Inflammatory Bowel Disease Flare Research Articles

Inflammatory Bowel Disease Outcomes Following Fecal Microbiota Transplantation for Recurrent C. difficile Infection.

Recurrent Clostridioides difficile infection (CDI) in patients with inflammatory bowel disease (IBD) is a clinical challenge. Fecal microbiota transplantation (FMT) has emerged as a recurrent CDI therapy. Anecdotal concerns exist regarding worsening of IBD activity; however, prospective data among IBD patients are limited. Secondary analysis from an open-label, prospective, multicenter cohort study among IBD patients with 2 or more CDI episodes was performed. Participants underwent a single FMT by colonoscopy (250 mL, healthy universal donor). Secondary IBD-related outcomes included rate of de novo IBD flares, worsening IBD, and IBD improvement-all based on Mayo or Harvey-Bradshaw index (HBI) scores. Stool samples were collected for microbiome and targeted metabolomic profiling. Fifty patients enrolled in the study, among which 15 had Crohn's disease (mean HBI, 5.8 ± 3.4) and 35 had ulcerative colitis (mean partial Mayo score, 4.2 ± 2.1). Overall, 49 patients received treatment. Among the Crohn's disease cohort, 73.3% (11 of 15) had IBD improvement, and 4 (26.6%) had no disease activity change. Among the ulcerative colitis cohort, 62% (22 of 34) had IBD improvement, 29.4% (11 of 34) had no change, and 4% (1 of 34) experienced a de novo flare. Alpha diversity significantly increased post-FMT, and ulcerative colitis patients became more similar to the donor than Crohn's disease patients (P = 0.04). This prospective trial assessing FMT in IBD-CDI patients suggests IBD outcomes are better than reported in retrospective studies.

S0773 Association of Statins and NSAIDS With Flare of Inflammatory Bowel Diseases (IBD)

INTRODUCTION: In animal models, statins (Hydroxymethylglutaryl-CoA (HMG-CoA) reductase inhibitors) have been shown to inhibit pro-inflammatory gene expression by blocking Nf-kB (Nuclear Factor kappa-light-chain-enhancer) signaling. Effect of statin on flare of Inflammatory bowel disease (IBD) has not been well studied. Statins also have antifibrotic activity which is unrelated to the anti-inflammatory effect of the drug. Previous studies on impact of Nonsteroidal anti-inflammatory drugs (NSAIDS) on IBD have shown increased as well as decreased flares. We aimed to look at whether use of statins and NSAIDS was associated with reduced rate of flares in patients of IBD, Ulcerative Colitis (UC) and Crohn’s Disease (CD). METHODS: We performed a retrospective cohort study on all patients in our IBD database after obtaining approval from Institutional review board (IRB). IBD patients exposed to statin and NSAIDS were compared to unexposed patients. Outcome was evaluated using Chi-square (X2) analysis. P < 0.05 was considered significant. RESULTS: Our study included 2978 patients. Of these, 1595 had UC, 1367 had CD and rest had IC (Indeterminate colitis). Six hundred sixty-eight patients had statin use and 2310 had no statin use. Statin use was associated with increased flare of IBD in general as well as strongly associated with UC flare (P = .042 and .005 respectively). There was no association between statin exposure and CD flare (P = .984). Exposure to NSAIDS was not associated with increased or decreased frequency of flares in IBD, including UC, CD, and IC (Table 1). CONCLUSION: Our observational analysis showed that statin use is associated with decreased flares of UC but not with CD. Anti-inflammatory effect of statin could be effective in reducing the inflammation seen in mucosa in UC. In CD, antifibrotic effect of the statins may help in prevention of transmural involvement of the gastrointestinal tract and reduce complications, including flares. NSAIDS exposure was not associated with flare of CD. Prospective and randomized control trial studies on effect of statins and NSAIDS on IBD are necessary in future.Table 1.: showing statin and NSAID exposure with IBD flares

S0729 All-Cause Hospitalization Rates Among IBD Patients in a Tertiary-Care Academic Hospital

