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Lee JL, Yoon YS, Lee HG, Kim YI, Kim MH, Kim CW, Park IJ, Lim SB, Yu CS. New anti-mesenteric delta-shaped stapled anastomosis: Technical report with short-term postoperative outcomes in patients with Crohn's disease. World J Gastrointest Surg 2024; 16:2592-2601. [PMID: 39220078 PMCID: PMC11362929 DOI: 10.4240/wjgs.v16.i8.2592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/19/2024] [Accepted: 07/17/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND Medical treatment for Crohn's disease (CD) has continuously improved, which has led to a decrease in surgical recurrence rates. Despite these advancements, 25% of patients will undergo repeat intestinal surgery. Recurrence of CD commonly occurs on the mesentery side of the anastomosis site. AIM To compare the new anti-mesenteric side-to-side delta-shaped stapled anastomosis (DSA) with the conventional stapled functional end-to-end anastomosis (CSA). METHODS This retrospective study included CD patients who underwent ileo-ileal or ileo-colic anastomosis between January 2020 and December 2023. The DSA technique employed a stapler to maintain the concept of anti-mesentery side-to-side anastomosis by performing a 90° vertical closure of the open window compared with the CSA technique. At the corner where the open window is closed, the DSA avoids forming a pouch and creates an anastomosis resembling a delta shape within the intestinal lumen. We compared demographics, preoperative condition, operative findings, and operative outcomes for the two techniques. RESULTS The study included 175 patients, including 92 in the DSA group and 83 in the CSA group. The two groups were similar in baseline characteristics, preoperative medical treatment, and operative findings except for the Montreal classification location. The 30-days postoperative complication rate was significantly lower in the DSA group compared with the CSA group (16.3% vs 32.5%, P = 0.009). Ileus incidence was significantly lower in the DSA group than in the CSA group (4.3% vs 14.5%, P = 0.033), and the hospital stay was shorter in the DSA group than in the CSA group (5.67 ± 1.53 days vs 7.39 ± 3.68 days, P = 0.001). CONCLUSION The DSA technique was feasible and showed comparable postoperative outcomes with lower short-term complications compared with the CSA technique. Further studies on CD recurrence and long-term complications are warranted.
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Affiliation(s)
- Jong Lyul Lee
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Yong Sik Yoon
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Hyun Gu Lee
- Department of Surgery, Gangdong Kyung Hee University Hospital, Seoul 05278, South Korea
| | - Young Il Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Min Hyun Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Chan Wook Kim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
| | - Chang Sik Yu
- Division of Colon and Rectal Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, South Korea
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Liu SH, Kang JC, Hu JM, Chen CY, Lin KH, Pu TW. Treatment of benign rectal stricture caused by repeated anal insertion by endoscopy and balloon dilation: A case report. World J Gastrointest Endosc 2024; 16:91-97. [PMID: 38464821 PMCID: PMC10921150 DOI: 10.4253/wjge.v16.i2.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/28/2023] [Accepted: 01/22/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Benign rectal strictures can be categorized as primary (disease-related) and secondary (surgical anastomosis-related). Secondary strictures arise from surgical complications, whereas primary strictures have diverse etiologies, including various inflammatory conditions. Benign strictures are usually managed by surgery and endoscopy. We present an unusual etiology of benign rectal stricture caused by the repeated insertion of foreign objects into the rectum for sexual purposes, resulting in rectal injury and subsequent chronic inflammation. CASE SUMMARY A 53-year-old man presented to the outpatient clinic of the Colorectal Surgery Department with symptoms of chronic constipation and bloody stools. The patient previously experienced rectal injury due to foreign object insertion for sexual purposes. Colonoscopy revealed benign circumferential narrowing of the rectum. He underwent treatment by endoscopic argon plasma coagulation and balloon dilation and follow-up as an outpatient for 4 months. A colonoscopy at the end of the follow-up period revealed no evidence of rectal stricture relapse. CONCLUSION A history of rectal injury, followed by chronic inflammation, should be considered in patients with benign rectal strictures. Management with endoscopic argon plasma coagulation and balloon dilation can prevent the need for surgical resection of benign rectal strictures.
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Affiliation(s)
- Shih-Hung Liu
- Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Jung-Cheng Kang
- Division of Colon and Rectal Surgery, Department of Surgery, Taiwan Adventist Hospital, Taipei 105, Taiwan
| | - Je-Ming Hu
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Chao-Yang Chen
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Kuan-Hsun Lin
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Ta-Wei Pu
- Division of Colon and Rectal Surgery, Department of Surgery, Songshan Branch, Tri-Service General Hospital, National Defense Medical Center, Taipei 105, Taiwan
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Gonczi L, Lakatos L, Golovics PA, Ilias A, Pandur T, David G, Erdelyi Z, Szita I, Al Khoury A, Lakatos PL. Declining Trends of Reoperations and Disease Behaviour Progression in Crohn's Disease over Different Therapeutic Eras-A Prospective, Population-Based Study from Western Hungary between 1977-2020, Data from the Veszprem Cohort. J Crohns Colitis 2023; 17:1980-1987. [PMID: 37422727 PMCID: PMC10798863 DOI: 10.1093/ecco-jcc/jjad117] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND AND AIMS Few population-based studies have investigated long-term surgery rates for Crohn's disease [CD]. Our aim was to analyse disease progression and surgery rates in a population-based cohort over different therapeutic eras, based on the time of diagnosis: cohort-A [1977-1995], cohort-B [1996-2008], and cohort-C [2009-2018]. METHODS A total of 946 incident CD patients were analysed (male/female: 496/450; median age at diagnosis: 28 years [y]; interquartile range [IQR]: 22-40]). Patient inclusion lasted between 1977 and 2018. Immunomodulators have become widespread in Hungary since the mid-1990s and biologic therapies since 2008. Patients were followed prospectively, with both in-hospital and outpatient records reviewed regularly. RESULTS The probability of disease behaviour progression from inflammatory [B1] to stenosing or penetrating phenotype [B2/B3] significantly decreased (27.1 ± 5.3%/21.5 ± 2.5%/11.3 ± 2.2% in cohorts A/B/C, respectively, after 5 years; 44.3 ± 5.9%/30.6 ± 2.8%/16.1 ± 2.9% after 10 years, respectively; [pLogRank <0.001]). The probability of first resective surgery between cohorts A/B/C were 33.3 ± 3.8%/26.5 ± 2.1%/28.1 ± 2.4%, respectively, after 5 years; 46.1 ± 4.1%/32.6 ± 2.2%/33.0 ± 2.7% after 10 years, respectively; and 59.1 ± 4.0%/41.4 ± 2.6% [cohorts A/B] after 20 years. There was a significant decrease in first resective surgery risk between cohorts A and B [plog rank = 0.002]; however, no further decrease between cohorts B and C [plog rank = 0.665]. The cumulative probability of re-resection in cohorts A/B/C was decreasing over time (17.3 ± 4.1%/12.6 ± 2.6%/4.7 ± 2.0%, respectively, after 5 years [plog rank = 0.001]). CONCLUSION We report a continuous decline in reoperation rates and disease behaviour progression in CD over time, with the lowest values in the biologic era. In contrast, there was no further decrease in the probability of first major resective surgery after the immunosuppressive era.
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Affiliation(s)
- Lorant Gonczi
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Laszlo Lakatos
- Department of Gastroenterology, Ferenc Csolnoky Hospital, Veszprem, Hungary
| | - Petra A Golovics
- Department of Gastroenterology, Hungarian Defence Forces Medical Centre, Budapest, Hungary
| | - Akos Ilias
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Tunde Pandur
- Department of Gastroenterology, Grof Eszterhazy Hospital, Papa, Hungary
| | - Gyula David
- Department of Gastroenterology, Ferenc Csolnoky Hospital, Veszprem, Hungary
| | - Zsuzsanna Erdelyi
- Department of Gastroenterology, Ferenc Csolnoky Hospital, Veszprem, Hungary
| | - Istvan Szita
- Department of Gastroenterology, Ferenc Csolnoky Hospital, Veszprem, Hungary
| | | | - Peter L Lakatos
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
- Division of Gastroenterology, McGill University Health Center, Montreal, QC, Canada
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Irwin J, Lord A, Ferguson E, Simms LA, Hanigan K, Montoya CA, Radford-Smith G. A Method Using Longitudinal Laboratory Data to Predict Future Intestinal Complication in Patients with Crohn's Disease. Dig Dis Sci 2023; 68:596-607. [PMID: 36125595 PMCID: PMC9905172 DOI: 10.1007/s10620-022-07639-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/20/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Stenosis, fistulization, and perforation of the bowel are severe outcomes which can occur in patients with Crohn's disease. Accurate prediction of these events may enable clinicians to alter treatment strategies and avoid these outcomes. AIMS To study the correlation between longitudinal laboratory testing and subsequent intestinal complications in patients with Crohn's disease. METHODS An observational cohort of patients with Crohn's disease at a single center were analyzed between 01/01/1994 and 06/30/2016. A complication was defined as the development of an intestinal fistula, stenosis, or perforation. Exploratory analysis using Cox regression was performed to select the best statistical method to represent longitudinal laboratory data. Cox regression was used to identify laboratory variables independently associated with the development of a subsequent complication. A clinical scoring tool was designed. RESULTS In 246 patients observed over a median of 5.72 years, 134 complications occurred. Minimum or maximum value in a preceding window period of one year was most strongly associated with subsequent complication. A Longitudinal Laboratory score of ≥ 2 (maximum albumin level < 39 g/L = 1, maximum mean cell volume < 88 fL = 1, minimum platelet count > 355 × 109/L = 1, minimum C reactive protein > 5 mg/L = 1) was 62% sensitive and 91% specific in identifying patients who develop a subsequent complication. CONCLUSION A consistent reduction in serum albumin and mean cell volume, and a consistent increase in platelet count and C reactive protein were associated with a subsequent complication in patients with Crohn's disease. Longitudinal laboratory tests may be used as described in this paper to provide a rational for earlier escalation of therapy.
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Affiliation(s)
- James Irwin
- QIMR Berghofer Medical Research Institute, Brisbane, Australia.
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.
- Department of Gastroenterology, Palmerston North Hospital, 50 Ruahine Street, Palmerston North, 4442, New Zealand.
| | - Anton Lord
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Emma Ferguson
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Lisa A Simms
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | | | - Carlos A Montoya
- Smart Foods Innovation Centre of Excellence, AgResearch Limited, Te Ohu Rangahau Kai Facility, Palmerston North, 4474, New Zealand
- Riddet Institute, Massey University, Te Ohu Rangahau Kai Facility, Palmerston North, 4474, New Zealand
| | - Graham Radford-Smith
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Ahmed Ali U, Kiran RP. Surgery for Crohn’s disease: upfront or last resort? Gastroenterol Rep (Oxf) 2022; 10:goac063. [PMID: 36381220 PMCID: PMC9645354 DOI: 10.1093/gastro/goac063] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/30/2022] [Indexed: 11/11/2022] Open
Abstract
Crohn’s disease (CD) can involve the entire gastrointestinal tract from the mouth to the anus and can lead to a constellation of symptoms. With the advancement of effective medical treatments for CD, a tendency has emerged to consider surgical treatment as a last resort. This potentially has the disadvantage of delaying surgery and if it fails might leave patients sicker, less well nourished, and with more severe complications. As with most non-malignant diseases, the choice of surgery vs medical treatment is a patient’s personal preference under the guidance of the treating physician, except in extreme situations where surgery might be the only option. In this article, we will discuss the available evidence regarding the optimal timing of surgery in CD, focusing on whether early surgery can bring benefits in terms of disease control, symptom relief, and quality of life.
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Affiliation(s)
- U Ahmed Ali
- Division of Colorectal Surgery, New York–Presbyterian/Columbia University Medical Center, New York, USA
| | - Ravi P Kiran
- Corresponding author. Division of Colorectal Surgery, New York–Presbyterian/Columbia University Medical Center, 177 Fort Washington Avenue, 7th Floor South Knuckle, New York, NY 10032, USA.
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The Role of Inflammation in Crohn's Disease Recurrence after Surgical Treatment. J Immunol Res 2020; 2020:8846982. [PMID: 33426097 PMCID: PMC7781709 DOI: 10.1155/2020/8846982] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction Postoperative recurrence after surgery for Crohn's disease (CD) is virtually inevitable, and its mechanism is poorly known. Aim To review the numerous factors involved in CD postoperative recurrence (POR) pathogenesis, focusing on single immune system components as well as the immune system as a whole and highlighting the clinical significance in terms of preventive strategies and future perspectives. Methods A systematic literature search on CD POR, followed by a review of the main findings. Results The immune system plays a pivotal role in CD POR, with many different factors involved. Memory T-lymphocytes retained in mesenteric lymph nodes seem to represent the main driving force. New pathophysiology-based preventive strategies in the medical and surgical fields may help reduce POR rates. In particular, surgical strategies have already been developed and are currently under investigation. Conclusions POR is a complex phenomenon, whose driving mechanisms are gradually being unraveled. New preventive strategies addressing these mechanisms seem promising.
