Patients with extraintestinal manifestations have a higher risk of developing pouchitis in ulcerative colitis: multivariate analysis

Background: Restorative proctocolectomy and ileal pouch‐anal anastomosis (IPAA) have been the surgical treatments of choice for ulcerative colitis (UC). However, the IPAA is sometimes complicated with pouchitis. Furthermore, the cumulative risk and risk factors for developing pouchitis in patients with UC undergoing IPAA have not been reported in any Asian population. The aim of our study is to clarify the cumulative risk and risk factors for developing pouchitis in Japanese patients with UC undergoing IPAA. Methods: Fifty‐eight patients with UC undergoing IPAA were retrospectively evaluated for the presence of pouchitis, gender, age of onset, history of smoking, presence of extraintestinal manifestations (EIMs) and type of operation. The diagnosis of pouchitis was based on the pouchitis disease activity index. The cumulative risk and risk factors for developing pouchitis were assessed. Results: The cumulative risks for developing pouchitis at 1 and 5 years were 9.0% and 14.4%, respectively. The estimated risks of pouchitis at 5 years was 48.1% in patients with EIMs and 4.6% in those without. Both univariate and multivariate analyses revealed that the presence of EIMs is a significant risk factor (hazard ratio 16.85, 95% confidence interval 3.12–91.00; P?=?0.001). Conclusions: The presence of EIMs is a significant risk factor for the development of pouchitis in Japanese patients with UC undergoing IPAA.     

Pouchitis in pediatric ulcerative colitis: A multicenter study on behalf of Italian Society of Pediatric Gastroenterology,Hepatology and Nutrition

BackgroundData on the epidemiology and risk factors for pouchitis following restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) in pediatric patients with ulcerative colitis (UC) are scarce.AimsTo determine incidence, risk factors and clinical outcome of pouchitis following IPAA in children.MethodsThis multicenter, retrospective cohort study, included all pediatric UC patients who underwent colectomy and IPAA from January 2010 to December 2016.ResultsEighty-five patients were enrolled. During a median post-surgical period of 24.8 (range: 1.0–72.0) months following IPAA, 38 (44.7%) patients developed pouchitis, including 6 (15.8%) who developed chronic pouchitis. Kaplan–Meier survival estimates of the cumulative probability for pouchitis were 14.6% at 1 year and 27.3% and 51.5% at 2 and 5 years, respectively. Multiple Cox regression model showed that older age at colectomy (hazard ratio, HR: 0.89, p = 0.008) was a protective factor, whereas chronic active colitis as indication for surgery (HR: 4.45, p < 0.001), and a 3-stage IPAA (HR: 2.86, p = 0.028) increased the risk for pouchitis.ConclusionsLong-term risk for pouchitis is significantly high in pediatric-onset UC after IPAA. Younger age at colectomy, chronic active colitis as indication for surgery and 3-stage IPAA may increase the risk for pouchitis.     

Risk factors for nephrolithiasis in patients with ileal pouches

Background and aimsRestorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become a standard of care in patients with ulcerative colitis (UC). Nephrolithiasis is common in patients with inflammatory bowel disease (IBD), but has never been studied as a complication of IPAA. We aimed to assess the risk factors for nephrolithiasis in patients with IPAA.MethodsUsing an IRB-approved, prospectively maintained pouch registry, we identified 1221 patients between 2000 and 2010. Those with post-IPAA nephrolithiasis served as the study group whereas IPAA patients without nephrolithiasis served as the controls. Demographic and clinical variables were analyzed using multivariable logistic regression to identify risk factors.ResultsThere were a total of 218 IPAA patients: 81 with nephrolithiasis (37%) and 137 without (63%). Of the 81 patients in the study group, 17 were excluded due to limited clinical data. Three risk factors were found to be associated with nephrolithiasis: the presence of extra-intestinal manifestations (odd's ratio [OR] = 2.9, 95% confidence interval [CI]: 1.4, 5.8, p = 0.003), no use of antibiotics (OR = 3.2, 95% CI: 1.5, 6.5, p = 0.002) and low serum bicarbonate level (OR = 0.87, 95% CI: 0.77, 0.99, p = 0.038).ConclusionNephrolithiasis was a common finding in our patients with IPAA. As pouch patients with nephrolithiasis can develop adverse clinical complications, those with at least one of the risk factors we identified may need to be monitored more closely and possibly receive prophylactic treatment with oral bicarbonate.     

