different IBD patients. Deeper understanding
of disease pathogenesis and the unique characteristics of IBD in the Asia–Pacific region,
combined with reasonable and practical guidelines for drug management and the future use
of biological agents would improve the therapeutic outlook of IBD in this region.
Key words
Asia–Pacific, consensus, inflamatory bowel
disease, management.
Accepted for publication 1 July 2006.
Correspondence
Dr Qin Ouyang, Department of
Gastroenterology, West China Hospital,
Sichuan University, 37 Guoxue Lane,
Chengdu 610041, China. Email:
qin_ouyang@tom.com
Introduction
In recent years a significant increase in the incidence and preva-
lence of inflammatory bowel disease (IBD) observed in Asia–
Pacific countries has prompted the gastroenterologists in this
region to search for an optimal diagnostic and management strat-
egy for patients with IBD. The clinical epidemiology, diagnosis
and treatment of IBD in this region are somewhat different from
those in Western countries. Differences in the environmental and
genetic background of the population in a particular geographic
location contribute to this variance. Infectious diseases, especially
intestinal tuberculosis and other intestinal infections, are common
in this region; they have added to the complexity in the diagnosis
and treatment of patients with IBD. Furthermore, no management
guidelines for IBD have been formulated for the Asia–Pacific
region.
With the intention to solve these issues, Professor Shu-Dong
Xiao, the President of Asia–Pacific Digestive Week (APDW) 2004
proposed to organize an Asia–PacificWorking Party to draw up the
management guidelines of IBD and to plan a working process with
doi:10.1111/j.1440-1746.2006.04674.x
1772 Journal of Gastroenterology and Hepatology 21 (2006) 1772–1782 © 2006 The Authors
Journal compilation © 2006 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
some large-scale background investigations of IBD. The working
party members included IBD experts, leading gastroenterologists
and researchers in this region, and consisted of Dharmika Djojon-
ingrat (Jakarta), Claudio Fiocchi (Cleveland), Kwong Ming Fock
(Singapore), Peter Gibson (Melbourne), KL Goh (Kuala Lumpur),
Won Ho Kim (Seoul), Shiu-Kum Lam (Hong Kong), Ropert
Leong (Sydney), San-Ren Lin (Beijing), Sathaporn Manatsathit
(Bangkok), Qin Ouyang (Chengdu), Haruhiko Ogata (Tokyo), CJ
Ooi (Singapore), Guo-Zong Pan (Beijing), Jose D Sollano, Jr
(Manila), Joseph Sung (Hong Kong), Rakesh Tandon (New Delhi),
Shu-Dong Xiao (Shanghai), and Jia-Ju Zheng (Suzhou). In addi-
tion, Ren-Wei Hu (Chengdu), andYu-Fang Wang (Chengdu) acted
as coordinators.
A Working Party Meeting on IBD was held from 8 to 10 July
2004 in Sanya, Hainan Province, China, which consisted of
plenary and state-of-the-art updates and lectures, the questionnaire
investigation about management of IBD for participants, three
working group discussion key issues in depth and present them to
the symposium. The contents were considered very relevant to the
need of primary care physicians and gastroenterologists in this
region. The evidence-based approach was used to answer the ques-
tions and formulate statements on the management of IBD. The
consensus was presented and ratified at the APDW 2004 in
Beijing, and revised as follows.
Epidemiology of inflammatory bowel
disease in Asia
Several recent Asian studies confirm that the incidence and preva-
lence of both ulcerative colitis (UC) and Crohn’s disease (CD) are
lower than that in North America and Europe. While this is true,
Asia is a very diverse continent and marked differences have been
reported in various geographic areas, and an increased incidence
and prevalence of IBD are seen in this region. To address these
issues, a series of questions were raised and discussed at the
APWP-IBD in Sanya.
What is the incidence and prevalence of IBD in
Asia?
The incidence of UC ranged from 1.0 to 2.0 per 100 000 person
years.1–4 The incidence of CD ranges from 0.5 to 1.0 per 100 000
person years.4,5 The prevalence of UC has ranged from 4.0 to 44.3
per 100 000 and that of CD from 3.6 to 7.7 per 100 000.6,7 Ulcer-
ative colitis appears to be more common than CD in Asia.
In a recent study from South Korea, the prevalence of UC was
7.5/100 000. In studies from Singapore, the prevalence of UC and
CD was 17/100 000 and 3.6/100 000, even higher than that
recently reported from Japan, with a total of more than 100 000
IBD cases in this country, whereas in China the speculated preva-
lence varies between 11.6/100 000 and 1.4/100 000, respectively.
The lower prevalence of IBD is not universal in this region, the
unexpectedly high prevalence of UC in India being 42.8–44.3/
100 000.8
In general, however, there has been a paucity of good studies
carried out in Asia. Apart from Japan, there is no established IBD
register in Asian countries and many studies are hospital based or
studies on subpopulations.
Compared to time trends in the West, there appears to be a time
lag phenomenon involving incidence and and prevalence of IBD
with regard to the Asian experience. In addition to geographic
differences, ethnic differences have been observed in multiracial
Asian countries such as Singapore and Malaysia, where the inci-
dence and prevalence among Indian populations have been con-
sistently reported to be higher compared to that of Malay and
Chinese populations.7,9
Are there any differences in age and gender
distribution between Asian and Western
patients?
The peak age of onset of UC and CD has varied among different
studies but appears to be broadly similar to the Western experi-
ence. In a Japanese nationwide survey, the peak age of onset was
20–29 years for UC and 15–24 years for CD,1whereas the median
age of diagnosis in a Korean study was 35 years.3In the Leong
et al. study from Hong Kong and China the mean age of diagnosis
of CD was 33.1 years and 37.2 years, respectively.4Similarly, in a
more recent review from China, the mean age of CD was
37.7 years, and 44.0 years for UC.10 There is some weak and
inconclusive evidence of a bimodal age of onset of IBD in Asian
patients.4
In the Morita et al. survey in Japan, CD was twice as common
in male as in female subjects.1In the Leong et al. study, CD was
2.5-fold more common in male subjects.4Men appear to be at
greater risk for CD, but gender differences are not as obvious
among UC patients.10,11
Is there a family history and any associations
between smoking, appendectomy in Asian
patients?
Kitahora et al. found a strong familial occurrence in UC among
Japanese patients.12 In a Korean study, a similar familial aggrega-
tion was also reported.13
The association of smoking and CD has not been well studied
among Asian patients. In one study on CD, previous and current
smokers combined were at greater risk of developing CD.4Con-
versely, a study from Japan found a protective effect of smoking
for UC.14 Nam et al. found that appendectomy was protective
against UC in their group of Korean patients.15
Are there any differences in clinical
presentation of UC and CD in Asian patients?
