Obesity in Inflammatory Bowel Disease: A Marker of Less Severe Disease

Bariatric Surgery and Its Complications in Inflammatory Bowel Disease Patients

Recent data have suggested that bariatric procedures, especially laparoscopic sleeve gastrectomy (SG), are safe and effective weight loss measures in patients with inflammatory bowel disease (IBD). But most of the studies have looked at short-term outcomes, and there is a general lack of awareness of underlying disease processes and baseline comorbidities in IBD patients undergoing bariatric procedures. Postbariatric issues in IBD patients including diarrhea from dumping syndrome, choleretic diarrhea, a high prevalence of small intestinal bacterial overgrowth, gastroesophageal reflux disease, Barrett's esophagus, stomal ulcerations, stenosis, and renal and gallstones can complicate the natural history of IBD. This could lead to unnecessary hospitalizations, change of medical therapy, and poor surgical and quality of life outcomes. In this review, we will discuss major complications after common bariatric procedures (SG, Roux-en-Y gastric bypass, and gastric banding) and suggest possible management strategies.

Safety and Efficacy of Bariatric Surgery in Inflammatory Bowel Disease Patients: a Systematic Review and Meta-analysis

BACKGROUND

The safety and efficacy of bariatric surgery in inflammatory bowel disease (IBD) patients is poorly understood. We conducted a systematic review and meta-analysis studying safety and efficacy of bariatric surgery in IBD patients as well as the impact of bariatric surgery on IBD course.

METHODS

We conducted a comprehensive search of multiple databases (through September 2019) to identify studies that reported outcome of bariatric surgery in IBD patients. Outcomes assessed included the pooled rate of adverse events, change in medications after bariatric surgery, and 12-month excess weight loss (EWL) and body mass index (BMI) reduction after bariatric surgery.

RESULTS

A total of 10 studies were included in final analysis. The pooled rate of early and late adverse events was 15.9% (95% CI, 9.3-25.9) and 16.9% (95% CI, 12.1-23.1), respectively. The rate of adverse events in Roux-en-Y gastric bypass was 45.6% (95% CI, 21.9-71.4) compared with 21.6% (95% CI, 11.1-38) in sleeve gastrectomy (p = 0.11). The pooled rate of 12-month EWL and BMI reduction after surgery was 66.1% (95% CI, 59.8-72.3%) and 13.7 kg/m² (95% CI, 12.5-14.9), respectively. The pooled rate of decrease, increase, and no change of IBD medications were 45.6% (95% CI, 23.8-69.2), 11% (95% CI, 6.3-18.4), and 57.6% (95% CI, 39.2-74.1), respectively.

CONCLUSIONS

Bariatric surgery has acceptable safety and efficacy profile in IBD patients. Nearly half of patients had decrease in their IBD medications after bariatric surgery, and only 10% experienced therapeutic escalation following bariatric surgery. Sleeve gastrectomy may be the preferred procedure in this population.

Effect of Lifestyle Factors on Outcomes in Patients With Inflammatory Bowel Diseases

Various lifestyle factors including physical activity and obesity, stress, sleep, and smoking may modify the risk of developing inflammatory bowel diseases (IBDs). In patients with established IBD, these lifestyle factors may significantly impact the natural history and clinical outcomes. Recreational exercise decreases the risk of flare and fatigue in patients with IBD. In contrast, obesity increases the risk of relapse and is associated with higher anxiety, depression, fatigue, and pain and higher health care utilization. Obesity also modifies pharmacokinetics of biologic agents unfavorably and is associated with a higher risk of treatment failure. Sleep disturbance is highly prevalent in patients with IBD, independent of disease activity, and increases the risk of relapse and chronic fatigue. Similarly, stress, particularly perceived stress rather than major life events, may trigger symptomatic flare in patients with IBD, although its impact on inflammation is unclear. Cigarette smoking is associated with unfavorable outcomes including the risk of corticosteroid dependence, surgery, and disease progression in patients with Crohn's disease; in contrast, smoking does not significantly impact outcomes in patients with ulcerative colitis, although some studies suggest that it may be associated with a lower risk of flare. The effect of alcohol and cannabis use in patients with IBD is inconsistent, with some studies suggesting that cannabis may decrease chronic pain in patients with IBD, without a significant effect of biological remission. Although these lifestyle factors are potentially modifiable, only a few interventional studies have been conducted. Trials of structured exercise and psychological therapy including mindfulness-based therapies such as meditation and yoga and gut-directed hypnotherapy have not consistently demonstrated benefit in clinical and/or endoscopic disease activity in IBD, although may improve overall quality of life.

A food pyramid, based on a review of the emerging literature, for subjects with inflammatory bowel disease

Emerging literature suggests that diet plays an important modulatory role in inflammatory bowel disease (IBD) through the management of inflammation and oxidative stress. The aim of this narrative review is to evaluate the evidence collected up till now regarding optimum diet therapy for IBD and to design a food pyramid for these patients. The pyramid shows that carbohydrates should be consumed every day (3 portions), together with tolerated fruits and vegetables (5 portions), yogurt (125ml), and extra virgin olive oil; weekly, fish (4 portions), white meat (3 portions), eggs (3 portions), pureed legumes (2 portions), seasoned cheeses (2 portions), and red or processed meats (once a week). At the top of the pyramid, there are two pennants: the red one means that subjects with IBD need some personalized supplementation and the black one means that there are some foods that are banned. The food pyramid makes it easier for patients to decide what they should eat.

Management of Inflammatory Bowel Diseases in Special Populations: Obese, Old, or Obstetric

The epidemiology of inflammatory bowel disease (IBD) is progressively evolving impacting the type of patients with IBD we will see in clinical practice. In this review, we discuss specific challenges and solutions in the management of (1) obese, (2) older and (3) obstetric (pregnant) patients with IBD. With the global obesity epidemic, almost 1 in 3 patients with IBD are obese. Obesity is associated with greater difficulty in achieving remission, higher risk of disease relapse and higher burden and costs of hospitalization in patients with IBD. Obese patients also have inferior response to biologic therapy related to altered pharmacokinetics and obesity-mediated chronic inflammation. Surgical management of obese patients with IBD is also challenging. Similar to obesity, the prevalence of IBD in older patients is rising and it is anticipated that almost one-third of patients with IBD will be older than 60 years within the next decade. Older patients present unique diagnostic and therapeutic dilemmas, and management of these individuals warrants careful consideration of the risks of disease-related versus treatment-related complications, non-IBD-related extra-intestinal complications (eg, cardiovascular disease, malignancy), in the context of individual values, preferences, functional status and comorbidities. With evolving therapeutics, medical management of IBD surrounding pregnancy continues to be challenging. Overall, the management of pregnant patients requires a pro-active, multidisciplinary approach, with an emphasis on optimal disease control not just during, but prior to pregnancy. This often involves continuation of highly effective therapies, of which the vast majority are safe during pregnancy and breastfeeding, resulting in a reduction of risk of adverse maternal fetal outcomes.

ESPEN practical guideline: Clinical Nutrition in inflammatory bowel disease

The present guideline is the first of a new series of "practical guidelines" based on more detailed scientific guidelines produced by ESPEN during the last few years. The guidelines have been shortened and now include flow charts that connect the individual recommendations to logical care pathways and allow rapid navigation through the guideline. The purpose of the present practical guideline is to provide an easy-to-use tool to guide nutritional support and primary nutritional therapy in inflammatory bowel disease (IBD). The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. In 40 recommendations, general aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.

Comparison of Real-World Outcomes of Infliximab versus Adalimumab in Biologic-Naïve Korean Patients with Ulcerative Colitis: A Population-Based Study

PURPOSE

Data on the comparative effectiveness of infliximab (IFX) or adalimumab (ADA) in patients with ulcerative colitis (UC) are extremely limited, especially in the Asian population. We compared clinically important outcomes [colectomy, UC-related emergency room (ER) visits, UC-related hospitalizations, and need for corticosteroids] for these two biologics in biologic-naïve Korean patients with UC.

MATERIALS AND METHODS

Using National Health Insurance claims, we collected data on patients who were diagnosed with UC and exposed to IFX or ADA between 2010 and 2016.