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7
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Popa SL, Pop C, Dumitrascu DL. Diet Advice for Crohn's Disease: FODMAP and Beyond. Nutrients 2020; 12:3751. [PMID: 33291329 PMCID: PMC7762196 DOI: 10.3390/nu12123751] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
Crohn's disease (CD) is a chronic, progressive, and destructive granulomatous inflammatory bowel disorder that can involve any part of the gastrointestinal tract. It has been presumed that different types of diet might improve gastrointestinal symptoms in CD patients. The aim of this review was to clarify the efficiency and indications of a low-"fermentable oligo-, di-, mono-saccharides and polyols" (FODMAP) diet (LFD) in CD and to further analyze the available data on other types of diets. PubMed, Cochrane Library, EMBASE and WILEY databases were screened for relevant publications regarding the effect of FODMAP diets on CD. Our search identified 12 articles analyzing the effect of an LFD in CD, 5 articles analyzing the effect of a Mediterranean diet (MD), 2 articles analyzing the effect of a vegetarian diet (VD), and 2 articles analyzing the effect of a low-lactose diet (LLD). The majority of the studies included in this review show the significant efficiency of the LFD in CD patients. We found significant evidence demonstrating that the LFD has a favorable impact on gastrointestinal symptoms in CD patients. Notwithstanding the evidence, it remains to be established if an LFD is more efficient than other types of diets in the short term and especially in the long term.
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Affiliation(s)
- Stefan L. Popa
- 2nd Medical Department, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania; (S.L.P.); (D.L.D.)
| | - Cristina Pop
- Department of Pharmacology, Physiology, and Pathophysiology, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania
| | - Dan L. Dumitrascu
- 2nd Medical Department, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania; (S.L.P.); (D.L.D.)
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Elmoursi A, Barrett TA, Perry C. Double Biologic Therapy for Refractory Stricturing Crohn's Disease: A Successful Case of Deep Remission with Ustekinumab and Vedolizumab. Inflamm Bowel Dis 2020; 26:e62-e63. [PMID: 32386054 DOI: 10.1093/ibd/izaa092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Stricturing Crohn's disease (CD) is a severe phenotype that presents unique challenges to therapeutic management. Emerging literature suggests that anti-TNF monoclonal antibody (mAb) therapies are inadequate for preventing progression to stricture. We hereby present a case of a patient with refractory CD who required multiple surgical resections despite several anti-TNF treatment regimens. Subsequent surgical complications were avoided after changing to combination vedolizumab and ustekinumab therapies every 4 weeks. This case argues for a tailored approach to CD therapy based on disease phenotype and demonstrates that combination therapy with ustekinumab and vedolizumab is a viable option for patients with stricturing disease.
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Affiliation(s)
- Ahmed Elmoursi
- Division of Gastroenterology, Department of Internal Medicine, University of Kentucky, USA
| | - Terrence A Barrett
- Division of Gastroenterology, Department of Internal Medicine, University of Kentucky, USA
| | - Courtney Perry
- Division of Gastroenterology, Department of Internal Medicine, University of Kentucky, USA
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9
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Strictureplasty for Crohn’s disease of the small bowel in the biologic era: long-term outcomes and risk factors for recurrence. Tech Coloproctol 2020; 24:711-720. [DOI: 10.1007/s10151-020-02208-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/01/2020] [Indexed: 02/08/2023]
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10
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Evaluating the Comparative Effectiveness of Two Diets in Pediatric Inflammatory Bowel Disease: A Study Protocol for a Series of N-of-1 Trials. Healthcare (Basel) 2019; 7:healthcare7040129. [PMID: 31683925 PMCID: PMC6956096 DOI: 10.3390/healthcare7040129] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/09/2019] [Accepted: 10/23/2019] [Indexed: 01/27/2023] Open
Abstract
Inflammatory bowel disease (IBD) affects 3 million children and adults in the US. Treatment involves medications with considerable risk profiles. Dietary modification, such as the specific carbohydrate diet (SCD), may be helpful in treating IBD, but there is insufficient evidence of its effectiveness. N-of-1 trials are ideal for addressing this important research question. The Personalized Research on Diet in Ulcerative Colitis and Crohn’s Disease (PRODUCE) study employs a series of 50 individual N-of-1 trials that compare the SCD to a modified SCD. Treatment periods are assigned in blocks of two, with each patient completing two balanced treatment blocks. Patients are randomized to start with the SCD or modified SCD and alternate between conditions for four eight-week periods. A mobile app guides collecting and viewing data, transitioning diets, and reviewing personal results. Primary outcomes include patient reported outcomes (PROs) of stool frequency, stool consistency, pain interference, and gastrointestinal (GI) symptom severity. We examine changes in inflammation via fecal calprotectin. Participants will receive a personalized answer regarding comparative effectiveness between the SCD and a less restrictive diet option (modified SCD), as well as compared to their baseline diet. We will aggregate the results of completed N-of-1 trials across patients to estimate population level comparative effectiveness of these treatments and the effectiveness of each diet.
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Schoepfer A, Santos J, Fournier N, Schibli S, Spalinger J, Vavricka S, Safroneeva E, Aslan N, Rogler G, Braegger C, Nydegger A. Systematic Analysis of the Impact of Diagnostic Delay on Bowel Damage in Paediatric Versus Adult Onset Crohn's Disease. J Crohns Colitis 2019; 13:1334-1342. [PMID: 31002741 DOI: 10.1093/ecco-jcc/jjz065] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Length of diagnostic delay is associated with bowel strictures and intestinal surgery in adult patients with Crohn's disease [CD]. Here we assessed whether diagnostic delay similarly impacts on the natural history of paediatric CD patients. METHODS Data from the Swiss IBD Cohort Study were analysed. Frequency of CD-related complications [bowel stenosis, perianal fistula, internal fistula, any fistula, resection surgery, fistula/abscess surgery, any complication] at diagnosis and in the long term [up to 30 years after CD diagnosis] was compared between paediatric patients [diagnosed <18 years] and adult patients [diagnosed ≥18 years] using multivariate Cox proportional hazard regression modelling. RESULTS From 2006 to 2016, 387 paediatric and 1163 adult CD patients were included. Median [interquartile range: IQR] diagnostic delay was 3 [1-9] for the paediatric and 6 [1-24] months for the adult group, respectively. Adult onset CD patients presented at diagnosis more frequently with bowel stenosis [p <0.001] and bowel surgery [p <0.001] compared with paediatric CD patients. In the long term, length of diagnostic delay was significantly associated with bowel stenosis [p = 0.001], internal fistula [p = 0.038], and any complication [p = 0.024] in the adult onset CD population. No significant association between length of diagnostic delay and CD-related outcomes in the long term was observed in the paediatric population. CONCLUSIONS Adult CD patients have longer diagnostic delay compared with paediatric CD patients and present at diagnosis more often with bowel stenosis and surgery. Length of diagnostic delay was found to be predictive for CD-related complications only in the adult but not in the paediatric CD population.
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Affiliation(s)
- Alain Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois [CHUV] and University of Lausanne, Lausanne, Switzerland
| | - Jessica Santos
- Division of Paediatric Gastroenterology, Centre Hospitalier Universitaire Vaudois [CHUV] and University of Lausanne, Lausanne, Switzerland
| | - Nicolas Fournier
- Institute of Social and Preventive Medicine [IUMSP], Lausanne University Hospital, Lausanne, Switzerland
| | - Susanne Schibli
- Division of Paediatric Gastroenterology, Children's Hospital LUKS, Lucerne, Switzerland
| | - Johannes Spalinger
- Division of Paediatric Gastroenterology, Children's Hospital LUKS, Lucerne, Switzerland.,Division of Gastroenterology, University Children's Hospital of Bern, Bern, Switzerland
| | - Stephan Vavricka
- Center for Gastroenterology and Hepatology, Zurich, Switzerland.,Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Nurullah Aslan
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois [CHUV] and University of Lausanne, Lausanne, Switzerland
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Christian Braegger
- Division of Gastroenterology and Nutrition, University Children's Hospital Zurich, Zurich, Switzerland
| | - Andreas Nydegger
- Division of Paediatric Gastroenterology, Centre Hospitalier Universitaire Vaudois [CHUV] and University of Lausanne, Lausanne, Switzerland
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12
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Yu CS, Jung SW, Lee JL, Lim SB, Park IJ, Yoon YS, Kim CW, Yang SK, Ye BD, Park SH, Han M, Kim JC. The Influence of Preoperative Medications on Postoperative Complications in Patients After Intestinal Surgery for Crohn's Disease. Inflamm Bowel Dis 2019; 25:1559-1568. [PMID: 30753560 DOI: 10.1093/ibd/izz010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Many patients with Crohn's disease (CD) are treated with medications, including steroids, immunomodulators, and anti-tumor necrosis factor alpha (anti-TNF-α) agents, at the time of surgery. This study evaluated the effects of these medications on postoperative complications in CD patients. METHODS This retrospective study analyzed patients who underwent bowel resection for CD between January 2006 and December 2015. Postoperative complications were defined as a Clavien-Dindo classification of grade 2A or higher within the first 30 days after surgery. RESULTS Of the 817 patients enrolled, 687 patients received bowel resection and anastomosis without stoma formation. Of 687 patients, 381 (55.5%) were being treated with preoperative medications at the time of surgery (medication group) and 306 (44.5%) were not (nonmedication group). The overall rate of postoperative complications was not different between the medication and nonmedication groups (23.4% vs 21.9%, P = 0.36). Preoperative treatments with immunomodulators plus anti-TNF-α agents (relative risk [RR], 2.314; 95% confidence interval [CI], 1.126-4.753; P = 0.022) and treatment with immunomodulators plus steroids (RR, 2.536; 95% CI, 1.124-5.725; P = 0.025) were risk factors for infectious complications. Preoperative treatments with immunomodulators plus anti-TNF-α agents (RR, 2.731; 95% CI, 1.102-6.769; P = 0.03) and treatment with immunomodulators plus steroids (RR, 3.118; 95% CI, 1.169-8.320; P = 0.023) were significantly associated with increased risk of intra-abdominal sepsis. CONCLUSIONS Preoperative treatments with immunomodulators plus anti-TNF-α agents or steroids were risk factors for infectious complications, especially intra-abdominal sepsis in patients who underwent bowel resection and anastomosis.
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Affiliation(s)
- Chang Sik Yu
- Departments of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Woo Jung
- Departments of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jong Lyul Lee
- Departments of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seok-Byung Lim
- Departments of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - In Ja Park
- Departments of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yong Sik Yoon
- Departments of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chan Wook Kim
- Departments of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Suk-Kyun Yang
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Byong Duk Ye
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Hyoung Park
- Departments of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Minkyu Han
- Departments of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin Cheon Kim
- Departments of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Lee HW, Park SJ, Jeon SR, Ye BD, Park JJ, Cheon JH, Kim TI, Kim WH. Long-Term Outcomes of Endoscopic Balloon Dilation for Benign Strictures in Patients with Inflammatory Bowel Disease. Gut Liver 2019; 12:530-536. [PMID: 29730904 PMCID: PMC6143444 DOI: 10.5009/gnl17396] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 01/08/2018] [Accepted: 02/09/2018] [Indexed: 12/14/2022] Open
Abstract
Background/Aims Benign intestinal strictures are common complications in patients with inflammatory bowel disease (IBD). This study aimed to assess the long-term prognosis of endoscopic balloon dilation (EBD) to treat benign strictures in IBD patients. Methods Patients with IBD who had benign strictures and who underwent EBD in four tertiary referral university hospitals between January 2004 and February 2014 were retrospectively reviewed. Technical success was defined as the ability to pass the scope through the stricture after balloon dilation, and clinical success was defined as improved obstructive symptoms. Results Forty-two benign strictures were identified in 30 patients (15 males and 15 females). Technical success was achieved in 26 patients (86.7%) at the first EBD attempt and in all 30 patients (100%) at the second EBD attempt. Clinical success was seen in 28 patients (93.3%). The median follow-up duration was 134.8 months (range, 10.2 to 252.0 months), and recurrence occurred in eight patients (26.7%), who required repeat EBD. The median duration to relapse was 1.7 months (range, 0.2 to 6.3 months). During repeat EBD, perforation occurred in two cases (6.7%), which were both clipped successfully. Finally, only one patient (3.3%) underwent surgery for the relief of recurrent obstructive symptoms during the follow-up period. Conclusions The experience of 10 years shows that EBD is safe and effective for the treatment of benign strictures in IBD patients. Importantly, EBD may allow long-term effective palliation of the symptoms associated with benign intestinal strictures in IBD patients.
