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.     

Psychiatric illness in patients with inflammatory bowel disease.

One hundred and sixty two consecutive patients attending a clinic for inflammatory bowel disease (91 Crohn's, 71 ulcerative colitis) were assessed for the presence of anxiety and depression using a simple self-rating questionnaire (HAD scale) and a detailed evaluation (DSM-III). The overall prevalence of psychiatric illness (DSM-III) in ulcerative colitis and Crohn's disease was 34% and 33% respectively. There was no statistically significant association in ulcerative colitis patients between the presence of psychiatric illness and the present physical illness. Psychiatric illness was more common in the physically ill patients with Crohn's disease, compared with those who were well: 50% v 8% (p less than 0.01), using (HAD) criteria 66% v 37% (p less than 0.001). The presence of patients between the presence of psychiatric illness and the presence of physical illness. Psychiatric who were well: 50% v 8% (p less than 0.01) by DSM-III criteria, using (HAD) criteria 66% v 37% (p less than 0.001). The presence of psychiatric illness adversely affected physical recovery. Seventeen percent recovered when psychiatrically ill v 53% when psychiatrically well (p less than 0.025). The HAD scale was assessed as a screening method for psychiatric illness in this medical setting and had a sensitivity of 76% and a specificity of 79%.     

Pulmonary complications in patients with inflammatory bowel disease.

BACKGROUND/AIMS: Between 1996 and 1998 we investigated the occurrence of lung disorders in 82 patients with inflammatory bowel disease (30 patients with ulcerative colitis and 52 patients with Crohn's disease) and a control group of 60 subjects. The aim of our study was to determine the occurrence of pulmonary complications in patients with inflammatory bowel disease, to investigate whether ulcerative colitis or Crohn's disease are connected with a typical lung function disorder, with the inflammatory activity of the disease or if they depend on the presence of other extraintestinal manifestations. METHODOLOGY: We investigated the occurrence of lung disorders in terms of the following parameters: clinical pulmonary symptoms, chest radiography and pulmonary function tests (body plethysmography, pneumotachography, lung transfer capacity for carbon monoxide, and blood gas analysis). RESULTS: Lung function abnormalities were significantly more frequent in patients with inflammatory bowel disease as compared to controls (p<0.001). There was no apparent correlation between these abnormalities and either bowel disease activity or drug administration (sulphasalazine, mesalazine). CONCLUSIONS: Despite the lack of radiological abnormalities, we identified a high incidence of pulmonary function abnormalities (suspicious of interstitial lung disorder) in patients with inflammatory bowel disease; 56.7% of patients with ulcerative colitis and 57.7% of patients with Crohn's disease had reduced lung transfer factor.     

Updated bone mineral density status in Saudi patients with inflammatory bowel disease

BACKGROUND Little is known about inflammatory bowel disease(IBD) burden and its impact on bone mineral density(BMD) among adult patients in Saudi Arabia. To the best of our knowledge, our study is the only study to give an update about this health problem in adult Saudi patients with IBD. IBD is a great risk factor for reduced BMD due to its associated chronic inflammation, malabsorption, weight loss and medication side effects. Consequently, screening for reduced BMD among patients with IBD is of utmost importance to curb and control anticipated morbidity and mortality among those patients.AIM To assess the relationship between IBD and BMD in a sample of adult Saudi patients with IBD.METHODS Ninety adult patients with IBD-62 Crohn's disease(CD) and 28 ulcerative colitis(UC)-were recruited from King Fahad Specialist Hospital gastroenterology clinics in Buraidah, Al-Qassim. All enrolled patients were interviewed for their demographic information and for IBD-and BMD-related clinical data. All patients had the necessary laboratory markers and dual-energy x-ray absorptiometry scans to evaluate their BMD status. Patients were divided into two groups(CD and UC) to explore their clinical characteristics and possible risk factors for reduced BMD.RESULTS The CD group was significantly more prone to osteopenia and osteoporosis compared to the UC group; 44% of the CD patients had normal BMD, 19% had osteopenia, and 37% had osteoporosis, while 78% of the UC patients had normal BMD, 7% had osteopenia, and 25% had osteoporosis(P value 0.05). In the CD group, the lowest t-score showed a statistically significant correlation with body mass index(BMI)(r = 0.45, P 0.001), lumbar z-score(r = 0.77, P 0.05) and femur z-score(r = 0.85, P 0.05). In the UC group, the lowest t-score showed only statistically significant correlation with the lumbar z-score(r = 0.82, P 0.05) and femur z-score(r = 0.80, P 0.05). The ROC-curve showed that low BMI could predict the lowest t-score in the CD group with the best cut-off value at ≤ 23.43(m/kg2); area under the curve was 0.73(95%CI: 0.59–0.84), with a sensitivity of 77%, and a specificity of 63%.CONCLUSION Saudi patients with IBD still have an increased risk of reduced BMD, more in CD patients. Low BMI is a significant risk factor for reduced BMD in CD patients.     