RESULTS

A total of 862 new users of biologics were included, of whom 630 were treated with IFX and 232 were treated with ADA. Over a median follow-up of 1.8 years after starting biologic therapy, there were no significant differences in the risk of colectomy [adjusted hazard ratio (aHR), 1.87; 95% confidence interval (CI), 0.30-11.63], ER visits (aHR, 1.58; 95% CI, 0.79-3.16), hospitalizations (aHR, 0.83; 95% CI, 0.59-1.17), and corticosteroid use (aHR, 1.16; 95% CI, 0.76-1.78) between IFX and ADA users. These results were stable even when only patients who used biologics for ≥6 months were analyzed. Additionally, these results were unchanged in patients treated with biologic monotherapy or combination therapy with immunomodulators.

CONCLUSION

In this nationwide population-based study, there was no significant difference in the risk of colectomy, ER visits, hospitalizations, and corticosteroid use between IFX and ADA users. Our findings indicate that IFX and ADA have comparable effectiveness in biologic-naïve Korean patients with UC.

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.

Role of Obesity, Mesenteric Adipose Tissue, and Adipokines in Inflammatory Bowel Diseases

Inflammatory bowel diseases (IBDs) are a group of disorders which include ulcerative colitis and Crohn's disease. Obesity is becoming increasingly more common among patients with inflammatory bowel disease and plays a role in the development and course of the disease. This is especially true in the case of Crohn's disease. The recent results indicate a special role of visceral adipose tissue and particularly mesenteric adipose tissue, also known as "creeping fat", in pathomechanism, leading to intestinal inflammation. The involvement of altered adipocyte function and the deregulated production of adipokines, such as leptin and adiponectin, has been suggested in pathogenesis of IBD. In this review, we discuss the epidemiology and pathophysiology of obesity in IBD, the influence of a Western diet on the course of Crohn's disease and colitis in IBD patients and animal's models, and the potential role of adipokines in these disorders. Since altered body composition, decrease of skeletal muscle mass, and development of pathologically changed mesenteric white adipose tissue are well-known features of IBD and especially of Crohn's disease, we discuss the possible crosstalk between adipokines and myokines released from skeletal muscle during exercise with moderate or forced intensity. The emerging role of microbiota and the antioxidative and anti-inflammatory enzymes such as intestinal alkaline phosphatase is also discussed, in order to open new avenues for the therapy against intestinal perturbations associated with IBD.

Metabolic Syndrome in Inflammatory Bowel Disease: Association with Genetic Markers of Obesity and Inflammation

Background: This study analyzed poorly understood relationship of two overlapping conditions: metabolic syndrome (MeS) and inflammatory bowel disease (IBD), both associated with inflammation in the visceral adipose tissue. Methods: Newly diagnosed 104 IBD patients, of which 50 Crohn's disease (CD) and 54 ulcerative colitis (UC), and 45 non-IBD controls were examined for MeS-related obesity and lipid markers. Th-17 immune genes IL17A, IL17F, IL23A, and TLR9 mRNAs were measured in intestinal mucosa by qRT-PCR. Subjects were genotyped for obesity-associated FTO variant rs9939609 by polymerase chain reaction-amplification refractory mutation system. Results: CD was associated with MeS (P = 0.01), while both CD and UC were associated with central obesity (P = 10^-5, P = 0.002, respectively) and low levels of high-density lipoprotein (HDL) cholesterol (P = 5 × 10^-6, P = 6 × 10^-6, respectively). IBD lipid profile was characterized by decreased total and HDL cholesterol, while low-density lipoprotein cholesterol was reduced only in CD. Negative correlations were found between total cholesterol and CD activity index (P = 0.005), waist circumference and IL17A as well as IL17F mRNA levels in inflamed CD colon (P = 0.003, P = 0.001, respectively). Carriers of FTO rs9939609 AA genotype showed increased risk of CD (OR 2.6, P = 0.01). Conclusions: MeS, central obesity, and dyslipidemia could be important for IBD pathogenesis. This could influence therapeutic approaches and prevention strategies in high-risk groups.

Obesity and Weight Gain Since Early Adulthood Are Associated With a Lower Risk of Microscopic Colitis

BACKGROUND & AIMS

Obesity promotes intestinal inflammation and might contribute to the pathogenesis of inflammatory bowel disease. We examined the association between obesity and risk of microscopic colitis in a prospective cohort study.

METHODS

We collected data from 192,101 women enrolled in the Nurses' Health Study (NHS) (from 1986 through 2014) or the NHSII (from 1991 through 2015). Anthropomorphic and lifestyle information were self-reported biennially. Obesity was defined using body mass index (BMI). Microscopic colitis was confirmed by review of medical records. We used Cox proportional hazard models to estimate adjusted hazard ratios (aHRs) and 95% CIs.

RESULTS

Among the participants in the NHS and NHSII, we confirmed 244 cases of microscopic colitis during 4,223,868 person-years of follow-up evaluation. Higher BMI was associated inversely with risk of microscopic colitis (Ptrend < .001). Compared with women with BMIs ranging from 18.5 to 20.9 kg/m², the aHRs were 0.61 (95% CI, 0.41-0.91) for overweight women (BMI, 25-29.9 kg/m²) and 0.50 (95% CI, 0.32-0.79) for obese women (BMI ≥ 30 kg/m²). The aHR for each 5-kg/m² increase in BMI was 0.79 (95% CI, 0.69-0.90). Weight gain since early adulthood (age, 18 y) also was associated inversely with risk of microscopic colitis (Ptrend = .001). The aHR for each 10-kg weight gain since early adulthood was 0.85 (95% CI, 0.77-0.94). The associations were not modified by age, cohort, physical activity, or smoking status (all Pinteraction ≥ .26).

CONCLUSIONS

Unlike many other immune- and metabolic-related disorders, obesity and weight gain since early adulthood were associated with a lower risk of microscopic colitis, based on an analysis of participants in the NHS and NHSII.

ZNF133 is associated with infliximab responsiveness in patients with inflammatory bowel diseases

BACKGROUND AND AIM

Infliximab has been widely prescribed for treating inflammatory bowel disease (IBD). However, the response rates to infliximab differ among patients. Therefore, we aimed to identify the genetic and clinical markers that predict infliximab response.

METHODS

A total of 139 Korean patients with IBD who received infliximab were classified according to infliximab response as follows: (i) primary response vs nonresponse and (ii) sustained response vs loss of response. We performed an association study using whole-exome sequencing data to identify genetic variants associated with infliximab response. Candidate variants were validated in 77 German patients with IBD. Stepwise multivariate logistic regression was performed to identify predictors.

RESULTS

We found five candidate variants that were associated with primary nonresponse to infliximab (P < 5 × 10^-6 ). Of the five variants, rs2228273 in ZNF133 was validated in German (combined P = 6.49 × 10^-7 ). We also identified the best genetic variant (rs9144, P = 4.60 × 10^-6 ) associated with the loss of infliximab response. In multivariate regression analysis, rs2228273 (P = 2.10 × 10^-5 ), concurrent azathioprine/6-mercaptopurine use, and bodyweight at the first infliximab use (< 50 kg) were associated with primary nonresponse. In addition, the Crohn's disease activity index at the first infliximab use and rs9144 (P = 0.001) were independently associated with the loss of response in patients with Crohn's disease.

CONCLUSIONS

We identified clinical and genetic markers associated with infliximab response in IBD patients. Our findings could provide insights to maximize the efficacy of infliximab therapy in IBD patients.

Outcomes of inflammatory bowel disease surgery in obese versus non-obese patients: a meta-analysis

BACKGROUND

Obesity is considered a risk factor for many chronic diseases and obese patients are often considered higher risk surgical candidates. The aim of this meta-analysis was to evaluate the outcomes of obese (body mass index ≥ 30 kg/m²) versus non-obese patients undergoing surgery for inflammatory bowel disease (IBD).

METHODS

PubMed, Scopus, and Embase libraries were searched up to March 2019 for studies comparing outcomes of obese with non-obese patients undergoing surgery for IBD. A meta-analysis was conducted using Review Manager software to create forest plots and calculate odds ratios and mean differences.