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Affiliation(s)
- Hye Won Lee
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Seong Ran Jeon
- Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Gastroenterology and Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Jun Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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14
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Coffey CJ, Kiernan MG, Sahebally SM, Jarrar A, Burke JP, Kiely PA, Shen B, Waldron D, Peirce C, Moloney M, Skelly M, Tibbitts P, Hidayat H, Faul PN, Healy V, O’Leary PD, Walsh LG, Dockery P, O’Connell RP, Martin ST, Shanahan F, Fiocchi C, Dunne CP. Inclusion of the Mesentery in Ileocolic Resection for Crohn's Disease is Associated With Reduced Surgical Recurrence. J Crohns Colitis 2018; 12:1139-1150. [PMID: 29309546 PMCID: PMC6225977 DOI: 10.1093/ecco-jcc/jjx187] [Citation(s) in RCA: 233] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Inclusion of the mesentery during resection for colorectal cancer is associated with improved outcomes but has yet to be evaluated in Crohn's disease. This study aimed to determine the rate of surgical recurrence after inclusion of mesentery during ileocolic resection for Crohn's disease. METHODS Surgical recurrence rates were compared between two cohorts. Cohort A [n = 30] underwent conventional ileocolic resection where the mesentery was divided flush with the intestine. Cohort B [n = 34] underwent resection which included excision of the mesentery. The relationship between mesenteric disease severity and surgical recurrence was determined in a separate cohort [n = 94]. A mesenteric disease activity index was developed to quantify disease severity. This was correlated with the Crohn's disease activity index and the fibrocyte percentage in circulating white cells. RESULTS Cumulative reoperation rates were 40% and 2.9% in cohorts A and B [P = 0.003], respectively. Surgical technique was an independent determinant of outcome [P = 0.007]. Length of resected intestine was shorter in cohort B, whilst lymph node yield was higher [12.25 ± 13 versus 2.4 ± 2.9, P = 0.002]. Advanced mesenteric disease predicted increased surgical recurrence [Hazard Ratio 4.7, 95% Confidence Interval: 1.71-13.01, P = 0.003]. The mesenteric disease activity index correlated with the mucosal disease activity index [r = 0.76, p < 0.0001] and the Crohn's disease activity index [r = 0.70, p < 0.0001]. The mesenteric disease activity index was significantly worse in smokers and correlated with increases in circulating fibrocytes. CONCLUSIONS Inclusion of mesentery in ileocolic resection for Crohn's disease is associated with reduced recurrence requiring reoperation.
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Affiliation(s)
- Calvin J Coffey
- Department of Surgery, University Hospital Limerick, Limerick, Ireland,Graduate Entry Medical School, University of Limerick, Limerick, Ireland,Centre for Interventions in Infection, Inflammation and Immunity [4i], University of Limerick, Limerick, Ireland,Corresponding author: Professor J. Calvin Coffey, PhD, FRCSI, Surgical Professorial Unit, University Hospital Limerick, Limerick, Ireland. Tel.: +353-61-482412; fax: +353-61-482410;
| | - Miranda G Kiernan
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland,Centre for Interventions in Infection, Inflammation and Immunity [4i], University of Limerick, Limerick, Ireland
| | - Shaheel M Sahebally
- Department of Surgery, University Hospital Limerick, Limerick, Ireland,Graduate Entry Medical School, University of Limerick, Limerick, Ireland,Centre for Interventions in Infection, Inflammation and Immunity [4i], University of Limerick, Limerick, Ireland
| | - Awad Jarrar
- Lerner College of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - John P Burke
- Centre for Colorectal Disease, St Vincent’s University Hospital, Dublin, Ireland,School of Medicine, University College Dublin, Dublin, Ireland
| | - Patrick A Kiely
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland,Centre for Interventions in Infection, Inflammation and Immunity [4i], University of Limerick, Limerick, Ireland,Health Research Institute [HRI], University of Limerick, Limerick, Ireland
| | - Bo Shen
- Lerner College of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA,Departments of Gastroenterology/Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - David Waldron
- Department of Surgery, University Hospital Limerick, Limerick, Ireland
| | - Colin Peirce
- Department of Surgery, University Hospital Limerick, Limerick, Ireland
| | - Manus Moloney
- Department of Gastroenterology, University Hospitals Limerick, Limerick, Ireland
| | - Maeve Skelly
- Department of Gastroenterology, University Hospitals Limerick, Limerick, Ireland
| | - Paul Tibbitts
- Department of Surgery, University Hospital Limerick, Limerick, Ireland,Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Hena Hidayat
- Department of Surgery, University Hospital Limerick, Limerick, Ireland
| | - Peter N Faul
- Department of Pathology, University Hospitals Limerick, Limerick, Ireland
| | - Vourneen Healy
- Department of Pathology, University Hospitals Limerick, Limerick, Ireland
| | - Peter D O’Leary
- Department of Surgery, University Hospital Limerick, Limerick, Ireland
| | - Leon G Walsh
- Department of Surgery, University Hospital Limerick, Limerick, Ireland,Graduate Entry Medical School, University of Limerick, Limerick, Ireland,Centre for Interventions in Infection, Inflammation and Immunity [4i], University of Limerick, Limerick, Ireland
| | - Peter Dockery
- Department of Anatomy, National University of Ireland Galway, Galway, Ireland
| | - Ronan P O’Connell
- Centre for Colorectal Disease, St Vincent’s University Hospital, Dublin, Ireland,School of Medicine, University College Dublin, Dublin, Ireland
| | - Sean T Martin
- Centre for Colorectal Disease, St Vincent’s University Hospital, Dublin, Ireland
| | - Fergus Shanahan
- Department of Medicine, Alimentary Pharmabiotic Centre, University College Cork, Cork, Ireland
| | - Claudio Fiocchi
- Departments of Gastroenterology/Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA,Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Colum P Dunne
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland,Centre for Interventions in Infection, Inflammation and Immunity [4i], University of Limerick, Limerick, Ireland
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15
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Banerjee R, Pal P, Girish BG, Reddy DN. Risk factors for diagnostic delay in Crohn's disease and their impact on long-term complications: how do they differ in a tuberculosis endemic region? Aliment Pharmacol Ther 2018; 47:1367-1374. [PMID: 29572889 DOI: 10.1111/apt.14617] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 08/30/2017] [Accepted: 02/26/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND The diagnosis of Crohn's disease (CD) can be delayed in clinical practice. In tuberculosis endemic areas, empirical anti-tubercular therapy further delays treatment. AIM(S) To assess risk factors for diagnostic delay and its impact on the long-term complications of Crohn's disease in India where tuberculosis is endemic. METHODS Data from a large prospectively established inflammatory bowel disease registry were analysed retrospectively. The time from onset of symptoms to diagnosis (diagnostic delay) was calculated and categorised into two groups based on median diagnostic delay. The risk factors for delay including anti-tubercular therapy were analysed. Logistic regression analysis was done to assess impact of diagnostic delay on development of stenotic and fistular complications including need for surgery. RESULTS Seven hundred and twenty Crohn's disease patients (60.3% male, median: 28 years) were included. Main outcome measures were stenosis, fistula and need for surgery. Subjects with diagnostic delay >18 months (median) developed significantly higher stenotic complications and surgery (OR 4.12; 95% CI: 2.74-6.33, P < 0.001 and OR 2.41, 95% CI: 1.68-3.42, P < 0.001), respectively, compared to those ≤18 months. There was no difference in the development of fistulous complications. 193/720 (27%) received anti-tubercular therapy which significantly contributed to diagnostic delay (OR: 2.47; 95% CI: 1.76-3.47, P < 0.001) with 47% showing initial clinical response (Crohn's disease activity index- CDAI decrease >100). Moreover, the incidence of stenotic complications was significantly higher in patients who had received prior anti-tubercular therapy (55/193 (28.49%) vs 78/527 (14.8%), P < 0.001, OR: 2.60, 95% CI: 1.64-4.12). CONCLUSIONS Diagnostic delay in Crohn's disease is associated with significantly higher stenotic complications and need for surgery. Empirical anti-tubercular therapy is the single largest contributor to diagnostic delay in tuberculosis endemic areas. Despite initial clinical response to anti-tubercular therapy, long-term stenotic complications are higher.
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Affiliation(s)
- R Banerjee
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - P Pal
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - B G Girish
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D N Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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16
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Ustekinumab and Vedolizumab Dual Biologic Therapy in the Treatment of Crohn's Disease. Case Rep Med 2017; 2017:5264216. [PMID: 29250117 PMCID: PMC5698793 DOI: 10.1155/2017/5264216] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 10/15/2017] [Indexed: 11/24/2022] Open
Abstract
We present a case of refractory ileocolonic Crohn's disease in a 27-year-old female treated with dual ustekinumab and vedolizumab biologic therapy. She had mucosal healing for the first time in 13 years after a 10-month treatment of ustekinumab overlapped with 6 months of vedolizumab. No side effects were observed during the 6 months of dual biologic therapy. Short-term dual biologic therapy may be considered as a treatment option for induction of remission in refractory cases of Crohn's disease.
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17
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Yan L, Wang L, Bai J, Miao X, Zeng W, Hua X, Ni R, Zhang D, Tang Q. Chromosome region maintenance-1 (CRM1) regulates apoptosis of intestinal epithelial cells via p27kip1 in Crohn's disease. Clin Res Hepatol Gastroenterol 2017; 41:445-458. [PMID: 28286054 DOI: 10.1016/j.clinre.2017.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 01/03/2017] [Accepted: 01/25/2017] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To investigate the role of chromosome region maintenance-1 (CRM1) in Crohn's disease (CD) and its potential pathological mechanisms. METHODS The expression and distribution of CRM1 in mucosal biopsies from patients with active CD and normal controls were detected by immunohistochemistry (IHC). We established a murine model of acute colitis induced by 2,4,6-trinitrobenzene sulfonic acid (TNBS). Western blot was performed to investigate the expression levels of CRM1, apoptotic markers (active caspase-3 and cleaved PARP), p27kip1 and p-p27ser10. IHC was performed to evaluate the distribution of CRM1, and double immunofluorescence (IF) was performed to evaluate the co-localization of CRM1 and active capase-3. Cells of the human intestinal epithelial cell line HT-29 were incubated with tumor necrosis factor-α (TNF-α) to establish an apoptotic in vitro model. Western blot was performed to determine the expression levels of CRM1, active caspase-3, cleaved PARP and p-p27ser10. Cytoplasmic and nuclear extracts were assessed to examine the translocation of CRM1. The interaction between CRM1 and p27kip1 was assessed by co-immunoprecipitation (co-IP) assays. Furthermore, we used small interfering RNA (siRNA) to knock down the protein expression of CRM1 in HT-29 cells and then measured the expression of active caspase-3, cleaved PARP and p-p27ser10. Flow cytometry was used to determine the effect of CRM1 on intestinal epithelial cell (IEC) apoptosis. RESULTS We observed up-regulation of CRM1 accompanied by elevated levels of IEC apoptotic markers (active caspase-3 and cleaved PARP) and p-p27ser10 in IECs of patients with active CD and in TNBS-induced colitis model cells. However, the expression of p27kip1 was negatively correlated with the expression patterns of CRM1, p-p27ser10 and apoptotic biochemical markers. Co-localization of CRM1 and active caspase-3 in IECs of the TNBS group further indicated the possible involvement of CRM1 in IEC apoptosis. By employing TNF-α-treated HT-29 cells as an in vitro IEC apoptosis model, we found that the expression levels of CRM1 and p-p27ser10 were in accordance with active caspase-3 and cleaved PARP. In addition, immunoprecipitation confirmed the physical interaction between CRM1 and p27kip1. siRNA knockdown of CRM1 significantly inhibited the phosphorylation of p27kip1 and the expression of active caspase-3 and cleaved PARP. In addition, flow cytometry analysis also showed that silencing CRM1 by siRNA inhibited TNF-α-induced cellular apoptosis in HT-29 cells. CONCLUSIONS Up-regulated CRM1 may facilitate IEC apoptosis possibly through p27kip1 in CD, indicating an important role of CRM1 in the pathophysiology of CD.
