Initial Diagnosis Of Crohn's Disease Research Articles

Prevalence and predictors of severe Crohn’s disease at a tertiary hospital in South Africa

Background Predicting severe Crohn's disease (SCD) can assist in planning risk reduction therapy for SCD, thereby improving disease outcomes. Objective To determine the prevalence and predictors of SCD in a sample of South African patients. Methods This was a retrospective chart review of patients with Crohn's disease (CD) attending the Gastroenterology Unit at a tertiary hospital in Durban, South Africa. Demographic and clinical variables at diagnosis of CD were collected and analysed for statistical association with development of SCD (defined as the presence of >/= 1 of the following over the course of CD: complex perianal disease, colonic resection >/= 2 small bowel resections, a single small bowel resection > 50cm, or construction of a definitive stoma). The prognostic utility of statistically significant variables was investigated by establishing their sensitivity, specificity, and predictive values for SCD. Results The study consisted of 93 patients. The rate of SCD was 64.5%, with 63.3 % of patients developing SCD within 1 year of CD diagnosis. Ileocolonic location (p = 0.046) and penetrating disease at initial diagnosis of CD (p = 0.021) were statistically associated with SCD. The sensitivity, specificity, positive predictive value, and negative predictive value of ileocolonic location for SCD was 72.7%, 47.4%, 66.7% and 54.6%. The sensitivity, specificity, positive predictive value, and negative predictive value of penetrating disease for SCD was 85.7%, 41.7%, 30.0% and 91.0%. Conclusion Most patients with CD developed SCD within 1 year of their CD diagnosis. CD with a penetrating phenotype at diagnosis is a good predictor for the devleopment of SCD and should be further investigated.

Significance of granulomas in the outcomes of Crohn's disease patients.

BackgroundThe presence of granulomas in the gastrointestinal (GI) tract is one of the characteristic histologic features of Crohn’s disease (CD). The clinical significance of granulomas remains unclear. In this study, we aimed to determine whether the presence of granulomas on endoscopic pinch biopsy or surgical resection from the upper or lower GI tract is associated with worse outcomes among patients with CD.MethodsThis was a retrospective chart review of patients with CD evaluated at a tertiary care center between 1996 and 2019. Patients were divided into 2 groups based on the presence or absence of granulomas on GI histology. Clinical and laboratory data, and outcomes of interest, were obtained from the electronic medical records. Patients’ characteristics and outcomes were compared between the 2 groups.ResultsA total of 237 patients were included in our study; 41 (17.3%) had granulomas on their biopsy/resection specimen. The presence of granulomas in the GI tract was significantly associated with the development of intra-abdominal abscesses and/or fistulas (P=0.037), greater utilization of immunomodulators (P=0.029), and greater use of immunosuppressive medications (immunomodulator and/or biologic therapy) (P=0.015). No significant differences were found between the 2 groups in terms of number of hospitalizations, presence of perianal disease, intestinal resection, mean age, mean age at initial diagnosis of CD, duration of disease, sex, or smoking history.ConclusionsThe presence of granulomas in the GI tract of CD patients may serve as a prognostic biomarker of worse disease severity. Larger studies are needed to better validate this finding.