RESULTS

Four thousand three hundred and eleven patients from five observational studies were included. Obese patients were older at the time of surgery and more likely to have diabetes. Obese patients had longer operative times (MD 23.28, 95% CI 14.63-31.93, p < 0.001), higher intra-operative blood loss (MD 45.32, 95% CI 5.89-84.76, p = 0.02), longer length of stay (MD 0.90, 95% CI 0.60-1.20, p < 0.001), higher wound infection rates (OR 1.76, 95% CI 1.39-2.23, p < 0.001), and higher total postoperative complication rates (OR 1.33, 95% CI 1.04-1.70, p = 0.02).

CONCLUSIONS

Obesity is associated with significantly worse outcomes following IBD-specific surgery, including longer operative times, greater blood loss, longer length of stay, higher wound infection rates, and higher total postoperative complication rates. Clinicians should be mindful of these increased risks when counselling patients and consider weight reduction strategies where possible.

Relationship(s) between obesity and inflammatory bowel diseases: possible intertwined pathogenic mechanisms

The inflammatory bowel diseases, Crohn's and ulcerative colitis have increased in incidence and prevalence from the mid-eighteen to the late nineteen centuries. From then to the current twenty-first century there has been a more rapid expansion of these disease to areas previously experiencing low rates. This latter expansion coincides with the current obesity pandemic which also began toward the end of the last century. Although the two diseases have radically different frequencies, there are interesting links between them. Four areas link the diseases. On an epidemiological level, IBD tends to follow a north-south gradient raising the importance of vitamin D in protection. Obesity has very weak relationship with latitude, but both diseases follow adult lactase distributions colliding in this plane. Is it possible that obesity (a low vitamin D condition with questionable response to supplements) reduces effects in IBD? On a pathogenic level, pro-inflammatory processes mark both IBD and obesity. The similarity raises the question of whether obesity could facilitate the development of IBD. Features of the metabolic syndrome occur in both, with or without obesity in IBD. The fourth interaction between the two diseases is the apparent effect of obesity on the course of IBD. There are suggestions that obesity may reduce the efficacy of biologic agents. Yet there is some suggestion also that obesity may reduce the need for hospitalization and surgery. The apparent co-expansion of both obesity and IBD suggests similar environmental changes may be involved in the promotion of both.

Prevalence and Factors Associated With Fatigue in Patients With Inflammatory Bowel Disease: A Multicentre Study

BACKGROUND AND AIMS

The aims of this study were to determine the prevalence of fatigue in patients with inflammatory bowel disease [IBD], to identify the factors associated with fatigue and its severity, to assess the impact of fatigue on quality of life [QoL], and to evaluate the relationship between fatigue and sleep disorders.

METHODS

This was a prospective multicentre study conducted at 22 Spanish centres. Consecutive patients followed at IBD Units were included. Fatigue was evaluated with the Fatigue Severity Scale [FSS] and the Fatigue Impact Scale [FIS]. Quality of life and sleep quality were assessed using the IBD Questionnaire-Short Form [IBDQ-9] and the Pittsburgh Sleep Quality Index [PSQI], respectively.

RESULTS

A total of 544 consecutive adult IBD patients were included [50% women, mean age 44 years, 61% Crohn's disease]. The prevalence of fatigue was 41% (95% confidence interval [CI] = 37-45%). The variables associated with an increased risk of fatigue were: anxiety [OR = 2.5, 95% CI = 1.6-3.7], depression [OR = 2.4, 95% CI = 1.4-3.8], presence of extraintestinal manifestations [EIMs] [OR = 1.7, 95% CI = 1.1-2.6], and treatment with systemic steroids [OR = 2.8, 95% CI = 1.4-5.7]. The presence of EIMs [regression coefficient, RC = 8.2, 95% CI = 2.3-14.2], anxiety [RC = 25.8, 95% CI = 20.0-31.5], depression [RC = 30.6, 95% CI = 24.3-37.0], and sleep disturbances [RC = 15.0, 95% CI = 9.3-20.8] were associated with severity of fatigue. Patients with fatigue had a significantly decreased IBDQ-9 score [p < 0.001].

CONCLUSIONS

The prevalence of fatigue in IBD patients is remarkably high and has a negative impact on QoL. Therapy with systemic steroids is associated with an increased risk of fatigue. The severity of fatigue is associated with anxiety, depression, sleep disorders, and the presence of EIMs. Fatigue was not associated with anaemia, disease activity or anti-TNF therapy.

Hepatic steatosis and patients with inflammatory bowel disease: when transient elastography makes the difference

BACKGROUND

Recent studies suggest an increased prevalence of hepatic steatosis (HS) in patients with inflammatory bowel disease (IBD). Features such as chronic inflammation, previous surgeries, drug-induced hepatotoxicity, malnutrition, and intestinal dysbiosis seem to be involved in its pathogenesis.

AIMS

The aim of this study was to assess the frequency of HS in patients with IBD quantified by controlled attenuation parameter (CAP) and by clinical-analytical scores: Hepatic Steatosis Index (HSI) and Fatty Liver Index (FLI). The secondary aim was to investigate risk factors associated with HS in patients with IBD.

PATIENTS AND METHODS

A cross-sectional study was carried out including consecutive outpatients observed in our department between January and March 2017. HS was defined as HSI of at least 36 or FLI of at least 60 or CAP of greater than 248.

RESULTS

A total of 161 patients were included, with a mean age of 40.6±12.8 years. There were 86 (53.4%) female patients. Overall, 62.7% had Crohn's disease and 37.1% had ulcerative colitis. Moreover, 73 (45.3%) patients had CAP greater than 248, 27 (16.8%) had FLI greater than 60, and 46 (28.6%) had HSI greater than 36.We found that patients with CAP of greater than 248 were more frequently obese (28.8 vs. 0.0% P<0.001), male (57.5 vs. 37.5% P=0.011), and presented more frequently with metabolic syndrome (23.9 vs. 4.5% P <0.001). With regard to IBD factors, patients with HS had a higher frequency of previous surgeries (31.5 vs. 12.5% P=0.003). In multivariate analysis, only male sex [odds ratio: 5.7 (95% confidence interval: 2.0-15.9); P=0.001] and previous surgeries [odds ratio: 5.9 (95% confidence interval: 1.5-22.9); P=0.011] were independent risk factors of HS.

CONCLUSION

In our cohort, the frequency of HS varied between 16.8 and 45.3% defined by noninvasive methods. We found that male sex and previous history of surgery were the independent risk factors of HS when quantified by transient elastography.

Systematic review of nutrition screening and assessment in inflammatory bowel disease

BACKGROUND

Malnutrition is prevalent in inflammatory bowel disease (IBD). Multiple nutrition screening (NST) and assessment tools (NAT) have been developed for general populations, but the evidence in patients with IBD remains unclear.

AIM

To systematically review the prevalence of abnormalities on NSTs and NATs, whether NSTs are associated with NATs, and whether they predict clinical outcomes in patients with IBD.

METHODS

Comprehensive searches performed in Medline, CINAHL Plus and PubMed. Included: English language studies correlating NSTs with NATs or NSTs/NATs with clinical outcomes in IBD. Excluded: Review articles/case studies; use of body mass index/laboratory values as sole NST/NAT; age < 16.

RESULTS

Of 16 studies and 1618 patients were included, 72% Crohn’s disease and 28% ulcerative colitis. Four NSTs (the Malnutrition Universal Screening Tool, Malnutrition Inflammation Risk Tool (MIRT), Saskatchewan Inflammatory Bowel Disease Nutrition Risk Tool (SaskIBD-NRT) and Nutrition Risk Screening 2002 (NRS-2002) were significantly associated with nutritional assessment measures of sarcopenia and the Subjective Global Assessment (SGA). Three NSTs (MIRT, NRS-2002 and Nutritional Risk Index) were associated with clinical outcomes including hospitalizations, need for surgery, disease flares, and length of stay (LOS). Sarcopenia was the most commonly evaluated NAT associated with outcomes including the need for surgery and post-operative complications. The SGA was not associated with clinical outcomes aside from LOS.

CONCLUSION

There is limited evidence correlating NSTs, NATs and clinical outcomes in IBD. Although studies support the association of NSTs/NATs with relevant outcomes, the heterogeneity calls for further studies before an optimal tool can be recommended. The NRS-2002, measures of sarcopenia and developments of novel NSTs/NATs, such as the MIRT, represent key, clinically-relevant areas for future exploration.

