Time Of Inflammatory Bowel Disease Diagnosis Research Articles

Errors in the care of inflammatory bowel disease patients: “Errata” Study

Abstract Introduction Errors are very common in daily clinical practice; however, they can be prevented. Our aim was to identify the most common errors in the outpatient management of inflammatory bowel disease (IBD) patients. Material and methods Patients diagnosed with IBD, being treated at our IBD Unit and who were referred for a second opinion were consecutively enrolled. Data on the strategies implemented by their previous physicians were obtained. These strategies were compared with the currently recommended diagnostic and therapeutic procedures. Results Seventy-four IBD patients were enrolled. Prior to care in our Unit, screening for tobacco use had been performed in 50% of Crohn's disease patients, while smoking cessation counselling had been provided in 29%. At the time of IBD diagnosis, the hepatitis B virus immunisation status had been investigated in 16% of the patients, the hepatitis C virus status in 15%, and the varicella status in 7%. Seven percent of the patients had been vaccinated against hepatitis B virus, and 3% against influenza, tetanus and pneumococcus. Sixty-seven percent of the patients with an indication for use of 5-aminosalicylic acid and 37% of those with an indication for immunosuppressants had received the indicated drug. Discussion Errors in the outpatient management of IBD patients are very common and relevant.

Errores en la atención de los pacientes con enfermedad inflamatoria intestinal: estudio «ERRATA»

IntroductionErrors are very common in daily clinical practice; however, they can be prevented. Our aim was to identify the most common errors in the outpatient management of inflammatory bowel disease (IBD) patients. Material and methodsPatients diagnosed with IBD, being treated at our IBD Unit and who were referred for a second opinion were consecutively enrolled. Data on the strategies implemented by their previous physicians were obtained. These strategies were compared with the currently recommended diagnostic and therapeutic procedures. ResultsSeventy-four IBD patients were enrolled. Prior to care in our Unit, screening for tobacco use had been performed in 50% of Crohn's disease patients, while smoking cessation counselling had been provided in 29%. At the time of IBD diagnosis, the hepatitis B virus immunization status had been investigated in 16% of the patients, the hepatitis C virus status in 15%, and the varicella status in 7%. Seven percent of the patients had been vaccinated against hepatitis B virus, and 3% against influenza, tetanus and pneumococcus. Sixty-seven percent of the patients with an indication for use of 5-aminosalicylic acid and 37% of those with an indication for immunosuppressants had received the indicated drug. DiscussionErrors in the outpatient management of IBD patients are very common and relevant.

P069 MALIGNANCY RISK IN VETERAN PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A RETROSPECTIVE COHORT STUDY

The association between inflammatory bowel disease (IBD) and colorectal cancer is well-known. However, the relationship between IBD and other malignancies has been less clearly defined in the literature to date. The objective of this study was to evaluate the types of malignancies that veteran patients with IBD at our facility have been diagnosed with. Additionally, we were interested in seeing whether there was a temporal relationship between the time of IBD diagnosis and the time to cancer diagnosis. We performed a retrospective cohort study using patient medical records at the Michael E. DeBakey VA Medical Center in Houston, TX. The cohort consisted of 676 patients with a confirmed diagnosis of IBD. Of these patients, 120 had been diagnosed with a malignancy between 1990 and 2018. The medical records were reviewed and data concerning patient gender, race, ethnicity, age at IBD diagnosis, type of cancer diagnosis, and age at cancer diagnosis were analyzed. Out of the 676 patients at our facility with a known diagnosis of IBD, 99.3% were male, 0.7% female, 96.1% Caucasian, 3% black, and 0.9% of other races/ethnicities. The average age at IBD diagnosis was 50.6 years. In the study period, 120 IBD patients were diagnosed with a malignancy. The most commonly represented malignancies were prostate (25.8%), non-melanoma skin cancers (15%), lung (12.5%), colorectal (12.5%), and bladder (10%). The mean time from IBD diagnosis to cancer diagnosis was 19 years (6.9). In a cohort of Veterans with IBD who were subsequently diagnosed with cancer, prostate cancer was the most common, followed by lung, colorectal and bladder cancer. Most cancers occur greater than 10 years after IBD diagnosis. The prevalence of observed cancers after IBD diagnosis is higher than the expected age-adjusted cancer prevalence in the non-IBD population.

The prevalence, characteristics, and determinants of anaemia in newly diagnosed patients with inflammatory bowel disease.

