Fistulizing Disease Research Articles

Predictors of health-related quality of life in patients with Crohn’s disease receiving biological therapy

Background and Aim Health-related quality of life (HRQoL) is impaired in patients with Crohn’s disease (CD). This study aimed to identify the impact of clinical disease activity on HRQoL in CD patients treated with biological agents. Methods Patients with moderate to severe active CD treated with biological agents in Denmark were included from 2016–2018. Disease related symptoms were assessed via the Harvey Bradshaw Index. HRQoL was measured on the Short Health Scale (SHS). Multivariable linear regression models were conducted separately for each SHS item and average SHS score stratified for sex, adjusting for clinical manifestation and age. Results In total, 1,181 CD patients were included. The mean age was 33 years and 56% were women. Abdominal pain (range of regression coefficients 1.18–1.42), number of liquid stools (0.33–0.58), and the appearance of a new rectal fistula (0.91–1.32) affected all domains in the SHS negatively for men and women. Arthralgia (0.47–0.67) and abdominal mass (0.54–0.62) affected 4 out of 5 items on SHS negatively for women and men, respectively. Female sex was found a predictor of lower HRQoL across all SHS items, whereas age and fistulizing disease, as phenotype, were not associated with lower HRQoL. Conclusions Abdominal pain, number of liquid stools, a new rectal fistula, arthralgia for women, clinically assessed abdominal mass for men as well as female sex, were all found to be predictors of decreased HRQoL.

The Phenotypic Spectrum of New-onset IBD in Canadian Children of South Asian Ethnicity: A Prospective Multi-Centre Comparative Study.

Canadian-born children of South Asian [SA] ethnicity develop inflammatory bowel disease [IBD] at similar rates to those among Caucasian children. We evaluated the variation in phenotypic spectrum of IBD in SA and Caucasian children in a national paediatric inception cohort of new-onset IBD. Patients aged <17 years, enrolled in a Canadian nationwide inception cohort study, were included. Baseline demographic and IBD phenotypic features were compared between SA and Caucasian children. Longitudinal outcomes through 18 months of follow-up were compared matched by propensity scores. Of 1156 children enrolled over 2014 to 2019, 623 were Caucasian [98% and 88% parents Canadian born] and 114 SA [79% Canadian born, 87% parents SA born]. Fewer SAs have a first-degree relative with IBD, 6% vs 19% in Caucasians, p = 0.002. SAs present at a younger age, median age 11.4 years (interquartile range [IQR] 9.2-14.3) vs 13 years [IQR 10.9-15 years], p = 0.03 and more commonly with a UC/IBD-U [ulcerative colitis/IBD-unclassified] subtype [ratio of UC/IBD-U to CD 1.2:1 vs 1:1.8 for Caucasians, p <0.001]. Additionally, a greater proportion of SA CD patients present with colonic-only disease [colonic-only CD/UC/IBD-U in SAs 67% vs 57% for Caucasians, p = 0.001], and among those with CD, colonic CD in SAs 31% vs 23% in Caucasians, p = 0.20]. Perianal fistulising disease was also numerically more common in SAs (14 [27%] vs 64 [18%], p = 0.06]. Adjusting for differences in phenotypic presentation, anti-tumour necrosis factor [TNF] exposure, and time to initiation was similar, and two-thirds of children, whether anti-TNF exposed or naïve, were in corticosteroid-free clinical remission at 18 months irrespective of ethnicity. The phenotypic spectrum of new-onset IBD in SA children differs from that of Caucasian children, but treatment and clinical course are similar within phenotypic subgroups.

Editorial: assessment of inflammatory bowel disease: a picture is worth a thousand words. Authors' reply

LINKED CONTENTThis article is linked to Friedman et al and Horjus‐Talabur Horje &amp; van Bodegraven papers. To view these articles, visit https://doi.org/10.1111/apt.16452 and https://doi.org/10.1111/apt.16476

Managing Complex Perianal Fistulizing Disease.

Perianal disease is a particularly morbid phenotype of Crohn's disease, affecting up to one third of patients, with a significantly diminished quality of life. Conventional medical therapy and surgical interventions have limited efficacy. Medical treatment options achieve long-term durable remission in only a third of patients. Therefore, most patients undergo an operation, leaving them with a chronic seton or at risk of incontinence with multiple interventions. Mesenchymal stem cell therapy is an emerging therapy without risk of incontinence and improved efficacy as compared with conventional therapy. Laser therapy is another new intervention. Unfortunately, up to 40% of patients still require a stoma related to perianal fistulizing disease.

