Complicated Crohn Research Articles

An overview of the role of exclusive enteral nutrition for complicated Crohn's disease.

The role and efficacy of exclusive enteral nutrition (EEN) in the treatment of luminal Crohn’s disease (CD) has been well established over the last 2 decades. Consequently, in many centers nutritional therapy is now considered first line therapy in the induction of remission of active CD. However, the use of nutritional therapy in complicated CD has yet to be fully determined. This article aimed to review case reports and clinical trials published in the last decade that have considered and evaluated nutritional therapy in the setting of complicated CD in children and adults. Published literature focusing upon the use of nutritional therapy as part of medical therapy in the management of complicated CD were identified and reviewed. Although there continue to be various interventions utilized for complicated CD, the currently available literature demonstrates that nutritional therapies, especially EEN, have important roles in the management of these complex scenarios. Further assessments, involving large numbers of patients managed with consistent approaches, are required to further substantiate these roles.

Perianal fistulas in CED: from mouse model to clinic

Perianal fistulas in CED: from mouse model to clinic Abstract. Fistulas are one of the most severe complications in Crohn's disease patients (CD). More than one third of Crohn's disease patients will suffer from mainly perianal fistulas during the course of their disease. Options for fistula treatment are scarce and their efficacy is often insufficient. In particular, complex fistulas often can only insufficiently be treated and complete and longstanding fistula closure occurs only in about one third of the patients. One of the big challenges in this area is that, on the one hand, fistula pathogenesis is only partially understood, and, on the other, no well-established in vivo model for Crohn's fistula exists that could be used for preclinical studies. From a histopathologic perspective, a fistula is a tube-like formation that is covered by epithelial-like cells. Our current research findings suggests that fistulas development in Crohn's disease patients due to epithelial-to-mesenchymal transition (EMT) which occurs during wound healing and invasive cell growth. Cytokines and growth factors, such as TNF, IL-13 and TGFβ, seem to play a prominent role during fistula development. Current treatment strategies for Crohn's fistula include medcial treatment as well as surgical approaches, often used in combination. Routinely used medications mainly include antibiotics, immunosuppressives and anti-TNF antibodies. Recent studies also indicate that adipose tissue-derived or bone marrow-derived mesenchymal stem cells might be a promising novel approach for fistula therapy. However, often available medications are insufficient and surgery is needed what often also does not provide durable relief. So, it is obvious that novel treatment approaches are urgently needed to improve our understanding of fistula pathogenesis and to develop novel therapeutic strategies for the patients.

Gut Microbial Signatures Underline Complicated Crohn's Disease but Vary Between Cohorts; An In Silico Approach.

Microflora dysbiosis is implicated in the pathophysiology of Crohn's disease. This work analyzes differences in microbial communities and relevant metabolic pathways among the nonstricturing nonpenetrating (B1), stricturing (B2), and penetrating (B3) subphenotypes of Crohn's disease vs healthy controls. We conducted a bioinformatics analysis using the QIIME pipeline and the Calypso, linear discriminant analysis effect size, Phylogenetic Investigation of Communities by Reconstruction of Unobserved States, and STAMP tools on publicly available 16S bacterial rRNA sequencing data from terminal ileum mucosal biopsies of healthy controls and the 3 subphenotypes of Crohn's disease. We analyzed differences in microbial diversity and taxonomy, inferred active metabolic pathways via relevant genes' abundance, and detected bacterial families that could serve as biomarkers. Microbiota α-diversity was decreased within all 3 Crohn's disease subphenotypes vs control samples, with more significant reductions in B2 and B3 compared with B1. β-diversity analysis identified similar microbial patterns in B2 and B3 samples, different from those of B1 and from those of healthy controls. Abundance analysis of microbial families in cohorts, beyond altered abundances compared with healthy controls, highlighted significant differences between the B2 and B3 subphenotypes and the B1 subphenotype. A similar pattern was observed in the inference of microbial metabolomics: the B2 and B3 cohorts had different predicted metabolotypes from the B1 cohort, in addition to differences observed in Crohn's disease vs healthy controls. Our findings indicate distinct microbiome signatures in complicated Crohn's disease subphenotypes and provide the basis for further investigation into the role of gut microflora in the natural course of Crohn's disease.

Preoperative evaluation of small bowel complications in Crohn's disease: comparison of diffusion-weighted and contrast-enhanced MR imaging.

