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Anto VP, Ramos AE, Mollen KP. Ouch, my pouch! a clinician's guide to pouchitis. Semin Pediatr Surg 2024; 33:151406. [PMID: 38636151 DOI: 10.1016/j.sempedsurg.2024.151406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Pouchitis is defined as inflammation of the ileal pouch created during a restorative proctocolectomy with ileal pouch-anal anastomosis. Although the incidence of this inflammatory condition is high, the exact etiology often remains unclear and the management challenging. In this review, we summarize the clinical presentation, pathogenesis, diagnosis, and management of this common complication.
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Affiliation(s)
- Vincent P Anto
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anna E Ramos
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kevin P Mollen
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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2
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Fadel MG, Geropoulos G, Warren OJ, Mills SC, Tekkis PP, Celentano V, Kontovounisios C. Risks Factors Associated with the Development of Crohn's Disease After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: A Systematic Review and Meta-Analysis. J Crohns Colitis 2023; 17:1537-1548. [PMID: 36961323 PMCID: PMC10588783 DOI: 10.1093/ecco-jcc/jjad051] [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: 01/02/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Following ileal pouch-anal anastomosis [IPAA] for ulcerative colitis [UC], up to 16% of patients develop Crohn's disease of the pouch [CDP], which is a major cause of pouch failure. This systematic review and meta-analysis aimed to identify preoperative characteristics and risk factors for CDP development following IPAA. METHODS A literature search of the MEDLINE, EMBASE, EMCare and CINAHL databases was performed for studies that reported data on predictive characteristics and outcomes of CDP development in patients who underwent IPAA for UC between January 1990 and August 2022. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. RESULTS Seven studies with 1274 patients were included: 767 patients with a normal pouch and 507 patients with CDP. Age at UC diagnosis (weighted mean difference [WMD] -2.85; 95% confidence interval [CI] -4.39 to -1.31; p = 0.0003; I2 54%) and age at pouch surgery [WMD -3.17; 95% CI -5.27 to -1.07; p = 0.003; I2 20%) were significantly lower in patients who developed CDP compared to a normal pouch. Family history of IBD was significantly associated with CDP (odds ratio [OR] 2.43; 95% CI 1.41-4.19; p = 0.001; I2 31%], along with a history of smoking [OR 1.80; 95% CI 1.35-2.39; p < 0.0001; I2 0%]. Other factors such as sex and primary sclerosing cholangitis were found not to increase the risk of CDP. CONCLUSIONS Age at UC diagnosis and pouch surgery, family history of IBD and previous smoking have been identified as potential risk factors for CDP post-IPAA. This has important implications towards preoperative counselling, planning surgical management and evaluating prognosis.
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Affiliation(s)
- Michael G Fadel
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Georgios Geropoulos
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Oliver J Warren
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Sarah C Mills
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Paris P Tekkis
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | - Valerio Celentano
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, UK
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3
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Barnes EL, Darlington K, Herfarth HH. Disease Monitoring of the Ileoanal Pouch: How to Utilize Biomarkers, Imaging, and Pouchoscopy. Curr Gastroenterol Rep 2022; 24:127-136. [PMID: 36255602 DOI: 10.1007/s11894-022-00850-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 12/04/2022]
Abstract
PURPOSE OF REVIEW Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis has been associated with multiple short- and long-term complications. In this review, we examine the role of biomarkers, imaging, and pouchoscopy in the assessment of patients after ileal pouch-anal anastomosis, with a particular focus on the emergence of novel biomarkers and techniques for evaluating and risk stratifying patients after this procedure in the hopes of improving outcomes in this specific population. RECENT FINDINGS There are indications that that the incidence of pouchitis may be increasing in recent decades. Calprotectin and other non-invasive imaging tests such as ultrasound may offer advantages in distinguishing patients with inflammatory conditions of the pouch from other etiologies. In the search for other biomarkers that may identify patients at risk for inflammatory conditions of the pouch, the stool microbiota and metabolomics may play a key role in identifying those patients at greatest risk for complications. Advances in biomarkers, imaging, and standardized pouchoscopy scoring offer immediate improvements in clinical care and will prompt future research efforts.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Campus Box #7080 130 Mason Farm Road, 27599-7080, Chapel Hill, NC, USA. .,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Kimberly Darlington
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Campus Box #7080 130 Mason Farm Road, 27599-7080, Chapel Hill, NC, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Campus Box #7080 130 Mason Farm Road, 27599-7080, Chapel Hill, NC, USA.,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Takakura WR, Mirocha J, Ovsepyan G, Zaghiyan KN, Syal G, Fleshner P. Magnitude of Preoperative C-Reactive Protein Elevation Is Associated With De Novo Crohn's Disease After Ileal Pouch-Anal Anastomosis in Patients With Severe Colitis. Dis Colon Rectum 2022; 65:399-405. [PMID: 34657077 DOI: 10.1097/dcr.0000000000002148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Total proctocolectomy with ileal pouch-anal anastomosis has become the standard procedure for patients with medically refractory ulcerative colitis, although a subset will develop de novo Crohn's disease. OBJECTIVE In this study, we investigated the association of preoperative C-reactive protein levels with the development of de novo Crohn's disease after ileal pouch-anal anastomosis. DESIGN A prospectively maintained database of patients undergoing ileal pouch-anal anastomosis was reviewed. PATIENTS Preoperative C-reactive protein levels were compared between patients who developed de novo Crohn's disease and those who did not. De novo Crohn's disease was defined as small-bowel inflammation proximal to the ileal pouch or perianal disease identified more than 3 months after ileostomy closure. To minimize the heterogeneity of the timing of preoperative C-reactive protein measurement and the severity of ulcerative colitis, only hospitalized patients who had proctocolectomy for severe ulcerative colitis were included in the study. MAIN OUTCOME MEASURES Development of de novo Crohn's disease was analyzed. RESULTS Of 105 patients, 23 (22%) developed de novo Crohn's disease. Having C-reactive protein in the third tertile significantly increased the risk of developing de novo Crohn's disease (HR 3.44, 95% CI 1.10- 10.70, p = 0.03) compared to in the first tertile. In a multivariable model, a C-reactive protein in the third or second tertile vs the first tertile and younger age was associated with the development of de novo Crohn's disease. LIMITATIONS Limited to only hospitalized patients with severe ulcerative colitis. CONCLUSIONS In hospitalized patients undergoing ileal pouch-anal anastomosis for medically refractory ulcerative colitis, higher preoperative C-reactive protein levels appear to increase the risk of developing de novo Crohn's disease. See Video Abstract at http://links.lww.com/DCR/B750.LA MAGNITUD DE LA ELEVACIÓN PREOPERATORIA DE LA PROTEÍNA C REACTIVA SE ASOCIA CON APARICIÓN DE UNA ENFERMEDAD DE CROHN DE NOVO DESPUÉS DE UNA ANASTOMOSIS DE BOLSA ILEAL AL ANO EN PACIENTES CON COLITIS SEVERAANTECEDENTES:La proctocolectomía total con anastomosis bolsa ileal-anal se ha convertido en el procedimiento estándar para los pacientes con colitis ulcerativa refractaria al tratamiento médico, aunque un subgrupo desarrollará una enfermedad de Crohn de novo.OBJETIVO:En este estudio investigamos la asociación de los niveles de proteína C reactiva preoperatoria con el desarrollo de la enfermedad de Crohn de novo, después de la anastomosis bolsa ileal-anal.DISEÑO:Se revisó una base de datos recolectada en forma prospectiva, de pacientes sometidos a anastomosis bolsa ileal-anal.PACIENTES:Se compararon los niveles de proteína C reactiva preoperatoria entre los pacientes que desarrollaron la enfermedad de Crohn de novo y los que no la desarrollaron. La enfermedad de Crohn de novo se definió como una inflamación del intestino delgado proximal a la bolsa ileal o una enfermedad perianal identificada más de 3 meses después del cierre de la ileostomía. Para minimizar la heterogeneidad del momento de la medición de la proteína C reactiva preoperatoria y la gravedad de la colitis ulcerativa, solo se incluyeron en el estudio los pacientes hospitalizados que se sometieron a una proctocolectomía por colitis ulcerativa grave.PRINCIPALES MEDIDAS DE RESULTADO:se analizó el desarrollo de la enfermedad de Crohn de novo.RESULTADOS:De 105 pacientes, 23 (22%) desarrollaron enfermedad de Crohn de novo. Tener una proteína C reactiva en el tercer tercil aumentó significativamente el riesgo de desarrollar la enfermedad de Crohn de novo (HR 3,44, IC del 95%: 1,10-10,70, p = 0,03) en comparación con el primer tercil. En un modelo multivariable, una proteína C reactiva en el tercer o segundo tercil frente al primer tercil y una edad más joven se asoció con el desarrollo de la enfermedad de Crohn de novo.LIMITACIONES:Limitado solo a pacientes hospitalizados con colitis ulcerativa grave.CONCLUSIONES:En pacientes hospitalizados sometidos a anastomosis bolsa ileal-anal por colitis ulcerativa refractaria al tratamiento médico, niveles más elevados de proteína C reactiva preoperatoria parecen aumentar el riesgo de desarrollar enfermedad de Crohn de novo. Consulte Video Resumen en http://links.lww.com/DCR/B750. (Traducción-Eduardo Londoño-Schimmer).