Colonic disease recurrence following proctectomy with end colostomy for anorectal Crohn’s disease

In patients with anorectal Crohn's disease, it remains uncertain whether a total proctocolectomy with end ileostomy or proctectomy with end colostomy should be recommended due to the unknown rate of disease recurrence in the remaining colon. A retrospective review of all patients with a known diagnosis of Crohn's disease who underwent a proctectomy with end colostomy for distal Crohn's disease between January 1, 2010 and January 1, 2019 at two IBD referral centres was conducted. Data collected included patient demographics, surgical variables at the time of proctectomy, and postoperative clinical, endoscopic and surgical recurrence rates. A total of 63 patients were included; mean age was 47years (SD 15years) and 32 (50.8%) were female. The majority of patients underwent a proctectomy with end colostomy (n=56; 88.9%) while the remaining seven patients (11.1%) underwent a proctectomy with end colostomy and concurrent ileocectomy. A total of 55 patients (87.3%) had proctitis, 51 (81%) had perianal fistulating disease, and 34 (54%) had anal canal stenosis or ulceration. Most patients had medically refractory disease (n=54; 85.7%) versus neoplasia (n=9; 14.3%). The median length of long-term follow-up was 17.7months (IQR: 4.72, 38.7months). During that time, 14 (22.2%) experienced clinical recurrence, 10 of 34 evaluated (29.4%) had endoscopic recurrence, and 3 (4.76%) required a completion total abdominal colectomy for recurrent medically refractory disease in the colon. Colonic recurrence remains low following proctectomy and descending colostomy suggesting this operative management strategy is reasonable in Crohn's patients with distal disease.

P321 Cessation of Anti-Tumour Necrosis Factor Therapy in Patients with Perianal Fistulizing Crohn’s Disease: Individual Patient Data Meta-Analysis of 323 patients from 12 studies

Abstract Background The risk of relapse after anti-tumour necrosis factor [TNF] therapy cessation in Crohn’s disease [CD] patients with perianal fistulas is unclear. We aimed to assess the risk of relapse after anti-TNF cessation in a large cohort and to identify risk factors. Methods A systemic literature search was conducted to identify cohort studies reporting on the incidence of relapse after cessation of anti-TNF therapy in CD patients. Individual patient data [IPD] were requested from the original study cohorts. Inclusion criteria for IPD-meta-analysis (IPD-MA) included age ³ 18 years, perianal fistulizing CD as indication for start of anti-TNF therapy, minimal treatment duration ³3 doses, and remission of luminal and perianal CD at cessation of anti-TNF therapy. Primary outcome was CD relapse [either perianal or luminal]. Perianal fistula relapse was defined as recurrence of draining perianal fistula related to previous or new fistula tracks, or abscess. Luminal relapse was defined as a clinical, biochemical, endoscopic, or radiological relapse requiring treatment or dose optimization of IBD medication or surgery. In a secondary analysis, risk factors associated with relapse were assessed using multivariate logistic regression analysis. Results A total of 307 patients from 12 studies in 9 countries were included in this IPD-MA. The median duration of anti-TNF treatment prior to therapy cessation was 14 months [IQR 6.1 – 29.9]. In 272/307 patients [89%] anti-TNF therapy was started for active perianal fistula and in 34 [11%] for both active perianal fistula and luminal CD. 169 patients [55%] developed a relapse [either perianal or luminal] after a median follow-up after cessation of 25 months [IQR 12 – 54]. Overall cumulative incidence of relapse was 31% and 43% at 1 and 2 years after anti-TNF cessation. Risk factor for CD relapse include upper GI involvement (L4) [HR 1.9], whereas older age [A3 vs A1, HR 0.48] and continuation of concomitant immunomodulators [HR 0.62] were protective factors. For a subgroup of patients with active perianal fistula and in luminal remission at start of anti-TNF, the cumulative incidence relapse rates were 25% and 43% at 1 and 2 years. No considerable differences in risk factors were found within this subgroup regarding risk of recurrence. Of the 179 patients who relapsed, 104 were retreated with anti-TNF with a response rate of 85%. Conclusion According to this IPD-MA, approximately two-thirds of CD patients with perianal fistula remain in remission with regard to fistulizing and luminal disease during 2 years after cessation of anti-TNF therapy. Further risk stratification based on perianal fistula characteristics is required.