IntroductionAnaemia is the most common extraintestinal manifestation of inflammatory bowel disease, which has a negative impact on quality of life.AimTo determinate the prevalence, risk factors, and aetiology of anaemia in newly diagnosed patients with inflammatory bowel disease (IBD).Material and methods: We included 136 newly diagnosed patients with IBD. We analysed patient age, sex, laboratory tests, endoscopic and radiological examination, length of stay, and the course of hospitalisation.ResultsAnaemia at the time of IBD diagnosis was detected in 89 (65.4%) patients: 51 (57.3%) patients with ulcerative colitis vs. 38 (42.7%) patients with Crohn’s disease; p = 0.052. Female patients were more frequently anaemic than male patients (59.6% vs. 40.4%; p = 0.001). Anaemia was more often diagnosed in Crohn’s disease patients with ileocolonic involvement compared to other types of disease location (70.96% vs. 56.52%, respectively; p = 0.03). The prevalence of anaemia at the time of diagnosis for ulcerative colitis patients increased with disease extension: for extensive colitis anaemia was diagnosed in 64.71% compared to 35.29% in limited extension (p < 0.05). Anaemic patients were hospitalised for significantly longer than patients with no anaemia (7.95 ±3.8 days vs. 5.88 ±2.7 days for Crohn’s disease; p = 0.02 and 9.02 ±5.0 days vs. 5.00 ±2.4 days for ulcerative colitis; p < 0.05).ConclusionsAnaemia represents a frequent complication of IBD not only during the long-term course of the disease, but also at the moment of diagnosis. Anaemia is one of the factors extending the time of hospitalisation. Female sex and disease extent are strong determinant factors connected with anaemia.

Risk factors for colorectal neoplasia in patients with underlying inflammatory bowel disease: a multicenter study.

BackgroundThis study sought to evaluate the risk factors for the development of colitis-associated neoplasia (CAN) in Chinese patients with inflammatory bowel disease (IBD).MethodsIBD patients who developed CAN between 1999 and 2016 were identified from eight medical centers. In addition to initial pathology evaluation, a CAN diagnosis was confirmed by two expert pathologists. Patients with CAN (n = 29) were compared with non-CAN controls (n = 87). Matching was performed for gender and IBD type with a ratio of three controls to one subject.ResultsOf the 29 patients with CAN, 8 (27.6%) had colorectal cancer (CRC), 20 (69.0%) had a final diagnosis of low-grade dysplasia and 1 (3.4%) had high-grade dysplasia. Multivariate analysis revealed that an older age at the time of IBD diagnosis and a longer IBD duration were independent risk factors for the development of CAN, with odds ratios of 1.09 [95% confidence interval (CI): 1.04–1.14, P < 0.001] and 1.14 (95% CI: 1.03–1.27, P = 0.013), respectively. Comparison between IBD patients with CRC and those with dysplasia indicated that the former were older at the time of IBD diagnosis (P = 0.012) and had longer IBD durations (P = 0.019).ConclusionsOlder age at the time of IBD diagnosis and longer IBD duration were found to be associated with the development of CAN in IBD patients.

Role of colectomy in preventing recurrent primary sclerosing cholangitis in liver transplant recipients.

To study the published evidence on the impact of colectomy in preventing recurrent primary sclerosing cholangitis (rPSC). An unrestricted systematic literature search in PubMed, EMBASE, Medline OvidSP, ISI Web of Science, Lista (EBSCO) and the Cochrane library was performed on clinical studies investigating colectomy in liver transplantation (LT) recipients with and without rPSC in the liver allograft. Study quality was evaluated according to a modification of the methodological index for non-randomized studies (MINORS) criteria. Primary endpoints were the impact of presence, timing and type of colectomy on rPSC. Overall presence of inflammatory bowel disease (IBD), time of IBD diagnosis, posttransplant IBD and immunosuppressive regimen were investigated as secondary outcome. The literature search yielded a total of 180 publications. No randomized controlled trial was identified. Six retrospective studies met the inclusion criteria of which 5 studies were graded as high quality articles. Reporting of IBD was heterogenous but in four publications, either inflammatory bowel disease, ulcerative colitis or in particular active colitis post-LT significantly increased the risk of rPSC. The presence of an intact (i.e., retained) colon at LT was identified as risk factor for rPSC in two of the high quality studies while four studies found no effect. Type of colectomy was not associated with rPSC but this endpoint was underreported (only in 33% of included studies). Neither tacrolimus nor cyclosporine A yielded a significant benefit in disease recurrence of primary sclerosing cholangitis (PSC). The data favours a protective role of pre-/peri-LT colectomy in rPSC but the current evidence is not strong enough to recommend routine colectomy for rPSC prevention.

Inflammatory Bowel Disease and Parkinson's Disease: A Nationwide Swedish Cohort Study.