There does not appear to be any significant difference between the
extent of disease in UC between Asian and Western patients,
although great variability has been reported. Both Yang et al. from
Korea and Ling et al. from Singapore reported approximately
equal proportions of patients with distal, left-sided and extensive
disease.3,11 However, Jiang and Cui reported that 70% of patients
had proctitis.10 Extra-intestinal manifestations have been reported
in 2–34% of patients with UC.9,10,16 Disease involvement in CD is
predominantly ileocolonic with approximately 30% of patients
having colonic involvement and 10–20% having only small intes-
tinal involvement. Perianal disease occurs in 2–30% of patients,
but it is generally less common than in Western patients.
Q Ouyang et al. Management of IBD in the Asia–Pacific region
1773Journal of Gastroenterology and Hepatology 21 (2006) 1772–1782 © 2006 The Authors
Journal compilation © 2006 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
Based on long-term follow-up studies from Japan, both UC and
CD have very good long-term prognosis, which is similar or supe-
rior to that of Western patients.17–19
Are there any differences in genetic
susceptibility to CD in Asian compared with
Western patients?
Although there are variations in the human leukocyte antigen
(HLA) in UC patients, the most noticeable difference in Asian
patients is in regard to CD. Three studies from Japan, Korea and
China have shown the absence of the NOD2/CARD15 gene in
Asian patients.20–22 This genetic difference may underlie the lower
frequency of the disease in Asia as compared with the West.
Diagnosis of inflammatory bowel
disease
Diagnosis of IBD poses two major problems. One is the lack of a
gold standard, represented by histological or serological confirma-
tion; the second is the number of conditions that mimic IBD and
require to be considered in the differential diagnosis. The diagno-
sis of IBD is established through a global assessment of the clini-
cal presentation, radiographic, endoscopic and pathologic
findings.23 During the APWP-IBD Sanya, pertinent questions
regarding IBD diagnosis and differential diagnosis were raised and
consensus responses were obtained based on review of the litera-
ture and the individual experience of the experts. They are sum-
marized here.
Diagnostic criteria for IBD
Various diagnostic classifications of IBD are available, including
Mendeloff’s criteria,24 the Lennard-Jones criteria,25 the interna-
tional multicentre scoring system of the Organization Mondiale de
Gastroenterologie (OMGE),26 and the diagnostic criteria of
Japanese Research Society on IBD.27
Modified Mendeloff criteria plus key points of the Lennard-
Jones criteria, commonly used criteria, are presented here.
Ulcerative colitis
Definite (i) History of diarrhea or rectal bleeding for 6 weeks or
more with: (ii) at least one sigmoidoscopy or colonoscopy reveal-
ing one or more of the following: mucosal friability, petechial
hemorrhage, diffuse inflammatory ulceration; radiological evi-
dence of ulceration or narrowing/shortening of the colon; charac-
teristic macroscopic and microscopic changes in a specimen
obtained by surgical resection or biopsy.
Probable (i) A compatible sigmoidoscopy, colonoscopy, or
barium enema with inadequate history; (ii) a compatible history
with dubious sigmoidoscopic or colonoscopic appearance and no
barium enema; (iii) an adequate history but dubious radiological
findings and no sigmoidoscopy or colonoscopy report; and (iv) a
characteristic macroscopic appearance of the operative specimen
with an uncertain histology.
After exclusion of infectious colitis, ischemic colitis, radiation
colitis, solitary rectal ulcer, findings compatible with CD, if com-
patible histology is found, such as continuous mucosal inflamma-
tion without granulomas and rectal involvement with continuity of
the colon, the diagnosis is regarded as ‘definite’; in the absence of
histological confirmation, the diagnosis is regarded as ‘probable’.
Crohn’s disease
Definite Characteristic pathological and histological findings in
an operative specimen showing segmental, transmural lesions, fis-
suring ulcers, and non-caseating granulomas and lymphoid aggre-
gates in the lamina propria and submucosa.
Probable (i) A laparotomy report of characteristic naked-eye
appearance of the bowel but no specimen for histology; (ii) an
equivocal histological report from an operative specimen with
characteristic macroscopic features; (iii) a colonoscopic report
compatible with CD, and biopsy histologic features strongly sug-
gestive of CD; and (iv) a radiologic examination showing chronic
inflammation with obstruction or fistulae.
After exclusion of infections (particularly intestinal tuberculosis
[TB]), ischemia, radiation, lymphoma or carcinoma, if granulomas
are present with at least another criteria or, in the absence of
granulomas, with three of the characteristic lesions, such as skip
lesions, discrete ulcers, fissuring ulcers, fistulae, strictures or aph-
thoid ulcers etc., a diagnosis of CD is regarded as ‘definite’; if two
criteria without granuloma are present, the diagnosis is regarded as
‘probable’.
The term ‘indeterminate colitis’ should be used when only the
colon is involved and the diagnosis of UC or CD is impossible
based on the aforementioned criteria.
The criteria used by the Japanese Research Society on IBD are
outlined as follows.
Ulcerative colitis
(A) Symptoms: continuous or repeated bloody diarrhea; (B) endo-
scopy: diffuse inflammation, loss of vascular pattern, friability
(bleeding at contact), abundant mucus and (i) granular appearance;
(ii) multiple erosions, ulcers; and (iii) pseudopolyps, loss of haus-
tration (lead-pipe pattern), lumen narrowing, and colonic shorten-
ing. (C) Histology: active: inflammatory cells infiltration, crypt
abscess, goblet cell depletion. Remission: crypt architectural
abnormalities (distortion branching), atrophic crypts.
These changes usually begin in the rectum and extend proxi-
mally in continuity. Definite diagnosis: A+one item of B and C.
Crohn’s disease
Major findings (A) Longitudinal ulcer, (B) cobblestone appear-
ance, (C) non-caseating granuloma.
Minor findings (D) Irregular-shaped ulcer or aphthoid ulcers, (E)
irregular-shaped ulcer or aphthoid in upper and lower gastrointes-
tinal tract.
Management of IBD in the Asia–Pacific region Q Ouyang et al.
1774 Journal of Gastroenterology and Hepatology 21 (2006) 1772–1782 © 2006 The Authors
Journal compilation © 2006 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
Definite diagnosis: (i) C along with either A or B; (ii) C and D
or E. Suspect: (i) A or B, but cannot exclude ischemic colitis or
ulcerative colitis; (ii) C; (iii) D or E.
The criteria are quite simple and easy to apply, but the exclusion
criteria should be applied first; in particular the epidemic infec-
tious disease should be excluded first in this region.
