Complication Of Crohn's Disease Research Articles

Radiologic Predictors of Surgery in Newly Diagnosed Pediatric Crohn Disease Patients.

The aim of the present study was to assess whether small bowel imaging conducted at the time of diagnosis could be used as a predictor of small bowel surgical intervention in a population of pediatric patients with Crohn disease (CD). A retrospective analysis of small bowel imaging within 30 days of diagnosis of pediatric CD was conducted. Patients were divided into 2 groups based on small bowel imaging: those with no or minor abnormalities (71%) and those with more extensive or obstructive abnormalities (29%). Medical records were reviewed for small bowel surgical intervention and clinic follow-up visits. A total of 232 patients were included in the study group (average age at diagnosis 11.7 years). Twenty-seven patients (12%) underwent small bowel surgical intervention. The relative risk for small bowel surgical intervention was 2.91 in the group with more extensive imaging abnormalities. The majority of increased surgical risk occurred in the first year after diagnosis, when the normal-minor group had a 2% surgical risk and the more abnormal group had a 17% surgical risk. Both groups had a 2% to 3% surgical risk per year after the first year. Small bowel imaging at the time of diagnosis in pediatric CD can help predict the risk of small bowel surgical intervention and should be recommended for all newly diagnosed patients. Nearly one third of our cohort underwent small bowel surgical intervention through 8 years of follow-up. Surgical complications of CD often occur in the small bowel, and counseling families about surgical risk is an integral part of pediatric CD management.

Serologic Anti-GP2 Antibodies Are Associated with Genetic Polymorphisms, Fibrostenosis, and Need for Surgical Resection in Crohn's Disease.

The presentation of Crohn's disease (CD) is heterogeneous and often leads to serious complications and need for surgery. We tested serum anti-zymogen granule glycoprotein 2 (GP2) antibodies, including its novel isoform alpha, for association with genetic variants, diagnosis, disease stratification, and prediction of CD courses in a combined cross-sectional and cohort study. Serum samples of 303 CD, 108 ulcerative colitis, 72 other inflammatory gastrointestinal diseases, and 206 controls without predominant gastrointestinal diseases controls (HC) were tested for the presence of Anti-GP2 and Anti-Saccharomyces cervisiae (ASCA) by enzyme-linked immunosorbent assay. Genetic analysis was performed using the Illumina Immunochip. GP2 IgA and IgG had the highest discriminatory capability for CD versus ulcerative colitis and CD versus inflammatory gastrointestinal diseases. We identified an association of GP2 IgA and IgG each with 5 distinct single-nucleotide polymorphisms. Levels of anti-GP2 IgG were moderately associated with ileal disease location. Interestingly, both, anti-GP2 IgA and IgG were exclusively associated with the occurrence of stenosis and need for surgery, independently of disease location, but not with fistulizing CD, early disease onset or disease activity. ASCA IgG and IgA were qualitatively and quantitatively linked to CD, CD complications, and need for surgery. Increased levels of ASCA IgG and IgA and positivity for ASCA IgG, but neither levels nor positivity for GP2 IgG or IgA were predictive of the earlier occurrence of complications or surgery. Anti-GP2 antibodies may aid as a tool for diagnosis and differentiation of CD and could indicate a more complicated CD course.

East Meets West: The Increasing Incidence of Inflammatory Bowel Disease in Asia as a Paradigm for Environmental Effects on the Pathogenesis of Immune-Mediated Disease

East Meets West: The Increasing Incidence of Inflammatory Bowel Disease in Asia as a Paradigm for Environmental Effects on the Pathogenesis of Immune-Mediated Disease

