Diagnosis and treatment of perianal Crohn disease: NASPGHAN clinical report and consensus statement

The impact of surgical therapies for inflammatory bowel disease on female fertility

BACKGROUND

Women with inflammatory bowel disease (IBD) may require surgery, which may result in higher risk of infertility. Restorative proctocolectomy with ileal anal pouch anastomosis (IPAA) may increase infertility, but the degree to which IPAA affects infertility remains unclear, and the impact of other surgical interventions on infertility is unknown.

OBJECTIVES

Primary objective• To determine the effects of surgical interventions for IBD on female infertility.Secondary objectives• To evaluate the impact of surgical interventions on the need for assisted reproductive technology (ART), time to pregnancy, miscarriage, stillbirth, prematurity, mode of delivery (spontaneous vaginal, instrumental vaginal, or Caesarean section), infant requirement for resuscitation and neonatal intensive care, low and very low birth weight, small for gestational age, antenatal and postpartum hemorrhage, retained placenta, postpartum depression, gestational diabetes, and gestational hypertension/preeclampsia.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, and the Cochrane IBD Group Specialized Register from inception to September 27, 2018, to identify relevant studies. We also searched references of relevant articles, conference abstracts, grey literature, and trials registers.

SELECTION CRITERIA

We included observational studies that compared women of reproductive age (≥ 12 years of age) who underwent surgery to women with IBD who had a different type of surgery or no surgery (i.e. treated medically). We also included studies comparing women before and after surgery. Any type of IBD-related surgery was permitted. Infertility was defined as an inability to become pregnant following 12 months of unprotected intercourse. Infertility at 6, 18, and 24 months was included as a secondary outcome. We excluded studies that included women without IBD and those comparing women with IBD to women without IBD..

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies and extracted data. We used the Newcastle-Ottawa Scale to assess bias and GRADE to assess the overall certainty of evidence. We calculated the pooled risk ratio (RR) and 95% confidence interval (CI) using random-effects models. When individual studies reported odds ratios (ORs) and did not provide raw numbers, we pooled ORs instead.

MAIN RESULTS

We identified 16 observational studies for inclusion. Ten studies were included in meta-analyses, of which nine compared women with and without a previous IBD-related surgery and the other compared women with open and laparoscopic IPAA. Of the ten studies included in meta-analyses, four evaluated infertility, one evaluated ART, and seven reported on pregnancy-related outcomes. Seven studies in which women were compared before and after colectomy and/or IPAA were summarized qualitatively, of which five included a comparison of infertility, three included the use of ART, and three included other pregnancy-related outcomes. One study included a comparison of women with and without IPAA, as well as before and after IPAA, and was therefore included in both the meta-analysis and the qualitative summary. All studies were at high risk of bias for at least two domains.We are very uncertain of the effect of IBD surgery on infertility at 12 months (RR 5.45, 95% CI 0.41 to 72.57; 114 participants; 2 studies) and at 24 months (RR 3.59, 95% CI 1.32 to 9.73; 190 participants; 1 study). Infertility was lower in women who received laparoscopic surgery compared to open restorative proctocolectomy at 12 months (RR 0.70, 95% CI 0.38 to 1.27; 37 participants; 1 study).We are very uncertain of the effect of IBD surgery on pregnancy-related outcomes, including miscarriage (OR 2.03, 95% CI 1.14 to 3.60; 776 pregnancies; 5 studies), use of ART (RR 25.09, 95% CI 1.56 to 403.76; 106 participants; 1 study), delivery via Caesarean section (RR 2.23, 95% CI 1.00 to 4.95; 20 pregnancies; 1 study), stillbirth (RR 1.96, 95% CI 0.42 to 9.18; 246 pregnancies; 3 studies), preterm birth (RR 1.91, 95% CI 0.67 to 5.48; 194 pregnancies; 3 studies), low birth weight (RR 0.61, 95% CI 0.08 to 4.83), and small for gestational age (RR 2.54, 95% CI 0.80 to 8.01; 65 pregnancies; 1 study).Studies comparing infertility before and after IBD-related surgery reported numerically higher rates of infertility at six months (before: 1/5, 20.0%; after: 9/15, 60.0%; 1 study), at 12 months (before: 68/327, 20.8%; after: 239/377, 63.4%; 5 studies), and at 24 months (before: 14/89, 15.7%; after: 115/164, 70.1%; 2 studies); use of ART (before: 5.3% to 42.2%; after: 30.3% to 34.3%; proportions varied across studies due to differences in which women were identified as at risk of using ART); and delivery via Caesarean section (before: 8/73, 11.0%; after: 36/75, 48.0%; 2 studies). In addition, women had a longer time to conception after surgery (two to five months; 2 studies) than before surgery (5 to 16 months; 2 studies). The proportions of women experiencing miscarriage (before: 19/123, 15.4%; after: 21/134, 15.7%; 3 studies) and stillbirth (before: 2/38, 5.3%; after: 3/80: 3.8%; 2 studies) were similar before and after surgery. Fewer women experienced gestational diabetes after surgery (before: 3/37, 8.1%; after: 0/37; 1 study), and the risk of preeclampsia was similar before and after surgery (before: 2/37, 5.4%; after: 0/37; 1 study). We are very uncertain of the effects of IBD-related surgery on these outcomes due to poor quality evidence, including confounding bias due to increased age of women after surgery.We rated evidence for all outcomes and comparisons as very low quality due to the observational nature of the data, inclusion of small studies with imprecise estimates, and high risk of bias among included studies.

