Setting Of Inflammatory Bowel Disease Research Articles

Distal cap–assisted EMR allows the safe and effective resection of adherent dysplastic lesions in the setting of inflammatory bowel disease: a multicenter retrospective study (with video)

Endoscopic mucosal resection (EMR) is established as the primary approach for large/complex dysplastic lesions. However, submucosal fibrosis caused by previous attempts at removal, biopsy, inflammation, or tattoo can cause a benign "negative lift sign" and create difficulty for EMR. Here, we present the use of distal-cap assisted EMR (EMR-DC) specifically for the use of resecting dysplastic colon lesions when submucosal fibrosis is present in IBD patients. 16 IBD patients were retrospectively evaluated from two high volume centers. The patient demographics, lesion pathology and classification, outcomes including time and success of resection, SAEs within 30 days of the procedure, and efficacy were measured. 75% of patients treated with EMR-DC achieved complete resection with 0 serious adverse events within 30 days of the procedure. EMR-DC represents an attractive option for the resection of adherent dysplastic lesions in chronic IBD which is effective, safe, and inexpensive.

Acinetobacter species secrete compounds that promote intestinal inflammation

Background: The gut microbiota is known to impact multiple aspects of human health, including immune modulation, nutrient uptake, cell metabolism, and defense against pathogens. The composition and diversity of the gut microbiota is known to be altered in the setting of inflammatory bowel disease (IBD). IBD, which encompasses the subsets Crohn’s Disease and Ulcerative Colitis, is a life-long condition characterized by chronic inflammation of the gastrointestinal tract. It has long been speculated that gut bacteria drive or exacerbate inflammation in IBD patients, but few studies have identified bacterial candidates. Analysis of 3,853 publicly available RNA-Seq samples revealed that Acinetobacter calcoaceticus was one of the top 10 highest elevated bacteria in Crohn's Disease patients. Acinetobacter are well-characterized by their antibiotic resistance, but little is known about its relationship to the intestine. We hypothesize that A. calcoaceticus stimulates intestinal inflammation and exacerbates colitis. Materials & Results: To identify if A. calcoaceticus could stimulate inflammation, we generated inside out mouse jejunal and colonic organoids and added live A. calcoaceticus bacteria to the cultures. As a positive control, we added another Acinetobacter species A. baumannii and as a negative control, we added E. coli Nissle. After 6 hrs, we observed significant expression of pro-inflammatory cytokines in response to A. calcoaceticus and A. baumannii, while E. coli Nissle did not generate the same responses. To further investigate the compounds responsible to inflammation, we grew our bacterial strains and exposed Caenorhabditis elegans to the bacterial secreted compounds. Similar to our organoid experiments, A. calcoaceticus and A.baumannii were lethal to worms, while E. coli had no effect on C. elegans viability. Next, we sought to address the effects of Acinetoacter on the gut in vivo. We oral gavaged adult BALB/c mice with A. calcoaceticus, A. baumannii and E. coli Nissle and found that in the setting of a complex gut microbiota, these bacteria alone did not stimulation inflammation. However, supplementation of anbitioics prior to introduction of our bacteria resulted in a loss of protection and enhanced inflammation. To model IBD, we administered 2,4,6-trinitrobenzene sulfonic acid (TNBS) and induced colitis and then treated mice with our bacterial strains. We found that TNBS treated mice receiving A. calcoaceticus and A. baumannii lost more weight and had worse histological scores than mice treated with vehicle control and TNBS; indicating A. calcoaceticus worsens intestinal inflammation. Conclusions: These data show that A. calcoaceticus can promote intestinal inflammation and may be a contributing factor to the inflammation experienced by IBD patients. Funding Sources for this project include: 1T32GM132055-01, The Histochemical Society’s Cornerstone Grant and the Porter Physiology Development Fellowship. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

"Clinicians Are From Mars and Pathologists Are From Venus" Revisited: Synoptic Reports Improve Clinician Comprehension of Pathology Reports in Inflammatory Bowel Disease.

