Inflammatory bowel disease: An evaluation of health information on the internet

Table 4 Examples of assessment of the content of some websites on inflammatory bowel disease

Website Number	Title	Areas of deficiencies	Suggestions for improvement
45	Crohn's Disease Diagnosis, New health guide	Symptoms of Crohn's disease are briefly mentioned. Some details are needed to explain the common presenting symptoms. No mention of differential diagnosis. No mention of investigations needed to confirm the diagnosis. Nothing is mentioned about treatment of Crohn's disease.	Symptoms may include abdominal pain, typically in the right lower quadrant, diarrhoea, some blood may be present in stools, fatigue. In more severe disease fever, and weight loss may be present. Some patients may have nausea, and abdominal distention together with abdominal pain. It is worth to mention that Crohn's disease is a lifelong illness (chronic disease). People who have Crohn's will experience periods of flare-ups, when their symptoms are active, and other times when their symptoms go into remission. Up to 30% of patients may have changes in the area around the anus including anal fistulas (internal tracts connecting the anal lumen with the skin around the anus), abscess, skin tags, and anal fissures. About 10%-20% of patients also have joint pains, lower back pain, skin rash known as erythema nodosum, and eye changes. (images showing some of these changes will enhance this part). A section discussing investigations should be added. In addition to detailed medical history, the treating doctor will initiate the evaluation by testing for infectious conditions that can cause inflammation of the colon, screen for endocrine-metabolic disorders such as excessive activity of the thyroid gland. Therefore biochemical tests and stool tests are needed. Endoscopic evaluation (colonoscopy) should be carried out in patients who have symptoms suggestive of inflammatory bowel disease and no evidence for an infection to explain symptoms. Small bowel images, computed tomography (CT) enterography may also be needed. Nutritional changes, medical and surgical treatment should be briefly discussed.
53	Ulcerative Colitis, Crohn's and Colitis Canada	Symptoms are briefly stated. No mention of differential diagnosis, investigations and no discussion of medical and surgical treatment.
64	Inflammatory Bowel Disease (IBD), MUSC Health	Symptoms of inflammatory bowel disease are not clearly written. One would wonder, are "bowel sores" and "intestinal bleeding" symptoms? Differential diagnosis is not mentioned. The approach for diagnosing inflammatory bowel disease is not mentioned and the treatment of IBD is not explained.	As discussed earlier.
68	Crohn's Disease Symptoms and Warning Signs, SymptomsFind	Although symptoms of Crohn's disease are mentioned briefly, they are not explained. Mild, moderate and severe inflammatory bowel disease are stated but not explained. This should be explained in a simple language. Complications are mentioned but there was no mention how the disease is diagnosed, and what investigations are needed. Nothing is mentioned about nutritional changes, medical and surgical treatment of inflammatory bowel disease.	Patients are described to have mild ulcerative colitis when they have: -Fewer than four bowel motions (stools) per day. -No bleeding or small amounts of bleeding in their stools. -Normal erythrocyte sedimentation rate (ESR) -No fever, no anaemia and no increases in their heart rate, Patients are described to have moderate ulcerative colitis when they have: -More than four stools per day. -Mild elevation in ESR. Patients are described to have severe ulcerative colitis when they have: -More than six stools a day (loose stools). -Fever, rapid heartbeat, and anaemia. -Elevated ESR. The website may also mention changes that necessitate hospital admission and medical attention. Websites may provide key questions that patients may use when they review their treating doctors. Examples of these questions: •I wonder what's causing these symptoms? •What type of tests do I need? Do these tests require any special preparation? •What treatments are available, and which do you recommend? •Are there any medications that I should avoid? •Do I need to follow any dietary restrictions? •Are there any risks if I become pregnant? The MayoClinic website has listed a number of useful questions that patients can use.
12	Inflammatory Bowel Disease Center, cedars-Sinai.	Under symptoms of Crohn's disease, it is written, "The most common signs are pain in the stomach area (usually on the right side) and diarrhea", it is not clear what is meant by pain in the stomach area on the right side? Complications are provided but no signs are stated. No mention of differential diagnosis, no mention of investigations and possible findings. Nutritional changes, medical and surgical treatment are not explained.	The authors should differentiate between symptoms and signs. Scientific errors are noted in the website and common presenting symptoms should be stated. It may be useful to explain the symptoms under two main headings: symptoms in children, and symptoms in adults. Investigations needed to diagnose the disease should be discussed. Patients are usually interested to know more detail about these investigations. Information provided should answer questions such as -Name of the test -Why the test is need? -What is the test about? -Nature of the investigation (invasive vs non-invasive) -Are there special preparations needed prior to the test? -Any possible complications related to the investigation? -What can the results of the test tell the patient and the treating doctor? It is also important to state that IBD is an ongoing condition (chronic disease), so some of the tests may need to be repeated from time to time, or extra tests may be needed. These investigations may include: (1) Blood tests including full blood count, inflammatory markers tests including erythrocyte sedimentation rate (ESR), c-reactive protein (CRP), liver function tests, urea and electrolytes, and other biochemical tests, (2) stool tests including stool microscopy, stool culture and sensitivity, fecal markers such as fecal calprotectin, fecal lactoferrin, (3) Endoscopy including colonoscopy, sigmoidoscopy, proctoscopy, with biopsies for histological studies (4) radiological studies such as barium studies, CT scans, MRI scans and PET scans.