European Crohn's and Colitis Organisation Topical Review on IBD in the Elderly

Impact of COVID-19 in individuals with and without pre-existent digestive disorders with a particular focus on elderly patients

Coronavirus disease 2019 (COVID-19) has several extrapulmonary symptoms. Gastrointestinal (GI) symptoms are among the most frequent clinical manifestations of COVID-19, with severe consequences reported in elderly patients. Furthermore, the impact of COVID-19 on patients with pre-existing digestive diseases still needs to be fully elucidated, particularly in the older population. This review aimed to investigate the impact of COVID-19 on the GI tract, liver, and pancreas in individuals with and without previous digestive diseases, with a particular focus on the elderly, highlighting the distinctive characteristics observed in this population. Finally, the effectiveness and adverse events of the anti-COVID-19 vaccination in patients with digestive disorders and the peculiarities found in the elderly are discussed.

Older adults with acute severe ulcerative colitis have similar steroid non-response and colectomy rates as younger adults

BACKGROUND

There is paucity of data on outcomes of acute severe ulcerative colitis (ASUC) in older adults (≥ 60 years of age).

AIM

To assess steroid non-response rates during the index admission for ASUC in older adults. Secondary outcomes were response to medical rescue therapy and colectomy rates; at index admission, 3 and 12 mo.

METHODS

This retrospective multicentre cohort study included ASUC admissions who received intravenous steroids between January 2013 and July 2020 at two tertiary hospitals. Electronic medical records were reviewed to collect clinical, biochemical, and endoscopic data. A modified Poisson regression model was used for analysis.

RESULTS

Of 226 ASUC episodes, 45 (19.9%) occurred in patients ≥ 60 years of age. Steroid non-response rates were comparable in older adults and patients < 60 years of age [19 (42.2%) vs 85 (47%), P = 0.618, crude risk ratio (RR) = 0.89 [95% confidence interval (CI): 0.61-1.30], adjusted RR = 0.99 (0.44-2.21). Rates of response to medical rescue therapy in older adults was comparable to the younger cohort [76.5% vs 85.7%, P = 0.46, crude RR = 0.89 (0.67-1.17)]. Index admission colectomy [13.3% vs 10.5%, P = 0.598, crude RR = 1.27 (0.53-2.99), adjusted RR = 1.43 (0.34-6.06)], colectomy at 3 mo [20% vs 16.6%, P = 0.66, crude RR = 1.18 (0.61-2.3), adjusted RR = 1.31 (0.32-0.53)] and colectomy at 12 mo [20% vs 23.2%, P = 0.682, crude RR = 0.85 (0.45-1.57), adjusted RR = 1.21 (0.29-4.97)], were similar between the two groups.

CONCLUSION

In older adults with ASUC, the steroid non-response rate, response to medical rescue therapy, and colectomy rate at index admission, 3 and 12 mo is similar to patients less than 60 years of age.

Clinical characteristics of elderly-onset inflammatory bowel disease

Inflammatory bowel disease (IBD) is a group of chronic non-specific intestinal inflammatory diseases whose etiology has not been elucidated. The prevalence of elderly-onset IBD is increasing; however, its disease phenotype, pathophysiology, and clinical characteristics are different from those of adult-onset IBD. In order to better manage elderly IBD patients, it is becoming increasingly important to accurately describe the unique characteristics of elderly-onset IBD. Therefore, this article, based on the domestic and foreign literature reports from 2017 to now, describes the characteristics of elderly-onset IBD with regard to pathogenesis, epidemiological characteristics, clinical features, and treatment.

Ulva pertusa, a Marine Green Alga, Attenuates DNBS-Induced Colitis Damage via NF-κB/Nrf2/SIRT1 Signaling Pathways

Inflammatory bowel diseases (IBD) including Crohn's disease (CD) and ulcerative colitis (UC) represent gastrointestinal (GI) disorders associated with varied responses to microbial and environmental agents. Natural compounds have been suggested as a valid approach to the management of various GI diseases, particularly the green alga Ulva pertusa, belonging to the Ulvaceae family, which showed powerful biological properties. Here, we aimed to evaluate the effect and the mechanism of Ulva pertusa treatments in a murine model of DNBS-induced colitis. Colitis was induced by DNBS intrarectal installation (4 mg in 100 μL of 50% ethanol), while Ulva pertusa treatments (doses of 10, 50 and 100 mg/kg) were administered orally daily. Ulva pertusa, at the higher doses of 50 and 100 mg/kg, significantly reduced tissue damage DNBS-induced and the consequent inflammatory cascade via NF-κB inhibition. Furthermore, we demonstrated, for the first time, Ulva pertusa action on the SIRT1/Nrf2 axis, enhancing antioxidant response and the modulation of the apoptosis pathway colitis-induced, regulating the expression of p53, Bax, Bcl-2, and Caspases. Taken together, Ulva pertusa could be considered a valid approach for counteracting and blocking the progression of IBDs through modulation of the NF-κB/SIRT1/Nrf2 axis.

