Osteoporosis in patients with inflammatory bowel disease

Investigating the association between osteopenia and bowel perforation through a multicenter radiologic analysis

Anecdotal evidence from preliminary observations has noted multiple instances where osteoporosis is present in elderly patients before the clinical detection of bowel disease, even in the absence of overt gastrointestinal symptoms. However, any potential association between these conditions remains to be further investigated. This computed tomography (CT) study investigates whether patients with gastrointestinal (GI) perforation have lower bone mineral density (BMD) than age and sex matched controls. BMD was measured by drawing 3D regions of interest in the bone marrow of the L1-L3 vertebral bodies on CT scans of each of 37 GI perforations and matched controls. Spectrometric calibration of Hounsfield units to the mineral scale was performed with density measurements in the paravertebral muscles (erector spinae) and subcutaneous adipose tissue. The mean BMD of patients with GI perforation (135.9 ± 24.3 mg/ml) was significantly lower than that of controls (96.9 ± 27.5 mg/ml, p < 0.05). The calculated T-and Z-scores of bone mineral density were also significantly different between the two groups (p < 0.05 for each) and were - 2.9 (± 0.90) and - 0.8 (± 0.91) in patients with GI perforation and - 1.6 (± 0.83) and 0 (± 0.96) in the control group, respectively. The results imply that patients with gastrointestinal (GI) perforation have lower bone mineral density (BMD) than age-and sex-matched controls, posing the question whether the screening and aggressive management of osteoporosis is high-risk populations for gastrointestinal perforation can prevent gastrointestinal complications in targeted populations.

The association of inflammatory bowel disease with postoperative complications, re-admissions and emergency department visits following primary total hip arthroplasty

BACKGROUND

Inflammatory bowel disease (IBD) is a systemic inflammatory disorder of the gut. Few studies have evaluated whether patients with a history of IBD have worse outcomes following primary total hip arthroplasty (THA). Therefore, the purpose of this study was to evaluate whether IBD is associated with increased: (1) medical complications; (2) readmissions; and (3) emergency department (ED) visits.

METHODS

Using a nationwide claims database, patients with IBD undergoing primary THA were identified and matched to a comparison group according to age, sex and the Charlson Comorbidity Index. Outcomes assessed included the development of 90-day medical complications, 90-day re-admissions and 90-day ED visit rates. A p-value <0.0001 was considered statistically significant.

RESULTS

Patients with IBD had a greater incidence and odds ratio of total medical complications (31.90% vs. 11.47%; OR 2.89; p < 0.0001) compared with matched controls. IBD patients had significantly higher incidence and odds ratio of developing acute kidney injury (5.46 vs. 1.46%; OR 3.92; p < 0.0001), cerebrovascular accident (1.32 vs. 0.35%; OR 3.79; p < 0.0001), pneumonia (4.02 vs. 1.30%; OR 3.19; p < 0.0001), respiratory failure (1.21 vs. 0.41%; OR 2.94; p < 0.0001), deep vein thrombosis (0.89% vs. 0.30%; OR 2.93; p < 0.0001), and other adverse events. IBD patients also had higher incidence and odds ratio of 90-day re-admissions (4.20% vs. 3.23%; OR 1.31; p < 0.0001) and ED visits (6.56% vs. 3.99%; OR 1.69; p < 0.0001).

CONCLUSIONS

This study found that patients with IBD are at increased risk of 90-day medical complications, re-admissions, and ED visits. Due to its systemic nature, surgeons operating on these patients should be aware of the disease's extra-intestinal manifestations, and the potential postoperative risks in IBD patients. Providers should use this investigation when educating patients on potential risks of elective THA.

Progress of linking gut microbiota and musculoskeletal health: casualty, mechanisms, and translational values

The musculoskeletal system is important for balancing metabolic activity and maintaining health. Recent studies have shown that distortions in homeostasis of the intestinal microbiota are correlated with or may even contribute to abnormalities in musculoskeletal system function. Research has also shown that the intestinal flora and its secondary metabolites can impact the musculoskeletal system by regulating various phenomena, such as inflammation and immune and metabolic activities. Most of the existing literature supports that reasonable nutritional intervention helps to improve and maintain the homeostasis of intestinal microbiota, and may have a positive impact on musculoskeletal health. The purpose of organizing, summarizing and discussing the existing literature is to explore whether the intervention methods, including nutritional supplement and moderate exercise, can affect the muscle and bone health by regulating the microecology of the intestinal flora. More in-depth efficacy verification experiments will be helpful for clinical applications.

Risk Variants in or Near ZBTB40 AND NFATC1 Increase the Risk of Both IBD and Adverse Bone Health Outcomes Highlighting Common Genetic Underpinnings Across Both Diseases

BACKGROUND

Inflammatory bowel disease (IBD) is associated with an increased risk of osteoporosis and bone fracture. The aims of this study were to (1) confirm the association between IBD and low bone density and (2) test for shared risk variants across diseases.

METHODS

The study cohort included patients from the Michigan Genomics Initiative. Student's t tests (continuous) and chi-square tests (categorical) were used for univariate analyses. Multivariable logistic regression was performed to test the effect of IBD on osteoporosis or osteopenia. Publicly available genome-wide association summary statistics were used to identify variants that alter the risk of IBD and bone density, and Mendelian randomization (MR) was used to identify causal effects of genetically predicted IBD on bone density.

RESULTS

There were 51 405 individuals in the Michigan Genomics Initiative cohort including 10 378 (20.2%) cases of osteoporosis or osteopenia and 1404 (2.7%) cases of IBD. Patients with osteoporosis or osteopenia were more likely to be older (64 years of age vs 56 years of age; P < .001), female (67% vs 49%; P < .001), and have a lower body mass index (29 kg/m2 vs 30 kg/m2; P < .001). IBD patients with (odds ratio, 4.60; 95% confidence interval, 3.93-5.37) and without (odds ratio, 1.77; 95% confidence interval, 1.42-2.21) steroid use had a significantly higher risk of osteoporosis or osteopenia. Twenty-one IBD variants associated with reduced bone mineral density at P ≤ .05 and 3 IBD risk variants associated with reduced bone mineral density at P ≤ 5 × 10-8. Of the 3 genome-wide significant variants, 2 increased risk of IBD (rs12568930-T: MIR4418;ZBTB40; rs7236492-C: NFATC1). MR did not reveal a causal effect of genetically predicted IBD on bone density (MR Egger, P = .30; inverse variance weighted, P = .63).

CONCLUSIONS

Patients with IBD are at increased risk for low bone density, independent of steroid use. Variants in or near ZBTB40 and NFATC1 are associated with an increased risk of IBD and low bone density.

Current status of N-, O-, S-heterocycles as potential alkaline phosphatase inhibitors: a medicinal chemistry overview

Heterocycles are a class of compounds that have been found to be potent inhibitors of alkaline phosphatase (AP), an enzyme that plays a critical role in various physiological processes such as bone metabolism, cell growth and differentiation, and has been linked to several diseases such as cancer and osteoporosis. AP is a widely distributed enzyme, and its inhibition has been considered as a therapeutic strategy for the treatment of these diseases. Heterocyclic compounds have been found to inhibit AP by binding to the active site of the enzyme, thereby inhibiting its activity. Heterocyclic compounds such as imidazoles, pyrazoles, and pyridines have been found to be potent AP inhibitors and have been studied as potential therapeutics for the treatment of cancer, osteoporosis, and other diseases. However, the development of more potent and selective inhibitors that can be used as therapeutics for the treatment of various diseases is an ongoing area of research. Additionally, the study of the mechanism of action of heterocyclic AP inhibitors is an ongoing area of research, which could lead to the identification of new targets and new therapeutic strategies. The enzyme known as AP has various physiological functions and is present in multiple tissues and organs throughout the body. This article presents an overview of the different types of AP isoforms, their distribution, and physiological roles. It also discusses the structure and mechanism of AP, including the hydrolysis of phosphate groups. Furthermore, the importance of AP as a clinical marker for liver disease, bone disorders, and cancer is emphasized, as well as its use in the diagnosis of rare inherited disorders such as hypophosphatasia. The potential therapeutic applications of AP inhibitors for different diseases are also explored. The objective of this literature review is to examine the function of alkaline phosphatase in various physiological conditions and diseases, as well as analyze the structure-activity relationships of recently reported inhibitors. The present review summarizes the structure-activity relationship (SAR) of various heterocyclic compounds as AP inhibitors. The SAR studies of these compounds have revealed that the presence of a heterocyclic ring, particularly a pyridine, pyrimidine, or pyrazole ring, in the molecule is essential for inhibitory activity. Additionally, the substitution pattern and stereochemistry of the heterocyclic ring also play a crucial role in determining the potency of the inhibitor.

