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Sendid B, Cornu M, Cordier C, Bouckaert J, Colombel JF, Poulain D. From ASCA breakthrough in Crohn's disease and Candida albicans research to thirty years of investigations about their meaning in human health. Autoimmun Rev 2024; 23:103486. [PMID: 38040100 DOI: 10.1016/j.autrev.2023.103486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/23/2023] [Indexed: 12/03/2023]
Abstract
Anti-Saccharomyces cerevisiae antibodies (ASCA) are human antibodies that can be detected using an enzyme-linked immunosorbent assay involving a mannose polymer (mannan) extracted from the cell wall of the yeast S. cerevisiae. The ASCA test was developed in 1993 with the aim of differentiating the serological response in two forms of inflammatory bowel disease (IBD), Crohn's disease and ulcerative colitis. The test, which is based on the detection of anti-oligomannosidic antibodies, has been extensively performed worldwide and there have been hundreds of publications on ASCA. The earlier studies concerned the initial diagnostic indications of ASCA and investigations then extended to many human diseases, generally in association with studies on intestinal microorganisms and the interaction of the micro-mycobiome with the immune system. The more information accumulates, the more the mystery of the meaning of ASCA deepens. Many fundamental questions remain unanswered. These questions concern the heterogeneity of ASCA, the mechanisms of their generation and persistence, the existence of self-antigens, and the relationship between ASCA and inflammation and autoimmunity. This review aims to discuss the gray areas concerning the origin of ASCA from an analysis of the literature. Structured around glycobiology and the mannosylated antigens of S. cerevisiae and Candida albicans, this review will address these questions and will try to clarify some lines of thought. The importance of the questions relating to the pathophysiological significance of ASCA goes far beyond IBD, even though these diseases remain the preferred models for their understanding.
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Affiliation(s)
- Boualem Sendid
- INSERM U1285, CNRS UMR 8576, Glycobiology in Fungal Pathogenesis and Clinical Applications, Université de Lille, F-59000 Lille, France; Pôle de Biologie-Pathologie-Génétique, Institut de Microbiologie, Service de Parasitologie-Mycologie, CHU Lille, F-59000 Lille, France.
| | - Marjorie Cornu
- INSERM U1285, CNRS UMR 8576, Glycobiology in Fungal Pathogenesis and Clinical Applications, Université de Lille, F-59000 Lille, France; Pôle de Biologie-Pathologie-Génétique, Institut de Microbiologie, Service de Parasitologie-Mycologie, CHU Lille, F-59000 Lille, France
| | - Camille Cordier
- INSERM U1285, CNRS UMR 8576, Glycobiology in Fungal Pathogenesis and Clinical Applications, Université de Lille, F-59000 Lille, France; Pôle de Biologie-Pathologie-Génétique, Institut de Microbiologie, Service de Parasitologie-Mycologie, CHU Lille, F-59000 Lille, France
| | - Julie Bouckaert
- CNRS UMR 8576, Computational Molecular Systems Biology, Université de Lille, F-59000 Lille, France
| | - Jean Frederic Colombel
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Daniel Poulain
- INSERM U1285, CNRS UMR 8576, Glycobiology in Fungal Pathogenesis and Clinical Applications, Université de Lille, F-59000 Lille, France.
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Fadel MG, Geropoulos G, Warren OJ, Mills SC, Tekkis PP, Celentano V, Kontovounisios C. Risks Factors Associated with the Development of Crohn's Disease After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: A Systematic Review and Meta-Analysis. J Crohns Colitis 2023; 17:1537-1548. [PMID: 36961323 PMCID: PMC10588783 DOI: 10.1093/ecco-jcc/jjad051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Following ileal pouch-anal anastomosis [IPAA] for ulcerative colitis [UC], up to 16% of patients develop Crohn's disease of the pouch [CDP], which is a major cause of pouch failure. This systematic review and meta-analysis aimed to identify preoperative characteristics and risk factors for CDP development following IPAA. METHODS A literature search of the MEDLINE, EMBASE, EMCare and CINAHL databases was performed for studies that reported data on predictive characteristics and outcomes of CDP development in patients who underwent IPAA for UC between January 1990 and August 2022. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. RESULTS Seven studies with 1274 patients were included: 767 patients with a normal pouch and 507 patients with CDP. Age at UC diagnosis (weighted mean difference [WMD] -2.85; 95% confidence interval [CI] -4.39 to -1.31; p = 0.0003; I2 54%) and age at pouch surgery [WMD -3.17; 95% CI -5.27 to -1.07; p = 0.003; I2 20%) were significantly lower in patients who developed CDP compared to a normal pouch. Family history of IBD was significantly associated with CDP (odds ratio [OR] 2.43; 95% CI 1.41-4.19; p = 0.001; I2 31%], along with a history of smoking [OR 1.80; 95% CI 1.35-2.39; p < 0.0001; I2 0%]. Other factors such as sex and primary sclerosing cholangitis were found not to increase the risk of CDP. CONCLUSIONS Age at UC diagnosis and pouch surgery, family history of IBD and previous smoking have been identified as potential risk factors for CDP post-IPAA. This has important implications towards preoperative counselling, planning surgical management and evaluating prognosis.
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Affiliation(s)
- Michael G Fadel
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Georgios Geropoulos
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Oliver J Warren
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Sarah C Mills
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Paris P Tekkis
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | - Valerio Celentano
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, UK
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Connelly TM, Lincango E, Holubar SD. Crohn's of the Pouch: Now What? Clin Colon Rectal Surg 2022; 35:475-486. [PMID: 36591396 PMCID: PMC9797285 DOI: 10.1055/s-0042-1758139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Total proctocolectomy and ileal pouch anal anastomosis (IPAA) is the gold standard surgical treatment for the majority (∼90%) of ulcerative colitis (UC) patients. In cases of carefully selected Crohn's colitis patients without small bowel or perianal involvement an "intentional IPAA" may be a viable option for disease resection and restoration of intestinal continuity. More commonly, Crohn's is incidentally found either in the resection specimen or, more commonly, when inflammatory complications subsequently arise after pouch construction for UC or indeterminate colitis. These incidental Crohn's pouches may be diagnosed early or late period post-IPAA. Crohn's may manifest within the pouch, in the proximal small bowel, and/or distally in the rectal cuff or anus. Like intestinal Crohn's, Crohn's disease of the pouch may be of an inflammatory, fibrostenosing, or fistulizing phenotype. Treatment depends on the phenotype and includes medical treatment, most commonly in the form of tumor necrosis factor inhibitor medications; however, the newer small molecules offer a potential treatment for these patients. Surgery first entails treating the sequelae of Crohn's and is typically staged. In up to 60% of Crohn's pouches, particularly in fistulizing disease and/or recalcitrant perianal disease, the pouch fails and must be defunctioned or excised. In patients with Crohn's pouches in situ long term, outcomes including quality of life are comparable to patients who underwent IPAA for UC.
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Affiliation(s)
- Tara M. Connelly
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eddy Lincango
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Stefan D. Holubar
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Barnes EL, Darlington K, Herfarth HH. Disease Monitoring of the Ileoanal Pouch: How to Utilize Biomarkers, Imaging, and Pouchoscopy. Curr Gastroenterol Rep 2022; 24:127-136. [PMID: 36255602 DOI: 10.1007/s11894-022-00850-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 12/04/2022]
Abstract
PURPOSE OF REVIEW Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis has been associated with multiple short- and long-term complications. In this review, we examine the role of biomarkers, imaging, and pouchoscopy in the assessment of patients after ileal pouch-anal anastomosis, with a particular focus on the emergence of novel biomarkers and techniques for evaluating and risk stratifying patients after this procedure in the hopes of improving outcomes in this specific population. RECENT FINDINGS There are indications that that the incidence of pouchitis may be increasing in recent decades. Calprotectin and other non-invasive imaging tests such as ultrasound may offer advantages in distinguishing patients with inflammatory conditions of the pouch from other etiologies. In the search for other biomarkers that may identify patients at risk for inflammatory conditions of the pouch, the stool microbiota and metabolomics may play a key role in identifying those patients at greatest risk for complications. Advances in biomarkers, imaging, and standardized pouchoscopy scoring offer immediate improvements in clinical care and will prompt future research efforts.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Campus Box #7080 130 Mason Farm Road, 27599-7080, Chapel Hill, NC, USA. .,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Kimberly Darlington
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Campus Box #7080 130 Mason Farm Road, 27599-7080, Chapel Hill, NC, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Campus Box #7080 130 Mason Farm Road, 27599-7080, Chapel Hill, NC, USA.,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Verstockt B, Bressler B, Martinez-Lozano H, McGovern D, Silverberg MS. Time to Revisit Disease Classification in Inflammatory Bowel Disease: Is the Current Classification of Inflammatory Bowel Disease Good Enough for Optimal Clinical Management? Gastroenterology 2022; 162:1370-1382. [PMID: 34995534 DOI: 10.1053/j.gastro.2021.12.246] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 12/12/2022]
Abstract
Inflammatory bowel disease (IBD), historically subdivided into Crohn's disease and ulcerative colitis, is a very heterogeneous condition. While the tendency in medicine is to try to reduce complexity, IBD is a disease that cannot justify a one-size-fits-all principle. Our current clinical classification tools are suboptimal and need further refinement to capture, at least in part, the variety of phenotypes encountered in daily clinical practice. Although these revised classification tools alone will not be sufficient and should be complemented by more detailed molecular subclassifications, optimized clinical phenotypes can contribute to improved trial designs, future translational research approaches, and better treatment outcomes. In the current review, we discuss key clinical features important in IBD disease heterogeneity, tackle limitations of the current classification systems, propose some potential improvements, and raise priorities for future research in this domain.
