Influence of ileal pouch anal anastomosis on bone loss in ulcerative colitis patients

Vitamin D Deficiency is Common in Patients with Ulcerative Colitis After Total Proctocolectomy with Ileal Pouch Anal Anastomosis

In a retrospective study of 412 patients with ulcerative colitis who underwent total proctocolectomy with ileal pouch anal anastomosis and had subsequent pouchoscopy, low 25-hydroxyvitamin D was common and was not significantly associated with age, sex, ethnicity, or precolectomy medication use.

Diagnosis and classification of ileal pouch disorders: consensus guidelines from the International Ileal Pouch Consortium

Restorative proctocolectomy with ileal pouch-anal anastomosis is an option for most patients with ulcerative colitis or familial adenomatous polyposis who require colectomy. Although the construction of an ileal pouch substantially improves patients' health-related quality of life, the surgery is, directly or indirectly, associated with various structural, inflammatory, and functional adverse sequelae. Furthermore, the surgical procedure does not completely abolish the risk for neoplasia. Patients with ileal pouches often present with extraintestinal, systemic inflammatory conditions. The International Ileal Pouch Consortium was established to create this consensus document on the diagnosis and classification of ileal pouch disorders using available evidence and the panellists' expertise. In a given individual, the condition of the pouch can change over time. Therefore, close monitoring of the activity and progression of the disease is essential to make accurate modifications in the diagnosis and classification in a timely manner.

High-resolution Quantitative Computed Tomography Demonstrates Structural Defects in Cortical and Trabecular Bone in IBD Patients

BACKGROUND AND AIMS

To investigate the macro- and microstructural changes of bone in patients with inflammatory bowel disease [IBD] and to define the factors associated with bone loss in IBD.

METHODS

A total of 148 subjects, 59 with Crohn's disease [CD], 39 with ulcerative colitis [UC], and 50 healthy controls were assessed for the geometric, volumetric and microstructural properties of bone using high-resolution peripheral quantitative computed tomography. In addition, demographic and disease-specific characteristics of IBD patients were recorded.

RESULTS

IBD patients and controls were comparable in age, sex, and body mass index. Total [p = 0.001], cortical [p < 0.001], and trabecular volumetric bone mineral density [BMD] [p = 0.03] were significantly reduced in IBD patients compared with healthy controls. Geometric and microstructural analysis revealed significantly lower cortical area [p = 0.001] and cortical thickness [p < 0.001] without differences in cortical porosity, pore volume, or pore diameter. CD showed a more severe bone phenotype than UC: cortical bone loss was observed in both diseases, but CD additionally showed profound trabecular bone loss with reduced trabecular BMD [p = 0.008], bone volume [p = 0.008], and trabecular thickness [p = 0.009]. Multivariate regression models identified the diagnosis of CD, female sex, lower body mass index, and the lack of remission as factors independently associated with bone loss in IBD.

CONCLUSION

IBD patients develop significant cortical bone loss, impairing bone strength. Trabecular bone loss is limited to CD patients, who exhibit a more severe bone phenotype compared with UC patients.

Risk factors for osteoporosis in inflammatory bowel disease patients

Inflammatory bowel disease (IBD) patients exhibit higher risk for bone loss than the general population. The chronic inflammation causes a reduction in bone mineral density (BMD), which leads to osteopenia and osteoporosis. This article reviewed each risk factor for osteoporosis in IBD patients. Inflammation is one of the factors that contribute to osteoporosis in IBD patients, and the main system that is involved in bone loss is likely RANK/RANKL/osteoprotegerin. Smoking is a risk factor for bone loss and fractures, and many mechanisms have been proposed to explain this loss. Body composition also interferes in bone metabolism and increasing muscle mass may positively affect BMD. IBD patients frequently use corticosteroids, which stimulates osteoclastogenesis. IBD patients are also associated with vitamin D deficiency, which contributes to bone loss. However, infliximab therapy is associated with improvements in bone metabolism, but it is not clear whether the effects are because of inflammation improvement or infliximab use. Ulcerative colitis patients with proctocolectomy and ileal pouches and Crohn’s disease patients with ostomy are also at risk for bone loss, and these patients should be closely monitored.

