The MYTHS of De novo Crohn's Disease After Restorative Proctocolectomy with Ileal Pouch-anal Anastomosis for Ulcerative Colitis

BACKGROUND

1.1.Inflammatory Bowel Disease (IBD) are the manifestation of overzealous dys-regulated immune response in the intestinal tract, directed primarily against the indigenous microbes combined with defective functioning of anti-inflammatory pathways. Finding a trustable lead to predicting de novo Crohn's Disease (CD) prior to performing "pouch surgery", Restorative Proctocolectomy (RPC) with Ileal Pouch-Anal Anastomosis (IPAA) for UC and/or Indeterminate Colitis (IC) is clinically important and remains debatable. De novo CD is a subsequent long-term postoperative complication in IBD patients with Ulcerative Colitis (UC) undergoing IPAA. Herewith we discuss this understanding in laboratory-based basic science research, with its molecular application as a possible corner stone tool for clinical progress and success in the IBD Clinic. Crypt Paneth cell (PCs) secreted enteroendocrine alpha-defensin 5 (DEFA5)" if developed properly is likely to solve diagnostic and prognostic difficulty in IBD Clinics. DEFA5 has shown the ability to differentiate the predominant subtypes of colonic IBD (CC vs. UC) at first endoscopy biopsy, avoiding diagnosis delay prior to colectomy. In addition, DEFA5 accurately circumvents indeterminate colitis (IC) patients into accurate IBD subtype (UC or CC). Further, DEFA5 can be used in selecting CC patients that may have positive outcomes after IPAA surgery [1]. Furthermore, likewise, DEFA5 can predict UC patients likely to have positive or poor outcome, e.g. those patients that are likely to transform/ convert and adhere to de novo Crohn's after IPAA can be picked up in endoscopy biopsy before surgery.

AIM

1.2.To assessed comprehensive state-of-the-art understanding domains on the de novo Crohn's disease subsequent to IPAA surgery for ulcerative colitis.

METHODS

1.3.A literature search based on preferred reporting items for over-review and meta-analysis protocols (PRISMA-P) was performed. A comprehensive current search of PubMed, MEDLINE, CINAHL, Embase, Google® search engine and Cochrane Database of collected reviews was performed from January 1990 through December 2018. The search consists of retrospective studies and case reports of reporting postoperative de novo CD incidence and adverse events. Secondary and hand/manual searches of reference lists, other studies cross-indexed by authors, reviews, commentaries, books and meeting abstracts were also performed. Studies were included only if the diagnosis of de novo CD was established clinically and histologically based on inflammation of afferent limb(s) or perianal disease. The search excluded non-English language and non-human studies as well as editorials.

RESULTS

1.4.Published data on de novo CD developing after RPC with IPAA are still limited. A total of three hundred and sixty-five (#365) patients in 13 publications reported de novo CD after a median follow-up of 66 (range: 3-236) months. All patients were diagnosed with clinically active pouch CD during follow-up surveillance after IPAA for UC or IC. A de novo CD diagnosis depended on either inflammation in the mucosa involving the small intestine proximal to the ileal pouch any time after IPAA surgery and/or when perianal complications developed after closure of a temporary diverting loop ileostomy. Successful management is facilitated by co-operation within a multidisciplinary team of gastroenterologists and colorectal surgeons and closely involving the patient in therapeutic decisions. Awareness of symptoms leads to timely consultation, diagnosis, treatment and restoration of intestinal continuity.

CONCLUSION

1.5.The nature history and risk of de novo CD after IPAA for UC remains debatable. Chronic pouchitis and/or pouch failure often precedes a diagnosis of de novo CD. A successful management is facilitated by a triad cooperation between gastroenterologists, colorectal surgeons and the patient.

Ubiquitous Colonic Ileal Metaplasia Consistent with the Diagnosis of Crohn's Colitis among Indeterminate Colitis Cohorts

BACKGROUND

Inadequate differentiated diagnostic features of predominantly colonic inflammatory bowel diseases i.e., ulcerative colitis and Crohn's colitis, may lead to inexact diagnosis of "indeterminate colitis". About 15% of indeterminate colitis patients are diagnosed at colonoscopy, in colonic biopsies, and/or at colectomy. Managing outcomes of indeterminate colitis, given its unpredictable clinical presentation, depends on future diagnosis of colitis, Crohn's colitis or ulcerative colitis.

OBJECTIVE

Overview the diagnostic efficacy of ectopic colonic ileal metaplasia and human α-defens 5 (DEFA5 alias HD5) for accurate delineation of indeterminate colitis into authentic Crohn's colitis and/ or ulcerative colitis.

