Clinical outcome of Crohn's disease according to the Vienna classification: disease location is a useful predictor of disease course

Personalized Treatment for Crohn's Disease: Current Approaches and Future Directions

Crohn's disease is a complex, relapsing and remitting inflammatory disorder of the gastrointestinal tract with a variable disease course. While the treatment options for Crohn's disease have dramatically increased over the past two decades, predicting individual patient response to treatment remains a challenge. As a result, patients often cycle through multiple different therapies before finding an effective treatment which can lead to disease complications, increased costs, and decreased quality of life. Recently, there has been increased emphasis on personalized medicine in Crohn's disease to identify individual patients who require early advanced therapy to prevent complications of their disease. In this review, we summarize our current approach to management of Crohn's disease by identifying risk factors for severe or disabling disease and tailoring individual treatments to patient-specific goals. Lastly, we outline our knowledge gaps in implementing personalized Crohn's disease treatment and describe the future directions in precision medicine.

Idiopathic Ileal Ulceration After Intestinal Transplantation

Background

Idiopathic ileal ulceration after intestinal transplantation (ITx) has been discussed infrequently and has an uncertain natural history and relation to graft rejection. Herein, we review our experience with this pathology.

Methods

We retrospectively reviewed 225 ITx in 217 patients with minimum 1 y graft survival. Routine graft endoscopy was conducted up to twice weekly within the first 90 d after ITx, gradually decreasing to once yearly. Risks for ulceration over time were evaluated using Cox regression.

Results

Of 93 (41%) patients with ulcers, 50 were found within 90 d after ITx mostly via ileoscopy; delayed healing after biopsy appeared causal in the majority. Of the remaining 43 patients with ulcers found >90 d after ITx, 36 were after ileostomy closure. Multivariable modeling demonstrated within 90-d ulcer associations with increasing patient age (hazard ratio [HR], 1.027; P < 0.001) and loop ileostomy (versus Santulli ileostomy; HR, 0.271; P < 0.001). For ulcers appearing after ileostomy closure, their sole association was with absence of graft colon (HR, 7.232; P < 0.001). For ulcers requiring extended anti-microbial and anti-inflammatory therapy, associations included de novo donor-specific antibodies (HR, 3.222; P < 0.007) and nucleotide oligomerization domain mutations (HR, 2.772; P < 0.016). Whole-cohort post-ITx ulceration was not associated with either graft rejection (P = 0.161) or graft failure (P = 0.410).

Conclusions

Idiopathic ulceration after ITx is relatively common but has little independent influence on outcome; risks include ileostomy construction, colon-free ITx, immunologic mutation, and donor sensitization.

Diagnosis and Clinical Features of Perianal Lesions in Newly Diagnosed Crohn's Disease: Subgroup Analysis from Inception Cohort Registry Study of Patients with Crohn's Disease (iCREST-CD)

BACKGROUND AND AIMS

Perianal lesion is a refractory phenotype of Crohn's disease [CD] with significantly diminished quality of life. We evaluated the clinical characteristics of perianal lesions in newly diagnosed CD patients and the impact of perianal lesions on the quality of life in Japanese patients with CD.

METHODS

Patients newly diagnosed with CD after June 2016 were included between December 2018 and June 2020 from the Inception Cohort Registry Study of Patients with CD [iCREST-CD].

RESULTS

Perianal lesions were present in 324 [48.2%] of 672 patients with newly diagnosed CD; 71.9% [233/324] were male. The prevalence of perianal lesions was higher in patients aged <40 years vs ≥40 years, and it decreased with age. Perianal fistula [59.9%] and abscess [30.6%] were the most common perianal lesions. In multivariate analyses, male sex, age <40 years and ileocolonic disease location were significantly associated with a high prevalence of perianal lesions, whereas stricturing behaviour and alcohol intake were associated with low prevalence. Fatigue was more frequent [33.3% vs 21.6%] while work productivity and activity impairment-work time missed [36.3% vs 29.5%] and activity impairment [51.9% vs 41.1%] were numerically higher in patients with than those without perianal lesions.

CONCLUSIONS

At the time of CD diagnosis, approximately half of the patients had perianal lesions; perianal abscesses and perianal fistulas were the most common. Young age, male sex, disease location and behaviour were significantly associated with the presence of perianal lesions. The presence of perianal lesion was associated with fatigue and impairment of daily activities.

CLINICAL TRIALS REGISTRY

University Hospital Medical Information Network Clinical Trials Registry System [UMIN-CTR, UMIN000032237].

Evaluation of symptomatic small bowel stricture in Crohn's disease by double-balloon endoscopy

PURPOSE

To assess the efficacy of double-balloon endoscopy (DBE) for the detection of small-bowel strictures in Crohn's disease (CD).

METHODS

This tertiary-referral hospital cohort study was conducted between January 2018 and May 2022. CD patients with symptoms of small-bowel stricture were enrolled sequentially. All of the patients were subjected to both computed tomography enterography (CTE) and DBE, and their symptoms of stricture were assessed using the Crohn's Disease Obstructive Score (CDOS). The diagnostic yield of DBE was compared to that of CTE, and the relationship between the DBE findings and CDOS was investigated. The factors influencing the DBE diagnosis were examined using Cox regression analysis.

RESULTS

This study included 165 CD patients. The CDOS scores were higher in 95 patients and lower in 70 patients. DBE detected 92.7% (153/165) and CTE detected 85.5% (141/165) of the strictures. The DBE diagnostic yields were 94.7% (90/95) in the high CDOS patients and 91.4% (64/70) in the low CDOS patients (P = 0.13). Patients with a history of abdominal surgery and abscess had a lower diagnosis rate in the multivariate analysis.

CONCLUSION

DBE has been demonstrated to be an efficient diagnostic method for detecting small bowel strictures in CD patients. Additionally, there was no difference in the diagnostic yields between patients with low and high obstructive scores.

Clinical course of new-onset Crohn's disease in children and adolescents in dependency of age, initial location, initial severity level and therapy over the period 2000-2014 based on the Saxon Pediatric IBD-Registry in Germany

OBJECTIVE

In Saxony, the incidence of Crohn's disease (CD) in children and adolescents increased significantly from 3.3 per 100,000 person-years in 2000 to 5.1 in 2014. The aim of this study was to describe the initial characteristics and the clinical course of CD in children and adolescents and to identify drug treatment options associated with an advantage for a mild course or remission.

METHODS

Clinical data were collected from patients who suffered from inflammatory bowel disease (IBD) and were recruited in the Saxon Pediatric IBD-Registry. All children newly diagnosed with CD in this registry in Saxony between 2000 and 2014 were included in this registry study. Characteristics such as age, disease location and extra-intestinal manifestations at diagnosis were accessed. The severity level of the disease at diagnosis as well as at follow-up were analysed by PCDAI index. Patients were divided into 3 groups according to length of follow-up: 1-3 years, 4-6 years and 7-9 years after diagnosis. A logistic regression model was conducted to examine which baseline parameters are associated with disease progression.

