Risk of osteopenia after proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis

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.

Risk Factors for Worsening of Bone Loss in Patients Newly Diagnosed with Inflammatory Bowel Disease

Background. Bone loss is common in patients with inflammatory bowel disease (IBD). The aim of the present study was to determine the prevalence of metabolic bone disease in patients newly diagnosed with IBD and to identify the risk factors for bone loss over time. Methods. We performed a retrospective, both cross-sectional and longitudinal, study to extract the risk factors of bone loss (including osteopenia and osteoporosis) in patients newly diagnosed with IBD, using dual-energy X-ray absorptiometry (DXA). Results. A total of 639 patients newly diagnosed with IBD that had at least one DXA were included in the cross-sectional study. Osteopenia and osteoporosis were diagnosed in 24.6% and 5.4% of patients, respectively. Age at diagnosis, body mass index, and serum phosphorus were identified as independent factors associated with bone loss at baseline. A total of 380 of the 639 IBD patients (including 212 CD patients and 168 UC patients) with at least a second DXA scan were included in the longitudinal study. 42.6% of the patients presented a worsening of bone loss in the follow-up study. Menopause, albumin, and use of corticosteroids were identified as independent factors associated with worsening of bone loss. Conclusions. Metabolic bone disease is common in IBD patients, and there is a significant increase in prevalence of bone loss over time. Postmenopausal female, malnourished patients, and those requiring corticosteroid treatment are at risk for persistent bone loss. Therefore, BMD measurements and early intervention with supplementation of calcium and vitamin D are recommended in IBD patients with high-risk factors.

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.

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.

Risk factors for osteoporosis in Crohn's disease: infliximab, corticosteroids, body mass index, and age of onset

BACKGROUND

We analyzed the characteristics associated with increased risk of osteoporosis in patients with Crohn's disease in Malta.

METHOD

Eighty-three patients with histologically and endoscopically confirmed Crohn's disease underwent a DEXA bone density scan and their phenotypic characteristics were analyzed.

RESULTS

There was a significant association between body mass index and bone mineral density (P = 0.004) and a significant difference in the T scores of patients according to age at diagnosis (Montreal Classification: P = 0.0006) with patients diagnosed <17 years (n = 13) having lower T scores than those diagnosed at older age groups (n = 70). There was a significant difference between the T scores of patients on infliximab (n = 33) and those not on biological therapy (n = 50, P = 0.0058). Patients with high cumulative corticosteroid doses (>10 mg/d for >3 mo, n = 18) had lower bone mineral densities than patients who received smaller corticosteroid doses (P = 0.013). There was however no significant difference in the T scores of patients according to disease location (P = 0.18), disease type (P = 0.64), gender (P = 0.30), and history of ileal resection (P = 0.68). There was also no significant correlation between disease duration and T scores (hip) (P = 0.61).

CONCLUSIONS

Low body mass index, early disease onset, high corticosteroid doses and, anti-tumor necrosis factor α therapy are associated with increased risk of osteoporosis. Lower T scores in patients on infliximab occur as patients receiving this therapy have more severe inflammation, which is associated with elevated osteoclastogenic factors, rather than as a side-effect of the anti-tumor necrosis factor-α therapy.

Risk factors for nephrolithiasis in patients with ileal pouches

BACKGROUND AND AIMS

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become a standard of care in patients with ulcerative colitis (UC). Nephrolithiasis is common in patients with inflammatory bowel disease (IBD), but has never been studied as a complication of IPAA. We aimed to assess the risk factors for nephrolithiasis in patients with IPAA.

METHODS

Using an IRB-approved, prospectively maintained pouch registry, we identified 1221 patients between 2000 and 2010. Those with post-IPAA nephrolithiasis served as the study group whereas IPAA patients without nephrolithiasis served as the controls. Demographic and clinical variables were analyzed using multivariable logistic regression to identify risk factors.

