Tertiary Inflammatory Bowel Disease Center Research Articles

Uneventful Course in Patients With Inflammatory Bowel Disease During the Severe Acute Respiratory Syndrome Coronavirus 2 Outbreak in Northern Italy

Uneventful Course in Patients With Inflammatory Bowel Disease During the Severe Acute Respiratory Syndrome Coronavirus 2 Outbreak in Northern Italy

The awareness of the IBD nurse position among patients from an Italian tertiary IBD centre.

Inflammatory Bowel Disease (IBD) is a chronic condition characterized by acute relapses which have an important impact on the quality of life of patients, both physically and psychologically. In the personalized care of IBD patients, a key role is covered by the IBD nurse, who provides psychological and educational support, as well as a source of contact for all patients. Aim of the present study was to assess the perception of IBD patients about roles, competences and abilities of the IBD nurses in a specialized center. This is the base for further programs aiming to improve quality of care. A questionnaire composed of 15 statements regarding the role of the IBD nurse in their treatment was offered to all patients attending this IBD center over a 3-month period. Results were showed comparing those of patients currently receiving treatment with a biologic therapy to those receiving non-biologic therapy. Patients in this center have a poor awareness of the IBD nurse role, particularly those not receiving biologic treatment. Although most patients are aware that they can use the IBD nurse as a point of contact, the majority are not aware of the qualifications of the IBD nurse to discuss their treatment options and provide psychological support. Our survey shows that the figure of the IBD nurse is still poorly recognised by patients, with a likely resultant underutilisation of the services of a highly skilled and educated professional. Several key issues for improvement for the IBD nurse service have been raised by this study and warrant similar investigation in other centres.

P107 SINUSITIS IS A RISK FOR SUBSEQUENT INFLAMMATORY BOWEL DISEASE

Abstract Introduction The relationship between sinusitis and inflammatory bowel disease (IBD) has not yet been established. Though the two are characterized by dysfunction of the epithelial barrier, there lacks evidence on the relative contributions of infection or inflammation to this co-morbidity in IBD patients. Previous analysis from our group (ACG 2019) identified an increased prevalence of sinusitis among patients with IBD, but that work did not include a stratified analysis of IBD patients with sinusitis based on the order in which these conditions were diagnosed. Methods This is a retrospective study at our tertiary IBD center. We utilized our institution’s electronic medical record data warehouse of 2.4 million patients to identify those with diagnostic codes for both sinusitis (J32) and IBD (K50.90 and K51.90). Patients with a confirmed diagnosis of IBD and/or sinusitis between January 2000 and May 2019 and age ≥18 years were included. Demographic and disease related information were collected, including dates of diagnosis for both sinusitis and IBD. Categorical variables were analyzed using Fisher’s exact test and continuous variables were analyzed using Wilcoxon rank sum test. Results Of 14,366 patients with IBD, 386 patients (2.69%) were diagnosed with both IBD and sinusitis (IBD+S). The average age of IBD diagnosis in the IBD only group was 37.30 (18.76) years and IBD+S group was 38.36 (19.81) years (p = 0.27). Of the 386 patients with IBD+S, 268 (69.4%) were diagnosed with IBD before sinusitis and 118 (30.6%) were diagnosed with IBD after sinusitis (Table 1). The average age of IBD diagnosis in the IBD before sinusitis group was 33.2 ± 17.3 years, which was significantly younger than patients in the IBD after sinusitis group of 50.2 ± 20.2 years (p < 0.001). The average time between diagnoses was significantly more in the group diagnosed with IBD before sinusitis compared with the group diagnosed with IBD after sinusitis (7.64 ± 8.89 years vs 3.73 ± 3.16 years, respectively; p < 0.001). In addition, patients diagnosed with IBD after sinusitis were significantly less likely to be of white race, never smokers, have Crohn’s disease, bowel obstruction, or be receiving immunosuppressive medications. Conclusions There are significant differences in the characteristics of patients with IBD and sinusitis from IBD only patients, and even greater differences when stratifying the IBD+S group based on the order of diagnoses. Within the subgroup of IBD+S, most notably, patients with sinusitis first have an older age of IBD diagnosis. These findings suggest that a diagnosis of sinusitis should prompt consideration of co-existing or subsequent risk of IBD.

24 ENDOSCOPIC AND CLINICAL CHARACTERISTICS OF POUCHITIS INVOLVING THE RECTAL CUFF IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE TREATED BY PROCTOCOLECTOMY WITH ILEAL POUCH-ANAL ANASTOMOSIS