RESULTS

There were 338 children and adolescents with CD included in this registry study. At diagnosis, the median age of patients was 12.0 (0.7-14.9), 61.5% (n = 208) of the patients were male. The most common disease location observed in pediatric CD patients was the L3 (55%, n = 176). Patients aged 10-14 years were significantly more likely to present an L2 than patients aged 0-4 years (80.3%, n = 53 vs. 19.7%, n = 13, p = 0.01). During the follow-up, data from 71.3% (n = 241) othe patients were available. Disease activity measured by PCDAI decreased in 47.7% (n = 115) of the patients, 40.7% (n = 98) of the patients were stable and increased in 11.6% (n = 28) of the patients. Patients with intermediate/severe disease at onset were more likely to have an active disease at the end of follow up, too (p = 0.00). Logistic regression analysis of the initial characteristics showed that the age at diagnosis, gender, initial location and initial extra-intestinal manifestation are not associated with the progression of the disease (p>0.05). Furthermore, drug treatment options could be identified from our data, which are associated with benefits for a milder course or remission.

CONCLUSION

From 2000 to 2014, the health status of most pediatric patients with CD had improved or remained stable. Initial characteristics including age at diagnosis, initial localization and initial extra-intestinal manifestation are not associated with the progression of the disease, only the initial activity by PCDAI.

Variables associated with progression of moderate-to-severe Crohn's disease

OBJECTIVE

Determine the variables associated with hospitalisations in patients with Crohn's disease and those associated with surgery, intestinal resection, hospital readmission, need for multiple operations and immunobiological agent use.

DESIGN

A cross-sectional study was conducted from 2019 to 2021, using two centres for inflammatory bowel diseases in the Brazilian Public Health System.

RESULTS

This study included 220 patients. Only perianal disease was associated with hospitalisation (31.6% vs 13.0%, p=0.012). Stricturing or penetrating behaviour (35.8% vs 12.6%, p<0.001) and perianal disease (45.9% vs 9.9%, p<0.001) were associated with surgery. Ileal or ileocolonic location (80.0% vs 46.5%, p=0.044) and stricturing or penetrating behaviour (68.0% vs 11.2%, p<0.001) were associated with intestinal resection. Steroids use at first Crohn's disease occurrence and postoperative complications were associated with hospital readmission and need for multiple operations, respectively. Age below 40 years at diagnosis (81.3% vs 62.0%, p=0.004), upper gastrointestinal tract involvement (21.8% vs 10.3%, p=0.040) and perianal disease (35.9% vs 16.3%, p<0.001) were associated with immunobiological agent use.

CONCLUSION

Perianal disease and stricturing or penetrating behaviour were associated with more than one significant outcome. Other variables related to Crohn's disease progression were age below 40 years at diagnosis, an ileal or ileocolonic disease localisation, an upper gastrointestinal tract involvement, the use of steroids at the first Crohn's disease occurrence and history of postoperative complications. These findings are similar to those in the countries with a high prevalence of Crohn's disease.

Efficacy of Novel Ultrathin Single-Balloon Enteroscopy for Crohn's Disease: A Propensity Score-Matched Study

Background/Aims

The evaluation of small bowel lesions of Crohn's disease (CD) using balloon-assisted enteroscopy (BAE) is crucial because mucosal healing is associated with a good prognosis. However, BAE procedures are invasive, requiring sedation or analgesia to reduce the patient's pain. This study evaluated the clinical usefulness of a novel ultrathin single-balloon enteroscopy (SBE) procedure for CD.

Methods

This single-center retrospective study included 102 CD patients who underwent trans-anal SBE between January 2012 and May 2018. Of these patients, 82 underwent enteroscopy using conventional SBE, while 20 underwent ultrathin SBE. Patients were analyzed using propensity score matching, with 20 patients per group. The median duration of the examination, terminal ileum intubation rate, median cecum intubation time, median insertion depth, adverse events, and sedated dose in each group were compared.

Results

Before propensity score matching, the conventional SBE group had a larger number of surgical history patients than the ultrathin SBE group (p=0.05). After matching, the two groups did not significantly differ clinically. There were no significant differences in the mean duration of the examination, cecum intubation time, or terminal ileal intubation rate between ultrathin SBE and conventional SBE. The mean insertion depth of ultrathin SBE tended to be deeper than that of conventional SBE (p=0.09). The use of ultrathin SBE also reduced the sedative dose during needed for enteroscopy compared with conventional SBE (p=0.005).

Conclusions

Novel ultrathin SBE may be less painful for CD patients than conventional SBE.

Risk factors associated with progression to intestinal complications of Crohn disease

BACKGROUND

Crohn disease is a chronic bowel disease that causes serious complications. Prevalence of Crohn disease is increasing. Studies have shown that the behavior of the disease is not stable and severe complications secondary to behavior change over time have been shown. In this study, we aimed to evaluate the prognostic risk factors associated with phenotypic change in Crohn disease in a Turkish patient cohort.

METHODS

Patients followed up from March 1986 to August 2011 were evaluated for demographic and clinical characteristics to determine possible risk factors and initial clinical phenotype of the disease based on the Montreal classification. The cumulative probabilities of developing stricturing or penetrating intestinal complications were estimated using the Kaplan-Meier analysis. Univariate and multivariate Cox-proportional hazard models were used to assess associations between baseline clinical characteristics and intestinal complications.

RESULTS

Three hundred and thirty patients (mean age, 30.6 ± 11.1 years; 148 female) were included in the study. Mean follow-up duration was 7.4 ± 5.3 years (range: 1.0-25.0 years). At baseline 273 patients had inflammatory-type disease, 57 patients experienced stricturing/penetrating intestinal complications before or at the time of diagnosis. The cumulative probability of developing complicated disease was 37.4% at 5 years, 54.3% at 10 years, 78.8% at 25 years. Independent predictors associated with progression to intestinal complications were current smoking, perianal disease, extra-intestinal manifestations, and location of disease.

CONCLUSIONS

Location of disease is the most powerful indicator for the development of stenosis and penetrating complications in inflammatory-type disease. Patients with ileal involvement should be considered for more aggressive immunosuppressive therapy.

Diagnostic efficacy of double-balloon enteroscopy in patients with suspected isolated small bowel Crohn's disease

BACKGROUND

Owing to the development of double-balloon enteroscopy (DBE) and video capsule endoscopy (VCE) in recent years, direct visualization of the entire small intestinal mucosa has become possible. Because of the nonspecific symptoms and the anatomic location of the small bowel, diagnosis of isolated small bowel Crohn's disease (CD) remains a challenge. The aim of this research was to explore the value of DBE for isolated small bowel CD in situations where routine tests cannot confirm the diagnosis.

METHODS

This study included patients with suspected isolated small bowel CD who were hospitalized in Shengjing Hospital from April 2014 to June 2018. We included patients presenting with chronic diarrhea, abdominal pain, abdominal mass, perianal lesions, and systemic symptoms including weight loss, fever, and anemia after excluding infection factors. Patients with purely colonic CD were excluded from this cohort. Patients with suspected isolated small bowel CD underwent DBE.

