Impacts of perianal disease and faecal incontinence on quality of life and employment in 1092 patients with inflammatory bowel disease

The potential for medical therapies to address fistulizing Crohn's disease: a state-of-the-art review

INTRODUCTION

Crohn's disease (CD) is a chronic, relapsing immune mediated disease, which is one of the two major types of inflammatory bowel disease (IBD). Fistulizing CD poses a significant clinical challenge for physicians. Effective management of CD requires a multidisciplinary approach, involving a gastroenterologist and a GI surgeon while tailoring treatment to each patient's unique risk factors, clinical representations, and preferences.

AREAS COVERED

This comprehensive review explores the intricacies of fistulizing CD including its manifestations, types, impact on quality of life, management strategies, and novel therapies under investigation.

EXPERT OPINION

Antibiotics are often used as first-line therapy to treat symptoms. Biologics that selectively target TNF-α, such infliximab (IFX), have shown high efficacy in randomized controlled trials. However, more than 50% of patients lose response to IFX, prompting them to explore alternative strategies. Current options include adalimumab and certolizumab pegol combination therapies, as well as small-molecule drugs targeting Janus kinases such as Upadacitinib. Furthermore, a promising treatment for complex fistulas is mesenchymal stem cells such as Darvadstrocel (Alofisel), an allogeneic stem cell-based therapy. However, surgical interventions are necessary for complex cases or intra-abdominal complications. Setons and LIFT procedures are the most common surgical options.

Prevalence of faecal incontinence in patients with inflammatory bowel disease: Severity and its relationship with quality of life

AIMS

To describe the prevalence of faecal incontinence in patients with inflammatory bowel disease, assess its severity, and correlation with quality of life. We adhered to relevant EQUATOR guidelines, STROBE method.

DESIGN

Correlational-descriptive study.

METHODS

Hebrew-speaking patients seen at an inflammatory bowel disease clinic in a large tertiary medical center in Jerusalem between February 2020 and December 2020 completed the Faecal Incontinence Severity Index and the Faecal Incontinence Quality of Life Scale.

RESULTS

Ninety-six patients participated in the study, of which 70 (72.9%) had Crohn's disease, and 26 (27.1%) had ulcerative colitis. Eighty-five (88.5%) reported faecal incontinence with an overall Faecal Incontinence Severity Index mean of 27.66 (SD 15.99), yet only 14 (14.7%) reported that their physician or nurse inquired about faecal incontinence. Quality of life scores for patients with faecal incontinence was the lowest on the coping/behaviour scale (M = 2.44; SD 0.94) and the highest on the depression/self-perception scale (M = 2.86; SD 1.04). Significant correlations were found between faecal incontinence severity and quality of life in all scales except for self-embarrassment. Moderate correlations in the same scales were noted in patients with Ulcerative Colitis, while no significant correlations were found in the Crohn's Disease group.

CONCLUSION

A high proportion of inflammatory bowel disease patients reported faecal incontinence associated with impaired quality of life. Only a few were questioned about faecal incontinence by their physician or nurse.

IMPACT

There is limited literature regarding the prevalence and severity of faecal incontinence in inflammatory bowel disease patients. A high proportion of patients reported faecal incontinence, which negatively correlated with quality of life. Physicians and nurses must inquire about faecal incontinence to improve patient care.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Patient experiences in ulcerative colitis: conceptual model and review of patient-reported outcome measures

PURPOSE

To identify symptoms and their impacts on daily functioning and health-related quality of life (HRQoL) experienced by adult patients with ulcerative colitis (UC) and evaluate patient-reported outcome (PRO) measures for UC clinical studies.

METHODS

A conceptual model of symptoms and impacts of UC were developed from a literature review. PRO measures were identified from the literature, clinical trials databases, health technology assessment submissions, and regulatory label claims, and were selected for conceptual analysis based on disease specificity and use across information sources. PRO measures covering the most concepts when mapped against the conceptual model were assessed for gaps in psychometric properties using Food and Drug Administration (FDA) guidance and consensus-based standards for the selection of health measurement instruments (COSMIN) criteria.

RESULTS

The conceptual model grouped the 52 symptom concepts and 72 proximal and distal impacts into eight, two, and five dimensions, respectively. Of 65 PRO measures identified, eight underwent conceptual analysis. Measures covering the most concepts and assessed for psychometric properties were the Inflammatory Bowel Disease Questionnaire, Symptoms and Impacts Questionnaire for UC, UC-PRO symptoms modules, UC-PRO impact modules, and Crohn's and UC Questionnaire; all had good or excellent support for content validity. The UC-PRO Signs and Symptoms fully met FDA guidance and COSMIN criteria for content validity and most psychometric properties.

CONCLUSION

Existing PRO measures assess concepts relevant to patients with UC, but all PRO measures reviewed require further psychometric evaluation to demonstrate they are fit for purpose.

A nomogram to predict stoma creation in elective surgical resection for penetrating Crohn's disease

BACKGROUNDS

The decision to perform a stoma during surgical resection of penetrating Crohn's disease (CD) is a critical consideration. The objective of this study was to identify factors that influence stoma creation and develop a predictive nomogram model to assist surgeons in making optimal surgical decisions.

METHODS

A retrospective study was conducted at a tertiary center from December 1, 2012, to December 1, 2021, involving consecutive patients with penetrating CD who underwent elective surgical resection. The LASSO regression method was used to select preoperative predictors, and a nomogram was constructed using multivariate logistic regression. The performance of the nomogram was validated in an internal cohort by assessing its discrimination, calibration, and clinical usefulness.

RESULTS

The study included 405 cases in the training group and 135 cases in the validation group. Nine risk factors for stoma formation were identified, including disease location, fistula resulted from previous anastomosis, absence of preoperative exclusive enteral nutrition support, albumin levels below 35 g/L, C-reactive protein levels above 10 mg/L, hemoglobin levels below 100 g/L, perianal disease, internal fistula, and surgical approach. These risk factors were selected using the LASSO regression method, and a nomogram was developed based on them. The area under the curve and the coefficient of determination (R2) of the nomogram were 0.821 and 0.394, respectively. And the nomogram demonstrated good performance in the validation cohort.

CONCLUSIONS

The nomogram exhibited good predictive ability for stoma formation during elective surgical resection for penetrating CD, which can assist surgeons in making informed clinical decisions.