Abstract Background For patients with inflammatory bowel disease (IBD), surgical intervention is sometimes required due to medically refractory colitis or development of neoplasia. Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the most common procedure for patients with colitis. However, pouchitis can develop in up to 80% of patients after the surgery and significantly impairs quality of life. Despite the high prevalence of pouchitis, endoscopic phenotypes have not been clarified. This study assessed the frequency and characteristics of inflammation involving the rectal cuff. Methods This is a retrospective study from a tertiary IBD center of IBD patients treated by total proctocolectomy with IPAA and subsequently underwent pouchoscopies at the University of Chicago between January 2007 and September 2019. We reviewed the endoscopic findings in different areas of the pouch: the pre-pouch ileum, inlet, “tip of the J”, proximal and distal pouch, anastomosis, rectal cuff, anal canal, and perianal area. This analysis evaluated all available pouchoscopies per patient and included patients with normal cuff and those with cuffitis noted in every pouchoscopy. Demographic and endoscopic data were assessed to compare patients with normal cuff and those with cuffitis. Fisher’s test was used for a univariate analysis to assess factors contributing to cuffitis. Logistic regression analysis was performed as a multivariate analysis including univariate variables with a P-value < 0.15. Results We reviewed 1,081 pouchoscopies from 426 IBD patients who underwent proctocolectomy with IPAA and identified 184 patients (43%) with normal cuff and 107 (25%) with cuffitis. Of these 291 patients, 57% were men, 92% were Caucasian, the mean age at the diagnosis (SD) was 26 ± 12 years, and mean BMI 26 ± 5 kg/m2. The diagnosis before surgery for these patients were for ulcerative colitis (91%), indeterminate colitis (5.8%), and Crohn’s disease (1.7%). A significant difference (P = 0.003) was found in the frequency of pouchitis between patients with normal cuff (126/184, 69%) and those with cuffitis (90/107, 84%) (Table 1). Although not statistically significant, the frequency of pouch failure in patients with cuffitis (13/107, 12%) was higher than those with normal cuff (12/184, 6.5%). Multivariate analysis showed pouchitis was significantly associated with cuffitis (OR = 2.2; 95% CI = 1.2–4.2; P = 0.01) (Table 2). Endoscopic data showed that the pre-pouch ileum was significantly (P = 0.001) involved in patients with cuffitis (45/90, 50%) compared with those with normal cuff (36/126, 29%). Conclusion Our analysis of 291 patients suggested that cuff inflammation can be a significant risk factor of pouchitis and is significantly associated with the development of inflammation in the pre-pouch ileum. Cuffitis can be a therapeutic target to improve J pouch outcomes.

P849 Analysis of rectal swabs for microbiome sampling in a cohort of IBD patients during disease exacerbation. POLIBD survey results

Abstract Background There are only a few studies that have investigated the role of intestinal infections other than Clostridium difficile in Inflammatory Bowel Disease (IBD). Objectives: Our goal was to investigate the frequency of intestinal infections detected by rectal swabs in IBD patients during admission due to exacerbation of the disease. Methods We conducted a cross-sectional analysis of 299 patients who underwent microbiome sampling with the use of rectal swabs from January 1, 2017 to June 30, 2019, treated at a tertiary IBD centre in Poland. Our main goal was to assess the presence of any infection that could mimic or coexist with IBD exacerbation. Results A total of 299 patients were subjected to microbiological examination, including 61 patients with Crohn’s Disease (CD), 143 patients with Ulcerative Colitis (UC) and 95 patients with diarrhoea not related to IBD. Positive results of rectal swab culture were found in a total of 22 samples - in 17 patients with IBD and 5 patients without IBD. Among the IBD patients, positive rectal swab cultures were obtained in cases of UC - 13 samples, 76.5%, p <0.001, CD - 4 samples, 23.5% positive results, p = 0.001. In patients with IBD compared with patients without IBD, a higher incidence of intestinal infections was found (in patients with IBD 8.3%, p <0.001, in patients without IBD 5.2%, p < 0.001). Analysis of the results obtained showed seasonal variability in the number of positive microbiological tests found for cultures of rectal swabs in IBD patients. Positive results of rectal swabs from patients with IBD were significantly more frequent in the summer months - 12, 70.6%, p < 0.001 than in the winter months, when 5 positive test results were found (29.4%, p <0.001). Conclusion A retrospective analysis of rectal swabs for microbiome sampling collected from IBD patients during disease exacerbation treated in a tertiary IBD centre in Poland was performed. Intestinal infections, other than Clostridium difficile, were found in 17 patients with IBD symptoms. Positive results from rectal swabs of patients without symptoms of IBD were found in 5 cases. The evaluation of the obtained results shows that positive results of rectal swabs were found more often in samples taken from women (12 samples - 68.7%) than from men (5 samples - 29.3%).

