Longer-Term Outcomes of Nutritional Management of Crohn’s Disease in Children

Background

While the short-term benefits of exclusive enteral nutrition (EEN) for induction of remission in children with Crohn’s disease (CD) are well documented, the longer-term outcomes are less clear.

Aim

This retrospective study aimed to ascertain the outcomes for up to 24 months following EEN in a group of children with CD.

Methods

Children treated with EEN as initial therapy for newly diagnosed CD over a 5-year period were identified. Details of disease activity, growth, and drug requirements over the period of follow-up were noted. Outcomes in children managed with EEN were compared to a group of children initially treated with corticosteroids.

Results

Over this time period, 31 children were treated with EEN and 26 with corticosteroids. Twenty-six (84 %) of the 31 children treated with EEN entered remission. Children treated with EEN exhibited lower pediatric Crohn’s disease activity index (PCDAI) scores at 6 months (p = 0.02) and received lower cumulative doses of steroids over the study period (p < 0.0001) than the group treated with corticosteroids. Height increments over 24 months were greater in the EEN group (p = 0.01). Although the median times to relapse were the same, the EEN group had a lower incidence of relapse in each time interval and survival curve analysis showed lower risk of relapse (p = 0.008).

Conclusions

EEN lead to multiple benefits beyond the initial period of inducing remission for these children, with positive outcomes over 2 years from diagnosis. Of particular clinical relevance to growing children was the reduced exposure to corticosteroids.     

Management of Cardiac Amyloidosis: Do’s and Don’ts

Cardiac amyloidosis is a potentially deadly disease characterized by progressive infiltration of amyloid fibrils, and it is increasingly recognized as an underdiagnosed but important cause of heart failure. Given its unique pathogenesis, there are key differences in the management of cardiac amyloidosis compared with other forms of heart failure. Moreover, the 2 common forms of cardiac amyloidosis, transthyretin and light-chain amyloidosis, are distinct entities with varying clinical manifestations and prognoses, leading to the need for tailored approaches to management. In the past decade, there have been many significant advances in the diagnosis and treatment of both forms of cardiac amyloidosis. For example, in selected cases, transthyretin cardiac amyloidosis can be diagnosed noninvasively with the use of bone scintigraphy imaging, avoiding the need for a biopsy. Effective, more targeted therapies have been developed for both transthyretin and light-chain amyloidosis. However, these treatments are much more effective in early stages of disease before significant end-organ amyloid deposition has occurred. Consequently, it is increasingly imperative that clinicians aggressively screen at-risk groups, identify early signs of disease, and initiate treatment. Finally, once thought to be ill advised, heart transplantation should be considered in carefully selected patients with end-stage cardiac amyloidosis, because transplant outcomes in these patients is now similar to other those for other cardiomyopathies. Given these and other recent changes in clinical practice, this article discusses several key considerations for the clinical care of patients with cardiac amyloidosis.     

Adenocarcinoma of the Small Bowel Arising From a Previous Strictureplasty for Crohn’s Disease: Report of a Case

Small-bowel adenocarcinoma is an uncommon tumor, comprising<2 percent of all gastrointestinal tract malignancies. These tumors are known to occur in association with Crohn’s disease. To date, there have been only two documented cases of adenocarcinoma arising at the site of previous strictureplasty reported in the literature. We report the third such case in a patient with no other premalignant conditions affecting the small bowel and question whether we may see an increasing trend in this type of presentation.     

Crohn’s Disease Only Visible on Small Bowel Capsule Endoscopy: A New Entity

Digestive Diseases and Sciences - In rare cases, the diagnosis of Crohn’s disease (CD) can only be achieved using small bowel capsule endoscopy (SBCE). We investigate the characteristics of...     

Inflammatory Bowel Disease: A Patient’s and Caregiver’s Perspective

The purpose of this study was to conduct a survey examining the impact of inflammatory bowel disease (IBD) on patients’ and their caregivers’ daily activities. Questionnaires were distributed to patients registered in the APDI (Portuguese Association for IBD) database and their respective caregivers in 2007. Of 422 patient respondents, 251 had Crohn’s disease (CD) and 171 had ulcerative colitis (UC), with the majority of patients being women (58.1%) and aged over 40 years (37.4%). The number of disease flares experienced by IBD patients was slightly higher for patients with CD than for patients with UC (2.64 vs. 2.34), and surgery was more often required in CD patients as compared to UC patients (42.4 vs. 7%). Sixty percent (60%) of patients reported having no problems with mobility, daily activities, or personal hygiene; however, over half of all patients experienced some pain and anxiety. Adult patients and children and adolescents respectively experienced time off work or school due to their disease but caregivers were not affected in this regard. The caregivers life (N = 324) was affected by anxiety, with the major concern reported as the risk of the patient developing cancer. Both IBD patients and caregivers thought that the provision of information on new drugs and contact time with a doctor would have the biggest impact on improving care. The symptoms and complications of IBD have a considerable impact on the lives of patients and their caregivers, and several actions could be taken to improve their care.     