Budd-Chiari Syndrome and Portal Vein Thrombosis in Crohnʼs Disease

Introduction: Untreated Crohn's disease (CD) is a prothrombotic state associated with venous thromboembolism and can present with portal vein thrombosis, deep venous thrombosis and pulmonary embolism (PE). There are a handful reported cases of CD presenting as hepatic vein thrombosis or Budd-Chiari syndrome. Case description: A 27 year old male presented with hematochezia, abdominal pain, anasarca with ascites, fatigue and hepatomegaly. A year prior to presentation he developed hematochezia and was seen at a different hospital where he underwent colonoscopy that was suggestive of inflammatory bowel disease but was lost to follow up and remained untreated and continued to have intermittent hematochezia and abdominal pain. On admission his Hb was 5.7 g/dL with elevated ALT (83 U/L) and AST (81 U/L) and albumin of 2.1 g/dL. Stool studies were negative for C difficile toxins, ova & parasites, enteric cultures but positive for leukocytes. Colonoscopy was performed that showed terminal ileitis and pancolitis with rectal pseudopolyp formation. EGD demonstrated duodenal ulcerations and inflammation of pylorus which on biopsy showed non-necrotizing granuloma formation that was consistent with a diagnosis of CD (Figure 1). His hypoalbuminemia was suspected to be due to protein-losing enteropathy from active enterocolitis.Figure 1Paracentesis of the ascitic fluid showed a serum:ascites albumin gradient of >1.4 which suggested portal hypertension. CT scan of abdomen demonstrated hepatomegaly with thrombi in the inferior vena cava, portal vein and right hepatic vein (Figure 2). Liver biopsy showed extensive perivenular sinusoidal dilation, areas of hepatocyte atrophy and drop-out, and mild centrizonal fibrosis (Budd-Chiari syndrome; Figure 3). He was then anti-coagulated with heparin drip and transitioned to apixiban. His anasarca improved with diuretics and CD was treated with prednisone and mesalamine at the time of discharge. Discussion: Active CD is a prothrombotic state that can lead to Budd-Chiari syndrome and subsequent hepatocyte injury as a result of venous congestion. Protein losing enteropathy can develop as a result of untreated CD leading to anasarca and loss of procoagulant factors which further increases the risk of venous thrombosis. Early recognition of thrombotic complications of CD and initiation of anticoagulation is recommended to prevent hepatocyte injury from venous congestion or fatal complications like development of PE.Figure 2Figure 3

Factors Influencing the Persistence of Vedolizumab Use in IBD

Introduction: Vedolizumab (VDZ) is an effective therapy for both ulcerative colitis (UC) and Crohn's disease (CD). Several factors including disease phenotype, prior medications, reason for choosing VDZ and laboratory parameters, have been suggested to influence VDZ persistence. We aimed to explore the impact of these factors on the persistence of VDZ use in real-world practice. Methods: A retrospective chart review was performed for patients using VDZ between 7/1/2014-4/1/2016 at a single academic center. Demographic, disease phenotype and history details, medication history, laboratory data, and reason for VDZ initiation were extracted from electronic medical records. Kaplan-Meier curves using the life table method and proportional hazards models using Cox regression were performed using SAS 9.4. Results: Of 179 VDZ users, 73 had UC (40.8%) and 106 had CD (59.2%). Both UC and CD VDZ users had similar proportions of discontinuation (24.7% vs. 33.0%, P=0.198) and no difference in time to discontinuation among those who stopped (213.8 vs. 217.1 days, P=0.951). VDZ persistence did not vary by reason for initiation (prior treatment ineffective, allergy/intolerance, special population). Among patients with CD, neither fistulizing or stricturing disease (HR 1.30, 95%CI 0.66, 2.53) nor disease distribution (HR 1.104, 95%CI 0.53, 2.30) impacted VDZ persistence. The number of anti-TNF therapies was not associated with shorter persistence of VDZ use (HR 1.42, 95%CI 0.80, 2.32). However, the use of an immunomodulator (IMM) in combination with VDZ was associated with longer VDZ persistence (HR 0.42, 95%CI 0.22,0.79, Figure 1). An elevated CRP-to-albumin ratio at the end of VDZ induction was associated with shorter VDZ persistence (HR 1.67, 95%CI 1.10,2.53) on univariate analysis. Adjusting for demographic, phenotype, medication use and laboratory covariates, only combination IMM use was associated with increased VDZ persistence (HR 0.29, 95%CI 0.14,0.63).Figure 1Conclusion: In this uncontrolled retrospective chart review of real-world VDZ experience, we found no difference in persistence of VDZ use by reason for initiation, IBD type, stricturing or fistulizing CD complications, or anti-TNF exposure. This suggests these factors may not be helpful in selecting those best suited for VDZ use. Using an IMM in combination with VDZ significantly improved VDZ persistence. Further study is needed to determine factors identifying those patients best treated with VDZ.

