Management Of Crohn's Disease Research Articles

PGI7 Budget IMPACT of Capsule Endoscopy for Crohn's Disease Management in Spain

In Spain, endoscopic evaluation of Crohn’s disease with ileocolonoscopy±magnet resonance enteroscopy is the standard of care (SoC) for surveillance of the mucosa of the colon but not the small bowel (SB). Pan-intestinal video capsule endoscopy (PVCE) allows to visualize both the colon and small bowel in one exam, but the cost impact of introducing PVCE is unknown. From the National Healthcare System perspective, we estimate the budget impact of introducing PVCE in patients diagnosed with SB disease. A patient-level model was developed for describing the care pathway of the disease over a five-year time horizon in a cohort of 4,000 patients who started with CD surveillance at 1-year after diagnosis. A scenario using SoC for all patients was compared to a scenario in which SoC was considered for patients with colonic disease and PVCE (+patency capsule) was used for those patients with diagnosed SB disease. Information about efficacy, resource utilization, and unit costs (€2018) was taken from published sources and validated by Spanish experts. Sensitivity analyses were performed to assess the robustness of the model. Total costs per patient were lower when PVCE (+patency capsule) for SB diagnosed patients was used: €5,413 versus €5,464. Cost associated with monitoring increased by 7.1% (€851 vs €795) whereas pharmacological treatment, complications, and surgery costs all decreased: 1.5% (€3,089 vs €3,137), 4.9% (€577 vs €606), and 3.3% (€896 vs €926), respectively. suggested median total savings of €50 per patient, but it did not reach significance. 47% of patients were switched to PVCE over the time horizon, with the mean saving per switched-patient being €759. This simulation study suggests that using PVCE for patients with diagnosed SB disease is likely to reduce costs in the Spanish setting and could lead to reductions in surgery over a 5-year time period.

Clinical utilization of magnetic resonance enterography in small bowel Crohn's disease management: a retrospective tertiary centre experience.

Magnetic resonance enterography (MRE) is the mainstay imaging modality in the evaluation of small bowel Crohn's disease (CD) activity and its associated complications. Few studies have assessed the indications for ordering it and its association with management changes. The objective was to identify the current clinical utilization of MRE and associated management changes in patients with established small bowel CD. A retrospective audit was conducted on all patients with established CD who underwent MRE at a tertiary centre from November 2014 to December 2017. Clinical indications, radiological findings and management changes were obtained from patient records. A total of 220 patients underwent a total of 287 MRE examinations. The most common indications for ordering MREs were based on patient symptoms (n = 204, 71.1%) and routine disease surveillance (n = 57, 19.9%). The most common radiological findings were inflammation (n = 156, 54.4%) and strictures (n = 98, 34.1%). Management changes post MRE occurred in 152 of 287 (53%) cases. Of the 152 patients, 87 (57.2%) had changes in medical management, 40 (26.3%) had surgical or endoscopic intervention and 25 (16.4%) had both medical and surgical management changes. Management changes following MRE in patients with new or concerning symptoms were significantly higher than in surveillance patients (OR 4.1, P = 0.000003). This study provides a foundation for understanding the current utilization of MRE in small bowel CD at a tertiary centre. However, its role in altering management particularly within surveillance patients is yet to be defined. Future prospective trials are required to better delineate its role and develop an algorithm for small bowel CD management.

Postoperative Crohn's disease management.

Despite multiple advances in the medical treatment of Crohn's disease, it is recognized that a significant proportion of patients will ultimately require surgical resection at some point during their disease course. This review focuses on the postoperative management of patients with Crohn's disease, with the goal of preventing endoscopic and clinical recurrence, and future surgery. Surgery is an integral part of the multidisciplinary approach to the management of patients with Crohn's disease. Recent literature and guidelines have focused on a standardized and evidence-based approach to the management of patients in the postoperative setting. This approach should utilize risk stratification at the time of surgery, initiation of appropriate therapy among high-risk patients, and objective evaluation in the postoperative period, including ileocolonoscopy at 6-12 months after a surgical resection. A standardized approach to the postoperative management of patients with Crohn's disease is critical. Identifying those patients at high-risk for endoscopic and clinical recurrence is essential, as these patients will likely require early medical therapy. While novel objective assessments are emerging, all patients should undergo ileocolonoscopy at 6-12 months and further decision making should be based on the presence of endoscopic recurrence.

