Evolution of osteopenia in inflammatory bowel disease

OBJECTIVE: Our aim was the assessment of frequency and evolution of osteopenia in patients with inflammatory bowel disease and identification of related factors. METHODS: Bone mineral density (BMD) of the lumbar spine was measured in 54 patients with Crohn's disease (CD) and in 49 patients with ulcerative colitis (UC) and was repeated after a mean observation period of 21 (range, 8-50) months in 30 CD and 14 UC patients. Eighteen age-matched healthy subjects served as controls. Serum biochemistry (parathyroid hormone, osteocalcin, alkaline phosphatase, insulin-like growth factor 1, minerals, and markers of inflammation) was assessed at the time of the second BMD measurement. RESULTS: Reduced BMD values were found in 48% of CD, and in 38% of UC patients. Compared with control subjects, the mean BMD was significantly lower in CD (p < 0.003) and UC (p < 0.0001) patients. BMD was positively correlated with the body mass index (p < 0.05) and inversely correlated with the lifetime steroid dose (p < 0.03). After 21 months the BMD of CD patients was virtually unchanged, with an annual variation (%deltaBMD/yr) of -0.31 +/- 0.49, whether treated with steroids or not, whereas in UC patients the BMD decreased significantly (p < 0.02) with a %deltaBMD/yr of -2.47 +/- 0.82 (p < 0.02 vis CD). This decrease can be attributed to steroid treatment. No biochemical alterations were detected in patients with rapid bone loss, compared with those with stable BMD. CONCLUSIONS: Low bone density is frequent in both CD and UC, but apparently stable in CD. The evolution of BMD suggests that low bone density is associated with the pathogenesis of CD, whereas in UC it seems to be correlated with the side effects of corticosteroid treatment.     

Vaccinations in patients with inflammatory bowel disease

Treatment of inflammatory bowel disease (IBD) frequently requires administration of immunosuppressive therapies, which increases susceptibility to a number of infectious pathogens. However, many infections can be prevented by correct and appropriate utilization of vaccinations. While several guidelines have been published on vaccination schedules in patients with IBD, vaccination rates remain suboptimal and even lower than those in the general population. This is due to many factors including poor awareness of the importance of vaccines by gastroenterologists and general practitioners as well as potential prejudices of patients regarding the safety and benefits of vaccines. With the aim of increasing awareness about the key role of immunization in the management of patients with IBD, the present review examines the existing literature relating to the main vaccinations and their application in these patients. We also summarize current evidence in order to provide clinicians with an easy source of reference for the principal recommendations for prevention of infectious diseases in patients with IBD. In addition, the recommendations about traveling for IBD patients are briefly explored. Lastly, since it is important for gastroenterologists to be aware of recommendations on vaccination, we recommend implementing educational programs to ensure compliance with current guidelines.     

Communicating with patients with inflammatory bowel disease

Ulcerative colitis and Crohn's disease, the two main forms of inflammatory bowel disease (IBD), are chronic illnesses that affect hundreds of thousands of Americans. Patients with IBD suffer chronically from diarrhea, abdominal pain, gastrointestinal bleeding, malabsorption, and weight loss requiring continuous medical and surgical attention. Despite recent advances in therapy, IBD follows a course of exacerbations and remissions with approximately 25-50% of patients relapsing annually. Hence, these diseases are readily encountered in primary care and gastroenterology clinics. Though medical and surgical treatment options have improved significantly, little has been written about the psychosocial aspects of IBD. Currently, there is a paucity of data concerning effective communication methods enabling physicians to develop stronger rapport with patients suffering from IBD, the care of whom requires a multidisciplinary approach involving primary care physicians, gastroenterologists, and colorectal surgeons. Because IBD has a high morbidity, it is worthwhile to further investigate those social factors that will improve patients' quality of life. In this paper, we summarize some of the common problems that emerge when taking care of patients with IBD and provide initial guidelines based on the world literature regarding the management and education of patients with IBD. Both primary care physicians and specialists (gastroenterologists, colorectal surgeons) need to be aware of the questions and concerns of IBD patients and to be capable of dispensing the information in a clear and concise manner. Using the case scenario format, we review the most common aspects of communication for health care professionals taking care of IBD patients and suggest ways to establish and maintain long-term doctor-patient relationships. The two most significant interventions that dramatically improve quality of life and patient-physician relationships are proper patient education and appropriate treatment of concurrent depression and anxiety. We hope that our review will form a framework by which different members of the medical team learn their roles in the complex management decisions affecting IBD patients.     