Body mass index: Implications on disease severity and postoperative complications in patients with Crohn's disease undergoing abdominal surgery

BACKGROUND

Obesity is increasing in prevalence among patients with Crohn's disease, but how body mass index affects disease severity and postoperative outcomes remains unknown.

METHODS

A retrospective review of ileocolic resections for Crohn's disease performed at a single institution between January 2007 and December 2017 was conducted. On the day of surgery, patients were grouped by body mass index into underweight, normal weight, overweight, and obese categories. Intergroup comparisons and trend tests were performed on disease characteristics and postoperative outcomes. A multivariable model for superficial surgical site infection was constructed.

RESULTS

A total of 758 patients were identified; 80 (11%) patients were underweight, 372 (49%) were normal weight, 178 (23%) were overweight, and 128 (17%) were obese. Both fistulizing Crohn's phenotype and preoperative immunosuppression occurred less frequently in obese patients compared with other body mass index groups (both P < 0.01). Conversion to open surgery and superficial surgical site infection were increased in obese patients, and obesity was an independent risk factor for superficial surgical site infection on multivariable analysis (odds ratio 3.0, 95% confidence interval: 1.6-5.6).

CONCLUSION

Although obese patients had less severe Crohn's disease at the time of surgery, they experienced increased postoperative infectious complications. Preoperative weight loss and consideration of alternative wound closure methods may reduce these complications.

The Role of Adipose Tissue in the Pathogenesis and Therapeutic Outcomes of Inflammatory Bowel Disease

Though historically regarded as an inert energy store, adipose tissue is a complex endocrine organ, which is increasingly implicated in the pathogenesis of inflammatory bowel disease (IBD). Accumulating evidence points to visceral adipose tissue and specifically to its mesenteric component, or “creeping fat” as impacting on the disease course through its immunomodulatory properties. On the one hand, mesenteric fat acts as a physical barrier to inflammation and is involved in controlling host immune response to translocation of gut bacteria. On the other hand, however, there exists a strong link between visceral fat and complicated course of the disease with unfavorable therapeutic outcomes. Furthermore, “creeping fat” appears to play different roles in different IBD phenotypes, with the greatest pathogenetic contribution probably to an ileal form of Crohn’s disease. In this review, we summarize and discuss the existing literature on the subject and identify high-priority areas for future research. It may be that a better understanding of the role of mesenteric fat in IBD will determine new therapeutic targets and translate into improved clinical outcomes.

Impact of Obesity on Disease Activity and Patient-Reported Outcomes Measurement Information System (PROMIS) in Inflammatory Bowel Diseases

INTRODUCTION

We conducted a cohort study on the impact of obesity on disease activity and Patient-Reported Outcomes Measurement Information System (PROMIS) measures in the inflammatory bowel disease (IBD) Partners cohort.

METHODS

We performed a cross-sectional and longitudinal study within IBD Partners, an internet-based cohort of >15,000 patients living with Crohn's disease (CD) and ulcerative colitis (UC). We included adult patients with IBD, with recorded body mass index (BMI), with at least 6 months of follow-up, excluding patients with BMI < 18.5 kg/m. We evaluated the independent effect of World Health Organization classes of obesity on risk of clinical relapse or persistent disease activity (using validated disease activity indexes) and PROMIS measures, using multivariate logistic regression and linear regression, respectively.

RESULTS

We included 7,296 patients with IBD (4,748 patients with CD, 19.5% obese; 2,548 patients with UC with intact colon, 20.3% obese). Obesity was independently, and in a dose-dependent fashion, associated with an increased risk of persistent disease activity or relapse in both patients with CD (class II or III obesity vs normal BMI: adjusted odds ratio, 1.86; 95% confidence interval, 1.30-2.68) and UC (adjusted odds ratio, 2.97; 95% confidence interval, 1.75-5.17). Obesity was also independently associated with higher anxiety, depression, fatigue, pain, and inferior social function scores in patients with CD and UC at baseline and with worsening depression, fatigue, pain, and social function in patients with CD on longitudinal assessment.

DISCUSSION

Obesity at baseline is independently associated with worsening disease activity and PROMIS measures in patients with IBD.

Nutritional status as a predictor of hospitalization in inflammatory bowel disease: A review

BACKGROUND

Inflammatory bowel disease (IBD) presents an inflammatory picture that in the long run can lead to complications and consequently more hospitalizations compared to other diseases.

AIM

To evaluate the influence of nutritional status on the occurrence of IBD-related hospitalization.

METHODS

This integrative review was conducted in the online databases PubMed and MEDLINE, using the terms “obesity” and “malnutrition” accompanied by “hospitalization”, each combined with “Crohn’s disease” or “ulcerative colitis”. Only studies conducted with humans, adults, and published in English or Spanish were selected, and those that were not directly associated with nutritional status and hospitalization were excluded from this review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guide was used as the basis for selection of studies.

RESULTS

Of the 80 studies identified, only five met the proposal of this review. None evaluated the association of good nutritional status with the risk of hospitalization. Malnutrition had a strong correlation with the risk of hospitalization related to IBD, and there was disagreement among three studies regarding the association of obesity and hospitalization rates.

CONCLUSION

Few studies have evaluated nutritional status as a predictor of IBD-related hospitalization. The presence of malnutrition appears to be associated with hospitalization in these patients, but further studies are needed to elucidate the issue.

Dietary intake of fish, n-3 polyunsaturated fatty acids, and risk of inflammatory bowel disease: a systematic review and meta-analysis of observational studies

PURPOSE

Fish consumption and dietary intake of n-3 polyunsaturated acids (PUFAs) may be associated with inflammatory bowel disease (IBD). We aimed to conduct a systematic review and summarize published articles on the association between fish consumption and dietary intake of n-3 PUFAs with the risk of IBD.

METHODS

PubMed, Scopus, and Web of Science databases were used to conduct a comprehensive search and identify eligible literature published prior to January 2019. Fixed-effects model or random-effects models (DerSimonian-Laird method) were applied to pool the effect sizes. Cochrane Q test was used to trace the potential source of heterogeneity across studies.

RESULTS

12 studies (5 prospective and 7 case-control) were included in the systematic review, which ten of them were eligible for inclusion in the meta-analysis. Studies were included a total sample size of 282610 participants which 2002 of them were cases of IBD [1061 Crohn's disease (CD) and 937 ulcerative colitis (UC)]. A negative association was found between fish consumption and the incidence of CD (pooled effect size: 0.54, 95%CI: 0.31-0.96, P = 0.03). There was no relationship between total dietary n-3 PUFAs intake and IBD (pooled effect size: 1.17, 95%CI: 0.80-1.72, P = 0.41). A significant inverse association was observed between dietary long-chain n-3 PUFAs and the risk of UC (pooled effect size: 0.75, 95%CI: 0.57-0.98, P = 0.03). Moreover, no association was found between α-Linolenic acid (ALA) and IBD (pooled effect size: 1.17, 95%CI: 0.63-2.17, P = 0.62).

CONCLUSIONS

Findings showed a negative association between fish consumption and the risk of CD. Moreover, there was a significant inverse association between dietary long-chain n-3 PUFAs and the risk of UC.

Bariatric Surgery Is Acceptably Safe in Obese Inflammatory Bowel Disease Patients: Analysis of the Nationwide Inpatient Sample

BACKGROUND

The prevalence of obesity in patients with inflammatory bowel disease (IBD) has increased over the past decades. Data to support the safety of bariatric surgery (BAR) in IBD remain scarce. Our aim was to evaluate the safety and early postoperative complications of BAR in IBD patients.

METHODS

We used the Nationwide Inpatient Sample (NIS) 2011, 2012, and 2013 to perform a cohort study. The study group was all hospitalized patients between ages 18-90 years who underwent BAR with a discharge diagnosis of IBD as per the Ninth International Classification of Diseases codes (ICD-9). Adults who underwent BAR without ICD-9 codes of IBD were identified as the comparison group. Complications were compared using multivariate logistic regression analysis.

RESULTS

We identified 314,864 adult patients who underwent BAR between 2011 and 2013. Mean age was 45.5 ± 0.11 years, and 79% were females. Seven hundred and ninety patients had underlying IBD; 459 had Crohn's disease and 331 had ulcerative colitis. The remaining patients formed the comparison group. Mean length of hospital stay (LOS) was longer in the IBD group by 1 day (p = 0.01). The IBD group had a significantly higher risk of perioperative small bowel obstruction (SBO) (adjusted odds ratio, 4.0; 95%, CI; 2.2-7.4). Other technical and systemic complications were similar between the two groups, with no mortality reported in the IBD group.