Role of Diet in the Development and Management of Crohn's Disease.

This article provides an updated review on the role of diet in the risk of developing Crohn's disease (CD) and CD management, areas of ongoing study. Higher intake of dietary fiber (fruit fiber) has been associated with a reduced risk for CD. The exclusive enteral nutrition (EEN) diet remains the most validated nutritional recommendation for inducing remission in CD. The specific carbohydrate diet (SCD) has demonstrated reductions in CD severity scores in conjunction with medical therapies, and larger trials on its efficacy are ongoing. Several new exclusion diets modeled after EEN and SCD have shown potential efficacy in smaller studies that warrant replication. There is a paucity of clear dietary recommendations for the reduction in risk of CD clinical relapse. There are various components of diet that likely impact risk for CD development and contribute to its disease course; however, studies are often limited in their size or ability to demonstrate mechanistic causation. Further studies including diets that aim to expand on the restrictive nature of EEN may lead to stronger evidence for a diet-based approach to CD management.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease.

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

Precision Crohn's Disease Management Utilizing Predictive Protein Panels (ENvISION)

Precision Crohn's Disease Management Utilizing Predictive Protein Panels (ENvISION)

P006 Probiotics treatment in Crohn's disease: A systematic review and meta-analysis of randomized clinical trial

BACKGROUND: Crohn's disease (CD), a subtype of inflammatory bowel disease (IBD) is chronic idiopathic, relapsing nonspecific inflammatory characterized by transmural inflammation can involve any element of the gastrointestinal tract, although its etiology is unclear yet, the recent studies have shown the associations between the alteration of gut microbiota and CD, furthermore, several studies suggest using probiotic, prebiotic, and synbiotic agents to manipulate the gut microbiota in the management of Crohn's disease. This study aims to bring together the evidence available on the clinical effect of probiotics in Crohn's disease patients. METHODS: To identify all relevant studies, PubMed, MEDLINE, Scopus, Web of Science, and other databases were searched. Randomized clinical trials (RCTs) compared probiotic treatment with placebo were included in this meta-analysis. Primary outcomes were clinical remission and maintenance of remission. Secondary outcomes were adverse events, relapse rate, and endoscopic recurrence rate. RESULTS: Eight randomized clinical trials (RCTs) studies were included for meta-analysis. In the probiotic group, there was no significant difference in term of clinical remission compared to placebo, with an odds ratio of 0.89 (95% CI, 0.33–2.35; P > 0.05). Also, there was no significant difference in terms of adverse events rate between the 2 groups with 62 out of 162 (38.2%) in the probiotic group compared with 59 out of 162 (36.4%) in placebo groups; odds ratio 1.08 (95% CI, 0.08–1.78; P > 0.05). On the other hand, there was no significant difference in terms of relapse rate between 2 groups with 52 out of 124 (41.9%) in the probiotic group compared with 52 out of 121 (42.9%) in placebo groups; odds ratio 0.99 (95% CI, 0.58–1.69; P > 0.5). Regarding endoscopic recurrence rate, there was no significant difference in 2 groups of patients who underwent postoperative follow-up with 76 out of 137 (55.4%) in the probiotic group compared with 88 out 147 (59.8%) in placebo groups; odds ratio 0.86 (95% CI, 0.52–1.42; P > 0.05). CONCLUSION(S): Probiotic is potentially useful in Crohn's disease management. However, it appears to be effective for induction of remission, but with no significant major short-term benefits compared to the placebo group. Finally, there remain many unanswered questions that require further studies before probiotic can be considered for use in the treatment of Crohn's disease.

Maneuvering Clinical Pathways for Crohn's Disease.