RESULTS

In 16/18 patients, pathological findings were detected by DBE. In 12 of the cases, small bowel CD was confirmed. The remaining four patients were diagnosed with small bowel inflammation, duodenal carcinoma, ileum inflammation and small bowel ulcers. However, the diagnosis of CD was confirmed in 14/18 (78%) patients by taking into account the clinical presentation, endoscopic and histological results as well as the experimental treatment. DBE assisted in the diagnosis in 86% (12/14) of the patients.

CONCLUSIONS

In the diagnosis of small bowel CD, DBE is a helpful tool. Before assessment with DBE, clinical features, colonoscopy, and CT were used to initially assess the intestine. According to the lesions indicated by CT, we chose the most appropriate endoscope insertion route, and combined the endoscopic characteristics and pathological results of DBE to confirm the diagnosis.

A Cross-Sectional Study on Malnutrition in Inflammatory Bowel Disease: Is There a Difference Based on Pediatric or Adult Age Grouping?

BACKGROUND

Malnutrition, commonly observed in inflammatory bowel disease (IBD), is associated with increased morbidity and mortality and is attributed to multiple causes. The added energy costs of growth in the child and adolescent with IBD are an additional risk factor.

METHODS

The aim of the study was to perform a cross-sectional comparison of nutritional parameters in IBD between pediatric and adult cases.

RESULTS

We found that prevalence of undernutrition (low body mass index) and hypoalbuminemia was not different in pediatric, compared with adult patients. Anemia and iron deficiency were more often observed in pediatric subjects, compared with adults (59.1% vs 36.9%, respectively, P < 0.0001; and 37.9% vs 25.3%, P < 0.002). Vitamin B12 deficiency was significantly less common in the pediatric than in the adult group (5.4% vs 19.4%, P < 0.0001). Elevated C-reactive protein was more frequent in pediatric compared with adult cases (49.8% vs 38.4%, P < 0.01).

CONCLUSIONS

Patients with active Crohn's disease were more likely to be undernourished in both pediatric and adult populations. In both groups, predicators of undernutrition included low albumin levels (odds ratio [OR], 2.53; P < 0.006) and active disease (OR, 1.99; P < 0.03). Our results call for close surveillance of nutritional status for IBD patients, regardless of age.

Association of clinical and inflammatory markers with small bowel capsule endoscopy findings in Crohn's disease

BACKGROUND

Mucosal healing is an established treatment endpoint in Crohn's disease (CD). Still, clinical indices and inflammatory markers are used widely in CD surveillance.

AIM

The aim of this study was to investigate the diagnostic performance as well as the relationship of C-reactive protein (CRP) and Crohn's Disease Activity Index (CDAI) with small bowel capsule endoscopy's (SBCE) inflammation scoring index, the Lewis Score (LS).

PATIENTS AND METHODS

CDAI, CRP, and SBCE findings of 30 CD patients with isolated small bowel disease were retrieved from our academic institution patient records and were analyzed statistically.

RESULTS

SBCE showed significant mucosal inflammation [mean (SD) LS: 1599 (1380)], in nine (60.0%) of 15 patients who were in both clinical and biochemical remission. CDAI and CRP showed a weak and moderate correlation with LS (r=0.317, P=0.088 and r=0.516, P=0.004, respectively). The diagnostic performance of CDAI and CRP in predicting mucosal inflammation was as follows: sensitivity 23.8 and 52.4%; specificity 100 and 66.7%; positive predictive value 100 and 78.6%; and negative predictive value 36.0 and 37.5%. The area under the curve toward endoscopic activity prediction was 0.70 and 0.69, respectively.

CONCLUSION

Both CDAI and CRP underestimated endoscopic activity as expressed by the LS in a significant proportion of patients with quiescent disease.

Clinical presentation of Crohn's, ulcerative colitis, and indeterminate colitis: Symptoms, extraintestinal manifestations, and disease phenotypes

The incidence of inflammatory bowel disease (IBD) is rising with 25% of IBD diagnosed in children under 18 years of age. The clinical presentation of IBD in children is often vague leading to initial misdiagnosis as infectious colitis or irritable bowel syndrome. When IBD is identified, overlap in histologic and endoscopic features may lead to difficulty distinguishing Crohn's disease from ulcerative colitis, resulting in a higher frequency of the diagnosis indeterminate colitis or IBD unspecified. Recognizing the common and the atypical presentation of pediatric IBD and extraintestinal manifestations will aid in expeditious referral and early diagnosis. Activity severity scoring tools and more specific classification systems for pediatric IBD direct therapeutic algorithms and allow for improved longitudinal assessment since disease severity and location have been shown to be associated with outcome.

Vitamin B12 deficiency in inflammatory bowel disease: a prospective observational pilot study

BACKGROUND AND AIM

Diagnostic and management guidelines for vitamin B12 (cobalamin, Cbl) deficiency in inflammatory bowel disease (IBD) are lacking. True deficiency is defined as Cbl concentrations below reference range combined with elevated methylmalonic acid (MMA) concentrations. Studies analyzing Cbl status in IBD use only Cbl concentrations without confirmatory MMA. This study aims to determine the proportion of IBD patients with Cbl concentrations below reference range and their predisposing clinical and genetic characteristics. We then compared this to the proportion with true deficiency.

PATIENTS AND METHODS

In a prospective observational pilot study of adult IBD outpatients, Cbl concentrations, MMA levels, and fucosyltransferase 2 mutations were measured at clinic visits.

RESULTS

A total of 66 Crohn's disease (CD) and 30 ulcerative colitis (UC) patients were recruited. Mean Cbl concentrations (pmol/l) in CD (253.7) were not significantly lower than UC (320.5, P=0.24). Serum Cbl below reference range (<148) was observed in 7.6 and 10% of CD and UC patients, respectively (P=0.70). True deficiency in CD and UC was 3 and 3.3%, respectively (P=1.0). Patients with ileal resections more than 30 cm had lower mean Cbl concentrations (177, P=0.02) and a trend toward higher proportions with Cbl levels below reference range (40%, P=0.06), but not increased deficiency rates (0%, P=1.0). Disease location, severity, and fucosyltransferase 2 mutations were not associated with altered Cbl status.

CONCLUSION

True Cbl deficiency was rare in IBD patients in this study. A disparity in Cbl status exists when confirmatory MMA levels are used compared with Cbl concentrations alone. Asymptomatic IBD patients with low serum Cbl require confirmatory tests to guide management and avoid unnecessary treatment.

Montreal classification of patient operated for Crohn's disease and identification of surgical recurrence predictors

OBJECTIVE

to evaluate Crohn's disease recurrence and its possible predictors in patients undergoing surgical treatment.

METHODS

We conducted a retrospective study with Crohn's disease (CD) patients undergoing surgical treatment between January 1992 and January 2012, and regularly monitored at the Bowel Clinic of the Hospital das Clínicas of the UFMG.

