Inflammatory bowel disease in the older patient

Disease patterns in late-onset ulcerative colitis: Results from the IG-IBD "AGED study"

BACKGROUND

Late-onset UC represents an important issue for the near future, but its outcomes and relative therapeutic strategies are yet poorly studied.

AIM

To better define the natural history of late-onset ulcerative colitis.

METHODS

In a multicenter retrospective study, we investigated the disease presentation and course in the first 3 years in 1091 UC patients divided into 3 age-groups: diagnosis ≥65years, 40-64 years, and <40years. Disease patterns, medical and surgical therapies, and risk factors for disease outcomes were analyzed.

RESULTS

Chronic active or relapsing disease accounts for 44% of patients with late-onset UC. Across all age-groups, these disease patterns require 3-6 times more steroids than remitting disease, but immunomodulators and, to a lesser extent, biologics are less frequently prescribed in the elderly. Advanced age, concomitant diseases and related therapies were found to be inversely associated with the use of immunomodulators or biologics, but not with surgery.

CONCLUSIONS

The conclusion that late-onset UC follows a mild course may apply only to a subset of patients. an important percentage of elderly patients present with more aggressive disease. Since steroid use and surgery rates did not differ in this subgroup, lower use of immunosuppressive therapy and biologics may reflect concerns in prescribing these therapies in the elderly.

Inflammatory bowel disease cause-specific mortality: a primer for clinicians

BACKGROUND

Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC) is perceived to harbor significant morbidity but limited excess mortality, thought to be driven by colon cancer, compared with the general population. Recent studies suggest mortality rates seem higher than previously understood, and there are emerging threats to mortality. Clinicians must be up to date and able to clearly convey the causes of mortality to arm individual patients with information to meaningfully participate in decisions regarding IBD treatment and maintenance of health.

METHODS

A MEDLINE search was conducted to capture all relevant articles. Keyword search included: "inflammatory bowel disease," "Crohn's disease," "ulcerative colitis," and "mortality."

RESULTS

CD and UC have slightly different causes of mortality; however, malignancy and colorectal cancer-associated mortality remains controversial in IBD. CD mortality seems to be driven by gastrointestinal disease, infection, and respiratory diseases. UC mortality was primarily attributable to gastrointestinal disease and infection. Clostridium difficile infection is an emerging cause of mortality in IBD. UC and CD patients have a marked increase in risk of thromboembolic disease. With advances in medical and surgical interventions, the exploration of treatment-associated mortality must continue to be evaluated.

CONCLUSIONS

Clinicians should be aware that conventional causes of death such as malignancy do not seem to be as significant a burden as originally perceived. However, emerging threats such as infection including C. difficile are noteworthy. Although CD and UC share similar causes of death, there seems to be some differences in cause-specific mortality.

Natural history of elderly-onset inflammatory bowel disease: a population-based cohort study

Data on the natural history of elderly-onset inflammatory bowel disease (IBD) are scarce.

METHODS

In a French population-based cohort we identified 841 IBD patients >60 years of age at diagnosis from 1988 to 2006, including 367 Crohn's disease (CD) and 472 ulcerative colitis (UC).

RESULTS

Median age at diagnosis was similar for CD (70 years (IQR: 65-76)) and UC (69 years (64-74)). Median follow-up was 6 years (2-11) for both diseases. At diagnosis, in CD, pure colonic disease (65%) and inflammatory behaviour (78%) were the most frequent phenotype. At maximal follow-up digestive extension and complicated behaviour occurred in 8% and 9%, respectively. In UC, 29% of patients had proctitis, 45% left-sided and 26% extensive colitis without extension during follow-up in 84%. In CD cumulative probabilities of receiving corticosteroids (CSs), immunosuppressants (ISs) and anti tumor necrosis factor therapy were respectively 47%, 27% and 9% at 10 years. In UC cumulative probabilities of receiving CS and IS were 40% and 15%, respectively at 10 years. Cumulative probabilities of surgery at 1 year and 10 years were 18% and 32%, respectively in CD and 4% and 8%, respectively in UC. In CD complicated behaviour at diagnosis (HR: 2.6; 95% CI 1.5 to 4.6) was associated with an increased risk for surgery while CS was associated with a decreased risk (HR: 0.5; 0.3 to 0.8). In UC CS was associated with an increased risk (HR: 2.2; 1.1 to 4.6) for colectomy.

CONCLUSIONS

Clinical course is mild in elderly-onset IBD patients. This information would need to be taken into account by physicians when therapeutic strategies are established.