Colon epithelial cell-specific Bmal1 deletion impairs bone formation in mice

The circadian clock system regulates multiple metabolic processes, including bone metabolism. Previous studies have demonstrated that both central and peripheral circadian signaling regulate skeletal growth and homeostasis in mice. Disruption in central circadian rhythms has been associated with a decline in bone mineral density in humans and the global and osteoblast-specific disruption of clock genes in bone tissue leads to lower bone mass in mice. Gut physiology is highly sensitive to circadian disruption. Since the gut is also known to affect bone remodeling, we sought to test the hypothesis that circadian signaling disruption in colon epithelial cells affects bone. We therefore assessed structural, functional, and cellular properties of bone in 8 week old Ts4-Cre and Ts4-Cre;Bmal1fl/fl (cBmalKO) mice, where the clock gene Bmal1 is deleted in colon epithelial cells. Axial and appendicular trabecular bone volume was significantly lower in cBmalKO compared to Ts4-Cre 8-week old mice in a sex-dependent fashion, with male but not female mice showing the phenotype. Similarly, the whole bone mechanical properties were deteriorated in cBmalKO male mice. The tissue level mechanisms involved suppressed bone formation with normal resorption, as evidenced by serum markers and dynamic histomorphometry. Our studies demonstrate that colon epithelial cell-specific deletion of Bmal1 leads to failure to acquire trabecular and cortical bone in male mice.

Role of Vitamin K in Intestinal Health

Intestinal diseases, such as inflammatory bowel diseases (IBDs) and colorectal cancer (CRC) generally characterized by clinical symptoms, including malabsorption, intestinal dysfunction, injury, and microbiome imbalance, as well as certain secondary intestinal disease complications, continue to be serious public health problems worldwide. The role of vitamin K (VK) on intestinal health has drawn growing interest in recent years. In addition to its role in blood coagulation and bone health, several investigations continue to explore the role of VK as an emerging novel biological compound with the potential function of improving intestinal health. This study aims to present a thorough review on the bacterial sources, intestinal absorption, uptake of VK, and VK deficiency in patients with intestinal diseases, with emphasis on the effect of VK supplementation on immunity, anti-inflammation, intestinal microbes and its metabolites, antioxidation, and coagulation, and promoting epithelial development. Besides, VK-dependent proteins (VKDPs) are another crucial mechanism for VK to exert a gastroprotection role for their functions of anti-inflammation, immunomodulation, and anti-tumorigenesis. In summary, published studies preliminarily show that VK presents a beneficial effect on intestinal health and may be used as a therapeutic drug to prevent/treat intestinal diseases, but the specific mechanism of VK in intestinal health has yet to be elucidated.

The risk of revision following total hip arthroplasty in patients with inflammatory bowel disease, a registry based study

Inflammatory bowel disease (IBD) is characterized by chronic inflammation of the intestinal tract and is associated with decreased bone mineral density. IBD patients are at higher risk of osteopenia, osteoporosis and fracture compared to non-IBD patients. The impact of IBD on the performance of orthopedic implants has not been well studied. We hypothesized that a history of IBD at the time of primary total hip arthroplasty (THA) would increase the risk of subsequent failure as assessed by revision surgery. A retrospective implant survival analysis was completed using the Swedish Hip Arthroplasty Registry and the Sweden National Patient Register. A total of 150,073 patients undergoing THA for osteoarthritis within an 18-year period were included in the study. THA patients with (n = 2,604) and without (n = 147,469) a history of IBD at the time of THA were compared with primary revision as the main endpoint and adjusted using sex, age category and comorbidity (Elixhauser scores) as covariates. We found that patients with a history of IBD had a relatively higher risk of revision surgery for septic causes while the non-IBD patients had a relatively higher risk of revision for aseptic causes (p = 0.004). Our findings suggest there may be an association between gut health and THA performance.

Microscopic Colitis Is Not an Independent Risk Factor for Low Bone Density

BACKGROUND

Microscopic colitis (MC) is a subtype of inflammatory bowel disease (IBD) with overlapping risk factors for low bone density (LBD). While LBD is a known complication of IBD, its association with MC is not well-established.

AIMS

Assess the prevalence of LBD in MC compared to control populations, and evaluate if MC predicts LBD when controlling for confounders.

METHODS

Retrospective, observational case control study of adult patients with pathologically confirmed MC from 2005 to 2015. Bone density measurements were abstracted from dual-energy X-ray absorptiometry (DEXA) reports, and bone density was classified using T-score: normal (T ≥ - 1.0), osteopenia (- 1.0 > T > -2.5) or osteoporosis (T ≤ - 2.5). Demographics, disease, medication history and LBD risk factors were obtained from chart review. Prevalence of LBD was compared to national and local controls. A matched control cohort to MC patients without prior diagnosis of LBD was analyzed with logistic regression to assess the relationship of MC to LBD.

RESULTS

One hundred and eighteen patients with MC were identified. Osteopenia in women with MC was more prevalent compared to national controls (67% vs. 49%, p = 0.0004), and LBD was more prevalent in MC patients compared to local controls (82% vs. 55%, p < 0.0001). In MC patients without prior diagnosis of LBD matched to controls, there was a higher prevalence of osteopenia (53.2% vs. 36.7%, p = 0.04). However, after controlling for confounders, MC was not associated with LBD (OR 0.83, 95% CI 0.22, 3.16, p = 0.8).

CONCLUSIONS

While LBD was more prevalent in MC patients compared to control populations, with adjustment for key confounders (including BMI, steroids, smoking, vitamin D and calcium use), MC was not an independent predictor of LBD.

Diet and nutrition in the management of inflammatory bowel disease

The role of diet and its manipulation in the management of inflammatory bowel disease (IBD) is gradually acquiring central stage. Certain dietary factors have been identified as putative triggers in IBD as some other factors are found to be protective. The dietary manipulation as part of comprehensive IBD care should be done by the clinician in conjunction with a skilled dietitian. Nutritional deficiencies are common in patients with IBD and can have long-term effects on disease course and quality of life in these patients. So, early identification and correction of these deficiencies along with proper nutritional supplementation should be addressed routinely as a part of IBD management. Oral nutritional supplementation is sufficient for most patients, but in some sick patients, tube feeding may be necessary. Diet needs to be individualized based on the nutritional deficiencies and dietary triggers in a specific patient. Multiple specific diets, with elimination of components that trigger inflammation or addition of components that alter gut microbes in a favorable way, are now appearing as a treatment option in IBD, but more evidence is required before their universal recommendation. Though enteral nutrition (EN) (both exclusive enteral nutrition [EEN] and partial enteral nutrition [PEN]) have proven therapeutic role in pediatric IBD, their uses and role are now expanding in adult IBD patients as well.

The microbiota-gut-bone axis and bone health

The gastrointestinal tract is colonized by trillions of microorganisms, consisting of bacteria, fungi, and viruses, known as the "second gene pool" of the human body. In recent years, the microbiota-gut-bone axis has attracted increasing attention in the field of skeletal health/disorders. The involvement of gut microbial dysbiosis in multiple bone disorders has been recognized. The gut microbiota regulates skeletal homeostasis through its effects on host metabolism, immune function, and hormonal secretion. Owing to the essential role of the gut microbiota in skeletal homeostasis, novel gut microbiota-targeting therapeutics, such as probiotics and prebiotics, have been proven effective in preventing bone loss. However, more well-controlled clinical trials are still needed to evaluate the long-term efficacy and safety of these ecologic modulators in the treatment of bone disorders.