RESULTS

we evaluated 125 patients, 50.4% female, with a mean age of 46.12 years, the majority (63.2%) diagnosed between 17 and 40 years of age. The ileum was involved in 58.4%, whereas stenotic behavior was observed in 44.8%, and penetrating, in 45.6%. We observed perianal disease in 26.4% of cases. The follow-up average was 152.40 months. Surgical relapse occurred in 29.6%, with a median time of 68 months from the first operation.

CONCLUSION

The ileocolic location, penetrating behavior and perianal involvement (L3B3p) were associated with increased risk of surgical recurrence.

Clinical predictors of Crohn's disease course

A modern approach to Crohn's disease (CD) should be influenced by the patient's underlying prognosis. Here, I analyse the clinical factors predicting CD course on the basis of information obtained at diagnosis and in the year following diagnosis. Perianal disease at diagnosis appears to be a strong predictor of unfavourable outcome and has been associated with a more frequent use of immunosuppressive treatment. Early age at diagnosis, ileocolonic disease and extraintestinal manifestations are characteristics of patients at risk for more complicated disease. Otherwise, patients subjected to surgery at diagnosis or during the first year of follow-up appear to have a relatively benign outcome. Disease activity in the year after diagnosis appears to be a good predictor of future disease activity as about two-third of the patients who remain in remission tend to remain unchanged thereafter, whereas those patients treated with steroids have, manifestly, an unfavourable subsequent clinical course. Moreover, there is consistent evidence that active smoking is associated with a complicated disease course. The results of the studies reviewed suggest that the combination of 'phenotype at diagnosis' and 'comportment follow-up classification' in the year following diagnosis can be potentially useful prognostic factors in clinical practice. With the development of newer therapies in CD, there is a growing need to predict disease outcome, despite the difficult challenge in anticipating the future clinical course in a given patient.

Clinical features of Crohn's disease in Korean patients residing in Busan and Gyeongnam

BACKGROUND/AIMS

Crohn's disease (CD) is a chronic inflammatory bowel disease that presents with variable features and repeated disease aggravation. The incidence of CD is increasing in Korea. We evaluated the clinical features of CD in a study population in Busan and Gyeongnam, Korea.

METHODS

A hospital-based analysis included 619 patients diagnosed with CD between March 1986 and February 2013 from seven tertiary care hospitals in Busan and Gyeongnam. Individual case records were reviewed with regard to age at diagnosis, sex, disease location, disease behavior, and medical and surgical treatments received during the follow-up period.

RESULTS

The cumulative frequency of patients diagnosed with CD revealed a continued increase in the number of cases reported yearly. The male-to-female ratio was 2.5:1 and the median age at diagnosis was 24 years. At diagnosis, 114 (18.4%) had isolated small bowel disease, 144 (23.3%) had isolated colonic disease, and 358 patients (57.8%) presented with disease in the small bowel and colon. The number of patients presenting with stricturing or penetrating disease behavior was 291 (47%) at the final evaluation. In total, 111 (17.9%) patients underwent intestinal resections.

CONCLUSIONS

A continued increase in the number of patients diagnosed with CD was found in Busan and Gyeongnam as observed in other regions. We report results similar to that of other Korean studies in terms of sex distribution, age, and location of disease.

Risk factors for initial surgery in patients with Crohn's disease in Central China

PURPOSES

To establish the risk factors for initial surgery in patients with Crohn's disease (CD) in Central China.

METHODS

The subjects of this study were patients with CD treated at Zhongnan Hospital of Wuhan University, an IBD center in Wuhan City, Central China, between January, 1992 and June, 2012. We conducted uni- and multivariate analyses of the risk factors for initial surgery for CD in these patients.

RESULTS

A total of 197 patients with CD were included in this study. The cumulative incidence of initial surgery was 21.8, 28.9, and 32.5%, at 1, 5, and 10 years, respectively, after the onset of symptoms. Analysis using multivariate Cox models showed that the relative risk for initial surgery was lower in patients who were younger than 16 years at diagnosis (HR = 0.57, 95% CI 0.34-0.96, P = 0.034). The risk increased in patients with stricturing (HR = 4.75, 95% CI 2.48-9.11), those with CD showing penetrating behavior at diagnosis (HR = 5.14, 95% CI 2.54-10.39), and those with a history of appendectomy (HR = 1.87, 95% CI 1.03-3.40). Azathioprine (AZA) treatment appeared to decrease the risk for initial surgery in patients with non-penetrating and non-stricturing CD (HR = 0.14, 95% CI 0.13-3.10).

CONCLUSION

Age at diagnosis, disease behavior, and a history of appendectomy appeared to have an impact on the risk for initial surgery. AZA treatment might be helpful for decreasing the risk of needing initial surgery for patients in whom stricturing or fistulizing disease has not yet developed.

Vitamin B12 deficiency in inflammatory bowel disease: prevalence, risk factors, evaluation, and management

BACKGROUND

Management of vitamin B(12) (cobalamin, Cbl) deficiency in inflammatory bowel disease (IBD) is often not evidenced-based because of uncertainty on whether it causes enough malabsorption to result in clinical disease. This systematic review examines whether IBD predisposes to Cbl deficiency. We provide an approach to the management of abnormal Cbl values in IBD based on current literature and consensus-based guidelines.

METHODS

An extensive search of the Ovid MEDLINE and EMBASE databases by independent reviewers identified 42 articles with a total of 3732 patients evaluating Cbl deficiency in IBD.

RESULTS

Crohn's disease without ileal resection, regardless of disease location in the ileum, did not increase the risk for Cbl deficiency. Ileal resections greater than 30 cm were associated with Cbl deficiency in Crohn's disease, whereas those less than 20 cm were not. The effects of 20 to 30 cm resections were inconsistent. Ulcerative colitis did not predispose to deficiency. All studies failed to use confirmatory biomarker testing as stipulated by diagnostic guidelines for Cbl deficiency.

CONCLUSIONS

This literature does not support an association of Crohn's disease in general, regardless of ileal involvement, with Cbl deficiency. Only ileal resections greater than 20 cm in Crohn's disease predispose to deficiency and warrant treatment. Based on these findings, we suggest a diagnostic and therapeutic algorithm. All findings and recommendations require verification in further studies using confirmatory biomarkers as per diagnostic guidelines for Cbl deficiency. Serum Cbl levels alone are likely insufficient to diagnose deficiency in asymptomatic patients.

Comparative study of intestinal tuberculosis and primary small intestinal lymphoma

AIM: To characterize the clinical, radiological, endoscopic and pathological features of intestinal tuberculosis (ITB) and primary small intestinal lymphoma (PSIL).

METHODS: This was a retrospective study from February 2005 to October 2012 of patients with a diagnosis of ITB (n = 41) or PSIL (n = 37). All patients with ITB or PSIL underwent computed tomography (CT) and pathological examination. Thirty-five patients with ITB and 32 patients with PSIL underwent endoscopy. These patients were followed for a further 18 mo to ascertain that the diagnosis had not changed. Clinical, endoscopic, CT and pathological features were compared between ITB and PSIL patients.

