Colorectal cancers in ulcerative colitis from a low-prevalence area for colon cancer

Poor Diagnostic Reproducibility in the Identification of Nonconventional Dysplasia in Colitis Impacts the Application of Histologic Stratification Tools

Due to their increased cancer risk, patients with longstanding inflammatory bowel disease are offered endoscopic surveillance with concomitant histopathologic assessments, aimed at identifying dysplasia as a precursor lesion of colitis-associated colorectal cancer. However, this strategy is beset with difficulties and limitations. Recently, a novel classification criterion for colitis-associated low-grade dysplasia has been proposed, and an association between nonconventional dysplasia and progression was reported, suggesting the possibility of histology-based stratification of patients with colitis-associated lesions. Here, a cohort of colitis-associated lesions was assessed by a panel of 6 experienced pathologists to test the applicability of the published classification criteria and try and validate the association between nonconventional dysplasia and progression. While confirming the presence of different morphologic patterns of colitis-associated dysplasia, the study demonstrated difficulties concerning diagnostic reproducibility between pathologists and was unable to validate the association of nonconventional dysplasia with cancer progression. Our study highlights the overall difficulty of using histologic assessment of precursor lesions for cancer risk prediction in inflammatory bowel disease patients and suggests the need for a different diagnostic strategy that can objectively identify high-risk phenotypes.

Low prevalence of primary sclerosing cholangitis in patients with inflammatory bowel disease in India

BACKGROUND/AIMS

Primary sclerosing cholangitis (PSC) represents the most common hepatobiliary extraintestinal manifestation of inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's disease (CD). Limited data exist on PSC in patients with IBD from India. We aimed to assess the prevalence and disease spectrum of PSC in Indian patients with IBD.

METHODS

Database of IBD patients at 5 tertiary care IBD centers in India were analyzed retrospectively. Data were extracted and the prevalence of PSC-IBD was calculated.

RESULTS

Forty-eight patients out of 12,216 patients with IBD (9,231 UC, 2,939 CD, and 46 IBD unclassified) were identified to have PSC, resulting in a prevalence of 0.39%. The UC to CD ratio was 7:1. Male sex and pancolitis (UC) or colonic CD were more commonly associated with PSC-IBD. The diagnosis of IBD preceded the diagnosis of PSC in most of the patients. Majority of the patients were symptomatic for liver disease at diagnosis. Eight patients (16.66%) developed cirrhosis, 5 patients (10.41%), all UC, developed malignancies (3 colorectal cancer [6.25%] and 2 cholangiocarcinoma [4.16%]), and 3 patients died (2 decompensated liver disease [4.16%] and 1 cholangiocarcinoma [2.08%]) on follow-up. None of the patients mandated surgical therapy for IBD.

CONCLUSIONS

Concomitant PSC in patients with IBD is uncommon in India and is associated with lower rates of development of malignancies.

Correlation of ulcerative colitis and colorectal cancer: a systematic review and meta-analysis

BACKGROUND

A large number of studies have shown that ulcerative colitis (UC) can increase the risk of colorectal cancer (CRC). The purpose of the present study was to explore the specific mechanism of UC influence on CRC.

METHODS

We searched PubMed for articles related to CRC and colitis since the establishment of the database until April 2021. Keywords, such as ulcerative colitis, colorectal cancer, and relevance, were used for the article search. Two investigators read through the full text according to the inclusion and exclusion criteria to screen the articles. Cochrane system review manual (version 5.3) was adopted to evaluate the quality of the selected articles. Then, data was extracted, and the overall risk of UC patients into CRC, the course of the disease, and the region were systematically analyzed.

RESULTS

A total of 11 studies involving 26,765 patients with UC were included. The results showed that UC is one of the risk factors for CRC. we also found that geographical location also had an impact on the transition from UC to CRC, but the impact was not significant. Patients with colitis had a significantly higher rate of conversion to CRC after 10 to 20 years of disease.

DISCUSSION

A total of 11 articles were included to analyze the association between UC and CRC. The studies found that the location, duration, and geographical location of patients with UC directly affected the occurrence of CRC and are independent risk factors for the transformation of UC into CRC.

Secondary colon cancer in patients with ulcerative colitis: a systematic review and meta-analysis

BACKGROUND

A meta-analysis was conducted on the incidence of colon cancer in patients with ulcerative colitis (UC). This study aimed to evaluate the correlation between UC and colon cancer, and provide a theoretical guidance for clinical diagnoses and treatments of UC.