To compare the accuracy of MR enterography (MRE) using combined T2-weighted and contrast-enhanced (CE) sequences with that of combined T2- and diffusion-weighted (DW) sequences for the detection of complex enteric Crohn's disease (CD). Thirty-eight patients who underwent surgery for CD complications and preoperative MRE from 2011 to 2016 were included. MRE examinations were blindly analyzed independently by one junior and one senior abdominal radiologist for the presence of fistula, stenosis and abscesses. During a first reading session, T2-weighted images (WI), steady-state sequences and DW-MRE were reviewed (set 1). During a separate distant session, T2-WI, True-FISP and CE-MRE were reviewed (set 2). Performance of each reader was evaluated by comparison with the standard of reference established using intraoperative and pathological findings. Forty-eight fistulas, 43 stenoses and 11 abscesses were found. For the senior radiologist, sensitivity for the detection of fistula, stenosis and abscess ranged from 80% to 100% for set 1 and 88% to 100% for set 2 and specificity ranged from 56% to 70% for set 1 and 53% to 93% for set 2, with no significant difference between the sets (p = 0.342-0.429). For the junior radiologist, sensitivity ranged from 53% to 63% for set 1 and 64% to 88% for set 2 and specificity ranged from 0% to 25% for set 1 and 17% to 40% for set 2 (p = 0.001 and 0.007, respectively). For a senior radiologist, DW-MRE has similar sensitivity as CE-MRE for the detection of CD complications. For a junior radiologist, CE-MRE yields the best results compared with DW-MRE. • For experienced readers, DWI has similar diagnostic capability as contrast-enhanced MR imaging for the diagnosis of Crohn's disease complications. • For senior radiologists, gadolinium chelate injection could be waived for the diagnosis of Crohn's disease complications. • The interpretation of DWI for Crohn's disease complications requires some experience.

Active Tuberculosis Complicates the Diagnosis and Treatment of Fibrostenosing Crohnʼs Disease

62-year-old male with Crohn's disease (CD), presented for abdominal pain and weight loss. Patient was initially diagnosed with CD based of CTE 2 years prior. He was started on 5-ASA and lost to follow up. Upon re-presentation patient reported lower abdominal pain, hematochezia and weight loss. Lab evaluation negative. Colonoscopy showed a hepatic flexure stricture which could not be traversed. Biopsy showed mild to moderate chronic colitis with focal severe ulceration. CTE showed a 7 cm thickening and a focal hyper-enhancement of the ascending colon. We elected to resect due to his obstructive symptoms, weight loss and cancer risk. Surgery was to be followed by biologic therapy. In preparation for therapy QuantiFERON gold was positive. An ill-defined right upper lobe mass was seen on CXR. AFB in sputum confirmed active pulmonary tuberculosis. Active TB raised the possibility of an alternative diagnosis for the colonic stricture. The patient was started on 4 drug therapy. Following 10 weeks of therapy patient was deemed non-infectious and underwent a successful laparoscopic right hemicolectomy. Path showed focal mild to moderate chronic colitis with focal ulceration. Negative AFB stains. Post-op biologic therapy was anticipated. However, his active TB postponed initiation until completion of antibiotic therapy. As such the final plan was to perform colonoscopy 6 months post-op to assess for recurrent inflammation and if so would consider starting biologic therapy. The diagnostic dilemma of gastrointestinal TB and Crohn's disease is a common occurrence in TB endemic areas. It often presents similar to Crohn's disease with abdominal pain, weight loss, hematochezia, has similar imaging and endoscopic findings. It is important to differentiate between the two as they have opposing treatments. The risk of biologic therapy and re-activation of latent tuberculosis is well documented and screening for and surveying for TB is standard of care. But consideration of how to manage a patient with complicated Crohn's disease recently treated for active TB presents a dilemma. Biologic therapy is warranted to prevent recurrence of anastomotic stricture. A risk vs benefit discussion must be had and a suitable therapy individualized for the specific patient must be chosen. Vedolizumab, a gut specific, monoclonal antibody against a4b7 Integrin is considered to have a favorable safety profile with low incidence rates of serious infections.2057_A Figure 1. Histology2057_B Figure 2. Colon Resection Specimen

Does preoperative enteral or parenteral nutrition reduce postoperative complications in Crohn's disease patients: a meta-analysis.

