Incidence and risk of intestinal and extra-intestinal complications in Medicaid patients with inflammatory bowel disease: a 5-year population-based study

Prevalence of Hepatobiliary Manifestations in Inflammatory Bowel Disease: A GRADE Assessed Systematic Review and Meta-Analysis of more than 1.7 Million Patients

BACKGROUND AND AIMS

Inflammatory bowel disease [IBD] comprises an immune-mediated group of chronic gastrointestinal disorders. Patients with IBD may experience extraintestinal manifestations, such as hepatobiliary complications. This meta-analysis aims to assess the prevalence of different hepatic manifestations in IBD patients.

METHODS

For this systematic review and meta-analysis, PubMed, Scopus, Web of Science, and Embase were searched until July 20, 2022, by specifying keywords for IBD, hepatic manifestations, and study type. Full texts of cohort studies in English that examined the prevalence of different hepatic manifestations were included in this study. The primary outcome was the overall prevalence of hepatic manifestations in IBD patients. For the statistical analysis, a proportion by random effect model meta-analysis was performed. The registration number for the protocol of this study in PROSPERO is CRD42022369595.

RESULTS

From the 4421 articles retrieved from the primary search, 118 met the inclusion criteria and were included in the final analysis. After a pooled analysis of 1 729 128 patients, the overall prevalence of hepatic manifestations was 3.49% (95% confidence interval [CI]: 3.31-3.68%; I2: 99.55%). The pooled prevalence of non-alcoholic fatty liver disease in 228 216 patients was 26.1% [95% CI: 22.1-30.2%; I2: 99.018%]. After pooled analysis of 9642 patients, the prevalence of primary sclerosing cholangitis was 1.67% [95% CI: 1.47-1.88%; I2: 99.10%]. The pooled prevalence of biliary stones was 4.1% [95% CI: 3.6-4.7%; I2: 97.43%]. Autoimmune hepatitis (0.51% [95% CI: 0.26-0.75%]; I2: 85.36%) and portal vein thrombosis (0.21% [95% CI: 0.08-0.33%]; I2: 97.95%) are considered as rare manifestations.

CONCLUSION

This study summarizes the prevalence and importance of different hepatic manifestations in IBD patients. These findings are crucial for the management of extraintestinal manifestations, especially hepatic manifestations, in IBD patients.

Clinical codes combined with procedure codes increase diagnostic accuracy of Crohn's disease in a US Military health record

Background and aims

Previous examinations of International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes to predict accuracy of diagnosis in inflammatory bowel disease have had limited chart review to confirm diagnosis. We aimed to evaluate using the ICD-9-CM for identifying Crohn’s disease (CD) in a large electronic health record (EHR) database.

Methods

This is a retrospective case-control study with a 3:1 allocation of EHRs of active duty service members diagnosed with CD from 1996 to 2012. Subjects were selected by having two ICD-9-CM codes for CD and none for ulcerative colitis during the study period. Gastroenterologists reviewed each chart and confirmed the diagnosis of CD by analysing medication history and clinical, endoscopic, histological, and radiographic exams.

Results

300 cases of CD were selected; 14 cases were discarded due to lack of data, limiting analysis to 284 subjects. Two diagnostic codes for CD had sensitivity and specificity of 1.0 and 0.53 respectively, for confirmed CD. If two or more encounters listing CD were with a gastroenterologist, the sensitivity and specificity was 0.71 and 0.87 respectively. If two encounters included a colonoscopy was performed at the same time as a CD code, sensitivity and specificity was 0.49 and 0.88 respectively.

Conclusions

The relatively poor specificity of ICD-9-CM codes in making the diagnosis of CD should be taken into consideration when interpreting results and when conducting research using such codes. Limiting these codes to patients given this diagnosis by a gastroenterologist, or to those who had a colonoscopy at the time of a diagnosis, increases the specificity, although at cost of sensitivity, especially for colonoscopy.

Mast Cells Exert Anti-Inflammatory Effects in an IL10-/- Model of Spontaneous Colitis