Nutritional adequacy in surgical IBD patients

BACKGROUND & AIMS

Despite little evidence available to date, the dietary intake assessment is considered a useful tool to optimize dietary intervention for the improvement of the nutritional status of IBD patients. The primary aim was to compare the dietary intake of IBD patients scheduled for surgery with the dietary reference values (DRVs) for the Italian population (LARN) and the ESPEN guidelines for clinical nutrition in IBD. The secondary aim was to describe the dietary patterns of patients with CD and UC in relation to the disease-specific and nutritional parameters and to compare these results to a control group in order to evaluate if similar nutritional intakes than in oncologic patients are found in IBD.

METHODS

Between January 2019 and March 2020, 62 consecutive IBD patients (46 CD and 16 UC) with age from 18 to 79 years scheduled for surgery were recruited. Patients received a comprehensive nutritional assessment, including food or nutrition-related history, anthropometric and body composition measurements. A group of 61 oncologic patients scheduled for colorectal cancer (CRC) surgery was used as control.

RESULTS

IBD patients showed a higher caloric and nutritional intake than CRC group, despite a higher frequency of underweight, and a lower prevalence of overweight and obesity. IBD patients showed an inadequate intake of proteins, n-3 PUFA, fiber, iron, calcium, potassium, magnesium, zinc, vitamin D and vitamin B12 according to ESPEN guidelines for clinical nutrition in IBD and LARN. Oral intake was not influenced by gender, IBD subtype, longer duration of disease and previous surgery. In CD, fistulizing behaviour negatively influenced oral intake.

CONCLUSIONS

in IBD patients, the evaluation of macronutrients and micronutrients intake before surgery, can contribute to evaluate and to correct the onset of nutritional deficiencies. Specific dietary recommendations seem required, in order to integrate specific nutritional inadequacies. IBD patients referred to surgery have to be considered at high nutritional risk like oncologic patients are.

Phytochemicals affect T helper 17 and T regulatory cells and gut integrity: implications on the gut-bone axis

The pathology of osteoporosis is multifactorial, but a growing body of evidence supports an important role of the gut-bone axis, especially in bone loss associated with menopause, rheumatoid arthritis, and periodontal disease. Aberrant T cell responses favoring an increase in the ratio of T helper 17 cells to T regulatory cells play a critical role in the underlying etiology of this bone loss. Many of the dietary phytochemicals known to have osteoprotective activity such as flavonoids, organosulfur compounds, phenolic acids, as well as the oligosaccharides also improve gut barrier function and affect T cell differentiation and activation within gut-associated lymphoid tissues and at distal sites. Here, we examine the potential of these phytochemicals to act as prebiotics and immunomodulating agents, in part targeting the gut to mediate their effects on bone.

The association between irritable bowel syndrome and osteoporosis: a systematic review and meta-analysis

BACKGROUND

Recent studies have suggested that irritable bowel syndrome (IBS) could be a risk factor for osteoporosis although the evidence is still limited. The current study aimed to comprehensively examine the risk of osteoporosis among patients with IBS using systematic review and meta-analysis technique.

METHODOLOGY

Literature search was independently conducted by two investigators using MEDLINE, EMBASE, and Google Scholar database up to October 2019. Eligible study must evaluate whether patients with IBS have a higher risk of osteoporosis and/or osteoporotic fracture. It could be either cross-sectional study, case-control study, or cohort study. Point estimates and standard errors from each eligible study were combined together using the generic inverse variance method of DerSimonian and Laird.

RESULTS

Of the 320 articles identified from the three databases, four cohort and one cross-sectional study with 526,633 participants met the eligibility criteria and were included into the meta-analysis. All five studies investigated the risk of osteoporosis among patients with IBS, and the pooled analysis found that patients with IBS had a significantly higher risk of osteoporosis than individuals without IBS with the pooled risk ratio of 1.95 (95% CI, 1.04-3.64; I² 100%). Sensitivity analysis including only cohort studies found a lower RR (pooled RR 1.55; 95% CI, 1.39-1.72) with a lower I² (59%). Three studies investigated the risk of osteoporotic fracture, and the pooled analysis found that patients with IBS also had a higher risk of osteoporotic fracture than individuals without IBS with the pooled risk ratio of 1.58 although statistical significance was not reached (95% CI, 0.95-2.62; I² 99%). Sensitivity analysis including only cohort studies found a lower RR (pooled RR 1.27; 95% CI, 1.20-1.39) with a dramatically lower I² (0%). Limitations included high heterogeneity and reliance on diagnostic codes.

CONCLUSION

A significantly increased risk of osteoporosis among IBS patients was observed in this study. Early intervention to prevent the development of osteoporosis, such as weight-bearing exercise, adequate intake of vitamin D and calcium, and early screening for osteoporosis, may be beneficial to these patients although further studies are still required to confirm the efficacy and cost-effectiveness of this approach.

Prevalence, Risk Factors and Course of Osteoporosis in Patients with Crohn's Disease at a Tertiary Referral Center

Background: Patients with Crohn’s disease are at increased risk for fractures due to low bone mineral density (BMD). Real-world data are necessary to optimize surveillance and treatment strategies. Methods: Patients with Crohn’s disease who underwent at least one dual-energy X-ray absorptiometry (DXA) scans were recruited. The primary study endpoints were (1) prevalence of osteoporosis, and (2) factors influencing changes of BMD. To identify potential risk factors for reduced BMD, Mann–Whitney U-test was used for ordinal and continuous variables and x²-tests for categorical variables. Results with p < 0.05 were included in a multivariable analysis. To identify potential factors influencing changes in BMD, a generalized linear mixed model was applied. Results: 39.9% of the patients were diagnosed with normal BMD, 40.2% with osteopenia, and 19.8% with osteoporosis. The main risk factors for osteoporosis were low body mass index (BMI), previous bowel resections and male sex. The main risk factors for reduced BMD during further along the disease course were steroid use, history of immunomodulator treatment, female sex and decreased BMI. Conclusion: Low BMI, previous bowel resections and male sex were the main risk factors for the development of osteoporosis. Steroid use reduced BMD even under anti-inflammatory therapy, underlining that they should be used with great care in that patient group.

Inflammatory Bowel Disease and Risk of Osteoporotic Fractures: A Meta-Analysis

Introduction Inflammatory bowel disease (IBD) and its complications have been well-established. The literature shows an association between IBD and decreased bone mineral density in the adult population. However, most studies have reported an association between IBD and osteoporosis, while the risk of fractures has not been well-studied. The aim of this meta-analysis is to summarize the best available evidence regarding IBS and osteoporotic fractures. Methods A review of the literature using the MEDLINE and EMBASE databases was performed during November 2017. We included cross-sectional and cohort studies that reported the relative risks, odds ratios, and hazard ratios comparing the risk of developing osteoporotic fractures among patients with IBD patients, both ulcerative colitis (UC) and Crohn's disease (CD), versus patients without IBD as controls. The pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using the generic inverse-variance method. Results After a review of the literature, seven studies fulfilled the eligibility criteria established during the analysis. A significant association was found between IBD and osteoporosis, with a pooled OR of 1.32 (95% CI, 1.2 - 1.4). Low heterogeneity among the studies was found, I²=42.3. No publication bias was found using the Egger regression test p=0.18. Sensitivity analysis showed that the inclusion of data on children by Kappelman et al. (2007) did not change the results. Conclusion A significant association between IBD and the risk of developing osteoporotic fractures was observed in this study. There is a 32% increased risk, which is consistent with different cohort studies previously done.

Improving bone mineral density screening in patients with inflammatory bowel disease: a quality improvement report

The prevalence of osteopenia and osteoporosis in patients with inflammatory bowel disease (IBD) is estimated between 17% and 41%, partly due to repeat courses of glucocorticoids which enhance the risk for bone disease. Multiple gastroenterological and endocrine societies have established guidelines for bone mineral density (BMD) screening in patients with IBD, with estimates suggesting providers vary in their adherence. We aimed to improve the rate of BMD screening in patients with IBD in a large academic outpatient practice. Using the Plan-Do-Study-Act (PDSA) model, we first conducted a retrospective review and determined that only 10.8% of patients with IBD in our practice were adequately undergoing BMD screening. Over the course of five PDSA cycles, we conducted three interventions focusing on education and provider reminders. Through an informative lecture, a flyer and an electronic medical record-based prompt, we were able to increase our rate of BMD screening to 81.8%. Current rates of BMD screening in patients with IBD are not adequate. We demonstrate a simple quality improvement initiative that successfully improved our adherence to standards of practice.

