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Zeng Z, Jiang M, Li X, Yuan J, Zhang H. Precision medicine in inflammatory bowel disease. PRECISION CLINICAL MEDICINE 2023; 6:pbad033. [PMID: 38638127 PMCID: PMC11025389 DOI: 10.1093/pcmedi/pbad033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/13/2023] [Indexed: 04/20/2024] Open
Abstract
Inflammatory bowel disease (IBD) is an incurable disease characterized by remission-relapse cycles throughout its course. Both Crohn's disease (CD) and ulcerative colitis (UC), the two main forms of IBD, exhibit tendency to develop complications and substantial heterogeneity in terms of frequency and severity of relapse, thus posing great challenges to the clinical management for IBD. Current treatment strategies are effective in different ways in induction and maintenance therapies for IBD. Recent advances in studies of genetics, pharmacogenetics, proteomics and microbiome provide a strong driving force for identifying molecular markers of prognosis and treatment response, which should help clinicians manage IBD patients more effectively, and then, improve clinical outcomes and reduce treatment costs of patients. In this review, we summarize and discuss precision medicine in IBD, focusing on predictive markers of disease course and treatment response, and monitoring indices during therapeutic drug monitoring.
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Affiliation(s)
- Zhen Zeng
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu 610041, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Mingshan Jiang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu 610041, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Xi Li
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jing Yuan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu 610041, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Hu Zhang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
- Centre for Inflammatory Bowel Disease, West China Hospital, Sichuan University, Chengdu 610041, China
- Lab of Inflammatory Bowel Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu 610041, China
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Salvatori S, Neri B, Marafini I, Brigida M, Monteleone G. Emerging oral drug options for ulcerative colitis. Expert Opin Emerg Drugs 2023; 28:191-201. [PMID: 37668153 DOI: 10.1080/14728214.2023.2254686] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/22/2023] [Accepted: 08/30/2023] [Indexed: 09/06/2023]
Abstract
INTRODUCTION Despite the availability of a variety of therapeutic compounds and improved management strategies, one-third of UC patients with moderate-to-severe disease do not benefit from the existing treatments or experience drug-related side effects. This has boosted intensive research focusing on the development of new drugs for UC therapy. This article aims to summarize the available evidence on oral drugs, which are now being explored in clinical trials or are ready to enter the clinics. AREAS COVERED From May 15 to June 11, we searched on PubMed using the keywords 'oral drugs ulcerative colitis,' 'ulcerative colitis clinical trials,' 'UC phase 2 and 3 trials' excluding case reports, case series, phase 1 and 4 studies, and studies about approved therapies. EXPERT OPINION The findings discussed in this article suggest that the future treatment of UC patients will be probably characterized by the possibility of using various small-molecule drugs. All these new compounds, even those belonging to the same class, differ in terms of efficacy and safety. Identification of predictors of response could help optimize the efficacy and safety of these treatments, thus improving resource allocation through a pretreatment stratification of patients.
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Affiliation(s)
- Silvia Salvatori
- Gastroenterology Unit, Policlinico Universitario Tor Vergata, Rome, Italy
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Benedetto Neri
- Gastroenterology Unit, Policlinico Universitario Tor Vergata, Rome, Italy
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Irene Marafini
- Gastroenterology Unit, Policlinico Universitario Tor Vergata, Rome, Italy
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Mattia Brigida
- Gastroenterology Unit, Policlinico Universitario Tor Vergata, Rome, Italy
| | - Giovanni Monteleone
- Gastroenterology Unit, Policlinico Universitario Tor Vergata, Rome, Italy
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
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Spencer EA. Choosing the Right Therapy at the Right Time for Pediatric Inflammatory Bowel Disease: Does Sequence Matter. Gastroenterol Clin North Am 2023; 52:517-534. [PMID: 37543397 DOI: 10.1016/j.gtc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2023]
Abstract
Despite the enlarging therapeutic armamentarium, IBD is still plagued by a therapeutic ceiling. Precision medicine, with the selection of the "rights," may present a solution, and this review will discuss the critical process of pairing the right patient with right therapy at the right time. Firstly, the review will discuss the shift to and evidence behind early effective therapy. Then, it delves into promising future strategies of patient profiling to identify a patients' biological pathway(s) and prognosis. Finally, the review lays out practical considerations that drive treatment selection, particularly the impact of the therapeutic sequence.
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Affiliation(s)
- Elizabeth A Spencer
- Division of Pediatric Gastroenterology & Nutrition, Department of Pediatrics, Icahn School of Medicine, Mount Sinai, 17 East 102nd Street, 5th Floor, New York, NY 10029, USA.
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Acharya K, Bhardwaj V, Chuahan I, Mushfiq S, Bhatt S, Lamba BM. Comparison of Fecal Calprotectin with Different Endoscopic Scores in the Assessment of Ulcerative Colitis (UC) Activity and Its Utility in Differentiating IBS from IBD. Euroasian J Hepatogastroenterol 2023; 13:120-123. [PMID: 38222953 PMCID: PMC10785125 DOI: 10.5005/jp-journals-10018-1411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 11/15/2023] [Indexed: 01/16/2024] Open
Abstract
Background Ulcerative colitis (UC), a chronic inflammatory disease of gastrointestinal tract, can have initial presentation which is clinically difficult to differentiate from functional bowel disorders [irritable bowel syndrome (IBS) and irritable bowel disease (IBD)]. Conventional laboratory tests, such as erythrocyte sedimentation rate (ESR), C-reactive protein, and albumin express systemic patient responses instead of intestinal inflammation. In the last decade, fecal calprotectin, a calcium-binding protein, has been suggested as a sensitive marker of intestinal inflammation. However, only few studies have investigated its role in relation with the extent of the disease. Aim To evaluate the usefulness of fecal calprotectin as a biomarker for disease activity in UC, its correlation with disease extent and its utility in differentiating IBS from IBD. Methods A total of 75 patients (50 cases with colonoscopic evidence of inflammation and 25 cases with normal colonoscopic examination) were included in the study. Fecal calprotectin test was done on the day of colonoscopy. Severity of the disease was assessed by modified Mayo's endoscopy score (MMES). Results Age and baseline parameters were comparable in both the groups (UC and IBS). Patients in the ulcerative group had tachycardia (95 vs 74), high ESR (26 vs 20), high leukocytes count (9198 vs 8852), high fecal calprotectin (594 vs 29), low albumin (3.00 vs 3.80) and low hemoglobin (11 vs 13.40). Minimum and maximum MMES were 2 and 13.2. A significant correlation was observed between fecal calprotectin and MMES (p-value < 0.001). Conclusion Fecal calprotectin is a simple, noninvasive, cost-effective marker that is strongly associated with colorectal inflammation; moreover, it has better role in the differentiation of IBD (UC) from IBS. How to cite this article Acharya K, Bhardwaj V, Chuahan I, et al. Comparison of Fecal Calprotectin with Different Endoscopic Scores in the Assessment of Ulcerative Colitis (UC) Activity and Its Utility in Differentiating IBS from IBD. Euroasian J Hepato-Gastroenterol 2023;13(2):120-123.
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Affiliation(s)
- Kalpana Acharya
- Department of Gastroenterology, RML Hospital, New Delhi, India
| | | | - Imran Chuahan
- Department of Gastroenterology, RML Hospital, New Delhi, India
| | - Syed Mushfiq
- Department of Gastroenterology, SKIMS, Srinagar, Jammu and Kashmir, India
| | - Sunil Bhatt
- Department of Gastroenterology, RML Hospital, New Delhi, India
| | - Brij Mohan Lamba
- Department of Medicine, Sharda University, Noida, Uttar Pradesh, India
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Spencer EA, Agrawal M, Jess T. Prognostication in inflammatory bowel disease. Front Med (Lausanne) 2022; 9:1025375. [PMID: 36275829 PMCID: PMC9582521 DOI: 10.3389/fmed.2022.1025375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/14/2022] [Indexed: 11/13/2022] Open
Abstract
Personalized care in inflammatory bowel diseases (IBD) hinges on parsing the heterogeneity of IBD patients through prognostication of their disease course and therapeutic response to allow for tailor-made treatment and monitoring strategies to optimize care. Herein we review the currently available predictors of outcomes in IBD and those on the both near and far horizons. We additionally discuss the importance of worldwide collaborative efforts and tools to support clinical use of these prognostication tools.
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Affiliation(s)
- Elizabeth A. Spencer
- Division of Pediatric Gastroenterology and Nutrition, Icahn School of Medicine, Mount Sinai Hospital, New York, NY, United States
| | - Manasi Agrawal
- Division of Gastroenterology, Icahn School of Medicine, Mount Sinai Hospital, New York, NY, United States
- Center for Molecular Prediction of Inflammatory Bowel Disease, PREDICT, Aalborg University, Aalborg, Denmark
| | - Tine Jess
- Center for Molecular Prediction of Inflammatory Bowel Disease, PREDICT, Aalborg University, Aalborg, Denmark
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
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Oh CK, Lee HH, Kim JS, Lee BI, Cho YS. Appendiceal Orifice Inflammation Is Associated with Lower Rate of Complete Endoscopic Remission in Patients with Ulcerative Colitis. J Pers Med 2022; 12:748. [PMID: 35629170 PMCID: PMC9146904 DOI: 10.3390/jpm12050748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/25/2022] [Accepted: 05/03/2022] [Indexed: 11/17/2022] Open
Abstract
Appendiceal orifice inflammation (AOI) is commonly considered a skip lesion in ulcerative colitis (UC). However, the clinical significance of AOI in UC patients remains controversial. This study aimed to evaluate the clinical feature and long-term outcomes of AOI by comparing UC patients with and without AOI. This study was conducted as a retrospective design of patients who were newly diagnosed or referred within 3 months after diagnosis at Seoul St. Mary's Hospital from 1 January 2001 to 31 December 2020. All patients underwent index and follow-up colonoscopies. The long-term outcomes involved achieving complete endoscopic remission (ER), use of biologics, hospitalization, and proximal disease extension. Complete ER was defined as Mayo endoscopic subscore 0. In total, 318 UC patients were included, of which 140 had AOI. The baseline characteristics were not significantly different between AOI and non-AOI groups. The cumulative risk of complete ER was a significant difference between AOI and non-AOI groups (p = 0.041). The other cumulative risks of disease outcomes were not significantly different between AOI and non-AOI groups (use of biologics, p = 0.542; hospitalization, p = 0.795; proximal disease extension, p = 0.403). The multivariate Cox regression analysis also revealed that AOI was the significant factor of complete ER (hazard ratio, 0.656; 95% confidence interval, 0.462-0.932; p = 0.019) in UC patients. AOI shows a significant association with lower rate of complete ER in UC patients. Therefore, a meticulous treatment strategy may be recommended to achieve complete ER in UC patients with AOI.
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Affiliation(s)
- Chang Kyo Oh
- Division of Gastroenterology, Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Korea;
| | - Han Hee Lee
- Division of Gastroenterology, Department of Internal Medicine, Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul 07345, Korea;
| | - Jin Su Kim
- Division of Gastroenterology, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, The Catholic University of Korea, Seoul 03312, Korea;
| | - Bo-In Lee
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul 06591, Korea;
| | - Young-Seok Cho
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul 06591, Korea;
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Hao Y, Yzet C, McBride RB, Stock A, Tiratterra E, D'Errico A, Belluzzi A, Scaioli E, Gionchetti P, Roda G, Ungaro R, Colombel JF, Harpaz N, Ko HM. Baseline Histological Findings Do Not Predict the Risk of Subsequent Extension in Patients with Limited Ulcerative Colitis. Dig Dis Sci 2022; 67:1311-1319. [PMID: 33934255 DOI: 10.1007/s10620-021-06970-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 03/24/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Among patients with limited ulcerative colitis (UC), 30% ultimately extend to pancolitis and are at increased risk of adverse clinical outcomes. Risk of endoscopic extension has been found to correlate with clinical features such as early age of onset. AIMS We sought to determine whether histologic features correlate with disease extension. METHODS The study population consisted of 40 patients with UC from two large academic centers diagnosed between 2006 and 2017. Eligible cases had a diagnosis of endoscopically limited UC (Montreal E1 or E2) at baseline and ≥ 2 subsequent endoscopic examinations with biopsies. Severity of inflammation was scored using both the Mount Sinai Activity Index and Nancy Histological Index. RESULTS Patients were divided into two cohorts: those who progressed to pancolitis (Montreal E3) were defined as "Extenders" (n = 21), whereas "Non-extenders" (n = 19) were cases without progression in the follow-up period. The median follow-up time was 58.4 months. The histologic scores in the endoscopically involved mucosa of the index biopsies were not associated with subsequent extension of disease, overall. However, among extender cohort, the index histology scores correlated with biopsy scores at extension (r = 0.455, P = 0.044) and index severity was associated with a shorter time to extension (r = - 0.611, P = 0.003). Furthermore, female patients had a shorter time to extension (P = 0.013). CONCLUSIONS Histological severity of limited UC is not an independent predictor of extension in UC. However, among patients who subsequently extend, severe inflammation at baseline correlates with shorter progression time and severe inflammation when extension occurs. Patients with limited UC but severe histologic inflammation may warrant more frequent endoscopic surveillance.