RESULTS: Night sweating, fever, pulmonary TB and ascites were discovered significantly more often in ITB than in PSIL patients (P < 0.05), however, abdominal mass, hematochezia and intestinal perforation were found significantly more frequently in PSIL than in ITB patients (P < 0.05). Ring-like and rodent-like ulcers occurred significantly more often in ITB than in PSIL patients (P < 0.05), however, enterorrhagia and raised lesions were significantly more frequent in PSIL than in ITB patients (P < 0.05). The rate of granuloma was significantly higher in ITB than in PSIL patients (87.8% vs 13.5%, χ² = 43.050, P < 0.05), and the incidence of confluent granulomas with caseous necrosis was significantly higher in ITB than in PSIL patients (47.2% vs 0.0%, χ² = 4.034, P < 0.05). Multi-segmental lesions, mural stratification, mural gas sign, and intestinal stricture were more frequent in ITB than in PSIL patients (P < 0.05), however, a single-layer thickening of bowel wall, single segmental lesions, and intussusception were more common in PSIL than in ITB patients (P < 0.05). Necrotic lymph nodes, comb sign and inflammatory mass were more frequent in ITB than in PSIL patients (P < 0.05). The bowel wall enhancement in ITB patients was greater than that in PSIL patients (P < 0.05), while the thickening and lymph node enlargement in PSIL patients were higher than those in ITB patients (P < 0.05).

CONCLUSION: Combined evaluation of clinical, radiological, endoscopic and pathological features is the key to differentiation between ITB and PSIL.

Incidence and paris classification of pediatric inflammatory bowel disease

New epidemiological data suggest that the incidence of inflammatory bowel disease (IBD) is increasing. As a result the burden of disease accounts for more strains to the health care system. The clinical variability queries whether disease characteristics are related to clinical outcome. Our aim was to delineate the latest results of incidence trends in pediatric IBD and to compare the first experiences with Paris Classification. Incidence of pediatric IBD has been increasing in Western Europe and in Eastern Europe. To better characterize IBD, Paris Classification was introduced and validated recently. Ileocolonic involvement is the most characteristic disease location in Crohn's disease (CD) based on applying Paris Classification. The rate of perianal disease and complicated behaviour in CD was similar. It is of interest that CD patients with colonic involvement were less likely to have stricturing disease compared with patients with ileal involvement. In addition, pancolitis dominated in ulcerative colitis (UC). However, most countries lack prospective, nationwide epidemiological studies to estimate incidence trends. This review emphasizes the importance of nationwide registries that enroll all pediatric IBD cases serving reliable data for "everyday practice." These first reports have shown that Paris Classification is a useful tool to determine the pediatric IBD phenotype.

Double-balloon enteroscopy in the diagnosis of suspected isolated Crohn's disease of the small bowel

BACKGROUND AND AIM

Diagnosis of Crohn's disease (CD) with isolated involvement of the small bowel remains a major challenge. Diagnostic procedures allowing direct insight into the midgut have become available with the introduction of double-balloon enteroscopy (DBE) and video-capsule endoscopy (VCE). The aim of the present study was to evaluate the role of DBE in the diagnosis of isolated CD of the small bowel.

METHODS

Sixteen patients (seven males) with suspected CD of the small bowel after exclusion of abnormal changes in the upper gastrointestinal tract and colon by esophagogastroduodenoscopy and colonoscopy including histology underwent DBE and high-resolution transabdominal ultrasound.

RESULTS

In seven of 16 (44%) patients, abnormal macroscopic findings were detected by DBE (e.g. ileitis terminalis, inflammatory stenosis, aphthous lesions or jejunal ulcers). In one of thecases, histology confirmed pathognomonic findings consistent with CD. However, the diagnosis of CD was confirmed in 11/16 (69%) patients taking into account the clinical presentation and course of the disease as well as the endoscopic and imaging results.

CONCLUSIONS

In cases of CD with clinical expression limited to the small bowel, DBE is a helpful tool. Nevertheless, in these patients, the combination of clinical findings and additional imaging modalities is required for confirmation of the diagnosis. A suggestive medical history, high-resolution ultrasound, EGD and colonoscopy lead the algorithm before the assessment with DBE.

Clinical profile and predictors of disease behavior and surgery in Indian patients with Crohn's disease

BACKGROUND

Recent years have seen the emergence of Crohn's disease (CD) in India and the predictors of disease behavior and surgery in these patients are not known.

METHODS

The demographic and clinical profiles of patients diagnosed to have CD from January 1995 to December 2008 were analyzed retrospectively and associations with disease behavior and surgery were determined using multivariate analysis.

RESULTS

Two hundred and twenty-three patients (age 35 ± 14.7 years, males 57.9 %) were included. Extraintestinal manifestations were noted in 27.4 % patients. There was a median delay of 24 months to diagnosis; 66 (29.6 %) patients received antitubercular therapy prior to diagnosis. The most common site of involvement was ileocolonic (40.4 %), and the most common disease behavior was nonstricturing and nonpenetrating (57.8 %). The disease was moderate to severe in 79 %. Around 40 % patients had a relapsing course of illness. Seventy-three patients (32.7 %) had at least one surgical intervention. Independent associations with aggressive disease behavior included the presence of small bowel disease and longer duration of illness. Predictors of surgical intervention were male sex, small bowel disease, perianal disease, and aggressive disease behavior.

CONCLUSION

Diagnosis of CD is still delayed in India. Longer duration of illness predicted aggressive disease behavior. Surgery was performed more often in males with aggressive disease involving the small bowel and perianal area.

Dyspeptic symptoms and delayed gastric emptying of solids in patients with inactive Crohn's disease

Background

Patients with Crohn’s disease (CD) have been shown to present dyspeptic symptoms more frequently than the general population. Some of these symptoms could be related to motility disorders to some degree. Then, we propose to investigate whether gastric emptying of solids in patients with inactive CD is delayed and to determine the relationships between gastric emptying and dyspeptic symptoms in inactive CD.

Methods

Twenty-six patients with inactive Crohn’s disease, as defined by a Crohn’s Disease Activity Index (CDAI) < 150, underwent a gastric emptying test by breath test using ¹³C octanoic acid coupled to a solid meal and answered a validated questionnaire (The Porto Alegre Dyspeptic Symptoms Questionnaire) to assess dyspeptic symptoms. Patients with scores ≥ 6 were considered to have dyspepsia. The control group was composed by 19 age- and sex-matched healthy volunteers.

Results

Patients with CD had a significantly longer t 1/2 and t lag (p<0.05) than the controls. CD patients with dyspepsia had significantly (p<0.05) prolonged gastric emptying when compared to patients without dyspeptic symptoms. When the individual symptom patterns were analyzed, only vomiting was significantly associated with delayed gastric emptying (p<0.05). There was no difference between the subgroups of patients with respect to gender, CDAI scores, disease location, clinical behavior (obstructive/obstructive) or previous gastrointestinal surgery.

Conclusion

Delayed gastric emptying in inactive Crohn’s disease patients seems to be associated with dyspeptic symptoms, particularly vomiting, even without any evidence of gastrointestinal obstruction.