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Affiliation(s)
- Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Chronic Diseases and Metabolism, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Brian Bressler
- Division of Gastroenterology, Department of Medicine, St. Paul's Hopsital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Helena Martinez-Lozano
- Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Dermot McGovern
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Mark S Silverberg
- Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
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Bresteau C, Amiot A, Kirchgesner J, de'Angelis N, Lefevre JH, Bouhnik Y, Panis Y, Beaugerie L, Allez M, Brouquet A, Carbonnel F, Meyer A. Chronic pouchitis and Crohn's disease of the pouch after ileal pouch-anal anastomosis: Incidence and risk factors. Dig Liver Dis 2021; 53:1128-1135. [PMID: 33931341 DOI: 10.1016/j.dld.2021.03.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/07/2021] [Accepted: 03/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Restorative proctocolectomy with ileal-pouch anal-anastomosis (IPAA) is the operation of choice for patients with ulcerative colitis (UC) or with inflammatory bowel diseases unclassified (IBDU). AIMS to assess the incidence and risk factors of chronic pouchitis (CP) and Crohn's disease of the pouch (CDP) in patients with UC or IBDU. METHODS We conducted a retrospective study. We included consecutive patients who underwent IPAA between 2011 and 2019. The main outcome was the occurrence of CP or CDP. We looked for risk factors with multivariable and a least absolute shrinkage and selection operator (LASSO) Cox models. RESULTS 247 patients were included. The 5-year cumulative incidence of CP or CDP was 35.3% (95%CI: 26.2-43.2). In multivariable analysis, diagnosis of IBDU, age less than 35 years at surgery and extra-intestinal manifestations other than articular and primary sclerosing cholangitis were associated with higher incidence. The LASSO analysis identified these three prognostic factors and articular manifestations. In patients with two or more prognostic factors, 5-year cumulative incidence, was 65.2% (95%CI: 41.8-79.2). CONCLUSIONS Five years after IPAA, approximately one-third of patients had either CP or CDP. Risk factors were IBDU, an age less than 35 years at surgery, articular manifestations and other extra-intestinal manifestations.
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Affiliation(s)
- Clément Bresteau
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Université Paris Saclay, CHU Bicêtre, 78, rue du Général Leclerc, Le Kremlin Bicêtre 94270, France
| | - Aurélien Amiot
- Assitance-Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, EA7375, Universite Paris Est Creteil, Créteil, France
| | - Julien Kirchgesner
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Nicola de'Angelis
- Assitance-Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, EA7375, Universite Paris Est Creteil, Créteil, France
| | - Jérémie H Lefevre
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Yoram Bouhnik
- Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, Université de Paris, Clichy, France
| | - Yves Panis
- Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, Université de Paris, Clichy, France
| | - Laurent Beaugerie
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Matthieu Allez
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, Université de Paris, Paris, France
| | - Antoine Brouquet
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Université Paris Saclay, CHU Bicêtre, 78, rue du Général Leclerc, Le Kremlin Bicêtre 94270, France
| | - Franck Carbonnel
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Université Paris Saclay, CHU Bicêtre, 78, rue du Général Leclerc, Le Kremlin Bicêtre 94270, France.
| | - Antoine Meyer
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Université Paris Saclay, CHU Bicêtre, 78, rue du Général Leclerc, Le Kremlin Bicêtre 94270, France
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Shen B, Kochhar GS, Kariv R, Liu X, Navaneethan U, Rubin DT, Cross RK, Sugita A, D'Hoore A, Schairer J, Farraye FA, Kiran RP, Fleshner P, Rosh J, Shah SA, Chang S, Scherl E, Pardi DS, Schwartz DA, Kotze PG, Bruining DH, Kane SV, Philpott J, Abraham B, Segal J, Sedano R, Kayal M, Bentley-Hibbert S, Tarabar D, El-Hachem S, Sehgal P, McCormick JT, Picoraro JA, Silverberg MS, Bernstein CN, Sandborn WJ, Vermeire S. Diagnosis and classification of ileal pouch disorders: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol Hepatol 2021; 6:826-849. [PMID: 34416186 DOI: 10.1016/s2468-1253(21)00101-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis is an option for most patients with ulcerative colitis or familial adenomatous polyposis who require colectomy. Although the construction of an ileal pouch substantially improves patients' health-related quality of life, the surgery is, directly or indirectly, associated with various structural, inflammatory, and functional adverse sequelae. Furthermore, the surgical procedure does not completely abolish the risk for neoplasia. Patients with ileal pouches often present with extraintestinal, systemic inflammatory conditions. The International Ileal Pouch Consortium was established to create this consensus document on the diagnosis and classification of ileal pouch disorders using available evidence and the panellists' expertise. In a given individual, the condition of the pouch can change over time. Therefore, close monitoring of the activity and progression of the disease is essential to make accurate modifications in the diagnosis and classification in a timely manner.
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Affiliation(s)
- Bo Shen
- Center for Interventional Inflammatory Bowel Disease, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA.
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Revital Kariv
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Xiuli Liu
- Department of Pathology and Immunology, Washington University, MO, USA
| | - Udayakumar Navaneethan
- IBD Center and IBD Interventional Unit, Center for Interventional Endoscopy, Orlando Health, Orlando, FL, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Raymond K Cross
- Inflammatory Bowel Disease Program, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Akira Sugita
- Department of Clinical Research and Department of Inflammatory Bowel Disease, Yokohama Municipal Citizens Hospital Yokohama, Japan
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Belgium
| | - Jason Schairer
- Department of Gastroenterology, Henry Ford Health System, Detroit, MI, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - Philip Fleshner
- Division of Colorectal Surgery, University of California-Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Joel Rosh
- Department of Pediatric Gastroenterology, Goryeb Children's Hospital-Atlantic Health, Morristown, NJ, USA
| | - Samir A Shah
- Alpert Medical School of Brown University and Miriam Hospital, Gastroenterology Associates, Providence, RI, USA
| | - Shannon Chang
- Division of Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Ellen Scherl
- New York Presbyterian Hospital, Jill Roberts Center for IBD, Weill Cornell Medicine, Gastroenterology and Hepatology, New York, NY, USA
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - David A Schwartz
- Department of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Paulo G Kotze
- IBD Outpatients Clinic, Catholic University of Paraná, Curitiba, Brazil
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Bincy Abraham
- Houston Methodist and Weill Cornell Medical College, Houston, TX, USA
| | - Jonathan Segal
- Department of Gastroenterology and Hepatology, Hillingdon Hospital, Uxbridge, UK
| | - Rocio Sedano
- Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada
| | - Maia Kayal
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Stuart Bentley-Hibbert
- Department of Radiology, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - Dino Tarabar
- IBD Clinical Center, University Hospital Center Dr Dragiša Mišović, Belgrade, Serbia
| | - Sandra El-Hachem
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Priya Sehgal
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - James T McCormick
- Division of Colon and Rectal Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Joseph A Picoraro
- Department of Pediatrics, Columbia University Irving Medical Center-Morgan Stanley Children's Hospital, New York, NY, USA
| | - Mark S Silverberg
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, Toronto, ON, Canada
| | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - William J Sandborn
- Department of Gastroenterology, University of California San Diego, San Diego, CA, USA
| | - Séverine Vermeire
- Department of Gastroenterology, University hospitals Leuven, Leuven, Belgium
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Outcomes Following Pouch Formation in Paediatric Ulcerative Colitis: A Study From the Porto Group of ESPGHAN. J Pediatr Gastroenterol Nutr 2020; 71:346-353. [PMID: 32541197 DOI: 10.1097/mpg.0000000000002805] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Contemporary pediatric data on pouch outcomes are sparse, especially in the era of laparoscopic surgeries. We aimed to assess outcomes and predictors in children with ulcerative colitis/inflammatory bowel disease (IBD)-unclassified who underwent colectomy and ileal pouch-anal anastomosis. METHODS This was a multicenter retrospective cohort study from 17 IBD centers affiliated with the pediatric IBD Porto group of ESPGHAN. An electronic REDcap system was used to collate baseline characteristics, demographic, clinical, management and surgical data, short- and long-term outcomes, and to identify potential predictors of pouch outcome. RESULTS Of the 129 patients included, 86 (67%) developed pouchitis during follow-up of median 40 months (interquartile range 26-72), of whom 33 (26%) with chronic pouchitis. Patients operated on by surgeons performing <10 pouch surgeries/year had a higher rate of chronic pouchitis (11/27 [41%] vs 8/54 [15%], P = 0.013) on both univariable and multivariable analyses and also associated with time to pouchitis (P = 0.018) and chronic pouchitis (P = 0.020). At last follow-up, overall pouch performance was rated good/excellent in 86 (74%) patients. Time from colectomy to pouch formation was not associated with pouch outcomes. Despite higher rate of nonsevere surgical complications among children undergoing colectomy at <10 years of age (7/16 [44%] vs 10/92 [11%], P = 0.003), functional outcome and pouchitis rate did not differ. CONCLUSIONS Pouchitis rate in children with ulcerative colitis/IBD unclassified is high. Surgeon experience is the major modifiable risk factor for pouch outcome. Our analyses suggest that pouch surgery can also be performed successfully in young children.
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Barnes EL, Kochar B, Jessup HR, Herfarth HH. The Incidence and Definition of Crohn's Disease of the Pouch: A Systematic Review and Meta-analysis. Inflamm Bowel Dis 2019; 25:1474-1480. [PMID: 30698715 PMCID: PMC6703435 DOI: 10.1093/ibd/izz005] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND A subset of patients who undergo total proctocolectomy with ileal pouch-anal anastomosis (IPAA) creation for ulcerative colitis (UC) will later develop Crohn's disease (CD) of the pouch, which has been associated with significant morbidity. We aimed to analyze the incidence of CD of the pouch and to review the existing diagnostic criteria utilized. METHODS A systematic search performed through March 1, 2018, identified 12 studies that reported the incidence of CD of the pouch after IPAA for UC or indeterminate colitis (IC). We compiled all diagnostic criteria utilized in these studies and then performed a meta-analysis using random effects modeling to estimate the overall incidence of CD of the pouch in this population. RESULTS Among 4843 patients with an IPAA for UC or IC, 10.3% of patients were ultimately diagnosed with CD of the pouch (95% confidence interval [CI], 6.1%-15.4%). The most commonly reported diagnostic criteria were (1) presence of fistula/fistulae, (2) stricture involving the pouch or prepouch ileum, and (3) presence of prepouch ileitis. In a secondary analysis, excluding those studies that included patients with a preoperative diagnosis of IC, the incidence of CD of the pouch was 12.4% (95% CI, 9.0%-16.1%). CONCLUSIONS The estimated incidence of 10.3% will assist gastroenterologists and surgeons in preoperative counseling regarding the potential to develop CD of the pouch. There is an unmet need for common diagnostic criteria for a more standardized approach to the diagnosis of CD of the pouch.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,Address correspondence to: Edward L. Barnes, MD, MPH, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, 130 Mason Farm Road, Bioinformatics Building, CB #7080, Chapel Hill, NC 27599-7080 ()
| | - Bharati Kochar
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Hilary R Jessup
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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10
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Goren I, Godny L, Reshef L, Yanai H, Gophna U, Tulchinsky H, Dotan I. Starch Consumption May Modify Antiglycan Antibodies and Fecal Fungal Composition in Patients With Ileo-Anal Pouch. Inflamm Bowel Dis 2019; 25:742-749. [PMID: 30535148 DOI: 10.1093/ibd/izy370] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Inflammatory bowel diseases (IBDs) are characterized by serologic responses to glycans. Patients with ulcerative colitis (UC) after proctocolectomy with ileo-anal anastomosis (pouch surgery) may develop inflammation (pouchitis) that resembles Crohn's disease (CD). We hypothesized that patients' serologic responses were affected by their consumption of dietary sugars. This study analyzed the correlations between antiglycan antibody expression and dietary sugar consumption in patients with UC pouch and the evolution in antibody levels over time. METHODS Patients were followed prospectively for 2 consecutive visits. The following antiglycan carbohydrate antibodies were detected by enzyme-linked immunosorbent assay: antichitobioside (ACCA), antilaminaribioside (ALCA), antimannobioside (AMCA), and anti-Saccharomyces cerevisiae (ASCA) antibodies. Patients completed a food frequency questionnaire. The fungal community in patients' fecal samples was analyzed by sequencing the internal transcribed spacer 2 (ITS2) region of nuclear ribosomal DNA. RESULTS We included 75 UC pouch patients aged 45.2 ± 14 years who underwent pouch surgery 9.8 ± 6.7 years previously. Of these patients, 34.7% (n = 26) showed seropositivity for antiglycan antibodies. Starch consumption was significantly higher in patients with positive serologic responses (P = 0.05). Higher starch consumption was associated with higher AMCA and ACCA titers, which increased by 4.08% (0.8%-7.4%; P = 0.014) and 4.8% (0.7%-9.1%; P = 0.007), respectively, for each 10-g increase of dietary starch. The per-patient change in the relative abundance of Candida albicans in fecal samples correlated positively with changes in starch consumption (Spearman's r = 0.72; P = 0.012). CONCLUSIONS Starch consumption correlated with positive antiglycan serology (ACCA and AMCA), suggesting that increased dietary starch intake may promote a specific immune response in patients with IBD.