Few studies have examined the association between inflammatory bowel disease (IBD) and Parkinson's disease (PD). To estimate the incidence and relative risk of PD development in a cohort of adult IBD, we included all incident IBD patients (n = 39,652) in the Swedish National Patient Register (NPR) between 2002 and 2014 (ulcerative colitis [UC]: n = 24,422; Crohn's disease [CD]: n = 11,418; IBD-unclassified [IBD-U]: n = 3812). Each IBD patient was matched for sex, age, year, and place of residence with up to 10 reference individuals (n = 396,520). In a cohort design, all incident PD occurring after the index date was included from the NPR. In a case-control design, all incident PD occurring before the index date was included. The association between IBD and PD and vice versa was investigated by multivariable Cox and logistic regression. In IBD, there were 103 cases of incident PD, resulting in hazard ratios (HRs) for PD of 1.3 (95% confidence interval [CI], 1.0-1.7; P = 0.04) in UC, 1.1 (95% CI, 0.7-1.7) in CD, and 1.7 (95% CI, 0.8-3.0) in IBD-U. However, these effects disappeared when adjusting for number of medical visits during follow-up to minimize potential surveillance bias. In a case-control analysis, IBD patients were more likely to have prevalent PD at the time of IBD diagnosis than matched controls, with odds ratios of 1.4 (95% CI, 1.2-1.8) in all IBD patients, 1.4 (95% CI, 1.1-1.9) for UC, and 1.6 (95% CI, 1.1-2.3) for CD patients alone. IBD is associated with an increased risk of PD, but some of this association might be explained by surveillance bias. 10.1093/ibd/izy190_video1izy190.video15785623138001.

Evidence‐based consensus on opportunistic infections in inflammatory bowel disease

Evidence‐based consensus on opportunistic infections in inflammatory bowel disease

The Influence of Hormonal Fluctuation on Inflammatory Bowel Disease Symptom Severity-A Cross-Sectional Cohort Study.

Many women with inflammatory bowel disease (IBD) report changes in symptoms in association with hormonal changes during menses, pregnancy, and hormonal contraceptive use, suggesting a hormonal influence on disease activity. We aimed to identify and characterize IBD symptom fluctuations in women during times of hormonal variation. From June 2012 through September 2012, women enrolled in Crohn's and Colitis Foundation of America Partners , an online Internet cohort of patients with IBD, were invited to participate in this study. Using a 5-point Likert scale, participants were asked to rate symptom changes during their menstrual cycle, pregnancy, the postpartum period, and after menopause. Clinical and demographic differences were assessed using univariate and multivariable methods. A total of 1,203 female patients with Crohn's disease (CD) and ulcerative colitis (UC) participated (64% CD, 34% UC). Over half of the women with IBD reported worsening symptoms during menses. Symptom changes were similar between women with CD vs UC, except in pregnancy, where symptom worsening during pregnancy was more commonly seen in UC than CD (P = 0.02). Overall, women reporting symptom worsening were younger at the time of IBD diagnosis (P < 0.01), had lower quality of life (SIBDQ) scores (P < 0.01), and had a higher BMI (25 vs 24) than women without symptom worsening. Women with IBD report changes in symptom severity during times of hormone fluctuation. Further clarification of the role of hormones in IBD is warranted in order to understand these relationships and to identify potential management strategies for women with IBD and hormonally sensitive gastrointestinal symptoms.

Intestinal Inflammation Does Not Predict Nonalcoholic Fatty Liver Disease Severity in Inflammatory Bowel Disease Patients.

Nonalcoholic fatty liver disease (NAFLD) is a common cause of hepatic steatosis in patients with inflammatory bowel disease (IBD). Both metabolic syndrome (MetS) and intestinal inflammation are implicated in NAFLD pathogenesis. We performed a retrospective cohort study of patients with IBD and NAFLD seen in our health system from January 1997 to December 2011 to examine associations between IBD severity and phenotype; MetS; and NAFLD fibrosis as estimated by the NAFLD Fibrosis Score (NFS). A total of 84 patients were included in our analysis (24 UC, 60 CD). 23% of patients had MetS. IBD patients with MetS were significantly older at the time of IBD diagnosis (44 vs. 33, p=0.005) and NAFLD diagnosis (55 vs. 47, p=0.018). IBD patients with MetS had higher ALT (54 vs. 38U/L, p=0.02) and AST (52 vs. 35 U/L, p=0.004). Comparing MetS patients to non-MetS IBD patients, there was no significant difference between IBD medication use (i.e., steroids, anti-TNFs, and immunomodulators) or NAFLD medication use, other than statins. Both UC and CD patients with concomitant MetS had significantly higher NFS scores than non-MetS patients: UC (-0.4 vs. -2.5, p=0.02) and CD (-0.8 vs. -2.3, p=0.03). IBD disease severity, disease location, or IBD medication use was associated with NAFLD severity. To our knowledge, this is the first study to demonstrate that NAFLD severity in both UC and CD IBD patients is associated with the presence of MetS but not with the severity of IBD.