RESULTS

There were a total of 218 IPAA patients: 81 with nephrolithiasis (37%) and 137 without (63%). Of the 81 patients in the study group, 17 were excluded due to limited clinical data. Three risk factors were found to be associated with nephrolithiasis: the presence of extra-intestinal manifestations (odd's ratio [OR]=2.9, 95% confidence interval [CI]: 1.4, 5.8, p=0.003), no use of antibiotics (OR=3.2, 95% CI: 1.5, 6.5, p=0.002) and low serum bicarbonate level (OR=0.87, 95% CI: 0.77, 0.99, p=0.038).

CONCLUSION

Nephrolithiasis was a common finding in our patients with IPAA. As pouch patients with nephrolithiasis can develop adverse clinical complications, those with at least one of the risk factors we identified may need to be monitored more closely and possibly receive prophylactic treatment with oral bicarbonate.

Evaluating pouch problems

IPAA is a technically demanding procedure that requires appropriate skills and expertise. Adverse sequelae of IPAA are common. Accurate diagnosis and classification of pouch disorders and associated complications are important for proper management and prognosis. Based on presenting symptoms, appropriate and combined diagnostic modalities should apply. A multidisciplinary approach involving gastroenterologists, colorectal surgeons, gastrointestinal pathologists, and gastrointestinal radiologists is advocated for diagnosis and treatment of pouch disorders.

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

BACKGROUND AND AIM

Patients with ulcerative colitis (UC) are at an increased risk for low bone mineral density (BMD). It is unclear whether proctocolectomy with ileal pouch-anal anastomosis (IPAA) for UC alters the risk of bone loss. The aim of this study was to compare BMD in UC patients with and without IPAA.

METHODS

A total of 267 patients with UC and IPAA (study group) were compared to 119 UC patients without IPAA (control group) in this cross-sectional study. The demographic and clinical variables including dual-energy X-ray absorptiometry scan results were compared. Patients were classified as having normal or low BMD, based on the criteria by the International Society for Clinical Densitometry. Univariate and multivariate analyses were performed to assess risk factors associated with low BMD. Age, gender, race, smoking status, steroid use, alcohol use, body mass index, years of absent estrogen protection, use of calcium, vitamin D supplements and disease duration were selected as covariates.

RESULTS

83 (31.1%) had low BMD in the study group vs. 18 (15.1%) in the control group (p=0.001). 2/13 (15.4%) had low BMD before surgery. The mean age of patients in the study and control groups were 44.7 ± 14.1 vs. 52.4 ± 17.7 years, respectively (p<0.001). The hip BMD was lower in the study group (0.93 ± 0.17 g/cm2) than that in the control group (0.98 ± 0.17 g/cm2) (p=0.038). Fragility fracture was documented in 23 (8.6%) patients in the study group vs. 3 (2.5%) in the control group (p=0.038) Sixty-four (24.0%) of the study group patients were using corticosteroids after surgery in contrast to 93 (78.2%) in the control group (p<0.001). On multivariable analyses, covariate adjusted factors associated with a low BMD in UC patients were advanced age [odds ratio (OR) 1.51 per 5 years; 95% confidence interval [CI], 1.34-1.71], low body mass index (OR=2.37 per 5 kg/m(2) decrease; 95% CI, 1.68-3.36), and the presence of IPAA (OR=6.02; 95% CI, 2.46-14.70). For the 13 IPAA patients who had information available, BMD before IPAA was low. After a median of 46 (Range 7-84) months after IPAA, BMD improved in 7/13 patients (53.8%), while it continued to be low in 6/13 (46.2%) patients.

CONCLUSIONS

Low BMD is common in patients with UC. The risk appears to persist even after colectomy and IPAA surgery suggesting that these patients need to be monitored for bone loss.

