Association of extraintestinal manifestations of inflammatory bowel disease in a province of western Hungary with disease phenotype: Results of a 25-year follow-up study

Inflammatory bowel disease and African Americans: a systematic review

BACKGROUND

Inflammatory bowel disease (IBD) is comprised of Crohn's disease (CD) and ulcerative colitis (UC). There are conflicting reports on whether African Americans have a more severe disease course, presentation, and more frequent extraintestinal manifestations (EIM). We examined the precise nature of this relationship by conducting a systematic review.

METHODS

Using predefined inclusion criteria we searched multiple healthcare databases and Grey literature. Eight reports met the inclusion criteria. Using the parameters as defined in the Montreal classification and the presence or absence of EIM, we compared IBD in African Americans and Caucasians.

RESULTS

Over 2000 IBD cases were pooled from 8 reports with African Americans comprising 17%. African Americans and Caucasians had similar distribution of types of IBD, with CD being more common than UC in both groups (CD 76% versus 68% and UC 24% versus 32%, respectively). With respect to CD, both groups presented with nonstricturing and nonpenetrating disease behavior (55% versus 41%) more frequently and had similar rates of ileocolonic disease location (42% versus 38%), and presence of perianal disease (26% versus 29%). In UC patients, proctitis was the most frequent initial presentation in both races. Joint complications were the most frequent EIM in both African Americans (52%) and Caucasians (60%).

CONCLUSIONS

This study dispels the commonly held views that African Americans with IBD generally have more colonic disease, more severe disease behavior, and more perianal disease than Caucasians. African Americans also have similar variety and frequency of EIMs as compared to Caucasians.

Common misconceptions in the diagnosis and management of anemia in inflammatory bowel disease

Anemia is the most common systemic complication of inflammatory bowel disease (IBD); so common that it is almost invariably not investigated and rarely treated. Several misconceptions are the reason for these clinical errors, and our goal will be to review them. The most common misconceptions are: anemia is uncommon in IBD; iron deficiency is also uncommon; just by treating the intestinal disease, anemia will be corrected; iron deficiency is the only cause for anemia in IBD; ferritin is an accurate parameter for the diagnosis of iron deficiency in IBD; the impact of anemia on the quality of life of IBD patients is limited; iron supplementation is rarely needed in IBD; high-dose oral iron solves the problem of iron malabsorption in IBD; intravenous (IV) iron is dangerous and of no proven benefit in IBD; IV iron is useful only for severe anemia; and erythropoietin has no role in the treatment of IBD anemia. These misconceptions are not evidence-based. On the contrary, there is enough evidence to support the following statements: (a) anemia is very common in IBD, (b) anemia should be investigated with care because many factors can be responsible, (c) treatment of anemia results in clear improvement in the objective parameters of well-being, especially in the quality of life, (d) IV iron is safe and effective in the treatment of iron deficiency anemia in IBD patients, and (e) erythropoietin is useful in a subset of patients with refractory anemia. Anemia diagnosis and treatment must not be neglected in IBD patients, and several misconceptions should be promptly abandoned.

Early onset of ulcerative colitis: long-term follow-up with special reference to colorectal cancer and primary sclerosing cholangitis

OBJECTIVES

Ulcerative colitis (UC) is associated with an increased risk of colorectal cancer (CRC) and primary sclerosing cholangitis (PSC). The onset of UC at a young age has been considered a specific risk factor for CRC. This study reports the outcome with respect to DNA aneuploidy, dysplasia, CRC, and PSC in a cohort of patients with early-onset UC from a defined catchment area who were followed up for 45 years.

PATIENTS AND METHODS

The study period was from 1961 through 2005. In all, 46 children and adolescents, ages 18 or younger from our catchment area, were affected with UC during this time. Data were collected from our colonoscopic surveillance program and other medical records in the same hospital.

RESULTS

The incidence rate of UC was 1.6 children or adolescents per 100,000 inhabitants per year. The onset of disease was at age 14 years (mean and median), and the observed duration of disease was 0 to 44 years. Five patients died, 3 of them of intercurrent disease. CRC developed in 1 patient, and no death caused by this disease was observed. PSC was diagnosed in 4 patients, in all of whom the onset of UC occurred before age 15.

CONCLUSIONS

The earlier reports of increased risk of CRC in patients with early-onset UC was not seen in this study. This could be due to a high frequency of surgery together with a well-functioning surveillance program with excellent compliance. The recommendation of surgery in cases of high-grade dysplasia or repeated findings of low-grade dysplasia seems to be effective in the attempt to minimize the risk for CRC. We observed a rather high incidence of PSC, which may indicate that more attention should be paid to a search for this diagnosis in patients with early-onset UC.

Natural history of paediatric inflammatory bowel diseases over a 5-year follow-up: a retrospective review of data from the register of paediatric inflammatory bowel diseases

OBJECTIVES

The natural history of paediatric inflammatory bowel diseases (IBDs) is poorly understood. We aim to describe the disease course in this cohort and generate prognostic information for patients and clinicians.

MATERIALS AND METHODS

Patient records from 6 tertiary paediatric gastroenterology centres were reviewed to generate data concerning original diagnosis, change in diagnosis, family history, surgical interventions, growth, and presence of extragastrointestinal manifestations.

