Chronological Order of Appearance of Extraintestinal Manifestations Relative to the Time of IBD Diagnosis in the Swiss Inflammatory Bowel Disease Cohort

Extraintestinal manifestations at baseline, and the effect of tofacitinib, in patients with moderate to severe ulcerative colitis

INTRODUCTION

Extraintestinal manifestations (EIMs) in patients with ulcerative colitis (UC) are common. Tofacitinib is an oral, small molecule Janus kinase inhibitor for the treatment of UC. We evaluated the efficacy of tofacitinib in patients with EIMs, and the impact of tofacitinib on EIMs in patients with UC in the OCTAVE clinical program.

METHODS

Data from two 8-week induction studies (OCTAVE Induction 1 and 2) and a 52-week maintenance study (OCTAVE Sustain) were analyzed. The effect of tofacitinib on efficacy outcomes stratified by EIM status, proportion of predefined prior and active EIMs at baseline, and change from baseline in EIMs were determined at the end of the treatment period (weeks 8 or 52), or at early termination.

RESULTS

At baseline of OCTAVE Induction 1 and 2, and OCTAVE Sustain, 27.0% and 9.0% of patients had a history of EIMs (prior or active), respectively. Patients treated with tofacitinib 10 mg twice daily (BID) achieved remission and had endoscopic improvement in all studies, irrespective of any history of EIMs. A greater proportion of patients had active peripheral arthritis at baseline of OCTAVE Induction 1 and 2 versus OCTAVE Sustain. In OCTAVE Induction 1 and 2, similar proportions of tofacitinib and placebo-treated patients with active peripheral arthritis experienced either no change (81.3% and 85.7%, respectively) or an improvement (15.6% and 14.3%, respectively). By week 52 of OCTAVE Sustain, improvements in active peripheral arthritis were only observed in tofacitinib-treated patients (16.7% and 33.3% with tofacitinib 5 and 10 mg BID, respectively).

CONCLUSION

Any history of EIMs did not influence the efficacy of tofacitinib 10 mg BID for induction or maintenance of UC. The most common active EIM was peripheral arthritis, for which many patients in OCTAVE Induction 1 and 2, and OCTAVE Sustain, reported improvement or no change from baseline with tofacitinib treatment.Clinicaltrials.gov:NCT01465763; NCT01458951; NCT01458574.

Presymptomatic Crohn's Disease in a Young Patient Diagnosed Just After the Onset of Idiopathic Acute Pancreatitis

Acute pancreatitis is an extraintestinal manifestation of inflammatory bowel disease. There have been few reports describing acute pancreatitis preceding a diagnosis of inflammatory bowel disease. We herein report a rare case of a 16-year-old boy with presymptomatic Crohn's disease that was newly diagnosed just after the onset of idiopathic acute pancreatitis. Crohn's disease of any stage, much less in the presymptomatic stage, is rarely diagnosed just after the development of acute pancreatitis. The present case suggests that acute pancreatitis without an apparent cause in young or pediatric population can precede a diagnosis of presymptomatic Crohn's disease.

The Temporal Relationships and Associations between Cutaneous Manifestations and Inflammatory Bowel Disease: A Nationwide Population-Based Cohort Study

The temporal relationships between inflammatory bowel disease (IBD)-associated cutaneous manifestations and IBD remain uncertain, with existing evidence mostly from separate cross-sectional studies. We sought to determine the risks of IBD-related dermatologic diseases before and after the diagnosis of IBD. We identified 2847 cases of IBD and 14,235 matched controls from the Taiwan National Health Insurance Research Database between 2003 and 2014. The risks of cutaneous manifestations before and after the diagnosis of IBD were estimated with multivariable-adjusted analyses. At diagnosis, IBD was associated with atopic dermatitis (odds ratio (OR) = 1.61; 95% confidence interval (CI), 1.14-2.28), erythema nodosum (OR = 7.44; 95%CI, 3.75-14.77), aphthous stomatitis (OR = 2.01; 95%CI, 1.72-2.35), polyarteritis nodosa (OR = 5.67; 95%CI, 2.69-11.98), rosacea (OR = 1.67, 95%CI = 1.19-2.35), and cutaneous T cell lymphoma (OR = 21.27; 95%CI, 2.37-191.00). IBD was associated with the subsequent development of pyoderma gangrenosum (hazard ratio (HR) = 17.79; 95%CI, 6.35-49.86), erythema nodosum (HR = 6.54; 95%CI, 2.83-15.13), polyarteritis nodosa (HR = 2.69; 95%CI, 1.05-6.90), hidradenitis suppurativa (HR = 2.48; 95%CI, 1.03-5.97), psoriasis (HR = 2.19; 95%CI, 1.27-3.79), rosacea (HR = 1.92; 95%CI, 1.39-2.65), and aphthous stomatitis (HR = 1.45; 95%CI, 1.22-1.72). This study clarified the associations and temporal relationships between cutaneous manifestations and IBD, highlighting the need for interdisciplinary care in the patient with specific dermatologic diseases presenting with abdominal symptoms, or the IBD patients with cutaneous lesions.

Respiratory Tract Manifestations of Inflammatory Bowel Disease

Inflammatory bowel disease can manifest in many extraintestinal organ systems. The most frequently involved extraintestinal locations include the mucocutaneous, hepatobiliary, and ocular organ systems. The respiratory tract is less commonly involved and is therefore frequently overlooked. Consequently, it is believed that involvement of the respiratory tract in patients with inflammatory bowel disease is underreported. The pathogenesis is thought to be multifactorial, involving the common embryologic origin shared by the respiratory and luminal digestive tract, molecular mimicry, and immunologic interactions leading to immune-complex deposition in affected tissue. The spectrum of manifestations of the respiratory tract related to inflammatory bowel disease is broad. It not only includes direct involvement of the respiratory tract (ie, airways, interstitium, and pleura) but also can result as a consequence of systemic involvement such as in thromboembolic events. In addition, it may also be related to other conditions that affect the respiratory tract such as sarcoidosis and alpha-1 antitrypsin deficiency. Though some conditions related to respiratory tract involvement might be subclinical, others may have life-threatening consequences. It is critical to approach patients with suspected inflammatory bowel disease-related respiratory tract involvement in concert with pulmonology, infectious diseases, and any other pertinent experts, as treatments may require a multidisciplinary overlap of measures. Therefore, it is of paramount importance for the clinician to be aware of the array of respiratory tract manifestations of patients with inflammatory bowel disease, in addition to the possible spectrum of therapeutic measures.

Extraintestinal manifestation of inflammatory bowel disease in Asian patients: A multinational study

BACKGROUND/AIM

Although inflammatory bowel disease (IBD) incidence has increased over the past two decades in Asia, data on extraintestinal manifestations (EIMs) of IBD in Asian patients are limited. We aimed to evaluate the prevalence and clinical characteristics of EIMs in Asian IBD patients.

METHODS

In total, 1,764 patients (1,130 with ulcerative colitis [UC] and 634 with Crohn's disease [CD]) were recruited from 10 tertiary centers in Asia. The medical records of IBD patients were retrospectively reviewed for the presence, clinical characteristics, chronological order, and therapeutic management of EIMs.

RESULTS

EIMs were reported in 199 (11.3%) patients, of which 17 (1.0%) patients had multiple EIMs. EIMs were more prevalent in CD patients (P = 0.02). Multiple logistic regression analysis revealed that female sex (odds ratio [OR] 2.02, 95% confidence interval [CI] 1.15-3.55), stricture (OR 2.49, 95% CI 1.41-4.39) and female sex (OR 2.57, 95% CI 1.52-4.34), extensive colitis (OR 2.63, 95% CI 1.57-4.41) were associated with EIMs in CD and UC patients respectively. EIMs appeared in 8% of patients before IBD diagnosis; 95% of cases with EIM could be managed via first-line therapy.

CONCLUSION

EIM prevalence is lower among Asian IBD patients than among patients from Western countries; however, the risk factors for EIM were similar between both populations.