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Affiliation(s)
- Will R Takakura
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - James Mirocha
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gayane Ovsepyan
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Karen N Zaghiyan
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gaurav Syal
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Kayal M, Kohler D, Plietz M, Khaitov S, Sylla P, Greenstein A, Dubinsky MC. Early Pouchitis Is Associated With Crohn's Disease-like Pouch Inflammation in Patients With Ulcerative Colitis. Inflamm Bowel Dis 2022; 28:1821-1825. [PMID: 35188532 PMCID: PMC9924036 DOI: 10.1093/ibd/izac012] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Despite the initial diagnosis of ulcerative colitis (UC), approximately 10% to 20% of patients develop Crohn's disease-like pouch inflammation (CDLPI) after restorative proctocolectomy (RPC) with ileal pouch anal anastomosis (IPAA). The aim of this study was to evaluate whether early pouchitis, defined as pouchitis within the first year after IPAA, is a predictor of CDLPI. METHODS This was a retrospective cohort analysis of patients with UC or IBD unclassified (IBDU) who underwent RPC with IPAA at Mount Sinai Hospital between January 2008 and December 2017. The primary outcome was development of CDLPI. Predictors of CDLPI were analyzed via univariable and multivariable Cox regression models. RESULTS The analytic cohort comprised 412 patients who underwent at least 1 pouchoscopy procedure between 2009 and 2018. Crohn's disease-like pouch inflammation developed in 57 (13.8%) patients a median interval of 2.1 (interquartile range, 1.1-4.3) years after surgery. On univariable analysis, older age at colectomy (hazard ratio [HR], 0.97; 95% CI, 0.95-0.99) was associated with a reduced risk of CDLPI; although early pouchitis (HR, 2.43; 95% CI, 1.32-4.45) and a greater number of pouchitis episodes (HR, 1.38; 95% CI, 1.17-1.63) were associated with an increased risk. On multivariable analysis, early pouchitis (HR, 2.35; 95% CI, 1.27-4.34) was significantly associated with CDLPI. Time to CDLPI was significantly less in patients who developed early pouchitis compared with those who did not (P = .003). CONCLUSION Early pouchitis is significantly associated with subsequent CDLPI development and may be the first indication of enhanced mucosal immune activation in the pouch.
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Affiliation(s)
- Maia Kayal
- Address correspondence to: Maia Kayal, MD, The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA ()
| | | | - Michael Plietz
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sergey Khaitov
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Patricia Sylla
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander Greenstein
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marla C Dubinsky
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Kayal M, Bhagya Rao B, Bhattacharya A, Ungaro R. Clinical Challenge: From Ulcerative Colitis to Crohn's Disease-Like Pouch Inflammation. Dig Dis Sci 2021; 66:3300-3302. [PMID: 34415452 DOI: 10.1007/s10620-021-07220-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2021] [Indexed: 12/09/2022]
Affiliation(s)
- Maia Kayal
- Division of Gastroenterology, Icahn School of Medicine At Mount Sinai, New York, NY, USA.
| | - Bhavana Bhagya Rao
- Division of Gastroenterology, Icahn School of Medicine At Mount Sinai, New York, NY, USA
| | - Abhik Bhattacharya
- Division of Gastroenterology, Icahn School of Medicine At Mount Sinai, New York, NY, USA
| | - Ryan Ungaro
- Division of Gastroenterology, Icahn School of Medicine At Mount Sinai, New York, NY, USA
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Aboud C, Zamaria N, Cannistrà C. Treatment of hidradenitis suppurativa: Surgery and yeast (Saccharomyces cerevisiae)–exclusion diet. Results after 6 years. Surgery 2020; 167:1012-1015. [DOI: 10.1016/j.surg.2019.12.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 12/07/2019] [Accepted: 12/17/2019] [Indexed: 12/18/2022]
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8
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Pellino G, Vinci D, Signoriello G, Kontovounisios C, Canonico S, Selvaggi F, Sciaudone G. Long-Term Bowel Function and Fate of the Ileal Pouch After Restorative Proctocolectomy in Patients With Crohn's Disease: A Systematic Review With Meta-Analysis and Metaregression. J Crohns Colitis 2020; 14:418-427. [PMID: 31412119 DOI: 10.1093/ecco-jcc/jjz146] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Debate exists on whether ileal pouch anal anastomosis [IPAA] can be safely offered to patients diagnosed with Crohn's disease [CD]. Our aim was to assess the outcome of IPAA for CD vs ulcerative colitis [UC]. METHODS We used a PRISMA/MOOSE-compliant meta-analysis. Studies published between 1993 and 2018 were retrieved. Primary end points included complications. Secondary endpoints included functional outcome. The time of CD diagnosis was considered [intentional vs incidental IPAA]. RESULTS Eleven studies comprising 6770 patients [CD = 352, UC = 6418] were included, with 44-120 months of follow-up. Pouch fistulae were more common in CD (CD vs UC; odds ratio (OR) 6.08; p = 0.0003, GRADE+++), as were strictures [OR 1.82; p = 0.02, GRADE+++] and failure [OR 5.27; p < 0.0001, GRADE++++]. Compared with UC, postoperative CD diagnosis was associated with a much higher risk of fistulae [OR 6.23; p = 0.006, GRADE+++] and failure [OR 8.53; p < 0.0001, GRADE++++] than intentional IPAA in CD [fistula: OR 4.17; p = 0.04, GRADE+++; failure: OR 2.48; p = 0.009, GRADE++++]. Age at surgery was positively associated with failure in CD [p = 0.007]. Obstruction was more common after intentional IPAA for CD. The risk of pouchitis did not differ between CD and UC [OR 1.07, p = 0.76, GRADE+++]. CD patients were at a higher risk of seepage [OR 2.27; p = 0.010, GRADE++]. CONCLUSIONS Patients with CD have 5-fold higher risk of failure, and a 2-fold risk of strictures after IPAA compared with UC. The risk is much higher if diagnosis is performed after IPAA. Function in those who retain the pouch seemed similar to that of patients with UC. CD does not increase the risk of pouchitis. IPAA could be offered to a selected population of CD patients after proper preoperative counselling.[PROSPERO registry 116811].
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Affiliation(s)
- Gianluca Pellino
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Danilo Vinci
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Giuseppe Signoriello
- Section of Statistic, Department of Mental Health and Public Medicine, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Silvestro Canonico
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Selvaggi
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Guido Sciaudone
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
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Ahmed Z, Lysek M, Zhang N, Malik TA. Association Between Serological Markers and Crohn's Disease Activity. J Clin Med Res 2020; 12:6-12. [PMID: 32010416 PMCID: PMC6968925 DOI: 10.14740/jocmr4016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 11/20/2019] [Indexed: 11/20/2022] Open
Abstract
Background The aim was to study the association between six serological markers and Crohn’s disease (CD) activity at an inflammatory bowel disease (IBD) referral center. Methods We designed a retrospective cohort study using adults (> 18 years) with CD followed for at least 1 year at University of Alabama at Birmingham. Baseline serological markers ASCA-IgA, ASCA-IgG, anti-OmpC IgA, anti-CBir1 IgG, anti-A4Fla2 IgG and anti-FlaX IgG were drawn at initial visit. Poisson regression was used to assess the longitudinal relationship between these markers drawn at baseline and rate of active clinical disease during follow-up. Results Each marker, from 135 patients, was categorized into high vs. low. A Poisson regression model adjusted for age, gender, race, duration of disease, obesity, proton pump inhibitor; steroid and thiopurine use, and disease location demonstrated that CD patients with high anti-CBir1 IgG at baseline were approximately twice more likely to have active clinical disease (incidence rate ratio (IRR) 2.06, 95% confidence interval (CI) 1.28 - 3.33, P = 0.0032). The unadjusted Poisson regression model for A4Fla2 IgG antibody level did suggest that a high A4Fla2 IgG at baseline was associated with a higher likelihood of active CD (IRR 1.64, 95% CI 1.07, 2.53, P = 0.0238) which however, upon adjustment based on effect size, was not significant. The other four antibodies did not appear to predict clinical course. Conclusions High levels of anti-CBir1 IgG appear to be associated with a greater likelihood of active CD. Whether routine baseline testing for anti-CBir1 IgG to predict a more active clinical course is warranted needs more research.