P154 Sinusitis Prompts Evaluation for Co-existing or Subsequent inflammatory bowel disease

Abstract Background The relationship between sinusitis and inflammatory bowel disease (IBD) has not yet been established. Though the two are characterised by dysfunction of the epithelial barrier, there lacks evidence on the relative contributions of infection or inflammation to this co-morbidity in IBD patients. Previous analyses from our group identified an increased prevalence of sinusitis among patients with IBD, predictive factors of developing sinusitis in IBD, and differences in stratifying patients with IBD and sinusitis (IBD+S) based on order in which these conditions were diagnosed. We now report on the factors associated with the development of IBD in patients with sinusitis. Methods This is a retrospective study at our tertiary IBD center. We utilised our institution’s electronic medical record data warehouse of 2.4 million patients to identify those with diagnostic codes for both sinusitis (J32) and IBD (K50.90 and K51.90). Patients with a confirmed diagnosis of IBD and/or sinusitis between 1/2000–5/2019 and age ≥18 years were included. Demographic and disease-related information were collected. Categorical variables were analysed using Fisher’s exact test and continuous variables were analysed using Wilcoxon rank-sum test. Results Of 14,366 patients with IBD, 386 (2.69%) patients have IBD+S. Of the 386 IBD+S patients, 118 patients (30.6%) were diagnosed with sinusitis before IBD. These 118 IBD+S patients were included in univariate and multivariate analysis with 14,753 non-IBD patients with sinusitis. The average age at IBD diagnosis among all IBD patients was 37.32 ± 18.79 years, and the average age at sinusitis diagnosis for sinusitis patients was 40.93 ± 21.42 years. On multivariate analysis, age of sinusitis diagnosis >40 years old (OR 1.52, 95% CI 1.04–2.28), black race (OR 2.82, 95% CI 1.29–7.43), white race (OR 4.33, 95% CI 2.02–11.23), and female sex (OR 1.52, 95% CI 1.03–2.28) were significant predictors of IBD in sinusitis patients (Table 1A). In comparison, multivariate analysis showed that black race (OR 8.09, 95% CI 4.91–14.26), white race (OR 3.35, 95% CI 2.08–5.80), female sex (OR 1.51, 95% CI 1.22–1.87), and bowel obstruction (OR 2.00, 95% CI 1.53–2.58) were significantly associated with sinusitis in IBD patients (Table 1B). Conclusion Sinusitis patients diagnosed older than 40 years old have 1.5 greater odds of subsequent IBD, suggesting that a diagnosis of sinusitis should prompt consideration of co-existing or subsequent IBD risk. Female sex and race are shared factors in the risk of sinusitis in IBD patients and risk of IBD in sinusitis patients.

P353 Assessing compliance to screening for infectious diseases and vaccination in patients newly diagnosed with inflammatory bowel disease

Abstract Background Patients are frequently counselled on vaccinations and screened for infectious diseases prior to starting immune-modulating therapy; however, the most up-to-date ECCO guideline on the subject (1) recommends vaccination screening and completion at diagnosis. We assessed adherence to the ECCO guidelines in patients diagnosed with inflammatory bowel disease (IBD). Methods Medical records from 100 IBD patients up to 6 months of their diagnosis were analysed retrospectively at a tertiary IBD centre in the UK. Data were collected for infectious diseases screening, documentation of vaccination history and education/advice on vaccination. Vaccination rates for diphtheria, tetanus, pertussis, polio, hepatitis B, human papillomavirus (HPV), influenza, pneumococcal and varicella-zoster were documented if they were recorded in the medical notes. Results A total of 84% of patients were not screened for infectious diseases at diagnosis or within 6 months. Overall, 97% had no vaccination history documented and 97% were not advised to attend their GPs for vaccinations. Conclusion Despite the existence of international guidelines, poor compliance to vaccination in patients with IBD has been shown in line with previous reports (2). This suboptimal vaccination compliance could be partly due to poor documentation and the retrospective method of data collection. However, there is clearly an urgent need for education and execution of vaccination guidelines in IBD. This implementation of work is now ongoing at our unit through automatic formal standard vaccination notification on every IBD clinic visit, which will be further re-audited in 6 months’ time.

P255 Predictors of postoperative morbidity in patients with inflammatory bowel disease

Abstract Background More than half of patients suffering from inflammatory bowel disease (IBD) requires surgery in their lifetime. However, predictors of post-operative morbidity and mortality are poorly investigated. Our aim was to assess the predictors of post-operative mortality and morbidity in IBD. Methods retrospective cohort study enrolling all IBD subjects followed-up and operated at our tertiary IBD Centre from 2015 to 2018. For each patient, we evaluated patient-dependent (comorbidities, smoking, drugs, nutritional status), disease-dependent (disease duration, location, behaviour, extension), surgery-dependent variables (duration, emergency/election, laparoscopy/laparotomy, bowel/colic resection, length of intestinal resection). Results 158 subjects were operated during the period study (males 53.8%, Crohn’s disease 75.3%, mean age 41.9 + 16.2, disease duration 109.5 + 98.3 months); the majority (83%) underwent an elective surgery. No patient died. About morbidity, 40 (25.3%) developed post-operative complications: wound infection (8.9%), respiratory complications (6.9%), prolonged ileum (5.1%), anastomotic leak (3.2%), urinary infections (3.2%), abdominal abscess (3.2%), anastomotic bleeding (3.2%), other infections (2.5%), abdominal bleeding (1.9%), obstruction (1.3%). Two subjects (1.3%) required re-operation within 30 days. A surgery-duration <142 min was predictive for a better post-operative outcome (sensitivity 80%, specificity 42%, PPV 32%, NPV 85.9%). At binary logistic regression, stricturing/fistulizing behaviour (OR 3.7, 95% CI 1.6–6.4, p = 0.02), need for total parenteral nutrition (OR 4.1, 95% CI 2.4–9.2, p = 0.01), pre-operative bowel cleansing (OR 0.6, 95% CI 0.4–0.8, p = 0.01), surgery duration <142 min (OR 0.2, 95% CI 0.08–0.7, p = 0.03), were the only predictors for post-operative morbidities. A pre-operative BMI<24 was also predictive for anastomotic leak (OR 4.3, 95% CI 1.8–8.6, p = 0.02); pre-operative hypoalbuminemia was predictive for urinary infections (OR 2.5, 95% CI 1.8–7.9, p = 0.04); pre-operative infliximab was predictive for pneumonia (OR 3.8, 95% CI 2.2–6.3, p = 0.01); diabetes (OR 5.7, 95% CI 2.3–9.8, p < 0.01) and pre-operative steroids (OR 6.1, 95% CI 1.8–11.4, p < 0.01) were predictors of wound infection; need for TPN predicted prolonged ileum (OR 6.1, 95% CI 2.3–15.3, p = 0.03). Conclusion about a quarter of IBD patients undergoing surgery develops a post-operative complication, especially infective. Several patient-related, disease-related and surgery-related factors are predictive for post-operative morbidity. The recognition of these factors, as well the multidisciplinary approach (gastroenterologists, surgeons and nutritionists), and intensive preoperative management could be able to minimise these complications.

