European Crohn's And Colitis Organisation Research Articles

Letter: international IBD practice guidelines

SIRS, We welcome the opportunity to respond to the article by Feuerstein and colleagues which analyses the published inflammatory bowel disease (IBD) guidelines for quality of scientific evidence presented, any conflicts of interest declared, and attempts to compare them. The published guidelines have used a variety of methods to grade the levels of evidence presented and the authors merged them into a standard ABC(D) system. However, the methodology of this paper is flawed. The authors assigned a grade D level of evidence to any statement highlighted by a bullet point. This will reflect editorial layout of the guideline, overestimate the number of statements for which no evidence is available and misrepresent the quality of the guideline. The British Society of Gastroenterology (BSG) guidelines for the management of IBD in adults have recommendations listed in bullet point form. There are 47 statements with graded recommendations. A further 36 statements have no grade associated with them; half of these statements relate to drugs used in pregnancy and vaccines. These areas are never likely to be subject to randomised controlled trials. However, to label a statement such as ‘methotrexate is absolutely contra-indicated in pregnancy’ as level D because there is no accompanying grade of evidence would be wrong and misleading to readers, who may conclude that perhaps prescribing the drug is safe! Furthermore, Feuerstein and colleagues report a total of 100 recommendations within the BSG guidelines, and it is not clear how this figure was derived. Any attempt to draw comparisons between the published guidelines based on the percentage of grades A – D evidence reported will be flawed. The authors compared specific recommendations in Table 2. They report that the BSG recommends cessation of maintenance therapy for ulcerative colitis (UC) after a period of 4 years. This statement relates to the prescription of thiopurines and is reported out of context. The BSG stance on methotrexate for maintenance of UC is portrayed as out of step with the other guidelines. However, it takes into consideration more recent studies not referenced in other guidelines. The European Crohn’s and Colitis Organisation (ECCO) refers to the recent methotrexate studies, but the ECCO authors fail to make a recommendation, and cite on-going ECCO studies, which may influence their stance. On the subject of checking TPMT levels, the BSG level of evidence is misquoted. We agree, it is important to draw attention to author conflicts of interest. However, this does not equate to bias. The review process for BSG guidelines was rigorous and transparent. They were reviewed by two independent society committees and five external reviewers nominated by Gut. We agree, there is a need for stronger supporting evidence, up-to-date recommendations and transparency in guideline development. However, readers should exercise caution when interpreting this paper. Dr Craig Mowat, Dr Stuart Bloom on behalf of the British Society of Gastroenterology IBD Section.

PTU-068 Patient Awareness of Immunisation Guidelines in Inflammatory Bowel Disease

IntroductionImmunomodulator agents are commonly employed in the management of inflammatory bowel disease (IBD). These can increase the risk for opportunistic infections. This study aims to assess patient awareness for the...

PTU-065 Influenza Vaccination uptake in Inflammatory Bowel Disease- is there Room to Improve?

IntroductionThe aim of our study is to assess the seasonal influenza vaccination uptake in patients with inflammatory bowel disease (IBD)MethodsWe have conducted a telephonic survey of our IBD patients in...

Small bowel capsule endoscopy for management of Crohn's disease: Where do we stand?

During the pioneering phase of the use of video capsule endoscopy (VCE), the diagnosis and even the suspicion of Crohn’s disease was considered as an absolute contraindication to the performance of the procedure, because of the risk of capsule retention proximal to a stenosis. In subsequent years, the view has changed, and known or suspected Crohn’s disease is now the second most common indication for VCE, accounting for about 10–15% of the capsule procedures performed. However, Crohn’s disease is diagnosed on the basis of the combination of endoscopic, histological, radiological and biochemical investigations, and therefore, the value of VCE in this setting must be evaluated in the context of the different available techniques. To help establishing the role of VCE and other diagnostic techniques in the management of inflammatory bowel disease, the European Crohn’s and Colitis Organisation (ECCO) and the Organisation Mondiale d’Endoscopie Digestive (OMED) jointly organized a consensus meeting in Brussels in December 2008, which led to the publication of clinical practice guidelines [1]. The reasons why VCE is attractive for the management of Crohn’s disease are that in up to 30% of cases the disease is limited to the small bowel [2], that the technique has limited invasiveness and has the unique possibility of exploring the entire small bowel mucosa. However, VCE also has some drawbacks, such as the inability to take tissue samples, the risk of retention and the lack of a widely accepted classification of small bowel lesions in inflammatory bowel disease. The potential applications of capsule endoscopy in inflammatory bowel disease include the following clinical scenarios: patients with a clinical suspicion of Crohn’s disease, where VCE could help establishing a new diagnosis; patients with known Crohn’s disease, where VCE could help assessing the extent and severity of the disease, and thus assist in making treatment decisions; in previously operated patients, VCE could be used to evaluate the appearance of recurrences; patients with inflammatory bowel disease, unclassified (IBDU), where VCE could help distinguishing ulcerative colitis