METHODS

Articles were searched in Chinese database with "ulcerative colitis", "UC", "colon cancer", "colorectal cancer", "incidence", and "meta-analysis" as the search terms. Articles were searched in English database with "ulcerative colitis", "UC", "colon cancer", "incidence rate", and "meta-analysis" as the search terms. Moreover, articles with the topic of "correlation between UC and colon cancer" were screened. The quality of articles was assessed using Rev Man 5.3 software provided by Cochrane system.

RESULTS

Eleven articles were included, most of which were of medium and high quality. Results of meta-analysis showed that 12,216 patients with UC were included in this study, and 110 patients developed colon cancer. There was statistical heterogeneity (Chi2=103.10, I2=90%, P<0.00001). Random-effect model analyses showed that there were no significant differences between colon cancer in patients with UC and those without colon cancer (Z=12.44, P<0.00001). A systematic review of articles found that the course and development of colon cancer in patients with UC might affect the occurrence of colon cancer. UC was a risk factor for colorectal cancer.

DISCUSSION

It was found that the course of disease and the occurrence and development of UC might affect the occurrence of colon cancer through a systematic review of articles. UC was one of the risk factors of colorectal cancer.

A study on the potential role of autophagy-related protein 10 as a biomarker for ulcerative colitis

PURPOSE

Ulcerative colitis (UC) is a lifelong disease with unclear etiology and increasing prevalence worldwide. Autophagy has been reported to play roles in the pathogenesis and progression of UC. Here, we aimed to analyze the expression of autophagy related protein 10 (ATG10) and its regulator, micro-RNA (miR) 519a, in UC patients.

METHODS

The level of ATG10 in the serum, stool, and colon biopsies from 15 UC patients and 30 non-UC healthy individuals (HC) group was measured by ELISA. Also, the blood level of miR-519a was investigated by quantitative real-time PCR.

RESULTS

We found 13.63 ng/ml versus 0.99 ng/ml, 11.01 ng/ml versus 1.11 ng/ml and 6.41 ng/ml versus 3.21 ng/ml of ATG10 in the stool, colon tissue, and serum of UC and HC, respectively. There was no significant difference in the expression of miR-519a in the blood samples of UC and HC.

CONCLUSIONS

ATG10 might be a potential non-invasive diagnostic biomarker for UC.

Inflammatory bowel disease: An Indian perspective

Inflammatory bowel disease (IBD) in recent times is causing a significant healthcare burden as both ulcerative colitis and Crohn's disease (CD) require lifelong therapy and constant monitoring. The current review highlights the concerns in a country like India with special reference to the changing trends of IBD, risk attribution and the financial issues. Indian immigrants behave like residential Indians, whereas their children show IBD prevalence similar to the West, highlighting the role of environmental triggers. However, the environmental and genetic factors in Indians with IBD are not well understood. Men appear to be more frequently affected than women in India. The disease severity is milder in the patients, both males and females, but the risk for colorectal cancer (CRC) is similar to the West. The incidence of paediatric IBD is on the rise. The major burden of IBD in the Indian subcontinent at present is in children, adolescents and teens. Cost towards the management of complications, non-adherence to treatment, differentiating tuberculosis from CD and finally screening for CRC in patients with IBD are the points to ponder in the Indian scenario.

The controlling nutritional status score: A promising tool for nutritional screening and predicting severity in ulcerative colitis patients

INTRODUCTION AND AIMS

The controlling nutritional status (CONUT) score has previously been shown to be useful for nutritional assessment and the prediction of several inflammatory and neoplastic diseases. The aim of the present study was to evaluate the potential use of the CONUT score as a method for nutritional screening and predicting severity in ulcerative colitis (UC).

MATERIALS AND METHODS

The study was conducted on 60 patients diagnosed with UC. Demographic, clinical, and biochemical patient characteristics were collected from their clinical records, and disease severity was assessed using the Truelove and Witts scale (TWS). The risks for malnutrition were evaluated through the nutritional risk index and the CONUT score.

RESULTS

More than 90% of the UC patients presented with malnutrition risk, according to the scores analyzed. Patients with a high (>6points) CONUT score presented with moderate-to-severe activity on the TWS. A higher CONUT score was also associated with an increase in C-reactive protein (CRP) (P=.002) and erythrocyte sedimentation rate (ESR) (P=.009). The data analysis was performed utilizing the SPSS version 19 program.

CONCLUSIONS

The CONUT score could be a promising tool for evaluating nutritional status in UC patients and predicting UC severity.

Teasaponin Ameliorates Murine Colitis by Regulating Gut Microbiota and Suppressing the Immune System Response

Background: Dietary intervention is an exciting topic in current research of inflammatory bowel disease (IBD). The effect of teasaponin (TS) on IBD has not been fully elucidated. Here, we aim to investigate the intestinal anti-inflammatory activity of TS in a dextran sodium sulfate (DSS)-induced colitis mouse model and identify potential mechanisms.