P174 Defining Crohn’s Disease Strictures Using Intestinal Ultrasound Compared to Histopathology

Abstract Background Fibrostenotic Crohn’s Disease (CD) is a challenging phenotype often requiring surgical resection. MRE (magnetic resonance enterography) is commonly used to diagnose CD strictures, but is limited by access, cost, and long acquisition time. The CONSTRICT consensus criteria for defining CD strictures is based only on MRE or CT (computed tomography) and includes: increased bowel wall thickness (BWT), narrowed luminal apposition, and pre-stenotic dilation &amp;gt; 3cm. This definition has not been studied using intestinal US (IUS). IUS is a cost-effective, easily repeatable, and well-tolerated tool with similar sensitivity and specificity to MRE in diagnosing and monitoring CD. In patients with a confirmed CD stricture on ileal resection (gold standard for diagnosis), we aim to assess the applicability of CONSTRICT criteria in diagnosing strictures with IUS. Methods In this pilot study, thirty CD patients who underwent small bowel resection from 2015–2019 with IUS (fasting, no oral contrast) within 6 months prior to surgery (excluding fistulizing disease) were randomly identified for chart review Stricture was confirmed on resected ileum as microscopic presence of fibrosis, muscle hypertrophy, inflammation, and macroscopic localized luminal narrowing with decreased circumference on pathology. Student’s t-tests, sensitivities and specificities were calculated for IUS in detecting strictures. Results 20 out of 30 patients had fibrostenosis on pathology and IUS. Only 40% (8/20) met CONSTRICT criteria for stricture diagnosis on IUS, despite having a stricture on pathology. All patients had elevated BWT and luminal narrowing, but 60% (12/20) of patients did not have prestenotic dilation &amp;gt; 3cm. Mean dilation was 2.9 cm (SD 1.38) and was significantly different from the mean stricture diameter of 1.3cm (SD 0.59 cm, p=0.0001, 95% CI: 0.9–2.2). Mean BWT was 8.7 mm (SD: 2.5, range 5–15), and mean luminal apposition was 2.3 mm (SD 1.2, range 0.2–5.8mm). IUS has a sensitivity of 95.2% (CI: 76.2 - 99.9%) and specificity of 66.7% (29.9 - 92.5%) in detecting strictures, when compared to the gold standard. Conclusion Diagnosis of fibrostenotic CD with CONSTRICT criteria using CT/MR may not be applicable to IUS. Only 40% of patients met criteria despite histologic-confirmed strictures. Unlike MR/CTE, IUS is not routinely performed with oral contrast, and as a result prestenotic dilation may be underestimated. Thus, perhaps additional criteria of stricture diameter &amp;lt; 50% of prestenotic dilation size is more appropriate for IUS. This pilot study provides the initial data to further delineate the definition of strictures on IUS for future validation and will inform both clinical practice and trial design.

P280 Introduction of subcutaneous infliximab CT-P13 and vedolizumab in daily clinical practice: outstanding questions demonstrate the need for post-marketing studies

Abstract Background Although clinical trials led to the registration of subcutaneous (SC) infliximab CT-P13 (IFX) and SC vedolizumab (VDZ) for patients with Crohn’s disease (CD) and ulcerative colitis (UC), many practical aspects have not been addressed yet. We explored what strategy Belgian clinicians plan to follow once these formulations become available. Methods A 3-round Delphi process was initiated in Jan 2021. A core panel (4 IBD clinicians, 1 PKPD expert, 1 IBD nurse, 1 methodologist) developed a neutral video on the available data, as well as 65 statements and 9 multiple-choice questions related to the practical use of SC IFX and VDZ. The expert panel, consisting of 45 IBD clinicians (median [IQR] years of practice 19 [11-26] years), scored all statements on a 10-point Likert scale. We here present the results of the first Delphi round. The complete report will be available after the final Delphi round in May 2021. A ≥70% consensus level (scores 1-4 for disagreement, scores 7-10 for agreement) is foreseen. Results The majority of IBD clinicians expressed the need for more scientific data on switching from intravenous (IV) to SC therapy (Table 1). Furthermore, a minority would consider starting SC therapy after only two IV induction doses (Figure 1). Most clinicians would restrict switching to patients who achieved both clinical, biological response, and endoscopic response (Figure 2) and this only when receiving standard IV dosing of 5mg/kg IFX (75.5%) or 300mg VDZ every 8 weeks (68.9%). Both for IFX and VDZ, 57.1% of IBD clinicians would administer a first SC dose no later than 6 weeks after the last IV administration. The IBD clinicians highlighted the role of the IBD nurse in explaining and guiding a potential switch (82.2% IFX, 88.9% VDZ) and supervising the first SC administration (100.0% IFX, 95.5% VDZ). They emphasized the need for a clinical follow-up within 8 weeks (88.6% IFX, 88.9% VDZ). Although reactive therapeutic drug monitoring under SC therapy was considered helpful by IBD clinicians (77.8% IFX, 68.9% VDZ), they acknowledged the lack of an optimal serum concentration (73.4% IFX, 84.3% VDZ). Round one did not result in a consensus on using SC formulations in patients with quiescent perianal fistulising disease or a prior episode of acute severe UC. Finally, the optimal strategy in case of an objectified clinical relapse after switching to SC therapy seems is clearly unknown (83.3% IFX, 76.2% VDZ). Conclusion Although both SC IFX and SC VDZ will become available soon, the majority of IBD clinicians expressed the need for more scientific data on switching from IV to SC therapy. This Delphi process may indicate pivotal remaining research questions to be answered through post-marketing studies.