The treatments of Crohn′s disease complications

Crohn's disease (CD) complications include intestinal complications, parenteral complications, and systemic manifestations, of which intestinal complications are the most common. These complications result in serious damage to the quality of life, the risk of life-threatening may also appear. How to deal with these complications has become a major challenge for clinicians. CD requires a multidisciplinary treatment team, treatment complications versa. This review summarized the treatments of CD common complications. Key words: Crohn disease/CO/TH; Review

Hidradenitis supurativa y enfermedad de Crohn perianal: diagnóstico diferencial

The first description of perianal fistulas and complications in Crohn disease was made 75 years ago by Penner and Crohn. Published studies have subsequently confirmed that perianal fistulas are the most common manifestations of fistulising Crohn disease. Hidradenitis suppurativa was described in 1854 by a French surgeon, Aristide Verneuil. It is a chronic, inflammatory, recurrent and debilitating disease of the pilosebaceous follicle, that usually manifests after puberty with deep, painful and inflamed lesions in the areas of the body with apocrine glands, usually the axillary, inguinal and anogenital regions. The differential diagnosis between hidradenitis suppurativa and Crohn disease can be challenging, especially when the disease is primarily perianal. When they occur simultaneously, hidradenitis suppurativa and Crohn disease show severe phenotypes and patients can respond to anti-tumour necrosis factor therapy, although adalimumab is currently the only treatment with demonstrated efficacy in hidradenitis suppurativa and Crohn disease. In addition, there is sometimes a need for different complementary surgical procedures.

Postoperative Complications in Children With Crohn Disease Treated With Infliximab.

Infliximab (IFX) has become a mainstay of therapy for children with Crohn disease (CD). Despite medical advances, many children with CD, however, still require operative interventions. The risk of complications following resection in children treated with IFX remains largely unknown. We compare surgical outcomes stratified by IFX therapy in a cohort of children with CD who require bowel resection. We reviewed the postoperative complications in 123 children with CD who underwent bowel resection with primary anastomosis at our institution between 1977 and 2011. Demographics, medications, types of operations, and inpatient courses were analyzed. Complications and length of stay were compared based on medical therapy. Overall, the postoperative complication rate was 13%. Of the 123 surgical cases, 24 children had received IFX before their operation. In the children treated with IFX, we identified 3 major complications, including anastomotic leak, acute renal failure, and intraabdominal abscess. There were 9 major complications in the non-IFX group, including infections (2), intraabdominal abscesses (2), bowel obstruction, shock, supraventricular tachycardia, phlegmon, and anastomotic stricture. No significant differences in complication rates or postoperative lengths of stay were identified between those who did or did not receive IFX. In this cohort, surgical procedures in children and young adults treated with IFX were not associated with an increased number of complications or prolonged length of stay. Given that postoperative complications are infrequent in children, larger multicenter studies may be required to determine whether IFX therapy increases the risk of surgical complications in pediatric CD.

Preoperative oral polymeric diet enriched with transforming growth factor-beta 2 (Modulen) could decrease postoperative morbidity after surgery for complicated ileocolonic Crohn’s disease