AUTHORS' CONCLUSIONS

The effect of surgical therapy for IBD on female infertility is uncertain. It is also uncertain if there are any differences in infertility among those undergoing open versus laparoscopic procedures. Previous surgery was associated with higher risk of miscarriage, use of ART, Caesarean section delivery, and giving birth to a low birth weight infant, but was not associated with risk of stillbirth, preterm delivery, or delivery of a small for gestational age infant. These findings are based on very low-quality evidence. As a result, definitive conclusions cannot be made, and future well-designed studies are needed to fully understand the impact of surgery on infertility and pregnancy outcomes.

TNF-α-driven inflammation and mitochondrial dysfunction define the platelet hyperreactivity of aging

Aging and chronic inflammation are independent risk factors for the development of atherothrombosis and cardiovascular disease. We hypothesized that aging-associated inflammation promotes the development of platelet hyperreactivity and increases thrombotic risk during aging. Functional platelet studies in aged-frail adults and old mice demonstrated that their platelets are hyperreactive and form larger thrombi. We identified tumor necrosis factor α (TNF-α) as the key aging-associated proinflammatory cytokine responsible for platelet hyperreactivity. We further showed that platelet hyperreactivity is neutralized by abrogating signaling through TNF-α receptors in vivo in a mouse model of aging. Analysis of the bone marrow compartments showed significant platelet-biased hematopoiesis in old mice reflected by increased megakaryocyte-committed progenitor cells, megakaryocyte ploidy status, and thrombocytosis. Single-cell RNA-sequencing analysis of native mouse megakaryocytes showed significant reprogramming of inflammatory, metabolic, and mitochondrial gene pathways in old mice that appeared to play a significant role in determining platelet hyperreactivity. Platelets from old mice (where TNF-α was endogenously increased) and from young mice exposed to exogenous TNF-α exhibited significant mitochondrial changes characterized by elevated mitochondrial mass and increased oxygen consumption during activation. These mitochondrial changes were mitigated upon TNF-α blockade. Similar increases in platelet mitochondrial mass were seen in platelets from patients with myeloproliferative neoplasms, where TNF-α levels are also increased. Furthermore, metabolomics studies of platelets from young and old mice demonstrated age-dependent metabolic profiles that may differentially poise platelets for activation. Altogether, we present previously unrecognized evidence that TNF-α critically regulates megakaryocytes resident in the bone marrow niche and aging-associated platelet hyperreactivity and thrombosis.

Elicitation of Health-Related Utility in Perianal Fistula in Crohn's Disease

BACKGROUND AND OBJECTIVE

Perianal fistulae are a common complication of Crohn's disease (CD) and pose a substantial burden on quality of life. Data capturing health-related utility associated with perianal fistulae in CD are scarce. The current study aims to value health states related to different stages of the disease to quantitatively evaluate the impact of complex perianal fistulae on CD patients' quality of life.

METHODS

Eight health state descriptions associated with complex perianal fistulae in CD were developed following qualitative research with patients and validation by clinicians. Following pre-testing, a survey was administered online in two samples of UK respondents: the general population and patients with CD. A choice-based valuation technique, the time trade-off (TTO), was used for direct utility measurement. CD patients also valued their current health state using the TTO. Exclusion criteria for respondents displaying logical inconsistencies were applied.

RESULTS

Usable responses were received from 835 respondents, reflective of the UK population in age and sex, in the general population survey and 162 CD patients in the patient survey. Non-remission states were valued much lower than the remission state by both samples, ranging from 0.20 for proctectomy with a negative outcome to 0.66 for chronic symptomatic fistulae with mild symptoms. Patients currently experiencing fistulae reported lower values for current health than those without fistulae.

CONCLUSION

Low utility values were assigned to the non-remission health states for perianal fistulae in CD by the general public and patients with CD. This demonstrates the high humanistic burden of inadequately managed perianal fistula in CD.

Efficacy and Safety of Infliximab in Pediatric Crohn Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Crohn disease is an inflammatory bowel disease with intermittent symptoms relating to damage to the gastrointestinal tract. Compared with adult-onset Crohn disease, the childhood-onset form is more likely to be severe. Infliximab has shown efficacy in adult patients.

OBJECTIVE

To examine the efficacy and safety of infliximab in pediatric Crohn disease, by means of a systematic review.

DATA SOURCES

Three databases (MEDLINE, Embase, and Cochrane Central Register of Controlled Trials) and regulatory documents were searched from inception to December 2017. Clinical trial registries, conference abstracts, and reference lists were searched to March 2018.

STUDY SELECTION AND DATA EXTRACTION

Randomized controlled trials (RCTs) and prospective cohort studies that compared infliximab with active control were included in the analysis. Two reviewers independently performed screening, extracted data, and assessed risk of bias. The primary outcomes were induction and maintenance of endoscopic remission and severe adverse effects.

DATA SYNTHESIS

Three eligible RCTs comparing different dose regimens, 16 prospective cohort studies comparing infliximab with other therapies (adalimumab, exclusive enteral nutrition, or standard of care), and 3 prospective cohort studies comparing different infliximab regimens were identified. Meta-analysis of the RCTs showed no significant difference between infliximab every 8 weeks compared with longer intervals for maintenance of clinical remission (risk ratio [RR] 1.76, 95% confidence interval [CI] 0.98-3.19). Meta-analyses of the prospective cohort studies showed no significant differences between infliximab and adalimumab for maintenance of endoscopic remission (RR 1.07, 95% CI 0.60-1.92), between infliximab and exclusive enteral nutrition for induction of clinical remission (RR 1.09, 95% CI 0.82-1.45), or between infliximab and standard of care for maintenance of clinical remission at 6 and 12 months (RR 1.12, 95% CI 0.58-2.17, and RR 1.24, 95% CI 0.84-1.84, respectively).

CONCLUSIONS

Current evidence suggested comparable efficacy for infliximab and other therapies; however, the available literature was limited by risk of bias and small sample size. Further prospective studies are needed to confirm the efficacy and safety of this drug in pediatric Crohn disease.

