History Of Crohn's Disease Research Articles

Bone marrow adiposity in pediatric Crohn's disease.

Patients with Crohn's disease often have low bone mineral density and an increased risk of osteoporosis. Although decreased bone formation can be seen at diagnosis, the underlying pathophysiology of suboptimal bone accrual remains poorly understood. We sought to evaluate a novel mechanism affecting osteogenesis in patients with Crohn's disease. In this case series, we evaluated bone marrow composition at the distal femur and proximal tibia of the left knee measured via magnetic resonance (MR) spectroscopy and relaxometry in five adolescents with the diagnosis of Crohn's disease. The subjects were enrolled prospectively between 2011 and 2013 at Boston Children's Hospital. Additional clinical information, including DXA scans to evaluate bone mineral density and body composition, and Crohn's disease history, such as glucocorticoid use and disease duration, were assessed. Healthy adolescents have persistent hematopoietic marrow with only 40 to 50% fat in the long bone metaphyses. The current participants with Crohn's disease had increased marrow adiposity, with a mean fat fraction of 67.8%. There appeared to be a trend towards higher fat fraction with shorter disease duration, while participants with the longest disease duration had the lowest fat fraction. Participants also had decreased bone density, increased fat mass, and lower lean mass, as assessed by DXA and compared to pediatric reference data. Our MRI results demonstrate increased marrow adiposity in children with Crohn's disease, especially early in the course of the disease. DXA may better demonstrate longer-term effects on bone. Additional studies are needed to evaluate bone marrow composition in these patients and to elucidate further the inverse relationship between marrow adipocytes and osteogenesis, as well as the relationship between bone marrow adiposity and body composition.

26312 Lichen sclerosus associated with morphea in a patient treated with adalimumab

A 31-year old female with a history of Crohn disease that was well controlled on adalimumab presented with an asymptomatic 2 cm × 4 cm patch with central hypopigmentation, peripheral erythema, and fine overlying scale on her right lower back. Previous treatment with topical antifungals and topical steroids yielded no improvement. Dermoscopy revealed pronounced skin lines, yellowish-white keratotic follicular plugs, and scattered small foci of brown pigment. Biopsy demonstrated a square punch with homogenization of the papillary dermis, flattening of the rete ridges with epidermal atrophy, follicular plugging, dense hyperkeratosis, scattered pigment incontinence, and thick collagen bundles associated with a predominantly mid-dermal to deep perivascular and interstitial infiltrate composed of lymphocytes and plasma cells. With this presentation, the diagnosis of a lichen sclerosus et atrophicus and morphea overlap disorder was made. These entities can show significant histological overlap, but there are multiple reports of these diseases occurring concomitantly. There have also been reports of morphea associated with the use of adalimumab, which this patient had been using for 3 years previously. Dermoscopy has been used to describe and assist with the diagnosis of both of these conditions. Outstanding clinical, dermoscopy, and microscopic images will be presented.

A Case of Pseudomelanosis Duodeni: Striking Endoscopic Features With Subtle but Characteristic Pathologic Findings

Abstract A 72-year-old man was referred to the inflammatory bowel disease clinic for evaluation for possible Crohn disease. The patient was diagnosed with pan-ulcerative colitis in the late 1960s. He had medically refractory disease and required a total proctocolectomy with end ileostomy in the early 1970s. Since surgery, the patient has done well with his end ileostomy and has not required any inflammatory bowel disease medications. Over the past 14 months, he has developed intermittent foul-smelling serosanguinous drainage from his previous drained pilonidal cyst. His local gastroenterologist raised the concern for possible Crohn disease with perianal involvement. He has a significant family history of Crohn disease in his father. Past medical history includes chronic kidney disease, hypertension, diabetes, coronary artery disease, gout, and arthritis. Esophagogastroduodenoscopy (EGD) revealed diffuse brown to black speckled/tigroid spots in the entire examined duodenum. Duodenal biopsy showed scattered clusters of macrophages containing dark pigmented granules within the apical tips of the lamina propria. These pigmented granules were focally positive with iron staining. No villous blunting, intraepithelial lymphocytosis, granuloma, or significant inflammation was identified. The distinctive endoscopic and histologic features are diagnostic of pseudomelanosis duodeni. Pseudomelanosis duodeni is a rare benign entity characterized by diffuse black tigroid spots and aggregates of pigment-laden macrophages in the lamina propria. Results of iron staining are characteristically variable. Pseudomelanosis duodeni is seen in middle-aged to elderly adults. Most of the patients with pseudomelanosis duodeni are asymptomatic. Although the exact etiology remains unknown, pseudomelanosis duodeni has been reported to be associated with several medical conditions such as end-stage renal disease, hypertension, diabetes, heart failure, gastrointestinal hemorrhage, and medications, including oral iron therapy, furosemide, hydralazine, thiazide, and iron sulfate. Pathologists should be aware of this rare condition of the duodenum to make an accurate diagnosis of this rare entity.