Vedolizumab and Extraintestinal Manifestations in Inflammatory Bowel Disease

In Crohn's disease and ulcerative colitis, inflammation is not limited to the digestive tract. Extraintestinal manifestations (EIMs), which affect up to 50% of patients, can substantially impair quality of life. EIMs may parallel luminal disease activity or have an independent course. They most commonly involve the musculoskeletal system (e.g., peripheral or axial arthritis) and skin (e.g., erythema nodosum and pyoderma gangrenosum). Less commonly, the hepatobiliary tract (e.g., primary sclerosing cholangitis [PSC]) and the eye (e.g., episcleritis, scleritis, and uveitis) are involved. Although the pathophysiology of EIMs is poorly understood, they are likely either manifestations of a primary systemic immune disease with variable expression amongst organs, or secondary phenomena to bowel inflammation. Additional pathophysiologic mechanisms may include aberrant lymphocyte homing mediated by ectopic expression of gut-specific chemokines and adhesion molecules, cross-reactivity between microbial and self-antigens, autoantibodies against epitopes shared by the intestine and extraintestinal tissues, elevated serum concentrations of cytokines, and alterations in innate immunity. Many EIMs independent of intestinal disease activity can be successfully treated with tumor necrosis factor (TNF) antagonists. The efficacy of vedolizumab-a monoclonal antibody targeting the α4β7 integrin-for the treatment of EIMs is uncertain, but data are emerging from post hoc analyses of randomized controlled trials, prospective and retrospective cohort studies, and case series. Vedolizumab may be effective in treating EIMs related to luminal disease activity (e.g., type 1 peripheral arthritis and erythema nodosum) but has not shown biochemical improvement in PSC. Its postulated role in the development of de novo EIMs is heavily confounded by the high proportion of patients previously exposed to TNF antagonists; new EIMs could result from TNF antagonist treatment cessation rather than being caused by vedolizumab. A common limitation of clinical studies is the lack of multidisciplinary involvement in the diagnosis and monitoring of EIMs, which may lead to misdiagnosis and overreporting. Future studies should rigorously measure EIMs in parallel with objective measures of luminal disease activity to provide more robust data on the relative efficacy of new drugs, especially as increasing numbers of gut-selective compounds enter clinical development.

Indeterminate Colitis - Update on Treatment Options

Indeterminate colitis (IC) is described in approximately 5-15% of patients with inflammatory bowel disease (IBD). It usually reflects a difficulty or lack of clarity in distinguishing between ulcerative colitis (UC) and Crohn's disease (CD) on biopsy or colectomy specimens. The diagnostic difficulty may explain the variability in the reported prevalence and incidence of IC. Clinically, most IC patients tend to evolve over time to a definite diagnosis of either UC or CD. IC has also been interchangeably described as inflammatory bowel disease unclassified (IBDU). This review offers an overview of the available limited literature on the conventional medical and surgical treatments for IC. In contrast to the numerous studies on the medical management of UC and CD, there are very few data from dedicated controlled trials on the treatment of IC. The natural evolution of IC more closely mimics UC. Regarding medical options for treatment, most patients diagnosed with IC are treated similarly to UC, and treatment choices are based on disease severity. Others are managed similarly to CD if there are features suggestive of CD, including fissures, skin tags, or rectal sparing. In medically refractory IC, surgical treatment options are limited and include total proctocolectomy (TPC) and ileal pouch-anal anastomosis (IPAA), with its associated risk factors and complications. Post-surgical complications and pouch failure rates were historically thought to be more common in IC patients, but recent meta-analyses reveal similar rates between UC and IC patients. Future therapies in IBD are focused on known mechanisms in the disease pathways of UC and CD. Owing to the lack of IC-specific studies, clinicians have traditionally and historically extrapolated the data to IC patients based on their symptomatology, clinical course, and endoscopic findings.

Joint lesions in inflammatory bowel diseases: the analysis of the Moscow regional patient registry and a clinical case

Rationale: Extraintestinal manifestations (EIM) of an inflammatory bowel disease (IBD) are a sign of its more severe course. Joint lesions are most common among IBD EIM.

Aim: To evaluate the prevalence and types of joint lesions in the population of IBD patients of the Moscow region.

Materials and methods: We performed a  retrospective analysis of medical files of the patients who were admitted to the Moscow Region Inflammatory Bowel Disease Center (MONIKI) for examination and treatment from August 1, 2019, to March 1, 2020. The study included 70 patients with confirmed diagnoses of IBD and confirmed or suspected involvement of the joints.

Results: Thirty six of 70 patients with IBD and EIM (51.43%) had been diagnosed with Crohn's disease (CD), and 34 (48.57%) with ulcerative colitis (UC). The CD group included more men (n=21, 58.33%), whereas their proportion in the UC group was 47.02% (n=16). The mean age at CD diagnosis in the UC and CD groups was comparable: 38.3±13.7  years in men with CD and 40.5±12.8 years in men with UC, 37.7±11.1 years in women with CD and 35.7±14.0 in women with UC. The most prevalent among all IBD patients were X-ray negative peripheral arthralgias. Among joint lesions confirmed by radiological diagnostics, sacroileitis was most prevalent both in all IBD patients (24.3%), as well as in the UC group (17.6%), whereas in the CD patients its frequency was the same as that of ankylosing spondyloarthritis (AS) (30.6% of the cases). AS ranked second in the prevalence of joint lesions in the UC group (8.8%) and all IBD (20%). Psoriatic arthritis was diagnosed only in the CD patients (2 / 36). We describe a clinical case of CD with AS, complicated with psoriatic rash, treated with a  monoclonal antibody to tumor necrosis factor alfa (anti-TNF-α).

Conclusion: Peripheral arthropathias were most prevalent among all joint lesions in the group studied. EIM mirror a more aggressive phenotype of the disease and higher glucocorticosteroids requirements. Administration of anti-TNF-α agents allows for the control of both intestinal IBD manifestations and of the joint syndrome. However, drug-associated skin adverse event can occur during treatment with this drug class. In such a case, it is possible to switch the biological therapy to another class of drugs that we have demonstrated with the given clinical example.

Skin manifestations in spondyloarthritis

Spondyloarthritides (SpA) like psoriatic arthritis, axial spondyloarthritis/ankylosing spondylitis, reactive arthritis and inflammatory bowel disease (IBD)-associated SpA can present with characteristic skin manifestations. These SpA-associated skin disorders may precede joint involvement, reflect a loss of efficacy of a current systemic treatment or can even be treatment associated. Cutaneous manifestations in SpA not only add additional morbidity with physical impact but also impose a psychosocial burden on affected patients. Psoriasis (PsO) - the main skin disease in SpA - has a variety of clinical presentations, including plaque-type PsO, inverse PsO, guttate PsO, erythrodermic PsO, nail PsO and pustular types. SpA associated with IBD presents with neutrophilic and granulomatous skin disorders, including pyoderma gangrenosum, hidradenitis suppurativa and cutaneous Crohn's disease. Reactive arthritides has a favourable prognosis and may feature keratoderma blenorrhagicum or balanitis circinatum as typical skin manifestations. Immunologically, SpA-associated skin diseases share interleukin (IL)-17 and IL-23 dysregulation but show distinctive genetic and immunological profiles. Therefore, they vary in their treatment responses to targeted therapies with biologicals or small molecules. In this review, we highlight the clinical presentation of skin manifestations in SpA and discuss therapeutic approaches in this interdisciplinary field.

The IBIS-Q [IBd Identification of Spondyloarthritis Questionnaire]: A Novel Tool to Detect Both Axial and Peripheral Arthritis in Inflammatory Bowel Disease Patients

BACKGROUND AND AIMS

Both peripheral and axial spondyloarthritis [SpA] occur in inflammatory bowel disease [IBD] and represent the commonest extra-intestinal manifestation. We aimed to develop an easy and quick questionnaire through psychometric analysis, to identify peripheral and axial SpA in IBD patients within an integrated combined multidisciplinary rheumatological-gastroenterology clinic.

METHODS

Initially, SpA-IBD experts generated a 42-item list covering SpA manifestations including spinal, articular, and entheseal involvement. The new questionnaire was administered before routine clinical IBD assessment. On the same day, rheumatological assessment, blinded to both history and questionnaire results, was performed to explore the presence of the Assessment of SpondyloArthritis International Society [ASAS] criteria for SpA, diagnostic criteria for fibromyalgia [FM], and non-specific low back pain [NSLB]. Factorial analysis of questionnaire items to identify the main factors-receiver operating characteristic [ROC] curves for sensitivity/specificity and Youden index for cut-off-were performed.

RESULTS

Of the 181 consecutive patients, 56 met the ASAS SpA criteria [prevalence of 30%] with 10 new cases detected [5.5%: seven peripheral and three axial]. Through the psychometric and factorial analysis, we selected 14 items for the final questionnaire [named IBIS-Q]. The IBIS-Q was quick and performed well for detection of axial SpA and peripheral SpA (area under the curve [AUC] 0.88 with 95% confidence interval [CI] 0.830.93). A cut-off of three positive questions had a sensitivity 93% and specificity 77% for SpA patient identification.