INTRODUCTION: Studies have shown that the hospitalization rates for inflammatory bowel disease (IBD) patients in the United States have been increasing over the last decades despite advanced therapies. Some studies have investigated the reasons for inpatient admissions of IBD patients in specific populations, i.e. Veteran affair and pediatric hospitals, however few exist looking at hospitalization trends in general IBD patients in an academic hospital. METHODS: A list of IBD patients seen in outpatient clinics who were also hospitalized at Thomas Jefferson University Hospital from 11/01/2014 to 11/01/2019 was compiled. Via retrospective chart review, the data was analyzed for admission reason (IBD flare, IBD-related surgery/complication, IBD-related infection, or IBD-nonrelated). Average length of stay (LOS) for each reason was analyzed with ANOVA. Length of stay was also analyzed in ulcerative colitis (UC) admissions versus Crohn's disease (CD) and compared with t-test. The identified patients were then further divided by number of admissions (either 1, 2–3, or 3+) to characterize recurrent admissions. RESULTS: A total of 65 patients were identified for a total of 115 total admissions. The main reasons for admissions were found to be IBD flares (46.9%), IBD surgical procedures/surgical complications (20.0%), IBD-related infections (13.0%) and all other causes (20.0%). The average admission LOS was 5.0 ± 5.2 days, with LOS for specific reasons being: 4.7 ± 2.9 days for IBD flares, 4.4 ± 4.9 days for IBD surgeries/complications, 7.6 ± 10.5 days for IBD-related infections, and 4.5 ± 6.6 days for other causes. ANOVA revealed no statistical significance in LOS difference between all groups (P = 0.23). In total there were 94 CD admissions and 21 UC admissions, with an average LOS of 4.7 ± 4.9 days for CD and 6.3 ± 6.4 days for UC, but no significance on t-test (P = 0.10). 60.0% of patients had only 1 admission, 32.3% had 2-3, and 7.6% had 3+. CONCLUSION: High IBD admission rates cause a significant burden on healthcare costs. Our findings identified IBD admission trends in an academic center to understand why patients are being admitted, length of stay, and readmission rates. Studies from abroad have shown that interventions such as an IBD-patient-helpline reduce IBD-related admission rates. Given that majority of admissions are due to IBD complications with an average LOS of ∼5 days, future research would focus on a quality-improvement approach to reduce IBD-related admissions.Table 2.: This table shows the number of total Crohn's disease (CD) admissions and the total number of ulcerative colitis (UC) admissions for the 65 examined patients. The table also shows the average length of stay for each IBD sub-typeFigure 1.: This figure shows the percentage of number of admissions each patient with IBD has, and shows that majority (60%) have only 1 admission, but 40% have had re-admissions with nearly 8% having 3 or more admissions.Table 1.: This table shows reasons for admission, as well as the percentage of total admissions for that reason and the average length of stay (LOS) for each. IBD related infections had the longest LOS and the average total LOS for IBD admissions was 5 days

S0671 The Association of Frailty With Mortality and Relapse Frequency in Inflammatory Bowel Disease

INTRODUCTION: Frailty represents a state of diminished physiologic reserve. While the influence of frailty on gut immune response, inflame-aging and microbiome composition is subject to ongoing investigation, limited data exists on clinical outcomes in frail inflammatory bowel disease (IBD) patients. We tested the hypothesis that a modified frailty index will predict mortality and propensity for more frequent flares of inflammatory bowel disease. METHODs: An observational analysis of a retrospectively collected data from a single center in patients with Ulcerative Colitis and Crohn's disease was performed. Study period was 2008–2019. A 7 factor IBD frailty index was modified from the Canadian Study of Health and Aging Frailty Index. For each patient a frailty score and a frailty index were calculated. A frailty index of >0.27 was used to define a frailty. Multivariate logistic regression analyses were conducted to assess the probability of mortality and >5 IBD flares in frail and non-frail patients, while controlling for potential comorbid confounders. The calibration of logistic models was tested via Hosmer-Lemeshow test; predictive capacity was assessed via a c-statistic obtained from receiver operating curves. RESULTS: A total of 2978 patients were included; 53.5% with Ulcerative colitis, 0.5% with indeterminate colitis and the rest with Crohn's. The prevalence of frailty was 32% in this population of patients with IBD. Frail patients with IBD were more frequently older, female, had a higher mean BMI and were more often smokers (P < 0.001 for all via two-tailed t-tests and chi-square analysis). The prevalence of mortality in frail patients was statistically higher than the mortality prevalence in the non-frail (11.42% vs 3.75%, P < 0.01). Similarly, a higher proportion of frail patients experienced >5 IBD flares than non-frail patients (35.6% vs 27.5%, P < 0.001) through the study period. On regression analysis (Figure 1), frailty was associated with highest odds for mortality in patients with IBD (odds ratio 1.52, confidence interval 1.07–2.16, P = 0.01). Frail status did not predict the odds of having >5 IBD relapses as compared to non-frail patients (odds ratio 1.20, confidence interval 0.99–1.45, P = 0.05). CONCLUSION: This study provides the first evidence of an association between frailty and mortality in patients with inflammatory bowel disease. Potential areas of further investigation include phenotypic assessments of frailty, rather than an index approach utilized herein, in patients with IBD.Figure 1.: The Impact of Frailty on IBD Mortality.Figure 2.: The Impact of Frailty on IBD Flare Frequency.

