Self-reported depressive symptoms and suicidal feelings in perianal Crohn's disease

Does Combined Medical and Surgical Treatment Improve Perianal Fistula Outcomes in Patients With Crohn's Disease? A Systematic Review and Meta-Analysis

BACKGROUND

The optimal treatment of perianal fistulizing Crohn's disease [PFCD] is unknown. We performed a systematic review with meta-analysis to compare combined surgical intervention and anti-tumour necrosis factor [anti-TNF] therapy [combined therapy] vs either therapy alone.

METHODS

MEDLINE, EMBASE, and Cochrane databases were searched systematically up to end December 2023. Surgical intervention was defined as an exam under anaesthesia ± setons. We calculated weighted risk ratios [RRs] with 95% confidence intervals [CIs] for our co-primary outcomes: fistula response and healing, defined clinically as a reduction in fistula drainage or number of draining fistulas and fistula closure respectively.

RESULTS

Thirteen studies were analysed: 515 patients treated with combined therapy, 330 patients with surgical intervention, and 406 patients with anti-TNF therapy with follow-up between 10 weeks and 3 years. Fistula response [RR 1.10; 95% CI 0.93-1.30, p = 0.28] and healing [RR 1.06; 95% CI 0.86-1.31, p = 0.58] was not significantly different when comparing combined therapy with anti-TNF therapy alone. In contrast, combined therapy was associated with significantly higher rates of fistula response [RR 1.25; 95% CI 1.10-1.41, p < 0.001] and healing [RR 1.17; 95% CI 1.00-1.36, p = 0.05] compared with surgical intervention alone. Our results remained stable when limiting to studies that assessed outcomes within 1 year and studies where <10% of patients underwent fistula closure procedures.

CONCLUSION

Combined surgery and anti-TNF therapy was not associated with improved PFCD outcomes compared with anti-TNF therapy alone. Due to an inability to control for confounding and small study sizes, future, controlled trials are warranted to confirm these findings.

Perianal Fistulizing Crohn's Disease: Utilizing the TOpClass Classification in Clinical Practice to Provide Targeted Individualized Care

BACKGROUND & AIMS

Perianal fistulation is a challenging phenotype of Crohn's disease, with significant impact on quality of life. Historically, fistulae have been classified anatomically in relation to the sphincter complex, and management guidelines have been generalized, with lack of attention to the clinical heterogenicity seen. The recent 'TOpClass classification system' for perianal fistulizing Crohn's disease (PFCD) addresses this issue, and classifies patients into defined groups, which provide a focus for fistula management that aligns with disease characteristics and patient goals. In this article, we discuss the clinical applicability of the TOpClass model and provide direction on its use in clinical practice.

METHODS

An international group of perianal clinicians participated in an expert consensus to define how the TOpClass system can be incorporated into real-life practice. This included gastroenterologists, inflammatory bowel disease surgeons, and radiologists specialized in PFCD. The process was informed by the multi-disciplinary team management of 8 high-volume fistula centres in North America, Europe, and Australia.

RESULTS

The process produced position statements to accompany the classification system and guide PFCD management. The statements range from the management of patients with quiescent perianal disease to those with severe PFCD requiring diverting-ostomy and/or proctectomy. The optimization of medical therapies, as well as the use of surgery, in fistula closure and symptom management is explored across each classification group.

CONCLUSION

This article provides an overview of the system's use in clinical practice. It aims to enable clinicians to have a pragmatic and patient goal-centered approach to medical and surgical management options for individual patients with PFCD.

Prevalence and risk factors of depression among patients with perianal fistulizing Crohn's disease

BACKGROUND

Psychological distress, especially depression, associated with perianal fistulizing Crohn's disease (PFCD) is widespread and refractory. However, there is a surprising paucity of studies to date that have sought to identify the prevalence and risk factors of depression associated with PFCD.

AIM

To estimate the prevalence of depressive symptoms and investigate the depression-related risk factors in patients with PFCD.

METHODS

The study was conducted in the form of survey and clinical data collection via questionnaire and specialized medical staff. Depressive symptoms, life quality, and fatigue severity of patients with PFCD were assessed by Patient Health Questionnaire-9, Inflammatory Bowel Disease Patient Quality of Life Questionnaire (IBDQ), and Inflammatory Bowel Disease (IBD) Fatigue Patient Self-assessment Scale. The basic demographic information, overall disease features, perianal clinical information, and laboratory inflammation indicators were also gathered. Multivariate regression analysis was ultimately used to ascertain the risk factors of depression associated with PFCD.

RESULTS

A total of 123 patients with PFCD were involved, and 56.91% were suffering from depression. According to multivariate logistic regression analysis, Perianal Disease Activity Index (PDAI) score [odds ratio (OR) = 0.69, 95% confidence interval (CI): 0.50 to 0.95], IBDQ score (OR = 0.93, 95%CI: 0.88 to 0.97), modified Van Assche index (OR = 1.24, 95%CI: 1.01 to 1.53), and IBD Fatigue score (OR = 1.72, 95%CI: 1.23 to 2.42) were independent risk factors of depression-related prevalence among patients with PFCD (P < 0.05). Multiple linear regression analysis revealed that the increasing perianal modified Van Assche index (β value = 0.166, 95%CI: 0.02 to 0.31) and decreasing IBDQ score (β value = -0.116, 95%CI: -0.14 to -0.09) were independently associated with the severity of depression (P < 0.05).

CONCLUSION

Depressive symptoms in PFCD patients have significantly high prevalence. PDAI score, modified Van Assche index, quality of life, and fatigue severity were the main independent risk factors.

Where Are We and Where to Next?-The Future of Perianal Crohn's Disease Management

Perianal fistulizing Crohn's Disease (pCD) affects about 25% of patients with Crohn's Disease (CD). It remains a difficult entity to manage with a therapeutic ceiling of treatment success despite improving medical and surgical management. The refractory nature of the disease calls for an imminent need to better understand its immunopathogenesis and classification to better streamline our treatment options. In this article, we overview the current state of pCD management and discuss where the future of its management may lie.

Risk of Attempted Suicide Among Patients With IBD: A Nationwide Longitudinal Follow-up Study

BACKGROUND

Evidence suggests that IBD is related to an increased risk of depressive disorder and suicide.