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Affiliation(s)
- Yansheng Hao
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Clara Yzet
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France
| | - Russell B McBride
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aryeh Stock
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elisa Tiratterra
- Department of Medical and Surgical Sciences (DIMEC), Gastroenterology and Endoscopy Unit, Sant'Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Antonietta D'Errico
- 'F Addarii'' Institute of Oncology and Transplantation Pathology, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Andrea Belluzzi
- Department of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Eleonora Scaioli
- Department of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Paolo Gionchetti
- Department of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giulia Roda
- Inflammatory Bowel Disease Center, Department of Gastroenterology, Humanitas Clinical and Research Center -IRCCS, Milan, Italy
| | - Ryan Ungaro
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jean-Frederic Colombel
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Noam Harpaz
- Departments of Pathology and Medicine (Gastroenterology), Icahn School of Medicine At Mount Sinai, New York, NY, USA
| | - Huaibin Mabel Ko
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA.
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Krugliak Cleveland N, Torres J, Rubin DT. What Does Disease Progression Look Like in Ulcerative Colitis, and How Might It Be Prevented? Gastroenterology 2022; 162:1396-1408. [PMID: 35101421 DOI: 10.1053/j.gastro.2022.01.023] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/22/2022] [Accepted: 01/24/2022] [Indexed: 02/08/2023]
Abstract
Ulcerative colitis (UC) has been characterized by inflammation limited to the mucosa. Although sustained and durable remission has been associated with mucosal healing, the recurrent phenomenon of persistent clinical disease activity despite mucosal healing has been observed in clinical practice and across pivotal trials. Over time, UC appears to confer an increased risk of progression, defined as changes of disease phenotype; adverse transmural effects on the bowel wall; increased risk of neoplasia development; worsening colorectal function; and increased risk of colectomy, hospitalizations, and other extraintestinal comorbidities. Although the treatment paradigm for Crohn's disease has shifted toward early aggressive intervention to prevent disease progression and irreversible bowel damage, such urgency in efforts to halt disease progression in UC have been largely overlooked. This review summarizes the multiple facets of UC contributing to a modified perception of the disease as a progressive one. We propose further study of the natural history and priorities for further treatment goals that include these considerations.
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Affiliation(s)
| | - Joana Torres
- Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Lisbon, Portugal; Division of Gastroenterology, Hospital da Luz, Lisbon, Portugal
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois.
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Dahlgren D, Agréus L, Stålhammar J, Hellström PM. Ulcerative colitis progression: a retrospective analysis of disease burden using electronic medical records. Ups J Med Sci 2022; 127:8833. [PMID: 36337279 PMCID: PMC9602193 DOI: 10.48101/ujms.v127.8833] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/15/2022] [Accepted: 09/18/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Ulcerative colitis (UC) is a debilitating inflammatory bowel disease. Present knowledge regarding UC disease progression over time is limited. OBJECTIVE To assess UC progression to severe disease along with disease burden and associated factors. METHODS Electronic medical records linked with Swedish national health registries (2005-2015) were used to identify disease progression of UC. Odds of all-cause and disease-related hospitalization within 1 year were compared between patients with disease progression and those without. Annual indirect costs were calculated based on sick leave, and factors related to UC progression were examined. RESULTS Of the 1,361 patients with moderate UC, 24% progressed to severe disease during a median of 5.2 years. Severe UC had significantly higher odds for all-cause (OR [odds ratio] 1.47, 95% CI [confidence interval]: 1.12-1.94, P < 0.01) and UC-related hospitalization (OR 2.47, 95% CI: 1.76-3.47, P < 0.0001) compared to moderate disease. Average sick leave was higher in patients who progressed compared to those who did not (64.4 vs 38.6 days, P < 0.001), with higher indirect costs of 151,800 SEK (16,415 €) compared with 92,839 SEK (10,039 €) (P < 0.001), respectively. UC progression was related to young age (OR 1.62, 95% CI: 1.17-2.25, P < 0.01), long disease duration (OR 1.09, 95% CI: 1.03-1.15, P < 0.001), and use of corticosteroids (OR 2.49, 95% CI: 1.67-3.72, P < 0.001). CONCLUSION Disease progression from moderate to severe UC is associated with more frequent and longer hospitalizations and sick leave. Patients at young age with long disease duration and more frequent glucocorticosteroid medication are associated with progression to severe UC.
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Affiliation(s)
- David Dahlgren
- Department of Pharmaceutical Biosciences, Translational Drug Discovery and Development, Uppsala University, Uppsala, Sweden
| | - Lars Agréus
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Jan Stålhammar
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Per M. Hellström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Association Between Ex Vivo Human Ulcerative Colitis Explant Protein Secretion Profiles and Disease Behaviour. Dig Dis Sci 2022; 67:5540-5550. [PMID: 35288829 PMCID: PMC9652171 DOI: 10.1007/s10620-022-07411-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 01/18/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND The clinical course of ulcerative colitis (UC) is variable. There is an unmet clinical need for biomarkers of UC disease behaviour. We aimed to evaluate the association between ex vivo human UC explant conditioned media (explant-CM) secreted protein profiles and UC disease behaviour. METHODS UC patients undergoing endoscopy were prospectively recruited. Endoscopic biopsies were collected and explant-CM generated. Association between explant-CM protein secretion profiles and disease progression was evaluated. Disease progression was defined as the requirement for corticosteroid therapy, UC-related hospitalisation, UC-related surgery or the introduction of a new immunomodulatory agent. Association between explant-CM secreted protein profiles and anti-TNF failure status was also evaluated. p values < 0.05 were considered significant in analyses. RESULTS Twenty-four UC patients were included (age [median, range]) 55 [21-72] years; 50% female. Disease progression during follow-up occurred in twelve (50%) patients. Multivariate analysis, including endoscopic remission status, demonstrated reduced IL-2 secretion to be independently associated with UC disease progression, p = 0.01. In univariate analysis, anti-TNF failure status was associated with significantly increased IL-17A/F (p = 0.015) and IL-12 / IL-23p40 (p = 0.044) concentrations. In multivariate analysis, there was a trend towards an association between IL-17A/F and anti-TNF failure status (p = 0.069); FLT-1 was demonstrated to be independently associated with anti-TNF failure status (p = 0.016). CONCLUSION Reduced explant-CM secreted IL-2 is associated with UC disease progression. Increased secretion of IL-23 pathway-associated cytokines was observed in anti-TNF failure status consistent with previous reports. Ex vivo human UC explants, generated from endoscopic biopsies, have potential as precision medicine tools in inflammatory bowel disease.
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Wan J, Wang X, Zhang Y, Xue X, Jia H, Wang M, Liang J, Wu K. OUP accepted manuscript. Gastroenterol Rep (Oxf) 2022; 10:goac019. [PMID: 35599745 PMCID: PMC9114755 DOI: 10.1093/gastro/goac019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 11/17/2022] Open
Abstract
Background Ulcerative colitis (UC) is a chronic lifelong disease. The disease extent of UC can progress over time. This study aimed to assess whether cumulative inflammatory burden (CIB) is associated with disease extension in distal UC (proctitis [E1] and left-sided colitis [E2]) patients, and to develop a quantified indicator of CIB. Methods In this retrospective study based on a prospective registry, distal UC patients receiving colonoscopies in Xijing Hospital (Xi’an, China) from January 2000 to May 2019 were studied. We developed a new score, namely the time-adjusted average Mayo endoscopic score (TA-MES), calculated as dividing the sum of the cumulative average MES over a period of surveillance time by the length of the endoscopic examination interval, to quantify the CIB. Cox regression was used to identify other potential risk factors. Results A total of 295 UC patients were followed for 1,487.02 patient-years. Among them, 140 patients (47.5%) experienced disease extension. Multivariate analysis showed that the TA-MES was significantly associated with disease extension in E1 (hazard ratio [HR], 2.90; 95% confidence interval [CI], 1.58–5.33, P = 0.001) and E2 (HR, 1.89; 95% CI, 1.16–3.09, P = 0.011) patients. Other risk factors included hemoglobin of <90 g/L and appendiceal skip inflammation; the protective factors included age, E2 at diagnosis, former smoking, and 5-aminosalicylic acid dose. Otherwise, MES at diagnosis, maximal MES, and mean MES failed to estimate the risk of disease extension. Conclusion TA-MES is a good quantified indicator of CIB and is independently associated with increased disease extension in distal UC patients. Whether the dynamic multiple scoring system could be used as a risk factor in other chronic relapsing–remitting diseases is a direction for future research.
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Affiliation(s)
- Jian Wan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, Shaanxi, P. R. China
| | - Xuan Wang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi, P. R. China
| | - Yujie Zhang
- Department of Histology and Embryology, School of Basic Medicine, Xi’an Medical University, Xi’an, Shaanxi, P. R. China
| | - Xianmin Xue
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, Shaanxi, P. R. China
| | - Hui Jia
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, Shaanxi, P. R. China
| | - Min Wang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, Shaanxi, P. R. China
| | - Jie Liang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, Shaanxi, P. R. China
| | - Kaichun Wu
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, Shaanxi, P. R. China
- Corresponding author. Xijing Hospital of Digestive Diseases, Fourth Military Medical University, 127 Changle West Road, Xi’an, Shaanxi 710032, P. R. China. Tel: +86-29-84771502; Fax: +86-29-82539041;
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Zafer M, Zhang H, Dwadasi S, Goens D, Paknikar R, Dalal S, Cohen RD, Pekow J, Rubin DT, Sakuraba A, Micic D. A Clinical Predictive Model for One-year Colectomy in Adults Hospitalized for Severe Ulcerative Colitis. CROHN'S & COLITIS 360 2021; 4:otab082. [PMID: 36777555 PMCID: PMC9802419 DOI: 10.1093/crocol/otab082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Indexed: 11/13/2022] Open
Abstract
Background Models to predict colectomy in ulcerative colitis (UC) are valuable for identification, clinical management, and follow-up of high-risk patients. Our aim was to develop a clinical predictive model based on admission data for one-year colectomy in adults hospitalized for severe UC. Methods We performed a retrospective analysis of patients hospitalized at a tertiary academic center for management of severe UC from 1/2013 to 4/2018. Multivariate regression was performed to identify individual predictors of one-year colectomy. Outcome probabilities of colectomy based on the prognostic score were estimated using a bootstrapping technique. Results Two hundred twenty-nine individuals were included in the final analytic cohort. Four independent variables were associated with one-year colectomy which were incorporated into a point scoring system: (+) 1 for single class biologic exposure prior to admission; (+) 2 for multiple classes of biologic exposure; (+) 1 for inpatient salvage therapy with cyclosporine or a TNF-alpha inhibitor; (+) 1 for age <40. The risk probabilities of colectomy within one year in patients assigned scores 1, 2, 3, and 4 were 9.4% (95% CI, 1.7-17.2), 33.7% (95% CI, 23.9-43.5), 58.5% (95% CI, 42.9-74.1), 75.0% (95% CI, 50.5-99.5). An assigned score of zero was a perfect predictor of no colectomy. Conclusion Risk factors most associated with one-year colectomy for severe UC included: prior biologic exposure, need for inpatient salvage therapy, and younger age. We developed a simple scoring system using these variables to identify and stratify patients during their index hospitalization.