Cognitive impairment and vitamin B12: a review

BACKGROUND

This review examines the associations between low vitamin B12 levels, neurodegenerative disease, and cognitive impairment. The potential impact of comorbidities and medications associated with vitamin B12 derangements were also investigated. In addition, we reviewed the evidence as to whether vitamin B12 therapy is efficacious for cognitive impairment and dementia.

METHODS

A systematic literature search identified 43 studies investigating the association of vitamin B12 and cognitive impairment or dementia. Seventeen studies reported on the efficacy of vitamin B12 therapy for these conditions.

RESULTS

Vitamin B12 levels in the subclinical low-normal range (<250 ρmol/L) are associated with Alzheimer's disease, vascular dementia, and Parkinson's disease. Vegetarianism and metformin use contribute to depressed vitamin B12 levels and may independently increase the risk for cognitive impairment. Vitamin B12 deficiency (<150 ρmol/L) is associated with cognitive impairment. Vitamin B12 supplements administered orally or parenterally at high dose (1 mg daily) were effective in correcting biochemical deficiency, but improved cognition only in patients with pre-existing vitamin B12 deficiency (serum vitamin B12 levels <150 ρmol/L or serum homocysteine levels >19.9 μmol/L).

CONCLUSION

Low serum vitamin B12 levels are associated with neurodegenerative disease and cognitive impairment. There is a small subset of dementias that are reversible with vitamin B12 therapy and this treatment is inexpensive and safe. Vitamin B12 therapy does not improve cognition in patients without pre-existing deficiency. There is a need for large, well-resourced clinical trials to close the gaps in our current understanding of the nature of the associations of vitamin B12 insufficiency and neurodegenerative disease.

The effects of pre- and post-pregnancy inflammatory bowel disease diagnosis on birth outcomes

BACKGROUND

Inflammatory bowel diseases are frequent in women at their optimum age for reproduction. Possible effects on pregnancy are therefore of interest.

AIM

To assess pregnancy outcomes in 212 women: 135 of whom were diagnosed with inflammatory bowel disease before pregnancy and 77 after pregnancy.

METHODS

A clinical birth database was examined retrospectively. Odds ratios (ORs) for the main outcomes were calculated with 95% confidence intervals; these were adjusted for confounding factors.

RESULTS

Overall, pregnancy outcomes were good. No increased risk of preterm births or need for neonatal intensive care was observed. However, women with inflammatory bowel disease had more growth-retarded newborns, at an adjusted OR of 2.08 (1.26-3.44) and the mode of delivery was more frequently Caesarean section, with an OR of 2.75 (1.82-4.16). In the women who were diagnosed with inflammatory bowel disease after the pregnancy, we found no difference in the obstetric outcome as compared with the general obstetric population.

CONCLUSIONS

Most women with inflammatory bowel disease have a normal pregnancy outcome and, overall, inflammatory bowel disease during pregnancy poses low-to-moderate risks, the main concern being increased risk of impaired foetal growth. Normal maternal weight gain during pregnancy, possibly indicating a more stable disease, appeared to protect against adverse outcomes.

Risk factors associated with progression to intestinal complications of Crohn's disease in a population-based cohort

BACKGROUND AND AIMS

We sought to assess the evolution of Crohn's disease behavior in an American population-based cohort.

METHODS

Medical records of all Olmsted County, Minnesota residents who were diagnosed with Crohn's disease from 1970 to 2004 were evaluated for their initial clinical phenotype, based on the Montreal Classification. The cumulative probabilities of developing structuring and/or penetrating complications were estimated using the Kaplan-Meier method. Proportional hazards regression was used to assess associations between baseline risk factors and changes in behavior.

RESULTS

Among 306 patients, 56.2% were diagnosed between the ages of 17 and 40 years. Disease extent was ileal in 45.1%, colonic in 32.0%, and ileocolonic in 18.6%. At baseline, 81.4% had nonstricturing nonpenetrating disease, 4.6% had stricturing disease, and 14.0% had penetrating disease. The cumulative risk of developing either complication was 18.6% at 90 days, 22.0% at 1 year, 33.7% at 5 years, and 50.8% at 20 years after diagnosis. Among 249 patients with nonstricturing, nonpenetrating disease at baseline, 66 changed their behavior after the first 90 days from diagnosis. Relative to colonic extent, ileal, ileocolonic, and upper GI extent were significantly associated with changes in behavior, whereas the association with perianal disease was barely significant.

CONCLUSIONS

In a population-based cohort study, 18.6% of patients with Crohn's disease experienced penetrating or stricturing complications within 90 days after diagnosis; 50% experienced intestinal complications 20 years after diagnosis. Factors associated with development of complications were the presence of ileal involvement and perianal disease.

Capsule endoscopy has a significantly higher diagnostic yield in patients with suspected and established small-bowel Crohn's disease: a meta-analysis

OBJECTIVES

Capsule endoscopy (CE) has demonstrated superior performance compared with other modalities in its ability to detect early small-bowel (SB) Crohn's disease (CD), especially when ileoscopy is negative or unsuccessful. The aim of this study was to evaluate the diagnostic yield of CE compared with other modalities in patients with suspected and established CD using a meta-analysis.

METHODS

A thorough literature search for prospective studies comparing the diagnostic yield of CE with other modalities in patients with CD was undertaken. Other modalities included push enteroscopy (PE), colonoscopy with ileoscopy (C+IL), SB radiography (SBR), computed tomography enterography (CTE), and magnetic resonance enterography (MRE). Data on diagnostic yield among various modalities were extracted, pooled, and analyzed. Data on patients with suspected and established CD were analyzed separately. Weighted incremental yield (IYW) (diagnostic yield of CE-diagnostic yield of comparative modality) and 95% confidence intervals (CIs) of CE over comparative modalities were calculated.

RESULTS

A total of 12 trials (n=428) compared the yield of CE with SBR in patients with CD. Eight trials (n=236) compared CE with C+IL, four trials (n=119) compared CE with CTE, two trials (n=102) compared CE with PE, and four trials (n=123) compared CE with MRE. For the suspected CD subgroup, several comparisons met statistical significance. Yields in this subgroup were CE vs. SBR: 52 vs. 16% (IYw=32%, P<0.0001, 95% CI=16-48%), CE vs. CTE: 68 vs. 21% (IYw=47%, P<0.00001, 95% CI=31-63%), and CE vs. C+IL: 47 vs. 25% (IYw=22%, P=0.009, 95% CI=5-39%). Statistically significant yields for CE vs. an alternate diagnostic modality in established CD patients were seen in CE vs. PE: 66 vs. 9% (IYw=57%, P<0.00001, 95% CI=43-71%), CE vs. SBR: 71 vs. 36% (IYw=38%, P<0.00001, 95% CI=22-54%), and in CE vs. CTE: 71 vs. 39% (IYw=32%, P=or<0.0001, 95% CI=16-47%).

CONCLUSIONS

Our meta-analysis demonstrates that CE is superior to SBR, CTE, and C+IL in the evaluation of suspected CD patients. CE is also a more effective diagnostic tool in established CD patients compared with SBR, CTE, and PE.