Methods: We applied TS to mice with DSS-induced colitis and then monitored the body weight, disease activity index (DAI) daily. When sacrificed, the intestinal permeability was measured. The analysis of mucin and tight junction proteins was conducted. We detected the inflammatory cytokines, the immune cells and related inflammatory signaling pathways. In addition, the gut microbiota were analyzed by 16S rRNA sequencing and we also performed fecal microbiota transplantation (FMT).

Results: It showed that TS ameliorated the colonic damage by lowering the DAI, prolonging the colon length, reducing inflammatory cytokines and improving the mucus barrier. Parallel to down-regulation of the inflammatory cytokines, the fecal lipocalin 2, p-P65, p-STAT3, and neutrophil accumulation were also decreased in TS-treated mice. Microbiota characterization showed that Campylobacteria, Proteobacteria, Helicobacter, and Enterobacteriaceae were the key bacteria associated with IBD. In addition, TS could reverse the Firmicutes/Bacteroidetes (F/B) ratio and increase the beneficial bacteria, including Akkermansia and Bacteroides. TS ameliorated DSS-induced colitis by regulating the gut microbiota, and the gut microbiota could regulate gut inflammation.

Conclusions: These studies demonstrated that TS ameliorated murine colitis through the modulation of immune response, mucus barrier and gut microbiota, thus improving gut dysbiosis. In addition, the gut microbiota may play an important role in regulating the host's innate immune system, and the two coexist and are mutually beneficial. We provide a promising perspective on the clinical treatment of IBD.

The effect of intermittent hypoxia and fecal microbiota of OSAS on genes associated with colorectal cancer

Purpose

Colorectal cancer (CRC) is one of the common causes of cancer death worldwide. Obstructive sleep apnea syndrome (OSAS), sharing many risk factors in common with CRC, is prevalent among CRC patients. OSAS may promote the CRC development independently but the mechanism is still unknown. Intermittent hypoxia (IH) is one of the characteristics of OSAS, and hypoxia may influence the genes associated with CRC. Intestinal microbiota plays important role in CRC carcinogenesis, and OSAS patients have been shown to have intestinal microbiota dysbiosis. We hypothesized that IH and intestinal microbiota dysbiosis may be involved for CRC in patients with OSAS.

Methods

We established precancerous cell models of CRC with Immorto-Min colonic epithelial (IMCE) cells. First, the cells were exposed to IH in a special chamber for 4 h, 8 h, and 12 h. Feces from 6 patients with OSAS and 6 healthy controls were collected and made into sterile fecal fluid for incubation with IMCE cells for 12 h. The cells were then exposed to IH for 4 h, 8 h, and 12 h. After IH exposure, the expressions of genes and inflammation cytokines associated with CRC, such as β-catenin, STAT3, HIF-1α, IL-6, TNF-α, c-myc, and cyclinD1, were tested.

Results

IH activated the expression of HIF-1α and STAT3 both in mRNA and protein level (HIF-1α: P = 0.015 for mRNA level, P = 0.027 for protein level; STAT3: P = 0.023 for mRNA level, P = 0.023 for protein level), and promoted p-STAT3 shifting to the nucleus (P = 0.023). The mRNA of β-catenin (P = 0.022) and cyclinD1 (P = 0.023) was elevated, but there was no change for the β-catenin protein in the nucleus. Gut microbiota of OSAS patients promoted the expression of STAT3 (protein level: 0 h: P = 0.037; 4 h: P = 0.046; 8 h: P = 0.049; 12 h: P = 0.037), promoted p-STAT3 (4 h: P = 0.049; 8 h: P = 0.046; 12 h: P = 0.046) shifting to the nucleus, and also elevated the expression of IL-6 and TNF-α in mRNA level at 4 h (IL-6: P = 0.037, TNF-α: P = 0.037) and 8 h (IL-6: P = 0.037, TNF-α: P = 0.037). The protein of β-catenin in the nucleus was not affected by IH and gut microbiota from OSAS.

Conclusions

Our study demonstrated that IH and gut microbiota of patients with OSAS activated HIF-1α expression and STAT3 pathway in IMCE cells, with no influence on β-catenin pathway, which suggested that IH, STAT3 pathway, chronic inflammation, and intestinal microbiota dysbiosis may be involved in CRC carcinogenesis correlated with OSAS These findings must be interpreted cautiously and further research is necessary to clarify the causative steps in CRC development.

