Complication Of Crohn's Disease Research Articles

Body Mass Index, Genetic Susceptibility, and Risk of Complications Among Individuals with Crohn's Disease.

Obesity is associated with systemic and intestine-specific inflammation and alterations in gut microbiota, which in turn impact mucosal immunity. Nonetheless, a specific role of obesity and its interaction with genetics in the progression of Crohn's disease (CD) is unclear. We conducted a cross-sectional study of patients with CD enrolled in Prospective Registry in Inflammatory Bowel Disease Study at Massachusetts General Hospital (PRISM). Information on diagnosis of CD and its complications were collected and confirmed through review of medical records. A genetic risk score was calculated using previously reported single-nucleotide polymorphisms-associated genome-wide with CD susceptibility. We used logistic regression to estimate the effect of body mass index (BMI) and its interaction with genetic risk on risk of CD complications. Among 846 patients with CD, 350 required surgery, 242 with penetrating disease, 182 with stricturing disease, and 226 with perianal disease. There were no associations between obesity (BMI ≥ 30 kg/m2) and risk of perianal disease, stricturing disease, or surgery. Compared with normal-weight individuals with BMI < 25 kg/m2, obesity was associated with lower risk of penetrating disease (odds ratio [OR = 0.56; 95% confidence interval [CI], 0.31-0.99). This association persists among a subgroup of participants with available BMI before development of penetrating disease (OR = 0.40; 95% CI, 0.16-0.88). There were no interactions between BMI and genetic risk score on risk of CD complications (all P interaction > 0.28). Our data suggest that obesity does not negatively impact long-term progression of CD, even after accounting for genetic predisposition.

Evaluation of Crohn’s disease activity by MR enterography: Derivation and histopathological comparison of an MR-based activity index

AimsTo compose a qualitative magnetic resonance imaging (MRI) activity index showing Crohn disease (CD) activity, and to compare magnetic resonance enterography (MRE) findings with histopathology results. Materials and methodsTwenty-six patients (11 male and 15 female; mean age 36.7) who had MRE and colonoscopic biopsy between October 2011 and August 2012 were included in the study. On MRE the following parameters were evaluated: bowel wall thickness, bowel wall T2 signal, bowel wall contrast enhancement pattern and degree, length and number of involved bowel segments, perimural T2 signal, mesenteric inflammation, mesenteric lymph nodes and complications of CD. Each parameter was scored to calculate MRI activity index. Biopsy specimens were retrospectively evaluated, histopathologic and endoscopic acute inflammmation scores (AIS, eAIS) were calculated. Each parameter and total MRI activity index were compared with the pathology scores (AIS, eAIS) by Mann–Whitney U test and Spearman correlation. ResultsStatistically significant positive correlation was found between AIS and eAIS, mural thickness and eAIS. Moderate correlation was found between MRI activity index and eAIS, mural enhancement degree and eAIS; and poor correlation was found between mesenteric inflammation score and eAIS, MRI activity index and AIS, however they were not statistically significant. ConclusionsIn CD, bowel wall thickness measured by MRE is best correlated with the histopathologic results which are accepted as the reference standard. In cases with high MRI activity index, eAIS is also generally high. MRI activity index which is measured simply and noninvasively can be used in the follow up of CD.

CD36, fibroblasts and intestinal inflammation

Crohn's Disease (CD) is characterized by dysregulated intestinal inflammation with an unknown etiology. Intestinal fibrosis is a major pathophysiological complication of CD with features that include an overproduction of collagen, excessive contraction of intestine tissue, and intestinal stricture. Fibroblasts are mesenchymal cells that produce the excess collagen resulting in the aforementioned fibrosis. We have shown that intestinal fibroblasts express a variety of immune receptors. A reduction in CD36 (membrane‐bound and scavenger receptor that is an indicator of inflammation and interacts with TLR‐2, 4, and 6) on the surface of fibroblast results in a statistically significant reduction in transmigration of polymorphonuclear leukocytes (PMN) toward such fibroblasts. Dextran sodium sulfate (DSS) was administered to CD36‐deficient mice and age‐matched controls; DSS typically results in intestinal inflammation that is similar to that observed in Crohn's Disease. Results indicated that mouse PMN were less vigorous in their capacity to migrate toward fibroblasts and there was less inflammation observed in both the large and small intestine of CD36‐deficient mice. Results suggest that CD36 may play a prominent role in the inflammatory responses of fibroblasts in the intestine and highlight CD36 as a potential target receptor in the treatment of aberrant mucosal inflammation, which leads to fibrosis.