Estrogen modulation of the ethanol-evoked myocardial oxidative stress and dysfunction via DAPK3/Akt/ERK activation in male rats

Evidence suggests that male rats are protected against the hypotensive and myocardial depressant effects of ethanol compared with females. We investigated whether E2 modifies the myocardial and oxidative effects of ethanol in male rats. Conscious male rats received ethanol (0.5, 1 or 1.5g/kg i.v.) 30-min after E2 (1μg/kg i.v.) or its vehicle (saline), and hearts were collected at the conclusion of hemodynamic measurements for ex vivo molecular studies. Ethanol had no effect in vehicle-treated rats, but it caused dose-related reductions in LV developed pressure (LVDP), end-diastolic pressure (LVEDP), rate of rise in LV pressure (dP/dtmax) and systolic (SBP) and diastolic (DBP) blood pressures in E2-pretreated rats. These effects were associated with elevated (i) indices of reactive oxygen species (ROS), (ii) malondialdehyde (MDA) protein adducts, and (iii) phosphorylated death-associated protein kinase-3 (DAPK3), Akt, and extracellular signal-regulated kinases (ERK1/2). Enhanced myocardial anti-oxidant enzymes (heme oxygenase-1, catalase and aldehyde dehydrogenase 2) activities were also demonstrated. In conclusion, E2 promotes ethanol-evoked myocardial oxidative stress and dysfunction in male rats. The present findings highlight the risk of developing myocardial dysfunction in men who consume alcohol while receiving E2 for specific medical conditions.

Bone loss in patients with the ileostomy and ileal pouch for inflammatory bowel disease

Low bone mineral density (BMD) or low bone mass is common in patients with inflammatory bowel disease (IBD). Studies have shown that low BMD is also common in patients with ulcerative colitis (UC) even after colectomy and ileal pouch–anal anastomosis (IPAA). The reported frequency of osteopenia ranged from 26–55% and that of osteoporosis ranged from 13–32% in patients with IPAA. Increasing age, low body mass index, lack of calcium supplementation and high inflammatory activity with villous atrophy in the ileo-anal pouch are risk factors for low bone mass in pouch patients. Bone loss is also common in patients with IBD and ostomy. Current professional society guidelines do not specifically address the need for surveillance in patients with ileal pouches or ostomy. A growing body of evidence suggests that patients with ileal pouch or ostomy are at an increased risk of bone loss. Pending prospective studies, screening and surveillance using dual energy X-ray absorptiometry (DEXA) along with calcium/vitamin D supplementation may be beneficial in those patients.

Glucose intolerance and diabetes mellitus in ulcerative colitis: Pathogenetic and therapeutic implications

Diabetes mellitus is one of the most frequent co-morbidities of ulcerative colitis patients. The epidemiological association of these diseases suggested a genetic sharing and has challenged gene identification. Diabetes co-morbidity in ulcerative colitis has also relevant clinical and therapeutic implications, with potential clinical impact on the follow up and outcome of patients. These diseases share specific complications, such as neuropathy, hepatic steatosis, osteoporosis and venous thrombosis. It is still unknown whether the coexistence of these diseases may increase their occurrence. Diabetes and hyperglycaemia represent relevant risk factors for postoperative complications and pouch failure in ulcerative colitis. Medical treatment of ulcerative colitis in patients with diabetes mellitus may be particularly challenging. Corticosteroids are the treatment of choice of active ulcerative colitis. Their use may be associated with the onset of glucose intolerance and diabetes, with difficult control of glucose levels and with complications in diabetic patients. Epidemiologic and genetic evidences about diabetes co-morbidity in ulcerative colitis patients and shared complications and treatment of patients with these diseases have been discussed in the present review.

Risk factors and management of osteoporosis in inflammatory bowel disease

PURPOSE OF REVIEW

To provide a synopsis on established and new research evaluating bone disease in patients with inflammatory bowel disease (IBD).

RECENT FINDINGS

Persons with IBD, including Crohn's disease and ulcerative colitis are believed to be at high risk for osteoporosis and fracture. As osteoporosis is clinically silent and persons with IBD are not universally screened, the burden of bone disease in IBD has been difficult to accurately assess. It is also unclear whether bone disease is due to inflammatory activity, medication use, poor nutrient intake/absorption, or body habitus characteristics. Recent studies using population-wide databases of bone mineral density (BMD) analyses suggest that Crohn's disease is responsible for a small effect on BMD after adjusting for other risk factors for low BMD, whereas ulcerative colitis does not appear to confer an independent risk. Furthermore, IBD does not appear to be a risk for overall fracture once controlling for factors which are associated with both IBD and fracture risk. The ability to assess BMD on incidentally performed computed tomography scans may allow detection of low BMD in IBD patients.