P357 Long-term outcomes of biologic therapy in Crohn’s disease complicated with internal fistulizing disease: BIOSCOPE study from GETECCU

Abstract Background The prevalence of penetrating disease in Crohn’s disease (CD) increases progressively over time, and evidence on the medical treatment of this complication is limited. The aim of this study was to evaluate the efficacy of biologic agents in CD complicated with internal fistulising disease. Methods A retrospective analysis of all adult patients from the ENEIDA registry (&amp;gt;68,000 patients) with CD who received at least one biologic agent -anti-TNF, ustekinumab or vedolizumab- for penetrating disease was performed. Exclusion criteria comprised treatment for perianal disease, enterocutaneous, anastomotic or periostomal fistula tracts. The main outcomes were fistula-related surgery and fistula closure on cross-sectional imaging. Preestablished secondary outcomes included the rate of abdominal abscess, the need for percutaneous drainage, the changes in the number of fistula tracts, fistula closure rates, and the safety profile.The baseline characteristics were analyzed by means of descriptive statistics and were compared by non-parametric tests. Predictive factors associated with surgery and fistula closure were evaluated by a multivariable logistic regression and survival analyses. Results A total of 710 patients (median age 38 years [IQR, 28-48], 59% male, 55% L3) receiving 791 biologic treatments were included at 53 sites (701 anti-TNF, 71 ustekinumab, and 19 vedolizumab). Patients had a median of 1 (range 1-5) fistula tracts, 49% of them entero-enteric followed by entero-colic (28%). After a median follow-up of 59 months (IQR, 27-105), 244 patients (31%) required surgery due to internal fistulising complications after 8.5 months (IQR, 3-24). Patients with ileocolonic disease (OR 1.99 [1.22-3.23]), entero-urinary fistulas (OR 2.35 [1.17-4.73]), or with a stricture distal to the fistula (OR 2.1 [1.31-3.36]) showed a higher risk of surgery, with no differences between biologic drugs (Figure 1). Combination therapy reduced the risk of surgery (HR 0.58 [0.37-0.90]). Fistula closure was observed in 24% of patients after a median of 15 months (IQR, 7.5-27). Patients with a lower number of fistula tracts showed a higher probability of closure (OR 1.72 [1.09-2.7]). Conclusion A high proportion of patients with internal fistulizing CD benefit from biologic treatment after a median of 5 years. During this follow-up, around two thirds of patients are free of surgery and one in every four patients achieves fistula closure.

Gracilis Flap Reconstruction After Proctocolectomy for Malignancy and Inflammatory Bowel Disease.

Gracilis flap reconstruction (GFR) following abdominoperineal resection (APR) or proctocolectomy (PC) can reduce pelvic wound complications but has not been adequately assessed in the setting of immunosuppression, fistulous disease, and neoadjuvant chemoradiation. Patients undergoing APR/PC with GFR were retrospectively analyzed with regard to perioperative characteristics, and morbidity was assessed. Patients underwent GFR for rectal cancer (n = 28), anal cancer (n = 3), inflammatory bowel disease (n = 13), or benign fistulizing disease (n = 1). 22.2% were chronically immunosuppressed, and 66.7% underwent preoperative chemoradiation. Twenty (44.4%) patients had minor wound complications, all treated nonoperatively. Nine patients had major complications with 4 patients requiring reoperation. The 4 threatened flaps were unilateral, and all were salvaged. Donor site morbidity was minimal. Patients with major complications were older (56 vs. 71years, P = .030), and less likely to have pelvic drains (P = .018). In high-risk perineal wounds, GFR offers durable reconstruction with acceptably low morbidity.