A prior study in this journal, "Clinicians Are from Mars and Pathologists Are From Venus," demonstrated that clinicians can erroneously interpret pathology reports up to 30% of the time. After noticing reporting heterogeneity in the setting of inflammatory bowel disease (IBD), we speculated that a standardized synoptic report could improve gastroenterologist comprehension. To investigate the effect of a synoptic table on gastroenterologist comprehension of IBD pathology reports. We recruited gastroenterology fellows and faculty to participate in this study. All participants were given 6 pathology reports and asked if the following were present: active inflammation, chronic inflammation, IBD, and dysplasia. Participants were also asked to rate their confidence. After a 6-week washout period, the same questionnaire was distributed with a synoptic report. We performed paired t-tests to compare the mean accuracy and confidence scores between the preintervention and postintervention responses. A total of 39 physicians participated: 9 fellows and 30 faculty. Mean accuracy scores were higher after the intervention (0.81 versus 0.86; P < .001). Mean confidence was also higher after intervention, but this was not statistically significant (3.91 versus 3.98; P = .24). The improvement in accuracy scores after intervention confirms that clinician comprehension improved with the synoptic table. A synoptic report may provide a standardized way of communicating diagnostic information to clinicians in the setting of IBD and potentially other inflammatory conditions.

S4066 Collagenous Sprue in the Setting of Inflammatory Bowel Disease: A Diagnostic and Therapeutic Enigma

S4066 Collagenous Sprue in the Setting of Inflammatory Bowel Disease: A Diagnostic and Therapeutic Enigma

PD35-05 POSTERIOR URETHRAL RECONSTRUCTION AT THE TIME OF RECTOURETHRAL FISTULA REPAIR: TECHNIQUE AND OUTCOMES

You have accessJournal of UrologyCME1 Apr 2023PD35-05 POSTERIOR URETHRAL RECONSTRUCTION AT THE TIME OF RECTOURETHRAL FISTULA REPAIR: TECHNIQUE AND OUTCOMES Roger Khouri, Joao Pedro Emrich Accioly, Molly Dewitt-Foy, Hadley Wood, and Kenneth Angermeier Roger KhouriRoger Khouri More articles by this author , Joao Pedro Emrich AcciolyJoao Pedro Emrich Accioly More articles by this author , Molly Dewitt-FoyMolly Dewitt-Foy More articles by this author , Hadley WoodHadley Wood More articles by this author , and Kenneth AngermeierKenneth Angermeier More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003333.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Recto-urethral fistulas (RUF) remain a difficult management problem in reconstructive urology. The presence of posterior urethral stenosis or obliteration in association with RUF further complicates the situation and may have an impact on deciding whether the patient is a candidate for restorative reconstruction. To assess the impact of posterior urethral stenosis on outcomes following RUF repair, we present a cohort of 23 men who underwent posterior urethroplasty as part of their treatment. METHODS: We identified 130 men who underwent RUF repair at our institution between 2003-2021. Of these, 23 (18%) also underwent simultaneous posterior urethroplasty and were selected for in depth review. RESULTS: 15 men received prior radiation for prostate cancer: 6 EBRT and brachytherapy, 8 brachytherapy alone, and 1 EBRT alone. Of the 8 men who were not radiated, 4 underwent radical prostatectomy, 2 developed RUF following traumatic injuries, and 2 developed RUF in the setting of inflammatory bowel disease. 3 men (13%) underwent attempted RUF repair prior to referral. Initial management included fecal diversion in all 23 cases (mean 10.3 months prior to RUF repair) and suprapubic catheter placement in 20 (87%) at a mean of 6.4 months prior to surgery. RUF repair was performed via perineal approach in 22 cases (96%) and prone Kraske position in 1 (4%). At the time of surgery, 20 men (87%) had significant posterior urethral stenosis, and 3 (13%) had posterior urethral defects due to cavitation and tissue loss associated with RUF. Posterior urethroplasty involved the prostatomembranous urethra in 18 cases (79%), and vesicourethral anastomosis in 5 (22%). Urethroplasty was performed with anastomotic repair in 18 patients (79%) and using buccal mucosal graft in 5 (22%). Gracilis interposition was performed in 21 cases (91%). At a median follow up of 55.7 months (IQR, 23-82 months), 87% had successful RUF closure, with 3 patients experiencing RUF recurrence requiring further surgery. 14 men (61%) developed urinary incontinence, with 7 (30%) ultimately undergoing AUS placement. There were no isolated stricture recurrences requiring instrumentation. CONCLUSIONS: Posterior urethral stenosis or obliteration associated with RUF complicates a challenging problem. However, most of these patients can be successfully treated concurrent with RUF repair. This series demonstrates that patients with RUF should not be ruled out for restorative reconstructive surgery based on the presence of posterior urethral stenosis. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e976 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Roger Khouri More articles by this author Joao Pedro Emrich Accioly More articles by this author Molly Dewitt-Foy More articles by this author Hadley Wood More articles by this author Kenneth Angermeier More articles by this author Expand All Advertisement PDF downloadLoading ...