CONCLUSIONS

The IBIS-Q is a useful and simple tool to use in IBD clinics for SpA detection, with a good statistical performance. Further studies are needed to validate it.

Sex matters: impact on pathogenesis, presentation and treatment of inflammatory bowel disease

Inflammatory bowel disease (IBD), as do most chronic inflammatory disorders, displays unique features and confers different risk factors in male and female patients. Importantly, sex-based differences in IBD exist for epidemiological incidence and prevalence among different age groups, with men and women developing distinct clinical symptoms and disparity in severity of disease. In addition, the presentation of comorbidities in IBD displays strong sex differences. Notably, particular issues exclusive to women's health, including pregnancy and childbirth, require specific considerations in female patients with IBD of childbearing age that can have a substantial influence on clinical outcomes. This Review summarizes the latest findings regarding sex-based differences in the epidemiology, clinical course, comorbidities and response to current therapies in patients with IBD. Importantly, the latest basic science discoveries in this area of investigation are evaluated to provide insight into potential mechanisms underlying the influence of sex on disease pathogenesis, as well as to design more personalized and efficacious care, in patients with IBD.

Characterization and prevalence of extraintestinal manifestations in a cohort of patients with inflammatory intestinal disease in Medellin, Colombia

INTRODUCTION

Extraintestinal manifestations (EIMs) are frequent in patients with inflammatory bowel disease (IBD). Our objective is to characterize and determine the prevalence of MEIs in our cohort of patients with IBD.

PATIENTS AND METHODS

A retrospective study was carried out in adult patients with IBD at the Pablo Tobón Uribe Hospital in Medellín. Colombia. Articular MEIs, primary sclerosing cholangitis (PSC), both ophthalmological and dermatological, were considered. Absolute and relative frequencies were used. The Chi square test of independence was used to compare 2proportions and the odds ratio (OR) was estimated.

RESULTS

Our registry has 759 patients with IBD, 544 present UC (71.6%), 200 CD (26.3%) and 15 unclassifiable IBD (1.9%); 177 patients with IBD (23.3%) presented EIMs, 123 of 544 (22.6%) with UC and 53 of 200 (26.5%) with CD (OR: 0.81, 95% CI: 0.55-1.17, P=0.31). Regarding the type of EIMs, the articular ones were the most frequent (13.5%), more in CD than in UC (20.0 vs. 11.3%, OR 1.94, 95% CI: 1.25-3.00, P=0.0037). Patients with IBD and EIMs used more antibodies against tumor necrosis factor (anti-TNFs), compared to those without EIMs (43.5 vs. 18.5%, OR 3.38, 95% CI: 2.31-4.90, P=0.0001).

CONCLUSIONS

The prevalence of EIMs in our cohort is high (23.3%) and the most frequent type is joint. Anti-TNFs are most used when IBD and EIMs coexist. Our study provides valuable information on the association of EIMs and IBD in Latin America.

Oral manifestations of inflammatory bowel disease: the neglected piece of the puzzle

Inflammatory bowel disease (IBD) is a chronic relapsing remitting autoimmune disease including Crohn's disease and ulcerative colitis. IBD is associated with various extra-intestinal manifestations including oral manifestation. To date, only limited studies addressing the characteristics of the oral manifestations are available. The aim of the present review is to report the oral manifestations and their characteristics in IBD. A Medline/PubMed and Embase databases search were conducted and all relevant studies were extracted and analyzed. Overall, the oral manifestations in IBD were mostly associated with Crohn's disease rather than Ulcerative colitis where their prevalence ranged from 8 to 50%. Specific lesions for Crohn's disease include mucosal tags, cobblestoning and deep linear ulcerations with vertical fissures, while for ulcerative colitis, pyostomatisis vegetans was more disease specific. Notably, most of the oral manifestations were unrelated to disease activity, however more data are needed to accurately assess this correlation. Oral manifestations among IBD patients are not uncommon as Crohn's disease account for most of them. More data are warranted to precisely characterize their prevalence and association to intestinal activity.

Increased chronic pain in patients with ulcerative colitis is mostly associated to increased disease activity. A cross-sectional case-control study

BACKGROUNDS/AIMS

Musculoskeletal symptoms are common in patients with ulcerative colitis (UC), but no study has compared the prevalence of chronic pain to controls from a general population.

METHODS

Patients with UC (n = 1164) and controls (n = 3867) were sent questionnaires comprising demography, history of pain, pain localization and UC patients' Patient-Simple Clinical Colitis Activity Index. Chronic regional pain (ChRP) and chronic widespread pain (ChWP) were defined as having pain for at least 3 months.

RESULTS

The response rate for the patients with UC was 49.0% and for the control persons 61.7% (p < .001). The reported prevalence of ChRP and ChWP was higher in patients with UC versus controls (33.1% vs. 24.2%; p < .001 and 19.8% vs. 12.5%; p < .001). The patients with UC reported significantly more pain in the regions 'lower back', 'hip/upper leg' and 'lower leg/foot' compared to controls. The patients with P-SCCAI ≥ 5 (n = 121) reported more ChWP than patients with P-SCCAI <5 (n = 426) (46.3% vs. 12.7%; p < .001) and controls (n = 2425) (46.3 vs. 12.5%; p < .001) in all body regions. No significant difference in ChWP was found between patients with P-SCCAI <5 and controls (12.7% vs. 12.5%; p = .917).

CONCLUSIONS

Patients with UC reported more chronic pain than controls from the general population, especially from the lower back and hip region. Higher UC disease activity was associated with more pain in all body regions.

Extra-intestinal manifestations of inflammatory bowel diseases

Inflammatory bowel disease (IBDs), including the two main subtypes of Crohn's disease and ulcerative colitis, not only affects the gastrointestinal system, but also has a wide range of extra-intestinal manifestations (EIMs) that are major sources of morbidity and disability, and therefore represent what can be considered a real syndrome. The pathogenetic mechanisms underlying these EIMs are unknown, but some may share a common pathogenesis with IBD and others may be due to IBD treatment. The aim of this review is to examine our current knowledge of IBD EIMs and their treatment.

Clinical management of the most common extra-intestinal manifestations in patients with inflammatory bowel disease focused on the joints, skin and eyes

Extra-intestinal manifestations (EIMs) of inflammatory bowel disease (IBD) occur frequently and contribute to morbidity and reduced quality of life. The musculoskeletal, ocular and cutaneous organ systems are frequently involved in IBD-related EIMs. By focusing on manifestations involving the joints, skin and eyes, this review will discuss the most common clinically relevant and burdensome EIMs that affect IBD patients, and strives for early recognition, adequate treatment and timely referral. For this purpose, we aimed to create a comprehensive overview on this topic, with the main focus on the treatment of reactive and associated EIMs, including spondyloarthropathies, pyoderma gangrenosum, erythema nodosum, psoriasis and anterior uveitis. The recently developed biologicals enable simultaneous treatment of inflammatory disorders. This review can be used as a helpful guide in daily clinical practice for physicians who are involved in the treatment of IBD patients.

Cost Burden of Crohn's Disease and Ulcerative Colitis in the 10-Year Period Before Diagnosis-A Danish Register-Based Study From 2003-2015

BACKGROUND

The diagnostic delay in inflammatory bowel disease (IBD) is well known, yet the costs associated with diagnoses before IBD diagnosis have not yet been reported. This study explored societal costs and disease diagnoses 10 years before Crohn's disease (CD) and ulcerative colitis (UC) diagnosis in Denmark.

METHODS

This national register study included patients diagnosed between 2003 and 2015 identified in the Danish National Patient Registry (NPR) and controls who were individually matched on age and sex from the general population. Societal costs included health care services, prescription medicine, home care services, and labor productivity loss. Prediagnostic hospital contact occurring before CD or UC diagnosis was identified using the NPR. Average annual costs per individual were calculated before the patient's first CD or UC diagnosis. A 1-sample t test was then applied to determine significance in differences between cases and controls.

RESULTS

Among CD (n = 9019) and UC patients (n = 20,913) the average societal costs were higher throughout the entire 10-year period before the diagnosis date compared with the general population. The difference increased over time and equaled €404 for CD patients and €516 for UC patients 10 years before diagnosis and €3377 and €2960, respectively, in the year before diagnosis. Crohn's disease and UC patients had significantly more diagnoses before their CD and UC diagnosis compared with the general population.

