1
|
Adam H, Alqassas M, Saadah OI, Mosli M. Extraintestinal Manifestations of Inflammatory Bowel Disease in Middle Eastern Patients. J Epidemiol Glob Health 2020; 10:298-303. [PMID: 32959603 PMCID: PMC7758850 DOI: 10.2991/jegh.k.200330.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 03/01/2020] [Indexed: 01/06/2023] Open
Abstract
Background and Aims: The Inflammatory Bowel Diseases (IBDs), Crohn’s Disease (CD) and Ulcerative Colitis (UC), are gastrointestinal autoimmune disorders with many Extraintestinal Manifestations (EIMs). Previously reported incidences of EIMs in IBD patients have ranged from 10% to 50%. The large variation in occurrence of EIMs has been linked to genetic predisposition. Correlations between individual EIMs are unclear. Therefore, we aim to estimate the incidence of EIMs in a Middle Eastern cohort of patients with IBD and examine possible relationships with EIMs. Patients and Methods: We conducted a retrospective study involving all patients included in the King Abdulaziz University IBD information system registry between 2013 and 2018. Data on demographics, disease characteristics, and EIMs were extracted and analyzed using descriptive statistics: the standard Student’s t-test and chi-squared test. Logistic regression analysis was used to examine associations using STATA software version 11.2 (StataCorp, TX, USA). Results: We reviewed the electronic medical files of 284 patients with confirmed IBD, of which 158 (55.6%) were females, the mean age was 27.8 (±15) years; 146 (51.4%) patients had CD and 138 (48.6%) UC. The overall incidence risk of EIMs was 138 (52.3%) over a mean duration of follow up of 7.3 (±3.9) years. The most common EIM was arthritis (33%), followed by aphthous ulcers (16%). Pyoderma gangrenosum occurred in 8% of patients and appeared to be specific for CD patients (p = 0.002), whereas Primary Sclerosing Cholangitis (PSC) was more specific for UC (p = 0.001). Certain EIMs appeared to occur together such as arthritis with PSC (p = 0.001). Regression analysis identified disease type (in favor of UC; odds ratio = 0.50, p = 0.03) and age at the time of diagnosis (odds ratio = 1.04, p = 0.001) as the only significant predictors of EIMs. Conclusion: Our results demonstrate that more than half of IBD patients have at least one EIM. Contrary to what has often been reported, we found that EIMs occur more commonly in UC than CD. A multidisciplinary assessment is recommended as part of IBD management to improve overall health outcomes.
Collapse
Affiliation(s)
- Heba Adam
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Maryam Alqassas
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Omar I Saadah
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.,Inflammatory Bowel Disease Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mahmoud Mosli
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.,Inflammatory Bowel Disease Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
| |
Collapse
|
2
|
Abdul-fattah B, Al-Muriesh M, Huang CZ. Efficacy of topical calcineurin inhibitors in pyoderma gangrenosum. Dermatol Ther 2018; 31:e12697. [PMID: 30252999 DOI: 10.1111/dth.12697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 07/11/2018] [Accepted: 07/20/2018] [Indexed: 12/28/2022]
Affiliation(s)
- Bilal Abdul-fattah
- Department of Dermatology; Union Hospital, Tongji Medical College, Huazhong University of Science and Technology; Wuhan People's Republic of China
| | - Maher Al-Muriesh
- Department of Dermatology; Union Hospital, Tongji Medical College, Huazhong University of Science and Technology; Wuhan People's Republic of China
| | - Chang-zheng Huang
- Department of Dermatology; Union Hospital, Tongji Medical College, Huazhong University of Science and Technology; Wuhan People's Republic of China
| |
Collapse
|
3
|
Butts GT, Bishop PR, Wyatt JP, Nowicki MJ. Leukocytoclastic vasculitis in an adolescent with ulcerative colitis: Report of a case and review of the literature. SAGE Open Med Case Rep 2014; 2:2050313X14547609. [PMID: 27489650 PMCID: PMC4857370 DOI: 10.1177/2050313x14547609] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 07/07/2014] [Indexed: 01/01/2023] Open
Abstract
An adolescent female with long-standing, difficult-to-control ulcerative colitis developed leukocytoclastic vasculitis, a rare cutaneous extra-intestinal manifestation of the inflammatory bowel disease. The authors provide a literature review on leukocytoclastic vasculitis complicating ulcerative colitis. Furthermore, the clinical features of leukocytoclastic vasculitis are compared and contrasted with the more common cutaneous extra-intestinal manifestations of inflammatory bowel disease, erythema nodosum, and pyoderma gangrenosum.
