Higher Risk Of Colectomy Research Articles

P0579 Predictive Modeling for Colectomy Risk in Patients with Ulcerative Colitis and Primary Sclerosing Cholangitis: A Brazilian Multicentric Study Utilizing Machine Learning.

Abstract Background Ulcerative Colitis (UC) and Primary Sclerosing Cholangitis (PSC) are interrelated chronic inflammatory diseases. Patients with both conditions are at an elevated risk of colectomy, predominantly due to a higher incidence of dysplasia and colorectal cancer. Identify which patients are at higher risk of colectomy can be crucial to personalize their management. The primary objective was to develop a predictive model that can accurately forecast colectomy risk. Methods A cross-sectional study was conducted with patients from multiple tertiary centers across Brazil. We employed logistic regression and Random Forest (RF) models to analyze the data and identify significant predictors for colectomy. Data extraction was performed using Excel, and statistical analyses were conducted using R Studio. Results The study population comprised 83 individuals diagnosed with both UC and PSC. The mean age of the patients was 45 years (range 6 to 67), with 56 patients being male (67.5%). The mean age at diagnosis of UC and PSC was 32 years (range 18 to 77) and 36 years (range 8 to 72), respectively. Among patients with UC, the majority (74/83) had extensive colitis (89.2%), and 49.4% (41/83) had used at least one biological therapy. Only 13 patients (15.7%) required colectomy. Liver cirrhosis occurred in 15 cases (18.1%), and 11 patients (13.3%) required liver transplantation. Twelve patients (14.5%) had dysplasia or colorectal cancer. Our analysis identified several key predictors for colectomy. In the linear regression analysis, the duration of UC greater than 11 years significantly increased the risk of colectomy (OR=2.15, p=0.04). The presence of hepatic complications was associated with a tendency towards an increased risk of colectomy (OR=1.79, p=0.059). In the RF model, the presence of hepatic complications, and duration of UC greater than 11 years were significant predictors for colectomy. Protective factors identified by the RF model included use of biologic therapy, clinical and endoscopic remission. The RF model demonstrated an accuracy of 88.2%, outperforming the linear regression model and providing superior accuracy and robustness in predicting colectomy risk within the defined period. Conclusion Our study developed a predictive model using the RF algorithm, which demonstrated superior performance over linear regression in identifying high-risk patients for colectomy. This model can serve as a valuable tool in clinical practice, aiding in early intervention and tailored management strategies to mitigate severe outcomes in patients with UC and PSC. The use of RF provides a more reliable prediction, emphasizing the importance of machine learning in clinical decision-making. References Kim YS, Hurley EH, Park Y, Ko S. Treatment of primary sclerosing cholangitis combined with inflammatory bowel disease. Intest Res. 2023 Sep 1. doi:10.5217/ir.2023.00039. Epub ahead of print. PMID: 37519211. Kim YS, Hurley EH, Park Y, Ko S. Primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD): a condition exemplifying the crosstalk of the gut-liver axis. Exp Mol Med. 2023 Jul;55(7):1380-7. doi:10.1038/s12276-023-01042-9. PMID: 37464092; PMCID: PMC10394020. Greener JG, Kandathil SM, Moffat L, Jones DT. A guide to machine learning for biologists. Nat Rev Mol Cell Biol. 2022 Jan;23(1):40-55.

Early Biologic Treatment for Inflammatory Bowel Disease

This rapid review updates the evidence for early biologic treatment versus conventional step-up therapy for patients with luminal Crohn disease, fistulizing Crohn disease, or ulcerative colitis. Findings are based on 4 systematic reviews, 2 randomized controlled trials, and 3 updated clinical guidelines. Luminal Crohn Disease Three systematic reviews showed that early biologic treatment, initiated within 36 months of diagnosis, significantly improved clinical remission, mucosal healing, and reduced relapse rates, surgery needs, and disease progression compared to conventional strategies. Two randomized controlled trials found that early infliximab treatment led to better remission rates, quality of life, and safety outcomes compared with conventional treatment for both adults and children with newly diagnosed moderate-to-severe Crohn disease. These results are consistent with previous evidence suggesting that early biologic drugs improve clinical benefits compared with conventional strategies. Clinical guidelines generally recommend biologic drugs as third-line treatment. One guideline targets adults and children with severe, active Crohn disease, and another focuses on children and adolescents with luminal Crohn disease regardless of severity. Of these, 1 guideline recommends first-line biologics for high-risk pediatric patients. Fistulizing Crohn Disease One guideline recommends third-line infliximab for patients with active fistulizing Crohn disease who did not respond, did not tolerate or had a contraindication to conventional therapy. First-line anti–tumour necrosis factor therapy was only recommended for children and adolescents with fistulizing perianal Crohn disease. No evidence was identified for this population. Ulcerative Colitis In 1 systematic review, early biologics were found to be associated with a higher risk of colectomy. However, these findings should be interpreted with caution as they are based on evidence from 3 observational studies. One guideline recommends infliximab as a third-line option for acute severe cases contraindicated to or clinically inappropriate with ciclosporin.