CONCLUSIONS

Compared with the general population, the societal costs and number of additional diagnoses among CD and UC patients were substantially higher in the 10-year period before diagnosis.

Assessment of Occult Pulmonary Involvement in Ulcerative Colitis

INTRODUCTION

Nearly 50% of patients with inflammatory bowel disease (IBD) experience at least one extraintestinal manifestation. Bronchopulmonary involvement is rare in IBD. Pulmonary function test (PFT) abnormality in cases of ulcerative colitis (UC) has been reported to be 17-55%. Occult pulmonary disease may be diagnosed using variables of the PFT. Hence, we aim to evaluate the frequency and type of pulmonary dysfunction in patients with UC in remission.

METHODS

Eighty-three patients of UC in remission and 48 controls underwent the PFT including forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), Tiffeneau value (FEV1/FVC), and midexpiratory flow (MEF 25-75%) rate with a spirometer. The patients were divided based on the age of onset of UC into A1 (<16 years), A2 (16-40 years), and A3 (>40 years) and based on the extent of disease into E1 (proctitis), E2 (left-sided colitis), and E3 (extensive colitis).

RESULTS

Patients with UC had significantly abnormal PFT compared with controls (51 [61.5%] vss. 8 [16.67%]; p = 0.000). Patients with UC commonly had a restrictive pattern (33 [64.47%]) of PFT followed by small airway disease (11 [21.56%]) and obstructive pattern (7 [13.72%]). Pulmonary involvement in cases of UC was more in E3 followed by E2 and E1. Pulmonary involvement was more in the late age of onset of disease. BMI was positively and significantly correlated with FEV1 and FVC. Hemoglobin had a positive and significant correlation with FEV1 while a negative correlation with FEV1/FVC and MEF 25-75%. All predictors except for age were found to contribute in higher risk (OR > 1) for PFT abnormality.

CONCLUSION

Patients with UC have chronic pulmonary inflammation leading to different patterns of lung involvement in the form of restrictive, obstructive airway, and small airway disease. Patients with UC commonly have a restrictive pattern of pulmonary involvement. Impairment of the PFT is related to the disease extent and the age of onset of disease. Assessment of the PFT using a spirometer is a noninvasive, simple, cost-effective, and reliable method for early detection of occult pulmonary involvement in patients of UC.

Salivary and Serum Inflammatory Profiles Reflect Different Aspects of Inflammatory Bowel Disease Activity

BACKGROUND

Inflammatory bowel disease (IBD) can manifest both macroscopically and microscopically in the oral cavity; however, little is known about salivary changes in IBD. Therefore, this study aimed to assess salivary and circulatory inflammatory profiles in IBD and to compare their potential to reflect the presence and activity of IBD.

METHODS

We measured 92 known inflammatory proteins in serum and in unstimulated and stimulated whole saliva samples from patients with IBD with active intestinal inflammation (n = 21) and matched control patients (n = 22) by proximity extension assay. Fifteen of the patients with IBD returned 10 to 12 weeks after treatment escalation for resampling.

RESULTS

Sixty-seven of the proteins were detected in all 3 sample fluids but formed distinct clusters in serum and saliva. Twenty-one inflammatory proteins were significantly increased and 4 were significantly decreased in the serum of patients with IBD compared with that of the control patients. Two of the increased serum proteins, IL-6 and MMP-10, were also significantly increased in stimulated saliva of patients with IBD and correlated positively to their expressions in serum. None of the investigated proteins in serum or saliva were significantly altered by IBD treatment at follow-up. Overall, inflammatory proteins in serum correlated to biochemical status, and salivary proteins correlated positively to clinical parameters reflecting disease activity.

CONCLUSIONS

Saliva and serum inflammatory profiles in IBD share a similar composition but reflect different aspects of disease activity. The oral cavity reflects IBD through elevated IL-6 and MMP-10 in stimulated saliva.

Extraintestinal Manifestations and Other Comorbidities in Ulcerative Colitis and Crohn Disease: A Danish Nationwide Registry Study 2003-2016

BACKGROUND

Extraintestinal manifestations (EIMs) in inflammatory bowel disease (IBD) may be a frequent complication to an underlying abnormal immune response. This study investigated the occurrence of EIMs in Crohn disease (CD) and ulcerative colitis (UC) patients using population-based data in Denmark from 2003 to 2016.

METHODS

In this national registry-based study, incident CD and UC patients between 2003 and 2015 were matched on age and gender with non-IBD controls and followed until 2016. The selected EIMs for this study included 51 different diagnoses divided into biological systems of diseases, which were tested for differences in the timing and occurrence of EIMs.

RESULTS

The study cohort included 10,302 patients with CD and 22,144 patients with UC. The highest risk of patients experiencing EIM/comorbidities for the first time before their IBD diagnosis was in the skin and intestinal tract systems. For CD, the odds ratio of having an EIM before or after IBD diagnosis, as compared with controls, was significant in the skin, intestinal tract, hepatopancreatobiliary, musculoskeletal, ocular, renal, and respiratory systems. For UC, the risks were similar before and after UC diagnosis, apart from the nervous system where the odds ratio was significantly higher before the diagnosis of UC, and significantly lower after diagnosis for diseases in the ocular system.

CONCLUSIONS

EIMs in CD and UC patients may also precede their IBD diagnosis. These findings may indicate a significant diagnostic delay of CD and UC, and the occurrence of known EIMs should prompt physicians to look for patients possibly having underlying IBD.

Pathogenesis and clinical perspectives of extraintestinal manifestations in inflammatory bowel diseases

A considerable number of patients with inflammatory bowel disease (IBD) experience extraintestinal manifestations (EIMs), which can present either before or after IBD diagnosis. Unraveling the pathogenic pathways of EIMs in IBD is challenging because of the lack of reliable criteria for diagnosis and difficulty in distinguishing EIMs from external pathologies caused by drugs or other etiologies. Optimizing treatment can also be difficult. Early diagnosis and management of EIM revolve around multidisciplinary teams, and they should have the resources necessary to make and implement appropriate decisions. In addition, specialists of the affected organs should be trained in IBD treatment. Furthermore, patient awareness regarding the extraintestinal symptoms of IBD is of paramount importance for improving patient understanding of disease and health outcomes. Herein, we review the pathogenesis and clinical perspectives of EIMs in IBD.

Which long noncoding RNAs and circular RNAs contribute to inflammatory bowel disease?

Inflammatory bowel disease (IBD), a chronic relapsing gastrointestinal inflammatory disease, mainly comprises ulcerative colitis (UC) and Crohn’s disease (CD). Although the mechanisms and pathways of IBD have been widely examined in recent decades, its exact pathogenesis remains unclear. Studies have focused on the discovery of new therapeutic targets and application of precision medicine. Recently, a strong connection between IBD and noncoding RNAs (ncRNAs) has been reported. ncRNAs include microRNAs (miRNAs), long noncoding RNAs (lncRNAs), and circular RNAs (circRNAs). The contributions of lncRNAs and circRNAs in IBD are less well-studied compared with those of miRNAs. However, lncRNAs and circRNAs are likely to drive personalized therapy for IBD. They will enable accurate diagnosis, prognosis, and prediction of therapeutic responses and promote IBD therapy. Herein, we briefly describe the molecular functions of lncRNAs and circRNAs and provide an overview of the current knowledge of the altered expression profiles of lncRNAs and circRNAs in patients with IBD. Further, we discuss how these RNAs are involved in the nosogenesis of IBD and are emerging as biomarkers.

[Extraintestinal manifestations and intestinal complications in children with Crohn's disease: an analysis of 54 cases]

OBJECTIVE

To summarize the extraintestinal manifestations and intestinal complications in children with Crohn's disease (CD).

METHODS

The clinical data of 54 children who were diagnosed with CD in Peking Union Medical College Hospital from January 2008 to December 2018 were collected for retrospective analysis of extraintestinal manifestations and intestinal complications. According to the location of the lesion, the children were divided into ileocolonic group (30 cases), colonic group (6 cases), and ileal group (18 cases).