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Affiliation(s)
- Lijun Yan
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Liang Wang
- Department of Gastroenterology, Affiliated Hospital of Nantong University, Nantong, China
| | - Jian'an Bai
- Department of Gastroenterology, The Third Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Xianjing Miao
- Department of Gastroenterology, Affiliated Hospital of Nantong University, Nantong, China
| | - Weiwen Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiumei Hua
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Runzhou Ni
- Department of Gastroenterology, Affiliated Hospital of Nantong University, Nantong, China
| | - Dongmei Zhang
- Department of Pathogen Biology, Medical College, Nantong University; Jiangsu Province Key Laboratory for Inflammation and Molecular Drug Target, Nantong University, Nantong, China
| | - Qiyun Tang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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18
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Park JJ, Yang SK, Ye BD, Kim JW, Park DI, Yoon H, Im JP, Lee KM, Yoon SN, Lee H. [Second Korean Guidelines for the Management of Crohn's Disease]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 69:29-54. [PMID: 28135790 DOI: 10.4166/kjg.2017.69.1.29] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Crohn's disease (CD) is a chronic, progressive, and disabling inflammatory bowel disease (IBD) with an uncertain etiopathogenesis. CD can involve any site of the gastrointestinal tract from the mouth to the anus, and is associated with serious complications, such as bowel strictures, perforations, and fistula formation. The incidence and prevalence rates of CD in Korea are still lower compared with those in Western countries, but they have been rapidly increasing during the recent decades. Although there are no definitive curative modalities for CD, various medical and surgical therapies have been applied for the treatment of this disease. Concerning CD management, there have been substantial discrepancies among clinicians according to their personal experience and preference. To suggest recommendable approaches to the diverse problems of CD and to minimize the variations in treatment among physicians, guidelines for the management of CD were first published in 2012 by the IBD Study Group of the Korean Association for the Study of the Intestinal Diseases. These are the revised guidelines based on updated evidence, accumulated since 2012. These guidelines were developed by using mainly adaptation methods, and encompass induction and maintenance treatment of CD, treatment based on disease location, treatment of CD complications, including stricture and fistula, surgical treatment, and prevention of postoperative recurrence. These are the second Korean guidelines for the management of CD and will be continuously revised as new evidence is collected.
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Affiliation(s)
- Jae Jun Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Suk Kyun Yang
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Wook Kim
- Department of Internal Medicine, Inje University College of Medicine Ilsan Paik Hospital, Goyang, Korea
| | - Dong Il Park
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyuk Yoon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong Pil Im
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kang Moon Lee
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Sang Nam Yoon
- Department of Surgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Heeyoung Lee
- Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Seongnam, Korea
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19
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Hovde Ø, Høivik ML, Henriksen M, Solberg IC, Småstuen MC, Moum BA. Malignancies in Patients with Inflammatory Bowel Disease: Results from 20 Years of Follow-up in the IBSEN Study. J Crohns Colitis 2017; 11:571-577. [PMID: 28453756 DOI: 10.1093/ecco-jcc/jjw193] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 10/26/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Whether patients with inflammatory bowel diseases [IBDs] have increased risk of developing cancer has been debated. The aims of the study were to determine the prevalence of intestinal/extraintestinal cancers in an IBD cohort 20 years after diagnosis and to assess whether these patients had an increased cancer-specific risk compared with a matched control population. METHODS Patients with ulcerative colitis [UC] and Crohn's disease [CD] diagnosed 1990-1993 have been prospectively followed up for 20 years. Follow-up visits were carried out 1, 5, 10, and 20 years after inclusion. Data on all cancer cases, deaths, and causes of death were collected from the Cancer Registry of Norway and from the Norwegian Cause of Death Registry. RESULTS In all, 756 patients [519 UC and 237 CD] were diagnosed with IBD. Increased risk of cancer was seen in UC patients (hazard ratio [HR] = 1.40, 95% confidence interval [CI] 1.08-1.81, p < 0.01), but not in CD patients [HR = 1.23, 95% CI 0.80-2.03, p = 0.30]. Stratified by gender, our data revealed a statistically increased risk for all cancers only in male UC patients compared with the controls [HR = 1.51, 95% CI 1.08-2.11, p = 0.017]. In both groups breast cancer was seen more often than expected. CONCLUSIONS Male UC patients display an increased risk of development of colorectal cancer and, also all cancers combined, compared with the controls. In both UC and CD, standardized incidence ratio for breast cancer was increased.
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Affiliation(s)
- Øistein Hovde
- Department of Gastroenterology, Innlandet Hospital Trust, Gjøvik, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Marte Lie Høivik
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Magne Henriksen
- Department of Gastroenterology, Østfold Hospital, Fredrikstad, Norway
| | | | | | - Bjørn A Moum
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
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20
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Park JJ, Yang SK, Ye BD, Kim JW, Park DI, Yoon H, Im JP, Lee KM, Yoon SN, Lee H. Second Korean guidelines for the management of Crohn's disease. Intest Res 2017; 15:38-67. [PMID: 28239314 PMCID: PMC5323307 DOI: 10.5217/ir.2017.15.1.38] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 01/15/2017] [Accepted: 01/16/2017] [Indexed: 02/07/2023] Open
Abstract
Crohn's disease (CD) is a chronic, progressive, and disabling inflammatory bowel disease (IBD) with an uncertain etiopathogenesis. CD can involve any site of the gastrointestinal tract from the mouth to the anus, and is associated with serious complications, such as bowel strictures, perforations, and fistula formation. The incidence and prevalence rates of CD in Korea are still lower compared with those in Western countries, but they have been rapidly increasing during the recent decades. Although there are no definitive curative modalities for CD, various medical and surgical therapies have been applied for the treatment of this disease. Concerning CD management, there have been substantial discrepancies among clinicians according to their personal experience and preference. To suggest recommendable approaches to the diverse problems of CD and to minimize the variations in treatment among physicians, guidelines for the management of CD were first published in 2012 by the IBD Study Group of the Korean Association for the Study of Intestinal Diseases. These are the revised guidelines based on updated evidence, accumulated since 2012. These guidelines were developed by using mainly adaptation methods, and encompass induction and maintenance treatment of CD, treatment based on disease location, treatment of CD complications, including stricture and fistula, surgical treatment, and prevention of postoperative recurrence. These are the second Korean guidelines for the management of CD and will be continuously revised as new evidence is collected.
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Affiliation(s)
- Jae Jun Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Wook Kim
- Department of Internal Medicine, Inje University College of Medicine Ilsan Paik Hospital, Goyang, Korea
| | - Dong Il Park
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyuk Yoon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong Pil Im
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kang Moon Lee
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Suwon, Korea
| | - Sang Nam Yoon
- Department of Surgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Heeyoung Lee
- Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Seongnam, Korea
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21
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The suppressor of cytokine signaling SOCS1 promotes apoptosis of intestinal epithelial cells via p53 signaling in Crohn's disease. Exp Mol Pathol 2016; 101:1-11. [PMID: 27236107 DOI: 10.1016/j.yexmp.2016.05.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 05/18/2016] [Accepted: 05/19/2016] [Indexed: 12/17/2022]
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22
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Kwak MS, Kim KJ, Park SH, Yang DH, Ye BD, Byeon JS, Myung SJ, Yang SK. Elevated C-reactive protein is associated with disease progression in patients with mild Crohn's disease. SPRINGERPLUS 2016; 5:878. [PMID: 27386326 PMCID: PMC4920795 DOI: 10.1186/s40064-016-2606-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/16/2016] [Indexed: 02/07/2023]
Abstract
Background Few studies have been conducted on the progression of mild Crohn’s disease (CD). We aimed to investigate the natural course in mild CD patients with or without bowel damage, to identify predictors of bowel resection and to calculate the requirement for rescue medication. Methods A total of 104 patients with mild activity (150 < CDAI < 220) with or without bowel damage were identified from among 1050 CD patients between January 2008 and May 2014. Univariate and multivariate analysis was used to identify factors associated with bowel resection. The cumulative probabilities of bowel resection and rescue medication such as steroids or anti-TNF agents were calculated. Results The median follow-up duration was 28.2 months (IQR 26.7). Cumulative probabilities of bowel resection were 0.2, 11.8 and 42.4 % at 1, 3 and 5 years respectively. The CD patients with bowel damage had a higher bowel resection rate than those without bowel damage (P < 0.001). The cumulative probabilities of corticosteroid-requirement were 3.0, 19.6 and 78.4 % of patients at 1, 3 and 5 years, respectively, and 2.1, 11.9 and 56.1 %, in terms of the cumulative probabilities of requiring anti-TNF agents. Patients with elevated CRP (>1.6 mg/dL) were more likely to undergo bowel resection (P = 0.032). Conclusions Even in CD patients with mild disease activity, the cumulative probability of bowel resection is not low if they have bowel damage or elevated CRP at baseline. Mild CD patients with bowel damage or elevated CRP at baseline need special attention.
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Affiliation(s)
- Min Seob Kwak
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505 Republic of Korea
| | - Kyung-Jo Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505 Republic of Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505 Republic of Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505 Republic of Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505 Republic of Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505 Republic of Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505 Republic of Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-gu, Seoul, 05505 Republic of Korea
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Zhulina Y, Udumyan R, Tysk C, Montgomery S, Halfvarson J. The changing face of Crohn's disease: a population-based study of the natural history of Crohn's disease in Örebro, Sweden 1963-2005. Scand J Gastroenterol 2016; 51:304-13. [PMID: 26448101 DOI: 10.3109/00365521.2015.1093167] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Changes in medical therapy and surgery might have influenced the natural history of Crohn's disease (CD). Our aim was to explore the short-term outcome of CD and to specifically assess trends in disease phenotype, medications and surgery in the first five years from diagnosis. MATERIAL AND METHODS A population-based cohort comprising 472 CD patients diagnosed within the primary catchment area of Örebro University Hospital 1963-2005 were identified retrospectively and described. Data on medication, surgery, progression in disease location and behavior, were extracted from the medical records. Patients were divided into three cohorts based on year of diagnosis. RESULTS The proportion of patients with complicated disease behavior five years after diagnosis decreased from 54.4% (95%CI, 43.9-65.6) to 33.3% (27.4-40.0) in patients diagnosed 1963-1975 and 1991-2005, respectively (p = 0.002), whereas the proportion of patients progressing to complicated disease behavior was stable among those with non-stricturing, non-penetrating disease at diagnosis (p = 0.435). The proportion of patients undergoing surgery decreased from 65.8% (55.4-76.0) to 34.6% (28.6-41.5) in patients diagnosed 1963-1975 and 1991-2005, respectively (p < 0.001). The reduction in surgery preceded an increased use of immunomodulators and was explained by a decrease in surgery within three months from diagnosis (p = 0.001). CONCLUSIONS We observed a striking decrease in complicated disease behavior and surgery five years after CD diagnosis, the latter largely due to a decrease in early surgery. Our findings suggest that the introduction of new treatments alone does not explain the reduction in surgery rates, the increasing proportion of patients with inflammatory disease at diagnosis also play an important role.
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Affiliation(s)
| | - Ruzan Udumyan
- b Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine and Health , Örebro University , Örebro , Sweden
| | - Curt Tysk
- a Department of Gastroenterology and
| | - Scott Montgomery
- b Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine and Health , Örebro University , Örebro , Sweden ;,c Clinical Epidemiology Unit, Department of Medicine , Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden ;,d Department of Epidemiology and Public Health , University College London , London , UK
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24
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Nuij V, Fuhler GM, Edel AJ, Ouwendijk RJT, Rijk MCM, Beukers R, Quispel R, van Tilburg AJP, Tang TJ, Smalbraak H, Bruin KF, Lindenburg F, Peyrin-Biroulet L, van der Woude CJ. Benefit of Earlier Anti-TNF Treatment on IBD Disease Complications? J Crohns Colitis 2015. [PMID: 26223842 DOI: 10.1093/ecco-jcc/jjv130] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Anti-tumour necrosis factor [anti-TNF] treatment was demonstrated to have disease-modifying abilities in inflammatory bowel disease [IBD]. In this study, we aimed to determine the effect of anti-TNF treatment timing on IBD disease complications and mucosal healing [MH]. METHODS The following IBD-related complications were tested in relation to timing of anti-TNF therapy start in newly diagnosed IBD patients [n = 413]: fistula formation, abscess formation, extra-intestinal manifestations [EIM], surgery, referral to academic centre, and MH. RESULTS A total of 85 patients [21%] received anti-TNF (66 Crohn's disease [CD], 16 ulcerative colitis [UC], 3 inflammatory bowel disease unclassified [IBDU]) of whom 57% [48 patients] were treated < 16 months after diagnosis. Patients receiving anti-TNF early [< 16 months] did not differ from patients receiving anti-TNF late [> 16 months] regarding gender, age, smoking status, and familial IBD. More importantly, patients receiving anti-TNF early did not suffer less IBD-related complications during follow-up as compared with patients started on anti-TNF late, nor was more MH observed. Similar results were obtained when anti-TNF treated patient were stratified more stringently, ie < 12 months [40 patients] vs >2 4 months [24 patients]. Cox regression analysis showed no beneficial correlations between anti-TNF timing and IBD-related complications. Anti-TNF treated patients achieving MH were 11 times less likely to develop EIMs compared with patients who did not achieved MH while on anti-TNF. CONCLUSIONS This study was unable to confirm a benefit of earlier anti-TNF treatment on IBD disease complications. This could be explained by more aggressive treatment earlier in disease, resulting in fewer IBD complications. However, it seems more likely that inappropriate selection of patients for therapy leads to suboptimal treatment and subsequently suboptimal outcome.