Observational Burden of Illness Study in Patients With Crohn's Disease With and Without Perianal Fistulas in the United States

Background and Aims

This study compared disease burden, experiences, and health-related quality of life (HRQoL) between patients with Crohn's perianal fistulas (CPFs) and those with Crohn's disease (CD) without perianal fistulas (PFs; non-PF CD).

Methods

This cross-sectional, observational study was conducted in 3 cohorts of US patients aged 18-89 years with self-reported, physician-diagnosed CD: (1) non-PF CD; (2) CPF without PF-related surgery; and (3) CPF with PF-related surgery. Data on medical and surgical interventions, CD-specific symptoms, HRQoL (assessed using the Short Inflammatory Bowel Disease and 5-dimension EuroQol questionnaires), and fecal incontinence (assessed using Revised Faecal Incontinence Scale and Fecal Incontinence Quality of Life questionnaires) were collected via a web-enabled questionnaire.

Results

In total, 403 patients with CD completed the questionnaire (non-PF CD, n = 300; CPF without surgery, n = 51; CPF with surgery, n = 52). A high symptom burden was seen across cohorts. More patients with CPF underwent ≥1 CD-related surgery and experienced ≥1 failure of CD-related surgery (79% and 20%) vs non-PF CD (53% and 9%; P < .001). Overall HRQoL outcomes were worse for patients with CPF vs non-PF CD, with significantly worse Short Inflammatory Bowel Disease and 5-dimension EuroQol questionnaire scores for those without PF-related surgery (P < .01). Across all cohorts, 58% of patients reported experiencing fecal incontinence, which had a greater negative impact (higher Revised Faecal Incontinence Scale scores; lower Fecal Incontinence Quality of Life scores) in patients with CPF vs non-PF CD.

Conclusion

Patients with CPF experience substantial HRQoL burden, reflecting the impact of symptoms and medical/surgical interventions. These results may help to inform comprehensive care strategies to improve patient HRQoL.

Anorectal Function and Clinical Characteristics Associated with Faecal Incontinence in Patients with Crohn's Disease

BACKGROUND AND AIMS

Faecal incontinence is an important complaint reported by patients with Crohn's disease [CD] and it is associated with several disease-related mechanisms, including anorectal functional disorders. This study aimed to assess the anorectal function and clinical characteristics to identify parameters associated with faecal incontinence in CD patients.

METHODS

This is a cross-sectional study of 104 patients with CD, aged 18 years or older, from a referral centre between August 2019 and May 2021. Patients responded to a specific questionnaire, and underwent medical record review, proctological examination and anorectal functional assessment with anorectal manometry.

RESULTS

Of the 104 patients, 49% were incontinent. Patients with incontinence had a lower mean resting pressure [43.5 vs 53.1 mmHg; p = 0.038], lower mean squeeze pressure [62.1 vs 94.1 mmHg; p = 0.036] and lower maximum rectal capacity [140 vs 180 mL; p < 0.001]. Faecal incontinence was also associated with disease activity [p < 0.001], loose stools [p = 0.02], perianal disease [p = 0.006], previous anoperineal surgery [p = 0.048] and number of anorectal surgeries [p = 0.036].

CONCLUSIONS

This is the largest reported study describing manometric findings of Crohn's disease patients with and without faecal incontinence. Our results identified an association between faecal incontinence and functional disorders, in addition to clinical features in these patients. Functional assessment with anorectal manometry may help choose the best treatment for faecal incontinence in patients with CD.

Management of Perianal Crohn's Disease

Perianal Crohn's disease affects 25%-35% of patients with Crohn's disease and has proven to be one of the most difficult complications of the disease to treat. Patients with perianal Crohn's disease have lower health-related quality of life scores typically related to pain and fecal incontinence. In addition, patients with perianal Crohn's disease have higher rates of hospitalizations, surgeries, and overall healthcare costs. A multidisciplinary approach is necessary for the successful management of Crohn's disease with perianal fistula. Medical management is required to treat the underlying immune dysregulation to heal the luminal inflammation and the inflammation within the fistula tracts. Current options for medical therapy include biologics, dual therapy with thiopurines, therapeutic drug monitoring, and a close follow-up. Surgical management is critical to drain abscesses before immunosuppressive therapy and place setons when appropriate. Once the patient's inflammatory burden is well managed, definitive surgical therapies including fistulotomies, advancement flaps, and ligation of intersphincteric fistula tract procedures can be considered. Most recently, the use of stem cell therapy in the treatment of perianal fistula has given new hope to the cure of perianal fistula in Crohn's disease. This review will outline the most current data in the medical and surgical management of perianal Crohn's disease.

Autologous Fat Grafting: an Emerging Treatment Option for Complex Anal Fistulas

BACKGROUND

Autologous fat grafting (AFG) has shown promise in the treatment of complex wounds, with trials reporting good healing rates and safety profile. We aim to investigate the role of AFG in managing complex anorectal fistulas.

METHODS

This was a retrospective review of a prospectively maintained IRB-approved database. We examined the rates of symptom improvement, clinical closure of fistula tracts, recurrence, complications, and worsening fecal incontinence. Perianal disease activity index (PDAI) was obtained for patients undergoing combination of AFG and fistula plug treatment.

RESULTS

In total, 52 unique patients underwent 81 procedures, of which Crohn's was present in 34 (65.4%) patients. The majority of patients previously underwent more common treatments such as endorectal advancement flap or ligation of intersphincteric fistula tract. Fat-harvesting sites and processing technique were selected by the plastic surgeons based on availability of trunk fat deposits. When analyzing patients by their last procedure, 41 (80.4%) experienced symptom improvement, and 29 (64.4%) experienced clinical closure of all fistula tracts. Recurrence rate was 40.4%, and complication rate was 15.4% (7 postoperative abscesses requiring I&D and 1 bleeding episode ligated at bedside). The abdomen was the most common site of lipoaspirate harvest at 63%, but extremities were occasionally used. There were no statistically significant differences in outcomes when comparing single graft treatment to multiple treatments, Crohn's and non-Crohn's, different methods of fat preparation, and diversion.

CONCLUSION

AFG is a versatile procedure that can be done in conjunction with other therapies and does not interfere with future treatments if recurrence occurs. It is a promising and affordable method to safely address complex fistulas.

Efficacy and safety of mesenchymal stem cells in the treatment of perianal fistulas in Crohn's disease: a meta-analysis of randomized controlled trials

OBJECTIVES

Local mesenchymal stem cell (MSC) therapy for perianal fistulas in Crohn's disease (CD) has yielded promising results, but it still remains controversial. In this study, we aimed to conduct a meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy and safety of MSC therapy for perianal CD (pCD).

