Extraintestinal Manifestations of Inflammatory Bowel Disease

Preexisting autoimmune disease is a risk factor for immune-related adverse events: a meta-analysis

PURPOSE

Patients with preexisting autoimmune disease (PAD) are often excluded from clinical trials assessing immune checkpoint inhibitors (ICIs). Therefore, the safety of ICI therapy in patients with PAD remains unclear. Herein, we evaluated the incidence of immune-related adverse events (irAEs) in patients with PAD when compared with non-PAD patients.

METHODS

We searched MEDLINE/PubMed, Web of Science, and Google Scholar for eligible studies from inception to January 2021. Observational studies reporting the incidence of irAEs in patients with and without PAD were included. We then performed a meta-analysis of eligible studies using forest plots. The primary endpoint of this study was the incidence rate of irAEs between patients with and without PAD.

RESULTS

We identified three prospective and three retrospective studies involving 206 patients with PAD and 3078 patients without PAD. In the meta-analysis, 128 patients with PAD (62.1%) experienced irAEs, which occurred in 51.9% of non-PAD patients, resulting in an odds ratio (OR) of 2.14 (95% confidence interval [CI] 1.58-2.89). In the subgroup analysis, the incidence of irAEs was significantly higher in patients with PAD (OR = 2.19, 95% CI [1.55-3.08]). Furthermore, no significant heterogeneity or publication bias was detected, indicating that our meta-analysis could be generalized to clinical settings.

CONCLUSION

This meta-analysis demonstrated that PAD was a risk factor for irAE incidence. These results suggest that monitoring the occurrence of irAEs in patients with PAD is required to manage irAEs appropriately.

Anti-TNF-Related Leukocytoclastic Vasculitis in Ulcerative Colitis: A Case Report

BACKGROUND

The development of drugs directed against tumor necrosis factor (TNF)-α has dramatically modified the therapeutic approach to inflammatory bowel diseases: a larger use of such drugs has also led to a major knowledge about their adverse effects, especially on skin. The aim of this report was to describe a rare steroid-dependent form of leukocytoclastic vasculitis induced by an anti-TNF-α agent in a young woman with ulcerative colitis.

CASE PRESENTATION

A young girl with ulcerative colitis developed a form of leukocytoclastic vasculitis induced by an anti-TNF-α agent. Recurrent palpable purpuric lesions on her legs were the main cutaneous manifestation. Skin lesions were steroid-dependent, but improved after withdrawal of the anti-TNF-α agent and second-line immunosuppressant therapy.

CONCLUSIONS

The need to develop specific recommendations to guide the use of medications for managing skin reactions induced by anti-TNF-α drugs is herein emphasized.

Extraintestinal Manifestations in Patients with Inflammatory Bowel Disease: Study Based on the ENEIDA Registry

BACKGROUND

Patients with inflammatory bowel disease (IBD) may present extraintestinal manifestations (EIMs) that affect the joints, skin, eyes, and hepatobiliary area, among others.

AIMS

Our aim was to analyse the prevalence and characteristics of EIMs in patients with IBD and to identify the possible risk factors associated with the development of EIMs in the largest series published to date.

METHODS

Observational, cross-sectional study including patients from the Spanish ENEIDA registry promoted by GETECCU. We retrospectively identified all cases of EIMs in the ENEIDA registry until January 2018.

RESULTS

The study included 31,077 patients, 5779 of whom had at least one EIM (global prevalence 19%; 95% CI 18.2-19.0). Among the different types of EIMs, rheumatic manifestations had a prevalence of 13% (95% CI 12.9-13.7; 63% of EIMs), with a prevalence of 5% (95% CI 4.7-5.2) for mucocutaneous manifestations, 2.1% (95% CI 1.9-2.2) for ocular manifestations, and 0.7% (95% CI 0.6-0.8) for hepatobiliary manifestations. The multivariable analysis showed that the type of IBD (Crohn's disease, p < 0.001), gender (female, p < 0.001), the need for an immunomodulator (p < 0.001) or biologic drugs (p < 0.001), a previous family history of IBD (p < 0.001), and an extensive location of IBD (p < 0.001) were risk factors for the presence of EIMs.

CONCLUSIONS

One-fifth of patients with IBD may have associated EIMs, with rheumatic manifestations as the most frequent (> 60% of EIMs). Female patients with severe Crohn's disease represent the group with the highest risk of developing EIMs. These patients should therefore be specially monitored and referred to the corresponding specialist when suggestive symptoms appear.

A systematic review of gut microbiome and ocular inflammatory diseases: Are they associated?

The primary focus of this review was to establish the possible association of dysbiotic changes in the gut bacterial microbiomes with both intestinal and extra-intestinal diseases with emphasis on ocular diseases such as bacterial keratitis, fungal keratitis, uveitis, age-related macular degeneration, and ocular mucosal diseases. For this particular purpose, a systematic search was conducted using PubMed and Google Scholar for publications related to gut microbiome and human health (using the keywords: gut microbiome, ocular disease, dysbiosis, keratitis, uveitis, and AMD). The predictions are that microbiome studies would help to unravel dysbiotic changes in the gut bacterial microbiome at the taxonomic and functional level and thus form the basis to mitigate inflammatory diseases of the eye by using nutritional supplements or fecal microbiota transplantation.

Herb-partitioned moxibustion alleviates colonic inflammation in Crohn's disease rats by inhibiting hyperactivation of the NLRP3 inflammasome via regulation of the P2X7R-Pannexin-1 signaling pathway

Crohn's disease is a chronic inflammatory bowel disease and the NLRP3 inflammasome plays an important role in Crohn's disease. Previous studies have shown that Herb-partitioned moxibustion treating (at Qihai (CV 6) and Tianshu (ST 25)) prevented the excessive activation of the NLRP3 inflammasome and repaired damaged colonic mucosa in Crohn's disease. However, the mechanism by which Herb-partitioned moxibustion (at CV 6 and ST 25) regulates NLRP3 remains unclear. In this study, we treated Crohn's disease rats with herb-partitioned moxibustion (at CV 6 and ST 25) to investigate the mechanism by which Herb-partitioned moxibustion regulates the colonic NLRP3 inflammasome by observing colon length, the colon macroscopic damage indexes, and the expression of ATP, P2X7R, Pannexin-1, NF-κBp65, NLRP3, ASC, caspase-1, IL-1β and IL-18 in the colon in Crohn's disease. Here, this study shows that herb-partitioned moxibustion (at CV 6 and ST 25) can reduce colon macroscopic damage indexes and colon histopathological scores, alleviate colon shortening and block the abnormal activation of the NLRP3 inflammasome by inhibiting the ATP content and the expression of P2X7R, Pannexin-1 and NF-κBp65, thereby reducing the release of the downstream inflammatory cytokine IL-1β and ultimately suppressing colonic inflammation in Crohn's disease rats. This study for the first time identifies the mechanism by which herb-partitioned moxibustion (at CV 6 and ST 25) may inhibit the abnormal activation of the NLRP3 inflammasome by inhibiting the P2X7R-Pannexin-1 signaling pathway in Crohn's disease rats.

[How Should We Do Different Approach to Treat Inflammatory Bowel Disease by Gender Difference?]

Although not as prominent, there are gender/sex differences in incidence/prevalence, clinical manifestation and disease course, comorbidities, therapeutic response, and patients coping strategy to the disease of inflammatory bowel disease (IBD). In this review, current knowledge about gender-specific differences in IBD would be provided and how to apply this in clinical practice be discussed.

Faecal Calprotectin in Assessment of Mucosal Healing in Adults with Inflammatory Bowel Disease: A Meta-Analysis

Achieving mucosal healing in patients with inflammatory bowel disease is related to a higher incidence of sustained clinical remission and it translates to lower rates of hospitalisation and surgery. The assessment methods of disease activity and response to therapy are limited and mainly rely on colonoscopy. This meta-analysis reviews the effectiveness of using faecal calprotectin as a marker for mucosal healing in inflammatory bowel disease. Two meta-analyses were conducted in parallel. The analysis on the use of faecal calprotectin in monitoring mucosal healing in colonic Crohn’s disease is based on 16 publications (17 studies). The data set for diagnostic values of faecal calprotectin in ulcerative colitis is composed of 35 original publications (total 49 studies). The DOR for the use of faecal calprotectin in Crohn’s disease is estimated to be 11.20 and the area under the sROCis 0.829. In cases of ulcerative colitis, the DOR is 14.48, while the AUC sROC is 0.858. Heterogeneity of the studies was moderatetosubstantial. Collected data show overall good sensitivity and specificity of the faecal calprotectin test, as well as a good DOR. Thus, monitoring of mucosal healing with a non-invasive faecal calprotectin test may represent an attractive option for physicians and patients with inflammatory bowel disease.