Systematic review with meta-analysis: inflammatory bowel disease in the elderly

BACKGROUND

Elderly patients represent an increasing proportion of the inflammatory bowel disease (IBD) population.

AIM

To critically review available data regarding the care of elderly IBD patients.

METHODS

Bibliographic searches (MEDLINE) up to June 2013.

RESULTS

Approximately 10-15% of cases of IBD are diagnosed in patients aged >60 years, and 10-30% of the IBD population are aged >60 years. In the elderly, IBD is easily confused with other more common diseases, mainly diverticular disease and ischaemic colitis. The clinical features of IBD in older patients are generally similar to those in younger patients. Crohn's disease (CD) in elderly patients is characterised by its predominantly colonic localisation and uncomplicated course. Proctitis and left-sided ulcerative colitis are more common in patients aged >60 years. Infections are associated with age and account for significant mortality in IBD patients. The treatment of IBD in the elderly is generally similar. However, the therapeutic approach in the elderly should be 'start low-go slow'. The benefit of thiopurines in older CD patients remains debatable. Although the indications for anti-tumour necrosis factors in the elderly are generally similar to those for younger patients, lower response and higher adverse events have been reported in the elderly. Surgery in elderly patients does not generally differ. Ileal pouch-anal anastomosis can be successful, provided the patient retains good anal sphincter function.

CONCLUSIONS

Management of the older IBD patient differs from that of younger patients; therefore, conventional practice algorithms may have to be modified to account for advanced age.

Prognosis following emergency surgery for ulcerative colitis in elderly patients

Purpose

Since 2000, the incidence of ulcerative colitis (UC) in patients over 60 years old has been rapidly increasing. We reviewed our surgical experience of elderly patients with UC treated at our hospital.

Methods

Patients aged 60 years or older at the time of surgery were defined as “elderly”. The medical records of all elderly patients who underwent surgery for UC during a 26-year period were retrospectively analyzed.

Results

The prognosis of elderly patients who underwent emergency surgery was extremely poor: 8 (26.7 %) of 30 such patients died within 30 postoperative days (PODs), whereas only 1 (0.88 %) of 114 who underwent elective surgery died within 30 PODs. Respiratory tract infection and sepsis resulting from methicillin-resistant Staphylococcus aureus or mycotic infection were the most common causes of death after emergency surgery.

Conclusion

The prognosis of elderly UC patients undergoing emergency surgery is very poor; thus, physicians and surgeons should collaborate to treat severe and fulminant disease, to optimize the timing of surgery. Early decisions about emergency surgery for UC will reduce postoperative mortality, especially in elderly patients.

Comparison of demographic and clinical characteristics of patients with early vs. adult vs. late onset ulcerative colitis

BACKGROUND & AIMS

There is limited data comparing influence of age on the presentation, clinical course, and therapeutic response of patients with ulcerative colitis. We aimed to compare the demographic and clinical characteristics of patients diagnosed with UC in older age vs. adulthood vs. early age.

METHODS

Five-hundred sixty one patients with UC seen at our center from 1995 to 2011 were categorized into early onset (EO), adult onset (AO) and late onset (LO) due to age at date of initial diagnosis. Patients diagnosed younger than age 17 were defined as EO, while those diagnosed between 17 and 60 were defined as AO and older than age 60 as LO. All patients were analyzed for demographic and clinical characteristics.

RESULTS

There was a male predominancy among LO patients (50% vs. 57.7% vs. 78.6%, p=0.004). Patients with EO UC were more likely to be non-smokers (p<0.001), and had higher family history of UC (p=0.02). Patients with EO UC had more steroid use (p=0.03), total colectomy (p=0.04), presence of chronic active disease (p=0.04) rates when compared with AO and LO groups. Patients in EO group had higher overall probability of surgery in 1, 5 and 10 years, when compared with patients in LO group (p=0.02), but it wasn't different between EO and AO groups (p=0.09).

CONCLUSIONS

Our study showed that clinical course of UC was more aggressive in younger ages. Also the difference between the demographic characteristics suggests that different age groups have different risk factors for the disease development.

Old-age inflammatory bowel disease onset: A different problem?