Sa1233 Early Diagnosis of Crohn's Disease (CD) Is Associated With Lesser Complications

between OC use and risk of CD complications using a large population-based cohort. Methods: We conducted a prospective study of female CD patients identified from the inpatient and outpatient care components of the Swedish National Patient Register from 2002 to 2009 with follow up through December of 2012. Potential CD cases were eligible if they had at least two encounters in the hospital or outpatient clinics with primary or secondary diagnosis of CD (ICD9 = ‘555' and ICD10 = ‘K50'). Information on OC use was obtained from the Prescribed Drug Register starting in July of 2005 and updated until December of 2012. Primary outcome was defined as first CD-related surgery identified through surgical procedure codes from the National Patient Register. We used Cox proportional hazard modeling with time-varying covariates to estimate multivariable-adjusted hazard ratio (MV-adjusted HR) and 95% confidence interval (CI) while adjusting for age, duration of disease, number of encounters, education, and county of residence. Results: Among 6,788 incident cases of CD, we documented 200 cases of CD-related surgery over 50,400 person-years of follow up. Compared to non-users, current and past use of OC were not associated with risk of CD-related surgery (MV-adjusted HR = 0.89, 95% CI 0.54-1.47 and 0.61, 95% CI 0.33-1.31, respectively). The association did not appear to be modified by longer duration of use. Compared to non-users of OC, the MV-adjusted HRs of surgery were 0.63 (95% CI, 0.38-1.05) for less than two years of use, and 1.28 (95% CI, 0.632.60) for two or more years of use. In sensitivity analyses, we limited our cohort to participants with age of CD diagnosis less than or equal to 40 and obtained similar results: Compared to non-users of OC, the MV-adjusted HRs of surgery were 0.87 (95% CI, 0.51-1.47) for current users of OC and 0.63 (0.33-1.17) for past users of OC. Finally, we considered the possibility that prescribing OC maybe more common among patients with more severe disease and therefore performed lag analysis using prescription data from six months prior to each one-month follow up. Similar to our main analysis, there was no statistically significant association between OC use and risk of surgery among CD patients (MV-adjusted HR = 0.70, 95% CI 0.37-1.33 for past OC use and 0.87, 95% CI 0.51-1.47 for current OC use). Conclusions: In a large nationwide registry of CD patients, we did not detect an association between OC use and CD-related surgery.

Body fat composition assessment using analytic morphomics predicts infectious complications after bowel resection in Crohn's disease.

Decisions between medical and surgical management of Crohn's disease (CD) incorporate risk assessments for potential complications of each therapy. Analytic morphomics is a novel method of image analysis providing quantifiable measurements of body tissue composition, characterizing body fat more comprehensively than body mass index alone. The aim of this study was to determine the risk factors associated with postoperative complications in CD, incorporating fat composition analysis using analytic morphomics. We performed a retrospective review of adults undergoing bowel resection for CD between 2004 and 2011 at a single center. Computed tomography obtained within 30 days prior to surgery underwent morphomic analysis for fat characterization. Postoperative infectious complications were defined as the need for a postoperative abdominal drain, intravenous antibiotics, or reoperation within 30 days. Bivariate and multivariate analyses using logistic regression were used to generate a prediction model of infectious complications. A total of 269 subjects met selection criteria; 27% incurred postoperative infectious complications. Bivariate analysis showed hemoglobin, albumin, surgical urgency, high-dose prednisone use, and subcutaneous-to-visceral fat volume distribution as predictors of complications. Body mass index, anti-tumor necrosis factor alpha therapies, and immunomodulator use were not predictors of complication. Multivariate modeling demonstrated a c-statistic of 0.77 and a negative predictive value of 81.1% with surgical urgency (odds ratio = 2.78; 95% confidence interval, 1.46-6.02; P = 0.004), subcutaneous-to-visceral fat distribution (odds ratio = 2.01; 95% confidence interval, 1.20-3.19; P = 0.006), and hemoglobin (odds ratio = 0.69; 95% confidence interval, 0.55-0.85; P = 0.001) as predictors of infectious complication. Fat subtype and distribution are predictive of postoperative infectious complications after bowel resection for CD. Analytic morphomics provides additional body composition detail not captured by body mass index.