SUMMARY

Although reduced BMD and fracture are more common in persons with IBD, the precise burden is not well characterized. Also, the relative impact of IBD-associated factors and IBD-specific inflammation on bone health is still uncertain.

Comparison of fracture risk between patients with ileal pouch-anal anastomosis for ulcerative colitis and the general population

BACKGROUND

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for ulcerative colitis (UC). Little is known of how the operation affects bone metabolism and fracture risk. The aim of this retrospective cohort study was to investigate fracture risk and serum markers of bone metabolism following IPAA in a national cohort of Danish UC patients.

METHODS

Diagnostic codes for 1757 patients and 8785 controls were obtained from the National Patient Register while blood results were collected from a regional database. Postoperative fracture free survival was evaluated on a Kaplan-Meier plot. Fracture hazard ratios (HR) after IPAA were calculated from Cox proportional hazards regression analysis.

RESULTS

Fracture risk after IPAA was significantly reduced (adjusted HR = 0.49, 95% CI: 0.43; 0.55, p<0.001). Prior fractures and alcoholism independently increased fracture risk significantly. Osteoporotic fracture risk after IPAA was reduced, significantly for wrist fractures (aHR = 0.39, 95% CI: 0.22; 0.71, p = 0.002), and borderline insignificantly for spine fractures (aHR = 0.51, 95% CI: 0.26; 1.01, p = 0.054). Vitamin D and calcium levels were significantly higher in the patient group (61.2 nmol/L vs. 58.9 nmol/L, p = 0.04 and 1.24 mmol/L vs. 1.21 mmol/L, p<0.01, respectively), while parathyroid hormone and phosphate levels were significantly lower (4.9 pmol/L vs. 6.2 pmol/L, p<0.01 and 1.08 mmol/L vs. 1.12 mmol/L, p<0.01, respectively).

CONCLUSION

Fracture risk after IPAA is significantly reduced compared to the general population. Prospective studies are needed to verify the biochemical results.

Frequency, risk factors, and adverse sequelae of bone loss in patients with ostomy for inflammatory bowel diseases

BACKGROUND

Bone loss in patients with inflammatory bowel disease (IBD) with ostomy has not been systemically studied. The aims of the study were to evaluate the frequency, risk factors, and sequelae of bone loss in patients with IBD and stomas and to monitor the change in bone mineral density (BMD) over time after ostomy.

METHODS

A total of 126 patients met the inclusion criteria (i.e., those with IBD diagnosis and stoma), including ileostomy (N = 120), colostomy (N = 3), and jejunostomy (N = 3). BMD was measured on dual-energy X-ray absorptiometry (DEXA). Patients were classified as having normal or low BMD based on the International Society for Clinical Densitometry criteria. Thirty-two demographic and clinical variables were evaluated with logistic regression models.

RESULTS

At a median of 6.6 years (interquartile range, 2-18.7 yr) after stoma, 37 (29.4%) patients had a low BMD. On univariate analysis, there were no significant differences between the normal and low BMD groups in the following variables: gender, race, age at diagnosis of IBD, prevalence of Crohn's disease and ulcerative colitis, age at ostomy, duration from diagnosis to DEXA and from ostomy to DEXA, menopausal age, diabetes, hypothyroidism, renal stones, short bowel syndrome, history of smoking or excessive alcohol use, family history of IBD or osteoporosis, daily calcium and vitamin D supplement, estrogen replacement, and steroid use. Body mass index was significantly lower in the low BMD group than the normal BMD group (23.3 ± 5.5 versus 26.0 ± 5.2, P = 0.013). Fragility fracture occurred in 8 (21.6%) patients in low BMD group and 4 (4.5%) patients in normal BMD group (P = 0.006). In a multivariate analysis, low body mass index was the only covariate-adjusted factor associated with low BMD. In patients with multiple DEXA scans available over time after ostomy, hip BMD was found to improve marginally, and the lumbar and femoral BMD remained stable.

CONCLUSIONS

Low BMD was common in patients with IBD after ostomy, largely based on the findings in patients with CD with ileostomy. Fragility fracture was 5 times more frequent in patients with ostomy with low BMD compared with those with normal BMD. The low BMD was associated with a low body mass index. Screening and surveillance of BMD should routinely be performed, particularly in these patients at risk. Bone mass tends to stabilize over time after stoma.

Low levels of vitamin D are common in patients with ileal pouches irrespective of pouch inflammation

BACKGROUND

Vitamin D (25(OH) D3) levels in pouch patients are not well defined.

AIM

To evaluate the frequency and factors associated with low 25(OH) D3 levels in pouch patients with underlying inflammatory bowel disease (IBD).