Inflammatory bowel disease (IBD) in patients aged > 60 accounts for 10%-15% of cases of the disease. Diganostic methods are the same as for other age groups. Care has to be taken to distinguish an IBD colitis from other forms of colitis that can mimick clinically, endoscopically and even histologically the IBD entity. The clinical pattern in ulcerative colitis (UC) is proctitis and left-sided UC, while granulomatous colitis with an inflammatory pattern is more common in Crohn’s disease (CD). The treatment options are those used in younger patients, but a series of considerations related to potential pharmacological interactions and side effects of the drugs must be taken into account. The safety profile of conventional immunomodulators and biological therapy is acceptable but more data are required on the safety of use of these drugs in the elderly population. Biological therapy has risen question on the possibility of increased side effects, however this needs to be confirmed. Adherence to performing all the test prior to biologic treatment administration is very important. The overall response to treatment is similar in the different patient age groups but elderly patients have fewer recurrences. The number of hospitalizations in patients > 65 years is greater than in younger group, accounting for 25% of all admissions for IBD. Mortality is similar in UC and slightly higher in CD, but significantly increased in hospitalized patients. Failure of medical treatment continues to be the most common indication for surgery in patients aged > 60 years. Age is not considered a contraindication for performing restorative proctocolectomy with an ileal pouch-anal anastomosis. However, incontinence evaluation should be taken into account an individualized options should be considered

Biologic agent use varies inversely with age at diagnosis in Crohn's disease

BACKGROUND

For patients with Crohn's disease, age at onset is known to influence the clinical course of the illness.

AIMS

The aim of this study is to seek an association between age at onset of Crohn's disease and use of biologic agents for its treatment.

METHODS

We reviewed the medical records of 127 veteran patients with Crohn's disease treated at our hospital, and compared differences in age at disease onset between patients who had received biologics and those who had not.

RESULTS

The mean age of our patients was 54.9 ± 15.4 years, and 34% were currently receiving or had previously received treatment with a biologic agent. For those with biologic use, average age at time of diagnosis of Crohn's disease was 32.3 ± 12.2 years, compared with 43.7 ± 16.3 years for those who had not received biologics (P = 0.005). This relationship remained significant even after controlling for disease severity. The frequency of use of biologic agents varied inversely with age at diagnosis. For patients diagnosed before age 21 years, 55.5% had used biologics, whereas no patient >70 years of age at time of diagnosis had used biologics. We found no significant correlation between biologic use and duration of disease, smoking or ethnicity. Perianal disease and concomitant arthritis were both significantly associated with use of biologics.

CONCLUSIONS

In our veteran patients with Crohn's disease, frequency of treatment with a biologic agent varied inversely with age at disease onset.

Patients with late-adult-onset ulcerative colitis have better outcomes than those with early onset disease

BACKGROUND & AIMS

The influence of age on the presentation, clinical course, and therapeutic response of patients with adult-onset ulcerative colitis (UC) is understudied. Given potential age-related differences in risk factors and immune function, we sought to determine if disease behavior or clinical outcomes differed between patients diagnosed with UC in later versus earlier stages of adulthood.

METHODS

We performed a retrospective cohort study of 295 patients with UC seen at a tertiary care center from 2001 to 2008. Adult subjects newly diagnosed with UC between the ages of 18 and 30 years were defined as early onset, those newly diagnosed at age 50 or older were defined as late onset. The 2 groups were analyzed for differences in medication use and clinical end points, including disease extent, severity at the time of diagnosis, and steroid-free clinical remission at 1 year after disease onset.

RESULTS

Disease extent and symptom severity were similar between groups at the time of diagnosis. One year after diagnosis, more patients in the late-onset group achieved steroid-free clinical remission (64% vs 49%; P = .01). Among those who required systemic steroid therapy, more late-onset patients achieved steroid-free remission by 1 year (50% vs 32%; P = .01). Former smoking status was a more common risk factor in the late-onset cohort (P < .001), whereas more early onset patients had a positive family history (P = .008).

CONCLUSIONS

Patients with early and late-adult-onset UC have similar initial clinical presentations, but differ in disease risk factors. Late-onset patients have better responses to therapy 1 year after diagnosis.

Retrospective analysis of old-age colitis in the Dutch inflammatory bowel disease population

AIM: To describe the characteristics of Dutch patients with chronic inflammatory bowel disease (IBD) first diagnosed above 60 years of age-a disease also known as old-age colitis (OAC) and to highlight a condition that has a similar appearance to IBD, namely segmental colitis associated with diverticular disease (SCAD).

METHODS: A retrospective longitudinal survey of patient demographic and clinical characteristics, disease characteristics, diagnostic methods, management and course of disease was performed. The median follow-up period was 10 years.