METHODS

RCTs reporting MSC therapy for perianal fistulas in CD were searched and included. The effectiveness and safety data were analyzed using RevMan 5.3.

RESULTS

A total of 7 RCTs were included in this meta-analysis. The analysis showed that patients receiving MSC therapy presented a higher healing rate (HR) of pCD than those in the control group (odds ratio (OR)=1.42; 95% confidence interval (CI) 1.18, 1.71; P=0.0002). Compared with placebo (saline solution), MSC therapy improved the HR of pCD (OR=1.85; 95% CI 1.32, 2.60; P=0.0004). MSC therapy showed significant long-term efficacy (OR=1.36; P=0.009; 95% CI 1.08, 1.71). When MRI was used to evaluate fistula healing, a pooled analysis showed that the MSC group achieved a higher HR than the control group (OR=1.95; 95% CI 1.33, 2.87; P=0.0007). Allogeneic MSC therapy was superior to the control treatment in improving HR (OR = 1.97; 95% CI 1.40, 2.75; P<0.001). Furthermore, no significant differences were observed between MSC therapy and placebo in terms of adverse events (AEs) (OR = 1.16; 95% CI 0.76, 1.76; P = 0.48). None of the AEs were judged to be related to MSC treatment.

CONCLUSIONS

This meta-analysis of RCTs provided evidence that local MSC injection is safe and efficacious for perianal fistulas in CD. In addition, this treatment has favorable long-term efficacy and safety profiles.

Health-related quality of life in health states corresponding to different stages of perianal fistula associated with Crohn's disease: a quantitative evaluation of patients and non-patients in Japan

BACKGROUND

Perianal fistula (PF), a complication of Crohn's disease (CD), affects health-related quality of life (QOL).

OBJECTIVE

To elucidate QOL of health states corresponding to different stages of PF associated with CD in Japan.

METHOD

This cross-sectional, observational, web-based questionnaire survey assessed eight different health states in patients with CD and PF and individuals without CD (non-patients) from the Medilead Healthcare Panel (MHP) and determined the utility values (QOL scores) in each health state by the time trade-off method. In patients, we determined also the utility value of the current health state associated with CD and the PF. The analysis excluded respondents with logical inconsistencies.

RESULTS

The analysis included 82 patients and 576 non-patients with the same sex and age distribution as the Japanese population. In both groups, mean utility values were higher in remission (patients, 0.78; non-patients, 0.51) than in non-remission states, with lowest values for poor prognosis after proctectomy (patients, 0.13; non-patients, -0.10) and highest values for the state with mild symptoms (patients, 0.60; non-patients, 0.30). In patients, the mean utility value of the current health state was 0.71.

CONCLUSION

QOL decreases with increasing severity of PF and is lower for good prognosis after proctostomy than for remission.

Identification of the optimal medical and surgical management for patients with perianal fistulising Crohn's disease

AIM

The aim of our study was to assess the best medical and surgical approaches for perianal Crohn's disease (PCD) in order to identify an optimal combined medical and surgical treatment.

METHODS

Medical records of all patients with PCD treated with TNFα antagonists in two referral centres between 1998 and 2018 were reviewed. Predictors of long-term outcomes were identified using a Cox proportional hazard model.

RESULTS

A total of 200 patients were included. Fifty-three patients (26.5%) were treated with adalimumab and 147 (73.5%) with infliximab. A combination of TNFα antagonist with an immunosuppressant and the presence of proctitis were independently associated with fistula closure. Seton was placed in 127 patients (63.5%) before starting biological therapy. Eighty patients (40%) underwent additional perineal surgery. Prior PCD surgery, seton positioning, additional perineal surgery, and additional surgery within 52 weeks of anti-TNFα treatment were associated with an increased rate of fistula closure. Finally, medical combination therapy (anti-TNFα plus immunosuppressant) along with seton placement and additional surgery within 1 year was the best management for PCD patients (p = 0.02).

CONCLUSION

Combined medical and surgical management is required for the treatment of PCD patients. Medical combination therapy associated with seton placement and additional surgery within 1 year is the best management for PCD patients.

Faecal incontinence in inflammatory bowel disease: The Nancy experience

BACKGROUND

Faecal incontinence (FI) is a disabling condition in patients with inflammatory bowel disease (IBD). The diagnosis of FI is not easy as patients are reluctant to report this embarrassing symptom. The objectives of this study were to characterize the prevalence of FI in IBD patients using available scoring systems, and to identify associated risk factors.

METHODS

A FI clinic was implemented in routine practice between January 2020 and April 2021. FI was defined as a Wexner score ≥5. Factors associated with FI were analyzed.

RESULTS

A total of 319 consecutive patients with IBD were included. The prevalence of FI was 16.4% (53/319). Age >45 years at inclusion (Odd ratio (OR)=3.33, Confidence interval (CI) 95% 1.40-7.94), diarrhea (three stools at least per day) (OR=2.94, CI 95% 1.16-7.45), stool consistency according to the Bristol stool chart (OR=2.23, CI 95% 1.00-4.99), and abdominal pain (OR=2.24, CI 95% 1.10-4.53) were independently associated with FI in a multivariate model analysis.

CONCLUSIONS

Approximately one fifth of IBD patients reported FI in this real-world cohort, using an available scoring system. Increased age, diarrhea, stool consistency according to the Bristol stool chart, and abdominal pain were associated with FI. A systematic screening of FI would allow a better management of this disabling condition.

Faecal incontinence in adults

Faecal incontinence, which is defined by the unintentional loss of solid or liquid stool, has a worldwide prevalence of ≤7% in community-dwelling adults and can markedly impair quality of life. Nonetheless, many patients might not volunteer the symptom owing to embarrassment. Bowel disturbances, particularly diarrhoea, anal sphincter trauma (obstetrical injury or previous surgery), rectal urgency and burden of chronic illness are the main risk factors for faecal incontinence; others include neurological disorders, inflammatory bowel disease and pelvic floor anatomical disturbances. Faecal incontinence is classified by its type (urge, passive or combined), aetiology (anorectal disturbance, bowel symptoms or both) and severity, which is derived from the frequency, volume, consistency and nature (urge or passive) of stool leakage. Guided by the clinical features, diagnostic tests and therapies are implemented stepwise. When simple measures (for example, bowel modifiers such as fibre supplements, laxatives and anti-diarrhoeal agents) fail, anorectal manometry and other tests (endoanal imaging, defecography, rectal compliance and sensation, and anal neurophysiological tests) are performed as necessary. Non-surgical options (diet and lifestyle modification, behavioural measures, including biofeedback therapy, pharmacotherapy for constipation or diarrhoea, and anal or vaginal barrier devices) are often effective, especially in patients with mild faecal incontinence. Thereafter, perianal bulking agents, sacral neuromodulation and other surgeries may be considered when necessary.