Adolescent Female with Jaundice and Edema

An 18-year-old female presented to the emergency department at Texas Children's Hospital with intermittent symptoms of fever, nausea, poor food intake, fatigue, and shortness of breath in the past 3 months. The patient reported excessive weight loss of 10 lbs in the last month. On physical examination, her weight was 40.6 kg (89 lbs, 8.1 oz) and height was 153.4 cm, with a body mass index of 17.30 kg/m2. Other significant physical examination findings included scleral icterus, edema (4+ in bilateral lower extremities), and tachycardia. Abdominal examination was remarkable for the presence of distension and ascites, with tenderness in the left lower quadrant. Patient had a history of Crohn disease with several failed therapies and at presentation was on Cimzia®, an antitumor necrosis factor α (TNF-α) monoclonal antibody therapy, and prednisone. Initial laboratory results at the emergency department showed concentrations of sodium of 130 mmol/L, potassium of 3.4 mmol/L, chloride of 101 mmol/L, and albumin of 1.7 g/dL. She was then admitted to the intensive care unit (ICU)3 for intensive monitoring and correction of her electrolyte abnormalities. Further laboratory tests demonstrated hyperbilirubinemia (mainly conjugated bilirubin) and increased liver enzymes, including aspartate aminotransferase, alanine aminotransferase, and γ-glutamyltransferase, and increased prothrombin time and partial thromboplastin time (Table 1). Her …

Influence of NSAID Use Among Colorectal Cancer Survivors on Cancer Outcomes.

Colorectal cancer (CRC) is the third most common cancer diagnosed in men and women in the United States. Given the availability of effective screening, most tumors are found early enough to offer patients substantial long-term survival. Thus there is a resulting significant population of CRC survivors for whom modifiable risk factors for recurrence and survival would be of interest. We conducted a population-based retrospective cohort study among patients enrolled in 2 large Midwestern health plans for which claims data, including pharmacy fill data, and medical record data were available. Men and women who were 40 years of age or older at the time of CRC diagnosis with disease less than stage IV and no history of Crohn disease, ulcerative colitis, and irritable bowel syndrome were included. CRC cases diagnosed between January 1, 1990 and December 31, 2000 were included if they met the inclusion criteria. Adjusted Cox proportional hazard models were used with exposure modeled as a time-dependent covariate. We assessed progression-free survival, defined as an aggressive polyp or invasive disease, and overall survival. After adjustment for age at diagnosis, sex, race, body mass index, stage, side of initial tumor, and tumor histology, we found that current users of nonsteroidal anti-inflammatory drugs had a 3-fold decreased risk of recurrence and a >7-fold decreased risk of death. Our results are statistically significant with P-values <0.05. Our results suggest that current use of nonsteroidal anti-inflammatory drugs provides significant improvements in CRC outcomes.

Can ultrasound be used as the primary imaging in children with suspected Crohn disease?

There is growing literature on the use of ultrasound (US) for evaluation of Crohn disease in adults, but few studies have been conducted on children. Several studies demonstrated high accuracy of US in the diagnosis of Crohn disease. Using US as the primary screening imaging modality for Crohn disease can reduce health care costs, the need for sedation and ionizing radiation exposure. The aim of our study is to determine if US can be used for screening evaluation of pediatric Crohn disease. A prospective cohort study of pediatric patients undergoing MR enterography (MRE) for suspected or known history of Crohn disease was performed, with gray-scale and Doppler US of the terminal ileum done immediately before or after MRE. US images were interpreted by two radiologists (Reader 1 and Reader 2) not involved in image acquisition, in blinded and randomized fashion. US findings of Crohn disease including bowel wall thickening, wall stratification, increased vascularity on Doppler, lymphadenopathy, fat infiltration and extraintestinal complications were evaluated. MRE findings of terminal ileitis were considered the reference standard. Demographic data, body mass index (BMI), symptoms, and laboratory, endoscopic and histopathological data were obtained from electronic medical records. Forty-one patients (mean age: 13.7 years: 4.6-18.9 years) were evaluated. Mean BMI was 21.2 (range: 13-40.2); 10 patients (24.3%) were either overweight or obese. Final diagnoses were Crohn disease (n=24), ulcerative colitis (n=4) and normal/non-inflammatory bowel disease-related diagnoses (n=13). US demonstrated sensitivity of 67% and 78% and specificity of 78% and 83%, by Reader 1 and Reader 2, respectively. MRE sensitivity and specificity were 75% and 100%, respectively, compared to final clinicopathological diagnosis. Interobserver agreement between Reader 1 and Reader 2 was good (0.6< kappa <0.8). In screening for Crohn disease in children, US has limited sensitivity for detecting terminal ileitis.

