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We thank Drs Chen and Quigley for their comments regarding our manuscript[1, 2] and agree that the differentiation of Crohn's disease and irritable bowel syndrome (IBS) can present a diagnostic challenge. As we, and others, have shown, the difficulties of discriminating between active Crohn's disease and non-inflammatory symptoms can be somewhat obviated by reliance on objective biomarkers, such as C-reactive protein and faecal calprotectin, in addition to endoscopy.

However, we would disagree with the statement by Chen and Quigley that ‘IBS-type symptoms’ in IBD should be regarded as representing disease activity until proven otherwise. IBS-type symptoms are common in patients with inflammatory bowel disease (IBD), particularly Crohn's,[3] and it is important to determine whether the symptoms are truly due to active, inflammatory Crohn's before escalating treatment.

This is particularly critical when considering that our treatment paradigm has shifted to earlier use of antitumour necrosis factor therapies, often in combination with an immunomodulator, both potentially toxic and expensive medications. Unfortunately, due to the poor reliability and reproducibility of physician assessment of clinical symptoms and the Crohn's disease activity index (CDAI),[2] this will require the use of biomarkers, endoscopy and/or cross-sectional imaging in most cases. As Chen and Quigley point out, the CDAI was not designed as a diagnostic tool, but it is still used as a primary endpoint in most Crohn's clinical trials[4] and forms the basis for the licensing of most IBD drugs currently available in the United States and Europe.[5]

Acknowledgement

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  2. Acknowledgement
  3. References

The authors’ declarations of personal and financial interests are unchanged from those in the original article.2

References

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  2. Acknowledgement
  3. References