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Affiliation(s)
- Zunirah Ahmed
- Department of Medicine, University of Alabama at Birmingham Montgomery, AL 36116, USA
| | - Michael Lysek
- Department of Medicine, University of South Alabama, Mobile, AL 36617, USA
| | - Nan Zhang
- Department of Biostatistics, Mayo Clinic, Scottsdale, AZ 85259, USA
| | - Talha A Malik
- Department of Medicine-Gastroenterology, Mayo Clinic, Scottsdale, AZ 85259, USA
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10
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De Novo Crohn's Disease of the Pouch in Children Undergoing Ileal Pouch-Anal Anastomosis for Ulcerative Colitis. J Pediatr Gastroenterol Nutr 2019; 69:455-460. [PMID: 31136563 PMCID: PMC7408293 DOI: 10.1097/mpg.0000000000002406] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Approximately 10% of children with ulcerative colitis (UC) undergo colectomy with ileal pouch-anal anastomosis (IPAA). We aimed to describe the postoperative outcomes, with an emphasis on chronic pouch inflammation including de novo Crohn disease (CD) at a tertiary care inflammatory bowel disease center. METHODS Electronic medical records of all children who underwent colectomy ≤18 years between 2008 and 2017 were reviewed. Clinical and laboratory data were recorded. Primary outcome was frequency of chronic pouch inflammation including de novo CD. Secondary outcomes included early (≤30 days from index surgery) and late postoperative complications. Descriptive statistics (median and interquartile range) summarized the data and univariate analysis tested associations with outcomes. RESULTS Fifty-eight children underwent colectomy and 56 completed IPAA. Median age at diagnosis was 14 years (12-16.2) and at colectomy 16.2 years (14.2-17.7) with median follow-up of 13 months (5-43). Sixty-six percent underwent 3-stage IPAA and 78% were biologic exposed. Eleven had chronic pouchitis, 73% antibiotic refractory and 25% met criteria for de novo CD by median of 19 months (9-41). A total of 21% and 50% experienced early and late surgical complications, most commonly ileus and recurrent IPAA stricture. The pouch failure rate was 3.6%. Chronic pouch inflammation was associated with a later diagnosis of de novo CD (P = 0.0025). CONCLUSIONS In pediatric UC, CD is not uncommon after IPAA. Chronic pouch inflammation often precedes a diagnosis of de novo CD. Families should be informed of the short- and long-term outcomes in children before UC surgery.
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11
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Barnes EL, Kochar B, Jessup HR, Herfarth HH. The Incidence and Definition of Crohn's Disease of the Pouch: A Systematic Review and Meta-analysis. Inflamm Bowel Dis 2019; 25:1474-1480. [PMID: 30698715 PMCID: PMC6703435 DOI: 10.1093/ibd/izz005] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND A subset of patients who undergo total proctocolectomy with ileal pouch-anal anastomosis (IPAA) creation for ulcerative colitis (UC) will later develop Crohn's disease (CD) of the pouch, which has been associated with significant morbidity. We aimed to analyze the incidence of CD of the pouch and to review the existing diagnostic criteria utilized. METHODS A systematic search performed through March 1, 2018, identified 12 studies that reported the incidence of CD of the pouch after IPAA for UC or indeterminate colitis (IC). We compiled all diagnostic criteria utilized in these studies and then performed a meta-analysis using random effects modeling to estimate the overall incidence of CD of the pouch in this population. RESULTS Among 4843 patients with an IPAA for UC or IC, 10.3% of patients were ultimately diagnosed with CD of the pouch (95% confidence interval [CI], 6.1%-15.4%). The most commonly reported diagnostic criteria were (1) presence of fistula/fistulae, (2) stricture involving the pouch or prepouch ileum, and (3) presence of prepouch ileitis. In a secondary analysis, excluding those studies that included patients with a preoperative diagnosis of IC, the incidence of CD of the pouch was 12.4% (95% CI, 9.0%-16.1%). CONCLUSIONS The estimated incidence of 10.3% will assist gastroenterologists and surgeons in preoperative counseling regarding the potential to develop CD of the pouch. There is an unmet need for common diagnostic criteria for a more standardized approach to the diagnosis of CD of the pouch.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,Address correspondence to: Edward L. Barnes, MD, MPH, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Bioinformatics Building, CB #7080, Chapel Hill, NC 27599-7080 ()
| | - Bharati Kochar
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Hilary R Jessup
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Drews JD, Onwuka EA, Fisher JG, Huntington JT, Dutkiewicz M, Nogalska A, Nwomeh BC. Complications after proctocolectomy and ileal pouch-anal anastomosis in pediatric patients: A systematic review. J Pediatr Surg 2019; 54:1331-1339. [PMID: 30291026 DOI: 10.1016/j.jpedsurg.2018.08.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/20/2018] [Accepted: 08/29/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND/PURPOSE Colectomy with ileal pouch-anal anastomosis (IPAA) is the standard of care for patients with familial adenomatous polyposis (FAP) and refractory ulcerative colitis (UC). The rates of postoperative complications are not well established in children. The objective of this systematic review is to establish benchmark data for morbidity after pediatric IPAA. METHODS PubMed, Embase, and The Cochrane Library were searched for studies of colectomy with IPAA in patients ≤21 years old. UC studies were limited to the anti-tumor necrosis factor-α agents era (1998-present). All postoperative complications were extracted. RESULTS Thirteen studies met the inclusion criteria (763 patients). Compared to patients with FAP, UC patients had a higher prevalence of pouch loss (10.6% vs. 1.5%). Other major complications such as anastomotic leak, abscess, and fistula were uncommon (mean prevalence 4.9%, 4.2%, and 5.0%, respectively, for patients with UC; 8.7%, 4.2%, and 4.3% for FAP). The most frequent complication was pouchitis (36.4% of UC patients). CONCLUSIONS Devastating complications from colectomy and IPAA are rare, but patients with UC have poorer outcomes than those with FAP. Much of the morbidity may therefore stem from patient or disease factors. Multicenter, prospective studies are needed to identify modifiable risks in patients with UC undergoing IPAA. LEVEL OF EVIDENCE Prognostic, level II.
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Affiliation(s)
- Joseph D Drews
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205; Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Columbus, OH, USA 43210.
| | - Ekene A Onwuka
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205; Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Columbus, OH, USA 43210.
| | - Jeremy G Fisher
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205.
| | - Justin T Huntington
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205.
| | - Michał Dutkiewicz
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205.
| | - Agata Nogalska
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205.
| | - Benedict C Nwomeh
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA 43205; Department of Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Columbus, OH, USA 43210.
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Hendricks AJ, Hirt PA, Sekhon S, Vaughn AR, Lev-Tov HA, Hsiao JL, Shi VY. Non-pharmacologic approaches for hidradenitis suppurativa – a systematic review. J DERMATOL TREAT 2019; 32:11-18. [DOI: 10.1080/09546634.2019.1621981] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | - Penelope A. Hirt
- Department of Dermatology and Cutaneous Surgery, University of Miami, Miami, FL, USA
| | - Sahil Sekhon
- Department of Dermatology, University of California San Francisco, San Francisco, CA, USA
| | - Alexandra R. Vaughn
- Department of Dermatology, University of California Davis, Sacramento, CA, USA
| | - Hadar A. Lev-Tov
- Department of Dermatology and Cutaneous Surgery, University of Miami, Miami, FL, USA
| | - Jennifer L. Hsiao
- Division of Dermatology, University of California Los Angeles, Los Angeles, CA, USA
| | - Vivian Y. Shi
- Division of Dermatology, University of Arizona Department of Medicine, Tucson, AZ, USA
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Duarte-Silva M, Afonso PC, de Souza PR, Peghini BC, Rodrigues-Júnior V, de Barros Cardoso CR. Reappraisal of antibodies against Saccharomyces cerevisiae (ASCA) as persistent biomarkers in quiescent Crohn's disease. Autoimmunity 2019; 52:37-47. [PMID: 30884988 DOI: 10.1080/08916934.2019.1588889] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A clear correlation exists between microbiota and the dysregulation of the immune response in Inflammatory Bowel Diseases (IBD), which comprise Crohn's disease (CD) and ulcerative colitis (UC). These unbalanced reactions also involve humoral responses, with antibodies against Saccharomyces cerevisiae. Thus, here we aimed to quantify IgA and IgG specific to S. cerevisiae (ASCA) in quiescent CD and UC, to correlate the production of these antibodies with patient's inflammatory response and disease clinical presentation. Twenty-nine subjects (16 CD and 13 UC) and 45 healthy controls were enrolled in this study and had plasma samples tested for ASCA and cytokines (IL-2, IL-4, IL-6, IL-10, IFN-γ, TNF-α), besides clinical evaluation. IBD patients had increase IgA and IgG ASCA, especially those with colonic (L2) and fistulizing (B3) CD. Similarly, patients who dropped out the treatment had augmented ASCA, while IgG was reduced in those receiving sulfasalazine treatment. Furthermore, the quiescent CD patients had elevated IL-6 on plasma, especially in the absence of treatment, together with increased counter regulatory response of IL-10. There was a positive correlation between IgA and IgG on CD but not UC, as well as between IgA and TNF in total IBD patients. In addition, the levels of IgG x TNF, IgA x IL-10 and IgG x IL-10 were also correlated in CD, indicating that ASCA production may be influenced by the inflammatory response. Finally, we concluded that ASCA could be pointed as relevant biomarker of CD presentation and residual inflammation, even in clinical remission patients.
