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Brillantino A, Iacobellis F, Reginelli A, Monaco L, Sodano B, Tufano G, Tufano A, Maglio M, De Palma M, Di Martino N, Renzi A, Grassi R. Preoperative assessment of simple and complex anorectal fistulas: Tridimensional endoanal ultrasound? Magnetic resonance? Both? Radiol Med 2019; 124:339-349. [PMID: 30607867 DOI: 10.1007/s11547-018-0975-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 12/05/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE The purpose of the study is to evaluate the diagnostic value of tridimensional endoanal ultrasound (3D-EAUS) and magnetic resonance (MR) in the preoperative assessment of both simple and complex anorectal fistulas. METHODS All the patients referred for the treatment of anal fistulas were enrolled in this study and underwent, as preoperative assessment, anamnestic evaluation, clinical examination, and unenhanced and H2O2-enhanced 3D-EAUS and MR. The results of imaging evaluation were compared with surgical findings, considered as reference standard. RESULTS During the study period, 124 patients operated on for anal fistulas underwent complete preoperative imaging assessment. Perfect agreement between 3D-EAUS and surgery in the anal fistulas' severity grading was found (K = 1). The fistulas were classified as simple in 68/126 (53.9%) and complex in 58/126 (46.03%) cases, according to fistulas' Parks' classification and the most recent American Guidelines. In both simple and complex anal fistulas, 3D-EAUS did not show a significantly higher accuracy in the evaluation of internal openings, if compared with MR (P = 0.47; McNemar's Chi-square test). In the complex anal fistulas, MR showed a significantly higher accuracy in the evaluation of secondary extensions if compared with 3D-EAUS (P = 0.041; McNemar's Chi-square test), whereas in the simple anal fistulas, no significant difference was found. CONCLUSION In the preoperative work-up of patients with anorectal fistulas, 3D-EAUS may represent the first-line diagnostic tool. In cases of fistulas classified as complex by 3D-EAUS, MR may be indicated as adjunctive diagnostic imaging examination, to more carefully describe the fistulas' complete anatomy.
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Affiliation(s)
- Antonio Brillantino
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Francesca Iacobellis
- Department of Radiology, University of Campania "L. Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy.
| | - Alfonso Reginelli
- Department of Radiology, University of Campania "L. Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy
| | - Luigi Monaco
- Department of Surgery, "Villa Esther" Hospital, Via Due Principati 169, 83100, Avellino, Italy
| | - Biagio Sodano
- Department of Surgery, "Pellegrini" Hospital, ASL NA1 Centro, via Portamedina alla Pignasecca 41, 80134, Naples, Italy
| | - Giuseppe Tufano
- Department of Surgery, "Pellegrini" Hospital, ASL NA1 Centro, via Portamedina alla Pignasecca 41, 80134, Naples, Italy
| | - Antonio Tufano
- Department of Surgery, "Pellegrini" Hospital, ASL NA1 Centro, via Portamedina alla Pignasecca 41, 80134, Naples, Italy
| | - Mauro Maglio
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Maurizio De Palma
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Natale Di Martino
- Department of Surgery, University of Campania "L. Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy
| | - Adolfo Renzi
- "Villa delle Querce" Hospital, Via Battistello Caracciolo 48, 80136, Naples, Italy
| | - Roberto Grassi
- Department of Radiology, University of Campania "L. Vanvitelli", Piazza Miraglia 2, 80138, Naples, Italy
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Williams G, Williams A, Tozer P, Phillips R, Ahmad A, Jayne D, Maxwell-Armstrong C. The treatment of anal fistula: second ACPGBI Position Statement - 2018. Colorectal Dis 2018; 20 Suppl 3:5-31. [PMID: 30178915 DOI: 10.1111/codi.14054] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 02/16/2018] [Indexed: 02/08/2023]
Abstract
It is over 10 years since the first ACPGBI Position Statement on the management of anal fistula was published in 2007. This second edition is the result of scrutiny of the literature published during this time; it updates the original Position Statement and reviews the published evidence surrounding treatments for anal fistula that have been developed since the original publication.