OBJECTIVES

Whether IBD is an independent risk factor for suicide remains unclear.

DESIGN

A matched cohort study design.

SETTINGS

Taiwan National Health Insurance Research Database.

PATIENTS

A total of 3625 adults with IBD aged ≥20 years and 36,250 matched controls were selected between 1997 and 2013 and followed-up to the end of 2013.

MAIN OUTCOME MEASURES

Any suicide attempt was identified during the study period. Stratified Cox regression analysis was conducted on each matched pair to investigate the attempted suicide risk between the IBD and control groups.

RESULTS

The hazard ratio for any suicide attempt among the patients with IBD was 4.61 (95% CI, 3.29-6.48) compared with controls matched exactly for depressive disorder. No significant difference in suicide attempts was noted between patients with ulcerative colitis (HR, 4.12; 95% CI, 2.69-6.32) and patients with Crohn's disease (HR, 5.78; 95% CI, 3.27-10.22).

LIMITATIONS

The incidence of any suicide attempt may be underestimated.

CONCLUSION

IBD was an independent risk factor for attempted suicide. However, further studies are required to elucidate the definite pathomechanisms between IBD and suicide.

RIESGO DE INTENTO DE SUICIDIO ENTRE PACIENTES CON ENFERMEDAD INFLAMATORIA INTESTINAL UN ESTUDIO DE SEGUIMIENTO LONGITUDINAL A NIVEL NACIONAL

ANTECEDENTES: La evidencia sugiere que la enfermedad inflamatoria intestinal (EII) está relacionada con un mayor riesgo de trastornos depresivos y de suicidios.OBJETIVOS: Sin embargo, aún no está claro si la EII es un factor de riesgo independiente para llegar al suicidio.DISEÑO: Estudio de cohortes de tipo pareado.AJUSTES: Investigación en la base de datos del seguro nacional de salud de Taiwán.PACIENTES: Se seleccionaron un total de 3.625 adultos con EII de ≥20 años y 36.250 controes emparejados entre 1997 y 2013, se les dio un seguimiento hasta finales de 2013.PRINCIPALES MEDIDAS DE RESULTADO: Se identificó cualquier intento de suicidio durante el período del estudio. Se realizó un análisis de regresión de Cox estratificado en cada dupla apareada dentro la investigación del riesgo de intento de suicidio comparado entre los grupos de EII y el grupo control.RESULTADOS: El cociente de riesgo instantáneo (HR) para cualquier intento de suicidio entre los pacientes con EII fue de 4,61 (el intervalo de confianza [IC] del 95 %: 3,29-6,48) en comparación con los controles apareados exactamente en casos de trastorno depresivo. No se observaron diferencias significativas en los intentos de suicidio entre los pacientes con colitis ulcerosa (HR: 4,12, IC 95 %: 2,69-6,32) y enfermedad de Crohn (HR: 5,78, IC 95 %: 3,27-10,22).LIMITACIONES: La incidencia de cualquier intento de suicidio puede estar subestimada.CONCLUSIÓN: La EII fué un factor de riesgo independiente para el intento de suicidio. Sin embargo, se requieren más estudios para dilucidar los mecanismos patogénicos definitivos entre la EII y el suicidio. (Traducción-Dr. Xavier Delgadillo ).

A Decade of Waiting: Experiences of Women Living With Vulvar Crohn's Disease and Interactions With Healthcare Professionals Related to Their Sexual Well-Being: A Qualitative Study

Background

Vulvar Crohn's disease is a rare cutaneous manifestation of inflammatory bowel disease and to date, studies have reported on under 300 cases worldwide. The condition has an increased risk of malignancy, and diagnosis is often difficult. Treatment protocols are yet to be developed. This paper aimed to provide the first account of patients' experience of living with vulvar Crohn's.

Methods

A previous qualitative study exploring experiences of sexual well-being in inflammatory bowel disease and experiences of discussing sexual well-being with healthcare professionals found 3 participants who self-reported vulvar Crohn's disease. Data from the whole cohort (n = 43) were previously reported. Telephone semi-structured interviews were used for data collection. van Manen's phenomenology of practice framework informed analysis.

Results

Due to significant differences in experiences, this subgroup of 3 women with vulvar Crohn's warranted separate attention. The common theme of the group was A decade of waiting, describing the major delays experienced in being diagnosed. The symptoms reported appeared to be very severe, and sexual well-being was very negatively affected.

Conclusions

Women with vulvar Crohn's trust in healthcare professionals was eroded as a result of a decade delay in diagnosis, while the quality of life and relationships suffered.

Surgical management of complex perianal fistula revisited in a systematic review: a critical view of available scientific evidence

BACKGROUND

Treating complex perianal fistulas in Crohn's disease patients remains a challenge. Classical surgical treatments for Crohn's disease fistulas have been extrapolated from cryptoglandular fistulas treatment, which have different etiology, and this might interfere with its effectiveness, in addition, they increase fecal incontinence risk. Recently, new surgical techniques with support from biological approaches, like stem cells, have been developed to preserve the function of the sphincter. We have performed a systematic literature review to compare the results of these different techniques in the treatment of Crohn's or Cryptoglandular fistula.

METHODS

PubMed, EMBASE, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials were searched systematically for relevant articles. We included randomized controlled trials and observational studies that referred to humans, were written in English, included adults 18+ years old, and were published during the 10-year period from 2/01/2010 to 2/29/2020. Evidence level was assigned as designated by the Scottish Intercollegiate Guidelines Network.

RESULTS

Of the 577 citations screened, a total of 79 were ultimately included in our review. In Crohn's disease patients, classical techniques such as primarily seton, Ligation of Intersphincteric Fistula Tracks, or lay open, healing rates were approximately 50-60%, while in cryptoglandular fistula were around, 70-80% for setons or flaps. In Crohn's disease patients, new surgical techniques using derivatives of adipose tissue reported healing rates exceeding 70%, stem cells-treated patients achieved higher combined remission versus controls (56.3% vs 38.6%, p = 0.010), mesenchymal cells reported a healing rate of 80% at week 12. In patients with cryptoglandular fistulas, a healing rate of 70% using derivatives of adipose tissue or platelets was achieved, and a healing rate of 80% was achieved using laser technology. Fecal incontinence was improved after the use of autologous platelet growth factors and Nitinol Clips.