CONCLUSIONS

BAR in IBD patients has an acceptable safety profile, with immeditae risk limited to perioperative SBO and an apparently low risk of mortality or other major immediate postoperative complications.

Treatment Failure of TNF-α Inhibitors in Obese Patients With Inflammatory Bowel Disease-A Cohort Study

BACKGROUND

In treatment of inflammatory bowel disease (IBD) with anti-tumor necrosis factor-α agents (anti-TNF-α), obesity has been suspected as a cause of accelerated loss of response (LOR). We sought to determine whether overweight IBD patients have accelerated LOR when treated with anti-TNF-α agents, compared with normal weight IBD patients.

METHODS

We identified a cohort of adult IBD patients treated with anti-TNF-α agents at a Danish university hospital. Patients were grouped according to body mass index (BMI), and our main outcome was time to LOR. We performed survival analyses on LOR and calculated hazard ratios (HRs) with the normal weight group as the reference, while adjusting for confounders.

RESULTS

Of 210 eligible patients, 92 (44%) experienced LOR. One hundred eighty patients were treated with infliximab and 30 with adalimumab, 114 (54%) were normal weight, 51 (24%) were overweight, and 45 (21%) were obese. Regression analysis produced the following adjusted HRs, compared with the normal weight group: overweight 0.89 (95% confidence interval [CI], 0.51-1.56) and obese 1.31 (95% CI, 0.76-2.24), thus showing no statistically significant association between BMI and time to LOR. Subgroup analyses produced similar results, except for obese ulcerative colitis patients having an adjusted HR of 2.42 (95% CI, 1.03-5.70).

CONCLUSIONS

In IBD patients treated with anti-TNF-α agents, we found no overall association between increased BMI and accelerated LOR.

Obesity Does Not Affect Early Outcomes in Children With Newly Diagnosed Crohn Disease

The impact of obesity on pediatric Crohn disease (CD) remains poorly characterized. We aimed to evaluate disease-related outcomes in overweight and obese children with CD, compared to normal-weight children. We conducted a retrospective cohort study of children with newly diagnosed CD enrolled in the ImproveCareNow Network. Patients were stratified into normal weight, overweight, and obese groups using standardized weight percentiles. A total of 898 children were included, with 87 children (10%) being overweight and 43 children (5%) being obese; baseline characteristics were similar between groups. There was no significant difference in number of visits in remission during 1 year between normal weight, overweight, and obese children. At 1-year follow-up, nutritional status, growth status, or medication use also did not differ between groups. Hence, obesity does not appear to adversely affect CD outcomes in children with newly diagnosed CD in the first year after diagnosis.

Review article: the relationship between obesity, bariatric surgery, and inflammatory bowel disease

BACKGROUND

The convoluted relationship between obesity, bariatric surgery and inflammatory bowel disease (IBD) is of increasing interest.

AIM

To analyse evidence regarding the role of bariatric surgery in the development of de novo IBD and its impact on clinical outcomes and safety in patients with established IBD.

METHODS

A PubMed/Medline search was performed to identify studies reporting the development of IBD after bariatric surgery and the outcomes of IBD patients after bariatric surgery.

RESULTS

Eighty patients were reported to have developed de novo IBD after bariatric surgery (21% ulcerative colitis [UC], 75% Crohn's disease [CD]), mostly females. Roux-en-Y gastric bypass was the most frequent bariatric technique (80%). Symptoms related to IBD occurred within 1 month and 16 years after surgery. Regarding patients with known IBD undergoing bariatric surgery, 60 patients (35 CD, 24 UC, and 1 unclassified colitis) have been reported. Sleeve gastrectomy was the most frequent bariatric procedure, particularly in CD patients. Acute flares after surgery were observed in only four UC patients. In addition, two retrospective population-based studies described perioperative outcomes of bariatric surgery on IBD patients, demonstrating only a significant increase in small bowel obstruction in these patients.

CONCLUSIONS

Bariatric surgery in carefully selected patients with established IBD is technically feasible and probably safe. Development of de novo IBD should be taken into account in individuals with previous bariatric surgery who develop diarrhoea, anaemia or excessive weight loss.

Impact of Obesity on Short- and Intermediate-Term Outcomes in Inflammatory Bowel Diseases: Pooled Analysis of Placebo Arms of Infliximab Clinical Trials

Background and aims

To assess whether obesity may affect natural history of inflammatory bowel diseases (IBD), we conducted an individual participant data (IPD) pooled analysis of placebo arms, using data from clinical trials of infliximab in IBD and using the Yale Open Data Access (YODA) Project.

Methods

We obtained IPD from 4 placebo-controlled trials of infliximab in adults with IBD (ACCENT-I and ACCENT-II; ACT-1 and ACT-2). Patients were categorized into quartiles based on body mass index (BMI) or weight at time of trial entry. Primary outcome was clinical remission (Crohn's disease activity index [CDAI]<150, Mayo Clinic Score <3); secondary outcomes were clinical response and mucosal healing. Using multivariable logistic regression analysis, we compared association between quartiles of BMI (or weight) and achieving remission, after adjusting for sex, smoking, disease activity, and concomitant prednisone or immunomodulators.

Results

We included 575 placebo-treated patients (mean age 38 years, 51.6% males, 16% obese). Obesity was not associated with odds of achieving clinical remission (Q4 vs Q1: adjusted OR, 1.36; 95% CI, 0.65-2.89; P-value for trend = 0.57), clinical response (Q4 vs Q1: adjusted OR, 1.31; 95% CI, 0.61-2.81; P = 0.45), or mucosal healing remission (Q4 vs Q1: adjusted OR, 0.55; 95% CI, 0.12-2.34; P = 0.31). These results were consistent across strata based on disease type (CD and ulcerative colitis) and trial design (induction and maintenance therapy).

Conclusions

Based on IPD pooled analysis of placebo arms, obesity does not significantly impact short- and intermediate-term clinical outcomes in patients with IBD. The impact of obesity on long-term patient-important outcomes like surgery and hospitalization merits evaluation.

Obesity in Inflammatory Bowel Disease: Gains in Adiposity despite High Prevalence of Myopenia and Osteopenia

BACKGROUND

Rising rates of obesity have been reported in patients with inflammatory bowel disease (IBD); however, prospective data is lacking. The aim of this study is to prospectively evaluate body composition in adults with IBD over 24 months.

METHODS

Whole body dual energy X-ray absorptiometry (DXA) data was performed at 0 months, 12 months, and 24 months. Bone mineral density (BMD), fat mass index (FMI (kg)/height (m²)), appendicular skeletal muscle index (ASMI (kg)/height (m²)), visceral adipose tissue and the visceral adipose height index (VHI, VAT area (cm³)/height (m²)), and clinical and anthropometric assessments were performed at each time point. Multivariable linear mixed effects regression analyses were performed.

RESULTS

Initially, 154 participants were assessed at baseline (70% Crohn's disease, 55% male, median age 31 years), of whom 129 underwent repeated DXA at 12 months, and 110 underwent repeated DXA at 24 months. Amongst those undergoing repeated DXA, their body mass index (BMI) significantly increased over time, such that by 24 months, 62% of patients were overweight or obese (annual change BMI β = 0.43, 95%CI = [0.18, 0.67], p = 0.0006). Gains in BMI related to increases in both FMI and VHI (β = 0.33, 95%CI = [0.14, 0.53], p = 0.0007; β = 0.08, 95%CI = [0.02, 0.13], p = 0.001; respectively), whereas ASMI decreased (β = -0.07, 95%CI = [-0.12, -0.01], p = 0.01) with a concordant rise in rates of myopenia (OR = 3.1 95%CI = [1.2, 7.7]; p = 0.01). Rates of osteopenia and osteoporosis were high (37%), but remained unchanged over time (p = 0.23).

CONCLUSION

Increasing rates of obesity in patients with IBD coincide with decreases in lean muscle mass over time, while high rates of osteopenia remain stable. These previously undocumented issues warrant attention in routine care to prevent avoidable morbidity.