P570 The burden of anaemia remains significant over time in patients with inflammatory bowel disease at a tertiary referral centre

Abstract Background Anaemia is an important complication and/or extra-intestinal manifestation of inflammatory bowel disease (IBD), as well as a predictor of poor outcomes. The aim of this study was to determine the occurrence of anaemia and the frequency of anaemia screening over time, at a tertiary referral IBD centre. Methods We retrospectively reviewed the occurrence of anaemia at the time of referral or diagnosis and during follow-up at the McGill University Health Centre (MUHC) IBD centre. Consecutive patients presenting with an outpatient visit (‘index visit’) between July and December 2016 and between December 2018 and March 2019 were included. Disease characteristics, biochemistry and medical management, including the need for intravenous iron therapy were captured. Results 1356 and 1293 CD and UC patients [disease duration: 12 (IQR:6–22) and 10 (IQR: 5–19) years] were included in the 2 periods. The prevalence of moderate or severe anaemia at referral/diagnosis (15.4% and 8.5%) and during the follow-up (11.1% and 8.1%) was higher in CD than in UC patients, with a decrease of anaemia in CD patients between the 2 periods. The prevalence of any anaemia at follow-up was 22.4% and 18.7% in CD and in UC, while 82.7% of patients were tested at least once for anaemia during a 6-month period. UC patients with more extensive disease, treated with steroids or biologics at the time of referral but not during follow-up, active disease, or an elevated calprotectin at the time of assessment, and CD patients with active disease, elevated CRP or calprotectin at the time of assessment, with complicated disease, perianal involvement, previous respective surgery or colonic disease location, had a higher risk of anaemia. Intravenous iron therapy was prescribed in 46 patients (46.8% patients (37/79) with moderate or severe anaemia) with 72.3% having active disease (CD: 65.2%, steroid 83.3%, biological therapy: 78.6%, CRP: 97.8%, FCAL: 73.9%) in the second cohort. 91.3% of patients receiving intravenous iron had an extensive evaluation of anaemia pre- and post-therapy (CBC, ferritin, transferrin, TSAT, B12, folate). Anaemia improved by >2g/l in 56.5% after 4–6 weeks (intravenous iron dose >1000mg in 87% of patients). Four patients required a blood transfusion. Conclusion Anaemia occurred frequently in this IBD cohort, at referral to the centre and during follow-up, and contributes to the burden of IBD in referral populations. Most patients were assessed for anaemia regularly and with accurate anaemia workup in patients prescribed intravenous iron therapy, yet the targeted management of moderate to severe anaemia was suboptimal.

P320 Thrombocytosis in acute inflammatory bowel disease: a useful biomarker?