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Affiliation(s)
- Murillo Duarte-Silva
- a Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão Preto , Universidade de São Paulo , Ribeirão Preto , São Paulo , Brazil.,b Departamento de Bioquímica e Imunologia, Faculdade de Medicina de Ribeirão Preto , Universidade de São Paulo , Ribeirão Preto , São Paulo , Brazil
| | - Poliana Cristina Afonso
- c Instituto de Ciências Biológicas e Naturais, Universidade Federal do Triângulo Mineiro , Uberaba , Brazil
| | - Patrícia Reis de Souza
- a Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão Preto , Universidade de São Paulo , Ribeirão Preto , São Paulo , Brazil.,c Instituto de Ciências Biológicas e Naturais, Universidade Federal do Triângulo Mineiro , Uberaba , Brazil
| | - Bethânea Crema Peghini
- c Instituto de Ciências Biológicas e Naturais, Universidade Federal do Triângulo Mineiro , Uberaba , Brazil
| | - Virmondes Rodrigues-Júnior
- c Instituto de Ciências Biológicas e Naturais, Universidade Federal do Triângulo Mineiro , Uberaba , Brazil
| | - Cristina Ribeiro de Barros Cardoso
- a Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Faculdade de Ciências Farmacêuticas de Ribeirão Preto , Universidade de São Paulo , Ribeirão Preto , São Paulo , Brazil
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15
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Goren I, Godny L, Reshef L, Yanai H, Gophna U, Tulchinsky H, Dotan I. Starch Consumption May Modify Antiglycan Antibodies and Fecal Fungal Composition in Patients With Ileo-Anal Pouch. Inflamm Bowel Dis 2019; 25:742-749. [PMID: 30535148 DOI: 10.1093/ibd/izy370] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Inflammatory bowel diseases (IBDs) are characterized by serologic responses to glycans. Patients with ulcerative colitis (UC) after proctocolectomy with ileo-anal anastomosis (pouch surgery) may develop inflammation (pouchitis) that resembles Crohn's disease (CD). We hypothesized that patients' serologic responses were affected by their consumption of dietary sugars. This study analyzed the correlations between antiglycan antibody expression and dietary sugar consumption in patients with UC pouch and the evolution in antibody levels over time. METHODS Patients were followed prospectively for 2 consecutive visits. The following antiglycan carbohydrate antibodies were detected by enzyme-linked immunosorbent assay: antichitobioside (ACCA), antilaminaribioside (ALCA), antimannobioside (AMCA), and anti-Saccharomyces cerevisiae (ASCA) antibodies. Patients completed a food frequency questionnaire. The fungal community in patients' fecal samples was analyzed by sequencing the internal transcribed spacer 2 (ITS2) region of nuclear ribosomal DNA. RESULTS We included 75 UC pouch patients aged 45.2 ± 14 years who underwent pouch surgery 9.8 ± 6.7 years previously. Of these patients, 34.7% (n = 26) showed seropositivity for antiglycan antibodies. Starch consumption was significantly higher in patients with positive serologic responses (P = 0.05). Higher starch consumption was associated with higher AMCA and ACCA titers, which increased by 4.08% (0.8%-7.4%; P = 0.014) and 4.8% (0.7%-9.1%; P = 0.007), respectively, for each 10-g increase of dietary starch. The per-patient change in the relative abundance of Candida albicans in fecal samples correlated positively with changes in starch consumption (Spearman's r = 0.72; P = 0.012). CONCLUSIONS Starch consumption correlated with positive antiglycan serology (ACCA and AMCA), suggesting that increased dietary starch intake may promote a specific immune response in patients with IBD.
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Affiliation(s)
- Idan Goren
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lihi Godny
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leah Reshef
- Department of Molecular Microbiology and Biotechnology, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Henit Yanai
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Gophna
- Department of Molecular Microbiology and Biotechnology, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Hagit Tulchinsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Zhang H, Zeng Z, Mukherjee A, Shen B. Molecular diagnosis and classification of inflammatory bowel disease. Expert Rev Mol Diagn 2018; 18:867-886. [PMID: 30152711 DOI: 10.1080/14737159.2018.1516549] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Traditional diagnosis and classification of inflammatory bowel diseases (IBDs) have been based on clinical evaluation, laboratory testing, endoscopy, imaging, and histological examinations. With the advancement of medical technology, an increasing number of molecular surrogates are playing a key role in diagnosis, differential diagnosis, assessment of disease activity, prediction of clinical course, and therapeutic response of IBD. Areas covered: The authors review roles of both existing and emerging surrogates including genetic, serological, histologic, and fecal markers in diagnosis and classification of IBD. Comparisons in advantages and disadvantages of different markers have also been discussed. In addition, this review underscores controversial and unclear aspects which need further study. Expert commentary: IBD is characteristic of chronicity, relapse-remission and destructiveness. It is of great importance for clinicians to make an accurate diagnosis and classification. Current and new molecular markers perform well with acceptable sensitivity and specificity. The use of molecular markers in clinical practice needs to be further explored and then generalized. More work is warranted to identify novel useful markers and elucidate how to apply them together with current markers in clinical settings.
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Affiliation(s)
- Hu Zhang
- a Center for Inflammatory Bowel Disease & Department of Gastroenterology , West China Hospital, Sichuan University , Chengdu , China
| | - Zhen Zeng
- a Center for Inflammatory Bowel Disease & Department of Gastroenterology , West China Hospital, Sichuan University , Chengdu , China
| | - Arjudeb Mukherjee
- b West China School of Medicine , Sichuan University , Chengdu , China
| | - Bo Shen
- c Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, The Cleveland Clinic Foundation , Cleveland , Ohio , USA
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17
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Dalal RL, Shen B, Schwartz DA. Management of Pouchitis and Other Common Complications of the Pouch. Inflamm Bowel Dis 2018; 24:989-996. [PMID: 29688472 DOI: 10.1093/ibd/izy020] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the preferred surgical treatment for refractory or complicated ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Pouchitis is the most common complication of this procedure and can occur in about 50% of patients. Treatment of pouchitis depends on the phenotype of disease. Pouchitis can be classified as acute, chronic/refractory, or secondary pouchitis, which includes pouchitis occurring due to Crohn's disease (CD). CD of the pouch is becoming an increasingly recognized problem, and management is challenging. This article reviews the literature and offers treatment recommendations regarding management of pouchitis and CD of the pouch.
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Affiliation(s)
- Robin L Dalal
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bo Shen
- Department of Gastroenterology/Hepatology, the Cleveland Clinic, Foundation, Cleveland, Ohio
| | - David A Schwartz
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
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18
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Abel AG, Chung A, Paul E, Gibson PR, Sparrow MP. Patchy colitis, and young age at diagnosis and at the time of surgery predict subsequent development of Crohn's disease after ileal pouch-anal anastomosis surgery for ulcerative colitis. JGH Open 2018; 2:8-14. [PMID: 30483556 PMCID: PMC6207023 DOI: 10.1002/jgh3.12035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 10/18/2017] [Accepted: 11/30/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIM A proportion of patients having total proctocolectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) are later diagnosed with Crohn's disease (CD). The aim of this study was to identify preoperative and perioperative predictors for the subsequent development of CD in patients who had IPAA for presumed UC. METHODS A retrospective case-control study of patients undergoing IPAA surgery for presumed UC was undertaken. Cases were patients who had a revised diagnosis of CD after surgery. Preoperative and perioperative variables were examined and analyzed. RESULTS Fifteen cases were compared with 39 controls. Patients aged ≤25 years at initial UC diagnosis were more likely to develop CD compared to those aged >25 years (odds ratio, OR [95% confidence interval, CI]: 7.1 [1.6-31.3]; P = 0.01). Patients aged ≤30 years at the time of colectomy had an increased risk of subsequent development of CD compared to those aged >30 years (OR [95% CI]: 4.5 [1.3-16.0]; P = 0.02). Cases were more likely to have patchy colitis on their colectomy specimen (OR [95% CI]: 6.7 [1.1-41.8]; P = 0.04). There was no significant difference between groups regarding transmural inflammation, ileitis, or fissuring ulcers on colectomy specimens, or preoperative C-reactive protein (CRP), albumin, family history, and smoking status. CONCLUSION Predictors of the development of CD in the pouch include young age at diagnosis and at the time of surgery, and patchy colitis in the resected colon.