A Potential Role for Stress-Induced Microbial Alterations in IgA-Associated Irritable Bowel Syndrome with Diarrhea

SummaryStress is a known trigger for flares of inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS); however, this process is not well understood. Here, we find that restraint stress in mice leads to signs of diarrhea, fecal dysbiosis, and a barrier defect via the opening of goblet-cell associated passages. Notably, stress increases host immunity to gut bacteria as assessed by immunoglobulin A (IgA)-bound gut bacteria. Stress-induced microbial changes are necessary and sufficient to elicit these effects. Moreover, similar to mice, many diarrhea-predominant IBS (IBS-D) patients from two cohorts display increased antibacterial immunity as assessed by IgA-bound fecal bacteria. This antibacterial IgA response in IBS-D correlates with somatic symptom severity and was distinct from healthy controls or IBD patients. These findings suggest that stress may play an important role in patients with IgA-associated IBS-D by disrupting the intestinal microbial community that alters gastrointestinal function and host immunity to commensal bacteria.

S0770 A Predictive Model of Length of Stay in Inflammatory Bowel Disease Patients Hospitalized With Flare: A Multicenter Study

INTRODUCTION: Hospitalization for flare of inflammatory bowel disease (IBD) is associated with significant morbidity and healthcare costs. We aimed to examine the relationship between IBD severity at presentation and adverse outcomes in patients hospitalized with flare. Additionally, we aimed to create and validate a predictive model for length of stay (LOS) using markers of disease severity. METHODS: We conducted a retrospective cohort study of IBD patients hospitalized with flare at two urban academic medical centers. We collected demographic and IBD-related data including the presence of Clostridioides difficile and markers of disease severity at presentation. The primary outcome was a composite of adverse inpatient IBD outcomes, including LOS >7 days, anti-TNF administration, and surgery. The data was split into training (70%) and validation (30%) samples. Employing variables of disease severity, models (including logistic regression, Classification and Regression Tree (CART), and Random Forest (RF) modeling techniques) were created to predict LOS >7 days using the training sample. These models were adjusted for surgery and anti-TNF administration, and their performance was subsequently validated. RESULTS: A total of 187 IBD patients hospitalized with flare were included (Table 1). The composite primary outcome was achieved in 71 patients (38%) with 51 (27%) hospitalized for >7 days. In univariate analyses, C-reactive protein and C. difficile positivity correlated with anti-TNF administration and surgery (Table 2). Adjusting for anti-TNF administration and surgery, tachycardia (OR 1.07; 95% CI 1.05–1.10), hypotension (1.07; 1.03–1.11), hypoalbuminemia (2.87; 1.81–4.74), leukocytosis (1.17; 1.09–1.27), anemia (1.10; 1.05–1.15) and C. difficile positivity (2.63; 1.27–5.47) were predictive of prolonged LOS (Table 2). In multivariate analyses, tachycardia predicted the primary composite outcome of all adverse effects (OR 1.07; 95% CI 1.03–1.11). C. difficile positivity (OR 4.33; 95% CI 1.36–14.9), hypoalbuminemia (3.25; 1.29–9.01), and tachycardia (1.11; 1.06–1.16) predicted prolonged LOS (>7 days). The CART and RF models had acceptable accuracy, sensitivity, and specificity for predicting LOS >7 days (Table 3). CONCLUSION: C. difficile positivity, hypoalbuminemia, and tachycardia at presentation predicted prolonged length of stay in a multicenter cohort of IBD patients hospitalized with flare. CART and Random Forest models perform well in predicting prolonged length of stay in these patients.Table 1.: DemographicsTable 2.: Univariate logistic regression of disease severity and outcomes, odds ratio (OR). OR for systolic and diastolic blood pressure, albumin, and hematocrit is shown as 1/OR for interpretabilityTable 3.: Performance of predictive models for length of stay >7 days

S0790 Correlations of Pain, Sleep, and Physical Activity in Hospitalized Subjects With Inflammatory Bowel Disease