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Affiliation(s)
- Maryam Zafer
- Department of Internal Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Hui Zhang
- The Center for Health and the Social Sciences, University of Chicago, Chicago, IL, USA
| | - Sujaata Dwadasi
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Donald Goens
- Department of Internal Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Raghavendra Paknikar
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Sushila Dalal
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Russell D Cohen
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Joel Pekow
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - David T Rubin
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Atsushi Sakuraba
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Dejan Micic
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA,Address correspondence to: Dejan Micic, MD, 5841 South Maryland Avenue, MC4076, Chicago, IL 60637, USA. Telephone: 773-702-9200 ()
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Raine T, Verstockt B, Kopylov U, Karmiris K, Goldberg R, Atreya R, Burisch J, Burke J, Ellul P, Hedin C, Holubar SD, Katsanos K, Lobaton T, Schmidt C, Cullen G. ECCO Topical Review: Refractory Inflammatory Bowel Disease. J Crohns Colitis 2021; 15:1605-1620. [PMID: 34160593 DOI: 10.1093/ecco-jcc/jjab112] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Inflammatory bowel disease is a chronic disease with variable degrees of extent, severity, and activity. A proportion of patients will have disease that is refractory to licensed therapies, resulting in significant impairment in quality of life. The treatment of these patients involves a systematic approach by the entire multidisciplinary team, with particular consideration given to medical options including unlicensed therapies, surgical interventions, and dietetic and psychological support. The purpose of this review is to guide clinicians through this process and provide an accurate summary of the available evidence for different strategies.
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Affiliation(s)
- Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, TARGID - IBD, KU Leuven, Leuven, Belgium
| | - Uri Kopylov
- Department of Gastroenterology, Sheba Medical Center, Ramat Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Rimma Goldberg
- Department of Gastroenterology, Monash Health and School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Raja Atreya
- Department of Medicine 1, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - John Burke
- Colorectal and General Surgery, Beaumont Hospital, Dublin, Ireland
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Charlotte Hedin
- Karolinska Institutet, Department of Medicine Solna, Stockholm, Sweden
- Karolinska University Hospital, Gastroenterology Unit, Department of Gastroenterology, Dermatovenereology and Rheumatology, Stockholm, Sweden
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Ioannina, Greece
| | - Triana Lobaton
- Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Carsten Schmidt
- Medical Faculty of the Friedrich Schiller University, Jena, Germany
| | - Garret Cullen
- Centre for Colorectal Disease, St Vincent's University Hospital and School of Medicine, University College Dublin, Gastroenterology, Dublin, Ireland
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14
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Agrawal M, Spencer EA, Colombel JF, Ungaro RC. Approach to the Management of Recently Diagnosed Inflammatory Bowel Disease Patients: A User's Guide for Adult and Pediatric Gastroenterologists. Gastroenterology 2021; 161:47-65. [PMID: 33940007 PMCID: PMC8640961 DOI: 10.1053/j.gastro.2021.04.063] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/29/2021] [Accepted: 04/27/2021] [Indexed: 12/13/2022]
Abstract
Inflammatory bowel diseases (IBDs), including Crohn's disease and ulcerative colitis, are chronic, progressive, immune-mediated diseases of adults and children that have no cure. IBD can cause significant morbidity and lead to complications such as strictures, fistulas, infections, and cancer. In children, IBD can also result in growth impairment and pubertal delays. IBD is highly heterogenous, with severity ranging from mild to severe and symptoms ranging from mild to debilitating. Delay in IBD diagnosis, especially in Crohn's disease, is common and associated with adverse outcomes. Early diagnosis and prompt institution of treatment are the cornerstones for improving outcomes and maximizing health. Early diagnosis requires a low threshold of suspicion and red flags to guide early specialist referral at the primary provider level. Although the armamentarium of IBD medications is growing, many patients will not respond to treatment, and the selection of first-line therapy is critical. Risk stratification of disease severity, based on clinical, demographic, and serologic markers, can help guide selection of first-line therapy. Clinical decision support tools, genomics, and other biomarkers of response to therapy and risk of adverse events are the future of personalized medicine. After starting appropriate therapy, it is important to confirm remission using objective end points (treat to target) with continued control of inflammation with adjustment of therapy using surrogate biomarkers (tight control). Lastly, IBD therapy extends far beyond medications, and other aspects of the overall health and wellbeing of the patient are critical. These include preventive health, nutrition, and psychobehavioral support addressing patients' concerns around complementary therapy and medication adherence, prevention of disability, and ensuring open communication.
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Affiliation(s)
- Manasi Agrawal
- The Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Elizabeth A. Spencer
- The Division of Pediatric Gastroenterology and Nutrition, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jean-Frederic Colombel
- The Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ryan C. Ungaro
- The Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
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15
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Christensen B, Hanauer SB, Gibson PR, Turner JR, Hart J, Rubin DT. Segmental Histological Normalisation Occurs in Ulcerative Colitis but Does Not Improve Clinical Outcomes. J Crohns Colitis 2020; 14:1345-1353. [PMID: 32267926 PMCID: PMC7533894 DOI: 10.1093/ecco-jcc/jjaa068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Complete histological normalisation and reduction of inflammation severity in patients with ulcerative colitis are associated with improved clinical outcomes, but the clinical significance of normalisation of only segments of previously affected bowel is not known. We examined the prevalence, pattern, predictors, and clinical outcomes associated with segmental histological normalisation in in patients with ulcerative colitis. METHODS Medical records of patients with confirmed ulcerative colitis and more than one colonoscopy were sought. Segmental histological normalisation was defined as histological normalisation of a bowel segment [rectum, left-sided or right-sided colon] that had previous evidence of chronic histological injury. We assessed the variables influencing these findings and whether segmental normalisation was associated with improved clinical outcomes. RESULTS Of 646 patients, 32% had segmental and 10% complete histological normalisaton when compared with their maximal disease extent. Most [88%] had segmental normalisation in a proximal-to-distal direction. Others had distal-to-proximal or patchy normalisation. On multivariate analysis, only current smoking [p = 0.040] and age of diagnosis ≤16 years [p = 0.028] predicted segmental histological normalisation. Of 310 who were in clinical remission at initial colonoscopy, 77 [25%] experienced clinical relapse after median 1.3 [range 0.06-7.52] years. Only complete histological normalisation of the bowel was associated with improved relapse-free survival (hazard ratio [HR] 0.23; 95% confidence interval [CI] 0.08-0.68; p = 0.008]. CONCLUSIONS Segmental histological normalisation occurs in 32% of patients with ulcerative colitis and is increased in those who smoke or were diagnosed at younger age. Unlike complete histological normalisation, segmental normalisation does not signal improved clinical outcomes.
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Affiliation(s)
- Britt Christensen
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
- Department of Gastroenterology, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Gastroenterology, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Stephen B Hanauer
- Digestive Disease Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Jerrold R Turner
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - John Hart
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
- Department of Pathology, University of Chicago Medicine, Chicago, IL, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
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Abstract
Ulcerative colitis (UC) is a chronic inflammatory bowel disease associated with considerable disease burden. We review some current misconceptions about UC in adults with the aim of optimizing care for patients. Although UC and Crohn's disease (CD) are considered discrete diseases, distinctions between them are not always clear-cut and phenotypes may change over time. Patient management should take into account disease manifestations, disease severity and extent, and response to prior treatments. Although disease extent often defines severity, distal UC is not always less disabling than extensive disease as patients can progress to more extensive disease. In addition, severe proctitis can give rise to severe and debilitating symptoms, with a substantial impact on health-related quality of life. UC carries an increased risk of colorectal cancer (CRC) compared with CD; however, more recent data indicate a similar risk of CRC in CD with colonic involvement as with UC. Corticosteroids are widely used to induce remission in UC, and prolonged use of steroids in patients with UC is common, but corticosteroid-free maintenance of remission is an important therapeutic goal. Although biologic therapies provide a valuable treatment option in UC, they are not clinically effective in all patients and are also associated with secondary loss of response.
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17
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Koliani-Pace JL, Siegel CA. Prognosticating the Course of Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2019; 29:395-404. [PMID: 31078243 DOI: 10.1016/j.giec.2019.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Both Crohn's disease and ulcerative colitis are inflammatory bowel diseases (IBD) that can lead to progressive irreversible bowel damage. Selecting the most appropriate therapy for patients is a challenge because not all patients diagnosed with IBD have complications, and the amount of time to develop a complication is different for individuals. Models using patient characteristics, genetics, and immune responses help identify those patients who require early aggressive therapy with a goal to modify their disease course. Future research will help identify the role that the microbiome, metagenomics, metaproteomics, and microRNAs play in a patient prognosis.
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Affiliation(s)
- Jenna L Koliani-Pace
- Inflammatory Bowel Disease Center, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Dartmouth-Hitchcock, 1 Medical Center Drive, Lebanon, NH 03766, USA
| | - Corey A Siegel
- Inflammatory Bowel Disease Center, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
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18
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Macaluso FS, Cavallaro F, Felice C, Mazza M, Armuzzi A, Gionchetti P, Vecchi M, Orlando A. Risk factors and timing for colectomy in chronically active refractory ulcerative colitis: A systematic review. Dig Liver Dis 2019; 51:613-620. [PMID: 30826279 DOI: 10.1016/j.dld.2019.01.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND In patients with chronic refractory ulcerative colitis (UC) the precise timing for indication to colectomy is unclear. AIMS We performed a systematic review of the literature on the risk factors for colectomy in patients with chronic refractory UC in the biologic era. METHODS PubMed Central/Medline and Embase were systemically searched for records published between January 2000 and December 2017. Current evidence was summarized and filtered by expert opinion. RESULTS 70 studies were included in the qualitative synthesis. Several factors were found to be associated with a higher or reduced risk for colectomy, including variables at baseline - such as progression from proctitis/left-sided to extensive colitis, extensive colitis at diagnosis, high baseline C Reactive Protein or erythrocyte sedimentation rate, male gender, and younger age at diagnosis - previous medical history, and factors arising during therapy with biologics, including the absence of clinical response after induction with infliximab or adalimumab, and the lack of mucosal healing during therapy with anti-TNFs. CONCLUSIONS Two main points may help physicians to decide when the surgical option may be considered in patients with chronic refractory UC: (1) a first risk stratification can be obtained by analyzing factors at baseline and medical history, including the previous exposure to anti-TNFs; (2) during therapy with biologics, the early assessment (after 12-16 weeks of treatment) of clinical and endoscopic response is a strong predictor of the subsequent risk of colectomy.
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Affiliation(s)
| | - Flaminia Cavallaro
- Gastroenterology & Digestive Endoscopy Unit, IRCCS Policlinico San Donato, Milano, Italy
| | - Carla Felice
- IBD Unit, "Presidio Columbus" Foundation Hospital "A. Gemelli IRCCS" - Sacro Cuore Catholic University, Rome
| | - Marta Mazza
- Department of Medical and Surgical Sciences (DIMEC), Policlinico S.Orsola-Malpighi, University of Bologna, Italy
| | - Alessandro Armuzzi
- IBD Unit, "Presidio Columbus" Foundation Hospital "A. Gemelli IRCCS" - Sacro Cuore Catholic University, Rome
| | - Paolo Gionchetti
- Department of Medical and Surgical Sciences (DIMEC), Policlinico S.Orsola-Malpighi, University of Bologna, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Organ Transplantation, University of Milan, Italy
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Zittan E, Muir J, Milgrom R, Berns M, Gralnek IM, Cohen Z, Riddell R, Silverberg MS. Preoperative exposure to anti-tumor necrosis factor therapy in ulcerative colitis patients undergoing ileal pouch-anal anastomosis (IPAA) is not associated with histological fibrosis: A case control study. Int J Surg 2019; 65:80-85. [DOI: 10.1016/j.ijsu.2019.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 01/15/2019] [Accepted: 03/22/2019] [Indexed: 01/30/2023]
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Sedano Muñoz R, Quera Pino R, Ibáñez Lazo P, Figueroa Corona C, Flores Pérez L. Aminosalicylates, thiopurines and methotrexate in inflammatory bowel disease: Is it possible to discontinue the treatment? GASTROENTEROLOGIA Y HEPATOLOGIA 2019; 42:339-347. [PMID: 30954317 DOI: 10.1016/j.gastrohep.2019.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 06/09/2023]
Abstract
The current goals of treatment in inflammatory bowel disease, both Crohn's disease and ulcerative colitis, are to achieve clinical, endoscopic and ideally histological remission and improve the quality of life of these patients. Current therapies are effective in achieving remission in most cases, but there is a lack of clear guidelines on their optimal duration. This review aims to evaluate the current evidence on the withdrawal of therapy with 5-aminosalicylates, thiopurines and methotrexate. We also aim to identify which specific group of patients, while in remission and in the absence of risk factors, may be able to discontinue therapy without a significant risk of relapse.