Elderly onset age is associated with low efficacy of first anti-tumor necrosis factor treatment in patients with inflammatory bowel disease

The outcomes of patients with elderly onset (EO) inflammatory bowel disease (IBD) treated with anti-tumor necrosis factor (TNF) remains uncertain. The present study evaluated the efficacy and safety of anti-TNF treatment for bio-naïve EO-IBD. Elderly patients were defined as those 60 years and older, and further divided into those with EO (Elderly-EO) and those with non-elderly onset (Elderly-NEO). A total of 432 bio-naïve patients were enrolled in this multicenter observational study, comprising 55 with Elderly-EO (12.7%), 25 with Elderly-NEO (5.8%), and 352 under age 60 (Non-elderly, 81.5%). After 52 weeks of anti-TNF treatment, clinical and steroid-free remission rates were significantly lower in Elderly-EO than in Non-elderly (37.7% and 60.8%; P = 0.001, and 35.9% and 57.8%; P = 0.003, respectively), and comparable between Elderly-NEO and Non-elderly. Multivariate analysis revealed that elderly onset was a significant factor for both clinical remission (OR, 0.49, 95% CI 0.25–0.96) and steroid-free remission (OR, 0.51, 95% CI 0.26–0.99) after 52 weeks of anti-TNF treatment. The rate of cumulative severe adverse events was significantly higher in Elderly-EO than in Non-elderly (P = 0.007), and comparable between Elderly-NEO and Non-elderly. In conclusion, anti-TNF treatment for bio-naïve EO-IBD may be less effective and raise safety concerns.

How to Choose the Biologic Therapy in a Bio-Naïve Patient with Inflammatory Bowel Disease

The availability of biologic therapies in inflammatory bowel disease (IBD) is increasing significantly. This represents more options to treat patients, but also more difficulties in choosing the therapies, especially in the context of bio-naïve patients. Most evidence of safety and efficacy came from clinical trials comparing biologics with placebo, with a lack of head-to-head studies. Network meta-analysis of biologics and real-world studies have been developed to solve this problem. Despite the results of these studies, there are also other important factors to consider before choosing the biologic, such as patient preferences, comorbidities, genetics, and inflammatory markers. Given that resources are limited, another important aspect is the cost of biologic therapy, since biosimilars are widely available and have been demonstrated to be effective with a significant decrease in costs. In this review, we summarize the evidence comparing biologic therapy in both Crohn´s disease (CD) and ulcerative colitis (UC) in different clinical situations. We also briefly synthesize the evidence related to predictors of biologic response, as well as the biologic use in extraintestinal manifestations and the importance of the drug-related costs.

Clinical characteristics of ulcerative colitis in elderly patients

The incidence of ulcerative colitis (UC) in elderly patients is increasing. Elderly UC patients are likely to exhibit distinct features both at diagnosis and during follow-up. Age-related problems, including complications, immune dysfunction, and multidrug use, make the diagnosis and treatment of elderly UC more challenging. Suboptimal treatment considering adverse events leads to poor clinical outcome in elderly UC patients. Here, we reviewed the epidemiology, clinical presentation, medical therapy, colorectal cancer surveillance of UC in elderly patients.

The elderly IBD patient in the modern era: changing paradigms in risk stratification and therapeutic management

The incidence and prevalence of inflammatory bowel disease (IBD) is rising in the elderly population. Compared with patients with onset during their younger years, patients with elderly onset IBD have a distinct clinical presentation, disease phenotype, and natural history. Genetics contribute less to pathogenesis of disease, whereas biological changes associated with aging including immunosenescence, dysbiosis, and frailty have a greater impact on disease outcomes. With the advent of an increasingly wider array of biologic and small-molecule therapeutic options, data regarding efficacy and safety of these agents in elderly IBD patients specifically are paramount, given the unique characteristics of this population.

A Validated Prognostic Model and Nomogram to Predict Early-Onset Complications Leading to Surgery in Patients With Crohn's Disease

BACKGROUND

Predicting aggressive Crohn's disease is crucial for determining therapeutic strategies.

OBJECTIVE

We aimed to develop a prognostic model to predict complications leading to surgery within 1 year after diagnosis of Crohn's disease and to create a nomogram to facilitate clinical decision making.

DESIGN

This is a retrospective study.

SETTING

This study was conducted from January 2012 to December 2016 in a single tertiary IBD center.

PATIENTS

Patients diagnosed with Crohn's disease showing B1 behavior according to the Montreal classification were included.

MAIN OUTCOME MEASURES

We measured the occurrence of complications that would ultimately lead to surgery, including severe GI bleeding (Glasgow-Blatchford score ≥6), stenosis, and perforations, confirmed by endoscopy, CT scan, and/or interventional radiology.