RESULTS

Data were collected on 116 children with Crohn disease (CD), 74 with ulcerative colitis (UC), and 20 with indeterminate colitis (IC), followed for a mean period of 3.42, 3.3, and 2.9 years from date of diagnosis, respectively. A male predominance is demonstrated in CD. Revision of diagnosis in patients with IC is mainly to UC, with most children receiving a definitive diagnosis within 2 years of initial presentation. Of the children with UC, 17.6% underwent 1 or more major operations with a median time to surgery of 1.92 years. Of children with CD, 11.6% underwent 1 or more major intraabdominal procedures with a median time to surgery of 1.83 years. We recorded a positive family history in 2.7%, 8.2%, and 10% of cases for CD, UC, and IC, respectively. For both boys and girls with CD, but only for boys with UC, height standard deviation score became more negative over time.

CONCLUSIONS

This retrospective study quantifies certain distinctions between IBDs diagnosed in paediatric and adult populations. We document a trend toward male predominance in children with CD. We also note impaired linear growth in children with CD, whereas it appears maintained in girls with UC. We also have recorded a low incidence of IBDs in the families of this cohort and suggest that environmental influences may be of greater importance. We document that major intraabdominal surgery may be required in about 15% of patients with either UC or CD within 2 years of diagnosis, and that the majority of those diagnosed initially with IC will be reclassified as either UC or CD within 2 years.

New serological markers for inflammatory bowel disease are associated with earlier age at onset, complicated disease behavior, risk for surgery, and NOD2/CARD15 genotype in a Hungarian IBD cohort

BACKGROUND

Antibodies to Saccharomyces cerevisiae (S. cerevisiae) (ASCA) and porin protein-C of Escherichia coli (anti-OmpC) are associated with disease phenotype and may be of diagnostic importance in inflammatory bowel diseases (IBD). Our aim was to determine whether a panel of new antibodies against bacterial proteins and carbohydrates could help differentiate among the various forms of IBD, and whether they were associated with particular clinical manifestations in a Hungarian cohort of IBD patients.

METHODS

Six hundred fifty-two well-characterized, unrelated, consecutive IBD patients (CD [Crohn's disease] 557, men/women 262/295, duration 8.1 +/- 11.3 yr; ulcerative colitis [UC] 95, men/women 44/51, duration 8.9 +/- 9.8 yr) and 100 healthy and 48 non-IBD gastrointestinal (GI) controls were investigated. Sera were assayed for anti-OmpC and antibodies against a mannan epitope of S. cerevisiae (gASCA), laminaribioside (ALCA), chitobioside (ACCA), and mannobioside (AMCA). TLR4 and NOD2/CARD15 variants were tested by polymerase chain reaction/restriction fragment length polymorphism (PCR-RFLP). Detailed clinical phenotypes were determined by reviewing the patients' medical charts.

RESULTS

Sixty-six percent of the CD patients had at least one of the investigated antibodies. Among glycan antibodies, gASCA or the combination of gASCA and atypical perinuclear antineutrophil cytoplasmic antibodies (pANCA) was most accurate for differentiating between CD and UC. ASCA and gASCA assays performed similarly. Increasing amount and level of antibody responses toward gASCA, ALCA, ACCA, AMCA, and OmpC were associated with more complicated disease behavior (P < 0.0001) and need for surgery in CD (P= 0.023). A serological dosage effect was also observed. gASCA and AMCA antibodies were associated with NOD2/CARD15, in addition to a gene-dosage effect. No serotype-phenotype associations were found in UC.

CONCLUSIONS

Antibody response to this new panel of serological markers was associated with complicated disease phenotype, NOD2/CARD15 genotype, and a need for surgery in this eastern European IBD cohort.

Outcome of childhood ulcerative colitis at 2 years

AIM

Ulcerative Colitis (UC) has an incidence of 1.4 per 100,000 in childhood. There is a paucity of data regarding outcome particularly with the increased use of early immunosuppression. This study reviews outcome at 2 years in a cohort with UC referred to a single centre.

METHOD

Patients were recruited on the basis of a diagnosis made between 2000 and 2003 as a consecutive cohort. All had UC according to standard clinicopathological criteria. Children with indeterminate colitis were excluded. Follow-up data was collected at 2 years by case notes review.

RESULTS

Thirty-two children are reported. The median age at diagnosis was 11 years (range 2-16). All were treated with corticosteroids and 5-ASA derivatives at diagnosis. The majority of patients (94%, 30/32) received more than one course of steroids. By 2 years azathioprine use was high with 75% (24/32) of patients on treatment for steroid-dependent disease. There were 6 extra-intestinal manifestations and 8 disease related complications occurring in 12 patients (38%). The colectomy rate was 9% (3/32) for unresponsive disease.

CONCLUSION

There is a high need for Azathioprine in childhood UC. Colectomy rate at 2 years was around 10%. Extra-intestinal manifestations and disease related complications are common.

