What is the recommended approach for evaluating and managing chronic inflammation?

Evaluation of Chronic Inflammation

Begin with measurement of C-reactive protein (CRP) and complete blood count (CBC) as initial laboratory markers, followed by disease-specific biomarkers and imaging based on the clinical context and organ system involved. 1

Initial Laboratory Assessment

Essential Blood Tests

• CRP measurement is the primary systemic inflammatory marker, with levels >10 mg/L indicating significant inflammation 1
• Complete blood count to identify:
  • Thrombocytosis (chronic inflammatory response)
  • Anemia (severe or chronic active disease)
  • Leukocytosis (possible infectious complication) 1
• ESR broadly correlates with clinical severity when CRP is elevated 1
• Electrolytes, liver function tests, and albumin to assess systemic impact and identify hypoalbuminemia associated with severe inflammation 1

Important caveat: Laboratory markers of chronic inflammation may be normal in mild disease, and neither CRP nor ESR is specific enough to differentiate inflammatory conditions from infectious causes 1

Disease-Specific Biomarker Strategy

For Inflammatory Bowel Disease

• Fecal calprotectin is an accurate marker of colonic inflammation and should be measured in suspected IBD 1
• Biomarker assessment every 2-4 months during active treatment, with CRP <5 mg/L and fecal calprotectin <250 mg/g as targets 1
• Stool specimens for microbiological analysis to exclude infectious causes, specifically C. difficile toxin 1

For Inflammatory Arthritis

• Initial radiography of the affected joint area is the first-line imaging method 1
• MRI or ultrasound complements radiography when initial films are normal or to assess soft tissue involvement 1
• Avoid CT and nuclear medicine studies as initial tests 1

Endoscopic and Imaging Evaluation

When to Perform Endoscopy

• Flexible sigmoidoscopy or colonoscopy with histological analysis is required at diagnosis of suspected IBD 1
• Repeat endoscopy 6-12 months after treatment initiation to confirm mucosal healing, even after symptom resolution 1
• Endoscopy may be required to confirm disease relapse 1

Cross-Sectional Imaging Indications

• CT or MR enterography for small bowel Crohn's disease to assess:
  • Number and location of involved segments
  • Presence of strictures with upstream dilation
  • Penetrating complications (fistulae, abscesses) 1
• Imaging is primarily indicated to rule out inflammatory spondyloarthropathy or red flags, not for routine diagnosis of mechanical joint pain 2

Monitoring Strategy Based on Clinical Context

Symptomatic Patients

Biomarker-based assessment is superior to symptom-based evaluation alone for treatment decisions 1

• Check CRP and fecal calprotectin every 2-4 months during active treatment 1
• Treatment escalation should be based on persistently elevated biomarkers (CRP >5 mg/L or fecal calprotectin >250 mg/g) combined with symptoms 1
• This approach achieves higher rates of deep remission (37% vs 23%) compared to symptom-based management alone 1

Asymptomatic Patients

• Do not rely on symptom assessment alone, as 20-35% of patients with gastrointestinal symptoms may be in endoscopic remission, and inflammation often persists without symptoms 1
• Continue biomarker monitoring to detect subclinical inflammation 1
• Transition to endoscopic evaluation after biomarker normalization 1

Critical Pitfalls to Avoid

• Do not skip infectious workup: Always exclude common pathogens and C. difficile before attributing symptoms to chronic inflammation 1
• Do not interpret normal inflammatory markers as excluding disease: Mild or moderate disease may have normal CRP and ESR 1
• Do not use imaging findings alone: Active versus inactive disease on imaging does not always equate to histologically, endoscopically, or clinically active disease 1
• Do not delay diagnosis: Thorough baseline assessment prevents diagnostic delays and enables appropriate treatment selection 1

Standardized Documentation

Record all parameters in a standardized fashion to enable longitudinal evaluation 1:

• Specific biomarker values with dates
• Extent and location of disease involvement
• Presence of complications (strictures, fistulae, abscesses)
• Response to prior treatments

This systematic approach allows objective monitoring for tight disease control, with the ultimate goal of preventing progressive tissue damage, reducing long-term disability, and maintaining quality of life 1, 3, 4.