INTRODUCTION: Patients with inflammatory bowel disease (IBD) are often treated for pain with opioids when hospitalized. Pain may interfere with sleep and activity, but these associations are poorly understood in patients with IBD. We developed a proactive pain regimen for hospitalized adults with IBD and compared it to usual (reactive) care in a randomized, controlled trial. Within this trial, we analyzed sleep and physical activity as correlates of pain and opioid use. METHODS: Hospitalized patients with IBD enrolled in a randomized, controlled trial of proactive vs reactive pain control were provided a wearable sleep/activity tracker (Fitbit®). Daily time spent sleeping, steps taken, the number of times a person slept, and sleep quality (deep, light, and rapid eye movement REM) were compared against daily average pain scores and daily morphine milligram equivalents (MME) by Pearson’s correlation. A mixed model regression was performed to compare steps taken and time slept between the two pain control groups. We performed a subgroup analysis for subjects admitted for IBD flare using Wilcoxon Rank Sum Test. RESULTS: Thirty-three subjects enrolled in the trial; 1 withdrew consent and was excluded from analysis. 17 were randomized to the proactive arm and 15 to the reactive (control) group. Fifteen subjects in the proactive arm and 11 subjects in the reactive arm had sleep/activity data available for analysis. Baseline characteristics were similar between the two groups (Table 1). Overall, pain was not associated with sleep or step count, but increased daily MME was associated with a shorter time spent in deep sleep (r = -0.27, P = 0.046) (Table 2). There was no difference in the number of steps taken (1607 ± 536 vs 1022 ± 352 steps P = 0.18) and no difference in time spent sleeping (345 ± 99 vs 348 ± 148 minutes, P = 0.63) between the proactive and reactive groups, respectively (Figure 1). A subgroup analysis of subjects in IBD flare showed that subjects on the proactive arm took more daily steps averaged throughout the hospitalization (2231 ± 1567 vs 1056 ± 671, P = 0.03). CONCLUSION: There were no differences in sleep quantity or step counts among subjects receiving proactive vs reactive pain control. However, use of opiates for pain control was associated with less time spent in deep sleep. Larger studies are needed to clarify the impact of pain control and opiates on sleep and activity in hospitalized patients with IBD.Table 1.: Baseline characteristics of subjects enrolled. No significant difference was seen. CRP = C-reactive proteinTable 2.: Pearson Correlation between average daily pain and daily MME vs steps and stages of sleep. A higher daily MME is correlated with a reduction in time spent in deep sleep. †n = 74, *n = 98, and **n = 54; person-days data was used for analysis. MME = morphine milligram equivalentsFigure 1.: A) depicts minutes slept and B) depicts steps taken by each subject on their respective hospitalization days. There was no statistically significant difference between the two groups.

S0698 More Pathogens, Less Insight: Comparing Extended Stool PCR Panels to Basic Stool PCR Panels

INTRODUCTION: Stool Polymerase Chain Reaction (PCR) panels can be used to rapidly detect specific pathogens responsible for gastrointestinal (GI) infections. This is particularly important in patients with inflammatory bowel diseases (IBD) as the symptoms of IBD flare often overlaps with those of GI infections. While the increased risk of Clostridioides difficile (C. difficile) among IBD patients is well established, the risk of other gastrointestinal pathogens is less well studied. Our study compares the utility of two stool PCR panels that tests for 22 pathogens in IBD patients hospitalized for gastrointestinal symptoms. METHODS: We retrospectively reviewed the electronic medical records of adult patients with IBD hospitalized at a southeastern New England hospital between January 1, 2017 and April 1, 2019. Patients were included if they had a stool PCR panel test and symptoms consistent with an IBD flare or infectious gastroenteritis. Patients with positive C. difficile stool PCR or culture were excluded. Statistical analysis with generalized linear mixed modeling was used to compare the utility of the basic verses extended stool PCR panels. RESULTS: A total of 770 IBD patients (82.5% Caucasian, 56.6% female; mean age 49.51 years, SD = 19.42) with 1,189 hospitalizations were included in the study. The basic stool PCR panel yielded positive results (13/1651, 0.79%) slightly more often than the extended stool PCR panel (14/2354, 0.59%) (Table 1). In general, the most common pathogens detected were Enteropathogenic Escherichia Coli (2.38%), Norovirus (2.38%), and Sapovirus (2.38%) (Table 1). On linear mixed modeling (Table 2), none of the factors were associated with a significantly increased utility of performing an extended stool PCR panel over a basic panel except when comparing patients on IBD medication (P = 0.0433) or those who presented with nausea (P = 0.0477). Participants who identified as Asian were more likely to have a positive test result compared to participants who identified as white for both tests (basic, P = 0.0147; extended, P = 0.0969). CONCLUSION: Our study identified no advantage when ordering the extended stool PCR panel over the basic stool PCR panel in hospitalized IBD patients. While the extended stool PCR stool panel identified some unique bacteria/viruses, these cases were extremely rare and without clinical predictors. Clinicians should be judicious when ordering extended stool PCR panels for IBD patients as they have low positive rates and may not change medical management.Table 1.: Detection rate of non-C. difficile pathogens using the basic stool PCR panel verses the extended stool PCR panel among hospitalized IBD patientsTable 2.: Model Results Estimating Probability of a Positive Test

S2292 Gastrointestinal Manifestations in Patients With Inflammatory Bowel Disease and Novel Coronavirus Infection