A176 THE IMPACT OF COVID-19 ON ANXIETY, DEPRESSION, AND STRESS IN WOMEN WITH INFLAMMATORY BOWEL DISEASE: A CROSS-SECTIONAL SURVEY

BackgroundWomen with inflammatory bowel disease (IBD) are at an increased risk of mental-health illness and reduced fertility.AimsTo determine the impact of the coronavirus disease 2019 (COVID-19) pandemic on the mental-health and pregnancy plans of women with IBD.MethodsWomen with IBD (age 18–45) were asked to anonymously complete surveys on baseline demographics, IBD characteristics, and mental health comorbidities. They were also asked to comment on prior symptoms consistent with COVID-19 and whether they were tested for the virus. Finally, patients were asked to complete three mental health surveys to reflect on anxiety (Generalized Anxiety Disorder-7 (GAD7)), depression (Patient Health Questionnaire-9 (PHQ9)), and stress (Perceived Stress Scale (PSS)) symptoms prior to and during the pandemic. Total scores were reported as continuous variables and means with standard deviations (SD) were compared using paired T-tests.ResultsTwenty-nine patients (12 UC, 17 CD) were included. 14 patients were preconception, 12 were pregnant, and 3 were post-partum. The mean age was 31.4 (SD 3.7). Fifteen of 29 (51.7%) of patients were on anti-tumor necrosis factor therapy. Twelve (41.4%) and 6 (20.7%) patients had pre-morbid anxiety and depression prior to the pandemic. COVID-19 symptoms were reported in 8 patients (27.5%). Six patients had undergone COVID-19 testing, all of whom had a negative test. Four patients indicated that COVID-19 had negatively affected their plans for pregnancy, with reasons reported including fear of the hospital (n=1), fear of COVID-19 impact on the fetus (n=2), and uncertainty on the duration of COVID-19 (n=1). During the pandemic, fourteen of 28 (50%) patients experienced symptoms of anxiety (GAD score > 5), with a majority (70%) experiencing mild symptoms (score 5–9). During the pandemic, 60.7% (17/28) and 71.4% (20/28) reported symptoms of depression (PHQ9 > 4) and at least moderate stress (PSS > 14) respectively. Furthermore, compared to pre-pandemic, 57.1% (16/28) and 67.9% (19/28) had an increase in depression and stress symptoms during the pandemic respectively. This appeared to only apply to those with CD, but not UC (Table 1). Compared to pre-pandemic, those with stricturing CD appeared to have higher stress scores whereas those with fistulizing and perianal disease appeared to have higher depression scores during the COVID-19 pandemic (Table 1). A lower house-hold income and a reduction in exercise during the COVID-19 pandemic appeared to increase the risk of stress, depression, and anxiety symptoms.ConclusionsOver half of women with IBD indicate worsening of anxiety, depression, and stress symptoms during the COVID-19 pandemic. It remains critical that health-care professionals address these mental health concerns during these otherwise difficult times. Funding AgenciesNone

MRI of Perianal Crohn Disease: Technique and Interpretation.

Magnetic resonance imaging (MRI) has emerged as the imaging method of choice for evaluation of perianal fistulizing disease. As treatment of Crohn disease and associated perianal fistulas has evolved to include a combination of systemic treatments and surgical interventions, perianal MRI provides critical information to guide treatment selection and timing. Radiologists need to be familiar with the normal regional anatomy to accurately describe perianal fistulas and any associated complications which can then be used to classify fistulas based on several available classification systems. Following treatment, MRI can provide information that suggests treatment success or failure. We propose a perianal fistula reporting template that includes the necessary information to convey fistula complexity, guide treatment, and evaluate treatment response. This review article will also discuss the postoperative appearance of many treatments currently used for management of perianal fistulizing disease and some associated complications.

Management of perianal fistula in inflammatory bowel disease: identification of prognostic factors associated with surgery.