A suggested guideline from China paid more attention to the
scrutinizing and evaluation of the patients, and the exclusion cri-
teria applied first.28
Differential diagnosis of IBD
Differentiating IBD from acute self-limiting colitis and
amoebic colitis
Acute self-limiting colitis (ASLC) by definition resolves generally
in <4 weeks. An infectious etiology is often suspected, such as
Salmonella, Shigella, Clostridium difficile,Escherichia coli,
E. histolytica. Acute onset of illness with fever and more than 10
bowel movements/24 h is seen in more than three-fourths of the
patients. Stool cultures are positive in less than half of cases, but
they may help the diagnosis. Fecal leukocytes are insensitive
markers of infection because they are seen in both ASLC and IBD,
but increased platelet is not commonly seen in ASLC.29 The
colonic mucosa crypts are generally normal, which is character-
ized by a predominantly polymorphonuclear infiltrate in the
lamina propria; giant cells and rarely granulomas may be seen in
the upper part of the mucosa (e.g. in lymphogranuloma venereum,
syphilis). The diagnosis of amoebiasis is made by identifying
trophozoites in fresh stools, mucosal exudates or mucosal biop-
sies. Serology may be useful. A total of 75–85% of patients with
acute amoebic colitis have detectable anti-amoebic antibodies at
the time of presentation.
Differentiating Crohn’s disease from TB
Because of the similarity of clinical, endoscopic, radiologic and
pathological findings of CD and TB, there may be a 50–70%
misdiagnosis rate between the two conditions. Diagnosis of CD
should always be made with caution in this region and TB must be
excluded first. Distinguishing clinical features include perianal
involvement and intestinal fistulae for CD, and past or present
history for TB. Endoscopic features may help distinguish these
two conditions. Helpful endoscopic features include longitudinal
ulcers for CD and transverse ulcers for TB.30,31 Histopathological
features are most useful in distinguishing between the two condi-
tions.32 The presence of small, discrete, loose granulomas without
caseation both in the bowel and in mesenteric lymph nodes are
characteristic of CD. But large, dense, confluent granulomas with
caseation and acid-fast bacilli (AFB) positivity are characteristic
of TB. In cases where TB cannot not excluded, a therapeutic trial
of antituberculosis therapy for a period of 4–8 weeks is justified. A
TB DNA analysis on the tissues with TB-specific primer could be
helpful. The positivity could reach 70% for TB cases, which is
useful for differentiation.33,34 Details are given in Table 1.
Differentiating Crohn’s disease from Behcet’s disease
The following diagnostic criteria for Behcet’s disease are recom-
mended by the International Study group for Behcet’s disease:35 (i)
recurrent oral ulcers: occurring at least three times in the past
12 months; (ii) recurrent genital ulceration; (iii) ocular lesions:
anterior uveitis, posterior uveitis, retinal vasculitis; (iv) skin
lesions: erythema nodosum, pseudofolliculitis, papulopustular
lesions, aceniform nodules; (v) positive pathergy test: pricking a
sterile needle into the patient’s forearm; an aseptic erythematous
nodule or pustule >2 mm in diameter at 24–48 h are judged as
positive.
For a definitive diagnosis the patient must have recurrent oral
ulceration plus two other features in the absence of clinical expla-
nations.
The HLA typing may also be helpful in the differential diag-
nosis. The prevalence of the HLA-B51 allele is high among
patients with Behçet’s disease.
Other differential diagnoses
In ischemic colitis rectal sparing usually occurs; histology may
show hemosiderin-laden macrophages and sparing of the lower
crypts with preferential damage to the superficial epithelium.
Microscopic colitis includes collagenous colitis and lympho-
cytic colitis, and should be considered when painless, large-
volume diarrhoea is present without bleeding. Endoscopy is
usually normal, and the diagnosis rests on demonstration of a thick
collagenous band in the subepithelium or an increased number of
intra-epithelial lymphocytes.
Radiation colitis, diversion colitis, and non-steroidal anti-
inflammatory drug enteropathy should be considered when a
Table 1 Features differentiating CD from TB
Crohn’s Intestinal TB
Age (years) 20–50 Any age
Sex (M:F) 3:1 1:3
Obstructive symptoms Occasional Frequent
Perianal disease/fistula Frequent Rare
Ulcer/stricture Long deep
multiple
Transverse
<3cm
Histology
Granulomas +++
Granuloma >200 mm– ++
>5 g/section – ++
Caseation – ++
Confluence – ++
Location of granulomas
Mucosa ++
Submucosa – +
Granulation tissue – +
Microgranulomas +–
Disproportionate
submucosal inflammation
+/– +
AFB – +
TB DNA analysis – +
AFB, acid-fast bacilli; CD, Crohn’s disease; TB, tuberculosis.
Q Ouyang et al. Management of IBD in the Asia–Pacific region
1775Journal of Gastroenterology and Hepatology 21 (2006) 1772–1782 © 2006 The Authors
Journal compilation © 2006 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
compatible history is present. The diagnosis of Henoch-Schonlein
purpura is made with the demonstration of IgA deposition in
purpuric skin rashes, kidneys or bowel.
Malignant lymphoma usually presents in young individuals
with progressively severe diarrhea, hematochezia and abdominal
pain. Histology is decisive for the diagnosis. Colon cancer usually
presents with hematochezia with or without abdominal pain and
obstruction. Colonoscopy with biopsy could be used for the
diagnosis.
For some cases difficult to differentiate, 3–6 months of follow
up is recommended to make a definite diagnosis of IBD.
Differentiating ulcerative colitis from Crohn’s disease
The major morphological and structural differences between the
two forms of IBD are outlined in Table 2, and the differentiating
histological features are outlined in Table 3.
Essentials for diagnosis of IBD
A complete diagnosis of IBD should include clinical type, distri-
bution and extent of disease, severity and activity of disease for
better therapeutic strategy and prognostic evaluation. Extra-
intestinal manifestations and complications should also be
included. The most important aspects of diagnosis are the distri-
bution, activity and severity of the disease, which impact on the
management strategy, the route of medication and the prognosis of
the disease.
Diagnostic approach to IBD
The diagnostic process should be standardized for better
practice.28
When UC is suspected clinically, the recommended stepwise
diagnostic approach is the following.
(1) Routine fecal examinations and cultures should be carried
out to rule out diseases such as bacillary dysentery, amoe-
biasis, schistosomiasis etc.
(2) Colonoscopic examination and biopsy should be done,
except for patients with fulminant disease.
(3) Barium enema should be performed if necessary.
(4) Routine laboratory examinations such as the complete
blood count (CBC), plasma protein, erythrocyte sedimen-
tation rate (ESR), and C-reactive protein (CRP) tests are
helpful. Plain radiology, blood electrolytes and culture
might be necessary for severe cases.
(5) Endoscopic proctitis (or cryptogenic colitis) cannot be
diagnosed as UC and cannot be used as a clinical
diagnosis.
When CD is suspected clinically, the recommended stepwise
diagnostic approach is the following (once TB infection has been
excluded by relevant examinations, such as chest X-ray, old tuber-
culin test and serum purified protein derivative antibody test etc.).
(1) Endoscopy, contrast GI examination, or videocapsule
endoscopy should be done according to the possible
involved segments.
(2) Computed tomography or ultrasonography might be
needed for involved bowel wall and extra-intestinal
complications.