Higher infliximab and adalimumab trough levels are associated with fistula healing in patients with fistulising perianal Crohn’s disease

BACKGROUND

Tumor necrosis factor-alpha inhibitors, including infliximab and adalimumab, are effective medical treatments for perianal fistulising Crohn’s disease (CD), but not all patients achieve fistula healing.

AIM

To determine the correlation between perianal fistula healing and closure with infliximab and adalimumab trough levels.

METHODS

In this multicentre retrospective study conducted across four tertiary inflammatory bowel disease centres in Australia, we identified CD patients with perianal fistulae on maintenance infliximab or adalimumab who had a trough level within twelve weeks of clinical assessment. Data collected included demographics, serum infliximab and adalimumab trough levels (mg/L) within 12 wk before or after their most recent clinical assessment and concomitant medical or surgical therapy. The primary outcome was fistula healing, defined as cessation in fistula drainage. The secondary outcome was fistula closure, defined as healing and closure of all external fistula openings. Differences between patients who did or did not achieve fistula healing were compared using the chi-square test, t test or Mann-Whitney U test.

RESULTS

One hundred and fourteen patients (66 infliximab, 48 adalimumab) were included. Forty-eight (72.7%) patients on maintenance infliximab achieved fistula healing and 18 (27.3%) achieved fistula closure. Thirty-seven (77%) patients on maintenance adalimumab achieved fistula healing and 17 (35.4%) achieved fistula closure. Patients who achieved fistula healing had significantly higher infliximab and adalimumab trough levels than patients who did not [infliximab: 6.4 (3.8-9.5) vs 3.0 (0.3-6.2) mg/L, P = 0.003; adalimumab: 9.2 (6.5-12.0) vs 5.4 (2.5-8.3) mg/L, P = 0.004]. For patients on infliximab, fistula healing was associated with lower rates of detectable anti-infliximab antibodies and younger age. For patients on adalimumab, fistula healing was associated with higher rates of combination therapy with an immunomodulator. Serum trough levels for patients with and without fistula closure were not significantly different for infliximab [6.9 (4.3-10.2) vs 5.5 (2.5-8.3) mg/L, P = 0.105] or adalimumab [10.0 (6.6-12.0) vs 7.8 (4.2-10.0) mg/L, P = 0.083].

CONCLUSION

Higher maintenance infliximab and adalimumab trough levels are associated with perianal fistula healing in CD.

Health Care Costs and Resource Utilization Among Patients With Crohn's Disease With and Without Perianal Fistula

BACKGROUND

Perianal fistula (PAF), a complication of Crohn's disease (CD), is associated with substantial economic costs and poor prognosis. We determined prevalence of PAF CD in the United States and compared costs and health care resource utilization (HRU) of PAF CD patients with matched non-PAF CD patients.

METHODS

This was a retrospective cohort study of claims data from the IBM MarketScan Commercial Database from October 1, 2015, to September 30, 2018. Eligible patients were aged 18 to 89 years with ≥2 CD diagnoses. Patients with PAF CD had ≥1 PAF diagnosis or procedure code and were matched with non-PAF CD patients. Cumulative prevalence of PAF CD in the US population was calculated across total patients in MarketScan. All-cause and gastrointestinal (GI)-related costs and HRU were compared between groups using a generalized linear model (GLM).

RESULTS

Cumulative 3-year prevalence of PAF was 7.70% of patients with CD (N = 81,862) and 0.01% of the US population. Among PAF CD (n = 1218) and matched non-PAF CD (n = 4095) patients, most all-cause costs and HRU were GI-related. Mean total all-cause and GI-related health care costs per patient and per year for PAF CD were $85,233 and $71,612, respectively, vs $40,526 and $29,458 for non-PAF CD (P < .0001). Among PAF CD vs non-PAF CD patients, GLM-adjusted proportions of patients with GI-related inpatient, outpatient, or pharmacy visits, mean GI-related inpatient length of stay, and mean GI-related surgeries were higher (P < .0001 for all comparisons).

CONCLUSIONS

Costs and HRU are significantly higher for patients with PAF CD vs non-PAF CD patients, highlighting the economic burden of the disease.

Systematic Review and Meta-analysis on the Incidence, Prevalence and Determinants of Discomfort in Inflammatory Bowel Disease

Background

The symptom burden in inflammatory bowel disease (IBD) has a significant negative impact on the health-related quality of life (HRQOL). Patients with IBD report physical, psychological and social discomfort even during remission.

Aim

To synthesize the best available evidence to determine the worldwide incidence, prevalence and determinants of discomfort in adults with inflammatory bowel disease (IBD).

Methods

Following PRISMA recommendations, we searched the Medline, CINAHL, PsycInfo, Embase, Cochrane, Campbell and JBI Evidence Synthesis databases for studies on either incidence or prevalence of discomfort in English until January 2021. Data were extracted using the Joanna Briggs Institute's standardized extraction tools. Data that directly reported or could be used to calculate the incidence and prevalence of discomfort were extracted. Ten studies were eligible for inclusion in this review. Overall, the methodological quality of the included studies was considered moderate. Data measuring the incidence of discomfort in 6 out of 10 identified studies using the same measurement tool (EQ-5D) were pooled in a meta-analysis. Additional results have been presented in a narrative form, including tables.

Results

There is no standardized definition or tool utilized to describe or measure discomfort in IBD. Synthesized findings demonstrate that discomfort is prevalent among adults living with IBD. Determinants of discomfort included health literacy, disease activity, hospitalization/surgery, age and gender, delayed diagnosis, local practice standards and quality of IBD care.

Conclusions

More research is needed to identify the impact of discomfort on health-related outcomes for people with IBD and consequently appraise discomfort interventions for their efficacy.

Managing complex perianal disease after anti-TNF failure: Where to go next?

