Inflammatory Bowel Disease Population Research Articles

P687 Prevalence of iron deficiency and anaemia in the outpatient Inflammatory Bowel Disease population: a Dutch national cross-sectional study

Abstract Background Iron deficiency (ID) and anaemia in Inflammatory Bowel Disease (IBD) are associated with reduced quality of life, worse disease outcomes, and an increase in healthcare costs. In the European guidelines, anaemia is listed as one of the treatment goals. The data on the prevalence of anaemia and ID are inconsistent. Therefore, we evaluated the prevalence of ID, anaemia, and potential risk factors in a large Dutch outpatient population. Methods Between January and November 2021, consecutive adult outpatients with IBD, who did not have significant comorbidities associated with anaemia, were included in this study across 16 general, teaching, and academic hospitals within the Netherlands. Besides demographic and clinical data, relevant biochemical parameters such as haemoglobin (Hb), Mean Corpuscular Volume (MCV), iron indices, and inflammatory markers (e.g., C-reactive protein (CRP) and faecal calprotectin (FCP)) were extracted from medical records. Active IBD was defined by either CRP >5mg/L or FCP >150mg/g. ID was defined by ferritin <100µg/L in case of inflammation and <30µg/L in quiescent IBD, or transferrin saturation <20%. The Dutch national reference range was used to define anaemia: Hb <7.5mmol/L or <8.5mmol/L for females and males, respectively. The data were analysed by stratifying patients into Crohn’s Disease (CD) and Ulcerative Colitis (UC) groups, with the latter also including patients with IBD-unclassified (IBDU). Results In total, 2197 patients (1271 CD, 849 UC, and 77 IBDU) were included in the study. The overall prevalence of anaemia, iron-deficiency anaemia (IDA), and ID was: 18.0%, 12.2%, and 43.4%, respectively. The prevalence of all three conditions did not differ between the CD and UC groups (P>0.05). Severe anaemia (Hb<6.2 mmol/L) was observed only in 28 patients. ID was more frequently observed in biochemically active IBD compared with quiescent IBD (70.8% versus 23.9%; P<0.001). Female gender, younger age, low MCV, and a twofold increase in biochemical inflammation were associated with ID development in multivariable analysis: Log2FCP [OR 1.39; 95% CI: 1.29–1.50; P<0.001] and Log2platelets [OR 1.85; 95% CI: 1.16–2.95; P<0.01]. In multivariable analysis, low ferritin and MCV, inflammation, older age, and male gender were associated with a higher risk of anaemia; however, disease location or behaviour did not affect the risk of developing anaemia or ID. Conclusion One in five ambulatory IBD patients presents with anaemia that is primarily caused by ID. Inflammation increases the risk of ID and anaemia regardless of IBD type or disease location. High ID prevalence suggests the need for screening and treatment optimisation.

Outcomes in patients with inflammatory bowel disease and acute gastrointestinal symptoms who test indeterminate for Clostridioides difficile.

BackgroundInflammatory bowel disease (IBD) and Clostridioides difficile infection (CDI) can present with similar symptoms. The current preferred method for diagnosing CDI is the nucleic acid amplification test (NAAT) for C. difficile in stool, followed by reflex toxin enzyme immunoassay (EIA) when NAAT is positive. The clinical significance of NAAT(+)/EIA(-) in the IBD population is uncertain.MethodsThis retrospective cohort included IBD patients who presented with acute onset of gastrointestinal symptoms and a C. difficile NAAT(+) test. The primary outcome was C. difficile recurrence within 12 months. Other outcomes examined included hospital admissions within 30 days of CDI, change of IBD maintenance therapy within 90 days of CDI, and complications such as bowel resection or death.ResultsA total of 71 patients were included. Eighty-four percent of the tests were EIA(-) and among the EIA(-) 88% were treated with antibiotics. Outcomes between EIA(+) and EIA(-) were not significantly different in terms of recurrences, admissions, changes to IBD medications or complications. Outcomes were also similar when comparing those who received antibiotic therapy to those who did not.ConclusionsOur cohort did not demonstrate a significant difference in outcomes between EIA(+) and EIA(-) C. difficile patients. Treatment for EIA(-) patients did not improve outcomes. Even though there may be a role for antibiotic therapy in IBD patients who test NAAT(+)/EIA(-) for C. difficile, further studies will be needed to identify that subpopulation.

