Mucocutaneous manifestations in inflammatory bowel disease

Clinical course and prognostic disparities of pyoderma gangrenosum based on underlying disease: A long-term comparative study in 124 patients

BACKGROUND AND OBJECTIVES

Pyoderma gangrenosum (PG) is associated with inflammatory bowel disease (IBD), autoimmune and connective tissue diseases, and hematologic malignancies. The impact of these underlying diseases on the clinical course and outcomes of PG remains poorly understood. This study investigates the influence of systemic disease associations on the progression, treatment response, and prognosis of PG.

PATIENTS AND METHODS

This study followed a cohort of 124 patients diagnosed with PG at a multidisciplinary referral institution between 2007 and 2024. Patients were stratified into four groups: IBD-associated PG (n = 52), autoimmune and connective tissue disease-associated PG (n = 24), hematologic malignancy-associated PG (n = 15), and idiopathic PG (n = 33). Outcomes, including remission and relapse rates, were analyzed using Kaplan-Meier survival curves and Cox proportional hazards models.

RESULTS

IBD-associated PG had the most favorable outcomes, with 75% of patients achieving remission at 12 months (M12) (Hazard Ratio [HR]: 2.56; 95% Confidence Interval [95%CI]: 1.49-4.35). Autoimmune and connective tissue disease-associated PG was the most treatment-refractory, with only 8.3% achieving remission at M12 (HR: 0.21; 95% CI: 0.10-0.50). Relapse occurred in 26.1% of patients, with no significant difference across the groups (p = 0.8). Bullous PG, predominantly linked to hematologic malignancies, exhibited accelerated healing but also a high rate of malignant transformations near PG onset.

CONCLUSIONS

IBD-associated PG followed a more favorable clinical course compared to autoimmune and connective tissue diseases or hematologic conditions, highlighting the importance of tailored treatment approaches based on underlying disease associations.

The causal relationship between inflammatory bowel diseases and erythema nodosum: a bidirectional two-sample mendelian randomization study

BACKGROUND

Individuals with inflammatory bowel disease (IBD) exhibit a heightened likelihood of developing erythema nodosum (EN), but the presence of causal link is unknown. The purpose of the present research was to investigate this connection using a bidirectional two-sample Mendelian randomization (MR) analysis.

METHODS

Summarized statistics for EN were sourced from the FinnGen consortium of European ancestry. The International Inflammatory Bowel Disease Genetic Consortium (IBDGC) was used to extract summary data for IBD. The inverse variance weighted (IVW) technique was the major method used to determine the causative link between them.

RESULTS

The study evaluated the reciprocal causal link between IBD and EN. The IVW technique confirmed a positive causal link between IBD and EN (OR = 1.237, 95% CI: 1.109-1.37, p = 1.43 × 10- 8), as well as a strong causality connection between Crohn's disease (CD) and EN (OR = 1.248, 95% CI: 1.156-1.348, p = 1.00 × 10- 4). Nevertheless, a causal connection between ulcerative colitis (UC) and EN could not be established by the data. The reverse MR research findings indicated that analysis indicated that an increase in EN risks decreased the likelihood of UC (OR = 0.927, 95% CI: 0.861-0.997, p = 0.041), but the causal association of EN to IBD and CD could not be established.

CONCLUSION

This investigation confirmed that IBD and CD had a causal connection with EN, whereas UC did not. In addition, EN may decrease the likelihood of UC. Further study must be performed to uncover the underlying pathophysiological mechanisms producing that connection.

A systematic review and meta-analysis of extra-intestinal manifestation of inflammatory bowel disease in the Eastern Mediterranean Region (EMRO) countries

Background

Inflammatory bowel disease which is subgrouped mainly to ulcerative colitis and Crohn's disease is thought to be a multi-organ disease. Most organs can be involved in the disease course in addition to gastrointestinal tract involvement. In this systematic review we aimed to assess the prevalence of these manifestations in Eastern Mediterranean Regional Office (EMRO) countries.

Method

The present systematic review and meta-analysis study was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guideline. Joanna Briggs Institute (JBI) Critical Appraisal Checklist was admired for the quality evaluation of the included studies. For determining the heterogeneity, we used Cochran test and I2 statistics.

Result

Finally, 12 studies were included in our study. Based on the results of our study the prevalence of arthritis in ulcerative colitis and Crohn's disease patients was 7.1% (95% CI: 2.6-18.2%) and 13.5% (95% CI: 2.6-47.3%), respectively. Prevalence of arthralgia in ulcerative colitis patients was 18.4% (95% CI: 14.3-23.3%). skin involvement prevalence was 9.9% (95% CI 4.7-19.6%) in inflammatory bowel disease (IBD) patients. ocular involvement prevalence was 7.2% (95% CI 17-25.8%) in IBD patients. PSC prevalence in ulcerative colitis and Crohn's disease patients was 3.5% (95% CI: 1.7-7.3%) and 2.7% (95% CI: 1.3-5.5%), respectively.

Conclusion

Based on the results of this study arthralgia and arthritis were the most common extra-intestinal manifestation of IBD followed by dermatologic and ocular involvements. This extra-intestinal manifestation can challenge the patients' management and identifying their pattern is important during the disease course.

Prevalence of Extraintestinal Manifestations in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis

BACKGROUND

Inflammatory bowel disease (IBD) is a multisystem disease impacting various body systems including musculoskeletal, ocular, skin, hepatobiliary, pulmonary, cardiac, and haematological systems. The extraintestinal manifestations of IBD are frequent, common in both ulcerative colitis (UC) and Crohn's disease (CD), and impact the morbidity and mortality of patients.

METHODS

The Embase, Embase classic, and PubMed databases were searched between January 1979 and December 2021. A random effects model was performed to find the pooled prevalence of joint, ocular, and skin extraintestinal manifestations of UC and CD.

RESULTS

Fifty-two studies were included that reported on 352 454 patients. The prevalence of at least 1 joint, ocular, or skin extraintestinal manifestation in all IBD, UC, and CD was 24%, 27%, and 35% respectively. The prevalence between UC and CD were similar for pyoderma gangrenosum and axial joint manifestations. Ocular manifestations were found to be more common in CD than in UC. Peripheral joint manifestations and erythema nodosum were found to be more common in CD than UC.

DISCUSSION

To our knowledge, this is the first meta-analysis that reports on the prevalence of at least 1 joint, ocular, or skin extraintestinal manifestation in IBD. Our results are largely consistent with figures and statements quoted in the literature. However, our findings are based on significantly larger cohort sizes. Thus, our results have the potential to better power studies and more accurately counsel patients.