(3) Laboratory examinations as used in UC for activity and
severity assessment of the disease. Biopsy from involved
area for pathological figures and AFB, and TB DNAanaly-
sis on TB and CD tissues with TB special primers if
possible.
Further directions for diagnosis of IBD
There is a need to implement objective diagnostic criteria for UC
and CD in the Asia–Pacific region. This is essential to minimize
confusion and misdiagnosis, which arise in studies on epidemiol-
ogy as well as in studies elucidating etiopathogenesis. The differ-
ential criteria between intestinal tuberculosis and CD are
Table 2 Clinical and endoscopic features between UC and CD
Ulcerative colitis Crohn’s disease
Site of disease Colon only Any part of GI tract
Distribution Diffuse Focal (segmental)-skip
areas
Mucosa and
submucosa
Transmural
Complications
Fistulae &
abscesses
Rare Common
Strictures Uncommon Common
Cancer risk More common Less
Colonoscopic
appearance
Diffuse friability or
ulceration
Focal aphthous ulcers
Lineal ulcers
Cobblestones
Anal lesion Rare Approximately 75%
CD, Crohn’s disease; GI, gastrointestinal; UC, ulcerative colitis.
Table 3 Differential histology between UC and CD
Ulcerative colitis Crohn’s disease
Mucosal inflammation
characteristic
Patchy transmural inflammation
Width of submucosa normal or
often reduced
Submucosal width normal or
increased
Intense vascularity, little edema Vascularity seldom prominent,
edema marked
Focal lymphoid hyperplasia
restricted to submucosa,
mucosa and superficial
submucosa
Focal lymphoid hyperplasia in
mucosa, serosal
and pericolic in mucosa,
serosal and pericolic tissues
Crypt abscesses very common Crypt abscesses fewer in
number
Epithelioid cell granulomas
absent from bowel and
lymph nodes
Epithelioid cell granulomas in
60–70% of cases in bowel
and lymph nodes
Fissuring absent Fissuring very common
Precancerous epithelial change
occurs
Precancerous change
uncommon
Anal lesions: non-specific
inflammation
Anal epithelioid cell granulomas
often present
Management of IBD in the Asia–Pacific region Q Ouyang et al.
1776 Journal of Gastroenterology and Hepatology 21 (2006) 1772–1782 © 2006 The Authors
Journal compilation © 2006 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
particularly important because TB is still rampant in this region
and the incidence of CD is also on the rise in this region. The
diagnostic markers from serum, feces and tissue will be helpful for
the diagnosis of IBD and for differential diagnosis. Evolution of
genetic assays as diagnostic tools should be one of the forward
leaps in this area.
Management of inflammatory bowel
disease from an Asia–Pacific
standpoint
A search of publications from the Asia–Pacific region over the last
15 years was performed using Medline. There was a paucity of
studies on practical clinical treatment, while published literature
on advanced therapies used for treatment of IBD in this region was
available.36–39 In APWP-IBD Sanya, the following questions
regarding IBD management were raised and a consensus was
obtained based on a review of literature and experiences of experts.
Are there guidelines available for IBD
management in Western countries?
Guidelines for IBD management in the USA, UK and other
Western countries have been published and regularly revised. The
American College of Gastroenterology (ACG) published its
revised guidelines for the management of CD and UC in 200140
and 2004,41 respectively. The highlights include reference to
evidence-based data through an extensive review of recent litera-
ture and presentation of the evidence level for each opinion; but
less attention to diagnosis. More detailed descriptions of manage-
ment strategies for UC and CD with novel biological therapy,
mainly for CD.42
Guidelines for the management of IBD have also been prepared
by the British Society of Gastroenterology and published
recently.43 The scheduled review of guidelines within 3 years takes
account of new evidence. Beside the management of IBD in dif-
ferent situations, the guidelines also included service delivery,
patient perspective, and associated aspects of IBD management. A
suggested guideline from China paid more attention to the scruti-
nizing and evaluation of the patients, and also some basic prin-
ciples for management of IBD.28 All these guidelines should serve
as a major reference for our management consensus.44
What are the goals of IBD treatment?
The goals of IBD treatment are to induce and maintain remission
of both clinical symptoms and mucosal inflammation, and to
re-establish the intestinal barrier, so as to reduce relapse and com-
plication, and to improve quality of life.45
How should patients with IBD be evaluated
before treatment?
Before starting treatment, patients need to be re-evaluated for
correct diagnosis, and to ensure that other colitis and colonic
lesions have been excluded. The anatomical location and extent of
inflammation, severity and disease activity, presence of extra-
intestinal manifestations and complications etc. should be scruti-
nized to decide the best form of treatment. It is essential to
remember that a correct diagnosis is based on the combination of
clinical, endoscopic, radiological and histological data.
Do we need to use disease activity indices for
evaluation and how should they be used?
In clinical practice, complex clinical or laboratory-based disease
activity indices (DAI) for UC and CD would not be necessary. The
physician subjective clinical assessment is generally sufficient for
evaluation, but a simplified DAI can be helpful for a quantitative
estimate of disease activity and response to therapy.
The Sutherland index (also called Mayo indices) for UC and
the Harvey–Bradshaw index for CD are recommended in practice,
as described in Tables 4 and 5.
These simplified DAI, combined with routine laboratory
parameters such as CBC with platelets, ESR, CRP and serum
albumin levels, should be sufficient for the initial assessment and
monitoring of response to treatment. During follow up the clinical
indices should be measured again and, in addition, the laboratory
tests that were originally abnormal should be repeated. The fre-
quency of follow-up visits, and measurements of DAI, and labo-
ratory studies will depend on the severity of IBD at the time of the
initial evaluation.
What are the treatment recommendations for
induction and maintenance of remission in UC?
Induction of remission
For mild active distal UC with disease <25 cm, topical
5-aminosalicylic acid (5-ASA) is the first line therapy.
For colitis from >25 cm up to the splenic flexure, oral
5-ASA +topical 5-ASA is indicated. Combined therapy is better
than single treatment.
Table 4 Sutherland disease activity index
01 2 3
Diarrheal frequency Normal 1–2/day 3–4/day >5/day
>normal >normal >normal
Rectal bleeding None Streaks Obvious Mostly
Mucosal appearance Normal Mild friability Moderate friability Exudation, spontaneous bleeding
Physician rating of disease activity Moderate Normal Mild Severe
Total score =sum of the item scores
<2, remission; 3–5, mildly active; 6–10, moderately active; 11–12, severe active.
Q Ouyang et al. Management of IBD in the Asia–Pacific region
1777Journal of Gastroenterology and Hepatology 21 (2006) 1772–1782 © 2006 The Authors
Journal compilation © 2006 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
For moderate active UC extending beyond the splenic flexure
and up to the cecum (extensive), optimal oral 5-ASA combines
with topical 5-ASA/steroid should be given depending on rectal
symptoms. After 2–4 weeks of 5-ASA, if the patient fails to
respond with the treatment, then oral glucocorticoids (GCS)
should be started.