Smoking habits in patients with inflammatory bowel disease

The proportion of smokers in this study was significantly lower among patients with ulcerative colitis (13%) than among patients with Crohn's disease (47%), the difference being significant for both sexes and for the age groups both below and above 40 years. The proportion of male ex-smokers among patients with ulcerative colitis (28%) was higher than among patients with Crohn's disease (8%), whereas the proportions of non-smokers differed less. Many of the patients with ulcerative colitis who had a late onset were male ex-smokers. The smoking patients with ulcerative colitis were mainly women. They smoked less than the smoking patients with Crohn's disease and less than the ex-smokers in each group. No smoking patient with ulcerative colitis smoked greater than 20 cigarettes/day. In the group of male ex-smokers with ulcerative colitis, there was an accumulation of onsets during the 4 years after the definitive smoking stop. The number of colectomies performed on patients with ulcerative colitis did not vary with smoking habits. In the group of ex-smokers the colectomy was performed after the smoking stop in 19 out of 20 patients.     

Spleen size in patients with inflammatory bowel disease

The finding that splenic atrophy is associated with a high complication rate in colitis has led to a long-term, prospective study of spleen size in inflammatory bowel disease. The spleen has been measured in 116 patients undergoing laparotomy for inflammatory bowel disease —2-80 Crohn's disease and 36 ulcerative colitis—from 1975 to 1985. Small spleen size, of lesser degree than that of classic splenic atrophy, is associated with presurgery disease complications as well as infective problems after surgery. Spleen size was not related to site or extent of disease, or to recurrence, but the wide range of spleen size seen in inflammatory bowel disease, comparable to that seen in malignancy suggests that more sophisticated tests of splenic function might show a closer correlation with disease patterns Dr. Jorge Pereira was supported by a fellowship from Rotary International.     

Cytomegalovirus infection in patients with inflammatory bowel disease

OBJECTIVE: It has been suggested that, in inflammatory bowel disease, cytomegalovirus behaves in the intestine as a nonpathogenic bystander, and even its finding in intestinal mucosa has unclear clinical relevance. We report our experience with a small series of patients with refractory inflammatory bowel disease and cytomegalovirus infection and their clinical outcome. METHODS AND RESULTS: Nine patients with moderate-severe attacks of inflammatory bowel disease did not respond to i.v. prednisone (1 mg/kg/day) for a mean of 24 days. Four of these patients were further treated with i.v. cyclosporine A (4 mg/kg/day). Cytomegalovirus infection was diagnosed in two patients after resection for treatment failure. In the remaining patients, cytomegalovirus infection was diagnosed in endoscopic mucosal biopsies and i.v. ganciclovir was then administered at a dose of 10 mg/kg/day for 2-3 wk. Five of these patients went into clinical remission, allowing corticosteroid and cyclosporine A discontinuation. Follow-up biopsies were performed and in all cases cytomegalovirus could not be detected in the colonic tissue. Two patients needed to be treated with intravenous cyclosporine A after antiviral therapy because of persistence of clinical symptoms despite the elimination of cytomegalovirus infection. CONCLUSIONS: Cytomegalovirus infection may play a role in the natural history of refractory inflammatory bowel disease and in some of its complications. The clearance of cytomegalovirus in colonic mucosa may lead some of these patients to remission.     

Fracture-associated hospitalizations in patients with inflammatory bowel disease

Background  

Maintenance of bone health is an important concern in patients with inflammatory bowel disease (IBD). They may frequently have impaired bone density resulting in greater incidence of fractures.     

Osteoporosis in patients with inflammatory bowel disease.

Bone mineral content in spinal trabecular and peripheral cortical bone was measured in 75 unselected patients with small and/or large intestinal inflammatory bowel disease. Osteoporosis, defined as a bone mineral content greater than 2 SD below the age and sex matched normal mean value was present in 23 patients (30.6%). Three amenorrhoeic females aged 34, 38, and 42 years had severe clinical osteoporosis and a further three patients had one or more vertebral crush fractures. Eighteen of the 23 patients with osteoporosis had small intestinal disease with one or more resections and the mean lifetime steroid dose in those with osteoporosis was significantly higher than in those with normal bone mineral content. Bone mineral content in spinal trabecular bone showed significant negative correlations with lifetime steroid dose and serum alkaline phosphatase and a significant positive correlation with serum albumin. Peripheral cortical bone mineral content was positively correlated with body weight, height and body mass index. We conclude that the prevalence of osteoporosis is increased in patients with inflammatory bowel disease, severe clinical osteoporosis developing in some relatively young patients. The pathogenesis of this bone loss is probably multifactorial; steroid therapy is likely to be an important contributory factor.     

Cancer prevention in patients with inflammatory bowel disease

Colorectal cancer is an important, and often dreaded, consequence of long-standing UC and Crohn's colitis. Surveillance colonoscopy, despite its limitations, is beneficial for detecting earlier stage cancers and, probably, mortality reduction. Agents such as anti-inflammatory medications, folic acid, and ursodeoxycholic acid show promise for chemoprevention in this disease. Future research will help to define better the natural history of dysplasia in IBD, and to determine how molecular approaches may be integrated into surveillance programs to reduce CRC risk.     