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Affiliation(s)
- Alexandra G Abel
- Department of GastroenterologyThe Alfred HospitalMelbourneVictoriaAustralia
| | - Alvin Chung
- Department of GastroenterologyEastern HealthMelbourneVictoriaAustralia
| | - Eldho Paul
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of Clinical HematologyThe Alfred HospitalMelbourneVictoriaAustralia
| | - Peter R Gibson
- Department of GastroenterologyThe Alfred HospitalMelbourneVictoriaAustralia
| | - Miles P Sparrow
- Department of GastroenterologyThe Alfred HospitalMelbourneVictoriaAustralia
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19
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Gu P, Kapur A, Li D, Haritunians T, Vasiliauskas E, Shih DQ, Targan SR, Spiegel BM, McGovern DP, Black JT, Melmed GY. Serological, genetic and clinical associations with increased health-care resource utilization in inflammatory bowel disease. J Dig Dis 2018; 19:15-23. [PMID: 29251413 PMCID: PMC6023617 DOI: 10.1111/1751-2980.12566] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 12/05/2017] [Accepted: 12/12/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Inflammatory bowel diseases (IBD) are associated with significant morbidity and economic burden. The variable course of IBD creates a need for predictors of clinical outcomes and health resource utilization (HRU) to guide treatment decisions. We aimed to identify clinical, serological or genetic markers associated with inpatient resource utilization in patients with ulcerative colitis (UC) and Crohn's disease (CD). METHODS Patients with IBD with available genetic and serological data who had at least one emergency department visit or hospitalization in a 3-year period were included. The primary outcome measure was HRU, as measured by the All Patient Refined Diagnosis Related Group classification system. Univariate and multivariate linear and logistic regression models were used to identify the associations with HRU. RESULTS Altogether 858 (562 CD and 296 UC) patients were included. Anti-CBir1 seropositivity (P = 0.002, effect size [ES]: 0.762, 95% confidence interval [CI] 0.512-1.012) and low socioeconomic status (P = 0.005, ES: 1.620 [95% CI 1.091-2.149]) were independently associated with a high HRU. CD diagnosis (P = 0.006, ES: -0.701 [95% CI -0.959 to -0.443]) was independently associated with a low inpatient HRU. CONCLUSION In patients with IBD who required at least one emergency department visit or hospitalization, anti-CBir1 antibody status may be a useful biomarker of HRU when formulating management strategies to reduce disease complications and resource utilization.
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Affiliation(s)
- Phillip Gu
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Anshika Kapur
- F Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Dalin Li
- F Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Talin Haritunians
- F Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Eric Vasiliauskas
- F Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - David Q. Shih
- F Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephan R. Targan
- F Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Brennan M.R. Spiegel
- Center for Outcomes Research and Education, Cedars-Sinai Health System, Los Angeles, CA
| | - Dermot P.B. McGovern
- F Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jeanne T. Black
- Resource & Outcomes Management Department, Cedars-Sinai Health System, Los Angeles, CA
| | - Gil Y. Melmed
- F Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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20
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Liska D, Mino J. When “pouchitis” isn׳t pouchitis: Crohn׳s disease and surgical complications. SEMINARS IN COLON AND RECTAL SURGERY 2017. [DOI: 10.1053/j.scrs.2017.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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21
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Robbins L, Zaghiyan K, Melmed G, Vasiliauskas E, Ahmed S, McGovern D, Rabizadeh S, Singh N, Landers C, Ippoliti A, Shih D, Targan S, Fleshner P. Outcomes with Anti-Tumour Necrosis Factor-Alpha Therapy and Serology in Patients with Denovo Crohn's Disease After Ileal Pouch Anal Anastomosis. J Crohns Colitis 2017; 11:77-83. [PMID: 27466172 DOI: 10.1093/ecco-jcc/jjw134] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/31/2016] [Accepted: 06/03/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS A subset of patients who undergo ileal pouch-anal anastomosis [IPAA] for ulcerative colitis [UC] will later be diagnosed with denovo Crohn's disease [CD]. These patients have a higher risk of pouch failure. In this study we evaluated inflammatory bowel disease [IBD] serology in patients with denovo CD and examined the success of anti-tumour necrosis factor-alpha [anti-TNFα] therapy in preventing ileostomy in denovo CD patients who failed anti-TNFα therapy before IPAA. METHODS A prospectively maintained database of patients undergoing IPAA was reviewed to identify patients who developed denovo CD [defined as small bowel inflammation above the pouch inlet or pouch fistula/perianal disease appearing more than 3 months after stoma closure]. Clinical characteristics and IBD serology were analysed. Treatment failure was defined as pouch failure requiring ileostomy or pouchectomy. RESULTS Of 350 patients included in the study, 92 [26%] patients developed denovo CD. Significantly more denovo CD patients had anti-I2 positivity postoperatively versus preoperatively [p = 0.007]. Anti-TNFα therapy successfully treated denovo CD in 28 out of 38 [74%] patients. Out of 17 patients with denovo CD who had failed to respond to anti-TNFα agents before surgery and were treated with anti-TNFα therapy after surgery, 12 [71%] patients responded to treatment. CONCLUSIONS I2 serology may possibly help identify patients who have developed or are at risk for developing denovo CD. Anti-TNFα therapy for denovo CD after IPAA can help prevent permanent ileostomy in almost 75% of cases, even in patients who previously failed anti-TNFα treatment before surgery.
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Affiliation(s)
- Lori Robbins
- Departments of Medicine, Colon and Rectal Surgery
| | | | | | | | | | | | - Shervin Rabizadeh
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Namita Singh
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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The Immunological Basis of Inflammatory Bowel Disease. Gastroenterol Res Pract 2016; 2016:2097274. [PMID: 28070181 PMCID: PMC5192315 DOI: 10.1155/2016/2097274] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 10/20/2016] [Accepted: 11/16/2016] [Indexed: 01/30/2023] Open
Abstract
Inflammatory bowel diseases (IBDs) are chronic ailments, Crohn's disease and ulcerative colitis being the most important. These diseases present an inflammatory profile and they differ according to pathophysiology, the affected area in the gastrointestinal tract, and the depth of the inflammation in the intestinal wall. The immune characteristics of IBD arise from abnormal responses of the innate and adaptive immune system. The number of Th17 cells increases in the peripheral blood of IBD patients, while Treg cells decrease, suggesting that the Th17/Treg proportion plays an important role in the development and maintenance of inflammation. The purpose of this review was to determine the current state of knowledge on the immunological basis of IBD. Many studies have shown the need for further explanation of the development and maintenance of the inflammatory process.
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23
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Peyrin-Biroulet L, Germain A, Patel AS, Lindsay JO. Systematic review: outcomes and post-operative complications following colectomy for ulcerative colitis. Aliment Pharmacol Ther 2016; 44:807-16. [PMID: 27534519 DOI: 10.1111/apt.13763] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 06/02/2015] [Accepted: 07/22/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Colectomy for ulcerative colitis is associated with short- and long-term complications. Estimates of the frequency of such complications are variable and may have changed since the introduction of biological therapy. Understanding the true burden of surgical complications is important to clinicians in assessing risks and benefits of colectomy vs. continued medical therapy. AIM To ascertain the outcomes of colectomy and ileal pouch surgery in patients with ulcerative colitis in the biologics era. METHODS Embase, MEDLINE and The Cochrane Library were searched for studies (2002-2015) reporting the outcomes of colorectal procedures (total and subtotal colectomy, IPAA with J-, S-, W-pouch) in adults with ulcerative colitis. Conferences proceedings (2011-2015) were hand-searched. RESULTS We identified 28 studies (20,801 patients) reporting outcomes from procedures conducted from 2002-2015. Early complications (≤30 days post-operatively), reported in 10 studies, occurred in 9-65% of patients with ulcerative colitis; late complications (>30 days post-operatively) occurred in 17-55% of patients. Most frequent short-term complications: infectious complications and ileus (mean incidence 20% and 18%). Most frequent long-term complications: pouchitis, faecal incontinence and small bowel obstruction (mean incidence 29%, 21% and 17%). Rates of early infection and late pouch failure decreased from 22% and 13% in 2002-2009 to 11% and 2% in 2010-2015. The mean incidence of post-operative mortality was 1.0% across 11 studies. CONCLUSIONS Early and late complications arise in about one-third of patients undergoing surgery for ulcerative colitis. While colorectal surgical procedures are recommended for a specific group of patients, the post-operative complications associated with these procedures should not be underestimated.