Ulcerative colitis: Addressing the manifestations, the role of fecal microbiota transplantation as a novel treatment option and other therapeutic updates

The prevalence and incidence of Ulcerative Colitis (UC), a recurrent and remitting inflammatory condition, are rising. Any part of the colon may be affected, beginning with inflammation of the mucosa in the rectum and continuing proximally continuously. Bloody diarrhea, tenesmus, fecal urgency, and stomach pain are typical presenting symptoms. Many patients present with extraintestinal manifestations (EIMs) including musculoskeletal, ocular, renal, hepatobiliary, and dermatological presentation, among others. Most cases are treated with pharmacological therapy including mesalazine and glucocorticoids. Fecal microbiota transplantation (FMT) is a novel procedure that is increasingly being used to treat UC, however, its use yet remains controversial because of uncertain efficacy. FMT can lower gut permeability and consequently disease severity by boosting short-chain fatty acids production, helping in epithelial barrier integrity preservation. Upadacitinib (JAK Kinase inhibitor) is another newer treatment option, which is an FDA-approved drug that is being used to treat UC. This review article provides a comprehensive review of the EIMs of UC, the role of FMT along with various recent clinical trials pertaining to FMT as well as other diagnostic and therapeutic updates.

The Prevalence of Ocular Extra-Intestinal Manifestations in Adults Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

Patients with inflammatory bowel disease (IBD) have a greater frequency of ocular extra-intestinal manifestations (O-EIMs) than the general population, while Crohn's disease (CD) and ulcerative colitis (UC) have inconsistent prevalence, according to previous studies. This study aimed to examine the prevalence of O-EIMs in CD and UC, respectively. We systemically reviewed O-EIMs and IBD across several online databases. Inclusion criteria are as follows: (1) observational studies examining the association between O-EIMs and IBD, such as cross-sectional, case-control, or cohort studies; (2) human and adult individuals; and (3) with case and control groups consisting of patients with and without O-EIMs, respectively. Patients under the age of 18 or any study on pediatric IBD will be excluded. The prevalence of uveitis in adults was determined by 21 studies comprising 190,941 individuals with IBD, including 62,874 CD and 128,067 UC. The pooled analysis revealed significantly increased odds of uveitis in patients with CD than with UC (pooled odd ratio (OR) 1.603, 95% confidence interval 1.254-2.049). The subgroup analysis revealed that European populations had significantly higher odds of developing uveitis and episcleritis in patients with CD than UC (pooled OR 1.683 and 2.401, respectively). Although O-EIMs may be the prodrome of IBD, no consistent finding was obtained as a result of the high heterogeneity from the two included studies. This meta-analysis indicates the significantly increased odds of uveitis in adults with CD than those with UC. In subgroup analysis, European with CD seemed to have higher odds of uveitis and episcleritis than those with UC. Nonetheless, the link between O-EIMs and IBD remained unclear.

Mucocutaneous manifestations in patients with inflammatory bowel disease: a decade study from a Greek cohort

BACKGROUND

We sought to investigate the prevalence of mucocutaneous manifestations (MCM) and potential associations with clinical characteristics in Greek patients with IBD.

METHODS

This was a retrospective observational single-center study. Patients with IBD diagnosis attending a tertiary referral hospital in Heraklion, Crete, from January 2010 to January 2020 were included. Data were extracted with relevant medical information from the IBD registry. Standard statistical tests, descriptive statistics tests, chi-square, Pearson correlation and multivariate analysis tests were performed, using IBM SPSS Statistics 25.

RESULTS

A total of 806 IBD patients were included in the study: 463 (57.4%) males, 441 (54.7%) Crohn's Disease, 352 (43.7%) ulcerative colitis and 13 (1.6%) IBD unclassified (IBD-U). Mean age was 50.67 ± 17.67 years, mean age of IBD diagnosis 36.67 ± 16.53 years and mean disease duration 13.65 ± 9.89 years. The prevalence of MCM was 171/806 (21.2%), 9.65% in ulcerative colitis and 30.84% in CD. The presence of MCM was significantly correlated with younger age of IBD diagnosis, longer IBD duration, CD diagnosis, inflammatory behavior and ileal or ileocolonic location of CD, extensive colitis in ulcerative colitis, intestinal manifestations (EIMs) and treatment with immunosuppressant or anti-TNFa. The development of MCM was independently associated with the presence of other EIMs odds ratio (OR), 4.03 [95% confidence interval (CI), 2.60-6.24; P < 0.001] and treatment with immunosuppressant (OR, 1.87; 95% CI, 01.14-3.07; P = 0.013) or anti-TNFa (OR = 2.47; 95% CI, 1.59-3.84; P < 0.01).

CONCLUSIONS

In our study, about one-fifth of IBD patients developed MCM that was more frequently present in CD than in ulcerative colitis.

Extra-Intestinal Manifestations of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is associated with extra-intestinal manifestations (EIMs) that tend to parallel intestinal activity and have a debilitating effect on the quality of life. EIMs primarily affect the joints, skin, and eyes with less frequent involvement of the liver, kidney, and pancreas. This article reviews the prevalence of musculoskeletal, dermatological, ocular, and other manifestations in IBD and their coalition with underlying intestinal inflammation. EIMs occurring independently of intestinal activity are managed by targeted therapies, categorical regimens, and specific treatments. On the other hand, EIMs paralleling the bowel activity are carefully monitored while the IBD is brought under control. Since the etiology of the disease is responsible for the development of the EIMs, the research scrutinizes the identified pathogenic mechanisms that tend to involve genetic susceptibility, aberrant self-recognition, and autoantibodies directed against organ-specific antigens shared by intestinal and extra-intestinal organs. This article also provides an overview of the epidemiology, clinical features, diagnostic modalities, and management of the EIMs associated with IBD.

Dermatological Manifestations in Inflammatory Bowel Diseases

Inflammatory bowel diseases (IBDs) may be associated with extra-intestinal manifestations. Among these, mucocutaneous manifestations are relatively frequent, often difficult to diagnose and treat, and may complicate the course of the underlying disease. In the present review, a summary of the most relevant literature on the dermatologic manifestations occurring in patients with inflammatory bowel diseases has been reviewed. The following dermatological manifestations associated with IBDs have been identified: (i) specific manifestations with the same histological features of the underlying IBD (occurring only in Crohn's disease); (ii) cutaneous disorders associated with IBDs (such as aphthous stomatitis, erythema nodosum, psoriasis, epidermolysis bullosa acquisita); (iii) reactive mucocutaneous manifestations of IBDs (such as pyoderma gangrenosum, Sweet's syndrome, bowel-associated dermatosis-arthritis syndrome, aseptic abscess ulcers, pyodermatitis-pyostomatitis vegetans, etc.); (iv) mucocutaneous conditions secondary to treatment (including injection site reactions, infusion reactions, paradoxical reactions, eczematous and psoriasis-like reactions, cutaneous infections, and cutaneous malignancies); (v) manifestations due to nutritional malabsorption (such as stomatitis, glossitis, angular cheilitis, pellagra, scurvy, purpura, acrodermatitis enteropathica, phrynoderma, seborrheic-type dermatitis, hair and nail abnormalities). An accurate dermatological examination is essential in all IBD patients, especially in candidates to biologic therapies, in whom drug-induced cutaneous reactions may assume marked clinical relevance.

