The changing face of treatment for Crohn's disease

Detailed Multi-Dimensional Assessment of Fatigue in Inflammatory Bowel Disease

Background

Fatigue is a symptom commonly reported by patients with inflammatory bowel disease (IBD). Treating any underlying inflammation in active disease improves the health outcomes and decreases fatigue, but fatigue still persists in remission, negatively affecting patients' quality of life and posing a challenge for the treating physician. The aim of this study was to describe the prevalence of fatigue in patients with IBD and investigate possible contributing factors.

Methods

Recruited IBD patients from the Otago region in southern New Zealand were asked to complete demographic, physical activity (IPAQ) and fatigue questionnaires (Brief Fatigue Inventory, Multidimensional Fatigue Inventory). Disease activity and factors contributing to fatigue were assessed through self-reporting and laboratory biomarkers.

Results

One hundred and thirteen of the contacted 469 IBD patients participated in the study. Depending on the questionnaire used, the prevalence of fatigue in IBD was high in remission (39.5-44.2%) but significantly higher (p < 0.001) in active disease (80.0-82.9%). Several factors such as age, disease duration, level of physical activity, gender and diet were found to be associated with increased fatigue and were attributed to either mental or physical fatigue categories. Multifactorial Fatigue Inventory provided insights into different types of fatigue, and revealed a significant mental fatigue component in both active and remission disease patients. Iron deficiency was not associated with fatigue levels.

Conclusions

Fatigue in IBD is multi-faceted and highly prevalent in both active and remission IBD. Further investigations, addressing the complexity of the symptom and its reporting are needed.

Surgical repair and biological therapy for fecal incontinence in Crohn's disease involving both sphincter defects and complex fistulas

BACKGROUND AND AIMS

Surgeons have traditionally tried to avoid any complex surgical procedures in Crohn's patients with complex perianal diseases because of the fear of complications, worsening the patient's condition and risking an eventual proctectomy. The introduction of biological therapy has changed the management of Crohn's disease. This study assesses the long-term success of addressing defects in anal sphincter and complex fistula when patients receive anti-TNF-α antibodies.

METHODS

Ten consecutive patients were prospectively scheduled for induction therapy with 5mg/kg Infliximab at week 0, 2 and 6 and maintenance every 8 weeks associated with azathioprine. Elective surgery was performed conducting a simultaneous approach to the sphincter defect and fistula tracts. Outcomes were long-term continence, complications which were assessed by a Wexner's score along with a complementary questionnaire. Statistical analysis was performed using general linear model of repeated measures.

RESULTS

Three patients had complications related to surgery: two abscesses and low intersphincteric fistula and one case of rectal stenosis causing fecal urgency. There was no suture dehiscence. Wexner's score improved at 12 months (10.0±2.4 vs. 18.0±2.6; p=0.003) and over time (48 month 9.5±2.8; p=0.001). These scores were significantly worse when patients had urgency before treatment (12.8±1.2 vs. 9.5±2.8; p=0.03) but not when the urgency appeared later. No patient remained incontinent to solid stools. Three patients had occasional incontinence to liquid stools associated to disease reactivation.

CONCLUSION

Surgical repair and immunomodulator therapy with infliximab could be an option in incontinent patients with Crohn's disease involving both a sphincter defect and severe or refractory fistulas.