Long-term outcome after intestinal resection for Crohn's disease

Objective. To assess the need for intestinal repeat resection for recurrence of Crohn's disease in patients observed for more than 20 years after the first resection. Material and methods. Data were gathered retrospectively from the medical records of 53 (28 F) consecutive patients with Crohn's disease from May 1954 to December 2002. Median age at first intestinal resection was 24.5 (range 13–65) years, and median observation time thereafter was 26.5 (20.1–48.6) years. Disease location and behaviour were defined according to the Vienna classification. Results. The 53 patients had an average 2.7 and a median 2 intestinal resections. Out of 144 intestinal resections (77.1%) 111 were performed during the first three operations; no alterations in distribution of ileal, ileocolic and colic resections were found. From the first to the third operation there was an increase in penetrating disease from 15% to 39% (p=0.046) concomitant with a decrease in stricturing disease from 72% to 44% (p=0.048) of the patients. There was also a corresponding decrease in ileocolic disease from 45% to 5% (p=0.003) and a tendency towards an increase in ileal disease from 38% to 67%. One patient died (1.8%) from rectosigmoid perforation after the third resectional operation. Six patients needed reoperation (11.3%) for ileus, anastomotic bleeding, rectosigmoidal perforation and abdominal pain. Thirty-four patients (64.2%) needed intestinal repeat resection (median 8.3 years) during 25.3 years after the first repeat resection. Conclusions. This study indicates a diminution of Crohn's disease activity with time, as demonstrated by no need for intestinal repeat resection more than 25 years after the first resection.     

Capsule endoscopic features of Crohn's disease

Background: Crohn's disease (CD) is becoming increasingly recognized in Indian patients. As this disease often affects the small bowel, capsule endoscopy can help diagnose this disease and add valuable information regarding the extent of the disease. Our aim is to report our experience with the wireless capsule endoscope in patients with either known or suspected CD. Methods: Patients referred for capsule endoscopy with known or suspected CD were studied. All patients underwent precapsule endoscopy colonoscopy and small bowel series examination. After an overnight fast and bowel preparation, the capsule was ingested and the data were recorded for 8 h on the external recording device. A gastroenterologist experienced in reading capsule endoscopy interpreted images. Results: Eleven patients (mean age 42 years [range 14–70], 7 males) underwent capsule examination. Seven patients had symptoms suggestive of CD with no precapsule evidence of the disease, one had suspected small bowel pseudo‐obstruction and three had known CD. All patients had lesions in the small intestine consistent with CD. Two patients had strictures that led to a retained capsule, despite precapsule small bowel series. Conclusions: Capsule endoscopy is emerging as a small bowel imaging modality that can greatly assist in making the diagnosis of CD. Small bowel radiology is unreliable in excluding strictures that may cause capsule retention.     

Usefulness of the capsule endoscopy Crohn's disease activity index in assessing the necessity of early additional treatment in patients with Crohn's disease in clinical remission

The Capsule Endoscopy Crohn''s Disease Activity Index (CECDAI) was recently reported as a new scoring system to evaluate the mucosal lesions of patients with Crohn''s disease (CD). We investigated whether CECDAI is useful for assessing the necessity of early additional treatment in patients with CD in clinical remission.Twenty-one patients with small intestinal CD in clinical remission underwent capsule endoscopy (CE). The CECDAI and Lewis score (LS) were used to evaluate the intestinal lesions. We analyzed the correlations between several biomarkers and CECDAI or LS and examined the changes in therapeutic regimens based on the CECDAI.CE identified intestinal abnormalities in most CD patients in clinical remission: 81.0% and 85.7%, as assessed using CECDAI and LS, respectively. A significant positive correlation was observed between the CDAI and LS (P = .025), as well as between CDAI and CECDAI (P = .014) in these cases. Compared to LS, CECDAI scores were more evenly distributed. No significant correlations were observed between endoscopic scores and serum markers, including CRP, hemoglobin, and albumin levels. Additional treatment was performed significantly more often in patients with moderate-severe disease activity (CECDAI ≥5.8) (P = .012) than in those with normal (CECDAI <3.5) and mild (3.5≤CECDAI<5.8) disease activity. Resection of the small intestine did not affect the small bowel transit time or CE score.CECDAI is useful in evaluating mucosal lesions in small bowel CD patients in clinical remission and helps in assessing the requirement for additional treatment for these patients, including those who undergo intestinal resection.     

A prospective study of fecal calprotectin and lactoferrin as predictors of small bowel Crohn's disease in patients undergoing capsule endoscopy

Background: Capsule endoscopy (CE) is often used to investigate small bowel Crohn's disease (CD).