As one of the clinical manifestations of inflammatory bowel disease (IBD), perianal fistula disease (PFD) can potentially impact the patient quality of life. The management of PFD employs a multidisciplinary approach which includes antibiotics, biological therapies, immunomodulators, and surgery. We analyzed the outcome and prognostic factors of anal fistula surgery in IBD patients. We conducted a retrospective study of IBD patients undergoing elective surgery for anal fistula between January 2015 and December 2018 at our University Department of Surgery. We collated demographic factors, disease activity, imaging (MRI and endoanal ultrasound), surgical interventions, and medical treatment assessing the rate of fistula closure and fecal incontinence, 2 months and 1 year after surgery. Thirty-five IBD patients with anal fistula underwent surgery (28 Crohn's disease, four ulcerative colitis, and three indeterminate colitis). Twenty-seven patients presented with complex fistulas and eight with simple fistulas with 10 patients undergoing single-stage surgery. In 25 patients, a two-stage surgical approach was planned and performed (draining seton plus medical treatment and then second-stage surgery with curative intent). At 1 year of follow-up, the fistula healing rate was 50% for single-stage surgery and 60% for two-stage surgery (P = 0.09). Overall, 19.2% of patients developed postoperative fecal incontinence. A time interval greater than 12 months between surgeries is a favorable prognostic factor for fistula healing with the two-stage approach (P = 0.002). In our retrospective study, two-stage surgery in IBD patients presenting with complex perianal fistulous disease results in a better medium-term outcome with a longer time interval between surgeries.

P011 Physical Activity Levels in Daily Life of Patients with Moderate-to-Severe Crohn's Disease Before and After Infliximab-Induced Remission.

BACKGROUND: Although the role of physical activity (PA) in inflammatory bowel disease (IBD) patients is not well defined, several studies about its effect on disease’s etiology and activity have addressed this issue. In addition, Crohn’s disease (CD) patients seem to have a lower level of PA and this behavior is associated with disease activity. This study evaluated a cohort of patients with moderately-to-severely active CD submitted to anti-TNF therapy in order to compare the exercise capacity and physical activity in daily life before and after anti-TNF-therapy induced remission. It is hypothesized that CD patients who achieved anti-TNF-therapy-induced remission present significant improvement in the previous levels of exercise capacity and PA in daily life. METHODS: In this prospective longitudinal study conducted between March 2015 and June 2018, 44 adult outpatients with active CD were evaluated at two different moments: before infliximab (IFX) administration and 24 weeks after infliximab therapy. We included patients with CD, aged ≥ 18 years and under 65 years, with a 3-month history of active disease, defined as a Harvey-Bradshaw index (HBI) score of 8 or higher and a serum level of C-reactive protein of more than 5.0 mg per liter, with indication for anti-tumor necrosis factor alpha therapy, i.e. refractory disease unresponsive to conventional therapies or steroid-dependent and those presenting with aggressive disease or features of poor prognosis prediction, such as extensive bowel disease, complex fistulizing disease, or severe endoscopic lesion as defined by the presence of deep and extensive ulcers. Eligible patients received induction therapy consisting of intravenous injections of 5 mg/Kg of IFX at weeks 0, 2, and 6 followed by maintenance infusion (5 mg/Kg) at weeks 14 and 22. Participants were followed until week 24. Patients were evaluated for PA in daily life using accelerometer, exercise capacity, peripheral muscle strength, anthropometry, and body composition. The primary endpoint was an increase in the total number of steps/day in daily life at week 24 in CD patients achieving IFX-induced remission. Secondary endpoints included improvement in the shuttle walking test (SWT), the handgrip strength (HS), active time, and inactive time. RESULTS: Thirty-eight (86.4%) patients achieved infliximab-induced remission at the end of 24 weeks and presented a significant increment from baseline in number of steps taken of 1092 (7440 ± 2980 vs. 6348 ± 3177, respectively; P = 0.006). The inactive time was significantly reduced when compared to baseline period (454.2 ± 106.3 vs. 427.9 ± 97.8, respectively; P = 0.033). There was no difference in the distance walked before and after IFX therapy. CONCLUSION: Infliximab-induced remission followed by maintenance therapy has shown to be effective for increasing PA levels in daily life as shows by increase in the number of steps taken per day as well as by reduced inactive time on patients with moderately-to-severely active CD. Given the important role of PA for patients with CD, anti-TNF therapy may be useful therapeutic strategy along with targeted PA recommendations for increasing PA levels. Furthermore, strategies of treatment associated with an exercise program must be considered for this population.