Crohn's disease management has changed significantly with increasing use of biologics. We review the recent literature on the clinical management of Crohn's disease and new approaches in selecting and optimizing therapy. Recent studies have addressed the efficacy of proactive anti-TNFα trough level monitoring, the efficacy of biosimilars, and the efficacy and immunogenicity of newer biologics including anti-integrin therapy and anti-IL12/23 therapy. Optimizing anti-TNFα therapy according to trough concentrations correlates with improved remission rates. Patients can be switched from the reference drug to a biosimilar, or vice versa, without a measurable change in efficacy, safety, or immunogenicity. Immunomodulators are effective in decreasing immunogenicity and boosting anti-TNFα drug level. The anti-integrin and anti-IL12/23 therapies are effective as induction and maintenance therapy with low immunogenicity and excellent safety profiles. Patients at high risk for post-operative recurrence should be started on a biologic therapy within 4weeks post-op. Multiple biologic therapies are currently available for treatment of Crohn's disease including anti-TNFα therapy, anti-integrin therapy, and anti-IL12/23 therapy. The choice of first-line therapy should be based on individual risk-benefit analysis, route of administration, and patient preference. Patient with inadequate response should have their trough level checked and therapy optimized. Therapeutic prophylaxis for post-operative recurrence should be based on patient's risk factors for recurrence.

Appropriateness of Biologics in the Management of Crohn's Disease Using RAND/UCLA Appropriateness Methodology.

3 classes of biologics are now available for the treatment of Crohn's disease. The availability of multiple treatment options has led to questions regarding the appropriateness of each agent for a given patient. We aimed to evaluate physician preferences for the use of specific biologic agents in a variety of Crohn's disease management scenarios using the RAND/UCLA Appropriateness Methodology. A panel consisting of members of the CINERGI group (Canadian IBD Network for Research and Growth in Quality Improvement) was assembled. A literature review was performed on factors identified as influential upon choice of biologic therapy. Clinical scenarios were developed, and panelists rated the appropriateness of biologic therapy classes in each scenario individually and again during a face-to-face meeting after moderated discussion. Two hundred eighty-eight modifications of 3 clinical scenarios were rated. Factors that influenced biologic choice included perianal disease, antidrug antibody status, extraintestinal manifestations, consideration of potential pregnancy, and history of serious infection or malignancy. Anti-TNF therapy was considered appropriate in the postoperative patient. Ustekinumab and vedolizumab were considered appropriate in patients without perianal disease over the age of 65 with a history of malignancy or serious infection. The use of anti-TNF therapy was considered inappropriate in some scenarios whereby drug level was adequate and no antidrug antibody (ADA) was detectable. We evaluated the appropriateness of the 3 available classes of biologics in a number of scenarios for the treatment of Crohn's disease. History of serious infection and malignancy, particularly in individuals over 65 years, and consideration of future pregnancy were patient-specific variables that impacted treatment decisions. These findings can serve as a guide for providers considering biologic therapy in patients with Crohn's disease.