A Surprising Granulomatous Cheilitis

Question: A 17-year-old Algerian girl who had lived in France for 2 years was referred to our dermatologic unit for a painful infiltrated crusty cheilitis. She was under anti–tumor necrosis factor-α (anti-TNF-α) therapy for active Crohn disease (CD). CD was diagnosed in 2011 on rectal bleeding, weight loss and ileal ulcerations at colonoscopy. She was previously treated with 5-ASA and azathioprine without efficacy. Adalimumab was introduced in May 2015 after a pretherapeutic evaluation that included negative interferon-gamma release assay (IGRA). Dose of adalimumab was majored to 40 mg per week in December 2015 because her CD remained active. Four months later, labial lesions appeared, with edema and vesicles, and progressed to a painful infiltrated and crusty cheilitis. Antibiotics and valaciclovir treatments were unsuccessful. Oral examination revealed a unilateral cobblestone aspect with pustules on the lip mucosa without affecting the rest of oral cavity (Figure A, B). A centimetric right cervical adenopathy was noticed. She did not have any other complaints, and the rest of physical findings were normal. Laboratory results from blood chemistry, complete blood cell count, liver, and kidney analysis were within reference range. C-reactive protein was elevated (117 mg/L). Infectious workup (human immunodeficiency virus and syphilitic serology, leishmania, and herpes polymerase chain reaction) was negative. Standard chest radiography was normal. Magnetic resonance enterography revealed an asymptomatic terminal ileitis with an enhancement of the submucosa. Labial biopsies showed an epithelioid and giant cell granuloma without caseous necrosis (Figure C); Ziehl-Neelsen, Grocott and periodic acid–Schiff stains were negative for acid-fast bacilli and fungi, respectively. No viral inclusion body was seen. What is the diagnosis? Look on page 1240 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. Initially, we suspected cutaneous metastatic Crohn’s disease. Indeed, she had severe CD resistant to a classical dose of adalimumab, and histology revealed a noncaseous granulomatous skin lesion. Negative special stains for bacteria, fungi, and parasites failed to show any microbiologic organism. New lip biopsies were performed for tuberculosis (TB) cultures, IGRA was repeated, and her treatment was intensified with infliximab and azathioprine. Two weeks later, Mycobacterium tuberculosis culture was positive on the tissue specimen. IGRA, negative before anti-TNF-α therapy, was positive. A computed tomography scan revealed nodular and micronodular opacities in superior lobes, associated with ground glass opacities. M tuberculosis was secondary found in sputum cultures. The new retained diagnosis was a TB cutis orificialis or orificial TB,1Kakisi O.K. Kechagia A.S. Kakisis I.K. et al.Tuberculosis of the oral cavity: a systematic review.Eur J Oral Sci. 2010; 118: 103-109Crossref PubMed Scopus (69) Google Scholar secondary to autoinoculation from an active pulmonary TB under anti-TNF-α therapy for a CD. After 3 weeks of anti-TB therapy and infliximab discontinuation, the lesions started to heal and showed complete resolution at the end of 6 months of treatment. Because the distinction between intestinal TB and CD is a significant source of error, colonoscopy was repeated and confirmed ileitis (Figure D). Biopsies showed a focally active ileitis with granuloma and rare giant cells without caseous necrosis. Ziehl-Neelsen staining and culture were negative after 3 months. These findings were consistent with the initial diagnosis of CD. The main cause of diagnosis error is the absence on caseous necrosis and the lack of sensibility of Ziehl stain on histologic analyses.2Wei J.-P. Wu X.-Y. Gao S.-Y. et al.Misdiagnosis and mistherapy of Crohn’s disease as intestinal tuberculosis: case report and literature review.Medicine (Baltimore). 2016; 95: e2436Crossref PubMed Scopus (11) Google Scholar TB in a context of anti-TNF-α therapy is difficult to diagnose with few symptoms, extrapulmonary presentations, and a potentially severity with a rapid evolution. This observation suggests a repeated screening for TB during the follow-up of these patients, all the more if other risk factors are associated, namely, concomitant immunosuppressant use, a history of latent or active TB, birth or travel in endemic region of TB, and/or exposure to a person with TB.3Shim T.S. Diagnosis and treatment of latent tuberculosis infection in patients with inflammatory bowel diseases due to initiation of anti-tumor necrosis factor therapy.Intest Res. 2014; 12: 12-19Crossref PubMed Google Scholar

Serum α1-antitrypsin levels as a marker of activity in pediatric inflammatory bowel disease

: The purpose of this study was to evaluate the use of the acute-phase serum protein α1-antitrypsin (α1-AT) compared with the erythrocyte sedimentation rate (ESR), platelet count, and hemoglobin level in screening for inflammation in newly diagnosed and known patients with inflammatory bowel disease (IBD). The serum α1-AT level, ESR, platelet count, and hemoglobin values of 154 children who were initially evaluated for possible IBD, as well as of 113 children with known IBD, were compared to evaluate their value as markers of inflammatory activity. Of the 154 children evaluated for IBD, 103 did not have IBD, 28 were diagnosed with Crohn's disease (CD), and 23 were found to have ulcerative colitis (UC). The sensitivity and specificity for CD was for α1-AT, 100%, 92%; for ESR, 68%, 94%; and for UC was for α1-AT, 70%, 92%; for ESR, 61%, 94%. In the 113 children with known IBD (66 CD, 47 UC), the sensitivity and specificity for predicting disease activity was for CD for α1-AT, 94%, 59%; for ESR, 52%, 63%; and for UC was for α1-AT, 79%, 76%; and for ESR, 59%, 82%. The determination of serum α1-AT levels was more sensitive and specific than the ESR in the initial diagnosis of CD and in predicting subsequent disease activity in both CD and UC.