RESULTS

The mean follow-up period was 54 months (SD 13 months). Of the 614 eligible patients, 13.5% developed complications leading to surgery. Multivariable logistic regression revealed the independent predictors of early-onset complications to be age (adjusted odds ratio per 10-year increase in age = 0.4; 95% CI, 0.2-0.8; p = 0.004), disease duration (adjusted odds ratio = 2.7, 95% CI, 1.9-3.8; p < 0.001), perianal disease (adjusted odds ratio = 16.0; 95% CI, 4.3-59.9; p < 0.001), previous surgery (adjusted odds ratio = 3.7; 95% CI, 1.6-8.6; p = 0.003), and extraintestinal manifestations (adjusted odds ratio = 7.6; 95% CI, 2.3-24.9; p = 0.001). The specificity and sensitivity of the prognostic model were 88.3% (95% CI, 84.8%-91.2%) and 96.6% (95% CI, 88.1%-99.6%), and the area under the curve was 0.97 (95% CI, 0.95-0.98). This model was validated with good discrimination and excellent calibration using the Hosmer-Lemeshow goodness-of-fit test. A nomogram was created to facilitate clinical bedside practice.

LIMITATIONS

This was a retrospective design and included a small sample size from 1 center.

CONCLUSIONS

Our validated prognostic model effectively predicted early-onset complications leading to surgery and screened aggressive Crohn's disease, which will enable physicians to customize therapeutic strategies and monitor disease. See Video Abstract at http://links.lww.com/DCR/B442.Registered at Chinese Clinical Trial Registry (ChiCTR1900025751).

UN MODELO DE PRONSTICO VALIDADO Y UN NOMOGRAMA PARA PREDECIR COMPLICACIONES PRECOCES QUE REQUIRAN CIRUGA EN PACIENTES CON ENFERMEDAD DE CROHN

ANTECEDENTES:Predecir una enfermedad de Crohn muy agresiva es fundamental para determinar la estrategia terapéutica.OBJETIVO:Desarrollar un modelo de pronóstico para predecir las complicaciones que requieran cirugía dentro el primer año al diagnóstico de enfermedad de Crohn y crear un nomograma para facilitar la toma de decisiones clínicas.DISEÑO:El presente etudio es retrospectivo.AJUSTE:Estudio realizado entre Enero 2012 y Diciembre 2016, en un único centro terciario de tratamiento de enfermedad inflamatoria intestinal.PACIENTES:Se incluyeron todos aquellos pacientes diagnosticados de enfermedad de Crohn que mostraban manifestaciones tipo B1 según la clasificación de Montreal.PRINCIPALES MEDIDAS DE RESULTADO:Medimos la aparición de complicaciones que finalmente conducirían a una cirugía, incluida la hemorragia digestiva grave (puntuación de Glasgow-Blatchford ≥ 6), estenosis y perforaciones, confirmadas por endoscopía, tomografía computarizada y / o radiología intervencionista.RESULTADOS:El período medio de seguimiento fue de 54 meses (desviación estándar 13 meses). De los 614 pacientes elegibles, el 13,5% desarrolló complicaciones que llevaron a cirugía. La regresión logística multivariable reveló que los predictores independientes de complicaciones de inicio temprano eran la edad (razón de probabilidades ajustada [ORa] por aumento de 10 años en la edad = 0,4; intervalos de confianza del 95% [IC del 95%]: 0,2-0,8, p = 0,004), duración de la enfermedad (ORa = 2,7, IC del 95%: 1,9-3,8, p <0,001), enfermedad perianal (ORa = 16,0, IC del 95%: 4,3-59,9, p <0,001), cirugía previa (ORa = 3,7, 95% IC: 1,6-8,6, p = 0,003) y manifestaciones extraintestinales (ORa = 7,6, IC del 95%: 2,3-24,9, p = 0,001). La especificidad y sensibilidad del modelo pronóstico fueron 88,3% (IC 95%: 84,8% -91,2%) y 96,6% (IC 95%: 88,1% -99,6%), respectivamente, y el área bajo la curva fue 0,97 (95% % CI: 0,95-0,98). Este modelo fue validado con buena discriminación y excelente calibración utilizando la prueba de bondad de ajuste de Hosmer-Lemeshow. Se creó un nomograma para facilitar la práctica clínica al pié de la cama.LIMITACIONES:Diseño retrospectivo que incluyó un tamaño de muestra pequeña en un solo centro.CONCLUSIONES:Nuestro modelo de pronóstico validado predijo eficazmente las complicaciones precoces que conllevaron a cirugía y la detección de enfermedad de Crohn agresiva, lo que permitió a los médicos personalizar las estrategias terapéuticas y controlar la enfermedad. Consulte Video Resumen en http://links.lww.com/DCR/B442.Registrado en el Registro de Ensayos Clínicos de China (ChiCTR1900025751).

The clinical practice of ulcerative colitis in elderly patients: An investigation using a nationwide database in Japan

Background and Aim

The number of elderly patients with ulcerative colitis (UC) is increasing worldwide. The clinical practice of associated treatment is still unclear. Therefore, we aimed to analyze clinical treatment realities and mortality in elderly and non‐elderly patients with UC.

Methods

We collected UC patients' data using the diagnosis procedure combination (DPC) database system and divided eligible patients into elderly (≥65 years) and non‐elderly (≤64 years) groups. We investigated and compared their therapeutic histories (medical treatments vs. surgery). Logistic regression analysis was conducted to identify clinical factors affecting surgery and in‐hospital death in each group.