Optimal dose: sulfasalazine at 3–6 g/day; mesalamine at
2–4.8 g/day; balsalazide at 4–6.75 g/day; olsalazine at 2 g/day.
The dose could be tailored according to body mass index and
personal experience.
For severe extensive colitis if an oral GCS approach fails or
disease is refractory to oral treatment, the patients should be hos-
pitalized for i.v. GCS. If GCS have been used for 7–10 days and
failed, cyclosporine can be considered, although approximately
50% of patients will eventually need colectomy at 1-year follow
up. Antibiotics should be considered for infectious complications,
or if the patient appears clinically toxic, until the blood culture
reports come back negative. Patients with fulminant colitis are
treated similarly but observed closely and a decision regarding
surgery should be made within 7–14 days of.
Based on Japanese studies, leukocyte removal therapy (leuko-
cytapheresis), which downregulates pro-inflammatory cytokine
products and adhesion molecules, could be used for refractory and
severe UC cases.46 A multicenter control trial found a higher effec-
tiveness of leukocytapheresis than prednisone (74% vs 38%),
which is now considered to be one of the standard treatments to
avoid surgery.47
Maintenance of remission
Maintenance therapy is recommended for all patients, except those
with a mild first attack or limited lesions who went into complete
remission with initial treatment; it is also recommended if the
relapses occur within 6 months of remission induction.
Regardless of how remission was induced, oral 5-ASA is rec-
ommended at the same dose that induced remission, and dose
reduction is not recommended, except for sulfasalazine (SASP)
because of intolerance of side-effects.
The 5-ASA maintenance is always recommended for long-term
utility. The patient should be informed to take 5-ASA for the
‘foreseeable future’, which can be defined as a 3–5-year period or
even lifelong. Glucocorticoids are not recommended for mainte-
nance.
Failure of maintenance
This is defined as more than two flare-ups in a 1-year period. If
remission is not achieved with optimal 5-ASA doses, check treat-
ment adherence and medication of patients carefully. Add immu-
nosuppressives with doses of 6-mercaptopurine (6-MP) at 0.75–
1.5 mg/kg per day; or azathioprine (AZA) at 1.5–2.5 mg/kg per
day. If relapse is severe, use the same regimen that achieved the
initial induction of remission and follow closely until the remis-
sion is achieved. Probiotics could be tried.
Chronic active recurrent disease
An optimal dose of oral 5-ASA and immunosuppressives is rec-
ommended. The patient should be advised to take 5-ASA for
lifelong maintenance therapy or for the foreseeable future, which
can be defined as a 3–5-year period or remission for 2 years. If
5-ASA and immunosuppressives fail, colectomy or biologicals
should be considered, such as infliximab, or probiotics. But GCS
are not recommended. Colectomy is indicated for severe dysplasia
and cancer.
What are the treatment recommendations for
induction and maintenance of remission in CD?
Induction of remission
For all CD patients it is mandatory to stop smoking. For mild
disease of the small bowel, high-dose 5-ASA as initial therapy, or
antibiotics (metronidazole or ciprofloxacin) are recommended, but
usually not as first-line therapy because of side-effects. For colonic
CD, 5-ASA and/or antibiotics, SASP is effective, but beware of
side-effects.
For moderate disease in small bowel, budenoside/prednisone
and/or antibiotics are recommended, but 5-ASA is not recom-
mended. For colonic moderate CD, GCS, 5-ASA or antibiotics are
recommended. Topical 5-ASA may be effective in left-sided
colonic CD.
For severe disease of the small bowel and colon, i.v. GCS and
antibiotics are appropriate, but 5-ASA is not recommended. Con-
sider immunosuppressives as adjunctive therapy, AZA and 6-MP
act slowly, which precludes their use as a sole therapy. Biologicals,
such as infliximab, are effective, but are better to be avoided for
obstructive CD cases. For all severe cases, nutritional therapy
should be considered, either elemental or polymeric diets are
adjunctive. Total parenteral nutrition should be used in cases of
significant nutritional deficiency.
Table 5 Harvey-Bradshaw CDAI
Symptom Severity Score
General
well-being
Well 0
Slightly poor 1
Poor 2
Very poor 3
Extremely poor 4
Abdominal
pain
None 0
Mild 1
Moderate 2
Severe 3
Diarrhea 1 for each liquid
stool per day
Abdominal
mass
None 0
Dubious 1
Definite 2
Definite with tenderness 3
Complications Arthralgia, uveitis, erythema
nodosum, pyoderma
gangrenosum,
aphthous ulcer, anal
fissure, new fistula or
abscess
1 for each item
CDAI, Crohn’s disease activity index.
<4, remission; 5–8, moderate; >9, severe.
Management of IBD in the Asia–Pacific region Q Ouyang et al.
1778 Journal of Gastroenterology and Hepatology 21 (2006) 1772–1782 © 2006 The Authors
Journal compilation © 2006 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
Maintenance of remission
Cessation of smoking is of critical importance. Start maintenance
therapy during the induction phase regardless of disease severity.
The 5-ASA has limited benefit for CD maintenance. Salfasalazine
is not recommended because of the high incidence of side-effects.
The patient should be advised to take 5-ASA for the foreseeable
future, which can be defined as a 3–5-year period or even longer.
Azathioprine and 6-MP are effective for maintenance of remission,
but are reserved as second-line therapy because of the potential
toxicity. Methotrexate could be used i.m. or s.c. in cases of failure
or intolerance to AZA or 6-MP. The GCS are not effective for
maintenance, although budesonide has been used for long periods,
in chronic active CD. Infliximab is effective in patients who
responded to initial therapy, if used at regular intervals, but it is
better to combine it with other options.
Failure of remission or maintenance
In cases of failure of remission or maintenance, new biologicals or
surgery should be considered.
Gastroduodenal involvement
The same therapy as for small bowel is recommended, plus acid
suppression (proton pump inhibitors).
Perianal disease
Antibiotics are first-line therapy. Drainage of abscesses and place-
ment of setons should be used if appropriate. Infliximab is effec-
tive for active disease. For maintenance also consider antibiotics,
drainage of abscesses, infliximab, and immunosuppressives.
Complications
For obstruction/strictures, consider surgery. For inflammatory
complications, the same therapy as for induction of remission, is
recommended. For fistulas, apply the same therapy as for induc-
tion of remission, also consider infliximab and/or surgery. For
entero-enteric, -vesical, -vaginal fistulas, apply the same therapy
as for the induction of remission, and consider surgery on a case-
by-case basis.
What is the role of new biological agents for
the treatment of IBD in the Asia–Pacific
region?