P190. Computed tomography enterography and biomarkers in detecting active and complicated small bowel Crohn's Disease

P190. Computed tomography enterography and biomarkers in detecting active and complicated small bowel Crohn's Disease

Role of wireless capsule endoscopy in the follow-up of inflammatory bowel disease.

The introduction of wireless capsule endoscopy in 2000 has revolutionized our ability to visualize parts of the small bowel mucosa classically unreached by the conventional endoscope, and since the recent introduction of colon capsule endoscopy, a promising alternative method has been available for the evaluation of large bowel mucosa. The advantages of wireless capsule endoscopy include its non-invasive character and its ability to visualize proximal and distal parts of the intestine, while important disadvantages include the procedure's inability of tissue sampling and significant incompletion rate. Its greatest limitation is the prohibited use in cases of known or suspected stenosis of the intestinal lumen due to high risk of retention. Wireless capsule endoscopy plays an important role in the early recognition of recurrence, on Crohn's disease patients who have undergone ileocolonic resection for the treatment of Crohn's disease complications, and in patients' management and therapeutic strategy planning, before obvious clinical and laboratory relapse. Although capsule endoscopy cannot replace traditional endoscopy, it offers valuable information on the evaluation of intestinal disease and has a significant impact on disease reclassification of patients with a previous diagnosis of ulcerative colitis or inflammatory bowel disease unclassified/indeterminate colitis. Moreover, it may serve as an effective alternative where colonoscopy is contraindicated and in cases with incomplete colonoscopy studies. The use of patency capsule maximizes safety and is advocated in cases of suspected small or large bowel stenosis.

Risk of Repeat Surgery for Perianal Crohn Disease

See Article on Page 176-181 Perianal involvement of Crohn disease (CD) is known to be a common complication of CD. Due to the wide variety of anal manifestations of CD, the exact prevalence of perianal Crohn disease (PCD) is not known. However, it is estimated that a majority of patients with CD may undergo surgical treatment for PCD. The most common causes of operative treatment are perianal abscesses and anal fistulas because surgical treatment is mandatory to control acute sepsis. Contrary to fistulas of a cryptoglandular origin, those of CD are different in terms of pathogenesis and clinical course. Due to the unpredictable clinical course and increased risk of recurrence, conservative treatment is generally accepted to be more appropriate for treating patients with PCD. Repeated surgical treatment may deteriorate continence, which results in decreased quality of life for the patient. Therefore, an estimate of the clinical course and a prediction of recurrence after surgical treatment have clinical significance in the treatment of patients with PCD. Despite the clinical importance of PCD, literature concerning the risk factors of repeat surgical treatment for PCD is scarce. A recent retrospective study reported the cumulative risks of reoperation for patients operated on for PCD, as well as the related risk factors [1]. According to the study, the risk of reoperation increases during the disease's course, reaching up to 50% after the first surgical treatment, and risk factors associated with reoperation are a young age at the onset of CD, a history of abdominal surgery for CD, and the type of surgery. Although some controversies may exist, the risk of reoperation most likely increases in proportion to the time. Therefore, early onset of CD may be related with an increased risk of reoperation for PCD. Also, considering that the clinical course of CD with fistulizing PCD seems to be more aggressive, patients with abdominal surgery may have aggressive PCDs. Concerning surgical treatment, conservative treatment is recommended. However, a curative treatment such as a fistulotomy can be done in selected cases [2]. Compared with incision and drainage or seton placement, a fistulotomy or a fistulectomy would reduce the risk of reoperation because of the its radical characteristics. However, the choice of radical treatment should be prudent because of sphincter division, the risk of incontinence, and compromised wound healing. While this study is a clinically significant attempt to investigate factors related with repeat surgery, it lacks data regarding whether and how the usage of a biologic agent influences the clinical course of PCD. Some reports showed the effectiveness of using the anti-tumor necrosis factor (TNF) antibody in fistula healing for Crohn anal fistulas [3,4]. Although anti-TNF therapy seems to be promising, a multidisciplinary approach is mandatory because surgical treatment is essential to control acute sepsis and may be a preliminary procedure to enhance the effect of medical treatment.