Results

The rates of systemic steroid injection, molecular targeting drug usage, and surgery were not different between the two age groups. Meanwhile, the rate of in‐hospital death in elderly patients was higher than that in non‐elderly patients (2.7% vs. 0.19%, P < 0.0001). Multivariate analysis revealed that lower body mass index, treatment at an academic hospital, smoking history, molecular targeting drug use, and treatment with systemic steroid injection affected the rate of surgery in the elderly group. Multivariate analysis also revealed that male and older age affected the rate of in‐hospital death in the elderly group. Similar tendencies were also recognized in the non‐elderly group.

Conclusions

The clinical practice of treating elderly patients with UC is overall not different from treating non‐elderly patients with UC. Although the form of medical treatment and surgery rate for elderly patients with UC may not be significantly different from non‐elderly patients, the rate of in‐hospital death for elderly patients is higher.

Evidence-based clinical practice guidelines for inflammatory bowel disease 2020

Inflammatory bowel disease (IBD) is a general term for chronic or remitting/relapsing inflammatory diseases of the intestinal tract and generally refers to ulcerative colitis (UC) and Crohn's disease (CD). Since 1950, the number of patients with IBD in Japan has been increasing. The etiology of IBD remains unclear; however, recent research data indicate that the pathophysiology of IBD involves abnormalities in disease susceptibility genes, environmental factors and intestinal bacteria. The elucidation of the mechanism of IBD has facilitated therapeutic development. UC and CD display heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management depends on the understanding and tailoring of evidence-based interventions by physicians. In 2020, seventeen IBD experts of the Japanese Society of Gastroenterology revised the previous guidelines for IBD management published in 2016. This English version was produced and modified based on the existing updated guidelines in Japanese. The Clinical Questions (CQs) of the previous guidelines were completely revised and categorized as follows: Background Questions (BQs), CQs, and Future Research Questions (FRQs). The guideline was composed of a total of 69 questions: 39 BQs, 15 CQs, and 15 FRQs. The overall quality of the evidence for each CQ was determined by assessing it with reference to the Grading of Recommendations Assessment, Development and Evaluation approach, and the strength of the recommendation was determined by the Delphi consensus process. Comprehensive up-to-date guidance for on-site physicians is provided regarding indications for proceeding with the diagnosis and treatment.

Ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory bowel disease of unknown aetiology affecting the colon and rectum. Multiple factors, such as genetic background, environmental and luminal factors, and mucosal immune dysregulation, have been suggested to contribute to UC pathogenesis. UC has evolved into a global burden given its high incidence in developed countries and the substantial increase in incidence in developing countries. An improved understanding of the mechanisms underlying UC has led to the emergence of new treatments. Since the early 2000s, anti-tumour necrosis factor (TNF) treatment has significantly improved treatment outcomes. Advances in medical treatments have enabled a paradigm shift in treatment goals from symptomatic relief to endoscopic and histological healing to achieve better long-term outcomes and, consequently, diagnostic modalities have also been improved to monitor disease activity more tightly. Despite these improvements in patient care, a substantial proportion of patients, for example, those who are refractory to medical treatment or those who develop colitis-associated colorectal dysplasia or cancer, still require restorative proctocolectomy. The development of novel drugs and improvement of the treatment strategy by implementing personalized medicine are warranted to achieve optimal disease control. However, delineating the aetiology of UC is necessary to ultimately achieve disease cure.

Restorative surgery for ulcerative colitis in the elderly: an analysis of ileal pouch-anal anastomosis procedures from the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) for ulcerative colitis(UC) can be performed as either 2- or 3-stage procedure. IPAA in the elderly has been reported as safe and feasible, but little work to date has assessed outcomes by procedure. The aim of our study was to assess use and short-term outcomes of 2- and 3-stage IPAA in older adults.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was searched for ≥ 65-year-old patients who underwent IPAA for UC in 2- or 3-stage from 2012 to 2016. The primary endpoint was the rate and trends of the two approaches over time. Secondary endpoints included 30-day adverse events and complication-associated costs.

RESULTS

Overall, 123 patients were included: 77.5% (n = 83) 2-stage and 40 (32.5%) 3-stage IPAA. Mean age was 68.7 ± 3.9 years, with 43 (34.9%) women. The use of the 3-stage IPAA increased over time (18.8% in 2012 vs. 33.3% in 2016), with decreasing use of 2-stage IPAA(81.3% vs. 66.7%, p < 0.001). The morbidity associated with the procedures decreased over time, overall (81.3% in 2012 and 51.5% in 2016, p < 0.001) and in each group individually. No differences were observed in postoperative complications across groups (45.8% 2-stage, 32.5% 3-stage). The overall mean costs of care when no postoperative complications occurred was $25,910, vs. $38,577 when any complication occurred (p < 0.001), but no differences were observed between groups.

CONCLUSIONS

In a national analysis, there was a trend of increasing 3-stage vs. 2-stage IPAA for UC in older Americans. Complications and complication-associated costs were comparable across approaches, suggesting that the choice of procedure type should be based on the specific patient comorbidities and surgeon preferences.

Elderly-onset vs adult-onset ulcerative colitis: a different natural history?