CONCLUSION

New surgical techniques showed better healing rates in Crohn's disease patients than classical techniques, which have better results in cryptoglandular fistula than in Crohn's disease. Healing rates for complex cryptoglandular fistulas were similar between the classic and new techniques, being the new techniques less invasive; the incontinence rate improved with the current techniques.

Association of inflammatory bowel disease with suicidal ideation, suicide attempts, and suicide: A systematic review and meta-analysis

OBJECTIVE

Inflammatory bowel disease (IBD) is associated with psychiatric comorbidities. However, the association between IBD and suicidal ideation or suicide attempts has not been well established. This study aimed to perform a systematic review and meta-analysis to elucidate the relationship between IBD and suicidal ideation, suicide attempts, and suicide.

METHODS

We systematically searched five electronic databases - PubMed, Embase, CENTRAL, Web of Science, and PsycINFO - from their inception to January 28, 2022. Quality assessment, data synthesis, subgroup analyses, sensitivity analyses, and publication bias assessment were performed on the included studies.

RESULTS

We identified 28 studies with 1,047,755 patients with IBD. The pooled prevalence of suicidal ideation in patients with IBD was 17.3% (95% CI, 9.5%-25.2%). Patients with IBD were associated with an increased risk of suicide attempts (relative risk [RR], 1.39; 95% CI, 1.08-1.79) and suicide deaths (RR, 1.25; 95% CI, 1.09-1.43) than the controls without IBD. Patients with Crohn's disease subtypes, female IBD, pediatric-onset IBD, young adult IBD, and short-duration IBD had a particularly high risk for suicide.

CONCLUSION

Patients with IBD had a high prevalence of suicidal ideation and a significantly higher likelihood of suicide attempts and suicide. Caring for patients with IBD, including their mental health needs, may require concerted efforts among gastroenterologists and other healthcare providers.

Natural History of Perianal Crohn's Disease: Long-term Follow-up of a Population-Based Cohort

BACKGROUND AND AIMS

The natural history of perianal Crohn's disease (PCD) remains poorly described and is mainly based on retrospective studies from referral centers. The aim of this study was to assess the incidence, outcomes and predictors of the onset of PCD.

METHODS

All incident cases of patients diagnosed with possible CD were prospectively registered from 1994 to 1997 in Brittany, a limited area in France. At diagnosis, the clinical features of perianal disease were recorded. All patient charts were reviewed from the diagnosis to the last clinic visit in 2015.

RESULTS

Among the 272 out of 331 incident CD patients followed up, 51 (18.7%) patients had PCD at diagnosis. After a mean follow-up of 12.8 years, 93 (34%) patients developed PCD. The cumulative probabilities of perianal CD occurrence were 22%, 29%, and 32% after 1 year, 5 years, and 10 years, respectively. The cumulative probabilities of anal ulceration were 14%, and 19% after 1 year and 10 years, respectively. Extraintestinal manifestations were associated with the occurrence of anal ulceration. The cumulative probabilities of fistulizing PCD were 11%, 16%, and 19% after 1 year, 5 years, and 10 years, respectively. Extraintestinal manifestations, rectal involvement and anal ulceration were predictors of fistulizing PCD. The cumulative probability of developing anal stricture was 4% after 10 years.

CONCLUSIONS

PCD is frequently observed during CD, in approximately one-third of patients. These data underline the need for targeted therapeutic research on primary perianal lesions (proctitis, anal ulceration) to avoid the onset of fistulizing perianal disease.

Surgical closure, mainly with glue injection and anti-tumour necrosis factor α, in fistulizing perianal Crohn's disease: A multicentre randomized controlled trial

AIM

In patients with fistulizing perianal Crohn's disease (CD), the need for a secondary surgical step is not defined. The aim was to assess the efficacy of surgical closure compared to a single seton removal in patients with drained fistulizing perianal CD treated with adalimumab.

METHODS

This was a multicentre, randomized controlled trial, comparing seton removal + surgical closure (closure group) to seton removal alone (control group) with a stratification according to the American Gastroenterological Association classification. The primary end-point was fistula closure at month 12 defined by the association of the following criteria: no seton, absence of a visible external opening, absence of discharge from the tract after finger compression, absence of an internal opening, absence of perianal pain/abscess and absence of fistula-related abnormalities.

RESULTS

Among the 64 included patients (262 expected) (48 complex fistula, 75%), 33 were randomized to the closure group and 31 to the control group. In the closure group, 26 patients (78.8%) had glue. At month 12, overall fistula closure was achieved in 35 of the evaluable 58 patients (60%): 18/32 (56%) in the surgery group and 17/26 (65%) in the control group (P = 0.479). In the closure group, fistula closure was observed in 13/25 (52%) and 5/7 (71%) patients with complex and simple fistula respectively (P = 0.426), compared with 12/18 (67%) and 5/8 (63%), respectively in the control group (P = 1.000).

CONCLUSIONS

Seton removal alone seems to be no more effective than a secondary surgical step (in particular glue injection) in patients having fistulizing perianal CD controlled by an initial drainage combined with adalimumab. The results should be interpreted with caution.

Occurrence of mental disorders in nonspecific inflammatory bowel diseases: a primary or secondary problem in relation to the biological therapy used?

Introduction: Nonspecific inflammatory bowel diseases include Crohn’s disease (CD) and ulcerative colitis (CU – colitis ulcerosa), which are chronic diseases characterized by periods of exacerbation and remission. Extraintestinal complications caused by the disease and the applied treatment, mainly steroid therapy, constitute a predisposition to infections and mental disorders such as depressive disorders with apathy, slowness of movement or agitation, and even manic syndromes.

Aim and method: The aim of this study was to review the literature on the occurrence of primary and secondary mental disorders in the course of inflammatory bowel diseases. The literature in the Google Scholar database was reviewed using the following keywords: colitis ulcerosa, Crohn disease, depression, mental disorders, inflammatory bowel disease. The time descriptors 2011-2021 were also used.

Conclusions: The review of epidemiological studies shows that the most common mental disorders in nonspecific inflammatory bowel diseases are anxiety and depression disorders. The effect of steroid therapy on the development of mental disorders is equally significant. Most of the available empirical data relating to corticosteroids confirm the correlation between the drugs and depressive symptoms, and other psychiatric effects, including mania and psychosis.