DESIGN

We describe a targeted protein for potentially differentiating indeterminate colitis into an accurate clinical subtype diagnosis of inflammatory bowel diseases i.e., ulcerative colitis and Crohn's colitis.

PATIENTS

Twenty-one patients with the clinically inexact diagnosis of indeterminate colitis were followed, reassessed and data analyzed.

MAIN OUTCOME MEASURES

We observed that (i) some patients had their original diagnosis changed from indeterminate colitis to either ulcerative colitis or Crohn's colitis; and (ii) human α-defensin 5 is aberrantly overexpressed in Crohn's colitis.

RESULTS

Fifteen of the twenty-one (71.4%) patients with indeterminate colitis had their inconclusive diagnosis changed; nine patients changed to ulcerative colitis and six to Crohn's colitis. In human colon surgical samples, Human α-defensin-5 was significantly upregulated in Crohn's colitis. In addition, Human α-defensin 5 processing enzyme, matrix metalloptotease-7 was inversely expressed compared to Human α- Defensin 5.

LIMITATION

Due to the sequence homology of the α-defensin class of proteins, preceding efforts to raise antibodies (Abs) against DEFA5 have limitations to produce adequate specificity. The Abs used in previous assays recognizes the α-defensins, active α-defensins 5 and inactive pro- α-defensins 5. Monoclonal antibodies (mAbs) to determine specificity and sensitivity of α-defensins 5, which is diagnostic of CC disease, and NOT other α-defensins is the limitation to overcome.

CONCLUSION

It is feasible to differentiate ulcerative colitis from Crohn's colitis among patients with inexact diagnosis of indeterminate colitis using Human α-defensin 5 as a molecular biosignature delineator.

Managing Pregnancy and Nursing Affecting African American Women with Inflammatory Bowel Disease: Clinical Outcomes and Parenthood

Inflammatory bowel disease (IBD) is a term for two autoimmune diseases encompassing Crohn's disease (CD) and ulcerative colitis (UC) which are lifelong diseases affecting more than 3 million adults (1.3%) in the United States. IBD is characterized by chronic inflammation of the whole digestive system which results in damage to the gastrointestinal (GI) tract. IBD often emerges during adolescence and young adulthood. Maternal morbidity includes physical and psychological conditions that result from or are aggravated by pregnancy and have an adverse effect on a woman's health, the baby's health or both. Some women have health challenges that arise before or during pregnancy that could lead to complications. It is recommended for women to receive health care counseling before and during pregnancy. Compared to other developed countries, the United States has the highest rate of women dying of pregnancy related complications. During the past 25 years maternal mortality has been getting worse. African American women (AAW) with and/or without IBD are dying at significantly higher rates than other groups. This is linked to several factors, i.e., systemic, institutionalized, and structural racism in health-care delivery and subsequent toxic stress from people's lived experiences of racism, limited knowledge about healthcare system function, lack of access to healthcare, (inclusiveness and insurance policies) all of which negatively impact these patients. African Americans (AAs) are also up to three times as likely to experience severe maternal morbidity: unexpected outcomes of labor and delivery, deficient or lacking prenatal care and social determinants of health like lack of transportation, adequate employment, limited literacy, and limited healthcare access contribute to poor health outcomes. Studies on IBD patients indicate Medicaid expansion is associated with reduced rates of maternal morbidity, particularly for African American Women (AAW) and increased access to preconception and prenatal services that make pregnancy and childbirth safer for parent and baby. Herein we examine the physiological changes of pregnancy in patients diagnosed with inflammatory bowel disease and their relationship perinatal outcomes and parenthood.

Observations in the blood lipid profile in patients undergoing restorative proctocolectomy

BACKGROUND

Ileal dysfunction, and resection or exclusion may affect intestinal bile acid resorption resulting in alterations in serum lipid concentration. In restorative proctocolectomy, the different procedures may involve the ileum in all three ways.

AIM

The aim of the present study was to analyse possible changes of the blood lipid profile during the different steps of restorative proctocolectomy operative procedure.

METHOD

There were nineteen elective patients on their ordinary diet and 19 emergency patients on total parenteral nutrition. The former group were primarily operated on with colectomy; ileoanal pouch and loop ileostomy while the later group had had an emergency colectomy and terminal ileostomy before the pouch operation. Thirty five of the patients had ulcerative colitis, 2 had familial colon polyposis and 1 familial cancer syndrome. Blood specimens were collected in the mornings with the patients in a fasting state. The emergency patients were on unchanged ordinary diet during the preoperative period. Serum cholesterol and triglyceride were determined by enzymatic methods. Lipoproteins, studied only in the elective patients, were analysed by a combination of ultracentrifugation and precipitation. Student's t-test with Bonferroni's correction for multiple comparisons was used for statistic calculations.