Background

Incidence of ulcerative colitis (UC) in elderly population is increasing because of ageing and because of its minimal impact on life span. Data on natural history, outcomes and therapeutic strategies are limited.

Our aim is to characterize UC in elderly-onset patients followed at our Inflammatory Bowel Disease outpatient clinic and compare with adult-onset UC.

Methods

From January 2000 to June 2019, 94 patients with UC diagnosed after the age of 65 years (elderly group, E-O) were identified and matched 1–1 according to gender and calendar year of diagnosis with patients diagnosed with UC at age between 40 and 64 years (adult age, A-O).

Results

Comorbidity Index (3.8 vs 1.6, p < 0.0005) was higher for elderly UC patients. Symptoms at presentation were similar between the two groups, although abdominal pain was more common in adults, and weight loss was more common in the elderly. At diagnosis, left colitis (61% vs 39%) and proctitis (14% vs 26%) (p = 0.011) were more frequent in the elderly. Therapy and clinical behaviour were similar. Surgery was more frequently performed in the elderly (20% vs 9%, p = 0.02), while biological therapy was less used (2.1% vs 22%, p < 0.0005). Complications were more frequent in the elderly. Extraintestinal manifestations were lower in elderly patients (9.6% vs 19.2%, p = 0.061). Time to first relapse was similar between the two groups. Mortality (p < 0.0005) was higher in elderly patients.

Conclusions

Ulcerative Colitis has similar presentation and behaviour in elderly and adults patients. However, the elderly are more fragile because of comorbidities, increased risk of infections and disease-related complications.

Elderly-onset Crohn's disease remarkably responsive to ustekinumab: a case report

BACKGROUND

Crohn's disease is intractable and is frequently diagnosed in younger people. No clear policies exist regarding medical treatment for seniors with this disease, and its diagnosis and treatment are often hindered by difficulties attributable to comorbidities, complex differential diagnoses, and polypharmacy. We describe an elderly-onset Crohn's disease patient showing a marked remission-maintaining effect with no adverse events after administration of ustekinumab.

METHODS AND RESULTS

A 75-year-old patient with Crohn's disease and a history of pulmonary tuberculosis had first presented to our hospital at age 64 years and was hospitalized. Based on physical examinations, colonoscopy, and blood test results, Crohn's disease was diagnosed. The patient experienced secondary losses of responsiveness to two tumor necrosis factor (TNF)-alpha inhibitors, and after repeated hospital admissions, she was administered ustekinumab. The patient's symptoms, endoscopic findings, Crohn's Disease Activity Index, serum albumin, and physical activity levels improved markedly, and disease remission has been maintained for 2 years to date.

CONCLUSION

Ustekinumab is an effective treatment option for elderly patients with intractable Crohn's disease when TNF-alpha inhibitors are ineffective.

Trends and risk factors of elderly-onset Crohn’s disease: A nationwide cohort study

BACKGROUND

The incidence of inflammatory bowel disease (IBD) is increasing in Asia. Numerous risk factors associated with IBD development have been investigated.

AIM

To investigate trends and environmental risk factors of Crohn’s disease (CD) diagnosed in persons aged ≥ 40 years in South Korea.

METHODS

Using the National Health Insurance Service database, a total of 14060821 persons aged > 40 years who underwent national health screening in 2009 were followed up until December 2017. Patients with newly diagnosed CD were enrolled and compared with non-CD cohort. CD was identified according to the International Classification of Diseases 10th revision and the rare/intractable disease registration program codes from the National Health Insurance Service database. The mean follow-up periods was 7.39 years. Age, sex, diabetes, hypertension, smoking, alcohol consumption, regular exercise, body mass index, anemia, chronic kidney disease (CKD) and dyslipidemia were adjusted for in the multivariate analysis model.

RESULTS

During the follow-up, 1337 (1.33/100000) patients developed CD. Men in the middle-aged group (40-64 years) had a higher risk than women [adjusted hazard ratio (aHR) 1.46, 95% confidence interval (CI): 1.29-1.66]; however, this difference tended to disappear as the age of onset increases. In the middle-aged group, patients with a history of smoking [aHR 1.46, 95%CI: 1.19-1.79) and anemia (aHR 1.85, 95%CI: 1.55-2.20) had a significantly higher CD risk. In the elderly group (age, ≥ 65 years), ex-smoking and anemia also increased the CD risk (aHR 1.68, 95%CI: 1.22-2.30) and 1.84 (95%CI: 1.47-2.30, respectively). Especially in the middle-aged group, those with CKD had a statistically elevated CD risk (aHR 1.37, 95%CI: 1.05-1.79). Alcohol consumption and higher body mass index showed negative association trend with CD incidence in both of the age groups. [Middle-aged: aHR 0.77 (95%CI: 0.66-0.89) and aHR 0.73 (95%CI: 0.63-0.84), respectively] [Elderly-group: aHR 0.57 (95%CI: 0.42-0.78) and aHR 0.84 (95%CI 0.67-1.04), respectively]. For regular physical activity and dyslipidemia, negative correlation between CD incidences was proved only in the middle-aged group [aHR 0.88 (95%CI: 0.77-0.89) and aHR 0.81 (95%CI: 0.68-0.96), respectively].