Treatment of metastatic cutaneous Crohn disease with certolizumab

Metastatic Crohn disease is a rare cutaneous manifestation of Crohn disease characterized by granulomatous lesions discontinuous with the diseased areas of the gastrointestinal tract. We report a case of a 32-year-old woman with history of Crohn disease who was admitted for treatment of cellulitis after presenting with a tender erythematous plaque of the left calf. Microbiological tests including tissue cultures were negative. A skin biopsy revealed granulomatous dermatitis consistent with metastatic cutaneous Crohn disease. Owing to concomitant perianal fistulas and abscesses and prior infusion reaction to infliximab, the patient was treated with certolizumab, a pegylated tumor necrosis factor (TNF) inhibitor combined with methotrexate resulting in complete resolution of the skin lesion. This case emphasizes the importance of recognizing this rare skin manifestation of Crohn disease and adds certolizumab as one of TNF inhibitors useful in the treatment of metastatic cutaneous Crohn disease.

75-Year-Old Man With Abdominal Pain and Reflux

75-Year-Old Man With Abdominal Pain and Reflux

Granulomatous Interstitial Nephritis as a Manifestation of Crohn Disease

Granulomatous interstitial nephritis is a rare extraintestinal manifestation of Crohn disease that has been described previously in 4 patients. We report a 23-year-old man with a history of Crohn disease since age 6 years who was admitted to the hospital for weight loss, fever, and bloody diarrhea in the midst of a recent flare up during the past 2 months. Investigations revealed anemia, high erythrocyte sedimentation rate, high C-reactive protein level, and an elevated serum creatinine level. Histopathologic examination of tissue specimens obtained at renal biopsy demonstrated granulomatous interstitial nephritis. Crohn disease needs to be in the differential diagnosis of granulomatous interstitial nephritis and can be a manifestation of drug allergy or the Crohn disease itself.

Intraperitoneal and Extraperitoneal Colonic Perforation Following Diagnostic Colonoscopy

Both intraperitoneal and extraperitoneal colonic perforations have been reported after colonoscopy; however, cases with combined types of perforation are rare. We present the case of a 55-year-old man with a history of Crohn disease who complained of acute abdominal pain after a diagnostic colonoscopy. Abdominal computed tomography scan showed extensive pneumoperitoneum, pneumoretroperitoneum, pneumomediastinum, and leftsided pneumothorax. Exploratory laparotomy was performed, and the patient underwent subtotal colectomy and end ileostomy with placement of a left-sided chest drain for the left-sided pneumothorax. The patient was discharged home postoperatively in good condition. As the utility of colonoscopy continues to broaden, its complications will also be more common. Whereas intraperitoneal perforation is a known and not uncommon complication, extraperitoneal perforation is an uncommon complication. Combined intraperitoneal and extraperitoneal perforation is extremely rare, with only a few cases reported in the literature. Early diagnosis and operative management resulted in a satisfactory outcome in this particular case.

Abdominal Aortitis Associated with Crohn Disease

Bronx Lebanon Hospital Center, Bronx, New York, USA Correspondence: Dr Hassan Tariq, Bronx Lebanon Hospital Center, 1650 Selwyn Avenue, Suite 10C, Bronx, New York 10457, USA. Telephone 718-900-1234, e-mail htariq@bronxleb.org Received for publication July 31, 2013. Accepted September 19, 2013 Case Presentation A 26-year-old woman who was diagnosed with Crohn disease when she was 12 years of age presented with a two-week history of nausea, vomiting, worsening diarrhea and bilateral lower abdominal pain. The patient had a protracted history of Crohn disease treated with mesalamine, tapering short courses of corticosteroids for exacerbations and then 6-mercaptopurine therapy initiated three years before this presentation. Nine months before the patient presented, she was also started on subcutaneous adalimumab and maintained on a dose of 40 mg every other week. Her white blood cell count was 10×109/L (65.5% segmented neutrophils, 28.9% lymphocytes, 4.8% monocytes), with a hemoglobin level of 123 g/L and a platelet count of 164 ×109/L. An abdominal computed tomography scan revealed multifocal areas of mural thickening with narrowing in the colon (Figure 1), long-segment minimal thickening with narrowing of the upper abdominal aorta and maximal luminal narrowing in an infrarenal aortic segment (Figure 2). These findings were suggestive of aortitis, which is very rarely associated with Crohn disease.