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Affiliation(s)
- G Williams
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - A Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - P Tozer
- St Mark's Hospital, Harrow, London, UK
| | | | - A Ahmad
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Jayne
- University of Leeds, Leeds, UK
| | - C Maxwell-Armstrong
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
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The comparison of CT fistulography and MR imaging of perianal fistulae with surgical findings: a case-control study. Abdom Radiol (NY) 2016; 41:1474-83. [PMID: 27034072 DOI: 10.1007/s00261-016-0722-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the diagnostic efficacies of CT fistulography and MRI, in the diagnostic work-up of perianal fistula patients. MATERIALS AND METHODS All 41 patients who were included in the study (36 males and 5 females, with an average age of 41 years) underwent CT fistulography and MRI examinations prior to surgery. The fistula characteristics obtained from these examinations were compared with the surgical findings. The comparative results were evaluated by means of the Kappa analysis method. RESULTS CT fistulography predicted the correct perianal fistula classification in 30 (73.1%) of the 41 patients, whereas MRI correctly defined fistula classification in 38 (92.7%) of these patients (the K values were 0.621 and 0.896, respectively; with p < 0.001). CT fistulography depicted 29 secondary extensions in 16 patients, whereas MR imaging revealed 28 secondary extensions in 15 patients. A substantial agreement was found between surgical findings and two modalities (K value was 0.789 and 0.793 for CT fistulography and MRI, respectively, with a p value < 0.001). In terms of locations of internal openings, CT fistulography was able to detect the locations in 28 patients (68.2%), whereas MRI was more successful in this aspect, with a number of 35 patients (85.3%). Granulation tissues, inflammation and edema around the fistula, abscesses, and fistular wall fibrosis were also evaluated. CONCLUSION CT fistulography and MRI have different advantages in the diagnosis of perianal fistulas. A good command of knowledge concerning the issue may be a key factor in modality decision.
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Use of a Balloon Rectal Catheter in Magnetic Resonance Imaging of Complex Anal Fistula to Improve Detection of Internal Openings. J Comput Assist Tomogr 2016; 40:543-50. [DOI: 10.1097/rct.0000000000000400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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MR imaging of perianal fistulas in Crohn's disease: sensitivity and specificity of STIR sequences. Radiol Med 2015; 121:243-51. [PMID: 26643166 DOI: 10.1007/s11547-015-0603-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 11/03/2015] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Although some studies proved the role of STIR sequences in the evaluation of perianal fistulas in Crohn's Disease (CD), contrast medium is still injected in many institutions since there is not a validated reference MR protocol. Our purpose was to evaluate the role of the STIR sequence in the detection and characterization of perianal fistulae comparing it to the post-contrast T1 sequence and correlating it with rectal examination under anesthesia. MATERIALS AND METHODS We retrospectively reviewed all clinical records of 31 CD patients, suspected of having perianal fistulas, who had been submitted to an MR study before and after contrast medium injection and surgical exploration under anesthesia within the same month. Perianal fistulas were classified according to the Parks' criteria. Finally, comparison between STIR and post-contrast T1-weighted fat saturated sequences was done. RESULTS 29 fistulas were detected in 25 patients who underwent an MR study. There was no significant difference between MR imaging and exploration under anesthesia. For the detection of perianal fistulas of any type, there was a perfect statistical agreement between gadolinium-enhanced and STIR sequences (kappa value = 1). CONCLUSION STIR sequences represent a valid alternative to the T1-weighted sequences acquired after the injection of contrast medium, allowing the identification of the primary fistula, any secondary ramification, and complications of the disease.