Extraintestinal manifestations at baseline, and the effect of tofacitinib, in patients with moderate to severe ulcerative colitis

INTRODUCTION

Extraintestinal manifestations (EIMs) in patients with ulcerative colitis (UC) are common. Tofacitinib is an oral, small molecule Janus kinase inhibitor for the treatment of UC. We evaluated the efficacy of tofacitinib in patients with EIMs, and the impact of tofacitinib on EIMs in patients with UC in the OCTAVE clinical program.

METHODS

Data from two 8-week induction studies (OCTAVE Induction 1 and 2) and a 52-week maintenance study (OCTAVE Sustain) were analyzed. The effect of tofacitinib on efficacy outcomes stratified by EIM status, proportion of predefined prior and active EIMs at baseline, and change from baseline in EIMs were determined at the end of the treatment period (weeks 8 or 52), or at early termination.

RESULTS

At baseline of OCTAVE Induction 1 and 2, and OCTAVE Sustain, 27.0% and 9.0% of patients had a history of EIMs (prior or active), respectively. Patients treated with tofacitinib 10 mg twice daily (BID) achieved remission and had endoscopic improvement in all studies, irrespective of any history of EIMs. A greater proportion of patients had active peripheral arthritis at baseline of OCTAVE Induction 1 and 2 versus OCTAVE Sustain. In OCTAVE Induction 1 and 2, similar proportions of tofacitinib and placebo-treated patients with active peripheral arthritis experienced either no change (81.3% and 85.7%, respectively) or an improvement (15.6% and 14.3%, respectively). By week 52 of OCTAVE Sustain, improvements in active peripheral arthritis were only observed in tofacitinib-treated patients (16.7% and 33.3% with tofacitinib 5 and 10 mg BID, respectively).

CONCLUSION

Any history of EIMs did not influence the efficacy of tofacitinib 10 mg BID for induction or maintenance of UC. The most common active EIM was peripheral arthritis, for which many patients in OCTAVE Induction 1 and 2, and OCTAVE Sustain, reported improvement or no change from baseline with tofacitinib treatment.Clinicaltrials.gov:NCT01465763; NCT01458951; NCT01458574.

A real world investigation on prevalence, clinical features, and therapy of inflammatory bowel disease in the city of Messina, Italy

BACKGROUND

The absence of a national register of inflammatory bowel diseases (IBD) hinders effective health care planning in Italy.

AIMS

to investigate prevalence of IBD in the city of Messina, Italy, based on General Practitioner (GP) records, and to establish current treatments prescribed by different health care providers.

METHODS

data were extracted from GP databases with the help of disease-specific healthcare cost exemption codes combined with ICD9 codes for ulcerative colitis (UC) and Crohn's disease (CD), and prescription for mesalazine. Disease and treatment-related data were collected together with information on employment status and the current healthcare provider.

RESULTS

Eighty-six GPs participated covering a population of 100,834 people. IBD prevalence (419/105) was 80% higher than estimates of the Regional Health Authorities. Incidence showed a seven-fold increase over the past 30 years. Only 51% of CD and 26% of UC patients were followed by a dedicated IBD centre with more frequent prescriptions of immunomodulators and biologics (p<0.001) compared to GPs.

CONCLUSIONS

Real world data show much higher figures on IBD prevalence than administrative estimates. Differences in therapeutic approaches between IBD-specialists and non-specialists may reflect poor confidence in managing immunosuppressive therapies by the latter, but may lead to inadequate therapy and cancer surveillance.

Systemic lupus erythematosus complicated by Crohn's disease with rectovaginal fistula

BACKGROUND

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease, and few cases combine with Crohn's disease. We present the first SLE patient concurrent with Crohn's disease and rectovaginal fistula. She was successfully treated with vedolizumab and surgical intervention. Besides, she also had a rare opportunistic infection, cryptococcal pneumonia, in previous adalimumab treatment course.

CASE

A 57 year-old female had SLE in disease remission for 27 years. She suffered from progressive rectal ulcers with anal pain and bloody stool, and Crohn's disease was diagnosed. She received adalimumab, but the lesion still progressed to a rectovaginal fistula. Besides, she suffered from an episode of cryptococcal pneumonia under adalimumab treatment course. Therefore, we changed the biologics to vedolizumab, and arrange a transverse colostomy for stool diversion. She had clinical remission without active inflammation, but the fistula still persisted. Then, she received a restorative proctectomy with colo-anal anastomosis and vaginal repair. Follow-up endoscopy showed no more rectal ulcers or fistula tracts, and contrast enema also noted no residual rectovaginal fistula.

CONCLUSION

When a SLE patient had unusual rectal ulcers, Crohn's disease should be considered. Biologics combined with surgical intervention is an optimal solution for Crohn's disease with rectovaginal fistula. Although cryptococcal pneumonia is a rare opportunistic infection in the biological treatment, we should always keep it in mind.

Hypophosphatemia after high-dose intravenous iron treatment in patients with inflammatory bowel disease: Mechanisms and possible clinical impact

BACKGROUND

High-dose intravenous iron is an effective treatment option for iron deficiency (ID) or ID anaemia (IDA) in inflammatory bowel disease (IBD). However, treatment with ferric carboxymaltose (FCM) has been associated with the development of hypophosphatemia.

AIM

To investigate mechanisms behind the development of hypophosphatemia after intravenous iron treatment, and disclose symptoms and clinical manifestations related to hypophosphatemia short-term.

METHODS

A prospective observational study of adult IBD patients with ID or IDA was conducted between February 1, 2017 and July 1, 2018 at two separate university hospitals in the southeast region of Norway. Patients received one dose of 1000 mg of either FCM or ferric derisomaltose (FDI) and were followed for an observation period of at least 7 wk. Blood and urine samples were collected for relevant analyses at baseline, week 2 and at week 6. Clinical symptoms were assessed at the same timepoints using a respiratory function test, a visual analogue scale, and a health-related quality of life questionnaire.

RESULTS

A total of 106 patients was available for analysis in this study. The FCM treatment group consisted of 52 patients and hypophosphatemia was present in 72.5% of the patients at week 2, and in 21.6% at week 6. In comparison, the FDI treatment group consisted of 54 patients and 11.3% of the patients had hypophosphatemia at week 2, and 3.7% at week 6. The difference in incidence was highly significant at both week 2 and 6 (P < 0.001 and P < 0.013, respectively). We observed a significantly higher mean concentration of intact fibroblast growth factor 23 (P < 0.001), a significant rise in mean urine fractional excretion of phosphate (P = 0.004), a significant decrease of 1,25-dihydroxyvitamin D (P < 0.001) and of ionised calcium levels (P < 0.012) in the FCM-treated patients compared with patients who received FDI. No clinical symptoms could with certainty be related to hypophosphatemia, since neither the respiratory function test, SF-36 (36-item short form health survey) or the visual analogue scale scores resulted in significant differences between patients who developed hypophosphatemia or not.

CONCLUSION

Fibroblast growth factor 23 has a key role in FCM induced hypophosphatemia, probably by inducing loss of phosphate in the urine. Short-term clinical impact of hypophosphatemia was not demonstrated.

Natural-Derived Polysaccharides From Plants, Mushrooms, and Seaweeds for the Treatment of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic inflammatory disease impairing the gastrointestinal tract, and its incidence and prevalence have been increasing over time worldwide. IBD greatly reduces peoples' quality of life and results in several life-threatening complications, including polyp, toxic colonic dilatation, intestinal perforation, gastrointestinal bleeding, and cancerization. The current therapies for IBD mainly include drugs for noncritical patients and operation for critical patients. However, continuous use of these drugs causes serious side effects and increased drug resistance, and the demand of effective and affordable drugs with minimal side effects for IBD sufferers is urgent. Natural-derived polysaccharides are becoming a research hotspot for their therapeutic effects on IBD. This study focuses on the research progress of various natural polysaccharides from plants, seaweeds, and mushrooms for the treatment of IBD during recent 20 years. Regulation of oxidative stress, inflammatory status, gut microbiota, and immune system and protection of the intestinal epithelial barrier function are the underlying mechanisms for the natural-derived polysaccharides to treat IBD. The excellent efficacy and safety of polysaccharides make them promising candidates for IBD therapy.

Eye disorders in patients with celiac disease and inflammatory bowel disease: A study using clinical data warehouse

BACKGROUND AND AIM

To analyze the prevalence of ophthalmic manifestations in patients with celiac disease, Crohn's disease and ulcerative colitis in Munich/Germany.