Biologic therapy in the management of extraintestinal manifestations of inflammatory bowel disease

The inflammatory bowel diseases (IBD), notably Crohn's disease (CD) and ulcerative colitis (UC), are systemic inflammatory diseases primarily involving the gastrointestinal tract. Twenty percent to 40% of patients with IBD develop extraintestinal inflammation and symptoms, known as extraintestinal manifestations (EIMs).1-7 The most common EIMs affect the joints, skin, eyes, and biliary tract. The EIMs associated with IBD bear a negative impact on patients with UC and CD. Thus, the successful treatment of EIMs is essential for improving the quality of life of IBD patients. For most EIMs, their resolution often parallels that of the active IBD in both timing and therapy required. However, some EIM such as axial arthritis, pyoderma gangrenosum, uveitis, and primary sclerosing cholangitis run a clinical course independent of IBD disease activity. The advent of biologic response modifiers, e.g., tumor necrosis factor-alpha (TNF) inhibitors, has improved the treatment of IBD and its associated EIMs. This article reviews the therapeutic experiences of the 2 most widely used anti-TNF neutralizing antibodies, infliximab and adalimumab, for immune-mediated EIM of IBD.

Extra-intestinal manifestations of Crohn's disease

Extra-intestinal manifestations occur in at least 25% of Crohn's disease patients. Some extra-intestinal manifestations, such as erythema nodusum and peripheral arthropathy, will wax and wane in keeping with bowel inflammation. The more severe cutaneous ulcerations, uveitis, and axial arthropathy may precede bowel disease or persist after it subsides. Screening may be appropriate for eye disease and for osteoporosis to prevent complications. Medical management for extra-intestinal manifestations is similar to treatment for the bowel symptoms of Crohn's disease, with corticosteroids the mainstay. Pain and depression are associated with inflammatory bowel disease, and their control benefits patients. Recent small studies with anti-tumor necrosis factor (TNF) agents are promising for most extra-intestinal manifestations of Crohn's disease, and may permit more steroid-sparing disease control in the future.

Seroreactivity to microbial components in Crohn's disease is associated with ileal involvement, noninflammatory disease behavior and NOD2/CARD15 genotype, but not with risk for surgery in a Hungarian cohort of IBD patients

BACKGROUND

Antibodies directed against Saccharomyces cerevisiae (ASCA), perinuclear components of neutrophils (pANCA), and porin protein C of Escherichia coli (anti-OmpC) are reported to be associated with disease phenotype and may be of diagnostic importance in inflammatory bowel disease (IBD). Since limited data are available from Eastern Europe, we assessed the above antibodies in Hungarian IBD patients.

METHODS

In all, 653 well-characterized, unrelated consecutive IBD patients (Crohn's disease [CD]: 558, m/f: 263/295, duration: 8.1 +/- 10.7 years; ulcerative colitis [UC]: 95, m/f: 44/51, duration: 8.9 +/- 9.8 years) and 100 healthy subjects were investigated. Sera were assayed for anti-Omp and ASCA by enzyme-linked immunosorbent assay (ELISA) and ANCA by indirect immunofluorescence assay (IIF). TLR4 and NOD2/CARD15 variants were tested by polymerase chain reaction/restriction fragment length polymorphism (PCR-RFLP). Detailed clinical phenotypes were determined by reviewing the medical charts.

RESULTS

Anti-Omp, ASCA, and atypical pANCA antibodies were present in 31.2%, 59.3%, and 13.8% of CD, 24.2%, 13.7%, and 48.5% of UC patients, and in 20%, 16%, and 5.6% of controls, respectively. ASCA and anti-Omp positivity were associated with increased risk for CD (odds ratio [OR](ASCA) = 7.65, 95% confidence interval [CI]: 4.37-13.4; OR(Omp) = 1.81, 95% CI: 1.08-3.05). In a logistic regression analysis, anti-Omp and ASCA were independently associated with ileal and noninflammatory disease, but not with a risk for surgery or response to steroids or infliximab. A serology dosage effect was also observed. ASCA and anti-Omp antibodies were associated with NOD2/CARD15, in addition to a gene dosage effect. No associations were found in UC.

CONCLUSIONS

Serological markers were useful in the differentiation between CD and UC in an Eastern European IBD cohort. Reactivity to microbial components was associated with disease phenotype and NOD2/CARD15 genotype, further supporting the role of altered microbial sensing in the pathogenesis of CD.

ATP-binding cassette transporter ABCG2 (BCRP) and ABCB1 (MDR1) variants are not associated with disease susceptibility, disease phenotype response to medical therapy or need for surgeryin Hungarian patients with inflammatory bowel diseases

OBJECTIVE

MDR1 (ABCB1), a member of the ATP-binding cassette (ABC) transporters, is an attractive candidate gene for the pathogenesis of inflammatory bowel diseases (IBD) and perhaps for response to therapy. Since limited data are available on MDR1 and ABCG2 polymorphisms in East European IBD patients, the aim of this study was to investigate ABCG2 and MDR1 variants and responses to medical therapy and/or disease phenotype in Hungarian patients.

MATERIAL AND METHODS

A total of 414 unrelated IBD patients (Crohn's disease (CD): 265, age: 35.2+/-12.1 years, duration: 8.7+/-7.6 years and ulcerative colitis (UC): 149, age: 44.4+/-15.4 years, duration: 10.7+/-8.9 years) and 149 healthy subjects were investigated. ABCG2 G34A, C421A and MDR1 C3435T, G2677T/A single nucleotide polymorphisms (SNPs) were detected using real-time polymerase chain reaction (PCR). Detailed clinical phenotypes were determined by reviewing the medical charts.