Systematic Review and Meta-Analysis: Seroprevalence, Vaccination Rates, and Response for Hepatitis A in Inflammatory Bowel Disease

Introduction Guidelines recommend hepatitis A virus (HAV) vaccination in individuals with inflammatory bowel disease (IBD). We performed a systematic review to inform the clinical practice regarding this guidance. Methods After a PubMed and Embase search, duplicates were removed and the remaining titles screened for studies reporting relevant outcomes. Pooled seroprevalence rates for HAV, pooled vaccination rates, and pooled seroconversion rates were calculated. We also calculated pooled relative risk of seroprevalence for HAV among IBD and control population. Heterogeneity was investigated using subgroup analysis. Results The pooled seroprevalence of HAV antibodies in patients with IBD (14 studies, 2,370 patients) was 0.36 (95% confidence interval [CI]: 0.22–0.53, I 2 = 95%). On comparing the seroprevalence of HAV in IBD with controls (4 studies), the pooled relative risk was not different between the two (0.94, 95% CI: 0.66–1.34, I 2 = 76%). The pooled seroconversion rate after two doses of HAV vaccination (5 studies, 221 patients) was 0.93 (95% CI: 0.88–0.96, I 2 = 0%). Three studies (104 patients) reported on the seroconversion after a single dose of HAV vaccination and the pooled seroconversion rate was 0.47 (95% CI: 0.35–0.59, I 2 = 20%). The pooled vaccination rate for hepatitis A among patients with IBD (18 studies, 9,521 patients) was 0.21 (95% CI: 0.14–0.30, I 2 = 99%). Conclusion Hepatitis A vaccine has good immunogenicity in patients with IBD. The decision to routinely vaccinate IBD patients may be made in light of underlying seroprevalence of HAV.

Growth Failure in Pediatric Inflammatory Bowel Disease: A Preliminary Analysis

Background: Inflammatory bowel disease (IBD) is a chronic relapsing disease, characterized by chronic inflammation of the gastrointestinal tract (GIT). The incidence of IBD has been increasing over the last two decades, for example, from 1999- 2008 incidence increased from 21.3 to 26.2 per 100,000. Inflammatory bowel disease is mainly classified into two types: Crohn’s disease (CD), and ulcerative colitis (UC). Both types can be identified and distinguished through laboratory tests such as ESR, CRP, and fecal calprotectin, radiographic imaging, and direct visualization via colonoscopy. The etiology of growth failure in IBD, BMI z-score of less than -2.5, is poorly understood; however, chronic inflammation, low-calorie intake, and consequential steroid treatment are the most important factors. This study aims to determine the incidence of growth failure and associated factors in pediatric patients with IBD.
 Methods: This was a retrospective cohort study of children aged 15 years and below, with the diagnosis of IBD. Data were obtained from the pediatric gastroenterology department pediatric inflammatory bowel disease database from 2007 to 2017. Our study identifies the prevalence of growth failure via a calculated BMI z-score of less than -2.5 among the pediatric inflammatory bowel disease (PIBD) population. The Chi-square test is used for categorical data and Wilcoxon rank-sum test for continuous data. A p-value <0.05 was considered statistically significant. All analyses were carried out with Stata IC/15.1 (StataCorp LP, College Station, TX, USA).
 Results: A total of 36 patients were included. The mean age of children with growth failure at the time of IBD diagnosis was 8 (±4), and more than half of them (58.3%) were boys. The incidence of growth failure at the time of diagnosis was 22.2% and declined to 11.1% over 26 months. Furthermore, the mean BMI z-score gradually improved from -0.741 to -0.1 over the same period of follow-up after proper management and multidisciplinary involvement.
 Conclusion: Growth failure in IBD patients according to our data is uncommon, however, it was reduced by 50% over 26 months. This could be attributed to nutritional status improvement over the management period. We recommend following the stepwise approach according to the severity of the disease and managing IBD patients by a multidisciplinary team. However, due to the relatively small sample size and low growth failure incidence, a large-scale study is recommended to determine any causal relations.

High But Inequitable COVID-19 Vaccine Uptake Among Patients with Inflammatory Bowel Disease

Coronavirus disease 2019 (COVID-19) vaccines are recommended for all patients with inflammatory bowel disease (IBD).1 Patients with IBD historically have had low vaccine uptake relative to the general population.2 However, a recent survey suggested a rate higher than that of the general population with regard to COVID-19 vaccine intent among the IBD population. Their study was limited being that 96% of the patients surveyed identified as White, and 88% had attained a bachelor's degree or higher level of education.3 Therefore, these findings may not be representative of the IBD population as a whole. Previous studies have indeed identified disparities in influenza vaccine uptake within the IBD population.4,5.

Corticosteroid and Biologic Use Not Associated With Adverse Outcomes for Inflammatory Bowel Disease Patients Hospitalized With COVID-19.