INTRODUCTION: There has been speculation about the level of risk and severity of symptoms in patients with Inflammatory Bowel Disease (IBD). Studies have shown that patients with Crohn’s disease and Ulcerative Colitis (UC) have increased expression of Angiotensin-converting Enzyme 2 (ACE 2) in their inflamed guts.2 SARS-CoV-2 uses ACE2 on the host receptor to enter into cells.1 The utilization of immunosuppressants or immunomodulators is another consideration that needs to be made for patients with IBD. We present a case series of 2 patients with different forms of IBD as well as differing forms of management. CASE DESCRIPTION/METHODS: Case 1: 64-year-old AA female with a PMH of CD, DM2, HTN, and Breast Cancer presented to the ER with fevers, cough, and myalgias for 5 days. SARS-CoV-2 PCR was collected. The patient was admitted five days later due to worsening symptoms of dyspnea, fevers, and diarrhea. Her physical exam was within normal limits. Initial management included initiation of broad spectrum intravenous antibiotics, cessation of immunosuppressant Azathioprine, continuation of Cholestyramine, and Hydroxychloroquine. RNA PCR returned positive for Sars-Cov-2. Stool studies collected during hospitalization were significant for lactoferrin and osmolality (390 mOsm/kg). Stool infectious studies were negative. Case 2:50-year-old AA female with PMH of UC presented with symptoms of fevers and dyspnea. SARS-CoV-2 PCR collected and she was discharged. The patient returned to the ER with 1 week worsening GI symptoms. Symptoms of previous flares were sharp hypogastric pain associated with increased frequency of hematochezia and tenesmus different from the symptoms experienced during this admission. DISCUSSION: This is the first case series of patients with IBD on immunomodulators who developed gastrointestinal manifestations of COVID-19. A dilemma faced in both of the patients presented was whether their symptoms were secondary to COVID-19 or IBD flare. ACE2 is ubiquitously expressed in the gastrointestinal tract with upregulation in IBD. Specific guidance on Covid-19 infected patients has been published for patients with IBD stratified by risk. IBD medication management varied drastically in our two cases. Studies have shown an increased risk of viral infection in clinically active IBD with exposure to thiopurines and so Azathioprine was held in Patient 1. In contrast it was felt appropriate to continue 5-Aminosalicylic acid in patient 2. Both IBD patients had extended clinical courses but positive outcomes.Table 1Table 2

S2235 Therapeutic Hyperbaric Oxygen Therapy Saves the Day in a Patient With Severe Refractory Pan-Ulcerative Colitis

INTRODUCTION: Despite current conventional treatments including steroids, immunomodulators, and anti-inflammatory medications, many patients with recurrent flares of ulcerative colitis (UC) often require more intensive therapy including biologics, and even colectomy. A dysregulated immune response to intestinal mucosal hypoxia contributes to the pathogenesis of UC, resulting in a loss of epithelial barrier function, translocation of luminal antigens into mucosa, and subsequent inflammation, making targeting of hypoxia-sensitive pathways a promising therapeutic approach.1 Recent literature supports the therapeutic potential of adjunctive hyperbaric oxygen therapy (HBOT).2 We present a case in which HBOT was used to help induce remission in an inpatient with severe refractory UC. CASE DESCRIPTION/METHODS: A 32-year-old male with a history of severe, chronic pan-UC presented to our clinic with a severe flare. Previously, he had a lack of response on multiple drug regimens to include azathioprine and infliximab. He was actively on vedolizumab therapy with minimal clinical and endoscopic response despite adequate levels and no antibodies detected. After missing an infusion, he developed an acute flare; presenting with >7 bloody bowel movements daily, fatigue, tenesmus, and a 20lb weight loss. Colonoscopy on hospital day (HD) 1 showed Mayo 3 pancolitis with biopsies negative for CMV. He received daily methylprednisolone and repeat induction dosing of vedolizumab with minimal clinical response. He subsequently underwent three 30-minute sessions of HBOT with significant symptomatic improvement. Tenesmus resolved and stools became non-bloody and semi-formed by the day of discharge. At 3-month follow-up, he remained in clinical remission with a normal fecal calprotectin on vedolizumab. DISCUSSION: Twenty-five percent of patients with UC will develop severe, acute exacerbations of disease during their lifetime. Despite advancements in treatment, half of these patients will fail subsequent medical rescue therapy, and an additional half of those will require colectomy within five years.3 Hyperbaric oxygen therapy is safe, well tolerated, and may play a role in inducing remission.4 The ability to increase tissue oxygen delivery to inflamed bowel to ultimately revert inflammatory pathways and promote healing may help avoid colectomy in select patients.5 Further research and ongoing clinical trials are necessary to investigate and better define the role of HBOT in inflammatory bowel disease.Figure 1.: Endoscopic view of the distal colon showing severe inflammation.Figure 2.: Endoscopic view of the sigmoid colon showing severe inflammation.Figure 3.: Endoscopic view of the rectum showing severe inflammation.

S3476 SARS-CoV-2 Infection in a Patient With Crohn’s Disease Currently on Infliximab Therapy: A Case Report