CONCLUSION

History of cigarette smoking, anemia, underweight and CKD are possible risk factors for CD in Asians aged > 40 years.

Inflammatory bowel disease (IBD) position statement of the Italian Society of Colorectal Surgery (SICCR): general principles of IBD management

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of inflammatory bowel disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the general principles of surgical treatment of inflammatory bowel disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

Electroacupuncture and Moxibustion Regulate Hippocampus Glia and Mitochondria Activation in DSS-Induced Colitis Mice

Objectives

To study the influence of electroacupuncture (EA) and moxibustion on the hippocampus astrocyte and microglia activation in the ulcerative colitis model and to evaluate the mitochondria activity.

Methods

2.5% dextran sodium sulfate-induced colitis mice were treated by EA or moxibustion. Intestinal pathological structure was observed by hematoxylin and eosin (H&E) staining; the expression of GFAP or S100b (markers for astrocyte), Iba-1 (a marker for microglia), and Mitofilin (a marker for mitochondria) in hippocampus was detected by immunofluorescence staining or western blot.

Results

The results demonstrated that both EA and moxibustion could improve the morphology of distal colonic mucosal epithelia in DSS-induced colitis mice. Expression of GFAP in the hippocampus was significantly increased after EA or moxibustion treatment. The effects were further supported by WB results. Meanwhile, expression of mitofilin in the hippocampus CA1 and CA3 regions showed the same trend as that of GFAP. Expression of Iba-1 in the hippocampus showed no significant difference after EA or moxibustion treatment, while the state of microglia changed from resting in control mice to activated state in colitis mice.

Conclusion

EA and moxibustion were able to modulate the activation of astrocyte, microglial, and mitochondria in the hippocampus area in the colitis model.

Remission of ulcerative colitis flare-up induced by nivolumab

BACKGROUND

Immune checkpoint inhibitors (ICIs) have been used to treat many cancers, but ICIs are rarely administered for malignant tumours coexisting with inflammatory bowel disease.

METHODS AND RESULTS

We report a 77-year-old man experiencing an ulcerative colitis (UC) flare-up after receiving nivolumab as third-line therapy for multiple metastases of renal cell carcinoma. Mild UC (proctitis form) had been diagnosed at age 59 years and remission was maintained for 17 years with only a low dose of 5-ASA. After nivolumab treatment, the patient developed diarrhoea, bloody stools and was hospitalised. Computed tomography revealed inflammation involving the entire colon and endoscopy revealed severe UC exacerbation. Histological analysis showed UC findings and also increased crypt apoptosis which is unusual for inflammatory bowel diseases, while being typical of ICI-induced colitis. As with ICI-induced colitis, this exacerbation was strongly suggested to have been caused by nivolumab, although remission was achieved by increasing the 5-ASA dose to 4000 mg without prednisolone.

CONCLUSION

The administration of ICI for UC is not as yet sufficiently safe and further research is required.

Intake of dietary fibre, red and processed meat and risk of late-onset Chronic Inflammatory Diseases: A prospective Danish study on the "diet, cancer and health" cohort

Background: Human and animal studies support the involvement of diet in the development of CID -chronic inflammatory diseases such as inflammatory bowel disease, psoriasis, rheumatoid arthritis, psoriatic arthritis, and multiple sclerosis. Objective: This cohort study aimed to investigate the association between intake of fibre, red and processed meat, and occurrence of late-onset CID (50+ years of age) in the DCH: Danish Diet, Cancer and Health cohort. We hypothesised that risk of late-onset CID would be lower among those with high intake of fibre and/or low intake of meat compared to individuals with low fibre and/or high meat intake. Methods: The DCH recruited 56,468 individuals, aged 50-64 years, between 1993 and 1997. At recruitment, diet intake was registered using food frequency questionnaires as well as lifestyle factors in 56,075 persons. Exposure variables were generated as sex-adjusted tertiles of fibre and meat (g/day). Development of CIDs was identified in national registries. Hazard ratios (HR) of late-onset CIDs (adjusted for age, sex, energy intake, alcohol, smoking, education, comorbidity, and civil status) were estimated for all three exposure variables. Results: During follow-up of 1,123,754 years (median (Interquartile range) = 22.2 (20.1-23.1)), 1,758 (3.1%) participants developed at least one CID. The adjusted HRs for developing CID (low fibre 1.04 [0.89-1.22] and medium fibre 1.04 [0.91-1.18] (high fibre as reference), and medium meat 0.96 [0.86-1.09] and high meat 0.94 [0.82-1.07] (low meat as reference)) or the individual diseases were not statistically significant. Conclusion: This large study did not support that a high intake of fibre and/or a low intake of meat had a high impact on the risk of late-onset CID.

Safety and effectiveness of granulocyte and monocyte adsorptive apheresis in patients with inflammatory bowel disease in special situations: a multicentre cohort study

BACKGROUND

The available information on granulocyte and monocyte adsorptive apheresis (GMA) in patients with inflammatory bowel disease (IBD) under special situations remains unclear. We conducted a retrospective, multicentre cohort study to evaluate the safety and effectiveness of GMA in patients with IBD under special situations.