Crohn's disease (CD) patients frequently develop complications that require surgery for management. The high prevalence of malnutrition in CD patients presents a challenge because poor preoperative nutritional status has been shown to increase postoperative complications. In this study, we assessed whether preoperative enteral nutrition (EN) or total parenteral nutrition (TPN) decreases postoperative complications in CD patients. A three-point systematic and comprehensive literature search was carried out on multiple databases followed by a meta-analysis with results presented as odds ratio (OR) using two models, the Mantel-Haenszel model and the DerSimonian and Laird model. The I measure of inconsistency was utilized to assess heterogeneity. If statistically significant heterogeneity was identified, the results underwent a separate sensitivity analysis. Five studies met inclusion criteria totaling 1111 CD patients. The rate of postoperative complications in the group receiving preoperative nutrition (EN or TPN) support was 20.0% compared with 61.3% in the group who had standard care without nutrition support [OR=0.26, 95% confidence interval (CI): 0.07-0.99, P<0.001]. Postoperative complications occurred in 15.0% of patients in the group who received preoperative TPN compared with 24.4% in the group who did not (OR=0.65, 95% CI: 0.23-1.88, P=0.43). Postoperative complications occurred in 21.9% in the group who received preoperative EN compared with 73.2% in the group that did not received preoperative EN (OR=0.09, 95% CI: 0.06-0.13, P<0.001). Preoperative nutrition supplementation reduces postoperative complications in CD patients. In particular, EN in CD patients before undergoing surgery is superior to standard of care without nutrition support with a number needed to treat of 2. There is a trend toward TPN being superior to standard of care without nutrition support, but this trend did not reach statistical significance. Further studies are necessary to evaluate specific components in EN or TPN that may be most beneficial for CD patients requiring surgical intervention.

ANALYSIS OF RISK FACTORS AND POSTOPERATIVE COMPLICATIONS IN PATIENTS WITH CROHN'S DISEASE.

The post-operative complications rate is greater in patients with Crohn's disease than in other abdominal surgeries due to other benign conditions. Prevention and management of such complications are important factors in the care of these patients. The objectives of this research are to analyze the rate of postoperative complications and the major risk factors in patients with Crohn's disease. A descriptive and retrospective study based on analysis of medical records of patients with Crohn's disease undergoing ileal and/or colonic resection, which analyzed the main surgical complications and their major risk factors. Forty-four surgical procedures and thirty-seven patients were analyzed. Most were female (56.7%). Postoperative complications were observed in 18 (40.9%) surgeries. The disease duration (P=0.04), the penetrating behavior (P=0.013), the time between diagnosis and the first surgery (P=0.04), malnutrition with low body mass index (BMI), duration of surgery (P=0.016), and the size of the removed specimen (P=0.014) were associated with higher rates of complications. The use of drugs blocking tumor necrosis factor up to eight weeks before surgery was not significantly associated with higher complications rates or increased need for reoperation. The complication rate observed in this study is similar to published data. The duration of the disease, the penetrating behavior, the size of the removed specimen, the duration of the surgery, and BMI are important risk factors for perioperative complications in Crohn's disease.

Risk Factors for Early Surgery and Surgical Complications in Crohn's Disease

In recent decades, developments in drug therapy have significantly postponed the need for surgery. Nevertheless, the majority of patients with Crohn's disease still require one or more surgical interventions during the course of their disease. An analysis of epidemiological data as well as the surgical results of our own patients should help to identify risk factors for early surgery, re-operations and perioperative complications. A retrospective analysis including 120 consecutive patients with Crohn's disease and needing surgical intervention was carried out at the University Hospital of Rostock (UMR), Germany. Statistical analysis was performed using SPSS. A total of 284 operations were recorded in 120 patients, of which 207 were performed on the UMR. The mean age at first surgery was 38 years (range: 17 - 66); initial diagnosis of Crohn's was on average at the age of 30 (range: 9 - 62). Each patient was operated 2 - 3 times during the course of their disease (range 1 - 9). Patients older than 30 years had significantly shorter time interval to the first operation. The number of operations per patient was significantly influenced by the localisation and behaviour of the disease. Penetrative behavior was associated with more frequent operations and terminal ileum involvement (L1) with significantly less frequent operations. Risk factors for complication of at least grade III according to Clavien-Dindo included greater age at surgery and at first diagnosis, decreased albumin levels and increased CRP. Anastomotic leakages were also associated with these risk factors as well as preoperative intake of > 20 mg prednisolone equivalent per day or cumulative dosage of 280 mg over the last 14 days prior to surgery. Anastomosis configuration and microscopic involvement of the resection margins had no statistically significant influence on the development of anastomotic leakage. Diagnosis after the age of 30 was associated with a significantly earlier need for surgery in this analysis. Patients with terminal ileum involvement (L1) had a significantly lower surgical frequency than patients with colon or combined Crohn's disease. Age, albumin, CRP and a steroid medication > 20 mg per day were predictors for perioperative complications.