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Affiliation(s)
- Idan Goren
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lihi Godny
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leah Reshef
- Department of Molecular Microbiology and Biotechnology, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Henit Yanai
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Gophna
- Department of Molecular Microbiology and Biotechnology, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Hagit Tulchinsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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11
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Ben-Shachar S, Finezilber Y, Elad H, Rabinowitz K, Goren I, Isakov O, Yanai H, Dotan I. Genotype-Serotype Interactions Shed Light on Genetic Components of Inflammatory Bowel Diseases. Inflamm Bowel Dis 2019; 25:336-344. [PMID: 30265311 DOI: 10.1093/ibd/izy231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND We evaluated the impact of variations in ATG16L1 and NOD2 and genes on serologic responses in patients with inflammatory bowel disease (IBD). METHODS We recruited 308 IBD patients: 130 with Crohn's disease (CD), 67 with ulcerative colitis (UC), 111 with UC and an ileal pouch (UC-pouch), and 74 healthy controls. NOD2 variants (1007fs, G908R, R702W) and the ATG16L1 A300T variant were analyzed. The antiglycan antibodies anti-Saccharomyces cerevisiae (ASCA), antilaminaribioside (ALCA), antichitobioside (ACCA), and antimannobioside carbohydrate (AMCA) were analyzed by enzyme-linked immunosorbent assay. RESULTS Antichitobioside was positive in 28% of patients with CD carrying the ATG16L1 A300T variant (either heterozygote or homozygote) compared with only 3% in those without the variant (P < 0.001). Anti-Saccharomyces cerevisiae was positive in 86% of patients with CD carrying the NOD2 1007fs variant compared with 36% in those without the variant (P < 0.001). UC-pouch patients with the NOD2 1007fs variant had elevated ASCA and ALCA levels compared with those without the variant (50% vs 7%, P = 0.004, and 50% vs 8%, P = 0.006, respectively). Importantly, ATG16L1 A300T and NOD2 variants were not associated with serologic responses in healthy controls and unoperated UC patients. Multivariate analysis demonstrated that these genetic variants are the main factors associated with specific antiglycan antibody levels in CD and pouch patients. CONCLUSIONS Genetic variants may have disease-specific phenotypic (serotypic) effects. This implies that genetic risk factors may also be disease modifiers.
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Affiliation(s)
| | - Yael Finezilber
- IBD Center, Department of Gastroenterology and Liver Diseases
| | - Hofit Elad
- IBD Center, Department of Gastroenterology and Liver Diseases
| | | | - Idan Goren
- IBD Center, Department of Gastroenterology and Liver Diseases
| | | | - Henit Yanai
- IBD Center, Department of Gastroenterology and Liver Diseases
| | - Iris Dotan
- IBD Center, Department of Gastroenterology and Liver Diseases
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12
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Cummings D, Cruise M, Lopez R, Roggenbuck D, Jairath V, Wang Y, Shen B, Rieder F. Loss of tolerance to glycoprotein 2 isoforms 1 and 4 is associated with Crohn's disease of the pouch. Aliment Pharmacol Ther 2018; 48:1251-1259. [PMID: 30411391 DOI: 10.1111/apt.15034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 08/30/2018] [Accepted: 10/04/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Zymogen granule glycoprotein 2 (GP2) is a major autoantigen of Crohn's disease-specific pancreatic autoantibodies. AIM To test a link between loss of tolerance to isoforms of GP2 and pouch disorders in a cross-sectional study in ulcerative colitis patients with ileal pouch-anal anastomosis (IPAA). METHODS Serum samples of 117 consecutive ulcerative colitis patients after IPAA were tested for presence of Anti-GP2 isoforms 1 (GP21 ) & 4 (GP24 ) IgG and IgA as well as anti-Saccaromyces cervisiae (ASCA) IgG and IgA antibodies in a blinded fashion via enzyme-linked immunosorbent assay. Pouch disorders were diagnosed based on clinical, endoscopic, histological and radiographic criteria. Crohn's disease of the pouch was defined as involvement of the small bowel mucosa proximal to the ileal pouch with Crohn's disease, development of perianal complications or pouch fistula more than 3 months after ileostomy closure. RESULTS Positivity and level of Anti-GP21 IgG (AUC 0.77; P < 0.001 & P = 0.02, respectively), Anti-GP24 IgG (AUC 0.74; P < 0.001 & P = 0.025, respectively) and Anti-GP24 IgA (AUC 0.77; P < 0.001 to P = 0.018, respectively) were specifically associated with Crohn's disease of the pouch. Anti-GP2 was not associated with endoscopic or histological pouch disease activity index. Neither positivity nor levels of ASCA IgG (AUC 0.63; P = 0.12 & P = 0.35, respectively) or ASCA IgA (AUC 0.67; P = 0.38 & P = 0.53) were associated with pouch phenotypes. CONCLUSIONS The novel anti-GP21 and GP24 antibodies are associated with Crohn's disease of the pouch in ulcerative colitis patients after IPAA. Serological anti-GP2 antibodies could aid in diagnosis of Crohn's disease of the pouch.
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Affiliation(s)
- Donelle Cummings
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic Foundation, Cleveland, Ohio.,Division of Gastroenterology and Hepatology, Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Michael Cruise
- Department of Anatomic Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Rocio Lopez
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Dirk Roggenbuck
- Faculty Environment and Natural Sciences, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg, Germany
| | - Vipul Jairath
- Department of Medicine, University of Western Ontario, London, ON, Canada.,Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio.,University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bo Shen
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Florian Rieder
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio.,Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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13
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Turner D, Ruemmele FM, Orlanski-Meyer E, Griffiths AM, de Carpi JM, Bronsky J, Veres G, Aloi M, Strisciuglio C, Braegger CP, Assa A, Romano C, Hussey S, Stanton M, Pakarinen M, de Ridder L, Katsanos K, Croft N, Navas-López V, Wilson DC, Lawrence S, Russell RK. Management of Paediatric Ulcerative Colitis, Part 1: Ambulatory Care-An Evidence-based Guideline From European Crohn's and Colitis Organization and European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 67:257-291. [PMID: 30044357 DOI: 10.1097/mpg.0000000000002035] [Citation(s) in RCA: 232] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The contemporary management of ambulatory ulcerative colitis (UC) continues to be challenging with ∼20% of children needing a colectomy within childhood years. We thus aimed to standardize daily treatment of pediatric UC and inflammatory bowel diseases (IBD)-unclassified through detailed recommendations and practice points. METHODS These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the Paediatric IBD Porto group of European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). An extensive literature search with subsequent evidence appraisal using robust methodology was performed before 2 face-to-face meetings. All 40 included recommendations and 86 practice points were endorsed by 43 experts in Paediatric IBD with at least an 88% consensus rate. RESULTS These guidelines discuss how to optimize the use of mesalamine (including topical), systemic and locally active steroids, thiopurines and, for more severe disease, biologics. The use of other emerging therapies and the role of surgery are also covered. Algorithms are provided to aid therapeutic decision-making based on clinical assessment and the Paediatric UC Activity Index (PUCAI). Advice on contemporary therapeutic targets incorporating the use of calprotectin and the role of therapeutic drug monitoring are presented, as well as other management considerations around pouchitis, extraintestinal manifestations, nutrition, growth, psychology, and transition. A brief section on disease classification using the PIBD-classes criteria and IBD-unclassified is also part of these guidelines. CONCLUSIONS These guidelines provide a guide to clinicians managing children with UC and IBD-unclassified management to provide modern management strategies while maintaining vigilance around appropriate outcomes and safety issues.