Ulcerative colitis

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

Risk factors for ulcerative colitis-associated colorectal cancer: A retrospective cohort study

Inflammatory bowel disease is associated with an increased risk of colorectal cancer. The study aims to identify the risk factors for ulcerative colitis-colorectal cancer and to perform a survival curve analysis of the outcome.This retrospective cohort study included 254 patients from March 2016 to October 2017. Age, age at diagnosis, follow-up time, smoking status, and family history of colorectal cancer were analyzed as risk factors for colorectal cancer.The mean patient age was 46.6 ± 16.9 years; 5.5% of the patients were smokers and 49.6% had pancolitis. Six patients (2.36%) had colorectal cancer, which was associated with age at diagnosis (odds/hazard ratio 1.059 [95% confidence interval: 1.001-1.121]; P = .04), family history of colorectal cancer (12.992 [1.611-104.7]; P = .02), and follow-up time (0.665 [0.513-0.864]; P = .002). Active smoking was the main identified risk factor, after both logistic (8.477 [1.350-53.232]; P = .02) and Cox proportional-hazards (32.484 [2.465-428.1]; P = .008) regression analysis. The risk of colorectal cancer was 3.17% at 10 years and 4.26% at 20 years of follow-up.Active smoking and family history were identified as risk factors for colorectal cancer. These findings should aid the early identification of patients who require vigorous surveillance, and prevent exposure to risk factors.

Inflammatory bowel disease in India: challenges and opportunities

Evidence is emerging that inflammatory bowel diseases (IBDs) are becoming increasingly prevalent in developing countries, altering the previously held view that these were diseases of the West. Within this is a substantial increase in the burden of this disease in India, a matter of great importance to the country itself as well as in furthering our understanding of the disease. There is comparatively less data on this, both from the epidemiological standpoint as well as on disease pathogenesis in this particular cohort and is very much a subject matter of evolving understanding and research. This article aims to look at the changing global distribution of the disease and its implications. The Indian disease phenotype, and the aetiology of disease development will also be addressed with particular focus on differing pathogenetic processes in the Indian subpopulation, with consideration of what clues may be offered by the increasing incidence of the disease in this developing nation. Available evidence will be evaluated with the objective of providing a comprehensive overview of the development of IBD in India.

Salidroside attenuates dextran sulfate sodium-induced colitis in mice via SIRT1/FoxOs signaling pathway

Salidroside (Sal), the active ingredient of Rhodiola rosea L, has various pharmacological activities, including antioxidant, anti-inflammatory and anti-tumor activities. Recently, studies have shown that oxidative stress and apoptosis are related to the pathogenesis of inflammatory bowel disease. Therefore, we evaluated the effects of Sal on oxidative stress and apoptosis in colitis mice through the SIRT1/FoxOs pathway. To induce the colitis model, mice continuously consumed water containing 3% DSS for 7 days; some mice were also treated with Sal and the SIRT1/FoxOs pathway blocker selisistat (Ex527). Changes in body weight, DAI, colon length and colon tissue histology as well as SOD, GSH-Px and CAT activities were measured. The expression of SIRT1, FoxO1, FoxO3a, FoxO4, caspase-3, cleaved-caspase-3, Bax and Bcl-2 in colorectal tissues was detected by RT-PCR and Western blotting. The study showed that Sal decreased the DAI score, weight loss, colon shortening and colon tissue damage in colitis mice. Sal inhibited oxidative stress by upregulating SOD, GSH-Px and CAT while suppressing colonic apoptosis by downregulating the expression of Bax, caspase-3, and cleaved-caspase-3 and upregulating the expression of Bcl-2. Sal also activated SIRT1/FoxOs signaling, which increased the expression of SIRT1, FoxO1, FoxO3a and FoxO4 in colon tissue. Furthermore, SIRT1/FoxOs pathway inhibition using Ex527 partially eliminated the effect of Sal on colitis mice. The study manifested that Sal may protect colitis mice by activating the SIRT1/FoxOs pathway, which is related to oxidative stress and apoptosis in colon tissues.

Gut microbiota contributes to the distinction between two traditional Chinese medicine syndromes of ulcerative colitis

BACKGROUND

Ulcerative colitis (UC) is considered to be closely associated with alteration of intestinal microorganisms. According to the traditional Chinese medicine (TCM) theory, UC can be divided into two disease syndromes called Pi-Xu-Shi-Yun (PXSY) and Da-Chang-Shi-Re (DCSR). The relationships among gut microbiota, TCM syndromes, and UC pathogenesis have not been well investigated.

AIM

To investigate the role of gut microbiota in UC and the distinction of microbiota dysbiosis between PXSY and DCSR syndromes.