INTRODUCTION: Disease severity of SARS-CoV-2 is correlated with patient age and comorbidities. One population initially thought to be at increased risk of infection are patients with Inflammatory Bowel Disease (IBD). Understanding how this population is affected by SARS-CoV-2 is necessary for effective detection and management. We present the case of COVID-19 in a young Crohn’s disease patient on Infliximab. CASE DESCRIPTION/METHODS: A 24-year-old female with Crohn’s disease on Infliximab presented febrile with anosmia on 3/11. Five days later she developed myalgias, chest pain, coughing, and sneezing. She denied fever, dyspnea and GI upset. Presumed to be seasonal allergies, she was instructed to monitor symptoms. On 3/27, she developed a fever of 99.5 deg F. COVID-19 testing was performed and returned positive on 3/30. She completed 14-day quarantine with symptom resolution on 4/7, unremarkable lab work and chest X-ray with no signs of pneumonia. However, on 4/20, she had recurrence of symptoms, including worsening dyspnea and chest pain. Telehealth visit the next day revealed resting O2 sat of 98%, 6 minute walking desaturation test with O2 sat of 96% and heart rate of 119 bpm. The patient also reported coughing and increasing dyspnea. Two minutes later, heart rate normalized to 82 bpm and O2 sat was 97%. The patient was followed by a dedicated COVID-19 clinic until complete symptom resolution. DISCUSSION: In this case, our patient presented febrile with dyspnea five days after her Infliximab infusion. Current literature suggests IBD patients on immunotherapy are not at higher risk of contracting COVID-19 [1]. Also, many reports link symptoms of nausea, vomiting, and diarrhea with this infection. In a recent case report, an elderly woman with Ulcerative Colitis had initially presented with signs of IBD flare, instead of typical URI symptoms, which unfortunately resulted in misdiagnosis and her fatality [2]. Our patient did not exhibit GI distress. Lastly, she had symptom resurgence after 12 days of being asymptomatic, which has yet to be described in an IBD patient. Considering the complexity of this coronavirus, more information is needed to understand varying manifestations and its implications in IBD patients.

S3404 Medullary Carcinoma of Colon Found in a Patient With Ulcerative Colitis and Primary Sclerosing Cholangitis

INTRODUCTION: Medullary carcinoma of the colon is a relatively rare entity that is observed in only 5 to 8 cases for every 10,000 colon cancers diagnosed. It usually presents in the right colon, and it is more common in African Americans and patients with Lynch syndrome. Diagnosis is made on histology with expression of markers such as calretinin and CK7. CASE DESCRIPTION/METHODS: A 30-year-old African American man with a past medical history of ulcerative colitis on mesalamine and primary sclerosing cholangitis presented originally to an Trinitas Hospital with anemia and hematochezia. At the time, it was thought that he was having an ulcerative colitis flare, and he was treated with steroids. He underwent a colonoscopy with evidence of multiple anal and rectal ulcers. Around that time he was found to have bilateral lower extremity DVTs and an IVC filter was placed. He was readmitted shortly after discharge back to Trinitas and was found to be septic with e. coli bacteremia. A CT scan showed a right lower quadrant necrotic mass and he was transferred to University Hospital in Newark for further work-up as it is unclear if this mass is infectious or malignant and he will require surgical evaluation. On repeat colonoscopy, it was found that there was a large, friable mass located in the ascending colon that appeared malignant and spanned 3-4 cm. It was transversable with the colonoscope. Multiple biopsies were taken with cold forceps. Additionally, hot snare was used to cut off a larger segment which was retrieved with a basket. Pathology initially returned showing adenocarcinoma, but upon further examination, additional markers and immunostains were applied, and a final diagnosis of primary medullary carcinoma of the colon was made. Due to suspicious looking mass as well as patient's continued anemia, resection was offered and the patient accepted. Resection completed surgically with no immediate post-operative complications. DISCUSSION: To date, no reports of primary medullary carcinoma of the colon has been diagnosed in a patient presenting with primary sclerosing cholangitis, and only one case found in a patient with ulcerative colitis. In general, medullary carcinoma of the colon has a more favorable prognosis than adenocarcinoma of similar staging, with an overall 5-year survival rate of ∼65%. Treatment can consist of chemotherapy with oxaliplatin-xeloda.

Should inflammatory bowel disease be a contraindication to radiation therapy: a systematic review of acute and late toxicities

AbstractBackground:Inflammatory bowel disease (IBD) [i.e., Crohn’s disease (CD) and ulcerative colitis (UC)] has been considered a relative contraindication for radiation therapy (RT) to the abdomen or pelvis, potentially preventing patients with a diagnosis of IBD from receiving definitive therapy for their malignancy.Method:Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) conventions, a PubMed/MEDLINE literature search was conducted using the keywords RT, brachytherapy, inflammatory bowel disease, Crohn’s disease, ulcerative colitis and toxicity.Results:A total of 1,206 publications were screened with an addition of 8 studies identified through hand searching. Nineteen studies met the inclusion criteria for quantitative analysis. The total population across all studies was 497 patients, 50·5% having UC, 37% having CD and an additional 12·5% having unspecified IBD. Primary gastrointestinal malignancy (55%) followed by prostate cancer (40%) composed the bulk of the population. Acute and late grade 3 or greater gastrointestinal specific toxicity ranged from 0–23% to 0–13% respectively for those patients with IBD treated with RT to the abdomen or pelvis. In the literature reviewed, RT does not appear to increase fistula or stricture formation or IBD flares; however, one study did note RT to be a statistically significant risk factor for subsequent IBD flare on multivariate analysis.Conclusions:A review of reported acute and late toxicities suggests that patients with IBD should still be considered for definitive radiotherapy. Patient characteristics including IBD distribution relative to the irradiated field, inflammatory activity at the time of radiation, overall disease severity and disease phenotype in the case of CD (fistulising versus stricturing versus inflammatory only) should be considered on an individual basis when evaluating potential patients. When possible, advanced techniques with strict organ at risk dose constraints should be employed to limit toxicity in this patient population.