Higher Postinduction Infliximab Serum Trough Levels Are Associated With Healing of Fistulizing Perianal Crohn's Disease in Children

BACKGROUND

There is some evidence in adults that higher serum infliximab (IFX) levels are needed to adequately treat fistulizing perianal Crohn's disease (CD). However, data in children are lacking. We aimed to determine postinduction serum trough IFX levels that are associated with healing of fistulizing perianal CD (PCD) at week 24.

METHODS

In a multicenter inception cohort study, consecutive children younger than age 17 years with fistulizing perianal CD treated with IFX between April 2014 and June 2017 who had serum trough IFX titers measured before the fourth infusion were included. Area under the receiver operating characteristic curve (AUROC) was calculated to determine the best cutoff to predict fistula healing.

RESULTS

A total of 667 children with Crohn's disease were recruited, with 85 (12.7%) patients diagnosed with fistulizing PCD. There were 27 of 52 (52%) children in whom pre-fourth infusion IFX levels were measured (mean age, 12.57 ± 5.12 years). At week 24, 14 of 27 (52%) patients responded with healing/healed PCD, whereas the rest had ongoing active fistulizing disease. The median IFX pre-fourth dose level in the responders was 12.7 ug/mL, compared with 5.4 ug/mL in the active disease group (P = 0.02). There was a strong correlation between IFX levels and healing of fistulizing PCD at week 24 (r = 0.65; P < 0.001). The AUROC was 0.80 (95% confidence interval, 0.64-0.97; P = 0.007) for pre-fourth IFX level to predict response of fistulizing PCD at week 24, and a level of 12.7 ug/mL best predicted fistula healing.

CONCLUSIONS

Higher trough IFX levels are associated with healing of fistulizing perianal CD.

Trends and Attributable Costs of Anorectal Involvement in Pediatric Crohn's Disease

BACKGROUND

Pediatric Crohn's disease (CD) with anorectal involvement has not been well characterized. We sought to describe trends in the prevalence of pediatric CD with anorectal involvement and its influence on health-care utilization.

MATERIALS AND METHODS

Patients (<21 y of age) with an International Classification of Diseases, Ninth Revision diagnosis of CD (555.X) were identified in the Kid's Inpatient Database (2003, 2006, 2009, 2012) and stratified by anorectal involvement based on the International Classification of Diseases, Ninth Revision diagnosis and procedural codes. Patient characteristics and resource utilization (length of stay [LOS] and costs) were compared between CD patients with and without anorectal involvement using univariate and multivariable analyses. Propensity score matching was used to estimate attributable LOS and costs.

RESULTS

There were 26,029 patients with CD identified in the study interval. Of these, 1706 (6.6%) had anorectal involvement. Those with anorectal disease were younger (age 16 versus 17 y old), more likely to be male (59.4% versus 49.9%) and black or Hispanic (24.7% versus 18.2%), and were more commonly treated in urban teaching hospitals compared with rural or nonteaching hospitals (83.2% versus 70.9%) (P < 0.001 for all). The proportion of patients with anorectal involvement increased over time (odds ratio 1.03, 95% confidence interval 1.02-1.05). After propensity score matching, attributable LOS and costs were 0.5 d and approximately $1600, respectively.

CONCLUSIONS

There has been an increase in the proportion of pediatric CD hospitalizations with anorectal manifestations. This pattern of disease is associated with longer hospitalization and higher costs compared with CD alone. Further research is required to understand the underlying etiology of these observed trends.

MR Imaging of Perianal Fistulas

In this article, we begin with an introduction of the perianal region anatomy, then review the definition, etiology, epidemiology, and 2 major classification systems of perianal fistulas. The role of MR imaging for assessment of perianal fistulas is mainly discussed. Finally, the medical and surgical treatment principles are reviewed.

Comparison of Transperianal Ultrasound With Colonoscopy and Magnetic Resonance Imaging in Perianal Crohn Disease

OBJECTIVE

Perianal fistulae and/or abscesses are common complications of Crohn disease (CD), especially in children. Magnetic resonance imaging (MRI) and gross examination under anesthesia are accurate diagnostic modalities for evaluating perianal lesions. Both methods, however, are expensive and have some limitations for use in children. This study aims to assess the accuracy of transperianal ultrasound (TPUS) and colonoscopic examination, compared with MRI, in pediatric patients with perianal CD (PACD).

METHODS

Thirty-eight children and adolescents with PACD who underwent MRI, TPUS, and gross colonoscopic examination under sedation were included. Fistulae were classified according to Parks' and St. James's University Hospital classifications. Abscesses were identified by their presence and location on each modality.

RESULTS

Fifty-nine fistulae (26 superficial, 23 intersphincteric, 10 transsphincteric) and 16 abscesses were detected using MRI. Fifty-nine fistulae and 10 abscesses were detected using TPUS. Forty-five fistulae (sensitivity 76.3%, positive predictive value [PPV] 84.2%, and kappa value 0.296] and 9 abscesses (sensitivity 56.3%, PPV 90.0%, and kappa value 0.624) on TPUS corresponded with MRI findings. Forty-six fistulae and fifteen abscesses were detected using colonoscopy. Forty fistulae (sensitivity 67.8%, PPV 89.9%, and kappa value 0.369) and 7 abscesses (sensitivity 43.8%, PPV 48.8%, and kappa value 0.304) on colonoscopy corresponded with MRI findings. With respect to abscess, agreement between TPUS and MRI was superior to that between colonoscopy and MRI (Spearman rho 0.651 vs 0.304, P = 0.007).

CONCLUSION

TPUS is an appropriate, simple, and real-time method for detecting perianal fistula and/or abscess, in children with PACD.