Modern surgical strategies for perianal Crohn's disease

One of the most challenging phenotypes of Crohn’s disease is perianal fistulizing disease (PFCD). It occurs in up to 50% of the patients who also have symptoms in other parts of the gastrointestinal tract, and in 5% of the cases it occurs as the first manifestation. It is associated with severe symptoms, such as pain, fecal incontinence, and a significant reduction in quality of life. The presence of perianal disease in conjunction with Crohn’s disease portends a significantly worse disease course. These patients require close monitoring to identify those at risk of worsening disease, suboptimal biological drug levels, and signs of developing neoplasm. The last 2 decades have seen significant advancements in the management of PFCD. More recently, newer biologics, cell-based therapies, and novel surgical techniques have been introduced in the hope of improved outcomes. However, in refractory cases, many patients face the decision of having a stoma made and/or a proctectomy performed. In this review, we describe modern surgical management and the most recent advances in the management of complex PFCD, which will likely impact clinical practice.

Management of Isolated Anal Strictures in Crohn's Disease.

Anorectal stricturing is a particularly morbid manifestation of Crohn's disease resulting in a diminished quality of life related to pain, incontinence, and recurrent operative interventions. To determine the role of medical therapy, endoscopic dilation, and surgical intervention for the treatment of isolated anorectal stricturing. An organized search of MEDLINE, PubMed, EMBASE, Scopus, and the Cochrane Database of Collected Reviews was performed from January 1, 1990 through May 1, 2020. Full text papers which included management of isolated anorectal strictures in the setting of Crohn's disease. Medical and surgical management. Symptomatic relief, need for proctocolectomy. Our search identified a total of 553 papers; after exclusion based on title (n = 430) and abstract (n = 47), 76 underwent full text review with 65 relevant to the management of anorectal strictures. A summary of the retrospective reports suggests that medical therapy can help control luminal inflammation, but fibrosis may ultimately set in resulting in a need for endoscopic or surgical intervention. Surgical options are limited in the anal canal due to inflammation and ulceration and concomitant perianal fistulizing disease. While fecal diversion can provide symptomatic relief, successful restoration of intestinal continuity remains uncommon and most patients ultimately undergo a total proctocolectomy with end ileostomy. Limited literature published, all retrospective in nature. Despite significant advances in medical and surgical therapy in Crohn's disease over the last decades, there is clearly an unmet need in the management of anorectal strictures in Crohn's disease.

Rapid weight gain in infliximab treated Crohn’s disease patients is sustained over time: real-life data over 12 months

Background Infliximab (IFX) is used in active Crohn’s disease for induction and maintenance of remission. There are scanty data on weight gain in IBD-patients under anti-TNF treatment. We investigated changes in weight and blood chemistry in anti-TNF-naïve Crohn’s disease patients during their first course of IFX. Methods Retrospective analysis of 110 patients (77 men, 33 women) aged 34 years (range 14–73), 54 with luminal and 56 with fistulising disease, given at least 3 infusions of IFX (range 3–11). Data regarding body weight, height, C-reactive protein (CRP), haemoglobin and S-albumin at baseline, before the third infusion, at three months and at 12 months were collected. Results At 6 weeks, 65 (59%) increased in weight, 73% and 76% at three and 12 months, respectively. There was an increase in median weight (1.7 kg, IQR = 3.1 kg) and BMI (0.5 kg/m2, IQR = 1.2 kg/m2) at 6 weeks, which persisted at three and 12 months (all p < .001). There was no difference between men and women. Young patients, patients with underweight or fistulising disease increased most in weight. Disease activity assessed by PGA and SES-CD decreased at all time points (p < .05). Increases in weight and BMI correlated with an increase in serum albumin and a decrease in CRP. Conclusion Approximately 60% of Crohn’s disease patients experience weight gain within the first six weeks of infliximab treatment. The weight increment correlates with improvements in inflammatory markers and disease activity. The causes of weight gain may be related to treatment induced metabolic changes and reduced inflammatory burden.