Abstract Background Differentiating between infectious gastroenteritis and a flare of inflammatory bowel disease (IBD) can be difficult. Small studies have shown that thrombocytosis may not occur in infectious gastroenteritis. We aimed to determine whether thrombocytosis is a reliable biomarker in distinguishing between these two diagnoses in patients presenting with diarrhoea. Methods A retrospective cohort study was conducted at a tertiary referral IBD centre. From January 2000 and December 2018, patients admitted with acute diarrhoea were included. Inclusion criteria were infective gastroenteritis, IBD flare or both. IBD diagnosis was confirmed by standard clinical, radiological and histopathological criteria. Clinical and biochemical parameters were collected. Results There were 351 infectious and 506 IBD flare cases. Among these 216 (42.8%) had Crohn’s disease, 276 (54.7%) ulcerative colitis, and 13(2.6%) had IBD-unclassified. Table 1 summarises the main results. Those with acute IBD flare had a longer duration of diarrhoea, bloody diarrhoea, lower albumin and anaemia (p < 0.05 for all comparisons). Patients with infectious diarrhoea were more likely to be older, female, have vomiting and fever and leucocytosis (p < 0.05 for all comparisons). Median platelet count was higher in patients with IBD flares, 334 vs. 220 (p < 0.001) and persisted on multivariate analysis (p < 0.001, OR1.45). On multivariate analysis, other significant associations for IBD flare were age (OR.85, p < 0.001) female sex (OR.23, p < 0.110), blood in faeces (OR 5.98, p < 0.001) vomiting (OR .17, p < 0.001) and albumin (OR.83, p = 0.02). A sub-analysis compared patients with known IBD and infectious gastroenteritis with an identified pathogen (n = 47), with those with an IBD flare alone showed no significant difference in platelet count between groups (419 vs. 465, respectively, p = 0.17). Conclusion Our study shows significant differences between clinical and biological markers in patients with acute IBD flares compared with those with infectious gastroenteritis. In particular, thrombocytosis occurs in IBD flares but not in infectious gastroenteritis. This biomarker can be used to differentiate between these diagnoses and guide management.

Effect of distance to specialist care for the diagnosis and disease outcome of inflammatory bowel disease in the Swiss inflammatory bowel disease cohort study.

Background:Inflammatory bowel disease (IBD) needs early interventions and an individual specialist–patient relationship. Distance from a tertiary IBD center might affect patient’s disease course and outcome. We investigated whether the patient-to-specialist distance has an impact on the disease course using the well-defined patient collective of the Swiss Inflammatory Bowel Disease Cohort Study (SIBDCS).Methods:Patient’s home address at diagnosis (postal zip code) was extracted from the SIBDCS database. Distance between each zip code and the nearest located IBD specialist center was calculated and classified into the following three sections based on proximity: <10 km (group 1); 10–35 km (group 2); >35 km (group 3).Results:Our study included in total 408 IBD patients [234 Crohn’s disease (CD), 154 ulcerative colitis (UC), 20 IBD unclassified (IBDU)]. Median age was lowest in group 2 at diagnosis (G1: 28 years; G2: 21 years, G3: 26 years, p < 0.01). The diagnostic delay did not differ between groups. CD patients in group 1 were treated more often with anti-tumor necrosis factor (TNF) agents (72% versus 56%, p = 0.04) and 5-aminosalicylates (44% versus 28%, p = 0.04) than in group 3. UC/IBDU patients in group 1 were treated more often with corticosteroids than patients in group 3 (83% versus 58%, p < 0.01). The occurrence of IBD-related surgeries did not differ between groups.Conclusions:Patient-to-specialist distance might affect drug treatment. However, disease course and the need for IBD-related surgery does not seem to be associated with a longer distance to specialist care in Switzerland.

No Increased Risk of Colorectal Neoplasia in Patients With Inflammatory Bowel Disease and Postinflammatory Polyps.

Patients with inflammatory bowel disease (IBD) who have postinflammatory polyps (PIPs) may have an increased risk of developing colorectal neoplasia. Current guidelines recommend an intensified surveillance strategy in these patients, although the evidence for this recommendation is conflicting. The aim of our study was to assess whether IBD patients with PIPs are at increased risk of colorectal neoplasia. We established a retrospective cohort in a tertiary IBD center with IBD patients undergoing colorectal cancer (CRC) surveillance in the current era. We compared cumulative incidences of colorectal neoplasia since IBD diagnosis between patients with and without PIPs and corrected for confounders. Second, we compared the risk of receiving a colectomy. In our cohort with >22 years of median follow-up, 154 of 519 patients had PIPs. PIPs were associated with extensive disease (odds ratio [OR], 2.76; 95% confidence interval [CI], 1.61-4.42; P < 0.001) and with more severe inflammation at colonoscopy (OR, 3.54; 95% CI, 2.28-5.50; P < 0.001). After correction for confounders, the presence of PIPs was not associated with development of colorectal neoplasia (hazard ratio [HR], 1.28; 95% CI, 0.85-1.93; P = 0.24) or with development of advanced neoplasia (HR, 1.38; 95% CI, 0.52-3.68; P = 0.52). There was a higher risk of colectomy in patients with PIPs (HR, 3.41; 95% CI, 1.55-7.54; P = 0.002). In this cohort, PIPs were associated with disease extent, inflammation, and higher rates of colectomy. However, the presence of PIPs was not associated with the development of neoplasia. These findings suggest that patients with PIPs may not need an intensified surveillance strategy.

Use, effectiveness and tolerability of budesonide-MMX in ulcerative colitis: A real-life experience.