Positioning of old and new biologicals and small molecules in the treatment of inflammatory bowel diseases.

The past decade has brought substantial advances in the management of inflammatory bowel diseases (IBD). The introduction of tumor necrosis factor (TNF) antagonists, evidence for the value of combination therapy, the recognition of targeting lymphocyte trafficking and activation as a viable treatment, and the need for early treatment of high-risk patients are all fundamental concepts for current modern IBD treatment algorithms. In this article, authors review the existing data on approved biologicals and small molecules as well as provide insight on the current positioning of approved therapies. Patient stratification for the selection of specific therapies, therapeutic targets and patient monitoring will be discussed as well. The therapeutic armamentarium for IBD is expanding as novel and more targeted therapies become available. In the absence of comparative trials, positioning these agents is becoming difficult. Emerging concepts for the future will include an emphasis on the development of algorithms which will facilitate a greater understanding of the positioning of novel biological drugs and small molecules in order to best tailor therapy to the patient. In the interim, anti-TNF therapy remains an important component of IBD therapy with the most real-life evidence and should be considered as first-line therapy in patients with complicated Crohn’s disease and in acute-severe ulcerative colitis. The safety and efficacy of these ‘older’ anti-TNF therapies can be optimized by adhering to therapeutic algorithms which combine clinical and objective markers of disease severity and response to therapy.

Predictive parameters of early postoperative complications in Crohn's disease: Single team experience.

Most of the patients with Crohn's disease (CD) may require at least one surgical procedure over their lifetime. However, these patients tend to have a high incidence of postoperative complications. The aim of this retrospective study was to investigate the predictive parameters of postoperative complications in CD. All consecutive patients with CD between March 2001 and March 2016 who underwent bowel resection were included to this study. Postoperative complications were divided as; major complications including anastomotic leakage, ostomy complications, acute mechanical intestinal obstruction and hemorrhage, and minor complications including wound infection. A total of 147 patients (74 females, 73 males) with a mean age of 36±11.9 years met the inclusion criteria. Behaviors of CD were stricturing in 90 (62%), fistulizing in 45 (30%) and inflammatory in 12 (8%) patients. Minimally invasive approach was applied in 35% (n=51) of the patients. Twentysix (17%) patients had early (≤30 days) postoperative surgical complications including anastomotic leak (n=10), intra-abdominal bleeding (n=2), complications related to ostomy (n=2), acute mechanical intestinal obstruction (n=1) and wound infection (n=11). Only fistulizing disease behavior was associated with early postoperative complications (p=0.014). This study suggests that postoperative complications are still more common in fistulizing CD. Surgical approach did not affect the complication rate. The decision should be individualized according to the prominent risk factors and surgeons' preference.

A rare case of a duodenocolic fistula in a 3-year old child

Intraintestinal fistula is an unnatural communication between the intestinal cavity and other parts of the gut. Duodenocolic fistulas are common in adult patients with duodenal peptic ulcer or colon malignancies. In children, the formation of intraintestinal fistulas is possible as a rare complication of necrotizing enterocolitis of the newborn, after swallowing of several (two and more) magnetic foreign bodies localized in different parts of the digestive tract, as well as a complication of Crohn's disease at an older age. The article presents a clinical case of a duodenocolic fistula in a 3-year-old child. The patient Sh., 3 years and 2 months old, was admitted to the Pediatric Department of our clinic with a malabsorption syndrome and complaints of periodic vomiting after meals, weakness, tiredness, unstable light grayish stools, flatulence, periodic abdominal pains, and weight loss. There were clinical signs of stage II hypotrophy, protein and energy insufficiency. Laboratory tests showed low protein, albumin, and cholesterol levels, hypochromic anemia; fecal steatorrhea, creatorrhea, and amilorrhea. The differential diagnosis included intestinal malabsorption syndrome, presumably of a secondary origin, intestinal infection, congenital pancreatic disease, hereditary metabolic disorders, cystic fibrosis, celiac disease, lambliosis, and tumor. Multiple endoscopic and radiological examinations of the gastrointestinal tract were performed, but the intraintestinal fistula was identified only after repeated examinations. The patient's medical history from the first referral to the final diagnosis lasted about 9 months. The mechanism of the fistula formation in this patient is unclear. The clinical manifestation corresponded to the location of the fistula. In the long-term, the functioning of pathological intraintestinal communication could have a negative impact on the growth and development of the child; mucosal atrophy of the descending part of the intestine would have been possible, with progressive cachexy that could have become fatal.