An automated identification and analysis of ontological terms in gastrointestinal diseases and nutrition-related literature provides useful insights

With an unprecedented growth in the biomedical literature, keeping up to date with the new developments presents an immense challenge. Publications are often studied in isolation of the established literature, with interpretation being subjective and often introducing human bias. With ontology-driven annotation of biomedical data gaining popularity in recent years and online databases offering metatags with rich textual information, it is now possible to automatically text-mine ontological terms and complement the laborious task of manual management, interpretation, and analysis of the accumulated literature with downstream statistical analysis. In this paper, we have formulated an automated workflow through which we have identified ontological information, including nutrition-related terms in PubMed abstracts (from 1991 to 2016) for two main types of Inflammatory Bowel Diseases: Crohn’s Disease and Ulcerative Colitis; and two other gastrointestinal (GI) diseases, namely, Coeliac Disease and Irritable Bowel Syndrome. Our analysis reveals unique clustering patterns as well as spatial and temporal trends inherent to the considered GI diseases in terms of literature that has been accumulated so far. Although automated interpretation cannot replace human judgement, the developed workflow shows promising results and can be a useful tool in systematic literature reviews. The workflow is available at https://github.com/KociOrges/pytag.

High and low body mass index may predict severe disease course in children with inflammatory bowel disease

OBJECTIVES

Inflammatory bowel disease (IBD) has been historically associated with underweight and malnutrition. The impact of both underweight and obesity on the clinical course of IBD in adults is controversial. This study described the association between body mass index (BMI) at diagnosis to disease course in children with IBD.

METHODS

We reviewed the medical records of children with IBD from the database of the 'Dana-Dwek' Children's Hospital between 2010 and 2016. Demographic and anthropometric data were collected as were disease characteristics, course and therapy. Patients were categorized in quartiles according to BMI percentiles at diagnosis (Q1-Q4).

RESULTS

Of 100 children who were identified, 62 had Crohn's disease (CD) and 38 had ulcerative colitis (UC). The median age (interquartile range, IQR) at diagnosis was 13.7 (range 11.9-15.2) years. The median (IQR) follow-up was 2.1 (1.2-3.8) years. At diagnosis, 46 children (46%) were in Q1, 20 (20%) in Q2, 19 (19%) in Q3 and 15 (15%) in Q4. Prolonged time to diagnosis was associated with BMI in Q1 and Q4, as well as high disease activity at diagnosis (p < .001). In a multivariate analysis, BMI in the lower and upper quartiles was associated with disease exacerbation (HR 3.212 and 4.651, respectively, p = .016) and anti-tumor necrosis factor (TNF) therapy (HR 4.489 and 3.972, respectively, p = .021).

CONCLUSIONS

BMI in the lower and upper quartiles was associated with more severe disease course in children with IBD. BMI may serve as a simple and highly accessible predictor of pediatric IBD course and prognosis.

Obesity and Response to Infliximab in Patients with Inflammatory Bowel Diseases: Pooled Analysis of Individual Participant Data from Clinical Trials

OBJECTIVES

To assess whether obesity may affect response to infliximab, we conducted an individual participant data pooled analysis using data from clinical trials of infliximab in inflammatory bowel diseases (IBD), using the Yale Open Data Access (YODA) Project.

METHODS

We analyzed individual participant data from four clinical trials of infliximab in adults with IBD (ACCENT-I, SONIC, ACT-1, and -2). Patients were categorized as obese (body mass index [BMI] ≥ 30 kg/m²) vs. non-obese, and by quartiles based on BMI or weight at time of trial entry. Primary outcome was clinical remission (Crohn's disease activity index [CDAI] < 150 or pediatric CDAI <10, Mayo Clinic Score <3); secondary outcomes were clinical response and mucosal healing. Multivariable logistic regression analysis was performed, after adjusting for sex, smoking, disease activity, and concomitant prednisone and/or immunomodulators.

RESULTS

We included 1205 infliximab-treated patients (mean age 37 years, 51.6% males, 14% obese). Obesity was not associated with odds of achieving clinical remission (obese vs. non-obese: adjusted OR, 0.93 [95% CI, 0.47-1.46]; Q4 vs. Q1: aOR, 0.94 [0.61-1.47], p-value for trend = 0.97), clinical response (Q4 vs. Q1: aOR, 0.84 [0.52-1.35], p = 0.45) or mucosal healing (Q4 vs. Q1: aOR, 1.13 [0.55-2.34], p = 0.95). These results were consistent across strata based on disease type (Crohn's disease and ulcerative colitis) and trial design (induction and maintenance therapy).

CONCLUSIONS

Based on individual participant data pooled analysis, obesity is not associated with inferior response to infliximab in patients with IBD. Future studies examining the association between obesity and fixed-dose therapies are warranted.

High body mass index is associated with increased risk of treatment failure and surgery in biologic-treated patients with ulcerative colitis

BACKGROUND

Though pharmacokinetic studies suggest accelerated biologic drug clearance with increasing body weight, evidence of obesity's impact on clinical outcomes in biologic-treated patients with ulcerative colitis (UC) is inconsistent.

AIM

To evaluate the impact of obesity on real world response to biological therapy in patients with UC.

METHODS

In a single-centre retrospective cohort study between 2011-2016 of biologic-treated patients with UC, we evaluated treatment response by baseline body mass index (BMI). Primary outcome was treatment failure (composite outcome of IBD-related surgery/hospitalisation or treatment modification including dose escalation, treatment discontinuation or addition of corticosteroids); secondary outcomes were risk of IBD-related surgery/hospitalisation and endoscopic remission. We conducted multivariate Cox proportional hazard analyses to evaluate the independent impact of BMI on clinical outcomes. Stratified analysis by weight-based regimens (infliximab) or fixed-dose regimens (adalimumab, golimumab, vedolizumab, certolizumab pegol) was performed.

RESULTS

We included 160 biologic-treated UC patients (50% males, 55% on infliximab) with median (IQR) age 36 y (26-52) and BMI 24.3 kg/m² (21.4-28.7). On multivariate analysis, each 1 kg/m² increase in BMI was associated with 4% increase in the risk of treatment failure (adjusted hazard ratio [aHR], 1.04 [95% CI, 1.00-1.08]) and 8% increase in the risk of surgery/hospitalisation (aHR, 1.08 [1.02-1.14]). The effect on treatment failure was seen in patients on weight-based dosing regimens or fixed-dose therapies.

CONCLUSION

BMI is independently associated with increased risk of treatment failure in biologic-treated patients with UC, independent of dosing regimen.

Patients with inflammatory bowel disease have higher abdominal adiposity and less skeletal mass than healthy controls

Background

Abdominal fat type and distribution have been associated with complicated Crohn’s disease and adverse postoperative outcomes. Few studies have assessed the abdominal distribution of fat and lean stores in patients with inflammatory bowel disease (IBD) and compared this with healthy controls. This retrospective study aimed to compare the abdominal body composition in IBD patients who failed medical treatment and who underwent computed tomography (CT) imaging prior to gastrointestinal surgery with healthy controls. Associations between preoperative abdominal body composition and postoperative outcomes within a year of surgery were explored.

Methods

Abdominal body composition was evaluated in 22 presurgical patients with medically refractory IBD (18 with Crohn’s disease) and 22 healthy controls, using routinely acquired CT. Total fat, subcutaneous fat, visceral fat, and skeletal muscle cross-sectional area were measured.

Results

An independent disease effect was observed, explaining a fat deposition excess of 38 cm² and a skeletal muscle deficit of 15 cm² in IBD. Abdominal skeletal muscle correlated with visceral fat for the control (rho=0.51, P=0.015), but not for the IBD group (rho=-0.13, P=0.553). A positive correlation observed between subcutaneous fat with skeletal muscle in the controls (rho=0.47, P=0.026) was inverted in the IBD group (rho=-0.43, P=0.045). Preoperative abdominal body composition was not predictive of postoperative outcomes.

Conclusions

A higher degree of abdominal adiposity, a lower skeletal mass and a larger body size for the same anthropometry can be expected in IBD patients. Preoperative abdominal body composition is not associated with surgical outcomes.

De-novo Inflammatory Bowel Disease After Bariatric Surgery: A Large Case Series

BACKGROUND

Case reports of inflammatory bowel diseases [IBD] have been reported in patients with a history of bariatric surgery. Our aim was to characterize patients who were diagnosed with IBD after having undergone bariatric surgery.