METHODS

A consecutive of 157 pouch patients was identified from our Pouchitis Registry. A sample of 155 ulcerative colitis (UC) patients without IPAA served as controls.

RESULTS

The mean age of the cohort was 37.5 ± 14.2 years, with 86 (54.8%) being female. Low 25(OH)D3 levels (<31 ng/mL) were detected in 69.4% of patients (N=109). 34 (21.7%) of the 157 patients examined were 25(OH)D3 deficient (<20 ng/mL). This was higher than the frequency of vitamin D insufficiency or deficiency in a sample of UC patients without IPAA. Between patients with and without normal 25(OH) D3 levels (>31 ng/mL), no differences were identified in terms of demographic, pouch, and medication variables. A low hemoglobin level was found to be associated with low 25(OH) D3 levels in both univariate (p=0.02) and multivariate analyses (odds ratio [OR]=3.37; 95% confidence interval [CI]: 1.41-8.06; p=0.01). Low levels of 25(OH)D3 was not related to markers of pouch inflammation, in particular there was no relation to pouchitis (OR=1.20; 95% CI: 0.41-3.52; p=0.74).

CONCLUSION

Low 25(OH)D3 level was common in this cohort, irrespective of inflammation of the pouch, possibly suggesting a strategy of routine testing in this population. Anemia was found to be associated with a low 25(OH)D3 level.

Diagnosis and therapeutic management of extra-intestinal manifestations of inflammatory bowel disease

Extra-intestinal manifestations (EIMs) are reported frequently in patients with inflammatory bowel disease (IBD) and may be diagnosed before, concurrently or after the diagnosis of IBD. EIMs in IBD may be classified based on their association with IBD disease activity. The first group has a direct relationship with the activity of the bowel disease and includes pauciarticular arthritis, oral aphthous ulcers, erythema nodosum and episcleritis. The second group of EIMs appears to follow an independent course from the underlying bowel disease activity and include ankylosing spondylitis and uveitis. The third group includes EIMs that may or may not be related to intestinal inflammation, such as pyoderma gangrenosum and probably primary sclerosing cholangitis (PSC). Genetic susceptibility, aberrant self-recognition and immunopathogenic autoantibodies against organ-specific cellular antigens shared by the colon and extra-colonic organs may contribute to the pathogenesis and development of these EIMs. The use of biological agents in the IBD armamentarium has expanded the treatment options for some of the disabling EIMs and these agents form the cornerstone in managing most of the disabling EIMs. PSC is one of the most common hepatobiliary manifestations associated with IBD in which no clear treatment options exist other than endoscopic therapy and liver transplantation. Future research targeting the pathogenesis, early diagnosis and treatment of these EIMs is required.

Diagnosis and therapeutic management of extra-intestinal manifestations of inflammatory bowel disease

Extra-intestinal manifestations (EIMs) are reported frequently in patients with inflammatory bowel disease (IBD) and may be diagnosed before, concurrently or after the diagnosis of IBD. EIMs in IBD may be classified based on their association with IBD disease activity. The first group has a direct relationship with the activity of the bowel disease and includes pauciarticular arthritis, oral aphthous ulcers, erythema nodosum and episcleritis. The second group of EIMs appears to follow an independent course from the underlying bowel disease activity and include ankylosing spondylitis and uveitis. The third group includes EIMs that may or may not be related to intestinal inflammation, such as pyoderma gangrenosum and probably primary sclerosing cholangitis (PSC). Genetic susceptibility, aberrant self-recognition and immunopathogenic autoantibodies against organ-specific cellular antigens shared by the colon and extra-colonic organs may contribute to the pathogenesis and development of these EIMs. The use of biological agents in the IBD armamentarium has expanded the treatment options for some of the disabling EIMs and these agents form the cornerstone in managing most of the disabling EIMs. PSC is one of the most common hepatobiliary manifestations associated with IBD in which no clear treatment options exist other than endoscopic therapy and liver transplantation. Future research targeting the pathogenesis, early diagnosis and treatment of these EIMs is required.

Indian Society of Gastroenterology consensus on ulcerative colitis

In 2010, the Indian Society of Gastroenterology's Task Force on Inflammatory Bowel Diseases undertook an exercise to produce consensus statements on ulcerative colitis. This consensus, produced through a modified Delphi process, reflects our current understanding of the definition, diagnostic work up, treatment and complications of ulcerative colitis. The consensus statements are intended to serve as a reference point for teaching, clinical practice, and research in India.