Long-term outcomes of pediatric inflammatory bowel disease

The incidence and prevalence of childhood-onset inflammatory bowel diseases (IBD), including subtypes Crohn's disease and ulcerative colitis, have risen dramatically in recent years, and have emerged globally as important pediatric chronic diseases. Therefore, health care providers are more frequently encountering very young children with IBD, a chronic and incurable condition requiring life-long therapy. These children are living long lives with IBD and therefore knowledge of long-term outcomes is increasingly important to better counsel families and determine the best course of treatment. This review summarizes the current knowledge and literature surrounding long-term outcomes of pediatric IBD, with emphasis on the following areas: need for surgery due to complicated disease behavior, risk of disease remission and recurrence, mental health and psychosocial well-being, educational outcomes, linear growth impairment, cancer risk, and mortality. In addition, we review recent research about predicting negative long-term outcomes in children with IBD.

The Characteristics and Long-term Outcomes of Pediatric Crohn's Disease Patients with Perianal Disease

BACKGROUND

Data on the outcomes of children with perianal Crohn's disease are limited. We aimed to assess phenotypic features at diagnosis and long-term disease-specific outcomes of this phenotype.

METHODS

The medical records of 296 pediatric onset patients with Crohn's disease, diagnosed from 2001 to 2015, were reviewed retrospectively. Baseline characteristics included age, sex, severity indices, laboratory data, endoscopic findings, and anthropometric measurements. Main outcome measures included time to first flare, hospitalization, surgery, and biological therapy.

RESULTS

Of the 296 included patients (median age 14.2 years), 70 (24%) had nonfistulizing perianal findings, whereas only 40 (13%) had fistulizing perianal disease at diagnosis. Perianal involvement was associated with female sex (P = 0.01), whereas fistulizing perianal disease resulted in a greater use of immunomodulators (P = 0.01). Time to hospitalization was shorter for both nonfistulizing and fistulizing perianal disease (hazard ratio [HR] 1.66 and 1.34, respectively, P = 0.027) and time to biological therapy (HR 2.1 and 1.7, respectively, P = 0.002). There were no differences in time to first flare or surgery. During a median follow-up of 8.5 years, additional 26 patients (10%) developed fistulizing perianal disease after a median time of 3.5 years. The presence of nonfistulizing disease at diagnosis was a significant risk factor for the development of fistulizing perianal disease (HR 3.4, P = 0.002). At the end of follow-up, complicated disease was more common in patients with any perianal involvement (P = 0.01).

CONCLUSIONS

Pediatric patients with Crohn's disease with both nonfistulizing and fistulizing disease have worse clinical outcomes. Nonfistulizing disease is a risk factor for the development of fistulizing disease over time.

MR Imaging of Perianal Crohn Disease

Pelvic magnetic resonance (MR) imaging is currently the standard for imaging perianal Crohn disease. Perianal fistulas are a leading cause of patient morbidity because closure often requires multimodality treatments over a prolonged period of time. This review summarizes clinically relevant anal sphincter anatomy, imaging methods, classification systems, and treatment objectives. In addition, the MR appearance of healing perianal fistulas and fistula complications is described. Difficult imaging tasks including the assessment of rectovaginal fistulas and ileoanal anastomoses are highlighted, along with illustrative cases. Emerging innovative treatments for perianal Crohn disease are now available and have the promise to better control sepsis and maintain fecal continence. Different treatment modalities are selected based on fistula anatomy, patient factors, and management goals (closure versus sepsis control). Radiologists can help maximize patient care by being familiar with MR imaging features of perianal Crohn disease and knowledgeable about what features may influence therapy decisions. ^© RSNA, 2017 Online supplemental material is available for this article.

Diagnosis and management of inflammatory bowel disease in children

Inflammatory bowel diseases (IBD), including Crohn's disease and ulcerative colitis, are lifelong conditions that often begin in childhood. The implications of IBD are of particular importance in children because of the potential negative effects on growth, development, psychosocial function, and overall wellbeing. The key management strategy is to achieve sustained control of intestinal inflammation and monitor for potential complications of the disease and side effects of therapies. Overall, the evidence on the management of IBD in children is less extensive than in adults, but good quality multicenter studies and various guidelines and society consensus statements are available. This review summarizes the evidence on the pathophysiology, diagnosis, and approaches to management of children and adolescents with IBD.

Differential Diagnosis of Diaper Dermatitis

Mild diaper dermatitis often occurs in children before toilet training is complete, particularly from 9 to 12 months of age, and the most common presentation is an irritant contact dermatitis. Diaper dermatitis may account for up to 25% of dermatology visits to health care providers during the first year of life. Fortunately, since the introduction of hypoallergenic, superabsorbent modern disposable diapers, the incidence and severity of irritant and allergic contact dermatitis has decreased dramatically. Diaper dermatitis broadly refers to skin disorders that occur in the diaper area, such as skin eruptions triggered by diapers, rashes exacerbated by the diaper, and other events that occur in the diaper area. A number of skin conditions that can occur anywhere on the skin may present with distinctive findings in the diaper area. The following discussion will review the most common triggers of diaper dermatitis and contact irritant dermatitis, while focusing on the skin conditions that may be associated or overlap clinically with contact dermatitis.

What is the optimal surgical strategy for complex perianal fistulous disease in pediatric Crohn's disease? A systematic review

PURPOSE

Perianal fistulous disease is present in 10-15% of children with Crohn's disease (CD) and is frequently complex and refractory to treatment, with one-third of patients having recurrent lesions. We conducted a systematic review of the literature to examine the best surgical strategy or strategies for pediatric complex perianal fistulous disease (CPFD) in CD.

METHODS

We searched CENTRAL, MEDLINE, EMBASE, and CINAHL for studies discussing at least one surgical strategy for the treatment of pediatric CPFD in CD. Reference lists of included studies were hand-searched. Two researchers screened all studies for inclusion, quality assessed each relevant study, and extracted data.