P822 Therapeutic Management And Risk Of Colectomy In Patients With Acute Severe Ulcerative Colitis And Previous Exposure To Anti-Tnf Drugs. A Cohort Study Of Geteccu

Abstract Background There are few data regarding the management on acute severe ulcerative colitis (ASUC) flare in patients with previous anti-TNF exposure. We evaluated the medical management, the risk of colectomy and factors associated comparing with a bionaive cohort. Methods A retrospective and multicentric study of GETECCU. Patients with ASUC episode between 2010-2020 were included in two cohorts: bio-exposed (cohort 1) and bio-naive (cohort 2). Patients with previous other biologics or JAK inhibitors exposure were excluded. Steroid response was defined as reduction of bowel movements and C Reactive Protein (CRP). Rescue therapy was used after steroid failure and maintenance therapy after steroid or rescue therapy response/remission. Clinical effectiveness of rescue and maintenance therapy was analyzed using partial mayo score (clinical response with decreased of 2-3 points, clinical remission ≤2). Colectomy rate was evaluated at short and long-term using survival analysis and was compared using cox logistic regression. Results Finally, 461 patients were included from 33 centres. Basal characteristics and medical management are shown in Table 1. Bioexposed patients received steroid therapy less frequently (82 vs 97%, p 0.001). Comparing with bionaive cohort, there were differences between medical management although steroid response and the use of rescue therapy were similar. However, clinical remission at one year was lower (44 vs 59%, p 0.03). Colectomy rates at 1 and 12 months were of 15 and 17% in Cohort 1, respectively. Comparing with bionaive cohort, there were a higher risk of colectomy at short and long-term, HR 2.46 (1.57-3.87, p 0.001) (Figure 1). There were no factors associated with colectomy at one year. Response to steroids was the only protective factor of colectomy at one year (RR 0.17, 0.07-0.45, p 0.001). Conclusion Management of ASUC in bio-exposed patients is heterogeneus and differs from bionaive patients. The risk of colectomy is increased. Although the response to medical treatment is not negligible, special efforts in standardizing therapies are warranted in order to improve prognosis.

P1001 Predictive factors of colectomy in patients admitted with Acute Severe Ulcerative Colitis

Abstract Background Acute severe ulcerative colitis (ASUC) is a life-threatening condition which requires quick decision making and urgent treatment. To facilitate this process, it is essential to identify patients at a high risk of emergency colectomy. The aim of this study is to identify predictors for emergency colectomy in patients with ASUC. Methods A retrospective study of 121 patients admitted with ASUC to a single gastroenterology centre between 2010 and 2020 was performed. Clinical and demographic data, laboratory and endoscopic examinations results were analysed as potential predictors of colectomy. Albumin and C-reactive protein (CRP) levels were recorded at baseline and at the 3rd day after intravenous steroids (IVS) initiation. Results 119 patients initially received IVS, while 2 patients with suspected intestinal perforation underwent emergency colectomy on the first day. 64 (53%) were women, with a median age of all patients of 33 (IQR 27-49) yrs. 15 (12.4%) patients admitted with ASUC underwent colectomy, while mortality rate during hospitalization was 1.7%. During the entire follow-up period, with a median duration of 46.5 months (23-88.25), colectomy was performed in 19 (15.7%) patients. Overall, in the study group, colectomy rate at 1 month, 3 months and 2 years were 12.4%, 12.4%, and 14.0%, respectively. Assessing further outcomes after colectomy, during the follow-up period, 13 (68.4%) achieved clinical remission, 1 died during the operation, and 5 (26.3%) patients still have an active course of the disease requiring immunosuppressive treatment. When comparing patients in the colectomy group (n=13) with patients who avoided colectomy during this hospitalization (n=105), no significant differences were found in age, sex, duration of illness, body mass index, endoscopic activity, the use of prednisolone or azathioprine prior to admission or previous treatment with biologics. The presence of cytomegalovirus and Clostridium difficile infection was also not associated with a higher risk of colectomy. Significant differences between the groups were found comparing the laboratory findings: the strongest predictor of colectomy was the CRP/albumin ratio at day 3 after IVS initiation (median value was 1.26 (0,81-3,26) in colectomy group vs. 0,64 (0,25-1,36) in non-colectomy group, p<0.001). The difference was also observed when comparing albumin (median 26 (24-28) vs. 29 (27-32), p=0.012) and CRP (median 33 (25-83) vs. 16 (8-37), p=0.003) levels separately on the 3rd day, while at baseline there was no significant differences in laboratory findings. Conclusion A low serum albumin level, higher CRP and CRP/albumin ratio are predictive factors of emergency colectomy in ASUC patients.

Fecal lactoferrin early predicts long-term outcomes in ulcerative colitis: A post-hoc analysis of the UNIFI and PURSUIT trials.