METHODS

From May 2015 to February 2016, UC patients presenting to LongHua Hospital who met the established inclusion and exclusion criteria were enrolled in this retrospective study. Fresh stool specimens of UC patients with PXSY or DCSR were collected. The feces of the control group came from the health examination population of Longhua Hospital. The composition of gut bacterial communities in stool samples was determined by the pyrosequencing of 16S ribosomal RNA. The high-throughput sequencing reads were processed with QIIME, and biological functions were predicted using Phylogenetic Investigation of Communities by Reconstruction of Unobserved States.

RESULTS

The composition of gut bacterial communities in 93 stool samples (30 healthy controls, 32 patients with PXSY syndrome, and 31 patients with DCSR syndrome) was determined by the pyrosequencing of 16S ribosomal RNA. Beta diversity showed that the composition of the microbiota was different among the three groups. At the family level, Porphyromonadaceae, Rikeneliaceae, and Lachnospiraceae significantly decreased while Enterococcus, Streptococcus, and other potential pathogens significantly increased in UC patients compared to healthy subjects. At the genus level, Parabacteroides, Dorea, and Ruminococcus decreased while Faeca-libacterium showed increased abundance in UC compared to healthy controls. Five differential taxa were identified between PXSY and DCSR syndromes. At the genus level, a significantly increased abundance of Streptococcus was observed in DCSR patients, while Lachnoclostridium increased in PXSY patients. The differential functional pathways of the gut microbiome between the PXSY and DCSR groups mainly included lipid metabolism, immunity, and the metabolism of polypeptides.

CONCLUSION

Our study suggests that the gut microbiota contributes to the distinction between the two TCM syndromes of UC.

The Complex Puzzle of Interactions Among Functional Food, Gut Microbiota, and Colorectal Cancer

Colorectal cancer exerts a strong influence on the epidemiological panorama worldwide, and it is directly correlated to etiologic factors that are substantiated by genetic and environmental elements. This complex mixture of factors also has a relationship involving the structural dependence and composition of the gut microbiome, leading to a dysbacteriosis process that may evolve to serious modifications in the intestinal lining, eventually causing the development of a neoplasm. The gastrointestinal tract presents defense strategies and immunological properties that interfere in intestinal permeability, inhibiting the bacterial translocation, thus maintaining the integrity of intestinal homeostasis. The modulation of the intestinal microbiome and the extinction of risk factors associated with intestinal balance losses, especially of environmental factors, make cell and defense alterations impossible. This modulation may be conducted by means of functional foods in the diet, especially soluble fibers, polyunsaturated fatty acids, antioxidants and prebiotics that signal immunomodulatory effects in the intestinal microbiota, with preventive and therapeutic action for colorectal cancer. In summary, this review focuses on the importance of dietary modulation of the intestinal microbiota as an instrument for dysbacteriosis and, consequently, for the prevention of colorectal cancer, suggesting anticarcinogenic, and antiangiogenic properties. Among the intestinal modulating agents considered here are functional foods, especially flaxseed, oat and soy, composing a Bioactive Food Compound.

Colorectal cancer prevention in patients with ulcerative colitis

Ulcerative colitis is characterized by chronic inflammation, which may lead to the accumulation of high levels of pro-inflammatory cytokines within the colonic mucosa, and thus to dysplastic lesions and cancer. Although the trend is decreasing, ulcerative colitis patients still have a 2.4 fold higher risk of colorectal cancer compared to the general population. The key task is to control colonic inflammation, and a rapid step-up approach while closely monitoring intestinal inflammation are recommented. Surveillance colonoscopy program demonstrated its efficacy for reducing the incidence of colorectal cancer in ulcerative colitis. The impact of medication on the reduction of colorectal cancer risk was hardly investigated and it remains unclear whether they have intrinsic anti-neoplastic properties or only downregulate inflammatory pathways. Several studies showed a decreased risk of colorectal cancer in ulcerative colitis patients treated with 5-aminosalicylic acid and chemoprevention with mesalamine compounds is currently recommended. The current level of evidence is too low for thiopurines and anti-TNFα agents. Large, prospective cohort studies are ongoing and are likely to bring new findings about the impact of drugs on colorectal cancer risk in the current era of biologics.

Systematic review with meta-analysis: thiopurines decrease the risk of colorectal neoplasia in patients with inflammatory bowel disease

BACKGROUND

Patients with inflammatory bowel disease (IBD) have a high risk of developing colorectal neoplasia.

AIM

To investigate whether thiopurines can decrease the risk of developing colorectal neoplasia in patients with ulcerative colitis (UC) or Crohn's disease (CD).