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Brillantino A, Iacobellis F, Di Sarno G, D'Aniello F, Izzo D, Paladino F, De Palma M, Castriconi M, Grassi R, Di Martino N, Renzi A. Role of tridimensional endoanal ultrasound (3D-EAUS) in the preoperative assessment of perianal sepsis. Int J Colorectal Dis 2015; 30:535-42. [PMID: 25728829 DOI: 10.1007/s00384-015-2167-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of this study was to evaluate the accuracy of tridimensional endoanal ultrasound (3D-EAUS) in the diagnosis of perianal sepsis comparing the results with the surgical findings, considered as reference standard. METHODS From January 2009 to January 2013, all the patients referred for the assessment and treatment of perianal sepsis with suspected anorectal origin were enrolled in the study. All patients gave informed written consent. Prior to surgery, all the patients underwent anamnestic evaluation, clinical examination, and unenhanced and H2O2-enhanced 3D-EAUS. Surgery was performed by a colorectal surgeon blinded to the 3D-EAUS results. RESULTS A total of 212 patients with suspected perianal suppurations were assessed during the study period. In 12 patients, the H2O2-enhanced 3D-EAUS was not performed, and so, they were excluded from the study. Very good agreement between 3D-EAUS and examination under anesthesia (EUA) in the classification of primary fistula tracts (kappa = 0.93) and in the identification of fistula internal opening (kappa = 0.97) was found. There was a good concordance (kappa = 0.71) between 3D-EAUS and surgery in the detection of fistula secondary extensions. The overall sensitivity and specificity of 3D-EAUS in the diagnosis of perianal sepsis were 98.3 and 91.3% respectively. CONCLUSION 3D-EAUS is a safe and reliable technique in the assessment of perianal sepsis. It may assist the surgeon in delineating the fistula tract anatomy and in determining the origin of sepsis, supporting the preoperative planning of definitive and appropriate surgical therapy.
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Affiliation(s)
- Antonio Brillantino
- Emergency Department "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
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Abstract
Perianal fistula is a clinical entity with multiple surgical treatment options. Recently, magnetic resonance imaging (MRI) has emerged as an important imaging modality in the management of perianal fistulas. It provides accurate description of the fistula within the anal canal in relation to the sphincter complex and other pelvic floor structures as well as the associated complications such as abscess. By understanding the surgical viewpoint, the appearance of perianal fistulas, associated complications, and post-treatment findings of commonly used surgical interventions can more accurately be interpreted to aid clinicians. The objective of the article is to review MRI indications and findings, radiological versus surgical classification schemes, and surgical treatment options for perianal fistulas.
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Abstract
Symptoms thought related to hemorrhoids must be carefully considered before intervention. The first line of therapy for any hemorrhoidal complaint remains conservative management with increased fluid and fiber intake and appropriate modification of toileting behavior. Bleeding in grades 1 and 2 hemorrhoids that does not respond to this can be satisfactorily and safely managed with office-based therapies; some grade 3 hemorrhoids would also respond to this, though more treatment sessions would likely be required. Operative therapy is the best choice for management of persistently symptomatic grade 2 disease and for grades 3 and 4 symptomatic hemorrhoids as well. With proper patient selection and preparation, along with a familiarity with instrumentation and techniques, good results can be obtained with newer operative interventions for internal hemorrhoids. Outcomes must always be compared with those obtained with classic excisional hemorrhoidectomy.
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Garcia EB, Rademacher N, McCauley CT, Gaschen L. Navicular bone osteomyelitis and navicular bursitis with associated fistula diagnosed with magnetic resonance fistulography in the horse. EQUINE VET EDUC 2013. [DOI: 10.1111/eve.12004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- E. B. Garcia
- Department of Veterinary Clinical Sciences; Section of Diagnostic Imaging; Louisiana State University
| | - N. Rademacher
- Department of Veterinary Clinical Sciences; Section of Diagnostic Imaging; Louisiana State University
| | - C. T. McCauley
- Equine Health Studies Program; School of Veterinary Medicine; Louisiana State University; Louisiana USA
| | - L. Gaschen
- Department of Veterinary Clinical Sciences; Section of Diagnostic Imaging; Louisiana State University
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Sun MRM, Smith MP, Kane RA. Current techniques in imaging of fistula in ano: three-dimensional endoanal ultrasound and magnetic resonance imaging. Semin Ultrasound CT MR 2009; 29:454-71. [PMID: 19166042 DOI: 10.1053/j.sult.2008.10.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Perianal fistula is an abnormal communication between the anal canal and perianal skin. The majority of perianal fistulous disease results from either cryptoglandular inflammation or Crohn's disease. These groups differ in pathophysiology, prognosis, and strategies for imaging and treatment. Endoanal ultrasound and magnetic resonance imaging represent current imaging strategies for evaluating perianal fistulas and may be used alone or in combination. The use of three-dimensional technique and peroxide fistulography optimize the ultrasound evaluation of perianal fistula. The use of multiple imaging planes and sequences including fat suppression and contrast enhancement optimize the magnetic resonance imaging protocol. Examples of the imaging appearance of perianal fistulas and a proposed flowchart for imaging modality selection are provided.