Budesonide-MMX has an established role in the management of relapsing mild-to-moderate ulcerative colitis. Data regarding effectiveness and tolerability in real-life clinical practice are limited. The aim of this study was to assess the use of budesonide-MMX in ulcerative colitis, as well as short-term effectiveness and tolerability in real-life practice. We conducted a retrospective study of adult patients with mild-to-moderate ulcerative colitis treated with budesonide-MMX at four tertiary inflammatory bowel disease centres in Italy from June 2016 to February 2018. Demographic and clinical features of patients, the use of budesonide-MMX, disease course and concomitant therapy were recorded. The primary outcome assessed was clinical remission at 2 months. A total of 82 patients with active mild-to-moderate ulcerative colitis were included in the study with a mean age of 45.9 years and a median partial Mayo Score of 4 (interquartile range 3-5). A total of 41 patients were male. Overall, 36 had extensive colitis, 38 left-sided colitis and eight proctitis. Treatments at the time of inclusion included 10 patients receiving biologic therapy, seven azathioprine and 54 mesalazine or salazopyrin. The main reasons for the addition of budesonide-MMX were clinical relapse (47.5%) or inadequate response to current therapy (39.0%). In total, 50% of patients achieved clinical remission, whereas 9.8% had clinical improvement. No response was noted in 40.2% of subjects. Using multivariate binary logistic regression, a moderate degree of activity was the main independent predictor of non-response. Eight significant adverse effects were reported in six patients with three discontinuing treatment. In real-life clinical practice, budesonide-MMX is commonly used in combination with other therapies, both for acute disease flares and for partial response to therapy.

669 Increased Prevalence of Sinusitis Among Patients With Inflammatory Bowel Disease

INTRODUCTION: Sinusitis is characterized by inflammation of sinus tissue by infectious or noninfectious agents. The pathophysiology of sinusitis involves a combination of an inflammatory response by the nasal mucosa and, in some cases, excess bacteria growth. Though it is thought that similar dysfunction of the epithelial barrier in the gut with inflammatory bowel disease (IBD) occurs in the nasal passage with sinusitis, there has not yet been an established association between the two, and there are limited data describing the relationship between IBD and acute or chronic maxillofacial sinus inflammation or infection. METHODS: This is a retrospective study at our tertiary IBD center. We used our institution's anonymized electronic medical record data warehouse to identify patients with diagnostic codes for both sinusitis (J32) and IBD (K50.90 and K51.90), and recorded directionality of diagnoses and medication exposures. Patients with a confirmed diagnosis of IBD between January 2000 and May 2019 and age ≥18 years were included. Demographic and disease related information were collected. Categorical variables were analyzed using Fisher's exact test and continuous variables were analyzed using Wilcoxon rank sum test. RESULTS: The data warehouse includes 2.4 million patients in the time period defined, of which 14379 have IBD. There were 13446 non-IBD patients with a diagnostic code for sinusitis (0.56%), and 387 IBD patients with a code for sinusitis (2.69%; OR 4.8, 95% CI 4.3-5.3). We did not identify directionality in sinusitis diagnosis in IBD. Univariate analysis is reported in Table 1. Among the IBD patients, multivariate analysis adjusting for age of IBD diagnosis, sex, and race identified female gender (OR 1.47, 95% CI 1.19-1.83), black/African-American race (OR 3.75, 95% CI 1.55-12.34), history of bowel obstruction (OR 1.68, 95% CI 1.28-2.18), and past or current use of steroids (OR 2.51, 95% CI 1.99-3.19) as risk factors for having sinusitis in IBD. No significant differences were observed in average age at IBD diagnosis, smoking status, other immune medications or IBD type (Crohn's disease or ulcerative colitis). CONCLUSION: In our tertiary center, IBD patients had nearly 5-fold greater odds of sinusitis than non-IBD patients. Female gender, black/African-American race, bowel obstruction, and steroid use was associated with a diagnosis of sinusitis associated with IBD. Additional evaluation of these risk factors and potential screening and prevention strategies are warranted.

785 Real World Application of the “Prometheus IBD Sgi Diagnostic” as a Baseline Test at a Tertiary Care IBD Referral Center

INTRODUCTION: Prometheus IBD sgi Diagnostic (SGI) is an Inflammatory Bowel Disease (IBD) advanced diagnostic test developed by Prometheus Laboratories. It employs a diagnostic algorithm combining serologic, genetic, and inflammatory markers to help with clinical decision making in determining the accuracy of a diagnosis of IBD in patients suspected to have the disease. Moreover, among those it identifies as having IBD, it also seeks to assist in distinguishing those with Crohn's vs. those with ulcerative colitis (UC). In this observational clinical decision making study, we sought to examine the real world application of the SGI at a single tertiary care IBD practice especially in correctly identifying those with Crohn's vs. those with UC. METHODS: We included all adult IBD patients seen at a single tertiary IBD center practice from 2014 to 2017 that had baseline SGI done and during care at the practice, had a diagnosis of IBD (Crohn's or UC) established. We calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and area under the curve based on results of SGI at baseline visit and the eventual established diagnosis of UC or CD. RESULTS: Of a total of 275 patients, there were 96 (34.9%) male patients and 179 (65.1%) female patients. The median age of these patients was 45.8. There were a total of 201 patients with biopsy proven CD. Of these, 104 were identified as having CD based on the baseline SGI and 97 who were identified as not having CD. Based on these data, the sensitivity of the SGI for CD at the practice was 52%, specificity was 88%, PPV was 92%, NPV was 40.1%, diagnostic accuracy was 61.5%, and Area under ROC was 70%. There were 66 patients with biopsy proven UC. Of these, 44 were identified as having UC based on the baseline SGI and 22 were identified as not having UC. Based on these data, the sensitivity of the SGI for UC at the practice was 67%, specificity was 85%, PPV was 58%, NPV was 89%, accuracy was 80%, and Area under ROC was 76%. CONCLUSION: Based on the results of this study, we conclude that the SGI is not a robust initial test in identifying those with Crohn's or those with UC. However, in a cohort of IBD patients seen at a tertiary care IBD practice, it is reasonably specific and accurate when it comes to correctly confirming Crohn's and even more so UC in patients with a caveat that the results should be interpreted in the proper clinical context and with the backing of other clinical indicators.