RESULTS

In the 54 children, the mean age at diagnosis was 14.5±2.7 years, and the median duration from disease onset to definite diagnosis was 20 months (range: 1-36 months). Twenty-four patients (44%) had extraintestinal manifestations, with the two most common manifestations being growth retardation (11 cases, 20%) and oral mucosal ulcer (10 cases, 19%), followed by arthritis (2 cases, 4%), erythema nodosum (2 cases, 4%), and cholecystitis (2 cases, 4%). There were no significant differences in the incidence of extraintestinal manifestations among the three groups (P=0.792). The most common intestinal complications were anal fistula/perianal abscess (13 cases, 24%), followed by intestinal fistula (5 cases, 9%) and intestinal obstruction (4 cases, 7%). There was a significant difference in the incidence of intestinal complications among the three groups (P=0.0406). No intestinal complications were reported in the colonic group.

CONCLUSIONS

Extraintestinal manifestations and intestinal complications are common in children with CD. Perianal examinations should be performed in children with suspected CD. Intestinal complications are less common in children with colonic CD, which may be associated with relatively mild disease condition.

Global Prevalence and Bidirectional Association Between Psoriasis and Inflammatory Bowel Disease-A Systematic Review and Meta-analysis

BACKGROUND AND AIMS

Epidemiological studies have established an association between psoriasis and inflammatory bowel disease [IBD], i.e. ulcerative colitis [UC] and Crohn's disease [CD], but results are inconsistent. The aim of this study was therefore to quantify the prevalences and association between IBD and psoriasis.

METHODS

PubMed, Web of Science, and EMBASE were searched from database inception through April 2018 for studies reporting data on psoriasis among patients with IBD and vice versa. Meta-analysis was performed to estimate, respectively, the prevalences and association between IBD and psoriasis. Data extraction was according to the PRISMA guideline, and quality assessment was made using the Newcastle-Ottawa Scale. The main outcomes were the proportion of psoriasis patients with IBD and vice versa, as well as the association (odds ratio [OR]) of IBD in psoriasis and psoriasis in IBD, respectively.

RESULTS

Based on quantitative analysis of 93 studies, the prevalence of psoriasis in CD and in UC was 3.6% (95% confidence interval [CI] 3.1%-4.6%) and 2.8% [95% CI 2.0%-3.8%] respectively. The prevalence of CD and UC was 0.7% [95% CI 0.2%-1.3%] and 0.5% [95% CI 0.3%-0.8%], respectively, among patients with psoriasis. Presence of CD or UC was significantly associated with psoriasis, with OR 2.0 [95% CI 1.4-2.9] and OR 1.5 [95% CI 1.2-2.0], respectively. Presence of psoriasis was significantly associated with CD: OR 2.2 [95% CI 1.6-3.1] and with UC: OR 1.6 [95% CI 1.3-2.0].

CONCLUSIONS

We found significant bidirectional associations between psoriasis and IBD, warranting increased awareness among clinicians in the diagnostic process, especially in children and adolescents with IBD. Last, this study showed an increased frequency of paradoxical psoriasis in patients treated with biologics.

The Impact of Spondyloarthritis and Joint Symptoms on Health-Related Quality of Life and Fatigue in IBD Patients. Results From a Population-Based Inception Cohort (20-Year Follow-up in the Ibsen Study)

BACKGROUND

Patients with inflammatory bowel disease (IBD) often suffer from musculoskeletal manifestations. Health-related quality of life (HRQoL) and fatigue are known to be associated with IBD activity and musculoskeletal complaints. The aim of this study was to determine the association between spondyloarthritis, arthralgia, or back pain and the patient-reported outcomes of HRQoL and fatigue in IBD patients 20 years after their diagnosis.

METHODS

The IBSEN cohort was followed prospectively for 20 years. At the 20-year follow-up, the patients answered detailed questionnaires regarding rheumatological manifestations, intestinal symptoms, HRQoL, and fatigue. Multiple regression analyses were used to evaluate associations between spondyloarthritis or joint symptoms and HRQoL or fatigue. Sex, IBD diagnosis, and age were included in all the multiple regression models, in addition to other clinically relevant confounders.

RESULTS

In total, 441 patients (94%) completed the questionnaires at the 20-year follow-up. The criteria for spondyloarthritis (axial or peripheral) were fulfilled in 158 patients (36%), current back pain during the previous 3 months was reported by 79 patients (18%), and current arthralgia was reported by 178 patients (40%). Current back pain and arthralgia were independently associated with lower HRQoL, higher levels of fatigue, and chronic fatigue. A diagnosis of spondyloarthritis was not associated with reduced HRQoL or fatigue when adjusted for possible confounders.

CONCLUSIONS

Current joint symptoms in IBD patients 20 years after diagnosis were associated with poorer HRQoL, higher levels of fatigue, and chronic fatigue, whereas spondyloarthritis did not impact HRQoL or fatigue negatively in this cohort.

Cutaneous manifestations in inflammatory bowel disease (Review)

Inflammatory bowel disease (IBD) is defined as a chronic condition characterized by unpredictable relapsing episodes of gastrointestinal inflammation. IBD is not limited to the gastrointestinal tract and should be considered a systemic disease which can involve any organ. Cutaneous manifestations in IBD are frequent and comprise a broad spectrum of diseases, ranging from mild to severe and sometimes debilitating lesions. Some of the cutaneous manifestations can present signs of an underlying intestinal disease, leading to the screening for non-detected IBD even in the absence of symptoms. Cutaneous EIMs are divided into 4 categories: i) Disease-specific lesions that show the same histopathologic findings as the underlying gastrointestinal disease, ii) reactive lesions which are inflammatory lesions that share a common pathogenetic mechanism but do not share the same pathology with the gastrointestinal disease, iii) associated conditions are more frequently observed in the context of IBD, without sharing the pathogenetic mechanism or the histopathological findings with the underlying disease and iv) drug-related skin reactions.

[Musculoskeletal Manifestation in Inflammatory Bowel Disease]

Almost 50% of patients with inflammatory bowel disease (IBD) exhibit at least one extra-intestinal manifestation in their lifetime. Extra-intestinal manifestations of IBD are often associated with the intestinal disease activity, reducing the quality of life of the patient but rarely leading to fatal complications. Musculoskeletal involvement is the most frequent extra-intestinal manifestation of patients with IBD but this rarely occurs before IBD is diagnosed. They are manifested in various forms, such as arthropathy, fibromyalgia, and osteoporosis. Therefore, a multidisciplinary team approach including gastroenterologists and rheumatologists are necessary for optimal treatment. This review focuses on the diagnosis and treatment of musculoskeletal manifestations of IBD from the perspectives of rheumatologists who can assist gastroenterologists.

Incidence of Immune-Mediated Inflammatory Diseases Among Patients With Inflammatory Bowel Diseases in Denmark

BACKGROUND & AIMS

It is not clear whether the co-occurrence of immune-mediated inflammatory diseases (IMIDs) affects the course of inflammatory bowel diseases (IBD). We investigated the occurrence of IMIDs in relation to onset of IBD and the effects of concurrent IMIDs on IBD outcomes in a nationwide study of the Danish population.

METHODS

We used a nationwide cohort of all individuals diagnosed with IBD, including Crohn's disease (CD) or ulcerative colitis (UC), in Denmark from 2007 through 2016 (n = 14,377). Patients were match with individuals without IBD from the general population (controls, n = 71,885). All cohort members were followed from birth until 2016, their migration, or their death. The occurrence of IMIDs was assessed using the Danish national patient register and Registry of Medicinal Products Statistics.

RESULTS

A total of 3,235 patients with a diagnosis of IBD (22.5%) has also received a diagnosis of an IMID; most IMIDs occurred before the onset of IBD (n = 2,600, 80.3%). The most common IMIDs observed were psoriasis, asthma, type 1 diabetes, and iridocyclitis. Patients with IBD treated with infliximab were at reduced risk of developing IMIDs (CD adjusted odds ratio [aOR], 0.52; 95% CI, 0.34-0.81 and UC aOR, 0.47; 95% CI, 0.29-0.76). Co-occurrence of IMIDs increased the risk of surgery in patients with CD that developed IMIDs after CD onset (aOR, 2.30; 95% CI, 1.46-4.20) but not in UC.

CONCLUSIONS

In a nationwide study of the Danish population, 22.5% of patients with IBD also had at least 1 concurrent IMID. Co-occurrence of IMIDs increased the risk of surgery in patients with CD.

Uveitis manifestations in patients of the Swiss Inflammatory Bowel Disease Cohort Study

BACKGROUND

The knowledge about risk factors for the onset of uveitis manifestations in patients with inflammatory bowel disease (IBD) is still limited. Here, we aimed to provide an overview of the clinical factors associated with the onset of uveitis in the Swiss IBD Cohort Study (SIBDCS).