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Affiliation(s)
- Rocío Sedano Muñoz
- Servicio de Gastroenterología, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Rodrigo Quera Pino
- Programa Enfermedad Inflamatoria Intestinal, Servicio de Gastroenterología, Clínica las Condes, Santiago, Chile.
| | - Patricio Ibáñez Lazo
- Programa Enfermedad Inflamatoria Intestinal, Servicio de Gastroenterología, Clínica las Condes, Santiago, Chile
| | - Carolina Figueroa Corona
- Programa Enfermedad Inflamatoria Intestinal, Servicio de Gastroenterología, Clínica las Condes, Santiago, Chile
| | - Lilian Flores Pérez
- Programa Enfermedad Inflamatoria Intestinal, Servicio de Gastroenterología, Clínica las Condes, Santiago, Chile
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Qiu Y, Chen B, Li Y, Xiong S, Zhang S, He Y, Zeng Z, Ben-Horin S, Chen M, Mao R. Risk factors and long-term outcome of disease extent progression in Asian patients with ulcerative colitis: a retrospective cohort study. BMC Gastroenterol 2019; 19:7. [PMID: 30630426 PMCID: PMC6327558 DOI: 10.1186/s12876-018-0928-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 12/27/2018] [Indexed: 02/07/2023] Open
Abstract
Background The incidence of Ulcerative colitis (UC) in Asia is increasing but reports on its long-term course are few. The aim of this study was to identify risk factors predictive of extent progression in Asian patients with UC and to evaluate the clinical outcome by longitudinal follow-up. Methods We retrospectively analyzed 518 UC patients without ascending colon involvement at diagnosis who were regularly followed and underwent colonoscopy between 2003 and 2016 in an Asian tertiary referral center. Proximal disease extension and associated risk factors were analyzed. Results A total of 91 (17.6%) patients experienced proximal disease extension followed for a median period of 7.5 years. The median time for extent extension was 16.1 months (interquartile range (IQR) 8.3–42.2). The cumulative rate of disease extension was 9.9, 14.9, 19.6, 24.6 and 30.5% at 1,2,3,4 and 5 years after diagnosis. 43 (12.0%) patients with E1/E2 progressed to E3, and 40 (21.9%) with E1 progressed to E2. Of patients diagnosed with E3 involvement limited to the hepatic flexure distally, 8 (13.3%) progressed to pancolitis. Cox regression analysis found that disease extent at diagnosis was the sole predictor of disease extension (odds ratio (OR),1.74, 95% confidence interval (CI) 1.18–2.57, p = 0.01). Proximal disease extension was associated with disease relapse (p = 0.03) and increased use of steroids and immunosuppressive agents (p < 0.01). Conclusion UC is a dynamic disease and that the disease extension in Asians was comparable to that in Caucasians. Proximal disease extension increased the risk of disease flare and treatment intensification.
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Affiliation(s)
- Yun Qiu
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan II Road, Guangzhou, 510080, People's Republic of China
| | - Baili Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan II Road, Guangzhou, 510080, People's Republic of China
| | - Yufei Li
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan II Road, Guangzhou, 510080, People's Republic of China
| | - Shanshan Xiong
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan II Road, Guangzhou, 510080, People's Republic of China
| | - Shenghong Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan II Road, Guangzhou, 510080, People's Republic of China
| | - Yao He
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan II Road, Guangzhou, 510080, People's Republic of China
| | - Zhirong Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan II Road, Guangzhou, 510080, People's Republic of China
| | - Shomron Ben-Horin
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan II Road, Guangzhou, 510080, People's Republic of China.,Department of Gastroenterology, Sheba Medical Center & Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan II Road, Guangzhou, 510080, People's Republic of China
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan II Road, Guangzhou, 510080, People's Republic of China. .,Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, USA.
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22
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Butera A, Sanchez M, Pronio A, Amendola A, De Nitto D, Di Carlo N, Lande R, Frasca L, Borrini F, Pica R, Boirivant M. CD3+CD4+LAP+Foxp3-Regulatory Cells of the Colonic Lamina Propria Limit Disease Extension in Ulcerative Colitis. Front Immunol 2018; 9:2511. [PMID: 30425718 PMCID: PMC6219428 DOI: 10.3389/fimmu.2018.02511] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 10/10/2018] [Indexed: 12/15/2022] Open
Abstract
Background and Aims: In ulcerative colitis (UC), inflammation begins in the rectum and can extend proximally throughout the entire colon. The extension of inflammation is an important determinant of disease course, and may be limited by the action of regulatory T cells (Tregs). In this cross-sectional study, we evaluated the relationship between UC extension and the proportions of CD3+CD4+Foxp3+ and CD3+CD4+LAP+Foxp3-Tregs in the colonic lamina propria (LP) of 79 UC patients and 29 controls. The role of these cells in UC extension was also investigated in the murine oxazolone-induced colitis model. Methods: Patients: Disease extension was classified according to the Montreal classification. Where possible, endoscopic biopsies of involved and uninvolved tissue were obtained from UC patients. Mouse model: Colitis was induced by intrarectal oxazolone administration. Lamina propria mononuclear cells were isolated from patient biopsies and mouse colon tissue using enzymatic method and the percentage of CD3+CD4+Foxp3+ and CD3+CD4+LAP+Foxp3-cells evaluated by immunofluorescence. Confocal microscopy was applied for the visualization and quantification of CD4+LAP+ cells on tissue histological sections. Results: In UC patients with distal colitis the proportion of LP CD3+CD4+Foxp3+ Tregs was significantly higher in inflamed tissue than uninvolved tissue. As opposite, the proportion of LP CD3+CD4+LAP+ Tregs was significantly higher in uninvolved tissue than involved tissue. Both LP CD3+CD4+Foxp3+ and LP CD3+CD4+LAP+ Tregs proportion in involved tissue was significantly higher than in controls irrespective of the extension of inflammation. In mice with oxazolone-induced distal colitis, treatment with LAP-depleting antibody was associated with the development of extensive colitis. Conclusions: Our findings suggest that CD3+CD4+LAP+Foxp3-Tregs limit the extension of inflammatory lesions in UC patients.
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Affiliation(s)
- Alessia Butera
- Pharmacological Research and Experimental Therapy Section, National Center for Drug Research and Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Massimo Sanchez
- Cytometry Unit-Core Facilities, Istituto Superiore di Sanità, Rome, Italy
| | - Annamaria Pronio
- Department of General Surgery "P. Stefanini", Sapienza University, Rome, Italy
| | - Antonello Amendola
- Unit of Arbo, Hanta and Emerging Viruses, National Reference Laboratory for Arboviruses, Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | | | - Nazzareno Di Carlo
- Pharmacological Research and Experimental Therapy Section, National Center for Drug Research and Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Roberto Lande
- Pharmacological Research and Experimental Therapy Section, National Center for Drug Research and Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Loredana Frasca
- Pharmacological Research and Experimental Therapy Section, National Center for Drug Research and Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | | | - Roberta Pica
- IBD, GE Unit, Sandro Pertini Hospital, Rome, Italy
| | - Monica Boirivant
- Pharmacological Research and Experimental Therapy Section, National Center for Drug Research and Evaluation, Istituto Superiore di Sanità, Rome, Italy
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Liefferinckx C, Franchimont D. Viewpoint: Toward the Genetic Architecture of Disease Severity in Inflammatory Bowel Diseases. Inflamm Bowel Dis 2018; 24:1428-1439. [PMID: 29788122 DOI: 10.1093/ibd/izy109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Indexed: 02/07/2023]
Abstract
Inflammatory bowel disease (IBD) is characterized by uneven disease courses with various clinical outcomes. A few prognostic markers of disease severity may help stratify patients and identify those who will benefit the most from early aggressive treatment. The concept of disease severity remains too broad and vague, mainly because the definition must embrace several disease mechanisms, mainly inflammation and fibrosis, with various rates of disease progression. The magnitude of inflammation is an obvious key driver of disease severity in IBD that ultimately influence disease behavior. Advances in the genetics underlying disease severity are currently emerging, but attempts to overlap the genetics of disease susceptibility and severity have until now been unsatisfactory, suggesting that the genetic architecture of disease severity may be distinct from the genetics of disease susceptibility. In this review, we report on the current knowledge on disease severity and on the main research venues to decipher the genetic architecture of disease severity.
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Affiliation(s)
| | - Denis Franchimont
- Department of Gastroenterology, Erasme Hospital, ULB, Brussels, Belgium
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24
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Kobayashi T, Hisamatsu T, Suzuki Y, Ogata H, Andoh A, Araki T, Hokari R, Iijima H, Ikeuchi H, Ishiguro Y, Kato S, Kunisaki R, Matsumoto T, Motoya S, Nagahori M, Nakamura S, Nakase H, Tsujikawa T, Sasaki M, Yokoyama K, Yoshimura N, Watanabe K, Katafuchi M, Watanabe M, Hibi T. Predicting outcomes to optimize disease management in inflammatory bowel disease in Japan: their differences and similarities to Western countries. Intest Res 2018; 16:168-177. [PMID: 29743830 PMCID: PMC5934590 DOI: 10.5217/ir.2018.16.2.168] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 09/22/2017] [Accepted: 10/19/2017] [Indexed: 12/13/2022] Open
Abstract
Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is a chronic inflammatory disease of the gastrointestinal tract, with increasing prevalence worldwide. IBD Ahead is an international educational program that aims to explore questions commonly raised by clinicians about various areas of IBD care and to consolidate available published evidence and expert opinion into a consensus for the optimization of IBD management. Given differences in the epidemiology, clinical and genetic characteristics, management, and prognosis of IBD between patients in Japan and the rest of the world, this statement was formulated as the result of literature reviews and discussions among Japanese experts as part of the IBD Ahead program to consolidate statements of factors for disease prognosis in IBD. Evidence levels were assigned to summary statements in the following categories: disease progression in CD and UC; surgery, hospitalization, intestinal failure, and permanent stoma in CD; acute severe UC; colectomy in UC; and colorectal carcinoma and dysplasia in IBD. The goal is that this statement can aid in the optimization of the treatment strategy for Japanese patients with IBD and help identify high-risk patients that require early intervention, to provide a better long-term prognosis in these patients.