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Affiliation(s)
- Dan Turner
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Frank M Ruemmele
- Université Paris Descartes, Sorbonne Paris Cité, APHP, Hôpital Necker Enfants Malades, Paris, France
| | | | - Anne M Griffiths
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Gabor Veres
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialistic Surgery, University of Campania "Luigi Vanvitelli," Napoli, Italy
| | | | - Amit Assa
- Schneider Children's Hospital, Petach Tikva, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Claudio Romano
- Pediatric Department, University of Messina, Messina, Italy
| | - Séamus Hussey
- National Children's Research Centre, Royal College of Surgeons of Ireland and University College Dublin, Dublin, Ireland
| | | | - Mikko Pakarinen
- Helsinki University Children's Hospital, Department of Pediatric Surgery, Helsinki, Finland
| | - Lissy de Ridder
- Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Nick Croft
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Victor Navas-López
- Pediatric Gastroenterology and Nutrition Unit. Hospital Materno, IBIMA, Málaga, Spain
| | - David C Wilson
- Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - Sally Lawrence
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
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14
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Khan F, Gao XH, Singh A, Philpott JR, Shen B. Vedolizumab in the treatment of Crohn's disease of the pouch. Gastroenterol Rep (Oxf) 2018; 6:184-188. [PMID: 30151202 PMCID: PMC6101609 DOI: 10.1093/gastro/goy014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 05/04/2018] [Indexed: 12/15/2022] Open
Abstract
Background Our recent study showed the efficacy and safety of vedolizumab in the treatment of chronic antibiotic-refractory pouchitis. However, there are no published studies on its efficacy and safety in Crohn’s disease (CD) of the pouch. The aim of this study was to assess the efficacy and safety of vedolizumab in those patients. Methods This case series included all eligible patients with CD of the pouch from our prospectively maintained, IRB-approved Pouchitis Registry from 2015 to 2017. Disease activity in pouch patients can be monitored using the modified Pouchitis Disease Activity Index (mPDAI). mPDAI is the 18-point pouchitis disease activity index consisting of three principal component scores: symptom (range, 0–6 points), endoscopy, (range 0–6 points), and histology (range, 2–6 points). Pre- and post- treatment (minimum 6 months) pouchoscopy and clinical visits were used to calculate mPDAI. Results A total of 12 patients were included in this study, who had restorative proctocolectomy with ileal pouch anal anastomosis for medically refractory ulcerative colitis (UC). The mean age at the time of pre-colectomy diagnosis of UC was 25.0 ± 11.5 years. The mean current age was 41.0 ± 12.1 years, nine (75.0%) were female, three (25.0%) had smoked and eight (66.7%) had used anti-tumor necrosis factor agents prior to vedolizumab use. The mean duration of vedolizumab use was 1.0 ± 6.4 years. There was a significant reduction in mPDAI symptom subscores after vedolizumab therapy (3.50 ± 1.93 vs 5.08 ± 0.79, P = 0.015). The pre- and post-treatment mean endoscopy subscores were 1.25 ± 1.36 and 0.91 ± 1.50 in the afferent limb (P = 0.583); 2.58 ± 1.68 and 2.27 ± 2.05 (P = 0.701) in the pouch body; and 2.67 ± 1.93 and 2.09 ± 2.12 (P = 0.511) in the cuff, respectively. None of the patients experienced side effects throughout the vedolizumab therapy. Conclusion The findings of our study suggests that vedolizumab appears to be effective and safe in reducing the symptoms in patients with CD of the pouch.
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Affiliation(s)
- Freeha Khan
- Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xian-Hua Gao
- Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amandeep Singh
- Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jessica R Philpott
- Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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15
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Abel AG, Chung A, Paul E, Gibson PR, Sparrow MP. Patchy colitis, and young age at diagnosis and at the time of surgery predict subsequent development of Crohn's disease after ileal pouch-anal anastomosis surgery for ulcerative colitis. JGH Open 2018; 2:8-14. [PMID: 30483556 PMCID: PMC6207023 DOI: 10.1002/jgh3.12035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 10/18/2017] [Accepted: 11/30/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIM A proportion of patients having total proctocolectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) are later diagnosed with Crohn's disease (CD). The aim of this study was to identify preoperative and perioperative predictors for the subsequent development of CD in patients who had IPAA for presumed UC. METHODS A retrospective case-control study of patients undergoing IPAA surgery for presumed UC was undertaken. Cases were patients who had a revised diagnosis of CD after surgery. Preoperative and perioperative variables were examined and analyzed. RESULTS Fifteen cases were compared with 39 controls. Patients aged ≤25 years at initial UC diagnosis were more likely to develop CD compared to those aged >25 years (odds ratio, OR [95% confidence interval, CI]: 7.1 [1.6-31.3]; P = 0.01). Patients aged ≤30 years at the time of colectomy had an increased risk of subsequent development of CD compared to those aged >30 years (OR [95% CI]: 4.5 [1.3-16.0]; P = 0.02). Cases were more likely to have patchy colitis on their colectomy specimen (OR [95% CI]: 6.7 [1.1-41.8]; P = 0.04). There was no significant difference between groups regarding transmural inflammation, ileitis, or fissuring ulcers on colectomy specimens, or preoperative C-reactive protein (CRP), albumin, family history, and smoking status. CONCLUSION Predictors of the development of CD in the pouch include young age at diagnosis and at the time of surgery, and patchy colitis in the resected colon.
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Affiliation(s)
- Alexandra G Abel
- Department of GastroenterologyThe Alfred HospitalMelbourneVictoriaAustralia
| | - Alvin Chung
- Department of GastroenterologyEastern HealthMelbourneVictoriaAustralia
| | - Eldho Paul
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of Clinical HematologyThe Alfred HospitalMelbourneVictoriaAustralia
| | - Peter R Gibson
- Department of GastroenterologyThe Alfred HospitalMelbourneVictoriaAustralia
| | - Miles P Sparrow
- Department of GastroenterologyThe Alfred HospitalMelbourneVictoriaAustralia
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16
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Gu P, Kapur A, Li D, Haritunians T, Vasiliauskas E, Shih DQ, Targan SR, Spiegel BM, McGovern DP, Black JT, Melmed GY. Serological, genetic and clinical associations with increased health-care resource utilization in inflammatory bowel disease. J Dig Dis 2018; 19:15-23. [PMID: 29251413 PMCID: PMC6023617 DOI: 10.1111/1751-2980.12566] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 12/05/2017] [Accepted: 12/12/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Inflammatory bowel diseases (IBD) are associated with significant morbidity and economic burden. The variable course of IBD creates a need for predictors of clinical outcomes and health resource utilization (HRU) to guide treatment decisions. We aimed to identify clinical, serological or genetic markers associated with inpatient resource utilization in patients with ulcerative colitis (UC) and Crohn's disease (CD). METHODS Patients with IBD with available genetic and serological data who had at least one emergency department visit or hospitalization in a 3-year period were included. The primary outcome measure was HRU, as measured by the All Patient Refined Diagnosis Related Group classification system. Univariate and multivariate linear and logistic regression models were used to identify the associations with HRU. RESULTS Altogether 858 (562 CD and 296 UC) patients were included. Anti-CBir1 seropositivity (P = 0.002, effect size [ES]: 0.762, 95% confidence interval [CI] 0.512-1.012) and low socioeconomic status (P = 0.005, ES: 1.620 [95% CI 1.091-2.149]) were independently associated with a high HRU. CD diagnosis (P = 0.006, ES: -0.701 [95% CI -0.959 to -0.443]) was independently associated with a low inpatient HRU. CONCLUSION In patients with IBD who required at least one emergency department visit or hospitalization, anti-CBir1 antibody status may be a useful biomarker of HRU when formulating management strategies to reduce disease complications and resource utilization.
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Affiliation(s)
- Phillip Gu
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Anshika Kapur
- F Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Dalin Li
- F Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Talin Haritunians
- F Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Eric Vasiliauskas
- F Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - David Q. Shih
- F Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephan R. Targan
- F Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Brennan M.R. Spiegel
- Center for Outcomes Research and Education, Cedars-Sinai Health System, Los Angeles, CA
| | - Dermot P.B. McGovern
- F Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jeanne T. Black
- Resource & Outcomes Management Department, Cedars-Sinai Health System, Los Angeles, CA
| | - Gil Y. Melmed
- F Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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17
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Ramage L, Yen C, Qiu S, Simillis C, Kontovounisios C, Tan E, Tekkis P. Does a missed obstetric anal sphincter injury at time of delivery affect short-term functional outcome? Ann R Coll Surg Engl 2018; 100:26-32. [PMID: 29022787 PMCID: PMC5838671 DOI: 10.1308/rcsann.2017.0140] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2017] [Indexed: 12/15/2022] Open
Abstract
Introduction This study aimed to ascertain whether missed obstetric anal sphincter injury at delivery had worse functional and quality of life outcomes than primary repair immediately following delivery. Materials and methods Two to one propensity matching was undertaken of patients presenting to a tertiary pelvic floor unit with ultrasound evidence of missed obstetric anal sphincter injury within 24 months of delivery with patients who underwent primary repair at the time of delivery by parity, grade of injury and time to assessment. Outcomes compared included Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ), Wexner Incontinence Score, Short Form-36, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire and anorectal physiology results. Results Thirty-two missed anal sphincter injuries were matched two to one with sixty-two patients who underwent primary repair of an anal sphincter defect. Mean time to follow-up was 9.31 ± 6.79 months. Patients with a missed anal sphincter injury had suffered more incontinence, as seen in higher the Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ; 30.56% ± 14.41% vs. 19.75% ± 15.65%, P = 0.002) and Wexner scores (6.00 ± 3.76 vs. 3.67 ± 4.06, P = 0.009). They also had a worse BBUSQ urinary domain score (28.25% ± 14.9% vs. 17.01 ± 13.87%, P = 0.001) and worse physical functioning as measured by the Short Form-36 questionnaire (P = 0.045). There were no differences in other outcomes compared, including anorectal physiology and sexual function. Discussion In the short-term, patients with a missed obstetric anal sphincter injury had significantly worse faecal incontinence and urinary function scores, however quality of life and sexual function were largely comparable between groups. Conclusions Longer-term follow-up is needed to assess the effects of missed obstetric anal sphincter injury over time.