METHODS

This study included patients with ulcerative colitis (UC) or Crohn's disease who had at least one special situation feature and who had received GMA between November 2013 and March 2017. The incidence of adverse events (AEs) was compared in relation to the special situation, and patient background factors related to an AE were identified. For patients with UC, clinical remission was defined as a partial Mayo score of ≤2.

RESULTS

A total of 437 patients were included in this study. The incidence of AEs among the elderly patients (11.2%) was similar in all patients (11.4%), whereas the incidences of AEs in patients on multiple immunosuppressant medications (15.2%), patients with anaemia (18.1%) and paediatric/adolescent patients (18.9%) were higher than that in all patients (11.4%). In multivariate analysis, anaemia and concomitant immunosuppressant medications were independently associated with the incidence of AEs. Clinical remission was achieved in 46.4% of the patients with UC.

CONCLUSIONS

The incidence of AEs in the elderly patients was not higher than that in all patients, whereas the incidence of AE was higher in patients with anaemia and those on multiple immunosuppressant medications than that in all patients. GMA is a safe treatment option in elderly patients with IBD.

How to manage IBD in the 'elderly'

As the incidence of inflammatory bowel disease (IBD) rises and the global population ages, the number of older people living with these conditions will inevitably increase. The challenges posed by comorbid conditions, polypharmacy, the unintended consequences of long-term treatment and the real but often underestimated mismatch between chronological and biological ages underpin management. Significantly, there may be differences in disease characteristics, presentation and management of an older patient with IBD, together with other unique challenges. Importantly, clinical trials often exclude older patients, so treatment decisions are frequently pragmatic, extrapolated from a number of sources of evidence and perhaps primarily dictated by concerns around adverse effects. This review aimed to discuss the epidemiology, clinical features and considerations with management in older patients with IBD.

IBD prevalence in Lothian, Scotland, derived by capture-recapture methodology

OBJECTIVE

IBD prevalence is estimated to be rising, but no detailed, recent UK data are available. The last reported prevalence estimate in the UK was 0.40% in 2003. We aimed to establish the current, and project future, prevalence in Lothian, Scotland.

DESIGN

We conducted an all-age multiparameter search strategy using inpatient IBD international classification of disease (ICD-10) coding (K50/51)(1997-2018), IBD pathology coding (1990-2018), primary and secondary care prescribing data (2009-2018) and a paediatric registry, (1997-2018) to identify 'possible' IBD cases up to 31/08/2018. Diagnoses were manually confirmed through electronic health record review as per Lennard-Jones/Porto criteria. Autoregressive integrated moving average (ARIMA) regression was applied to forecast prevalence to 01/08/2028.

RESULTS

In total, 24 601 possible IBD cases were identified of which 10 499 were true positives. The point prevalence for IBD in Lothian on 31/08/2018 was 784/100 000 (UC 432/100 000, Crohn's disease 284/100 000 and IBD unclassified (IBDU) 68/100 000). Capture-recapture methods identified an additional 427 'missed' cases (95% CI 383 to 477) resulting in a 'true' prevalence of 832/100 000 (95% CI 827 to 837).Prevalence increased by 4.3% per year between 2008 and 2018 (95% CI +3.7 to +4.9%, p<0.0001). ARIMA modelling projected a point prevalence on 01/08/2028 of 1.02% (95% CI 0.97% to 1.07%) that will affect an estimated 1.53% (95% CI 1.37% to 1.69%) of those >80 years of age.

CONCLUSIONS

We report a rigorously validated IBD cohort with all-age point prevalence on 31/08/2018 of 1 in 125, one of the highest worldwide.

Elderly patients with inflammatory bowel disease: Updated review of the therapeutic landscape

High-quality data remains scarce in terms of optimal management strategies in the elderly inflammatory bowel disease (IBD) population. Indeed, available trials have been mostly retrospective, of small sample size, likely owing to under-representation of such a population in the major randomized controlled trials. However, in the last five years, there has been a steady increase in the number of published trials, helping clarify the estimated benefits and toxicity of the existing IBD armamentarium. In the Everhov trial, prescription strategies were recorded over an average follow-up of 4.2 years. A minority of elderly IBD patients (1%-3%) were treated with biologics within the five years following diagnosis, whilst almost a quarter of these patients were receiving corticosteroid therapy at year five of follow-up, despite its multiple toxicities. The low use of biologic agents in real-life settings likely stems from limited data suggesting lower efficacy and higher toxicity. This minireview will aim to highlight current outcome measurements as it portends the elderly IBD patient, as well as summarize the available therapeutic strategies in view of a growing body of evidence.