Multidisciplinary management of gastrointestinal fibrotic stenosis in Crohn's disease.

Crohn's disease (CD) is a chronic inflammatory bowel disease that can involve virtually any part of the gastrointestinal tract. CD complications are the main indications for surgery. A large proportion of these interventions are due to stricturing disease. Although immunosuppressive treatments have been used more frequently during the last 25 years, there is no significant decrease in the need for surgery in patients with CD. Unfortunately, surgery is not curative, as the disease ultimately reoccurs in a substantial subset of patients. To best identify the patients who will require a specific treatment and to plane the most appropriate therapeutic approach, it is important to precisely define the type, the size, and the location of CD stenosis. Diagnostic approaches aim to distinguish fibrotic from inflammatory strictures. Medical therapy is required for inflammatory stenosis. Mechanical treatments are required when fibrotic CD strictures are symptomatic. The choice between endoscopic balloon dilation, stricturoplasty, and laparoscopic or open surgery is based on the presence of perforating complications, the remaining length of small bowel, and the number and length of strictures. The non-hierarchical decision-making process for the treatment of fibrotic CD therefore requires multidisciplinary clinical rounds with radiologists, gastroenterologists, interventional endoscopists, and surgeons.

The Respective Role of Medical and Surgical Therapy for Enterovesical Fistula in Crohn’s Disease

There are very few reports available on the role of medical and surgical therapy for enterovesical fistula (EVF) in Crohn's disease (CD). The goal of this study was to investigate the respective role of medical and surgical therapy. Thirty-seven patients with EVF in CD, who were consecutively admitted to our institution between 2004 and 2011, underwent initial medical treatment. Medical records were abstracted from our prospective CD database. We performed a univariate analysis of risk factors for surgery. The origin of EVF was ileal (ileovesical fistula, 78.4%) and sigmoidal (sigmoidovesical and ileosigmoidovesical fistula, 21.6%). After medical therapy (antibiotics, azathioprine, steroids, infliximab, or a combination), 13/37 (35.1%) patients achieved long-term remission over a mean period of 4.7 years and avoided surgery. Surgery was performed in 24/37 (64.9%) patients presenting with intractable disease. Univariate analysis showed that the significant risk factors for surgery included sigmoid-originated EVF (P=0.019) and concurrent CD complications (P=0.001), such as small bowel obstruction, abscess formation, enterocutaneous fistula, enteroenteric fistula, and persistent ureteral obstruction or urinary tract infection. For patients with ileovesical fistula alone, medical therapy is the first choice. For patients with ileovesical fistula accompanied by other CD complications, surgical intervention will most likely be needed. Patients with sigmoidovesical or ileosigmoidovesical fistula are more likely to require surgery than an uncomplicated ileovesical fistula.

Hemoglobin and hematocrit levels in the prediction of complicated Crohn's disease behavior--a cohort study.

BackgroundMarkers that predict the occurrence of a complicated disease behavior in patients with Crohn's disease (CD) can permit a more aggressive therapeutic regimen for patients at risk. The aim of this cohort study was to test the blood levels of hemoglobin (Hgb) and hematocrit (Hct) for the prediction of complicated CD behavior and CD related surgery in an adult patient population.MethodsBlood samples of 62 CD patients of the German Inflammatory Bowel Disease-network “Kompetenznetz CED” were tested for the levels of Hgb and Hct prior to the occurrence of complicated disease behavior or CD related surgery. The relation of these markers and clinical events was studied using Kaplan-Meier survival analysis and adjusted COX-proportional hazard regression models.ResultsThe median follow-up time was 55.8 months. Of the 62 CD patients without any previous complication or surgery 34% developed a complication and/or underwent CD related surgery. Low Hgb or Hct levels were independent predictors of a shorter time to occurrence of the first complication or CD related surgery. This was true for early as well as late occurring complications. Stable low Hgb or Hct during serial follow-up measurements had a higher frequency of complications compared to patients with a stable normal Hgb or Hct, respectively.ConclusionsDetermination of Hgb or Hct in complication and surgery naïve CD patients might serve as an additional tool for the prediction of complicated disease behavior.