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Affiliation(s)
- L Ramage
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust , London , UK
| | - C Yen
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust , London , UK
| | - S Qiu
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust , London , UK
| | - C Simillis
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust , London , UK
| | - C Kontovounisios
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust , London , UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust , London , UK
| | - E Tan
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust , London , UK
- Department of Colorectal Surgery, Singapore General Hospital , Republic of Singapore
| | - P Tekkis
- Department of Surgery and Cancer, Chelsea and Westminster Hospital, Imperial College London NHS Trust , London , UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust , London , UK
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18
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Robbins L, Zaghiyan K, Melmed G, Vasiliauskas E, Ahmed S, McGovern D, Rabizadeh S, Singh N, Landers C, Ippoliti A, Shih D, Targan S, Fleshner P. Outcomes with Anti-Tumour Necrosis Factor-Alpha Therapy and Serology in Patients with Denovo Crohn's Disease After Ileal Pouch Anal Anastomosis. J Crohns Colitis 2017; 11:77-83. [PMID: 27466172 DOI: 10.1093/ecco-jcc/jjw134] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/31/2016] [Accepted: 06/03/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS A subset of patients who undergo ileal pouch-anal anastomosis [IPAA] for ulcerative colitis [UC] will later be diagnosed with denovo Crohn's disease [CD]. These patients have a higher risk of pouch failure. In this study we evaluated inflammatory bowel disease [IBD] serology in patients with denovo CD and examined the success of anti-tumour necrosis factor-alpha [anti-TNFα] therapy in preventing ileostomy in denovo CD patients who failed anti-TNFα therapy before IPAA. METHODS A prospectively maintained database of patients undergoing IPAA was reviewed to identify patients who developed denovo CD [defined as small bowel inflammation above the pouch inlet or pouch fistula/perianal disease appearing more than 3 months after stoma closure]. Clinical characteristics and IBD serology were analysed. Treatment failure was defined as pouch failure requiring ileostomy or pouchectomy. RESULTS Of 350 patients included in the study, 92 [26%] patients developed denovo CD. Significantly more denovo CD patients had anti-I2 positivity postoperatively versus preoperatively [p = 0.007]. Anti-TNFα therapy successfully treated denovo CD in 28 out of 38 [74%] patients. Out of 17 patients with denovo CD who had failed to respond to anti-TNFα agents before surgery and were treated with anti-TNFα therapy after surgery, 12 [71%] patients responded to treatment. CONCLUSIONS I2 serology may possibly help identify patients who have developed or are at risk for developing denovo CD. Anti-TNFα therapy for denovo CD after IPAA can help prevent permanent ileostomy in almost 75% of cases, even in patients who previously failed anti-TNFα treatment before surgery.
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Affiliation(s)
- Lori Robbins
- Departments of Medicine, Colon and Rectal Surgery
| | | | | | | | | | | | - Shervin Rabizadeh
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Namita Singh
- Inflammatory Bowel Disease Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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19
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Abstract
Radiation therapy is a viable option in managing potentially life-threatening malignancies including prostate cancer. It is known that pelvic radiation can result in injury of the distal large bowel with the development of radiation proctitis. Despite reports from retrospective studies, there is a lack of direct endoscopic and histologic evidence of external pelvic radiation injury to the ileal pouch-anal anastomosis. We present a case of a 68-year-old male with pouchitis resulting from pelvic radiation for prostate cancer.
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Schieffer KM, Williams ED, Yochum GS, Koltun WA. Review article: the pathogenesis of pouchitis. Aliment Pharmacol Ther 2016; 44:817-35. [PMID: 27554912 PMCID: PMC5785099 DOI: 10.1111/apt.13780] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/03/2015] [Accepted: 08/04/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND A total proctocolectomy followed by ileal pouch-anal anastomosis is a potentially curative surgery for ulcerative colitis or familial adenomatous polyposis. About 5-35% of patients with ulcerative colitis and 0-11% of patients with familial adenomatous polyposis develop subsequent inflammation of the ileal pouch termed pouchitis. AIM To provide a comprehensive analysis of the research studying the possible pathogenesis of pouchitis. The goals were to identify promising areas of investigation, to help focus clinicians, researchers and patients on how to better understand and then potentially manage ileal pouchitis, and to provide avenues for future research investigations. METHODS This review examined manuscripts from 1981 to 2015 that discussed and/or proposed hypotheses with supportive evidence for the potential underlying pathogenic mechanism for pouchitis. RESULTS The pathogenesis of pouchitis is not definitively understood, but various hypotheses have been proposed, including (i) recurrence of ulcerative colitis, (ii) dysbiosis of the ileal pouch microbiota, (iii) deprivation of nutritional short-chain fatty acids, (iv) mucosal ischaemia and oxygen-free radical injury, (v) host genetic susceptibility and (vi) immune dysregulation. However, none of these alone are able to fully explain pouchitis pathogenesis. CONCLUSIONS Pouchitis, similar to inflammatory bowel disease, is a complex disorder that is not caused by any one single factor. More likely, pouchitis occurs through a combination of both dysregulated host inflammatory mechanisms and interaction with luminal microbiota.
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Affiliation(s)
- Kathleen M. Schieffer
- Department of Surgery, Division of Colon and Rectal Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA 17033
| | - Emmanuelle D. Williams
- Department of Medicine, Division of Gastroenterology, The Pennsylvania State University, College of Medicine, Hershey, PA, USA 17033
| | - Gregory S. Yochum
- Department of Surgery, Division of Colon and Rectal Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA 17033,Department of Biochemistry & Molecular Biology, The Pennsylvania State University, College of Medicine, Hershey, PA, USA 17033
| | - Walter A. Koltun
- Department of Surgery, Division of Colon and Rectal Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA 17033
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Abstract
Crohn's disease (CD) of the pouch is an increasingly recognized diagnosis after ileal pouch-anal anastomosis. This post-ileal pouch-anal anastomosis diagnosis in conjunction with pouchitis remains the leading reason for pouch excision. Unfortunately, CD of the pouch remains a difficult diagnosis with lack of a uniform definition largely because of its similarity to common postoperative pouch complications, including pouchitis, abscess formation, or stricture at the anastomosis. Once diagnosed, treatment algorithms largely include multimodal therapy including biologics. This review focuses on the definition, etiology, diagnosis, and treatment for CD of the pouch, a postoperative de novo diagnosis of CD.
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Kelly OB, Rosenberg M, Tyler AD, Stempak JM, Steinhart AH, Cohen Z, Greenberg GR, Silverberg MS. Infliximab to Treat Refractory Inflammation After Pelvic Pouch Surgery for Ulcerative Colitis. J Crohns Colitis 2016; 10:410-7. [PMID: 26721938 PMCID: PMC4946767 DOI: 10.1093/ecco-jcc/jjv225] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Revised: 10/06/2015] [Accepted: 10/08/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Inflammatory pouch complications refractory to first-line therapies remain problematic following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). We evaluated infliximab efficacy and associations with therapeutic response. METHODS Data from individuals who underwent colectomy and IPAA for UC (2000-2014) were reviewed. Patients with chronic refractory pouchitis (CP) and Crohn's disease (CD)-like outcomes treated with infliximab were included. Pre-treatment parameters and response at median 8 (initial) and 48 weeks (sustained) were measured. Complete response was defined as symptomatic and endoscopic resolution with modified Pouchitis Disease Activity Index (mPDAI) <5. Partial response included mPDAI improvement >2. Serum was analysed for Anti-Saccharomyces cerevisiae antibodies (ASCA), anti-OmpC, anti-CBir1 and perinuclear Anti-Neutrophil Cytoplasmic Antibodies (pANCA). RESULTS One hundred and fifty-two patients with CP or a CD-like phenotype were identified. Forty-two were treated with infliximab (33% male; age 32.6±2.6 years, 28.5% CD-like). Post-induction response was achieved in 74% (48% complete) and sustained response in 62.6% (29.6% complete). Mean mPDAI and C-reactive protein declined from 8.5±0.3 to 2±3.4 (p < 0.002) and from 29.48±6.2 to 5.76±1.6mg/L (p < 0.001), respectively. Female gender, smoking and presence of anti-CBir1 were associated with infliximab use (p < 0.01) but not response. Pre-treatment mPDAI <10 (p < 0.01), resolution of rectal bleeding (p < 0.001 ) and week 8 endoscopic activity were associated with sustained response (p = 0.04; odds ratio [OR] 2.2; 95% confidence interval [CI] 1.1-16.5]). More than 2 positive antimicrobial antibody titres were associated with non-response (p < 0.05), but did not retain significance in multivariate analysis (p = 0.197; OR 0.632; 95% CI 0.31-1.2). CONCLUSIONS Infliximab can effectively treat inflammatory pouch complications. Pre-treatment mPDAI <10 and early endoscopy may identify responders.
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Affiliation(s)
- Orlaith B. Kelly
- Division of Gastroenterology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Morgan Rosenberg
- Division of Gastroenterology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Andrea D. Tyler
- Zane Cohen Center for Digestive Disease, Mount Sinai Hospital, Toronto, Canada
| | - Joanne M. Stempak
- Zane Cohen Center for Digestive Disease, Mount Sinai Hospital, Toronto, Canada
| | - A. Hillary Steinhart
- Division of Gastroenterology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Zane Cohen
- Zane Cohen Center for Digestive Disease, Mount Sinai Hospital, Toronto, Canada
| | - Gordon R. Greenberg
- Division of Gastroenterology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Mark S. Silverberg
- Division of Gastroenterology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
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Nonbloody Diarrhea but Not Significant Weight Loss at Diagnosis Is Associated with the Development of Denovo Crohn's Disease After Ileal Pouch-anal Anastomosis for Ulcerative Colitis. Inflamm Bowel Dis 2016; 22:654-61. [PMID: 26595552 DOI: 10.1097/mib.0000000000000630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Denovo Crohn's disease (CD) develops in 5% to 10% of patients after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) leading to increased morbidity and rates of pouch failure. Initial nonbloody diarrhea and weight loss at diagnosis are independent risk factors for a change in diagnosis from UC to CD in nonsurgical patients. We investigated whether these features were risk factors for denovo CD in a longitudinal cohort of patients with UC undergoing IPAA. METHODS Prospective profiles of patients with UC undergoing IPAA followed over a 22-year period by 1 surgeon were analyzed. Denovo CD was diagnosed when mucosal inflammation (5 or more ulcers) involved the small bowel mucosa proximal to the ileal pouch any time after surgery and/or when a pouch fistula or other perianal complication developed more than 3 months after ileostomy closure. Patients with inflammatory bowel disease unclassified, acute pouchitis, chronic pouchitis, and those lost to follow-up were excluded from analysis. Cox regression analysis was performed for statistical significance. RESULTS Of the 199 study patients included in the analysis, denovo CD developed in 42 patients (21%). Patients who developed denovo CD had an increased incidence of nonbloody diarrhea (n = 12; 29%) compared with patients who had no evidence of pouch inflammation (n = 25; 16%) (P = 0.03). In contrast, the incidence of weight loss was not significantly increased in patients with denovo CD (n = 7; 17%) compared with patients who never had pouch inflammation (n = 16; 10%) (P = 0.12). CONCLUSIONS Initial nonbloody diarrhea is associated with denovo CD after IPAA. This association warrants close consideration before surgery.