Fecal lactoferrin (FL) is associated with disease activity and relapse in ulcerative colitis. However, whether FL could early predict long-term outcomes in ulcerative colitis is poorly understood. This post-hoc analysis included participants who received biologics and had available data of FL concentration at week 4 from the UNIFI and PURSUIT trials (n=1063). Therapeutic outcomes, including clinical remission, endoscopic improvement and remission, and histological improvement and remission, were evaluated at the end of maintenance therapy. The incidence of colectomy was observed from week 0 to maximum week 228 in the PURSUIT trial (n=667). Multivariate logistic and Cox proportional-hazard regression were conducted to evaluate the associations between FL and therapeutic outcomes and colectomy, respectively. A high FL level at week 4 was associated with poor long-term clinical, endoscopic and histologic outcomes. FL >84.5μg/mL predicted a low likelihood of clinical (OR [95% CI]: 0.43 [0.32, 0.57]; p<0.001), endoscopic (OR [95% CI]: 0.40 [0.29, 0.56]; p<0.001), and histological (OR [95% CI]: 0.27 [0.14, 0.53]; p<0.001) remission. Moreover, week-4 FL could add prognostic value to fecal calprotectin and clinical and endoscopic scores for informing long-term therapeutic outcomes. For the risk of colectomy, patients with week-4 FL <20.1 and ≥20.1µg/mL had an incidence rate of 1.10% and 6.39%, respectively. Patients with FL ≥20.1µg/mL had a 995% higher risk of colectomy (HR [95% CI], 10.95 [1.45, 82.74]). FL could be a promising prognostic biomarker for long-term therapeutic outcomes and risk of colectomy in patient of ulcerative colitis.

Efficacy of biologic and small molecule agents as second-line therapy after exposure to TNF inhibitors in patients with ulcerative colitis: A propensity-matched cohort study.

There is limited real-world data on comparative effectiveness of different biologic or small molecule agents as second-line therapies in patients with ulcerative colitis (UC) with prior exposure to a tumour necrosis factor inhibitor (TNFi). We conducted a retrospective cohort study using TriNetX, a multi-institutional database to assess the efficacy of tofacitinib, vedolizumab and ustekinumab in patients with ulcerative colitis (UC) with prior exposure to a TNFi. Failure of medical therapy was defined as a composite outcome of intravenous steroids or colectomy within 2 years. One-to-one propensity score matching was performed for demographics, disease extent, mean haemoglobin, C-reactive protein, albumin and calprotectin, prior IBD medications and steroid use between cohorts. Among 2141 patients with UC and prior exposure to TNFi, 348 (16.2%), 716 (33.4%) and 1077 (50.3%) were switched to tofacitinib, ustekinumab and vedolizumab, respectively. After propensity-score matching, there was no difference in the composite outcome (aOR: 0.77, 95% CI: 0.55-1.07) but higher risk of colectomy (aOR: 2.69, 95% CI: 1.31-5.50) in the tofacitinib cohort than the vedolizumab cohort. There was no difference in the risk of composite outcome (aOR: 1.29, 95% CI: 0.89-1.86) but higher risk of colectomy (aOR: 2.63, 95% CI: 1.24-5.58) in the tofacitinib cohort than the ustekinumab cohort. The vedolizumab cohort had a higher risk of composite outcome (aOR: 1.67, 95% CI: 1.29-2.16) than the ustekinumab cohort. Ustekinumab might be the preferred second-line therapy over tofacitinib and vedolizumab in patients with UC that were previously exposed to a TNFi.

P875 Disease course of Ulcerative Colitis during the first ten years following diagnosis in a prospective European population-based inception cohort – the Epi-IBD cohort

Abstract Background The Epi-IBD cohort is a prospective European population-based cohort of 1,390 patients diagnosed in 2010 and 2011 with inflammatory bowel disease (IBD) according to Copenhagen criteria in centres from Eastern and Western European countries. The study aims at describing differences in incidence, treatment strategies, disease course and prognosis of ulcerative colitis (UC) Eastern and Western Europe. Methods UC patients were followed prospectively from the time of diagnosis until December 31st, 2020, death, emigration or loss of follow-up. Clinical data on surgery, hospitalizations and medical treatment were captured throughout the follow-up period and entered in a validated web-database, www.epi-ibd.org. Associations between colectomy and covariates were analysed by multivariate Cox regression analyses. Results A total of 816 UC patients aged ≥15 years from 21 centres in 5 Eastern and 11 Western European countries were included. Overall, 51 (6%) patients underwent colectomy. A total of 190 (23%) patients were hospitalized at least once for their UC. Cancer was diagnosed in 28 (3%) patients, including 4 colorectal cancers. The use of medical therapy was comparable across Eastern and Western European centres (Table 1). During follow-up, 121 out of 776 (16%) patients with limited UC (proctitis or left-sided colitis) progressed to extensive colitis. The median time to progression was 21 (IQR: 8-48) months from diagnosis. No patients from Eastern Europe were exposed to biological therapy prior to change in disease extent, compared to 6 out of 98 patients (6%) from Western Europe. Multivariate Cox regression analysis showed no difference in risk of colectomy according to European region (Eastern vs. Western Europe, HR: 1.05, 95%CI: 0.48-2.29). Early intervention with biologicals (within 6 months) was associated with higher risk of colectomy (HR: 3.06, 95% CI: 1.23-7.58), and so was early introduction of immunomodulators (HR: 2.35, 95%CI: 1.16-4.76). Progression in disease extent to extensive colitis was significantly associated with higher risk of surgery (HR: 5.30, 95% CI: 2.36-11.90) and similarly extensive colitis at diagnosis compared to proctitis (HR: 3.48, 95% CI: 1.12-10.82). Conclusion After 10 years of follow up in this European multicentre study, only 6% percent had a colectomy performed. Despite the widespread use of immunomodulators and biologicals, 16% of patients with limited disease extent progressed to extensive colitis which was associated with higher risk of surgery. The need for early introduction of biological therapy and immunomodulators might predict risk of surgery.