Crohn's disease is a chronic inflammatory bowel disease that affects various intestinal segments and can involve the perianal region. Although anti-tumor necrosis factor (TNF) agents have revolutionized the management of Crohn's disease and improved the prognosis for patients with perianal Crohn's disease (pCD), their long-term effectiveness is limited: over 60% of patients relapse after one year of maintenance therapy. In recent years, significant advances have been made in the treatment of complex perianal fistulas after anti-TNF failure. Concomitant treatment with antibiotics and immunosuppressants improves the effectiveness of anti-TNF agents. Therapeutic drug monitoring and dose adjustment of anti-TNF therapy (targeting a higher trough level) might also improve treatment response. Novel therapeutic strategies might provide new opportunities for pCD management; for example, ustekinumab might be effective after anti-TNF treatment failure, although more studies are needed. As suggested in recent international guidelines, mesenchymal stem cell injection might be an effective, safe treatment for complex pCD.

[Inflammatory Bowel Disease - Challenges in the Workplace and Support for Coping with Disease]

PURPOSE

Patients with inflammatory bowel diseases (IBD) are often impaired in their ability to be employed due to IBD symptoms. The aim of this study was to explore work-related problems and support requested by IBD patients and develop rehabilitation programs meeting their needs.

METHODS

A total of 235 IBD patients (97 rehabilitants, 138 outpatients) completed a questionnaire assessing disease-specific impairments, work-related concerns and the need for support services. Subjective work disability was determined with the SPE scale.

RESULTS

Participants were on average 46 years old, 60% were women, 45% suffered from Crohn's disease and 67% worked full-time; 72% (n=170) had a negative subjective prognosis of gainful employment. Participants reported an average of 12 disease-specific and 22 work-related problems. About 50% of the participants reported disease-specific problems, namely fatigue (66%), weakness (55%) and urge to pass stool (55%). The three most common work-related problems affecting more than 50% of the respondents almost every day were reduced work ability (56%), worrying about not being fully efficient (55%) and stress at work (53%). Support services requested were counselling for information on the disease (91%), treatment options (88%), social law benefits (85%) and exercises to increase physical fitness (84%).

CONCLUSION

The wide range of work-related physical and psychosocial impairments affecting IBD patients reveals a need to extend current rehabilitation services, with a stronger occupational focus and to implement a standardized screening for work-related problems. Disease-specific support services can be developed and addressed in a multimodal and interdisciplinary setting such as the rehabilitation sector.

Perianal Crohn's disease: clinical implications, prognosis and use of resources

AIM OF THE STUDY

to investigate the prevalence of perianal disease, the associated phenotypical factors, its influence over prognosis and its impact in the use of health resources for patients with Crohn's disease.

METHODS

a unicentric retrospective observational study in which we include 430 patients with Crohn's disease tracked through a monographical consultation of intestinal inflammatory disease. We analysed demographic and phenotypical data of Crohn's disease, pharmacological and surgical treatments, complementary tests carried out and hospital admissions, carrying out also a comparative study between those patients without perianal disease and those with perianal disease in simple both form and complex form.

RESULTS

the prevalence of perianal disease was 40.2%, with fistulas and abcesses being the most frequent manifestations. These appearences were associated with rectum affected and the existence of extra-intestinal manifestations. The patients with perianal disease most frequently required immuno-suppressant and biological treatment, but no further abdominal surgery. Amongst the patients with perianal disea-se there was also more frequently the need of biologics to luminal disease (42.8% vs. 30.7%). Furthermore, it required a greater use of explorations aimed at the studio of perianal disease and recto-colonoscopies, but not more MR/CT enterography.

CONCLUSIONS

perianal disease has a high prevalence among patients with Crohn's disease, especially when the rectum is affected. It is associated with a worse prognosis, requiring more frequently biological treatments as much because of perianal evolution such as luminal, especially in cases of complex perianal disease. This condition calls for more hospital admissions and the carrying out of complementary tests.

Prospective randomised controlled trial of adults with perianal fistulising Crohn's disease and optimised therapeutic infliximab levels: PROACTIVE trial study protocol

INTRODUCTION

Perianal fistulising Crohn's disease (pfCD) can be somewhat treatment refractory. Higher infliximab trough levels (TLIs) may improve fistula healing rates; however, it remains unclear whether escalating infliximab therapy to meet higher TLI targets using proactive, or routine, therapeutic drug monitoring (TDM) improves outcomes. This randomised controlled trial aimed to assess whether infliximab therapy targeting higher TLIs guided by proactive TDM improves outcomes compared with standard therapy.

METHODS AND ANALYSIS

Patients with active pfCD will be randomised 1:1 to either the proactive TDM arm or standard dosing arm and followed up for 54 weeks. Patients in the proactive TDM arm will have infliximab dosing optimised to target higher TLIs. The targets will be TLI ≥ 25 µg/mL at week 2, ≥ 20 µg/mL at week 6 and ≥ 10 µg/mL during maintenance therapy. The primary objective will be fistula healing at week 32. Secondary objectives will include fistula healing, fistula closure, radiological fistula healing, patient-reported outcomes and economic costs up to 54 weeks. Patients in the standard dosing arm will receive conventional infliximab dosing not guided by TLIs (5 mg/kg at weeks 0, 2 and 6, and 5 mg/kg 8 weekly thereafter). Patients aged 18-80 years with pfCD with single or multiple externally draining complex perianal fistulas who are relatively naïve to infliximab treatment will be included. Patients with diverting ileostomies or colostomies and pregnant or breast feeding will be excluded. Fifty-eight patients per arm will be required to detect a 25% difference in the primary outcome measure, with 138 patients needed to account for an estimated 6.1% primary non-response rate and 10% dropout rate.

ETHICS AND DISSEMINATION

Results will be presented in peer-reviewed journals and international conferences. Ethics approval has been granted by the South Western Sydney Local Health District Human Research Ethics Committee in Australia.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12621000023853); Pre-results.

Predictors of reoperation for perianal fistula in Crohn's disease

OBJECTIVE

Treating perianal fistula in cases of Crohn's disease (CD) remains challenging and the postoperative recurrence rate of perianal fistula is 22%-28%. This study aimed to identify the predictive risk factors for reoperation in Korean CD patients with perianal fistula.

METHODS

Medical records of the patients with clinically and pathologically confirmed CD who underwent surgical treatment for perianal fistulas at four referral centers in Korea between March 2010 and February 2020 were retrospectively reviewed. The rate of reoperation due to perianal fistula recurrence, which was defined as any subsequent surgery for perianal fistula or abscess, and the potential risk factors for reoperation were analyzed.