METHODS

We included epidemiological and clinical data from 1840 patients with Crohn's disease (CD) and 1426 patients with ulcerative colitis (UC) followed up in the SIBDCS between 2006 and 2018. Associations between disease characteristics and uveitis were assessed in univariate and multivariate analyses.

RESULTS

Overall, we identified 285 patients with uveitis. Uveitis was more frequent in patients with CD (11.1%; 205 of 1635) than UC (5.6%; 80 of 1346; odds ratio 2.11, p < 0.001). The occurrence of uveitis manifestations in patients with UC and CD was significantly associated with the onset of other extraintestinal manifestations, also in multivariate analyses. The onset of uveitis was associated with the hallmark features of severe disease in both CD and UC, including a higher clinical disease activity index and the use of immunomodulators or calcineurin inhibitors. In CD, uveitis was more frequent in females and showed a positive correlation with a positive family history of IBD.

CONCLUSIONS

Our data demonstrate that uveitis in IBD occurs more often in CD as well as in women and is associated with a more severe disease course. This might guide physicians' awareness in at-risk patients to the presence of uveitis extraintestinal manifestations and help to improve patient care.

Risk factors associated with extraintestinal manifestations in children with inflammatory bowel disease

OBJECTIVES

Extraintestinal manifestations (EIM) are common complications of inflammatory bowel disease (IBD) associated with morbidity and reduced quality of life (QOL). The aim of this study was to identify and validate predictors for EIM in children with IBD.

METHODS

The medical records of children with IBD were retrospectively reviewed, and EIM present before diagnosis and those detected during follow-up, were recorded.

RESULTS

One-hundred children were included, and their median age (interquartile range) was 13.9 (11.9-15.2) years. Forty-six (46%) children had EIM, including 10 (10%) whose EIM was present before diagnosis and 36 (36%) during follow-up. The most common EIMs were aphthous stomatitis (18%), arthralgia (14%), dermatologic manifestations (8%), and arthritis (6%). A body mass index in the lower or upper quartile (hazard ratio [HR] 9.30 and 23.71, respectively, p < 0.001), moderate-to-severe disease activity (HR 4.43, p < 0.001), extensive Crohn's disease (HR 3.43, p = 0.025), lower hemoglobin level (HR 2.29, p < 0.001), lower albumin level (HR 2.86, p = 0.029), and higher C-reactive protein level (HR 1.04, p < 0.001) at diagnosis were identified as risk factors for EIM during follow-up.

CONCLUSIONS

Identification of risk factors at IBD diagnosis may help healthcare providers to predict EIM in children with IBD and to improve their management for lessening morbidity and enhancing QOL.

Bone alterations in inflammatory bowel diseases

Inflammatory bowel diseases (IBDs) are characterized by a multifactorial partially unknown etiology that involves genetic, immunological and environmental factors. Up to 50% of IBD patients experience at least one extraintestinal manifestation; among them is the involvement of bone density which is referred to as metabolic bone disease (MBD), including osteopenia and osteoporosis. Bone alterations in IBDs population appear to have a multifactorial etiology: Decreased physical activity, inflammation-related bone resorption, multiple intestinal resections, dietary malabsorption of minerals and vitamin D deficiency, genetic factors, gut-bone immune signaling interaction, steroid treatment, microbiota and pathogenic micro-organisms interaction, and dietary malabsorption of minerals, that, all together or individually, may contribute to the alteration of bone mineral density. This review aims to summarize the prevalence and pathophysiology of metabolic bone alterations in IBD subjects outlining the main risk factors of bone fragility. We also want to underline the role of the screening and prophylaxis of bone alterations in Crohn's disease and ulcerative colitis patients and the importance of treating appropriately MBD.

Long-term implications of structured transition of adolescents with inflammatory bowel disease into adult health care: a retrospective study

Background

We aimed to evaluate the long-term clinical and socioeconomic outcome of structured transition care in adolescents with inflammatory bowel disease (IBD).

Methods

We compared the clinical long-term course of 24 patients with and 11 patients without structured transition care within 24 months before and 24 months after transfer from paediatric to adult health care. Socio-economic parameters and quality of life were assessed by IBD Questionnaire (IBDQ-32) and additional items. Treatment costs were calculated for medication, surgery and hospitalisation.

Results

The percentage of transfer group patients with an IBD-related intestinal complication was higher compared to the transition group (64% vs. 21%, p = 0.022). We also found a tendency towards a higher number of IBD-related surgery in the transfer group compared to the transition group (46% vs. 13%, p = 0.077). Transfer group patients received higher mean cumulated doses of radiation compared with the transition group (4.2 ± 5.3 mSv vs. 0.01 ± 0.01 mSv, p = 0.036). Delayed puberty was only noted in the transfer group (27%, p = 0.025). Mean expenditures for surgeries and hospitalisation tended to be lower in the transition group compared to transfer group patients (744 ± 630€ vs. 2,691 ± 4,150€, p = 0.050). Sexual life satisfaction was significantly higher (p = 0.023) and rates of loose bowel movements tended to be lower (p = 0.053) in the transition group.

Conclusions

Structured transition of adolescents with IBD from paediatric into adult health care can lead to important clinical and economic benefits.

Electronic supplementary material

The online version of this article (10.1186/s12876-019-1046-5) contains supplementary material, which is available to authorized users.

Diagnosis and treatment of dermatologic diseases in inflammatory bowel disease

PURPOSE OF REVIEW

Dermatologic manifestations in patients with inflammatory bowel disease (IBD) are increasingly recognized as related disorders, secondary to specific therapies used to treat IBD, or complications of IBD itself. These dermatologic manifestations can be difficult to manage.

RECENT FINDINGS

We summarize three categories of dermatologic manifestations in this review: extraintestinal cutaneous disorders, paradoxical manifestations to biologic therapies, and other drug-induced cutaneous manifestations. In particular, we provide current data surrounding clinical characteristics, epidemiology, and treatment modalities for individual cutaneous manifestations.

SUMMARY

Many extraintestinal cutaneous manifestations can be managed by optimized treatment of IBD itself, as shared treatment pathways exist. Paradoxical reactions to biologic agents may be driven by the individual biologic therapy. In these instances, if topical therapies or immunomodulators are not effective in treating the paradoxical cutaneous reaction, a change of class may be required. Nonmelanoma and melanoma skin cancers have been linked to specific therapies for IBD (including thiopurines and antitumor necrosis factor alpha agents, respectively). Therefore, optimizing preventive efforts towards skin cancer is warranted. Recognition of these cutaneous disorders by the practicing gastroenterologist is important, as is collaboration with dermatology for management of many cutaneous disorders.

Ulcerative Colitis

Ulcerative colitis (UC) is a chronic inflammatory bowel disease that can involve any aspect of the colon starting with mucosal inflammation in the rectum and extending proximally in a continuous fashion. Typical symptoms on presentation are bloody diarrhea, abdominal pain, fecal urgency, and tenesmus. In some patients, extraintestinal manifestations may predate the onset of gastrointestinal symptoms. A diagnosis of UC is made on the basis of presenting symptoms consistent with UC as well as endoscopic evidence showing continuous and diffuse colonic inflammation that starts in the rectum. Biopsies of the colon documenting chronic inflammation confirm the diagnosis of UC. Most cases are treated with pharmacological therapy to first induce remission and then to maintain a corticosteroid-free remission. There are multiple classes of drugs used to treat the disease. For mild to moderate UC, oral and rectal 5-aminosalycilates are typically used. In moderate to severe colitis, medication classes include thiopurines, biological agents targeting tumor necrosis factor and integrins, and the small-molecule Janus kinase inhibitors. However, in up to 15% of cases, patients in whom medical therapy fails or who have development of dysplasia secondary to their long-standing colitis will require surgical treatment. Finally, to minimize the complications of UC and adverse events from medications, a working collaboration between primary care physicians and gastroenterologists is necessary to make sure that vaccinations are optimized and that patients are screened for colon cancer, skin cancer, bone loss, depression, and other treatable and preventable complications.

Extraintestinal Manifestations of Inflammatory Bowel Disease: Epidemiology, Etiopathogenesis, and Management

PURPOSE OF REVIEW

Extraintestinal manifestations (EIMs) of inflammatory bowel disease (IBD) represent a complex array of disease processes with variable epidemiologic penetrance, genetic antecedents, and phenotypic presentations. The purpose of this review is to provide an overview of primary and secondary EIMs as well as salient treatment strategies utilized.