Older age is a risk factor for inadequate energy intake during acute, severe IBD and is associated with shorter time to relapse

Background Effects of nutritional intake on inflammatory bowel disease (IBD) flare resolution are unknown. We hypothesised that nutritional factors during hospitalisation for acute severe IBD are associated with risk of subsequent relapse. We also studied risk factors for inadequate energy intake. Methods Patients admitted to the Karolinska Hospital Gastroenterology ward with IBD flare during 2015–2016 were retrospectively identified. In total, 91 patients were included. Data on nutrition, disease factors, inflammatory markers, and daily energy requirement were extracted. Requirement of new systemic steroid prescription, intensification of biological therapy, readmission, surgery, and calprotectin level were individually used as proxies for disease relapse. Follow-up was one year after discharge. Adjustments for age and sex were made where appropriate. Results Overall, 19%, 31%, and 45% of patients had days with energy intake <30, <50, and <70% of calculated requirement. Older age was associated with a higher number of days with energy intake <30, <50, and <70% of calculated requirement (regression coefficient 0.03, 0.04, 0.06 respectively, p = .012, .017, .008). The number of days with energy intake <30 and <70% of the calculated requirement and the length of the hospitalisation were associated with shorter time to new steroid prescription (hazard ratio 1.3, 1.1, 1.04 respectively, p = .016, .034, .011). CRP and calprotectin were not associated with relapse. Conclusion Older age is a predictor of inadequate energy intake during hospitalisation for acute severe IBD. Inadequate energy intake adjusted for age and sex during IBD flare was better predictor of time to the next steroid-requiring relapse than inflammatory markers.

90-Day Specific Readmission for Clostridium difficile Infection After Hospitalization With an Inflammatory Bowel Disease Flare: Outcomes and Risk Factors.

Patients with inflammatory bowel disease (IBD) have an increased risk for Clostridium difficile infection (CDI) and carry significantly higher morbidities and mortality than those without IBD. We aimed to investigate disease-specific readmission rates and independent risk factors for CDI within 90 days of an index hospitalization for an IBD flare. The Nationwide Readmission Database was queried for the year 2016. We collected data on hospital readmissions of 50,799 adults who were hospitalized for urgent IBD flare and discharged. The primary outcome was disease-specific readmission rate for CDI within 90 days of discharge. The secondary outcomes were readmission rate of colonoscopic procedures, morbidities (including mechanical ventilation and shock), and hospital economic burden. The risk factors for readmission were identified using Cox regression analysis. The 90-day specific readmission rate was 0.1% (N = 477). A total of 3,005 days were associated with readmission, and the total health care in-hospital economic burden of readmission was $19.1 million (in charges) and $4.79 million (in costs). Independent predictors during index admission for readmission were mechanical ventilation for >24 hours (hazard ratio [HR], 6.62, 95% confidence interval [CI], 0.80-54.57); history of previous CDI (HR, 5.48; 95% CI, 3.66-8.19); HIV-positive status (HR, 4.60; 95% CI, 1.03-20.50); alcohol abuse disorders (HR, 2.06; 95% CI, 1.15-3.70); Parkinson's disease (HR, 4.68; 95% CI, 1.65-13.31); index admission for noncomplicated ulcerative colitis (HR, 4.72; 95% CI, 2.99-7.45]-), complicated ulcerative colitis (HR, 4.49; 95% CI, 2.80- 7.18), or noncomplicated Crohn disease (HR, 2.54; 95% CI, 2.80-4.04); and hospital length of stay (HR, 1.01; 95% CI, 1.01-1.02). The 90-day CDI-specific readmission rate after the index admission of IBD flares was 0.1%. We found risk factors for CDI-associated readmissions such as history of Parkinson's disease, prior CDI, HIV-positive status, and alcohol abuse disorder. Finally, our study also revealed a high health care cost, charges, and burden.

Management of Clostridioides difficile infection in patients with inflammatory bowel disease.