Clinical analysis of enteral nutrition therapy in the treatment of complications of Crohn′s disease

Objective To investigate the therapeutic value of enteral nutrition in disease activity, nutritional status and complications of patients with Crohn′s disease (CD). Methods From January 2015 to February 2017, 64 CD patients with malnutrition in the First Affiliated Hospital of Soochow University were selected and received basic treatment with enteral nutrition. Before enteral nutrition and three months after therapy, white blood cell (WBC), red blood cell (RBC), hemoglobin, platelet, total protein, albumin, erythrocyte sedimentation rate (ESR) and C-reaction protein (CRP) were examined; Crohn′s disease activity index (CDAI) was calculated; abdominal and perianorectal lesions of patients were observed by small intestinal computed tomography (CT), abdominal ultrasound and anus magnetic resonance imaging (MRI). Paired t test and McNemar test were performed for statistical analysis. Results Compared with those before enteral nutrition treatment, who received enteral nutrition for three months, the levels of WBC, platelet, ESR, CRP and CDAI scores of CD patients were lowered ((7.83±3.61)×109/L vs. (4.82±2.26)×109/L, (272.52±191.79)×109/L vs. (166.17±67.18)×109/L, 33.5 mm/1 h vs. 5.5 mm/1 h, 21.70 mg/L vs. 1.97 mg/L, 220.75±119.71 vs. 33.48±20.22), and the differences were statistically significant (t=13.14 and 10.02; Z=501.50 and 57.80; t=25.44, all P<0.01). The levels of RBC, hemoglobin, total protein, albumin increased ((4.17±0.97)×1012/L vs. (4.97±0.98)×1012/L, (115.33±40.38) g/L vs. (133.88±43.87) g/L, (57.82±19.46) g/L vs. (69.68±16.53) g/L, (34.32±16.85) g/L vs. (43.29±17.57) g/L), and the differences were statistically significant (t=-10.45, -7.12, -11.44 and -6.87, all P<0.01). The CDAI scores of patients with remission of abdominal pelvic diseases and intestinal stenosis were both lower than those of patients without remission (214.3±113.54 vs. 296.77±60.24, 219.31±104.74 vs. 221.04±121.47), and the differences were statistically significant (both t=28.91, both P<0.05). Three months after enteral nutrition treatment, the remission patients of perianal lesions, abdominal pelvic diseases and intestinal stenosis were 28, 14 and 18 cases, respectively. Conclusion CD patients can achieve clinical remission with enteral nutrition treatment, which also prevent and treat CD related malnutrition and may prove to be a safe and first-line therapeutic approach. Key words: Crohn disease; Enternal nutrition; Perianal lesions; Abdominal pelvic lesions; Stenosis; Clinical significance

Preoperative Ustekinumab Treatment Is Not Associated With Increased Postoperative Complications in Crohn's Disease: A Canadian Multi-Centre Observational Cohort Study.