Objective: Exclusive polymeric diet enriched with transforming growth factor-beta 2 (ANS-TGF-β2) has been used for remission induction and maintenance in pediatric Crohn’s disease (CD). Its use in the preoperative setting has never been evaluated. The aim of this study was to evaluate preoperative ANS-TGF-β2 to decrease postoperative complications after surgery for complicated ileocolonic CD.Methods: From 2011 to 2015, data of all consecutive patients who underwent elective surgery for ileocolonic CD were collected prospectively. Preoperative, exclusive ANS-TGF-β2 was administered in high-risk patients with complicated CD. Complicated CD was defined by the presence of obstructive symptoms, and/or steroid treatment, and/or preoperative weight loss >10% and/or perforating CD. Outcomes of high-risk patients receiving preoperative ANS-TGF-β2 were compared to those of low-risk patients with no complicated CD who underwent upfront surgery.Results: Fifty-six patients underwent surgery for ileocolonic CD. Among them, 35 high-risk patients received preoperative ANS-TGF-β2 and 21 low-risk patients underwent upfront surgery. Preoperative full-dose ANS-TGF-β2 was feasible in 34/35 high-risk patients. Discontinuation of steroids during preoperative ANS-TGF-β2 could be achieved in 10/16 patients (62.5%). Postoperative complications rates were 8/35 (23.8%) and 5/21 (22.9%) in high-risk and low-risk patients, respectively (p = 1). Temporary ileocolostomy rates in high-risk patients and in low-risk patients were 4/35 (11%) and 0/21, respectively (p = 0.286)Conclusion: Preoperative ANS-TGF-β2 is feasible in most high-risk patients with complicated ileocolonic CD and could limit the deleterious effects of risk factors of postoperative morbidity. These results need to be confirmed in a large randomized controlled trial.

Small intestine contrast ultrasonography for the detection and assessment of Crohn disease: A meta-analysis.

Background:Crohn disease (CD) is a chronic relapsing disease. Imaging modalities are essential for the diagnosis and assessment of CD. Small intestine contrast ultrasonography (SICUS) is a well-tolerated, noninvasive and radiation-free modality and has shown potential in CD assessment. We aimed at evaluating the diagnostic accuracy of SICUS in the detection and assessment of small-bowel lesions and complications in CD.Methods:We searched PubMed database for relevant studies published before April 24, 2016. We integrated the true positive, false positive, false negative, and true negative into the pooled estimates of sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio. Forest plots were to represent the pooled results of all studies.Results:Thirteen articles were finally considered eligible. The pooled sensitivity and specificity of SICUS in detecting small-bowel lesions were 0.883 (95% confidence interval (CI) 0.847–0.913) and 0.861 (95% CI 0.828–0.890), respectively. The pooled diagnostic odds ratio was 39.123 (95% CI 20.014–76.476) and the area under the curve of summary receiver operating characteristic was 0.9273 (standard error: 0.0152). In subgroup analyses, SICUS represented fine sensitivity and specificity in proximal and distal small intestine lesion, as well as in CD-related complications such as stricture, dilation, abscess, and fistula.Conclusion:SICUS is accurate enough to make a complete assessment about the location, extent, number, and almost all kinds of complications in CD small-bowel lesions.

Anti-food and anti-microbial IgG subclass antibodies in inflammatory bowel disease

Objectives: Inflammatory bowel disease (IBD), particularly Crohn’s disease (CD), is associated with increased microbial-specific IgG and IgA antibodies, whereas alterations of anti-food antibodies are still disputed. The knowledge about IgG subclass antibodies in IBD is limited. In this study we analysed IgG subclass antibodies specific for nutritional and commensal antigens in IBD patients and controls.Methods: Serum IgG1, IgG2, IgG3 and IgG4 specific for wheat and milk extracts, purified ovalbumin, Escherichia coli and Bacteroides fragilis lysates and mannan from Saccharomyces cerevisiae were analysed by ELISA in patients with CD (n = 56), ulcerative colitis (UC; n = 29), acute gastroenteritis/colitis (n = 12) as well as non-inflammatory controls (n = 62).Results: Anti-Saccharomyces cerevisiae antibodies (ASCA) of all IgG subclasses and anti-B. fragilis IgG1 levels were increased in CD patients compared to UC patients and controls. The discriminant validity of ASCA IgG2 and IgG4 was comparable with that of ASCA pan-IgG and IgA, whereas it was inferior for ASCA IgG1/IgG3 and anti-B. fragilis IgG1. Complicated CD defined by the presence of perianal, stricturing or penetrating disease phenotypes was associated with increased ASCA IgG1/IgG3/IgG4, anti-B. fragilis IgG1 and anti-E. coli IgG1 levels. Anti-food IgG subclass levels were not different between IBD patients and controls and did not correlate with food intolerance. In contrast to anti-microbial Abs, food-specific IgG responses were predominately of the IgG4 isotype and all food-specific IgG subclass levels correlated negatively with age.Conclusion: Our study supports the notion that the adaptive immune recognition of food and commensal antigens are differentially regulated.