High incidence of surgery and initiation of medical therapies after colectomy for ulcerative colitis or inflammatory bowel disease unclassified

Background and aimsDespite novel medical therapies, colectomy has a role in the management of patients with ulcerative colitis (UC) and inflammatory bowel disease unclassified (IBDU). This study aimed to determine the incidence of unplanned surgery and initiation of immunomodulatory or biologic therapy (IMBT) after colectomy in patients with UC or IBDU, and identify associated factors.MethodsData of patients with preoperative diagnosis of UC or IBDU who underwent colectomy and were followed up at a single tertiary centre was retrospectively collected. The primary outcome was the risk of unplanned surgery and initiation of IMBT during follow-up after colectomy. Secondary outcomes were development of Crohn's disease-like (CDL) complications and failure of reconstructive techniques.Results68 patients were included. After a median follow-up of 9.9 years, 32.4% of patients underwent unplanned surgery and IMBT was started in 38.2%. Unplanned surgery-free survival was 85% (95% confidence interval [CI] 73.8–91.6%) at 1 year, 76% (95% CI 63.2–84.9%) at 5 years and 69.1% (95% CI 55–79.6%) at 10 years. IMBT-free survival was 96.9% (95% CI 88.2–99.2%) at 1 year, 77.6% (95% CI 64.5–86.3%) at 5 years and 63.3% (95% CI 48.8–74.7%) at 10 years. 29.4% of patients met criteria for CDL complications. CDL complications were significantly associated to IMBT (hazard ratio 4.5, 95% CI 2–10.1).ConclusionIn a retrospective study, we found a high incidence of unplanned surgery and IMBT therapy initiation after colectomy among patients with UC or IBDU. These results further question the historical concept of surgery as a “definitive” treatment.     

Neoplasia in the ileoanal pouch following colectomy in patients with ulcerative colitis and primary sclerosing cholangitis

Background & AimsPrimary sclerosing cholangitis (PSC) is typically associated with inflammatory bowel disease (IBD), particularly ulcerative colitis (UC). PSC–IBD patients are at an increased risk for colorectal neoplasia. The ileal pouch-anal anastomosis (IPAA) is a treatment option for patients with medically refractory UC or neoplasia. However, little is known about the development of pouch neoplasia in PSC–UC patients following an IPAA. We aim to describe the incidence of pouch neoplasia in PSC–UC patients after an IPAA.MethodsWe conducted a retrospective chart review of patients with a confirmed diagnosis of PSC and IBD who underwent colectomy with IPAA followed by pouch surveillance between 1995 and 2012.ResultsSixty-five patients were included in the cohort and were followed up from the time of colectomy/IPAA for a median of 6 years. The most common indications for surgery were low-grade dysplasia (LGD) and refractory colitis. Only 3 patients developed evidence of neoplasia (LGD n = 1, high-grade dysplasia n = 1, adenocarcinoma n = 1). The cumulative 5-year incidence of pouch neoplasia was 5.6% (95% confidence intervals [CI], 1.8%–16.1%).ConclusionBased on our short-term follow-up, surveying the pouch frequently appears to be an unnecessary practice in PSC–IBD patients. Longer follow-up will be needed to develop an optimal surveillance strategy for the development of dysplasia and cancer in such patients.     

Patients with extraintestinal manifestations have a higher risk of developing pouchitis in ulcerative colitis: multivariate analysis

BACKGROUND: Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) have been the surgical treatments of choice for ulcerative colitis (UC). However, the IPAA is sometimes complicated with pouchitis. Furthermore, the cumulative risk and risk factors for developing pouchitis in patients with UC undergoing IPAA have not been reported in any Asian population. The aim of our study is to clarify the cumulative risk and risk factors for developing pouchitis in Japanese patients with UC undergoing IPAA. METHODS: Fifty-eight patients with UC undergoing IPAA were retrospectively evaluated for the presence of pouchitis, gender, age of onset, history of smoking, presence of extraintestinal manifestations (EIMs) and type of operation. The diagnosis of pouchitis was based on the pouchitis disease activity index. The cumulative risk and risk factors for developing pouchitis were assessed. RESULTS: The cumulative risks for developing pouchitis at 1 and 5 years were 9.0% and 14.4%, respectively. The estimated risks of pouchitis at 5 years was 48.1% in patients with EIMs and 4.6% in those without. Both univariate and multivariate analyses revealed that the presence of EIMs is a significant risk factor (hazard ratio 16.85, 95% confidence interval 3.12-91.00; P=0.001). CONCLUSIONS: The presence of EIMs is a significant risk factor for the development of pouchitis in Japanese patients with UC undergoing IPAA.     