Letter: real‐life management of new onset ulcerative colitis and proctitis

We read with interest the study of Richter et al. about the treatment of new onset ulcerative colitis (UC) in a large, American, insurance database cohort.1 The study provides robust data on how UC is managed in real life. As expected, most patients with UC were initially managed with oral 5-ASA, whereas the majority of those with ulcerative proctitis (UP) were treated with topical mesalazine. Optimistically, the authors concluded that care of these patients appears consistent with treatment guidelines. However, we believe that there are some issues that should be carefully addressed. First, 5-ASA combination therapy (oral and rectal) was prescribed in only a small proportion of patients (<20%). As stated in the consensus of the European Crohn's and Colitis Organization (ECCO),2 5-ASA combination therapy should be the treatment of choice for those patients with left-sided or extensive UC with mild-to-moderate activity. Combination therapy has proven to achieve more rapid clinical improvement than monotherapy, and some controlled studies suggest even significantly higher remission rates.3 Moreover, topical 5-ASA (suppositories or enemas) was prescribed as monotherapy in only half of the patients, whereas oral 5-ASA was used as monotherapy in almost 20%. It is known that 5-ASAs achieve the lowest mucosal concentrations at the rectum when administered orally, and both ECCO and the American College of Gastroenterology recommend topical therapy for distal forms of colitis, mainly in UP.2, 4 Second, a large proportion of patients did not follow maintenance therapy after induction of remission. In fact, 40% of those UC patients who began oral 5-ASA, 70% of UP patients who were initially treated with mesalazine suppositories, and even 40–50% of those patients who began oral or systemic glucocorticsteroids, did not receive any medication for the rest of the year. This appears to be of great relevance given that UC is a chronic relapsing disease, even more so in patients with extensive UC or those who required systemic glucocorticosteroids.5, 6 Furthermore, deep control of the inflammatory activity seems to be the key to prevent dysplasia in a long-term basis.7 Finally, we would like to emphasise that lack of adherence to clinical guideline recommendations seems to be relatively common in real life. Thus, a cross-sectional survey was recently conducted in Spain to assess the adherence to the ECCO guidelines on mild-to-moderate UC.8 We surveyed gastroenterologists specialised in inflammatory bowel disease (GSIBDs) and general gastroenterologists (GGs). Although agreement with the guidelines was, in general, relatively high, remarkably discrepancies included that only 25% of the GGs used the combination of oral and topical 5-ASA for treating extensive UC vs. 45% of the GISBDs. In addition, indefinite treatment with 5-ASA was prescribed by only 26% of the GGs vs. 41% of the GSIBDs. Declaration of personal and funding interests: None.

Management of Pediatric Ulcerative Colitis

Pediatric ulcerative colitis (UC) shares many features with adult-onset disease but there are some unique considerations; therefore, therapeutic approaches have to be adapted to these particular needs. We aimed to formulate guidelines for managing UC in children based on a systematic review (SR) of the literature and a robust consensus process. The present article is a product of a joint effort of the European Crohn's and Colitis Organization (ECCO) and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). A group of 27 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to ESPGHAN and ECCO members. A list of 23 predefined questions were addressed by working subgroups based on a SR of the literature. A total of 40 formal recommendations and 68 practice points were endorsed with a consensus rate of at least 89% regarding initial evaluation, how to monitor disease activity, the role of endoscopic evaluation, medical and surgical therapy, timing and choice of each medication, the role of combined therapy, and when to stop medications. A management flowchart, based on the Pediatric Ulcerative Colitis Activity Index (PUCAI), is presented. These guidelines provide clinically useful points to guide the management of UC in children. Taken together, the recommendations offer a standardized protocol that allows effective, timely management and monitoring of the disease course, while acknowledging that each patient is unique.