RESULTS

Fifty-one patients at a mean age of 22 years were included in the study. During a median follow-up period of 26 months (range 2-89 mo), 21 (41.2%) patients underwent reoperation because of recurrent perianal fistula or abscess. The median interval from the first surgery to reoperation was 13 months. A multivariate Cox regression analysis revealed that drug escalation (from 5-aminosalicylic acid [5-ASA] to thiopurine or from 5-ASA or thiopurine to anti-tumor necrosis factor agents) after the first surgery was associated with a reduced likelihood of reoperation (hazard ratio 0.316, 95% confidence interval 0.117-0.858, P = 0.024).

CONCLUSIONS

The postoperative recurrence rate was relatively high (41.2%) after the first surgery for perianal fistula in Korean patients with CD. Drug escalation therapy after the first surgery may help reduce the need for reoperation for perianal fistula.

Work and School Absenteeism in Inflammatory Bowel Disease Patients in Jeddah, Saudi Arabia: A Cross-Sectional Study

Background:

Inflammatory bowel disease (IBD), which can have a considerable effect on quality of life, productivity and performance, is typically diagnosed during periods of life in which patients have academic and career-related responsibilities.

Objective:

The objective of the study was to determine the effect of IBD symptoms on work and school absenteeism in patients from Saudi Arabia.

Patients and Methods:

This cross-sectional survey included patients diagnosed with IBD, aged >8–60 years, at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. The validated 32-question IBD quality-of-life questionnaire was used to elicit information regarding quality of life and another 9-question validated questionnaire was used to assess work and school absenteeism. A logistic regression analysis was used to identify possible determinants of absenteeism.

Results:

A total of 123 IBD patients were included, with a 1:1 male-to-female ratio. The median age at presentation was 26 years (range: 8–59 years), 56.9% had Crohn's disease, and 43.1% had ulcerative colitis. Further, 58 (47.2%) were employed, 49 (39.8%) were students and 16 (13%) were unemployed. Forty-seven (43.9%) participants reported absenteeism: 26 were employees (55.3%) and 21 were students (44.7%). A binary logistic regression analysis identified IBD subtype (P = 0.006) and the presence of perianal disease (P = 0.028) as clinical predictors for absenteeism from school or work. A feeling of abdominal pain (P = 0.015), fatigue (P = 0.015) and difficulty taking part in social engagements (P < 0.001) were also significantly associated with absenteeism.

Conclusions:

A sizeable proportion of the participants reported absenteeism owing to the effects of IBD. IBD subtype, perianal disease, presence of ongoing abdominal pain, fatigue and difficulty in social engagement were strongly associated with nonattendance.

Fecal Incontinence in Inflammatory Bowel Disease

BACKGROUND

Fecal incontinence (FI) is frequently reported in inflammatory bowel disease (IBD).

METHODS

We retrospectively reviewed data from the Study of a Prospective Adult Research Cohort with IBD registry.

RESULTS

Three hundred forty-seven patients had Crohn disease and 145 had ulcerative colitis. 14.2% of patients reported FI. FI was associated with active disease. FI was not associated with disease location, phenotype, or perianal involvement. Greater than 50 years of age or 15 years of disease increased the odds of FI and remission decreased the odds of FI.

CONCLUSIONS

Further research into the mechanism of FI in IBD is needed.

Does Perianal Disease Influence the Efficacy of Combination Therapy in Crohn's Disease?

BACKGROUND

Perianal disease is associated with a disabling course of Crohn's disease (CD). We aim to study the impact of perianal disease on CD remission rates, after a 1-year course of infliximab in combination therapy with azathioprine.

METHODS

This was a retrospective, single-center cohort study, including consecutive CD patients on combination therapy, followed for 1 year since induction. The outcome variable was split into clinical and endoscopic remissions. The correlation toward the outcome variable was assessed with univariate and multivariate analysis and a survival assessment, using SPSS software.

RESULTS

We assessed 74 CD patients, of whom 41 (55.4%) were female, with a mean age of 36 years. Thirty-nine percent of the patients presented perianal disease at diagnosis (n = 29). We documented 70.3% clinical and 47.2% endoscopic remissions. Several variables had statistical significance toward the outcomes (endoscopic and clinical remissions) in the univariate analysis. After adjusting for confoundment, patients with perianal disease presented an odds ratio (OR) of 0.201 for achieving endoscopic remission (CI: 0.054-0.75, p value 0.017) and an OR of 0.203 for achieving clinical remission (CI: 0.048-0.862, p value 0.031). Sixty-six patients (89.2%) presented an initial response to treatment, from whom, 20 (30.3%) exhibited at least 1 disease relapse (clinical and/or endoscopic). Patients with perianal disease presented higher probability of disease relapse, displaying statistically significant difference on Kaplan-Meier curves (Breslow p value 0.043).

CONCLUSION

In the first year of combination therapy, perianal disease is associated with an 80% decrease in endoscopic and clinical remission rates and higher ratio of disease relapse.

Pedictors of Perianal Fistula Relapse in Crohn's Disease

BACKGROUND

Despite an optimal medico-surgical management of perineal Crohn's disease (PCD), fistula relapse still occurs in 30% of patients. Our aim was to determine predictors of fistula relapse in patients in remission after treatment of a PCD lesion.

METHODS

Consecutive patients treated for fistulizing PCD have been included in a retrospective study when they achieved fistula remission within 3 months after the surgery. Remission was defined as the absence of any draining fistula at clinical examination. Primary outcome was the occurrence of a fistula relapse, defined as a subsequent perianal draining fistula or an abscess confirmed clinically and/or by pelvic MRI.

RESULTS

One hundred and thirty-seven patients (57% female, median age: 35 years) corresponding to 157 abscess events, including 120 (76.4%) treated by anti-TNF after drainage, achieved fistula remission after surgery. During the follow-up period (median duration: 43 months [interquartile range 26 to 64]), 34 (22%) patients experienced a fistula relapse within a median time of 1.8 years. Survival without fistula was 96.7% at 1 year, 78.4% at 3 years, and 74.4% at 5 years. Fistula relapse rates were not different in patients receiving infliximab or adalimumab (P = 0.66). In patients treated by anti-TNF at inclusion, discontinuation of anti-TNF therapy (odds ratio 3.49, P = 0.04), colonic location (OR 6.25, P = 0.01), and stricturing phenotype (odds ratio 4.39, P = 0.01) were independently associated with fistula relapse in multivariate analysis.