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Abstract
Inflammation in inflammatory bowel diseases (IBD) has been linked to a loss of tolerance to self-antigens suggesting the existence of autoantibodies in specific disease phenotypes. However, the lack of clearly defined autoantigenic targets has slowed down research. Genome-wide association studies have identified an impressive number of immune-related susceptibility loci for IBD with no clearly discernible pattern among them. Growing evidence supports the hypothesis that innate immune responses to a low-diversity and impaired gut microbiota may be of key importance in initiating and perpetuating chronic inflammation in IBD. Increasing evidence suggests that reduced microbial diversity and microbial-mucosal epithelium interaction (including adhesion and clearance) are critically involved in IBD pathogenesis. Along these lines the discovery of autoantigenic targets in Crohn's disease (CD) has refocused research in IBD on the possible role of autoimmune responses. The identification of the major zymogen granule membrane glycoprotein 2 (GP2) as an autoantigen in CD patients and its proposed role in the sensing of the microbiota lends credence to this trend. Loss of tolerance to GP2 occurs in up to 40% of patients with CD. Corresponding autoantibodies appear to be associated with distinct disease courses (types or phenotypes) in CD. Here, we critically review autoantibodies in CD for their impact on clinical practice and future IBD research. The immunomodulatory role of GP2 in innate and adaptive intestinal immunity is also discussed.
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Yamamoto-Furusho JK, Sarmiento Aguilar A. Frequency, Clinical Features and Factors Associated with Pouchitis after Proctocolectomy with Ileo-Pouch-Anal Anastomosis in Patients with Ulcerative Colitis: A Latin-American Country Retrospective-Cohort Study. Dig Surg 2015; 32:489-95. [PMID: 26609703 DOI: 10.1159/000441427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 09/29/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND Pouchitis is the most common complication of proctocolectomy with ileo-pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). No previous study in Mexico has evaluated this issue; our aim was to evaluate its frequency, clinical characteristics and factors associated with its presence in Mexican patients with UC and IPAA. METHODS Retrospective-cohort study including 70 patients with histopathological diagnosis of UC and IPAA between 1983 and 2014 from inflammatory bowel disease clinic of a tertiary care center. The statistical analysis used descriptive statistics, chi-square and Fisher's exact test for categorical variables and Student's t test for numeric variables. Univariate analysis was performed to identify the factors associated. RESULTS Patients presenting with pouchitis accounted for 48.6%. From the 34 cases, 12 (35.3%) had inactive pouchitis; 7 (20.6%) active acute pouchitis; 15 (44.1%) chronic active pouchitis. On average, pouchitis occurred 5.37 years after IPPA. Factors probably associated with its occurrence were the presence of autoimmune concomitant diseases (ACDs; p = 0.06, OR 4.40, 95% CI 0.84-22.9) and extra-intestinal manifestations (EIMs; p = 0.05, OR 2.53, 95% CI 0.96-6.64), which was also probably associated with chronic active pouchitis (p = 0.06, OR 0.31, 95% CI 0.07-1.31). CONCLUSIONS The frequency of pouchitis is high in Mexican UC patients after IPAA. ACDs and EIMs were probably associated with its development.
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Affiliation(s)
- Jesús K Yamamoto-Furusho
- Inflammatory Bowel Disease Clinic, Department of Gastroenterology, Instituto Nacional de Ciencias Mx00E9;dicas y Nutricix00F3;n Salvador Zubirx00E1;n, Mexico City, Mexico
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Dubinsky M, Braun J. Diagnostic and Prognostic Microbial Biomarkers in Inflammatory Bowel Diseases. Gastroenterology 2015; 149:1265-1274.e3. [PMID: 26284597 PMCID: PMC5302020 DOI: 10.1053/j.gastro.2015.08.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 08/08/2015] [Accepted: 08/12/2015] [Indexed: 12/14/2022]
Abstract
The microbiome plays multifaceted roles in the pathogenesis of inflammatory bowel diseases (IBD). Accordingly, the clinical challenge of patient heterogeneity in disease phenotype and response to treatment should in part be addressed by biomarkers that detect the host response to microbiota, and the levels of microbial taxa and products eliciting the host response in susceptible individuals. Molecular analysis has revealed much evidence for microbial taxonomic membership and microbial products in association with IBD, but their utility as clinical biomarkers is still in its infancy. A rich area of progress has been the development and validation of host serologic microbial biomarkers, which have achieved a distinctive position in the diagnosis and prognosis in IBD, and as a template for defining other categories of microbial biomarkers in disease state and phenotype.
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Affiliation(s)
- Marla Dubinsky
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Jonathan Braun
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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Liu Z, Shen B. Overcoming difficulty in diagnosis and differential diagnosis of Crohn's disease: the potential role of serological and genetic tests. Expert Rev Mol Diagn 2015; 15:1133-41. [PMID: 26295589 DOI: 10.1586/14737159.2015.1068121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Crohn's disease (CD) represents a heterogeneous group of chronic inflammatory disorders with various phenotypes. Establishing a definite diagnosis of CD should be based upon a combined assessment of clinical, endoscopic, radiological and pathological features. Although segmental disease distribution, transmural inflammation and non-caseating epithelioid granulomas have been considered as a 'hallmarks' for CD, clear diagnosis of CD in some patients has been challenging, due to overlapping endoscopic, radiographic and histologic features with other inflammatory bowel disease-like conditions. Laboratory markers (serological and genetic tests) may provide additional clues for the diagnosis and differential diagnosis of CD. This review focuses on the application of the currently available serological and genomic markers and in diagnosis and differential diagnosis of CD.
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Affiliation(s)
- Zhaoxiu Liu
- a 1 Department of Gastroenterology, Affiliated Hospital of Nantong University, Jiangsu, China
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28
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Abstract
The disease spectrum and natural course of Crohn's disease and ulcerative colitis are highly variable. The majority of Crohn's disease patients will require surgery at a certain stage in their disease compared to only a fraction of the ulcerative colitis patients. Similarly, some patients are destined to experience an indolent disease course while others will require early intensive therapy. Ideally, these subtypes of patients should be identified as early as possible with the help of reliable prognostic factors in order to guide personalized therapeutic decisions. In this review, the authors focused on the most relevant reports on the use of different prognostic factors to predict disease course, postoperative recurrence and response to therapy in patients with inflammatory bowel disease. The last 15 years have seen a wealth of novel genetic and serological markers of disease severity. Nevertheless, none of these markers have proven to be superior to careful clinical phenotyping and endoscopic features early in the disease course. Future attempts should apply an integrated approach that unites clinical, serological and (epi)genetic information with environmental influences, with a clear focus on the microbiome to ultimately identify molecular-based and clinically relevant subgroups.
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29
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Kevans D, Waterman M, Milgrom R, Xu W, Van Assche G, Silverberg M. Serological markers associated with disease behavior and response to anti-tumor necrosis factor therapy in ulcerative colitis. J Gastroenterol Hepatol 2015; 30:64-70. [PMID: 25041458 DOI: 10.1111/jgh.12661] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Information is limited on the relationship between serological markers and disease behavior and anti-tumor necrosis factor-α (anti-TNF) therapy response in ulcerative colitis (UC). This study aimed to determine the association between serological markers and unfavorable UC behavior defined as need for colectomy or UC-related hospitalization. The association between serological markers and requirement for and outcome of anti-TNF therapy was also evaluated. METHODS Two hundred thirty patients were studied. Requirement for colectomy, UC-related hospitalization, and anti-TNF therapy were documented. Response to anti-TNF therapy at 1 year and rates of therapy discontinuation were recorded. Titers of perinuclear anti-neutrophil cytoplasmic antibodies (pANCAs), anti-Saccharomyces cerevisiae antibody (ASCA), and antibody to Escherichia Coli outer membrane porin (anti-OmpC) were determined. Antibody reference ranges were used to dichotomize subjects into seropositive and seronegative groups. Where multiple tests were performed, P-values were Bonferroni corrected (pcorr). RESULTS Extensive colitis was associated with requirement for colectomy and UC-related hospitalization, HR 7.7 (95% confidence interval [CI] 1.9-32.2) pcorr = 0.03 and HR 2.7 (95% CI 1.5-4.6), pcorr = 0.006, respectively. No serological variable was associated with unfavorable UC behavior. Anti-OmpC positivity was associated with a lack of response to anti-TNF therapy at 1 year (odds ratio 0.14 [95% CI 0.03-0.60], pcorr = 0.04) and increased likelihood of therapy discontinuation (HR 2.2 [95% CI 1.1-4.7], P = 0.03). CONCLUSION Extensive colitis is associated with unfavorable disease course in UC. Anti-OmpC holds promise as a biomarker of anti-TNF therapy response in UC; however, prospective studies are required before it can be incorporated into routine clinical practice.
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Affiliation(s)
- David Kevans
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Canada; Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
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Knights D, Silverberg MS, Weersma RK, Gevers D, Dijkstra G, Huang H, Tyler AD, van Sommeren S, Imhann F, Stempak JM, Huang H, Vangay P, Al-Ghalith GA, Russell C, Sauk J, Knight J, Daly MJ, Huttenhower C, Xavier RJ. Complex host genetics influence the microbiome in inflammatory bowel disease. Genome Med 2014; 6:107. [PMID: 25587358 PMCID: PMC4292994 DOI: 10.1186/s13073-014-0107-1] [Citation(s) in RCA: 261] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 11/13/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Human genetics and host-associated microbial communities have been associated independently with a wide range of chronic diseases. One of the strongest associations in each case is inflammatory bowel disease (IBD), but disease risk cannot be explained fully by either factor individually. Recent findings point to interactions between host genetics and microbial exposures as important contributors to disease risk in IBD. These include evidence of the partial heritability of the gut microbiota and the conferral of gut mucosal inflammation by microbiome transplant even when the dysbiosis was initially genetically derived. Although there have been several tests for association of individual genetic loci with bacterial taxa, there has been no direct comparison of complex genome-microbiome associations in large cohorts of patients with an immunity-related disease. METHODS We obtained 16S ribosomal RNA (rRNA) gene sequences from intestinal biopsies as well as host genotype via Immunochip in three independent cohorts totaling 474 individuals. We tested for correlation between relative abundance of bacterial taxa and number of minor alleles at known IBD risk loci, including fine mapping of multiple risk alleles in the Nucleotide-binding oligomerization domain-containing protein 2 (NOD2) gene exon. We identified host polymorphisms whose associations with bacterial taxa were conserved across two or more cohorts, and we tested related genes for enrichment of host functional pathways. RESULTS We identified and confirmed in two cohorts a significant association between NOD2 risk allele count and increased relative abundance of Enterobacteriaceae, with directionality of the effect conserved in the third cohort. Forty-eight additional IBD-related SNPs have directionality of their associations with bacterial taxa significantly conserved across two or three cohorts, implicating genes enriched for regulation of innate immune response, the JAK-STAT cascade, and other immunity-related pathways. CONCLUSIONS These results suggest complex interactions between genetically altered host functional pathways and the structure of the microbiome. Our findings demonstrate the ability to uncover novel associations from paired genome-microbiome data, and they suggest a complex link between host genetics and microbial dysbiosis in subjects with IBD across independent cohorts.