RESULTS

Preoperatively, the emergency group had significantly lower serum cholesterol but not serum triglycerides values compared to the elective group. This finding is probably due to difference in the preoperative nutrition. The cholesterol levels among patients who received steroids in the two groups were compared and found to be significantly lower in the emergency group. Later, no significant differences concerning cholesterol and triglycerides were found between the groups. The cholesterol level was not significantly different in the elective group between patients who receive hydrocortisone and those who did not. During the period with loop ileostomy cholesterol was significantly lowered while the triglycerides were significantly increased compared to the preoperative values of the elective group. The decrease of serum cholesterol levels was correlated to the length of the excluded ileum. During the same period alpha-lipoprotein decreased significantly and reached values below the normal of the reference material. Beta-lipoproteins, which were subnormal already preoperatively, increased but not significantly. Pre-beta-lipoproteins were at the same level at all stations. At 12 months with functioning pouches all analysed values, with the exception of beta-lipoproteins. were within the normal limits set by the reference material. In the emergency group the patterns for triglycerides and cholesterol were similar but for the preoperatively depressed cholesterol values. After 12 months with functioning pouch the serum cholesterol and triglycerides were at the same level as for the elective patients.

CONCLUSION

A serum lipid profile was studied in patients undergoing restorative proctocolectomy. Serum cholesterol and alpha-lipoprotein decreased and triglycerides increased when the patients had a diverting loop ileostomy. At 12 months after it's closure and with a functioning pouch, the patients had the same profile as the elective patients preoperatively, and with exception of beta-lipoproteins within normal limits in spite of the loss of the colon and the construction of a pouch of the distal ileum.

Inflammatory Bowel Disease On-Line Web-Based Guide to Health Professionals and Patients in Developing and African Nations

INTRODUCTION

1.1.Inflammatory Bowel Disease (IBD) is recklessly evolving worldwide as incautious disaster, especially in developing nations as a regional duplicitous emergence disease. It has come to light that adaptive Western culture, rapid urbanization lifestyle in the developing nations has been seen to be associated with this increasing trend incidence. Apparent unclassified strategic challenge assessment of how key trends and uncertainties might lead the world over the next decades to help developing nations and plan for the long term. Healthcare professionals are faced with limited resource and unequipped laboratories for IBD diagnostics, prognostics and monitoring management. Limited knowledge on IBD among developing nation's physician's/healthcare providers is painstaking and indisputable challenge. With the emergence of advanced communications technology, the internet offers diverse, substantial, easily accessible, and educational resources that are more time- and cost-efficient than conventional modes of knowledge acquisition. An On-Line Web-Based Resources about IBD, as a guide would greatly assist health professionals and patients.

METHODS

1.2.We performed a literature search according to PRISMA-P (preferred reporting items for review and meta-analysis and searches in PubMed (MEDLINE database) to identify and select peer-reviewed articles allied to web-based educational accoutrements for IBD.

RESULTS

1.3.In developing nations, locally trained physicians have limited knowledge on IBD. Mostly, IBD is not included in their training Core Curriculum and research in this field/area is limited in these countries. The healthcare approaches, both at the primary care and referral levels, many times lack the essential regular clinical guidance and laboratory evaluation assessments needs for monitoring patients. Moreover, increasing treatment costs impose additional burden on the healthcare systems. Expensive pharmacological biosimilar and biologic agents/drugs, new treatment targets, and new quality indicators in patient health quality of life and care are significant challenge in addition to early manifestations of IBD are likely to be missed at most health institutions.

CONCLUSION

1.4.We herewith summarize an on-line web-based e-learning guide for IBD-related educational resources to assist physicians, healthcare personnel and patients worldwide, especially in the developing nations where the epidemiological monitoring studies are limited, due to a lack of medical surveillance systems and reliable and unified registries and databases.