Exam 1: Association Between Long-term Oral Contraceptive Use and Risk of Crohn's Disease Complications in a Nationwide Study

Exam 1: Association Between Long-term Oral Contraceptive Use and Risk of Crohn's Disease Complications in a Nationwide Study

Serologic microbial associated markers can predict Crohn's disease behaviour years before disease diagnosis

Patients with Crohn's disease (CD) have serologic responses to various microbial antigens. Serologic markers are associated with aggressive forms of disease and can be detected before onset of symptoms. Their utility in pre-clinical disease or prediction of complicated disease course before diagnosis is unclear. To evaluate the pattern of serologic anti-microbial antibodies long prior to diagnosis and the subsequent risk of complicated Crohn's disease at diagnosis. Sera from 100 US military personnel with Crohn's disease were obtained from the Department of Defense Serum Repository. For each patient, four samples were obtained at different time points before and around diagnosis, and were tested for 6 microbiota-directed antibodies (ASCA-IgA, ASCA-IgG, anti-OmpC, anti-CBir1, anti-A4-Fla2 and anti-FlaX). Associations between the presence and accumulation of Crohn's disease anti-microbial antibodies before diagnosis and with the later development of complications were evaluated. Overall, 65 patients were positive for at least one Crohn's disease associated anti-microbial antibody in the earliest available sample, at a median of 6 years before Crohn's disease diagnosis (interquartile range, 5.6-8.2). The number of positive anti-microbial antibodies increased up to the time of Crohn's disease diagnosis. Complicated disease developed around the time of diagnosis in 24 patients. The proportion of positive antimicrobial antibodies before diagnosis was higher in patients with complicated vs. noncomplicated Crohn's disease. There was an inverse relationship between the time to first complication and the magnitude of serologic response before diagnosis. The presence and accumulation of circulating anti-microbial antibodies years before Crohn's disease diagnosis was associated with complicated Crohn's disease at or shortly after diagnosis.

Amyloidosis in Inflammatory Bowel Disease: A Systematic Review of Epidemiology, Clinical Features, and Treatment.

Amyloidosis is a rare complication of inflammatory bowel disease [IBD]; its low prevalence has hindered both descriptive and therapeutic studies. The aim of this study was to estimate the prevalence of amyloidosis in IBD and the risk factors associated with this complication. This paper presents an observational study, followed by a systematic review of the epidemiological and clinical characteristics of the disease and a review of the diagnostic and therapeutic options. The prevalence of amyloidosis among IBD patients is 0.53% (95% confidence interval [CI]: 0.32-0.75), although epidemiological data suggest that it may be under-diagnosed. The phenotype most frequently associated with amyloidosis is males with aggressive and extensive Crohn's disease, fistulising behaviour, perianal disease, and extra-intestinal complications, with the development of proteinuria and renal failure. Identifying risk factors of amyloidosis in IBD patients and screening for proteinuric renal dysfunction are useful to improve diagnostic accuracy. Referral of biopsies to a tertiary centre should also be considered, to improve diagnostic accuracy. Although there is no reliable evidence on the effectiveness of treatment, it seems reasonable to treat the underlying disease with potent immunosuppression to minimise inflammatory activity, thereby switching off amyloidogenesis.