Summary: As with most chronic diseases, the prevalence of anxiety and depression disorders is higher in nonspecific inflammatory bowel diseases than in the general population.

Ustekinumab for Perianal Crohn's Disease: The BioLAP Multicenter Study From the GETAID

INTRODUCTION

New therapeutic options for patients with Crohn's disease (CD) with perianal lesions failing anti-tumor necrosis factor (TNF) agents are needed. We aimed to assess the effectiveness of ustekinumab in perianal CD (pCD) and predictors of clinical success in a real-life multicenter cohort.

METHODS

We conducted a national multicenter retrospective cohort study in patients with either active or inactive pCD who received ustekinumab. In patients with active pCD at treatment initiation, the success of ustekinumab was defined by clinical success at 6 months assessed by the physician's judgment without additional medical or surgical treatment for pCD. Univariate and multivariable logistic regression analyses were performed to identify predictors of success. In patients with inactive pCD at ustekinumab initiation, the pCD recurrence-free survival was calculated using the Kaplan-Meier method.

RESULTS

Two hundred seven patients were included, the mean age was 37.7 years, the mean duration of CD was 14.3 years, and the mean number of prior perianal surgeries was 2.8. Two hundred five (99%) patients had previously been exposed to at least 1 anti-TNF and 58 (28%) to vedolizumab. The median follow-up time was 48 weeks; 56/207 (27%) patients discontinued therapy after a median time of 43 weeks. In patients with active pCD, success was reached in 57/148 (38.5%) patients. Among patients with setons at initiation, 29/88 (33%) had a successful removal. The absence of optimization was associated with treatment success (P = 0.044, odds ratio 2.74; 95% confidence interval: 0.96-7.82). In multivariable analysis, the number of prior anti-TNF agents (≥3) was borderline significant (P = 0.056, odds ratio 0.4; 95% confidence interval: 0.15-1.08). In patients with inactive pCD at initiation, the probability of recurrence-free survival was 86.2% and 75.1% at weeks 26 and 52, respectively.

DISCUSSION

Ustekinumab appears as a potential effective therapeutic option in perianal refractory CD. Further prospective studies are warranted.

Medical-surgical Combined Approach in Perianal Fistulizing Crohn's Disease (CD): Doing it Together

Fistulising perianal Crohn's disease (pCD) is an aggressive phenotype, and patients not only suffer from perianal manifestations but also a worsening course for their luminal disease. This article describes the 6 key steps clinicians need to consider when managing patients with pCD which include; (i) ensuring a prompt diagnosis, (ii) multi-disciplinary management, (iii) psychological support, (iv) using multimodal medical and surgical treatment strategies, (v) continually monitoring and optimising therapy and (vi) ensuring that patients have a way of accessing care if required. Patients with fistulising pCD often have an unpredictable disease course and complete remission can be elusive. As such, a considered and nuanced approach is essential keeping the wider multi-disciplinary team and the patient involved in all decision making.

Association Between Steroid-Sparing Therapy and the Risk of Perianal Fistulizing Complications Among Young Patients With Crohn Disease

Importance

Perianal fistulizing complications (PFCs) develop in 15% to 30% of patients with Crohn disease (CD), are difficult to treat, worsen quality of life, increase cost of care, and commonly recur. Evidence-based strategies to prevent PFCs are lacking.

Objectives

To investigate the effectiveness of medical therapy for reducing risk of PFCs among young people with CD and to test the hypothesis that steroid-sparing therapy (SST) use would be associated with reduced risk of PFC development.

Design, Setting, and Participants

In this comparative effectiveness analysis of commercial administrative claims from January 1, 2001, through June 30, 2016, patients who did or did not initiate SST were matched via propensity score to adjust for all available confounders. Using Optum's Clinformatics Data Mart, a deidentified database of US commercial administrative claims, all patients aged 5 to 24 years with CD (January 1, 2001, through June 30, 2016) were identified. The index date was the CD diagnosis date. Patients with PFCs or SST use at or before CD diagnosis were excluded. The dates of analysis were October 2017 to February 2020.

Exposures

The primary exposure of interest was SST initiation, including immunomodulators and/or anti-tumor necrosis factor α (anti-TNFα) medications, initiated before either PFC development or the end of the study period.

Main Outcomes and Measures

The primary outcome was PFC development. Propensity score matching was used to balance baseline characteristics. Cox proportional hazards multivariable regression analyses were used to estimate hazard ratios (HRs) with 95% CIs for PFC development.

Results

Among 2214 young people with CD without PFCs identified, the mean (SD) age at CD diagnosis was 17.0 (4.5) years, and 1151 (52.0%) were male. Among the cohort, 1242 patients (56.1%) initiated SST before PFC development or the end of 24-month follow-up. After propensity score matching, 972 patients remained in each treatment group. Overall, 384 of 1944 (19.8%) developed PFCs within 2 years of the index date. The use of SST was associated with a 59% decreased risk of PFC development (hazard ratio [HR], 0.41; 95% CI, 0.33-0.52; P < .001) in 2 years compared with no SST use. Among those who developed PFCs, 55% fewer SST users underwent ostomy than SST nonusers. The use of immunomodulators alone, anti-TNFα alone, and combination therapy was associated with 52% (HR, 0.48; 95% CI, 0.37-0.62; P < .001), 47% (HR, 0.53; 95% CI, 0.36-0.78; P = .001), and 83% (HR, 0.17; 95% CI, 0.09-0.30; P < .001) reductions in the risk of 2-year PFC development, respectively, compared with no SST use.

Conclusions and Relevance

In this study, PFC development was common among young patients with CD. The use of SST was lower than expected. Compared with no SST, patients who initiated SST were 59% less likely to develop PFCs and fewer underwent ostomy. These results indicate that PFCs may be preventable and emphasize the importance of considering SST for all patients with CD.

Vedolizumab for perianal Crohn's disease: a multicentre cohort study in 151 patients

BACKGROUND

The management of Crohn's disease patients with perianal lesions and anti-TNF failure is challenging.

AIMS

To assess the effectiveness of vedolizumab in perianal Crohn's disease and the predictors of success in a real-life cohort.