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.

Pyoderma Gangrenosum in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Pyoderma gangrenosum (PG) is an uncommon but severe extra-intestinal manifestation (EIM) of inflammatory bowel disease (IBD). The incidence and risk factors for PG are disputed.

AIMS

To assess the incidence of PG and identify factors associated with PG in IBD patients.

METHODS

A search of electronic databases (Ovid and PubMed) was conducted between 1966 and 2019. Studies that calculated the incidence of PG in IBD patient cohorts were included. Patient demographics, IBD subtype, and EIM presence were recorded. A review of our institutional database of 1057 IBD patients was conducted. A multivariate regression model and meta-analysis were conducted to identify risk factors for PG. A random effects model was used to combine the data of included studies.

RESULTS

Fourteen studies were included in addition to 1057 IBD patients and 26 PG cases from the Louisville cohort. In total, there were 379 cases of PG in the cumulative cohort of 61,695 IBD patients. The PG incidence in individual studies ranged from 0.4 to 2.6%. In the institutional cohort, ocular EIMs and a permanent stoma were significant risk factors for PG. In the meta-analysis, PG was associated with female gender (RR = 1.328, 95% CI 1.161-1.520), Crohn's disease (RR = 1.193, 95% CI 1.001-1.422), erythema nodosum (RR = 9.281, 95% CI 6.081-14.164), and ocular EIM (RR = 4.55, 95% CI 3.04-6.81). There was study heterogeneity when assessing IBD subtype, ocular, and joint EIMs.

CONCLUSIONS

There are conflicting data on the incidence and risk factors for PG. This meta-analysis confirms an association between PG and female gender, Crohn's disease, erythema nodosum, and ocular EIM that have been described in smaller studies.

The development of extraintestinal manifestation and related risk factors in Crohn's patients

BACKGROUND

Crohn's disease (CD) primarily involves gastrointestinal tract; however, it can present with extraintestinal manifestations (EIMs), which leads to significant morbidity. Frequency of EIMs and associated risk factors vary due to genetic and environmental differences in studies.

AIM

To examine the frequency and risk factors associated with EIMs in CD.

METHOD

Patients with CD under follow-up from March 1986 to October 2011 were included in this study. Demographics, type of EIMs, autoimmune diseases, and clinical features of CD were recorded. Frequency of EIMs and associated risk factors were analyzed.

RESULTS

Three hundred thirty-six patients with CD were included in the study (mean follow-up duration 7.54 years). 55.4% (n: 186) were male and the mean age at diagnosis of CD was 30.6 years (range, 10.3-68.2 years). At least one EIM was detected in 47.3% and multiple EIMs in 22.9% of the cohort. Oral, joint, and skin involvements (32.4%, 24.7%, 9.2%, respectively) were the most common EIMs. Female gender (OR: 2.19, 95% CI: 1.34-3.58, p = 0.001), corticosteroid usage (OR: 2.32, 95% CI: 1.28-4.22, p = 0.007), and positive family history (OR: 5.61, 95% CI: 1.95-3.58, p = 0.001) were independent risk factors for EIM development. Colonic involvement (OR: 3.93, 95% CI: 1.59-9.68, p = 0.003), no surgical operation (OR: 2.31, 95% CI: 1.14-4.68, p = 0.020), and corticosteroid usage (OR: 2.85, 95% CI: 1.07-7.61, p = 0.037) were independent risk factors for multiple EIM development.

CONCLUSION

Although the immunological and clinical associations between EIMs and CD cannot be fully elucidated, identifying specific relationships of immune-mediated diseases will help to better understand CD pathogenesis.

Global Prevalence and Bidirectional Association Between Psoriasis and Inflammatory Bowel Disease-A Systematic Review and Meta-analysis

BACKGROUND AND AIMS

Epidemiological studies have established an association between psoriasis and inflammatory bowel disease [IBD], i.e. ulcerative colitis [UC] and Crohn's disease [CD], but results are inconsistent. The aim of this study was therefore to quantify the prevalences and association between IBD and psoriasis.

METHODS

PubMed, Web of Science, and EMBASE were searched from database inception through April 2018 for studies reporting data on psoriasis among patients with IBD and vice versa. Meta-analysis was performed to estimate, respectively, the prevalences and association between IBD and psoriasis. Data extraction was according to the PRISMA guideline, and quality assessment was made using the Newcastle-Ottawa Scale. The main outcomes were the proportion of psoriasis patients with IBD and vice versa, as well as the association (odds ratio [OR]) of IBD in psoriasis and psoriasis in IBD, respectively.

RESULTS

Based on quantitative analysis of 93 studies, the prevalence of psoriasis in CD and in UC was 3.6% (95% confidence interval [CI] 3.1%-4.6%) and 2.8% [95% CI 2.0%-3.8%] respectively. The prevalence of CD and UC was 0.7% [95% CI 0.2%-1.3%] and 0.5% [95% CI 0.3%-0.8%], respectively, among patients with psoriasis. Presence of CD or UC was significantly associated with psoriasis, with OR 2.0 [95% CI 1.4-2.9] and OR 1.5 [95% CI 1.2-2.0], respectively. Presence of psoriasis was significantly associated with CD: OR 2.2 [95% CI 1.6-3.1] and with UC: OR 1.6 [95% CI 1.3-2.0].

CONCLUSIONS

We found significant bidirectional associations between psoriasis and IBD, warranting increased awareness among clinicians in the diagnostic process, especially in children and adolescents with IBD. Last, this study showed an increased frequency of paradoxical psoriasis in patients treated with biologics.

Therapeutic Efficacy of the Combination Therapy of Corticosteroids and 5-Aminosalicylic Acid for Treatment of Pyoderma Gangrenosum with Ulcerative Colitis

Background:

Pyoderma gangrenosum (PG) in inflammatory bowel disease (IBD) is a rare cutaneous condition and its treatment remains controversial due to limited data.