Diversity of Gut Microbiota Affecting Serum Level of Undercarboxylated Osteocalcin in Patients with Crohn's Disease

Several reports have indicated a possible link between decreasing plasma levels of vitamin K and bone mineral density. It has been suggested that intestinal bacteria contribute to maintenance of vitamin K. Several factors are involved in the reduction of vitamin K in patients with Crohn’s disease (CD). We aimed to assess the relationship between gut microbiota and alternative indicators of vitamin K deficiency in patients with CD. We collected the feces of 26 patients with clinically inactive CD. We extracted 16S rRNA from the intestinal bacteria in the feces and amplified it by polymerase chain reaction. The generated polymerase chain reaction product was analyzed using a 16S metagenomic approach by Illumina Miseq platform. Serum undercarboxylated osteocalcin concentration was used as an alternative indicator of vitamin K deficiency. There was a significant negative correlation between serum undercarboxylated osteocalcin and mean Chao1 index in cases of low activity. The diversity of the gut microbiota was significantly lower, and Ruminococcaceae and Lachnospiraceae were significantly decreased in the vitamin K-deficient group in comparison to the vitamin K-normal group. Taken together, these data suggested the significance of investigating the gut microbiota even in patients with clinically inactive CD for improving patients’ vitamin K status.

Crohn Disease and Fracture Risk Assessment With FRAX

Background

Studies are inconsistent whether people with Crohn disease (CD) have an increased fracture risk.

This study showed that patients with Crohn’s disease (CD) had a higher ten year probability of fracture, assessed by the fracture assessment tool FRAX, and more fractures, but the proportion of CD patients with a fracture was not significantly higher than that of controls.

Methods

Forty-nine CD and 49 controls participated. All 98 completed a health questionnaire. A score with the fracture assessment tool FRAX &gt; 15% was considered risk factor for fracture.

Results

Mean FRAX score for 49 CD was 10.1 ± 10.3% and for 49 controls 5.0 ± 3.9% (P = 0.002). The variables correlated with fracture were being female (P = 0.04) and having a fractured mother (P = 0.002).

Conclusion

The CD group had significantly higher FRAX scores and more fractures, but the proportion of CD subjects with a fracture was not significantly higher than that of controls.

Findings of CT-Derived Bone Strength Assessment in Inflammatory Bowel Disease Patients Undergoing CT Enterography in Clinical Practice

BACKGROUND

Inflammatory bowel disease (IBD) patients are at risk of developing complications from metabolic bone disease, but the exact prevalence is unknown. We evaluated fracture risk in IBD patients using (1) biomechanical CT analysis (BCT) using bone strength and bone mineral density (BMD), (2) Cornerstone guidelines, and (3) other clinical features predicting fracture risk.

METHODS

A retrospective review of consecutive IBD patients who underwent CT enterography (CTE) with BCT from March 2014 to March 2017 was performed. Measured outcomes were overall fracture risk classification (not increased, increased, or high) and femoral neck BMD World Health Organization classification (normal, osteopenia, or osteoporosis).

RESULTS

Two hundred fifty-seven patients with IBD underwent CTE and BCT. Fracture risk was classified as not increased in 45.5% (116/255) of patients, increased in 44.7% (114/255), and high in 9.8% (25/255). Femoral neck BMD was classified as normal in 56.8% (142/250), osteopenia in 37.6% (94/250), and osteoporosis in 5.6% (14/250). In multivariate analysis, only increasing age was associated with increased fracture risk (odds ratio, 1.06; 95% confidence interval, 1.04-1.08; P < 0.001). Cornerstone guidelines were met by 35.3% (41/116), 56.1% (64/114), and 76.0% (19/25) of patients in the not increased, increased, and high-risk groups, respectively (P = 0.0001). No Cornerstone criteria were met by 40% (56/139) of patients in the increased and high-risk groups.

CONCLUSIONS

Using BCT, increased or high fracture risk was detected in more than half of this cohort, the prevalence being associated with increased age. A significant proportion of patients with increased or high fracture risk did not meet Cornerstone guidelines. Therefore, IBD patients who do not meet Cornerstone guidelines may benefit from BCT screening.

Epithelial Barrier Function in Gut-Bone Signaling

The intestinal epithelial barrier plays an essential role in maintaining host homeostasis. The barrier regulates nutrient absorption as well as prevents the invasion of pathogenic bacteria in the host. It is composed of epithelial cells, tight junctions, and a mucus layer. Several factors, such as cytokines, diet, and diseases, can affect this barrier. These factors have been shown to increase intestinal permeability, inflammation, and translocation of pathogenic bacteria. In addition, dysregulation of the epithelial barrier can result in inflammatory diseases such as inflammatory bowel disease. Our lab and others have also shown that barrier disruption can have systemic effects including bone loss. In this chapter, we will discuss the current literature to understand the link between intestinal barrier and bone. We will discuss how inflammation, aging, dysbiosis, and metabolic diseases can affect intestinal barrier-bone link. In addition, we will highlight the current suggested mechanism between intestinal barrier and bone.

Mycobacterial infection influences bone biomarker levels in patients with Crohn's disease

Patients with Crohn's disease (CD) have higher risk for osteoporosis following decreased level of osteocalcin. We hypothesize that active inflammation following Mycobacterium avium subsp. paratuberculosis (MAP) infection results in elevation of undercarboxylated osteocalcin (ucOC) and downregulation of active osteocalcin in CD patients and cow-disease model (Johne's disease). In this study, we measured ucOC, active osteocalcin, and calcium levels in sera from 42 cattle (21 infected with MAP and 21 healthy cattle), 18 CD patients, and 20 controls. The level of ucOC in MAP⁺ bovine samples was higher than that in MAP^- controls (318 ± 57.2 nmol/mL vs. 289 ± 95.8 nmol/mL, P > 0.05). Consequently, mean calcium level in bovine MAP⁺ was significantly higher than that in bovine-MAP^- samples (9.98 ± 0.998 mg/dL vs. 7.65 ± 2.12 mg/dL, P < 0.05). Also, the level of ucOC was higher in CD-MAP⁺ than in CD-MAP^- (561 ± 23.7 nmol/mL vs. 285 ± 19.6 nmol/mL, P < 0.05). Interestingly, the mean osteocalcin level in MAP⁺ bovine was lower than that in MAP^- bovine (797 ± 162 pg/mL vs. 1190 ± 43 pg/mL) and it was lower in CD-MAP⁺ than in CD-MAP^- infection (1.89 ± 0.184 ng/mL vs. 2.19 ± 0.763 ng/mL) (P < 0.05). The correlation between MAP infection and elevation of sera ucOC, reduction of active osteocalcin and increased calcium supports MAP infection role in CD and complications with osteoporosis.

Re-evaluating osteoporosis and fracture risk in Crohn's disease patients in the era of TNF-alpha inhibitors

INTRODUCTION

Patients with Crohn's disease (CD) are at increased risk for osteoporosis and fractures as compared to the general population. Recently, various cytokines including tumor necrosis factor (TNF)-alpha are found to play a major role in bone health. In this study, we aimed to gain a better understanding of the risk factors for osteoporosis and vitamin D deficiency in the era of TNF-alpha inhibitors.

METHODS

We conducted a retrospective review of 464 consecutive patients with CD in our GI clinic between 2008 and 2015. Statistical analysis was performed using the student t-test and chi-square test.

RESULTS

CD patients treated with TNF-alpha inhibitors (TNF) and those who are anti-TNF naïve (NB) had similar rates of vitamin D deficiency, insufficiency and normal vitamin D-25-OH levels. Similarly, rates of osteoporosis (16% vs 18%), osteopenia (53% vs 57%) and normal bone density (31% vs 25%) were comparable between the TNF and NB groups respectively. However, Z-scores at the spine (-0.47 vs -0.05) were significantly lower in the TNF group (p = .03). Interestingly, rates of osteoporosis in the NB group were drastically different before and after age 60 (3.6% vs 30%) with no major difference in the TNF group (15% vs 18%). Bone density was positively correlated with BMI (Pearson's R = 0.39) and negatively correlated with age and smoking status (R= -0.25).