METHODS

We conducted a nationwide multicentre cohort study in patients with perianal Crohn's disease who received vedolizumab. In patients with active perianal Crohn's disease, the success of vedolizumab was defined by clinical success (no draining fistula at clinical examination and no anal ulcers for primary lesions) at 6 months without medical or surgical treatment for perianal Crohn's disease. Logistic regression analyses were performed to identify predictors of success. In patients with inactive perianal Crohn's disease, recurrence was defined by the occurrence of lesions and/or the need for medical or surgical treatments.

RESULTS

One hundred and fifty-one patients were included. Among them 102 patients had active perianal disease, 33 (32.4%) males, mean age 39.8 years, mean Crohn's disease duration 14.6 years; 101 (99%) had received at least one anti-TNF. The median follow-up time was 52 weeks. Sixty-eight per cent of patients discontinued therapy after a median time of 33 weeks. Vedolizumab success was reached in 23/102 (22.5%). Among patients with setons at initiation, 9/61(15%) had a successful removal. In multivariable analysis, factors associated with success were the number of prior biologic agents (≥3, odds ratio, OR: 0.20, 95% CI 0.04-0.98) and no antibiotics at initiation (OR: 4.76, 95% CI 1.25-18.19). In 49 patients with inactive perianal Crohn's disease, perianal disease recurred in 15/49 (30.6%), 11/49 (22.4%) needed dedicated treatments. Median time to recurrence was 22 weeks.

CONCLUSIONS

We identified a low rate of success of vedolizumab in patients with active perianal Crohn's disease, and nearly one third of patients with inactive perianal Crohn's disease had perianal recurrence. Further evaluation is warranted in prospective studies.

Refractory Complex Crohn's Perianal Fistulas: A Role for Autologous Microfragmented Adipose Tissue Injection

BACKGROUND

Complex perianal fistulas represent one of the most challenging manifestations of Crohn's disease. Combined surgical and medical therapy with biologic drugs today represent the first-line treatment option, but its efficacy does not exceed 60%. Recently, new therapeutic approaches, such as the use of mesenchymal stromal cells, have shown promising results. The adipose tissue is an abundant and easy to access source. The effectiveness, safety, and feasibility of local injections of microfragmented adipose tissue in patients with refractory complex fistulizing perianal Crohn's disease (PCD) were evaluated.

METHODS

Fifteen patients with persistent complex fistulizing PCD after biosurgical approach and subsequent surgical "rescue" repair were treated in S. Orsola-Malpighi Hospital with a single-local administration of microfragmented adipose tissue prepared using a minimal manipulation technique (Lipogems) in a closed system. Clinical outcomes were determined at 24-week follow-ups assessing success rate, defined as combined clinical and radiological remission.

RESULTS

Upon clinical examination at 24 weeks, 10 patients had combined remission (clinical and radiographic), 4 patients showed improvements, and 1 patient failed. The results were confirmed in all patients by pelvic MRI. No relevant postoperative complications nor adverse events were reported.

CONCLUSION

These results suggest that the local injection of autologous microfragmented adipose tissue is a safe and promising "rescue therapy" for patients with multiresistant complex fistulizing PCD. This approach might be proposed as routine because it is affordable, is minimally invasive, has no risk of sphincteric damage, and can be carried out in a day-surgery setting.

Efficacy of Tumour Necrosis Factor-alpha therapy in paediatric Crohn's disease patients with perianal lesions: a systematic review

Introduction: Anti-Tumor Necrosis Factor-alpha (TNF-α) therapy, primarily infliximab and adalimumab, are now increasingly used to induce and maintain disease remission in the pediatric perianal Crohn's disease (CD) population, however, their optimal use has not yet been defined in the pediatric setting.Areas covered: In accordance with a published protocol (PROSPERO no. CRD42019118838), we systematically and critically evaluated all published evidence on the efficacy and safety of anti-TNF-α in children with perianal CD, in the PubMed, MEDLINE, Embase, Cochrane and clinicalTrials.gov databases until October, 18^th, 2018. We included in our systematic review 29 articles yielding a total of 565 perianal CD patients aged between 9 months to 18 years.Expert opinion: According to low-quality evidence from small, uncontrolled and heterogeneous descriptive studies, and very few randomized controlled trial, nearly three-fifths children with perianal CD achieved remission with anti-TNF-α treatment and in approximately 40% remission was maintained after 12 months, with practically low discontinuation rate due to serious adverse events. More than half of the patients achieved complete fistula closure. There is still a need for more robust evidence adequately assessing the efficacy and safety of anti-TNF-α therapy in pediatric perianal CD, as well as in comparison with other therapies.

Role of Fecal Diversion in Complex Crohn's Disease

Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in progressive tissue damage, which can result in strictures, fistulae, and abscesses formation. The triggering mechanism is thought to be in the fecal stream, and diversion of this fecal stream is sometimes required to control disease when all other avenues of medical and surgical management have been exhausted. Fecal diversion can be temporary or permanent with the indications being defunctioning a high-risk anastomosis, as a result of a surgical complication, for disease control, or due to severe colonic, rectal, or perianal disease. The incidence of ostomy formation in CD has increased epidemiologically over time. The primary indication for ostomy formation is severe perianal fistulizing disease. However, while 64% of patients have an early clinical response after diversion for refractory perianal CD, restoration of bowel continuity is attempted in only 35% of patients, and is successful in only 17%. The current review discusses the indications for ostomy creation in complex CD, strategies for procedure selection, and patient outcomes.

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.

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

BACKGROUND

Patient reported outcomes regarding perianal disease and faecal incontinence in the community-based inflammatory bowel disease population are poorly described.

AIMS

To determine the impacts of perianal disease and faecal incontinence on quality of life and employment in inflammatory bowel disease patients.

METHODS

For this cross-sectional study, a comprehensive survey was sent out to members of the Dutch National Crohn's and Colitis patient organisation. Validated questionnaires regarding faecal incontinence and active perianal disease were used to estimate its prevalence's. The effect on the quality of life (36-Item Short Form Survey) and on employment status (multivariate binary regression analysis) was assessed in this inflammatory bowel disease population.