Dietary Support in Elderly Patients with Inflammatory Bowel Disease

Ageing of the human population has become a big challenge for health care systems worldwide. On the other hand, the number of elderly patients with inflammatory bowel disease (IBD) is also increasing. Considering the unique clinical characteristics of this subpopulation, including many comorbidities and polypharmacy, the current therapeutic guidelines for the management of IBD should be individualized and applied with caution. This is why the role of non-pharmacological treatments is of special significance. Since both IBD and older age are independent risk factors of nutritional deficiencies, appropriate dietary support should be an important part of the therapeutic approach. In this review paper we discuss the interrelations between IBD, older age, and malnutrition. We also present the current knowledge on the utility of different diets in the management of IBD. Considering the limited data on how to support IBD therapy by nutritional intervention, we focus on the Mediterranean and Dietary Approaches to Stop Hypertension diets, which seem to be the most beneficial in this patient group. We also discuss some new findings on their hypothetical anti-inflammatory influence on the course of IBD.

A Comprehensive Review of the Diagnosis and Pharmacological Management of Crohn's Disease in the Elderly Population

Crohn's disease (CD) in the elderly is rising in prevalence, which is related to an increase in its incidence and improving life expectancies. There are differences in the presentation, natural history, and treatment of CD between adult-onset patients who progress to older age and patients who are initially diagnosed at an older age. Presentation at an older age may also delay or make diagnosis challenging due to accumulating co-morbidities that mimic inflammatory bowel disease. Differences exist between adult- and older-onset disease, yet many guidelines do not specifically distinguish the management of these two distinct populations. Identifying patients at high risk for progression or aggressive disease is particularly important as elderly patients may respond differently to medical and surgical treatment, and may be at higher risk for adverse effects. Despite newer agents being approved for CD, the data regarding efficacy and safety in the elderly are currently limited. Balancing symptom management with risks of medical and surgical therapy is an ongoing challenge and requires special consideration in these two distinct populations.

Management of elderly ulcerative colitis in Japan

Japan has the largest aging society, where many elderly people have intractable diseases including ulcerative colitis (UC). Along with the increasing total number of UC patients, the number of elderly UC patients has also been increasing and will continue to do so in the future. Although the clinical features and natural history of UC in the elderly have many similarities with UC in the non-elderly population, age-specific concerns including comorbidities, immunological dysfunction, and polypharmacy make the diagnosis and management of elderly UC challenging compared to UC in non-elderly patients. Based on increasing data related to elderly UC patients from Japan, as well as other countries, we reviewed the epidemiology, clinical course, differential diagnosis, management of comorbidities, surveillance, medical therapy, and surgery of UC in the elderly.

The Management of Inflammatory Bowel Disease in Elderly: Current Evidence and Future Perspectives

Data on the elderly population with inflammatory bowel disease (IBD) are scarce, as this population is normally excluded from clinical trials. With an ageing population and an overall increasing prevalence of IBD; the incidence of IBD in elderly is rising. Comorbidities, wide differential diagnosis and polypharmacy make the diagnosis and management of the disease in elderly more challenging compared to that in younger adults. The knowledge of specific requirements for the management and treatment of IBD in advanced age may help in the framing of the definition of the appropriate care of this patient group. This manuscript reviews the most recent knowledge in the epidemiology, diagnosis and management of IBD in this population.

Management of inflammatory bowel disease in older persons: evolving paradigms

The incidence and prevalence of inflammatory bowel disease (IBD) is increasing, and considering the aging population, this number is set to increase further in the future. The clinical features and natural history of elderly-onset IBD have many similarities with those of IBD in younger patients, but with significant differences including a broader differential diagnosis. The relative lack of data specific to elderly patients with IBD, often stemming from their typical exclusion from clinical trials, has made clinical decision-making somewhat challenging. Treatment decisions in elderly patients with IBD must take into account age-specific concerns such as comorbidities, locomotor and cognitive function, and polypharmacy, to set realistic treatment targets in order to enable personalized treatment and minimize harm. Notwithstanding paucity of clinical data, recent studies have provided valuable insights, which, taken together with information gleaned from previous studies, can broaden our understanding of IBD. These insights may contribute to the development of paradigms for the holistic and, when possible, evidence-based management of this potentially vulnerable population and are the focus of this review.

Endoscopic recommendations for colorectal cancer screening and surveillance in patients with inflammatory bowel disease: Review of general recommendations

Screening for colorectal cancer (CRC) in patients with inflammatory bowel disease (IBD) is recommended by all scientific societies. However, there are differences in the recommendations they make regarding screening and surveillance. We address a series of questions that come up in the daily clinical practice of a physician. The first two questions that are raised are: (1) Who should be offered screening for CRC? and (2) When should the first colonoscopy be performed? The next step is to decide who should undergo endoscopic surveillance and at what intervals they should be performed. Chromoendoscopy is emerging as the recommended endoscopic technique for screening and surveillance. The terminology for describing lesions detected with endoscopy is also changing. The management of visible lesions or non-visible dysplasia is also a motive for the review. We end the review by addressing the follow-up for endoscopically resected lesions. These questions often cannot be answered easily due to the varying degrees of evidence available; therefore, we have made some general recommendations based on those made by the various guidelines and consensuses. The first screening colonoscopy should be offered 8 years after a IBD diagnosis and we recommend that patients be stratified according to the individual risk for each for endoscopic surveillance intervals.