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Affiliation(s)
- L Peyrin-Biroulet
- Inserm U954 and Department of Gastroenterology, Nancy University Hospital, Université de Lorraine, Vandouvre-lès-Nancy, France
| | - A Germain
- Inserm U954 and Department of Digestive Surgery, Nancy University Hospital, Université de Lorraine, Vandoeuvre-lès-Nancy, France
| | | | - J O Lindsay
- Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, London, UK.
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Schieffer KM, Williams ED, Yochum GS, Koltun WA. Review article: the pathogenesis of pouchitis. Aliment Pharmacol Ther 2016; 44:817-35. [PMID: 27554912 PMCID: PMC5785099 DOI: 10.1111/apt.13780] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/03/2015] [Accepted: 08/04/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND A total proctocolectomy followed by ileal pouch-anal anastomosis is a potentially curative surgery for ulcerative colitis or familial adenomatous polyposis. About 5-35% of patients with ulcerative colitis and 0-11% of patients with familial adenomatous polyposis develop subsequent inflammation of the ileal pouch termed pouchitis. AIM To provide a comprehensive analysis of the research studying the possible pathogenesis of pouchitis. The goals were to identify promising areas of investigation, to help focus clinicians, researchers and patients on how to better understand and then potentially manage ileal pouchitis, and to provide avenues for future research investigations. METHODS This review examined manuscripts from 1981 to 2015 that discussed and/or proposed hypotheses with supportive evidence for the potential underlying pathogenic mechanism for pouchitis. RESULTS The pathogenesis of pouchitis is not definitively understood, but various hypotheses have been proposed, including (i) recurrence of ulcerative colitis, (ii) dysbiosis of the ileal pouch microbiota, (iii) deprivation of nutritional short-chain fatty acids, (iv) mucosal ischaemia and oxygen-free radical injury, (v) host genetic susceptibility and (vi) immune dysregulation. However, none of these alone are able to fully explain pouchitis pathogenesis. CONCLUSIONS Pouchitis, similar to inflammatory bowel disease, is a complex disorder that is not caused by any one single factor. More likely, pouchitis occurs through a combination of both dysregulated host inflammatory mechanisms and interaction with luminal microbiota.
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Affiliation(s)
- Kathleen M. Schieffer
- Department of Surgery, Division of Colon and Rectal Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA 17033
| | - Emmanuelle D. Williams
- Department of Medicine, Division of Gastroenterology, The Pennsylvania State University, College of Medicine, Hershey, PA, USA 17033
| | - Gregory S. Yochum
- Department of Surgery, Division of Colon and Rectal Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA 17033,Department of Biochemistry & Molecular Biology, The Pennsylvania State University, College of Medicine, Hershey, PA, USA 17033
| | - Walter A. Koltun
- Department of Surgery, Division of Colon and Rectal Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA 17033
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Calderón-Gómez E, Bassolas-Molina H, Mora-Buch R, Dotti I, Planell N, Esteller M, Gallego M, Martí M, Garcia-Martín C, Martínez-Torró C, Ordás I, Singh S, Panés J, Benítez-Ribas D, Salas A. Commensal-Specific CD4(+) Cells From Patients With Crohn's Disease Have a T-Helper 17 Inflammatory Profile. Gastroenterology 2016; 151:489-500.e3. [PMID: 27267052 DOI: 10.1053/j.gastro.2016.05.050] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 05/27/2016] [Accepted: 05/29/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Crohn's disease (CD) has been associated with an altered immune response to commensal microbiota, mostly based on increased seroreactivity to microbial proteins. Although T cells are believed to contribute to the development of CD, little is known about the antigens involved. We investigated the antigen-specificity of T cells isolated from patients with CD. METHODS We isolated peripheral blood mononuclear cells from 65 patients with CD and 45 healthy individuals (controls). We investigated T-cell reactivity to commensal microbial antigens using proliferation assays (based on thymidine incorporation and carboxyfluorescein succinimidyl ester dilution). Gene expression patterns were determined using microarray and real-time polymerase chain reaction analyses. Cytokines, chemokines, and antibodies were measured by enzyme-linked immunosorbent assay, flow cytometry, or multiplex cytokine assays. Intestinal crypts were obtained from surgical resection specimens of 7 individuals without inflammatory bowel disease. We examined the effects of commensal-specific CD4(+) T cells on primary intestinal epithelial cells from these samples. RESULTS The bacterial proteins FlaX, A4-fla2, and YidX increased proliferation of CD4(+) T cells isolated from peripheral blood of patients with CD compared with controls. In blood samples from controls, CD4(+) T cells specific for FlaX, A4-fla2, or YidX had a T-helper (Th)1 phenotype; a larger proportion of CD4(+) T cells specific for these proteins in patients with CD had a Th17 phenotype or produced Th1 and Th17 cytokines. When supernatants collected from commensal-specific CD4(+) T cells from patients with CD were applied to healthy intestinal epithelial cells, the epithelial cells increased the expression of the chemokine (C-X-C motif) ligand 1 (CXCL1), CXCL8 and the CC chemokine ligand 20 (CCL20). CONCLUSIONS A larger proportion of commensal-specific CD4(+) T cells from patients with CD have a Th17 phenotype or produce Th1 and Th17 cytokines, compared with T cells from controls; this might contribute to intestinal inflammation in patients with CD. These cells might be targeted for treatment of CD. The transcriptional data of commensal-specific CD4(+) T cells from healthy individuals and CD patients have been deposited in the Gene Expression Omnibus at the National Center for Biotechnology Information (accession no: GSE70469).
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Affiliation(s)
- Elisabeth Calderón-Gómez
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Helena Bassolas-Molina
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Rut Mora-Buch
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Isabella Dotti
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Núria Planell
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain; Bioinformatics Platform, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Míriam Esteller
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Marta Gallego
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Mercè Martí
- Laboratory of Cellular Immunology, Institute of Biotechnology and Biomedicine, Autonomous University of Barcelona, Bellaterra, Barcelona, Spain
| | - Carme Garcia-Martín
- Laboratory of Cellular Immunology, Institute of Biotechnology and Biomedicine, Autonomous University of Barcelona, Bellaterra, Barcelona, Spain
| | - Carlos Martínez-Torró
- Laboratory of Cellular Immunology, Institute of Biotechnology and Biomedicine, Autonomous University of Barcelona, Bellaterra, Barcelona, Spain
| | - Ingrid Ordás
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Sharat Singh
- Department of Research and Development, Prometheus Laboratories, San Diego, California
| | - Julian Panés
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Daniel Benítez-Ribas
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Azucena Salas
- Department of Gastroenterology, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.
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Abstract
Crohn's disease (CD) of the pouch is an increasingly recognized diagnosis after ileal pouch-anal anastomosis. This post-ileal pouch-anal anastomosis diagnosis in conjunction with pouchitis remains the leading reason for pouch excision. Unfortunately, CD of the pouch remains a difficult diagnosis with lack of a uniform definition largely because of its similarity to common postoperative pouch complications, including pouchitis, abscess formation, or stricture at the anastomosis. Once diagnosed, treatment algorithms largely include multimodal therapy including biologics. This review focuses on the definition, etiology, diagnosis, and treatment for CD of the pouch, a postoperative de novo diagnosis of CD.