RESULTS: Of a total of 1100 IBD patients attending the Department of Gastroenterology, 59 (5%) [median age 82 years (range 64-101); 25 male (42%)] were identified. These patients were diagnosed with ulcerative colitis (n = 37, 61%), Crohn’s disease (n = 14, 24%), and indeterminate colitis (n = 8, 15%). Remission was induced in 40 (68%) patients within a median interval of 6 mo (range 1-21) and immunosuppressive therapy was well tolerated. Histological evaluation based on many biopsy samples and the course of the disease led to other diagnosis, namely SCAD instead of IBD in five (8%) patients.

CONCLUSION: OAC is not an infrequent problem for the gastroenterologist, and should be considered in the evaluation of older patients with clinical features suggestive of IBD. Extra awareness and extensive biopsy sampling are required in order to avoid an erroneous diagnosis purely based on histological mimicry of changes seen in SCAD, when diagnosing IBD in the presence of diverticulosis coli.

Age at onset of inflammatory bowel disease and the risk of surgery for non-neoplastic bowel disease

BACKGROUND

There is conflicting data regarding the response to medical and surgical therapy for inflammatory bowel disease with respect to age at disease onset.

AIM

To determine if the age at onset of Crohn's disease and ulcerative colitis is a risk factor for surgery for non-neoplastic bowel disease.

METHODS

This was a case-control study of patients evaluated between 1998 and 2001. Cases had undergone an initial operation for bowel disease. Controls were matched 1:1 for gender, disease subtype, date of first visit (+/-2 years), time from diagnosis prior to first visit (+/-3 years) and duration of follow-up. Association with age, disease extent, smoking history, medication use and co-morbidities vs. case/control status was assessed using multiple variable conditional logistic regression to estimate the odds ratio (OR) and 95% confidence intervals (CI) for undergoing surgery.

RESULTS

Among 132 Crohn's patients, older patients had lower odds for surgery (OR per 5 years, 0.86; 95% CI: 0.75-0.98). The rate of surgery for non-neoplastic bowel disease was not significantly associated with disease distribution, co-morbidities or cigarette smoking. Among 234 ulcerative colitis patients, the rate of surgery was unrelated to age, disease extent, co-morbidities or cigarette smoking,

CONCLUSIONS

For Crohn's disease, but not ulcerative colitis, the risk of surgery for non-neoplastic bowel disease decreases with increasing age at diagnosis, irrespective of disease distribution and history of cigarette smoking.

Risk factors and indications for colectomy in ulcerative colitis patients are different according to patient's clinical background

PURPOSE

Despite progress in medical treatment for ulcerative colitis, a considerable fraction of ulcerative colitis patients undergo colectomy. We analyzed the clinical variables of ulcerative colitis patients and determined the risk factors and indications for colectomy.

METHODS

The clinical records of 981 consecutive Japanese patients with ulcerative colitis were reviewed both retrospectively and prospectively.

RESULTS

Of 981 patients with ulcerative colitis, 85 patients underwent colectomy. Multivariate analysis indicated that male gender (risk ratio, 2.16; 95 percent confidence interval, 1.37-3.42), onset year during and after 2000 (risk ratio, 2.85; 95 percent confidence interval, 1.31-6.22), severe disease activity (risk ratio, 2; 95 percent confidence interval, 1.15-3.48), corticosteroid resistance (risk ratio, 7.05; 95 percent confidence interval, 4.29-11.59), and complications because of corticosteroid administration (risk ratio, 3.55; 95 percent confidence interval, 2.08-6.06) were significant risk factors for colectomy. In patients with disease duration of more than five years, only corticosteroid resistance and complications because of corticosteroid were significant risk factors for colectomy. When we stratified indications for colectomy for the 85 cases via patient disease duration, massive hemorrhage was a relatively frequent cause of colectomy in patients with a disease duration of less than five years (P = 0.091). On the other hand, colon dysplasia or cancer was a major cause for colectomy in patients with a disease duration of more than ten years (P = 0.0001).

CONCLUSIONS

In ulcerative colitis patients, the risk factors and indications for colectomy were different according to the patient's clinical background. Our findings may help to predict patients with ulcerative colitis who have a high risk for colectomy.

Increasing incidences of inflammatory bowel disease and decreasing surgery rates in Copenhagen City and County, 2003-2005: a population-based study from the Danish Crohn colitis database

OBJECTIVES

A continuous increase in the incidence of inflammatory bowel disease (IBD), Crohn's disease (CD), ulcerative colitis (UC), and indeterminate colitis (IC) has been suggested. Since Denmark provides excellent conditions for epidemiological research, we aimed to describe contemporary IBD incidence rates and patient characteristics in Copenhagen County and City.