Magnetic Resonance Enterography in Evaluation and Management of Children With Crohn’s Disease

The role of radiologic evaluation in Crohn's disease (CD) has undergone a recent paradigm shift in which the radiologist adds value to the multidisciplinary team by longitudinally assessing therapeutic response and identifying treatment-modifying subtypes, such as fibrostenotic or fistulizing disease. Magnetic resonance enterography (MRE) has become the primary imaging modality used. The combination of multiplanar, multiparametric, and multiphasic contrast-enhanced imaging with the high spatial resolution and very high tissue contrast of MR imaging allows for detailed evaluation of intra-abdominal pathology, without the risk of cumulative radiation exposure. MRE provides the benefit of a complete evaluation of mural, extramural, and even extraintestinal manifestations and complications of CD in a single examination. Cine motility sequences and diffusion-weighted imaging may further increase sensitivity and specificity. MRE represents an ideal imaging modality for initial evaluation, assessment of therapeutic response, and evaluation of complications in patients with CD.

Is Rifaximin Effective in Maintaining Remission in Crohn's Disease?

Background: Recent studies indicate that persistent intestinal inflammation in patients with Crohn's disease (CD) might be caused by abnormal intestinal microbiota. This hypothesis may suggest a beneficial effect of antibiotics in CD therapy. So far, guidelines do not recommend antibiotics except in the treatment of complicated CD, and there are few studies on the effects of rifaximin in these patients. Methods: Between December 2011 and December 2012, we performed a blinded randomized trial in 168 patients with a previous history of moderately active CD concerning the efficacy of rifaximin. All the patients had previously achieved remission with standard therapy (prednisone/budesonide). Data from patients receiving 800 mg of rifaximin (83 patients) twice a day for 12 weeks were compared with those from patients who received placebo (83 patients). The primary endpoint was maintaining remission during the follow-up. Results: All the patients (100%; 83/83) on 800 mg of rifaximin were in remission after 12 weeks of treatment in comparison with 84% (70/83) of the placebo group. This significant difference was also persistent at the 24-week follow-up [78% (65/83) vs. 41% (34/83), respectively]. The last evaluation performed at 48 weeks revealed disease activity in 45% (38/83) of the patients of the rifaximin group, i.e. a significant decrease compared with the placebo group [75% (63 of 83)]. Conclusions: Remission previously obtained with standard treatment can be sustained in patients with moderately active CD after the administration of 800 mg of rifaximin.

In Crohn's disease fibrosis-reduced expression of the miR-29 family enhances collagen expression in intestinal fibroblasts

Intestinal fibrosis with stricture formation is a complication of CD (Crohn's disease) that may mandate surgical resection. Accurate biomarkers that reflect the relative contribution of fibrosis to an individual stricture are an unmet need in managing patients with CD. The miRNA-29 (miR-29) family has been implicated in cardiac, hepatic and pulmonary fibrosis. In the present study, we investigated the expression of miR-29a, miR-29b and miR-29c in mucosa overlying a stricture in CD patients (SCD) paired with mucosa from non-strictured areas (NSCD). There was significant down-regulation of the miR-29 family in mucosa overlying SCD compared with mucosa overlying NSCD. miR-29b showed the largest fold-decrease and was selected for functional analysis. Overexpression of miR-29b in CD fibroblasts led to a down-regulation of collagen I and III transcripts and collagen III protein, but did not alter MMP (matrix metalloproteinase)-3, MMP-12 and TIMP (tissue inhibitor of metalloproteinase)-1 production. TGF (transforming growth factor)-β1 up-regulated collagen I and III transcripts and collagen III protein as a consequence of the down-regulation of miR-29b, and TGF-β1-induced collagen expression was reversed by exogenous overexpression of miR-29b. Furthermore, serum levels of miR-29 were lower in patients with stricturing disease compared with those without. These findings implicate the miR-29 family in the pathogenesis of intestinal fibrosis in CD and provide impetus for the further evaluation of the miR-29 family as biomarkers.