P-218 Using Quality Improvement to Increase Utilization of Enteral Therapy in Pediatric Crohn Disease

Enteral nutrition therapy (EN) is safe and effective for induction of remission in Crohn's disease (CD) but is underutilized in the United States due to multiple perceived barriers. We implemented a protocol to initiate and overcome barriers related to EN. We hypothesized that implementing this protocol using a quality improvement-based approach would increase utilization of EN and induce remission of CD. In July 2013, we developed and implemented an algorithm for administration of EN. Tools were developed for providers to effectively discuss EN with patients and families, initiate the correct amount of formula, record use, and document medical necessity. Dietitians provided follow –up and providers assessed response. For induction of remission, children were given polymeric formula meeting 90% to 100% of their caloric requirements over a 12-week period. To assess improvement in utilization, we compared the average number of patients per month who were prescribed EN before and after implementing the protocol. Clinical outcomes were assessed for children ≤21 years with active CD and no history of prior intestinal resection that completed a minimum of 8 of the 12 weeks of EN between July 2013 and May 2015. The short pediatric Crohn's disease activity index (sPCDAI), body mass index (BMI), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), albumin, and hemoglobin were compared before and after induction with EN. Between July 2013 and May 2015, 65 patients with CD started EN; 5 were excluded because of inactive disease and three were lost to follow up. Of the 57 remaining patients (mean age 12.7 ± 2.9 years, 49% female, 86% white), 40 (70%) had ileocolonic disease and eleven (19%) had perianal phenotype. EN was started within four weeks of diagnosis for 42 (74%) patients. Average calories were 1798 (±348) or 90.2% of estimated caloric requirements. The average number of patients starting EN increased from 0.6 patients per month before to 3.4 after implementing the protocol (560% increase). Of the 57 patients who started EN, 24 (44%) both completed at least 8 weeks of treatment and achieved remission. Of the 29 who completed at least 8 weeks of EN and had follow up data, 24 (83%) achieved remission. In these patients, there was a significant reduction of sPCDAI (33 ± 15.7 to 9.5 ± 11.6, P < 0.0001) and ESR (27 ± 17 to 17 ± 10, P < 0.001) and an increase in albumin (4 ± 0.5 to 4.2 ± 0.4, P < 0.05). Changes in BMI, CRP, and hemoglobin were not statistically significant. Twenty-five children (44%) were unable to complete induction and finished an average of 4.3 weeks (±2). Twelve patients (48%) cited inability to drink the formula, 14 (56%) had inadequate response, and 4 (16%) stopped because of a complication of CD. Adverse events were reported in 25 patients (44%) including nausea, vomiting, diarrhea, and bloating. Systematic implementation of tools designed to increase utilization of EN is effective in overcoming perceived barriers and increasing the acceptance of primary enteral therapy. Remission was successfully achieved in children who completed induction therapy with EN.

Crohn’s Disease Fibroblasts Overproduce the Novel Protein KIAA1199 to Create Proinflammatory Hyaluronan Fragments

Background & AimsCrohn’s Disease (CD) is a chronic inflammatory disease of the gastrointestinal tract. Fibrosis, a serious complication of CD, occurs when activated intestinal fibroblasts deposit excessive amounts of extracellular matrix (ECM) in affected areas. A major component of the ECM is high-molecular-weight hyaluronan (HA) that, when depolymerized to low-molecular-weight fragments, becomes proinflammatory and profibrotic. Mechanisms for HA degradation are incompletely understood, but the novel protein KIAA1199 recently was discovered to degrade HA. We hypothesized that KIAA1199 protein is increased in CD colon fibroblasts and generates HA fragments that foster inflammation and fibrosis.MethodsFibroblasts were isolated from explants of surgically resected colon tissue from CD and non–inflammatory bowel disease control (ND) patients. Protein levels and tissue distribution of KIAA1199 were assessed by immunoblot and immunostaining, and functional HA degradation was measured biochemically.ResultsIncreased levels of KIAA1199 protein were produced and deposited in the ECM by cultured CD fibroblasts compared with controls. Treatment of fibroblasts with the proinflammatory cytokine interleukin (IL) 6 increased deposition of KIAA1199 in the ECM. CD fibroblasts also produce significantly higher levels of IL6 compared with controls, and antibody blockade of IL6 receptors in CD colon fibroblasts decreased the level of KIAA1199 protein in the ECM. Colon fibroblasts degrade HA, however, small interfering RNA silencing of KIAA1199 abrogated that ability.ConclusionsCD fibroblasts produce increased levels of KIAA1199 primarily through an IL6-driven autocrine mechanism. This leads to excessive degradation of HA and the generation of proinflammatory HA fragments, which contributes to maintenance of gut inflammation and fibrosis.