BackgroundTo date, studies investigating the inflammatory bowel disease (IBD) patient experience with coronavirus disease 2019 (COVID-19) have consistently reported that the observed rate of COVID-19 within this population is similar to the general population. Limited research has suggested that corticosteroid use in the IBD population may be associated with worse COVID-19 outcomes, but it is still yet to be determined if specific IBD-related clinical factors are associated with worse outcomes. Our goal was to describe clinical COVID-19 outcomes for IBD patients and to identify the clinical factors that may be associated with worse outcomes.MethodsIn this retrospective study, we utilized the inpatient database within the largest hospital network in the New York City Metropolitan area to identify all IBD patients with confirmed COVID-19.ResultsOf 83 IBD/COVID-19 patients presenting to a hospital network emergency room, 56 were hospitalized. Overall, 19.6% of hospitalized IBD patients died, compared with 22.2% of all hospital system COVID-19 patients during the time period. There was no association between pre-admission corticosteroid use or biologic treatment with a severe course of COVID-19.ConclusionsIn contrast to some prior reports, we did not observe an association of pre-admission corticosteroid use and adverse outcomes. While the mortality rate was high for IBD/COVID-19 patients, it was not greater than that for hospitalized COVID-19 patients generally. Though our results are encouraging, we continue to support the recommendations of the leading gastrointestinal and IBD societies to regard our patients as “at risk”, and to observe caution in their care.

P063 Prevalence in the Use of Complementary/Alternative Medicine in Patients With Inflammatory Bowel Disease from Centro Médico Nacional 20 de Noviembre.

Frequently, existing therapies for inflammatory bowel disease (IBD) do not achieve complete remission of the disease and are commonly associated with adverse effects. Therefore, patients regularly turn to complementary or alternative medicine (CAM). International CAM use in IBD patients ranges from 21% to 60%. There are no reported statistics of CAM use in the Mexican population who suffer IBD. This study´s objective was to determine the prevalence and characterize the use of CAM in our IBD population. Observational, cross-sectional, retrospective study in patients diagnosed with IBD belonging to our Institution's IBD center. The results were analyzed with measures of relative frequency, central tendency, and dispersion. A total of 52 patients with IBD (78% ulcerative colitis and 22% Crohn's disease) were included, 38.5% were exposed to CAM. A total of 27% used it as an aid in their IBD treatment. The remaining 11.5% used it for other reasons. Patients exposed to CAM for IBD averaged 51 ± 19 years, 64% were female and 71% had at least an undergraduate degree. The most used CAMs were acupuncture (42.8%), herbal (35.7%) and homeopathy (35.7%). Half of the patients used concomitantly two or more modalities, and 91.6% of the patients knew their diagnosis at the time that CAM was being used. The median exposure time to CAM was 4.5 ± 40.7 months. The main reasons for the use of CAM in IBD patients was as a complementary therapy in 58.3%, as the perception of lack of improvement was present in 33.3% of patients. Twenty-five percent of patients used CAM after a healthcare professional recommended it. CAM was used in 83.2% of patients with conventional treatment (Mesalamine: 74.6%, Mesalamine + Azathioprine: 8.3%) and only 16.5% were on biological therapy. A total of 58.3% CAM users perceived improvement in their symptoms. Currently 25% still use some modality of CAM. No statistically significant differences were found in sociodemographic variables and clinical outcomes when comparing the IBD group exposed to CAM vs the unexposed group. Exposure to CAM for IBD treatment had a prevalence of 27%. The main CAM modalities for IBD patients were acupuncture, herbal, and homeopathy. No relationship was demonstrated between the use of CAM in IBD patients and their clinical outcomes.

P058 Impact of Inflammatory Bowel Disease Treatment and Risk of Covid-19 Infection after Full Immunization: A Nationwide Analysis.

BACKGROUND: Acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has caused a major challenge in patients with Inflammatory Bowel Disease (IBD) as immunosuppression used to treat these patients may increase their risk for infection. This study examined the Covid-19 vaccination rates and the potential impact of IBD treatments on the SARS-CoV-2 infection rates after receiving full immunization against Covid-19. METHODS: We identified patients aged 18 to 90 who received the BNT162b2 (Pfizer–BioNTech), mRNA-1273 (Moderna), and Ad26.COV2.S (Johnson & Johnson) Covid-19 vaccines between January 20, 2020, and July 1, 2020, from 65 health organizations that are part of the TrinetX Research Network. The post-immunization Covid-19 infection rate was compared at 3 and 6 months between non-IBD versus IBD patients receiving treatment with biologic/small molecule (Certolizumab, Ustekinumab, Infliximab, Adalimumab, Vedolizumab, Tofacitinib), immunomodulators (Methotrexate, Azathioprine, Mercaptopurine, Mycophenolic acid, Mycophenolate mofetil), or other agents (Mesalamine, Sulfasalazine, Balsalazide, Budesonide). In order to control for potential confounders, propensity matched (PSM) was used to examine the cohorts. RESULTS: The total IBD cases identified was 140,493; of those, (n = 5,658) 4.02% were fully vaccinated (2 doses of Pfizer-BioNTech, 2 doses of Moderna, and 1 dose of Johnson & Johnson), and (n = 639) 0.45% were partially vaccinated (1 dose of Pfizer-BioNTech and 1 dose of Moderna). IBD cases on biologic/small molecule treatments (n = 1,315) were compared with the non-IBD population (n = 821,744), which created a well-matched PSM of (1,315/1,315). No significant difference was found for the Covid-19 infection rate at 3 months (36% vs 33.5%, P = 0.16) and at 6 months (37.0% vs 34.3%, P = 0.15). The IBD population that were on immunomodulators (n = 3,594) as part of their treatment were compared with the non-IBD population (n = 821,744), which created a well-matched PSM of (3,593/3,593). The Covid-19 infection rate at 3 months (33.8% vs. 37.2%, P = 0.03) and 6 months (35.1% vs. 38.7%, P = 0.002) showed a significant difference between these groups with higher rates in IBD patients. The authors examined other therapies among IBD cases (n = 1,199), which were compared with the non-IBD population of (n = 821,744); this created a well-matched PSM of (1,199/1,199). No significant difference was found for the Covid-19 infection rate at 3 months (36.7% vs. 35.7%, P = 0.61), and at 6 months (37.9% vs. 37.2%, P = 0.70). CONCLUSION: In a large nationwide database, the Covid-19 immunization rate among IBD patients was found to be suboptimal (4.02%). Only IBD patients on immunomodulators as a part of their treatment regimen were at an increased risk of Covid-19 infection post full vaccination at 3 and at 6 months. This may suggest that this population could benefit from an early booster against Covid-19.