METHODS

A total of 272,873 patients of Ludwig Maximilians Universitat Ophthalmological Hospital with eye disease were evaluated between 2003 and 2019. The International Classification of Diseases, 10th revision (ICD-10) of celiac disease Crohn's disease, ulcerative colitis, and all medical records which had the diagnosis of these diseases were analyzed.

RESULTS

A total of 272,873 patients were analyzed, with a mean age of 53 years, with approximately 48% female patients, and 51% male patients. We selected 72 patients with celiac disease (68% women and 32% men), with a minimum age of 8 years, maximum of 103 years, and an average of 52 years. The most common diagnoses were dry eye (32%) and cataract (12%). The mean intraocular pressure of patients with celiac disease was 15 mmHg. During the same study period, 103 patients with Crohn's disease were analyzed, with an average intraocular pressure of 14 mmHg.The minimum age of the patients was 12 years and a maximum of 93 years with an average age of 55 years, with 57% of females and 43% of males. The most common diagnoses were cataract (22%) and dry eye (19%). During the same study period, 99 patients with ulcerative colitis were analyzed, with an average intraocular pressure of 14 mmHg.The minimum age of the patients was 6 years and a maximum of 96 years, with an average age of 61 years, with 36% of females and 64% of males. The most common diagnoses were cataract (29.2%) and dry eye (12%).

CONCLUSIONS

The main ophthalmological manifestations of patients requiring eye follow-up were dry eye and cataract for all the diseases analyzed, which can be considered as coincident complications. None of the three diseases had increased intraocular pressure. Thus, celiac disease presented a profile of ophthalmological manifestation similar to the other intestinal inflammatory diseases studied.

Presymptomatic Crohn's Disease in a Young Patient Diagnosed Just After the Onset of Idiopathic Acute Pancreatitis

Acute pancreatitis is an extraintestinal manifestation of inflammatory bowel disease. There have been few reports describing acute pancreatitis preceding a diagnosis of inflammatory bowel disease. We herein report a rare case of a 16-year-old boy with presymptomatic Crohn's disease that was newly diagnosed just after the onset of idiopathic acute pancreatitis. Crohn's disease of any stage, much less in the presymptomatic stage, is rarely diagnosed just after the development of acute pancreatitis. The present case suggests that acute pancreatitis without an apparent cause in young or pediatric population can precede a diagnosis of presymptomatic Crohn's disease.

Deep Analysis of the Peripheral Immune System in IBD Reveals New Insight in Disease Subtyping and Response to Monotherapy or Combination Therapy

BACKGROUND

Inflammatory bowel disease (IBD) is a complex disease with variable presentation, progression, and response to therapies. Current disease classification is based on subjective clinical phenotypes. The peripheral blood immunophenome can reflect local inflammation, and thus we measured 39 circulating immune cell types in a large cohort of IBD and control subjects and performed immunotype:phenotype associations.

METHODS

We performed fluorescence-activated cell sorting or CyTOF analysis on blood from 728 Crohn's disease, 464 ulcerative colitis, and 334 non-IBD patients, with available demographics, endoscopic and clinical examinations and medication use.

RESULTS

We observed few immune cell types commonly affected in IBD (lowered natural killer cells, B cells, and CD45RA^- CD8 T cells). Generally, the immunophenome was distinct between ulcerative colitis and Crohn's disease. Within disease subtype, there were further distinctions, with specific immune cell types associating with disease duration, behavior, and location. Thiopurine monotherapy altered abundance of many cell types, often in the same direction as disease association, while anti-tumor necrosis factor (anti-TNF) monotherapy demonstrated an opposing pattern. Concomitant use of an anti-TNF and thiopurine was not synergistic, but rather was additive. For example, thiopurine monotherapy use alone or in combination with anti-TNF was associated with a dramatic reduction in major subclasses of B cells.

CONCLUSIONS

We present a peripheral map of immune cell changes in IBD related to disease entity and therapies as a resource for hypothesis generation. We propose the changes in B cell subsets could affect antibody formation and potentially explain the mechanism behind the superiority of combination therapy through the impact of thiopurines on pharmacokinetics of anti-TNFs.

Emerging treatment options for extraintestinal manifestations in IBD

Extraintestinal manifestations (EIMs) are frequently observed in IBDs and contribute considerably to morbidity and mortality. They have long been considered a difficult to treat entity due to limited therapy options, but the increasing use of anti-tumour necrosis factors has dramatically changed the therapeutic approach to EIM in recent years. Newly emerging therapies such as JAK inhibitors and anti-interleukin 12/23 will further shape the available armamentarium. Clinicians dealing with EIMs in everyday IBD practice may be puzzled by the numerous available biological agents and small molecules, their efficacy for EIMs and their potential off-label indications. Current guidelines on EIMs in IBD do not include treatment algorithms to help practitioners in the treatment decision-making process. Herein, we summarise knowledge on emerging biological treatment options and small molecules for EIMs, highlight current research gaps, provide therapeutic algorithms for EIM management and shed light on future strategies in the context of IBD-related EIMs.

Growth Delay in Inflammatory Bowel Diseases: Significance, Causes, and Management

Growth delay with height and weight impairment is a common feature of pediatric inflammatory bowel diseases (PIBD). Up to 2/3 of Crohn Disease patients have impaired weight at diagnosis, and up to 1/3 have impaired height. Ulcerative colitis usually manifests earlier with less impaired growth, though patients can be affected. Ultimately, growth delay, if not corrected, can reduce final adult height. Weight loss, reduced bone mass, and pubertal delay are also concerns associated with growth delay in newly diagnosed PIBD patients. The mechanisms for growth delay in IBD are multifactorial and include reduced nutrient intake, poor absorption, increased fecal losses, as well as direct effects from inflammation and treatment modalities. Management of growth delay requires optimal disease control. Exclusive enteral nutrition (EEN), biologic therapy, and corticosteroids are the primary induction strategies used in PIBD, and both EEN and biologics positively impact growth and bone development. Beyond adequate disease control, growth delay and pubertal delay require a multidisciplinary approach, dependent on diligent monitoring and identification, nutritional rehabilitation, and involvement of endocrinology and psychiatry services as needed. Pitfalls that clinicians may encounter when managing growth delay include refeeding syndrome, obesity (even in the setting of malnutrition), and restrictive diets. Although treatment of PIBD has improved substantially in the last several decades with the era of biologic therapies and EEN, there is still much to be learned about growth delay in PIBD in order to improve outcomes.

Selecting End Points for Disease-Modification Trials in Inflammatory Bowel Disease: the SPIRIT Consensus From the IOIBD

BACKGROUND AND AIMS

Inflammatory bowel diseases (IBD), encompassing Crohn's disease (CD) and ulcerative colitis (UC), are chronic and disabling disorders. Prospective disease-modification trials to prevent disease progression are eagerly awaited. However, disease progression is not clearly defined. The objective of the Selecting End PoInts foR Disease-ModIfication Trials (SPIRIT) initiative was to achieve international expert consensus on the endpoints to be used in future IBD-disease modification trials.

METHODS

This initiative under the auspices of the International Organization for the Study of Inflammatory Bowel Diseases (IOIBD) began with a systematic literature search to evaluate the current evidence on the definition of disease progression in IBD. On October 22, 2019, a consensus meeting took place during the United European Gastroenterology Week (UEGW) Congress in Barcelona, during which predefined proposed statements were discussed in a plenary session and voted on anonymously. Agreement was defined as at least 75% of participants voting for any one statement.

RESULTS

The group agreed that the ultimate therapeutic goal in both CD and UC is to prevent disease impact on patient's life (health-related quality of life, disability, fecal incontinence), midterm complications (encompass bowel damage in CD, IBD-related surgery and hospitalizations, disease extension in UC, extraintestinal manifestations, permanent stoma, short bowel syndrome), and long-term complications (gastrointestinal and extraintestinal dysplasia or cancer, mortality).

CONCLUSIONS

Recommendations on which goals to achieve in disease-modification trials for preventing disease progression in patients with IBD are proposed by the SPIRIT consensus. However, these recommendations will require validation in actual clinical studies before implementation in disease-modification trials.

Pulmonary Manifestations of Inflammatory Bowel Disease

The frequency of extraintestinal manifestations of inflammatory bowel disease (IBD) is observed in most of the patients. Extraintestinal manifestations of IBD have been implicated in all the anatomic sites of the pulmonary tree, and include airway inflammation of the bronchi and bronchioles and parenchymal inflammation. There is a wide range of pulmonary manifestations in IBD, and most of them look a lot like other diseases. Doctors should keep a track of these conditions to avoid unnecessary complications and to provide an early diagnosis with correct and efficient treatment. IBD-related respiratory disorders are treated depending on the patient, but in most of them, steroids are generally chosen first. Steroids, both inhalational and systemic, are the primary approach. Antibiotics could also be given if the patient has infections or suppuration, usually followed by surgeries. However, drug-induced complications and toxicity should be kept in mind.