Probiotic Treatment for Crohnʼs Disease: A Systematic Review and Meta-Analysis

Introduction: Crohn's disease(CD), a subtype of inflammatory bowel disease (IBD) is chronic idiopathic, relapsing nonspecific inflammatory characterized by transmural inflammation can involve any element of the gastrointestinal tract, Although its etiology is unclear yet, the recent studies have shown the associations between the alteration of gut microbiota and CD, furthermore, several studies suggest using probiotic, prebiotic, and synbiotic agents to manipulate the gut microbiota in the management of Crohn's disease. This study aims to bring together the evidence available on the clinical effect of probiotics in Crohn's disease patients. Methods: To identify all relevant studies, PubMed, Medline, Scopus, Web of Science, and other databases were searched. Randomized clinical trials (RCTs) compared probiotic treatment with placebo were included in this meta-analysis. Primary outcomes were clinical remission and maintenance of remission. Secondary outcomes were adverse events, relapse rate, and endoscopic recurrence rate. Results: Eight randomized clinical trials (RCTs) studies were included for meta-analysis. In the probiotic group, there was no significant difference in term of clinical remission compared to placebo, with an odds ratio of 0.89 (95% CI: 0.33-2.35, P>0.05). Also, there was no significant difference in terms of adverse events rate between the two groups with 62 out of 162 (38.2%) in the probiotic group compared with 59 out of 162 (36.4%) in placebo groups; odds ratio 1.08 (95% CI: 0.08-1.78, P>0.05). On the other hand, there was no significant difference in terms of relapse rate between two groups with 52 out of 124 (41.9%) in the probiotic group compared with 52 out of 121 (42.9%) in placebo groups; odds ratio 0.99 (95% CI: 0.58-1.69, P>0.5). Regarding endoscopic recurrence rate, there was no significant difference in two groups of patients who underwent postoperative follow-up with 76 out of 137 (55.4%) in the probiotic group compared with 88 out 147 (59.8%) in placebo groups; odds ratio 0.86 (95% CI: 0.52-1.42, P>0.05). Conclusion: Probiotic is potentially useful in Crohn's disease management. However, it appears to be effective for induction of remission, but with no significant major short-term benefits compared to placebo group. Finally, there remain many unanswered questions that require further studies before probiotic can be considered for use in the treatment of Crohn's disease.

Management of Crohn Disease in Adults

Sponsoring Organization: American College of Gastroenterology (ACG)Target Audience: Gastroenterology clinical providersBackground and ObjectiveThe ACG

Understanding Anti-TNF Treatment Failure: A Prospective Multi-Centre Study of Biologic Naive Patients with Active Luminal Crohn's Disease

