Location, location, location: Site of inflammatory bowel disease crucial

Genetic similarity suggests Crohn's disease and ulcerative colitis form a continuum of subtypes in the bowel

A new understanding of inflammatory bowel diseases has been prompted by the analysis of genetic and clinical data from more than 30,000 patients. This study reveals that genetic factors affect the location of the inflammation in the gut, with implications for diagnosis and treatment of patients.

The largest study of its kind, this research uncovers a continuum of inflammatory bowel diseases, and shows that genetic information could be used to reveal misdiagnoses. The research demonstrates the importance of worldwide clinical collaborations and using information about symptoms to better understand the genetics of complex diseases.

Inflammatory bowel disease (IBD) is an umbrella term for two related immune diseases: Crohn’s disease, which can affect any part of the digestive tract, and ulcerative colitis, which affects only the colon, or large bowel. However this research shows that a binary diagnosis of disease is oversimplified. Genetic data indicate that IBD is a complex continuum of disorders heavily influenced by the site of inflammation. While disease location in Crohn’s have long been recognised as important, the new observation that large bowel Crohn’s disease is half-way between ulcerative colitis and small bowel Crohn’s disease on this genetic spectrum suggests that important aspects of disease biology are associated with location.

“Patients who initially present with similar IBD symptoms progress in drastically different ways. Some experience a mild course of disease while others need invasive surgery. Our current symptom-led system of classification doesn’t clearly predict which path a particular patient is likely to take. Our genetic data reflect this same uncertainty.”

Dr Isabelle Cleynen A first author from the Wellcome Trust Sanger Institute and KU Leuven

Previous research on IBD had shown that the genes involved are largely shared between Crohn’s disease and ulcerative colitis, with only a small number of genes specific to each disease. The new study married this genetic information with clinical symptoms to try to understand the biology behind the disease.

Diagnosis is based on clinical evidence and symptoms, with different medication and surgery indicated for Crohn’s and ulcerative colitis. For some patients, clinicians find it difficult to diagnose which of these two diseases is presented. The genetic continuum between the two ends of the spectrum explains some of this difficulty in diagnosis and patients could benefit from re-classification.

At extreme ends of the continuum, genetic markers may have some diagnostic utility. Clinicians reassessed the records of outlier patients, who had genetic factors that strongly pointed to Crohn’s disease but had been originally diagnosed with ulcerative colitis, or vice-versa. They found that doctors had raised doubts about the diagnosis three times more often than for randomly chosen patients.

“For a small subset of patients, genetics can uncover a misdiagnosis. Working with clinicians we hope this will help prevent costly and traumatic unnecessary surgery. However, in the vast majority of cases, the genetic scores we’ve identified for each condition are not different enough to be used diagnostically. Further research, pairing genetic data with patient responses to treatment over time will help us to better understand what’s happening on a molecular level in patients with different forms of IBD.”

Dr Jeffrey Barrett A corresponding author from the Wellcome Trust Sanger Institute and Director of the Centre for Therapeutic Target Validation

To treat complex diseases, physicians need to understand the underlying biology. Genetic information could be used to inform treatment guidelines, or which patients to include in a clinical trial to obtain the clearest results. It is possible that certain trials may be appropriate for colonic Crohn’s disease and ulcerative colitis patients. Genetics could also be used as another piece of evidence to catch rare mistakes in diagnosis, which could prevent unnecessary surgery.

“In order to personalise treatments, we need to be open-minded about the clinical categories we have constructed by observing symptoms in isolation. It is crucial that clinicians and researchers continue to work closely together and to share comprehensive data that will help to solve this complex puzzle.”

Dr Charlie Lees A corresponding author, consultant gastroenterologist and senior lecturer at the University of Edinburgh

More information

Funding

National Association for Colitis and Crohn’s disease; Wellcome Trust grants 098051, 098759, 083948/Z07/Z, 085475/B/08/Z and 085475/Z?08Z; Medical Research Council UK; the Catherine McEwan Foundation; Peninsula College of Medicine and Dentistry, Exeter; the National Institute for Health Research; National Institute of Diabetes, Digestive and Kidney diseases IBD Genetics Consortium, which is funded by the following grants: DK062432, DK062423, DK076984 and DK084554; Crohn’s & Colitis Foundation of America, Senior Investigator award 5-229 and CA141743; Cedars-Sinai F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute Research Funds, grant PO1DK046763; Agency for Healthcare Research and Quality, grant 305479 from the European Union, and the Leona M. and Harry B. Helmsley Charitable Trust; Flemish Funds for Scientific Research; Walloon Region; FEDER; Politique Scientifique Fédérale; Fonds National de la Recherche Scientifique; Communauté Française de Belgique; Netherlands Organisation for Scientific Research, grant 016.136.308; German Ministry of Education and Research through the National Genome Research Network; Popgen biobank, through the Deutsch Forschungsgemeinschaft; DFG grant FR2821/2-1, DFG BR grant 1912/6-1; Else-Kröner-Fresenius-Stiftung; Italian Ministry of Health, grant GR-2008-1144485; Swedish Society of Medicine; Ihre Foundation; Örebro University Hospital Research Foundation; Karolinska Institute; the Swedish National Program for IBD Genetics; the Swedish Organization for IBD; Swedish Research Council, grant JH 521-2011-2764; SHS Aabenraa, Denmark; Royal Brisbane and Women’s Hospital Foundation; National Health and Medical Research Council, Australia; European Community.

Participating Centres

Wellcome Trust Sanger Institute; KU Leuven; Uiversité de Montréal and Montreal Heart Institute; Wellcome Trust Centre for Human Genetics, University of Oxford; Christ Church, University of Oxford; University of Chicago; Christian Albrechts-University; Peninsula College of Medicine and Dentistry; Viborg Regional Hospital; Hospital of Southern Jutland Aabenraa; Department of Gastroenterology and Hepatology; Royal Adelaide Hospital, Austria; Instituto di Ricovero e Cura a Carattere Scientifico-Casa Sollievo della Sofferenza Hospital; Azienda Ospedaliero Universitaria Careggi; University Hospital Munich-Grosshadern; Ludwig-Maximillians-University; Johns Hopkins University; Yale School of Medicine; Harvard Medical School; Sinai Medical Center; University of Pittsburgh School of Medicine; The University of Aukland; Christian-Albrechts-University; University of Otago, Christchurch Hospital; The Children’s Hospital of Philadelphia; Örebro University; University of Oslo; University of Edinburgh; Lithuanian University of Health Sciences; The University of Western Australia; University of Cambridge; Universite de Liege; Leiden University Medical Center; University of Groningen; Royal Hospital for Sick Children; University Hosptial Gathuisberg; Newcastle University; University of Toronto; Queensland Institute of Medical Research; University of Queensland; Cedars-Sinai Medical Center.