P034 State of Health Maintenance Among IBD Patients at a Tertiary Care Center in Abu Dhabi, United Arab Emirates.

Crohn's disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases (IBD) affecting 6.8 million persons globally. Treatment of IBD focuses largely on immune suppression or modulation using corticosteroids, aminosalicylates, thiopurines, or biologic agents. These agents are effective but most of them pose a risk of infections, cancers, and osteoporosis. Many of these complications can be prevented by implementing vaccination, cancer screening, and bone health programs. Despite the progress in IBD care, recent data suggest that many IBD patients do not get preventative services. Previous studies have examined rates of vaccinations and other health maintenance metrics in North America and Europe where IBD patients are mainly of European and African descent. In comparison, Middle Eastern and Asian descent persons comprise the majority of the IBD population in Abu Dhabi, the capital city of United Arab Emirates (UAE), a major country in the Gulf region of the Middle East. Little is known to date about the state of IBD preventative care in this region. We sought to assess the proportion of patients with IBD that underwent recommended vaccinations, cancer screening (surveillance colonoscopy, PAP smear, annual skin examination), and bone health evaluation at Sheikh Shakhbout Medical City (SSMC), the largest tertiary care hospital in Abu Dhabi. This study was a retrospective case series of adult IBD patients (>18 years) seen in the outpatient setting at SSMC from 2019 to 2020. Patients were identified based on ICD-10 codes for IBD [K50.90, K50.00, K51.90, and K50.80] as well as administrative/pharmacy records of the IBD agents (e.g. infliximab). Proportions were assessed using simple summary statistics and one sample proportion 95% confidence intervals were calculated. A total of 55 IBD patients were identified in our study with the majority being males (76.3%). The mean age was 31.6 years. Sixty-nine percent had Crohn's. Most of the patients were on infliximab (58.1%), followed by vedolizumab, ustekinumab, and adalimumab. The proportion of patients who received vaccinations was as follows; HAV (67%, 95% CI 28-100%), HBV (50%, 95% CI 28-72%), pneumococcal 23 (20%, 95% CI 9.4-31%), pneumococcal 13 (18.2%, 95% CI 8-28%) and influenza vaccine (16.4%, 95% CI 7-26%). Moreover, the study showed that the proportion of IBD patients who underwent recommended colonoscopy surveillance was 91% (95% CI 79-100%) and the proportion of women IBD patients who had recommended PAP smear was 30%, (95% CI 2-58%). Regarding bone health, the proportion who underwent DXA bone scans was 36%, (95% CI 24-49%) However, the compliance rate of the Tdap, HPV and Zoster vaccinations, and annual skin examination were poor warranting further quality improvement studies. This study revealed that the state of health maintenance among IBD patients seen at our facility before 2021 was largely dismal. Efforts are being taken to improve the proportion of patients who receive recommended vaccinations including annual influenza, pneumococcal 13 and 23, HPV, Zoster, and COVID-19 vaccines. Furthermore, there is a focus on bone health and skin cancer examinations with plans to calculate, report, and publish health maintenance data annually.

Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Epidemiology-The Trends of Disease Over Time.