RESULTS

The frequency of the ABCG2 and MDR1 SNPs was not significantly different among IBD, CD, UC patients and controls. There was no difference in risk for steroid resistance in CD patients carrying variant ABCG2 (19.6% versus non-carriers 18.4%, p=NS) or MDR1 3435T (CC: 22.2% versus CT/TT: 17.6%) alleles. In addition, carriage of the variant allele was not associated with disease phenotype, presence of extra-intestinal manifestations, smoking, response to infliximab therapy or the need for surgery. In UC, the carriage of variant ABCG2 alleles seemed to be preventive for arthritis (15.5% versus 31.7%, OR: 0.39, 95% CI: 0.16-0.98).

CONCLUSIONS

MDR1 and ABCG2 SNPs were not associated with disease susceptibility or disease phenotype in Hungarian patients, and variant alleles did not predict the response to medical therapy or the need for surgery. Further studies are needed to clarify the association between the presence of ABCG2 variants and arthritis in UC.

Haptoglobin polymorphisms are associated with Crohn's disease, disease behavior, and extraintestinal manifestations in Hungarian patients

Functional differences and association with inflammatory disorders were found relating to three major haptoglobin (Hp) phenotypes. Our aim was to investigate Hp polymorphisms in Hungarian patients with Crohn's disease (CD). Four hundred sixty-eight CD patients and 384 healthy controls were examined. Hp phenotypes were determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and immunoblotting of the sera. The frequency of the Hp(1) allele was significantly higher in CD (0.395; OR, 1.24; 95% CI, 1.02-1.52; P=0.03) compared to controls (0.345). In CD, Hp phenotype was associated with disease behavior (OR [Hp(2-1) vs other], 2.06; 95% CI, 1.29-3.28 for inflammatory behavior). Furthermore, an increased frequency of primary sclerosing cholangitis was observed in the Hp 2-2 compared to the Hp 1-1 phenotype (6.5% vs. 0.0%; P=0.039). We conclude that the Hp polymorphism is associated with CD, inflammatory disease behavior, and primary sclerosing cholangitis in Hungarian patients. Further studies are required to evaluate the significance of Hp polymorphisms in other populations from geographically diverse regions.

Relationship between clinical features of Crohn's disease and the risk of developing extraintestinal manifestations

OBJECTIVES

Crohn's disease is frequently associated with extraintestinal manifestations. The aim of this study was to evaluate the degree of association between the development of extraintestinal manifestations, the clinical forms of Crohn's disease according to the Vienna Classification and to the presence of several potential risk factors of the disease.

METHODS

One hundred and seventy-three consecutive Crohn's disease patients were studied. Sex, smoking habits, previous Crohn's disease-related surgery, family history of Crohn's disease, steroid dependency, steroid resistance and the presence of at least one mutant allele in any of the three considered variants of CARD15 gene were considered as potential risk factors. The Vienna Classification was applied, and the presence of extraintestinal manifestations was evaluated.

RESULTS

A total of 61 (35.3%) patients developed extraintestinal manifestations. They were more frequently seen in women than in men (41.1 vs. 26.7%), (odds ratio 1.92, 95% confidence interval: 0.99-3.70; P=0.05) and in steroid-dependent patients than in steroid responders (61.1 vs. 28.5%), (odds ratio 3.94, 95% confidence interval: 1.83-8.49; P<0.01). No relationship was found in general between the extraintestinal manifestations of Crohn's disease and smoking habits, previous Crohn's disease-related surgery, a family history of Crohn's disease, steroid resistance and CARD15 mutations. Such relationships were, however, detected for some individual extraintestinal manifestations as between both smoking habits (odds ratio 9.09, 95% confidence interval: 1.15-71.66; P<0.05) and the G908R CARD15 mutation (odds ratio 4.76, 95% confidence interval: 1.11-20.43; P<0.05), respectively, and erythema nodosum. Patients with any colonic involvement of Crohn's disease (L2+L3) suffered from extraintestinal manifestations of the disease more frequently than patients without colonic involvement (42.7 vs. 25.9%, respectively; odds ratio 2.12, 95% confidence interval: 1.10-4.07; P<0.05).

CONCLUSIONS

Female gender, steroid-dependency and colonic involvement are associated with the risk of developing extraintestinal manifestations of Crohn's disease.

Hypertrophic cardiomyopathy in a patient with Crohn's disease: A case report

Cardiac manifestations of Crohn's disease are rare; the most common is pericarditis. In the present report we briefly describe a 56-year-old man with Crohn's disease who presented to the emergency department due to paroxysmal atrial flutter. A transthoracic echocardiographic study revealed asymmetric left ventricular hypertrophy without outflow pressure gradient. Reviewing the literature, hypertrophic cardiomyopathy has not been previously described in patients with Crohn's disease.

Systematic review: managing anaemia in Crohn's disease

BACKGROUND

Anaemia is a serious complication of Crohn's disease that triggers hospitalization and, if not interfered with, may lead to death.

AIMS

To systematically summarize and compare the literature on anaemia in Crohn's disease.