The Temporal Relationships and Associations between Cutaneous Manifestations and Inflammatory Bowel Disease: A Nationwide Population-Based Cohort Study

The temporal relationships between inflammatory bowel disease (IBD)-associated cutaneous manifestations and IBD remain uncertain, with existing evidence mostly from separate cross-sectional studies. We sought to determine the risks of IBD-related dermatologic diseases before and after the diagnosis of IBD. We identified 2847 cases of IBD and 14,235 matched controls from the Taiwan National Health Insurance Research Database between 2003 and 2014. The risks of cutaneous manifestations before and after the diagnosis of IBD were estimated with multivariable-adjusted analyses. At diagnosis, IBD was associated with atopic dermatitis (odds ratio (OR) = 1.61; 95% confidence interval (CI), 1.14-2.28), erythema nodosum (OR = 7.44; 95%CI, 3.75-14.77), aphthous stomatitis (OR = 2.01; 95%CI, 1.72-2.35), polyarteritis nodosa (OR = 5.67; 95%CI, 2.69-11.98), rosacea (OR = 1.67, 95%CI = 1.19-2.35), and cutaneous T cell lymphoma (OR = 21.27; 95%CI, 2.37-191.00). IBD was associated with the subsequent development of pyoderma gangrenosum (hazard ratio (HR) = 17.79; 95%CI, 6.35-49.86), erythema nodosum (HR = 6.54; 95%CI, 2.83-15.13), polyarteritis nodosa (HR = 2.69; 95%CI, 1.05-6.90), hidradenitis suppurativa (HR = 2.48; 95%CI, 1.03-5.97), psoriasis (HR = 2.19; 95%CI, 1.27-3.79), rosacea (HR = 1.92; 95%CI, 1.39-2.65), and aphthous stomatitis (HR = 1.45; 95%CI, 1.22-1.72). This study clarified the associations and temporal relationships between cutaneous manifestations and IBD, highlighting the need for interdisciplinary care in the patient with specific dermatologic diseases presenting with abdominal symptoms, or the IBD patients with cutaneous lesions.

The Gut-Brain Axis and Its Role in Controlling Eating Behavior in Intestinal Inflammation

Malnutrition represents a major problem in the clinical management of the inflammatory bowel disease (IBD). Presently, our understanding of the cross-link between eating behavior and intestinal inflammation is still in its infancy. Crohn's disease patients with active disease exhibit strong hedonic desires for food and emotional eating patterns possibly to ameliorate feelings of low mood, anxiety, and depression. Impulsivity traits seen in IBD patients may predispose them to palatable food intake as an immediate reward rather than concerns for future health. The upregulation of enteroendocrine cells (EEC) peptide response to food intake has been described in ileal inflammation, which may lead to alterations in gut-brain signaling with implications for appetite and eating behavior. In summary, a complex interplay of gut peptides, psychological, cognitive factors, disease-related symptoms, and inflammatory burden may ultimately govern eating behavior in intestinal inflammation.

Respiratory Tract Manifestations of Inflammatory Bowel Disease

Inflammatory bowel disease can manifest in many extraintestinal organ systems. The most frequently involved extraintestinal locations include the mucocutaneous, hepatobiliary, and ocular organ systems. The respiratory tract is less commonly involved and is therefore frequently overlooked. Consequently, it is believed that involvement of the respiratory tract in patients with inflammatory bowel disease is underreported. The pathogenesis is thought to be multifactorial, involving the common embryologic origin shared by the respiratory and luminal digestive tract, molecular mimicry, and immunologic interactions leading to immune-complex deposition in affected tissue. The spectrum of manifestations of the respiratory tract related to inflammatory bowel disease is broad. It not only includes direct involvement of the respiratory tract (ie, airways, interstitium, and pleura) but also can result as a consequence of systemic involvement such as in thromboembolic events. In addition, it may also be related to other conditions that affect the respiratory tract such as sarcoidosis and alpha-1 antitrypsin deficiency. Though some conditions related to respiratory tract involvement might be subclinical, others may have life-threatening consequences. It is critical to approach patients with suspected inflammatory bowel disease-related respiratory tract involvement in concert with pulmonology, infectious diseases, and any other pertinent experts, as treatments may require a multidisciplinary overlap of measures. Therefore, it is of paramount importance for the clinician to be aware of the array of respiratory tract manifestations of patients with inflammatory bowel disease, in addition to the possible spectrum of therapeutic measures.

The "Gum-Gut" Axis in Inflammatory Bowel Diseases: A Hypothesis-Driven Review of Associations and Advances

In modern medicine, the oral cavity has often been viewed as a passive conduit to the upper airways and gastrointestinal tract; however, its connection to the rest of the body has been increasingly explored over the last 40 years. For several diseases, the periodontium and gingiva are at the center of this oral-systemic link. Over 50 systemic conditions have been specifically associated with gingival and periodontal inflammation, including inflammatory bowel diseases (IBD), which have recently been elevated from simple "associations" to elegant, mechanistic investigations. IBD and periodontitis have been reported to impact each other's progression via a bidirectional relationship whereby chronic oral or intestinal inflammation can impact the other; however, the precise mechanisms for how this occurs remain unclear. Classically, the etiology of gingival inflammation (gingivitis) is oral microbial dysbiosis in the subgingival crevice that can lead to destructive periodontal disease (periodontitis); however, the current understanding of gingival involvement in IBD is that it may represent a separate disease entity from classical gingivitis, arising from mechanisms related to systemic inflammatory activation of niche-resident immune cells. Synthesizing available evidence, we hypothesize that once established, IBD can be driven by microbiomial and inflammatory changes originating specifically from the gingival niche through saliva, thereby worsening IBD outcomes and thus perpetuating a vicious cycle. In this review, we introduce the concept of the "gum-gut axis" as a framework for examining this reciprocal relationship between the periodontium and the gastrointestinal tract. To support and explore this gum-gut axis, we 1) provide a narrative review of historical studies reporting gingival and periodontal manifestations in IBD, 2) describe the current understanding and advances for the gum-gut axis, and 3) underscore the importance of collaborative treatment and research plans between oral and GI practitioners to benefit this patient population.

Association between Optic Neuritis and Inflammatory Bowel Disease: A Population-Based Study

Extraintestinal manifestations are common in patients with inflammatory bowel disease (IBD), and optic neuritis (ON) is a rare but severe one. This study aimed to evaluate possible factors associated with ON in patients with IBD. Adult patients with IBD who were not with concomitant ON on the index date identified from the Taiwan National Health Insurance Research Database (NHIRD) from the years 2000 to 2013 were included. A four-fold matched group was selected using age, sex and year of index date for comparison. All the patients were followed up until the development of ON or the end of the study period. Data of included patients were extracted and analyzed statistically. The mean follow-up time for all patients was 7.13 ± 5.21 years. At the study period conclusion, eight (0.18%) and five (0.003%) patients with and without IBD, respectively, had developed ON (p = 0.001). Adjusted HRs showed that patients with IBD aged between 30 and 39 years, with comorbidities including neuromyelitis optica (NMO), acute disseminated encephalomyelitis (ADEM), systemic lupus erythematosus (SLE) and with a higher Charlson Comorbidity Index, had a significantly higher risk of developing ON (all p < 0.005). Among the eight IBD patients who developed ON, only one patient was diagnosed with Crohn’s disease, the male gender was slightly dominant, and two (25%) patients received antitumor necrosis factor α (anti-TNF α) treatment for IBD. Patients with IBD have a higher risk of developing ON compared to patients without IBD. ON occurs more frequently in IBD patients aged between 30 and 39 years, with comorbidities including NMO, ADEM and SLE. Other factors besides anti-TNF α treatment for IBD are more likely associated with the development of ON.

Extraintestinal manifestation of inflammatory bowel disease in Asian patients: A multinational study

BACKGROUND/AIM

Although inflammatory bowel disease (IBD) incidence has increased over the past two decades in Asia, data on extraintestinal manifestations (EIMs) of IBD in Asian patients are limited. We aimed to evaluate the prevalence and clinical characteristics of EIMs in Asian IBD patients.

METHODS

In total, 1,764 patients (1,130 with ulcerative colitis [UC] and 634 with Crohn's disease [CD]) were recruited from 10 tertiary centers in Asia. The medical records of IBD patients were retrospectively reviewed for the presence, clinical characteristics, chronological order, and therapeutic management of EIMs.