Out-of-pocket Cost Burden in Pediatric Inflammatory Bowel Disease: A Cross-sectional Cohort Analysis.

Pediatric inflammatory bowel disease (IBD), consisting of Crohn's disease (CD) and ulcerative colitis (UC), can result in significant morbidity requiring frequent health care utilization. Although it is known that the overall financial impact of pediatric IBD is significant, the direct out-of-pocket (OOP) cost burden on the parents of children with IBD has not been explored. We hypothesized that affected children with a more relapsing disease course and families in lower income strata, ineligible for need-based assistance programs, disparately absorb ongoing financial stress. We completed a cross-sectional analysis among parents of children with IBD residing in California using an online HIPAA-secure Qualtrics survey. Multicenter recruitment occurred between December 4, 2013 and September 18, 2014 at the point-of-care from site investigators, informational flyers distributed at regional CCFA conferences, and social media campaigns equally targeting Northern, Central, and Southern California. IBD-, patient-, and family-specific information were collected from the parents of pediatric patients with IBD patients younger than 18 years of age at time of study, carry a confirmed diagnosis of CD or UC, reside in and receive pediatric gastroenterology care in California, and do not have other chronic diseases requiring ongoing medical care. We collected 150 unique surveys from parents of children with IBD (67 CD; 83 UC). The median patient age was 14 years for both CD and UC, with an overall 3.7 years (SD 2.8 yr) difference between survey completion and time of IBD diagnosis. Annually, 63.6%, 28.6%, and 5.3% of families had an OOP cost burden >$500, >$1000, and >5000, respectively. Approximately one-third (36.0%) of patients had emergency department (ED) visits over the past year, with 59.2% of these patients spending >$500 on emergency department copays, including 11.1% who spent >$5000. Although 43.3% contributed <$500 on procedure and test costs, 20.0% spent >$2000 in the past year. Families with household income between $50,000 and $100,000 had a statistically significant probability (80.6%) of higher annual OOP costs than families with lower income <$50,000 (20.0%; P < 0.0001) or higher income >$100,000 (64.6%; P < 0.05). Multivariate analysis revealed that clinical variables associated with uncontrolled IBD states correlated to higher OOP cost burden. Annual OOP costs were more likely to be >$500 among patients who had increased spending on procedures and tests (odds ratio [OR], 5.63; 95% confidence interval [CI], 2.73-11.63), prednisone course required over the past year (OR, 3.19; 95% CI, 1.02-9.92), at least 1 emergency department visit for IBD symptoms (OR, 2.84; 95% CI, 1.33-6.06), at least 4 or more outpatient primary medical doctor visits for IBD symptoms (OR, 2.82; 95% CI, 1.40-5.68), and history of 4 or more lifetime hospitalizations for acute IBD care (OR, 2.60; 95% CI, 1.13-5.96). Previously undocumented, a high proportion of pediatric IBD families incur substantial OOP cost burden. Patients who are frequently in relapsing and uncontrolled IBD states require more acute care services and sustain higher OOP cost burden. Lower middle income parents of children with IBD ineligible for need-based assistance may be particularly at risk for financial stress from OOP costs related to ongoing medical care.

P-194 YI A Model Integrating Genetic and Environmental Factors Can Differentiate Crohnʼs Disease from Ulcerative Colitis