Development of self-management in pediatric inflammatory bowel disease: A qualitative exploration

Background: Self-management programs in pediatric chronic conditions, such as asthma and diabetes were effective in improving health-related outcomes. Similarly, self-management in the context of adult in inflammatory bowel disease (IBD) safely reduced healthcare costs. Nevertheless, evidence on self-management in pediatric IBD is scant. This study aims to explore self-management in pediatric IBD by exploring the childhood experience of IBD and how it is understood by the participants.Methods: Using a constructivist grounded theory approach, seven participants aged 8-17 years old were recruited in a tertiary metropolitan pediatric IBD center. Semi-structured interviews using topic guides and optional draw-and-write methods were used for data collection. Multi-level coding and constant comparison methods were utilised during data analysis.Results: The pediatric IBD self-management theory described the phenomenon of self-management through the relationship of categories that emerged from the study. Self-management starts off as a parent-dominant process that progressed to a more autonomous form with increasing disease experience. The experience was described as filled with struggles and a developing sense of control in managing these struggles. Autonomous self-management developed from the interaction of information, insight and integration. Enablers and deterrents were the contextual factors that influenced the development of self-management.Conclusions: Establishing identity both as a psychosocial developmental task and a disease-specific task is the core of self-management in childhood IBD. Future self-management programs should explore the role of structures around the child (family, school and healthcare systems) and the implementation of a proactive philosophy of involving children in managing their condition.

Fecal Microbiota Transplant for Recurrent Clostridium difficile Infection in Pediatric Inflammatory Bowel Disease.

Recurrent Clostridium difficile infection (RCDI) increases morbidity and mortality in patients with inflammatory bowel disease (IBD). Fecal microbiota transplant (FMT) is known to be very effective for RCDI in non-IBD patients with cure rates up to 91%. The same success rates of FMT have not been reported in patients with IBD with RCDI, and the data in pediatrics are limited. We aimed to determine the effectiveness of FMT for RCDI in established pediatric patients with IBD. We performed a retrospective chart review of pediatric patients with IBD and RCDI (≥3 episodes) who underwent FMT via colonoscopy at a tertiary care IBD center. The primary outcome was the rate of RCDI within 60 days post-FMT. The secondary outcomes were recurrence rate by 6 months, rate of colectomy, and time to recurrence. Of the 8 eligible patients, 6 had ulcerative colitis, 1 had IBD-unspecified, and 1 had Crohn disease. Median (interquartile range) age was 13 (11-14) years. All patients were on vancomycin at FMT. Two patients (25%) had RCDI by 60 days post-FMT and another 3 patients had RCDI between 60 days and 6 months. The median time to recurrence was 101 (40-139) days. Two patients (25%) who developed recurrence went to colectomy after FMT. With a cure rate of 75% at 60 days, FMT administered for the treatment of RCDI may be an effective treatment option in pediatric IBD. However, there appears to be a significant rate of late recurrence of C difficile infection after 60 days in these patients.

Development and Validation of a Novel Diagnostic Nomogram to Differentiate Between Intestinal Tuberculosis and Crohn's Disease: A 6-year Prospective Multicenter Study.

Differentiating Crohn's disease (CD) from intestinal tuberculosis (ITB) remains a diagnostic challenge. Misdiagnosis carries potential grave implications. We aimed to develop and validate a novel diagnostic nomogram for differentiating them. In total, 310 eligible patients were recruited from 6 tertiary inflammatory bowel disease centers. Among them, 212 consecutive patients (143 CD and 69 ITB) were used in the derivation cohort for the establishment of diagnostic equation and nomogram; 7 investigative modalities including clinical manifestations, laboratory results, endoscopic findings, computed tomography enterography features, and histology results were used to derive the diagnostic model and nomogram. Ninety-eight consecutive patients (76 CD and 22 ITB) were included for validation of the diagnostic model. Eight out of total 79 parameters were identified as valuable parameters used for establishing diagnostic equations. Two regression models were built based on 7 differential variables: age, transverse ulcer, rectum involvement, skipped involvement of the small bowel, target sign, comb sign, and interferon-gamma release assays (for model 1) or purified protein derivative (for model 2), respectively. Accordingly, 2 nomograms of the above 2 models were developed for clinical practical use, respectively. Further validation test verified the efficacy of the nomogram 1 with 90.9% specificity, 86.8% sensitivity, 97.1% PPV, 66.7% negative predictive value (NPV), and 87.8% accuracy for identifying CD, and the efficacy of the nomogram 2 with 100% specificity, 84.2% sensitivity, 100% positive predictive value, 64.7% NPV, and 87.8% accuracy for diagnosing CD. The derivation and validation cohorts identified and validated 2 highly accurate and practical diagnostic nomograms for differentiating CD from ITB. These diagnostic nomograms can be conveniently used to identify some difficult CD or ITB cases, allowing for decision-making in a clinical setting.