RESULTS

One non-randomized prospective and two retrospective studies met our inclusion criteria. Combined use of setons and infliximab therapy shows promise as a first-line treatment. A specific form of fistulectomy, "cone-like resection," also shows promise when combined with biologics. Endoscopic ultrasound to guide medical and surgical management is feasible in the pediatric population, though it is unclear if it improves outcomes.

CONCLUSION

There is a paucity of evidence regarding the treatment of CPFD in the pediatric population, and further research is required before recommendations can be made as to what, if any, surgical management is optimal.

Surgical Management of Crohn Disease in Children: Guidelines From the Paediatric IBD Porto Group of ESPGHAN

The incidence of Crohn disease (CD) has been increasing and surgery needs to be contemplated in a substantial number of cases. The relevant advent of biological treatment has changed but not eliminated the need for surgery in many patients. Despite previous publications on the indications for surgery in CD, there was a need for a comprehensive review of existing evidence on the role of elective surgery and options in pediatric patients affected with CD. We present an expert opinion and critical review of the literature to provide evidence-based guidance to manage these patients. Indications, surgical options, risk factors, and medications in pre- and perioperative period are reviewed in the light of available evidence. Risks and benefits of surgical options are addressed. An algorithm is proposed for the management of postsurgery monitoring, timing for follow-up endoscopy, and treatment options.

Surgery in Pediatric Crohn's Disease: Indications, Timing and Post-Operative Management

Pediatric onset Crohn's disease (CD) tends to have complicated behavior (stricture or penetration) than elderly onset CD at diagnosis. Considering the longer duration of the disease in pediatric patients, the accumulative chance of surgical treatment is higher than in adult onset CD patients. Possible operative indications include perianal CD, intestinal stricture or obstruction, abdominal abscess or fistula, intestinal hemorrhage, neoplastic changes and medically untreatable inflammation. Growth retardation is an operative indication only for pediatric patients. Surgery can affect a patient's clinical course, especially for pediatric CD patient who are growing physically and mentally, so the decision should be made by careful consideration of several factors. The complex and diverse clinical conditions hinder development of a systemized treatment algorithm. Therefore, timing of surgery in pediatric CD patients should be determined with individualized approach by an experienced and well organized multidisciplinary inflammatory bowel disease team. Best long-term outcomes will require proactive post-operative monitoring and therapeutic modifications according to the conditions.

Transperineal ultrasonography: First level exam in IBD patients with perianal disease

BACKGROUND

A pelvic magnetic resonance imaging (MRI) represents the front-line method for evaluating perianal disease in patients with inflammatory bowel disease (IBD). Recently, transperineal ultrasonography (TPUS) has been proposed as a simple, safe, time-sparing and useful diagnostic technique to assess different pathological conditions of the pelvic floor.

AIM

The aim of this prospective single centre study was to evaluate the accuracy of TPUS versus MRI for the detection and classification of perineal disease in IBD patients.

METHODS

From November 2013 to November 2014, 28 IBD patients underwent either TPUS or MRI. Fistulae and abscesses were classified according to Parks' and AGA's classification methods. A concordance was assessed by k statistics.

RESULTS

Overall, 33 fistulae and 8 abscesses were recognized by TPUS (30 and 7 by MRI, respectively). The agreement between TPUS and MRI was 75% according to Parks' classification (k=0.67) and 86% according to AGA classification (k=0.83), while it was 36% (k=0.34) for classifying abscesses.

CONCLUSIONS

TPUS proved to be as accurate as MRI for detecting superficial and small abscesses and for classifying perianal disease. Both examinations may be performed at the initial presentation of the patient, but TPUS is a cheaper, time-sparing procedure. The optimal use of TPUS might be in follow-up patients.

The two sides of the coin: Similarities and differences in the pathomechanisms of fistulas and stricture formations in irritable bowel disease

Fistulas and fibrosis or strictures represent frequent complications in irritable bowel disease (IBD) patients. To date, treatment options for fistulas are limited and surgery is often required. Similarly, no preventive treatment for fibrosis and stricture formation has been established. Frequently, stricture formation and fibrosis precede fistula formation, indicating that both processes may be connected or interrelated. Knowledge about the pathology of both processes is limited. A crucial role for the epithelial-to-mesenchymal transition (EMT) in fistula development has been demonstrated. Of note, EMT also plays a major role in the pathogenesis of fibrosis in many organs, and most likely also plays that role in the intestine. In addition, aberrant matrix remodeling, as well as soluble factors such as tumor necrosis factor (TNF), interleukin 13 (IL-13) and tumor growth factor beta (TGFβ) were involved, both in the onset of the fistula and fibrosis formation. Both fistulas and fibrosis may occur due to deregulated wound healing mechanisms from chronic and severe intestinal inflammation; however, further research is required to obtain a better understanding of the complex pathophysiology of fistula and intestinal fibrosis formation, to allow the development of new and more effective preventive treatment options for those important disease complications.

MR enterography: how to deliver added value

MR enterography (MRE) is increasingly vital to the diagnosis and follow-up of children with Crohn disease. This diagnostic test, which can provide valuable information regarding the presence of intestinal inflammation, intestinal and intra-abdominal complications, and extra-intestinal disease-related manifestations, has the potential to directly impact both medical and surgical decision-making. Consequently, it is imperative that the interpretation and reporting of these examinations provide as much clinical information as possible. This article reviews specific ways radiologists can provide added value when interpreting MRE examinations in the setting of pediatric Crohn disease by (1) establishing the true extent of disease involvement, (2) subjectively and objectively assessing response to medical treatment and (3) accurately characterizing disease-related complications.