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Affiliation(s)
- Dan Knights
- />Department of Computer Science and Engineering, University of Minnesota, Minneapolis, Minnesota 55455 USA
- />Broad Institute of Harvard and MIT, Cambridge, Massachusetts 02142 USA
- />Center for Computational and Integrative Biology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114 USA
- />Biotechnology Institute, University of Minnesota, St. Paul, Minnesota 55108 USA
| | - Mark S Silverberg
- />Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital IBD Group, University of Toronto, Toronto, Ontario M5G 1X5 Canada
| | - Rinse K Weersma
- />Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, 9700RB The Netherlands
| | - Dirk Gevers
- />Broad Institute of Harvard and MIT, Cambridge, Massachusetts 02142 USA
| | - Gerard Dijkstra
- />Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, 9700RB The Netherlands
| | - Hailiang Huang
- />Analytic and Translational Genetics Unit, Massachusetts General Hospital, Boston, Massachusetts 02114 USA
| | - Andrea D Tyler
- />Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital IBD Group, University of Toronto, Toronto, Ontario M5G 1X5 Canada
| | - Suzanne van Sommeren
- />Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, 9700RB The Netherlands
- />Department of Genetics, University Medical Center Groningen, Groningen, 9700RB The Netherlands
| | - Floris Imhann
- />Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, 9700RB The Netherlands
- />Department of Genetics, University Medical Center Groningen, Groningen, 9700RB The Netherlands
| | - Joanne M Stempak
- />Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital IBD Group, University of Toronto, Toronto, Ontario M5G 1X5 Canada
| | - Hu Huang
- />Biomedical Informatics and Computational Biology, University of Minnesota, Minneapolis, Minnesota 55455 USA
| | - Pajau Vangay
- />Biomedical Informatics and Computational Biology, University of Minnesota, Minneapolis, Minnesota 55455 USA
| | - Gabriel A Al-Ghalith
- />Biomedical Informatics and Computational Biology, University of Minnesota, Minneapolis, Minnesota 55455 USA
| | - Caitlin Russell
- />Center for Computational and Integrative Biology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114 USA
- />Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114 USA
| | - Jenny Sauk
- />Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114 USA
| | - Jo Knight
- />Department of Psychiatry, University of Toronto, Toronto, Ontario M5T 1R8 Canada
| | - Mark J Daly
- />Broad Institute of Harvard and MIT, Cambridge, Massachusetts 02142 USA
- />Department of Medicine, Analytic and Translational Genetics Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114 USA
- />Program in Medical and Population Genetics, Broad Institute of Harvard and MIT, Cambridge, Massachusetts 02142 USA
| | - Curtis Huttenhower
- />Broad Institute of Harvard and MIT, Cambridge, Massachusetts 02142 USA
- />Biostatistics Department, Harvard School of Public Health, Boston, Massachusetts 02115 USA
| | - Ramnik J Xavier
- />Broad Institute of Harvard and MIT, Cambridge, Massachusetts 02142 USA
- />Center for Computational and Integrative Biology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114 USA
- />Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114 USA
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Systematic review: new serological markers (anti-glycan, anti-GP2, anti-GM-CSF Ab) in the prediction of IBD patient outcomes. Autoimmun Rev 2014; 14:231-45. [PMID: 25462578 DOI: 10.1016/j.autrev.2014.11.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 11/08/2014] [Indexed: 12/20/2022]
Abstract
Traditionally, IBD diagnosis is based on clinical, radiological, endoscopic, and histological criteria. Biomarkers are needed in cases of uncertain diagnosis, or to predict disease course and therapeutic response. No guideline recommends the detection of antibodies (including ASCA and ANCA) for diagnosis or prognosis of IBD to date. However, many recent data suggest the potential role of new serological markers (anti-glycan (ACCA, ALCA, AMCA, anti-L and anti-C), anti-GP2 and anti-GM-CSF Ab). This review focuses on clinical utility of these new serological markers in diagnosis, prognosis and therapeutic monitoring of IBD. Literature review of anti-glycan, anti-GP2 and anti-GM-CSF Ab and their impact on diagnosis, prognosis and prediction of therapeutic response was performed in PubMed/MEDLINE up to June 2014. Anti-glycan, anti-GP2 and anti-GM-CSF Ab are especially associated with CD and seem to be correlated with complicated disease phenotypes even if results differ between studies. Although anti-glycan Ab and anti-GP2 Ab have low sensitivity in diagnosis of IBD, they could identify a small number of CD patients not detected by other tests such as ASCA. Anti-glycan Abs are associated with a progression to a more severe disease course and a higher risk for IBD-related surgery. Anti-GP2 Ab could particularly contribute to better stratify cases of pouchitis. Anti-GM-CSF Ab seems to be correlated with disease activity and could help predict relapses. These new promising biomarkers could particularly be useful in stratification of patients according to disease phenotype and risk of complications. They could be a valuable aid in prediction of disease course and therapeutic response but more prospective studies are needed.
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Mukewar S, Wu X, Lopez R, Shen B. Comparison of long-term outcomes of S and J pouches and continent ileostomies in ulcerative colitis patients with restorative proctocolectomy-experience in subspecialty pouch center. J Crohns Colitis 2014; 8:1227-36. [PMID: 24657364 DOI: 10.1016/j.crohns.2014.02.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 02/20/2014] [Accepted: 02/20/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are no published studies comparing pouch configurations and long-term adverse outcomes. AIM To evaluate outcomes of ulcerative colitis (UC) patients undergoing restorative proctocolectomy with S-, J- pouches or continent ileostomy (CI). METHODS We conducted a historical cohort study from the prospectively maintained Pouch Registry. Demographic and clinical variables were evaluated with univariate and multivariable analyses. RESULTS Fourty-five patients with S pouches and 36 with CI (33 K pouches and 3 Barnett continent ileal reservoirs) were compared with 215 J pouches serving as controls (ratio 1:2.5). In multivariable analysis, patients with S pouches were 93% less likely to develop chronic antibiotic-refractory pouchitis (CARP) than subjects with J pouches (odds ratio [OR]=0.07; 95% confidence interval: <0.001, 0.54; p<0.001). However, no significant difference in the frequency of CARP was found between the CI and J pouch groups (OR=0.68; 95% confidence interval: 0.17, 2.00, p=0.40). Patients with S pouches were 8 times more likely (95% confidence interval: 3.7, 17.5; p<0.001) and patients with CI 5.6 had times more likely (95% confidence interval: 2.4, 13.3; p<0.001) to have pouch surgery-related complications than those with J pouches. There was no difference in the rate of CD of the pouch, pouch-associated hospitalization and pouch failure between the S- pouch, CI and J- pouch groups. CONCLUSIONS Patients with J pouches appeared to have a greater risk for chronic pouchitis than those with S-pouches and but had a lower risk for developing pouch surgery-related complications than those with S pouches or CI.
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Affiliation(s)
- Saurabh Mukewar
- Departments of Gastroenterology/Hepatology, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Xianrui Wu
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rocio Lopez
- Department of Quantitative Health Sciences, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bo Shen
- Departments of Gastroenterology/Hepatology, The Cleveland Clinic Foundation, Cleveland, OH, USA.
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Ileal pouch symptoms do not correlate with inflammation of the pouch. Clin Gastroenterol Hepatol 2014; 12:831-837.e2. [PMID: 24075890 DOI: 10.1016/j.cgh.2013.09.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 09/04/2013] [Accepted: 09/06/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pouchitis is the most common complication after ileal pouch-anal anastomosis (IPAA). However, symptoms are not specific. The Pouchitis Disease Activity Index (PDAI) and the Pouchitis Activity Score (PAS) have been used to diagnose pouchitis. We evaluated the correlation between the clinical components of these scores and endoscopic and histologic findings. METHODS We performed a cross-sectional study, analyzing data from 278 patients from Mount Sinai Hospital (Toronto, Canada) who had an IPAA. Patients underwent pouchoscopy with a biopsy, and data were collected on patients' clinical status. The PDAI and PAS were calculated for each subject. The Spearman rank correlation (ρ) statistical test was used to evaluate correlations between the PDAI scores and PAS, and between total scores and subscores. RESULTS The total PDAI scores and PAS scores were correlated; the clinical components of each correlated with the total score (ρ = 0.59 and ρ = 0.71, respectively). However, we observed a low level of correlation between clinical and endoscopic or histologic subscores, with ρ of 0.20 and 0.10, respectively, by PDAI, and ρ of 0.19 and 0.04, respectively, by PAS. CONCLUSIONS There is a low level of correlation between clinical and endoscopic and histologic subscores of patients with IPAA; clinical symptoms therefore might not reflect objective evidence of inflammation. These findings, along with evidence of correlation between total scores and clinical symptoms, indicate that these indices do not accurately identify patients with pouch inflammation. Further research is required to understand additional factors that contribute to clinical symptoms in the absence of objective signs of pouch inflammation.
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Truta B, Li DX, Mahadevan U, Fisher ER, Chen YY, Grace K, Velayos F, Terdiman JP. Serologic markers associated with development of Crohn's disease after ileal pouch anal anastomosis for ulcerative colitis. Dig Dis Sci 2014; 59:135-45. [PMID: 24091907 DOI: 10.1007/s10620-013-2866-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 08/23/2013] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIMS One of the causes of pouch failure after ileal pouch anal anastomosis (IPAA) for ulcerative colitis (UC) is the development of de novo Crohn's disease (CD). Our aim was to clearly define factors associated with post-IPAA CD. METHODS We conducted a cross-sectional study to compare demographic, clinical, and serological characteristics of patients with and without post-IPAA CD. All subjects underwent testing for anti-neutrophil cytoplasm antibodies, anti-Saccaromyces cerevisiae antibodies, anti-outer membrane porin C antibodies, and anti-CBir1 flagellin (anti-CBir1). A multivariable model assessed factors associated with post-IPAA CD. RESULTS Thirty-nine subjects were enrolled in the study: 20 cases and 19 controls. Patients who developed post-IPAA CD were significantly younger (median 22 ± 9.9 vs. 30 ± 11.3, p = .027) at the time of UC diagnosis and exhibited more extraintestinal manifestations compared to controls (p = .023). No significant difference between the groups was found with respect to family history, smoking, duration of illness prior to colectomy, time to the onset of pouchitis, preoperative treatment, and indication for surgery. However, the post-operative serologic profile differed significantly with far more cases having elevated anti-CBir1 titers (p = .016, OR 8.81), the latter being the only independent predictor in the combined model. CONCLUSIONS Patients with Crohn's disease of the pouch were more likely to have elevated CBir1 antibodies titers than those with simple pouchitis and healthy pouches. The stability of the CBir1 antibodies (pre- and post-colectomy) must be further assessed to establish its value as an independent predictor for development of post-IPAA CD.