The effect of third-party reporting on adoption of evidence-based mesalazine regimens in ulcerative colitis: An observational study

Background and aimsThe optimal mesalazine dosing strategy for ulcerative colitis (UC) continues to evolve. The current study aimed to explore whether documenting drug use could prompt changes in prescribing habits. MethodsIn a multicenter, prospective, observational study, outpatients with active or quiescent UC were enrolled if they were receiving, or were planned to receive, sustained release mesalazine microgranules (Pentasa®). Clinical and prescribing data were collected at study entry, after 2 and 8weeks. Physician-reported influences on prescribing decisions were recorded at study entry. Results360 patients were analyzed (203 active UC, 157 remission). Prior to study entry, the range of oral mesalazine doses was 0.50–6.00g/day in active UC patients, and 0.50–4.00g/day for patients in remission. These changed to 1.50–5.00g/day and 1.00–4.00g/day, respectively, at study entry with little change thereafter. Use of a single daily mesalazine dose increased from 16.7% to 58.0% of active cases during the study, and from 5.9% to 46.8% in remission cases. Gastroenterologists reported that their basis for prescription decision-making was most frequently medical experience (80.8%), followed by guidelines (67.2%), further education or colleagues' recommendations (50.0%) and current study results (20.0%). ConclusionIn this analysis of mesalazine dosing in routine clinical practice, there was an improvement in adherence to European Crohn's and Colitis Organisation (ECCO) guidelines and in use of once-daily dosing, consistent with recent trial results, following documentation of dosing regimens. Written reporting of drug dosing schedules should be considered fundamental for chronic, complex diseases such as UC.

PWE-235 Screening using the European Crohn's and Colitis Organisation (ECCO) guidelines demonstrates high strongyloides sero-prevalence in migrants with inflammatory bowel disease

IntroductionStrongyloidiasis can persist and cause hyperinfection years after acquisition when host immunity is impaired. European Crohn's and Colitis Organisation guidelines1 on opportunisitc infections recommend that Inflammatory Bowel Disease (IBD) patients...

PTU-094 Immunisation of IBD patients on biologic therapy: an English district hospital experience

IntroductionPatients with IBD remain at risk of preventable infections due to immunomodulatory drugs. The European Crohns and Colitis Organisation (ECCO) Consensus document1 recommends immunising all such patients to Human Papilloma...

Adherence of gastroenterologists to European Crohn's and Colitis Organisation Consensus on Crohn's disease: A real-life survey in Spain

BackgroundThere is no information as to the extent by which Spanish gastroenterologists adhere to Crohn's disease (CD) management guidelines. The objective of this study was to evaluate the degree of adherence of Spanish gastroenterologists to the European Crohn's and Colitis Organisation (ECCO) guidelines and to determine whether differences in adherence exist between gastroenterologists specialized in inflammatory bowel diseases (GSIBDs) and general gastroenterologists (GGs). MethodsThis was a prospective, nation-wide, questionnaire-based survey covering aspects related to diagnosis, treatment, follow-up, and safety considered by the physicians in their daily management of CD, as well as demographic traits seen in clinical practice. ResultsThe overall degree of adherence to guidelines by both GSIBDs and GGs was high. However, the use of imaging techniques in diagnosis, follow-up, and in relapsed patients differed between the two groups. In the diagnosis of perianal disease, GSIBDs used magnetic resonance and surgical exploration under anesthesia more frequently than GGs. In terms of therapeutic choices, the adherence to guidelines was good in both groups. However, GSIBDs showed significantly higher adherence in some areas: thiopurines were used less in refractory cases and methotrexate was used more commonly in corticoid-dependent, azathioprine-intolerant patients, and in patients under biological treatment. Request for infection studies and vaccinations at diagnosis or prior to treatment was more common among GSIBDs. ConclusionsGuideline adherence among Spanish gastroenterologists is high. However, there are significant differences between IBD-specialized (more adherent in general) and non-specialized gastroenterologists.