Aims and Objectives:

The purpose of this study was to investigate the characteristics and treatment response to specific therapies of IBD-associated PG.

Methods:

In this retrospective study, we reviewed a series of cases of IBD-associated PG patients who presented at our institution, and collected clinical data, such as demographics, characteristics, subtype, and disease activity of IBD and specific therapies used and their treatment response.

Results:

In total, 42 cases were identified: 69% female and 92.9% with ulcerative colitis (UC). At PG diagnosis, 93% had active and 7% inactive IBD. PG ulcers occurred predominantly on the legs (33.3%); 14.3% had multiple lesions. In total, 20/39 UC patients received the combination therapy of systemic corticosteroids and 5-aminosalicylic acid (5-ASA) with a good response in 19 patients (95%). Seven patients received the monotherapy of 5-ASA with a response rate of 43%. Five patients were successfully treated with systemic corticosteroids alone. Other patients were treated with intravenous immunoglobulin, infliximab, or cyclophosphamide alone or in combination with corticosteroids and all showed a good response.

Conclusion:

Our study indicates the therapeutic efficacy of corticosteroids in combination with 5-ASA, which may be considered as the first-line therapy for UC-associated PG.

Metastatic vulvar Crohn's disease preceding intestinal manifestations: a case report and short review

Crohn's disease (CD) is a multi-systemic chronic granulomatous inflammatory disease with a constellation of extraintestinal manifestations affecting various organs, including the skin. Metastatic CD (MCD), defined as granulomatous lesions of the skin occurring at sites separate from the gastrointestinal (GI) tract in patients affected with CD, is the least common cutaneous manifestation, and it is occasionally the primary manifestation of the disease. It may precede any symptoms from the GI tract by months or even years, and it often remains undiagnosed. We present the case of a 42-year-old woman with a rare cutaneous manifestation of MCD involving the external genitalia. The cutaneous lesions of the mons pubis and vulva preceded GI manifestations of CD by 2 years. The patient was treated with azathioprine, oral steroids, and antibiotics. Reduction of the cutaneous nodules, discharge, and erythema was achieved, accompanied by relief of GI symptoms. Response to treatment was maintained during a follow-up of 6 months. In MCD, involvement of the external genitalia is exceedingly rare, with few documented cases in the literature. The integration of clinical information, microscopic findings, and exclusion of other cutaneous granulomatous processes is necessary in order to accurately diagnose this rare dermatologic entity and provide an opportunity for successful therapeutic intervention.

Diagnosis and treatment of dermatologic diseases in inflammatory bowel disease

PURPOSE OF REVIEW

Dermatologic manifestations in patients with inflammatory bowel disease (IBD) are increasingly recognized as related disorders, secondary to specific therapies used to treat IBD, or complications of IBD itself. These dermatologic manifestations can be difficult to manage.

RECENT FINDINGS

We summarize three categories of dermatologic manifestations in this review: extraintestinal cutaneous disorders, paradoxical manifestations to biologic therapies, and other drug-induced cutaneous manifestations. In particular, we provide current data surrounding clinical characteristics, epidemiology, and treatment modalities for individual cutaneous manifestations.

SUMMARY

Many extraintestinal cutaneous manifestations can be managed by optimized treatment of IBD itself, as shared treatment pathways exist. Paradoxical reactions to biologic agents may be driven by the individual biologic therapy. In these instances, if topical therapies or immunomodulators are not effective in treating the paradoxical cutaneous reaction, a change of class may be required. Nonmelanoma and melanoma skin cancers have been linked to specific therapies for IBD (including thiopurines and antitumor necrosis factor alpha agents, respectively). Therefore, optimizing preventive efforts towards skin cancer is warranted. Recognition of these cutaneous disorders by the practicing gastroenterologist is important, as is collaboration with dermatology for management of many cutaneous disorders.

Occurrence of skin manifestations in patients of the Swiss Inflammatory Bowel Disease Cohort Study

BACKGROUND/AIMS

Extraintestinal cutaneous manifestations of IBD represent a severe disease complication and an early and accurate treatment might positively influence the disease course. Using the patient collective of the Swiss IBD Cohort Study (SIBDCS), we analysed epidemiological as well as clinical factors being associated with the onset of pyoderma gangrenosum, erythema nodosum and aphthous ulcers in IBD patients.

METHODS

We included 3266 SIBDCs patients, 1840 with Crohn's disease (CD) and 1426 with ulcerative colitis (UC) or IBD unclassified (IBDU) and analysed the association of cutaneous manifestations with age, age at diagnosis time, type of disease, gender, family history, HLA-allotype, smoking, intestinal disease activity, therapy and other extraintestinal manifestations (EIM).

RESULTS

354 CD patients and 136 UC/IBDU patients presented with skin manifestations at any time during their disease course. In both, CD and UC, female gender and younger age at IBD diagnosis were significantly associated with extraintestinal skin manifestations. For CD, we also detected a positive family history as associated factor. As an indicator of more intensive intestinal disease activity, patients with cutaneous manifestations of IBD needed more frequently therapy with antibiotics, steroids, immunomodulators and anti-TNF. Multivariate analysis revealed female gender, younger age at diagnosis and presence of other extraintestinal manifestations as factors being associated with skin EIM in IBD patients and anti-TNF as well as immunomodulatory treatment in CD patients.

CONCLUSION

Our results suggest that young females with a positive family history of IBD might be at increased risk for the onset of skin manifestations and require a careful screening for such complications.

Prevalence of extraintestinal manifestations in Korean inflammatory bowel disease patients

Background

The prevalence of inflammatory bowel disease (IBD) in South Korea is increasing. Although extraintestinal manifestations (EIMs) are an important factor in the clinical outcomes of IBD patients, EIMs have not yet been investigated in Korea. Thus, we conducted a cross-sectional study to assess the prevalence of EIMs in Korean IBD patients.

Methods

The 2014 claims data from the National Health Insurance System (NHIS) of Korea were used. IBD patients were identified by codes for Crohn disease (CD) and ulcerative colitis (UC) in the NHIS registration system for rare or intractable diseases. International Classification of Diseases, Tenth Edition codes were used to identify EIM cases. To estimate the prevalence of EIMs in the general population of Korea, we used national sample data. Standardized prevalence ratios (SPRs) were calculated to compare the prevalence rates of EIMs among IBD patients to those among the general population of Korea.