Extraintestinal Crohn Disease Causing Bilateral Nasolacrimal Duct Obstruction

A 16-year-old boy presented with complaints of epiphora and bilateral palpably distended lacrimal sacs. He had a history of Crohn disease involving the small and large intestines, and a history of granulomatous cheilitis. Bilateral dacryocystorhinostomies were performed through an external approach and revealed multiple nodular masses in both lacrimal sacs, which on biopsy, contained granulomatous inflammation consistent with extraintestinal Crohn disease. A literature search from 1966 to the present using the PubMed database revealed three previous publications describing nasolacrimal duct obstruction associated with Crohn disease, but these cases did not show pathologic evidence of granulomatous inflammation. To our knowledge, this is the first reported case of extraintestinal Crohn disease with granulomatous inflammation affecting the lacrimal-outflow system.

A Case of Rectal Cancer Associated with a 15-year History of Crohn's Disease

クローン病に併発する悪性疾患の報告は増加している，しかしながら，クローン病に合併する腸管狭窄や瘻管形成のため，癌発生の早期診断は困難である.今回，クローン病の発症から15年を経て直腸癌を併発したと考える症例を経験した.内科的治療が行われていたが，発症後15年で直腸肛門周囲膿瘍を形成すると共に急速に直腸狭窄が進行した．内視鏡的に狭窄拡張術を行ったが効果を認めなかった．高度狭窄にて内視鏡観察が困難なため，colitic cancerを疑い透視下生検を行ったところ，低分化腺癌と診断された．腹会陰式直腸切断術を行い，術後抗癌剤治療を加えたものの早期に再発し予後不良であった.クローン病患者に対するサーベイランスを含む，併発癌に対し治癒可能な早期での発見方法を考えることが必要である.

On “Spondyloarthritis in a patient with unilateral buttock pain and history of Crohn disease.” Coronado RA, et al. Phys Ther. 2010;90:784–792.

First, I would like to commend the authors on describing a well-thought-out diagnostic approach when examining a patient with complex low back pain (LBP).1 I believe this article clearly shows how difficult the diagnostic process can be in patients with LBP. A critical question brought up by the authors of this case report is: should we move away from identifying specific tissue pathology or pain generators when trying to make a diagnosis in patients with LBP? I think this article gives us a clear reason why we should probably not . Although definitely …

Spondyloarthritis in a Patient With Unilateral Buttock Pain and History of Crohn Disease

Patients with inflammatory spinal conditions related to spondyloarthritis are rarely seen by primary care practitioners. However, patients with a history of inflammatory bowel disease and chronic low back or buttock pain should be examined carefully for the presence of spondyloarthritis, as proper management may include referral to a rheumatologist and appropriate medical intervention. A 27-year-old woman with a 6-month history of posterior buttock pain was referred for physical therapy with a diagnosis of piriformis syndrome. During the second physical therapy visit, a nonmechanical source of lumbopelvic pain was suspected, and the patient was referred for medical consultation. The patient underwent evaluation by a rheumatologist and was eventually diagnosed with spondyloarthritis associated with inflammatory bowel disease. The patient initiated treatment with anti-tumor necrosis factor medication to address the spondyloarthritis. Medical management resulted in significant improvement in all outcome measures. Clinical suspicion of spondyloarthritis is raised when specific historical, examination, and imaging findings are present. The posttest probability of spondyloarthritis is increased with the presence of inflammatory back pain and specific spondyloarthritic features, such as a positive history of inflammatory bowel disease, radiographic evidence of sacroiliitis, and improvement with anti-inflammatory medication. Referral of patients with these findings for a rheumatological evaluation is warranted, as these diseases are managed effectively with specific treatment.