The immunization status of patients with IBD is alarmingly poor before the introduction of specific guidelines

Introduction. With immunosuppressive therapy of inflammatory bowel diseases (IBDs) becoming more aggressive, the risk of serious infections is increasing. Guidelines are currently being modified in respect to advisable immunizations. The aim of this study was to evaluate the immunization habits of IBD patients in daily practice before the implementation of specific guidelines. Methods. Hundred and two consecutive patients attending the outpatients IBD clinic at our hospital were interviewed regarding their immunization record. In addition, hepatitis B and C, HIV, and cytomegalovirus (CMV) serostatus were measured following a European Crohn's and Colitis Organization (ECCO) consensus. Results. Hundred and two patients with IBD have been included; of these 72% were taking steroids, 46% azathioprine, and 23% anti-TNF medication. Nineteen percent of the study population had been vaccinated against influenza, 3% against pneumoccous pneumonia, 22% against hepatitis B, 5% against varizella, 55% against rubella/mumps/measles, and 63% against tetanus. Of those who had traveled, 9% had been vaccinated for hepatitis A and 1% for yellow fever. Reasons given for not being vaccinated were not being aware of the necessity in 45% of those questioned and being afraid in 17%. While no patient was tested positive for hepatitis B, HIV, and CMV-IgM, one female patient was tested positive for hepatitis C (antibody and PCR positive, genotype I), which was unknown at that point. Conclusion. Considering the high number of our patients receiving immunosuppressive therapy, the immunization record is alarmingly poor supporting the need for optimized IBD guidelines, better awareness, and patient education. In addition, the screening for chronic infections appears to be useful as suggested by the positive finding of a previously unknown hepatitis C.

Vaccination against opportunistic infections in patients with inflammatory bowel disease on immunomodulator therapy

IntroductionImmunomodulators (IM) and biological agents are now used more often and earlier in Inflammatory Bowel Disease (IBD), leading to an increase in opportunistic infections (OI). The RR of OI is...

Adalimumab in Crohn's Disease: Tips and Tricks After 5 Years of Clinical Experience

Three anti TNF-α agents have currently been approved for the treatment of moderate-to-severe or complicated Crohn's disease (CD): infliximab, certolizumab and adalimumab. Infliximab is effective in CD, but for reasons linked to its chimeric structure, response to treatment may be lost overtime and as a result, it can sometimes be unable to provide long term durable treatment of CD. Adalimumab, a fully human anti TNF-α antibody, demonstrates similar treatment efficacy as infliximab and certolizumab, and can easily be self-administered at home. A literature search in the Cochrane, MEDLINE, PUBMED, Ovid MEDLINER® and EMBASE databases has been performed on the efficacy, safety and the impact adalimumab has on the quality of life and natural history of CD. Abstracts presented at the DDW, UEGW and ECCO Congresses have also been reviewed as well as references from review articles, meta-analysis studies and published RCTs. Adalimumab induced remission of CD in 64% of patients, and maintained remission in more than 80% of initial responders. Adalimumab did not significantly increase the risk of adverse events compared with conventional medication up to 3 years of follow-up. Adalimumab reduces more than 50% the risk for hospitalisation and surgery due to CD. It is also effective for fistula closure, for the healing of the mucosa, and improving quality of life. Adalimumab is effective in the induction and maintenance of clinical remission in CD and is generally well tolerated. It has been proved to have a positive impact by improving quality of life of patients, and reducing the need for hospitalisation and surgery due to CD. According to the European Crohn's and Colitis Organisation (ECCO), infliximab or adalimumab can be used for the treatment of fistulizing CD.

Consensus for Managing Acute Severe Ulcerative Colitis in Children: A Systematic Review and Joint Statement From ECCO, ESPGHAN, and the Porto IBD Working Group of ESPGHAN