RESULTS

EIMs were reported in 199 (11.3%) patients, of which 17 (1.0%) patients had multiple EIMs. EIMs were more prevalent in CD patients (P = 0.02). Multiple logistic regression analysis revealed that female sex (odds ratio [OR] 2.02, 95% confidence interval [CI] 1.15-3.55), stricture (OR 2.49, 95% CI 1.41-4.39) and female sex (OR 2.57, 95% CI 1.52-4.34), extensive colitis (OR 2.63, 95% CI 1.57-4.41) were associated with EIMs in CD and UC patients respectively. EIMs appeared in 8% of patients before IBD diagnosis; 95% of cases with EIM could be managed via first-line therapy.

CONCLUSION

EIM prevalence is lower among Asian IBD patients than among patients from Western countries; however, the risk factors for EIM were similar between both populations.

Clinical and sonographic discrimination between fibromyalgia and spondyloarthopathy in inflammatory bowel disease with musculoskeletal pain

OBJECTIVES

Joint pain is common in subjects with IBD and is linked to several factors including SpA, drug therapy, concomitant OA or FM. The primary aim of this study was to estimate the prevalence of primary FM and concomitant FM and SpA in a cohort of patients with IBD utilizing clinical and US assessment.

METHODS

A total of 301 consecutive cases with IBD attending two IBD Units were assessed by a rheumatologist for Assessment of SpondyloArthritis International Society criteria fulfilment for SpA or the 2010 ACR criteria for FM. Some 158 cases also had US entheseal examination on large insertions in the upper and lower limbs.

RESULTS

Thirty-seven IBD patients (12%) met the ACR criteria for primary FM with 9% presenting with primary FM and 3.3% presenting with concomitant FM and SpA. Meeting FM criteria was not related to smoking, sedentary job, BMI or the presence of psoriasis. FM patients presented higher Leeds Enthesitis Index, BASDAI and BASFI scores than SpA patients. At US examination, patients who satisfied the Assessment of SpondyloArthritis International Society criteria for SpA had significantly higher mean enthesis or patient power Doppler positive as compared with the IBD and FM group (P < 0.001).

CONCLUSION

We found that FM occurred in 12% of SpA patients and in this setting SpA disease activity indices performed poorly. US examination in a large patient subgroup showed a promising discriminating capacity between FM and SpA in IBD patients.

Vedolizumab (Entyvio®) for the Treatment of Pyoderma Gangrenosum in a Crohn's Disease Patient

Vedolizumab is a humanized monoclonal integrin blocker with gut selective effects on lymphocyte trafficking. Its efficacy and safety for the treatment of moderate to severe Crohn’s disease and ulcerative colitis were demonstrated by phase III GEMINI studies (GEMINI 1 trial: Vedolizumab as Induction and Maintenance Therapy for Ulcerative Colitis; GEMINI 2 trial: Vedolizumab as Induction and Maintenance Therapy for Crohn's Disease). Post hoc analyses of the GEMINI studies further showed the potential benefit of vedolizumab for treating various extraintestinal manifestations, including arthralgias, pyoderma gangrenosum, erythema nodosum, and uveitis. However, findings lacked statistical significance highlighting the need for more clinical data describing vedolizumab’s effects on extraintestinal manifestations. There are currently few case reports describing the effect of vedolizumab on pyoderma gangrenosum specifically. We report a Crohn’s disease patient whose severe pyoderma gangrenosum of her legs, abdomen, and face have been inactive since starting vedolizumab.

Vedolizumab and Extraintestinal Manifestations in Inflammatory Bowel Disease

In Crohn's disease and ulcerative colitis, inflammation is not limited to the digestive tract. Extraintestinal manifestations (EIMs), which affect up to 50% of patients, can substantially impair quality of life. EIMs may parallel luminal disease activity or have an independent course. They most commonly involve the musculoskeletal system (e.g., peripheral or axial arthritis) and skin (e.g., erythema nodosum and pyoderma gangrenosum). Less commonly, the hepatobiliary tract (e.g., primary sclerosing cholangitis [PSC]) and the eye (e.g., episcleritis, scleritis, and uveitis) are involved. Although the pathophysiology of EIMs is poorly understood, they are likely either manifestations of a primary systemic immune disease with variable expression amongst organs, or secondary phenomena to bowel inflammation. Additional pathophysiologic mechanisms may include aberrant lymphocyte homing mediated by ectopic expression of gut-specific chemokines and adhesion molecules, cross-reactivity between microbial and self-antigens, autoantibodies against epitopes shared by the intestine and extraintestinal tissues, elevated serum concentrations of cytokines, and alterations in innate immunity. Many EIMs independent of intestinal disease activity can be successfully treated with tumor necrosis factor (TNF) antagonists. The efficacy of vedolizumab-a monoclonal antibody targeting the α4β7 integrin-for the treatment of EIMs is uncertain, but data are emerging from post hoc analyses of randomized controlled trials, prospective and retrospective cohort studies, and case series. Vedolizumab may be effective in treating EIMs related to luminal disease activity (e.g., type 1 peripheral arthritis and erythema nodosum) but has not shown biochemical improvement in PSC. Its postulated role in the development of de novo EIMs is heavily confounded by the high proportion of patients previously exposed to TNF antagonists; new EIMs could result from TNF antagonist treatment cessation rather than being caused by vedolizumab. A common limitation of clinical studies is the lack of multidisciplinary involvement in the diagnosis and monitoring of EIMs, which may lead to misdiagnosis and overreporting. Future studies should rigorously measure EIMs in parallel with objective measures of luminal disease activity to provide more robust data on the relative efficacy of new drugs, especially as increasing numbers of gut-selective compounds enter clinical development.

Case Report: Systemic Small-Vessel Vasculitis in an Adolescent With Active Ulcerative Colitis

Introduction: Small-vessel vasculitis (SVV) is a rare immunological disease that affects arterioles, capillaries and venules. It causes purpura, but can also manifest in other organs, including the gastrointestinal tract. SVV and inflammatory bowel disease (IBD) co-occur more frequently than would be expected by chance. Case description: A 16-year-old girl, who had been diagnosed with ulcerative colitis (UC) 2 years earlier at a general hospital, developed purpura, progressive abdominal pain with frequent bloody diarrhea and frontotemporal headache and swelling while on azathioprine and mesalamine maintenance therapy. Serology was positive for perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) without antiprotease- or myeloperoixidase antibodies. Endoscopy revealed active left-sided UC and atypical ulcerations in the ascending colon. Biopsies of these ulcerations and of affected skin revealed leukocytoclastic vasculitis. Initially this was interpreted as an extraintestinal manifestation of UC that would subside when remission was induced, consequently infliximab was started. Over the next 3 weeks she developed severe burning pain in her right lower leg that progressed to a foot drop with numbness and the purpura progressed to bullous lesions. The diagnosis was adjusted to ANCA-associated vasculitis with involvement of skin, bowel and peripheral nerves. Infliximab was discontinued and induction treatment with high-dose prednisolone and cyclophosphamide was given until remission of SVV and UC was achieved. Subsequently, infliximab induction and maintenance was re-introduced in combination with methotrexate. Remission has been maintained successfully for over 2 years now. The foot drop only partly resolved and necessitated the use of an orthosis. Conclusion: Pediatric patients with IBD who present with purpuric skin lesions and abdominal pain should be evaluated for systemic involvement of SVV, which includes endoscopic evaluation of the gastrointestinal tract. We discuss a practical approach to the diagnosis, evaluation and management of systemic SVV with a focus on prompt recognition and early aggressive therapy to improve outcome.

Joint lesions in inflammatory bowel diseases: the analysis of the Moscow regional patient registry and a clinical case

Rationale: Extraintestinal manifestations (EIM) of an inflammatory bowel disease (IBD) are a sign of its more severe course. Joint lesions are most common among IBD EIM.

Aim: To evaluate the prevalence and types of joint lesions in the population of IBD patients of the Moscow region.

Materials and methods: We performed a  retrospective analysis of medical files of the patients who were admitted to the Moscow Region Inflammatory Bowel Disease Center (MONIKI) for examination and treatment from August 1, 2019, to March 1, 2020. The study included 70 patients with confirmed diagnoses of IBD and confirmed or suspected involvement of the joints.