881 Effects of Telmisartan in Anal Sphincter Physiology in Asymptomatic Volunteers and Patients With Anal Sphincter Hypertension With Chronic Proctalgia

Background. Small intestine contrast ultrasonography (SICUS) can detect intestinal damage in patients with Crohn's disease (CD). We evaluated the diagnostic accuracy of SICUS in determining the site, extent, and complications of CD, compared with magnetic resonance (MR)-enterography as the standard. Methods. We performed a retrospective analysis of 52 patients with CD [(M=33; median age: 23, CD site: ileal 35 (67%), ileocolonic 13 (25%), jejuno-ileal, 3 (6%), colonic 1 (2%); behaviour: non-stricturing non-penetrating 8 (15%), structuring 27 (52%), penetrating 17 (33%); previous surgery 21 (40%); clinical indications: disease assessment 46 (89%), obstructive symptoms 6 (11%)] evaluated by SICUS and MRenterography 3 months apart, between January 2011 and October 2013. We evaluated disease site (based on bowel wall thickness), extent of lesions, presence of complications (stenosis, prestenotic dilation, abscess, or fistulas) using MR-Enterography as the standard. Sensitivity, specificity, and diagnostic accuracy were calculated. We determined the correlations in maximum wall thickness and disease extent in the small bowel between results from SICUS and MR-Enterography. Results. SICUS identified the site of small bowel CD with 96% sensitivity, 60% specificity, and 92% diagnostic accuracy; it identified the site of colon CD with 70% sensitivity, 92% specificity, and 87% diagnostic accuracy. Results from SICUS and MR-enterography correlated in determination of bowel wall thickness (rho=0.51) and disease extent (rho=0.72; P<.0001 for both). SICUS detected ileal stenosis with 90% sensitivity, 92% specificity, and 90% diagnostic accuracy, and pre-stenotic dilation with 66% sensitivity, 80% specificity, and 71% diagnostic accuracy. SICUS detected abscesses with 100% sensitivity, 100% specificity, and fistulas with 80% sensitivity, 81% specificity, and 81% diagnostic accuracy. Conclusion. SICUS identified lesions and complications in CD patients with high levels of sensitivity, specificity, and accuracy compared to MRenterography. SICUS might be used as an imaging tool as part of a focused diagnostic and follow up examination of patients with CD.

Mo1159 Contrast Enhanced Ultrasound as a Point-of-Care Technique in Complicated Crohn's Disease Patients

Mo1159 Contrast Enhanced Ultrasound as a Point-of-Care Technique in Complicated Crohn's Disease Patients

Su1294 Computed Tomography Enterography Versus Magnetic Resonance Enterography for Assessment of Disease Activity and Complications in Small Bowel Crohn's Disease: A Meta-Analysis of Head-to-Head Comparative Studies

Introduction. Infliximab has led to new therapeutic goals in Crohn's disease (CD) such as complete mucosal healing and improvement of quality of life. The current standard for assessing mucosal healing is endoscopy. However, frequent assessments are costly and uncomfortable to the patient. Non-invasive, accurate surrogate serum markers would therefore be welcomed to aid clinicians in predicting mucosal healing.Methods. In a retrospective study, 119 CD patients who started infliximab and who underwent serial endoscopies (before and during infliximab) were included. Serum samples were available at the time of endoscopy and levels of markers were correlated with the degree of healing (not healed, marked improvement or complete healing). Thirty-five biomarkers were measured in 181 serum samples with the use of CEER, a proprietary highly sensitive protein micro-array, or homogenous mobility shift assays (Prometheus Laboratories Inc., San Diego, CA). These markers included growth and repair factors, pro -and anti-inflammatory markers and the IBD SGI serology panel. Infliximab and antibodies to infliximab were also measured. Clinical information regarding age at sampling, gender, age at diagnosis, location of disease, anal involvement and previous surgery was included. For statistical analysis SPSS and R were used. Results. From the 119 CD patients, 64 CD patients showed complete healing with no relapse, whereas 55 CD patients never showed mucosal healing. Univariate analyses indicated that age and 12 serum markers (HGF, BTC, TWEAK, CRP, ICAM, SAA, VCAM, IL-2, IL-8, IFN-γ, IL-6 and IL-10) were significantly associated with mucosal healing (p 11.44 CU/ml, TWEAK>20.62 CU/ml and VCAM<4200 μg/ml) which resulted in a significant and gradual increased prediction of mucosal healing (Figure 1, linear-by-linear p<0.001). Conclusion. We have identified 1 clinical parameter and 4 serum markers as independent predictors of mucosal healing. All serum markers play a role in the pathogenic mechanisms of CD. HGF has a central role in angiogenesis and tissue regeneration, BTC is a member of the EGF family of growth factors, TWEAK is a cytokine that has overlapping signaling functions with TNF and VCAM is a cell-adhesion molecule. The combined biomarker panel could facilitate prediction of mucosal healing in the future.