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Affiliation(s)
- Veerle Nuij
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
| | - Gwenny M Fuhler
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
| | - Annemarie J Edel
- Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, The Netherlands
| | - Rob J T Ouwendijk
- Department of Gastroenterology and Hepatology, Ikazia Hospital, Rotterdam, The Netherlands
| | - Marno C M Rijk
- Department of Gastroenterology and Hepatology, Amphia Hospital, Breda, The Netherlands
| | - Ruud Beukers
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Antonie J P van Tilburg
- Department of Gastroenterology and Hepatology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands
| | - Thjon J Tang
- Department of Gastroenterology and Hepatology, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | - Hermen Smalbraak
- Department of Internal Medicine, Lievensberg Hospital, Bergen op Zoom, The Netherlands
| | - Karlien F Bruin
- Department of Gastroenterology and Hepatology, Tweesteden Hospital, Tilburg, The Netherlands
| | - Flordeliz Lindenburg
- Department of Gastroenterology and Hepatology, Franciscus Hospital, Roosendaal, The Netherlands
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Hepatology, Nancy University Hospital, Université de Lorraine, Vandoeuvre-les-Nancy, France
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25
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Abstract
INTRODUCTION Although medical management of Crohn's disease has changed in recent years, it is unclear whether surgical management has altered. We examined rate changes of surgical interventions, stoma constructions, and subset of ileostomy and colostomy constructions. MATERIALS AND METHODS We reviewed the Nationwide Inpatient Sample database from 1988 to 2011. We examined the number of Crohn's-related operations and stoma constructions, including ileostomies and colostomies; a multivariable logistic regression model was developed. RESULTS A total of 355,239 Crohn's-related operations were analyzed. Operations increased from 13,955 in 1988 to 17,577 in 2011, p < 0.001. Stoma construction increased from 2493 to 4283, p < 0.001. The subset of ileostomies increased from 1201 to 3169, p < 0.001 while colostomies decreased from 1351 to 1201, p = 0.05. Operation percentages resulting in stoma construction increased from 18 to 24 %, p < 0.001. Weight loss (OR 2.25, 95 % CI 1.88, 2.69) and presence of perianal fistulizing disease (OR 2.91, 95 % CI 2.31, 3.67) were most predictive for requiring stoma construction. CONCLUSIONS Crohn's-related surgical interventions and stoma constructions have increased. The largest predictors for stoma construction are weight loss and perianal fistulizing disease. As a result, nutrition should be optimized and the early involvement of a multidisciplinary team should be considered.
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26
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Niewiadomski O, Studd C, Hair C, Wilson J, Ding NS, Heerasing N, Ting A, McNeill J, Knight R, Santamaria J, Prewett E, Dabkowski P, Dowling D, Alexander S, Allen B, Popp B, Connell W, Desmond P, Bell S. Prospective population-based cohort of inflammatory bowel disease in the biologics era: Disease course and predictors of severity. J Gastroenterol Hepatol 2015; 30:1346-1353. [PMID: 25867770 DOI: 10.1111/jgh.12967] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/20/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM We have previously found high incidence of inflammatory bowel disease (IBD) in Australia. A population-based registry was established to assess disease severity, frequency of complications, and prognostic factors. METHODS Incident cases were prospectively identified over 4 years. Early disease severity was assessed according to need for hospitalization and resective surgery and medication use. RESULTS We report on the early outcomes (median 18 months, range 12-60 months) for 252 patients comprising 146 with Crohn's disease (CD), 96 with ulcerative colitis (UC), and 10 IBD undifferentiated. Eighty-seven percent of CD patients had inflammatory disease at diagnosis, and this reduced to 73% at 5 years (n = 38). Immunomodulators were prescribed in 57% of CD patients and 19% with UC. A third of all CD patients were hospitalized, the majority (77%) in the first 12 months. Risk factors for hospitalization included penetrating, perianal, and ileocolonic disease (P < 0.05). Twenty-four percent of UC patients were hospitalized, most within the first 12 months. Intestinal resection rates were 13% at 1 year in CD and 26% at 5 years. Risk factors include penetrating and stricturing disease (P < 0.001) and ileal involvement (P < 0.05). Colectomy rates in UC were 2% and 13% at 1 and 5 years. High C-reactive protein (CRP) at diagnosis was associated with colectomy. CONCLUSIONS A high rate of inflammatory disease, frequent immunomodulator use in CD, and a low rate of surgery in both CD and UC were identified. In CD, ileal involvement and complex disease behavior are associated with a more severe disease course, while in UC a high CRP predicted this outcome.
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Affiliation(s)
- Olga Niewiadomski
- Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Corrie Studd
- Gastroenterology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Chris Hair
- Gastroenterology, Barwon Health, Geelong, Victoria, Australia
| | - Jarrad Wilson
- Gastroenterology, North West Regional Hospital, Burnie, Tasmania, Australia
| | - Nik S Ding
- Gastroenterology, Barwon Health, Geelong, Victoria, Australia
| | - Neel Heerasing
- Gastroenterology, Barwon Health, Geelong, Victoria, Australia
| | - Alvin Ting
- Gastroenterology, Barwon Health, Geelong, Victoria, Australia
| | - John McNeill
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ross Knight
- Gastroenterology, Barwon Health, Geelong, Victoria, Australia
| | - John Santamaria
- Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Emily Prewett
- Gastroenterology, Barwon Health, Geelong, Victoria, Australia
| | - Paul Dabkowski
- Gastroenterology, Barwon Health, Geelong, Victoria, Australia
| | - Damian Dowling
- Gastroenterology, Barwon Health, Geelong, Victoria, Australia
| | - Sina Alexander
- Gastroenterology, Barwon Health, Geelong, Victoria, Australia
| | - Ben Allen
- Gastroenterology, Barwon Health, Geelong, Victoria, Australia
| | - Benjamin Popp
- Pathology, St John of God, Geelong, Victoria, Australia
| | - William Connell
- Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Paul Desmond
- Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Gastroenterology Department, University of Melbourne, Fitzroy, Victoria, Australia
| | - Sally Bell
- Gastroenterology, St Vincent's Hospital, Fitzroy, Victoria, Australia
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27
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van den Heuvel TRA, Jonkers DM, Jeuring SFG, Romberg-Camps MJL, Oostenbrug LE, Zeegers MP, Masclee AA, Pierik MJ. Cohort Profile: The Inflammatory Bowel Disease South Limburg Cohort (IBDSL). Int J Epidemiol 2015; 46:e7. [DOI: 10.1093/ije/dyv088] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Geltzeiler CB, Young JI, Diggs BS, Keyashian K, Deveney K, Lu KC, Tsikitis VL, Herzig DO. Strictureplasty for Treatment of Crohn's Disease: an ACS-NSQIP Database Analysis. J Gastrointest Surg 2015; 19:905-10. [PMID: 25617078 DOI: 10.1007/s11605-015-2749-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 01/07/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Strictureplasty is an alternative to resection for treatment of Crohn's disease (CD) strictures. It preserves bowel length, and specialized centers report favorable outcomes. Strictureplasty rates, however, are thought to be low, and it was recently removed from required cases for colon and rectal surgery residents. We examined operative characteristics, and trends in its use using a large national database. MATERIALS AND METHODS We examined the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2012, identifying patients with CD who underwent strictureplasty. We identified patient characteristics, outcome variables, and trends in utilization of strictureplasty. RESULTS A total of 9172 patients underwent surgery for CD. Two hundred fifty-six (2.8 %) underwent strictureplasty. Median preoperative albumin was 3.6. Preoperative steroid use and weight loss rates were 39 and 8 %. Rates of wound infection and organ space infection were 11 and 4 %. Rate of reoperation was 6 %. Outcomes did not change significantly over time (all p = NS). The proportion of CD operations that included a strictureplasty decreased from 5.1 to 1.7 % (OR 0.902 with each additional year, 95 % CI (0.852, 0.960), p < 0.001). CONCLUSION Strictureplasty as treatment for CD is decreasing in the ACS-NSQIP database. Infectious complications and reoperation rates following strictureplasty are low and have not changed over time.
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Affiliation(s)
- Cristina B Geltzeiler
- Department of Surgery, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Mail Code L223A, Portland, OR, 97239, USA,
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29
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Tang Q, Ji Q, Xia W, Li L, Bai J, Ni R, Qin Y. Pyruvate kinase M2 regulates apoptosis of intestinal epithelial cells in Crohn's disease. Dig Dis Sci 2015; 60:393-404. [PMID: 24817408 DOI: 10.1007/s10620-014-3189-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Accepted: 04/25/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pyruvate kinase M2 (PKM2), a key glycolytic enzyme, is involved in multiple cellular processes including apoptosis. Recently increased fecal PKM2 has been found in Crohn's disease (CD), but little is known regarding its function in the pathophysiology of the disease. AIM The intestinal expression of PKM2 and its involvement in CD was investigated. METHODS Pyruvate kinase M2 expression in mucosal biopsies from patients with CD and normal controls was detected by immunohistochemistry. A murine model of colitis induced by trinitrobenzenesulphonic acid (TNBS) was established and expression of PKM2, B cell lymphoma-extra large (Bcl-xl), active caspase-3 as well as cleaved poly (ADP-ribose) polymerase (PARP) was examined for association of PKM2 with intestinal epithelial cell (IEC) apoptosis. Furthermore, we treated human IEC line HT-29 by tumor necrosis factor-α (TNF-α) and used RNA interference to analyze the role of PKM2 in IEC apoptosis. RESULTS Intestinal expression of PKM2 was higher in patients with CD compared with normal controls mainly locating in IECs. In TNBS-induced colitis, up-regulation of PKM2 was accompanied by the elevated expression of Bcl-xl, active caspase-3, and cleaved PARP. PKM2 was co-localized with active caspase-3 in IECs marked by E-cadherin, suggesting its role in IEC apoptosis. Expression of PKM2 and Bcl-xl in TNF-α-induced HT-29 cells was increased, while TNF-α had no effect on cellular localization of PKM2. Furthermore, knockdown of PKM2 by siRNA could inhibit expression of Bcl-xl but enhance apoptosis in TNF-α-treated HT-29 cells. CONCLUSION The up-regulation of PKM2 might protect IECs against apoptosis possibly through Bcl-xl in CD, indicating its important role in the pathophysiology of CD.
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Affiliation(s)
- Qiyun Tang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
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30
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Vacuolar protein sorting 4B regulates apoptosis of intestinal epithelial cells via p38 MAPK in Crohn's disease. Exp Mol Pathol 2015; 98:55-64. [DOI: 10.1016/j.yexmp.2014.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 12/18/2014] [Indexed: 01/16/2023]
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31
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Church PC, Turner D, Feldman BM, Walters TD, Greer ML, Amitai MM, Griffiths AM. Systematic review with meta-analysis: magnetic resonance enterography signs for the detection of inflammation and intestinal damage in Crohn's disease. Aliment Pharmacol Ther 2015; 41:153-66. [PMID: 25403954 DOI: 10.1111/apt.13024] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 09/24/2014] [Accepted: 10/22/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND In the treatment of Crohn's disease (CD), mucosal healing has become a major goal, with the hope of avoiding intestinal damage from chronic inflammation. Magnetic resonance enterography (MRE) has emerged as a non-invasive means of monitoring inflammation and damage. AIMS As part of the development of MRE-based multi-item measures of inflammation and damage for paediatric studies, we carried out a systematic review and meta-analysis to identify MRE variables used to describe these two distinct concepts. METHODS 2501 studies of MRI and CD were identified. Studies written in any language reporting individual MRE signs for patients diagnosed with CD were included. Two-hundred-and-forty-four studies were fully reviewed and 62 were included (inflammation, n = 51; damage, n = 24). Sensitivity, specificity and associated confidence intervals were calculated, and hierarchical summary ROC curves were constructed for each MRE sign. RESULTS A total of 22 MRE signs were used to reflect inflammation, and 9 to reflect damage. Diagnostic accuracy of MRE signs of inflammation and damage was heterogeneous; however, wall enhancement, mucosal lesions and wall T2 hyperintensity were the most consistently useful for inflammation (most sensitivities >80% and specificities >90%), and detection of abscess and fistula were most consistently useful for damage (most sensitivities >90%, specificities >95%). CONCLUSIONS Identifying the best MRE variables to reflect inflammation and damage will maximise the utility of this rapidly emerging technique and is the first stage of constructing MRE-based indices for evaluating inflammation and intestinal damage.