Collapse
Affiliation(s)
- G Tyler Butts
- School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Phyllis R Bishop
- Division of Pediatric Gastroenterology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Julie P Wyatt
- Department of Dermatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Michael J Nowicki
- Division of Pediatric Gastroenterology, University of Mississippi Medical Center, Jackson, MS, USA
| |
Collapse
|
4
|
Wu XR, Mukewar S, Kiran RP, Remzi FH, Hammel J, Shen B. Risk factors for peristomal pyoderma gangrenosum complicating inflammatory bowel disease. J Crohns Colitis 2013; 7:e171-7. [PMID: 22959399 DOI: 10.1016/j.crohns.2012.08.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 08/01/2012] [Accepted: 08/01/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Risk factors for peristomal pyoderma gangrenosum (PPG) are not well defined. The aim of this study was to evaluate risk factors associated with development of PPG. METHODS Both PPG patients and controls were obtained by searching a database of the Cleveland Clinic using the ICD-9 code from March 2005 to May 2011. The control group was selected by matching for underlying diseases and type of stoma in a ratio of 3:1. Univariate and multivariate analyses were performed. RESULTS A total of 15 PPG cases and 45 controls were included. The mean age at the time of PPG diagnosis was 46.0 ± 14.4 years. The underlying disease was Crohn's disease in 7 patients (46.7%), ulcerative colitis in 7 (46.7%) and indeterminate colitis in 1 (6.7%). Eleven patients (73.3%) had end ileostomy, 3 (20.0%) had loop ileostomy and 1 (6.7%) had colostomy. Eleven patients (73.3%) had active intestinal disease. In multivariate analysis, female gender, the presence of concurrent autoimmune disorders, and a high body mass index (BMI) were significantly associated with the presence of PPG, with odds ratios of 8.385 (95% confidence interval [CI]: 1.496-46.982, p=0.015), 6.882 (95% CI:1.438-32.941, p=0.016), and 9.895 (95% CI: 1.970-43.704, p=0.005), respectively. After a median follow-up of 12.8 (interquartile range: 7.9-20.1) months with appropriate therapy, PPG healed in 8 patients (53.3%) and improved in 7 (46.7%) patients, after treatment. CONCLUSIONS Female gender, the presence of autoimmune disorders and a high BMI appeared to be associated with an increased risk for the development of PPG in IBD patients.
Collapse
Affiliation(s)
- Xian-rui Wu
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
| | | | | | | | | | | |
Collapse
|
5
|
Abstract
Parastomal pyoderma gangrenosum (PPG) is an unusual neutrophilic dermatosis characterized by painful, necrotic ulcerations occurring in the area surrounding an abdominal stoma. It typically affects young to middle-aged adults, with a slight female predominance. The underlying etiology for PPG remains enigmatic but aberrant immune response to injury may play a pivotal role. The reported risk factors for the development of PPG include the presence of extra-intestinal manifestations, autoimmune disorders and obesity, along with local factors, such as the presence of parastomal hernia or pressure ulcer. PPG can develop at any time after the stoma construction. The histopathological features of PPG are not pathognomonic and its diagnosis is mainly based on clinical features. The management of PPG often requires a multidisciplinary approach, with a combination of local wound care and systemic medications.