Impact of ileal pouch-anal anastomosis on the surgical outcome of orthotopic liver transplantation for primary sclerosing cholangitis

BackgroundThe definitive treatment for patients with primary sclerosing cholangitis (PSC) is orthotopic liver transplantation (OLT), while the surgical treatment of choice for UC is restorative protocolectomy with ileal pouch-anal anastomosis (IPAA). While studies to date show that OLT may impact the outcome of IPAA, the effect of IPAA on the surgical outcome of OLT is not known.MethodsAll eligible patients (those with PSC and OLT) from our prospectively maintained OLT and Pouch Databases were included. Patient and OLT graft survivals along with surgical outcomes were assessed. Univariable and multivariable analyses were performed.ResultsSeventy-nine patients with OLT for PSC were studied, including those with UC (PSC + OLT + UC, n = 27) or without UC (PSC + OLT, n = 30), and with UC and IPAA (PSC + OLT + UC + IPAA, n = 22). In the PSC + OLT + UC group, 23 (85.2%) had UC before OLT and 4 (14.8%) had UC diagnosed after OLT. In the PSC + OLT + UC + IPAA group, 9 (40.9%) had IPAA-then-OLT and 13 (59.1%) had OLT-then-IPAA, while 21 (95.5%) had UC before OLT and 1 (4.5%) had UC diagnosed after OLT. Kaplan–Meier survival curve showed no statistical differences in patient and graft survivals between the 3 groups. In univariable analysis, there was no statistical difference for acute and chronic rejection, hepatic artery thrombosis, stricture, bile leak and acute and chronic renal failure for the 3 groups. In multivariable analysis, no factors were found to be associated with bacteremia or intra-abdominal abscess.ConclusionsThe presence of the IPAA in OLT for PSC patients appears not to have a negative impact on patient and graft survivals and post-operative complications.     

Survival of ileal pouch anal anastomosis constructed after colectomy or secondary to a previous ileorectal anastomosis in ulcerative colitis patients: a population-based cohort study

Objectives: Ileorectal anastomosis (IRA) affects bowel function, sexual function and reproduction less negatively than ileal pouch anal anastomosis (IPAA), the standard reconstruction after colectomy for ulcerative colitis (UC). In younger UC patients, IRA may have a role postponing pelvic surgery and IPAA. The aim of the present study was to investigate the survival of IPAA secondary to IRA compared to IPAA as primary reconstruction, as this has not previously been studied in UC.

Patients and methods: All patients with UC diagnosis between 1960 and 2010 in Sweden were identified from the National Patient Registry. From this cohort, colectomized patients reconstructed with primary IPAA and patients reconstructed with IPAA secondary to IRA were identified. The survival of the IPAA was followed up until pouch failure, defined as pouchectomy and ileostomy or a diverting ileostomy alone.

Results: Out of 63,796 patients, 1796 were reconstructed with IPAA, either primarily (n?=?1720) or secondary to a previous IRA (n?=?76). There were no demographic differences between the groups, including length of follow-up (median 12.6 (IQR 6.7–16.6) years and 10.0 (IQR 3.5–15.9) years, respectively). Failure of the IPAA occurred in 103 (6.0%) patients with primary and in 6 (8%) patients after secondary IPAA (P?=?0.38 log-rank). The 10-year pouch survival was 94% (95% CI 93–96) for primary IPAA and 92% (81–97) for secondary.

Conclusions: Patients choosing IRA as primary reconstruction do not have an increased risk of failure of a later secondary IPAA in comparison with patients with primary IPAA.     