Inflammatory bowel disease (IBD) is a common diarrheal illness with gastrointestinal and extraintestinal manifestations and complications. The most common infectious complication associated with IBD is Clostridioides difficile infection (CDI). Active IBD predisposes to CDI due to alterations in the gut microbiome. C. difficile is a toxin producing bacterium leading to worsening of underlying IBD, increasing the risk of IBD treatment failure and an increased risk of hospitalization and surgery. Since the symptoms of CDI overlap with those of an IBD flare; it is prudent to recognize that the diagnosis of CDI is challenging and diagnostic tests (nucleic-acid and toxin-based assays) should be interpreted in context of symptoms and test performance. First line treatments for management of CDI in IBD include vancomycin or fidaxomicin. Recurrence prevention strategies should be implemented to mitigate recurrent CDI risk. One needs to monitor IBD disease progression and manage immunosuppression. The risk of recurrent CDI after a primary infection is higher in IBD compared to non-IBD patients. Microbiota restoration therapies are effective to prevent recurrent CDI in IBD patients. This review summarizes the epidemiology, pathophysiology, diagnostic testing, outcomes and management of both CDI and IBD, in CDI complicating IBD.

Positivity of Stool Pathogen Sampling in Pediatric Inflammatory Bowel Disease Flares and Its Association With Disease Course.

Acute exacerbations of inflammatory bowel disease (IBD) may involve enteric pathogen. We aimed to assess the frequency and outcomes of Clostridium difficille toxin (CDT) and non-CDT enteric infections in symptomatic pediatric patients with IBD. Patients' records were retrospectively searched for disease flares in which stool samples were collected for enteric pathogens. Each patient with a positive sample was matched with a patient with IBD flare and negative samples for analyzing 1-year outcomes following sampling. A total of 618 pediatric patients with IBD [Crohn's disease, n = 439 (71%), mean age at diagnosis 13.0 ± 3.4 years, girls, n = 264 (42.7%)] had 1048 stool samples during the study period (2001-2018). Of 914 bacterial cultures, 40 (4.3%) were positive, 30 (75%) of which, positive for Campylobacter jejuni. Of 393 samples for CDT, 28 (7.1%) were positive while parasitic infection rate was 21/529 (3.9%).Overall, 19 positive C jejuni cases and 19 positive CDT cases with matching controls were examined. During 12 months of follow-up, the mean number of disease flares and emergency room visits was higher among patients with positive CDT (1.5 ± 1.4 vs 0.5 ± 0.9, P = 0.019, 1.3 ± 1.5 vs 0.4 ± 0.8, P = 0.05, respectively) with a numeric increase of surgical interventions (3 vs 0, P = 0.08). There were no significant differences in disease outcomes between patients with C jejuni infections and matched controls. C difficile and C jejuni are the most common enteric infections among pediatric patients with IBD but only clostridial infection was associated with a more severe disease course within 12 months.

Inflammatory Bowel Disease Patients Hospitalized for Flares Are at Risk for Chronic Steroid Use Due to Lack of Clear Instructions at Discharge: A 15-Month Retrospective Study at a Private, Not-For-Profit Academic Hospital

Patients with inflammatory bowel disease (IBD) who are hospitalized with an IBD flare can be managed acutely with short-term (4-6 weeks) high dose glucocorticoid taper. Corticosteroid use beyond 3-4 months can cause serious and significant side effects. Thus, it is imperative for patients to be discharged with a prednisone tapering plan and steroid-sparing treatment strategy. This quality assessment project examines the rate at which IBD patients remain on high dose steroids 3 months after hospital discharge.

Outcomes of Fecal Microbiota Transplantation in Patients With Inflammatory Bowel Diseases and Recurrent Clostridioides difficile Infection

Outcomes of Fecal Microbiota Transplantation in Patients With Inflammatory Bowel Diseases and Recurrent Clostridioides difficile Infection

Patients with More Severe IBD Get Clostridioides difficile Rather than Clostridioides difficile Increasing the Severity of IBD.

Inflammatory bowel disease (IBD) patients who have Clostridioides difficile infection (CDI) have worse outcomes. We aimed to determine whether such outcomes are the result of CDI or whether CDI occurs in patients who have more severe IBD. This was a retrospective study of patients hospitalized for ≥ 2 IBD flares from 2010 to 2019. The primary outcome was time to IBD flare between hospitalizations. First, time to flare was compared between patients who were hospitalized for a flare complicated by CDI and subsequently for a CDI-negative flare (cohort A, denoted +/-) versus patients who were hospitalized for two CDI-negative flares (cohort B, -/-). Second, time between flares was compared within the subset of cohort A patients who had three flares (cohort C, -/+/-) before and after CDI. Time between flares was a median of 4months (IQR 1-9) among 51 cohort A patients versus 12months (IQR 6-38) among 51 cohort B patients (log-rank P < 0.01). In contrast, the median time between flares was similar within cohort C before and after CDI (log-rank P = 0.54). At time of the second IBD flare, patients in cohort A (+/-) were more likely to have moderate or severe disease compared to patients in cohort B (-/-). Patients with prior CDI had shorter time to subsequent IBD flare relative to their CDI-negative counterparts. This is not likely due to CDI itself because there was no difference in time between flares before versus after acquiring CDI. Rather, patients who acquire CDI may have more severe IBD.