Management of Raynaud’s Phenomenon and Digital Ischemia

Pain is the most common reason patients with inflammatory arthritis see a rheumatologist. Patients consistently rate pain as one of their highest priorities, and pain is the single most important determinant of patient global assessment of disease activity. Although pain is commonly interpreted as a marker of inflammation, the correlation between pain intensity and measures of peripheral inflammation is imperfect. The prevalence of chronic, non-inflammatory pain syndromes such as fibromyalgia is higher among patients with inflammatory arthritis than in the general population. Inflammatory arthritis patients with fibromyalgia have higher measures of disease activity and lower quality of life than inflammatory patients who do not have fibromyalgia. This review article focuses on current literature involving the effects of pain on disease assessment and quality of life for patients with inflammatory arthritis. It also reviews non-pharmacologic and pharmacologic options for treatment of pain for patients with inflammatory arthritis, focusing on the implications of comorbidities and concurrent disease-modifying antirheumatic drug therapy. Although several studies have examined the effects of reducing inflammation for patients with inflammatory arthritis, very few clinical trials have examined the safety and efficacy of treatment directed specifically towards pain pathways. Most studies have been small, have focused on rheumatoid arthritis or mixed populations (e.g., rheumatoid arthritis plus osteoarthritis), and have been at high risk of bias. Larger, longitudinal studies are needed to examine the mechanisms of pain in inflammatory arthritis and to determine the safety and efficacy of analgesic medications in this specific patient population.     

REVIEW: Adult Celiac Disease and the Severe “Flat” Small Bowel Biopsy Lesion

Classification of architectural changes in the small intestinal biopsy may be clinically useful to define the cause of diarrhea or suspected malabsorption, especially in adults. Pathologic changes may include severe (flat) or variably severe (mild or moderate) abnormalities. For some disorders, small bowel biopsy findings may be very distinctive and lead to a specific diagnosis. For others, like adult celiac disease, biopsy changes are less specific. Indeed, it is becoming increasingly appreciated that several conditions can produce similar histopathologic changes. Serological assays, including endomysial antibodies and tissue transglutaminase antibodies, may be very useful tools for screening and case finding in clinical practice. However, demonstration of characteristic changes in the small intestinal biopsy is critical, along with a gluten-free diet response.     

Small cell carcinoma of the lung--to operate or not? Surgical experience and results

From 1962 to 1979, out of 549 patients with small cell bronchial carcinoma (= 15% of all bronchial carcinomas) treated in our clinic, 109 (20%) underwent thoracotomy and 94 (17%) resection. The recurrence free 3-year survival rate for resected patients was 22%, and after 5 years 14 of the 94 (15%) were still alive, using absolute numbers including postoperative deaths. From 1962 to 1975 only patients in stages T1 N0 M0 or T2 N0 M0 survived, with one survivor in stage T1 N2 M0. In the period from 1976 to 1979 patients with tumors in more advanced stages were resected: now those with T1 N1 M0, T1 N2 M0 and predominantly with T2 N1 M0 survived, which can be attributed to the effect of more intensive chemotherapy. Sixty-eight percent of the operations were pneumonectomies; the exploratory thoracotomy rate was 14%. Surgical therapy was seen as an integral part of an oncological regime applied in suitable types of tumor. When the tumor was identified only after resection, 3 courses of a combined chemotherapy including cranial radiation were performed, with additional topical radiation in cases of N2 or T3 forms. When the diagnosis was ascertained preoperatively, 2 (to 3) courses of chemotherapy were followed by resection of the entire area affected, and then by a further 2 (to 3) courses of combined chemotherapy with cranial radiation. A prerequisite for resection in these cases was that the tumor had regressed as a result of the first courses of chemotherapy. In cases of initially inoperable tumors, "residual surgery" appears justified if adequate regression occurs as a result of chemotherapy in view of the large number of local recurrences following chemo(/radio-)therapy alone. Palliative resection is not indicated in small cell bronchial carcinomas, nor is surgery indicated in cases of primarily inoperable tumors which do not react to chemotherapy.     