Cytokine production in patients with inflammatory bowel disease.

The production of cytokines in peripheral blood mononuclear leukocytes of patients with inflammatory bowel disease was investigated. T cell subset analysis and differential white blood cell counts were also performed. Thirty five patients with ulcerative colitis, 14 with Crohn's disease, and 15 age matched healthy volunteers were studied. No differences were observed in T cell subsets and OKT4/OKT8 ratios in patients with ulcerative colitis or Crohn's disease compared with controls. Interleukin 1 beta production was significantly increased in active ulcerative colitis and Crohn's disease, compared with values in controls, but returned to control levels in the inactive stages. In addition, in active ulcerative colitis and Crohn's disease, there were significant correlations between the interleukin 1 beta production and the ulcerative colitis activity index or Crohn's disease activity index. Interleukin 2 production was also significantly increased in the active ulcerative colitis and significantly correlated to the activity index, but there was no change in Crohn's disease patients compared with controls. Gamma interferon production in patients was the same as that in controls. This study suggests that the interleukin 1 beta and 2 values in peripheral mononuclear leukocytes of active untreated inflammatory bowel disease are indicators of the disease states of ulcerative colitis or Crohn's disease, or both.     

Guidelines for immunizations in patients with inflammatory bowel disease

During the past 2 decades, medical therapy for Crohn's disease (CD) and ulcerative colitis (UC) has grown to incorporate a variety of immunesuppressing agents. At the same time, basic insights into the aberrant mucosal immune response underlying inflammatory bowel disease (IBD) have expanded dramatically. The interplay of host susceptibility to infection and the safety and efficacy of immunization for vaccine-preventable diseases has been explored in other immune-mediated disease states but only rarely in IBD. The purpose of this review is to formulate best-practice recommendations for immunization in children and adults with IBD by considering the effects of the IBD disease state and its treatments on both the safety and efficacy of immunization. To do so, we first considered the routine recommendations for immunization of children, adults and distinct populations at increased risk for vaccine-preventable disease. Because it was rarely possible to examine direct data on safety and efficacy of immunization in IBD populations, we relied to a large extent upon extrapolation from similar populations and from knowledge of basic mechanisms. The literature suggests that efficacy of immunization may be diminished in some patients whose immune status is compromised by immune suppression. However, except for live agent vaccines, most immunizations may be safely administered to patients with IBD even when immune compromised. Conversely, protection against vaccine-preventable illness may be of even greater benefit to those at risk for morbid or lethal complications of infections because of an immune compromised state. We conclude that for most patients with IBD, recommendations for immunization do not deviate from recommended schedules for the general population.     

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.     

Reduced bone density in patients with inflammatory bowel disease.

BACKGROUND: Reduced bone mineral density in patients with inflammatory bowel disease is thought to be due to disturbances in calcium homeostasis or the effects of corticosteroid treatment. AIMS: To assess the prevalence and mechanism of reduced bone mineral density in 79 patients with inflammatory bowel disease (44 with Crohn's disease, 35 with ulcerative colitis) who did not have significant risk factors for low bone densities. METHODS: Dual x ray absorptiometry was used to measure bone mineral density and serum and urinary markers of osteoblast (alkaline phosphatase, procollagen 1 carboxy terminal peptide and osteocalcin) and osteoclast (pyridinoline, deoxypyridinoline, and type 1 collagen carboxy terminal peptide) activities to assess bone turnover. RESULTS: There was a high prevalence of low bone mineral density (prevalence of T scores < -1.0 from 51%-77%; T scores < -2.5 (osteoporosis) from 17%-28%) with hips being more often affected than vertebrae (p < 0.001). Reduced bone mineral density did not relate to concurrent or past corticosteroid intake, or type, site, or severity of disease. Whereas calcium homeostasis was normal, bone markers showed increased bone resorption without a compensatory increase in bone formation. CONCLUSIONS: The greater prevalence of reduced hip bone mineral density, as opposed to vertebral, mineral density and the pattern of a selective increase in bone resorption contrasts with that found in other known causes of metabolic bone disease.     