Clinical relevance of changes in bone metabolism in inflammatory bowel disease

Low bone mineral density is an established, frequent, but often neglected complication in patients with inflammatory bowel disease (IBD). Data regarding the diagnosis, therapy and follow-up of low bone mass in IBD has been partially extrapolated from postmenopausal osteoporosis; however, the pathophysiology of bone loss is altered in young patients with IBD. Fracture, a disabling complication, is the most important clinical outcome of low bone mass. Estimation of fracture risk in IBD is difficult. Numerous risk factors have to be considered, and these factors should be weighed properly to help in the identification of the appropriate patients for screening. In this editorial, the authors aim to highlight the most important clinical aspects of the epidemiology, prevention, diagnosis and treatment of IBD-related bone loss.

Laboratory tests for patients with ileal pouch-anal anastomosis: clinical utility in predicting, diagnosing, and monitoring pouch disorders

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for patients with medically refractory ulcerative colitis (UC) or UC-associated dysplasia, and for the majority of patients with familial adenomatous polyposis. Pouchitis and other complications of IPAA are common. There are scant data on laboratory markers for the evaluation and diagnosis of pouch disorders. The presence of immunogenotypic markers such as genetic polymorphisms of interleukin-1 (IL-1) receptor antagonist, NOD2/CARD15, Toll-like receptor, and tumor necrosis factor-alpha has been reported to be associated with pouchitis. Immunophenotypic/serologic markers such as perinuclear antineutrophil cytoplasmic antibody and anti-CBir1 have been investigated as possible markers for predicting and diagnosing pouchitis. Fecal markers including lactoferrin and calprotectin seem to be useful in distinguishing inflammatory from noninflammatory pouch disorders. In our practice, we have encountered a large number of pouch patients with Clostridium difficile infection. Laboratory evaluation provides information on the etiology and pathogenesis of pouchitis, and it also helps practicing clinicians with accurate diagnosis, differential diagnosis, disease stratification, and management of ileal pouch disorders.

Risk factors for low bone mass in patients with ulcerative colitis following ileal pouch-anal anastomosis

OBJECTIVES

Bone mineral density (BMD) can be adversely affected by the chronic nature of inflammatory bowel disease. Ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for patients with ulcerative colitis (UC) who require proctocolectomy. There are few data on BMD in UC patients with IPAA. The aim of the study was to assess the prevalence and risk factors associated with low BMD in UC patients after IPAA.

METHODS

A total of 327 eligible patients with UC and IPAA from the Pouchitis Clinic were enrolled. Dual-energy X-ray absorptiometry was performed. Patients were classified as having normal or low BMD, based on the criteria by the International Society for Clinical Densitometry. A total of 39 demographic and clinical variables were evaluated with logistic regression models.

RESULTS

Of 327 patients with a median of 4 years after IPAA, 105 (32.1%) had low BMD. Fragility fracture was documented in 11 patients (10.5%) in the low BMD group and in 13 of 222 patients (5.9%) in the normal BMD group (P=0.14). In the multivariable analysis, covariate-adjusted factors associated with a low BMD were advanced age (odds ratio (OR) =1.64 per 5 years; 95% CI, 1.44-1.87), low body mass index (OR=0.43 per 5 kg/m(2); 95% CI, 0.30-0.62), and non-use of daily calcium supplement (OR=0.53; 95% CI, 0.29-0.96). Pouch-associated factors were not found to be significantly associated with the bone loss.

CONCLUSIONS

Low BMD was common in patients with UC, even after colectomy and IPAA. Low BMD in this patient population was associated with certain risk factors, some of which may be modifiable.

A proposed classification of ileal pouch disorders and associated complications after restorative proctocolectomy

Both medical and surgical therapies for ulcerative colitis have inherent advantages and disadvantages that must be balanced for patients with moderate to severe disease. Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for the majority of patients with ulcerative colitis who require proctocolectomy. However, adverse sequelae of mechanical, inflammatory, functional, neoplastic, and metabolic conditions related to the pouch can occur postoperatively. Recognition and familiarization of the disease conditions related to the ileal pouch can be challenging for practicing gastroenterologists. Accurate diagnosis and classification of the disease conditions are imperative for proper management and prognosis.