S2306 Bad to the Bone: A Rare Case of Fistulizing Disease Extending to the Sacrum

INTRODUCTION: Fistula formation commonly occurs between intestines and other epithelial-lined hollow organs such as the bladder, skin, vagina, or other regions of the gastrointestinal tract. Infrequently, a connection can form between the bowel and the vertebral column and lead to vertebral osteomyelitis. We present the case of a young male with significant abdominal pathology found to have sacral osteomyelitis in the setting of fistula formation between the small bowel and sacrum. CASE DESCRIPTION/METHODS: A 27-year-old male with a history of opioid dependence and abdominal gunshot wound requiring subtotal colectomy with ileo-rectal anastomosis presented with progressive, bloody diarrhea and poor appetite. The patient reported history of previous colonoscopies with balloon dilations of strictures but never diagnosed with inflammatory bowel disease (IBD) or started on any therapies. On exam, the patient was emaciated with multiple clean abdominal scars and diffuse, mild abdominal tenderness. Labs showed microcytic anemia with hemoglobin of 8, elevated fecal calprotectin (402) and CRP (15.1) without leukocytosis, and negative tissue transglutaminase. His stool studies and gastrointestinal pathogen panel were negative for Clostridium difficile or other pathogens. Computed Tomography of the abdomen found enteritis and proctocolitis and concern for possible osteomyelitis of the sacrum and coccyx. Magnetic resonance enterography found multiple entero-colonic fistulas and active inflammatory disease of the small bowel, inflammation of the sacral nerve roots, and concern for fistulization between the small bowel and sacrum. Subsequent flexible sigmoidoscopy found ulcerated friable mucosa and pseudomembranes in the rectum. Pathology showed nonspecific chronic inflammation and was negative for Clostridium difficile. He was started on Rifaximin for empiric treatment of small intestinal bacterial overgrowth with improvement in diarrhea and is planned for further IBD workup to assess the status of his fistulizing disease. DISCUSSION: While most enteric fistulas occur due to prior abdominal surgery complications, 10-15% occur from inflammation and infection associated with Crohn’s disease. Rarely, fistulas can develop between bowel and vertebra, and osteomyelitis may result due to translocation of gut flora from the intestine to the spine via the fistula as seen in our patient. Ultimately, this uncommon presentation should prompt investigation into etiology and use imaging to guide aggressive management.Figure 1.: Rectal ulcer seen on flexible sigmoidoscopy.Figure 2.: MRE showing evidence of a fistula from the small bowel to the sacrum.

Incidence and Outcomes of Home Parenteral Nutrition in Patients With Crohn Disease in Olmsted County, Minnesota.

BackgroundWe sought to estimate the incidence of home parenteral nutrition (HPN) use in a population-based cohort of patients with Crohn disease (CD), and to assess clinical outcomes and complications associated with HPN.MethodsWe used the Rochester Epidemiology Project (REP) to identify residents of Olmsted County, who were diagnosed with CD between 1970 and 2011, and required HPN.ResultsFourteen out of 429 patients (3.3%) with CD received HPN (86% female). Eleven patients (79%) had moderate–severe CD and 12 patients (86%) had fistulizing disease. Thirteen patients (93%) underwent surgery, primarily due to obstruction. Among CD incidence cases, the cumulative incidence of HPN from the date of CD diagnosis was 0% at 1 year, 0.5% at 5 years, 0.8% at 10 years, and 2.4% at 20 years. Indications for HPN included short bowel syndrome in 64%, malnutrition in 29%, and bowel rest in 21%. The median duration of HPN was 2.5 years. There was an average weight gain of 1.2 kg at 6 months, an average weight loss of 1.4 kg at 1 year, and a further weight loss of 2.2 kg at 2 years from the start of HPN. Patients were hospitalized a mean of 5 times after the start of HPN, mainly due to catheter-related bloodstream infections and thrombosis.ConclusionsLess than 4% of patients with CD need HPN. Most have moderate to severe disease with short bowel syndrome or malnutrition. Possible reasons for the patients’ weight loss could be noncompliance, and increased metabolic needs because of active disease.

Pancytopenia in a Young Male Patient With Inflammatory Bowel Disease

Question: A 20-year-old male college student with a history of Crohn’s disease was noted to have pancytopenia on routine lab monitoring. He was diagnosed with stricturing Crohn’s disease of the terminal ileum and colon over 10 years ago when he presented with weight loss and bloody diarrhea. He struggled with perianal fistulizing disease periodically. His Montreal classification was A1 L3 B2p. Previous therapies included corticosteroids, mesalamine, azathioprine, 6-MP, infliximab, adalimumab, methotrexate, and certolizumab often in combination.