Psychiatric comorbidities in patients with inflammatory bowel disease

Background

Psychiatric comorbidities are associated with inflammatory bowel disease (IBD). We conducted an observational study to evaluate the prevalence of depression and anxiety in patients with IBD.

Methods

Seventy consecutive consenting patients with IBD (62 ulcerative colitis [UC], 8 Crohn’s disease [CD]; 40 males, mean age [SD] 36.2 [11.3] years) and 100 healthy volunteers (44 males, age 31.22 [SD] [10.5] years) as controls were enrolled. All participants were directed to take self-assessment tests, Patient Health Questionnaire -9 (PHQ-9) and Symptom Checklist Anxiety Scale (SCL-A20). Participants having a score ≥ 10 on PHQ-9, or ≥ 29 on SCL-A20 were administered the Hamilton Depression Rating Scale (HAM-D) or Hamilton Anxiety (HAM-A) scales, respectively. The severity of depression and anxiety was graded with HAM-D and HAM-A scales, respectively. The protocol was approved by the Institutional Ethics Committee.

Results

The prevalence of depression (34.3% vs. 5%, p?<?0.0001, OR 9.7) and anxiety (18.6% vs. 2%, p?=?0.0002, OR 11.17) was higher in patients with IBD as compared to controls. The severity of depression was higher in patients compared to controls (mean rank 17 vs. 7, p?=?0.04). The prevalence of depression was not different between UC and CD; all IBD patients with anxiety had UC. The mean duration of disease and history of corticosteroid treatment or surgery for IBD were not associated with the presence of depression or anxiety. Patients with severe CD (Crohn’s disease activity index, CDAI?>?450) had more severe depression. The severity of UC did not correlate with severity of anxiety or depression in UC.

Conclusions

Anxiety and depression are more prevalent in IBD patients as compared to healthy individuals.

     

Surveillance of patients with inflammatory bowel disease

Patients with inflammatory bowel disease involving the colon are at increased risk for developing colorectal cancer. Colonoscopy surveillance is important to identify and treat IBD associated dysplasia. The SCENIC consensus provides evidence-based recommendations for optimal surveillance and management of dysplasia in IBD. Chromoendoscopy, with the surface application of dyes to enhance mucosal visualization, is the superior endoscopic surveillance strategy to detect dysplasia. Most dysplasia is visible, and can be endoscopically resected. Future studies should determine the effect of new surveillance strategies on the incidence of CRC and mortality in patients with IBD.     

炎症性肠病患者肠黏膜组织细胞凋亡

炎症性肠病(inflammatory bowel disease,IBD)是发生在胃肠道慢性非特异性炎症性疾病,其病因及发病机制尚未十分明确,可能与环境因素、遗传因素和免疫因素等有关.研究表明细胞凋亡在IBD的发病中起着重要的作用,表现为炎症肠黏膜组织内存在细胞凋亡紊乱,肠上皮细胞凋亡过度、黏膜固有层组织内淋巴细胞凋亡抵抗,以及PMN凋亡迟滞.这是造成IBD肠道炎症发生和持续的重要原因.研究发现发生细胞凋亡的主要机制在于激活了Fas/FasL信号传导途径、Bcl-2和Bax调节途径而实施的.研究细胞凋亡机制对揭示IBD的发病机制.靶向性阻断细胞凋亡通路治疗IBD发生有重要意义.     

Prevalence of inflammatory bowel disease in patients with airways disease

BACKGROUND: Case reports and case series have suggested an association between inflammatory bowel disease (IBD) and airways disease, but there are no data demonstrating a higher prevalence of IBD among patients with airways disease. Furthermore, no consistent radiological, pulmonary or pathological abnormalities have been demonstrated in patients with both conditions. AIMS: To determine the prevalence of IBD among patients with airways disease and to evaluate clinical and pathophysiological features. METHODS: A retrospective analysis of outpatients with airways disease over a 10-year period. RESULTS: IBD was four times more prevalent among patients with airways disease compared with published local IBD prevalence [Odds Ratio 4.26, 95% CI 1.48, 11.71, p=0.006; Crohn's disease OR 5.96, 95% CI 1.94, 18.31, p=0.002 and ulcerative colitis OR 4.21, 95% CI 1.71, 10.41, p=0.001]. IBD was more frequent in all types of airways disease except asthma; the association was particularly strong for conditions associated with productive cough. All except 1 patient had established IBD before the onset of respiratory symptoms. There were no obvious radiological differences between ulcerative colitis and Crohn's disease cases. There was a trend for a higher lymphocyte count (despite a tendency to lower blood lymphocyte count) but lower sputum neutrophil count in patients with Crohn's disease compared with ulcerative colitis. There were no significant differences in physiological measurements of pulmonary function between the two types of IBD. CONCLUSION: Our findings support an association between airways disease and inflammatory bowel disease, particularly non-asthmatic airways disease with productive cough.