Advances in the understanding of the mechanisms of gut inflam-
mation have led to the development of a whole series of new
agents that specifically block molecules with pro-inflammatory
activity or supply an excess of molecules with natural anti-
inflammatory activity. Such agents, called ‘biological agents’ or
simply ‘biologicals’, are revolutionizing the treatment of IBD in
Western countries. Although not readily accessible, these agents
will eventually become available in the Asia–Pacific region. In this
regard, local physicians and health officials should alert pharma-
ceuticals regarding the emergence of IBD. Based on their biologi-
cal properties, they can be classified as agents that neutralize the
cytokine tumor necrosis factor-a(TNF-a), agents that block cell
adhesion molecules, natural anti-inflammatory agents, and miscel-
laneous agents.
Anti-tumor necrosis factor-aagents
Tumor necrosis factor-ais a potent pro-inflammatory molecule
and its blockade has proven to be beneficial in IBD. The antibody
infliximab, that neutralizes the biological activity of TNF-aand
induces apoptosis (cell death) of TNF-a-bearing immune cells, is
now recognized as the most effective biological for the treatment
of CD,48 not only for active disease, but also for maintenance and
treatment of fistulas.49,50 The apparent beneficial effects of inflix-
imab in UC have been recently reported.51 Being a foreign protein,
infliximab can cause infusion reactions and autoimmune phenom-
ena that reduce response to treatment, and the concomitant use of
antihistaminic drugs and immunosuppressive therapy is now rou-
tine.52 In addition to infliximab, various other anti-TNF-aagents
have been developed that display variable therapeutic effects.
Etanercept, a genetically engineered fusion protein consisting of
two p75 chains of the TNF-areceptor, is safe but not effective for
the treatment of CD patients,53 even though it works well in rheu-
matoid arthritis. Certolizumab (CDP870) is a humanized anti-
TNF-aantibody currently undergoing clinical trials for CD and
with a good therapeutic potential.54
Anti-cell adhesion molecule agents
Cell adhesion molecules can promote inflammation by enhancing
cell-to-cell contact or promoting influx of leukocytes into diseased
tissues. Blocking of intercellular adhesion molecule-1 with the
antisense oligonucleotide ISIS-2302 (alicaforsen) did not have
clinical efficacy in CD patients as measured by steroid-free remis-
sion.55 Natalizumab, an antibody against integrin-a4, a molecule
that mediates leukocyte homing to the gut, appears to be effective
in CD.56 However, recent reports of progressive multifocal leu-
koencephalopathy in patients receiving natalizumab may severely
limit the usefulness of this anti-cell adhesion molecule approach.57
Anti-inflammatory agents
One of the most effective anti-inflammatory molecules is
interleukin-10 (IL-10), which also has a strong immunosuppres-
sive function. In spite of promising preliminary results, s.c. admin-
istration of recombinant IL-10 failed to induce remission in CD
patients,58 and this agent is not longer being tested in clinical trials.
Miscellaneous agents
A variety of other biologicals have been tested as novel therapies
for IBD. A monoclonal antibody against IL-12 induces clinical
response and remission in patients with active CD.59 A possible
beneficial effect was also seen in a pilot trial with an anti-IL-6
receptor monoclonal antibody given to patients with active CD.60
Sargramostin, a recombinant hematopoietic granulocyte–
macrophage colony-stimulating factor that stimulates innate
immunity, has been given to CD patients under the assumption that
this condition is a form of innate immunity deficiency. A full
clinical response was not achieved, but disease activity decreased
Q Ouyang et al. Management of IBD in the Asia–Pacific region
1779Journal of Gastroenterology and Hepatology 21 (2006) 1772–1782 © 2006 The Authors
Journal compilation © 2006 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
and quality of life improved.61 Epidermal growth factor promotes
epithelial healing, and enemas containing this factor were found to
be effective in patients with left-sided UC,62 while recombinant
interferon-b-1a was ineffective in a trial of steroid-refractory UC
patients.63
How should we approach surveillance for
colonic carcinoma in IBD?
There is no large-scale report about malignancy of IBD in the
Asia–Pacific region, only individual case reports on colon cancer
or malignant lymphoma from UC. The implication of dysplasia
from UC has long been noted. It is advisable to carry out serial
colonoscopies in patients who have extensive colitis for
8–10 years. Patients with primary sclerosing cholangitis (PSC)
have a high risk of colon cancer and should be screened frequently.
If dysplasia is detected, obtain a second opinion from another
gastrointestinal pathologist and, if confirmed as severe dysplasia,
then colectomy is advisable. For mild dysplasia, repeat the
colonoscopy in 3–6 months.
How important is alternative therapy for IBD
therapy in the Asia–Pacific region?
Because of the relative lack of resources and financial means for
IBD treatment in most of the Asian countries, special attention
should be paid to cost-effectiveness. Also, because of the history
and tradition of alternative medicine and Chinese medicine, there
is much experience available in this region. Germinated barley
foodstuffs, curcumin and different varieties of traditional Chinese
medicine have been tried in some countries in this area. In the
many traditional remedies used in this area, there are plenty of
components with antibiotic, prebiotic, immunomodulatory or
motility regulating effects. In some reports on the treatment of
IBD, especially when combined with Western medicines, better
efficacy has been obtained, but this must be further analyzed and
evaluated scientifically with modern medical methods.
Conclusion
In the Asia–Pacific region, similar management guidelines as those
in Western countries are being used in most countries. But a
precise diagnosis, a stepwise diagnosis procedure, and especially
the exclusion of infectious enterocolitis and TB, should be
stressed. Apart from routine treatment, some advanced therapies
and alternative medications have been used in this region. Cyta-
pheresis, infliximab, and herbal medicine have been used with
favorable results. But some basic principles on the management
should be emphasized because of the emergence of IBD in most of
the countries in this region. This preliminary consensus will be
helpful in achieving a uniformity of management in the emerging
arena of IBD and should be revised regularly. With better under-
standing of the pathogenesis of IBD, newer modes of management
of the disease will achieve better results. Such an approach is
certain to improve the outcome of patients with IBD in the Asia–
Pacific Region.64,65
Acknowledgments
We are very grateful to Beaufour-Ipsen (Tianjin) Pharmaceutical
and Astrazeneca (Wuxi) Pharmaceutical for their generous finan-
cial support.
References
1 Morita N, Toki S, Hirohashi T et al. Incidence and prevalence of
inflammatory bowel disease in Japan: nationwide epidemiological
survey during the year 1991. J. Gastroenterol. 1995; 30 (Suppl. 8):
1–4.
2 Radhakrishnan S, Zubaidi G, Daniel M, Sachdev GK, Mohan AN.
Ulcerative colitis in Oman. A prospective study of the incidence and
disease pattern from 1987 to 1994. Digestion 1997; 58: 266–70.
3 Yang SK, Hong WS, Min YI et al. Incidence and prevalence of
ulcerative colitis in the Songpa-Kangdong District, Seoul, Korea,
1986–1997. J. Gastroenterol. Hepatol. 2000; 15: 1037–42.