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Affiliation(s)
- Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Tadakazu Hisamatsu
- The Third Department of Internal Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Yasuo Suzuki
- Department of Internal Medicine, Toho University Sakura Medical Center, Sakura, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Akira Andoh
- Department of Gastroenterology, Shiga University of Medical Science, Otsu, Japan
| | - Toshimitsu Araki
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Ryota Hokari
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Hideki Iijima
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hiroki Ikeuchi
- Department of Inflammatory Bowel Disease, Division of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoh Ishiguro
- Department of Gastroenterology and Hematology, Hirosaki National Hospital, Hirosaki, Japan
| | - Shingo Kato
- Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Reiko Kunisaki
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Satoshi Motoya
- IBD Center, Sapporo-Kosei General Hospital, Sapporo, Japan
| | - Masakazu Nagahori
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shiro Nakamura
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tomoyuki Tsujikawa
- Department of Gastroenterology and Hepatology, Higashi-Ohmi General Medical Center, Higashiomi, Japan
| | - Makoto Sasaki
- Division of Gastroenterology, Department of Internal Medicine, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Kaoru Yokoyama
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Naoki Yoshimura
- Division of Gastroenterology, Department of Medicine, Tokyo Yamate Medical Center, Tokyo, Japan
| | - Kenji Watanabe
- Department of Intestinal Inflammation Research, Hyogo College of Medicine, Nishinomiya, Japan
| | | | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
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Rinawi F, Assa A, Hartman C, Mozer Glassberg Y, Nachmias Friedler V, Rosenbach Y, Silbermintz A, Zevit N, Shamir R. Long-term Extent Change of Pediatric-Onset Ulcerative Colitis. J Clin Gastroenterol 2018; 52:326-332. [PMID: 28067753 DOI: 10.1097/mcg.0000000000000741] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Data describing extent change (progression or regression) in pediatric-onset ulcerative colitis (UC) are scarce. GOAL We aimed to describe extent change in pediatric-onset UC during long-term follow-up and to assess predictors of extent change. STUDY Medical charts of pediatric-onset UC patients with at least 5-year follow-up were analyzed retrospectively. Disease extent was determined using the Paris classification. It was examined at diagnosis and during follow-up at different time points. The impact of possible predictors on extent change including age at diagnosis, gender, clinical manifestations, disease, severity indices, and different therapeutic regimens during disease course was assessed. RESULTS Patients (n=134, 55% males) were followed for a median duration of 13.1 (range, 5 to 28) years. Median age at diagnosis was 13.1 (range, 2 to 17.8) years. Of 134 patients, 40.5% had extensive or pancolitis, 33.5% left-sided colitis, and 26% had proctitis at diagnosis. On follow-up (n=117), 45% had unchanged disease extent, 35% experienced extent progression, whereas 20% experienced regression of disease extent. The multivariate Cox models demonstrated that among children with left-sided disease at diagnosis, presence of extraintestinal manifestations (hazard ratio, 5.19; P=0.022), and higher pediatric UC activity index (hazard ratio, 8.77; P=0.008) were associated with extent progression to extensive disease. Predictors of extent regression have not been identified. CONCLUSIONS Disease extent changes significantly over time in pediatric-onset UC. In our cohort, presence of extraintestinal manifestation and higher pediatric UC activity index score at diagnosis were associated with progression from limited to extensive disease during follow-up.
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Affiliation(s)
- Firas Rinawi
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva
| | - Amit Assa
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Corina Hartman
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Yael Mozer Glassberg
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Vered Nachmias Friedler
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva
| | - Yoram Rosenbach
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva
| | - Ari Silbermintz
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva
| | - Noam Zevit
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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Kovacs G, Sipeki N, Suga B, Tornai T, Fechner K, Norman GL, Shums Z, Antal-Szalmas P, Papp M. Significance of serological markers in the disease course of ulcerative colitis in a prospective clinical cohort of patients. PLoS One 2018; 13:e0194166. [PMID: 29590158 PMCID: PMC5874003 DOI: 10.1371/journal.pone.0194166] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 02/13/2018] [Indexed: 12/20/2022] Open
Abstract
Background & aims To determine the prognostic potential of classic and novel serologic antibodies regarding unfavorable disease course in a prospective ulcerative colitis (UC) patient cohort, since few and conflicting data are available in the literature regarding this matter. Methods 187 consecutive patients were studied prospectively (median follow-up: 135 months) from a single referral IBD center in Hungary. Sera were tested for different IgA/IgG type autoantibodies (anti-neutrophil cytoplasmic [ANCA], anti-DNA-bound-lactoferrin [anti-LFS], anti-goblet cell [anti-GAB] and anti-pancreatic [PAB: anti-CUZD1 and anti-GP2)]) by indirect immunofluorescence technique and for anti-microbial (anti-Saccharomyces cerevisiae [ASCA] IgG/IgA and anti-OMP Plus™ IgA) antibodies by enzyme-linked immunosorbent assays. Results A total of 73.6%, 62.4% and 11.2% of UC patients were positive for IgA/IgG type of atypical perinuclear-ANCA, anti-LFS and anti-GAB, respectively. Occurrences of PABs were 9.6%, while ASCA IgA/IgG and anti-OMP IgA were 17.6% and 19.8%, respectively. Antibody status was stable over time. IgA type PABs were more prevalent in patients with primary sclerosing cholangitis (37.5% vs. 4.7% for anti-CUZD1 and 12.5% vs. 0% for anti-GP2, p<0.001 for both). IgA type ASCA and anti-CUZD1 antibodies were associated with higher risk of requirement for long-term immunosuppressant therapy in Kaplan-Meier analysis (pLogRank <0.01 for both). However, in multivariate Cox-regression analysis only ASCA IgA (HR: 2.74, 95%CI: 1.46–5.14, p<0.01) remained independent predictor. UC-related hospitalization due to disease activity was only associated with multiple antibody positivity (for 3 or more; HR 2.03 [95% CI: 1.16–3.56]; p = 0.013). None of the individual antibodies or their combination was associated with the risk of development of extensive disease or colectomy. Conclusion Even with low prevalence rates, present study gives further evidence to the role of certain antibodies as markers for distinct phenotype and disease outcome in UC. Considering the result of the multivariate analysis the novel antibodies investigated do not seem to be associated with poor clinical outcome in UC, only a classic antibody, IgA subtype ASCA remained an independent predictor of long-term immunosuppressive therapy.
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Affiliation(s)
- Gyorgy Kovacs
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Nora Sipeki
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Boglarka Suga
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tamas Tornai
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Kai Fechner
- Institute of Experimental Immunology, Euroimmun AG, Lübeck, Germany
| | - Gary L. Norman
- Inova Diagnostics, Inc., San Diego, California, United Statesof America
| | - Zakera Shums
- Inova Diagnostics, Inc., San Diego, California, United Statesof America
| | - Peter Antal-Szalmas
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Maria Papp
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- * E-mail:
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Burisch J, Ungaro R, Vind I, Prosberg MV, Bendtsen F, Colombel JF, Vester-Andersen MK. Proximal Disease Extension in Patients With Limited Ulcerative Colitis: A Danish Population-based Inception Cohort. J Crohns Colitis 2017; 11:1200-1204. [PMID: 28486626 PMCID: PMC6279091 DOI: 10.1093/ecco-jcc/jjx066] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 05/06/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Disease extent in ulcerative colitis [UC] is dynamic and can progress over time. Little is known about risk factors for UC extension in the era of biologics. We investigated the risk of UC extension and subsequent risk of surgery in a Danish population-based cohort. METHODS All incident UC cases in a strictly defined Copenhagen area between 2003 and 2004 were followed prospectively through 2011. Disease extension was defined as patients with limited UC [E1 or E2] at diagnosis having progressed from the initial extent by colonoscopy or surgery to E2 or extensive colitis [E3]. Associations between progression or colectomy and multiple covariates were analysed by Cox regression analysis. RESULTS Of 300 UC patients, 220 [73%] had E1 or E2 at diagnosis. During follow-up, 50 [23%] patients with E1/E2 progressed to E3, and 22 [10%] with E1 progressed to E2. Disease extent at diagnosis was the sole predictor of extension to E3. A total of 18 [8%] patients with E1/E2 at diagnosis had a colectomy. Progression from E1/E2 to E3, female gender and a history of smoking were risk factors for colectomy. CONCLUSION After 7 years of follow-up, 33% of patients with limited UC experienced disease extension. Only extent at diagnosis was a clinical predictor for disease extension. The risk of colectomy was increased in former smokers and patients who progressed to extensive colitis. This highlights the need to prevent disease progression in patients with limited UC, and to identify new histological or molecular markers that might help stratify risks for disease progression.
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Affiliation(s)
- Johan Burisch
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark,Corresponding author: Johan Burisch, MD, PhD, Gastrounit, Medical Division, Copenhagen University Hospital, Hvidovre, Kettegård Allé 30, 2750 Hvidovre, Denmark.
| | - Ryan Ungaro
- Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Ida Vind
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Michelle V Prosberg
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Flemming Bendtsen
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Jean-Frederic Colombel
- Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Marianne K. Vester-Andersen
- Gastrounit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark,Department of Internal Medicine, Zealand University Hospital, Køge, Denmark
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Ribaldone DG, Dileo I, Pellicano R, Resegotti A, Fagoonee S, Vernero M, Saracco G, Astegiano M. Severe ulcerative colitis: predictors of response and algorithm proposal for rescue therapy. Ir J Med Sci 2017; 187:385-392. [PMID: 28756540 DOI: 10.1007/s11845-017-1666-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 07/19/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is no agreeing if rescue therapy can avoid short-term colectomy in patients treated for severe steroid-refractory ulcerative colitis. AIMS The aim of our study was to identify predictors of response to infliximab and cyclosporine A. METHODS In this cross-sectional study, 49 patients with severe ulcerative colitis were included. Response to therapy was defined as three or more point reductions in Mayo score after 6 months of treatment and avoidance of colectomy after 1 year. The predictors analysed were gender, age, time from ulcerative colitis diagnosis, months of steroid or/and azathioprine therapy before onset of the severe phase, smoking habits, extension of the disease, laboratory analyses and Mayo score. RESULTS Patients treated with infliximab showed a statistically significant higher response rate in case of moderate Mayo score (P = 0.04). Ex-smokers had very low chance of response to infliximab (P = 0.03). In the group treated with cyclosporine A, patients with C-reactive protein >3 mg/L had a response rate significantly higher than those with C-reactive protein <3 mg/L (P = 0.03); those with negative C-reactive protein and moderate Mayo score did not responded to therapy, while in the ones with elevated C-reactive protein and/or severe Mayo score, 15 versus 4 responded (P = 0.008). CONCLUSIONS Our data suggest that cyclosporine A is advisable in ex-smokers. In never smokers or active smokers, infliximab can be prescribed in case of Mayo score ≤10 and/or negative CRP, while cyclosporine A is indicated in case of Mayo score >10 and positive CRP.
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Affiliation(s)
- D G Ribaldone
- Gastroenterology-U, General and Specialist Medicine Department, Città della Salute e della Scienza of Turin, C.so Bramante 88, 10126, Turin, Italy. .,Department of Gastroenterology and Hepatology, Molinette Hospital-S.G.A.S, Via Cavour 31, 10123, Turin, Italy.
| | - I Dileo
- Unit of Gastroenterology and Hepatology, Molinette Hospital, 10126, Turin, Italy
| | - R Pellicano
- Unit of Gastroenterology and Hepatology, Molinette Hospital, 10126, Turin, Italy
| | - A Resegotti
- Fourth General Surgery Department, Città della Salute e della Scienza, Azienda Ospedaliera ed Universitaria, 10126, Turin, Italy
| | - S Fagoonee
- Institute for Biostructures and Bioimages-CNR c/o Molecular Biotechnology Center, University of Torino, 10126, Turin, Italy
| | - M Vernero
- Unit of Gastroenterology and Hepatology, Molinette Hospital, 10126, Turin, Italy
| | - G Saracco
- Department of Medical Sciences, University of Torino, 10126, Turin, Italy
| | - M Astegiano
- Unit of Gastroenterology and Hepatology, Molinette Hospital, 10126, Turin, Italy
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29
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Lamba MJ, Tharayil VS, Gearry RB. Editorial: does disease extension lead to disease progression in proctitis? Aliment Pharmacol Ther 2017. [PMID: 28621077 DOI: 10.1111/apt.14129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- M J Lamba
- Department of Gastroenterology, Christchurch Hospital, Christchurch, New Zealand
| | - V S Tharayil
- Department of Gastroenterology, Christchurch Hospital, Christchurch, New Zealand
| | - R B Gearry
- Department of Gastroenterology, Christchurch Hospital, Christchurch, New Zealand.,Department of Medicine, University of Otago, Christchurch, New Zealand
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Ungaro R, Mehandru S, Allen PB, Peyrin-Biroulet L, Colombel JF. Ulcerative colitis. Lancet 2017; 389:1756-1770. [PMID: 27914657 PMCID: PMC6487890 DOI: 10.1016/s0140-6736(16)32126-2] [Citation(s) in RCA: 2101] [Impact Index Per Article: 300.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/15/2016] [Accepted: 07/21/2016] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis is a chronic inflammatory disease affecting the colon, and its incidence is rising worldwide. The pathogenesis is multifactorial, involving genetic predisposition, epithelial barrier defects, dysregulated immune responses, and environmental factors. Patients with ulcerative colitis have mucosal inflammation starting in the rectum that can extend continuously to proximal segments of the colon. Ulcerative colitis usually presents with bloody diarrhoea and is diagnosed by colonoscopy and histological findings. The aim of management is to induce and then maintain remission, defined as resolution of symptoms and endoscopic healing. Treatments for ulcerative colitis include 5-aminosalicylic acid drugs, steroids, and immunosuppressants. Some patients can require colectomy for medically refractory disease or to treat colonic neoplasia. The therapeutic armamentarium for ulcerative colitis is expanding, and the number of drugs with new targets will rapidly increase in coming years.