Current management of intestinal bowel disease: the role of surgery

Inflammatory bowel disease (IBD) is a chronic affection, in which the two main phenotypical components are Crohn's disease and ulcerative colitis. In both diseases, medical treatment has the main role; in some phases of the natural history of IBD, surgery becomes an important therapeutic tool. The IBD represents a model of multidisciplinary management. Timing represents the key issue for proper management of IBD patients. For acute and severe IBD, the surgery can be a salvage procedure. Today, the laparoscopic approach plays an important role in armamentarium of the surgeon. Several articles compared the short- and long-term results between laparoscopic and open approaches in IBD. The aim of this review is to focus the role of surgery in IBD as well as the role of laparoscopic approach, and principally, the "state of the art" for surgical treatment, sometimes very challenging for surgeon, in all clinical features of IBD by a review of literature highlighted by the most recent international guidelines.

Results of the Fifth Scientific Workshop of the ECCO (II): Pathophysiology of Perianal Fistulizing Disease

The fifth scientific workshop of the European Crohn's and Colitis Organization (ECCO) focused on the relevance of fistulas to the disease course of patients with Crohn's disease (CD). The objectives were to reach a better understanding of the pathophysiological mechanisms underlying the formation of CD fistulas; to identify future topics in fistula research that could provide insights into pathogenesis; to develop novel therapeutic approaches; and to review current therapeutic strategies (with clarification of existing approaches to prevention, diagnosis and treatment). The results of the workshop are presented in two separate manuscripts. This manuscript describes current state-of-the-art knowledge about fistula pathogenesis, including the roles of epithelial-to-mesenchymal transition and cytokine matrix remodelling enzymes, and highlights the common association between fistulas and stenosis in CD. The review also considers the possible roles that genetic predisposition and intestinal microbiota play in fistula development. Finally, it proposes future directions and needs for fistula research that might substantially increase our understanding of this complex condition and help unravel novel therapeutic strategies and specific targets for treatment. Overall, it aims to highlight unanswered questions in fistula research and to provide a framework for future research work.

Recurrent Pediatric Perianal Swelling

Pediatric inflammatory bowel disease is a chronic gastrointestinal disease consisting of Crohn's disease (CD) and ulcerative colitis (UC). Both disease processes can share similar clinical symptoms including abdominal pain, diarrhea, hematochezia, and weight loss; CD can also be complicated by penetrating and fistulizing disease. Perianal skin tags, perianal abscesses, recto-cutaneous fistulae, and rectal stenosis are among the phenotypic characteristics of perianal CD. Current treatment strategies are focused on the surgical drainage of abscesses and the closure of fistulous tracts as well as controlling intestinal inflammation with the use of immunomodulators (6-mercaptopurine and methotrexate) and biologics (infliximab and adalimumab). Current guidelines by the American Gastroenterology Association and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition recommend a combination of surgical intervention and medical management for the treatment of perianal CD.

Methotrexate for the Management of Crohn's Disease in Children

OBJECTIVE

To review the literature evaluating methotrexate as a treatment option for Crohn's disease (CD) in pediatric patients.

DATA SOURCES

A search of PubMed electronic database (1966 to August 2015) and secondary resources was performed using the terms methotrexate, Crohn's, and inflammatory bowel disease. Other relevant articles cited within identified articles were also utilized.

STUDY SELECTION AND DATA EXTRACTION

Data sources were limited to English-language studies that included children less than 18 years of age. In total, 10 clinical studies met the criteria.

DATA SYNTHESIS

Awareness of the risk of hepatosplenic T-cell lymphoma associated with anti-tumor necrosis factor and thiopurine therapies has renewed interest in methotrexate to treat CD in children. According to data from 10 predominantly retrospective studies, children treated with oral or subcutaneous methotrexate once weekly had remission rates of 25% to 53% at 1 year. Adverse effects most often included nausea and vomiting, elevated liver function tests, headache, and hematological toxicity. The evidence to support methotrexate is limited by inconsistent study design and poorly described dosage regimens. It has been most frequently evaluated in patients with prior thiopurine exposure and has not been thoroughly evaluated as first-line therapy.

CONCLUSIONS

Based on results of retrospective studies, methotrexate is useful in the treatment of pediatric CD in those who fail thiopurine therapy. Remission rates with methotrexate are similar to those for thiopurine therapy, although no studies directly compare these agents. Although preliminary results are promising, prospective studies are needed to assess the use of methotrexate as initial first-line therapy in the pediatric CD population.

The impact of perianal disease in young patients with inflammatory bowel disease

BACKGROUND

Perianal disease is a potentially significant source of morbidity for patients with inflammatory bowel disease (IBD). We sought to identify the impact of perianal disease on IBD outcomes in children, adolescents, and young adults.

METHODS

We studied 12,465 inpatient admissions for patients ≤20 years old with IBD in 2009 using the Kids' Inpatient Database (KID). Patients were stratified by their principal diagnosis of ulcerative colitis (UC) or Crohn's disease (CD). Perianal disease (perianal abscess, anal fissure, or anal fistula), complex fistulas (rectourethral, rectovaginal, or enterovesical), and growth failure were defined by ICD-9 codes. Logistic regression was performed adjusting for CD or UC, gender, age, need for surgical intervention, fistulas, or growth failure.

RESULTS

Of the 511 (4.1%) patients with perianal disease, 480 had CD (94%, p < 0.001). Girls were less likely to suffer perianal disease (OR = 0.63, CI 0.52-0.76, p < 0.001). Those with perianal disease were more likely to suffer complex fistulas (OR = 3.5, CI 1.98-6.20, p < 0.001) but less likely to suffer enteroenteral fistulas (OR = 0.30, CI 0.15-0.63, p = 0.001) than those without perianal disease. Perianal disease did not increase the incidence of growth failure (p = 0.997) but doubled the likelihood of an operation of any type during admission (p < 0.001). Additionally, patients with perianal disease spent on average 1.29 more days in the hospital (7.45 vs. 6.16 days, p < 0.001) and accrued $5838 extra in hospital charges (p = 0.005).