BackgroundUstekinumab (UST), an anti-IL12/23 inhibitor is indicated for moderate-to-severe Crohn’s disease (CD). However, it is unclear if patients treated with UST are at increased risk for postoperative complications.AimTo evaluate the postoperative safety outcomes in UST-treated CD patients.MethodsA multicentre cohort study of UST-treated CD patients at two tertiary care centres (University of Calgary, University of Alberta, Canada) undergoing abdominal surgery between 2009 and 2016 was performed. Postoperative outcomes were compared against a control cohort of anti-TNF-treated patients over the same time-period. The primary outcome was occurrence of postoperative complications up to six months postoperatively, stratified by timing (early <30 days vs. late complications ≥30 days).ResultsTwenty UST-treated patients and 40 anti-TNF-treated patients were included with a median preoperative treatment exposure of 6.5 months and 18 months, respectively (p=0.01). Bowel obstruction was the most common surgical indication in both cohorts. UST-treated patients were more likely to require an ostomy (70.0% vs. 12.5%, p<0.001) and be on combination therapy with either systemic corticosteroids or concurrent immunomodulators (azathioprine or methotrexate) (25.0% vs. 2.5%, p=0.01). Despite the increased concomitant use of immunosuppression in the UST-treated cohort, there were no significant differences in early or late postoperative wound infections (1/20 in UST-cohort, 2/40 in anti-TNF cohort, p=1.00), anastomotic leak (0/20 in UST-cohort, 3/40 in anti-TNF cohort, p=0.54), or postoperative ileus/obstruction (3/20 in UST-cohort, 4/40 in anti-TNF cohort, p=0.67).ConclusionsCD patients receiving preoperative UST did not experience an increase in postoperative complications, despite increased use of concurrent immunosuppression.

Su1923 - Rate and Risk Factors for Post-Operative Complications in Crohn's and Colitis Patients Undergoing Non-Inflammatory Bowel Disease Surgery

Su1923 - Rate and Risk Factors for Post-Operative Complications in Crohn's and Colitis Patients Undergoing Non-Inflammatory Bowel Disease Surgery

Treatment of complicated Crohn's disease with vedolizumab

Treatment of complicated Crohn's disease with vedolizumab

DNA polymorphisms predict time to progression from uncomplicated to complicated Crohn's disease.

Most patients with Crohn's disease (CD) are diagnosed with the uncomplicated inflammatory form of the disease (Montreal stage B1). However, the majority of them will progress to complicated stricturing (B2) and penetrating (B3) CD during their lifetimes. The aim of our study was to identify the genetic factors associated with time to progression from uncomplicated to complicated CD. Patients with an inflammatory phenotype at diagnosis were followed up for 10 years. Genotyping was carried out using Illumina ImmunoChip. After quality control, association analyses, Bonferroni's adjustments, linear and Cox's regression, and Kaplan-Meier analysis were carried out for 111 patients and Manhattan plots were constructed. Ten years after diagnosis, 39.1% of the patients still had the inflammatory form and 60.9% progressed to complicated disease, with an average time to progression of 5.91 years. Ileal and ileocolonic locations were associated with the complicated CD (P=1.08E-03). We found that patients with the AA genotype at single-nucleotide polymorphism rs16857259 near the gene CACNA1E progressed to the complicated form later (8.80 years) compared with patients with the AC (5.11 years) or CC (2.00 years) genotypes (P=3.82E-07). In addition, nine single-nucleotide polymorphisms (near the genes RASGRP1, SULF2, XPO1, ZBTB44, HLA DOA/BRD2, HLA DRB1/HLA DQA1, PPARA, PUDP, and KIAA1614) showed a suggestive association with disease progression (P<10). Multivariate Cox's regression analysis on the basis of clinical and genetic data confirmed the association of the selected model with disease progression (P=5.73E-16). Our study confirmed the association between the locus on chromosome 1 near the gene CACNA1E with time to progression from inflammatory to stricturing or penetrating CD. Predicting the time to progression is useful to the clinician in terms of individualizing patients' management.

Inferior vena cava thrombosis as a complication of Crohn’s disease

Twenty-nine years old male, a case of Crohn's disease diagnosed by histopathology 5 years back, when he developed a perforative peritonitis. Resection and anastomosis was done, and he was started on Mesalamine therapy. Patient stopped the drug 8 months back and presented with cough for 1-month duration. HRCT chest showed IVC thrombosis. CECT abdomen showed intrahepatic extension of thrombus with active colitis and absent left testicle in scrotum with no intra-abdominal testicle. Coagulation parameters were normal. Colonoscopy and biopsy was done showing features of active Crohn's disease. Patient was restarted on Mesalamine and anticoagulation. Follow up imaging showed features of resolution of thrombus.

Ocular Manifestations of Paediatric Inflammatory Bowel Disease: A Systematic Review and Meta-analysis.