RECENT FINDINGS

While the genetic antecedents remain incompletely understood, the treatment armamentarium for EIMs has expanded with new pharmaceutical drug classes that effectively treat IBD. EIMs are an increasingly recognized complication of IBD that require prompt recognition, multidisciplinary management, and a multifaceted therapeutic approach. This review highlights the complexities and ramifications of EIM management and offers therapeutic guidance.

The appearance of joint manifestations in the Swiss inflammatory bowel disease cohort

Background/Aims

Extraintestinal manifestations (EIM) involving joints, skin, eyes and liver represent an important problem in the treatment of IBD patients. The aim of this study was to identify factors that are associated with the occurrence of joint EIM and therefore allow an early diagnosis and guide medical treatment.

Methods

We studied clinical and epidemiological data from 3298 patients included in the Swiss IBD Cohort Study (SIBDCS), 1860 suffered from Crohn’s disease (CD) and 1438 from ulcerative colitis or IBD unclassified (UC/IBDU).

Results

We found female gender as well as a longer disease duration and activity (specified as CDAI or MTWAI, respectively) to be related to the appearance of arthritis/arthralgia, but also sacroiliitis/ankylosing spondylitis in IBD patients. IBD patients with arthritis/arthralgia or sacroiliitis/ankylosing spondylitis were more often treated with anti-TNF and patients with arthritis/arthralgia underwent more often IBD-related surgeries. We revealed that eye or skin EIM were more frequent in patients with arthritis/arthralgia or sacroiliitis/ankylosing spondylitis. In multivariate analysis, we confirmed female gender, longer disease duration, IBD-related surgery, presence of other EIM and treatment with anti-TNF to be independent risk factors for the onset of arthritis/arthralgia in CD and UC/IBDU patients.

Conclusion

In this study, we demonstrated that markers for a more severe disease course were associated with the onset of joint EIM in IBD patients. Our data suggest that in particular females under anti-TNF treatment and patients suffering from non-joint and/or IBD-related surgery should be close and carefully monitored for presence of arthritis or sacroiliitis/ankylosing spondylitis.

The Pathogenesis of Extraintestinal Manifestations: Implications for IBD Research, Diagnosis, and Therapy

This article reports on the sixth scientific workshop of the European Crohn's and Colitis Organisation [ECCO] on the pathogenesis of extraintestinal manifestations [EIMs] in inflammatory bowel disease [IBD]. This paper has been drafted by 15 ECCO members and 6 external experts [in rheumatology, dermatology, ophthalmology, and immunology] from 10 European countries and the USA. Within the workshop, contributors formed subgroups to address specific areas. Following a comprehensive literature search, the supporting text was finalized under the leadership of the heads of the working groups before being integrated by the group consensus leaders.

Extraintestinal manifestations in inflammatory bowel disease - epidemiology, genetics, and pathogenesis

Inflammatory bowel disease (IBD) is a chronic inflammatory disorder, primarily of, but not restricted to the gut. Extraintestinal manifestations (EIMs) are frequently observed and involve the joints, eyes, hepatobiliary tract, and skin. Areas covered: In this review, we discuss classical EIM focusing on epidemiology, genetics, and pathogenesis, highlighting recent advances in the understanding of EIM. We further discuss treatment-induced immunological phenomena, which are increasingly recognized and might challenge IBD-treating physicians in the era of biological treatment. Expert opinion: EIM considerably contributes to morbidity and mortality. Genetic studies have revealed a common genetic background between EIM and IBD and among specific EIM. Identified protein interactions have been shown to cluster in shared biological pathways. However - despite these recent advances - pathogenesis of EIM is at best partially understood. Several pathogenic mechanisms have been proposed such as upregulation of tumor necrosis factor, aberrant lymphocyte homing, and cross-reactive antigen presentation. It still remains unclear whether EIM is a direct result of the inflammatory process in the gut or rather a consequence of a shared genetic background leading to dysfunctional immune responses to environmental stimuli. Exploration and understanding of EIM genetics and pathophysiology will pave the road for better and more efficacious treatment options in the future.

Red flags for appropriate referral to the gastroenterologist and the rheumatologist of patients with inflammatory bowel disease and spondyloarthritis

Collaboration between gastroenterologists and rheumatologists is recommended for the correct management of patients with associated spondyloarthritis (SpA) and inflammatory bowel disease (IBD). We aimed to establish the appropriateness of several red flags for a prompt specialist referral. A systematic review of the literature was performed using the GRADE method to describe the prevalence of co-existing IBD-SpA and the diagnostic accuracy of red flags proposed by a steering committee. Then, a consensus among expert gastroenterologists and rheumatologists (10 in the steering committee and 13 in the expert panel) was obtained using the RAND method to confirm the appropriateness of each red flag as 'major' (one sufficient for patient referral) or 'minor' (at least three needed for patient referral) criteria for specialist referral. The review of the literature confirmed the high prevalence of co-existing IBD-SpA. Positive and negative predictive values of red flags were not calculated, given the lack of available data. A consensus among gastroenterology and rheumatology specialists was used to confirm the appropriateness of each red flag. Major criteria to refer patients with SpA to the gastroenterologist included: rectal bleeding, chronic abdominal pain, perianal fistula or abscess, chronic diarrhoea and nocturnal symptoms. Major criteria to refer patients with IBD to the rheumatologist included: chronic low back pain, dactylitis, enthesitis and pain/swelling of peripheral joints. Several major and minor red flags have been identified for the diagnosis of co-existing IBD-SpA. The use of red flags in routine clinical practice may avoid diagnostic delay and reduce clinic overload.

A comprehensive review and update on ulcerative colitis. Dis Mon 2019;65:100851. [PMID: 30837080 DOI: 10.1016/j.disamonth.2019.02.004]

Ulcerative colitis (UC) is a chronic idiopathic inflammatory bowel disorder of the colon that causes continuous mucosal inflammation extending from the rectum to the more proximal colon, with variable extents. UC is characterized by a relapsing and remitting course. UC was first described by Samuel Wilks in 1859 and it is more common than Crohn's disease worldwide. The overall incidence and prevalence of UC is reported to be 1.2-20.3 and 7.6-245 cases per 100,000 persons/year respectively. UC has a bimodal age distribution with an incidence peak in the 2nd or 3rd decades and followed by second peak between 50 and 80 years of age. The key risk factors for UC include genetics, environmental factors, autoimmunity and gut microbiota. The classic presentation of UC include bloody diarrhea with or without mucus, rectal urgency, tenesmus, and variable degrees of abdominal pain that is often relieved by defecation. UC is diagnosed based on the combination of clinical presentation, endoscopic findings, histology, and the absence of alternative diagnoses. In addition to confirming the diagnosis of UC, it is also important to define the extent and severity of inflammation, which aids in the selection of appropriate treatment and for predicting the patient's prognosis. Ileocolonoscopy with biopsy is the only way to make a definitive diagnosis of UC. A pathognomonic finding of UC is the presence of continuous colonic inflammation characterized by erythema, loss of normal vascular pattern, granularity, erosions, friability, bleeding, and ulcerations, with distinct demarcation between inflamed and non-inflamed bowel. Histopathology is the definitive tool in diagnosing UC, assessing the disease severity and identifying intraepithelial neoplasia (dysplasia) or cancer. The classical histological changes in UC include decreased crypt density, crypt architectural distortion, irregular mucosal surface and heavy diffuse transmucosal inflammation, in the absence of genuine granulomas. Abdominal computed tomographic (CT) scanning is the preferred initial radiographic imaging study in UC patients with acute abdominal symptoms. The hallmark CT finding of UC is mural thickening with a mean wall thickness of 8 mm, as opposed to a 2-3 mm mean wall thickness of the normal colon. The Mayo scoring system is a commonly used index to assess disease severity and monitor patients during therapy. The goals of treatment in UC are three fold-improve quality of life, achieve steroid free remission and minimize the risk of cancer. The choice of treatment depends on disease extent, severity and the course of the disease. For proctitis, topical 5-aminosalicylic acid (5-ASA) drugs are used as the first line agents. UC patients with more extensive or severe disease should be treated with a combination of oral and topical 5-ASA drugs +/- corticosteroids to induce remission. Patients with severe UC need to be hospitalized for treatment. The options in these patients include intravenous steroids and if refractory, calcineurin inhibitors (cyclosporine, tacrolimus) or tumor necrosis factor-α antibodies (infliximab) are utilized. Once remission is induced, patients are then continued on appropriate medications to maintain remission. Indications for emergency surgery include refractory toxic megacolon, colonic perforation, or severe colorectal bleeding.