P291 Long term outcomes of children with ulcerative colitis after acute severe colitis: a multicenter study from the GETAID pédiatrique group

Abstract Background Acute Severe Colitis (ASC) is a frequent and severe complication of ulcerative colitis (UC) that can occur at any time during the disease. Its prognosis can be severe with a high risk of colectomy. The use of immunosuppressants and more recently biotherapies seem to reduce the risk of colectomy. We wished to study the long-term evolution of paediatric-onset UC patients after ASC. Methods This retrospective study was conducted in 12 centres of the GETAID paediatric in France. Data on patients with UC aged &amp;lt; 18 years admitted with ASC (defined as paediatric ulcerative colitis activity index [PUCAI] score ≥ 65) between January 2010 and January 2021 were collected at discharge and at 1, 3 and 5 years after admission. The primary outcome of our study was colectomy-free rates at one year. A univariate analysis comparing the profile at diagnosis and at ASC of patients who underwent colectomy, and others was performed to look for prognostic factors associated with the risk of surgery. Results Of the 102 patients admitted with ASC, 95 [93%] were treated with corticosteroids. Forty-six [48%] patients were escalated to second-line therapy, mainly to infliximab. Nine patients [8.8%] underwent colectomy before discharge. Long-term follow-up showed colectomy-free rates were 83%, 76% and 72% at 1, 3 and 5 years after initial ASC admission, respectively. In a multivariate analysis, active disease, and use of methotrexate were significantly associated with a higher risk of colectomy. A short delay between diagnosis and ASC, rapid steroid use for ASC and second line therapy with azathioprine and Infliximab were significantly associated with a lower risk of colectomy. Conclusion The rate of colostomy remains high after an episode of acute colitis despite the earlier use of biotherapies. But long-term outcome of paediatric-onset UC patients is good with sustained clinical and biological remission.

S856 Predictors of Colectomy in Acute Severe Ulcerative Colitis

Introduction: Up to 30% of patients admitted with acute severe ulcerative colitis (UC) will require a colectomy despite advances in medical therapies. Our aim was to assess the risk factors for colectomy in patients hospitalized with acute severe ulcerative colitis using initial admission data. Methods: This is a single-center, retrospective study of all patients hospitalized with acute severe UC from 1/1/2012-11/1/2021. Patients who underwent colectomy (during the admission or after discharge) were compared with patients who did not have a colectomy. Continuous variables were analyzed using an unpaired student’s t-test. Categorical variables were analyzed using a Pearson’s chi-square test. Variables with p< 0.05 on univariate analysis were identified and incorporated as independent variables in a multivariate regression model. Results: A total of 168 patients hospitalized with acute severe UC were included (52.4% were male; mean age was 39.8 ±17.2 years). The median disease duration was 2.5 years (IQR 1-10) and 64.9% (n=109) of the cohort were biologic naïve. A total of 31 patients (18.5%) required a colectomy. On univariate analysis, the following factors were associated with a higher risk of colectomy: female sex (70.9% vs 42.3%, p=0.004), lower hemoglobin (10.5 vs 12 g/dL, p=0.002), lower albumin level (3.2 vs 3.5 g/dL, p=0.015). Patients who were on oral corticosteroids on admission had a higher risk of colectomy (70.9% vs 48.9%, p=0.02) while patients who were biologic naïve had a lower risk of colectomy (41.9% vs 70.1%, p=0.003). C-reactive protein level on admission was not associated with risk of colectomy (Table). A multivariate logistic regression model comprising the above variables showed that female sex (p=0.019) and lower hemoglobin (p=0.048) were independently associated with an increased risk of colectomy. Conclusion: In our cohort, approximately one fifth of patients with acute severe UC required a colectomy. Female sex and lower hemoglobin on admission were independently associated with a higher risk of colectomy while biologic naïve patients had a lower risk of colecomy. Further studies to assess if earlier treatment could further lower colectomy rates are needed. Table 1. - Baseline Characteristics Variables Colectomy (n=31) No colectomy (n=137) p-value Patient characteristics Age, mean (SD) 40.5 (19.7) 39.6 (16.7) 0.82 Female, n (%) 22 (70.9) 58 (42.3) 0.004 Disease activity Pancolitis, n (%) 20 (64.5) 97 (70.8) 0.75 Disease duration in years, mean (SD) 6.3 (7.9) 6.9 (9.4) 0.71 Presence of extraintestinal manifestations, n (%) 1 (3.2) 12 (8.8) 0.29 Smoking, n (%) 2 (6.5) 7 (5.1) 0.58 Concomitant CMV infection, n (%) 2 (6.5) 1 (0.7) 0.08 Concomitant C. difficile infection, n (%) 1 (3.2) 8 (5.8) 0.56 Labs at presentation Hemoglobin g/dL, mean (SD) 10.5 (2.2) 12.0 (2.6) 0.002 C-reactive protein md/dL, mean (SD) 85.7 (61.2) 80.4 (84.9) 0.73 Albumin g/dL, mean (SD) 3.2 (0.7) 3.5 (0.6) 0.015 Medications Biologic naïve, n (%) 13 (41.9) 96 (70.1) 0.003 Inpatient infliximab rescue, n (%) 16 (51.6) 51 (37.2) 0.14 On oral corticosteroid at time of admission, n (%) 22 (70.9) 67 (48.9) 0.026 Statins on admission, n (%) 4 (12.9) 9 (6.6) 0.44 Chronic outpatient opioid use, n (%) 3 (9.7) 10 (7.3) 0.65 Inpatient opioid, n (%) 17 (54.8) 72 (52.6) 0.82 On IMM on admission, n (%) 1 (3.2) 13 (9.5) 0.25 SD: standard deviation; CMV: cytomegalovirus; C. difficile: Clostridiodes difficle; IMM: immunomodulator.