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Affiliation(s)
- P C Church
- Division of Gastroenterology, Hepatology & Nutrition, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Lobatón T, Guardiola J, Rodriguez-Moranta F, Millán-Scheiding M, Peñalva M, De Oca J, Biondo S. Comparison of the long-term outcome of two therapeutic strategies for the management of abdominal abscess complicating Crohn's disease: percutaneous drainage or immediate surgical treatment. Colorectal Dis 2014; 15:1267-72. [PMID: 24102970 DOI: 10.1111/codi.12419] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 03/21/2013] [Indexed: 02/08/2023]
Abstract
AIM The management of abdominal abscesses complicating Crohn's disease is complex and involves a difficult choice between medical, radiological and surgical procedures. The long-term outcome was compared for two strategies for the management of abdominal abscess: percutaneous drainage (PD) followed by rescue surgery in the case of failure vs direct immediate surgery (IS). We also compared the results of IS with surgery performed after PD failure. METHODS We retrospectively identified 44 patients with Crohn's disease with an abdominal abscess from January 2000 to December 2009. Therapeutic success was defined as abscess resolution and no reappearance within 1 year of follow-up. RESULTS The first therapeutic approach was PD in 22 cases and IS in the other 22 cases. IS had a higher therapeutic success rate than PD (95.5% vs 27.2% respectively; P < 0.001). PD was the only independent variable related to treatment failure in the multivariate analysis after adjustment for possible confounders such as abscess size, multilocularity, presence of fistula and corticosteroid use (OR 88.26, 95% CI 7.38-1055.36; P < 0.001). Surgery after failure of PD (n = 16) was associated with longer total hospitalization (56.12 ± 35.89 vs 27.52 ± 15.11 days; P = 0.017) and longer postoperative stay (44.0 ± 83.7 vs 14.3 ± 30 days; P = 0.179) and needed a second operation more often (5/16, 31% vs 1/22, 4.5%; P = 0.065) than IS. CONCLUSIONS Percutaneous drainage provided durable abscess resolution in only one-third of the patients compared with more than 90% of those treated with IS. In addition, surgery performed after PD failure results in a poorer outcome than IS.
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Affiliation(s)
- T Lobatón
- Department of Gastroenterology, Bellvitge University Hospital - IDIBELL, Barcelona, Spain
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33
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Mandel MD, Balint A, Golovics PA, Vegh Z, Mohas A, Szilagyi B, Szabo A, Kurti Z, Kiss LS, Lovasz BD, Gecse KB, Farkas K, Molnar T, Lakatos PL. Decreasing trends in hospitalizations during anti-TNF therapy are associated with time to anti-TNF therapy: Results from two referral centres. Dig Liver Dis 2014; 46:985-990. [PMID: 25156871 DOI: 10.1016/j.dld.2014.07.168] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 07/15/2014] [Accepted: 07/20/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hospitalization is an important outcome measure and a major driver of costs in patients with inflammatory bowel disease. We analysed medical and surgical hospitalization rates and predictors of hospitalization before and during anti-TNF therapy. METHODS Data from 194 consecutive patients were analysed retrospectively (males, 45.4%, median age at diagnosis, 24.0 years, infliximab/adalimumab: 144/50) in whom anti-TNF therapy was started after January 1, 2008. Total follow-up was 1874 patient-years and 474 patient-years with anti-TNF exposure. RESULTS Hospitalization rates hospitalization decreased only in Crohn's disease (odds ratio: 0.59, 95% confidence interval: 0.51-0.70, median 2-years' anti-TNF exposure) with a same trend for surgical interventions (p=0.07), but not in ulcerative colitis. Need for hospitalization decreased in Crohn's disease with early (within 3-years from diagnosis, p=0.016 by McNemar test), but not late anti-TNF exposure. At logistic regression analysis complicated disease behaviour (p=0.03), concomitant azathioprine (p=0.02) use, but not anti-TNF type, gender, perianal disease or previous surgeries were associated with the risk of hospitalization during anti-TNF therapy. CONCLUSION Hospitalization rate decreased significantly in patients with Crohn's disease but not ulcerative colitis after the introduction of anti-TNF therapy and was associated with time to therapy. Complicated disease phenotype and concomitant azathioprine use were additional factors defining the risk of hospitalization.
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Affiliation(s)
- Michael D Mandel
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Anita Balint
- 1st Department of Medicine, University of Szeged, Szeged, Hungary
| | - Petra A Golovics
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Zsuzsanna Vegh
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Anna Mohas
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Blanka Szilagyi
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Agnes Szabo
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Zsuzsanna Kurti
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Lajos S Kiss
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Barbara D Lovasz
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Krisztina B Gecse
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Klaudia Farkas
- 1st Department of Medicine, University of Szeged, Szeged, Hungary
| | - Tamas Molnar
- 1st Department of Medicine, University of Szeged, Szeged, Hungary
| | - Peter L Lakatos
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary.
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Kim KO, Jang BI, Lee SH. Does carotid intima-media thickness increase in patients with inflammatory bowel disease? Intest Res 2014; 12:293-8. [PMID: 25374495 PMCID: PMC4214956 DOI: 10.5217/ir.2014.12.4.293] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 04/24/2014] [Accepted: 04/24/2014] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Mesenteric microvascular thrombosis has been implicated as a contributing factor to the pathogenesis of inflammatory bowel disease (IBD). The aim of the current study was to assess the possibility of subclinical atherosclerosis in patients with IBD by measuring their carotid intima-media thickness (c-IMT). Methods Thirty-eight patients with IBD who were followed-up for at least 3 years participated. Patients with a history of cardiovascular disease and known risk factors for atherosclerosis were excluded. As a control group, 38 healthy patients matched for age and gender without atherosclerosis risk factors were included. Carotid ultrasonography was performed in all patients and controls. Patient baseline characteristics and laboratory parameters were recorded to evaluate atherosclerosis risk factors. Results The mean age of patients with IBD was 38.5±6.62 years. Twenty-three patients with IBD were diagnosed with ulcerative colitis and the other 15 cases were diagnosed with Crohn's disease. The median duration of disease was 52.0 months. Serologic markers such as erythrocyte sedimentation rate, C-reactive protein (CRP), and cholesterol levels differed significantly, however, there was no significant difference in c-IMT between patients with IBD and those in the control group (0.53±0.10 mm vs. 0.53±0.07; P=0.85). Multivariate analysis revealed that body mass index, CRP, disease duration, and age were significantly correlated with c-IMT in patients with IBD. Conclusions The results of the current study did not show an increase in c-IMT in patients with IBD. Further studies that include more subjects and a longer follow-up period will be necessary in order to evaluate the risk of atherosclerosis in Korean patients with IBD.
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Affiliation(s)
- Kyeong Ok Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Byung Ik Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Si Hyung Lee
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Comparable short- and long-term outcomes of colonoscopic balloon dilation of Crohn's Disease and benign non-Crohn's Disease strictures. Inflamm Bowel Dis 2014; 20:1739-46. [PMID: 25153504 DOI: 10.1097/mib.0000000000000145] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The response of Crohn's disease (CD) stricture to endoscopic therapy compared with non-CD stricture is unknown. Our aim was to compare the short- and long-term outcomes of endoscopic management of those strictures. METHODS All eligible patients with benign non-CD strictures who underwent the endoscopic balloon dilation between January 2002 and September 2013 were included. Patients with CD strictures were randomly selected with a ratio (CD versus non-CD strictures) of 2:1. RESULTS A total of 90 patients were included, including 30 (33.3%) with non-CD strictures and 60 (66.7%) with CD strictures. Patients with CD strictures were younger than those with non-CD strictures at the time of disease diagnosis (25.8 ± 11.1 versus 50.5 ± 17.5; P < 0.001) and at the time of the first dilation (43.9 ± 12.4 versus 55.8 ± 13.9; P < 0.001). There were no significant differences in characteristics of strictures and their endoscopic treatments between the CD and non-CD groups, except for the percentage of patients who were ever treated with intralesional corticosteroid injection (25.0% versus 6.7%, P = 0.046). Patients in the 2 groups had similar technical success rates (94.0% versus 93.9%, P = 1.00). Few patients in CD stricture group required emergency room visits due to obstructive symptoms from recurrence of disease (1.7% versus 16.7%, P = 0.02). There were on procedure-related complications in either of the 2 groups. CONCLUSIONS The efficacy and safety of endoscopic balloon dilation in the treatment of CD and non-CD strictures seemed to be comparable.
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Magro F, Santos-Antunes J, Vilas-Boas F, Rodrigues-Pinto E, Coelho R, Ribeiro OS, Lopes S, Macedo G. Crohn's disease outcome in patients under azathioprine: a tertiary referral center experience. J Crohns Colitis 2014; 8:617-625. [PMID: 24332869 DOI: 10.1016/j.crohns.2013.11.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 11/17/2013] [Accepted: 11/18/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Azathioprine is of major importance in the treatment of Crohn's disease; its efficacy has been showed in several works, but real-life data regarding its use is scarce. Our aim was to address the outcome of patients with Crohn's disease under azathioprine in the real-life setting. METHODS Crohn's disease patients followed at an Inflammatory Bowel Disease Outpatient Clinic under azathioprine were consecutively enrolled, being allocated in one of four groups. Two groups included patients on treatment with this drug, regarding its two major indications - prevention of post-operative recurrence and steroid-dependent disease; a third group included patients who needed infliximab in addition to azathioprine and a fourth group comprised patients who did not tolerate azathioprine. RESULTS A total of 221 patients were enrolled, 180 on azathioprine due to steroid-dependency (64 needing additional treatment with infliximab) and 41 for prevention of post-operative recurrence. Steroid-free remission was obtained in 48%. Immunosuppression decreased the number of hospitalized patients (64% vs 36%; p<0.001), but not the surgery rates per person per year. Azathioprine as a post-operative drug was effective in decreasing hospitalizations. The addition of infliximab decreased the number of patients hospitalized (p=0.009) and hospitalization rates per person per year (p<0.001), but had no effect in the surgery rates per person per year. Sixty patients (23%) experienced adverse effects with AZA, 39 requiring discontinuation of the drug. CONCLUSIONS In this real-life study, azathioprine had a long-term steroid sparing effect and reduced hospitalizations. Combination with infliximab reduced hospitalizations but did not decrease the surgery rate.
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Affiliation(s)
- Fernando Magro
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto, Portugal; Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Portugal; Institute for Molecular and Cell Biology, Porto, Portugal.
| | - João Santos-Antunes
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto, Portugal; Department of Biochemistry (U38-FCT), Faculty of Medicine, University of Porto, Portugal
| | - Filipe Vilas-Boas
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto, Portugal
| | | | - Rosa Coelho
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto, Portugal
| | - Orquídea Silva Ribeiro
- Centre for Research in Health Informatics Systems and Technologies (CINTESIS), Faculty of Medicine, University of Porto, Portugal
| | - Susana Lopes
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Faculty of Medicine, Hospital de São João, Porto, Portugal
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Mandel MD, Miheller P, Müllner K, Golovics PA, Lakatos PL. Have biologics changed the natural history of Crohn's disease? Dig Dis 2014; 32:351-359. [PMID: 24969279 DOI: 10.1159/000358135] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Crohn's disease (CD) is a progressive condition, with most patients developing a penetrating or stricturing phenotype over time. The introduction of anti-tumor necrosis factor (TNF) therapies over the past 10-15 years, which was supported by accumulating evidence both from trials and clinical practice, has led to a significant change in patient management, monitoring, and treatment algorithms. Anti-TNF therapy was demonstrated to be effective for both luminal and fistulizing disease. Regular therapy with both infliximab and adalimumab was shown to increase the likelihood of clinical remission and mucosal healing, as well as to reduce the need for surgery and hospitalization in both clinical trials and clinical practice, especially in patients with pediatric-onset CD, shorter disease duration, and when used in combination with immunosuppressives. This has led to new treatment goals and to the use of early aggressive medical therapy in a selected group of patients with a worse prognosis. Exploratory clinical trials are underway to determine if further optimization of therapies and treatment beyond clinical remission leads to superior disease outcomes. However, more long-term clinical data are needed to assess whether an early, aggressive therapeutic strategy employing anti-TNF, alone or in combination with biologicals, can further improve long-term disease outcomes in both pediatric patients and young adults.