METHODS

For this systematic review the literature was searched for English-language articles using anaemia, Crohn* and IBD as key words. 144 articles were identified and sorted according to the following topics: prevalence, aetiology, diagnostic tests and therapy.

RESULTS

The reported prevalence of anaemia varied between 6.2% and 73.7%, with higher reported frequencies in older studies and in in-patients. Iron deficiency is the most common underlying condition. Vitamin B12 deficiency is related to the extent of ileal resection but has rarely impact on anaemia. Diagnostic criteria are not established and treatment guidelines are missing. Oral iron supplementation seems effective for short periods but intolerance leads to discontinuation in up to 21%. Eleven of 11 studies show that oral iron enhances intestinal inflammation and colon carcinogenesis in animal models of colitis. Intravenous iron supplementation with iron sucrose has been tested in over 250 Crohn's disease patients, is safe, effective and does not carry such hazards.

CONCLUSIONS

As disease activity is determining the degree of anaemia in Crohn's disease, implementation of more effective therapy for Crohn's disease will lower its incidence. However, further studies regarding the safety and effectiveness of iron supplementation are needed.

Is the incidence and prevalence of inflammatory bowel diseases increasing in Eastern Europe?

Limited data are available on the frequency of inflammatory bowel diseases in East European countries. A recent study from Hungary reported an increasing incidence rate for ulcerative colitis (from 1.6 to 11.0) and for Crohn's disease (from 0.4 to 4.7) from 1977 to 2001. A similar trend was seen in Croatia. In contrast, other countries (for example, Czech Republic, Poland, Romania, Slovakia, and Baltic countries) reported low incidence and prevalence rates. This review will discuss the available data on the epidemiology of inflammatory bowel diseases in Eastern Europe, as well as consider the possible factors responsible for the differences seen between countries and epidemiological trends.

Management of inflammatory bowel diseases in Eastern Europe

Limited data are available on the management of inflammatory bowel diseases (IBD) in East European countries. The diagnostic tools and most treatment options are also available in Eastern Europe. The diagnostic procedures commonly used became more sophisticated in the past few years, with a greater use of computed tomography/magnetic resonance imaging and serology testing; however, double contrast barium enema, enteroclysis, and endoscopy remained standard. The medical therapy and surgical strategies are also somewhat different from those applied in Western countries. In ulcerative colitis, besides mesalazine, the use of sulphasalazine is still frequent, while azathioprine is only used in a minority of patients. The use of conventional corticosteroids is common and the rate of non-colorectal cancer associated colectomies is low. In contrast, 5-aminosalicylates are still used for maintenance in Crohn's disease and azathioprine is generally less frequently given compared with Western Europe. Biological agents have also become available about five years ago, yet their use is restricted mainly to specialised centres.

Extraintestinal manifestations of inflammatory bowel diseases

Inflammatory bowel diseases are associated with extraintestinal manifestations involving almost every organ system in the body. They occur in approximately 20% to 40% of patients with inflammatory bowel diseases. Immune-related and genetic mechanisms play an important role in the pathogenesis of these complications. Peripheral arthritis, erythema nodosum, and episcleritis respond to the treatment of the underlying intestinal inflammation, whereas axial arthropathy, pyoderma gangrenosum, and uveitis do not. Immunomodulator therapy, particularly with biologic agents has been shown to be effective in treating some of the extraintestinal manifestations. Early recognition and treatment are crucial in preventing major morbidity.

Crohn's disease is associated with polymorphism of CARD15/NOD2 gene in a Hungarian population

Crohn's disease (CD) is commonly classified as an immune-mediated disorder, but genetic and environmental factors seem to be important in its pathogenesis. Mutations within the CARD15/NOD2 gene have been associated with CD in the Caucasian population. The aim of our work was to investigate the allele frequency and clinical impact of the three common mutations in Hungarian CD patients and healthy controls. Seventy-four CD patients and 107 controls were examined. The genotyping of the three common CARD15/NOD2 mutations (Arg702Trp, Gly908Arg, and Leu1007fsinsC) was carried out by restriction fragment length polymorphism (RFLP) and amplification refractory mutation system (ARMS) techniques. The demographic and clinical parameters were correlated with chi(2) analysis. The overall prevalence of CARD15/NOD2 mutations in the Hungarian CD patients (33.78%) was significantly higher than in healthy control individuals (16.23%) (P < 0.025). The allele frequency of the Gly908Arg mutation did not differ, but the Arg702Trp and Leu1007fsinsC mutation were more common in CD patients than in controls. The onset of CD occurs about three years earlier in CARD15/NOD2 carriers. Carriage of the Arg702Trp and Leu1007fsinsC allele within the CARD15/NOD2 gene is associated with CD. These data are in line with similar findings showing a role of the CARD15/NOD2 protein in the etiopathogenesis of CD. The genotyping of these mutations might be used to identify high-risk patients.

Multifocal posterior uveitis in Crohn's disease

PURPOSE

To report a case of rare posterior eye manifestation of Crohn's disease preceding recurrence of inflammatory bowel disease.

METHODS

Case report with ophthalmoscopic findings, fluorescein/indocyanin green angiograms, automated perimetry and multifocal-ERG.