METHODS

All patients diagnosed with IBD during 2003-2005 were followed prospectively. Demographic and clinical characteristics, such as disease extent, extraintestinal manifestations, smoking habits, medical treatment, surgical interventions, cancer, and death, were registered.

RESULTS

Five-hundred sixty-two patients were diagnosed with IBD, resulting in mean annual incidences of 8.6/10(5) for CD, 13.4/10(5) for UC, and 1.1/10(5) for IC. Time from onset to diagnosis was 8.3 months in CD and 4.5 months in UC patients. A family history of IBD, smoking, and extraintestinal manifestations was significantly more common in CD than in UC patients. Only 0.6% of UC patients had primary sclerosing cholangitis. In CD, old age at diagnosis was related to pure colonic disease, whereas children significantly more often had proximal and extensive involvement. Twelve percent of CD patients and 6% of UC patients underwent surgery during the year of diagnosis, significantly less than earlier reported.

CONCLUSIONS

The incidence of IBD in Copenhagen increased noticeably during the last decades. Time from onset of symptoms until diagnosis decreased markedly, extent of CD was related to age at diagnosis, and the risk of surgery was low in UC.

Crohn's disease in the over-60 age group: a population based study

OBJECTIVES

Late-onset Crohn's disease (CD) may show a distinctive pattern of expression. The aim of our study was to describe the incidence or presentation of CD in the elderly and compare the outcomes in patients < 60 years or > or = 60 years at diagnosis.

METHODS

The study included a population based inception cohort of all incident CD cases diagnosed in Brittany (France) between 1994 and 1997. Sixty-three patients were > or = 60 years and 201 were < 60 years at diagnosis. The physicians managing the patients used standardized questionnaires to collect the study data. The questionnaires on outcomes and treatments were completed in 2002.

RESULTS

In patients > or = 60 years, the annual incidence was 2.5 per 10 persons and clinical features were similar to those in younger patients, except for a higher rate of colon involvement. Among older patients, those with diverticula (29/63, 46%) were more likely to have granulomas (58% vs 33% of patients without diverticula, P < 0.04), but the diagnosis of CD was confirmed by lesions remote from the diverticula in most cases (23/29). Early resection rates were not higher in older patients, who were less likely to require immunosuppressants or re-admission for CD flares, as compared to younger patients. Five year mortality in older patients was 16% but was unrelated to CD.

CONCLUSIONS

In Brittany, the age specific incidence, clinical features, and prognosis of CD among the elderly are comparable to those in younger individuals. Colon involvement is more common. Concomitant diverticular disease is common and should prompt a search for CD lesions at other sites to confirm the diagnosis. Older patients are less likely to require immunosuppressants or admission for flares.

Inflammatory bowel disease in the elderly

Approximately 15% of all patients with IBD first develop symptoms after age 65. As the number of elderly in the population continues to grow, clinicians should expect to see a greater number of elderly IBD patients. In general, the presenting features of IBD are similar to those encountered in younger patients, but the broad differential diagnosis of colitis in the elderly can make definitive diagnosis more challenging. Although most therapies for IBD have not been studied specifically in the elderly, as a general rule, medical and surgical treatment options are the same regardless of age. Osteoporosis, a condition generally associated with aging, should be managed aggressively in patients with IBD because many older persons already have a substantial baseline risk for accelerated bone loss.

Diverticular colitis: diagnosis and management

Diverticular colitis is a recently recognized nosological entity in which a chronic focal mucosal sigmoid colitis occurs in association with diverticulosis. It usually presents with rectal bleeding and may be difficult to distinguish clinically, endoscopically and pathologically from other segmental colitides including ulcerative, Crohn's, ischaemic, infective and NSAID-induced colitis as well as diverticulitis. Uncontrolled data suggests that most patients respond satisfactorily to treatment with a high fibre diet, antibiotics and/or aminosalicylates, but a minority with persistent or recurrent symptoms require sigmoid resection. This paper reviews the literature on diverticular colitis and concludes with an algorithm suggesting the optimal management of patients who present with rectal bleeding in association with segmental sigmoid colitis and diverticulosis.

Gender-related differences in the clinical course of Crohn's disease

OBJECTIVE

The aim of this study was to analyze the clinical and epidemiological differences between women and men affected by Crohn's disease.

METHODS

The clinical course of 275 female Crohn's disease patients was compared with that of 266 male patients.