Crohn's disease (CD) and ulcerative colitis (UC) are 2 related yet different forms of chronic inflammatory bowel disease (IBD). Clinically, it is relevant to differentiate these 2 forms of disease and adopt specific treatment modalities. Discriminative tools combining different bio-molecular markers have been proposed but there is a lack of replication in independent cohorts. The aim of this study was to derive a model integrating genetic markers and environmental factors to differentiate CD from UC using a discovery cohort and an independent replication cohort. The Wellcome Trust Case-Control Consortium (WTCCC) IBD GWAS (1,748 CD and 2,361 UC; non-Jewish, European ancestry) served as a discovery cohort to identify genetic variants which were differentially associated with CD versus UC. The CC/UP cohort, an ongoing IBD GWAS (692 CD and 566 UC; non-Jewish, European ancestry) served as an independent replication cohort. In the CC/UP cohort, questionnaires were used to assess demographic and environmental factors including ethnicity, history of appendectomy (prior to IBD diagnosis), and tobacco use (classified as current smoker versus past smoker or never smoker at the time of IBD diagnosis). History of appendectomy and current smoking status prior to the IBD diagnosis were compared between CD and UC. Discriminative accuracy was evaluated using the area under the receiver operating characteristic curves (AUC). AUCs of different models were statistically compared through the SAS 9.2 GPLOT procedures. In the WTCCC discovery cohort, comparing CD versus UC, there were 121 single nucleotide polymorphisms (SNP) with nominal P values less than 10E-05. To avoid collinearity between markers, stepwise backward procedure (threshold of P < 0.01) was adopted and selected 79 SNPs into the model [AUC: 0.91, 95% CI, ±0.004]. We applied the same model of 79 SNPs in the independent CC/UP cohort and found an AUC of 0.74 [95% CI, ±0.01]. Furthermore, in the CC/UP cohort, current smoking and appendectomy prior to IBD diagnosis were significantly associated with CD versus UC (Odds ratios (OR) = 6.12 [3.79–9.88], P < 10E-07, and OR = 3.03 [1.48–6.23], P = 0.002, respectively). A model integrating genetic markers and environmental factors (current smoking and appendectomy before the diagnosis of IBD) had a discriminative accuracy between CD versus UC with an increase in AUC from 0.74 to 0.78 [95% CI, ±0.01] (P < 10E-06). Through 2 independent cohorts, we identified a model integrating genetic markers (79 SNPs) and environmental factors (current smoking and history of appendectomy before IBD diagnosis) with modest discriminatory power to differentiate CD from UC [AUC: 0.78]. Potential clinical applications of this work include applying genetic and environmental risk modeling to predict complicated disease outcomes and to potentially guide disease-specific treatment choices.

Endoscopic Surveillance Patterns of Polypoid Dysplasia Among Patients With Inflammatory Bowel Disease

Introduction: The current strategy of close endoscopic surveillance following resection of polypoid dysplasia (sporadic adenoma-like lesions) in patients with ulcerative colitis is accepted; however, the follow-up interval is not well defined. The purpose of this study is to describe the community based surveillance colonoscopy recommendations following the resection of polypoid dysplasia in inflammatory bowel disease (IBD) patients. Methods: We performed a single-center case series of patients with IBD who received surveillance colonoscopies from 1998 to 2011. Patients with IBD were identified by ICD-9 code and a manual chart review was performed to confirm the diagnosis of IBD. Review of the colonoscopy and pathology reports was performed to identify cases of polypectomy with pathologic confirmation of dysplasia or indeterminate for dysplasia. Among these patients, recommendations and intervals for subsequent colonoscopies as well as the presence of subsequent dysplasia were reviewed. Results: Forty patients with a total of 134 colonoscopies were included in this study. The patients had a mean age of 45 years at the time of IBD diagnosis, 97% were men and 77% were white. A total of 81 sporadic appearing polyps were identified and resected, including 78 with low-grade dysplasia (LGD) and 3 with high-grade dysplasia (HGD). Among those patients with LGD, recommendations were made for repeat colonoscopy in less than 1 year for 5 cases, 1-2 years for 15 cases and more than 2 years for 9 cases. There was no documentation in the medical records regarding surveillance interval among 12 cases with LGD. Of the 27 patients with LGD, 67% underwent at least one subsequent surveillance colonoscopy, among which 13 additional sporadic adenomas were identified. None of the patients had subsequent HGD or colorectal cancer in a mean follow up of 10.4 years. Among the 3 patients with HGD, surgical resection was recommended for 2 patients. One patient underwent total proctocolectomy with no additional dysplasia identified on surgical pathology. One patient declined surgery and had no further follow-up. The third patient had 2 subsequent colonoscopies in the following 5.5 years prior to his death unrelated to IBD: the first did not identify dysplasia and the second had lesions that were indeterminate for dysplasia in the setting of active colitis. Conclusion: We observed a wide variation in surveillance recommendations after polypectomy in patients with IBD, from less than 1 year to greater than 2 years. We observed no colorectal cancer or advanced adenomas among IBD patients after polypectomy for sporadic- appearing polyps. Further studies defining optimal surveillance intervals after polypectomy for polypoid dysplasia are required.

Feasibility of Venous Thromboembolism Prophylaxis During Inflammatory Bowel Disease Flares in the Outpatient Setting