Collapse
Affiliation(s)
- Xian-Rui Wu
- Department of Colorectal Surgery, the Cleveland Clinic Foundation,Cleveland, Ohio, USA and Department of Gastroenterology/Hepatology, the Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | |
Collapse
|
6
|
Ahronowitz I, Harp J, Shinkai K. Etiology and management of pyoderma gangrenosum: a comprehensive review. Am J Clin Dermatol 2012; 13:191-211. [PMID: 22356259 DOI: 10.2165/11595240-000000000-00000] [Citation(s) in RCA: 265] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by painful, necrotic ulceration. It typically affects patients in the third to sixth decades of life, with almost equal incidence in men and women. PG occurs most frequently on the lower extremities. Five clinical variants are currently recognized: classic, bullous, pustular, vegetative, and peristomal types. Half of PG cases are seen in association with systemic disease. Mimickers include infection, vascular insufficiency ulcers, systemic vasculitides, autoimmune disease, cancer, and exogenous tissue injury, among others. PG is often a diagnosis of exclusion, as there are no specific laboratory or histopathologic findings to confirm the diagnosis. PG thus presents many clinical challenges: it is difficult to diagnose, is frequently misdiagnosed, and often requires a work-up for underlying systemic disease. Successful management of PG typically requires multiple modalities to reduce inflammation and optimize wound healing, in addition to treatment of any underlying diseases. Prednisone and cyclosporine have been mainstays of systemic treatment for PG, although increasing evidence supports the use of biologic therapies, such as tumor necrosis factor-α inhibitors, for refractory cases of PG. Here, we review the clinical presentation and pathophysiology of PG, as well as its associated conditions, diagnostic work-up, and management.
Collapse
Affiliation(s)
- Iris Ahronowitz
- Department of Dermatology, University of California, San Francisco, 94115, USA
| | | | | |
Collapse
|
7
|
Larsen S, Bendtzen K, Nielsen OH. Extraintestinal manifestations of inflammatory bowel disease: epidemiology, diagnosis, and management. Ann Med 2010; 42:97-114. [PMID: 20166813 DOI: 10.3109/07853890903559724] [Citation(s) in RCA: 181] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Abstract Extraintestinal manifestations occur rather frequently in inflammatory bowel disease (IBD), e.g. ulcerative colitis (UC) and Crohn's disease (CD). The present paper provides an overview of the epidemiology, clinical characteristics, diagnostic process, and management of rheumatic, metabolic, dermatologic (mucocutaneous), ophthalmologic, hepatobiliary, hematologic, thromboembolic, urinary tract, pulmonary, and pancreatic extraintestinal manifestations related to IBD. Articles were identified through search of the PubMed and Embase databases, the Cochrane Library, and the web sites of the European Agency for the Evaluation of Medicinal Products (EMEA) and the US Food and Drug Administration (FDA) (cut-off date October 2009). The search terms 'Crohn's disease', 'inflammatory bowel disease', or 'ulcerative colitis' were combined with the terms 'adalimumab', 'anemia', 'arthritis', 'bronchiectasis', 'bronchitis', 'cutaneous manifestations', 'erythema nodosum', 'extraintestinal manifestations', 'hyperhomocysteinemia', 'infliximab', 'iridocyclitis', 'lung disease', 'ocular manifestations', 'osteomalacia', 'pancreatitis', 'primary sclerosing cholangitis', 'renal stones', 'sulfasalazine', 'thromboembolism', and 'treatment'. The search was performed on English-language reviews, practical guidelines, letters, and editorials. Articles were selected based on their relevance, and additional papers were retrieved from their reference lists. Since some of the diseases discussed are uncommon, valid evidence of treatment was difficult to obtain, and epidemiologic data on the rarer forms of extraintestinal manifestations are scarce. However, updates on the pathophysiology and treatment regimens are given for each of these disorders. This paper offers a current review of original research papers and randomized clinical trials, if any, within the field and makes an attempt to point out practical guidelines for the diagnosis and treatment of various extraintestinal manifestations related to IBD.