Ocular extraintestinal manifestations [O-EIMs] are known complications of Crohn's disease [CD], ulcerative colitis [UC], and inflammatory bowel disease unclassified [IBD-U]. However, data on their prevalence in children are scarce and there are no clear recommendations on what follow-up should be offered. We aimed to review available data on O-EIMs in children. In January 2018, we performed a systematic review of published English literature using PubMed and EMBASE databases and disease-specific queries. Fifteen studies [7467 patients] reported data on O-EIMs prevalence in children. Overall prevalence of O-EIMs was 0.62-1.82%. Uveitis was the most common O-EIM. Meta-analysis showed that children with CD are at increased risk of O-EIMs as compared with children with UC and IBD-U (odds ratio [OR] 2.70, 95% confidence interval [CI] 1.51-4.83). Five studies [357 patients] reported data on ophthalmological screening in asymptomatic children: mild asymptomatic uveitis was identified in a variable proportion of patients [1.06-23.1%], more frequently in male patients with CD and colonic involvement. No evidence of ocular complications from untreated uveitis was detected. A total of 23 case reports [24 patients] were identified. Data on O-EIMs in children are scarce. Prevalence of O-EIMs is lower than in adults but may be underestimated because of the possibility of asymptomatic uveitis; however, the long-term significance of this condition is unknown. Children with CD may be at increased risk of O-EIMs. No recommendations on routine ophthalmological examination can be made, but a low threshold for ophthalmological referral should be maintained. Larger studies in paediatric IBD populations are needed.

Adalimumab and postoperative complications of elective intestinal resections in Crohn's disease: a propensity score case-matched study.

data are scarce regarding the effect of preoperative Adalimumab (ADA) in postoperative complications in Crohn's disease (CD) patients. to compare the rates of postoperative complications after intestinal resections in CD, with and without previous exposure to ADA. case-matched retrospective observational study of patients submitted to intestinal resections for CD. The patients were allocated to 2 groups, according to their previous exposure to ADA before surgery. The patients under ADA therapy were matched with controls (patients without previous biologics) with the propensity score method (PSM), according to age at surgery, CD location (Montreal L) and phenotype (Montreal B). Medical and surgical complications were compared. 123 patients were initially considered, 71 with previous biologics (32 under ADA therapy) and 52 without. The PSM selected 25 ADA patients to be matched with 25 controls from the non-biologics group. There was no difference regarding overall surgical complications (40% in the control vs 36% in the ADA group; p=1.0000) or medical complications (36% vs 12% in the control and ADA groups, respectively; p=0.095). In univariate analysis, previous ADA was not considered a risk factor for higher postoperative complication rates. Stomas were considered a risk factor for surgical complications, and previous steroids were associated to higher medical complicationrates. preoperative ADA did not influence the rates of medical and surgical complications after elective intestinal resections for CD. This was the first study to include exclusively patients under ADA therapy. This article is protected by copyright. All rights reserved.

Does a histologically inflamed resection margin increase postoperative complications in patients with Crohn’s disease?

Objectives: Our study assessed whether the presence of histologically inflamed resection margins increased postoperative anastomotic complications in Crohn’s disease (CD) patients. We also examined the influence of other risk factors for postoperative complications.Materials and methods: Presence of chronic inflammation and activity of inflammation was scored from the resection margin specimens of 70 patients undergoing surgery due to CD. Anastomotic complications were recorded with a one-month follow-up. We also analysed other risk factors for postoperative complications, such as patient age, previous surgeries, preoperative C-reactive protein, faecal calprotectin, albumin and haemoglobin levels, American Society of Anesthesiologists (ASA) classification, preoperative immunosuppressive medication, surgical approach and the presence of intraoperative fistula or abscess.Results: In total, 46 patients (65.7%) had active inflammation in the bowel resection margin – 12 patients (17.1%) with mild, five patients (7.1%) with moderate and 29 patients (41.4%) with strong activity. We found 14 (20.0%) postoperative complications, of which three (4.6%) were anastomotic. The presence of active inflammation at the resection margin did not significantly influence the occurrence of postoperative anastomotic complications. None of the other risk factors examined significantly increased postoperative complications among our sample.Conclusions: After bowel-sparing surgery for CD, the frequency of histologically inflamed resection margins is high. However, postoperative complication rate remains low. The current practice with resection of only the most affected bowel segments for CD seems to be a safe choice. We still need further research concerning risk factors for postoperative complications in Crohn’s patients.