Inflammatory bowel disease (IBD) patients are at increased risk of venous thromboembolism (VTE), which is most pronounced during a disease flare. We explored the cost-effectiveness of pharmacological VTE prophylaxis in an outpatient setting. Markov decision analysis was conducted from a societal perspective to compare the relative costs and effectiveness of pharmacological VTE prophylaxis versus no anticoagulation during ambulatory IBD flares among a hypothetical cohort of 10,000 IBD patients. The time horizon was from time of IBD diagnosis until death. Univariate and probabilistic sensitivity analyses were performed. In base case analysis, VTE prophylaxis was, compared with no anticoagulation, associated with higher average costs (U.S. $141,036 versus $90,338) and quality-adjusted life-years (QALYs) (22.29 versus 22.25), yielding an incremental cost-effectiveness ratio of $1,267,450/QALY. Venous thromboembolism prophylaxis resulted in higher unadjusted life-years (47.76 life-years versus 46.67 life-years) and lower lifetime risk of VTE (6.2% versus 9.3%). The number needed to treat to prevent one VTE event over a lifetime was 32.3. Univariate sensitivity analysis showed that the incremental cost-effectiveness ratio was most sensitive to variations in the efficacy of VTE prophylaxis. In probabilistic sensitivity analysis, only 20% of 1000 simulated trials showed that VTE prophylaxis increased QALYs. In the remaining 80%, it was associated with both higher costs and fewer QALYs. Although the administration of pharmacological VTE prophylaxis during IBD flares in the outpatient setting was associated with increased life-years and reduced VTE events, it was not cost effective. Moreover, the benefits of VTE prophylaxis were not robust to probabilistic sensitivity analysis.

Pediatric and Adult Patients Had a Similar Pouch Survival Rate after Restorative Proctocolectomy

There were limited data in the literature on the long-term pouch outcomes in children who underwent restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). The aim of this study was to compare long-term pouch outcomes in pediatric and adult patients. Consecutive inflammatory bowel disease (IBD) patients with ileal pouches seen in our Pouchitis Clinic from 2002-2012 were studied. The pouch outcome in pediatric patients was evaluated in comparison with adults by both univariate and multivariate analyses. All eligible patients were included into the study (N = 1,289), of whom 108 (8.4%) were pediatric patients (<18 years). Male accounted for 50.9% of pediatric patients and 55.5% of adults. Pediatric patients had a younger age at the time of IBD diagnosis and pouch construction and a shorter duration from IBD diagnosis to colectomy. Fewer pediatric patients had a history of smoking (9.3% vs. 20.7%, P = 0.004), concomitant extra-intestinal manifestations (21.5% vs. 39.1%, P<0.001), and dysplasia as the indication for colectomy (0.9% vs. 13.6%, P<0.001) than the adults. On the other hand, pediatric patients had higher rates of pouch surgery-associated complications (21.3% vs. 13.9%, P = 0.036), postoperative pouch-associated hospitalization (25.9% vs. 13.4%, P<0.001) and postoperative use of anti-TNF biologics (16.7% vs. 7.9%, P = 0.002) than the adults. Pouch failed in 100 patients (7.8%) after a mean follow-up of 10.6±6.8 years, including 13 (12.0%) in the pediatric group and 87 (7.4%) in the adult group (P = 0.082). Risk factors for pouch failure in the multivariate analysis included preoperative use of anti-TNF biologics, postoperative use of anti-TNF biologics, Crohn's disease of pouch, pouch surgery-related complications and postoperative pouch-associated hospitalization. However, pediatric patients were not found to be significantly associated with pouch failure in neither the univariate nor multivariate analyses, with a hazard ratio of 0.67 (95% confidence interval: 0.36-1.24, P = 0.2) from the multivariate analysis. Pediatric patients suffered from a higher incidence of postoperative pouch complications than adults; however the long-term pouch retention rates were comparable.

Inflammatory Bowel Disease-Associated With Colorectal Cancers in Korea: A Single-Center Experience

Although a colorectal cancer (CRC) is a well-known complication of inflammatory bowel disease (IBD), the epidemiology and characteristics of CRC associated with IBD in Asians are still unclear. We retrospectively reviewed the medical records of IBD patients who were registered at the Asan Medical Center from July 1989 to August 2012. Patients who were diagnosed with CRC at the time of or after diagnosis of IBD were identified. A total of 3575 patients with definite IBD (1877 with ulcerative colitis [UC] and 1698 with Crohn's disease [CD]), were enrolled and 25 patients diagnosed with IBD-associated colorectal adenocarcinoma (15 with UC and 10 with CD) were identified. There were 14 females (56%) and the median age at diagnosis of CRC was 43.1 years (interquartile range [IQR], 32.0-52.1 years). Two UC patients had combined primary sclerosing cholangitis. The median interval from IBD diagnosis to cancer diagnosis was 11 years (IQR, 5.1-16.8 years). Five patients (20%) were diagnosed with cancer at the time of IBD diagnosis. Three patients (12%) had synchronous lesions. The histologies of CRCs were as follows; moderately differentiated adenocarcinoma in 11 (44%), mucinous adenocarcinoma in 6 (24%), poorly differentiated adenocarcinoma in 4 (16%), well differentiated adenocarcinoma in 3 (12%), and signet ring cell carcinoma in 1 (4%). The stage distribution of cancer was as follows; I in 3 (12%), II in 8 (32%), III in 5 (20%) and IV in 9 (36%). The cumulative risk of CRC in IBD, UC and CD patients were 0.6%, 0.7% and 0.5%, respectively after 10 years and 5.8%, 5.1% and 7.2% respectively after 20 years. The IBD-associated CRC tends to show an advanced stage at diagnosis. The risk of CRC in Korean IBD patients appears to be comparable to that of Western IBD patients.