Emergency laparoscopic ileo-colic resection and primary intracorporeal anastomosis for Crohn's acute ileitis with free perforation and faecal peritonitis: first ever reported laparoscopic treatment.

IntroductionLaparoscopy for abdominal surgical emergencies is gaining increasing acceptance given the spreading of advanced laparoscopic skills among modern surgeons, as it may allow at the same time an accurate diagnosis and appropriate treatment of acute abdomen. The use of the laparoscopic approach also in case of diffuse peritonitis is now becoming accepted provided hemodynamic stability, despite the common belief in the past decades that such severe condition represented an indication for conversion to open surgery or an immediate contraindication to continue laparoscopy. Crohn’s Disease (CD) is a rare cause of acute abdomen and peritonitis, only a few cases of CD acute perforations are reported in the published literature; these cases have always been approached and treated by open laparotomy.Case descriptionWe report on a case of a faecal peritonitis due to an acute perforation caused by a terminal ileitis in an undiagnosed CD. The patient underwent diagnostic laparoscopy followed by a laparoscopic ileo-colic resection and primary intracorporeal anastomosis, with a successful postoperative outcome.ConclusionsComplicated CD has to be considered within the possible causes of small bowel non-traumatic perforation. Emergency laparoscopy with resection and primary intra-corporeal anastomosis can be feasible and may be a safe and effective minimally invasive alternative to open surgery even in case of faecal peritonitis, in selected stable patients and in presence of appropriate laparoscopic colorectal surgical skills and experience. To the best of our knowledge the present experience is the first ever reported case managed with a totally laparoscopic extended ileocecal resection with intracorporeal anastomosis in case of acutely perforated CD and diffuse peritonitis.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-015-1619-x) contains supplementary material, which is available to authorized users.

Laparoscopic ileocecal resection in acute and chronic presentations of Crohn's disease. A single center experience.

The terminal ileum is the most involved tract in Crohn's disease. The obstruction in this location is the most frequent complication. Acute or chronic presentations can occur. Surgery finds a role in the management of chronic strictures and in acute clinical presentations with complications not improving with conservative therapy. We investigate the outcome of patients with obstruction of the ileo-cecal bowel tract laparoscopically managed. It was analyzed the average operative time (OT), the conversion rate and the occurrence of re-operation due to surgical complications. 21 patients underwent an ileocecal resection for complicated Crohn's disease between January 2013 and December 2014. The admissions were performed in emergency in 42% of patients. The preintervention hospital stay was 5.8 (Sd 6.23). The mean operative time was 154 min (Sd 41). 28% of the procedures were converted to open surgery. The average hospital stay was 10 days (Sd 5) in uncomplicated patients. The morbidity rate was 28%. In 19% of cases a re-intervention was needed due to anastomotic leakage (3pts) and one hemoperitoneum for bleeding from the suture line. Laparoscopy seems an affordable technique in the management of obstructive pattern of Crohn's disease. It should be the preferable approach in young patients that probably will be submitted to subsequent surgery for the same disease; in fact, the reduced adhesions formation provided by the less bowel manipulation make easy the subsequent access. Older patients had usually more post-operative morbidity and mortality mostly due to pre-existing conditions; if possible in these patients the treatment should be medical.

A validated web-based tool to display individualised Crohn's disease predicted outcomes based on clinical, serologic and genetic variables.