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Affiliation(s)
- Ryan Ungaro
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Saurabh Mehandru
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Patrick B Allen
- Division of Gastroenterology, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, University Hospital of Nancy-Brabois, Vandoeuvre-les-Nancy, France
| | - Jean-Frédéric Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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31
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Panes J, Jairath V, Levesque BG. Advances in Use of Endoscopy, Radiology, and Biomarkers to Monitor Inflammatory Bowel Diseases. Gastroenterology 2017; 152:362-373.e3. [PMID: 27751880 DOI: 10.1053/j.gastro.2016.10.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 10/07/2016] [Accepted: 10/11/2016] [Indexed: 02/07/2023]
Abstract
Crohn's disease and ulcerative colitis are heterogeneous inflammatory bowel diseases, and therapeutic requirements vary among patients. We have a limited capacity to predict disease progression for individual patients, therefore it is important that they are evaluated for the presence of active disease when symptoms are mild or even absent, when patients are more likely to respond to new treatment interventions. It then is important to monitor responses to treatment, to quickly identify those therapies that are ineffective, modify or change therapy, and avoid disease complications. Studies are underway to assess the effects of different monitoring strategies. Because of the heavy burden of severe inflammatory bowel disease on patients' health and quality of life, and the association between intestinal healing and disease progression in high-risk patients, a treat-to-target strategy (based on tissue healing) is likely to be optimal.
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Affiliation(s)
- Julian Panes
- Department of Gastroenterology Hospital Clinic of Barcelona, Institud d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.
| | - Vipul Jairath
- Department of Medicine, Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Robarts Clinical Trials. Inc, Western University, London, Ontario, Canada
| | - Barrett G Levesque
- Robarts Clinical Trials. Inc, Western University, London, Ontario, Canada
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Torres J, Caprioli F, Katsanos KH, Lobatón T, Micic D, Zerôncio M, Van Assche G, Lee JC, Lindsay JO, Rubin DT, Panaccione R, Colombel JF. Predicting Outcomes to Optimize Disease Management in Inflammatory Bowel Diseases. J Crohns Colitis 2016; 10:1385-1394. [PMID: 27282402 PMCID: PMC5174730 DOI: 10.1093/ecco-jcc/jjw116] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/29/2016] [Accepted: 05/26/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Efforts to slow or prevent the progressive course of inflammatory bowel diseases [IBD] include early and intensive monitoring and treatment of patients at higher risk for complications. It is therefore essential to identify high-risk patients - both at diagnosis and throughout disease course. METHODS As a part of an IBD Ahead initiative, we conducted a comprehensive literature review to identify predictors of long-term IBD prognosis and generate draft expert summary statements. Statements were refined at national meetings of IBD experts in 32 countries and were finalized at an international meeting in November 2014. RESULTS Patients with Crohn's disease presenting at a young age or with extensive anatomical involvement, deep ulcerations, ileal/ileocolonic involvement, perianal and/or severe rectal disease or penetrating/stenosing behaviour should be regarded as high risk for complications. Patients with ulcerative colitis presenting at young age, with extensive colitis and frequent flare-ups needing steroids or hospitalization present increased risk for colectomy or future hospitalization. Smoking status, concurrent primary sclerosing cholangitis and concurrent infections may impact the course of disease. Current genetic and serological markers lack accuracy for clinical use. CONCLUSIONS Simple demographic and clinical features can guide the clinician in identifying patients at higher risk for disease complications at diagnosis and throughout disease course. However, many of these risk factors have been identified retrospectively and lack validation. Appropriately powered prospective studies are required to inform algorithms that can truly predict the risk for disease progression in the individual patient.
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Affiliation(s)
- Joana Torres
- Surgical Department, Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Portugal
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Flavio Caprioli
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano and Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Policlinico di Milano, Milan, Italy
| | - Konstantinos H Katsanos
- Division of Gastroenterology, Department of Internal Medicine, School of Medical Sciences, University of Ioannina, Ioannina, Greece
| | - Triana Lobatón
- Department of Gastroenterology, Germans Trias i Pujol University Hospital, Badalona, Barcelona, Spain
| | - Dejan Micic
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
- Barts Health NHS Trust, Royal London Hospital, Whitechapel, London, UK
| | - Marco Zerôncio
- Inflammatory Bowel Disease Unit, Potiguar University School of Medicine, Natal, Brazil
| | - Gert Van Assche
- Division of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - James C Lee
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - James O Lindsay
- Barts Health NHS Trust, Royal London Hospital, Whitechapel, London, UK
| | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
- Barts Health NHS Trust, Royal London Hospital, Whitechapel, London, UK
| | - Remo Panaccione
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Jean-Frédéric Colombel
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Preoperative Anti-tumor Necrosis Factor Therapy in Patients with Ulcerative Colitis Is Not Associated with an Increased Risk of Infectious and Noninfectious Complications After Ileal Pouch-anal Anastomosis. Inflamm Bowel Dis 2016; 22:2442-7. [PMID: 27607335 DOI: 10.1097/mib.0000000000000919] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND There are conflicting data regarding the effect of previous exposure to anti-tumor necrosis factor (anti-TNF) therapy on complication rates after pelvic pouch surgery for patients with ulcerative colitis (UC). In particular, there is concern surrounding the rates of pouch leaks and infectious complications, including pelvic abscesses, in anti-TNF-treated subjects who require ileal pouch-anal anastomosis (IPAA) surgery. METHODS A retrospective study was performed in UC subjects who underwent IPAA between 2002 and 2013. Demographic data, clinical data, use of anti-TNF therapy, steroids, immunosuppressants, and surgical outcomes were assessed. RESULTS Seven hundred seventy-three patients with UC/IPAA were reviewed. Fifteen patients were excluded from the analysis because of missing data. There were 196 patients who were exposed to anti-TNF therapy and 562 patients who were not exposed to anti-TNF therapy preoperatively. There were no significant differences in the postoperative IPAA leak rate between those exposed to anti-TNF therapy and the control group (n = 26 [13.2%] versus 66 [11.7%], respectively, P = 0.44). In addition, there were no significant differences in the postoperative 2-stage IPAA leak rate in those who had been operated on within 15 days from the last anti-TNF dose (n = 10), within 15 to 30 days (n = 17), or 31 to 180 days (n = 54) (10%, 5.9%, and 14.8% respectively, P = 0.43) nor were there differences based on the presence of detectable infliximab serum levels. CONCLUSIONS Preoperative anti-TNF therapy in patients with UC is not associated with an increased risk of infectious and noninfectious complications after IPAA including pelvic abscesses, leaks, and wound infections.
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Anzai H, Hata K, Kishikawa J, Ishii H, Yasuda K, Otani K, Nishikawa T, Tanaka T, Kiyomatsu T, Kawai K, Nozawa H, Kazama S, Yamaguchi H, Ishihara S, Sunami E, Watanabe T. Appendiceal orifice inflammation is associated with proximal extension of disease in patients with ulcerative colitis. Colorectal Dis 2016; 18:O278-82. [PMID: 27354363 DOI: 10.1111/codi.13435] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 04/28/2016] [Indexed: 12/24/2022]
Abstract
AIM Ulcerative colitis (UC) is considered to be a disease of continuous mucosal inflammation extending proximally from the rectum. However, appendiceal orifice inflammation (AOI) is a skip lesion with segments of continuous involvement from the rectum. The aim of this study was to examine the clinical characteristics and clinical course, particularly focused on proximal extension, of UC in patients with AOI. METHOD A retrospective evaluation of patients with UC who underwent total colonoscopy at the Department of Surgical Oncology, The University of Tokyo, from 2004 to 2014. The degree of AOI was graded endoscopically as follows: 0 (no inflammation); 1 (slight oedema); 2 (moderate inflammation); and 3 (marked inflammation). A total of 189 patient records were reviewed retrospectively. The presence of AOI was analysed with regard to the clinical information of each patient, and its association with proximal extension of proctitis or left-sided colitis was evaluated. RESULTS Of 189 patients with UC who underwent total colonoscopy at our institution, 92 were diagnosed with pancolitis, 50 with left-sided colitis and 47 with proctitis. Endoscopic findings of AOI were observed in 26 patients, including 11 (12.0%) with pancolitis, six (12.0%) with left-sided colitis and nine (19.1%) with proctitis. During follow up, proximal extension of the disease occurred in all nine patients with proctitis AOI. CONCLUSION AOI is more frequently observed in patients with proctitis. Our results showed correlations between AOI and subsequent proximal extension of mucosal inflammation in patients with proctitis.
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Affiliation(s)
- H Anzai
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - K Hata
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - J Kishikawa
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - H Ishii
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - K Yasuda
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - K Otani
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - T Nishikawa
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - T Tanaka
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - T Kiyomatsu
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - K Kawai
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - H Nozawa
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - S Kazama
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - H Yamaguchi
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - S Ishihara
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - E Sunami
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - T Watanabe
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
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Wanderås MH, Moum BA, Høivik ML, Hovde &O. Predictive factors for a severe clinical course in ulcerative colitis: Results from population-based studies. World J Gastrointest Pharmacol Ther 2016; 7:235-241. [PMID: 27158539 PMCID: PMC4848246 DOI: 10.4292/wjgpt.v7.i2.235] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/27/2015] [Accepted: 03/14/2016] [Indexed: 02/06/2023] Open
Abstract
Ulcerative colitis (UC) is characterized by chronic inflammation of the large bowel in genetically susceptible individuals exposed to environmental risk factors. The disease course can be difficult to predict, with symptoms ranging from mild to severe. There is no generally accepted definition of severe UC, and no single outcome is sufficient to classify a disease course as severe. There are several outcomes indicating a severe disease course, including progression of the disease’s extension, a high relapse rate, the development of acute severe colitis, colectomy, the occurrence of colorectal cancer and UC-related mortality. When evaluating a patient’s prognosis, it is helpful to do so in relation to these outcomes. Using these outcomes also makes it easier to isolate factors predictive of severe disease. The aims of this article are to evaluate different disease outcomes and to present predictive factors for these outcomes.