Mast cells are well established as divergent modulators of inflammation and immunosuppression, but their role in inflammatory bowel disease (IBD) remains to be fully defined. While previous studies have demonstrated a proinflammatory role for mast cells in acute models of chemical colitis, more recent investigations have shown that mast cell deficiency can exacerbate inflammation in spontaneous colitis models, thus suggesting a potential anti-inflammatory role of mast cells in IBD. Here, we tested the hypothesis that in chronic, spontaneous colitis, mast cells are protective. We compared colitis and intestinal barrier function in IL10^−/− mice to mast cell deficient/IL10^−/− (double knockout (DKO): Kit^Wsh/Wsh × IL10^−/−) mice. Compared with IL10^−/− mice, DKO mice exhibited more severe colitis as assessed by increased colitis scores, mucosal hypertrophy, intestinal permeability, and colonic cytokine production. PCR array analyses demonstrated enhanced expression of numerous cytokine and chemokine genes and downregulation of anti-inflammatory genes (e.g., Tgfb2, Bmp2, Bmp4, Bmp6, and Bmp7) in the colonic mucosa of DKO mice. Systemic reconstitution of DKO mice with bone marrow-derived mast cells resulted in significant amelioration of IL10^−/−-mediated colitis and intestinal barrier injury. Together, the results presented here demonstrate that mast cells exert anti-inflammatory properties in an established model of chronic, spontaneous IBD. Given the previously established proinflammatory role of mast cells in acute chemical colitis models, the present findings provide new insight into the divergent roles of mast cells in modulating inflammation during different stages of colitis. Further investigation of the mechanism of the anti-inflammatory role of the mast cells may elucidate novel therapies.

The Prevalence and Incidence of Axial and Peripheral Spondyloarthritis in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis

BACKGROUND AND AIMS

Inflammatory bowel disease [IBD] is a chronic disease which affects up to 0.5% of the population. Various extraintestinal manifestations occur, among which are rheumatic manifestations, grouped together under the name spondyloarthritis. The objective of this systematic review and meta-analysis was to give a systematic overview of the prevalence and incidence of spondyloarthritis in patients with inflammatory bowel disease.

METHODS

We systematically searched Embase, Pubmed, OvidSP, Scopus, and Web-of-Science databases from inception to August 2016. All articles that addressed the prevalence or incidence of the different features of spondyloarthritis in adult inflammatory bowel disease patients were included. Methodological quality was assessed using a modified quality assessment tool developed for prevalence studies.

RESULTS

A total of 71 studies were included, reporting on the prevalence of sacroiliitis, ankylosing spondylitis, arthritis, enthesitis, and dactylitis. Pooled prevalences were calculated for sacroiliitis (10%; 95% confidence interval [CI] 8-12%), ankylosing spondylitis [3%; 95% CI 2-4%], and arthritis [13%; 95% CI 12-15%]. Geographical area, setting and use of different criteria contribute to the large heterogeneity. Few estimates were available for enthesitis [prevalence range from 1% to 54%] and dactylitis [prevalence range from 0% to 6%]. Only three incidence studies were identified, which report cumulative incidences from 5 to 30 years.

CONCLUSIONS

Spondyloarthritis occurs in up to 13% of patients with IBD. Ankylosing spondylitis is the least common [3%] followed by sacroiliitis [10%] and peripheral arthritis [13%].

Amyloidosis in Inflammatory Bowel Disease: A Systematic Review of Epidemiology, Clinical Features, and Treatment

BACKGROUND AND AIMS

Amyloidosis is a rare complication of inflammatory bowel disease [IBD]; its low prevalence has hindered both descriptive and therapeutic studies. The aim of this study was to estimate the prevalence of amyloidosis in IBD and the risk factors associated with this complication.

METHODS

This paper presents an observational study, followed by a systematic review of the epidemiological and clinical characteristics of the disease and a review of the diagnostic and therapeutic options.

RESULTS

The prevalence of amyloidosis among IBD patients is 0.53% (95% confidence interval [CI]: 0.32-0.75), although epidemiological data suggest that it may be under-diagnosed. The phenotype most frequently associated with amyloidosis is males with aggressive and extensive Crohn's disease, fistulising behaviour, perianal disease, and extra-intestinal complications, with the development of proteinuria and renal failure.

CONCLUSIONS

Identifying risk factors of amyloidosis in IBD patients and screening for proteinuric renal dysfunction are useful to improve diagnostic accuracy. Referral of biopsies to a tertiary centre should also be considered, to improve diagnostic accuracy. Although there is no reliable evidence on the effectiveness of treatment, it seems reasonable to treat the underlying disease with potent immunosuppression to minimise inflammatory activity, thereby switching off amyloidogenesis.

Mortality associated with medical therapy versus elective colectomy in ulcerative colitis: a cohort study

BACKGROUND

Ulcerative colitis (UC) can be treated with surgery or medications. Patients often must choose between long-term immunosuppressant therapy or total colectomy. Whether one of these treatment approaches has a mortality benefit is uncertain.

OBJECTIVE

To determine whether patients with advanced UC treated with elective colectomy have improved survival compared with those treated with medical therapy.

DESIGN

Retrospective matched cohort study.

SETTING

Data from all 50 states for Medicaid beneficiaries (2000 to 2005), Medicare beneficiaries (2006 to 2011), and dual-eligible persons (2000 to 2011).

PATIENTS

830 patients with UC pursuing elective colectomy and 7541 matched patients with UC pursuing medical therapy.