Background: Anti-tumour necrosis factor (TNF) drugs have revolutionised Crohn's disease management but treatment failure is common. We sought clinical and pharmacokinetic factors that predict and mitigate primary non-response at week 14, non-remission at week 54, and adverse events leading to drug withdrawal. Methods: We conducted a prospective observational UK-wide study in 1610 biologic naive patients with active luminal Crohn's disease (955 infliximab [753 Remicade; 202 biosimilar CT-P13] and 655 adalimumab). Findings: Primary non-response (PNR) occurred in 23·8% (95% CI 21·4%-26·2%), non-remission in 63·1% (95% CI 60·3%-65·8%), and adverse events curtailed treatment in 7·8% (95% CI 6·6%-9·2%) patients. The only independent risk factor for PNR was low drug level. The optimal week 14 drug levels associated with remission at weeks 14 and 54 were 7 mg/L and 12 mg/L for infliximab and adalimumab, respectively. Continuing standard dosing regimens after PNR was rarely helpful: only 12·4% (14/113; 95% CI 6·9%-19·9%) entered remission by week 54. Obesity, smoking, low albumin levels, higher baseline markers of disease activity, and development of anti-drug antibodies were associated with low drug levels, which mediated week 54 non-remission. Immunogenicity rates at week 54 were 62·8% (95% CI 59·0-66·3%) for infliximab and 28·5% (95% CI 24·0-32·7%) for adalimumab. For both drugs, sub-optimal week 14 drug levels were the main determinant of immunogenicity; whilst subsequent anti-drug antibody formation was the principle factor accounting for low drug levels. Combination thiopurine or methotrexate therapy mitigated this risk with similar effect sizes for both anti-TNF drugs and for infliximab led to lower week 54 non-remission rates. Interpretation: Anti-TNF treatment failure is common and associated with low drug levels, partly mediated by immunogenicity Clinical trials are required to investigate whether personalised induction regimens and treatment-to-target dose intensification improve outcomes. Funding: Charities: CORE, CCUK, C3. Unrestricted grants: Abbvie, Merck Sharp & Dohme, NAPP, Pfizer and Celltrion. Declaration of Interest: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and declare: N.A.K has consulted for Falk and received honoraria from Falk, Allergan, Pharmacosmos and Takeda for unrelated topics and is a deputy editor of Alimentary Pharmacology & Therapeutics Journal; G.A.H reports non-financial support from AbbVie, outside the submitted work; and that he is now an employee of AbbVie and owns stock in the company; M.R. is an employee of AbbVie and owns stock in the company; D.G. reports honoraria from AbbVie; G.J.W has consulted for AbbVie and received honoraria from Falk and AbbVie for unrelated topics and a fellowship from NIHR; A.H has served as consultant, advisory board member or speaker for AbbVie, Atlantic, Bristol-Myers Squibb, Celltrion, Falk, Ferring, Janssen, MSD, Napp Pharmaceuticals, Pfizer, Pharmacosmos, Shire and Takeda and also serves on the Global Steering Committee for Genentech outside the submitted work;. S.S reports personal fees from AbbVie, Merck, Takeda, grants from Takeda, Tillotts, AbbVie, Merck, outside the submitted work; P.M.I reports personal fees from Abbvie, Janssen, Pfizer, Sandoz, VH squared, Samsung Bioepis, and Ferring , grants from MSD, grants and personal fees from Takeda, non-financial support from Falk, outside the submitted work; D.McG reports grants from NIH and Helmsley Charitable Trust, during the conduct of the study; grants and personal fees from Janssen, Precision IBD Inc, Second Genome, Qu Biologics, Pfizer, Gilead and Takeda, outside the submitted work; C.W.L reports grants and personal fees from Abbvie and Gilead personal fees from GSK, Janssen, Takeda, Amgen, Pfizer, Samsung Bioepis, Celgene, grants outside the submitted work; J.R.F.C reports personal fees from Abbvie, grants and personal fees from Takeda, Hospira and Biogen, personal fees from Janssen, MSD, Celltrion, NAPP, and Sandoz, outside the submitted work; J.L has served as consultant, advisory board member or speaker for Shire (International/UK) AbbVie, Atlantic, BMS, Celltrion, Falk, Ferring (International/UK), Janssen, MSD, Napp Pharmaceuticals, Pfizer, GSK, Allergan, Cornerstone US, and Takeda and has received travel support from AbbVie, Warner Chilcot, Takeda and Pfizer outside the submitted work; R.K.R reports honoraria from Abbvie, Ferring , Therakos and Celltrion, grants from Nestec, outside the submitted work; J.R.G received honoraria from Falk, Abbvie and Shield therapeutics for unrelated topics. T.A has received unrestricted research grants, advisory board fees, speaker honorariums and support to attend international meetings from AbbVie, Merck, Janssen, Takeda, Ferring, Tillotts, Ferring, Pfizer, NAPP, Celltrion, Hospira for unrelated topics, no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. H.G, B.H, C.B, M.H.P, T.M, A.T, R.N, 473 S.B, N.C, N.M.H, P.H, S.L, M.P, J.C.M have no conflicts of interest to declare. Ethical Approval: The South West Research Ethics committee approved the study (REC Reference: 12/SW/0323) in January 2013.

Anti-TNF Therapeutic Drug Monitoring in Postoperative Crohn's Disease.

Anti-TNF prevents postoperative Crohn's disease recurrence in most patients but not all. This study aimed to define the relationship between adalimumab pharmacokinetics, maintenance of remission and recurrence. As part of a study of postoperative Crohn's disease management, some patients undergoing resection received prophylactic postoperative adalimumab. In these patients, serum and fecal adalimumab concentration and serum anti-adalimumab antibodies [AAAs] were measured at 6, 12 and 18 months postoperatively. Levels of Crohn's disease activity index [CDAI], C-reactive protein [CRP] and fecal calprotectin [FC] were assessed at 6 and 18 months postoperatively. Body mass index and smoking status were recorded. A colonoscopy was performed at 6 and/or 18 months. Fifty-two patients [32 on monotherapy and 20 on combination therapy with thiopurine] were studied. Adalimumab concentration did not differ significantly between patients in endoscopic remission vs recurrence [Rutgeerts ≥ i2] [9.98µg/mL vs 8.43 µg/mL, p = 0.387]. Patients on adalimumab monotherapy had a significantly lower adalimumab concentration [7.89 µg/mL] than patients on combination therapy [11.725 µg/mL] [p = 0.001], and were significantly more likely to have measurable AAA [31% vs 17%, p = 0.001]. Adalimumab concentrations were lower in patients with detectable AAA compared with those without [3.59 µg/mL vs 12.0 µg/mL, p < 0.001]. Adalimumab was not detected in fecal samples. Adalimumab serum concentrations were lower in obese patients compared with in non-obese patients [p = 0.046]. Adalimumab concentration in patients treated with adalimumab to prevent symptomatic endoscopic recurrence postoperatively is, for most patients, well within the therapeutic window, and is not significantly lower in patients who develop recurrence compared with in those who remain in remission. Mechanisms of anti-TNF failure to prevent postoperative recurrence remain to be determined in these patients.