Anterior ischemic optic neuropathy in a patient with Crohn's disease and aberrant MTHFR and GPIIIa gene variants

Large spectrums of ophthalmic manifestations from the anterior to the posterior segment have been so far reported in patients with inflammatory bowel disease. Anterior ischemic optic neuropathy is caused by acute ischemic infarction of the optic nerve head and is distinguished in two different types, non-arteritic anterior ischemic optic neuroparhy (NAION) which is the most frequent type and arteritic anterior ischemic optic neuropathy. Non-arteritic anterior ischemic optic neuroparhy may result in severe visual field loss. We present the case of a 69 year-old man with known history of Crohn's disease that was referred to the Department of Ophthalmology after noticing sudden blurred vision of his left eye. Ophthalmologic examination revealed a corrected visual acuity of 8/10 OS and 10/10 OD. Pupil examination showed a relative afferent pupillary defect of the left pupil and fluoroangiography revealed hyperfluorescence of the left optic disc, indicating edema and NAION attack on his left eye. Genetic analysis showed that the patient was homozygous for MTHFR C677T genetic polymorphism and A1/A2 heterozygous for GPIIIa polymorphism.

Increased Response and Remission Rates in Short-Duration Crohn's Disease With Subcutaneous Certolizumab Pegol: An Analysis of PRECiSE 2 Randomized Maintenance Trial Data

We sought to analyze the efficacy (response and remission) and safety data from the PRECiSE 2 trial of certolizumab pegol according to duration of Crohn's disease since diagnosis at baseline. Responders to induction treatment with certolizumab pegol at week 6 in PRECiSE 2 (n=425) were randomized to receive certolizumab pegol 400 mg (n=215) or placebo (n=210) until week 26. Logistic regression analysis identified factors linked to Crohn's disease history (short duration, no prior infliximab use, no corticosteroids, no operations) as prognostics of outcome. Efficacy (response, remission) and safety data were reanalyzed according to duration of Crohn's disease since diagnosis at baseline. The proportions of patients in response at study end were inversely related to duration of Crohn's disease. Maintenance of response with certolizumab pegol was achieved in 89.5% of patients with a diagnosis <1 year (P<0.01 vs. placebo), compared with 57.3% of patients with a diagnosis > or = 5 years (P<0.001 vs. placebo). Corresponding remission rates were 68.4% (P<0.05 vs. placebo) and 44.3% (P<0.001 vs. placebo), respectively. Response and remission rates did not differ significantly by disease duration in placebo subgroups. Incidences of adverse events were unaffected by duration of disease at baseline. These data suggest that patients treated with certolizumab pegol 400 mg earlier rather than later, with a confirmed Crohn's disease diagnosis, may achieve better treatment outcomes.

Reversible dementia with parkinsonian features associated with budesonide use

A 51-year-old man was referred for neurologic consultation because of increasing forgetfulness, difficulty walking, frequent falls, apathy, and decreased motivation to perform activities of daily living such as bathing, cooking, and driving, over a 6-month period. He had a history of Crohn disease (CD), diabetes, and coronary artery disease. Current medications included amlodipine, rosiglitazone, hydrochlorothiazide, and budesonide. He was treated with oral prednisone for CD in the past with excellent response. Two years before evaluation, he developed multiple side-effects including weight gain, edema, and hypertension that precluded the use of prednisone. Nine months prior to his presentation, he was started on oral budesonide at 9 mg/day. He tolerated the new medication well and had none of the side-effects previously noted. However, he experienced a relapse of his CD 6 weeks after an attempt was made to discontinue budesonide, and the medication was restarted. On initial examination, he had a Mini-Mental State Examination (MMSE) score …

Small bowel obstruction secondary to a giant enterolith complicating Crohn’s disease

Enterolith formation associated with Crohn's disease is a very uncommon clinical entity. To describe a case of sub-acute small bowel obstruction secondary to a giant enterolith in a patient with Crohn's disease. A 54-year-old male with a history of Crohn's disease presented with sub-acute small bowel obstruction secondary to a giant enterolith. The diagnosis was confirmed utilising plain film radiography and computed tomography Plain film radiography and computed tomography play a central role in establishing the diagnosis of this rare complication of Crohn's disease and assist in planning surgical intervention.

Infectious scleritis caused by Bacillus species bacteria

A case of infectious scleritis with recurrent abscess formation developed in a 26-year-old man with a history of Crohn disease. Culture of the abscess contents yielded Bacillus species. An excisional biopsy of the abscess was performed, and the patient was treated with aggressive antibiotic therapy. Infectious scleritis involving Bacillus species bacteria likely has not been previously reported in the literature. Bacillus species bacteria should be considered a posible agent of infectious scleritis.