CONCLUSIONS

TNF group patients were diagnosed with osteoporosis from an earlier age compared to NB group but with a smaller increase in osteoporosis after menopause. Further prospective studies are necessary to further determine the role of anti-TNF medications in osteoporosis.

Suppressor of cytokine signaling 2 (Socs2) deletion protects bone health of mice with DSS-induced inflammatory bowel disease

Individuals with inflammatory bowel disease (IBD) often present with poor bone health. The development of targeted therapies for this bone loss requires a fuller understanding of the underlying cellular mechanisms. Although bone loss in IBD is multifactorial, the altered sensitivity and secretion of growth hormone (GH) and insulin-like growth factor-1 (IGF-1) in IBD is understood to be a critical contributing mechanism. The expression of suppressor of cytokine signaling 2 (SOCS2), a well-established negative regulator of GH signaling, is stimulated by proinflammatory cytokines. Therefore, it is likely that SOCS2 expression represents a critical mediator through which proinflammatory cytokines inhibit GH/IGF-1 signaling and decrease bone quality in IBD. Using the dextran sodium sulfate (DSS) model of colitis, we reveal that endogenously elevated GH function in the Socs2^−/− mouse protects the skeleton from osteopenia. Micro-computed tomography assessment of DSS-treated wild-type (WT) mice revealed a worsened trabecular architecture compared to control mice. Specifically, DSS-treated WT mice had significantly decreased bone volume, trabecular thickness and trabecular number, and a resulting increase in trabecular separation. In comparison, the trabecular bone of Socs2-deficient mice was partially protected from the adverse effects of DSS. The reduction in a number of parameters, including bone volume, was less, and no changes were observed in trabecular thickness or separation. This protected phenotype was unlikely to be a consequence of improved mucosal health in the DSS-treated Socs2^−/− mice but rather a result of unregulated GH signaling directly on bone. These studies indicate that the absence of SOCS2 is protective against bone loss typical of IBD. This study also provides an improved understanding of the relative effects of GH/IGF-1 signaling on bone health in experimental colitis, information that is essential before these drugs are explored as bone protective agents in children and adults with IBD.

Summary: Using a mouse model of inflammatory bowel disease, this article provides an improved understanding of the relative effects of GH/IGF-1 on bone health in experimental colitis.

Widely differing screening and treatment practice for osteoporosis in patients with inflammatory bowel diseases in the Swiss IBD cohort study

Low bone mineral density (BMD) and osteoporosis remain frequent problems in patients with inflammatory bowel diseases (IBDs). Several guidelines with nonidentical recommendations exist and there is no general agreement regarding the optimal approach for osteoporosis screening in IBD patients. Clinical practice of osteoporosis screening and treatment remains insufficiently investigated.In the year 2014, a chart review of 877 patients included in the Swiss IBD Cohort study was performed to assess details of osteoporosis diagnostics and treatment. BMD measurements, osteoporosis treatment, and IBD medication were recorded.Our chart review revealed 253 dual-energy x-ray absorptiometry (DXA) scans in 877 IBD patients; osteoporosis was prevalent in 20% of tested patients. We identified widely differing osteoporosis screening rates among centers (11%-62%). A multivariate logistic regression analysis identified predictive factors for screening including steroid usage, long disease duration, and perianal disease; even after correction for all risk factors, the study center remained a strong independent predictor (odds ratio 2.3-21 compared to the center with the lowest screening rate). Treatment rates for patients with osteoporosis were suboptimal (55% for calcium, 65% for vitamin D) at the time of chart review. Similarly, a significant fraction of patients with current steroid medication were not treated with vitamin D or calcium (treatment rates 53% for calcium, 58% for vitamin D). For only 29% of patients with osteoporosis bisphosphonate treatment was started. Treatment rates also differed among centers, generally following screening rates. In patients with longitudinal DXA scans, calcium and vitamin D usage was significantly associated with improvement of BMD over time.Our analysis identified inconsistent usage of osteoporosis screening and underuse of osteoporosis treatment in IBD patients. Increasing awareness of osteoporosis as a significant clinical problem in IBD patients might improve patient care.

Bone biomarker for the clinical assessment of osteoporosis: recent developments and future perspectives

Bone biomarkers included formation, resorption and regulator are released during the bone remodeling processes. These bone biomarkers have attracted much attention in the clinical assessment of osteoporosis treatment in the past decade. Combination with the measurement of bone mineral density, the clinical applications of bone biomarkers have provided comprehensive information for diagnosis of osteoporosis. However, the analytical approaches of the bone biomarkers are still the challenge for further clinical trials. In this mini-review, we have introduced the functions of bone biomarkers and then recently developed techniques for bone biomarker measurements have been systematically integrated to discuss the possibility for osteoporosis assessment in the early stage.

Efficacy and safety of medical therapy for low bone mineral density in patients with Crohn disease: A systematic review with network meta-analysis

BACKGROUND

Low bone mineral density (BMD) is a frequent complication of inflammatory bowel disease (IBD), particularly in patients with Crohn disease (CD). The aim of our study is to determine the efficacy and safety of different drugs used to treat low BMD in patients with CD.

METHODS

PUBMED/MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched for eligible studies. A random-effects model within a Bayesian framework was applied to compare treatment effects as standardized mean difference (SMD) with their corresponding 95% credible interval (CrI), while odds ratio (OR) was applied to compare adverse events with 95% CrI. The surface under the cumulative ranking area (SUCRA) was calculated to make the ranking of the treatments for outcomes.

RESULTS

Twelve randomized controlled trials (RCTs) were eligible. Compared with placebo, zoledronate (SMDs 2.74, 95% CrI 1.36-4.11) and sodium-fluoride (SMDs 1.23, 95% CrI 0.19-2.26) revealed statistical significance in increasing lumbar spine BMD (LSBMD). According to SUCRA ranking, zoledronate (SUCRA = 2.5%) might have the highest probability to be the best treatment for increasing LSBMD in CD patients among all agents, followed by sodium-fluoride (27%). For safety assessment, the incidence of adverse events (AEs) demonstrated no statistical difference between agents and placebo. The corresponding SUCRA values indicated that risedronate (SUCRA = 77%) might be the most safe medicine for low BMD in CD patients and alendronate ranked the worst (SUCRA = 16%).

CONCLUSIONS

Zoledronate might have the highest probability to be the best therapeutic strategy for increasing LSBMD. For the safety assessment, risedronate showed the greatest trend to decrease the risk of AEs. In the future, more RCTs with higher qualities are needed to make head-to-head comparison between 2 or more treatments.

Prevalence of osteoporosis in the Italian population and main risk factors: results of BoneTour Campaign

BACKGROUND

BoneTour is a campaign conducted throughout the Italian territory for the assessment of Italian people bone status and for the prevention of osteoporosis.

METHODS

A total of 7305 sequential subjects of both sexes were screened, collecting clinical data through the FRAX™ questionnaire, and measuring heel bone stiffness by Quantitative Ultrasonography (QUS). The 10-year risk for hip and major osteoporotic fractures was calculated taking into account personal or family history of fragility fracture, smoking, alcohol abuse, rheumatoid arthritis, prolonged steroids assumption. Additional risk factors were evaluated, including early menopause, poor sunlight exposure, low dietary calcium intake, physical inactivity, number of pregnancies, months of lactation, tobacco cigarettes smoked per year, specific causes of secondary osteoporosis. Through a correlation study, the influence of each factor on the development of osteoporosis was analyzed.

RESULTS

As many as 18 % of women suffer from osteoporosis, as defined by QUS T-score. The calculation of FRAX™ confirmed the weight of the already known risk factors. The correlation study revealed the significance of some additional factors, such as hyperthyroidism, nephrolithiasis, Crohn disease, ulcerative colitis, celiac disease, poor sun exposure, and oophorectomy before age 50.