Pediatric and Adult Patients Had a Similar Pouch Survival Rate After Restorative Proctocolectomy

There were limited data in the literature on the long-term pouch outcomes in children who underwent restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). The aim of this study was to compare long-term pouch outcomes in pediatric and adult patients. Consecutive inflammatory bowel disease (IBD) patients with ileal pouches seen in our Pouchitis Clinic from 2002-2012 were studied. The pouch outcome in pediatric patients was evaluated in comparison with adults by both univariate and multivariate analyses. All eligible patients were included into the study (N = 1,289), of whom 108 (8.4%) were pediatric patients (<18 years). Male accounted for 50.9% of pediatric patients and 55.5% of adults. Pediatric patients had a younger age at the time of IBD diagnosis and pouch construction and a shorter duration from IBD diagnosis to colectomy. Fewer pediatric patients had a history of smoking (9.3% vs. 20.7%, P = 0.004), concomitant extra-intestinal manifestations (21.5% vs. 39.1%, P < 0.001), and dysplasia as the indication for colectomy (0.9% vs. 13.6%, P < 0.001) than the adults. On the other hand, pediatric patients had higher rates of pouch surgery-associated complications (21.3% vs. 13.9%, P = 0.036), postoperative pouch-associated hospitalization (25.9% vs. 13.4%, P < 0.001) and postoperative use of anti-TNF biologics (16.7% vs. 7.9%, P = 0.002) than the adults. Pouch failed in 100 patients (7.8%) after a mean follow-up of 10.6±6.8 years, including 13(12.0%) in the pediatric group and 87 (7.4%) in the adult group (P = 0.082). Risk factors for pouch failure in the multivariate analysis included preoperative use of anti-TNF biologics, postoperative use of anti-TNF biologics, Crohn's disease of pouch, pouch surgery-related complications and postoperative pouch-associated hospitalization. However, pediatric patients were not found to be significantly associated with pouch failure in neither the univariate nor multivariate analyses, with a hazard ratio of 0.67 (95% confidence interval: 0.36-1.24, P = 0.2) from the multivariate analysis. Pediatric patients suffered from a higher incidence of postoperative pouch complications than adults; however the long-term pouch retention rates were comparable.

Cumulative Risk of Non-Melanoma Skin Cancer in a Population-Based Cohort of Inflammatory Bowel Disease

Purpose: Recent data on the risk of non-melanoma skin cancer (NMSC) in patients with inflammatory bowel disease (IBD) from the United States are limited. We studied the prevalence of NMSC in a population-based cohort of IBD patients from Olmsted County, Minnesota. Methods: This was a retrospective study of Olmsted County residents who were diagnosed with IBD between 1980 and 2004, and followed through death, migration out of the county, or last follow-up (approximately 2009). The resources of the Rochester Epidemiology Project were used to identify cohort patients with NMSC, which were all confirmed through medical record review. We estimated the cumulative risk of NMSC in patients from time of IBD diagnosis and their 95% confidence intervals (CI) using the Kaplan-Meier method (Greenwood method). The associations between demographic factors and IBD subtype with time to NMSC diagnosis were assessed using a Cox proportional hazards model. Results: Five hundred thirty-one IBD patients (287 ulcerative colitis [UC], 244 Crohn's disease [CD]) were followed up for 7826 person-years (median follow-up per patient, 14.7 years). Thirty-six patients were diagnosed with at least one NMSC at least 30 days after the diagnosis of IBD. The cumulative risk of NMSC after IBD diagnosis was 1.8% after 5 years (95% CI, 0.6%-2.9%), 5.2% after 10 years (3.1%-7.2%) and 7.9% after 20 years (5.0%-10.7%). None of the patients who were diagnosed with IBD under the age of 20 years had developed NMSC after 20 years of follow-up, while the cumulative risk for those diagnosed with IBD after age 55 was 6.8% after 5 years (95% CI, 1.4%-12.0%), 17.0% after 10 years (7.9%-25.3%), and 24.3% after 20 years (12.1%-42.9%). In proportional hazards analysis, there was no association between time to NMSC and IBD subtype or gender. Patients diagnosed with IBD between 40 and 55 years had a threefold risk of NMSC relative to those diagnosed under the age of 30 years (hazard ratio [HR], 2.9; 95% CI, 1.03-8.2), while patients diagnosed with IBD after the age of 55 years had a 10-fold elevation in risk (HR, 10.5; 95% CI, 4.0-27.8). Conclusion: In this population-based North American inception cohort of IBD, the cumulative risk of NMSC was 7.9% after 20 years of IBD. Age at diagnosis of IBD was significantly associated with this risk, but not gender or IBD subtype. Future studies will compare this risk to that in the general population and will assess the effect of medications on this risk.