4 Leong RW, Lau JY, Sung JJ. The epidemiology and phenotype of
Crohn’s disease in the Chinese population. Inflamm. Bowel Dis.
2004; 10: 646–51.
5 Al-Ghamdi AS, Al-Mofleh IA, Al-Rashed RS et al. Epidemiology
and outcome of Crohn’s disease in a teaching hospital in Riyadh.
World J. Gastroenterol. 2004; 10: 1341–4.
6 Sood A, Midha V, Sood N, Bhatia AS, Avasthi G. Incidence and
prevalence of ulcerative colitis in Punjab, North India. Gut 2003; 52:
1587–90.
7 Lee YM, Fock K, See SJ, Ng TM, Khor C, Teo EK. Racial
differences in the prevalence of ulcerative colitis and Crohn’s disease
in Singapore. J. Gastroenterol. Hepatol. 2000; 15: 622–5.
8 Ouyang Q, Tandon R, Gol KL et al. The emergence of inflammatory
bowel disease in the Asian Pacific region. Curr. Opin. Gastroenterol.
2005; 21: 408–13.
9 Tan YM, Goh KL. Ulcerative colitis in a multiracial Asian country:
racial differences and clinical presentation in Malaysian patients.
World J. Gastroenterol. 2005; 11: 5859–62.
10 Jiang XL, Cui HF. An analysis of 10218 ulcerative colitis cases in
China. World J. Gastroenterol. 2002; 8: 158–61.
11 Ling KL, Ooi CJ, Luman W, Cheong WK, Choen FS, Ng HS.
Clinical characteristics of ulcerative colitis in Singapore, a
multiracial city-state. J. Clin. Gastroenterol. 2002; 35: 144–8.
12 Kitahora T, Utsunomiya T, Yokota A. Epidemiological study of
ulcerative colitis in Japan: incidence and familial occurrence. The
Epidemiology Group of the Research Committee of Inflammatory
Bowel Disease in Japan. J. Gastroenterol. 1995; 30 (Suppl. 8): 5–8.
13 Park ER, Yang SK, Myung SJ et al. Familial occurrence of
ulcerative colitis in Korea. Korean J. Gastroenterol. 2000; 36:
770–4.
14 A case-control study of ulcerative colitis in relation to dietary and
other factors in Japan. The Epidemiology Group of the Research
Committee of Inflammatory Bowel Disease in Japan. J.
Gastroenterol. 1995; 30 (Suppl. 8): 9–12.
15 Nam SW, Yang SK, Jung HY et al. Appendectomy and the risk of
developing ulcerative colitis: results after control of smoking factor.
Korean J. Gastroenterol. 1998; 32: 55–60.
16 Law NM, Lim CC, Chong R, Ng HS. Crohn’s disease in the
Singapore Chinese population. J. Clin. Gastroenterol. 1998; 26:
27–9.
17 Okada M, Sakurai T, Yao T et al. Clinical course and long-term
prognosis of Crohn’s disease in Japan. J. Gastroenterol. 1994; 29:
406–14.
18 Hiwatashi N, Yao T, Watanabe H et al. Long-term follow-up study
of ulcerative colitis in Japan. J. Gastroenterol. 1995; 30 (Suppl. 8):
13–16.
Management of IBD in the Asia–Pacific region Q Ouyang et al.
1780 Journal of Gastroenterology and Hepatology 21 (2006) 1772–1782 © 2006 The Authors
Journal compilation © 2006 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
19 Iida M, Yao T, Okada M. Long-term follow-up study of Crohn’s
disease in Japan. The Research Committee of Inflammatory Bowel
Disease in Japan. J. Gastroenterol. 1995; 30 (Suppl. 8): 17–19.
20 Inoue N, Tamura K, Kinouchi Y et al. Lack of common NOD2
variants in Japanese patients with Crohn’s disease. Gastroenterology
2002; 123: 86–91.
21 Croucher PJ, Mascheretti S, Hampe J et al. Haplotype structure and
association to Crohn’s disease of CARD15 mutations in two
ethnically divergent populations. Eur. J. Hum. Genet. 2003; 11:
6–16.
22 Leong RW, Armuzzi A, Ahmad T et al. NOD2/CARD15 gene
polymorphisms and Crohn’s disease in the Chinese population.
Aliment. Pharmacol. Ther. 2003; 17: 1465–70.
23 Sands BE. From symptom to diagnosis: clinical distinctions among
various forms of intestinal inflammation. Gastroenterology 2004;
126: 1518–32.
24 Calkins BM, Lilienfeld AM, Garland CF, Mendeloff AI. Trends in
incidence rates of ulcerative colitis and Crohn’s disease. Dig. Dis.
Sci. 1984; 29: 913–20.
25 Lennard-Jones JE. Classification of inflammatory bowel disease.
Scand. J. Gastroenterol. Suppl. 1989; 170: 2–6;discussion 16–19.
26 Myren J, Bouchier IA, Watkinson G, Softley A, Clamp SE,
de Dombal FT. The OMGE multinational inflammatory bowel
disease survey 1976–1986. A further report on 3175 cases. Scand. J.
Gastroenterol. Suppl. 1988; 144: 11–19.
27 Shivananda S, Hordijk ML, Ten Kate FJ, Probert CS, Mayberry JF.
Differential diagnosis of inflammatory bowel disease. A comparison
of various diagnostic classifications. Scand. J. Gastroenterol. 1991;
26: 167–73.
28 Chinese Society of Gastroenterology. Suggested guideline for the
diagnosis and treatment of inflammatory bowel disease. Chin. J. Dig.
Dis. 2001; 2: 202–8.
29 Anand BS, Malhotra V, Bhattacharya SK et al. Rectal histology in
acute bacillary dysentery. Gastroenterology 1986; 90: 654–60.
30 Liu TH, Pan GZ, Chen MZ. Crohn’s disease. Clinicopathologic
manifestations and differential diagnosis from enterocolonic
tuberculosis. Chin. Med. J. (Engl.) 1981; 94: 431–40.
31 Bhargava DK, Tandon HD, Chawla TC, Shriniwa S, Tandon BN,
Kapur BML. Diagnosis of ileocecal and colonic tuberculosis by
colonoscopy. Gastrointest. Endosc. 1985; 31: 68–70.
32 Tandon HD, Prakash A. Pathology of intestinal tuberculosis and its
distinction from Crohn’s disease. Gut 1972; 13: 260–9.
33 Anand BS, Schneider FE, El-Zaatari FA, Shawar RM, Clarridge JE,
Graham DY. Diagnosis of intestinal tuberculosis by polymerase
chain reaction on endoscopic biopsy specimens. Am. J.
Gastroenterol. 1994; 89: 2248–9.
34 Gan HT, Ouyang Q, Bu H. Polymerase chain reaction assay in
differentiating intestinal tuberculosis from Crohn’s disease. Chin. J.