Serum biochemical evaluation of patients with functional pouches ten to 20 years after restorative proctocolectomy

BACKGROUND

Restorative proctocolectomy with an ileal pouch-anal anastomosis is a surgical treatment of choice for ulcerative colitis and familial adenomatous polyposis (FAP). Pouchitis is a significant enigmatic morbidity. In the long-term, these patients, we anticipated, would experience biochemical profiling alterations after years of retaining functionally acceptable pouches. This pilot study was aimed at assessing results of essential biochemical variables more than 10 years after surgery.

METHODS

The investigation was carried out in 91 patients; 39 were women. Eight-eight had ulcerative colitis, while three had FAPs. The hand-sewn ileal reservoirs after mucoso-proctocolectomy were 66 S and 25 J. The analyses were compared short-term vs long-term. Patients were investigated and were their own control.

RESULTS

Long-term, incidence of acute and chronic pouchitis was 2 and 13%. Eleven and 4% of patients had hypomagnesaemia and hypocalcaemia. Mean levels were significantly enhanced (p<0.01 and p<0.0002). Hypomagnesaemia corresponded to episodes of pouchitis and was corrected with oral magnesium and antibiotics. Hypoferric anaemia was diagnosed in 7% and treated with oral iron tablets. Chronic pouchitis and recurrent pouch mucosa bleeding were the cause. Hypohemoglobinemia and hypocyanocobalaminemia were noted in 5% and 5%, respectively. Erythrocyte sedimentation rate and white blood cells were supra-normal in 13 and 10%, which corresponded with pouchitis. A significant (p<0.03) steady rise of mean serum immunoglobulin G without correlation to pouchitis was noted.

CONCLUSION

Long-term functional results did not deteriorate. Pouchitis was a significant enigmatic morbidity. Severe or chronic pouchitis complicated hypoferric and vitamin B(12) anemia and hypomagnesaemia.

Review article: Osteoporosis and inflammatory bowel disease

Studies using dual-energy X-ray absorptiometry have suggested a high prevalence of osteoporosis in inflammatory bowel disease. However, population-based data on fracture incidence suggest only a small increased risk of fracture amongst patients with inflammatory bowel disease compared with the general population. Therefore, it would be helpful to identify patients with inflammatory bowel disease at particularly high risk for fracture so that these risks might be modified or interventions might be undertaken. The data on calcium intake as a predictor of bone mineral density are conflicting. Although there are data suggesting that a one-time survey to determine current calcium intake will not help to predict bone mineral density in inflammatory bowel disease, persistently reduced calcium intake does appear to lead to lower bone mineral density. In the general population, body mass is strongly correlated with bone mineral density, which also appears to be true in Crohn's disease. Hence, subjects with inflammatory bowel disease and considerable weight loss, or who are obviously malnourished, could be considered for bone mineral density testing, and the finding of a low bone mineral density would suggest the need for more aggressive nutritional support. Although vitamin D is undoubtedly important in bone health, vitamin D intake and serum vitamin D levels do not correlate well with bone mineral density. Sex hormone deficiency can also adversely affect bone health, although a well-developed strategy for sex hormone measurements in patients with inflammatory bowel disease remains to be established. Ultimately, the determination of genetic mutations that accurately predict fracture susceptibility may be the best hope for developing a simplified strategy for managing bone health in inflammatory bowel disease. The therapy of osteoporosis in inflammatory bowel disease has been adapted from other osteoporosis settings, such as post-menopausal or corticosteroid-induced osteoporosis. To date, there remains no therapy proven to be efficacious in inflammatory bowel disease-related osteoporosis; however, calcium and vitamin D supplementation and bisphosphonates have their roles.