Results

A total of 13,925 CD patients and 29,356 UC patients were identified. CD and UC patients were different in terms of demographics and utilization of medication. Among the 17 EIMs investigated, pyoderma gangrenosum, osteomalacia, Sweet syndrome, and scleritis were observed in very few patients. The SPRs were greater than 1 for all EIMs. Aphthous stomatitis, rheumatoid arthritis, and osteoporosis were highly prevalent in both CD and UC patients, but the SPRs of the EIMs were not high.

Conclusion

The study confirmed that EIMs are more prevalent among IBD patients than among the general population of Korea. The prevalence of EIMs in IBD patients suggests the need for greater attention and effort in clinical practice.

Cutaneous Morbidity Among Inflammatory Bowel Disease Patients: A Cohort Study

BACKGROUND AND AIMS

Patients with inflammatory bowel diseases are prone to cutaneous manifestations. The aim of this study was to investigate their prevalence, type and association to demographic and clinical factors.

METHODS

This was a cross-sectional study. Information relative to patients of a central Portuguese hospital with a definitive diagnosis of an inflammatory bowel disease, who were prospectively recruited, was collected.

RESULTS

The final cohort included 342 patients, 62% of whom had Crohn's disease and 38% had ulcerative colitis. Cutaneous extraintestinal manifestations were present in 44.4% of all patients; this prevalence was lower [14.9%] when excluding cutaneous manifestations secondary to nutrition deficiency or drugs. These skin lesions were classified as granulomatous [0.3%], reactive [4.4%], immunologically associated [10.5%] and secondary to nutritional deficiencies [6.4%] or to bowel-related therapy [29.5%]. Excluding those secondary to nutrition or drugs, cutaneous manifestations were significantly associated with females (odds ratio [OR] 3.210 [1.625-6.340], p = 0.001) and younger patients (OR 0.954 [0.924-0.985], p = 0.004). Additionally, their occurrence was related to patients up to 16 years (OR 13.875 [1.332-144.484], p = 0.028) among the Crohn's disease sub-cohort, whereas in the ulcerative colitis sub-cohort they were more likely to occur in patients with extensive colitis (OR 5.317 [1.552-18.214], p = 0.008).

CONCLUSIONS

Nearly half of the patients analysed had at least one cutaneous extraintestinal manifestation. The fact that certain lesions tend to be more common among patients with defined characteristics should alert the physicians and allow an early diagnosis and, when pertinent, a reference to dermatology.

CT and MRI of Rare Extraintestinal Manifestations of Inflammatory Bowel Disease in Children and Adolescents

Inflammatory bowel disease (IBD) is associated with a spectrum of extraintestinal manifestations (EIMs) affecting many organ systems. EIMs can occur in more than 40% of patients with IBD and are associated with significant morbidity. They occur at any time point in the course of disease, often during an active phase of bowel inflammation, but sometimes preceding bowel disease. Prompt recognition of EIMs enables timely and more effective therapy. Physicians who image patients with IBD should be aware of the myriad extraintestinal conditions that may be detected on imaging studies, both within and outside of the abdomen, as they may predate the diagnosis of IBD. Cross-sectional imaging of unusual conditions associated with IBD will be presented, including pathology in the hepatobiliary, pancreatic, genitourinary, musculoskeletal, mucocutaneous, vascular, neurologic, and pulmonary systems.

Pyoderma Gangrenosum among Patients with Inflammatory Bowel Disease: A Descriptive Cohort Study

BACKGROUND

Pyoderma gangrenosum (PG) is a severe extraintestinal manifestation of inflammatory bowel disease (IBD).

OBJECTIVE

To better characterize PG features and management among an IBD cohort.

METHODS

Subjects with PG were identified using a large database at a tertiary center. Patient demographics and clinical characteristics were summarized using descriptive statistics.

RESULTS

Eighty patients with an episode(s) of PG were identified, yielding an overall prevalence of 1.9%. Overall, 93% of patients with PG had some degree of colonic inflammation. Thirty-one (39%) patients required hospitalization for PG. Underlying bowel disease was active at the time of PG episode(s) in 52 (65%) patients. The PG location was variable, with the lower extremity being the most common. Most patients (71.3%) required multiple therapies to achieve PG healing.

CONCLUSIONS

We describe one of the largest case series of PG among patients with IBD. The variety of treatment strategies used highlights the lack of clear guidelines in managing this complex group of patients.

Extraintestinal manifestations of inflammatory bowel disease and intestinal tuberculosis: Frequency and relation with disease phenotype

BACKGROUND

Extraintestinal manifestations (EIMs) in inflammatory bowel disease (IBD) including ulcerative colitis (UC) and Crohn's disease (CD), as well as intestinal tuberculosis (ITB) from Asia, are underreported. We, therefore, describe the prevalence of EIMs in Indian IBD and ITB patients and study their relationship with disease extent and severity in IBD.

METHODS

This retrospective single-center study included all IBD and ITB patients evaluated from January 2005 to July 2012. Disease profile and frequencies of arthropathies (peripheral and central) and ocular (episcleritis, iritis/uveitis), oral (aphthous stomatitis), skin (erythema nodosum, pyoderma gangrenosum, psoriasis), hepatobiliary (primary sclerosing cholangitis), and thromboembolic manifestations were analyzed.

RESULTS

Of 1,652 patients (1146 UC, 303 CD, 203 ITB), frequency of any EIM was 33.2 %, 38.3 %, and 14.3 % in UC, CD, and ITB patients, respectively. Thromboembolism was more common among UC patients with pancolitis than proctitis (p < 0.001) and left-sided colitis (p = 0.02). Primary sclerosing cholangitis was seen in 0.4 % UC patients. Steroid-dependent UC patients had higher frequency of any EIM, peripheral arthropathy, or thromboembolism than patients with no or infrequent steroid requirement (p < 0.05). Peripheral arthropathy (p = 0.02), erythema nodosum (p = 0.01), and aphthous stomatitis (p = 0.004) were more common with CD than with UC patients. Patients with colonic CD had higher frequency of peripheral arthropathy, any EIM, and multiple EIMs than ileal or ileocolonic disease (p < 0.05). Relative to ITB, CD patients had higher frequencies of peripheral arthropathy (p < 0.001), aphthous stomatitis (p = 0.01), any EIM (p < 0.001), and multiple EIMs (p < 0.001).

CONCLUSIONS

In Indian IBD and ITB patients, EIMs appear to be related to disease severity in UC and disease location in CD and are significantly more common in CD than in ITB. Overall prevalence of EIMs in these patients is similar to that of the West.

Mucocutaneous manifestations of inflammatory bowel disease in Turkey

BACKGROUND

Mucocutaneous manifestations of inflammatory bowel diseases are relatively common; the mean incidence is around 10% at the time of diagnosis. However, during follow-up, an increased variety of skin lesions, granulomatous cutaneous disease, reactive skin eruptions, nutritional defiencies, and other associated conditions may develop.