P008 IMPACT OF A MULTIDISCIPLINARY E-BOARD FOR COMPLEX INFLAMMATORY BOWEL DISEASE MANAGEMENT

Managing patients with inflammatory bowel disease (IBD) in the modern era requires an interdisciplinary approach among a wide range of specialties with expertise in IBD. However, specialty IBD care is not available at all medical institutions. We herein assess the impact of a biweekly multidisciplinary IBD case conference at a tertiary referral center that incorporates videoconferencing to community-based centers (IBD eBoard) on the management of complex IBD cases. From February 2017 through October 2018, data was collected prospectively during each IBD eBoard conference. Collected data included the number and role of internal attendees, the number of external attendees (via videoconferencing), external attendee site, case presenter, presented case diagnosis, and specific question(s). Outcomes of the discussion were then recorded, including if the initial diagnosis was changed and any recommended testing, medical, and surgical treatments Since its inception in February 2017, a total of 34 IBD eBoard conferences have taken place, with an average of 18.8 internal attendees and 5.6 external attendees from 6 community-based centers, including one in China. Attendees have included gastroenterologists, colorectal surgeons, radiologists, pathologists, nurse practitioners, fellows, residents, and study coordinators, among others. In total, 85 individual cases were presented (4 cases presented a second time and 1 case presented a third time). Six cases were presented externally via videoconference technology, with a community hospital in China being the furthest location geographically. Of the 85 new cases presented, the initial diagnosis was changed in 8 (9.4%). Recommendations for further diagnostic testing were made in 41 of the 90 presented cases (45.6%), while recommendations for changes in medical and surgical IBD management were made in 60 (66.7%) and 45 (50%) cases, respectively. Our IBD eBoard offers a unique opportunity for improving the care of complex IBD patients by combining the multidisciplinary expertise of a tertiary referral IBD center with videoconference technology to allow for outreach consultation to smaller, community-based centers. Through collaborative discussion, this approach appears to significantly impact the management of presented cases. This model is likely easily reproducible among other IBD centers. To implement more widely, further work is necessary to determine the long-term impact and cost-effectiveness of such an approach.

P008 IMPACT OF A MULTIDISCIPLINARY E-BOARD FOR COMPLEX INFLAMMATORY BOWEL DISEASE MANAGEMENT

Managing patients with inflammatory bowel disease (IBD) in the modern era requires an interdisciplinary approach among a wide range of specialties with expertise in IBD. However, specialty IBD care is not available at all medical institutions. We herein assess the impact of a biweekly multidisciplinary IBD case conference at a tertiary referral center that incorporates videoconferencing to community-based centers (IBD eBoard) on the management of complex IBD cases. From February 2017 through October 2018, data was collected prospectively during each IBD eBoard conference. Collected data included the number and role of internal attendees, the number of external attendees (via videoconferencing), external attendee site, case presenter, presented case diagnosis, and specific question(s). Outcomes of the discussion were then recorded, including if the initial diagnosis was changed and any recommended testing, medical, and surgical treatments Since its inception in February 2017, a total of 34 IBD eBoard conferences have taken place, with an average of 18.8 internal attendees and 5.6 external attendees from 6 community-based centers, including one in China. Attendees have included gastroenterologists, colorectal surgeons, radiologists, pathologists, nurse practitioners, fellows, residents, and study coordinators, among others. In total, 85 individual cases were presented (4 cases presented a second time and 1 case presented a third time). Six cases were presented externally via videoconference technology, with a community hospital in China being the furthest location geographically. Of the 85 new cases presented, the initial diagnosis was changed in 8 (9.4%). Recommendations for further diagnostic testing were made in 41 of the 90 presented cases (45.6%), while recommendations for changes in medical and surgical IBD management were made in 60 (66.7%) and 45 (50%) cases, respectively. Our IBD eBoard offers a unique opportunity for improving the care of complex IBD patients by combining the multidisciplinary expertise of a tertiary referral IBD center with videoconference technology to allow for outreach consultation to smaller, community-based centers. Through collaborative discussion, this approach appears to significantly impact the management of presented cases. This model is likely easily reproducible among other IBD centers. To implement more widely, further work is necessary to determine the long-term impact and cost-effectiveness of such an approach.