At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, there were many unknowns: transmission vectors of the virus, appropriate intervention strategies and if being immunocompromised due to inflammatory bowel disease (IBD), for example, or medications put a person at increased risk for severe COVID-19. Imposing and relaxing of public health restrictions at different times and in different regions in Canada led to different epidemiologies of the virus in different provinces and territories. In order to understand the waxing and waning of waves of the COVID-19 pandemic, it is necessary to understand the effective reproductive number (Rt) and the countervailing forces that exert upward or downward pressure on the spread of the virus at a given point in time. As many regions in Canada deal with a third wave, the primary forces affecting the Rt of severe acute respiratory syndrome coronavirus 2 are variants of concern and the increasing vaccinations of Canadians leading to increased population-level immunity. Fortunately, for the IBD population, current research suggests that those with IBD are not at increased risk of contracting COVID-19, nor of having a more severe disease course when compared to the general population.

Association of Fecal Calprotectin With Endoscopic and Histologic Activity in Pediatric Inflammatory Bowel Disease

Objectives: Fecal calprotectin (FC) is a noninvasive marker of intestinal inflammation used for screening and ongoing monitoring of inflammatory bowel disease (IBD); it is unclear the association of specific FC values with disease activity. The aim of our study was to examine the association of FC values with endoscopic and histologic severity. Methods: We performed a retrospective chart review of patients who had FC done between 30 days and 1 day before colonoscopy at our institution. IBD patients were graded using the simple endoscopic score for Crohn’s disease or Mayo endoscopic score for ulcerative colitis. Histologic slides were graded using the Geboes method. Results: Three-hundred thirty-one patients were included in the study and 107 had IBD. For endoscopy, median FC was lowest for all IBD patients with no disease (181 μg/g) and highest in severe disease (921 μg/g), with significant difference between no disease and moderate and severe disease (P = 0.019, 0.003), and between mild and severe disease (P = 0.012). For histology, median FC was lowest with no disease (328 μg/g) and highest in severe disease (895 μg/g), with significant difference between no disease and moderate and severe disease (P = 0.021, 0.018). The control population had a significantly lower median FC than the IBD population in endoscopic remission (35.5 versus 181 μg/g; P = 0.018). Conclusions: There was a linear increase in FC values associated with increasing disease severity in the undifferentiated IBD cohort. Values for IBD patients in endoscopic remission were significantly different from our control population. FC may be a useful noninvasive marker to assess disease severity.

Severe COVID-19 in inflammatory bowel disease patients in a population-based setting.

ObjectiveData on the course of severe COVID-19 in inflammatory bowel disease (IBD) patients remains limited. We aimed to determine the incidence rate and clinical course of severe COVID-19 in the heavily affected South-Limburg region in the Netherlands.MethodsAll COVID-19 patients admitted to the only two hospitals covering the whole South-Limburg region between February 27, 2020 and January 4, 2021 were included. Incidence rates for hospitalization due to COVID-19 were determined for the IBD (n = 4980) and general population (n = 597,184) in South-Limburg.ResultsDuring a follow-up of 4254 and 510,120 person-years, 20 IBD patients (0.40%; 11 ulcerative colitis (UC), 9 Crohn’s disease (CD)) and 1425 (0.24%) patients from the general population were hospitalized due to proven COVID-19 corresponding to an incidence rate of 4.7 (95% Confidence interval (CI) 3.0–7.1) and 2.8 (95% CI 2.6–2.9) per 1000 patient years, respectively (Incidence rate ratio: 1.68, 95% CI 1.08–2.62, p = 0.019). Median age (IBD: 63.0 (IQR 58.0–75.8) years vs. general population: 72.0 (IQR 62.0–80.0) years, p = 0.10) and mean BMI (IBD: 24.4 (SD 3.3) kg/m2 vs. general population 24.1 (SD 4.9) kg/m2, p = 0.79) at admission were comparable in both populations. As for course of severe COVID-19, similar rates of ICU admission (IBD: 12.5% vs. general population: 15.7%, p = 1.00), mechanical ventilation (6.3% vs. 11.2%, p = 1.00) and death were observed (6.3% vs. 21.8%, p = 0.22).ConclusionWe found a statistically significant higher rate of hospitalization due to COVID-19 in IBD patients in a population-based setting in a heavily impacted Dutch region. This finding reflects previous research that showed IBD patients using systemic medication were at an increased risk of serious infection. However, although at an increased risk of hospitalization, clinical course of severe COVID-19 was comparable to hospitalized patients without IBD.