OBJECTIVE

The objective of this study was to evaluate the prevalence of the mucocutaneous manifestations and their association with gender, duration of disease, arthritis, location of the bowel disease, and disease activity.

METHODS

Fifty-six patients with ulcerative colitis (UC) and 36 patients with Crohn disease (CD) who were in follow-up in the Istanbul Medeniyet University Göztepe Training and Research Hospital Department of Gastroenterology were included in the study. Whole-body dermatologic examinations were performed for all patients, and patient files were evaluated for mucocutaneous manifestations.

RESULTS

Of the 92 patients, 49 (53.26%) presented with at least one mucocutaneous manifestation (58.9% of patients with UC and 44.4% of patients with CD). Of these, 38 (41.3%) had at least one reactive skin eruption. Aphthous stomatitis was noted in 33 patients (35.86%) and became the most common mucocutaneous manifestation. Granulomatous cutaneous diseases were detected in 18 patients (19.57%), and none of the patients had a nutritional deficiency-associated skin condition. Only 3 patients (3.26%) had erythema nodosum and 2 patients (2.17%) had pyoderma gangrenosum.

CONCLUSIONS

We found that mucocutaneous manifestations of inflammatory bowel diseases are more common than thought and are more common in UC than in CD. No association was detected between mucocutaneous manifestions and gender, duration of disease, arthritis, location of the bowel disease, and activity of the disease.

Crohn's disease presenting as vulvar edema in a 15-year-old girl

BACKGROUND

Vulval involvement is an uncommon extraintestinal manifestation of Crohn's disease, and it is very rare in children. Patients with vulval CD typically present with erythema and edema of the labia majora, which can progresses to extensive ulcer formation. Vulval CD can appear before or after intestinal problems or it may occur simultaneously.

OBSERVATION

We present a 15-years-old girl with bilateral labial hypertrophy which revealed a Crohn's disease. The course of her lesion was independent of the intestinal disease and responded significantly to medical treatment including Mesalamine, corticosteroid and local care.

CONCLUSIONS

We emphasize that although vulval involvement in childhood is uncommon, Crohn's disease must be considered in the differential diagnosis of nontender, red, edematous lesions of the genital area.

Leukocytoclastic vasculitis in an adolescent with ulcerative colitis: Report of a case and review of the literature

An adolescent female with long-standing, difficult-to-control ulcerative colitis developed leukocytoclastic vasculitis, a rare cutaneous extra-intestinal manifestation of the inflammatory bowel disease. The authors provide a literature review on leukocytoclastic vasculitis complicating ulcerative colitis. Furthermore, the clinical features of leukocytoclastic vasculitis are compared and contrasted with the more common cutaneous extra-intestinal manifestations of inflammatory bowel disease, erythema nodosum, and pyoderma gangrenosum.

Upper limb erythema nodosum: the first presentation of Crohn's disease

Key Clinical Message

Inflammatory bowel disease can present with extraintestinal features as the patient's only complaint. The erythema nodosum (EN) initially affected the upper limbs only, reminding us that signs do not always present in a classical fashion. The presence of EN should prompt the clinician to look for any underlying cause.

Articular and other Immune-Mediated Extra-Intestinal Manifestations in Inflammatory Bowel Diseases

The articular involvement in patients with inflammatory bowel diseases is included in the group of immune-mediated extra-intestinal manifestations, occurring approximately in a range from 6.2–36% of the patients. This group is also made up of the skin and eyes manifestations, that usually but not invariably are correlated with intestinal inflammatory disease activity. Rheumatic manifestations are the most frequent extra-intestinal findings of this group with a prevalence from 20–50%. They are divided into two different clinical subsets: peripheral and axial joint involvement (including sacroiliitis with or without spondylitis). Peripheral arthritis is the most frequent finding in both Crohn's disease and ulcerative colitis, occurring with a frequency ranging from 17–20%, and it is more common in Crohn's disease. Axial involvement is more common in Crohn's disease (5–22%) than in ulcerative colitis (2–6%) and generally the prevalence of sacroiliitis (asymptomatic and symptomatic) is between 12–20% and of spondylitis is between 2–16%. The IBD is also associated with other rheumatic diseases such as rheumatoid arthritis, Sjogren syndrome, Takayasu arteritis and fibromyalgia. The management of patients with EA requires an active cooperation between gastroenterologists and rheumatologists.

Predictive factors for erythema nodosum and pyoderma gangrenosum in inflammatory bowel disease

BACKGROUND AND AIM

To identify predictive factors related to the development of erythema nodosum and pyoderma gangrenosum, in patients with inflammatory bowel disease (IBD).

METHODS

Epidemiological and clinical data from 270 patients with Crohn's disease (CD) and 125 patients with ulcerative colitis (UC) were collected between 2003 and 2011. The variables retrospectively analyzed were: gender, age at diagnosis, type of IBD (CD or UC), smoking habit, pattern of disease (IBD), location and extension, family history, previous IBD-related surgery, other extraintestinal manifestations (EIMs), and previous biological and immunosuppressive therapy.

RESULTS

Thirty-seven patients showed at least one cutaneous manifestation. These lesions were more frequent in women (15.4%) than in men (4.2%; P = 0.0001) and in CD (12.2%) than in UC patients (3.2%; P = 0.005). These manifestations were more frequently associated with other EIMs (25% vs 7.2%; P = 0.0001), and they were less frequent in patients who received a previous biological therapy for IBD (6.8% vs 11.2%; P = 0.1). Patients with skin manifestations were younger at diagnosis of IBD than those patients without them (26.3 ± 10 vs 32.9 ± 14.5, P = 0.008). Independent variables significantly associated with development of skin manifestations were: female (P = 0.008), previous biological therapy (P = 0.007), age at diagnosis (young, P = 0.026), type of IBD (CD, P = 0.043) and presence of other EIMs (P = 0.0001).

CONCLUSION

Predictive factors involved in the development of main cutaneous manifestations are: female, CD, young age at diagnosis of IBD, and presence of other EIMs. Early use of biological therapies prevents the development of cutaneous manifestations.

Biological Therapy for Pyoderma Gangrenosum

Introduction: pyoderma gangrenosum (PG) is a rare and severe neutrophilic dermatosis associated with inflammatory bowel disease (IBD) and other systemic diseases such as rheumatoid arthritis and hematological malignancies. Diagnosis is based on clinical criteria and exclusion of other skin disorders. There is no gold standard for the treatment of PG; traditionally intravenous corticosteroids are used, but recently the use of drugs that inhibit tumor necrosis factor alpha (TNF-alpha) has changed the management of PG, showing great effectiveness.