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Nonbloody Diarrhea but Not Significant Weight Loss at Diagnosis Is Associated with the Development of Denovo Crohn's Disease After Ileal Pouch-anal Anastomosis for Ulcerative Colitis. Inflamm Bowel Dis 2016; 22:654-61. [PMID: 26595552 DOI: 10.1097/mib.0000000000000630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Denovo Crohn's disease (CD) develops in 5% to 10% of patients after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) leading to increased morbidity and rates of pouch failure. Initial nonbloody diarrhea and weight loss at diagnosis are independent risk factors for a change in diagnosis from UC to CD in nonsurgical patients. We investigated whether these features were risk factors for denovo CD in a longitudinal cohort of patients with UC undergoing IPAA. METHODS Prospective profiles of patients with UC undergoing IPAA followed over a 22-year period by 1 surgeon were analyzed. Denovo CD was diagnosed when mucosal inflammation (5 or more ulcers) involved the small bowel mucosa proximal to the ileal pouch any time after surgery and/or when a pouch fistula or other perianal complication developed more than 3 months after ileostomy closure. Patients with inflammatory bowel disease unclassified, acute pouchitis, chronic pouchitis, and those lost to follow-up were excluded from analysis. Cox regression analysis was performed for statistical significance. RESULTS Of the 199 study patients included in the analysis, denovo CD developed in 42 patients (21%). Patients who developed denovo CD had an increased incidence of nonbloody diarrhea (n = 12; 29%) compared with patients who had no evidence of pouch inflammation (n = 25; 16%) (P = 0.03). In contrast, the incidence of weight loss was not significantly increased in patients with denovo CD (n = 7; 17%) compared with patients who never had pouch inflammation (n = 16; 10%) (P = 0.12). CONCLUSIONS Initial nonbloody diarrhea is associated with denovo CD after IPAA. This association warrants close consideration before surgery.
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Dubinsky M, Braun J. Diagnostic and Prognostic Microbial Biomarkers in Inflammatory Bowel Diseases. Gastroenterology 2015; 149:1265-1274.e3. [PMID: 26284597 PMCID: PMC5302020 DOI: 10.1053/j.gastro.2015.08.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 08/08/2015] [Accepted: 08/12/2015] [Indexed: 12/14/2022]
Abstract
The microbiome plays multifaceted roles in the pathogenesis of inflammatory bowel diseases (IBD). Accordingly, the clinical challenge of patient heterogeneity in disease phenotype and response to treatment should in part be addressed by biomarkers that detect the host response to microbiota, and the levels of microbial taxa and products eliciting the host response in susceptible individuals. Molecular analysis has revealed much evidence for microbial taxonomic membership and microbial products in association with IBD, but their utility as clinical biomarkers is still in its infancy. A rich area of progress has been the development and validation of host serologic microbial biomarkers, which have achieved a distinctive position in the diagnosis and prognosis in IBD, and as a template for defining other categories of microbial biomarkers in disease state and phenotype.
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Affiliation(s)
- Marla Dubinsky
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Jonathan Braun
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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29
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Liu Z, Shen B. Overcoming difficulty in diagnosis and differential diagnosis of Crohn's disease: the potential role of serological and genetic tests. Expert Rev Mol Diagn 2015; 15:1133-41. [PMID: 26295589 DOI: 10.1586/14737159.2015.1068121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Crohn's disease (CD) represents a heterogeneous group of chronic inflammatory disorders with various phenotypes. Establishing a definite diagnosis of CD should be based upon a combined assessment of clinical, endoscopic, radiological and pathological features. Although segmental disease distribution, transmural inflammation and non-caseating epithelioid granulomas have been considered as a 'hallmarks' for CD, clear diagnosis of CD in some patients has been challenging, due to overlapping endoscopic, radiographic and histologic features with other inflammatory bowel disease-like conditions. Laboratory markers (serological and genetic tests) may provide additional clues for the diagnosis and differential diagnosis of CD. This review focuses on the application of the currently available serological and genomic markers and in diagnosis and differential diagnosis of CD.
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Affiliation(s)
- Zhaoxiu Liu
- a 1 Department of Gastroenterology, Affiliated Hospital of Nantong University, Jiangsu, China
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30
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Quezada SM, Rustgi A, Jambaulikar GD, Cross RK. Differential response to microbial antigens by age of diagnosis in patients with Crohn's disease. Clin Exp Gastroenterol 2015; 8:169-74. [PMID: 26089697 PMCID: PMC4467647 DOI: 10.2147/ceg.s69905] [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] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Fifteen percent of incident Crohn's disease (CD) cases are diagnosed at older ages and demonstrate colonic location and inflammatory behavior. Serologic responses to gut microbial antigens are associated with specific phenotypes, and may differ by age at diagnosis. Our aim was to identify an association between age at diagnosis of CD and responses to gut microbial antigens. PATIENTS AND METHODS Levels of anti-Saccharomyces cerevisiae antibodies (ASCA) immunoglobulins A and G (IgA and IgG), antibodies to Escherichia coli outer membrane porin-C (anti-Omp-C), antibodies to clostridial flagellin (anti-CBir-1), and perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA) were compared in patients by age in three diagnosis groups: patients diagnosed at ages of <40, ≥40-59, and ≥60 years. For each antigen, patients with antibody levels in the first, second, third, and fourth quartile were assigned a score of 1, 2, 3, or 4, respectively. Individual scores were added to create a quartile sum score representing cumulative quantitative immune response. RESULTS Eighteen, 17, and 12 patients were diagnosed at ages <40, 40-59, and ≥60 years, respectively. The majority (71%) had ileocolonic disease in the youngest group, compared to 36% in the oldest group (P=0.001). Mean ASCA IgA and IgG titers were increased in the youngest age group compared to the older groups (P=0.19 and P=0.13, respectively). Mean quartile sum scores for antibody levels were 7.2±2.8 in those patients diagnosed at ages <40 years, 4.9±2.9 in the 40-59-year-old age group, and 5.6±2.6 in the ≥60-year-old age group (P=0.06). CONCLUSION A trend toward decreased cumulative immune responses to CD-associated gut antigens was observed in CD patients diagnosed at older ages compared to younger patients. Host responses to microbial antigens may be less important in older onset IBD and may contribute to the distinct phenotype in this group.
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Affiliation(s)
- Sandra M Quezada
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ankur Rustgi
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Guruprasad D Jambaulikar
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Raymond K Cross
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
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Effects of age at disease onset and at treatment on serology in inflammatory bowel diseases. Dig Dis Sci 2015; 60:278-9. [PMID: 25366149 DOI: 10.1007/s10620-014-3420-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 10/29/2014] [Indexed: 12/09/2022]
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Systematic review: new serological markers (anti-glycan, anti-GP2, anti-GM-CSF Ab) in the prediction of IBD patient outcomes. Autoimmun Rev 2014; 14:231-45. [PMID: 25462578 DOI: 10.1016/j.autrev.2014.11.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 11/08/2014] [Indexed: 12/20/2022]
Abstract
Traditionally, IBD diagnosis is based on clinical, radiological, endoscopic, and histological criteria. Biomarkers are needed in cases of uncertain diagnosis, or to predict disease course and therapeutic response. No guideline recommends the detection of antibodies (including ASCA and ANCA) for diagnosis or prognosis of IBD to date. However, many recent data suggest the potential role of new serological markers (anti-glycan (ACCA, ALCA, AMCA, anti-L and anti-C), anti-GP2 and anti-GM-CSF Ab). This review focuses on clinical utility of these new serological markers in diagnosis, prognosis and therapeutic monitoring of IBD. Literature review of anti-glycan, anti-GP2 and anti-GM-CSF Ab and their impact on diagnosis, prognosis and prediction of therapeutic response was performed in PubMed/MEDLINE up to June 2014. Anti-glycan, anti-GP2 and anti-GM-CSF Ab are especially associated with CD and seem to be correlated with complicated disease phenotypes even if results differ between studies. Although anti-glycan Ab and anti-GP2 Ab have low sensitivity in diagnosis of IBD, they could identify a small number of CD patients not detected by other tests such as ASCA. Anti-glycan Abs are associated with a progression to a more severe disease course and a higher risk for IBD-related surgery. Anti-GP2 Ab could particularly contribute to better stratify cases of pouchitis. Anti-GM-CSF Ab seems to be correlated with disease activity and could help predict relapses. These new promising biomarkers could particularly be useful in stratification of patients according to disease phenotype and risk of complications. They could be a valuable aid in prediction of disease course and therapeutic response but more prospective studies are needed.