METHODS

Electronic medical records were reviewed at two institutions to identify patients who developed de-novo Crohn's disease or ulcerative colitis [UC] after bariatric surgery. Data on demographics, type of bariatric surgical procedure, IBD subtype, phenotype and medication usage were obtained. The incidence rate of de-novo IBD after bariatric surgery [per 100000 person-years] and standardized incidence ratio [SIR] were estimated from a prospective bariatric surgery database.

RESULTS

A total of 44 patients with de-novo IBD after bariatric surgery were identified [31 Crohn's disease, 12 UC, one IBD unclassified]. Most patients were female [88.6%], with median age at IBD onset of 44 years [IQR, 37-52] and median time to IBD diagnosis after bariatric surgery of 7 years [IQR, 3-10]. Sixty-eight per cent underwent Roux-en-Y gastric bypass. In the prospective database, the incidence of IBD in patients who underwent bariatric surgery was 26.7 per 100000 person-years [4.5 for UC and 22.3 for Crohn's disease]. The age-adjusted SIR ranged from 3.56 in the 40-49 year age group to 4.73 in the 30-39 year age group.

CONCLUSION

We described a case series of patients developing de-novo IBD after bariatric surgery. There appears to be a numerically higher incidence of Crohn's disease in this population. Confirmation of causality is required in larger patient cohorts.

Higher Morbidity of Monogenic Inflammatory Bowel Disease Compared to the Adolescent Onset Inflammatory Bowel Disease

PURPOSE

Monogenic inflammatory bowel disease (IBD) patients do not respond to conventional therapy and are associated with a higher morbidity. We summarized the clinical characteristics of monogenic IBD patients and compared their clinical outcomes to that of non-monogenic IBD patients.

METHODS

We performed a retrospective cohort study of all children <18 years old who were diagnosed with IBD between 2005 and 2016. A total of 230 children were enrolled. Monogenic IBD was defined as a presentation age less than 6 years old with confirmation of a genetic disorder. We subdivided the groups into monogenic IBD (n=18), non-monogenic very early-onset IBD (defined as patients with a presentation age <6 years old without a confirmed genetic disorder, n=12), non-monogenic IBD (defined as all patients under 18 years old excluding monogenic IBD, n=212), and severe IBD (defined as patients treated with an anti-tumor necrosis factor excluding monogenic IBD, n=92). We compared demographic data, initial pediatric Crohn disease activity index/pediatric ulcerative colitis activity index (PCDAI/PUCAI) score, frequency of hospitalizations, surgical experiences, and height and weight under 3rd percentile among the patients enrolled.

RESULTS

The initial PCDAI/PUCAI score (p<0.05), incidence of surgery per year (p<0.05), and hospitalization per year (p<0.05) were higher in the monogenic IBD group than in the other IBD groups. Additionally, the proportion of children whose weight and height were less than the 3rd percentile (p<0.05 and p<0.05, respectively) was also higher in the monogenic IBD group.

CONCLUSION

Monogenic IBD showed more severe clinical manifestations than the other groups.

Obese Patients Undergoing Ileal Pouch-Anal Anastomosis: Short-and Long-term Surgical Outcomes

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for patients with chronic ulcerative colitis. Little is known about the impact of obesity on operative characteristics, short-term postoperative complications and long-term functional outcomes after IPAA.

METHODS

A retrospective review of all patients undergoing IPAA for chronic ulcerative colitis at a single tertiary referral center between January 2002 and August 2013 was performed. Thirty-day postoperative complications and long-term functional outcomes were analyzed according to body mass index.

RESULTS

Nine hundred nine IPAAs (154 obese [body mass index ≥ 30] and 755 not obese [body mass index < 30]) were performed during the study period. For 2-stage IPAA, obese patients were less likely to undergo laparoscopic IPAA (P < 0.0001), had greater estimated blood loss (P = 0.005), and longer operative times (P = 0.02). For 3-stage IPAA, obese patients were less likely to undergo a laparoscopic procedure (P = 0.03), had greater estimated blood loss (P < 0.0001), and longer operative times (P = 0.0002). Postoperatively, obese patients had a longer length of stay after a 2-stage procedure (P = 0.009), an increased rate of superficial surgical site infections (P = 0.003), and an increased rate of urinary tract infections (P = 0.03). Of the 61% (n = 546) of patients with IPAA with long-term (median 5.0 years) follow-up, there were no significant differences in functional outcomes including incontinence, frequency of bowel movements, pad usage, and pouchitis between the groups.

CONCLUSIONS

Obesity impacts intraoperative complexity and 30-day postoperative outcomes. Long-term functional outcomes are not affected. These findings underscore the need to counsel patients on preoperative weight loss before undergoing elective IPAA.

Using molecular functional networks to manifest connections between obesity and obesity-related diseases

Obesity is a primary risk factor for many diseases such as certain cancers. In this study, we have developed three algorithms including a random-walk based method OBNet, a shortest-path based method OBsp and a direct-overlap method OBoverlap, to reveal obesity-disease connections at protein-interaction subnetworks corresponding to thousands of biological functions and pathways. Through literature mining, we also curated an obesity-associated disease list, by which we compared the methods. As a result, OBNet outperforms other two methods. OBNet can predict whether a disease is obesity-related based on its associated genes. Meanwhile, OBNet identifies extensive connections between obesity genes and genes associated with a few diseases at various functional modules and pathways. Using breast cancer and Type 2 diabetes as two examples, OBNet identifies meaningful genes that may play key roles in connecting obesity and the two diseases. For example, TGFB1 and VEGFA are inferred to be the top two key genes mediating obesity-breast cancer connection in modules associated with brain development. Finally, the top modules identified by OBNet in breast cancer significantly overlap with modules identified from TCGA breast cancer gene expression study, revealing the power of OBNet in identifying biological processes involved in the disease.

Significance of non-alcoholic fatty liver disease in Crohn's disease: A retrospective cohort study

AIM

The prevalence of non-alcoholic fatty liver disease (NAFLD) and Crohn's disease (CD) is increasing. The aim of our study was to evaluate the prevalence of NAFLD in patients with CD, as well as to investigate the effect of NAFLD on the disease course of CD.

METHODS

Our retrospective cohort study included 303 patients who underwent abdominal ultrasound for CD and NAFLD diagnosis at our center between November 2008 and October 2014. Serum C-reactive protein (CRP) level and rate of remission, defined by a score <150 on the Crohn's Disease Activity Index, were compared between CD patients with and without NAFLD, using multivariate logistic regression. The effect of NAFLD on the surgery-free interval was evaluated using Cox proportional hazards models, adjusted for potential demographic confounders.

RESULTS

Non-alcoholic fatty liver disease was diagnosed in 66 (21.8%) patients in our study cohort and was associated with lower CRP levels (0.58 vs. 2.18 mg/dL, P < 0.0001) and a higher rate of remission (75.9% vs. 53.7%, P = 0.0024). Non-alcoholic fatty liver disease was identified as an independent predictor of a negative CRP level (<0.3 mg/dL; odds ratio, 1.85; 95% confidence interval, 1.03-3.37) and higher rate of remission (odds ratio, 2.57; 95% confidence interval, 1.21-5.80). Non-alcoholic fatty liver disease was associated with longer surgery-free interval (log-rank test, P = 0.0035), with NAFLD identified as a positive predictor of surgery-free interval (P = 0.0014).

CONCLUSIONS

Non-alcoholic fatty liver disease may offer a protective effect in patients with CD and could be used as a prognostic marker in patients with CD.

Comparison of Infliximab and Adalimumab in Biologic-Naive Patients With Ulcerative Colitis: A Nationwide Danish Cohort Study

BACKGROUND & AIMS

This study compares the effectiveness and safety of infliximab and adalimumab in biologic-naive patients with ulcerative colitis (UC), in a nationwide register-based propensity score-matched cohort study.

METHODS

From 1719 adults with UC, between ages 15 and 75 years in Denmark treated with either infliximab or adalimumab as their first biologic agent, we compared rates of all-cause hospitalization, UC-related hospitalization, major abdominal surgery, and serious infections after a variable 2:1 propensity score matching, accounting for baseline clinical characteristics, disease severity, health care utilization, and use of UC-related medications.