Ileorectal anastomosis in comparison with ileal pouch anal anastomosis in reconstructive surgery for ulcerative colitis — a single institution experience

IntroductionIleal pouch anal anastomosis (IPAA) is the standard procedure for reconstruction after colectomy for ulcerative colitis (UC). However, ileorectal anastomosis (IRA) as an alternative has, recently experienced a revival. This study from a single center compares the clinical outcomes of these procedures.MethodsFrom 1992 to 2006, 253 patients consecutively underwent either IRA (n=105) or IPAA (n=148). Selection to either procedure was determined on the basis of rectal inflammation, presence of dysplasia/cancer or patient preferences. Patient-records were retrospectively evaluated. Mean follow-up time was 5.4 and 6.3 years respectively.ResultsMajor postoperative complications occurred in 12.4% of patients after IRA and in 12.8% after IPAA (ns). Complications of any kind after IRA or IPAA, even including subsequent stoma-closure, occurred in 23.8% and 39.9% respectively (p < 0.01). Estimated cumulative failure rates after 5 and 10 years were 10.1% and 24.1% for IRA and 6.1% and 18.6% for IPAA respectively (ns). The most common cause for failure was intractable proctitis (4.8%) and unspecified dysfunction (4.8%) respectively. At follow-up 76.9% of patients with IRA had proctitis and 34.1% with IPAA had pouchitis. Estimated cumulative cancer-risk after 10, 20 and 25 year duration of disease was 0.0%, 2.1% and 8.7% for IRA. Figures for IPAA were 0.7%, 1.8% and 1.8% (ns).ConclusionFailure-rates did not significantly differ between patients operated with IRA or IPAA. Patients operated with IPAA had a higher cumulative number of postoperative complications. The high long-term cancer-risk after IRA indicates that this procedure should be an interim solution in younger patients.     

Incidence and prevalence of inflammatory bowel diseases in gastroenterology primary care setting

BackgroundThe incidence of inflammatory bowel diseases (IBDs) has markedly increased over the last years, but no epidemiological study has been performed in gastroenterology primary care setting. We describe the epidemiology of IBD in a gastroenterology primary care unit using its records as the primary data source.MethodsCase finding used predefined read codes to systematically search computer diagnostic and prescribing records from January 2009 to December 2012. A specialist diagnosis of Ulcerative colitis (UC), Crohn's disease (CD), inflammatory bowel disease unclassified (IBDU) or segmental colitis associated with diverticulosis (SCAD), based on clinical, histological or radiological findings, was a prerequisite for the inclusion in the study. Secondary, infective and apparent acute self-limiting colitis were excluded.ResultsWe identified 176 patients with IBD in a population of 94,000 with a prevalence 187.2/100,000 (95% CI: 160.6–217.0). Between 2009 and 2012 there were 61 new cases. In particular, there were 23 new cases of UC, 19 new cases of CD, 15 new cases of SCAD, and 4 new cases of IBDU. The incidence of IBD was 16.2/100,000 (95% CI 12.5–20.7) per year. The incidence per year was 6/100,000 (95% CI 3.8 to 8.9) for UC, 5/100,000 (95% CI 3.0–7.7) for CD, 4/100,000 (95% CI 2.3–6.5) for SCAD, and 1/100,000 (95% CI 0.3–2.6) for IBDU.ConclusionsWe assessed for the first time which is the prevalence and incidence of IBD in a gastroenterology primary care unit. This confirms that specialist primary care unit is a key factor in providing early diagnosis of chronic diseases.     

The natural history of pediatric-onset IBD-unclassified and prediction of Crohn’s disease reclassification: a 27-year study

Objectives: A definitive diagnosis of Crohn’s disease (CD) or ulcerative colitis (UC) in patients who were initially diagnosed as inflammatory bowel disease-unclassified (IBDU) remains challenging. Our aims were to describe the natural history of pediatric-onset IBDU patients during prolonged period of follow up and to identify associated predictors for CD reclassification among them.

Materials and methods: In this retrospective single center study, out of 723 patients with pediatric onset IBD, we identified 53 patients (7.3%) diagnosed with IBDU at the Schneider Children’s Medical Center of Israel between 1986 and 2013. Potential predictors for CD reclassification including age at diagnosis, gender, clinical manifestations, disease extent and laboratory findings were assessed.

Results: The median follow-up was 6.8 (±?6.7) years. Reclassification to CD was observed in 24/53 (45%) of patients. The median interval from diagnosis to CD reclassification was 9.4 years. In 58% of these patients, CD reclassification occurred within 5 years from diagnosis. Multivariate Cox models showed that familial history of CD and hypoalbuminemia at diagnosis were significantly associated with CD reclassification (HR 11.3, p?=?.02 and HR 5.3, p = .03, respectively). All other assessed clinical, laboratory and endoscopic parameters did not serve as predictors for CD reclassification later on.