TRENDS IN ADMISSIONS, OUTCOMES AND FINANCIAL BURDEN OFC. DIFFICILE INFECTION RELATED HOSPITALIZATIONS AMONG INFLAMMATORY BOWEL DISEASE PATIENTS: A NATIONWIDE ANALYSIS

Abstract INTRODUCTION Inflammatory bowel disease (IBD) patients with colonic involvement are known to have microbiome changes which may increase their risk of C. difficile infection (CDI). We conducted an analysis to describe the implications of CDI on hospitalized IBD patients. METHODS We used the National Inpatient Sample database from 2007 through 2018, to identify patients admitted with primary or secondary diagnosis of IBD using the ICD-9 or ICD-10 codes. We identified CDI as well as colectomy using diagnostic codes. We identified trends in nationwide estimates for annual admissions, age at admission, length of stay (LOS), in-patient mortality, Elixhauser comorbidity index and total hospital charge (adjusted for inflation). We used the Cochran-Armitage test for trend significance. RESULTS Between 2007 and 2018, there were an estimated total of 3,728,348 admissions with IBD, of which 161,744 patients had CDI (4.3%). Median age at admission was 52 years, with 56.7% females. There was a rising trend of CDI among IBD patients, from 2.9% in 2007 to a peak of 5.4% in 2015 with a decline towards the end of study period at 4.4% in 2018. Mean score for Elixhauser comorbidity index increased from 4.6 to 7.4 (p-trend &amp;lt;0.05) for non-CDI subgroup and from 9.9 to 11.4 (p-trend &amp;lt;0.05) for CDI subgroup during the study period. The median LOS was 4 days for patients without CDI vs 6 days with CDI. Trend in LOS was stable for patients without CDI but decreased from 8 days to 5 days over the 12-year study period for patients with CDI (p-trend &amp;lt;0.05). Overall, among patients with IBD, the risk of colectomy was 5.3%. Risk was higher in CDI subgroup (7.3% vs 5.2%, RR 1.41, 95% CI 1.39 - 1.44). The overall mortality among IBD patients was 1.6% with no significant trend observed over time. All cause in-hospital mortality was significantly higher among patients with concomitant CDI (6.8%) vs without CDI (1.4%) (RR 4.99, 95% CI 4.89 - 5.10). Within CDI subgroup, there was a trend of decrease in mortality from 7-11% in the beginning of the study, to about 3-3.5% towards the end of the study period (p-trend &amp;lt;0.05). After adjusting for inflation, there was a significant increase in charges among both subgroups: increased from $28,575 in 2007 to $68,614 in 2018 (p-trend &amp;lt;0.005) for non-CDI subgroup and from $57,987 in 2007 to $95,799 in 2018 (p-trend &amp;lt;0.005) for CDI subgroup. Overall charges were significantly higher for CDI subgroup. CONCLUSION The incidence of CDI in IBD patients increased over the study period with stability towards the latter half. Hospitalized IBD patients with concomitant CDI have a higher comorbidity index, a longer length of stay, a higher risk of colectomy and an increased risk of mortality when compared to those without CDI. Total hospitalization charges are also significantly higher with CDI subgroup and have been increasing overtime.

Colectomy Incidence Rates in Five-Year Data From the Observational Postmarketing Ulcerative Colitis Study of Originator Infliximab.