MEASUREMENTS

The primary outcome was time to death. Cox proportional hazards models were used to compare the survival of patients with advanced UC treated with elective colectomy or medical therapy. The models controlled for significant comorbid conditions through matched and adjusted analysis.

RESULTS

The mortality rates associated with elective surgery and medical therapy were 34 and 54 deaths per 1000 person-years, respectively. Elective colectomy was associated with improved survival compared with long-term medical therapy (adjusted hazard ratio [HR], 0.67 [95% CI, 0.52 to 0.87]), although this result did not remain statistically significant in all sensitivity analyses. Post hoc analysis by age group showed improved survival with surgery in patients aged 50 years or older with advanced UC (HR, 0.60 [CI, 0.45 to 0.79]; P = 0.032 for age-by-treatment interaction).

LIMITATIONS

Retrospective nonrandomized analysis is subject to residual confounding. The source cohort was derived from different databases throughout the study. Sensitivity and secondary analyses had reduced statistical power.

CONCLUSION

Elective colectomy seemed to be associated with improved survival relative to medical therapy among patients aged 50 years or older with advanced UC.

PRIMARY FUNDING SOURCE

National Institutes of Health and Agency for Healthcare Research and Quality.

Early investigational TNF receptor antagonists for the treatment of ulcerative colitis

INTRODUCTION

Ulcerative colitis (UC) is a life-long, immunologically mediated condition that results from an inappropriate activation of the mucosal immune system by intestinal luminal antigens in genetically susceptible individuals. TNF-α is a pro-inflammatory cytokine central to UC pathogenesis.

AREAS COVERED

This review examines the evidence for the use of the anti-TNF (αTNF) medications infliximab, adalimumab, certolizumab and golimumab in the management of UC. It highlights the newer biosimilar agents that are becoming available and the early stage investigation of an orally administered αTNF agent.

EXPERT OPINION

αTNF therapy is effective but only in a proportion of UC patients. As there is now strong evidence that UC is not just a single disease but a series of phenotypes with distinct genetic, serological and environmental aspects, understanding the heterogeneity of the innate immunological response in UC could allow for better targeted patient management. Identifying differences in the efficacy of the various αTNF agents is difficult as there are no head-to-head studies, but only infliximab has proven clinical efficacy in the management of acute severe colitis. Biosimilars to the αTNF agents are now available and with the added competition, medications costs should fall allowing for greater patient access.

Challenges in designing a national surveillance program for inflammatory bowel disease in the United States

This review describes the history of U.S. government funding for surveillance programs in inflammatory bowel diseases (IBD), provides current estimates of the incidence and prevalence of IBD in the United States, and enumerates a number of challenges faced by current and future IBD surveillance programs. A rationale for expanding the focus of IBD surveillance beyond counts of incidence and prevalence, to provide a greater understanding of the burden of IBD, disease etiology, and pathogenesis, is provided. Lessons learned from other countries are summarized, in addition to potential resources that may be used to optimize a new form of IBD surveillance in the United States. A consensus recommendation on the goals and available resources for a new model for disease surveillance are provided. This new model should focus on "surveillance of the burden of disease," including (1) natural history of disease and (2) outcomes and complications of the disease and/or treatments.

Prediction of disease complication occurrence in Crohn's disease using phenotype and genotype parameters at diagnosis

BACKGROUND AND AIMS

Complications associated with Crohn's disease (CD) are common and influence treatment decisions and outcomes. Appropriate early treatment may offer a therapeutic advantage to patients. The aim of our study was to indentify predictive factors for occurrence of complications at the time of CD diagnosis.

METHODS

The study population consisted of 269 CD patients treated during a ten year period. Risk factors compared between complicated and non-complicated disease included phenotypical characteristics, disease classification and the presence of NOD2/CARD15 mutations and single nucleotide polymorphisms in selected autophagy and phagosome genes.

RESULTS

Complete data was obtained for 146 patients with an average follow up of 12years. Sixty five patients (44%) developed a complication during follow up. The only independent risk factors associated with developing a complication were smoking and male gender. There was no association between developing complications and the presence of selected SNPs (P=0.07 for Tyrosine residue on both alleles in NCF4 SNP rs4821544 and P=0.06 for a Guanine residue on both alleles in ATG16L SNP rs2241880). Multivariate analysis using a backwards logistic regression model left only male gender as an independent statistically significant association with complicated disease (OR 2.6017, 95% CI: 1.17 to 5.75). The median time to developing a complication was 4years, and the most common complication was the need for surgical intervention (54%).

CONCLUSIONS

In the present study, a risk factor for developing CD complication was male gender. Further studies are warranted to assess additional risk factors and how such findings should affect therapy.