Adenocarcinoma at the Ileostomy Site After a Proctocolectomy for Ulcerative Colitis and/or Familial Adenomatous Polyposis: An Overview

Adenocarcinoma that occurs at the ileostomy site after proctocolectomy (TPC) with an end ileostomy for ulcerative colitis (UC) and/or familial adenomatous polyposis (FAP) is a late and uncommon complication. To ascertain the rate of adenocarcinoma at the empirical ileostomy site following TPC, a review of the literature was conducted. PubMed, MEDLINE, the Cumulative Index of Nursing and Allied Health Literature, EMBASE, Google search engine, and the Cochrane Database were investigated for research published between January 1975 and December 2016. Search criteria included English language and human-only publications; broad search terms related to UC, FAP, ileostomy procedures, and dysplasias were used. Abstracts were eliminated if they were foreign language and nonhuman studies; editorials also were excluded. Secondary and hand/manual searches of reference lists, other studies cross-indexed by authors, reviews, commentaries, books, and meeting abstracts also were performed. Data extracted included age at diagnosis, operation technique, interval to ileostomy cancer, age when cancer was diagnosed, histology for both UC and FAP patients, and subsequent treatment. Papers were included on the basis of available evidence for each specific point of interest. Final and conclusive agreement was assessed with the k statistics during the title review and abstract review. Studies that did not report original data also were excluded. A total of 5753 publications were identified; 5697 publications did not conform to inclusion criteria and were eliminated. Among the reviewed publications (all case studies), 57 patients were diagnosed with ileostomy adenocarcinoma after TPC; 42 had UC, and 15 had FAP. The interval between TPC operation and ileostomy cancer diagnosis ranged from 3 to 51 years for UC and from 9 to 40 years for FAP, with a mean interval of 30 and 26 years, respectively. Biopsies were performed of all polypoid lesions found at the stoma site. Patients were treated with wide excision and refashioning (diversion) of the stoma. While adenocarcinoma arising at the mucocutaneous junction at the ileostomy site with adjacent skin invasion after TPC for UC and FAP appears to be rare, patients and clinicians need to be aware of this potential complication even years after surgery and regular screening is recommended.

A study of plasma immunoglobulins profile in connection with restorative proctocolectomy

BACKGROUND

Restorative proctocolectomy is an operative procedure that in principle means proctocolectomy, preserving the anal sphincters and construction of an ileal pouch which is sutured to the dentate line. The method is used mostly in case of surgical treatment of ulcerative colitis or familial polyposis coli. The procedure means different manipulations with the distal ileum that may influence the function of gut-associated lymphoid tissues, a major subdivision of the immune system.

AIM

The aim of the present investigation was to study the plasma concentration of immunoglobulins in connection with the restorative proctocolectomy operation.

METHODS

Forty five patients received an ileoanal pouch (IAP) because of ulcerative colitis. Twenty seven patients were males and 18 females. The mean age was 34 (range 18-55) years. Twenty six patients were first operated on emergency by subtotal colectomy with terminal ileostomy. In a second operation, the rectum was excised and an ileoanal pouch and a loop ileostomy that diverted the bowel content from the distal ileum was performed. Eighteen elective patients had their colectomy performed at the same time as the pouch operation. As a last procedure the diverting loop ileostomy was closed and thereby the distal ileum and the ileoanal pouch was put into function. Blood samples for plasma immunoglobulin analyses was collected from the patients before the colectomy, after colectomy with terminal ileostomy before construction of the pouch, during the period with pouches prior to loop ileostomy closure and 12 months after its closure. Immunoglobulins in plasma were determined by nephelometry method. The data was analyzed statistically by ANOVA and linear regression analysis.

RESULTS

There was a significant difference preoperatively, in plasma immunoglobulin G (P-IgG) between the patients who were operated on electively compared to the emergency patients (p < 0.03). This was the only significant difference between values for the emergency and elective groups throughout the study. In the emergency patients after colectomy and with terminal ileostomy plasma immunoglobulin A (P-IgA) and immunoglobulin A (P-IgM) concentrations in plasma had increased significantly compared to preoperative (p < 0.03) and (p < 0.002) respectively. During the time with loop ileostomy plasma IgM was still found to be significantly elevated (p < 0.02) compared to the level before colectomy. In the electively operated patients plasma IgA and IgM were significantly increased after colectomy and pouch construction during the time with loop ileostomy compared to preoperatively (p < 0.04) and (p < 0.0004). After 12 months with functional pouches the plasma immunoglobulins in both groups were similar to the elective patients preoperatively.

CONCLUSION

The immunoglobulins IgG, IgA and IgM were studied in connection with restorative proctocolectomy. Preoperatively, IgG was found to be significantly lower in emergency compared to elective patients. The difference is probably due to increased losses and impaired production of IgG in the acute phase of ulcerative colitis. IgA and IgM were found to increase significantly after colectomy and construction of an ileostomy but how these measures were responsible for the changes could not be determined in the present study. Twelve months after loop ileostomy closure there were no longer any significant changes of the immunoglobulins compared to elective patients with ulcerative colitis preoperatively.