Immunomodulators are associated with a lower risk of first surgery among patients with non-penetrating non-stricturing Crohn's disease

OBJECTIVES

Early immunomodulator therapy may alter the natural history of Crohn's disease in certain patients. We determined whether immunomodulator use was associated with a lower risk of first surgery among patients with non-stricturing non-penetrating Crohn's disease.

METHODS

A total of 159 consecutive patients with non-penetrating non-stricturing Crohn's disease from 1994 to 2005 were retrospectively identified and followed from diagnosis to either first surgery (surgery group) or last clinic follow-up (medication group) in a historical cohort analysis. Immunomodulator use, duration, disease location, age at diagnosis, smoking, family history, and decade of diagnosis were compared. Cox proportional hazards models were adjusted for propensity score to determine whether immunomodulator use lasting >6 months decreased the risk of first surgery and whether duration of therapy affected risk.

RESULTS

The median duration of follow-up was similar (6.0 vs. 5.5 years), age at diagnosis 10 years earlier, and isolated colonic disease three times less common (18 vs. 49%) in the surgery group as compared with the medication group. Immunomodulator use increased with time but overall was less common in the surgical group (24 vs. 48%). In the multivariate Cox proportional hazards model immunomodulator use was associated with a lower risk of surgery (hazard ratio, 0.41; 95% confidence interval 0.21-0.81) after adjustment for propensity score. Similarly, risk of surgery declined with duration of use.

CONCLUSIONS

Immunomodulator use is associated with a decreased risk of first surgery among patients with non-stricturing non-penetrating CD. Early immunomodulator therapy may be beneficial in preventing first surgery in this population that has yet to develop penetrating or fistulizing complications.

Differentiating intestinal tuberculosis from Crohn's disease: a diagnostic challenge

With the changing epidemiology of Crohn's disease (CD) and intestinal tuberculosis (ITB), we are in an era where the difficulty facing physicians in discriminating between the two diseases has increased, and the morbidity and mortality resulting from a delayed diagnosis or misdiagnosis is considerably high. In this article, we examine the changing trends in the epidemiology of CD and ITB, in addition to clinical features that aid in the differentiation of both diseases. The value of various laboratory, serological, and the tuberculin skin tests are reviewed as well. The use of an interferon-gamma-release assay, QuantiFERON-TB Gold, in the workup of these patients and its value in populations where the bacillus Calmette-Guérin vaccine is still administered is discussed. Different radiological, endoscopic, and pathological similarities and features that can aid the clinician in reaching a rapid diagnosis are reviewed as well. The association between mycobacteria and CD, the concerns with the practice of antituberculosis medication trials in areas where tuberculosis (TB) is endemic, as well as extrapulmonary TB induced by the use of antitumor necrosis factor-alpha agents are delineated in this article. Furthermore, we propose an algorithm for the investigation of patients in whom the differential diagnosis encompasses CD and ITB.

Influence of phenotype at diagnosis and of other potential prognostic factors on the course of inflammatory bowel disease

OBJECTIVES

Disease course in inflammatory bowel disease (IBD) is variable and difficult to predict. To optimize prognosis, it is of interest to identify phenotypic characteristics at disease onset and other prognostic factors that predict disease course. The aim of this study was to evaluate such factors in a population-based IBD group.

METHODS

IBD patients diagnosed between 1 January 1991 and 1 January 2003 were included. A follow-up questionnaire was developed and medical records were reviewed. Patients were classified according to phenotype at diagnosis and risk factors were registered. Disease severity, cumulative medication use, and "surgical" and "nonsurgical" recurrence rates were calculated as outcome parameters.

RESULTS

In total, 476 Crohn's disease (CD), 630 ulcerative colitis (UC), and 81 indeterminate colitis (IC) patients were diagnosed. In CD (mean follow-up 7.6 years), 50% had undergone resective surgery. In UC (mean follow-up 7 years), colectomy rate was 8.3%. First year cumulative recurrence rates per 100 patient-years for CD, UC, and IC were 53, 44, and 42%, respectively. In CD, small bowel localization and stricturing disease were negative prognostic factors for surgery, as was young age. Overall recurrence rate was increased by young age and current smoking. In UC, extensive colitis increased surgical risk. In UC, older age at diagnosis initially increased recurrence risk but was subsequently protective.

CONCLUSIONS

This population-based IBD study showed high recurrence rates in the first year. In CD, small bowel localization, stricturing disease, and young age were predictive for disease recurrence. In UC, extensive colitis and older age at diagnosis were negative prognostic predictors.

Infliximab treatment for symptomatic Crohn's disease strictures

BACKGROUND

Some reports have suggested that infliximab may induce obstructive symptoms and, although there is no firm evidence, it is usually contra-indicated in-patients with Crohn's disease (CD) and strictures.

AIMS

To evaluate the effect of infliximab on symptomatic strictures of the small intestine in CD and to identify predictive factors of clinical response.

METHODS

This retrospective study included symptomatic patients treated with infliximab after conventional treatment had failed. The short-term (week 8) and long-term results were classified according to predefined criteria as complete, partial response, or failure.

RESULTS

Before infliximab, 18 patients had complete obstruction or intermittent chronic abdominal pain. Fourteen patients were treated by corticosteroids and 13 received immunosuppressive drugs. At week 8, complete, partial response and failure were observed in 10, 7 and 1 patients, respectively. Fourteen patients continued maintenance infliximab treatment after week 8. During the most recent evaluation (median follow-up: 18 months), 8 patients were on maintenance infliximab treatment; only eight were still on prednisone; there were five complete responses, 10 partial responses and three failures. Initiating prednisone or increasing its dosage was the only factor associated with a short-term complete response.

CONCLUSIONS

Infliximab may be effective in patients with symptomatic strictures from CD, and should be tested before considering surgery.

Serum YKL-40 as a marker of disease activity and stricture formation in patients with Crohn's disease

BACKGROUND AND AIM

YKL-40 is secreted by macrophages and neutrophils and is a growth factor for vascular endothelial cells and fibroblasts. Elevated serum levels of YKL-40 have been reported in patients with various inflammatory conditions and ongoing fibrosis. The aim of this study was to investigate the relationship between serum concentrations of YKL-40 and disease activity, acute phase reactants, and the presence of strictures in patients with Crohn's disease (CD).

METHODS

We studied the serum concentrations of YKL-40 in 41 patients with CD, in which 12 had an endoscopically- or radiologically-proven stricture formation. Forty-six age- and sex-matched healthy volunteers served as controls and a multivariate regression analysis was performed to find out the independent predictors of intestinal strictures and clinical activity.

RESULTS

The serum YKL-40 concentrations in the patients were significantly higher than that in the healthy controls (105.69 +/- 88.08 ng/mL [range 20.23-333.57]vs 44.92 +/- 24.89 ng/mL [range 18.31-113.43], P = 0.000) and patients with a stricture formation had significantly higher YKL-40 levels than those without strictures (167.50 +/- 119.30 ng/mL [range 23.62-333.57]vs 80.12 +/- 56.38 ng/mL [range 20.23-259.19], P = 0.003). Significant correlations were noted between YKL-40 levels and clinical activity (r = 0.681; P = 0.000) and the presence of intestinal strictures (r = 0.457; P = 0.003). The multivariate regression analysis found the serum YKL-40 levels to be an independent predictor of intestinal strictures (P = 0.001) and clinical activity (P = 0.001).