RESULTS

Mean age at onset of symptoms and at diagnosis was 25.7 yr versus 27.7 yr and 28.8 yr versus 30.7 yr in women and men, respectively. Mean lag-time between onset of symptoms and establishment of the diagnosis were similar in both groups, without differences in presenting symptoms and initial localization of lesions. In women, however, some extraintestinal manifestations of Crohn's disease were found to occur more often. The percentage of patients who underwent an abdominal operation was quite similar in both groups (81% vs 77%). Mean lag-time between onset of symptoms and first bowel resection was not different. However, the lag-time between bowel resection and recurrence of disease was significantly shorter in women than in men (respectively, 4.8 yr vs 6.5 yr, p = 0.04), particularly regarding primary ileocecal resections. Overall, ileocecal resections were significantly more frequently performed in female than male patients (44% and 32%, respectively, p = 0.004). Female patients were also found to have significantly more often relatives in the first or second degree affected by Crohn's disease than male patients (15% vs 8.3%, p = 0.02).

CONCLUSIONS

Extraintestinal manifestations occur more often in female Crohn's disease patients than in male patients. Furthermore, an ileocecal resection, which is accompanied by an earlier recurrence, is more often performed in female than in male patients. Female patients have more often relatives with the same disease.

Crohn's colitis-like changes in sigmoid diverticulitis specimens is usually an idiosyncratic inflammatory response to the diverticulosis rather than Crohn's colitis

The clinical outcome and optimum classification of patients who have sigmoid resection specimens that show the histologic features of Crohn's disease (CD) and diverticulitis is not well defined. Historically, these patients were considered to have coexistent diseases, but recent studies have suggested that the CD-like changes are part of the inflammatory reaction of the diverticulitis. Sorting out these issues has been complicated by the lack of distinction between patients with and without CD in other regions of the bowel, short clinical follow-up periods, and small numbers of patients. We report on the clinical outcome and histology of 29 patients who had sigmoid resection specimens with diverticulitis and CD-like changes. Of the 25 patients who had no prior or concurrent CD at the time of surgery, 23 remained free of CD during the follow-up period (median, 6.0 yrs) and two developed CD in other regions of the bowel. All four patients with CD prior to their sigmoid resection continued to have active CD postoperatively. There were no histologic features of the sigmoid resection specimens that could be associated with the outcome of the patient. These results suggest that CD-like changes within the sigmoid resection specimen are an idiosyncratic inflammatory response to the diverticulosis rather than coexistent CD in the overwhelming majority of patients who do not have prior or concurrent CD at the time of sigmoid resection. Pathologists should be wary about making the diagnosis of sigmoid CD in the context of diverticulitis unless there is CD in other parts of the bowel.

Abdominal surgery in the older Crohn's population

BACKGROUND

The surgical literature perceives that the elderly cohort of Crohn's patients may have increased risk with surgery.

METHODS

A retrospective review and prospective database analysis of all patients with histologically proven Crohn' s disease who had a laparotomy at a single Sydney teaching hospital were performed. The last laparotomy of each patient was included in the analysis for morbidity and mortality to assess whether an older cohort was at an increased risk.

RESULTS

A total of 156 patients had 298 laparotomies for histopathologically proven Crohn's disease. The frequency distribution of age at last laparotomy was bimodal, and the statistically determined cut-off age between younger and older cohorts was 55 years. Thirty-three patients were older than 55 years. There was no difference in duration of symptoms before first diagnosis (older, 17 months vs younger, 25 months), previous number of Crohn's operations (42.4 vs 39.8%), or duration of known Crohn's disease. Isolated large bowel disease was more common in the elderly cohort (42.4 vs 18.7%, chi2 = 8.09, P < 0.01). Small bowel and ileocaecal resections were more common in the younger cohort (72.4 vs 51.6%, chi2 = 5.19, P < 0.025). There was one death in each cohort (overall mortality 1.3%) and anastomotic leak rates (defined as the number of leaks per number of patients with anastomoses), were 4.3% (older) vs 5.3% (younger) despite frank sepsis present in 21.2% of all subjects at the time of surgery. The older group had more cardiac (18.2 vs 0.8%, P < 0.001) and respiratory complications (18.2 vs 2.4%; P = 0.0003) and a longer mean but not median postoperative hospital admission.

CONCLUSIONS

In conclusion, clinical features and presentation are similar in the older and younger Crohn's patients having a laparotomy. However, in the older patient there is a greater likelihood of large bowel disease, ileocaecal resection is done less commonly, there is a higher risk of minor cardiopulmonary postoperative complications, but with similar mortality and anastomotic leak rates to the younger patient.