CONCLUSIONS

The high prevalence of secondary osteoporosis in the Italian population clearly indicates the importance of additional risk factors not yet included in the FRAX™ algorithm, for which preventive measures should be considered. Screening campaigns may allow both early diagnosis and access to treatment.

Prediction of low bone mineral density in patients with inflammatory bowel diseases

BACKGROUND

Low bone mineral density (BMD) remains a frequent problem in patients with inflammatory bowel diseases (IBD). There is no general agreement regarding osteoporosis screening in IBD patients.

METHODS

Cases of low BMD and disease characteristics were retrieved from 3172 patients of the Swiss IBD cohort study. Multivariate logistic regression analysis was conducted for predictive modeling. In a subgroup of 877 patients, 253 dual-energy X-ray absorptiometry (DXA) scans were available for validation.

RESULTS

Low BMD was prevalent in 19% of patients. We identified seven predictive factors: type of IBD, age, recent steroid usage, low body mass index, perianal disease, recent high disease activity and malabsorption syndrome. Low BMD could be predicted with a sensitivity of 79% and a specificity of 64%, a positive predictive value (PPV) of 35% and a negative predictive value (NPV) of 93%. The area under the curve of the receiver operating characteristics was 0.78. In the validation cohort we calculated a PPV of 26% and an NPV of 88%.

CONCLUSION

We provide a comprehensive analysis of risk factors for low BMD and propose a predictive model with seven clinical variables. The high NPV of models such as ours might help in excluding low BMD to prevent futile investigations.

An Increased Serum N-Terminal Telopeptide of Type I Collagen, a Biochemical Marker of Increased Bone Resorption, Is Associated with Infliximab Therapy in Patients with Crohn's Disease

BACKGROUND

Osteopenia and osteoporosis are considered to be extra-intestinal manifestations of inflammatory bowel disease (IBD). Anti-tumor necrosis factor (TNF)-α biologics have been introduced as novel medications for an active IBD. However, it is still not well documented whether anti-TNF-α affects the frequency of bone loss or abnormality of bone mineral markers among patients with IBD.

AIMS

This study was to investigate the biochemical basis of low bone mineral density (BMD) and increased turnover in IBD during infliximab (IFX) therapy.

METHODS

Forty patients with Crohn's disease (CD), 80 patients with ulcerative colitis (UC), and 65 age- and gender-matched controls were included. BMD was measured with dual-energy X-ray absorptiometry, and vitamins K and D were measured as serum undercarboxylated osteocalcin (ucOC) and 1,25-(OH)2D, respectively. Bone formation and resorption were based on measuring bone-specific alkaline phosphatase (BAP) and serum N-terminal telopeptide of type I collagen (NTx), respectively.

RESULTS

Significantly lower BMD was found in patients with UC and CD as compared to controls (P < 0.05). BAP, 1,25-(OH)2D, ucOC, and NTx were significantly higher in CD patients, but not in UC patients as compared to controls (P < 0.05). Further, serum NTx level was significantly higher in CD patients who were receiving IFX as compared to CD patients who were not receiving IFX (P < 0.01).

CONCLUSIONS

A lower BMD and higher bone metabolism markers were found in CD patients as compared to controls or UC patients. A significant increased serum level of NTx, a biochemical marker of increased bone resorption, was observed in CD patients during IFX therapy.

Piroxicam treatment augments bone abnormalities in interleukin-10 knockout mice

BACKGROUND

Osteoporosis and fractures are common complications of inflammatory bowel disease. The pathogenesis is multifactorial and has been partly attributed to intestinal inflammation. The aim of this study was to evaluate bone status and assess the association between bone loss and gut inflammation in an experimental colitis model.

METHODS

Colitis was induced in interleukin-10 knockout mice (PAC IL-10 k.o.) by peroral administration of piroxicam for 12 days. The degree of colitis was assessed by clinical, macroscopic, and microscopic evaluation. Trabecular and cortical bone microarchitecture of tibia were determined using micro-computed tomography. Moreover, the serum levels of bone formation and bone resorption biomarkers were measured, and inflammatory protein profiling was performed on colons.

RESULTS

PAC IL-10 k.o. mice developed severe colitis, characterized by hyperplasia and focal transmural inflammation, which was consistent with Crohn's disease-like pathology. The gut inflammation was accompanied by a 14% and 12% reduction in trabecular thickness relative to piroxicam-treated wild type and untreated wild type mice, respectively (P < 0.001). The trabecular bone structure was also changed in PAC IL-10 k.o. mice, whereas no differences in cortical bone geometry were observed. The trabecular thickness was inversely correlated with serum levels of CTX (r = -0.93, P = 0.006). Moreover, numerous inflammatory mediators, including RANKL and osteoprotegerin, were significantly increased in the colon of PAC IL-10 k.o. mice.

CONCLUSIONS

PAC IL-10 k.o. mice develop bone loss and changed trabecular structure, as a result of increased bone resorption. Thus, the PAC IL-10 k.o. model could be a useful experimental model in preclinical research of inflammatory bowel disease-associated bone loss.

Risk factors for decreased bone mineral density in inflammatory bowel disease: A cross-sectional study

BACKGROUND & AIM

Although inflammatory bowel disease (IBD) patients are at risk for metabolic bone disease, studies analyzing this correlation have identified various risk factors, including disease phenotype, age, sex and steroid therapy. Furthermore, few studies have assessed risk factors for bone loss in Japanese IBD patients. This study analyzed risk factors for metabolic bone disease in Japanese IBD patients.

METHODS

This cross-sectional study assessed 388 patients with IBD aged 20-50 years, including 232 with ulcerative colitis (UC) and 156 with Crohn's disease (CD). Bone mineral density of the femoral neck, total femur and lumbar spine was quantified by dual-energy X-ray absorptiometry. The blood concentrations of bone metabolism markers were measured. History of smoking and bone fracture, and nutritional intake were assessed using questionnaires.

RESULTS

Of the 388 patients with IBD, 78 (20.1%; UC, 17.2%; CD, 24.4%) had osteopenia and 17 (4.4%; UC, 3.4%; CD, 5.8%) had osteoporosis, as assessed by T-score. Bone mineral density of the lumbar vertebrae was lower in males than in females. Multivariate regression analysis showed that risk factors for bone loss in UC patients were male sex, low body mass index (BMI), high steroid dose and disease location. Risk factors for bone loss in CD patients were male sex and low BMI.

CONCLUSION

Among Japanese patients with IBD, male sex and low BMI were associated with increased risk for metabolic bone disease. In addition, Steroid therapy shouldn't be indiscriminate in UC patients. These findings may help identify patients at particularly high risk of metabolic bone disease and may help implement appropriate therapies in a timely manner and improve long-term quality of life.

Relationship between Helicobacter pylori infection (HP) and bone mineral density (BMD) in elderly people

BACKGROUND

Low bone mass is a frequent complication of chronic inflammatory disease. The pathogenesis of osteoporosis in chronic inflammatory disease may be secondary to releases of cytokines such as TNF- and IL6. Chronic gastritis due to helicobacter pylori (HP) infection may lead to decreased bone mineral density (BMD) and predispose patients to osteoporosis. The objective of this study was to determine the BMD status in HP positive patients with gastritis versus HP negative cases.

METHODS

In this cross-sectional study, we enrolled 967 participants aged 60 years old and more from Amirkola Health Study Ageing Project. Seven-hundred and fifty eight HP positive and 209 HP negative patients were analyzed. BMD was measured by dual-energy x-ray absorptiometry (DXA) method in the spine and femoral neck in all participants.

RESULTS

The mean age in HP+ and HP- negative patients was 68.3±6.8 and 69.3±7.4 years, respectively. BMD g/cm2 in the spine and femoral neck did not differ between the two groups (P=0.19 and 0.22 respectively). The prevalence of osteoporosis did not also differ across the two groups as well. There was no relationship between the level of antibodies against HP and BMD.

CONCLUSION

According to the findings of this study, H. pylori infection is not associated with BMD changes in the elderly population.