Early treatment for Crohn's disease (CD) with immunomodulators and/or anti-TNF agents improves outcomes in comparison to a slower 'step up' algorithm. However, there remains a limited ability to identify those who would benefit most from early intensive therapy. To develop a validated, individualised, web-based tool for patients and clinicians to visualise individualised risks for developing Crohn's disease complications. A well-characterised cohort of adult patients with CD was analysed. Available data included: demographics; clinical characteristics; serologic immune responses; NOD2 status; time from diagnosis to complication; and medication exposure. Cox proportional analyses were performed to model the probability of developing a CD complication over time. The Cox model was validated externally in two independent CD cohorts. Using system dynamics analysis (SDA), these results were transformed into a simple graphical web-based display to show patients their individualised probability of developing a complication over a 3-year period. Two hundered and forty three CD patients were included in the final model of which 142 experienced a complication. Significant variables in the multivariate Cox model included small bowel disease (HR 2.12, CI 1.05-4.29), left colonic disease (HR 0.73, CI 0.49-1.09), perianal disease (HR 4.12, CI 1.01-16.88), ASCA (HR 1.35, CI 1.16-1.58), Cbir (HR 1.29, CI 1.07-1.55), ANCA (HR 0.77, CI 0.62-0.95), and the NOD2 frameshift mutation/SNP13 (HR 2.13, CI 1.33-3.40). The Harrell's C (concordance index for predictive accuracy of the model) = 0.73. When applied to the two external validation cohorts (adult n = 109, pediatric n = 392), the concordance index was 0.73 and 0.75, respectively, for adult and pediatric patients. A validated, web-based tool has been developed to display an individualised predicted outcome for adult patients with Crohn's disease based on clinical, serologic and genetic variables. This tool can be used to help providers and patients make personalised decisions about treatment options.

Prevalence of Gastroesophageal Reflux Disease (GERD) Symptoms and Proton Pump Inhibitor (PPI) Use in Patients With Crohn Disease (CD) Treated at a Tertiary Care Inflammatory Bowel Disease Center

Introduction: GERD is commonly diagnosed by improvement of upper gastrointestinal (UGI) symptoms on PPI therapy. Similar symptoms are reported in patients with CD and whether this is a manifestation of UGI CD or GERD is unclear. Data on the prevalence of GERD in CD do not exist. A preliminary study of patients with CD has shown gastroduodenal histologic findings of granulomas and focally enhanced gastritis, which are more specific to UGI CD, in 12% of patients with upper endoscopy (Diaz et al, 2015). Given the potential long-term side effects of PPIs, our aim was to evaluate the prevalence of PPI use and reported GERD symptoms in patients with CD. Methods: We performed a retrospective chart review of 499 patients with CD seen between September 2009 to May 2015 and grouped them using the Montreal Classification (MC). Each encounter was evaluated for pyrosis, regurgitation, globus, dysphagia, odynophagia, chest pain, postprandial abdominal pain, early satiety, bloating, and nausea. Use of acid suppressive therapy prior to the first visit and current use were also recorded, as were gastric emptying and pH studies if available. Results: The mean age of our 499 patient cohort was 39 years (range: 17-80), 49% males, mean BMI= 24.7 (range: 13-52). By MC criteria, 186 (37%) were L1, 80 (16%) were L2, 218 (44%) were L3, and 15 (3%) had upper and lower GI CD. Less than 5% of patients had gastric emptying or pH studies. 108 (21.6%) patients were on medications prior to their first visit with indications unknown and 111 (22.2%) patients were on acid suppressive therapy. Of the patients on acid suppressive therapy, 61% were not assessed for pyrosis, 88% were not assessed for regurgitation, and 82% were not assessed for postprandial abdominal pain. Other classic GERD symptoms were not assessed at higher rates (Table 2). Bloating and nausea were reported in 43 and 45% of patients on acid suppressive therapy, respectively.Table 2: Upper GI Symptoms Assessed While on Acid Suppressive TherapyConclusion: Many patients with CD are on PPI therapy without proper symptom screening or existing indications. Nausea and bloating are commonly reported in these patients and whether that is related to UGI CD, dyspepsia, or true GERD is unknown. Given the potential side effects of PPIs and the complications of CD, appropriate screening should be done to minimize PPI use. Further studies should prospectively evaluate CD patients through validated GERD questionnaires and endoscopic biopsies to better analyze which CD patients would benefit from PPI use.Table 1: Baseline Characteristics