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Affiliation(s)
- Maryellen R M Sun
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA 02115, USA.
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Williams JG, Farrands PA, Williams AB, Taylor BA, Lunniss PJ, Sagar PM, Varma JS, George BD. The treatment of anal fistula: ACPGBI position statement. Colorectal Dis 2007; 9 Suppl 4:18-50. [PMID: 17880382 DOI: 10.1111/j.1463-1318.2007.01372.x] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- J G Williams
- McHale Centre, New Cross Hospital, Wolverhampton, UK.
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Ergen FB, Arslan EB, Kerimoglu U, Akata D. Magnetic resonance fistulography for the demonstration of anovaginal fistula: an alternative imaging technique? J Comput Assist Tomogr 2007; 31:243-6. [PMID: 17414761 DOI: 10.1097/01.rct.0000237807.65381.a8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Anovaginal fistulae (AVF) are frequently seen in patients with inflammatory bowel disease, especially in Crohn disease with active colonic inflammation. Herein, we report a 21-year-old woman with Crohn disease suffering from vaginal discharge and anal pain. Although clinical presentation was very suggestive of AVF, physical examination and colonoscopy were inconclusive. We used an alternative technique and performed magnetic resonance fistulography by applying rectal contrast for the demonstration of AVF.
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Affiliation(s)
- Fatma Bilge Ergen
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey.
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Abstract
Treating common benign anal diseases has evolved towards more outpatient procedures with better outcome. However, minimizing post-procedure morbidities such as pain and the avoidance incontinence remain the most significant concerns. We introduce some controversies and highlight the developments in current surgical practice for the treatment of common anal problems.
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Affiliation(s)
- Ismail Sagap
- Department of Colorectal Surgery (A-30), Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Abstract
Fistula in ano is a common condition that often recurs despite seemingly adequate surgery, usually because of infection that was missed at surgery. It is now increasingly recognized that preoperative imaging can help identify infection that would have otherwise gone unidentified. In particular, magnetic resonance (MR) imaging findings have been shown to influence surgery and markedly diminish the chance of recurrence; thus, preoperative imaging will become increasingly routine in the future. In this article, the authors describe the pathogenesis, classification, and imaging of fistula in ano, with an emphasis on MR imaging. Most important, the authors describe how the radiologist is well placed to answer the surgical riddles that must be solved for treatment to be effective.
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Affiliation(s)
- Steve Halligan
- Department of Specialist Radiology, University College Hospital, Level 2, Podium, 235 Euston Road, London NW1 2BU, England
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Sungurtekin U, Sungurtekin H, Kabay B, Tekin K, Aytekin F, Erdem E, Ozden A. Anocutaneous V-Y advancement flap for the treatment of complex perianal fistula. Dis Colon Rectum 2004; 47:2178-83. [PMID: 15657671 DOI: 10.1007/s10350-004-0744-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE The treatment of intersphincteric and low transsphincteric fistula is well defined, but controversy remains around the management of complex perianal fistula. This study was designed to assess the utility of anocutaneous flap repair in complex types of perianal fistula. METHODS Sixty-five perianal fistula in 65 patients treated with anocutaneous advancement flap for the complex fistula, between April 1998 and December 2002, are included this prospective study. Mean age was 34 +/- 2.1 (range, 24-53) years. Magnetic resonance imaging was used for the diagnosis of fistula. Excision of the internal opening and the overlying anoderm, curettage of the fistula tract, closure of internal opening with absorbable polyglactin 3/0 suture, and drainage of the external opening(s) by insertion of penrose drain were common operational steps. Outcome was evaluated in terms of healing and incontinence. RESULTS Successful healing of 59 of 65 complex fistulas was achieved using this technique with no disturbance of continence and minimal complications. Mean follow-up and complete healing time were 32 +/- 0.6 (range, 12-52) months and 5.4 +/- 0.8 (range, 3-7) weeks respectively. CONCLUSIONS Although the study cases were relatively small in number, this report showed that clinical results of anocutaneous advancement flap are acceptable. However, large studies are needed to reach an ultimate conclusion for assessing the place of anocutaneous flap advancement in complex fistula.