S3327 Positive Attitudes Towards Telehealth During the COVID-19 Pandemic: A Strong Sign for Continued Use in the IBD Population

Introduction: At the University of Virginia (UVA), the arrival of the COVID19 pandemic caused the rapid implementation of telehealth following a three-week moratorium on non-urgent clinic appointments. This rapid implementation provided an opportunity to assess patient attitudes towards telemedicine, and evaluate its potential for continued use post-pandemic. Patients with inflammatory bowel disease (IBD) could benefit from this novel platform given their need for serial follow ups and, at times, urgent evaluations for concerning symptoms. Additionally, many patients with IBD require regular administration of biologic agents and the effect of the pandemic on patient adherence with these medications has yet to be fully identified. Methods: All patients in the UVA IBD clinic with a telehealth appointment between March 16 and August 31 received an invitation to complete a survey on their experience. The survey contained three instruments assessing demographics, attitudes and barriers to telehealth, and medication non-compliance. Invitations were provided at follow-up clinic visits, as well as through the Mychart app or physical mail. A retrospective chart review was also conducted to determine the disease state based on provider documentation or supporting results from endoscopic exams or laboratory testing. REDCap was used to administer the survey and store responses. Results: Of the forty patients who responded, 87% reported very little or no difficulty using telehealth, 95% rated their experience with telehealth as either the same or better than in-person care, and 78% said they would prefer a telehealth appointment over an in-person visit in the future. Of the 27 patients who reported being treated with a biologic agent, none reported any modifications to their medication schedule or missed doses. Conclusion: This patient survey demonstrated a favorable patient experience with telemedicine utilized in the care of patients with IBD. In this group of those who received telemedicine, medication non-adherence was not reported. It remains to be explored if this was the result of the continued access to providers that telehealth provided or due to other patient factors.Table 1.: Patient assessment of telehealth relative to in-person clinic visits.

S3679 Development of Eosinophilic Esophagitis Following Adalimumab Treatment in Two Adolescents With Crohn's Disease

Introduction: Adalimumab is an anti-tumor necrosis factor-alpha (TNF-alpha) used in the treatment of Crohn’s disease (CD). There have been reported associations of CD and Eosinophilic Esophagitis (EoE); A recent study found that the prevalence of Inflammatory Bowel Disease (IBD) in the EoE population was 2.2% and the prevalence of EoE in the IBD population was 1.5%. A second study found that patients with IBD are four times more likely to develop EoE than the general population. In a small case series, 10 children with CD were diagnosed with EoE while on biologic therapy with infliximab. We describe two adolescents who developed EoE while on adalimumab therapy for CD. Case Description/Methods: Case 1: A 16-year-old male with CD and Down’s syndrome underwent an upper endoscopy and colonoscopy for monitoring of IBD activity. On gross examination, the esophagus appeared erythematous and biopsies of the mid and distal esophagus revealed 50-100 eos/hpf consistent with EoE. He had initiated adalimumab therapy three years prior to EoE diagnosis when esophageal biopsies were normal. Adalimumab level at this time was 6.79 ug/mL. He had no issues with dysphagia, but his weight gain was sub-optimal. After initiation of topical esophageal steroid therapy his weight gain improved and adalimumab therapy has been continued. Due to the current pandemic, follow up biopsies have been postponed. Case 2: A 14-year-old female with CD underwent an upper endoscopy and colonoscopy for monitoring of IBD activity. On gross examination, the esophagus had furrowing and biopsies of the mid and distal esophagus revealed 25-50 eos/hpf consistent with EoE. She had initiated adalimumab therapy one year prior to EoE diagnosis when esophageal biopsies showed mild chronic esophagitis (0-2 eos/hpf). Colonic biopsies showed active disease. Adalimumab level at this time was 17 ug/mL. She reported symptoms of dysphagia. Adalimumab therapy was changed to infliximab due to insufficient disease control and she was started on a high dose proton pump inhibitor to treat EoE with resolution of dysphagia. Due to the current pandemic, follow up biopsies have been postponed. Discussion: These two cases highlight the development of EoE in children with IBD on anti-TNF therapy. To our knowledge, based on a PubMed search, this is the first case report of children developing EoE while on adalimumab therapy for CD.

S830 Real World Assessment of Factors Influencing Fecal Calprotectin Test Completion Rates

Introduction: Individuals on immunosuppression were excluded from COVID-19 vaccine clinical trials which led to their emergency use authorization (EUA). As a result, patients with inflammatory bowel disease (IBD) who are frequently treated with immune suppressing medications have questions about COVID-19 vaccine effectiveness. Data of vaccine effectiveness and immune response in the IBD population are urgently needed to guide vaccination strategies. This study aimed to assess serologic response after completion of COVID-19 vaccine series in a large IBD population across the US. Methods: Partnership to Report Effectiveness of Vaccination in populations Excluded from iNitial Trials of COVID (PREVENT-COVID) is a prospective observational cohort study of IBD patients who received any COVID-19 vaccine granted EUA in the US. Enrolled participants had the option to provide serum samples to evaluate antibody development 8 weeks following completion of COVID-19 vaccine series. Quantitative analysis of anti-receptor binding domain (RBD) IgG antibodies specific to SARS-CoV-2 was performed using the LabCorp Cov2Quant IgG assay. Qualitative assessment of nucleocapsid antibodies as an indicator of past infection was also completed. This analysis included participants who completed vaccination series and laboratory testing prior to 6/17/ 21. Individuals who reported prior COVID infection and/or had positive nucleocapsid antibody were excluded. Descriptive statistics were performed to characterize the study population and antibody response. Results: A total of 788 participants with IBD (mean age 48 yrs, 73% female) were included, and 752/ 788 [95.4%, 95% confidence interval (CI) 93.7-96.7%] had detectable anti-RBD antibodies. Additional demographic characteristics and distribution of antibody response across medication classes are shown in Table 1. Antibody response was generally similar across age group, vaccine type, and IBD medication class (Figure 1);however, individuals receiving corticosteroids (n=35) had reduced antibody response with 85.7% (95% CI 70.6-93.7) having detectable antibodies vs 95.9% (95% CI 94.2-97.1) in non-steroid users. Conclusion: A vast majority of our IBD cohort including those on immunosuppressive therapies demonstrated humoral immune response after completion of COVID-19 vaccine series. Longer term data are needed to assess durability of antibody response, but this emerging data provides reassurance that most IBD medications do not significantly diminish response to COVID-19 vaccination.