Risk and Management of Intra-Abdominal Abscess in Crohn's Disease Treated with Infliximab

Background and Aims: Infliximab (IFX) is a monoclonal antibody used to treat patients with Crohn's disease (CD). Intra-abdominal abscess formation is a major complication of CD with negative effects on patient prognosis. We have analyzed risk factors for abscess formation in CD patients treated with IFX. Methods: CD patients who received IFX between January 2000 and April 2011 at Keio University Hospital were analyzed retrospectively. Risk factors for abscess formation were assessed by univariate and multivariate logistic regression analyses. Results: Intra-abdominal abscess was seen in 15 of 258 patients. Univariate analyses showed serum C-reactive protein (CRP) concentration at 14 weeks after initiation of IFX (p = 0.021), serum albumin concentration at week 0 (p = 0.022) and week 14 (p = 0.004), the presence of anal lesions (p = 0.036), progression of intestine deformation (p = 0.015) and early loss of response to IFX (p < 0.0001) to be risk factors. Multivariate analysis showed that CRP concentration at 14 weeks [odds ratio (OR) 1.361] and loss of IFX response within 6 months (OR 5.361) were independent risk factors. Conclusions: Abscess formation should be suspected in patients with symptoms of CD recurrence during IFX therapy. Uncontrolled CRP concentration and early loss of response to IFX are risk factors.

The effect of immunomodulators and biologics on indication for surgical bowel resection in children with Crohn's disease.

Despite advances in medical therapies, many children with Crohn's disease (CD) will require bowel resection. Although previous registry studies have attempted to identify risk factors for surgery, the effect of immunomodulators and biologics (IMB) on surgical indications has not been well characterized. We reviewed a series of 125 children with CD who underwent bowel resection with reanastomosis between 1977 and 2011 and were followed up for at least 6 months. We compared patients who underwent surgery for perforating disease (abscess or internal fistula) and patients who were operated on for medically refractory or fibrostenosing disease. Between these 2 groups, we examined medications received before surgery. Other demographic and disease-specific covariates were examined. Of the 82 patients who received IMB before surgery, only 19 patients (23%) required surgery for a perforating complication of CD, whereas 63 patients (77%) required surgery for strictures or medically refractory disease. In contrast, of the 43 patients who did not receive IMB preoperatively, 20 patients (45%) developed a perforating complication and 23 patients (53%) required surgery for strictures or refractory disease. These differences across groups were significant, with a lower rate of operation for perforating disease among patients receiving preoperative IMB therapy (P = 0.007). In our surgical cohort, children with CD who were treated with IMB were less likely to have surgery for perforating disease. This finding raises the possibility that the administration of IMB in children who require surgery may be associated with a difference in disease behavior.

Risk Stratification of Emergency Department Patients With Crohn's Disease Could Reduce Computed Tomography Use by Nearly Half

Computed tomography (CT) is a useful tool for assessing disease activity and excluding complications in patients with Crohn's disease (CD). However, excessive radiation increases risk for malignancy. We aimed to identify automatable algorithms with high negative predictive values for significant CT findings in patients with CD who present at the emergency department. We conducted a retrospective review of a tertiary center's medical records to identify adults diagnosed with CD who presented from 2000 through 2011. Logistic regression was used to model complications (perforations, abscesses, or other serious findings) and inflammation. There were 1095 visits made by 613 individuals that included a CT scan within 24 hours of arrival. The average number of CT scans was 1.8 (range, 1-31). Complications of CD were observed in 16.8% of CT scans, inflammation in 54.5%, and new/worse findings in 67.2%. On the basis of 10-fold cross-validation, the area under the receiver operating characteristic curve value for the complications model was 0.80 (95% confidence interval, 0.74-0.86) and for the inflammation model was 0.71 (95% confidence interval, 0.68-0.74). Scanning only patients with model-predicted complications would reduce scans by 43.0%, with a miss rate of 0.8% (4 of 491). Patients presenting to the emergency department with CD are frequently assessed by CT. However, no significant findings are observed in 32.8%, and only 17% have complications from CD. We created models to identify patients not likely to have significant findings from CT with high negative predictive values; these could aid physicians in avoiding CT scans for many patients. Studies are needed to validate these models beyond a single center.