This analysis of the Observational Postmarketing Ulcerative Colitis Study examined incidence rates of colectomy in patients with ulcerative colitis who received originator infliximab (IFX) or conventional therapies (ConvRx) as per their treating physician. Cox proportional hazards models compared time to colectomy for both treatment groups. A secondary analysis examined colectomy incidence rates based on IFX exposure timing (defined by a 90-day window after the last IFX dose date). Of 2239 patients with data, 1059 enrolled in IFX and 1180 enrolled in ConvRx (including 296 patients who switched to IFX). Patients in the IFX group had more severe disease at baseline vs the ConvRx group (percentage with baseline partial Mayo score 7-9: 46.0% vs 30.5%, respectively). During 5 years of follow-up, 271 patients (12.1% of enrolled patients) had colectomy. Enrollment in the IFX group was associated with a higher risk of colectomy (hazard ratio = 3.12; 95% confidence interval, 2.25-4.34; P < 0.001) compared with enrollment in the ConvRx group. A total of 174 colectomies occurred in the IFX group, but 97 of these colectomies occurred ≥90 days after the last IFX dose date. Colectomy was reported at a higher rate in the IFX group than in the ConvRx group, although patients in the IFX group had more severe disease at baseline and most of the colectomies occurred after patients had been off of IFX for ≥90 days.

No Increased Risk of Colorectal Neoplasia in Patients With Inflammatory Bowel Disease and Postinflammatory Polyps.

Patients with inflammatory bowel disease (IBD) who have postinflammatory polyps (PIPs) may have an increased risk of developing colorectal neoplasia. Current guidelines recommend an intensified surveillance strategy in these patients, although the evidence for this recommendation is conflicting. The aim of our study was to assess whether IBD patients with PIPs are at increased risk of colorectal neoplasia. We established a retrospective cohort in a tertiary IBD center with IBD patients undergoing colorectal cancer (CRC) surveillance in the current era. We compared cumulative incidences of colorectal neoplasia since IBD diagnosis between patients with and without PIPs and corrected for confounders. Second, we compared the risk of receiving a colectomy. In our cohort with >22 years of median follow-up, 154 of 519 patients had PIPs. PIPs were associated with extensive disease (odds ratio [OR], 2.76; 95% confidence interval [CI], 1.61-4.42; P < 0.001) and with more severe inflammation at colonoscopy (OR, 3.54; 95% CI, 2.28-5.50; P < 0.001). After correction for confounders, the presence of PIPs was not associated with development of colorectal neoplasia (hazard ratio [HR], 1.28; 95% CI, 0.85-1.93; P = 0.24) or with development of advanced neoplasia (HR, 1.38; 95% CI, 0.52-3.68; P = 0.52). There was a higher risk of colectomy in patients with PIPs (HR, 3.41; 95% CI, 1.55-7.54; P = 0.002). In this cohort, PIPs were associated with disease extent, inflammation, and higher rates of colectomy. However, the presence of PIPs was not associated with the development of neoplasia. These findings suggest that patients with PIPs may not need an intensified surveillance strategy.

Obesity Is Associated with Increased Risk of Colectomy in Inflammatory Bowel Disease Patients Hospitalized with Clostridium difficile Infection.

Obesity and inflammatory bowel disease (IBD) are associated with increased risk of Clostridium difficile infection (CDI). The effect of obesity on IBD course and development of complications is poorly understood. We performed this study to examine the effect of obesity on CDI-related morbidity and mortality in hospitalized patients with IBD. We used data from the National Inpatient Sample across five study years (2010-2014) to identify patients ≥ 18years hospitalized with both CDI and IBD. We compared the outcomes of in-hospital mortality, partial or total colectomy, hospital length of stay, and hospital charges between obese and non-obese IBD-CDI patients. Analysis included univariate and multivariate linear and logistic regression analyses. Of 304,298 hospitalized patients with IBD, 13,517 (4.4%) patients had CDI. Of these, 996 (7.4%) patients were obese. Obese IBD-CDI patients had a higher risk of colectomy (adjusted odds ratio, AOR 1.60, 95% CI 1.30-1.96; p < 0.001), longer hospital length of stay (difference 0.8days, 95% CI 0.02-1.58; p = 0.04), and higher hospital charges (difference $11,051, 95% CI 1939-20,163; p = 0.02) than non-obese IBD-CDI patients, but no significant difference in mortality was found between the two groups. Obesity is associated with a 60% increase in the risk of colectomy, longer hospital stay, and higher charges in IBD patients hospitalized with CDI. Further epidemiological and clinical studies are needed to confirm these findings.

P352 Is diagnostic delay associated with the risk of colectomy in patients with ulcerative colitis? Results of a study of the Austrian IBD study group

Long diagnostic delay is frequent in inflammatory bowel disease and has been described to be associated with an increased risk for intestinal surgery in patients with Crohn’s disease. We sought to investigate the effect of diagnostic delay on the risk of surgery in patients with ulcerative colitis (UC). In a multicentre cohort study adult patients with UC attending 18 Austrian outpatient clinics were recruited between May 2014 and July 2015 to complete a multi-item questionnaire recording medical characteristics including diagnostic delay. Diagnostic delay was defined as the time period from the first symptom onset to diagnosis of UC. Patients without surgery were compared with those who had undergone colectomy. The survey preparation, data capturing, and exploratory data analysis were performed by using EvaSys software and SPSS. 400 patients with UC (192 females) were analysed. The median age at diagnosis was 28 years (IQR 22–41 years) and the median duration of disease was 8 years (IQR 3–16 years). 22 patients (12 females) had undergone colectomy. The median diagnostic delay in UC patients with surgery was significantly shorter than in patients without surgery (median 0.19 years (IQR 0.03–0.28 years) vs. median 0.28 years (IQR 0.19–0.87 years); p < 0.0001). The probability to be diagnosed with UC after first symptom onset is given in Figure 1. Patients with surgery had a longer duration of disease (median 18 years (IQR 10–27 years) vs. median 8 years (IQR 3–15 years; p < 0.0001). Time to diagnosis of UC (years) by colectomy during the further course of the disease In this large Austrian referral centre based UC cohort a short diagnostic delay was associated with a higher risk of colectomy. This might reflect disease severity at the time of disease onset and the subsequent course of disease.