CONCLUSION

Patients with CD, particularly those with a stricture formation, have significantly higher levels of YKL-40. YKL-40 seems to be a useful marker of disease activity as well as stricture formation in patients with CD.

Through the endoscope balloon dilation of ileocolonic strictures: prognostic factors, complications, and effectiveness

BACKGROUND/AIMS

About half of all Crohn's disease (CD) patients undergo surgery at some point, many because of strictures. An alternative possibility is to dilate strictures endoscopically. However, little is known about prognostic factors.

PATIENTS AND METHODS

Thirty-two patients with primary CD (n=2), radiogenic strictures (n=1), or postoperative strictures (27 because of CD; 2 after resection because of cancer), were planned to undergo colonoscopic dilatation of which 25 patients were dilated (10 men; 15 women; median age 48). Length of stenosis, diameter of stricture, balloon size, smoking status, ulcer in the stricture, passage postdilatation, hemoglobin level, complications, redilatation, and subsequent surgery were recorded. Only patients with at least 6 months follow up were included.

RESULTS

Five out of 32 patients had no stenosis, marked inflammation, or fistulas adjacent to the stricture. One patient each had a long stricture (8 cm) or a filiform stenosis ruling out dilatation [technical success, 25/27 (92.6%)]. Among these 25 patients, 39 colonoscopies with 51 dilatations were performed. After a single dilatation, 52% were asymptomatic while 48% needed another intervention, half of them surgery. Bleeding without need for transfusion occurred in 3 out of 39 colonoscopies and one perforation required surgery. Significant prognostic factors were smoking and ulcers in the stricture (P<0.05 each). Some ulcers led to intussusception requiring surgery in spite of good dilatation results.

CONCLUSION

Through the endoscope balloon stricture dilatation is a relatively safe and often effective treatment modality in ileocolonic strictures. The presence of ulcers in the stricture have a worse outcome as do smokers.

Association of MTRR 66A>G polymorphism with superoxide dismutase and disease activity in patients with Crohn's disease

OBJECTIVES

The aim of this study was to evaluate the association of nutritional (folate, vitamin B12) and genetic (MTHFR, MTR, MTRR, TCN) determinants of homocysteine metabolism and of superoxide dismutase with Crohn's disease (CD).

METHODS

One hundred forty patients with CD were compared with 248 matched healthy controls.

RESULTS

Plasma homocysteine levels were higher in CD patients than controls (11.8 vs 10.4 micromol/L, P= 0.0004). Vitamin B12 and folate levels were lower in CD subjects compared to controls (207 vs 255 pmol/L, P= 0.0082, and 8.6 vs 11 nmol/L, P= 0036, respectively). Patients with a personal history of ileal resection, ileitis, or colectomy had significantly lower vitamin B12 levels. In multivariate analysis, vitamin B12 and MTHFR 677 TT carriers were the two significant independent factors of plasma homocysteine >15 micromol/L in CD patients (P= 0.0187 and 0.0048, respectively). The significant association between homocysteine and vitamin B12 levels remained significant only in patients with the highest superoxide dismutase values (P < 0.0001). The MTRR AA genotype was a significant independent predictor of CD risk (odds ratio 3.7, 95% CI 1.218-11.649, P= 0.0213). The level of superoxide dismutase was significantly higher (P= 0.0143) and was correlated with Crohn's Disease Activity Index (CDAI) scores (P for trend = 0.0276) in patients carrying MTRR AA genotype.

CONCLUSIONS

Vitamin B12 and MTHFR 677 TT genotype are the main determinants of hyperhomocysteinemia in CD patients. The association of MTRR 66A>G polymorphism with oxidant stress and disease activity provides rationale for screening vitamin deficiencies in these patients.

Review article: Inflammatory bowel disease and genetics

INTRODUCTION

Inflammatory bowel disease (IBD) comprising ulcerative colitis (UC) and Crohn's disease (CD) is multigenic disorder. Tremendous progress has been achieved in unravelling the genetic background of IBD. It has led to the discovery of mutations in NOD2 associated with ileal CD and numerous other genes have been found to be associated with IBD susceptibility.

METHODS

A review of the literature on the genetic background of IBD was performed.

RESULTS

It is only partially understood how mutations in NOD2 lead to CD. Mouse models, in vitro data and studies in humans offer conflicting data as regards whether there is a loss or gain of function of NOD2 in CD. Several additional genes have been identified of which only a few are currently being recognized as potential disease causing or disease modifying genes. Promising candidate genes include TLR4, MDR1, NOD1 (CARD4), DLG5 as well as the IBD5 locus including SLC22A4/5.

CONCLUSIONS

Although genetic research has not yet led to a better prediction of the disease course or patient selection for medical therapy, remarkable progress has been made in the understanding of the pathogenesis of IBD. For future genetic research, accurate phenotyping of patients is very important and large population-based cohorts are needed. Eventually, genetic research may be able to classify different disease phenotypes on a more detailed molecular basis and may provide important contributions in the development of new therapeutic approaches.

Phenotype classification in IBD: Is there an impact on therapy?

This review summarizes the current phenotypic classifications of inflammatory bowel disease (IBD) and outlines their implications for diagnosis, therapy, prognosis, clinical trial design, and genotype-phenotype correlations.

Clinical course in Crohn's disease: results of a Norwegian population-based ten-year follow-up study

BACKGROUND & AIMS

Most studies concerning the clinical course in CD are retrospective or based on selected patient groups. Our aim was to assess the course of CD in a prospective population-based follow-up study and to identify possible prognostic risk factors for complications on the basis of information obtained at initial diagnosis.

METHODS

From 1990-1994, a population-based cohort of 843 new cases of inflammatory bowel disease was recruited in South-Eastern Norway. The cohort was systematically followed up at 1, 5, and 10 years after diagnosis.

RESULTS

Of 237 patients classified as CD, 197 completed the 10 years of follow-up, 18 died, and 22 were lost to follow-up. The cumulative relapse rate during the first 10 years was 90% (95% confidence interval, 86%-94%), and the cumulative probability of surgery was 37.9% (95% confidence interval, 31.4%-44.4%). Terminal ileal location (P < .001), stricturing (P = .004), penetrating behavior (P < .001), and age younger than 40 years (P = .03) at diagnosis were independent risk factors for subsequent surgery. A total of 53% (n = 105) of the patients had developed stricturing or penetrating disease at 10 years. A large proportion of patients (44%) were in clinical remission during the last 5 years of follow-up.

CONCLUSIONS

The prognosis for CD seems better than previously reported. The probability of surgery was low, and fewer than expected developed complicated disease behavior. Nevertheless, the cumulative relapse rate of 90% and the finding of prognostic risk factors for subsequent surgery might call for attention to early effective medical treatment strategies.