Acute severe ulcerative colitis (ASC) is a potentially life-threatening disease. We aimed to formulate guidelines for managing ASC in children based on systematic review of the literature and robust consensus process. This manuscript is a product of a joint effort of the ECCO (European Crohn's and Colitis Organization), the Pediatric Porto Inflammatory Bowel Disease (IBD) Working group of ESPGHAN (European Society of Pediatric Gastroenterology, Hepatology, and Nutrition) and ESPGHAN. A group of 19 experts in pediatric IBD participated in an iterative consensus process including two face-to-face meetings. A total of 17 predefined questions were addressed by working subgroups based on a systematic review of the literature. The recommendations and practice points were eventually endorsed with a consensus rate of at least 95% regarding: definitions, initial evaluation, standard therapy, timing of second-line therapy, the role of endoscopic evaluation and heparin prophylaxis, how to administer second-line medical therapy, how to assess response, surgical considerations, and discharge recommendations. A management flowchart is presented based on daily scoring of the Pediatric Ulcerative Colitis Activity Index (PUCAI), along with 28 formal recommendations and 34 practice points. These guidelines provide clinically useful points to guide the management of ASC in children. Taken together, the recommendations offer a standardized protocol that allows effective monitoring of disease progress and timely treatment escalation when needed.

IBD Around the world: Comparing the epidemiology, diagnosis, and treatment

Every May 29th the World Gastroenterology Organization (WGO) celebrates World Digestive Health Day (WDHD) and initiates a worldwide public health campaign through its 110 national societies and 50,000 members. Each year focuses on a particular digestive disorder in order to increase general public awareness of prevention and therapy. 2010 is dedicated to inflammatory bowel disease (IBD). Upon this occasion a WGO IBD task force was compiled from leading international specialists and researchers. The task force also included members of the American Gastroenterological Association (AGA), International Organization for the Study of Inflammatory Diseases (IOIBD) and the European Crohn's and Colitis Organization (ECCO) of the United European Gastroenterology Federation (UEGF). The goal of the task force was to bring together IBD specialists from around the world to discuss the epidemiology, diagnosis, and management of IBD within different regions. This is a summary of the WGO task force meeting at the American Gastroenterological Association's (AGA) Digestive Disease Week, held in New Orleans, Louisiana, USA, May, 2010. The expert panel identified the most pressing issues in IBD worldwide: reliable epidemiological data, global collaboration in clinical and basic research, the approach to distinguishing intestinal tuberculosis from Crohn's disease, access to specialist care and access to the latest diagnostic and therapeutic strategies.

Adherence of gastroenterologists to European Crohn's and Colitis Organisation consensus on ulcerative colitis: A real-life survey in Spain

Background & aimsA European consensus on the management of ulcerative colitis (UC) was recently published; however, there is no adequate evidence about adherence to such guidelines among gastroenterologists. This knowledge would allow the local evaluation of the situation and the adoption of actions to reduce the existent clinical variability. MethodsA cross-sectional survey was conducted in Spain to assess the adherence to the European Crohn's and Colitis Organisation (ECCO) guidelines on mild to moderate UC. We surveyed 700 gastroenterologists, and finally a total of 530 gastroenterologists specialised in inflammatory bowel disease (GSIBDs) and general gastroenterologists (GGs), responded to the survey (76%). ResultsAgreement with the guidelines was high; discrepancies included that only 25% of the GGs used the combination of oral and topical 5-aminosalycilic acid (5-ASA) for treating extensive UC vs 45% of the GISBDs. In addition, topical rectal steroids were considered as effective as topical mesalazine by 48% of the GGs vs 31% of the GSIBDs, indefinite treatment with 5-ASA was prescribed by only 26% of the GGs vs 41% of the GSIBDs, and the once daily dosing of 5-ASA was generally used by 46% of the GGs vs 51% of the GSIBDs. ConclusionsThe questionnaire showed a high degree of agreement between GGs and GSIBDs. Nevertheless, the GSIBD group showed closer agreement with the ECCO guidelines. Furthermore, some shortcomings were found in the GG group, in which increased maintenance treatment with 5-ASA, the use of a single daily dose of 5-ASA, and the use of combined oral and topical treatment for distal colitis should be advised.