Type 2 Autoimmune Pancreatitis and Ulcerative Colitis an Uncommon Association: About One Case

Autoimmune pancreatitis is one of the less recognised associations and remains poorly understood. The overall reported prevalence of autoimmune pancreatitis in inflammatory bowel disease patients is 0.4% [5, 6] considering the only two studies in the literature specifically examining this issue, and that concern Asian populations. Autoimmune pancreatitis in the setting of inflammatory bowel disease is challenging to diagnose but a clinically important entity to recognize and treat. Here we report a case of a 43-year-old women followed for ulcerative colitis, presented with epigastric pain and dyspepsia symptoms associeted to steatorrhea and 12 kg weight loss in 2 months. Laboratory tests found fasting plasma glucose at 1.27 g/l. HbA1c was 8%, IgG4 Levels were normal and the fecal elastase level was low. Magnetic resonance imaging of abdomen revealed a swollen pancreas especially in the uncus. The Bilio-pancreatic endoscopic ultrasound showed heterogeneous hypoechoic lesion of the pancreas head. And the biopsy of the pancreas revealed signs compatible with autoimmune pancreatitis type 2. A final diagnosis of ulceratice colitis associated autoimmune pancreatitis type 2 was made and the patient was treated with corticosteroids, with impressive improvement during his follow-up. In the context of inflammatory bowel disease, autoimmune pancreatitis is a rare and challenging to identify condition. The creation of clear guidelines and diagnostic standards for autoimmune pancreatitis is anticipated to improve awareness of the condition and result in a rise in the number of confirmed cases during the ensuing years.

S937 Venous Thromboembolism in the Setting of Inflammatory Bowel Disease: A Multi-Centric Retrospective Analysis

Introduction: Inflammatory bowel disease (IBD) is a systemic inflammatory condition with an increased risk of venous thromboembolism (VTE). The most common sites include deep veins of lower extremities and pulmonary vasculature, and rarely cerebrovascular veins which can significantly increase morbidity and mortality. While the higher incidence of VTE in IBD has been well established, standardized risk assessment models for VTE do not consider the presence of IBD as a high-risk factor. Methods: A retrospective chart review of 261 randomly selected patients with IBD over the last 5 years was performed. Patients with an incidence of VTE in the last 5 years (2017-2022) were identified. Baseline characteristics, site of VTE, use of anticoagulation for VTE prophylaxis, and anticoagulant used were collected. Descriptive statistics were used to analyze the incidence of VTE and the percentage of patients on anticoagulation. Results: The 5-year incidence of VTE in the studied 259 patients was 13.51% (35) of which 11.2% (29) had DVT, 3.5% (9) had both DVT and PE, and 2.3% (6) had only PE. The average age of the patients with VTE was 57.4 ± 12.3 years; 37% (13) were men and 63% (22) were women; 66% (23) were Caucasian, 31% (11) were African American, and 3% (1) were Pacific-islander. Of the 259 patients, 133 (51.4%) received VTE prophylaxis during hospitalizations, while 126 (48.6%) did not. Of the patients who received prophylaxis, the incidence of VTE was 4.5% (6 of 133) whereas the incidence was 23% (29 of 126) in those who did not receive VTE prophylaxis. Of the 133 patients who were on anticoagulation, 11 were on NOACs (8.3%), 38 were on heparin (28.6%), 81 were on LMWH (60.9%), and 3 were on warfarin (2.2%). Of the 6 patients who had an incidence of VTE on anticoagulation, 3 were on NOACs, 1 was on heparin, 1 was on LMWH, and 1 was on warfarin. Conclusion: Being a chronic inflammatory state, IBD is associated with a 2-3 times higher incidence of VTE. However, multiple factors exist in both the pathophysiology and treatment of the disease that may contribute to the development of VTE. Numerous factors such as surgeries, use of steroids, and gender have been implicated in increasing the risk for VTE. There is a wide scope for further research regarding the same. Despite conclusive evidence, at most centers, the presence of IBD is not considered to be a high-risk factor for VTE warranting anticoagulation. Awareness and education are the cornerstones to cause a momentous change in practice patterns.Figure 1.: Proportion of IBD patients on different anticoagulants and the incidence of VTE while on them

Symptoms associated with healthcare resource utilization in the setting of inflammatory bowel disease