Validation of a CT-derived method for osteoporosis screening in IBD patients undergoing contrast-enhanced CT enterography

OBJECTIVES

Osteoporosis and bone fractures are of particular concern in patients with inflammatory bowel disease (IBD). Biomechanical computed tomography (BCT) is an image-analysis technique that can measure bone strength and dual-energy X-ray absorptiometry (DXA)-equivalent bone mineral density (BMD) from noncontrast CT images. This study seeks to determine whether this advanced technology can be applied to patients with IBD undergoing CT enterography (CTE) with IV contrast.

METHODS

Patients with IBD who underwent a CTE and DXA scan between 2007 and 2011 were retrospectively identified. Femoral neck BMD (g/cm(2)) and T-scores were measured and compared between DXA and BCT analysis of the CTE images. Femoral strength (Newtons) was also determined from BCT analysis.

RESULTS

DXA- and CTE-generated BMD T-score values were highly correlated (R(2)=0.84, P<0.0001) in this patient cohort (n=136). CTE identified patients with both osteoporosis (sensitivity, 85.7%; 95% confidence interval (CI), 48.7-97.4 and specificity, 98.5%; 95% CI, 94.5-99.6) and osteopenia (sensitivity, 85.1%; 95% CI, 72.3-92.6 and specificity, 85.4%; 95% CI, 76.6-91.3). Of the 16 patients who had "fragile" bone strength by BCT (placing them at the equivalent high risk of fracture as for osteoporosis), 6 had osteoporosis and 10 had osteopenia by DXA.

CONCLUSIONS

CTE scans can provide hip BMD, T-scores, and clinical classifications that are comparable to those obtained from DXA; when combined with BCT analysis, CTE can identify a subset of patients with osteopenia who have clinically relevant fragile bone strength. This technique could markedly increase bone health assessments in IBD patients already undergoing CTE to evaluate small bowel disease.

Frequency, risk factors, and adverse sequelae of bone loss in patients with ostomy for inflammatory bowel diseases

BACKGROUND

Bone loss in patients with inflammatory bowel disease (IBD) with ostomy has not been systemically studied. The aims of the study were to evaluate the frequency, risk factors, and sequelae of bone loss in patients with IBD and stomas and to monitor the change in bone mineral density (BMD) over time after ostomy.

METHODS

A total of 126 patients met the inclusion criteria (i.e., those with IBD diagnosis and stoma), including ileostomy (N = 120), colostomy (N = 3), and jejunostomy (N = 3). BMD was measured on dual-energy X-ray absorptiometry (DEXA). Patients were classified as having normal or low BMD based on the International Society for Clinical Densitometry criteria. Thirty-two demographic and clinical variables were evaluated with logistic regression models.

RESULTS

At a median of 6.6 years (interquartile range, 2-18.7 yr) after stoma, 37 (29.4%) patients had a low BMD. On univariate analysis, there were no significant differences between the normal and low BMD groups in the following variables: gender, race, age at diagnosis of IBD, prevalence of Crohn's disease and ulcerative colitis, age at ostomy, duration from diagnosis to DEXA and from ostomy to DEXA, menopausal age, diabetes, hypothyroidism, renal stones, short bowel syndrome, history of smoking or excessive alcohol use, family history of IBD or osteoporosis, daily calcium and vitamin D supplement, estrogen replacement, and steroid use. Body mass index was significantly lower in the low BMD group than the normal BMD group (23.3 ± 5.5 versus 26.0 ± 5.2, P = 0.013). Fragility fracture occurred in 8 (21.6%) patients in low BMD group and 4 (4.5%) patients in normal BMD group (P = 0.006). In a multivariate analysis, low body mass index was the only covariate-adjusted factor associated with low BMD. In patients with multiple DEXA scans available over time after ostomy, hip BMD was found to improve marginally, and the lumbar and femoral BMD remained stable.

CONCLUSIONS

Low BMD was common in patients with IBD after ostomy, largely based on the findings in patients with CD with ileostomy. Fragility fracture was 5 times more frequent in patients with ostomy with low BMD compared with those with normal BMD. The low BMD was associated with a low body mass index. Screening and surveillance of BMD should routinely be performed, particularly in these patients at risk. Bone mass tends to stabilize over time after stoma.

Extraintestinal manifestations and complications in IBD

More than one-third of patients with IBD are affected by extraintestinal manifestations or extraintestinal complications beyond the intestinal manifestation of the disease. The most common manifestations include arthropathies, mucocutaneous and ophthalmological manifestations, as well as conditions affecting the hepatobiliary system, both in Crohn's disease and ulcerative colitis. However, less frequent manifestations, such as pulmonary or neurological manifestations, should also be considered in patients with IBD. Several extraintestinal manifestations follow the course of the underlying intestinal activity, whereas others are independent from the intestinal inflammation. Extraintestinal complications such as iron-deficiency anaemia and osteoporosis are consequences of the intestinal disease or of disease-specific treatment. As extraintestinal manifestations and complications strongly influence quality of life, and to avoid severe complications, adequate treatment is mandatory in affected patients. We provide a comprehensive overview of different extraintestinal manifestations and complications, including their management, in patients with IBD.

The natural history of ulcerative colitis in a pediatric population: a follow-up population-based cohort study

BACKGROUND

The natural history of ulcerative colitis (UC) has been poorly studied in children.

METHODS

We performed a retrospective study in children diagnosed with UC with a follow-up. The diagnosis of UC was based on clinical, radiologic, endoscopic, and histologic examinations. We estimated the occurrence of colectomy, proctitis, and extraintestinal manifestations (EIMs) at the onset of the diagnosis and at the end of the study period.

RESULTS

We identified 115 UC patients between 1986 and 2003 with a mean age at diagnosis of 10.6 ± 5.1 years. The cumulative rate of colectomy was 4.1% at 1 year, and 16% at 10 years. EIMs were experienced by 20% of the children; 48% had arthritis, 35% had sclerosing cholangitis, and 17% had aphthous stomatitis. Proctitis was noted in 29 patients and it was not associated with an increased risk of colectomy (relative risk = 1.4; 95% CI = 0.7-4.5), and girls were twice more likely to develop proctitis. The pathologic reading for disease extensions was recorded for all children at entry and only 62 children had pathological results at maximum follow-up. At entry, 25% of the children only had ulcerative proctitis (E1) localization, 40% had left-sided UC (E2), and 35% had extensive UC (E3). Among the patients with E1 localization, 20% had progressed to E2 and 80% had progressed to E3; among the patients with E2 localization, 40% had progressed to E3. Age, gender, and EIMs at time of diagnosis were not associated with extension of disease at maximal follow-up. The Z score of body mass index (BMI) of children was significantly higher at the end of the study. At diagnosis, 85% of patients received 5-aminosalicyclic acid, 60% received steroids, and 11% received an immunomodulator. The majority of patients were still using systemic steroids at and after 5 years from their entry date. Only 32 of the 91 children on steroids did not receive an immunomodulator.

CONCLUSION

Pediatric UC is associated with high rates of EIMs and colectomy that are not dependent on age, gender, or race, but is associated with a high rate of proctitis among girls. Understanding the clinical course of UC can optimize therapeutic interventions.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Nutritional management of Crohn's disease

Nutritional care and therapy forms an integral part of the management of patients with Crohn's disease (CD). Nutritional deficiencies result from reduced oral intake, malabsorption, medication side effects and systemic inflammation due to active disease. Enteral nutrition has a role in support for the malnourished patient, as well as in primary therapy to induce and maintain remission. The use of parenteral nutrition in CD is mainly limited to the preoperative setting or for patients with intestinal failure, but does not offer any additional advantage over EN in disease control. Dietary modifications, including elimination-reintroduction diets and a low fermentable, oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet may improve symptoms but there are currently no data to suggest that these approaches have any role in the induction or maintenance of remission.

Increased risk of osteoporosis-related fractures in patients with irritable bowel syndrome

We sought to determine whether patients with irritable bowel syndrome (IBS) have an increased risk of osteoporosis and related fractures using the Nationwide Emergency Department Sample (NEDS). Patients with IBS had increased adjusted odds of osteoporosis and osteoporotic fractures compared to the non-IBS control group, controlling for known risk factors for osteoporosis. Screening measures to identify osteoporosis in this group are advised.