Conclusions: In our cohort, a substantial high proportion of pediatric onset IBDU patients were later re-diagnosed as CD. Only a family history of CD and hypoalbuminemia could predict reclassification among IBDU patients.     

Original research: Incidence and prevalence of inflammatory bowel disease in Devon,UK

Background and aimsWe sought to define temporal changes in prevalence of inflammatory bowel disease (IBD) in East Devon, UK, in order to facilitate service planning over the next 5 years.MethodsMultiple primary and secondary care databases were used to identify and verify cases. Point prevalence and incidence of IBD were reported in April 2017 and from 2008 to 2016, respectively. Future prevalence and healthcare activity requirements were estimated by linear regression.ResultsPrevalence of ulcerative colitis (UC), Crohn’s disease (CD) and inflammatory bowel disease unclassified (IBDU) were 479.72, 265.94 and 35.34 per 100 000 persons, respectively. In 2016, the incidence rates of UC, CD and IBDU were 15.4, 10.7 and 1.4 per 100 000 persons per year, respectively. There were no significant changes in the incidence of CD (p=0.49, R=0.26) or UC (p=0.80, R=0.10). IBD prevalence has increased by 39.9% (95% CI 28.2 to 53.7) in the last 10 years without differences in the rate of change between UC and CD. Overall, 27% of patients were managed in primary care, a quarter of whom were eligible but not receiving endoscopic surveillance. Outpatient clinics, MRI and biologic use, but not helpline calls, admissions, or surgeries increased over and above the change in IBD prevalence.ConclusionsWe report one of the highest prevalence and incidence rates of IBD from Northern Europe. Overall, IBD incidence is static, but prevalence is increasing. We estimate that 1% of our population will live with IBD between 2025 and 2030.     

The complete picture of changing pediatric inflammatory bowel disease incidence in Spain in 25 years (1985–2009): The EXPERIENCE registry

ObjectivesA growing incidence of pediatric IBD (PIBD) in southern Europe has been recently reported. The SPIRIT registry (1996–2009) confirmed these tendencies in Spain. Our aim is to obtain data from 1985 to 1995 and describe the complete picture of PIBD presentation changes in Spain in the last 25 years.MethodsA retrospective survey of incident PIBD in the period 1985–1995 was performed. Patients' data were obtained from the hospitals' databases and compared with the published data from the 1996 to 2009 period. Seventy-eight IBD reference centers took part in this survey.ResultsData from 495 patients were obtained: 278 CD (56.2%), 198 UC (40%), and 19 IBDU (3.8%); 51.7% were female, with higher predominance both in UC (58.6%) and in IBDU (57.9%), but not in CD (46.4%). Median (IQR) age at diagnosis was 12.9 (10.0–15.7) years, with significant differences among IBD subtypes: CD: 13.1 (10.8–16.0) vs UC: 12.4 (9.4–15.1) vs IBDU: 7.5 (3.0–13.0) (p ≤ 0.001). These results are significantly different to the ones in the SPIRIT registry, with a higher proportion of IBDU, younger age and male predominance. The data from both periods taken together give a complete picture of a 25–year period. An annual increase of incident patients was observed, with a ten-fold increase over this period.ConclusionThese data extend the epidemiological trends to a full 25–year period (1985–2009). PIBD incidence in Spain has experienced a sixteen-fold increase. The IBD subtype, localization of the affected segment, age- and sex distribution observed are in accordance with our previously published ones of 1996–2009.     

Colectomy for patients with ulcerative colitis and primary sclerosing cholangitis — What next?