Better Outcomes with Biomarker Use in Crohn Disease Management

Researchers conducted an industry-funded, open-label, randomized, controlled trial of traditional Crohn disease management based on symptom scores

Development of Clinical Prediction Models for Surgery and Complications in Crohn's Disease.

Crohn's disease-related complications account for a substantial proportion of inflammatory bowel disease-associated health care expenditure. Identifying patients at risk for complications may allow for targeted use of early therapeutic interventions to offset this natural course. We aimed to develop risk prediction models for Crohn's disease-related surgery and complications. Using data from the Randomised Evaluation of an Algorithm for Crohn's Disease cluster-randomised clinical Trial [REACT], which involved 1898 patients from 40 community practices, separate prediction models were derived and internally validated for predicting Crohn's disease-related surgery and disease-related complications [defined as the first disease-related surgery, hospitalisation, or complication within 24 months]. Model performance was assessed in terms of discrimination and calibration, decision curves, and net benefit analyses. There were 130 [6.8%] disease-related surgeries and 504 [26.6%] complications during the 24-month follow-up period. Selected baseline predictors of surgery included age, gender, disease location, Harvey-Bradshaw Index [HBI] score, stool frequency, antimetabolite or 5-aminosalicylate use, and the presence of a fistula, abscess, or abdominal mass. Selected predictors of complications included those same factors for surgery, plus corticosteroid or anti-tumour necrosis factor use, but excluded 5-aminosalicylate use. Discrimination ability, as measured by validated c-statistics, was 0.70 and 0.62 for the surgery and complication models, respectively. Score charts and nomograms were developed to facilitate future risk score calculation. Separate risk prediction models for Crohn's disease-related surgery and complications were developed using clinical trial data involving community gastroenterology practices. These models could be used to guide Crohn's disease management. External validation is warranted.

Implementing a self-management strategy in inflammatory bowel disease (IBD): patient perceptions, clinical outcomes and the impact on service

IntroductionPatient self-management and its service integration is not a new concept but it may be a key component in the long-term sustainability of inflammatory bowel disease (IBD) service provision, when...

Crohn's disease diagnosis, treatment approach, and management paradigm: what the radiologist needs to know.

Crohn's disease is one of the major subtypes of idiopathic inflammatory bowel disease and is characterized by chronic transmural intestinal inflammation of the gastrointestinal tract anywhere from mouth to the anus, with a predilection for the small bowel. Cross-sectional imaging with computed tomography and magnetic resonance enterography plays a key role in confirming diagnosis, identifying and managing complications, assessing disease severity, and identifying response to medical therapy. This review will focus on the role of radiologists in the diagnosis and assessment of Crohn's disease. Additionally, a review of current medical therapy approaches, available medications, and side effects will be discussed. The review will also highlight key complications of medical therapy and associated diseases that should be evaluated by the radiologist with cross-sectional imaging.

Radiological Response Is Associated With Better Long-Term Outcomes and Is a Potential Treatment Target in Patients With Small Bowel Crohn's Disease.