METHODS

We conducted a meta-analysis of 24 observational studies involving 76,999 participants to evaluate the risks of developing colorectal neoplasia in IBD patients receiving thiopurine treatment. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) for the risks of colorectal neoplasia were calculated using a random-effects model.

RESULTS

The overall pooled estimate revealed a protective effect of thiopurine use on colorectal neoplasia in patients with IBD (OR = 0.63, 95% CI 0.46-0.86). The effect was significant in UC patients (OR = 0.67, 95% CI 0.45-0.98), but was not significant in CD patients (OR = 1.06, 95% CI 0.54-2.09). Thiopurines exposure significantly decreased the risk of colorectal cancer (CRC) (OR = 0.65, 95% CI 0.45-0.96) and advanced colorectal neoplasia (CRC and/or high-grade dysplasia) (OR = 0.62, 95% CI 0.44-0.89), but did not decrease the risk of dysplasia alone (OR = 0.90, 95% CI 0.37-2.21). Tendencies towards the protective effect of thiopurines were distinct in clinic-based studies (OR = 0.59, 95% CI 0.42-0.82) and case-control studies (OR = 0.40, 95% CI 0.26-0.62), but not in population-based studies (OR = 0.95, 95% CI 0.55-1.62) and cohort studies (OR = 0.98, 95% CI 0.81-1.18). Interestingly, studies conducted in Europe (OR = 0.48, 95% CI 0.31-0.77), rather than in North America (OR = 0.91, 95% CI 0.67-1.24), showed the protective effect of thiopurines.

CONCLUSIONS

This meta-analysis revealed an antineoplastic effect of thiopurines on colorectal neoplasia in patients with IBD, particularly amongst patients with UC.

Epidemiology of Inflammatory Bowel Disease in India: The Great Shift East

BACKGROUND

Inflammatory bowel disease (IBD), once considered to be a Western disease, is increasingly being reported from India and other Asian countries. The present review summarizes epidemiology and disease characteristics of IBD in India with reference to other Asian countries and the West.

SUMMARY

India is projected to have one of the highest disease burden of IBD across the globe. The overall genetic risk and microbial signature in Indian IBD patients are similar to those of patients in the West as demonstrated by the similar incidence of IBD in second-generation Indian immigrants and matching perturbations in the structural and functional component of gut microbiota in Indian studies. The concept of the hygiene hypothesis continues to remain controversial with Indian studies demonstrating contradictory findings. The disease characteristics, long-term outcomes including the risk of colorectal cancer, and the effect of pregnancy on IBD and vice versa in Indian patients with IBD are in general similar with few differences. Unlike patients in the West, very few Indian patients have a positive family history.

KEY MESSAGE

The Indian disease pattern is going through a phase of epidemiological transition with a surge in the incidence of IBD. The epidemiology and disease characteristics of IBD mirror the patterns observed in the West.

Long-term follow-up reveals high incidence of colorectal cancer in Indian patients with inflammatory bowel disease

BACKGROUND

As the magnitude of sporadic colorectal cancer (CRC) in India is low, magnitude of CRC in ulcerative colitis (UC) is also considered low. As a result, screening for CRC in UC although advocated may not be followed everywhere. We report our data of UC-related CRC from a low-incidence area of sporadic CRC.

METHODS

A total of 1012 patients with left-sided colitis/pancolitis having more than one full-length colonoscopy performed at least a year after the onset of symptoms were included in retrospective analysis of prospectively maintained case records. In addition, 136 patients with duration of disease >10 years underwent surveillance white-light colonoscopy prospectively during the study period.

RESULTS

A total of 1012 individuals were finally included (6542 person-years of follow-up, 68.5% males, disease duration: 6.4 ± 6.8 years). Twenty (1.97%) patients developed CRC. Two (10%) patients developed CRC during the first decade, 10/20 (50%) during the second and 8/20 (40%) after the second decade of disease. The cumulative risk of developing CRC was 1.5%, 7.2% and 23.6% in the first, second and third decade, respectively. Of 136 high-risk UC cases, five (3.6%) had CRC on screening colonoscopy. Disease duration and increasing age of onset were associated with higher risk of CRC.

CONCLUSIONS

Cumulative risk of CRC in Indian UC patients is as high as 23.6% at 30 years. The risk of CRC increases with increasing age of onset and increasing duration of disease. A low risk of sporadic CRC does not confer a low risk of UC-related CRC, and regular screening is warranted.