Aim: The aim of this study is to prospectively assess the value of fecal calprotectin and lactoferrin to predict CE findings.

Patients and methods: Sixty-eight consecutive patients that were referred for CE were included. Stool samples for calprotectin and lactoferrin and blood samples were collected for relevant parameters. Correlation between fecal markers and CE findings was assessed and receiver operating characteristic (ROC) curves were built to determine the predictive values of fecal markers for the diagnosis of CD.

Results: Fecal calprotectin data was available for all the patients and lactoferrin data for 38. CE findings compatible with CD were found in 23 (33%) patients and 45 (67%) were negative for CD. The average age of the CD group was 34 compared to 46 in the non-CD group (p?=?.048). Median calprotectin and lactoferrin in the CD group and in the control group were 169?mg/kg vs. 40 (p?=?.004) and 6.6?mg/kg vs. 1 (p?=?.051), respectively. The area under the ROC curve was 0.767 for calprotectin and 0.70 for lactoferrin. A fecal calprotectin concentration of 95?mg/kg and fecal lactoferrin of 1.05?mg/kg had a sensitivity, specificity, positive predictive value and negative predictive value of 77 and 73%, 60 and 65%, 50 and 50%, and 84 and 84% in predicting CE findings compatible with CD.

Conclusions: Fecal markers are simple and noninvasive surrogates for predicting CE findings compatible with CD. Fecal markers can help determine which patients should be referred for CE.

ClinicalTrials.gov Identifier: NCT01266629     

Postoperative outcome of Crohn's disease in 30 children

Background—Thirty children operated on forCrohn's disease (CD) were reviewed (1975-1994). The aim of the studywas to assess their postoperative outcome.
Patients—19 boys and 11 girls, aged 15.3 (2) years(range 11.3-20) at surgery were studied.
Results—Surgical indications were acutecomplications of CD and chronic intestinal illness. Six months aftersurgery, 11 of 12 patients had been weaned off steroids, and 22 of 23 patients were weaned off nutritional support; 17 patients withoutrecurrrence had a mean (SD) weight gain of 2.1 (8) kg and a height gainof 3.36 (3) cm. During 3.1 (2.7) years follow up, 12 patients (40%) had a recurrence of the disease after 19.4 (14) months (means (SD)):supra-anastomotic recurrence (six), severe perianal disease (two), andchronic illness (four). Six of 14 patients who were treated withmesalazine (13) or azathioprine (one) had recurrences. Thepostoperative recurrence rate was 50% at two years.
Conclusion—Surgical treatment modifies theimmediate outcome of severe or complicated CD, but does not preventrecurrence, despite localised resection or prophylactic postoperativetreatment. Extension of the disease before surgery seems to be a majorrisk factor for postoperative recurrence in children.

Keywords:Crohn's disease; surgery; children

     

Incidence of Crohn's disease in Stockholm County 1955-1989

Aim—To evaluate the incidence of Crohn'sdisease in Stockholm County between 1955 and 1989.
Methods—A cohort of 1936 patients withCrohn's disease was retrospectively assembled. Incidence rates andchanges in disease distribution were assessed.
Results—The mean increase inincidence was 15% (95% confidence intervals 12% to 18%) per fiveyear period with a mean annual incidence rate at 4.6/10⁵during the last two decades. The mean incidence for the entire studyperiod was similar for men and women. The mean age at diagnosis increased from 25 years in 1960-64 to 32 years in 1985-89, partly because of an increasing proportion of patients aged at least 60 yearsat diagnosis. The proportion of patients with colonic Crohn's diseaseat the time of diagnosis increased from 15% to 32% (17% difference;95% confidence intervals 12% to 23%) whereas the proportion ofpatients with ileocaecal disease decreased from 58% to 41% (17%difference; 95% confidence intervals 10% to 24%) during the studyperiod. Elderly patients had a higher proportion of small bowel diseaseand a lower proportion of ileocolonic disease compared with the youngerpatients.
Conclusion—The incidence rate ofCrohn's disease in Stockholm has stabilised at 4.6/10⁵ andthe proportion of elderly patients has increased during a 35 yearperiod. Colonic Crohn's disease has increased in frequency with areciprocal decrease in ileocaecal disease.

Keywords:Crohn's disease; inflammatory bowel disease; incidence; epidemiology

     

Laparoscopy in Crohn's disease

In Crohn's disease (CD) surgical management, laparoscopic approach offers several theoretical advantages over the open approach. However, the importance of inflammatory lesions associated with CD, and the frequent presence of adhesions from previous surgery have initially questioned its feasibility and safety. In the present review article we will discuss the role of laparoscopic approach for Crohn's disease surgical management, along with its potential benefits as compared to the open approach.     