Several symptoms have been connected to increased healthcare resource utilization (HRU) in the context of inflammatory bowel disease (IBD), including both Crohn’s disease (CD) and ulcerative colitis (UC). This study was designed to investigate the prevalence of IBD-associated symptoms and to determine whether any are independently associated with HRU. We undertook a retrospective analysis of data related to consecutive IBD patient encounters from a tertiary care referral center between 1/1/2015 and 8/31/2019. Demographics, clinical activity, endoscopic severity, IBD-related symptom scores, anxiety and depression scores, and other key clinical data were abstracted. Four hundred sixty-seven IBD patients [247f.: 220 m; 315 CD, 142 UC and 11 indeterminate colitis] were included in this study. The most common symptoms were fatigue (83.6%), fecal urgency (68.2%) and abdominal pain (63.5%). Fatigue, abdominal pain, anxiety or depression, corticosteroids, and opioids were each positively associated with HRU, while NSAID and mesalamine use were inversely associated on bivariate analysis. The only factor that demonstrated a statistically significant association with HRU in the whole cohort on multivariable analysis was abdominal pain. Abdominal pain is independently associated with HRU and should be specifically screened for in IBD patients to identify individuals at risk of undergoing expensive interventions. This study also reinforces the importance of optimizing diagnostic and therapeutic management of abdominal pain in IBD.

Adverse Neonatal Outcomes in the Setting of Inflammatory Bowel Disease [A241

INTRODUCTION: To examine neonatal outcomes among pregnant patients with inflammatory bowel disease (IBD). METHODS: A retrospective cohort study using linked vital statistics and hospital discharge data from California (2007–2011). We included singleton, non-anomalous pregnancies, using chi-square tests to compare demographics and outcomes of intrauterine fetal demise (IUFD), infant death, NICU admission &gt;24 hours, Apgar score &lt;7 at 5 minutes, and small for gestational age. Multivariate logistic regressions controlled for maternal age, race/ethnicity, education, and insurance. RESULTS: The cohort included 1,559 (0.06%) individuals with IBD. Compared to those without IBD, IBD patients were more likely to be White, older, highly educated, on private insurance, and with normal BMI. Pregnancies of patients with IBD were more likely to result in NICU admission (P&lt;.001), small for gestational age neonates (P=.004), or congenital anomaly (P=.049), but not IUFD (P=.105), infant death (P=.753), Apgar score &lt;7 (P=.261), macrosomia (P=.094), or birth injury (P=.262). On multivariate regression, IBD neonates were more likely to require NICU admission (aOR, 1.71; 95% CI, 1.48–1.98) or be small for gestational age (aOR, 1.55; 95% CI, 1.32–1.83), and less likely to have macrosomia (aOR, 0.75; 95% CI, 0.62–0.90). CONCLUSION: IBD neonates were more likely to require NICU admission and be small for gestational age, but less likely to have macrosomia. When adjusting for characteristics of IBD patients, IUFD, infant death, poor Apgar scores, congenital anomaly, and birth injury were not more likely. This study is limited by the small incidence of some outcomes. Further work should elucidate how IBD is related to these adverse neonatal outcomes.

Special Considerations of Anastomotic Leaks in Crohn's Disease.

Rates of anastomotic leak following intestinal resections in the setting of inflammatory bowel disease are significantly influenced by clinical characteristics. While the literature can be contradictory due to significant heterogeneity in the published data, several common themes appear to consistently arise. With respect to Crohn's disease, low serum albumin, preoperative abscess, reoperative abdominal surgery, and steroid use are associated with an increased risk of postoperative intra-abdominal septic complications. On the contrary, biologic therapy, immunomodulator use, and method of anastomosis appear not to confer increased anastomotic-related complications. Undoubtedly, a low rate of anastomotic leakage is inherent to procedures within colorectal surgery but diligent attention must be paid to identify, optimize, and, therefore, reduce known risks.

S2395 A Series of Unfortunate Events: A Unique Case of Multiple Small Bowel Malignancies in the Setting of Inflammatory Bowel Disease