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van der Valk ME, Mangen MJJ, Severs M, van der Have M, Dijkstra G, van Bodegraven AA, Fidder HH, de Jong DJ, van der Woude CJ, Romberg-Camps MJL, Clemens CHM, Jansen JM, van de Meeberg PC, Mahmmod N, van der Meulen-de Jong AE, Ponsioen CY, Bolwerk C, Vermeijden JR, Siersema PD, Leenders M, Oldenburg B. Evolution of Costs of Inflammatory Bowel Disease over Two Years of Follow-Up. PLoS One 2016; 11:e0142481. [PMID: 27099937 PMCID: PMC4839678 DOI: 10.1371/journal.pone.0142481] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 10/22/2015] [Indexed: 02/05/2023] Open
Abstract
Background With the increasing use of anti-TNF therapy in inflammatory bowel disease (IBD), a shift of costs has been observed with medication costs replacing hospitalization and surgery as major cost driver. We aimed to explore the evolution of IBD-related costs over two years of follow-up. Methods and Findings In total 1,307 Crohn's disease (CD) patients and 915 ulcerative colitis (UC) patients were prospectively followed for two years by three-monthly web-based questionnaires. Changes of healthcare costs, productivity costs and out-of-pocket costs over time were assessed using mixed model analysis. Multivariable logistic regression analysis was used to identify costs drivers. In total 737 CD patients and 566 UC were included. Total costs were stable over two years of follow-up, with annual total costs of €7,835 in CD and €3,600 in UC. However, within healthcare costs, the proportion of anti-TNF therapy-related costs increased from 64% to 72% in CD (p<0.01) and from 31% to 39% in UC (p < 0.01). In contrast, the proportion of hospitalization costs decreased from 19% to 13% in CD (p<0.01), and 22% to 15% in UC (p < 0.01). Penetrating disease course predicted an increase of healthcare costs (adjusted odds ratio (adj. OR) 1.95 (95% CI 1.02–3.37) in CD and age <40 years in UC (adj. OR 4.72 (95% CI 1.61–13.86)). Conclusions BD-related costs remained stable over two years. However, the proportion of anti-TNF-related healthcare costs increased, while hospitalization costs decreased. Factors associated with increased costs were penetrating disease course in CD and age <40 in UC.
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Affiliation(s)
- Mirthe E. van der Valk
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Marie-Josée J. Mangen
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Mirjam Severs
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Mike van der Have
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Ad A. van Bodegraven
- Department of Gastroenterology and Hepatology, VU University Medical Centre, Amsterdam, the Netherlands
- Department of Internal Medicine. Gastroenterology and Geriatrics, Atrium-Orbis Medical Centre, Heerlen-Sittard-Geleen, the Netherlands
| | - Herma H. Fidder
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Dirk J. de Jong
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre Nijmegen, Nijmegen, the Netherlands
| | - C. Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Mariëlle J. L. Romberg-Camps
- Department of Internal Medicine. Gastroenterology and Geriatrics, Atrium-Orbis Medical Centre, Heerlen-Sittard-Geleen, the Netherlands
| | - Cees H. M. Clemens
- Department of Gastroenterology and Hepatology, Diaconessenhuis, Leiden, the Netherlands
| | - Jeroen M. Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Paul C. van de Meeberg
- Department of Gastroenterology and Hepatology, Slingeland Hospital, Doetinchem, the Netherlands
| | - Nofel Mahmmod
- Department of Gastroenterology and Hepatology, Antonius Hospital, Nieuwegein, the Netherlands
| | | | - Cyriel Y. Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands
| | - Clemens Bolwerk
- Department of Gastroenterology and Hepatology, Reinier de Graaf Groep, Delft, the Netherlands
| | - J. Reinoud Vermeijden
- Department of Gastroenterology and Hepatology, Meander Medical Centre, Amersfoort, the Netherlands
| | - Peter D. Siersema
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Max Leenders
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, the Netherlands
- * E-mail:
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Safroneeva E, Vavricka S, Fournier N, Seibold F, Mottet C, Nydegger A, Ezri J, Straumann A, Rogler G, Schoepfer AM. Systematic analysis of factors associated with progression and regression of ulcerative colitis in 918 patients. Aliment Pharmacol Ther 2015; 42:540-8. [PMID: 26148503 DOI: 10.1111/apt.13307] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 11/30/2014] [Accepted: 06/16/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Studies that systematically assess change in ulcerative colitis (UC) extent over time in adult patients are scarce. AIM To assess changes in disease extent over time and to evaluate clinical parameters associated with this change. METHODS Data from the Swiss IBD cohort study were analysed. We used logistic regression modelling to identify factors associated with a change in disease extent. RESULTS A total of 918 UC patients (45.3% females) were included. At diagnosis, UC patients presented with the following disease extent: proctitis [199 patients (21.7%)], left-sided colitis [338 patients (36.8%)] and extensive colitis/pancolitis [381 (41.5%)]. During a median disease duration of 9 [4-16] years, progression and regression was documented in 145 patients (15.8%) and 149 patients (16.2%) respectively. In addition, 624 patients (68.0%) had a stable disease extent. The following factors were identified to be associated with disease progression: treatment with systemic glucocorticoids [odds ratio (OR) 1.704, P = 0.025] and calcineurin inhibitors (OR: 2.716, P = 0.005). No specific factors were found to be associated with disease regression. CONCLUSIONS Over a median disease duration of 9 [4-16] years, about two-thirds of UC patients maintained the initial disease extent; the remaining one-third had experienced either progression or regression of the disease extent.
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Affiliation(s)
| | - S Vavricka
- University Hospital Zurich, Zurich, Switzerland.,Stadtspital Triemli, Zurich, Switzerland
| | - N Fournier
- Centre Hospitalier Universitaire Vaudois et Université de Lausanne, Lausanne, Switzerland
| | - F Seibold
- Tiefenauspital Bern, Bern, Switzerland.,Inselspital/University Hospital Bern, Bern, Switzerland
| | - C Mottet
- Centre Hospitalier Universitaire Vaudois et Université de Lausanne, Lausanne, Switzerland.,Hôpital de Neuchâtel, Neuchâtel, Switzerland
| | - A Nydegger
- Centre Hospitalier Universitaire Vaudois et Université de Lausanne, Lausanne, Switzerland
| | - J Ezri
- Centre Hospitalier Universitaire Vaudois et Université de Lausanne, Lausanne, Switzerland
| | - A Straumann
- University Hospital of Basel, Basel, Switzerland.,Praxis Römerhof, Olten, Switzerland
| | - G Rogler
- University Hospital Zurich, Zurich, Switzerland
| | - A M Schoepfer
- Centre Hospitalier Universitaire Vaudois et Université de Lausanne, Lausanne, Switzerland
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Reinisch W, Reinink AR, Higgins PDR. Factors associated with poor outcomes in adults with newly diagnosed ulcerative colitis. Clin Gastroenterol Hepatol 2015; 13:635-42. [PMID: 24887059 DOI: 10.1016/j.cgh.2014.03.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 03/05/2014] [Accepted: 03/21/2014] [Indexed: 02/07/2023]
Abstract
It is a challenge to accurately identify patients with early stage ulcerative colitis (UC) who are at highest risk for a poor outcome and therefore might require salvage therapy. Several epidemiologic and clinical studies have analyzed factors associated with poor prognosis and increased risk for colectomy. We review prognostic factors for adults with newly diagnosed UC and discuss which patients might benefit from rapid and progressive therapy. Patients with poor prognoses tend to be young nonsmokers with high levels of inflammatory biomarkers, low levels of hemoglobin, and extensive disease, based on colonoscopy. We examine these risk factors in 2 hypothetical patients who have been newly diagnosed with UC.
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Affiliation(s)
- Walter Reinisch
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Andrew R Reinink
- Department of Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Peter D R Higgins
- Department of Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
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Stallmach A, Nickel L, Lehmann T, Bokemeyer B, Bürger M, Hüppe D, Kruis W, Nikolaus S, Preiss JC, Sturm A, Teich N, Schmidt C. Parameters of a severe disease course in ulcerative colitis. World J Gastroenterol 2014; 20:12574-12580. [PMID: 25253960 PMCID: PMC4168093 DOI: 10.3748/wjg.v20.i35.12574] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/12/2014] [Accepted: 06/26/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To detect high risk patients with a progressive disease course of ulcerative colitis (UC) requiring immunosuppressive therapy (IT).
METHODS: A retrospective, multicenter analysis of 262 UC patients from eight German tertiary inflammatory bowel disease centres was performed. Patients were divided into two groups depending on the patients need to initiate immunosuppressive therapy in the disease course. A comparison between the two groups was made with regard to demographics, clinical and laboratory parameters obtained within three months after UC diagnosis and the response to first medical therapy. Using this data, a prognostic model was established to predict the individual patients probability of requiring an immunosuppressive therapy.
RESULTS: In 104 (39.7%) out of 262 patients, UC therapy required an immunosuppressive treatment. Patients in this group were significantly younger at time of diagnosis (HR = 0.981 ± 0.014 per year, P = 0.009), and required significantly more often a hospitalisation (HR = 2.5 ± 1.0, P < 0.001) and a systemic corticosteroid therapy at disease onset (HR = 2.4 ± 0.8, P < 0.001), respectively. Response to steroid treatment was significantly different between the two groups of patients (HR = 5.2 ± 3.9 to 50.8 ± 35.6 compared to no steroids, P = 0.016 to P < 0.001). Furthermore, in the IT group an extended disease (HR = 3.5 ± 2.4 to 6.1 ± 4.0 compared to proctitis, P = 0.007 to P = 0.001), anemia (HR = 2.2 ± 0.8, P < 0.001), thrombocytosis (HR = 1.9 ± 1.8, P = 0.009), elevated C-reactive protein (CRP) (HR = 2.1 ± 0.9, P < 0.001), and extraintestinal manifestations in the course of disease (HR = 2.6 ± 1.1, P = 0.004) were observed. Six simple clinical items were used to establish a prognostic model to predict the individual risk requiring an IT. This probability ranges from less than 2% up to 100% after 5 years. Using this, the necessity of an immunosuppressive therapy can be predicted in 60% of patients. Our model can determine the need for an immunosuppressive drug therapy or if a “watch and wait” approach is reasonable already early in the treatment course of UC.
CONCLUSION: Using six simple clinical parameters, we can estimate the patients individual risk of developing a progressive disease course.
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Sandborn WJ, Hanauer S, Van Assche G, Panés J, Wilson S, Petersson J, Panaccione R. Treating beyond symptoms with a view to improving patient outcomes in inflammatory bowel diseases. J Crohns Colitis 2014; 8:927-35. [PMID: 24713173 DOI: 10.1016/j.crohns.2014.02.021] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 02/25/2014] [Accepted: 02/26/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Treatment goals in inflammatory bowel diseases are evolving beyond the control of symptoms towards the tight control of objectively-measured gastrointestinal inflammation. This review discusses the progress and challenges in adopting a treat-to-target approach in inflammatory bowel diseases. METHODS Evidence from the literature that highlights current thinking in terms of treating-to-target in patients with inflammatory bowel diseases is discussed. RESULTS Monitoring for objective evidence of inflammation using endoscopy, cross-sectional imaging or laboratory biomarkers may be a useful approach in inflammatory bowel diseases; however, setting the appropriate treatment goal remains a challenge. Deep remission (a composite of symptom control and mucosal healing) may now be a realistic target in Crohn's disease; however, it remains to be proven that achieving deep remission will modify the long-term disease course. Assessing prognosis at an early stage of the disease course is essential for the development of an appropriate management plan, with the rationale of adapting treatment to disease severity. An algorithm has been proposed for the treatment of early Crohn's disease that involves early treatment with immunosuppressants and tumour necrosis factor antagonists, in the hope of preventing structural bowel damage. CONCLUSIONS Treating beyond symptoms will require a clear management plan influenced by disease severity at presentation, clinical and biological prognostic factors, achievement and maintenance of clinical and biological remission and pharmacoeconomics.
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Affiliation(s)
- William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA.
| | - Stephen Hanauer
- Digestive Disease Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gert Van Assche
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Julián Panés
- Hospital Clinic University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Stephanie Wilson
- Departments of Radiology and Medicine, University of Calgary, Calgary, AB, Canada
| | - Joel Petersson
- Global Medical Affairs Gastroenterology, AbbVie, Rungis, France
| | - Remo Panaccione
- Department of Medicine, University of Calgary, Calgary, AB, Canada
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Abstract
BACKGROUND While therapeutic strategies able to change the natural history of inflammatory bowel diseases (IBD) are being developed, factors predicting aggressive disease are needed to be able to choose the appropriate therapeutic strategy for the individual patient based on the risk/benefit ratio. The aim of this review is to focus on the tools assisting the clinician in routine practice regarding the prediction of disease evolution. METHODS A literature review was performed, which was mainly based on PubMed search, using the following terms: Crohn's disease, ulcerative colitis, inflammatory bowel disease, genetics, serology, biomarkers, endoscopy, C-reactive protein, faecal calprotectin, disease evolution and complications. RESULTS For the prediction of disease evolution, clinical characteristics, particularly disease location and behaviour, are probably currently the most useful. In addition, a series of biomarkers, including genetic, serological and inflammatory markers, as well as characteristics of endoscopic lesions may have an added value. CONCLUSIONS Simple clinical, biological and endoscopic tools may help the clinician in predicting disease evolution in IBD. However, these tools are still insufficient, and prospective evaluation of new genetic and biological markers are needed.