Dig. 2001; 21: 215–18.
35 Lee RG. The colitis of Behcet’s syndrome. Am. J. Surg. Pathol.
1986; 10: 888–93.
36 Ogata H, Hibi T. Cytokine and anti-cytokine therapies for
inflammatory bowel disease. Curr. Pharm. Des. 2003; 9: 1107–13.
37 Chourasia MK, Jain SK. Pharmaceutical approaches to colon
targeted drug delivery systems. J. Pharm. Pharm. Sci. 2003; 6:
33–66.
38 Kohgo Y, Ashida T, Maemoto A, Ayabe T. Leukocytapheresis for
treatment of IBD. J. Gastroenterol. 2003; 38 (Suppl. 15): 51–4.
39 Isbister WH, Hubler M. Inflammatory bowel disease in Saudi
Arabia: presentation and initial management. J. Gastroenterol.
Hepatol. 1998; 13: 1119–24.
40 Hanauer SB, Sandborn W, Practice Parameters Committee of the
American College of Gastroenterology. Management of Crohn’s
disease in adults. Am. J. Gastroenterol. 2001; 96: 635–43.
41 Kornbluth A, Sachar DB, Practice Parameters Committee of the
American College of Gastroenterology. Ulcerative colitis practice
guidelines in adults (update). American College of Gastroenterology,
Practice Parameters Committee. Am. J. Gastroenterol. 2004; 99:
1371–85.
42 Egan LJ, Sandborn WJ. Advances in the treatment of Crohn’s
disease. Gastroenterology 2004; 126: 1574–81.
43 Carter MJ, Lobo AJ, Travis SP, IBD Section, British Society of
Gastroenterology. Guidelines for the management of inflammatory
bowel disease in adults. Gut 2004; 53 (Suppl. 5): V1–16.
44 Hanauer SB. Medical therapy for ulcerative colitis 2004.
Gastroenterology 2004; 126: 1582–92.
45 Fiocchi C. Inflammatory bowel disease pathogenesis: therapeutic
implications. Chin. J. Dig. Dis. 2005; 6: 6–9.
46 Andoh A, Ogawa A, Kitamura K et al. Suppression of
interleukin-1beta- and tumor necrosis factor-a-induced inflammatory
responses by leukocytapheresis therapy in patients with ulcerative
colitis. J. Gastroenterol. 2004; 39: 1150–7.
47 Sawada K, Kusugami K, Suzuki Y et al. Leukocytapheresis in
ulcerative colitis: results of a multicenter double-blind prospective
case-control study with sham apheresis as placebo treatment. Am. J.
Gastroenterol. 2005; 100: 1362–9.
48 Targan SR, Hanauer SB, van Deventer SJH et al. A short-term study
of chimeric monoclonal antibody cA2 to tumor necrosis factor afor
Crohn’s disease. N. Engl. J. Med. 1997; 337: 1029–35.
49 Hanauer SB, Feagan BG, Lichtenstein GR et al. Maintenance
infliximab for Crohn’s disease: the ACCENT I randomised trial.
Lancet 2002; 359: 1541–9.
50 Present DH, Rutgeerts P, Targan S et al. Infliximab for the treatment
of fistulas in patients with Crohn’s disease. N. Engl. J. Med. 1999;
340: 1398–405.
51 Rutgeerts P, Sandborn WJ, Feagan BG et al. Infliximab for induction
and maintenance therapy for ulcerative colitis. N. Engl. J. Med.
2005; 353: 2462–76.
52 Baert FJ, Noman M, Vermeire S et al. Influence of immunogenicity
on the long-term efficacy of infliximab in Crohn’s ileocolitis. N.
Engl. J. Med. 2003; 348: 601–8.
53 Sandborn WJ, Hanauer SB, Katz S et al. Etanercept for active
Crohn’s disease: a randomized, double-blind, placebo-controlled
trial. Gastroenterology 2001; 121: 1088–94.
54 Schreiber S, Rutgeerts P, Fedorak RN et al. A randomized,
placebo-controlled trial of certolizumab pegol (CDP870) for
treatment of Crohn’s disease. Gastroenterology 2005; 129: 807–18.
55 Schreiber S, Nicolaus S, Malchow H et al. Absence of efficacy of
subcutaneous antisense ICAM-1 treatment of chronic active Crohn’s
disease. Gastroenterology 2001; 120: 1339–46.
56 Ghosh S, Goldin E, Gordon FH et al. Natalizumab for active
Crohn’s disease. N. Engl. J. Med. 2003; 348: 24–32.
57 Berger JR, Koralnik IJ. Progressive multifocal leukoencephalopathy
and natalizumab: unforseen consequences. N. Engl. J. Med. 2005;
353: 414–16.
58 Schreiber S, Fedorak RN, Nielsen OH et al. Safety and efficacy of
recombinant human interleukin 10 in chronic active Crohn’s disease.
Gastroenterology 2000; 119: 1461–72.
59 Mannon PJ, Fuss IJ, Mayer L et al. Anti-interleukin-12 antibody for
active Crohn’s disease. N. Engl. J. Med. 2004; 351: 2069–79.
60 Ito H, Takazoe M, Fukuda Y et al. A pilot randomized trial of a
human anti-interleukin-6 receptor monoclonal antibody in active
Crohn’s disease. Gastroenterology 2004; 126: 989–96.
61 Korzenik JR, Dieckegraefe BK, Valentine JF, Hausman DF, Gilbert
MJ. Sargramostin for active Crohn’s disease. N. Engl. J. Med. 2005;
352: 2193–201.
62 Sinha A, Nightingale JMD, West KP, Berlanga-Acosta J, Playford
RJ. Epidermal growth factor enemas with oral mesalamine for
Q Ouyang et al. Management of IBD in the Asia–Pacific region
1781Journal of Gastroenterology and Hepatology 21 (2006) 1772–1782 © 2006 The Authors
Journal compilation © 2006 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
mild-to-moderate left-sided ulcerative colis or proctitis. N. Engl. J.
Med. 2003; 349: 350–7.
63 Musch E, Andus T, Kruis W et al. Interferon-b-1a for the treatment
of steroid-refractory ulcerative colitis: a randomized, double-blind,
placebo-controlled trial. Clin. Gastroenterol. Hepatol. 2005; 3:
581–6.
64 Kanauchi O, Mitsuyama K, Araki Y, Andoh A. Modification of
intestinal flora in the treatment of inflammatory bowel disease. Curr.
Pharm. Des. 2003; 9: 333–46.
65 Sandborn WJ, Targan SR. Biologic therapy of inflammatory bowel
disease. Gastroenterology 2002; 122: 1592–608.
Management of IBD in the Asia–Pacific region Q Ouyang et al.
1782 Journal of Gastroenterology and Hepatology 21 (2006) 1772–1782 © 2006 The Authors
Journal compilation © 2006 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