Results: Thirty six of 70 patients with IBD and EIM (51.43%) had been diagnosed with Crohn's disease (CD), and 34 (48.57%) with ulcerative colitis (UC). The CD group included more men (n=21, 58.33%), whereas their proportion in the UC group was 47.02% (n=16). The mean age at CD diagnosis in the UC and CD groups was comparable: 38.3±13.7  years in men with CD and 40.5±12.8 years in men with UC, 37.7±11.1 years in women with CD and 35.7±14.0 in women with UC. The most prevalent among all IBD patients were X-ray negative peripheral arthralgias. Among joint lesions confirmed by radiological diagnostics, sacroileitis was most prevalent both in all IBD patients (24.3%), as well as in the UC group (17.6%), whereas in the CD patients its frequency was the same as that of ankylosing spondyloarthritis (AS) (30.6% of the cases). AS ranked second in the prevalence of joint lesions in the UC group (8.8%) and all IBD (20%). Psoriatic arthritis was diagnosed only in the CD patients (2 / 36). We describe a clinical case of CD with AS, complicated with psoriatic rash, treated with a  monoclonal antibody to tumor necrosis factor alfa (anti-TNF-α).

Conclusion: Peripheral arthropathias were most prevalent among all joint lesions in the group studied. EIM mirror a more aggressive phenotype of the disease and higher glucocorticosteroids requirements. Administration of anti-TNF-α agents allows for the control of both intestinal IBD manifestations and of the joint syndrome. However, drug-associated skin adverse event can occur during treatment with this drug class. In such a case, it is possible to switch the biological therapy to another class of drugs that we have demonstrated with the given clinical example.

Splenic erythroid progenitors decrease TNF-α production by macrophages and reduce systemic inflammation in a mouse model of T cell-induced colitis

In inflammatory bowel disease (IBD), inflammation can occur beyond the intestine and spread systemically causing complications such as arthritis, cachexia, and anemia. Here, we determine the impact of CD45, a pan-leukocyte marker and tyrosine phosphatase, on IBD. Using a mouse model of T cell transfer colitis, CD25^- CD45RB^high CD4⁺ T cells were transferred into Rag1-deficient mice (RAGKO) and CD45-deficient RAGKO mice (CD45RAGKO). Weight loss and systemic wasting syndrome were delayed in CD45RAGKO mice compared to RAGKO mice, despite equivalent inflammation in the colon. CD45RAGKO mice had reduced serum levels of TNF-α, and reduced TNF-α production by splenic myeloid cells. CD45RAGKO mice also had increased numbers of erythroid progenitors in the spleen, which had previously been shown to be immunosuppressive. Adoptive transfer of these erythroid progenitors into RAGKO mice reduced their weight loss and TNF-α expression by splenic red pulp macrophages. In vitro, erythroid cells suppressed TNF-α expression in red pulp macrophages in a phagocytosis-dependent manner. These findings show a novel role for erythroid progenitors in suppressing the pro-inflammatory function of splenic macrophages and cachexia associated with IBD.

Infliximab is effective in the treatment of ulcerative colitis with dermatomyositis: A case report

BACKGROUND

Joint, skin, oral cavity, and eye lesions are the most common extraintestinal manifestations of ulcerative colitis that can occur before or after its onset. The cases of ulcerative colitis with dermatomyositis (DM) are rare. In this study, we report a rare case of ulcerative colitis with DM that was effectively treated with infliximab.

CASE SUMMARY

The patient was a 57-year-old female with a 2-year history of DM. The patient was admitted to hospital with abdominal pain, diarrhea, and blood in stool lasting for more than 2 mo. Colonoscopy revealed multiple erosions and ulcers in the entire colon and rectum. Pathological sections showed chronic inflammatory cell infiltration, especially neutrophil infiltration, in the colonic mucosa; therefore, the patient was diagnosed with ulcerative colitis. Preparations of 5-aminosalicylic acid was added to her treatment based on the original treatment for DM, but its effect was unsatisfactory. The patient’s discomfort was relieved after infliximab treatment.

CONCLUSION

Infliximab can improve DM in the treatment of ulcerative colitis. Specialists need to raise awareness about patients with inflammatory bowel disease who have rare extraintestinal manifestations.

Prevalence of pyoderma gangrenosum and Sweet´s syndrome in inflammatory bowel disease at a tertiary healthcare center

BACKGROUND AND AIM

dermatological manifestations are normally found in one third of patients with inflammatory bowel disease. In this study, the prevalence, clinical characteristics, intestinal disease activity, and treatment response of neutrophilic dermatoses (pyoderma gangrenosum and Sweet´s syndrome) were determined in patients with inflammatory bowel disease.

METHODS

a retrospective, observational study was performed in patients with inflammatory bowel disease and neutrophilic dermatoses between March 2012 and March 2018.

RESULTS

of 444 patients analyzed, 10 complied with the inclusion criteria. Seven had pyoderma gangrenosum and three presented Sweet's syndrome; and one patient developed both pathologies. The prevalence of neutrophilic dermatoses was 2.3 % (10/444), comprising 1.6 % with pyoderma gangrenosum and 0.7 % with Sweet's syndrome. Six out of seven patients with pyoderma gangrenosum were female and had ulcerative colitis. The most frequent clinical presentation of pyoderma gangrenosum was the ulcerative subtype. Active moderate-to-severe intestinal disease was found in 71.4 % of patients. Biological therapy was prescribed to three patients with partial response to corticosteroids and persistent intestinal disease activity. This therapy was not indicated for cutaneous manifestations only. Three patients with moderate-to-severe Crohn´s disease presented classical (n = 2) and pustular (n = 1) Sweet's syndrome. A complete response was achieved in all Sweet's syndrome cases treated with corticosteroids. Biological therapy was prescribed to control intestinal disease activity.

CONCLUSIONS

pyoderma gangrenosum was the most frequent cutaneous manifestation of neutrophilic dermatoses, predominantly in females with ulcerative colitis, and highly associated with intestinal disease activity. Anti-tumor necrosis factor was effective in patients with partial cutaneous and intestinal disease response.

Sex matters: impact on pathogenesis, presentation and treatment of inflammatory bowel disease

Inflammatory bowel disease (IBD), as do most chronic inflammatory disorders, displays unique features and confers different risk factors in male and female patients. Importantly, sex-based differences in IBD exist for epidemiological incidence and prevalence among different age groups, with men and women developing distinct clinical symptoms and disparity in severity of disease. In addition, the presentation of comorbidities in IBD displays strong sex differences. Notably, particular issues exclusive to women's health, including pregnancy and childbirth, require specific considerations in female patients with IBD of childbearing age that can have a substantial influence on clinical outcomes. This Review summarizes the latest findings regarding sex-based differences in the epidemiology, clinical course, comorbidities and response to current therapies in patients with IBD. Importantly, the latest basic science discoveries in this area of investigation are evaluated to provide insight into potential mechanisms underlying the influence of sex on disease pathogenesis, as well as to design more personalized and efficacious care, in patients with IBD.

Association between inflammatory bowel disease and prostate cancer: A large-scale, prospective, population-based study

Inflammatory bowel disease (IBD) is an established risk factor for colorectal cancer. Recent reports suggesting IBD is also a risk factor for prostate cancer (PC) require further investigation. We studied 218 084 men in the population-based UK Biobank cohort, aged 40 to 69 at study entry between 2006 and 2010, with follow-up through mid-2015. We assessed the association between IBD and subsequent PC using multivariable Cox regression analyses, adjusting for age at assessment, ethnic group, UK region, smoking status, alcohol drinking frequency, body mass index, Townsend Deprivation Index, family history of PC and previous prostate-specific antigen testing. Mean age at study entry was 56 years, 94% of the men were white, and 1.1% (n = 2311) had a diagnosis of IBD. After a median follow-up of 78 months, men with IBD had an increased risk of PC (adjusted hazard ratio [aHR] = 1.31, 95% confidence interval [CI] = 1.03-1.67, P = .029). The association with PC was only among men with the ulcerative colitis (UC; aHR = 1.47, 95% CI = 1.11-1.95, P = .0070), and not Crohn's disease (aHR 1.06, 95% CI = 0.63-1.80, P = .82). Results are limited by lack of data on frequency of health care interactions. In a large-scale, prospective cohort study, we detected an association between IBD, and UC specifically, with incident PC diagnosis.

Characterization and prevalence of extraintestinal manifestations in a cohort of patients with inflammatory intestinal disease in Medellin, Colombia

INTRODUCTION

Extraintestinal manifestations (EIMs) are frequent in patients with inflammatory bowel disease (IBD). Our objective is to characterize and determine the prevalence of MEIs in our cohort of patients with IBD.

PATIENTS AND METHODS

A retrospective study was carried out in adult patients with IBD at the Pablo Tobón Uribe Hospital in Medellín. Colombia. Articular MEIs, primary sclerosing cholangitis (PSC), both ophthalmological and dermatological, were considered. Absolute and relative frequencies were used. The Chi square test of independence was used to compare 2proportions and the odds ratio (OR) was estimated.