Case report: female patient, 23 years old, diagnosed with severe nonspecific ulcerative colitis (UC) three years ago, undergoing treatment with oral mesalamine and azathioprine. She developed PG fourteen days after hospital discharge; hospitalization was due to worsening of intestinal disease symptoms. She was successfully treated using biological therapy after unfavorable evolution with corticosteroid therapy.

Conclusion: PG, a rare extraintestinal manifestation of IBD of difficult resolution that has significant impact on patient quality of life. The use of biological therapy for PG has higher efficacy in the treatment of patients decreasing wound healing time and return to daily activities.

Review article: dermatological complications of immunosuppressive and anti-TNF therapy in inflammatory bowel disease

BACKGROUND

With the expanding list of medications available to treat patients with inflammatory bowel disease (IBD), it is important to recognise adverse events, including those involving the skin. Dermatological adverse events may be confused with extra-intestinal manifestations of IBD.

AIM

To review drug-related dermatological manifestations associated with immunosuppressive and anti-tumour necrosis factor (anti-TNF) therapy.

METHODS

The literature was searched on PubMed for dermatological adverse events in IBD.

RESULTS

Present thiopurine exposure was associated with a 5.9-fold [95% confidence interval (CI), 2.1-16.4] increased risk of developing non-melanoma skin cancer (NMSC). The peak incidence is highest in Caucasians over the age of 65 years with crude incidence rates of 4.0 and 5.7/1000 patient-years for present and previous use. In anti-TNF-exposed subjects, drug-induced lupus was reported in 1% of the cases and a psoriatic rash in up to 3% of the cases. Anti-TNF monotherapy increases the risk of NMSC ~2-fold to a rate of 0.5 cases per 1000 person-years. Cutaneous lymphomas have been rarely reported in subjects on thiopurine or anti-TNF drug monotherapy. Combination therapy seems to have an additive effect on the risk of developing NMSC and lymphoma.

CONCLUSIONS

Physicians need to be aware of the wide spectrum of dermatological complications of immunosuppressive and anti-TNF therapy in IBD, especially psoriasis and non-melanoma skin cancer. Vigilance and regular screening for non-melanoma skin cancer is recommended. Case discussions between gastroenterologists and dermatologists should be undertaken to best manage dermatological adverse events.

Enteropathic spondyloarthritis: from diagnosis to treatment

Enteropathic arthritis (EA) is a spondyloarthritis (SpA) which occurs in patients with inflammatory bowel diseases (IBDs) and other gastrointestinal diseases. Diagnosis is generally established on the medical history and physical examination. It was, generally, made according to the European Spondyloarthropathy Study Group (ESSG) criteria. Rheumatic manifestations are the most frequent extraintestinal findings of IBD with a prevalence between 17% and 39%, and IBD is associated, less frequently, with other rheumatic disease such as rheumatoid arthritis, Sjogren syndrome, Takayasu arteritis, and fibromyalgia. Although the pathogenesis of EA has not been plainly clarified, the most popular theory supposes that joint inflammation occurs in genetically predisposed subjects with bacterial gut infections, provided an important evidence for a possible relationship between inflammation of the gut mucosa and arthritis. The management of patients with EA requires an active cooperation between the gastroenterologist and rheumatologist.

Incidence, mortality, and disease associations of pyoderma gangrenosum in the United Kingdom: a retrospective cohort study

Pyoderma gangrenosum (PG) is an important disease with significant complications. The objectives of this study were to determine incidence and mortality of PG and strength of reported associations. A retrospective cohort study was completed using computerized medical records from the General Practice Research Database, a large representative UK database. Patients with PG and three groups of age-, sex-, and practice-matched controls--general population, rheumatoid arthritis (RA), and inflammatory bowel disease (IBD) controls--were included in the study. Incidence and mortality were determined and validation undertaken to inform diagnostic accuracy. In all there were 313 people with the median age of 59 (interquartile range 41-72) years, and of them 185 (59%) were female. The adjusted incidence rate standardized to European standard population was 0.63 (95% confidence interval (CI) 0.57-0.71) per 100,000 person-years. The risk of death was three times higher than that for general controls (adjusted hazard ratio=3.03, 95% CI 1.84-4.73, P<0.001), 72% higher than that for IBD controls (adjusted hazard ratio=1.72, 95% CI 1.17-2.59, P=0.013), with a borderline increase compared with RA controls (adjusted hazard ratio=1.55, 95% CI 1.01-2.37, P=0.045). Disease associations were present in 110 (33%) participants: IBD, n=67 (20.2%); RA, n=39 (11.8%); and hematological disorders, n=13 (3.9%). To our knowledge, there are no previous population-based studies of the epidemiology of PG, an important disease with significantly increased mortality.

Oral Crohn's disease: is it a separable disease from orofacial granulomatosis? A review

Symptomatic oral Crohn's disease is comparatively rare. The relationship between orofacial granulomatosis, (where there is granulomatous inflammation and ulceration of the mouth in the absence of gastrointestinal disease) and true oral Crohn's disease is discussed along with the plethora of clinical oral disease presentations associated with both disorders and the differential diagnosis of oral ulceration in patients presenting to a gastroenterological clinic. Specific oral syndromes are outlined including the association between oral manifestations in Crohn's disease and the pattern of intestinal disease and their relationship to other recorded extraintestinal manifestations. The histological and immunological features of oral biopsies are considered as well as the principles of management of symptomatic oral disease. At present, it is suggested that both orofacial granulomatosis and oral Crohn's disease appear to be distinct clinical disorders.

Frequency and risk factors for extraintestinal manifestations in the Swiss inflammatory bowel disease cohort

OBJECTIVES

Data on the frequency of extraintestinal manifestations (EIMs) in Crohn's disease (CD) and ulcerative colitis (UC) and analyses of their risk factors are scarce. We evaluated their prevalence and risk factors in a large nationwide cohort of inflammatory bowel disease (IBD) patients.

METHODS

IBD patients from an adult clinical cohort in Switzerland (Swiss IBD cohort study) were prospectively included. Data from validated physician enrolment questionnaires were analyzed.