PWE-032 Audit of prevention of opportunistic infections in immunosuppressed patients with inflammatory bowel disease: how close are we to the European Crohn's and Colitis Organisation guidelines?: Abstract PWE-032

Introduction The European Crohn's and Colitis Organisation (ECCO) has recently published recommendations on screening and prevention of opportunistic infections in inflammatory bowel disease (IBD) patients. These are based on expert opinion and available evidence, and are more extensive than previous guidelines. The aim of this audit is to compare current practice of screening for, and prevention of, opportunistic infections in our IBD clinic, with these recommendations, and to examine the implications of following the guidelines. Methods IBD patients at risk of opportunistic infections (as defined by ECCO; those treated with thiopurines, methotrexate, anti-TNF or prednisolone>20 mg daily for >2 weeks) were selected consecutively from our IBD clinic and infliximab infusion service from July to November 2009. A data collection sheet was completed for each patient by direct questioning in clinic and by review of patients' records. Information collected included; demographic and clinical details, immunosuppressive medication (IM), screening tests performed (HBsAg, anti-HBs, antiHBc, HCVAb, HIVAb, VZVAb (not applicable (n/a) if history of VZV infection), CXR and cervical smear (females)), and vaccinations given prior to treatment (Hepatits B, VZV (n/a if history of VZV infection), HPV (women<26 years), influenza and Streptococcus pneumoniae). A cost analysis of this screening and vaccination strategy was performed. Results Ninety patients (Crohn's disease (n=70), Ulcerative Colitis (n=19), IBD-unclassified (n=1)) were audited to the time of abstract submission. Of these, 46 were male and 44 female (median age 32 years). Forty-one percent of patients were taking thiopurine monotherapy, 34% concomitant thiopurine and anti-TNF therapy, 14% anti-TNF monotherapy, 6% prednisolone, and 5% methotrexate. The proportion of patients who had recommended screening tests and vaccinations are shown in the table. Patients on anti-TNF therapy were more likely to have undergone CXR, hepatitis B and C screening (p<0.05). The cost of these screening tests and vaccinations (excluding HPV) was GBP£255 per patient (equipment and manpower costs not included) ([Abstract 032][1]). View this table: Abstract PWE-032 Screening tests and vaccinations performed Conclusion Our current practice of screening for and prevention of opportunistic infections in at-risk IBD patients is not in line with recent ECCO recommendations. However, some of the ECCO recommendations are based on limited evidence. Therefore, ongoing audit and research, as well as proof of cost benefit, may be required before they gain widespread acceptance. [1]: #T1

Role of small-bowel endoscopy in the management of patients with inflammatory bowel disease: an international OMED–ECCO consensus

Crohn's disease and ulcerative colitis are lifelong diseases seen predominantly in the developed countries of the world. Whereas ulcerative colitis is a chronic inflammatory condition causing diffuse and continuous mucosal inflammation of the colon, Crohn's disease is a heterogeneous entity comprised of several different phenotypes, but can affect the entire gastrointestinal tract. A change in diagnosis from Crohn's disease to ulcerative colitis during the first year of illness occurs in about 10 % - 15 % of cases. Inflammatory bowel disease (IBD) restricted to the colon that cannot be characterized as either ulcerative colitis or Crohn's disease is termed IBD-unclassified (IBDU). The advent of capsule and both single- and double-balloon-assisted enteroscopy is revolutionizing small-bowel imaging and has major implications for diagnosis, classification, therapeutic decision making and outcomes in the management of IBD. The role of these investigations in the diagnosis and management of IBD, however, is unclear. This document sets out the current Consensus reached by a group of international experts in the fields of endoscopy and IBD at a meeting held in Brussels, 12-13th December 2008, organised jointly by the European Crohn's and Colitis Organisation (ECCO) and the Organisation Mondiale d'Endoscopie Digestive (OMED). The Consensus is grouped into seven sections: definitions and diagnosis; suspected Crohn's disease; established Crohn's disease; IBDU; ulcerative colitis (including ileal pouch-anal anastomosis [IPAA]); paediatric practice; and complications and unresolved questions. Consensus guideline statements are followed by comments on the evidence and opinion. Statements are intended to be read in context with qualifying comments and not read in isolation.

Crohn’s-like enterocolitis associated with mycophenolic acid treatment

In the European Crohn's and Colitis Organisation (ECCO) paper of 2006 ( Gut 2006; 55 (Suppl 1):i1–15), consensus on the diagnosis of Crohn’s disease was described. However, we were surprised...

The European consensus on ulcerative colitis: new horizons?

A European consensus on anything is not easy to achieve, and inflammatory bowel disease (IBD) is no exception. The European Crohn’s and Colitis Organisation (ECCO), has now published the Consensus...