Crohn's disease in the elderly: a comparison with young adults

We compare the clinicopathological features of 98 Crohn's disease (CD) patients with initial symptoms at 40 years of age or older (elderly; male n = 56, female n = 42) with those of 347 CD patients with onset of symptoms between the age of 16 and 40 years (young adults; male n = 166, female n = 181). The frequency of presenting symptoms, such as diarrhea, rectal blood loss, and weight loss were comparable in both groups, except for abdominal pain/cramps, which occurred somewhat less frequently in the elderly (59% vs. 71%, p < 0.05). The mean lag time between onset of symptoms and first visit to a general practitioner (GP) was considerably shorter in the elderly than in the young adults (0.2 years vs. 0.6 years, p < 0.001), as was the lag time between GP and referral to a specialist (0.6 years vs. 1.0 years, p < 0.07). Overall, this resulted in a significantly (p < 0.01) shorter time to establish the diagnosis in the elderly (1.8 years vs. 2.7 years). Crohn's disease as correct initial diagnosis was in the elderly less frequently observed than in the young adults (49% vs. 61%, p < 0.05), in contrast to diverticulitis (7.1% vs. 0%) and malignancy (6.1% vs. 0.9%), which were more frequently encountered as incorrect preliminary diagnosis in the elderly (both p < 0.005). The percentage of patients who underwent an abdominal operation was similar in both groups (83% vs. 77%), but the diagnosis CD was in the elderly more frequently established at first operation than in young adults (25% and 12%, p < 0.005). The elderly were found to undergo a bowel operation or resection earlier after onset of symptoms. The development of recurrence after bowel resection, although occurring in a lower percentage of patients, was significantly shorter than in the young adults (3.7 years vs. 5.8 years, p < 0.02). Arthritic extraintestinal manifestations were equally frequent in both groups, but elderly patients had significantly less relatives in the first or second degree affected by CD (3.1% vs. 12%, p < 0.02). We conclude that the diagnosis Crohn's disease is more readily established in elderly patients. Moreover, these patients less frequently have abdominal pain/cramps as a presenting symptom, a shorter time interval between onset of symptoms and first resection, and subsequent recurrence of the disease. In addition, elderly CD patients have less relatives affected by the same disease. Thus, CD in the elderly appears to be characterized by a more rapid development.

Inflammatory bowel disease in older patients

The onset of UC and CD may occur later in life. Although making the diagnosis of IBD in the elderly can be challenging, the clinical course, natural history, and response to treatment are similar for older and younger patients. In fact, both UC and CD tend to be less extensive in older patients, a feature that may contribute to the overall favorable prognosis for elderly patients with IBD. Overall mortality rates for both UC and CD appear to be similar to that of the general population except for those few patients that present with severe initial disease. Typical features of IBD in the elderly are summarized in Table 3. The differential diagnosis of IBD in the elderly includes infectious causes of enterocolitis, ischemic colitis, and diverticular disease as well as several other mimics of IBD. Awareness of the possibility of late-onset disease and the unique manifestations of disease in the elderly contributes to accurate diagnosis and timely treatment.

Complicated Crohn's disease in the over 70 age group

Crohn's disease is rare and is infrequently reported in the over 70 age group. Such patients often present urgently with acute complications of Crohn's disease. Seven patients with Crohn's disease all presented with complications. The diagnosis was initially unsuspected in these patients, and in 3 cases coexisting diverticular disease led to a delay in diagnosis. Three patients with ileocolic disease presented with peritonitis or bowel obstruction. In a further 2 patients a diagnosis of Crohn's disease was not made until after histological examination of resected tissue. It is likely that, as the population ages, more elderly patients will present with complicated Crohn's disease. Surgeons should be aware of this possibility to allow appropriate management of this condition, which generally has a favourable prognosis in this age group.

Clinical course of Crohn's disease in older patients. A retrospective study

The authors retrospectively reviewed the records of 50 patients whose initial diagnosis of Crohn's disease was made after the age of 50 years on the basis of strict histopathologic criteria. Progress of the 32 women and 18 men with a median age of 60 years (range, 50 to 78 years) was followed for a median of 95.5 months (range, 81.1 to 236.6 months). The most common presenting signs and symptoms were abdominal pain (82 percent), diarrhea (70 percent), weight loss (56 percent), bleeding from the gastrointestinal tract (26 percent), abdominal mass (16 percent), and fistula (14 percent). Initial operations performed were ileocolic resection (38 percent), proctocolectomy (16 percent), small bowel resection (10 percent), colostomy (2 percent), and a variety of segmental resections of the colon (34 percent). The overall recurrence rate of disease in patients in whom all obvious disease was resected, based on distribution of disease, was 80 percent (ileocolitis), 38 percent (ileitis), and 35 percent (colitis). Crohn's disease more often affects the distal gastrointestinal tract in older age groups. After resection, however, the clinical course is similar to that of the younger population. The high recurrence rate of Crohn's colitis is probably a result of the large number of initial segmental resections.