RESULTS

A total number of 1092 returned questionnaires (58% responders) were used for analysis; 750 respondents (69%) were female; mean age was 47 years (IQR 35-59). In 621 patients (57%) Crohn's disease, in 422 (39%) ulcerative colitis and in 49 (4%) patients unclassifiable inflammatory bowel disease was self-reported. The 114 patients (10%) with a stoma were excluded for continence related analyses. Faecal incontinence was reported in 555 patients (57%), was comparable between the different inflammatory bowel disease diagnoses and affected all 36-Item Short Form Survey subscales adversely (incontinence vs continence: Physical functioning 75 vs 84, P < 0.0001; Limitations due to physical health 49 vs 63, P < 0.0001; Limitations due to emotional problems 49 vs 64, P < 0.0001; Energy/fatigue 47 vs 53, P < 0.0001; Emotional well-being 71 vs 74, P = 0.005; Social functioning 63 vs 73, P < 0.0001; Pain 66 vs 75, P < 0.0001; General health 41 vs 48, P < 0.0001). Active perianal disease was reported in 39% Crohn's disease, 16% ulcerative colitis (84% fissures) and 20% unclassifiable inflammatory bowel disease patients. Faecal incontinence was more common in patients with perianal disease (67% vs 53%, P = 0.003). When correcting for age, disease duration, inflammatory bowel disease-related surgery and faecal incontinence, active perianal disease was independently affecting employment (OR 0.67; 95% CI 0.50-0.91; P = 0.01).

CONCLUSIONS

Faecal incontinence and perianal disease are quality of life determining factors. Faecal incontinence needs more attention among clinicians, and development of new (drug) therapies needs to be focussed on perianal disease.

Evaluation of Gastrointestinal Patient Reported Outcomes Measurement Information System (GI-PROMIS) Symptom Scales in Subjects With Inflammatory Bowel Diseases

OBJECTIVES

Patient reported outcomes (PROs) are important treatment endpoints in inflammatory bowel diseases (IBD). We evaluated the gastrointestinal (GI) PRO Measurement Information System (PROMIS) in IBD subjects.

METHODS

Crohn's and Colitis Foundation of America's Partners is an Internet-based cohort of IBD subjects. Participants complete surveys, including demographics, disease characteristics, PROMIS domains, disease activity (short Crohn's disease activity index or simple clinical colitis activity index) and quality of life (QoL) indices. In a nested cross-sectional study, we used univariate and bivariate analyses to assess associations between 8 GI-PROMIS domains (reflux, swallowing, diarrhea, nausea, belly pain, gas, incontinence, and constipation) and QoL and disease activity indices.

RESULTS

The study included 2,378 Crohn's Disease (CD) and 1,455 ulcerative colitis (UC) respondents with a median age of 41 years. Median disease duration was 11 years for CD subjects and 8 years for UC subjects; 57% of CD subjects and 42% of UC subjects were in remission. Among symptomatic CD subjects, those with active CD reported significantly worse symptoms on all 8 domains than those in remission. The same was observed for UC subjects with the exception of disrupted swallowing. IBD subjects with worse QoL reported significantly worse symptoms on all 8 domains compared to those with better QoL.

CONCLUSIONS

In IBD subjects experiencing GI symptoms, GI-PROMIS domains were strongly associated with disease activity and QoL indices. GI-PROMIS holds potential as PRO measures in IBD and correlates with other validated indices in this population.

Asians have more perianal Crohn disease and ocular manifestations compared with white Americans

Background

Inflammatory bowel disease (IBD) is increasing in Asians. We sought tobetter understand differences in IBD between Asians and whites in the United States (U.S.).

Methods

We used data from the Sinai-Helmsley Alliance for Research Excellence cohort to assess disease characteristics for U.S.-born Asians, Asian immigrants and whites. We used bivariate analyses to describe clinical characteristics by race. We used logistic regression to determine baseline odds of immunosuppression and binomial regression to estimate risk ratios for worsening disease at follow-up.

Results

We included 5,223 whites, 35 U.S.-born Asians and 81 Asian immigrants. Crohn's disease (CD) was present in 64% of whites, 40% of U.S.-born Asians and 51% of Asian immigrants. At baseline, 58% of whites, 62% of U.S.-born Asians and 67% of Asian immigrants were in remission by disease activity index score (p=0.238). There were no significant differences in CD location and behavior or ulcerative colitis (UC) extent. Asians had significantly more perianal disease than whites (33% versus 18%, p=0.007). Asians were more likely to have ocular manifestations compared with whites (3.4% versus 0.7%, p=0.022). Asians were also significantly less likely to be depressed than whites (25% versus 35%, p=0.022). Adjusting for confounders, Asians had half the odds of being treated with biologics compared with whites (OR: 0.45, 95% CI: 0.30-0.67). Adjusting for disease behavior and remission status, there were no differences in IBD-related surgery or hospitalization, new biologic or steroid prescription or relapse rates between Asians and whitesat follow-up.

Conclusion

Asians are more likely to have perianal disease and ocular extra-intestinal manifestations. After controlling for confounders, Asians were less likely to be treated with biologic agents. Despite this, there were no significant differences in outcome sover time between Asians and whites. Differences in disease phenotypes in Asians may reflect differences in genetics.

Psychometry and Pescatori projective test in coloproctological patients

Background

Psychological assessment is not commonly performed nor easily accepted by coloproctological patients. Our aim was to evaluate the psychological component of coloproctological disorders using uncommon tools.

Methods

The 21-Item Depression Anxiety and Stress Scale and the Pescatori projective test were applied to coloproctological outpatients of the Gastroenterology Department of our hospital as well as to healthy volunteers.

Results

Seventy patients (median age 47 years, 22 male) divided in 4 groups (functional constipation, constipated irritable bowel syndrome, benign anorectal disease and perianal Crohn’s disease) and 52 healthy volunteers (age 45 years, 18 male) completed the tests. Proctological patients showed higher scores of depression (P<0.001), anxiety (P<0.001), and stress (P<0.001) compared to healthy participants. Compared to the control group, patients with functional constipation, irritable bowel syndrome and perianal Crohn’s disease maintained the highest scores in all subscales (P<0.05), while patients with benign anorectal disease only had higher anxiety and stress (P<0.001) scores. The patients’ also showed lower scores in the Pescatori projective test (P=0.012). A weak association between the projective test and the depression subscale was found (P=0.05).

Conclusion

Proctological patients had higher scores of depression, anxiety and stress and lower scores in the Pescatori projective test compared to healthy controls.