Background and aimsPrimary sclerosing cholangitis (PSC) occurs in 2%–8% of patients who suffer from ulcerative colitis (UC). For patients who require colectomy, ileal pouch-anal anastomosis (IPAA) or ileorectal anastomosis (IRA) is employed to preserve continence.We evaluated the outcomes after IPAA and IRA for patients with UC–PSC, using patients with UC but without PSC as controls (UC-only group).PatientsIn a case–control study conducted at Sahlgrenska University Hospital, Sweden, patients with UC–PSC (N = 48; 31 IPAA and 17 IRA) were compared to patients with UC only (N = 113; 62 IPAA and 51 IRA). Functional outcomes (Öresland score), pouchitis, surgical complications, and failure were evaluated.ResultsFor patients with IPAA, the median Öresland scores were similar for the two groups: 5 (range, 0–13) for the UC-PSC group and 5 for the UC-only group (range, 0–12; p > 0.05). However, the IRA scores were significantly different at 7 (range, 2–11) and 3 (range, 0–11) for the respective groups (p = 0.005). Pouchitis was more frequent in patients with UC–PSC. Complication rates did not differ. For patients with IPAA, the failure rate was 16% for those in the UC-PSC group versus 6% for those in the UC-only group (p > 0.05); the corresponding results for IRA were 53% versus 22% (p = 0.03).ConclusionsFor cases of IPAA, pouchitis seems to be more common in patients with UC–PSC. However, the functional outcomes and failure rates are unaffected by concurrent PSC. For patients with UC–PSC, functional outcome is poor and the failure rate is high after IRA.     

Biopsychosocial determinants of health-related quality of life after ileal pouch anal anastomosis for ulcerative colitis

BACKGROUND: In patients with ileal pouch anal anastomosis (IPAA) the influences of psychosocial variables and of extraintestinal manifestations of ulcerative colitis (UC) on health-related quality of life (HRQOL) have not been studied so far. METHODS: 61 patients with UC (age 52.7+/-13.9 years; 47% female) completed the German version of the Inflammatory Bowel Disease Questionnaire (IBDQ-D), the Short Form Health Survey (SF - 36), the German version of the Hospital Anxiety and Depression Scale (HADS-D) and the Giessener Symptom List (GBB 24). Independent of their current clinical activity 37 patients underwent endoscopies. Pouchitis was defined by the Pouch Disease Activity Score (PDAI) > or = 7. Where possible, IPAA-patients were compared with the data for the German general population and with a clinical sample of patients with UC and no IPAA. RESULTS: Patients with IPAA complained more about fatigue and arthralgia and a reduced physical and mental health (SF-36) than the German general population (P < 0.01). The IBDQ-total score could be predicted (adjusted R2 = 29.1, P < 0.01) by the number of operations due to IPAA-related complications (beta = -18.8) and HADS-D-Anxiety scores > or = 11 (beta = -29.1). The IBDQ-subscale score "Bowel" could be predicted (adjusted R2 = 13.7, P = 0.04) by PDAI > or = 7 (beta = -9.2) and the subscale score "Systemic" (adjusted R2 = 13.3, P = 0.04) by the number of extraintestinal manifestations (beta = -1.9). CONCLUSIONS: HRQOL of patients with UC and IPAA is determined not only by IPAA-related factors but also by anxiety and extraintestinal manifestations with associated musculoskeletal pain.     

The findings of musculoskeletal ultrasonography on primary Sjögren’s syndrome patients in childhood with articular manifestations and the impact of anti-cyclic citrullinated peptide antibody

Abstract

Objective: We researched the findings of musculoskeletal ultrasound sonography (MSUS) on primary Sjogren’s syndrome in childhood (pSS-C) with articular manifestations. The correlation of rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA) were investigated to evaluate the usefulness of MSUS on their articular prognosis.

Method: The objective patients are pSS-C cases who visited our hospital complaining joint pain and/or joint swelling and for whom MSUS was performed.

Result: Eight patients included 6 female and 2 male, 5?RF-positive patients and 3 ACPA- positive patients. The mean age of onset was 11.1?±?3.0 years (352 physical joint findings and 284 MSUS findings. The number of joints found clinical articular manifestations was 58/352 joints, and arthritis detected by MSUS was 30/284 joints). In multivariate analysis, the odds ratio of clinical articular manifestations was significant high in RF-positivity (2.9, 95%CI 1.5–6.2). The odds ratio of arthritis detected by MSUS in ACPA-positivity was significant high (3.7, 95%CI 1.5–11.6), although odds ratio in RF-positivity had no statistical significance and a similar trend was seen in odds ratios of subclinical arthritis (4.9, 95%CI 1.6–18.0).

Conclusion: It was indicated that MSUS is useful for pSS-C. ACPA-positive pSS-C patients have arthritis and subclinical arthritis more frequently than ACPA-negative patients.     