CONCLUSIONS

Perianal disease in younger patients is associated with a longer length of stay, higher hospital charges, and increased rates of both perineal and abdominal operative procedures. These data support the notion that, similar to adults, the presence of perianal disease in pediatric Crohn's patients is associated with a more severe course.

Cone-like resection, fistulectomy and mucosal rectal sleeve partial endorectal pull-through in paediatric Crohn's disease with perianal complex fistula

BACKGROUND

Perianal abscesses and fistulae have been reported in approximately 15% of patients with paediatric Crohn's disease and they are associated with poor quality of life. Several surgical techniques were proposed for the treatment of perianal Crohn's disease, characterized by an elevated incidence of failure, incontinence, and relapse. Aim of our study was to present the technical details and results of our surgical technique in case of recurrent, persistent, complex perianal ano-rectal destroying Crohn's disease not responding to medical treatment.

METHODS

Data of patients who underwent surgical treatment (cone-like resection, fistulectomy, sphincter reconstruction, endorectal advancement sleeve flaps like in Soave endorectal pull-through) for complicated high-level trans, inter or suprasphincteric fistulae between January 2009 and June 2014 were retrospectively reviewed.

RESULTS

20 surgical procedures were performed in 11 patients (males 72.7%) with transsphincteric (n=5), intersphincteric (n=4) and suprasphincteric (n=2) fistulae. Three patients needed a second treatment. Two patients needed more than 2 surgeries and one temporary colostomy. No patient presented anal incontinence at 15 months' median follow-up.

CONCLUSIONS

Although several procedures may be required to obtain a complete remission of perianal lesions, in our series the proposed surgical technique seemed effective and safe, preserving anal continence in all treated cases and reducing the need of faecal diversion.

Imaging of perianal fistulizing Crohn's disease

Perianal fistula is a complication of Crohn's disease that carries a high morbidity. It is a channel that develops between the lower rectum, anal canal and perianal or perineal skin. The development of perianal fistulas typically connotes a more aggressive disease phenotype and may warrant escalation of treatment to prevent poor outcomes over time. Based on fistula anatomy, debris can form inside these tracts and cause occlusion, which subsequently leads to abscess formation, fever and malaise. The clinical presentation is often with complaints of pain, continuous rectal drainage of fecal matter as well as malodorous discharge. Considering that the presence of fistulas often indicates refractory and aggressive disease, early identification of its presence is important. Some patients may not have the classic symptoms of fistulizing disease at presentation and others may have significant scarring and/or pain from previous fistulizing episodes, which can make an accurate assessment on physical exam alone problematic. As a result, utilizing diagnostic imaging is the best means of identifying the early signs of perianal fistulas or abscess formation in these patients. Several imaging modalities exist which can be used for diagnosis and management. Endoscopic ultrasound and pelvic MRI are considered the most useful in establishing the diagnosis. However, a combination of multiple imaging modalities and/or examination under anesthesia is probably the most ideal. Incomplete characterization of the fistula tract(s) extent or the presence of abscess carries a high morbidity and far-reaching personal expense for the patient - promoting worsening of the disease.

Sphincter-sparing intersphincteric rectal resection as an alternative to proctectomy in long-standing fistulizing and stenotic Crohn's proctitis?

PURPOSE

Long-standing fistulizing and stenotic proctitis (LFSP) in Crohn's disease (CD) indicates the end stage of the disease. Definitive diversion such as proctectomy is considered to be the only surgical option. The impact of intersphincteric sphincter-sparing anterior rectal resection (IAR) as an alternative to proctectomy is unclear. The aim of this study was to evaluate feasibility, morbidity, outcome, and quality of life (QL) in patients with LFSP undergoing intended IAR.

PATIENTS AND METHODS

Out of a single institution database, 15 patients with LFSP intended for surgery from 856 patients with CD were selected for follow-up analyses.

RESULTS

In 12/15 cases, IAR was carried out while 3/15 patients underwent primary proctectomy due to malignancy (n = 2) or due to patient's wish (n = 1). In one case, IAR revealed unexpected malignancy, which led to secondary proctectomy. In patients with IAR, complete healing of fistulas and stenosis was observed in 46% (n = 5) while 36% (n = 4) of patients showed relapse of fistula and 18% (n = 2) developed restenosis. Ileostomy closure was performed in seven patients from which six patients remained stoma free. QL and fecal incontinence measured by standardized scoring systems were unchanged while stool frequency was reduced after IAR in patients with ileostomy closure. The rate of malignancy in this cohort was 20% (n = 3).

CONCLUSION

LFSP in CD was associated with 20% of malignant transformation. Although IAR fails to improve QL, it is a suitable procedure for the treatment of fistulas and stenosis associated with acceptable healing rates and can avoid a permanent stoma.

The role of surgery for children with perianal Crohn's disease

PURPOSE

Children with perianal Crohn's disease (PCD) are a unique and diverse patient population. The purpose of this study was to describe the spectrum of disease and role of surgery.

METHODS

A retrospective chart review of all children having at least one surgical intervention for PCD over 10 years was performed.

RESULTS

Fifty-seven patients (63% male) aged 0.5-17 (median 13) years were identified. Perianal disease consisted of skin tags (49%), superficial fistulae (49%), deep fistulae (37%), superficial abscesses (68%), deep abscesses (9%), skin breakdown (19%), and anal strictures (7%). 84% received anti-TNF therapy, with 27% treated with a second anti-TNF medication. Minor surgical procedures, commonly done during anti-TNF therapy, included abscess drainage (67%) and seton placement (33%). Major surgical procedures, done almost exclusively after anti-TNF failure, included defunctioning ileostomy (23%) and subtotal colectomy (9%). Follow-up ranged from 7 to 160 (median 54) months.