Obesity Is Associated With Increased Colectomy Rates and Hospitalization Charges in Patients With Ulcerative Colitis Flare: A Nationwide Outcome Analysis: 2017 Fellows-in-Training Award (Obesity Category): 2017 Presidential Poster Award

Introduction: Although uncommon in the past, the obesity rates have increased in recent years in patients with ulcerative colitis (UC). Due to the paucity of cases, the effect of obesity in the history of natural disease in UC is unclear. We aimed to determine if there is any difference in outcomes of patients admitted to the hospital with UC flare in presence of obesity vs non-obese controls. Methods: A retrospective cohort study was done using the United States 2013 National Inpatient Sample, the largest publically available inpatient database in the United States. All patients with ICD-9 CM codes for a primary diagnosis of UC were included. No exclusion criteria were used. We considered in-hospital mortality as primary outcome. Secondary outcomes were morbidity measured by colectomy, intensive care unit (ICU) admission, shock, multi-organ dysfunction (MOD) and malnutrition; resource utilization measured by abdominal ultrasound (US), abdominal CT scan (ACT), length of hospital stay (LOS), total parenteral nutrition (TPN) use, total hospitalization charges (TOC) and colonoscopy. Patients were classified as obese or non-obese diagnosis based on ICD-9 CM codes. Odds ratios and means were calculated using multivariate regression analysis, after being adjusted for age, sex, race, Charlson Comorbidity Index, median income in the patient's zip code, hospital region, rural location, size and teaching status. Results: A total of 37,610 patients with UC flare were included. Mean age was 44.6 years and 52.4% were female. 2,460 (6.5%) were obese. In-hospital mortality rate was 0.54% overall, 0.6% in obese and 0.54% in non-obese patients. Adjusted odds ratios, means and p values are shown in Table 1. On multivariate analysis, obese patients did not have higher in-hospital mortality rates (OR 1.02, 95% CI 0.31-3.36; p=0.97) compared to the non-obese population. Notably, in the morbidity analysis, the obese patients with UC had higher risk of colectomy (OR 1.84, 95% CI 1.39 - 2.45; p < 0.001), although no difference in shock, ICU admission or MOD differences were found. For resource utilization, total charges were higher in the obese group; no difference was found in LOS, US, TPN and ACT use between both groups.Table: Table. Odds ratio and p-values for mortality, morbidity and resource utilization in obese versus non-obese patients with ulcerative colitisConclusion: Obesity in patients presenting with ulcerative colitis flare is associated with increased risk of colectomy and higher hospitalization charges, without affecting other morbidity, resource utilization and mortality outcomes.

Appendectomy and the Risk of Colectomy in Ulcerative Colitis: A National Cohort Study.

Ulcerative colitis (UC) is a chronic inflammatory disease usually responding well to anti-inflammatory drugs but many patients will still need colectomy. Appendectomy is associated with a lower risk of later developing UC. We aimed to assess the longitudinal relationship between appendectomy, appendicitis, and disease course in UC patients. A national cohort of UC patients with a diagnosis in 1964-2010 was identified from the Swedish National Patient Register that also provided information regarding appendicitis and/or appendectomy before or after the UC diagnosis. The risk for colectomy and UC-related hospital admissions was evaluated. Among 63,711 UC patients, 2,143 had appendectomy and 7,690 underwent colectomy. Appendectomy for appendicitis before 20 years of age and for non-appendicitis at all ages before UC diagnosis was associated with a lower risk of colectomy (hazard ratio (HR) 0.44, 0.27-0.72 and HR 0.62, 0.43-0.90, respectively), and fewer hospital admissions (incidence rate ratio (IRR) 0.68, 95% confidence interval (CI) 0.64-0.73 and IRR 0.54, 0.47-0.63, respectively). Appendectomy for appendicitis after the UC diagnosis was associated with a higher risk of colectomy (HR 1.56, 1.20-2.03), whereas no such association was found for other pathology (HR 1.40, 0.79-2.47). Appendectomy early in life and before developing UC is associated with a lower risk of colectomy as well as UC-related hospital admissions. Appendectomy for appendicitis after established UC appears associated with a worse disease course, with an increased rate of subsequent colectomy.

Predictors of severe outcomes in patients with Clostridium difficile infection from a Hispanic population.