Hepatitis B Immunity and Response to Booster Vaccination in Children With Inflammatory Bowel Disease Treated With Infliximab

Hepatitis B virus (HBV) reactivation has been described in patients treated with infliximab for inflammatory bowel disease (IBD). This has resulted in a "black box" warning. Although universal vaccination against hepatitis B was implemented in the United States in 1991, up to 10% of vaccine recipients fail to respond with adequate anti-hepatitis B surface antibodies (anti-HBs) levels after a primary series of vaccinations. In addition, anti-HBs levels are expected to decline with time. The objectives of this study were to determine HBV immunity in children with IBD on infliximab therapy and to determine response to a booster dose of the HBV vaccine in patients who were found to be non-immune. This was a prospective cross-sectional, single-center study that included 100 pediatric IBD patients on infliximab. Serologic specimens were tested for hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc), and anti-HBs. Patients with an anti-HBs level ≥10 mIU/ml were considered to be immune. One booster dose was given to non-immune patients and a serum sample was collected after 4 weeks to assess the presence of anamnestic response (anti-HBs level ≥10 mIU/ml after booster). The mean age of the patients was 17.9 (±4.0) years. None of the patients were positive for HBsAg or anti-HBc. In all, 87 patients were vaccinated against HBV and 49/87 (56%) had immunity to HBV as defined by anti-HBs level ≥10 mIU/ml. The mean concentration of anti-HBs levels in immune patients was 295.6 (±350.6) mIU/ml. Older age, lower albumin levels, and the presence of pancolitis were associated with the absence of protective antibodies; however, infliximab dose, frequency, duration, and the concurrent use of immunomodulators were not significantly different between immune and non-immune patients. Thirty-four patients received booster immunization and 26/34 (76%) had an anamnestic response. Interestingly, non-responders were given infliximab with higher frequency (every 5.9 ± 1.2 weeks vs. every 7.1 ± 1.8 weeks, P=0.01). Overall, 75/87 (86%) of previously immunized patients were considered immune against HBV infection. In pediatric IBD patients seen at a large, urban tertiary care facility in the United States, a significant minority (13%) have not been vaccinated against HBV. Nearly one-half of all patients (and 44% of previously vaccinated patients) did not have protective anti-HBs levels. Moreover, of those previously vaccinated, a significant minority (14%) appear at risk for HBV because protective anti-HBs levels were absent and could not be elicited through booster immunization. Given the high risk for severe HBV infection in this group, efforts should be made to screen for HBV immunity at the time of IBD diagnosis. Booster immunization should be considered in patients without protective antibodies.

Inflammatory bowel disease and asthma: A population-based, case-control study

A few cross-sectional studies reported an increased risk of inflammatory bowel disease (IBD) among asthmatics. We conducted a population-based, case-control study that applied predetermined criteria for asthma and IBD to determine whether asthma, as a T-helper 2 (Th2) condition, reduces the risk of IBD, a Th1 condition. This was a population-based, case-control study using criteria-based ascertainment for IBD and asthma. Subjects were all Rochester, Minnesota, residents who had developed IBD between 1964 and 1983 and their age- and gender-matched controls, using 1:1 matching. Controls were randomly selected from the community using the Rochester Epidemiology Project database and confirmed not to have IBD. All cases and controls were merged with the database comprising all Rochester residents with or without asthma between 1964 and 1983. Of the 231 IBD cases, 55% had ulcerative colitis and the remainder had Crohn's disease. Of these, 50.4% were male and 98.1% were Caucasians. The mean age at the time of IBD diagnosis was 33.8 years. Four cases (1.7%) had asthma prior to the index date of IBD, whereas two controls (0.9%) had asthma (unadjusted odds ratio [OR]: 3.0, 95% confidence interval [CI]: 0.31-28.84, P = 0.34). Similarly, 16 IBD cases (6.9%) had asthma ever while 12 controls (5.2%) had asthma ever (unadjusted OR: 1.4, 95% CI: 0.62-3.38, P = 0.40). Asthma as a Th2 condition does not reduce the risk of IBD as a Th1 condition. Because of the limitations of our study and others, the association between asthma and IBD needs to be further studied.