Crohn's disease (CD) management targets mucosal healing on ileocolonoscopy as a treatment goal. We hypothesized that radiologic response is also associated with better long-term outcomes. Small bowel CD patients between 1 January 2002 and 31 October 2014 were identified. All patients had pre-therapy computed tomography enterography (CTE)/magnetic resonance enterography (MRE) with follow-up CTE or MRE after 6 months, or 2 CTE/MREs≥6 months apart while on maintenance therapy. Radiologists characterized inflammation in up to five small bowel lesions per patient. At second CTE/MRE, complete responders had all improved lesions, non-responders had worsening or new lesions, and partial responders had other scenarios. CD-related outcomes of corticosteroid usage, hospitalization, and surgery were assessed using Kaplan-Meier survival analysis and multivariable Cox models. CD patients (n=150), with a median disease duration of 9 years, had 223 inflamed small bowel segments (76 with strictures and 62 with penetrating, non-perianal disease), 49% having ileal distribution. Fifty-five patients (37%) were complete radiologic responders, 39 partial (26%), and 56 non-responders (37%). In multivariable Cox models, complete and partial response decreased risk for steroid usage by over 50% (hazard ratio (HR)s: 0.37 (95% confidence interval (CI), 0.21-0.64); 0.45 (95% CI, 0.26-0.79)), and complete response decreased the risk of subsequent hospitalizations and surgery by over two-thirds (HRs: HR, 0.28 (95% CI, 0.15-0.50); HR, 0.34 (95% CI, 0.18-0.63)). Radiological response to medical therapy is associated with significant reductions in long-term risk of hospitalization, surgery, or corticosteroid usage among small bowel CD patients. These findings suggest the significance of radiological response as a treatment target.

Tu1111 The Shift in Crohn's Disease Management: Can Medical Education Help Clinicians Improve Knowledge?

Tu1111 The Shift in Crohn's Disease Management: Can Medical Education Help Clinicians Improve Knowledge?

Histoplasma Meets Crohnʼs: A Rare Case of New Onset Ascites

Learning Objectives: 1) Recognize Crohn's Disease patients on immunosuppressive therapy are at increased risk of serious adverse events. 2) Recognize isolated Histoplasma peritonitis as a rare opportunistic infection in a Crohn's Disease patient on immunosuppressive therapy. 3)Discuss therapeutic options for Crohn's Disease in the setting of opportunistic infections. Case Description: A 53 yo male with history of Crohn's Disease presented to the ER with abdominal pain and fatigue of one month duration. He had associated fever, chills, and 15lb weight loss. He denied any nausea, vomiting, or diarrhea. His Crohn's Disease management was intermittent prednisone tapers and adalimumab. On presentation, vital signs were normal. Labwork was significant for WBC 8.8, ESR 39, CRP 13, and albumin 2.7. A CT Abdomen revealed wall thickening of the terminal ileum and cecum and moderate volume abdominal ascites. A paracentesis revealed yellow, hazy fluid with 6287 nucleated cells (7% neutrophils, 38% monocytes, 55% lymphocytes), total protein 4.5, and albumin 2.2. His serum-ascites albumin gradient was 0.5. Ascitic fluid bacterial culture, AFB smear and cytology were negative. Further labwork revealed a weakly positive urine and serum histoplama antigen. A diagnostic laparoscopy for peritoneal biopsy showed metastatic caking of the omentum and abdominal wall. Peritoneal biopsies revealed Histoplasma peritonitis. Peritoneal fluid was positive for histoplasma capsulatum. No evidence of disseminated Histoplasmosis was found in his lungs, central nervous system, or adrenal glands. Our patient completed two weeks of IV liposomal amphotericin B and was transitioned to oral itraconazole. Adalimumab was stopped and he was started on azathioprine and vedolizumab. With treatment, patient noticed remarkable improvement in abdominal symptoms and fatigue. Discussion: Crohn's Disease patients on immunosuppressive therapy are at risk for opportunistic infections. We present a Crohn's patient with intermittent prednisone use and adalimumab therapy with new onset non portal hypertensive ascites. To our knowledge, this is the first reported case of histoplasma peritonitis associated with immunosuppression in a patient with Crohn's Disease. Our patient was treated with vedolizumab, which has a lower serious infection profile and may be an alternative therapeutic option for Crohn's disease with opportunistic infections.