CONCLUSIONS

Pediatric PCD has a wide range of disease severity. Minor surgery provides adequate drainage before and during anti-TNF therapy, while major surgery plays a role in medically refractory disease. Appropriate surgical intervention remains an important part of the treatment paradigm.

Predictors of response to infliximab in paediatric perianal Crohn's disease

BACKGROUND

It is reported that 27-54% of paediatric patients with perianal Crohn's disease (CD) do not respond to infliximab (IFX).

AIM

To identify predictors of response to IFX in paediatric perianal CD.

METHODS

A retrospective cohort study of 101 paediatric patients treated with IFX between 2000 and 2011 for perianal CD in 22 French hospitals of the GETAID pédiatrique network was performed. Response was monitored after induction therapy and at 1 year. Complete response was defined by closure of all fistulas and complete healing of ulcers. Associations between baseline characteristics and (i) 1-year response and (ii) time of first relapse among initial responders were tested by logistic regression and Cox model respectively.

RESULTS

Eighty-nine patients (88%) responded to induction therapy (36 partial/53 complete). At 1 year, 76 patients (75%) were responders (22 partial/54 complete). Predictors of 1-year response were: number of fistulas ≤1 (OR: 3.76, 95% CI: 1.20-11.77, P = 0.03) and baseline Harvey-Bradshaw index <5 (OR: 3.72, 95% CI: 1.10-12.60, P = 0.03). Predictors of relapse among initial responders were: CD duration <10 months (OR: 3.31, 95% CI: 1.34-8.19, P = 0.0097) and number of fistulas >1 (OR: 2.79, 95% CI: 1.12-6.95, P = 0.028). Combined therapy with an immunomodulator was not associated with 1-year response or time of relapse.

CONCLUSION

Those patients with perianal Crohn's disease have better outcomes if they have less fistulas, a low baseline Harvey-Bradshaw Index or a longer duration of Crohn's disease.

Inflammatory bowel disease in pediatric and adolescent patients: a biomolecular and histopathological review

Crohn's disease (CD) and ulcerative colitis (UC) are the two main forms of inflammatory bowel disease (IBD) with both overlapping and distinct clinical, pathological and biomolecular features. It has been suggested that pediatric IBD is a distinct disease entity, with probably different disease subtypes.The aim of this study is to review and summarize the evolution of the current concept of pediatric IBD. The results of this review reinforce the idea that pediatric CD and UC may be further classified in various clinicopathologic entities. For clinicians and pathologists convenience, practical algorithms for the distinction of the various subphenotypes of pediatric IBD are also provided.

Treatment of complex perianal fistulas with seton and infliximab in adolescents with Crohn's disease

BACKGROUND AND AIMS

Treatment of complex perianal fistulas associated with Crohn's disease is challenging. In adults, seton drainage combined with infliximab therapy has proven to be more effective than either one alone. Results following such treatment among pediatric patients have not been reported previously. The aim of this study was to describe outcomes after combined seton and infliximab treatment for complex perianal fistulas in adolescents with Crohn's disease.

METHODS

We performed a retrospective medical record review of all consecutive Crohn's disease patients treated for perianal fistulas with seton drainage and infliximab between 2007 and 2013 (n=13). A follow-up interview was conducted at median of two years.

RESULTS

Median age at fistula diagnosis was 14years. Following seton placement in fistula tracks, infliximab induction was administered at weeks 0, 2, and 6 and maintenance therapy at 8-week intervals. Over 90% responded to seton drainage and infliximab induction. Final fistula response was obtained at median of 8weeks, being complete in 77% and partial in 15%. Setons were kept in place for median of 8months. Fistulas recurred in 23% over a year after the final response. At last follow-up, 85% still had a response and 70% were free from perianal symptoms. Most were still on anti-TNF-α therapy, but one third had switched to adalimumab. Patients' anorectal function was well preserved and overall satisfaction with the treatment was high.

CONCLUSIONS

The results suggest that combining seton drainage with infliximab therapy improves the perianal fistula response rates in pediatric patients.

Use of exclusive enteral nutrition is just as effective as corticosteroids in newly diagnosed pediatric Crohn's disease

BACKGROUND

The efficacy of exclusive enteral nutrition (EEN) in induction of remission in pediatric Crohn's disease (CD) is reported to be equivalent to that of corticosteroids (CS).

AIMS

Our objective was to compare the efficacy of EEN and CS in inducing remission in pediatric onset CD and the effects of the treatment on nutritional status and bone mineral density (BMD).

METHODS

Medical charts were retrospectively studied for patients diagnosed with CD between 2000 and 2010 at the Stollery children's hospital in Edmonton, Alberta. Anthropometric and dual-energy X-ray absorptiometry (DXA) data were collected to assess effects of therapy; clinical remission, relapse, and severity were defined on the basis of the pediatric Crohn's disease activity index.

RESULTS

To induce remission at first presentation, 36 patients (mean age 12.9 years) received EEN and 69 (mean age 11.2 years) received CS. Remission (88.9% in the EEN group versus 91.3% in the CS group (p=0.73) at 3 months) and relapse (40.6 vs. 28.6%, respectively (p=0.12) over 12 months) were similar in both treatment groups. Thirty-four patients had paired DXA scans at the time of diagnosis and one year later: 16 given EEN and 18 given CS. Change in BMD spine z-scores based on bone age adjusted for height and chronological age was greater for EEN patients but not statistically significant (Δz-score 0.30 vs. 0.03, p=0.28).

CONCLUSIONS

EEN has similar efficacy to corticosteroids; however, EEN may lead to better BMD accrual. EEN should be preferred to corticosteroids as first-line therapy for induction of remission in pediatric CD.