RESULTS

As compared with infliximab-treated patients, adalimumab-treated patients had higher rate of all-cause hospitalization (hazard ratio [HR], 1.84; 95% CI, 1.18-2.85) and a trend toward higher rate of UC-related hospitalization (HR, 1.71; 95% CI, 0.95-3.07), particularly in a stratum of patients on concomitant immunomodulator therapy. However, risk of abdominal surgery (HR, 1.35; 95% CI, 0.62-2.94) was not different between the 2 treatment groups. Risk of serious infection requiring hospitalization was significantly higher in adalimumab-treated patients (HR, 5.11; 95% CI, 1.20-21.80).

CONCLUSIONS

In this nationwide propensity score matched-cohort study of biologic-naive adults with UC, use of adalimumab as first-line biologic over infliximab was associated with higher risk of hospitalization and serious infections, although risk of surgery was not different. In the absence of head-to-head trials, this evidence may assist patients, health care providers, purchasers, and policy makers to make informed decisions that may improve health care in UC.

Inadequate Gestational Weight Gain, the Hidden Link Between Maternal IBD and Adverse Pregnancy Outcomes: Results from the Norwegian Mother and Child Cohort Study

BACKGROUND

Patients with inflammatory bowel disease (IBD) are in general prone to weight loss. We explored the risk of inadequate gestational weight gain (GWG), and the impact of GWG on adverse pregnancy outcomes, among mothers with IBD in the Norwegian Mother and Child Cohort Study (MoBa).

METHODS

The MoBa with 95,200 mothers enrolled from 1999 to 2008, comprised 217 mothers with ulcerative colitis and 166 with Crohn's disease. Demographics were ascertained through a basic questionnaire before the first ultrasound visit and an IBD history and disease activity during pregnancy through a questionnaire mailed out in 2013. Inadequate GWG was based on the US Institute of Medicine recommendations. The associations between IBD and inadequate GWG or adverse pregnancy outcomes were explored, adjusted for diabetes, hypertension, smoking, maternal age, education, and disease activity.

RESULTS

Mothers with Crohn's disease (34.3%) and ulcerative colitis (26.7%) were more frequently exposed to inadequate GWG compared with non-IBD mothers (19.4%) (adjusted odds ratio [aOR] = 2.02, 95% confidence interval [CI], 1.42-2.86 and aOR = 1.46, 95% CI, 1.04-2.05, respectively). Mothers with IBD with inadequate GWG (exposed) had a 2-fold risk of small for gestational age infants compared with exposed non-IBD mothers (aOR = 1.93, 95% CI, 1.13-3.29). Exposed mothers with Crohn's disease and ulcerative colitis had a several-fold increased risk of small for gestational age compared with nonexposed IBD mothers (aOR = 4.5, 95% CI, 1.3-16.2, aOR = 5.5, 95% CI, 1.6-18.5). Disease activity was associated with reduced GWG (<13 kg compared with >17.5 kg) (aOR = 3.34, 95% CI, 1.33-8.38).

CONCLUSIONS

Inadequate GWG should be considered as a risk factor for adverse pregnancy outcomes or as a marker of disease activity.

Dietary and metabolomic determinants of relapse in ulcerative colitis patients: A pilot prospective cohort study

AIM

To identify demographic, clinical, metabolomic, and lifestyle related predictors of relapse in adult ulcerative colitis (UC) patients.

METHODS

In this prospective pilot study, UC patients in clinical remission were recruited and followed-up at 12 mo to assess a clinical relapse, or not. At baseline information on demographic and clinical parameters was collected. Serum and urine samples were collected for analysis of metabolomic assays using a combined direct infusion/liquid chromatography tandem mass spectrometry and nuclear magnetic resolution spectroscopy. Stool samples were also collected to measure fecal calprotectin (FCP). Dietary assessment was performed using a validated self-administered food frequency questionnaire.

RESULTS

Twenty patients were included (mean age: 42.7 ± 14.8 years, females: 55%). Seven patients (35%) experienced a clinical relapse during the follow-up period. While 6 patients (66.7%) with normal body weight developed a clinical relapse, 1 UC patient (9.1%) who was overweight/obese relapsed during the follow-up (P = 0.02). At baseline, poultry intake was significantly higher in patients who were still in remission during follow-up (0.9 oz vs 0.2 oz, P = 0.002). Five patients (71.4%) with FCP > 150 μg/g and 2 patients (15.4%) with normal FCP (≤ 150 μg/g) at baseline relapsed during the follow-up (P = 0.02). Interestingly, baseline urinary and serum metabolomic profiling of UC patients with or without clinical relapse within 12 mo showed a significant difference. The most important metabolites that were responsible for this discrimination were trans-aconitate, cystine and acetamide in urine, and 3-hydroxybutyrate, acetoacetate and acetone in serum.

CONCLUSION

A combination of baseline dietary intake, fecal calprotectin, and metabolomic factors are associated with risk of UC clinical relapse within 12 mo.

The Impact of Obesity on the Clinical Course of Inflammatory Bowel Disease: A Meta-Analysis

Background

Obesity has been linked with a pro-inflammatory state and the development of inflammatory diseases, including inflammatory bowel disease (IBD). However, there is some controversy regarding whether obesity is associated with an adverse clinical course in patients with IBD. The aim of this meta-analysis was to assess the association between obesity and clinical outcomes in IBD patients.

Material/Methods

Electronic databases (PubMed, Embase, Cochrane Library, and Web of Science) were systematically searched for studies investigating the association between obesity and clinical outcomes in patients with IBD. A meta-analysis was performed using Review Manager software.

Results

Among the 4,798 articles identified, seven met the inclusion criteria for our meta-analysis. The pooled data revealed that obese patients were significantly less likely to undergo IBD-related surgery, receive hormone therapy, and experience hospitalization compared with non-obese patients. However, no statistically significant difference was observed in perianal disease, anti-TNF use, and immunomodulator use between the two groups.

Conclusions

Our meta-analysis indicated that clinical outcomes were significantly different in obese versus non-obese patients with IBD. We found that obesity was associated with a less severe disease course of IBD. Future prospective studies are needed to confirm the relationship between obesity and the clinical course of IBD.

Gastrointestinal Complications of Obesity

Obesity usually is associated with morbidity related to diabetes mellitus and cardiovascular diseases. However, there are many gastrointestinal and hepatic diseases for which obesity is the direct cause (eg, nonalcoholic fatty liver disease) or is a significant risk factor, such as reflux esophagitis and gallstones. When obesity is a risk factor, it may interact with other mechanisms and result in earlier presentation or complicated diseases. There are increased odds ratios or relative risks of several gastrointestinal complications of obesity: gastroesophageal reflux disease, erosive esophagitis, Barrett's esophagus, esophageal adenocarcinoma, erosive gastritis, gastric cancer, diarrhea, colonic diverticular disease, polyps, cancer, liver disease including nonalcoholic fatty liver disease, cirrhosis, hepatocellular carcinoma, gallstones, acute pancreatitis, and pancreatic cancer. Gastroenterologists are uniquely poised to participate in the multidisciplinary management of obesity as physicians caring for people with obesity-related diseases, in addition to their expertise in nutrition and endoscopic interventions.

Obesity in IBD: epidemiology, pathogenesis, disease course and treatment outcomes

Incidence of IBD is rising in parallel with overweight and obesity. Contrary to conventional belief, about 15-40% of patients with IBD are obese, which might contribute to the development of IBD. Findings from cross-sectional and retrospective cohort studies are conflicting on the effect of obesity on natural history and course of IBD. Most studies are limited by small sample size, low event rates, non-validated assessment of disease activity and lack robust longitudinal follow-up and have incomplete adjustment for confounding factors. The effect of obesity on the efficacy of IBD-related therapy remains to be studied, though data from other autoimmune diseases suggests that obesity results in suboptimal response to therapy, potentially by promoting rapid clearance of biologic agents leading to low trough concentrations. These data provide a rationale for using weight loss interventions as adjunctive therapy in patients with IBD who are obese. Obesity also makes colorectal surgery technically challenging and might increase the risk of perioperative complications. In this Review, we highlight the existing literature on the epidemiology of obesity in IBD, discuss its plausible role in disease pathogenesis and effect on disease course and treatment response, and identify high-priority areas of future research.