Collapse
Affiliation(s)
- Signe Larsen
- Department of Gastroenterology, Medical Section, Herlev Hospital, University of Copenhagen, Denmark
| | | | | |
Collapse
|
8
|
Santiago Sánchez-Mateos J, Martín Sáez E, Moreno Izquierdo R, González García C, Jaén Olasolo P. Fiebre, hematoquecia y úlceras cutáneas en un adulto joven. Rev Clin Esp 2008; 208:102-4. [DOI: 10.1157/13115209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
9
|
Okuma K, Mitsuishi K, Hasegawa T, Tsuchihashi H, Ogawa H, Ikeda S. A case report of steroid and immunosuppressant-resistant pyoderma gangrenosum successfully treated by granulocytapheresis. Ther Apher Dial 2008; 11:387-90. [PMID: 17845399 DOI: 10.1111/j.1744-9987.2007.00498.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Granulocytapheresis (GCAP) therapy is a newly developed therapeutic modality for inflammatory bowel diseases such as ulcerative colitis and Crohn's disease. Pyoderma gangrenosum (PG) is a chronic inflammatory skin disease characterized by the appearance of erythematous macules and plaques with pustules or nodules that rapidly progress to ragged, undermined multiple ulcers. We attempted GCAP therapy in a patient with PG resistant to prednisolone and various other immunosuppressants. GCAP therapy was initiated at three- to four-day intervals and a good response from all skin lesions, with eventual total epithelialization, was observed after 10 sessions of this therapy. Furthermore, circulating levels of inflammatory cytokines such as interleukin-8 (IL-8) and granulocyte colony stimulating factor (G-CSF) also decreased after the GCAP therapy. Our results suggest that GCAP is a safe and useful tool for the treatment of intractable PG, and that IL-8 and G-CSF are likely to be involved in the pathogenesis of PG.
Collapse
Affiliation(s)
- Keiko Okuma
- Department of Dermatology, Juntendo University School of Medicine, Tokyo, Japan.
| | | | | | | | | | | |
Collapse
|
10
|
Gisbert JP, Gomollón F. [Common errors in the management of the seriously ill patient with inflammatory bowel disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2007; 30:294-314. [PMID: 17493441 DOI: 10.1157/13101982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Javier P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Universidad Autónoma, Madrid, Spain.
| | | |
Collapse
|
11
|
Reguiaï Z, Grange F. The role of anti-tumor necrosis factor-alpha therapy in Pyoderma gangrenosum associated with inflammatory bowel disease. Am J Clin Dermatol 2007; 8:67-77. [PMID: 17428111 DOI: 10.2165/00128071-200708020-00002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pyoderma gangrenosum (PG) is an ulcerative neutrophilic dermatosis seen in 1-5% of patients with inflammatory bowel disease (IBD). The pathogenesis of PG remains unclear, but may be related to abnormal T-cell responses and production of tumor necrosis factor (TNF)-alpha, a powerful proinflammatory cytokine. Although their use is not supported by appropriately controlled trials, corticosteroids and systemic immunosuppressants are the classical cornerstones of treatment of PG, against which they have a nonspecific effect. Successful curative or symptomatic treatment of associated disorders may lead to an improvement in PG. A new era for the management of chronic inflammatory disease began with the advent of biotherapies and particularly anti-TNFalpha therapy, which allows for a specific intervention in the immune cascade. Anti-TNFalpha therapy has improved and broadened the therapeutic options for IBD and, therefore, has brought new perspectives to management of the extra-intestinal manifestations of this disorder, including PG. To date, infliximab, etanercept, and adalimumab have been used in the treatment of PG. Published data have demonstrated that infliximab is highly effective in the treatment of PG, whether associated with IBD or not. This treatment is generally well tolerated, even as long-term therapy. However, rare and serious complications have been reported. Although infliximab is a costly drug, its use should be considered for patients with PG and particularly with corticosteroid-refractory PG associated with IBD. Additional comparative long-term studies are needed to determine the long-term efficacy and safety of anti-TNFalpha therapy and define its role in the management of PG, with or without accompanying IBD.
Collapse
Affiliation(s)
- Ziad Reguiaï
- Department of Dermatology, Hôpital Robert Debré, Reims, France.
| | | |
Collapse
|