Risk of colorectal cancer in Asian patients with ulcerative colitis: a systematic review and meta-analysis

BACKGROUND

The increased risk of colorectal cancer in ulcerative colitis is well known. The risk of sporadic colorectal cancer in Asian populations is considered low and risk estimates of colorectal cancer related to ulcerative colitis from Asia vary. This meta-analysis is an Asian perspective on the risk of colorectal cancer related to ulcerative colitis.

METHODS

We searched PubMed and Embase for terms related to colorectal cancer in ulcerative colitis from inception to July 1, 2016. The search for published articles was done by country for all countries in Asia. We included studies with information on the prevalence and cumulative risk of colorectal cancer at various timepoints. A random-effects meta-analysis was done to calculate the pooled prevalence as well as a cumulative risk at 10 years, 20 years, and 30 years of disease.

FINDINGS

Our search identified 2575 articles; of which 44 were eligible for inclusion. Our analysis included a total of 31 287 patients with ulcerative colitis with a total of 293 reported colorectal cancers. Using pooled prevalence estimates from various studies, the overall prevalence was 0·85% (95% CI 0·65-1·04). The risks for colorectal cancer were 0·02% (95% CI 0·00-0·04) at 10 years, 4·81% (3·26-6·36) at 20 years, and 13·91% (7·09-20·72) at 30 years. Subgroup analysis by stratifying the studies according to region or period of the study did not reveal any significant differences.

INTERPRETATION

We found the risk of colorectal cancer in Asian patients with ulcerative colitis was similar to recent estimates in Europe and North America. Adherence to screening is therefore necessary. Larger population-based, prospective studies are required for better estimates of the risk.

FUNDING

Indo-US Science and Technology Forum.

Antioxidant Supplements and Gastrointestinal Diseases: A Critical Appraisal

The gastrointestinal tract digests and absorbs dietary nutrients, protects the body against physical and chemical damage from contents in its lumen, provides immunity against external antigens, and keeps an optimum environment for the gut microbiota. These functions cannot be performed normally in several diseases of which the following are discussed here: irritable bowel syndrome and inflammatory bowel disease, which includes Crohn's disease and ulcerative colitis. Because these diseases are associated with oxidative stress, a host of antioxidant supplements are used for maintenance and recovery of the gut functions. However, the benefits of these supplements have not been established. The available 80 human trials were rated for levels of confidence and for benefits of the antioxidant supplements. For Crohn's disease, the supplements for which clear benefits occurred in at least 2 studies were allopurinol, Boswellia serrata (frankincense or shallaki), Artemesia species (wormwood), Tripterygium wilfordii (léi gōng téng), and omega-3 fatty acids. Similar beneficial supplements for ulcerative colitis were allopurinol, Matricaria chamomilla (chamomile), Curcuma longa (curcumin in turmeric), and omega-3 fatty acids. There was also a clear benefit for ulcerative colitis in 2 studies where a multiherbal Chinese medicine preparation and an Ayurvedic medicine preparation were used. For irritable bowel syndrome, there was only a marginal benefit of some of the antioxidant supplements. Thus, some antioxidant supplements may be beneficial at certain stages of specific diseases. This is consistent with the current concept that antioxidants act by inhibiting oxidative stress pathways in a tissue- and environment-specific manner and not by simply acting as scavengers.

A low-cost method for chromoendoscopy for surveillance in ulcerative colitis

The risk of colorectal cancer in Indian patients with long-standing ulcerative colitis is high and similar to that in the West. Surveillance for dysplasia in these patients is therefore important. Recent studies and guidelines suggest an increasing role for chromoendoscopy-guided biopsy in surveillance for dysplasia. We report our experience with the technique of chromoendoscopy and an economical method of performing it. Reconstituting indigo carmine from a powder form rather than the dyes available commercially is a better economical alternative and should help make chromoendoscopy the standard of care for dysplasia surveillance across the country.

Inflammatory bowel disease in India - Past, present and future

There is rising incidence and prevalence of inflammatory bowel disease (IBD) in India topping the Southeast Asian (SEA) countries. The common genes implicated in disease pathogenesis in the West are not causal in Indian patients and the role of “hygiene hypothesis” is unclear. There appears to be a North-South divide with more ulcerative colitis (UC) in north and Crohn’s disease (CD) in south India. IBD in second generation Indian migrants to the West takes the early onset and more severe form of the West whereas it retains the nature of its country of origin in migrants to SEA countries. The clinical presentation is much like other SEA countries (similar age and sex profile, low positive family history and effect of smoking, roughly similar disease location, use of aminosalicylates for CD, low use of biologics and similar surgical rates) with some differences (higher incidence of inflammatory CD, lower perianal disease, higher use of aminosalicylates and azathioprine and lower current use of corticosteroids). UC presents more with extensive disease not paralleled in severity clinically or histologically, follows benign course with easy medical control and low incidence of fulminant disease, cancer, complications, and surgery. UC related colorectal cancer develop in an unpredictable manner with respect to disease duration and site questioning the validity of strict screening protocol. About a third of CD patients get antituberculosis drugs and a significant number presents with small intestinal bleed which is predominantly afflicted by aggressive inflammation. Biomarkers have inadequate diagnostic sensitivity and specificity for both. Pediatric IBD tends to be more severe than adult. Population based studies are needed to address the lacunae in epidemiology and definition of etiological factors. Newer biomarkers and advanced diagnostic techniques (in the field of gastrointestinal endoscopy, molecular pathology and genetics) needs to be developed for proper disease definition and treatment.