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Affiliation(s)
- Ugur Sungurtekin
- Department of General Surgery, Pamukkale University Faculty of Medicine, Denizli, Turkey.
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Hsu CH, Lee CM, Chia CF, Lin YH. F-18 Fluorodeoxyglucose Positron Emission Tomography in an Anorectal Fistula With Actinomycosis. Clin Nucl Med 2004; 29:452-3. [PMID: 15192476 DOI: 10.1097/01.rlu.0000129132.94660.4a] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Chung-Huei Hsu
- Department of Nuclear Medicine, Taipei Medical University Hospital, Taiwan.
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Abstract
The management of fistula-in-ano has been based on digital examination and operative findings. MR imaging has shown significant limitations to this approach, particularly in the management of recurrent fistula. The most cost-effective approach may be using a combination of endosonography and MR imaging. Preoperative confirmation of fistula complexity facilitates surgery planning of sphincter saving techniques and prevents sepsis being missed, which has been shown to reduce recurrence. Imaging has a significant role to play in this condition to improve patient outcome.
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Affiliation(s)
- Clive Bartram
- Department of Intestinal Imaging, Imperial College of London, Faculty of Medicine, London, United Kingdom.
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Hampe J, Frenzel H, Mirza MM, Croucher PJP, Cuthbert A, Mascheretti S, Huse K, Platzer M, Bridger S, Meyer B, Nürnberg P, Stokkers P, Krawczak M, Mathew CG, Curran M, Schreiber S. Evidence for a NOD2-independent susceptibility locus for inflammatory bowel disease on chromosome 16p. Proc Natl Acad Sci U S A 2002; 99:321-6. [PMID: 11752413 PMCID: PMC117559 DOI: 10.1073/pnas.261567999] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2001] [Accepted: 10/24/2001] [Indexed: 02/07/2023] Open
Abstract
Heritable predisposition to inflammatory bowel disease (IBD) has been demonstrated by epidemiological and genetic analysis. Linkage of IBD to broad regions of chromosome 16 has been established by analysis of multiple populations. NOD2, located on proximal 16q, was recently identified as an IBD gene. As the linkage regions on chromosome 16 are large, we have investigated the possibility that NOD2 is not the only IBD gene located on this chromosome. A high-density experiment using 39 microsatellite markers was performed to identify additional regions of association, and to indicate areas of interest for further investigation. A triple-peaked configuration of the linkage curve with peak logarithm of odds (lod) scores of 2.7, 3.2, and 3.1 was observed on proximal 16p, proximal 16q, and central 16q, respectively. The cohort was stratified by coding individuals carrying the NOD2 single nucleotide polymorphism (SNP)8 and SNP13 "unknown." Significance at the central peak, corresponding to the genomic location of NOD2, then decreased from 3.2 to 1.2. The maximal lod scores on the proximal p-arm (lod = 2.1) and central q-arm (lod = 2.6) changed only moderately. An exploratory association analysis (TRANSMIT) yielded a strong lead at D16S3068 (P = 0.00028). The region around this marker was further investigated by using anonymous SNPs. An associated haplotype containing three SNPs was identified (peak significance P = 0.00027, IBD phenotype). On stratification based on NOD2 genotype, this significance increased to P = 0.0001. These results confirm the importance of NOD2 and provide evidence for a second IBD gene located on chromosome 16p.
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Affiliation(s)
- Jochen Hampe
- Department of General Internal Medicine, Christian Albrechts University, 24118 Kiel, Germany
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