RESULTS

Our registry has 759 patients with IBD, 544 present UC (71.6%), 200 CD (26.3%) and 15 unclassifiable IBD (1.9%); 177 patients with IBD (23.3%) presented EIMs, 123 of 544 (22.6%) with UC and 53 of 200 (26.5%) with CD (OR: 0.81, 95% CI: 0.55-1.17, P=0.31). Regarding the type of EIMs, the articular ones were the most frequent (13.5%), more in CD than in UC (20.0 vs. 11.3%, OR 1.94, 95% CI: 1.25-3.00, P=0.0037). Patients with IBD and EIMs used more antibodies against tumor necrosis factor (anti-TNFs), compared to those without EIMs (43.5 vs. 18.5%, OR 3.38, 95% CI: 2.31-4.90, P=0.0001).

CONCLUSIONS

The prevalence of EIMs in our cohort is high (23.3%) and the most frequent type is joint. Anti-TNFs are most used when IBD and EIMs coexist. Our study provides valuable information on the association of EIMs and IBD in Latin America.

Assessment of left ventricular contractile functions in inflammatory bowel disease according to disease activity

OBJECTIVES

The study aimed to investigate the subclinical involvement of cardiac functions in patients with inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's disease (CD) according to their disease activity status by two-dimensional speckle tracking echocardiography (2DSTE).

METHODS

This prospective study included 72 consecutive patients with IBD and 93 age- and sex-matched healthy controls (HC). All participants underwent conventional and 2DSTE assessments. The IBD patients were subdivided into active disease and remission groups for further investigation of the effect of disease activity on left ventricular (LV) contractile functions.

RESULTS

The longitudinal strain values differed significantly between the IBD group and the control group (global longitudinal strain [GLS] from two-chamber view: [-15.74 ± 6.33]% vs [-18.8 ± 2.87]%, P = 0.001; GLS from four-chamber view: [-16.61 ± 9.91]% vs [-20.12 ± 2.57]%, P = 0.008; GLS: [-15.47 ± 6.87]% vs [-19.48 ± 2.16]%, P = 0.0001). The circumferential strain measurements showed a nonsignificant trend of depressed contractile functions in the IBD group. Patients with active IBD had similar GLS and global circumferential strain (GCS) values as those in remission. A correlation analysis revealed that the neutrophil-lymphocyte ratio was positively correlated and the platelet count was negatively correlated with GCS. Deterioration of LV diastolic functions examined with E/e' and mitral deceleration time was found in the IBD group compared with the controls.

CONCLUSIONS

LV global longitudinal contractile and diastolic functions were decreased in patients with IBD. Clinicians should maintain patients' remission periods and prevent flare-ups.

Growth and Puberty in Children with Inflammatory Bowel Diseases

Inflammatory bowel diseases (IBD) are gastrointestinal tract pathologies of unknown etiology; they have an alternating trend, with active and silent phases. IBD are classified in two main forms: ulcerative colitis (UC) and Crohn’s disease (CD). Both have chronic and recurrent course, gastrointestinal symptoms, and extraintestinal manifestations. The altered immune response role seems to be important both in UC and CD. In the majority of cases, CD begins with abdominal pain, diarrhea, decrease in appetite, and weight loss; there can be also perianal fistulas, rhagades, and perianal recurrent abscesses. In addition, retarded growth and delayed puberty can precede the development of the disease or can even be predominant at onset. Growth retardation is found in 40% of IBD patients, but the underlying mechanism of this and other extra-intestinal manifestations are partially known: the main hypotheses are represented by malnutrition and inflammatory response during the active phase of the disease. The increased level of pro-inflammatory cytokines can influence growth, but also the onset of puberty and its progression. In addition, it could be essential to clarify the role and the possible effects of all the currently used treatments concerning growth failure and delayed puberty.

Physical and Metabolic Changes after Ileal Pouch-Anal Anastomosis: A Case Study

This case study examined changes in body composition, resting metabolic rate (RMR), aerobic capacity, and daily physical activity in a patient who had ulcerative colitis and underwent ileal pouch-anal anastomosis (IPAA) surgery. Body composition, RMR, and peak oxygen consumption (VO₂peak) were assessed prior to surgery and four, eight, and 16 weeks after IPAA surgery. Daily physical activity data were extracted from a wrist-worn activity tracker preoperatively and 16 months postoperatively. At baseline, total body mass was 95.3 kg; body fat, 11.6%; lean body mass, 81.1 kg; RMR, 2416 kcal/d; and VO₂peak, 42.7 mL/kg/min. All values decreased from baseline at four weeks postoperatively, body mass was 85.2 kg (-10.5%); body fat, 10.9% (-6.0%); lean body mass, 73.1 kg (-9.9%); RMR 2210 kcal/d (-8.5%) and VO₂peak, 25.5 mL/kg/min (-40.3%). At 16 weeks postoperatively, most parameters were near their baseline levels (within 1-7%), exceptions were VO₂peak, which was 20.4% below baseline, and RMR, which increased to nearly 20% above baseline. After the patient had IPAA surgery, his total and lean body masses, RMR, and aerobic capacity were markedly decreased. Daily physical activity decreased postoperatively and likely contributed to the decreased aerobic capacity, which may take longer to recover compared to body composition and RMR parameters.

Symptoms of central sensitization in patients with inflammatory bowel diseases: a case-control study examining the role of musculoskeletal pain and psychological factors

OBJECTIVES

Musculoskeletal (MSK) pain is a common complaint in patients with inflammatory bowel diseases (IBD). MSK pain in IBD has previously demonstrated association with symptoms of central sensitization; however it is uncertain whether these symptoms are influenced simply by the presence of MSK pain and/or IBD. Primary aim of this study was to investigate whether symptoms of central sensitization differed across three groups: IBD patients with and without MSK pain and healthy controls. Secondary aim was to investigate between-group differences for measures of somatosensory functioning.

METHODS

Cross-sectional study was performed on adults with IBD. Assessments included: central sensitization inventory (CSI), pressure pain threshold, temporal summation, conditioned pain modulation, perceived stress, affect style, anxiety, depression, and pain catastrophizing. One-way analyses of variance and covariance were used to investigate between-group differences for measures of central sensitization and potential confounding by psychological factors.

RESULTS

Study participants (n=66) were age/gender matched across three study groups. Between-group differences were solely demonstrated for CSI scores [F(2,63)=19.835, p<0.001, r=0.62], with IBD patients with MSK pain demonstrating the highest CSI scores and healthy controls the lowest. After controlling for individual psychological features, post hoc comparisons indicated that CSI scores were significantly different between-groups (p≤0.025) after controlling for most psychological variables, with the exception of perceived stress (p=0.063) and pain catastrophizing (p=0.593).

CONCLUSIONS

IBD patients as a whole demonstrated significantly greater symptoms of central sensitization compared to healthy controls. However, IBD patients with persistent MSK pain demonstrated the greatest symptoms of central sensitization compared to patients without MSK pain and healthy controls. Between-group differences for CSI in IBD patients with MSK were not confounded by psychological features.

IMPLICATIONS

Study results indicate that persistent MSK pain in IBD represents patients with greater central sensitization symptomology. This increased symptomology is suggestive of underlying mechanisms related to central sensitization, highlighting patient potentially at risk for worse pain experiences.

The Impact of Intestinal Complications on Health Care Costs Among Patients With Inflammatory Bowel Disease Treated With Anti-Tumor Necrosis Factor Therapies

BACKGROUND

Although there is evidence that anti-tumor necrosis factor (TNF) utilization earlier in the inflammatory bowel disease (IBD) course and before the onset of disease-related complications leads to improved patient outcomes, the health care costs and utilization impact have not been well defined. This study assessed differences in health care utilization and costs among patients with IBD treated with anti-TNFs.

METHODS

Patients with a diagnosis of ulcerative colitis (UC) or Crohn disease (CD) between January 1, 2001, and December 31, 2014, were identified from a claims database. Patients were required to have ≥1 claim for a 5-aminosalicylic acid, corticosteroid, or immunomodulator after the IBD diagnosis and ≥1 anti-TNF drug claim after the first IBD treatment. Complication and noncomplication cohorts were identified based on disease-related complications and IBD-related hospitalizations or emergency department visits for 6 months before anti-TNF initiation. Generalized linear models were used to compare health care costs and utilization for the 12 months after anti-TNF initiation (follow-up).

RESULTS

The study included 6329 patients with CD and 4451 patients with UC. In patients with CD with complications, >33.7% had intestinal strictures and 6% had enteroenteric fistula before anti-TNF treatment. Patients with CD with complications incurred significantly higher IBD-related and all-cause health care costs during follow-up, and patients with UC experienced the same trends.