RESULTS

A total of 950 patients were included, 580 (61%) with CD (mean age 41 years) and 370 (39%) with UC (mean age 42 years). Of these, 249 (43%) of CD and 113 (31%) of UC patients had one to five EIMs. The following EIMs were found: arthritis (CD 33%, UC 21%), aphthous stomatitis (CD 10%, UC 4%), uveitis (CD 6%, UC 4%), erythema nodosum (CD 6%, UC 3%), ankylosing spondylitis (CD 6%, UC 2%), psoriasis (CD 2%, UC 1%), pyoderma gangrenosum (CD and UC each 2%), and primary sclerosing cholangitis (CD 1%, UC 4%). Multiple logistic regression identified the following risk factors for ongoing EIM in CD: active disease (odds ratio (OR)=1.95, 95% confidence interval (CI)=1.17-3.23, P=0.01), and positive IBD family history (OR=1.77, 95% CI=1.07-2.92, P=0.025). No risk factors were identified in UC patients.

CONCLUSIONS

EIMs are a frequent problem in CD and UC patients. Active disease and positive IBD family history are associated with ongoing EIM in CD patients. Identification of EIM prevalence and associated risk factors may result in increased awareness for this problem and thereby facilitating their diagnosis and therapeutic management.

Peripheral arthritis in the course of inflammatory bowel diseases

BACKGROUND

Musculoskeletal disorders are well-defined extra-intestinal manifestations of inflammatory bowel diseases (IBD). There is little data regarding the frequencies of IBD and extra-intestinal manifestations from Central and East Europe and Middle Eastern countries.

AIMS

To determine the prevalence of peripheral arthritis in IBD and to document the relationship to other extra-intestinal manifestations.

METHODS

Enrolled in the study were 357 patients who were diagnosed with IBD from December 2002 through January 2008. All of the patients underwent a detailed whole-body examination by a gastroenterologist and rheumatologist.

RESULTS

IBD-related peripheral arthritis (IBDPA) was found in 66 (18.5%) of the 357 patients (28.3% Crohn's disease, 13.5% ulcerative colitis; p=0.001 χ=11.62). IBDPA was more frequent in female patients (60.6 vs. 39.4%, p=0.000, χ=11.12). In eight (12.1%) cases, IBDPA occurred before the onset of IBD. Acute self-limiting episodes, recurrences of the attacks, and persistent symptoms of arthritis were present in 40 (60.6%), 26 (39.3%), and 29 (45.7%) patients, respectively. Arthritis was symmetrical in 33 (50%) cases. Knees (65.2%) and ankles (62.1%) were the most commonly affected joints. Erythema nodosum and pyoderma gangrenosum were more common among patients with IBDPA than patients without it (p=0.001, χ=10.49, and p=0.000 χ=25.77, respectively).

CONCLUSIONS

IBDPA is a frequent extra-intestinal complication of IBD. Those of female gender and the presence of Crohn's disease, erythema nodosum and pyoderma gangrenosum have a higher risk to develop IBDPA.

Links between oral and gastrointestinal health

PURPOSE OF REVIEW

To review the links between oral and gastrointestinal health and discuss their implications in clinical management.

RECENT FINDINGS

There are many instances in which changes that occur within the oral cavity reflect systemic disease elsewhere in the body. Oral manifestations may be the first sign of gastrointestinal disease. This is definitely the case in the inflammatory bowel diseases such as Crohn's disease and ulcerative colitis. However, although the oral manifestations are relatively well recognized, the links between pathobiology at different sites do not appear to be fully investigated in the literature. This is not the case with alimentary tract mucositis, a side effect of cancer treatment. Increasing interest in the pathobiology of mucositis and the links between changes that occur at different sites of the alimentary has changed the way that this common side effect of cancer treatment has been managed.

SUMMARY

Changes occurring in the oral cavity associated with systemic diseases, including gastrointestinal disease, have been long recognized. Further study into the pathobiology of oral links with inflammatory bowel disease is also recommended so that these diseases are better understood. Importantly, however, the oral manifestations of systemic disease must be highlighted so that, if they are the first manifestations that can be clinically recognized, patients can have appropriate investigations and be managed in a timely fashion. A multidisciplinary management of patients is crucial so that they receive appropriate and comprehensive healthcare.

Extraintestinal manifestations of inflammatory bowel disease: epidemiology, diagnosis, and management

Abstract Extraintestinal manifestations occur rather frequently in inflammatory bowel disease (IBD), e.g. ulcerative colitis (UC) and Crohn's disease (CD). The present paper provides an overview of the epidemiology, clinical characteristics, diagnostic process, and management of rheumatic, metabolic, dermatologic (mucocutaneous), ophthalmologic, hepatobiliary, hematologic, thromboembolic, urinary tract, pulmonary, and pancreatic extraintestinal manifestations related to IBD. Articles were identified through search of the PubMed and Embase databases, the Cochrane Library, and the web sites of the European Agency for the Evaluation of Medicinal Products (EMEA) and the US Food and Drug Administration (FDA) (cut-off date October 2009). The search terms 'Crohn's disease', 'inflammatory bowel disease', or 'ulcerative colitis' were combined with the terms 'adalimumab', 'anemia', 'arthritis', 'bronchiectasis', 'bronchitis', 'cutaneous manifestations', 'erythema nodosum', 'extraintestinal manifestations', 'hyperhomocysteinemia', 'infliximab', 'iridocyclitis', 'lung disease', 'ocular manifestations', 'osteomalacia', 'pancreatitis', 'primary sclerosing cholangitis', 'renal stones', 'sulfasalazine', 'thromboembolism', and 'treatment'. The search was performed on English-language reviews, practical guidelines, letters, and editorials. Articles were selected based on their relevance, and additional papers were retrieved from their reference lists. Since some of the diseases discussed are uncommon, valid evidence of treatment was difficult to obtain, and epidemiologic data on the rarer forms of extraintestinal manifestations are scarce. However, updates on the pathophysiology and treatment regimens are given for each of these disorders. This paper offers a current review of original research papers and randomized clinical trials, if any, within the field and makes an attempt to point out practical guidelines for the diagnosis and treatment of various extraintestinal manifestations related to IBD.

Natural history and complications of IBD

Inflammatory bowel diseases (IBD), mainly ulcerative colitis and Crohn's disease, are chronic, heterogenic, lifelong illnesses with young age of onset and a great potential for disability. The natural history of these diseases is influenced by multiple factors of environmental and genetic origin. Multidisciplinary research has increased our knowledge of the mechanisms involved during the development and outcome of the diseases, including disease complications. Immunomodulatory treatment has demonstrated greatly improved efficacy in moderate to severe disease activity. The long-term effect on the natural course of disease and sustained reduced burden on society over many years require study. This article summarizes recent knowledge on factors influencing the natural history of IBD, including the impact of treatment. Increased understanding of disease mechanisms is needed as a basis for new treatment strategies in the future.