Introduction: Crohn’s disease (CD) is known to increase malignancy risk. Both large and small bowel adenocarcinoma and intestinal carcinoid tumors have been reported at increased rates in patients with CD but rarely concurrently. Additionally, there is an association between Non-Hodgkin Lymphoma and CD, however this is attributed to the use of immunosuppressive medications. We present a patient with a history of follicular lymphoma and ileal CD who later developed two separate small bowel malignancies. Case description/methods: The patient is a 63-year-old male with hypertension, chronic kidney disease, pulmonary embolism, and follicular lymphoma. His follicular lymphoma was diagnosed in 2009 by axillary lymph node biopsy after presenting with lower extremity swelling, night sweats, and weight loss. Staging CT scans prior to treatment demonstrated thickening of the ileum. He was treated with chemotherapy for two years and then remained on maintenance therapy. Five years after diagnosis, the patient was evaluated for 20 years of intermittent diarrhea. Endoscopic evaluation revealed CD of his ileum as well as a duodenal nodule. Elevated serum gastrin and chromogranin A levels, a positive octreotide scan, and EUS fine needle aspiration confirmed the nodule as a stage 1 duodenal carcinoid tumor which was subsequently resected. The following year, he developed fatigue and was noted to have iron deficiency anemia. Repeat EGD and colonoscopy was unrevealing thus he had a video capsule study which demonstrated narrowing of his ileum. CT enteroclysis revealed inflammation in his ileum. He underwent a small bowel resection and surgical pathology confirmed intestinal-type moderately differentiated adenocarcinoma of the ileum. Discussion: This case describes a unique course of a patient with follicular lymphoma and CD developing two small bowel malignancies related to underlying CD. While there are reports of CD developing as a treatment related complication of NHL and NHL developing as a treatment related complication of CD, our patient likely had untreated CD at time of his lymphoma diagnosis. This untreated CD likely led to the development of adenocarcinoma and his carcinoid is also likely associated with his CD. While it is rare to develop multiple small bowel malignancies, this case highlights the importance of maintaining a high index of suspicion of symptom changes in CD patients as they may be indicative of treatment specific and/or CD complications which may ultimately change management.

Chronic Pain in the Inflammatory Bowel Disease Setting: An Undertreated and Inherently Complex Problem

Chronic Pain in the Inflammatory Bowel Disease Setting: An Undertreated and Inherently Complex Problem

Endoscopic submucosal dissection is safe and feasible, allowing for ongoing surveillance and organ preservation in patients with inflammatory bowel disease

Experience of endoscopic submucosal dissection (ESD) for colorectal lesions in the setting of inflammatory bowel disease (IBD) remains limited. The aim of this work was to determine the safety, feasibility and oncological outcomes of ESD in patients with IBD. A retrospective review of all adult patients (≥18years) with a known diagnosis of either ulcerative colitis (UC) or Crohn's disease (CD) who underwent advanced colonoscopy and ESD between 1 January 2014 and 1 October 2020. Data collected included patient demographics, disease characteristics, pathological variables and procedure-related complication rates. A total of 25 patients were included: 19 (76%) were male with a median age of 63years and disease duration of more than 10years. Sixteen had UC and nine had CD; the majority were taking corticosteroids, immunomodulators or monoclonal antibodies at the time of ESD. The median procedure time was 41min and the majority (n=18; 72%) utilized chromoendoscopy. The median lesion size was 30mm: eight had low-grade dysplasia, nine had high-grade dysplasia and three had adenocarcinoma and underwent oncological resection. None had surgical intervention for complication of ESD or perforation. A total of 23 (88%) had a complete R0 resection. Over a median follow-up of 19months, three were found to have dysplasia excised in polyps and none had subsequent adenocarcinoma. ESD in the setting of IBD is safe and effective for complete removal of large neoplastic lesions, allowing for ongoing endoscopic surveillance and organ preservation rather than surgical intervention.

Symptoms and Extraintestinal Manifestations in Active Cannabis Users with Inflammatory Bowel Disease.

Introduction: Cannabis use is common in the setting of inflammatory bowel disease (IBD). Patients frequently use cannabis to treat IBD-associated symptoms, and there is evidence that cannabis and its derivatives are helpful for this purpose. However, it is unclear how the symptom profiles of active IBD cannabis users and nonusers compare and how these symptoms may relate to their underlying disease state and/or complications. Materials and Methods: We performed a retrospective cohort study using a consented IBD natural history registry from a single tertiary care referral center between January 1, 2015 and August 31, 2020. We asked patients about current cannabis use and frequency. We also abstracted demographic and clinical characteristic information, including endoscopic severity, and totals and subscores of surveys assessing IBD characteristics, presence of anxiety/depression, and IBD-associated symptoms. We compared clinical and demographic factors of cannabis users and nonusers and developed a logistic regression model to evaluate for independent associations with cannabis use. Results: Three hundred eighty-three IBD patients met the inclusion criteria (206 females, 177 males; 258 Crohn's disease [CD], 118 ulcerative colitis, and 7 indeterminate colitis). Thirty patients (7.8%) were active cannabis users, consuming it for an average of 2.7 times per week. Cannabis users were more likely to report abdominal pain (83.3% vs. 61.7%), gas (66.7% vs. 45.6%), tenesmus (70.0% vs. 47.6%), and arthralgias (53.3% vs. 20.3%) compared to those that did not use cannabis (p<0.05 for each). Incidence of moderate-severe endoscopic inflammation was similar between cannabis users and nonusers, while CD-associated complications were more common in nonusers (39.1% vs. 69.7%, p<0.05). The only factor that demonstrated a significant association with cannabis use on multivariable analysis was arthralgia (p<0.01). Discussion: Active IBD cannabis users were more likely to report a variety of symptoms, including abdominal pain, gas, tenesmus, and arthralgias. However, they did not demonstrate more frequent active disease or IBD-associated complications, suggesting that other nonluminal factors influence their symptoms and/or decision to use cannabis. These findings demonstrate the importance of evaluating for extraintestinal contributors to symptom burden in IBD cannabis users, as well as the ongoing need to develop safer and more effective methods for recognizing and managing abdominal pain and other symptoms in this setting.