RESULTS

The perimetry revealed absolute and relative scotomas corresponding to multifocal inflammatory lesions in the retina and choroid, reduced a/b amplitudes in multifocal-ERG and hypofluorescent dots in angiography. Under oral prednisolone visual defects, ophthalmoscopic and angiographic findings resolved, while a/b amplitudes remained mildly reduced. The ocular changes occurred without systemic hypertension and were followed by a new episode of intestinal symptoms.

CONCLUSION

Multifocal inflammatory lesions in the retina and choroid in patients with Crohn's disease may occur and may precede a recurrent intestinal episode. Crohn's patients should be carefully followed up in collaboration with internal medicine specialists.

DLG5 R30Q is not associated with IBD in Hungarian IBD patients but predicts clinical response to steroids in Crohn's disease

BACKGROUND

Recent data suggest that haplotypic variants of the DLG5 gene on 10q23 are associated with susceptibility to inflammatory bowel disease (IBD) in Germany. In view of the geographical differences in frequency of genetic markers and the absence of data in Central European patients, our aim was to determine the DLG5 R30Q variant in Hungarian IBD patients.

MATERIALS AND METHODS

We investigated 773 unrelated IBD patients (age 38.1 +/- 10.3 years; duration, 8.8 +/- 7.5 years; Crohn's disease [CD]: 639; male/female, 309/330; duration, 8.4 +/- 7.1 years; ulcerative colitis [UC]: 134; male/female, 63/71; duration, 10.6 +/- 8.9 years) and 150 healthy subjects. DLG5 R30Q and TLR4 D299G variants were tested by polymerase chain reaction/restriction fragment length polymorphism. DNA was screened for NOD2/CARD15 mutations by denaturing high-performance liquid chromatography. Detailed clinical phenotype was determined by reviewing the medical charts.

RESULTS

The frequency of the R30Q variant allele was not significantly different in IBD (22.0%), CD (20.8%), and UC (27.6%) patients compared with healthy control subjects (28.0%). In CD, the 113A variant allele was associated with steroid resistance (16.3% vs noncarriers, 7.6%; odds ratio [OR], 2.4; 95% CI 1.3-4.5; P = 0.013). In a logistic regression model carriage of DLG5 R30Q, perianal involvement and frequent relapses were independently associated with steroid resistance. No phenotype-genotype associations were found in UC patients, although a trend toward more extensive disease was observed in carriers of the variant allele (OR = 2.1; 95% CI 0.95-4.4; P = 0.07).

CONCLUSIONS

The present data strongly contrast previous data from Germany. DLG5 113A is not associated with disease susceptibility, but there was a tendency for this allele to confer resistance to steroids. Further studies are required to evaluate the significance of DLG5 in other populations from geographically diverse regions.

Incidence of inflammatory bowel disease in Primorsko-goranska County, Croatia, 2000-2004: A prospective population-based study

OBJECTIVE

It has been suggested that the incidence of inflammatory bowel disease (IBD), which includes ulcerative colitis (UC) and Crohn's disease (CD), is higher in northern than in southern Europe. Recent epidemiological studies showed the loss of the previously described geographical north-south gradient. The aim of this study was to investigate the incidence of UC and CD in Primorsko-goranska County, Croatia.

MATERIAL AND METHODS

In the period 1 January 2000 to 31 December 2004 (5 years) all new patients diagnosed with IBD were prospectively identified according to a standard protocol for case ascertainment and definition. A total of 178 residents (81 F, 97 M) were newly diagnosed as having IBD during the study period. Of these, 70 had UC and 100 CD. Eight patients had indeterminate IBD. The data on patients were collected using a data form completed by gastroenterologists.

RESULTS

Annual age-standardized incidence rates were 4.3/10(5) (95% CI 2.6-6.0) for UC and 7.0/10(5) (95% CI 3.4-10.6) for CD. The highest incidence rate was observed in the age group 35-44 years for UC and the 25-34 years age group for CD. The incidence of IBD was higher in the urban than in the rural population, with the exception of on the islands.

CONCLUSIONS

The incidence of IBD was higher than previously observed in Croatia. Our results suggest that CD incidence rates in the northern coastal part of Croatia are currently comparable with those reported in northern Europe.

Current concept on the pathogenesis of inflammatory bowel disease-crosstalk between genetic and microbial factors: Pathogenic bacteria and altered bacterial sensing or changes in mucosal integrity take “toll”

The pathogenesis of inflammatory bowel disease (IBD) is only partially understood. Various environmental and host (e.g. genetic-, epithelial-, immune and non-immune) factors are involved. It is a multifactorial polygenic disease with probable genetic heterogeneity. Some genes are associated with IBD itself, while others increase the risk of ulcerative colitis (UC) or Crohn’s disease (CD) or are associated with disease location and/or behaviour. This review addresses recent advances in the genetics of IBD. The article discusses the current information on the crosstalk between microbial and genetic factors (e.g. NOD2/CARD15, SLC22A46A5 and DLG5). The genetic data acquired in recent years help in understanding the pathogenesis of IBD and can identify a number of potential targets for therapeutic intervention. In the future, genetics may help more accurately diagnose and predict disease course in IBD.