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Affiliation(s)
- Michael D Mandel
- First Department of Medicine, Semmelweis University, Budapest, Hungary
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Kwak MS, Kim DH, Park SJ, Kim TI, Hong SP, Kim WH, Cheon JH. Efficacy of early immunomodulator therapy on the outcomes of Crohn's disease. BMC Gastroenterol 2014; 14:85. [PMID: 24886458 PMCID: PMC4017088 DOI: 10.1186/1471-230x-14-85] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 04/28/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The natural course of Crohn's disease (CD), with continuing relapses and remissions, leads to irreversible intestinal damage. Early adoption of immunomodulator therapy has been proposed in order to address this; however, it is still uncertain whether early immunomodulator therapy could affect the natural course of the disease in real practice. We evaluated the efficacy of such therapy on the prognosis of newly diagnosed patients with CD. METHODS This retrospective study included 168 patients who were newly diagnosed with CD and who started treatment at Severance Hospital, Seoul, Korea between January 2006 and March 2013. The short- and long-term outcomes were compared between patients treated with early immunomodulator therapy and those treated with conventional therapy. RESULTS A Kaplan-Meier analysis identified that administration of immunomodulators within 6 months after diagnosis of CD was superior to conventional therapy in terms of clinical remission and corticosteroid-free remission rates (P=0.043 and P=0.035). However, P=0.827). Patients with a baseline elevated CRP level were more likely to relapse (P<0.005). Drug-related adverse events were more frequent in the early immunomodulator therapy group than in the conventional therapy group P=0.029). CONCLUSIONS Early immunomodulator therapy was more effective than conventional therapy in inducing remission, but not in preventing relapse. Baseline high CRP level was a significant indicator of relapse.
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Affiliation(s)
- Min Seob Kwak
- Department of Internal Medicine, Graduate School, Yonsei University College of Medicine, Seoul, Korea
| | - Duk Hwan Kim
- Department of Internal Medicine, Graduate School, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine, Graduate School, Yonsei University College of Medicine, Seoul, Korea
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine, Graduate School, Yonsei University College of Medicine, Seoul, Korea
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Pil Hong
- Department of Internal Medicine, Graduate School, Yonsei University College of Medicine, Seoul, Korea
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine, Graduate School, Yonsei University College of Medicine, Seoul, Korea
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Graduate School, Yonsei University College of Medicine, Seoul, Korea
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea
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Hovde Ø, Kempski-Monstad I, Småstuen MC, Solberg IC, Henriksen M, Jahnsen J, Stray N, Moum BA. Mortality and causes of death in Crohn's disease: results from 20 years of follow-up in the IBSEN study. Gut 2014; 63:771-5. [PMID: 23744613 DOI: 10.1136/gutjnl-2013-304766] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Population-based studies have shown a slightly decreased life expectancy in patients with Crohn's disease (CD). The primary aim of the present study was to evaluate mortality and causes of death 20 years after the diagnosis in a well defined population-based cohort of CD patients in Norway. DESIGN The Inflammatory Bowel South-Eastern Norway study has prospectively followed all patients diagnosed with CD in the period between 1 January 1990 and 31 December 1993 in four geographically well-defined areas. All patients (n=237) were age and sex matched with 25 persons from the same county selected at random from the general population. Data on death and causes of deaths were collected from the Norwegian Causes of Death Register. All causes and cause-specific mortality (gastrointestinal cancer, cancer and heart disease) were modelled with Cox regression model stratified by matched sets. Results are expressed as HRs with 95% CIs. RESULTS There was no significant difference between CD patients and controls in overall mortality (HR=1.35, 95% CI 0.94 to 1.94, p=0.10). Furthermore, there were no marked differences in deaths from gastrointestinal cancer, other cancers or cardiovascular diseases in the CD group compared with the controls. In the CD group, 13.9% had died compared with 12.7% in the control group (p=0.578). CONCLUSIONS In our population-based inception cohort followed for 20 years, there was no increased mortality or more deaths from cancer compared with the general population.
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Affiliation(s)
- Øistein Hovde
- Department of Gastroenterology, Innlandet Hospital Trust, , Gjøvik, Oppland, Norway
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Golovics PA, Mandel MD, Lovasz BD, Lakatos PL. Inflammatory bowel disease course in Crohn's disease: is the natural history changing? World J Gastroenterol 2014; 20:3198-3207. [PMID: 24696605 PMCID: PMC3964392 DOI: 10.3748/wjg.v20.i12.3198] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 12/12/2013] [Accepted: 01/19/2014] [Indexed: 02/06/2023] Open
Abstract
Crohn's disease (CD) is a multifactorial potentially debilitating disease. It has a variable disease course, but the majority of patients eventually develop penetrating or stricturing complications leading to repeated surgeries and disability. Studies on the natural history of CD provide invaluable data on its course and clinical predictors, and may help to identify patient subsets based on clinical phenotype. Most data are available from referral centers, however these outcomes may be different from those in population-based cohorts. New data suggest the possibility of a change in the natural history in Crohn's disease, with an increasing percentage of patients diagnosed with inflammatory disease behavior. Hospitalization rates remain high, while surgery rates seem to have decreased in the last decade. In addition, mortality rates still exceed that of the general population. The impact of changes in treatment strategy, including increased, earlier use of immunosuppressives, biological therapy, and patient monitoring on the natural history of the disease are still conflictive. In this review article, the authors summarize the available evidence on the natural history, current trends, and predictive factors for evaluating the disease course of CD.
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Park JJ. Appropriate administration timing and clinical indications of thiopurine in Crohn’s disease. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2014; 63:194-198. [PMID: 24783320 DOI: 10.4166/kjg.2014.63.3.194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Lobatón T, Vermeire S, Van Assche G, Rutgeerts P. Review article: anti-adhesion therapies for inflammatory bowel disease. Aliment Pharmacol Ther 2014; 39:579-94. [PMID: 24479980 DOI: 10.1111/apt.12639] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 12/31/2013] [Accepted: 01/08/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND A high proportion of patients with inflammatory bowel disease (IBD) do not achieve clinical remission with the current therapies including mesalazine (mesalamine), immunossupresants (IMS) and antibodies against tumour necrosis factor (anti-TNF). Moreover, IMS and anti-TNF involve a nonnegligible risk for infections and/or malignancies. The anti-adhesion molecules are one of the most interesting new treatments because of their gut-selectivity. AIM To review the physiopathology of the adhesion molecules and the current drugs targeting this mechanism. METHODS We performed a literature review in PubMed and in clinicaltrials.gov using the terms 'anti-adhesion molecules', 'inflammatory bowel disease', 'natalizumab', 'vedolizumab', 'AMG181', 'Etrolizumab', 'PF-00547659', 'AJM300', 'Alicaforsen' and 'CCX282-B' up to November 2013. RESULTS A total of eight drugs were found including those targeting the α4β1, α4β7 or αEβ7 integrins as well as the ICAM-1 and MAdCAM-1 addressins and the chemokine receptor 9. The rationale for these drugs is the blockade of gut-homing T lymphocytes and the ones targeting the α4β7/MAdCAM-1 interaction presented the most promising results in luminal disease. Vedolizumab, an α4β7 antibody, has completed phase 3 trials with very positive results especially for ulcerative colitis. However, many questions remain unanswered such as the effect of these therapies in perianal disease and extraintestinal manifestations. CONCLUSIONS The blockade of the α4β7/MAdCAM-1 interaction and especially vedolizumab is an effective and safe gut-specific treatment for IBD. Further studies are needed to clarify the efficacy and safety of the other anti-adhesion drugs and to define the specific indications of these therapies in the different scenarios of IBD.
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Affiliation(s)
- T Lobatón
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium
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Golovics PA, Lakatos L, Nagy A, Pandur T, Szita I, Balogh M, Molnar C, Komaromi E, Lovasz BD, Mandel M, Veres G, Kiss LS, Vegh Z, Lakatos PL. Is early limited surgery associated with a more benign disease course in Crohn's disease? World J Gastroenterol 2013; 19:7701-7710. [PMID: 24282358 PMCID: PMC3837269 DOI: 10.3748/wjg.v19.i43.7701] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 08/02/2013] [Accepted: 09/13/2013] [Indexed: 02/06/2023] Open
Abstract
AIM To analyze the difference in disease course and need for surgery in patients with Crohn's disease (CD). METHODS Data of 506 patients with incident CD were analyzed (age at diagnosis: 31.5 ± 13.8 years). Both hospital and outpatient records were collected prospectively with a complete clinical follow-up and comprehensively reviewed in the population-based Veszprem province database, which includes incident CD patients diagnosed between January 1, 1977 and December 31, 2008. Follow-up data were collected until December 31, 2009. All patients included had at least 1 year of follow-up available. Patients with indeterminate colitis at diagnosis were excluded from the analysis. RESULTS Overall, 73 patients (14.4%) required resective surgery within 1 year of diagnosis. Steroid exposure and need for biological therapy were lower in patients with early limited surgery (P < 0.001 and P = 0.09). In addition, surgery rates during follow-up in patients with and without early surgery differed significantly after matching on propensity scores (P < 0.001, HR = 0.23). The need for reoperation was also lower in patients with early limited resective surgery (P = 0.038, HR = 0.42) in a Kaplan-Meier and multivariate Cox regression (P = 0.04) analysis. However, this advantage was not observed after matching on propensity scores (P(Logrank) = 0.656, P(Breslow) = 0.498). CONCLUSION Long-term surgery rates and overall exposure to steroids and biological agents were lower in patients with early limited resective surgery, but reoperation rates did not differ.
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Diagnostic delay in Crohn's disease is associated with a complicated disease course and increased operation rate. Am J Gastroenterol 2013; 108:1744-53; quiz 1754. [PMID: 23978953 DOI: 10.1038/ajg.2013.248] [Citation(s) in RCA: 166] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 05/07/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The impact of diagnostic delay (a period from appearance of first symptoms to diagnosis) on the clinical course of Crohn's disease (CD) is unknown. We examined whether length of diagnostic delay affects disease outcomes. METHODS Data from the Swiss IBD cohort study were analyzed. Patients were recruited from university centers (68%), regional hospitals (14%), and private practices (18%). The frequencies of occurrence of bowel stenoses, internal fistulas, perianal fistulas, and CD-related surgery (intestinal and perianal) were analyzed. RESULTS A total of 905 CD patients (53.4% female, median age at diagnosis 26 (20-36) years) were stratified into four groups according to the quartiles of diagnostic delay (0-3, 4-9, 10-24, and ≥25 months, respectively). Median diagnostic delay was 9 (3-24) months. The frequency of immunomodulator and/or antitumor necrosis factor drug use did not differ among the four groups. The length of diagnostic delay was positively correlated with the occurrence of bowel stenosis (odds ratio (OR) 1.76, P=0.011 for delay of ≥25 months) and intestinal surgery (OR 1.76, P=0.014 for delay of 10-24 months and OR 2.03, P=0.003 for delay of ≥25 months). Disease duration was positively associated and non-ileal disease location was negatively associated with bowel stenosis (OR 1.07, P<0.001, and OR 0.41, P=0.005, respectively) and intestinal surgery (OR 1.14, P<0.001, and OR 0.23, P<0.001, respectively). CONCLUSIONS The length of diagnostic delay is correlated with an increased risk of bowel stenosis and CD-related intestinal surgery. Efforts should be undertaken to shorten the diagnostic delay.
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Cosnes J, Bourrier A, Laharie D, Nahon S, Bouhnik Y, Carbonnel F, Allez M, Dupas JL, Reimund JM, Savoye G, Jouet P, Moreau J, Mary JY, Colombel JF. Early administration of azathioprine vs conventional management of Crohn's Disease: a randomized controlled trial. Gastroenterology 2013; 145:758-65.e2; quiz e14-5. [PMID: 23644079 DOI: 10.1053/j.gastro.2013.04.048] [Citation(s) in RCA: 199] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 04/03/2013] [Accepted: 04/21/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Immunomodulator therapy is effective for patients with Crohn's disease (CD) but has not been shown to affect disease progression, presumably because it is given too late after diagnosis. We compared the efficacy of early treatment (within 6 months after diagnosis) with azathioprine versus conventional management of patients at high risk for disabling disease. METHODS We performed an open-label trial of adults with a diagnosis of CD for less than 6 months who were at risk for disabling disease. From July 2005 to November 2010, patients at 24 French centers were randomly assigned to treatment with azathioprine (2.5 mg ∙ kg(-1) ∙ day(-1), n = 65) or conventional management (azathioprine only in cases of corticosteroid dependency, chronic active disease with frequent flares, poor response to corticosteroids, or development of severe perianal disease) (n = 67). The primary end point was the proportion of trimesters spent in corticosteroid-free and anti-tumor necrosis factor (TNF)-free remission during the first 3 years after inclusion. RESULTS During the 3-year follow-up period, 16 patients in the azathioprine group were switched to mercaptopurine or methotrexate therapy because of intolerance or poor efficacy. Forty-one patients in the conventional management group required immunosuppressant therapy (61%; median time to first prescription, 11 months). In the azathioprine group, a median 67% of trimesters were spent in remission (interquartile range, 11%-85%) compared with 56% in the conventional management group (interquartile range, 29%-73%) (P = .69). Among secondary outcomes, a higher cumulative proportion of patients in the azathioprine group were free of perianal surgery than in the conventional management group (96% ± 3% and 82% ± 6% at month 36, respectively; P = .036). The cumulative proportion of patients free of intestinal surgery and anti-TNF therapy did not differ between groups. CONCLUSIONS Based on results from a clinical trial, administration of azathioprine within 6 months of diagnosis of CD was no more effective than conventional management in increasing time of clinical remission. Clinicaltrials.gov, Number NCT00546546.