Role of random biopsies in surveillance of dysplasia in ulcerative colitis patients with high risk of colorectal cancer

Background/Aims

Recent data suggest that the incidence of ulcerative colitis (UC) related colorectal cancer (CRC) in India is similar to that of West. The optimum method for surveillance is still a debate. Surveillance with random biopsies has been the standard of care, but is a tedious process. We therefore undertook this study to assess the yield of random biopsy in dysplasia surveillance.

Methods

Between March 2014 and July 2015, patients of UC attending the Inflammatory Bowel Disease clinic at the All India Institute of Medical Sciences with high risk factors for CRC like duration of disease >15 years and pancolitis, family history of CRC, primary sclerosing cholangitis underwent surveillance colonoscopy for dysplasia. Four quadrant random biopsies at 10 cm intervals were taken (33 biopsies). Two pathologists examined specimens for dysplasia, and the yield of dysplasia was calculated.

Results

Twenty-eight patients were included. Twenty-six of these had pancolitis with a duration of disease greater than 15 years, and two patients had associated primary sclerosing cholangis. No patient had a family history of CRC. The mean age at onset of disease was 28.89±8.73 years and the duration of disease was 19.00±8.78 years. Eighteen patients (64.28%) were males. A total of 924 biopsies were taken. None of the biopsies revealed any evidence of dysplasia, and 7/924 (0.7%) were indefinite for dysplasia.

Conclusions

Random biopsy for surveillance in longstanding extensive colitis has a low yield for dysplasia and does not suffice for screening. Newer techniques such as chromoendoscopy-guided biopsies need greater adoption.

How to Optimize Colon Cancer Surveillance in Inflammatory Bowel Disease Patients

Colitis-associated colorectal neoplasia (CRN) is a well-known complication of chronic inflammation of the colon either with ulcerative colitis (UC) or colonic Crohn's disease (CD). Studies have shown that inflammatory bowel disease (IBD) patients have an overall higher risk for colorectal dysplasia and cancer compared to the general population and this risk is further increased by certain associated factors, including extent of disease, duration of disease, and age at onset. In addition, other risk factors not related to IBD can also further increase the risk for CRN, such as a family history of sporadic colon cancer and a concomitant diagnosis of primary sclerosing cholangitis. The society guidelines mostly agree on the appropriate time to begin CRN surveillance but vary somewhat on the appropriate intervals between surveillance colonoscopies. In addition, there is not yet a consensus on the appropriate method for surveillance. In this review, we discuss the risk for CRN in colonic IBD, the associated factors that further increase the risk for CRN, the current surveillance guidelines and the current methods available for CRN surveillance.

Cancer surveillance in ulcerative colitis and Crohn's disease: new strategies

PURPOSE OF REVIEW

Inflammatory bowel disease (IBD) patients have a higher incidence of colon cancer than the general population. Colon cancer surveillance has traditionally involved taking numerous random biopsies to provide sufficient yield to detect dysplasia. Recently, consensus guidelines have been published which promote the use of chromoendoscopy for IBD colon cancer surveillance. This presents a new set of opportunities and challenges in the evaluation and management of dysplasia in IBD.

RECENT FINDINGS

Dysplasia, previously thought to be 'invisible' to the endoscopist, is now considered to be 'visible' in the majority of cases with the advent of the use of high-definition endoscopy and chromoendoscopy. This changes how we manage dysplastic lesions, providing the patient options for endoscopic resection rather than promoting total proctocolectomy.

SUMMARY

Implemention of chromoendoscopy may require additional training for endoscopists unfamiliar with the technique. However, if this proves to be cost-effective and provides a higher sensitivity in dysplasia detection, then widespread education and implementation will be well worth the efforts. To do so, future studies will need to prove its benefits in preventing or reducing colon cancer morbidity and mortality in this high-risk patient population.