Reduction in bone resorption by exogenous glucagon-like peptide-2 administration requires an intact gastrointestinal tract

Objective. According to epidemiological studies, smoking habit is strongly associated with inflammatory bowel disease. Non-smokers, and especially recent ex-smokers, have an increased risk of ulcerative colitis (UC). Conversely, concerning Crohn's disease, the risk is increased among smokers. Pouchitis is the major long-term complication of restorative proctocolectomy for UC, and seems to be pathogenetically related to this condition. The aims of this study were to test the hypothesis that smoking reduces the risk of pouchitis, and to investigate whether cessation of smoking precedes the onset of the inflammation. Material and methods. All living patients operated on for UC with proctocolectomy and ileal pouch anal anastomosis (IPAA) between November 1982 and November 1996 at Sahlgren's University Hospital were included in the study (n=410). Data concerning smoking habits and pouchitis were obtained from questionnaires and from medical records. The correlation between smoking habits and incidence of pouchitis was statistically evaluated by means of a survival test and a multivariate analysis, i.e. a Poisson model. Results. In all, 327 patients (80%) completed the questionnaires. Ninety-six (29%) of these patients had had at least one episode of pouchitis. Smoking habits during follow-up did not significantly influence the risk of pouchitis (p=0.29). Nor did smoking habits before and at the time of IPAA correlate with the incidence of pouchitis. Women had a decreased risk of pouchitis, compared to men (p=0.014). There was a non-significant tendency for smoking to increase the risk, which was more pronounced in women. Conclusions. Smoking does not decrease the risk of pouchitis following IPAA for UC, and in this respect the pathogenetic model of pouchitis, suggested to be a manifestation of UC, is not supported.     

Development of pouchitis following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis: A role for serological markers and microbial pattern recognition receptor genes

Background and AimsPouchitis, the most common complication after proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, has been attributed to altered composition of faecal flora. We investigated the role of antimicrobial and antiglycan antibodies and polymorphisms in microbial pattern recognition receptor genes.MethodsClinical charts of all 184 patients with ulcerative colitis who underwent IPAA between 1990–2004 were reviewed for pre- and post-operative disease course.ResultsFollow-up data were available in 172 patients [67 female, median age at proctocolectomy 39.1 years]. During a median follow-up of 6.7 (interquartile range 3.7–10.5) years, 80 patients (47%) developed at least one episode of pouchitis. Cox proportional-hazard regression identified extra-intestinal manifestations [HR 1.78 (95%CI 1.10–2.88), p = 0.020], a GT/TT genotype at Toll-like-receptor-1 S87I [HR 1.64 (1.01–2.66), p = 0.047], anti-chitobioside carbohydrate antibodies [HR 2.03 (1.11–3.70), p = 0.021] and young age at diagnosis [p = 0.003] to be independently associated with pouchitis. Factors associated with chronic pouchitis, diagnosed in 33 patients (19%), were extra-intestinal manifestations [HR 2.45 (1.07–5.62), p = 0.034], backwash ileitis [HR 3.15 (1.10–9.00), p = 0.032], outer-membrane porin antibodies [HR 2.67 (1.20–5.94), p = 0.016] and young age at proctocolectomy [p = 0.008].Conclusions:The reported association with antibodies and Toll-like-receptor-1 supports the pathophysiological role of the faecal flora in the development of pouchitis.     

Influence of ileal pouch anal anastomosis on bone loss in ulcerative colitis patients

Background and aim

Patients with ulcerative colitis (UC) are at an increased risk for low bone mineral density (BMD). It is unclear whether proctocolectomy with ileal pouch-anal anastomosis (IPAA) for UC alters the risk of bone loss. The aim of this study was to compare BMD in UC patients with and without IPAA.

Methods

A total of 267 patients with UC and IPAA (study group) were compared to 119 UC patients without IPAA (control group) in this cross-sectional study. The demographic and clinical variables including dual-energy X-ray absorptiometry scan results were compared. Patients were classified as having normal or low BMD, based on the criteria by the International Society for Clinical Densitometry. Univariate and multivariate analyses were performed to assess risk factors associated with low BMD. Age, gender, race, smoking status, steroid use, alcohol use, body mass index, years of absent estrogen protection, use of calcium, vitamin D supplements and disease duration were selected as covariates.