S947 Risk of Generalized Anxiety Disorder and Its Impact on Patients With Inflammatory Bowel Disease: A Nationwide Population-Based Cohort Study

Introduction: There is a higher rate of co-morbid psychiatric illnesses in patients with inflammatory bowel disease (IBD) compared to the general population. The literature on the association and impact of generalized anxiety disorder (GAD) on IBD remains limited. The primary aim of our study was to assess the outcomes and the risk of complications in patients with IBD and GAD. Methods: We performed a retrospective analysis in the IBM Explorys database (1999-2021), a pooled, national, de-identified clinical database of over 72 million unique patients from 26 health care networks and 300 hospitals. IBD patients were identified by a diagnosis of either ulcerative colitis (UC) or Crohn’s disease (CD) who had a gastroenterology provider plus any one IBD medication. GAD patients were identified by the diagnosis code of GAD plus any anti-depressant medication or class. Exclusion criteria included the following: cerebrovascular accident, lupus, rheumatoid arthritis, myocardial infarction, multiple sclerosis, diabetes, psoriasis, malignancy, alcohol/substance abuse, epilepsy, hypo/hyperthyroidism and fibromyalgia. Control group included non-IBD patients who had GAD. IBD outcomes evaluated were as follows: disease flare, biologic therapy, colon cancer, strictures, fistula, pouchitis, osteoporosis, malnutrition, and IBD surgery. These outcomes were compared in IBD patients with GAD and those without GAD. Odds ratio with 95% CI were calculated to assess risk of GAD and complications in UC or CD compared to control cohort. Results: A total of 49,090 patients were identified with a diagnosis of UC, of which 2,070 (4.22%) also had GAD. 62,480 patients were identified with CD, of which 3,270 (4.22%) had GAD. Patients with CD (OR 3.34, 95% CI 3.22–3.46, P < 0.0001) and UC (2.69, 2.58–2.81) were at a higher risk of GAD compared to control cohort. Patients with UC and GAD were at a higher risk for disease flare (1.53, 1.41-1.65), pouchitis (1.31, 1.12-1.53), and malnutrition (1.75, 1.52-2.02) when compared to control cohort (Figure 1). Patients with CD and GAD were at a higher risk for disease flare (1.47, 1.38-1.56) and malnutrition (1.85, 1.67-2.05) compared to control cohort (Figure 1). Conclusion: A diagnosis of GAD is more commonly present with IBD, with increased risk of UC/CD flares and malnutrition when compared to the general IBD population. This study highlights the importance for gastroenterologists to screen and address GAD in their IBD clinics as it may significantly impact the natural course of the disease.Figure 1.: Odds ratios with 95% confidence intervals of inflammatory bowel disease (UC and CD) outcomes and complications in patients with and without generalized anxiety disorder (GAD).Table 1.: Comparing baseline demographics in Ulcerative Colitis (UC) and Crohn’s Disease (CD) patients with generalized anxiety disorder (GAD) to those without GAD

Effects of Wine Components in Inflammatory Bowel Diseases.

With the rising prevalence of Inflammatory bowel disease (IBD) worldwide, and the rising cost of treatment with novel biological drugs, there is an increasing interest in various diets and natural foods as a potential way to control/modulate IBD. As recent data indicates that diet can modify the metabolic responses essential for the resolution of inflammation, and as wine compounds have been shown to provide substantial anti-inflammatory effect, in this review we aimed to discuss the current evidence concerning the impact of biological compounds present in wine on IBD. A number of preclinical studies brought forth strong evidence on the mechanisms by which molecules in wine, such as resveratrol or piceatannol, provide their anti-inflammatory, anti-oxidative, anti-tumor, and microbiota-modulation effects. However, concerning the effects of alcohol, it is still unclear how the amount of ethanol ingested within the framework of moderate wine consumption (1–2 glasses a day) affects patients with IBD, as human studies regarding the effects of wine on patients with IBD are scarce. Nevertheless, available evidence justifies the conductance of large-scale RCT trials on human subjects that will finally elucidate whether wine can offer real benefits to the IBD population.