Cyclosporin Pharmacokinetics after Intravenous and Oral Administration in Patients with Crohn's Disease

Cyclosporin kinetics were estimated after single-dose intravenous and oral administration in 12 patients with Crohn's disease in accordance with a three-compartment model with zero-order inputs. Cyclosporin was measured in whole blood with a specific monoclonal radioimmunoassay. The median bioavailability (f) was 23.7% (range, 0–49.1%); the distribution volume at steady state, 2.31/kg (range, 1.0–3.5 1/kg); clearance (CL), 7.6ml/min/kg (range, 4.8–10.8 ml/min/kg); and t_1/2(z) 7.9 h (range, 3.2–13.9 h). Both the extent and rate of bioavailability were significantly lower in six of the patients, who had low or undetectable cyclosporin levels during a preceding therapeutic trial. After repeated oral administration significant correlations were found between the single-dose f/CL ratios and the steady-state blood concentrations, indicating that the kinetics did not change markedly with time. We conclude that the disposition kinetics of cyclosporin in patients with Crohn's disease are comparable to those of other groups. whereas the bioavailability may be decreased. It is suggested that cyclosporin levels should be monitored closely, and intravenous treatment should be considered in patients with a rapid gut transit time. because cyclosporin absorption seems to follow zero-order kinetics.     

Genetic analyses of chromosome 12 loci in Crohn's disease

BACKGROUND AND AIMS: Inflammatory bowel disease (IBD) includes ulcerative colitis and Crohn's disease, both of which are multifactorial diseases involving the interaction of genetic and environmental factors. A region on chromosome 12 centred around the marker locus D12S83 has previously been associated with IBD predisposition. The aim of the study was to investigate this genetic region in an independent panel of European families affected by Crohn's disease. METHODS: A sample of 95 families with two or more affected relatives and 75 simplex nuclear families were genotyped for 19 microsatellite loci located on chromosome 12. A search for linkage and linkage disequilibrium was performed using non-parametric two point and multipoint analyses with the Analyze and Genehunter packages. RESULTS: No evidence of linkage or linkage disequilibrium was observed for any of the marker loci, including D12S83 (p=0.35 for the two point linkage test). Multipoint linkage analysis also failed to reveal positive linkage on chromosome 12. Power calculations allowed us to reject the hypothesis that the genetic region of chromosome 12 centred on D12S83 contains a susceptibility locus with a relative risk (lambda(s)) equal to or greater than 2.0 in these families. CONCLUSION: Failure to detect linkage or linkage disequilibrium in these families suggests that the chromosome 12 locus previously reported to be associated with genetic predisposition to IBD does not play a role in all European family samples. This observation is compatible with heterogeneity in the genetic basis of susceptibility to the disease and/or exposure to various environmental factors among Caucasian families.     

Infliximab improves inflammation and anthropometric measures in pediatric Crohn's disease

Background and Aim: Infliximab (IFX) is a monoclonal antibody licensed to treat medically refractory Crohn's disease (CD). Our aim was to elucidate the effects of IFX therapy on clinical, growth and serum parameters in children with CD in a single pediatric center in Sydney, Australia. Methods: A retrospective case series review of children treated with IFX for CD at Sydney Children's Hospital, Australia was undertaken, with a review of outcomes after starting IFX. Main outcome measures were response and remission (as measured according to improvements in Pediatric Crohn's Disease Activity Index scores and Physician Global Assessment), laboratory markers (C‐reactive protein, erythrocyte sedimentation rate, hemoglobin, white cell count, lymphocytes, neutrophils, platelets, albumin) and growth (Z scores). Results: The 16 patients included had a mean age at first infusion of 13.0 years (1.25–17.5 years). Six of 12 patients (with adequate data available) were in remission at 2 weeks following the first infusion. At 1 year, 10 of 12 patients (83%) were in remission. Mean C‐reactive protein and erythrocyte sedimentation rate had fallen significantly (P < 0.05) at 2 weeks (from 29 to 7 mg/L and 40 to 19 mm/h, respectively). Positive trends were observed for all other parameters, excluding lymphocytes and white cell count. At 1 year, mean Z score for body mass index improved significantly from ?0.9 to ?0.1 (P < 0.01). Conclusions: Disease activity subsides in most children treated with IFX for CD. IFX therapy also improves some growth parameters. The pattern of improvement requires further elucidation, as the results in the present study suggest differing dosing frequency of infusion may achieve better efficacy.