Inflammatory bowel disease arthropathy

Inflammatory bowel disease (IBD) is a common medical problem in the United States. There may be a genetic predisposition for the development of IBD. Gastrointestinal (GI) symptoms of IBD are often accompanied by symptoms in other body systems. Joint complaints are commonly noted in IBD patients, and may be the primary presenting complaint in some. The sports medicine physician must keep a high index of suspicion for IBD arthropathy in athletes who present with axial arthropathy or peripheral arthropathy that is not related to injury or overuse. Diagnosis may be difficult and relies on accurate diagnosis of the GI disease. Joint symptoms usually respond to treatment of the bowel disease. Other standard treatments of joint pain include ice, rest, rehabilitation exercises, and analgesics, although nonsteroidal anti-inflammatory drugs should be avoided as they may lead to a worsening of the GI symptoms. Exercise won't likely worsen IBD symptoms but whether exercise prevents IBD is still an area of debate.

Racial differences in disease phenotypes in patients with Crohn's disease

BACKGROUND

Our objectives were to assess the differences in perforating disease behavior, disease severity, and extraintestinal manifestations (EIM) in patients with Crohn's disease (CD) by race.

MATERIALS AND METHODS

We identified outpatients with CD evaluated at the University of Maryland Gastroenterology Faculty Practice office or the Baltimore Veterans Affairs Maryland Health Care System, from 1997 to 2005. We assessed age at diagnosis, disease behavior, disease location, need for surgery and EIM.

RESULTS

Race was not associated with perforating disease behavior (relative risk [RR] 0.79, 95% confidence interval [CI] 0.46-1.35), need for surgery (RR 0.89, 95% CI 0.56-1.12), and EIM of CD (RR 0.77, 95% CI 0.46-1.27). White patients were significantly more likely to have ileal disease, whereas African American patients were significantly more likely to have ileocolonic and colonic disease. Age at diagnosis younger than 40 years (odds ratio [OR] 4.41, 95% CI 1.84-10.56) and ileocolonic disease (OR 2.39, 95% CI 1.24-4.63) were independent risk factors for perforating disease behavior. Similarly, age at diagnosis younger than 40 (OR 2.79, 95% CI 1.45-5.33), ileal disease (OR 3.76, 95% CI 1.66-8.48), and ileocolonic disease (OR 2.57, 95% CI1.21-5.46) were associated with the need for surgery. Female gender (OR 4.23, 95% CI 1.87-9.58) and a positive family history of CD (OR 3.45, 95% CI 1.49-8.0) were associated with joint manifestations of CD.

DISCUSSION

We did not detect differences in disease behavior, severity, or joint EIM by race. Although African American patients were more likely to have ileocolonic or colonic disease, these factors did not affect disease behavior or severity.

Risk factors for ulcerative colitis-associated colorectal cancer in a Hungarian cohort of patients with ulcerative colitis: results of a population-based study

BACKGROUND

There is an increased risk of colorectal cancer (CRC) in ulcerative colitis (UC). The prevalence of UC-associated CRC is different in various geographic regions. The risk depends primarily on the duration and extent of disease. The aim of this study was to identify the risk factors for and the epidemiology of CRC in Hungarian patients with UC.

METHODS

We retrospectively evaluated the relevant epidemiological and clinical data of all patients with UC in Veszprem province in our 30-year IBD database (723 patients with UC; male/female, 380/343; non-CRC related colectomies, 3.7%).

RESULTS

CRC was diagnosed in 13 patients (13/8564 person-year duration) during follow-up. Age at diagnosis of CRC was at a median of 51 (range 27-70) years. Eight patients are still alive, 4 died of CRC, and 1 died of an unrelated cause. Longer disease duration, extensive colitis, primary sclerosing cholangitis, and dysplasia found in the biopsy specimen were identified as risk factors for developing CRC. The cumulative risk of developing CRC after a disease duration of 10 years was 0.6% (95% confidence interval [CI] 0.2%-1.0%); 20 years, 5.4% (95% CI 3.7%-7.1%); and 30 years, 7.5% (95% CI 4.8%-10.2%). CRC diagnosed at surveillance colonoscopy was associated with a tendency for longer survival (P = 0.08).

CONCLUSIONS

The cumulative risk of CRC was high in our patients with UC; however, it was lower compared with that reported in Western European and North American studies. CRC developed approximately 15 years earlier compared with sporadic CRC patients in Hungary. Longer disease duration, extensive colitis, dysplasia, and primary sclerosing cholangitis were identified as important risk factors for developing CRC.

[Extraintestinal manifestations in inflammatory bowel disease: differences between Crohn's disease and ulcerative colitis]

BACKGROUND AND OBJECTIVE

The true prevalence of the extraintestinal manifestations (EM) associated with inflammatory bowel disease (IBD) may vary depending on the geographic area, IBD population, location and duration of the disease, medication and diagnostic accuracy. The aim of this study was determine the prevalence of the major EM of IBD and their differences between Crohn's disease (CD) and ulcerative colitis (UC).

PATIENTS AND METHOD

A prospective study with a total of 566 patients (295 CD with median follow up 11.6 years [range: 2-32 years] and 271 UC with median follow up 10.4 years [range: 2-36 years]. Data related to the clinical course, EM and laboratory tests were obtained at diagnosis and during follow-up.