Crohn’s Colitis: The Incidence of Dysplasia and Adenocarcinoma in Surgical Patients

Purpose Data supporting an increased risk of colorectal cancer in patients with Crohn’s colitis are inconsistent. Despite this, clinical recommendations regarding colonoscopic screening and surveillance for patients with Crohn’s colitis are extrapolated from chronic ulcerative colitis protocols. The primary aim of our study was to determine the incidence of dysplasia and carcinoma in pathology specimens of patients undergoing segmental or total colectomy for Crohn’s disease of the large bowel. In addition, we sought to identify risk factors associated with the development of dysplasia and carcinoma. Methods We performed a retrospective review of all patients operated on at our institution for Crohn’s colitis between January 1992 and May 2004. Data were retrieved from patient charts, operative notes, and pathology reports. Logistic regression was used to model the probability of having dysplasia or adenocarcinoma. Results Two hundred twenty-two patients (138 females) who underwent surgical resection for the treatment of Crohn’s colitis were included in the study. Mean age at surgery was 41 (range, 15–82) years and the mean duration of disease was 10 (range, 0–53) years. There were five cases of dysplasia (2.3 percent) and six cases of adenocarcinoma (2.7 percent). Three patients with dysplasia and one with adenocarcinoma were diagnosed on preoperative colonoscopy; while the other cases were discovered incidentally on pathologic examination of resected specimens. Factors associated with the presence of dysplasia or adenocarcinoma included older age at diagnosis (38.2 vs. 30.3 years, P = 0.02), longer disease duration (16.0 vs. 10.1 years, P = 0.05), and disease extent (90 percent extensive vs. 59 percent limited, P = 0.05). Conclusions Patients with severe Crohn’s colitis requiring surgery are at significant risk for developing dysplasia and adenocarcinoma, particularly when diagnosed at an older age, after longer disease duration, and with more extensive colon involvement. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005. Reprints are not available     

Fistulating Anal Crohn’s Disease: Results of Combined Surgical and Infliximab Treatment

Introduction Infliximab is a monoclonal antibody against tumor necrosis factor-alpha, which has been shown to be effective in fistulating Crohn’s disease. The safety of infliximab in patients with potential perianal sepsis is uncertain. This study was designed to assess the safety and outcome of infliximab therapy combined with surgery for patients with fistulating anal Crohn’s disease. Methods All patients receiving infliximab for fistulating anal Crohn’s disease between 2000 and 2004 were studied. Patients’ demographics, clinical findings, magnetic resonance imaging, and examination under anesthesia were recorded. Perianal Crohn’s disease activity index before and 8 to 12 weeks after three infusions of infliximab (5 mg/kg) were recorded. Routine policy was to insert drainage seton sutures at the time of preinfliximab examination under anesthesia and then remove it after the second infusion. Complications of treatment and outcome at the last clinic follow-up were recorded. Results Twenty-two patients underwent infliximab treatment (6 males; median age, 35 (range, 16–60) years). Twenty-one patients had preinfliximab examination under anesthesia: 12 required abscess drainage; 17 had at least one drainage seton suture inserted. Fourteen patients underwent pretreatment magnetic resonance imaging to identify clinically occult collections. All but one patient were established on immunomodulator therapy before infliximab treatment. Perianal Crohn’s disease activity index improved significantly after infliximab infusion (preinfusion: median, 11, range, 8–17; postinfusion: median, 8, range, 5–16; P< 0.001). There were no serious complications of infliximab treatment. At median follow-up of 21 (range, 4–31) months, only four patients achieved sustained fistula healing. Five patients have required defunctioning or proctectomy. Four patients have required repeated infusions of infliximab. Conclusions Infliximab therapy in combination with examination under anesthesia/seton drainage is a safe and effective short-term treatment for fistulating anal Crohn’s disease. Long-term fistula healing rates are low. Presented at the Tripartite Colorectal Meeting, Dublin, Ireland, July 5 to 7, 2005.     

Hepatitis Delta: Epidemiology, Diagnosis and Management 36 Years After Discovery

With recent studies showing increased prevalence of hepatitis delta (HDV) even in the US, Australia, and some countries in Europe, and very high prevalence in endemic regions, HDV infection is far from being a disappearing disease. Although immigrants from endemic countries have been shown to have increased risk, studies have clearly shown that the disease is not solely appearing in traditional high-risk groups. Recent studies provide increasing evidence that sexual transmission may be an important factor in HDV infection spread. Based on the totality of evidence showing increased disease progression and substantially increased risk of cirrhosis in HDV-infected CHB patients, and the current studies showing higher than expected prevalence, it is time to call for HDV screening of all CHB patients. HDV viral load detection and measurement should be considered in all patients whether or not they are anti-HDV-positive. With universal screening of CHB patients for HDV, earlier diagnosis and consideration of treatment would be possible. Current treatment of HDV is IFN-based therapy with or without HBV antivirals, but current research indicates the possibility that prenylation inhibitors, entry inhibitors, HBsAg release inhibitors, or other therapies currently in the pipeline may provide more effective therapy in the future. In addition, universal screening would serve the important public health goal of allowing patients to be educated on their status and on the need for HDV-negative patients to protect themselves against superinfection and for HDV-infected patients to protect against transmission to others. Further studies and global awareness of HDV infection are needed.