CONCLUSION

In patients achieving fistula remission of PCD, relapse rates are low and are not different between infliximab and adalimumab. Discontinuation of anti-TNF therapy is associated with increased relapse rate.

Management of patients with complex perianal fistulas in Crohn's disease: Optimal patient flow in the Italian clinical reality

Perianal fistulizing Crohn's disease (PFCD) is a common, disabling and aggressive phenotype that negatively impacts on the quality of life of affected patients. Its successful treatment is still a struggle for both physicians and patients. Significant advances in the management of this condition have occurred in the last two decades holding promise for a better future. This culminated into the concept of a collaborative multidisciplinary approach using the latest medical therapies combined with modern surgical and endoscopic techniques. Despite this, PFCD management and treatment have not been standardized yet. Thus the gastroenterologist and surgeon have to be familiar with several approaches and/or techniques. The positioning of each therapeutic option will certainly evolve with new data, but for the time being it should be driven by patient's characteristics, physician's preference and/or experience, costs and availability in local practice. Additionally, patient's perception of benefits and risks of treatment may differ from those of physicians and recognition of this difference is a starting point for difficult clinical decision-making. In this paper, a multidisciplinary group of Italian IBD experts explore and discuss current medical and surgical therapeutic options, highlighting areas of unmet needs in PFCD, with particular focus on the optimal patient flow within the Italian clinical reality.

Incidence and Outcomes of Perianal Disease in an Asian Population with Crohn's Disease: A Nationwide Population-Based Study

BACKGROUND

Little is known about the natural history of perianal fistulas in Asian populations with Crohn's disease (CD).

AIMS

We investigated the incidence and outcomes of perianal CD (pCD) in Korean CD patients.

METHODS

A nationwide population-based cohort of 6265 CD patients diagnosed in 2010-2014 was analyzed to investigate the incidence and outcomes of pCD. The results were validated in a hospital-based cohort of 2923 CD patients diagnosed in 1981-2015. Factors associated with pCD development were analyzed. The incidence and outcomes of pCD were compared between the prebiologic and biologic eras.

RESULTS

pCD occurred in 39.2% of the population-based cohort and 56.1% of the hospital-based cohort during the median follow-up of 4.2 and 8.5 years, respectively. The cumulative incidence of pCD was 40.0% at 5 years after CD diagnosis in the population-based cohort and 62.5% at 20 years in the hospital-based cohort. In multivariate analysis, pCD development was positively associated with male sex, younger age and colonic involvement at diagnosis, early diagnosis, and CD diagnosis in the prebiologic era. The cumulative probability of proctectomy at 10, 20, and 30 years after pCD diagnosis was 2.9%, 12.2%, and 16.2%, respectively. The cumulative incidence of pCD occurring after CD diagnosis and the cumulative probability of proctectomy were significantly lower in the biologic era than in the prebiologic era (p < 0.001 and p = 0.03, respectively).

CONCLUSIONS

Compared with Western patients with CD, Korean patients show a high incidence of pCD but have a low probability of proctectomy, suggesting the favorable course of pCD.

Elicitation of Health-Related Utility in Perianal Fistula in Crohn's Disease

BACKGROUND AND OBJECTIVE

Perianal fistulae are a common complication of Crohn's disease (CD) and pose a substantial burden on quality of life. Data capturing health-related utility associated with perianal fistulae in CD are scarce. The current study aims to value health states related to different stages of the disease to quantitatively evaluate the impact of complex perianal fistulae on CD patients' quality of life.

METHODS

Eight health state descriptions associated with complex perianal fistulae in CD were developed following qualitative research with patients and validation by clinicians. Following pre-testing, a survey was administered online in two samples of UK respondents: the general population and patients with CD. A choice-based valuation technique, the time trade-off (TTO), was used for direct utility measurement. CD patients also valued their current health state using the TTO. Exclusion criteria for respondents displaying logical inconsistencies were applied.

RESULTS

Usable responses were received from 835 respondents, reflective of the UK population in age and sex, in the general population survey and 162 CD patients in the patient survey. Non-remission states were valued much lower than the remission state by both samples, ranging from 0.20 for proctectomy with a negative outcome to 0.66 for chronic symptomatic fistulae with mild symptoms. Patients currently experiencing fistulae reported lower values for current health than those without fistulae.

CONCLUSION

Low utility values were assigned to the non-remission health states for perianal fistulae in CD by the general public and patients with CD. This demonstrates the high humanistic burden of inadequately managed perianal fistula in CD.

Higher anti-tumor necrosis factor levels are associated with perianal fistula healing and fistula closure in Crohn's disease

OBJECTIVE

Limited data are available regarding the relationship between anti-tumor necrosis factor (TNF) drug/antibody levels and perianal fistula outcomes in Crohn's disease. The aims of this study were to assess the relationship between maintenance anti-TNF levels and perianal fistula outcomes.

METHODS

This was a retrospective cross-sectional study of patients receiving maintenance adalimumab or infliximab therapy (minimum 24 weeks) for the treatment of Crohn's disease with associated perianal fistulas, who had anti-TNF drug/antibody levels (trough for infliximab) measured within 4 weeks of clinical assessment. The primary outcome was the association of anti-TNF levels with perianal fistula healing defined as the absence of drainage. The secondary outcome was the association of anti-TNF levels with complete perianal fistula closure.

RESULTS

A total of 64 patients (adalimumab, n = 35; infliximab, n = 29) were included. Patients with fistula healing had higher levels of anti-TNF vs. those without fistula healing (adalimumab: 12.6 vs. 2.7 μg/mL, P < 0.01; infliximab: 8.1 vs. 3.2 μg/mL, P < 0.01). Patients with fistula closure also had significantly higher anti-TNF levels vs. those without fistula closure (adalimumab: 14.8 vs. 5.7 μg/mL, P < 0.01; infliximab: 8.2 vs. 3.2 μg/mL, P < 0.01). For adalimumab, receiver operator characteristic analysis identified an optimum level of >6.8 μg/mL and >9.8 μg/mL for fistula healing and closure, respectively. For infliximab, receiver operator characteristic analysis identified an optimum trough level of >7.1 μg/mL for both fistula healing and closure.

CONCLUSION

Higher maintenance anti-TNF levels are associated with perianal fistula healing and closure in Crohn's disease.