RESULTS

EM related with IBD appeared al least once in 46.6% of the patients. Joints manifestations were the most common EM. The EM were equal frequent in UC (51.5%) as in CD (42.2%). Hepatobiliary manifestations (odds ratio [OR] = 1.91; 95% confidence interval [CI] 1.15-3.16; p = 0.007), venous thromboembolism (OR = 4.26; 95% CI, 1.3-15.4; p = 0.006) and arthralgias (OR = 1.59; 95% CI, 1.01-2.5; p = 0.035) were more frequent in UC than CD. Erythema nodosum (OR = 2.35; 95% CI, 1.13-5.0; p = 0.013) and peripheral arthritis (OR = 1.95; 95% CI, 1.02-3.74; p = 0.029) were more frequent in CD. The prevalences of ocular, and the rest of joint manifestations were not different according to UC or CD.

CONCLUSIONS

Prevalence of EM in Spanish IBD patients is among the highest ever reported. The distribution of the EM observed is different between CD and UC. It is necessary to know to allow to prompt diagnosis and prevent undesirable complications.

Prevalence of cholelithiasis in patients with chronic inflammatory bowel disease

AIM: To investigate the effect of chronic inflammatory bowel disease (CIBD) specific risk factors for cholecystolithiasis, as duration and involvement pattern of the disease and prior surgery in patients with Crohn's disease (CD) and ulcerative colitis (UC).

METHODS: A total of 222 patients with CD (135 females, 87 males; average age, 35.8 ± 11.8 years; range 17-81 years) and 88 patients with UC (39 females, 49 males; average age, 37.2 ± 13.6 years; range 16-81 years) underwent clinical and ultrasound examinations. Besides age, sex and degree of obesity, patients? CIBD specific parameters, including duration and extent of disease and prior operations were documented and evaluated statistically using logistic regression.

RESULTS: The overall prevalence of gallbladder stone disease in patients with CD was 13% (n = 30). Only age could be shown to be an independent risk factor (P = 0.014). Compared to a collective representative for the general population in the same geographic region, the prevalence of cholecystolithiasis was higher in all corresponding age groups. Patients with UC showed an overall prevalence of gallbladder stone disease of only 4.6%.

CONCLUSION: Only age but not disease-specific factors such as duration and extent of disease, and prior surgery are independent risk factors for the development of cholecystolithiasis in patients with CIBD.

Strictureplasty

BACKGROUND

Advances in the use of bowel-sparing surgery for Crohn's disease have led to the development of strictureplasty as an important technique to conserve small bowel length and reduce morbidity associated with malabsorption.

METHODS

A literature review of long-term studies on strictureplasty was undertaken, and evidence of its safety and efficacy was evaluated.

RESULTS

The safety and efficacy of strictureplasty is confirmed in retrospective studies carried out over a period of 5-10 years, particularly when employed in patients at risk of short bowel syndrome, but certain questions regarding bowel function and disease activity after surgery remain unanswered. There is also concern that diseased tissue is left in situ after strictureplasty; this tissue has the potential for malignant transformation in the long term.

CONCLUSION

Strictureplasty has been used in surgery for Crohn's disease for the past 25 years. Studies have proven its efficacy in the treatment of carefully selected patients at risk of malabsorption owing to short bowel syndrome.

Thromboembolism--an important manifestation of inflammatory bowel disease

Thromboembolism is an extraintestinal manifestation and an important cause of mortality in inflammatory bowel disease (IBD). The risk of thromboembolism appears to be multifactorial and related to mucosal inflammatory activity in most patients. Various laboratory markers such as thrombin activatable fibrinolysis inhibitor (TAFI) levels have been linked with thrombophilia in IBD but no single laboratory marker has emerged with sufficient predictive value to identify patients at particular risk. Prospective multifactorial analyses will be required; in the interim, clinicians must be vigilant and address common risk factors for thromboembolism in all patients with IBD.

Atopic manifestations are more common in patients with Crohn disease than in the general population

BACKGROUND

The role of TNF-alpha in Crohn disease is now well established and anti-TNF-alpha is frequently used as a second- or third-line treatment. Tumor necrosis factor-alpha (TNF-alpha) is traditionally associated with macrophages but has recently also been found in mast cells of the ileal wall in patients with Crohn disease. As it is well known that mast cells and TNF-alpha play important roles in atopic manifestations like asthma, allergic rhinitis; and eczema the aim of this study was to investigate whether these are seen more commonly in Crohn patients than in the general population.

METHODS

Patients with Crohn disease (n = 308), aged 18-50 years, living in the Linköping region in southeast Sweden, were asked to answer a questionnaire regarding the presence of any kind of atopic manifestations. The questionnaire was also sent to 930 controls collected from the Southeastern Region Population Registry. The controls were matched according to age, sex, and place of residence.

RESULTS

The response rate among the Crohn patients was 91% (280/308) and among controls 84% (779/930). Eczema was a significantly more frequent manifestation, being almost twice as common in Crohn patients (27%) as in the general population (16%). Adjustment by logistic regression for place of residence, gender, age and coexistence of any other atopic manifestation did not change the odds ratios significantly.

CONCLUSION

Atopic manifestations as a group, and eczema as a single manifestation, are significantly more frequent in Crohn patients than in the general population.