Factors Associated with Anxiety and Depression in Korean Patients with Inactive Inflammatory Bowel Disease

BACKGROUND/AIMS

Psychological distress is highly prevalent in patients with inflammatory bowel disease (IBD). We evaluated the disease characteristics and socioeconomic factors associated with anxiety and depression in Korean patients with quiescent IBD.

METHODS

In total, 142 IBD patients (67 with Crohn's disease [CD] and 75 with ulcerative colitis [UC]) completed self-report questionnaires, including the Hospital Anxiety and Depression Score, the Modified Morisky Adherence Scale-8, the socioeconomic deprivation score, and the Crohn's and Colitis Knowledge Score questionnaires.

RESULTS

In the CD group, 30 patients (44%) were anxious, and 10 patients (15%) were depressed; in the UC group, 31 patients (41%) were anxious, and 18 patients (24%) were depressed. Using multivariate analysis, in the CD group, socioeconomic deprivation was associated with anxiety (p=0.03), whereas disease duration (p=0.04) and socioeconomic deprivation (p=0.013) were associated with depression. In the UC group, there was no significant independent predictor of anxiety and/or depression; however, low income tended to be associated with depression (p=0.096).

CONCLUSIONS

Despite clinical remission, a significant number of IBD patients present with anxiety and depression. IBD patients in remission, particularly those who are socioeconomically deprived, should be provided with appropriate psychological support.

Perianal Crohn Disease in a Large Multicenter Pediatric Collaborative

BACKGROUND

Although perianal complications of Crohn disease (CD) are commonly encountered in clinical practice, the epidemiology of perianal CD among populations of children is poorly understood. We sought to characterize the prevalence of perianal disease in a large and diverse population of pediatric patients with CD.

METHODS

We conducted retrospective analyses from a prospective observational cohort, the ImproveCareNow Network (May 2006-October 2014), a multicenter pediatric inflammatory bowel disease quality improvement collaborative. Clinicians prospectively documented physical examination and phenotype classification at outpatient visits. Perianal examination findings and concomitant phenotype change were used to corroborate time of new-onset perianal disease. Results were stratified by age, sex, and race and compared across groups with logistic regression. Cumulative incidence was estimated using Kaplan-Meier analyses and compared between groups with Cox proportional hazard regression models.

RESULTS

The registry included 7076 patients with CD (41% girls). Missing/conflicting entries resulted in 397 (6%) patient exclusions. Among the remaining 6679 cases, 1399 (21%) developed perianal disease. Perianal disease was more common among boys (22%) than girls (20%; P = 0.013) and developed sooner after diagnosis among those with later rather than early onset disease (P < 0.001). Perianal disease was also more common among blacks (26%) compared with whites (20%; P = 0.017). Asians with later onset CD developed perianal disease earlier in their disease course (P = 0.01). There was no association between disease location or nutritional status at diagnosis and later development of perianal disease.

CONCLUSIONS

In this large multicenter collaborative, we found that perianal disease is more common among children with CD than previously recognized. Differences in the development of perianal disease were found across racial and other subgroups. Treatment strategies are needed to prevent perianal disease development.

Motility Evaluation in the Patient with Inflammatory Bowel Disease

Patients with inflammatory bowel disease (IBD) suffer frequently from functional bowel diseases (FBD) and motility disorders. Management of FBD and motility disorders in IBD combined with continued treatment of a patient's IBD symptoms will likely lead to better clinical outcomes and improve the patient's quality of life. The goals of this review were to summarize the most recent literature on motility disturbances in patients with IBD and to give a brief overview of the ranges of motility disturbances, from reflux disease to anorectal disorders, and discuss their diagnosis and specific management.

Perianal Crohn's Disease is Associated with Distal Colonic Disease, Stricturing Disease Behavior, IBD-Associated Serologies and Genetic Variation in the JAK-STAT Pathway

BACKGROUND

Perianal Crohn's Disease (pCD) is a particularly severe phenotype associated with poor quality of life with a reported prevalence of 12%-40%. Previous studies investigating the etiology of pCD have been limited in the numbers of subjects and the intensity of genotyping. The aim of this study was to identify clinical, serological, and genetic factors associated with pCD.

METHODS

We performed a case-control study comparing patients with (pCD+) and without perianal (pCD) involvement in CD; defined as the presence of perianal abscesses or fistulae. Data on demographics and clinical features were obtained by chart review. Inflammatory bowel disease-related serology was determined by enzyme-linked immunosorbent assay. Genetic data were generated using Illumina genotyping platforms.

RESULTS

We included 1721 patients with CD of which 524 (30.4%) were pCD+ and 1197 were pPCD. pCD was associated with distal colonic disease (Odds ratio 5.54 [3.23-9.52], P < 0.001), stricturing disease behavior (1.44 [1.14-1.81], P = 0.002) and family history of inflammatory bowel disease (4.98 [3.30-7.46], P < 0.001). pCD was associated with higher anti-sacharomyces cerevisae antibodies IgA (P < 0.001) and OmpC (P = 0.008) antibody levels. pCD was associated with known inflammatory bowel disease loci, including KIF3B, CRTC3, TRAF3IP2, JAZF1, NRIP1, MST1, FUT2, and PTGER (all P < 0.05). We also identified genetic association with genes involved in autophagy (DAPK1, P = 5.11 × 10), TNF alpha pathways (NUCB2, P = 8.68 × 10; DAPK1), IFNg pathways (DAPK1; NDFIP2, P = 8.74 × 10), and extracellular matrix and scaffolding proteins (USH1C, P = 8.68 × 10; NDFIP2; TMC07, P = 8.87 × 10). Pathway analyses implicated the JAK-Stat pathway (pc = 3.72 × 10).

CONCLUSION

We have identified associations between pCD, more distal colonic inflammation, Crohn's disease-associated serologies, and genetic variation in the JAK-Stat pathway.