CONCLUSIONS

These results suggest that anti-TNF treatment after, rather than before, a patient develops complications leads to a higher economic burden. However, these findings could also result from patients with more severe disease having early complications that are more difficult to treat.

CRITICAL ANALYSIS OF ANTI-TNF USE IN THE ERA OF NEW BIOLOGICAL AGENTS IN INFLAMMATORY BOWEL DISEASE

BACKGROUND

Inflammatory bowel diseases (IBD), both Crohn's disease and ulcerative colitis, are chronic immune-mediated diseases that present a relapsing and remitting course and requires long-term treatment. Anti-tumor necrosis factor (anti-TNF) therapy has changed the management of the disease by reducing the need for hospitalizations, surgeries and improving patient´s quality of life.

OBJECTIVE

The aim of this review is to discuss the role of anti-TNF agents in IBD, highlighting the situations where its use as first-line therapy would be appropriate.

METHODS

Narrative review summarizing the best available evidence on the topic based on searches in databases such as MedLine and PubMed up to April 2020 using the following keywords: "inflammatory bowel disease'', "anti-TNF agents" and ''biologic therapy''.

CONCLUSION

Biological therapy remains the cornerstone in the treatment of IBD. In the absence of head-to-head comparisons, the choice of the biological agent may be challenging and should take into account several variables. Anti-TNF agents should be considered as first line therapy in specific scenarios such as acute severe ulcerative colitis, fistulizing Crohn's disease and extra-intestinal manifestations of IBD, given the strong body of evidence supporting its efficacy and safety in these situations.

Increased Risk of Inflammatory Bowel Disease Among Patients With Ankylosing Spondylitis: A 13-Year Population-Based Cohort Study

AIM

Ankylosing spondylitis (AS) primarily affects the axial skeleton and extraarticular structures. Small-scaled studies have reported that the incidence and prevalence of inflammatory bowel disease (IBD) are higher in patients with AS than in the general population. This study determined the incidence of IBD in patients with AS using a large scale population-based cohort dataset.

METHODS

This was a retrospective cohort study. Patient data were collected from the Taiwan National Health Insurance Research Database from 2000 to 2012. We enrolled 3,804 patients with AS and 7,608 non-AS patients. The endpoint was IBD diagnosis by using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding 555 and 556 after at least three outpatient visits or one hospital admission, until the end of 2012. The Kaplan-Meier analysis was performed to discriminate the cumulative incidence of IBD and the log-rank test was used to test the significance. A Cox proportional hazard model was used to estimate the hazard ratio (HR) for IBD between the AS and non-AS groups.

RESULTS

Among the population as a whole the Cox proportional hazard regression indicated that patients aged ≥65 years [adjusted HR (aHR): 2.48, 95% confidence interval (CI): 1.38-4.47] or with comorbidity of cancer (aHR: 3.51, 95% CI: 1.40-8.80) had a higher HR for IBD. Kaplan-Meier curves of cumulative incidence proportion of IBD indicated that patients with AS had a higher risk of IBD than the non-AS group in the subgroup aged <40 years (HR: 2.85, 95% CI: 1.51-5.40, p = 0.001).

CONCLUSIONS

Patients with AS aged <40 years had a higher IBD risk than did those without AS in Taiwan. Clinicians and patients should be aware of this association.

Mapping the relationships between inflammatory bowel disease and comorbid diagnoses to identify disease associations

BACKGROUND

Massive amounts of patient data are captured daily in electronic medical records (EMR). Utilizing the power of such large data may help identify disease associations and generate hypotheses that can lead to a better understanding of disease associations and mechanisms. We aimed to comprehensively identify and validate associations between inflammatory bowel disease (IBD) and concurrent comorbid diagnoses.

METHODS

We performed a cross-sectional study using EMR data collected between 1986 and 2009 at a large tertiary referral center to identify associations with a diagnosis of IBD. The resulting associations were externally validated using the Truven MarketScan database, a large nationwide dataset of private insurance claims.

RESULTS

A total of 6225 IBD patients and 31 125 non-IBD controls identified using EMR data were used to abstract 41 comorbid diagnoses associated with an IBD diagnosis. The strongest associations included Clostridiodes difficile infection, pyoderma gangrenosum, parametritis, pernicious anemia, erythema nodosum, and cytomegalovirus infection. Two IBD association clusters were found, including diagnoses of nerve conduction abnormalities and nonspecific inflammatory conditions of organs outside the gut. These associations were validated in a national cohort of 80 907 patients with IBD and 404 535 age- and sex-matched controls.

CONCLUSION

We leveraged a big data approach to identify several associations between IBD and concurrent comorbid diagnoses. EMR and big data provide the opportunity to explore disease associations with large sample sizes. Further studies are warranted to refine the characterization of these associations and evaluate their usefulness for increasing our understanding of disease associations and mechanisms.

A decrease in the tear secretion volume in a mouse model with ulcerative colitis

PURPOSE

Dry eye syndrome is known to develop from several systemic inflammatory diseases. Although dry eye may develop due to extraintestinal complications of ulcerative colitis (UC), the pathogenesis is not well-known. This study aimed to investigate whether there was decrease in the tear secretion volume in a mice model with UC; the difference between the control and dextran sodium sulphate (DSS)-treated group was also determined.

MATERIALS AND METHODS

This study included a mice model with UC induced by the oral administration of 5.0% DSS for 7 days. Following the DSS treatment, the tear volume was measured using the Schirmer's test. The colon and ocular tissues, including the lacrimal gland, were evaluated using histological and protein analyses. Additionally, tumour necrosis factor (TNF)-α and interleukin (IL)-6 in the plasma were determined. Differences between groups (DSS-treated versus control mice) were determined using Student's t-test.

RESULTS

The tear volume in DSS-treated mice was decreased compared to that in the control mice. Plasma levels of TNF-α and IL-6 in DSS-treated mice was higher than that of control. Morphological change was observed with the invasion of the inflammatory cell in the lacrimal gland of DSS-treated mice. Terminal deoxynucleotidyl transferase mediated deoxyuridine triphosphate nick end labelling (TUNEL)-positive cells were increased in the lacrimal glands of DSS-treated mice compared with control group. The distribution of aquaporin-5 expressed in the lacrimal gland of DSS-treated mice was decreased compared to that in the control group.

CONCLUSIONS

These findings suggest that a decrease in the tear volume in UC was associated with a functional decline in the inflamed lacrimal gland. This result therefore provides useful information that could contribute to the development of treatment approaches for dry eye associated with UC.

Extraintestinal Manifestations of Inflammatory Bowel Disease in Middle Eastern Patients

Background and Aims: The Inflammatory Bowel Diseases (IBDs), Crohn’s Disease (CD) and Ulcerative Colitis (UC), are gastrointestinal autoimmune disorders with many Extraintestinal Manifestations (EIMs). Previously reported incidences of EIMs in IBD patients have ranged from 10% to 50%. The large variation in occurrence of EIMs has been linked to genetic predisposition. Correlations between individual EIMs are unclear. Therefore, we aim to estimate the incidence of EIMs in a Middle Eastern cohort of patients with IBD and examine possible relationships with EIMs.

Patients and Methods: We conducted a retrospective study involving all patients included in the King Abdulaziz University IBD information system registry between 2013 and 2018. Data on demographics, disease characteristics, and EIMs were extracted and analyzed using descriptive statistics: the standard Student’s t-test and chi-squared test. Logistic regression analysis was used to examine associations using STATA software version 11.2 (StataCorp, TX, USA).

Results: We reviewed the electronic medical files of 284 patients with confirmed IBD, of which 158 (55.6%) were females, the mean age was 27.8 (±15) years; 146 (51.4%) patients had CD and 138 (48.6%) UC. The overall incidence risk of EIMs was 138 (52.3%) over a mean duration of follow up of 7.3 (±3.9) years. The most common EIM was arthritis (33%), followed by aphthous ulcers (16%). Pyoderma gangrenosum occurred in 8% of patients and appeared to be specific for CD patients (p = 0.002), whereas Primary Sclerosing Cholangitis (PSC) was more specific for UC (p = 0.001). Certain EIMs appeared to occur together such as arthritis with PSC (p = 0.001). Regression analysis identified disease type (in favor of UC; odds ratio = 0.50, p = 0.03) and age at the time of diagnosis (odds ratio = 1.04, p = 0.001) as the only significant predictors of EIMs.

Conclusion: Our results demonstrate that more than half of IBD patients have at least one EIM. Contrary to what has often been reported, we found that EIMs occur more commonly in UC than CD. A multidisciplinary assessment is recommended as part of IBD management to improve overall health outcomes.