Various Forms of Tuberculosis in Patients with Inflammatory Bowel Diseases Treated with Biological Agents.

Although there are undeniable advantages of treatment of the inflammatory bowel diseases, Crohn's disease, and ulcerative colitis, with biological agents, the increased susceptibility to tuberculosis should not be ignored. Tuberculosis is an infectious disease caused by the Mycobacterium tuberculosis complex which includes M. tuberculosis, M. bovis, and M. africanum. Primary tuberculosis is uncommon in the setting of inflammatory bowel disease: reactivation of latent tuberculosis is of greater concern. Consequently, latent infection should be excluded in patients who qualify for immunosuppressive treatments. Apart from the review of the literature, this article also presents three cases of different patterns of tuberculosis that occurred during treatment with infliximab, adalimumab, or vedolizumab. The first case reports a case of tuberculosis presenting as right middle lobe pneumonia. The second case featured miliary tuberculosis of the lungs with involvement of the mediastinal lymph nodes, liver, and spleen. The third patient developed a tuberculoma of the right parietal lobe and tuberculous meningitis. It is important to reiterate that every patient qualifying for a biologic agent should undergo testing to accurately identify latent tuberculosis, as well as precise monitoring for the possible development of one of the various forms or patterns of tuberculosis during treatment.

Активація пуринергічних сигнальних шляхів під час розвитку запальних захворювань кишечника

Inflammatory bowel disease is an important illness of unclear pathogenesis associated with major defects in mucosal immunoregulation and develops in genetically susceptible individuals. These abnormalities often occur in association with microbial dysbiosis and result in unfettered inflammation of the intestine and extraintestinal tissues. Such events result in long-term morbidity and possibly even death, in otherwise healthy adults and children. Dampening inflammation and re-establishing immune tolerance in inflammatory bowel disease remain the major therapeutic goal. However, existing inflammatory bowel disease therapies albeit providing recent advances, still largely rely on broad-based immunosuppression. For example, only around half of the patients treated with anti-TNF agents show substantive clinical responses. These improvements are often self-limited, while unfortunately increasing the risk of opportunistic infections. The purpose of the study was to investigate the control of mucosal immune responses, which are based on fundamental signaling pathways. Long-term interests in the regulation of purinergic signaling are now being leveraged to develop innovative and hopefully non-toxic therapies for inflammatory bowel disease. This review and the accompanying articles in this special issue address new therapeutic concepts in inflammatory bowel disease, as based on recent, linked work in hypoxia and purinergic signaling, mucosal barrier functions and microRNA biology. In several recent, comprehensive reviews, have already addressed the biological functions of ectoenzymes, such as CD39, CD73, and CD38, in the regulation of purinergic signaling and control of extracellular adenosine levels. Others, have noted the importance of these mechanisms in immunomodulation, as in cancer and inflammation. The ectonucleotidases of the CD39 family, in particular, have major impacts on the dynamic equilibrium of proinflammatory extracellular ATP, ADP nucleotides vs. the immunosuppressive potential of adenosine nucleosides. CD39 plays a dominant role in purinergic regulation of vascular inflammation, thrombosis, and the immune response in such settings. The relevance and importance of these purinergic signaling pathways in selected neoplastic states (lymphoma and chronic leukemia) and inflammatory diseases (sepsis and autoimmunity) have been already alluded to in recent work. A brief synopsis of the major components of purinergic signaling; chiefly for those not familiar to this field, will focus on very recent work detailing the immunomodulation of CD39 on T cells and other immune cells by both genetic and environmental factors in the setting of inflammatory bowel disease and experimental colitis, inclusive of the new roles for natural metabolites such as bilirubin, and will also briefly cover the role of CD39 expression on exosomes and microparticles, in control of inflammation in the gut and touch on the relevance of the microbiome. Lastly, it will cover the emerging importance of other NTPDases of the CD39 family and speculate on their role in controlling gut inflammation. Conclusion. Review of the literature with own data is devoted to description of the recent advances in the study purinergic signaling pathways implicated in immune dysregulation, in the pathogenesis of inflammatory bowel disease. Our focus in this review is on novel aspects of the functions of CD39 and related nucleoside triphosphate diphosphohydrolases in inflammatory bowel disease

Factors influencing cumulative radiation dose from percutaneous intra-abdominal abscess drainage in the setting of inflammatory bowel disease.