Occurrence of skin manifestations in patients of the Swiss Inflammatory Bowel Disease Cohort Study

BACKGROUND/AIMS

Extraintestinal cutaneous manifestations of IBD represent a severe disease complication and an early and accurate treatment might positively influence the disease course. Using the patient collective of the Swiss IBD Cohort Study (SIBDCS), we analysed epidemiological as well as clinical factors being associated with the onset of pyoderma gangrenosum, erythema nodosum and aphthous ulcers in IBD patients.

METHODS

We included 3266 SIBDCs patients, 1840 with Crohn's disease (CD) and 1426 with ulcerative colitis (UC) or IBD unclassified (IBDU) and analysed the association of cutaneous manifestations with age, age at diagnosis time, type of disease, gender, family history, HLA-allotype, smoking, intestinal disease activity, therapy and other extraintestinal manifestations (EIM).

RESULTS

354 CD patients and 136 UC/IBDU patients presented with skin manifestations at any time during their disease course. In both, CD and UC, female gender and younger age at IBD diagnosis were significantly associated with extraintestinal skin manifestations. For CD, we also detected a positive family history as associated factor. As an indicator of more intensive intestinal disease activity, patients with cutaneous manifestations of IBD needed more frequently therapy with antibiotics, steroids, immunomodulators and anti-TNF. Multivariate analysis revealed female gender, younger age at diagnosis and presence of other extraintestinal manifestations as factors being associated with skin EIM in IBD patients and anti-TNF as well as immunomodulatory treatment in CD patients.

CONCLUSION

Our results suggest that young females with a positive family history of IBD might be at increased risk for the onset of skin manifestations and require a careful screening for such complications.

The difference in extraintestinal manifestations of inflammatory bowel disease for children and adults

Extraintestinal manifestations (EIMs) are frequently observed in adult and pediatric patients with inflammatory bowel disease (IBD). The most common EIMs involve the joints, skin, and eyes, but they can affect various organs and result in significant morbidity. Since EIMs can appear years before the diagnosis of IBD is made, clinicians should be aware of their various manifestations to help decrease diagnostic delay of IBD and establish appropriate treatment plans.

High frequency of secondary, but not primary ocular manifestations of inflammatory bowel disease in patients treated at a tertiary care center

OBJECTIVE

Ocular manifestations of inflammatory bowel disease (IBD) are relevant complications of IBD. Only a few prospective studies are available on the characteristics of these manifestations. The aim of this study was to characterize the frequency of eye disease in patients with IBD, including primary and secondary ocular manifestations of IBD, and to identify patients who may need specialized ophthalmologic care.

PATIENTS AND METHODS

In a prospective observational study, patients with IBD were examined for ocular symptoms in comparison with control participants without IBD. All patients with IBD underwent a thorough ophthalmologic examination (including slit-lamp, tonometry, tear breakup time, Schirmer's test, and coherence tomography). The results were analyzed with respect to sociodemographic and disease-related characteristics.

RESULTS

A total of 61 patients (33 women, 39 Crohn's disease, 22 ulcerative colitis, age 43.3±12.9 years, disease duration 12.4±9.3 years) were included. Ophthalmologic symptoms were reported by 53 patients (86.9%, most frequently deterioration of vision 42.6%, foreign body sensation 36.1%) compared with 60.6% in healthy controls (P=0.001). A clinically relevant, previously undetected ophthalmologic diagnosis was identified in 56 patients (91.8% - dry eye syndrome 75.4%, cataract 67.2%, blepharitis 45.9%, fundus hypertonicus 14.8%, other 16.4%).

CONCLUSION

Although primary ocular manifestations of IBD are rare in intensively treated patients, the high frequency of unrecognized secondary manifestations should give reason to refer especially patients with longstanding or complicated IBD to an eye specialist - irrespective of ocular symptoms.

Is probiotic use beneficial for skin lesions in patients with inflammatory bowel disease?

Background: Inflammatory bowel diseases (IBDs) are associated with extraintestinal manifestations including skin lesions. The intestinal microflora plays a key role in the development and course of IBD. Aim: To examine the efficacy of probiotics and the occurrence of skin lesions in patients with IBD. Methods: The occurrence of cutaneous lesions in IBD patients from Northern Sardinia was analyzed according to demographic, anthropometrics, clinical features, treatments, and probiotic use expressed as the ratio of disease duration under probiotic treatment and the total disease duration. Results: In 170 IBD patients (59.4% women; UC: 61.2%) at least one skin lesion was present (8.2%) at diagnosis and in 30.6% developed during the follow-up. Psoriasis, erythema nodosum, and pyoderma gangrenosum were the most frequent. An inverse trend was observed between probiotics use and skin lesions occurrence after adjusting for confounders, including conventional treatment for IBD. The risk of developing at least one skin lesion was 1.40 for probiotic use between 5-19% of disease duration and 0.3 for probiotic use > 50%. Body mass index, Crohn phenotype, marriage, and potency of IBD-treatment were significant predictors for developing skin lesions. Conclusion: These findings suggest that probiotics may be an additional tool in the treatment of IBD.

The Association Between Arthralgia and Vedolizumab Using Natural Language Processing

BACKGROUND

The gut-selective nature of vedolizumab has raised questions regarding increased joint pain or arthralgia with its use in inflammatory bowel disease (IBD) patients. As arthralgias are seldom coded and thus difficult to study, few studies have examined the comparative risk of arthralgia between vedolizumab and tumor necrosis factor inhibitor (TNFi). Our objectives were to evaluate the application of natural language processing (NLP) to identify arthralgia in the clinical notes and to compare the risk of arthralgia between vedolizumab and TNFi in IBD.

METHODS

We performed a retrospective study using a validated electronic medical record (EMR)-based IBD cohort from 2 large tertiary care centers. The index date was the first date of vedolizumab or TNFi prescription. Baseline covariates were assessed 1 year before the index date; patients were followed 1 year after the index date. The primary outcome was arthralgia, defined using NLP. Using inverse probability of treatment weight to balance the cohorts, we then constructed Cox regression models to calculate the hazard ratio (HR) for arthralgia in the vedolizumab and TNFi groups.

RESULTS

We studied 367 IBD patients on vedolizumab and 1218 IBD patients on TNFi. Patients on vedolizumab were older (mean age, 41.2 vs 34.9 years) and had more prevalent use of immunomodulators (52.3% vs 31.9%) than TNFi users. Our data did not observe a significantly increased risk of arthralgia in the vedolizumab group compared with TNFi (HR, 1.20; 95% confidence interval, 0.97-1.49).

CONCLUSIONS

In this large observational study, we did not find a significantly increased risk of arthralgia associated with vedolizumab use compared with TNFi.

Ulcerative colitis in an adult patient mimicking Henoch-Schönlein purpura: A case report

RATIONALE

Ulcerative colitis (UC) is one of the chronic inflammatory diseases of the intestinal tract. UC being misdiagnosed as Henoch-Schönlein purpura (HSP) in the elderly has seldom been reported about.

PATIENT CONCERNS

A 64-year-old man was admitted to the hospital with petechiae and palpable purpura in lower limbs and abdominal pain for about 1 month.

DIAGNOSES

Colonoscopy demonstrated severe inflammation in the colon, mucosal congestion, and edema, and multiple hemorrhages and ulcerations, with purulent adhesions. A histopathologic examination of the colon biopsies revealed extensive infiltration of immune cells and mucosal ulcerations in the intestine. UC was diagnosed.

INTERVENTIONS

The patient was treated with prednisone (1.0 mg/kg/d) with progressive dose reduction.

OUTCOMES

The skin lesions were healed within 4 weeks, and his abdominal pain was alleviated remarkably. He is currently under follow-up.

LESSONS

As the treatment used for patients with HSP was not effective, it was advised that UC should be taken into consideration.

Complications of Treatments for Pediatric Rheumatic Diseases

Medications to treat children with rheumatic disease include disease-modifying antirheumatic drugs, glucocorticosteroids, and biologic response modifiers that target mediators and cells involved in autoimmunity and inflammation. Although usually well-tolerated, such medications have many possible side effects, of which primary care and emergency providers should be aware. Both disease and immunosuppression contribute to susceptibility to unusual and opportunistic infections, in addition to usual childhood infections for which these children should receive all applicable nonlive vaccines. Close coordination between the rheumatologist and other medical care providers is essential, because medication side effects, infections, and disease flares are difficult to distinguish, and may occur together.