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Affiliation(s)
- Jose-Manuel Benitez
- Department of Gastroenterology, CHU Liège, and GIGA Research, Liège University, Liège, Belgium
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Tyler AD, Milgrom R, Stempak JM, Xu W, Brumell JH, Muise AM, Sehgal R, Cohen Z, Koltun W, Shen B, Silverberg MS. The NOD2insC polymorphism is associated with worse outcome following ileal pouch-anal anastomosis for ulcerative colitis. Gut 2013; 62:1433-9. [PMID: 22879519 DOI: 10.1136/gutjnl-2011-301957] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Inflammatory complications after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) are common. OBJECTIVE To investigate whether genetic factors are associated with adverse pouch outcomes such as chronic pouchitis (CP) and a Crohn's disease-like (CDL) phenotype. DESIGN 866 patients were recruited from three centres in North America: Mount Sinai Hospital (Toronto, Ontario, Canada), the Cleveland Clinic (Cleveland, Ohio, USA) and Penn State Milton S Hershey Medical Center (Hershey, Pennsylvania, USA). DNA and clinical and demographic information were collected. Subjects were classified into post-surgical outcome groups: no chronic pouchitis (NCP), CP and CDL phenotype. RESULTS Clinical and genetic data were available on 714 individuals. 487 (68.2%) were classified as NCP, 118 (16.5%) CP and 109 (15.3%) CDL. The presence of arthritis or arthropathy (p=0.02), primary sclerosing cholangitis (p=0.009) and duration of time from ileostomy closure to recruitment (p=0.001) were significantly associated with outcome. The NOD2insC (rs2066847) risk variant was the single nucleotide polymorphism (SNP) most significantly associated with pouch outcome (p=7.4×10(-5)). Specifically, it was associated with both CP and CDL in comparison with NCP (OR=3.2 and 4.3, respectively). Additionally, SNPs in NOX3 (rs6557421, rs12661812), DAGLB (rs836518) and NCF4 (rs8137602) were shown to be associated with pouch outcome with slightly weaker effects. A multivariable risk model combining previously identified clinical (smoking status, family history of inflammatory bowel disease), serological (anti-Saccharomyces cerevisiae antibody IgG, perinuclear antineutrophil cytoplasmic antibody and anti-CBir1) and genetic markers was constructed and resulted in an OR of 2.72 (p=8.89×10(-7)) for NCP versus CP/CDL and 3.22 (p=4.11×10(-8)) for NCP versus CDL, respectively. CONCLUSION Genetic polymorphisms, in particular, the NOD2insC risk allele, are associated with chronic inflammatory pouch outcomes among patients with UC and IPAA.
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Affiliation(s)
- Andrea D Tyler
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
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Abstract
Ulcerative colitis is an idiopathic, chronic inflammatory disorder of the colonic mucosa, which starts in the rectum and generally extends proximally in a continuous manner through part of, or the entire, colon; however, some patients with proctitis or left-sided colitis might have a caecal patch of inflammation. Bloody diarrhoea is the characteristic symptom of the disease. The clinical course is unpredictable, marked by alternating periods of exacerbation and remission. In this Seminar we discuss the epidemiology, pathophysiology, diagnostic approach, natural history, medical and surgical management, and main disease-related complications of ulcerative colitis, and briefly outline novel treatment options. Enhanced understanding of how the interaction between environmental factors, genetics, and the immune system results in mucosal inflammation has increased knowledge of disease pathophysiology. We provide practical therapeutic algorithms that are easily applicable in daily clinical practice, emphasising present controversies in treatment management and novel therapies.
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Affiliation(s)
- Ingrid Ordás
- Division of Gastroenterology, University of California, San Diego, CA 92093-0956, USA
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Büning C, Geissler N, Prager M, Sturm A, Baumgart DC, Büttner J, Bühner S, Haas V, Lochs H. Increased small intestinal permeability in ulcerative colitis: rather genetic than environmental and a risk factor for extensive disease? Inflamm Bowel Dis 2012; 18:1932-9. [PMID: 22344959 DOI: 10.1002/ibd.22909] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 01/16/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND A disturbed epithelial barrier could play a pivotal role in ulcerative colitis (UC). We performed a family-based study analyzing in vivo gastrointestinal permeability in patients with UC, their healthy relatives, spouses, and controls. METHODS In total, 89 patients with UC in remission, 35 first-degree relatives (UC-R), 24 nonrelated spouses (UC-NR), and 99 healthy controls (HC) were studied. Permeability was assessed by a sugar-drink test using sucrose (gastroduodenal permeability), lactulose/mannitol (intestinal permeability), and sucralose (colonic permeability). Data were correlated with clinical characteristics including medical treatment. RESULTS Increased intestinal permeability was detected significantly more often in UC patients in remission (25/89, 28.1%) compared with HC (6/99, 6.1%; P < 0.001). Similar results were obtained in UC-R (7/35, 20.0%; P = 0.01 compared with HC) regardless of sharing the same household with the patients or not. No difference was found between UC-NR (3/24, 12.5%) and HC. Notably, in UC patients increased intestinal permeability was found in 12/28 patients (42.9%) with pancolitis, 7/30 (23.3%) patients with left-sided colitis, and in 2/19 (10.5%) patients with proctitis (P = 0.04). Gastroduodenal and colonic permeability were similar in all groups. Among patients on azathioprine, increased intestinal permeability was only seen in 1/18 (5.6%) patients. In contrast, in 24/70 (34.3%) patients without azathioprine, an increased intestinal permeability was found (P = 0.005). CONCLUSIONS An increased intestinal but not colonic permeability was found in UC patients in clinical remission that could mark a new risk factor for extensive disease location. Similar findings in healthy relatives but not spouses suggest that this barrier defect is genetically determined.
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Affiliation(s)
- Carsten Büning
- Department of Gastroenterology, Hepatology & Endocrinology, Charité, Campus Mitte, Berlin, Germany.
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Meier J, Sturm A. Current treatment of ulcerative colitis. World J Gastroenterol 2011; 17:3204-12. [PMID: 21912469 PMCID: PMC3158396 DOI: 10.3748/wjg.v17.i27.3204] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Revised: 06/20/2011] [Accepted: 06/27/2010] [Indexed: 02/06/2023] Open
Abstract
Ulcerative colitis (UC) is a chronic disease featuring recurrent inflammation of the colonic mucosa. The goal of medical treatment is to rapidly induce a steroid-free remission while at the same time preventing complications of the disease itself and its treatment. The choice of treatment depends on severity, localization and the course of the disease. For proctitis, topical therapy with 5-aminosalicylic acid (5-ASA) compounds is used. More extensive or severe disease should be treated with oral and local 5-ASA compounds and corticosteroids to induce remission. Patients who do not respond to this treatment require hospitalization. Intravenous steroids or, when refractory, calcineurin inhibitors (cyclosporine, tacrolimus), tumor necrosis factor-α antibodies (infliximab) or immunomodulators (azathioprine, 6-mercaptopurine) are then called for. Indications for emergency surgery include refractory toxic megacolon, perforation, and continuous severe colorectal bleeding. Close collaboration between gastroenterologist and surgeon is mandatory in order not to delay surgical therapy when needed. This article is intended to give a general, practice-orientated overview of the key issues in ulcerative colitis treatment. Recommendations are based on published consensus guidelines derived from national and international guidelines on the treatment of ulcerative colitis.
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Yoon JY, Cheon JH, Park JJ, Hong SP, Kim TI, Kim WH. Clinical outcomes and factors for response prediction after the first course of corticosteroid therapy in patients with active ulcerative colitis. J Gastroenterol Hepatol 2011; 26:1114-22. [PMID: 21299620 DOI: 10.1111/j.1440-1746.2011.06688.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Both clinical outcomes and factors predictive for poor response after an initial course of corticosteroids have not yet been well established in the treatment of moderate to severe ulcerative colitis (UC). We therefore evaluated the short- and long-term effects of corticosteroids and prognostic factors in UC patients after such therapy. METHODS We recruited consecutive patients who had moderate to severe UC and were treated with the first course of systemic corticosteroids between November 1996 and December 2007 using the database of Severance Hospital in Seoul, Korea. We then evaluated clinical outcomes at 1 month, 3 months, and 1 year after the initiation of corticosteroid treatment. RESULTS Our study included a total of 177 patients. At 1 month, complete remission was achieved in 70 patients (39.5%) and partial remission in 88 (49.7%). Fifteen patients (8.5%) were refractory to the treatment, and four (2.3%) underwent proctocolectomy. We observed prolonged response in 111 (64.9%) at 3 months and 95 (59.4%) patients at 1 year, corticosteroid dependency in 49 (28.7%) and 51 (31.9%) patients, and no response in 11 (6.4%) and 14 (8.7%) patients. A higher initial Mayo score was found to be the only poor prognostic factor at 1 month (P = 0.032) and 1 year (P < 0.001). CONCLUSIONS Our data showed that most Korean patients with active UC responded well to the first course of corticosteroid treatment. However, a considerable number of patients eventually turned out to be refractory to or dependent on this therapy. The initial higher Mayo score was strongly associated with poor outcomes.
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Affiliation(s)
- Jin Young Yoon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Louis E, Belaiche J, Reenaers C. Do clinical factors help to predict disease course in inflammatory bowel disease? World J Gastroenterol 2010; 16:2600-3. [PMID: 20518080 PMCID: PMC2880771 DOI: 10.3748/wjg.v16.i21.2600] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
While therapeutic strategies able to change the natural history of the disease are developing, it is of major importance to have available predictive factors for aggressive disease to try and target these therapeutic strategies. Clinical predictors have probably been the most broadly studied. In both Crohn’s disease (CD) and ulcerative colitis (UC), age at diagnosis, disease location and smoking habit are currently the strongest predictors of disease course. A younger age at onset is associated with more aggressive disease both in CD and UC. Disease location in CD is associated with different types of complications: surgery and recurrence in upper gastrointestinal and proximal small bowel disease; and surgery in distal small bowel disease and peri-anal lesions in rectal disease. In UC, extensive colitis is clearly been associated with more severe disease. Finally, active smoking globally increases disease severity in CD but decreases it in UC. Besides these important factors, others may predispose to some specific disease evolution and complications, and are also reviewed in the present paper.
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Kornbluth A, Sachar DB. Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 2010; 105:501-23; quiz 524. [PMID: 20068560 DOI: 10.1038/ajg.2009.727] [Citation(s) in RCA: 903] [Impact Index Per Article: 64.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Guidelines for clinical practice are aimed to indicate preferred approaches to medical problems as established by scientifically valid research. Double-blind placebo controlled studies are preferable, but compassionate-use reports and expert review articles are used in a thorough review of the literature conducted through Medline with the National Library of Medicine. When only data that will not withstand objective scrutiny are available, a recommendation is identified as a consensus of experts. Guidelines are applicable to all physicians who address the subject regardless of specialty training or interests and are aimed to indicate the preferable but not necessarily the only acceptable approach to a specific problem. Guidelines are intended to be flexible and must be distinguished from standards of care, which are inflexible and rarely violated. Given the wide range of specifics in any health-care problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the board of trustees. Each has been intensely reviewed and revised by the Committee, other experts in the field, physicians who will use them, and specialists in the science of decision analysis. The recommendations of each guideline are therefore considered valid at the time of composition based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at publication to assure continued validity. The recommendations made are based on the level of evidence found. Grade A recommendations imply that there is consistent level 1 evidence (randomized controlled trials), grade B indicates that the evidence would be level 2 or 3, which are cohort studies or case-control studies. Grade C recommendations are based on level 4 studies, meaning case series or poor-quality cohort studies, and grade D recommendations are based on level 5 evidence, meaning expert opinion.
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Affiliation(s)
- Asher Kornbluth
- Samuel Bronfman Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA.
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