Gastrointestinal motility and absorptive disorders in patients with inflammatory bowel diseases: Prevalence, diagnosis and treatment

Inflammatory bowel diseases (IBD), Crohn`s disease and ulcerative colitis, are chronic conditions associated with high morbidity and healthcare costs. The natural history of IBD is variable and marked by alternating periods of flare and remission. Even though the use of newer therapeutic targets has been associated with higher rates of mucosal healing, a great proportion of IBD patients remain symptomatic despite effective control of inflammation. These symptoms may include but not limited to abdominal pain, dyspepsia, diarrhea, urgency, fecal incontinence, constipation or bloating. In this setting, commonly there is an overlap with gastrointestinal (GI) motility and absorptive disorders. Early recognition of these conditions greatly improves patient care and may decrease the risk of mistreatment. Therefore, in this review we describe the prevalence, diagnosis and treatment of GI motility and absorptive disorders that commonly affect patients with IBD.

A 10-Year Follow-up Study of the Natural History of Perianal Crohn's Disease in a Danish Population-Based Inception Cohort

BACKGROUND

Perianal complications in patients with Crohn's disease are common and have a negative impact on the patients' quality of life. Data about the long-term disease course of perianal Crohn's disease in the era of biological treatment are limited. In this population-based cohort study, we sought to investigate the occurrence, clinical risk factors, and disease course of perianal disease.

METHODS

A total of 213 Crohn's disease patients were included in a prospective population-based inception cohort. Data were retrieved from medical records and national health administrative databases. Perianal disease was defined as a perianal fistula and/or abscess. Associations between outcomes and covariates were analyzed by Cox regression analysis.

RESULTS

A total of 48 (22.5%) patients developed perianal disease after 10 years. Colonic disease location (hazard ratio [HR], 1.99; 95% confidence interval [CI], 1.01-3.92) and penetrating behavior (HR, 5.65; 95% CI, 2.65-12.03) were associated with the development of perianal disease. The cumulative risk of undergoing abdominal surgery was 51% after 10 years. Patients with perianal disease had a higher rate of resection (HR, 3.92; 95% CI, 1.86-8.67) and hospitalization (HR, 1.01; 95% CI, 1.00-1.01). There was no significant difference in the rate of sick leave, unemployment, or disability pension between patients with and without perianal disease.

CONCLUSIONS

Patients with perianal disease carry a higher risk of surgery and hospitalization, and this suggests a more severe disease course and poorer prognosis among these patients, even in the era of biological treatment. These findings underline the importance of optimizing treatment strategies for patients with perianal disease.

Patient and general population values for luminal and perianal fistulising Crohn's disease health states

BACKGROUND

In patients with Crohn's disease (CD), luminal disease activity paralleled by perianal fistulas may seriously impair health-related quality of life (HRQoL). Health utility values are not available from patients with CD that reflect the health loss associated with both luminal and perianal CD.

OBJECTIVE

To generate utilities for luminal and concomitant perianal fistulising CD health states directly from patients and from members of the general public.

METHODS

A cross-sectional survey was undertaken enrolling CD patients and a convenience sample of members of the general population. Respondents were asked to evaluate four common CD heath states [severe luminal disease (sCD), mild luminal disease (mCD), severe luminal disease with active perianal fistulas (sPFCD), and mild luminal disease with active perianal fistulas (mPFCD)] by 10-year time trade-off (TTO). In addition, patients assessed their current HRQoL by the TTO method.

RESULTS

Responses of 206 patients (40.8% with perianal fistulas) and 221 members of the general population were analysed. Mean ± SD utilities among patients for sPFCD, sCD, mPFCD and mCD states were 0.69 ± 0.33, 0.73 ± 0.31, 0.80 ± 0.29 and 0.87 ± 0.26. Corresponding values in the general public were: 0.59 ± 0.31, 0.65 ± 0.29, 0.80 ± 0.26 and 0.88 ± 0.25. Patients with active perianal fistulas, previous non-resection surgeries, and higher pain intensity scores valued their current health as worse (p < 0.05).

CONCLUSIONS

TTO is a feasible method to assess HRQoL in patients with perianal fistulising disease, often not captured by health status questionnaires. Utilities from this study are intended to support the optimization of treatment-related decision making in patients with luminal disease paralleled by active perianal fistulas.

Mesenchymal stromal cells in the treatment of perianal fistulas in Crohn's disease

Significant unmet needs remain in patients with Crohn's disease and perianal fistulas. Mesenchymal stromal cells have potent immunomodulatory actions. The Phase II studies reported efficacy of local injection of mesenchymal stromal cells to achieve closure of fistulas. A Phase III trial demonstrated that in patients with Crohn's disease and refractory complex perianal fistulas, a single injection of 120 × 106 cells was superior to local injection of placebo associated with the same surgical procedure, in obtaining closure of the fistula tracts together with absence of abscesses >2 cm, 24 weeks after the injection, a stringent combined primary end point. The benefit over placebo was sustained 52 weeks after the single injection. The therapy is safe with adverse events limited to local pain.

The Relationship between Gender, Severity of Disease, Treatment Type, and Employment Outcome in Patients with Inflammatory Bowel Disease in Israel

INTRODUCTION

Since individuals with IBD typically experience symptoms during their prime years of employment, it raises the question about IBD impact on employment status. Most studies concentrated on absenteeism from work with varying results in different populations. However, absenteeism reflects only one dimension of the ability to work and does not expose the problem of inability to hold a full-time job.

AIMS

To evaluate the influence of IBD on unemployment and working hours in Israel. Secondary aims were to investigate the correlation between working hours and the type of medical treatment and the impact of severity of disease.

PATIENTS AND METHODS

Demographic data, employment status, number of weekly working hours, and disease parameters. The data was compared to that of the general Israeli population extracted from the website of the Central Bureau of Statistics.

RESULTS

242 IBD patients were interviewed. Patients median age was 37.04(IQR 30.23-44.68) years and 88 (36.4%) were men and 154 (63.6%) women. Diagnosis of CD was established in 167 (69%) patients and UC in 65 (26.9%). There was no significant reduction in employment rates or working hours among the IBD patients comparing to the general population. Immunosuppressive or biologic treatment did not influence employment status. The unemployed patients had higher disease severity (median 7.33, IQR 5-10.66) compared to employed patients (median 6, IQR 3.66-7.66; p=0.003).

CONCLUSIONS

Although IBD patients in Israel do not have higher unemployment, those with severe disease have lower proportion of employment.