Factors associated with complicated Clostridium difficile infection (CDI) may vary among populations, and predictors of severe outcomes in CDI have not been studied in Hispanic patients. The aim of this study was to identify factors associated with a higher risk of colectomy, all-cause mortality, and CDI-associated mortality in a Hispanic population. We performed a retrospective study of all hospitalized patients with a diagnosis of CDI between January 1, 2011 and September 30, 2015 in a 450-bed teaching hospital in Monterrey, northeast Mexico. Three main outcomes were defined: fulminant colitis with subsequent colectomy, all-cause mortality within 30days of diagnosis, and CDI-attributable mortality. Of 261 patients with diarrhea, 176 were diagnosed with CDI. For colectomy, Charlson comorbidity index, ICU stay and mechanical ventilation prior to CDI diagnosis, days with diarrhea prior to treatment, total days of hospital stay and days after CDI diagnosis, elevated ATLAS score, days of diarrhea post CDI treatment, and treatment failure significantly predicted the necessity of surgical treatment with colectomy. Treatment failure, persistent diarrhea, and a high ATLAS score were identified as risk factors for severe outcomes of CDI. A low albumin concentration and high creatinine were associated with higher overall mortality.

Appendectomy does not decrease the risk of future colectomy in UC: results from a large cohort and meta-analysis

ObjectivesEarly appendectomy is inversely associated with the development of UC. However, the impact of appendectomy on the clinical course of UC is controversial, generally favouring a milder disease course. We...

The impact of timing and duration of thiopurine treatment on colectomy in ulcerative colitis: a national population-based study of incident cases between 1989-2009.

The role of thiopurines in altering the risk of colectomy in ulcerative colitis (UC) remains unclear. To examine predictors of colectomy in UC and determine the impact of thiopurines on the risk of colectomy. We constructed a population-based cohort of incident cases of UC in the United Kingdom between 1989 and 2009. We determined trends in thiopurine usage and colectomy for three defined cohorts: era 1 (1989-1995), era 2 (1996-2002), era 3 (2003-2009). We used Cox regression to determine predictors of colectomy and quantified the impact of duration and timing of thiopurine use on the risk of colectomy. We identified 8673 incident cases of UC. 5-year colectomy rates increased from 4.2%, 5.1% to 6.9% (P=0.001) for era 1, era 2 and era 3, respectively, despite increasing thiopurine use. This was not significant after adjustment for predictors of colectomy (P=0.06). There was a higher risk of colectomy in men (HR 1.44, 95% CI: 1.19-1.73), those diagnosed at an early age (HR 1.35, 95% CI: 1.04-1.75; 16-24 vs. 25-64) and early steroid users (HR 1.94, 95% CI: 1.59-2.37). 5-ASA users were less likely to require a colectomy (HR 0.35, 95% CI: 0.28-0.44). Amongst thiopurine users, those treated for greater than 12months had a 71% reduction in risk of colectomy (HR 0.29, 95% CI: 0.21-0.40). Early thiopurines offered no additional benefit. Thiopurine exposure for greater than 12months reduces the likelihood of colectomy by 71%. Young men and those requiring steroids within 3months of diagnosis are at greatest risk of colectomy, and most likely to benefit from sustained thiopurine use.

Long-term combination therapy with infliximab plus azathioprine predicts sustained steroid-free clinical benefit in steroid-dependent ulcerative colitis.

Infliximab (IFX) has demonstrated effectiveness for inducing 12-month steroid-free clinical remission in patients with steroid-dependent ulcerative colitis (UC), but long-term data are lacking. The aim of the study was to describe the long-term outcome of IFX treatment in steroid-dependent UC and investigate if predictors of sustained clinical response and colectomy could be identified. Consecutive patients with steroid-dependent UC treated with IFX were studied. The coprimary prespecified outcomes were sustained clinical response in patients who achieved clinical remission or response after IFX induction and colectomy-free survival. Secondary analyses were addressed to look for predictors of sustained clinical response and colectomy. After induction, 76% (96/126) of patients achieved clinical benefit. The median duration of follow-up on IFX maintenance therapy was 41.5 months (interquartile range, 26-45). Sixty-four percent (46/96) of patients had sustained clinical response at median follow-up. Colectomy-free survival was 77% at median follow-up. Combination therapy of IFX with thiopurines was an independent predictor of sustained clinical response (P < 0.0001; hazard ratio [HR], 3.98; 95% confidence interval [CI], 1.73-9.14). Independent predictors of colectomy were Mayo endoscopic subscore of 3 at baseline (P = 0.04; HR, 2.77; 95% CI, 1.09-7.05) and high C-reactive protein after induction (P = 0.001; HR, 5.65; 95% CI, 2.03-15.7). Thiopurine naive status (P = 0.025; HR, 0.34; 95% CI, 0.13-0.87) was protective from colectomy. Long-term IFX treatment is effective in inducing sustained clinical response in patients with steroid-dependent UC. Combination therapy is predictive of sustained clinical response in the long-term. Patients with more severe endoscopic lesions at baseline and high C-reactive protein after induction are at higher risk of colectomy. Conversely, thiopurine naive status is protective from colectomy.