Vitamin D deficiency in patients with intestinal malabsorption syndromes--think in and outside the gut

There is a very high prevalence of vitamin D deficiency, which is defined by a serum level of 25-hydroxyvitamin D [25(OH)D] of lower than 20 ng/mL, in all populations of the world. Unfortunately, the prevalence of vitamin D deficiency in patients with intestinal malabsorption syndromes, including cystic fibrosis (CF), celiac disease (CD), short bowel syndrome and inflammatory bowel disease (IBD), is higher than that in the general population, indicating the presence of disease-specific causative factors. In this review, we aimed to present clinical findings to highlight the roles of insufficient exposure to sunlight and inflammation in the development of vitamin D deficiency in patients with intestinal malabsorption syndromes. Furthermore, we aimed to present experimental evidence that supported a role of vitamin D deficiency in the pathogenesis of IBD. Finally, we reviewed clinical intervention strategies aiming to normalize vitamin D status in and even to improve the conditions of patients and to discuss certain issues that needed to be addressed in future research.

Impact of drug therapy and surgery on quality of life in Crohn's disease: a systematic review

Crohn's disease is associated with substantially impaired health-related quality of life (HRQoL). Even in the absence of active disease, patients with Crohn's disease report lower HRQoL, poorer function, and greater concerns, than those without disease. Achievement of disease remission in Crohn's disease, whether by pharmacological or surgical means, is associated with improved HRQoL, although the durability of the improvement seen after intestinal resection is uncertain because of the high rate of postoperative disease recurrence. This review focuses on the available literature on HRQoL in patients with Crohn's disease with an emphasis on the effects of intestinal resection and immunomodulatory therapy.

Perianal disease is associated with psychiatric co-morbidity in Crohn's disease in remission

BACKGROUND AND AIM

Crohn's disease is a life-long inflammatory disease which can impair quality of life, in particular in patients with psychiatric co-morbidities such as depression and anxiety. The aim of this prospective cohort study was to assess the prevalence of depression and anxiety and related risk factors in patients with quiescent Crohn's disease.

METHODS

A consecutive series of adult patients with confirmed diagnosis of Crohn's disease, in clinical remission, were included and investigated during ambulatory visits using a standard questionnaire assessing demographic and clinical features of the disease. Within 1 month after the ambulatory visit, all patients were interviewed by phone to assess the presence of psychiatric disorders using standardized questionnaires. The questionnaire assessed the development of psychiatric disorders after the diagnosis of Crohn's disease, the use of antidepressant or antianxiety therapy and current anxiety or depression by means of the Hospital Anxiety and Depression Scale.

RESULTS

One hundred and ninety-five patients were included. Seventy-two (36.9 %) patients showed anxiety and/or depression symptoms, 46 (23.6 %) patients showed anxiety symptoms, 6 (3.1 %) patients showed depression symptoms and 20 (10.3 %) patients showed both symptoms. Forty-eight of these patients (58 %) were without any antidepressive or antianxiety treatment. Anxiety with or without depression was significantly correlated with female sex (p = 0.017), history of perianal disease (p = 0.003) and perianal surgery (p = 0.042).

CONCLUSION

Anxiety is a frequent, often untreated, condition in patient affected by Crohn's disease in clinical remission. Female sex, history of perianal disease and perianal surgery are major risk factors for anxiety.

Anorectal complications and function in patients suffering from inflammatory bowel disease: a series of patients with long-term follow-up

AIM

The aim of this study is to describe the long-term course of anorectal complains and function in a single centre cohort patients suffering from inflammatory bowel disease (IBD) with perianal lesions.

METHODS

Between 1993 and 2000, 56 IBD patients (43 Crohn's disease and 13 ulcerative colitis) with perianal complaints underwent anorectal function evaluation (AFE) (baseline). For follow-up, they were approached between 2010 and 2012 by sending questionnaires including Inflammatory Bowel Disease Quality of Life Questionnaire (IBDQ), Perianal Disease Activity Index (PDAI), faecal incontinence scale (Vaizey) and an invitation for AFE.

RESULTS

At follow-up, 46 patients (82 %) were available, 9 (16 %) were lost and 1 (2 %) had died. Thirty patients returned the questionnaires of which 17 also underwent AFE. The remaining 16 patients were interviewed by phone and were only willing to mention their anorectal complaints. Median follow-up was 14 year. In 25 of the 46 patients (54 %), perianal complaints persisted faecal incontinence (n = 7); soiling (n = 13) and active fistula (n = 5). Eighteen (39 %) patients had an active fistula at baseline and three persisted at follow-up. Two developed a new fistula. Mean IBDQ, Vaizey and PDAI were 178 (SD 29), 7 (SD 5) and 4.2 (SD 3.0), respectively. In 17 patients, who underwent AFE, anal endosonography showed healing in nine of the ten fistulas. Anal pressures as well as rectal capacity remained unaltered in the individual patient, but showed a large range within the group.

CONCLUSION

After 14 years, 54 % of the IBD patients with perianal lesions still have mild complaints. The quality of life remained moderate over a long period, which is concerning.

Similar risk of depression and anxiety following surgery or hospitalization for Crohn's disease and ulcerative colitis

OBJECTIVES

Psychiatric comorbidity is common in Crohn's disease (CD) and ulcerative colitis (UC). Inflammatory bowel disease (IBD)-related surgery or hospitalizations represent major events in the natural history of the disease. The objective of this study is to examine whether there is a difference in the risk of psychiatric comorbidity following surgery in CD and UC.

METHODS

We used a multi-institution cohort of IBD patients without a diagnosis code for anxiety or depression preceding their IBD-related surgery or hospitalization. Demographic-, disease-, and treatment-related variables were retrieved. Multivariate logistic regression analysis was performed to individually identify risk factors for depression and anxiety.

RESULTS

Our study included a total of 707 CD and 530 UC patients who underwent bowel resection surgery and did not have depression before surgery. The risk of depression 5 years after surgery was 16% and 11% in CD and UC patients, respectively. We found no difference in the risk of depression following surgery in the CD and UC patients (adjusted odds ratio, 1.11; 95% confidence interval, 0.84-1.47). Female gender, comorbidity, immunosuppressant use, perianal disease, stoma surgery, and early surgery within 3 years of care predicted depression after CD surgery; only the female gender and comorbidity predicted depression in UC patients. Only 12% of the CD cohort had ≥4 risk factors for depression, but among them nearly 44% subsequently received a diagnosis code for depression.

CONCLUSIONS

IBD-related surgery or hospitalization is associated with a significant risk for depression and anxiety, with a similar magnitude of risk in both diseases.