Patients with inflammatory bowel disease (IBD) are at risk for intra-abdominal abscesses requiring CT-guided drainage. These patients are at baseline risk of high cumulative radiation exposure from imaging, which may be exacerbated by CT-guided drainage. This study aimed to determine the radiation dose associated with percutaneous drainage in the setting of IBD and identify risk factors associated with high exposure. An IRB-approved single-center retrospective study was performed to identify patients with IBD who underwent percutaneous abscess drainage over a 5-year period. An episode of drainage was defined from drain placement to removal, with all intervening procedures and diagnostic CT scans included in the cumulative radiation dose. The mean cumulative effective dose for a drainage episode was 47.50mSv. The mean duration of a drainage episode was 68.7days. Patients with a cumulative dose greater than 50mSv required higher number of follow-up visits compared to patients with less than 50mSv (6.9 vs. 3.5, p = 0.003*). Patients with higher cumulative dose were also more likely to require drain upsize (54% vs. 13%, p = 0.01*) or additional drain placement (63% vs 24%, p = 0.03*) compared to patients with lower dose. Intra-abdominal abscess drainage may be associated with significant cumulative radiation exposure. Requirement of drain upsizing or additional drain placement were associated with higher cumulative radiation dose, which may be related to more severe underlying inflammatory bowel disease.

S0840 Abdominal Pain Is Independently Associated With Healthcare Resource Utilization in Inflammatory Bowel Disease

INTRODUCTION: Several symptoms, including fatigue and abdominal pain, have been connected to increased healthcare resource utilization (HRU) in the setting of inflammatory bowel disease (IBD), including both Crohn’s disease (CD) and ulcerative colitis (UC). However, it is unclear whether these links are due to other key coincident clinical factors, such as disease activity. We undertook this study to investigate the incidence of IBD-associated symptoms and to determine whether any are associated with HRU. METHODS: We performed a retrospective analysis using a consented IBD natural history registry from a single tertiary care referral center between 1/1/2015 and 8/31/2019. Demographics, endoscopic severity (using Mayo endoscopy sub-score for UC and Simple Endoscopic Score for CD), totals and sub-scores of surveys (Harvey-Bradshaw Index, Simple Clinical Colitis Activity Index, Hospital Anxiety and Depression Scale, Short Inflammatory Bowel Disease Questionnaire) assessing for mild or more severe abdominal pain, fatigue, anxiety/depression, gas, IBD-associated arthralgias and dermatopathies, diarrhea, rectal bleeding, fecal urgency and tenesmus were abstracted. We performed descriptive statistics and univariate analyses [evaluating clinical factors and the incidence of HRU (defined as IBD-related imaging, emergency room, hospitalization and/or surgery over the prior 12 months) associated with each symptom], followed by logistic regression analysis (incorporating key clinical factors previously associated with HRU and the symptoms above). RESULTS: 467 consecutively enrolled IBD patients [246f:221m; 314 CD, 142 UC and 11 indeterminate colitis] were included. 174 (37.3%) patients had moderate to severe endoscopic disease activity. The most common symptoms were fatigue (83.7%), fecal urgency (68.3%) and abdominal pain (63.6%). Fatigue, abdominal pain, and opioids were each positively associated with HRU, while NSAID use was inversely associated on univariate analysis (Table 1). The only factor that demonstrated a significant association with HRU on multivariable analysis was abdominal pain (Table 2). CONCLUSION: Abdominal pain is independently associated with HRU, even when considering inflammatory activity. Abdominal pain should be specifically screened for in IBD patients to identify individuals at risk of undergoing expensive interventions. This study also reinforces the importance of appropriate diagnostic and therapeutic management of abdominal pain in IBD.Table 1Table 2

S2248 “Blood in My Stool and Clot in My Brain”: A Case of Cerebrovascular Accident in Crohn's Disease