Evolution of the concept of proctosigmoiditis: clinical observation

Proctosigmoiditis, or distal colon ulcerative colitis, has been recognized as a clinical entity for over 50 years and considerable information has emerged from the study of the clinical course of patients with distal colon ulcerative colitis who are followed for a period of years. For most patients the condition is benign, although periods of exacerbation can occur between remissions, characterized by rectal bleeding. However, extension of the disease, development of cancer, and the requirement of surgery are all relatively unusual. It has recently been recognized that there are many other causes of proctitis than the idiopathic form, and this has raised important questions in differential diagnosis, particularly in the proctitis occurring in homosexual males. Proctitis, proctosigmoiditis, and distal colon ulceratice colitis and not Crohn's disease; conversely perianal fistulae and abscesses are rare in distal colon ulcerative colitis. Treatment with various forms of topical agents has often been satisfactory.

Crohn's disease of late onset in Blackpool

Fifty five (26%) of two hundred and fifteen patients presenting with Crohn's disease in the Blackpool area over a 15 year period (1969-1983) were over 60 years of age. There were twice as many women as men (38:17). In 60% disease was limited to the large bowel compared to only 29% in the younger age group. Many of these were women with mild distal colitis. Twenty one patients required operative management. In general, the prognosis was good in colonic disease, but in small bowel and ileocolonic disease the necessity for early operative intervention was potentially fatal. Delayed diagnosis, poor nutritional state and associated disease were relevant adverse factors. The majority of patients at the time of review were well and, where necessary, were coping satisfactorily with a stoma.

Indications for and results of operation in inflammatory bowel disease

Of 363 patients with inflammatory bowel disease presenting between 1972 and 1983, 166 required definitive operation. A classification by histological type distinguishes Crohn's disease (CD) from ulcerative colitis (UC) and indeterminate inflammatory bowel disease. CD is divided into predominantly ileal disease (81), total or subtotal colonic disease (74) and distal disease (22), whilst UC is classified into colonic (95) or distal disease (63). Most patients with ileal disease required operation for chronic persistent symptoms. In patients with total colonic involvement a greater proportion of patients with CD than those with UC came to surgery. Very few patients with distal disease required surgery. After resection for ileal disease there was a low incidence of anastomotic leakage (3%) and no operative mortality. There was an overall operative mortality of 8% after colonic resection. This was much lower in the non-urgent cases but rose to 12% in urgent cases.

Microvascular studies in non-specific inflammatory bowel disease

The microvasculature was investigated in the normal bowel and in ulcerative colitis and Crohn's disease. Tissue samples from postoperative colectomy specimens in which the microvasculature had been perfused with barium sulphate suspension were examined. Microradiography was used to study intramural vascular pattern which was abnormal in both disease states. A recently described radiograph fluorescence system was used to estimate barium concentration and hence microvascular volume in tissue samples. Highly significant negative correlations were demonstrated between barium concentration and age in normal bowel (n = 44; r = -0.669; p less than 0.001) and in segmental Crohn's disease (n = 11; r = -0.698; p = 0.017). Barium concentration was significantly reduced (p less than 0.05) in segmental Crohn's disease (n = 11) but remained normal in diffuse Crohn's disease of the colon (n = 6) and ulcerative colitis (n = 7). It is postulated that ischaemia may be a factor in the pathogenesis of segmental Crohn's disease in older patients.

Crohn's disease in the elderly

The natural history of Crohn's disease in 47 patients, 60 years of age or older at the time of diagnosis has been defined, and their clinical management and long term prognosis reviewed. Distal colonic involvement is common in this group while extensive colonic and diffuse small bowel disease is rare. Distal colonic involvement usually carries a good prognosis except for those few patients who present with perforation which accounts for most of the disease related mortality. The pattern of distal ileal disease is similar to that observed in the younger patients except for the acute nature of symptoms at first presentation, and the low recurrence rates after initial surgical resection.