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Werner L, Sturm A, Roggenbuck D, Yahav L, Zion T, Meirowithz E, Ofer A, Guzner-Gur H, Tulchinsky H, Dotan I. Antibodies against glycoprotein 2 are novel markers of intestinal inflammation in patients with an ileal pouch. J Crohns Colitis 2013; 7:e522-32. [PMID: 23639628 DOI: 10.1016/j.crohns.2013.03.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 03/02/2013] [Accepted: 03/20/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The Crohn's disease (CD)-specific pancreatic auto-antibodies (PAB), have been recently identified to target glycoprotein 2 (GP2). Pouchitis is an inflammation of the small bowel developing in up to 60% of ulcerative colitis patients undergoing proctocolectomy and ileal pouch anal anastomosis. Occurrence of CD-specific antibodies was reported to be a predictor of pouchitis. We aimed to assess the prevalence of anti-GP2 antibodies (anti-GP2) in the serum and feces of pouch patients and to correlate them with clinical parameters. Furthermore, we examined mucosal expression of the GP2 protein in the pouch. METHODS Pouch patients were prospectively recruited and checked for clinical, endoscopic, and laboratory markers of inflammation. IgG and IgA anti-GP2 levels in serum and fecal samples were determined using ELISA. GP2 protein was assessed by immunohistochemistry. RESULTS Anti-GP2 was elevated in both serum and fecal samples of patients with inflamed compared to those with non-inflamed pouches and patients with familial-adenomatous polyposis after surgery (p<0.05, respectively). Moreover, patients with CD-like complications exhibited significantly higher anti-GP2 titers than those without CD-like complications (p≤0.01). High levels of anti-GP2 correlated with more frequent bowel movements per day and with the presence of at least one anti-glycan antibody (p≤0.05). GP2 itself was more abundant in the mucosa of patients with chronic pouchitis. CONCLUSIONS Anti-GP2 exists in the serum and feces of pouch patients and correlates with pouch inflammation, and presence of other serological markers. Thus, anti-GP2 may contribute to better stratification of pouchitis, more-so when the inflammation exhibits CD-like complications.
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Affiliation(s)
- Lael Werner
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel.
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Agarwal S, Stucchi AF, Dendrinos K, Cerda S, O'Brien MJ, Becker JM, Heeren T, Farraye FA. Is pyloric gland metaplasia in ileal pouch biopsies a marker for Crohn's disease? Dig Dis Sci 2013; 58:2918-25. [PMID: 23543088 DOI: 10.1007/s10620-013-2655-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 03/19/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND Approximately 5-10 % of ulcerative colitis (UC) patients who undergo ileal pouch-anal anastomosis (IPAA) will develop postoperative complications such as refractory pouchitis or a change in diagnosis to Crohn's disease (CD). Serological markers and histologic aspects of the pouch such as pyloric gland metaplasia (PGM) have been associated with a risk for these complications. METHODS Twenty-eight IPAA patients with either CD of the pouch or chronic pouchitis (cases) and 36 IPAA controls who experienced a normal postoperative course were originally consented. Of these 64 subjects, 22 cases and 17 controls had histopathologic and serologic data available and were subsequently enrolled. Demographic and clinical data were entered into a database, blood analyzed for serological markers (Prometheus Labs, San Diego, CA) and biopsies of the pouch and the afferent limb reviewed by two GI pathologists. RESULTS Of the cases, 55 % (12/22) had evidence of PGM in their pouch and/or small bowel biopsies, as compared to 12 % (2/17) of the controls (p = 0.006). Of 13 subjects with CD, 77 % (10/13) were found to have PGM versus subjects with chronic pouchitis in which 22 % (2/9) were found to have PGM (p = 0.03). There was a trend of ASCA positivity (both IgG and IgA, p = 0.20) and of higher ASCA titer levels (p = 0.07) with postoperative complications. CONCLUSION This study suggests that the presence of ileal pouch PGM is associated with postoperative complications and favors a diagnosis of CD over UC with chronic pouchitis.
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Affiliation(s)
- Shuchi Agarwal
- Section of Gastroenterology, Boston University School of Medicine, 85 East Concord St. 7th Floor, Boston, MA, 02118, USA,
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35
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Cannistrà C, Finocchi V, Trivisonno A, Tambasco D. New perspectives in the treatment of hidradenitis suppurativa: surgery and brewer's yeast-exclusion diet. Surgery 2013; 154:1126-30. [PMID: 23891479 DOI: 10.1016/j.surg.2013.04.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 04/11/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hidradenitis suppurativa (HS), or acne inversa, is a chronic inflammatory skin disease characterized by abscesses, fistulating sinus tracts, and scarring. The exact pathogenesis of this disease remains unclear. We present our experience with HS and a possible cause of the disease and offer a surgical and clinical treatment that allows for disease resolution. METHODS We studied 12 patients who presented with axillary and perineal fistulas and underwent surgical excision (repaired by skin grafts or healing by secondary intention) or localized treatments followed by diet modification. All patients were found to have a specific immunology IgG reaction to brewer's yeast and wheat and were put on a controlled brewer's yeast-free diet for 12 months and followed monthly. RESULTS The diet demonstrated immediate stabilization of their clinical symptoms, and the skin lesions regressed over the 12-month treatment period. Similarly, all the patients demonstrated an immediate recurrence of skin lesions following accidental or voluntary consumption of beer or other foods containing brewer's yeast or wheat. The patients also demonstrated a return of their quality of life and activities, including the reestablishment of sexual activity in the patients with inguinal and perigenital lesions. CONCLUSION The results of the investigation suggested that the patients had severe reactions to brewer's yeast. Surgery followed by the elimination of the foods containing or made with the yeast resulted in a rapid stabilization of the dermatologic manifestation and a slow, but complete, regression of the skin lesions within a year. Despite the small number of patients in our study, our study could provide the basis for extensive and multicentric studies in order to better investigate this disabling and rare disease.
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Affiliation(s)
- Claudio Cannistrà
- Unit of Plastic Surgery, Department of General Surgery, Hôpital Bichat C.B., Paris, France
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Singh S, Sharma PK, Loftus EV, Pardi DS. Meta-analysis: serological markers and the risk of acute and chronic pouchitis. Aliment Pharmacol Ther 2013; 37:867-75. [PMID: 23480145 DOI: 10.1111/apt.12274] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 02/09/2013] [Accepted: 02/16/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Serological markers such as anti-neutrophil cytoplasmic antibody (ANCA) and anti-Saccharomyces cerevisiae antibody (ASCA) may be associated with pouchitis after ileal pouch-anal anastomosis (IPAA). AIM To perform a systematic review with meta-analysis of studies evaluating the association of ANCA and ASCA status with risk of acute and chronic pouchitis after IPAA. METHODS We searched multiple databases (upto September 2012) for studies reporting ANCA and/or ASCA status along with risk of acute or chronic pouchitis after IPAA in adults with ulcerative colitis (UC). We abstracted odds ratio (OR) or raw data from the individual studies to calculate summary OR estimates with 95% CIs using random-effects model. RESULTS Eight studies reporting 184 cases of acute pouchitis and six studies reporting 151 cases of chronic pouchitis were included. The odds of chronic pouchitis were 76% higher in ANCA-positive patients than ANCA-negative (six studies; OR: 1.76; 95% CI: 1.19-2.61; P < 0.01). ASCA-positivity was not associated with the risk of chronic pouchitis (three studies; OR: 0.89; 95% CI: 0.49-1.59; P = 0.68). Neither ANCA (eight studies; OR: 1.54; 95% CI: 0.79-3.02; P = 0.21) nor ASCA-positivity (two studies; OR: 1.28; 95% CI: 0.25-6.54; P = 0.77) were associated with the risk of acute pouchitis. CONCLUSIONS The risk of chronic pouchitis after IPAA is higher in ANCA-positive patients, but the risk of acute pouchitis is unaffected by ANCA status. ASCA status was not associated with the risk of acute or chronic pouchitis. This information may be used to counsel UC patients regarding their risk of pouchitis after IPAA.
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Affiliation(s)
- S Singh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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37
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Wahbeh GT, Suskind DL, Lee SD, Waldhausen JT, Murray KF. The pediatric pouch in inflammatory bowel disease: a primer for the gastroenterologist. Expert Rev Gastroenterol Hepatol 2013; 7:215-23. [PMID: 23445231 DOI: 10.1586/egh.12.70] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pediatric severe ulcerative colitis that is resistant to current medical treatment can successfully be managed surgically with a colectomy, ileal pouch creation and pouch-anal anastomosis. Key issues that should be considered and discussed before the pouch option can be offered include alternative surgical procedures, pouch function expectations, risk of surgical leak, pelvic sepsis, anastomotic strictures, acute and chronic pouch inflammation, Crohn's disease of the pouch and risk of reduced fertility for females. A long-term risk is malignancy of the residual colonic tissue. The decision to proceed with a pouch or not poses a substantial emotional burden to the child and family. Despite the risk of surgical complications and pouch inflammatory and functional challenges, the overwhelming majority of children and their families are satisfied with their pouch surgery outcomes. Further study is needed to assess preoperative risk predictors, prevention and treatment of complications.
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Affiliation(s)
- Ghassan T Wahbeh
- Inflammatory Bowel Disease Program, Seattle Children's Hospital, University of Washington, W7830, Gastroenterology, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
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