INTRODUCTION

Ulcerative colitis, Crohn's disease, and celiac disease have well-described augmented risk of osteoporosis and related fractures. We sought to determine whether IBS also indicates an increased risk of osteoporosis and related fractures.

METHODS

The 2008 NEDS database was used to determine the adjusted odds of osteoporosis and related fractures in IBS patients. Only fractures (pathologic wrist (733.12), vertebrae (733.13), and femur fractures (733.14), traumatic wrist (813.x), vertebrae (805.x-806.x), and hip fractures (820.x-821.x)) with a secondary diagnosis of osteoporosis (733.0x) were included in the analysis. A multivariate logistic regression analysis was performed, controlling for known risk factors for osteoporosis and related fractures.

RESULTS

We identified 317,857 ED visits in patients with a diagnosis of IBS. Of these, 17,752 carried a diagnosis of osteoporosis and 694 IBS patients had a concurrent diagnosis of a pathologic fracture of the wrist, hip, or vertebrae. A total of 1,503 IBS patients had a concurrent diagnosis of a traumatic fracture of the wrist, hip, or vertebra. Overall, patients with IBS had an increased adjusted odds of osteoporosis (odds ratio (OR) 4.28, 95% confidence interval (CI) 4.21-4.35) and osteoporotic fractures (OR 2.36, CI 2.26-2.47) compared to the non-IBS control group. The highest adjusted odds of fracture was seen at the wrist (OR 2.41, CI 2.10-2.77 compared to controls).

CONCLUSIONS

IBS patients are at an increased risk of osteoporosis and related fractures. Screening measures to identify osteoporosis and prevent fractures are advised.

The early onset of disease may be a risk factor for decreased bone mineral density in patients with inflammatory bowel disease

Background/Aims

The pathogenesis of bone loss in patients with inflammatory bowel disease (IBD) is complex, multifactorial, and only partly understood. We aimed to examine the extent and risk factors of bone mass reduction and to analyze the impact of early onset of a disease before attaining peak bone mass in IBD patients.

Methods

We compared the risk factors for osteoporosis and BMD at the lumbar spine and the hip bone in IBD patients.

Results

A total of 44 patients with IBD were enrolled. Twenty-one and 23 patients were diagnosed as IBD before and after the age of 30 and designated as group A and group B, respectively. Group A had significant bone mass reduction at the lumbar spine than group B (BMD, 1.01±0.10 vs. 1.14±0.17, p<0.01; T-score, -1.22±0.84 vs. -0.08±1.39, p<0.01; Z-score, -1.11±0.81 vs. -0.03±1.32, p<0.01, respectively). Multivariate analysis showed that patients diagnosed as IBD before the age of 30 had possible risk factor of bone mass reduction (hazard ratio, 3.96; p=0.06).

Conclusions

Bone mass reduction was more severe in patients who were diagnosed with IBD before the age of 30 than in those diagnosed after the age of 30.

The importance of vitamins D and K for the bone health and immune function in inflammatory bowel disease

PURPOSE OF REVIEW

This review summarizes the recent literature about the roles of vitamins D and K in bone metabolism and immunity-mediated inflammatory processes in inflammatory bowel diseases (IBDs).

RECENT FINDINGS

The levels of vitamins D and K are lower than normal in patients with IBD, especially in Crohn's disease. Although vitamins D and K are important for the maintenance of bone mineral density in non-IBD patients, an association between vitamins D or K and bone metabolism is not apparent in IBD patients. Recent studies showed that vitamins D and K are suggested to have immune-suppressive effects, both in animal models of colitis and human trials. In particular, vitamin D suppresses dendritic and T-cell functions by inhibiting the production of proinflammatory cytokines. Insufficiency of vitamin D is associated with the activated phenotype of IBD.

SUMMARY

Vitamins D and K potentially contribute to the maintenance of bone health in IBD, but this effect may be diminished by other factors such as steroid use, reduced exposure to sunlight, and inflammatory cytokines. Vitamin D and possibly vitamin K are suggested to be involved in the suppression of immune-mediated inflammation and modulation of disease activity.

T cell-mediated increased osteoclast formation from peripheral blood as a mechanism for Crohn's disease-associated bone loss

The pathophysiology of osteoporosis in patients with Crohn's disease (CD) is still not completely elucidated. In this study, we evaluated osteoclastogenesis from peripheral blood cells of CD patients and studied the role of lymphocytes and inflammatory cytokines in this process. Peripheral blood mononuclear cells from seven patients with quiescent CD and matched healthy controls were isolated, and separated into T cells, B cells, and a T- and B-cell depleted fraction. In various culture combinations, osteoclast formation in the absence of the osteoclastogenic factors RANKL and M-CSF was assessed by scoring the number of tartrate-resistant acid phosphatase (TRACP) positive multinucleated cells (MNCs). Cytokine levels in culture supernatants were measured. Formation of heterogeneous cell clusters in culture was noticed; a process that was inhibited by anti-LFA-1. In CD cultures, mean cluster area was up to threefold higher than in control cultures, and shown to be induced by T cells. Over tenfold higher numbers of TRACP(+) MNCs were found in CD cultures, but exclusively in cultures containing T cells. Formation of cell clusters correlated strongly with formation of TRACP(+) MNCs. Both cell cluster formation and osteoclast formation were related to IL-17 levels in vitro. In conclusion, osteoclastogenesis, preceded by cell cluster formation, is T cell-mediated and increased in patients with quiescent CD. Our findings suggest heterotypic interactions between osteoclast precursors and T cells to be a triggering step in osteoclast formation in CD. Furthermore, our results propose a possible role for IL-17 in osteoclastogenesis in CD patients, and as such in CD-associated bone loss.

Sclerostin: therapeutic horizons based upon its actions

Inactivating mutations of the SOST gene cause a reduction in sclerostin levels and are associated with high bone mass. The clinical phenotypes, sclerosteosis and van Buchem's disease, were described in 1950s. Much later, it was learned that both diseases are due to loss-of-function mutations in the SOST gene. As a regulator of an important osteoanabolic pathway, Wnt, inactivation of SOST leads to a stimulation of the pathway it regulates. The high bone mass in patients with either sclerosteosis or van Buchem's disease is associated with unusual skeletal strength; they do not fracture. Knowledge of this molecule and its actions led rather quickly to the development of anti-sclerostin antibodies that lead to marked increases in bone mass in both animals and human subjects. Blocking sclerostin action with anti-sclerostin antibodies is a promising new therapeutic approach to osteoanabolic therapy of osteoporosis.

Association of vitamin K deficiency with bone metabolism and clinical disease activity in inflammatory bowel disease

OBJECTIVE

Inflammatory bowel disease (IBD) is a chronic inflammatory process in the digestive tract and patients with IBD develop osteopenia. Although vitamins K and D are important for maintaining bone health and inhibiting inflammation, their roles in patients with IBD are not clear. We investigated the roles of vitamins K and D in the bone health and inflammation in patients with IBD.

METHODS

Bone mineral density (BMD) of patients with IBD (Crohn's disease [CD], n = 47, and ulcerative colitis [UC], n = 40) was measured with dual-energy X-ray absorptiometry. Vitamin K and D levels of patients with IBD and healthy volunteers (n = 41) were evaluated by measuring serum undercarboxylated osteocalcin and 1,25 dihydroxyvitamin D, respectively. Clinical activity index was evaluated in patients with CD and UC.

RESULTS

BMD was low in patients with CD and UC. Serum undercarboxylated osteocalcin levels were significantly higher in patients with CD, but not with UC, compared with healthy subjects, indicating that bone vitamin K is insufficient in patients with CD. The levels of undercarboxylated osteocalcin were significantly correlated with the clinical activity index of CD, although they were not correlated with BMD. The levels of 1,25 dihydroxyvitamin D were significantly lower in patients with CD and UC than in healthy subjects. The levels of 1,25 dihydroxyvitamin D were inversely correlated with BMD in patients with UC and were not correlated with the clinical activity index of CD.

CONCLUSION

Vitamins K and D are insufficient in patients with IBD. Insufficiency of vitamin K is suggested to be associated with inflammatory processes of CD.