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Affiliation(s)
- Jacques Cosnes
- Hôpital St-Antoine and Université Pierre et Marie Curie, Paris, France.
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Ueno F, Matsui T, Matsumoto T, Matsuoka K, Watanabe M, Hibi T, On Behalf of the Guidelines Project Group of the Research Group of Intractable Inflammatory Bowel Disease subsidized by the Ministry of Health, Labour and Welfare of Japan and the Guidelines Committee of the Japanese Society of Gastroenterology. Evidence-based clinical practice guidelines for Crohn's disease, integrated with formal consensus of experts in Japan. J Gastroenterol 2013; 48:31-72. [PMID: 23090001 PMCID: PMC3541931 DOI: 10.1007/s00535-012-0673-1] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 08/16/2012] [Indexed: 02/04/2023]
Abstract
Crohn's disease is a disorder of unknown etiology and complicated pathogenesis. A substantial amount of evidence has accumulated recently and has been applied to clinical practice. The present guidelines were developed based on recent evidence and the formal consensus of experts relevant to this disease. Here we provide an overview of these guidelines, as follows. Target disease: Crohn's disease Users: Clinical practitioners in internal medicine, surgery, gastroenterology, and general practice Purpose: To provide appropriate clinical indicators to practitioners Scope of clinical indicators: Concept of Crohn's disease, epidemiology, classifications, diagnosis, treatment, follow up, and special situations Intervention: Diagnosis (interview, physical examination, clinical laboratory tests, imaging, and pathology) and treatment (lifestyle guidance, drug therapy, nutritional therapy, surgery, etc.) Outcome assessment: Attenuation of symptoms, induction and maintenance of remission, imaging findings, quality of life (QOL), prevention of complications and harm of therapy Methods for developing these guidelines: Described in the text Basis of recommendations: Integration of evidence level and consensus of experts Cost-benefit analysis: Not implemented Evaluation of effectiveness: Yet to be confirmed Status of guidelines: Updated version of the first Guidelines published in 2010 Publication sources: Printed publication available and electronic information in preparation Patient information: Not available Date of publication: October 2011 These guidelines were intended primarily to be used by practitioners in Japan, and the goal of these guidelines is to improve the outcomes of patients with Crohn's disease.
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Affiliation(s)
| | - Toshiyuki Matsui
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Takayuki Matsumoto
- Division of Lower Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Katsuyoshi Matsuoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinano-machi Shinjuku, Tokyo, 160-8582 Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshifumi Hibi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinano-machi Shinjuku, Tokyo, 160-8582 Japan
| | - On Behalf of the Guidelines Project Group of the Research Group of Intractable Inflammatory Bowel Disease subsidized by the Ministry of Health, Labour and Welfare of Japan and the Guidelines Committee of the Japanese Society of Gastroenterology
- Ofuna Chuo Hospital, Kanagawa, Japan
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
- Division of Lower Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinano-machi Shinjuku, Tokyo, 160-8582 Japan
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
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Høivik ML, Bernklev T, Solberg IC, Cvancarova M, Lygren I, Jahnsen J, Moum B. Patients with Crohn's disease experience reduced general health and vitality in the chronic stage: ten-year results from the IBSEN study. J Crohns Colitis 2012; 6:441-53. [PMID: 22398064 DOI: 10.1016/j.crohns.2011.10.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 09/30/2011] [Accepted: 10/03/2011] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND AIMS Data on the long-term effects of Crohn's disease (CD) on health-related quality of life (HRQoL) is scarce. We aimed to determine the HRQoL in CD patients 10 years after disease onset, to compare the results to the general population and to identify variables that could affect HRQoL. METHODS CD patients from a population-based inception cohort (the IBSEN Study) met at a prescheduled ten-year follow-up. In addition to a structured interview, review of hospital records, clinical examination, laboratory tests and ileocolonoscopy, they completed a patient-reported questionnaire including the Short Form 36 (SF-36) and the Norwegian Inflammatory Bowel Disease Questionnaire (N-IBDQ). The SF-36 scores were compared to scores from the general population using one-sample t-tests. Standardized scores were calculated and interpreted according to Cohen's effect size index. The associations between relevant clinical and demographic factors and HRQoL were examined through linear regression analyses. RESULTS Ninety-nine patients completed the HRQoL questionnaires (response rate 86%). Median age 39 years, 42% women. Compared to the general population the patients reported significantly lower SF-36 scores on the general health and vitality dimensions. IBDQ total scores were in line with scores of patients in remission. Except for current symptom severity no clinical parameters affected HRQoL scores. Work status and sick leave affected HRQoL negatively. CONCLUSIONS In this chronic stage of CD, reduced general health and vitality scores need attention while reductions in disease specific HRQoL seem to be less predominant.
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Affiliation(s)
- Marte Lie Høivik
- Department of Gastroenterology, Division of Medicine, Oslo University Hospital, Norway.
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Golovics PA, Lakatos PL, Dávid G, Pandur T, Erdélyi Z, Horváth A, Mester G, Balogh M, Szipocs I, Molnár C, Komáromi E, Lovász BD, Szathmári M, Kiss LS, Lakatos L. [The effect of early immunosuppressive therapy on the rate of resections performed in patients with Chron's disease, in Veszprém county, Hungary, a population-based cohort study]. Orv Hetil 2012; 153:541-552. [PMID: 22450143 DOI: 10.1556/oh.2012.29331] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2024]
Abstract
UNLABELLED Medical therapy for Crohn's disease has changed significantly over the past 20 years with the increasing use of immunosuppressants. In contrast, surgery rates are still high and evidence about the the changes in the outcome of Crohn's disease over the past decades is scarce. AIMS The objective of this study was to analyze the evolution of the surgical rates and medical therapy in the population-based Veszprém county database. METHODS Data of 506 Crohn's disease patients were analyzed (age at diagnosis: 31.5 years, SD: 13.8 years). Both hospital and outpatient records were collected and comprehensively reviewed. The study population was divided into three groups based on the year of diagnosis (cohort A: 1977-1989, cohort B: 1990-1998 and cohort C: 1999-2008). RESULTS Overall azathioprine, systemic steroid, and biological (only available after 1998) exposure was 45.8, 68.6, and 9.5%, respectively. The 1 and 5-year probabilities of azathioprine use were 3.2 and 6.2% in cohort A, 11.4 and 29.9% in cohort B, and 34.8 and 46.2% in cohort C. In multivariate analysis, decade of diagnosis (P<0.001), age at onset (P = 0.008), disease behavior at diagnosis (P<0.001), and need for systemic steroids (P<0.001) were significantly associated with the time to initiation of azathioprine therapy. Early azathioprine use was significantly associated with the time to intestinal surgery in Crohn's disease patients; in a multivariate Cox analysis (HR: 0.43, 95% confidence interval (CI): 0.28-0.65) and after matching on propensity scores for azathioprine use (HR: 0.42,95% CI:0.26-0.67). CONCLUSIONS This population-based inception cohort showed that reduction in surgical rates was independently associated with increased and earlier azathioprine use.
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Affiliation(s)
- Petra Anna Golovics
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Belgyógyászati Klinika Budapest Korányi S. u. 2/A 1083
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49
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Lakatos PL, Golovics PA, David G, Pandur T, Erdelyi Z, Horvath A, Mester G, Balogh M, Szipocs I, Molnar C, Komaromi E, Veres G, Lovasz BD, Szathmari M, Kiss LS, Lakatos L. Has there been a change in the natural history of Crohn's disease? Surgical rates and medical management in a population-based inception cohort from Western Hungary between 1977-2009. Am J Gastroenterol 2012; 107:579-588. [PMID: 22233693 DOI: 10.1038/ajg.2011.448] [Citation(s) in RCA: 178] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Medical therapy for Crohn's disease (CD) has changed significantly over the past 20 years with increasing use of immunosuppressives. In contrast, surgery rates are still high and there is little evidence that disease outcomes for CD have changed over the past decades. The objective of this study was to analyze the evolution of the surgical rates and medical therapy in the population-based Veszprem province database. METHODS Data of 506 incident CD patients were analyzed (age at diagnosis: 31.5 years, s.d. 13.8 years). Both hospital and outpatient records were collected and comprehensively reviewed. The study population was divided into three groups by the year of diagnosis (cohort A: 1977-1989, cohort B: 1990-1998 and cohort C: 1999-2008). RESULTS Overall, azathioprine (AZA), systemic steroid, and biological (only available after 1998) exposure was 45.8, 68.6, and 9.5%, respectively. The 1- and 5-year probability of AZA use were 3.2 and 6.2% in cohort A, 11.4 and 29.9% in cohort B, and 34.8 and 46.2% in cohort C. In a multivariate Cox-regression analysis, decade of diagnosis (P < 0.001, hazard ratio (HR)(cohorts B-C): 2.88-6.53), age at onset (P = 0.008, HR: 1.76), disease behavior at diagnosis (P < 0.001, HR(complicated): 1.76-2.07), and need for systemic steroids (P < 0.001, HR: 2.71) were significantly associated with the time to initiation of AZA therapy. Early AZA use was significantly associated with the time to intestinal surgery in CD patients; in a multivariate Cox analysis (HR: 0.43, 95% confidence interval (CI): 0.28-0.65) and after matching on propensity scores for AZA use (HR: 0.42, 95% CI: 0.26-0.67). CONCLUSIONS This population-based inception cohort has shown that the recent reduction in surgical rates was independently associated with increased and earlier AZA use.
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Crandall WV, Margolis PA, Kappelman MD, King EC, Pratt JM, Boyle BM, Duffy LF, Grunow JE, Kim SC, Leibowitz I, Schoen BT, Colletti RB. Improved outcomes in a quality improvement collaborative for pediatric inflammatory bowel disease. Pediatrics 2012; 129:e1030-41. [PMID: 22412030 PMCID: PMC3313634 DOI: 10.1542/peds.2011-1700] [Citation(s) in RCA: 150] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Unintended variation in the care of patients with Crohn disease (CD) and ulcerative colitis (UC) may prevent achievement of optimal outcomes. We sought to improve chronic care delivery and outcomes for children with inflammatory bowel disease by using network-based quality improvement methods. METHODS By using a modified Breakthrough Series collaborative structure, 6 ImproveCareNow Network care centers tested changes in chronic illness care and collected data monthly. We used an interrupted time series design to evaluate the impact of these changes. RESULTS Data were available for 843 children with CD and 345 with UC. Changes in care delivery were associated with an increase in the proportion of visits with complete disease classification, measurement of thiopurine methyltransferase (TPMT) before initiation of thiopurines, and patients receiving an initial thiopurine dose appropriate to their TPMT status. These were significant in both populations for all process variables (P < .01) except for measurement of TPMT in CD patients (P = .12). There were significant increases in the proportion of CD (55%-68%) and UC (61%-72%) patients with inactive disease. There was also a significant increase in the proportion of CD patients not taking prednisone (86%-90%). Participating centers varied in the success of achieving these changes. CONCLUSIONS Improvements in the outcomes of patients with CD and UC were associated with improvements in the process of chronic illness care. Variation in the success of implementing changes suggests the importance of overcoming organizational factors related to quality improvement success.
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Affiliation(s)
- Wallace V. Crandall
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children’s Hospital, Columbus, Ohio
| | | | - Michael D. Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Eileen C. King
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jesse M. Pratt
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Brendan M. Boyle
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children’s Hospital, Columbus, Ohio
| | - Lynn F. Duffy
- Inova Fairfax Hospital for Children, Fairfax, Virginia
| | - John E. Grunow
- The Children’s Hospital at Oklahoma University Medical Center, Oklahoma City, Oklahoma
| | - Sandra C. Kim
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ian Leibowitz
- Inova Fairfax Hospital for Children, Fairfax, Virginia
| | - Bess T. Schoen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emory Children’s Center/Children’s Healthcare of Atlanta, Atlanta, Georgia; and
| | - Richard B. Colletti
- Department of Pediatrics, University of Vermont College of Medicine, Vermont Children’s Hospital at Fletcher Allen Health Care, Burlington, Vermont
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