INTRODUCTION: Stroke is the most common cause of disability in adults and the fifth most common cause of death in the United States. Common risk factors include hyperlipidemia, smoking, Diabetes mellitus, obesity, and heart disease. Specifically, in young adults, common culprits include congenital/acquired heart problems, hematologic conditions, metabolic disorder, drug ingestions, and vasculopathy. CASE DESCRIPTION/METHODS: The patient is a 23-year-old male with a history of Crohn's disease and small bowel obstruction who presented with a 2-week history of worsening generalized headaches. Home medications include Infiximab and Ferrous sulfate. Examination revealed left upper extremity 3/5 strength, pronator drift, decreased sensation to light touch, ataxia, and left blurry vision. Non-contrast CT head showed right transverse venous sinus thrombosis and acute right temporal/parietal intracranial hemorrhage. UDS was negative. The patient was started on IV heparin and transitioned to oral anticoagulation. Hypercoagulability workup by Hematology was negative, and Neurology ruled out common causes of stroke. All focal neurologic deficits have since resolved. DISCUSSION: We know of the many common risk factors that are related to strokes. In this particular case, what was interesting is that the patient is very young with a history that is significant for only Crohn's disease. There have been multiple reports of patients with Crohn's disease who developed strokes. So far, observational studies have provided conflicting findings on whether Crohn's disease is associated with a higher risk for cerebrovascular disease. Increased knowledge of this association, especially in younger patients, will allow clinicians to identify and potentially provide primary prevention for this population. Chronic inflammation disorders have been noted to have increased risk for vascular disease; however, in the setting of inflammatory bowel disease, the association seems to be heightened. A meta-analysis comprising of 8 observational studies included 126,493 IBD patients with 4748 cases of stroke, showing a statistically significant increased risk of stroke in patients with IBD. A retrospective study conducted in 2015 showed that 3 out of 1382 patients admitted for recurrent strokes had inflammatory bowel disease. With these findings, further investigational studies are needed to explore the mechanisms responsible for strokes in inflammatory bowel disease.

S3198 Antidepressant Use Is Associated With Poor Clinical Outcomes in the Setting of Inflammatory Bowel Disease

INTRODUCTION: Antidepressant medications (AMs) are frequently used in inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC). Many AMs are designed to enhance serotonin (5-HT) signaling. Increased 5-HT availability is associated with inflammation in animal models and human studies of IBD. We hypothesized that use of 5-HT-enhancing AMs would be associated with poor clinical outcomes in IBD. METHODS: We performed a retrospective cohort study using the Truven Health Marketscan® commercial claims database between 1/1/06 and 12/31/12. Participants (18–64 years) had at least 2 appropriate ICD-9 diagnoses for IBD, concurrent use of IBD medications, no other auto-inflammatory disease, at least 1 year of continuous enrollment before index diagnosis and 2 years after, during the study period. We identified new prescriptions of AM (includingselective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic, tetracyclics, monoamine oxidase inhibitors and other varieties) using the medication possession ratio (MPR; 80% adherence).Primary outcomes were: corticosteroid use, IBD-related complication (intestinal stricture and/or fistula), hospitalization, emergency room (ER) visit, IBD-related surgery and death within 2 years of IBD diagnosis or starting AM. We performed descriptive statisticsand calculatedadjusted hazard ratios (aHRs) comparing 2 groups (AM use vs. no AM use) for each of the outcomes above (adjusting for age, sex, comorbidity, IBD medication use and clinic visits). We also performed subgroup analyses considering IBD and AM subtype. RESULTS: 117,255 people had IBD (51.3% male; 55.6% UC). 7.1% used at least one AM during the follow-up period [most often a SSRI (4.9%) and/or SNRI (1.1%)]. AM users were younger, more likely female and to have several comorbidities, and used IBD-targeted medications more often (Table 1). Corticosteroid use, hospitalizations, ER visits and death were independently associated with AM use (Table 2).In the UC cohort, AM users were more likely to have complications [aHR = 1.90 (1.42–2.54), P < 0.0001)]. SSRIs were the only group independently associated with death [aHR = 7.93 (3.62–17.36), P < 0.0001]. CONCLUSION: We demonstrated that AM use is independently associated with an increased risk of many poor outcomes in IBD (including death). While further study is warranted, providers should exercise caution when using AM in IBD, particularly SSRIs.Table 1.: Demographic and Clinical Characteristics of Antidepressant Medication Users and Non-Users. AM = antidepressant medication; SD = standard deviation.Table 2.: Cox Proportional Hazards Model Evaluating Clinical Outcomes Associated with Antidepressant Use in the full IBD cohort.