Results

83 (31.1%) had low BMD in the study group vs. 18 (15.1%) in the control group (p = 0.001). 2/13 (15.4%) had low BMD before surgery. The mean age of patients in the study and control groups were 44.7 ± 14.1 vs. 52.4 ± 17.7 years, respectively (p < 0.001). The hip BMD was lower in the study group (0.93 ± 0.17 g/cm2) than that in the control group (0.98 ± 0.17 g/cm2) (p = 0.038). Fragility fracture was documented in 23 (8.6%) patients in the study group vs. 3 (2.5%) in the control group (p = 0.038) Sixty-four (24.0%) of the study group patients were using corticosteroids after surgery in contrast to 93 (78.2%) in the control group (p < 0.001). On multivariable analyses, covariate adjusted factors associated with a low BMD in UC patients were advanced age [odds ratio (OR) 1.51 per 5 years; 95% confidence interval [CI], 1.34–1.71], low body mass index (OR = 2.37 per 5 kg/m² decrease; 95% CI, 1.68–3.36), and the presence of IPAA (OR = 6.02; 95% CI, 2.46–14.70). For the 13 IPAA patients who had information available, BMD before IPAA was low. After a median of 46 (Range 7–84) months after IPAA, BMD improved in 7/13 patients (53.8%), while it continued to be low in 6/13 (46.2%) patients.

Conclusions

Low BMD is common in patients with UC. The risk appears to persist even after colectomy and IPAA surgery suggesting that these patients need to be monitored for bone loss.     

Inflammatory bowel disease in Tuzla Canton,Bosnia-Herzegovina: A prospective 10-year follow-up

BACKGROUNDThe incidence and prevalence of inflammatory bowel disease (IBD) vary between regions but have risen globally in recent decades. A lack of data from developing nations limits the understanding of IBD epidemiology.AIMTo perform a follow-up review of IBD epidemiology in the Tuzla Canton of Bosnia-Herzegovina during a 10-year period (2009-2019).METHODSWe prospectively evaluated the hospital records of both IBD inpatients and outpatients residing in Tuzla Canton for the specified period of time between January 1, 2009 and December 31, 2019. Since all our patients had undergone proximal and distal endoscopic evaluations at the hospital endoscopy unit, we used the hospital’s database as a primary data source, alongside an additional cross-relational search of the database. Both adult and pediatric patients were included in the study. Patients were grouped by IBD type, phenotype, age, and gender. Incidence rates were calculated with age standardization using the European standard population. Trends in incidence and prevalence were evaluated as a 3-year moving average and average annual percentage change rates.RESULTSDuring the 10-year follow-up period, 651 patients diagnosed with IBD were monitored (of whom 334, or 51.3%, were males, and 317, or 48.7%, were females). Of all the patients, 346 (53.1%) had been diagnosed with ulcerative colitis (UC), 292 (44.9%) with Crohn’s disease (CD), and 13 (2%) with indeterminate colitis (IC). We observed 440 newly diagnosed patients with IBD: 240 (54.5%) with UC, 190 (43.2%) with CD, and 10 (2.3%) with IC. The mean annual crude incidence rates were found to be 9.01/100000 population for IBD [95% confidence interval (CI): 8.17-9.85], with 4.91/100000 (95%CI: 4.29-5.54) for UC and 3.89/100000 (95%CI: 3.34-4.44) for CD. Calculated IBD prevalence in 2019 was 146.64/100000 (95%CI: 128.09-165.19), with 77.94/100000 (95%CI: 68.08-87.70) for UC and 65.77/100000 (95%CI: 54.45-74.1) for CD. The average annual IBD percentage change was 0.79% (95%CI: 0.60-0.88), with -2.82% (95%CI: -2.67 to -2.97) for UC and 6.92% (95%CI: 6.64-7.20) for CD. During the study period, 24,509 distal endoscopic procedures were performed. The incidence of IBD was 3.16/100 examinations (95%CI: 2.86-3.45) or 1.72/100 examinations (95%CI: 1.5-1.94) for UC and 1.36/100 examinations (95%CI: 1.17-1.56) for CD.CONCLUSIONTrends in the incidence and prevalence of IBD in Tuzla Canton are similar to Eastern European averages, although there are significant epidemiological differences within geographically close and demographically similar areas.