Escherichia coli antibodies in patients with inflammatory bowel disease.

Sera from 30 patients with inflammatory bowel disease (IBD) (16 with Crohn's disease (CD) and 14 with ulcerative colitis (UC) were assayed for the presence of antibodies against 159 Escherichia coli O-antigens and compared with sera from 16 matched control subjects. The majority of patients with IBD had agglutinating antibodies to a higher number of Escherichia coli O-antigens and in higher titres than the control group. The number of positive agglutinins was O-33 mean 13.8 in CD, O-26 mean 7.9 for UC, and O-7 mean 1.5 in controls. Eight patients with IBD and arthropathy had antibodies to fewer O-antigens (O-7 mean 3.2). The antibodies were in the IgG and IgM, in titres corresponding to original values. No specific O-serotypes were associated with IBD. Common serotypes, R-plasmid carrying serotypes, and those associated with shigella-like adult diarrhoea were detected. O14 was detected only in five patients and O119 in none. There was no correlation between the number of Escherichia coli agglutinins and the site and severity of the disease or type of therapy. It is suggested that the presence of the high numbers of Escherichia coli antibodies is secondary to the disease process and is unlikely to be causally involved in the pathogenesis of the disease, but may play a role in the perpetuation of the disease and in the extraintestinal complications.     

Employment problems and prospects for patients with inflammatory bowel disease.

A random sample of 170 patients (88 men) with chronic inflammatory bowel disease (75 ulcerative colitis) were first interviewed in 1978 about their employment status, problems at work, and influence of surgery. Surgery had been carried out on 120 and 53 had an ileostomy. After six years 144 (92%) of the 156 survivors replied to a follow up postal questionnaire. Of the initial sample, 122 (72%) were working and there were only three (1%) registered unemployed. After six years a similar proportion were working and only seven (5%) were unemployed. Continuity of employment was good with 57% in the same job. Changes in work because of health had been made by 72 patients mainly caused by bowel disease. After surgery 10% completely changed and 22% modified their work while a few had to retrain or retire. Panproctocolectomy and ileostomy resulted in more changes and longer time off work after surgery than colectomy and ileorectal anastomosis, with 35% and 17% respectively off work after one year. Problems at work, in particular general malaise and arthritis were experienced by 34 (28%) patients. Fewer problems were experienced by patients with a stoma who also had less sickness absence than those without a stoma. Colleagues and employers were usually supportive although some patients encountered discrimination especially those with a stoma or working in the food industry. Few patients had been counselled on their work. In general employment prospects and time off work were good and employers should be encouraged to take an optimistic and supportive role. Doctors should consider that convalescence after surgery may be longer than they perceive and must provide better counselling for patients.     

Influence of nutritional status in the postoperative period of patients with inflammatory bowel disease

Inflammatory bowel diseases(IBDs) are a group of chronic inflammatory diseases that affect the gastrointestinal tract, including Crohn's disease(CD) and ulcerative colitis. Surgery is a treatment option, and more than half of the patients with CD will undergo surgical interventions over the course of the disease. Postoperative complications are common in IBD patients, the most frequent being intraabdominal sepsis, infection of the surgical site, and adynamic ileum, and nutritional status is a factor that can influence postoperative outcome. Recent studies have shown that malnutrition, obesity, sarcopenia, and myosteatosis are predictors of surgical complications. However, most were retrospective studies with small patient samples and heterogeneity of clinical and nutritional assessment methods, which limit the extrapolation of data. Therefore, knowing the pathophysiological mechanisms of IBD and identifying the best parameters for assessing nutritional status are essential for prompt implementation of adequate nutritional interventions.     

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.     

Current status of ileorectal anastomosis for inflammatory bowel disease

Between September 1959 and December 1986, a total of 210 patients in a consecutive series were operated on for inflammatory bowel disease. One hundred ten (66 percent) had ileorectal anastomosis performed. There were no postoperative deaths. There were six failures in 53 ileorectal anastomoses for ulcerative colitis (11 percent), and five failures (8 percent) in 61 for Crohn's disease. The overall failure rate was 11 in 110 (10 percent). Ileorectal anastomosis, in suitable patients, is still a viable operation in the late 1980s. Read at the meeting of the American Society of Colon and Rectal Surgeons, Washington, D.C., April 5 to 10, 1987.