Specimen Adequacy and Clinicopathological Evaluation of Inflammatory Bowel Disease Colorectal Biopsies in Cipto Mangunkusumo Hospital Jakarta

Background: Colorectal mucosal biopsies account for majority of daily practice specimens in the field of gastrointestinal pathology. Most of them were sent for inflammatory bowel disease (IBD) evaluation. Due to broad spectrum of histologic findings and different stage of disease, pathologists often find difficulties on calling out diagnosis of IBD. This study aims to evaluate the adequacy of specimen, clinical characteristics, endoscopy and histologic findings of colorectal biopsies from IBD and non-IBD patients.Method: This cross-sectional study included 49 IBD and 49 non-IBD cases registered in the archives of Anatomical Pathology Department, Cipto Mangunkusumo National Referral Hospital Jakarta in 2019. The samples were evaluated for adequacy of specimen, clinical, endoscopy and histologic findings.Results: Most samples were adult with a slight female predominance. All request forms contained the clinical working diagnosis but only 26.5% and 20.4% of them provided clinical history and endoscopy findings. During histology evaluation, 59.2% of the specimen was considered sub-optimal. The most common histologic findings in both IBD and non-IBD groups were diffuse lymphoplasmacytic infiltration in the lamina propria and crypt distortion. Fibrosis/collagen deposition was found in 38.8% of IBD population compared to 12.2% of non-IBD population (p=0.003). Most IBD cases (55.1%) were categorized as active phase IBD.Conclusion: Since the most common histologic findings in IBD patients were also found in non-IBD patients, IBD diagnosis based on histopathology alone is highly inadvisable. However, there were also lack of clinical data and endoscopy findings in most of colorectal biopsies sent for IBD evaluation. Along with overlapping and unspecific morphology and suboptimal events during histological evaluation, all of this complicated the diagnosis of IBD. Hence multidisciplinary approach is required for a better IBD diagnosis and treatment.

Increasing rate of a positive family history of inflammatory bowel disease (IBD) in pediatric IBD patients.

The role of a positive family history in pediatric inflammatory bowel disease (IBD) in the era of biologic therapy has not been elucidated. We retrospectively reviewed the medical records of children with IBD and retrieved demographic and clinical characteristics, including the presence of a positive family history of IBD, IBD phenotype, disease course, and therapy. Overall, 325 children (age range at diagnosis 11-15years) were included, of whom 82 (25.2%) had a positive family history. Children diagnosed during 2016-2020 had a higher frequency of positive family history compared to those diagnosed during 2010-2015 (31.8% versus 20.7%, respectively, p = 0.024). Children with a positive family history had a higher risk for a stricturing phenotype than those with a negative family history (11.3% versus 2.8%, respectively, p = 0.052). They more often received nutritional therapy (53.7% versus 36.6%, p = 0.007) and less often received corticosteroids (36.6% versus 52.7%, p = 0.012). More children with a negative family history needed intensification of biologic therapy (p = 0.041).Conclusion: The rate of a positive family history of IBD in the pediatric IBD population is increasing. A positive family history may have some impact upon IBD phenotype but none on IBD outcome. What is Known: •Familial clustering of inflammatory bowel disease (IBD) has been reported in 5%-15% of IBD patients. •The investigation of the impact of a positive family history upon IBD characteristics and severity revealed conflicting results. What is New: •In this cohort of 325 children with IBD, 25.2% had a positive family history. •The rate of a positive family history of IBD in the pediatric IBD population is increasing. •A positive family history may have some impact upon IBD phenotype but none on IBD outcome.

The Pediatric Inflammatory Bowel Disease Medical Home: A Proposed Model.

Care for patients with inflammatory bowel disease (IBD) can be complex and costly. Care delivery models to address these challenges and improve care quality are essential. The patient-centered medical home (PCMH), which was developed in the primary care setting, has recently been applied successfully to the adult IBD population. Following the tenets of the PCMH, this specialty medical home (SMH) emphasizes team-based care that is accessible, comprehensive, patient/family-centered, coordinated, compassionate, and continuous and has demonstrated improved patient outcomes. Children and young adults with IBD have equally complex care needs, with additional challenges not faced by the adult population such as growth, physical and psychosocial development, and transition of care from pediatric to adult providers. Thus, we advocate that the components of the PCMH are equally-if not more-important in caring for the pediatric patient population. In this article, we review what is known about the application of the PCMH model in adult IBD care, describe care delivery within the Center for Pediatric and Adolescent IBD at Nationwide Children's Hospital as an example of a pediatric IBD medical home, and propose a research agenda to further the development and dissemination of comprehensive care delivery for children and adolescents with IBD.