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Werner L, Sturm A, Roggenbuck D, Yahav L, Zion T, Meirowithz E, Ofer A, Guzner-Gur H, Tulchinsky H, Dotan I. Antibodies against glycoprotein 2 are novel markers of intestinal inflammation in patients with an ileal pouch. J Crohns Colitis 2013; 7:e522-32. [PMID: 23639628 DOI: 10.1016/j.crohns.2013.03.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 03/02/2013] [Accepted: 03/20/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The Crohn's disease (CD)-specific pancreatic auto-antibodies (PAB), have been recently identified to target glycoprotein 2 (GP2). Pouchitis is an inflammation of the small bowel developing in up to 60% of ulcerative colitis patients undergoing proctocolectomy and ileal pouch anal anastomosis. Occurrence of CD-specific antibodies was reported to be a predictor of pouchitis. We aimed to assess the prevalence of anti-GP2 antibodies (anti-GP2) in the serum and feces of pouch patients and to correlate them with clinical parameters. Furthermore, we examined mucosal expression of the GP2 protein in the pouch. METHODS Pouch patients were prospectively recruited and checked for clinical, endoscopic, and laboratory markers of inflammation. IgG and IgA anti-GP2 levels in serum and fecal samples were determined using ELISA. GP2 protein was assessed by immunohistochemistry. RESULTS Anti-GP2 was elevated in both serum and fecal samples of patients with inflamed compared to those with non-inflamed pouches and patients with familial-adenomatous polyposis after surgery (p<0.05, respectively). Moreover, patients with CD-like complications exhibited significantly higher anti-GP2 titers than those without CD-like complications (p≤0.01). High levels of anti-GP2 correlated with more frequent bowel movements per day and with the presence of at least one anti-glycan antibody (p≤0.05). GP2 itself was more abundant in the mucosa of patients with chronic pouchitis. CONCLUSIONS Anti-GP2 exists in the serum and feces of pouch patients and correlates with pouch inflammation, and presence of other serological markers. Thus, anti-GP2 may contribute to better stratification of pouchitis, more-so when the inflammation exhibits CD-like complications.
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Affiliation(s)
- Lael Werner
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel.
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Tyler AD, Milgrom R, Stempak JM, Xu W, Brumell JH, Muise AM, Sehgal R, Cohen Z, Koltun W, Shen B, Silverberg MS. The NOD2insC polymorphism is associated with worse outcome following ileal pouch-anal anastomosis for ulcerative colitis. Gut 2013; 62:1433-9. [PMID: 22879519 DOI: 10.1136/gutjnl-2011-301957] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Inflammatory complications after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) are common. OBJECTIVE To investigate whether genetic factors are associated with adverse pouch outcomes such as chronic pouchitis (CP) and a Crohn's disease-like (CDL) phenotype. DESIGN 866 patients were recruited from three centres in North America: Mount Sinai Hospital (Toronto, Ontario, Canada), the Cleveland Clinic (Cleveland, Ohio, USA) and Penn State Milton S Hershey Medical Center (Hershey, Pennsylvania, USA). DNA and clinical and demographic information were collected. Subjects were classified into post-surgical outcome groups: no chronic pouchitis (NCP), CP and CDL phenotype. RESULTS Clinical and genetic data were available on 714 individuals. 487 (68.2%) were classified as NCP, 118 (16.5%) CP and 109 (15.3%) CDL. The presence of arthritis or arthropathy (p=0.02), primary sclerosing cholangitis (p=0.009) and duration of time from ileostomy closure to recruitment (p=0.001) were significantly associated with outcome. The NOD2insC (rs2066847) risk variant was the single nucleotide polymorphism (SNP) most significantly associated with pouch outcome (p=7.4×10(-5)). Specifically, it was associated with both CP and CDL in comparison with NCP (OR=3.2 and 4.3, respectively). Additionally, SNPs in NOX3 (rs6557421, rs12661812), DAGLB (rs836518) and NCF4 (rs8137602) were shown to be associated with pouch outcome with slightly weaker effects. A multivariable risk model combining previously identified clinical (smoking status, family history of inflammatory bowel disease), serological (anti-Saccharomyces cerevisiae antibody IgG, perinuclear antineutrophil cytoplasmic antibody and anti-CBir1) and genetic markers was constructed and resulted in an OR of 2.72 (p=8.89×10(-7)) for NCP versus CP/CDL and 3.22 (p=4.11×10(-8)) for NCP versus CDL, respectively. CONCLUSION Genetic polymorphisms, in particular, the NOD2insC risk allele, are associated with chronic inflammatory pouch outcomes among patients with UC and IPAA.
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Affiliation(s)
- Andrea D Tyler
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
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Tyler AD, Knox N, Kabakchiev B, Milgrom R, Kirsch R, Cohen Z, McLeod RS, Guttman DS, Krause DO, Silverberg MS. Characterization of the gut-associated microbiome in inflammatory pouch complications following ileal pouch-anal anastomosis. PLoS One 2013; 8:e66934. [PMID: 24086242 PMCID: PMC3782502 DOI: 10.1371/journal.pone.0066934] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 05/10/2013] [Indexed: 12/29/2022] Open
Abstract
Introduction Inflammatory complications following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) are common and thought to arise through mechanisms similar to denovo onset inflammatory bowel disease. The aim of this study was to determine whether specific organisms in the tissue-associated microbiota are associated with inflammatory pouch complications. Methods Patients having previously undergone IPAA were recruited from Mount Sinai Hospital. Clinical and demographic information were collected and a pouchoscopy with biopsy of both the pouch and afferent limb was performed. Patients were classified based on post-surgical phenotype into four outcome groups: familial adenomatous polyposis controls (FAP), no pouchitis, pouchitis, and Crohn’s disease-like (CDL). Pyrosequencing of the 16S rRNA V1-V3 hypervariable region, and quantitative PCR for bacteria of interest, were used to identify organisms present in the afferent limb and pouch. Associations with outcomes were evaluated using exact and non-parametric tests of significance. Results Analysis at the phylum level indicated that Bacteroidetes were detected significantly less frequently (P<0.0001) in the inflammatory outcome groups (pouchitis and CDL) compared to both FAP and no pouchitis. Conversely, Proteobacteria were detected more frequently in the inflammatory groups (P=0.01). At the genus level, organisms associated with outcome were detected less frequently among the inflammatory groups compared to those without inflammation. Several of these organisms, including Bacteroides (P<0.0001), Parabacteroides (P≤2.2x10-3), Blautia (P≤3.0x10-3) and Sutterella (P≤2.5x10-3), were associated with outcome in both the pouch and afferent limb. These associations remained significant even following adjustment for antibiotic use, smoking, country of birth and gender. Individuals with quiescent disease receiving antibiotic therapy displayed similar reductions in these organisms as those with active pouch inflammation. Conclusions Specific genera are associated with inflammation of the ileal pouch, with a reduction of typically ubiquitous organisms characterizing the inflammatory phenotypes.
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Affiliation(s)
- Andrea D. Tyler
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital Inflammatory Bowel Disease Group, Toronto, Ontario, Canada
| | - Natalie Knox
- Department of Animal Science, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Boyko Kabakchiev
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital Inflammatory Bowel Disease Group, Toronto, Ontario, Canada
| | - Raquel Milgrom
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital Inflammatory Bowel Disease Group, Toronto, Ontario, Canada
| | - Richard Kirsch
- Laboratory Medicine and Pathology, Mount Sinai Hospital, Toronto, Toronto, Ontario, Canada
| | - Zane Cohen
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital Inflammatory Bowel Disease Group, Toronto, Ontario, Canada
| | - Robin S. McLeod
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital Inflammatory Bowel Disease Group, Toronto, Ontario, Canada
| | - David S. Guttman
- Department of Cell and Systems Biology, University of Toronto, Toronto, Ontario, Canada
| | - Denis O. Krause
- Department of Animal Science, University of Manitoba, Winnipeg, Manitoba, Canada
- Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mark S. Silverberg
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital Inflammatory Bowel Disease Group, Toronto, Ontario, Canada
- * E-mail:
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Abstract
Inflammatory bowel diseases (IBDs; e.g., Crohn's disease [CD] and ulcerative colitis [UC]) are chronic immunologically mediated diseases characterized by frequent relapses, often requiring hospitalization and surgery. There is substantial heterogeneity in the progressive natural history of disease with cumulative accrual of bowel damage and impairment of functioning. Recent advances in therapeutics have significantly improved our ability to achieve disease remission; yet therapies remain expensive and are associated with significant side effects precluding widespread use in all patients with IBD. Consequently, algorithms for the management of patients with IBD require a personalized approach incorporating an individual's projected likely natural history, the probability of response to a specific therapeutic agent and an informed approach to management of loss of response to current therapies.
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Affiliation(s)
- Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, 9th Floor, Boston, MA 02114, USA.
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Roggenbuck D, Reinhold D, Werner L, Schierack P, Bogdanos DP, Conrad K. Glycoprotein 2 antibodies in Crohn's disease. Adv Clin Chem 2013; 60:187-208. [PMID: 23724745 DOI: 10.1016/b978-0-12-407681-5.00006-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The pathogenesis of Crohn's disease (CrD) and ulcerative colitis (UC), the two major inflammatory bowel diseases (IBD), remains poorly understood. Autoimmunity is considered to be involved in the triggering and perpetuation of inflammatory processes leading to overt disease. Approximately 30% of CrD patients and less than 8% of UC patients show evidence of humoral autoimmunity to exocrine pancreas, detected by indirect immunofluorescence. Pancreatic autoantibodies (PAB) were described for the first time in 1984, but the autoantigenic target(s) of PABs were identified only in 2009. Utilizing immunoblotting and matrix-assisted laser desorption ionization time-of-flight mass spectrometry, the major zymogen granule membrane glycoprotein 2 (GP2) has been discovered as the main PAB autoantigen. The expression of GP2 has been demonstrated at the site of intestinal inflammation, explaining the previously unaddressed contradiction of pancreatic autoimmunity and intestinal inflammation. Recent data demonstrate GP2 to be a specific receptor on microfold (M) cells of intestinal Peyer's patches, which are considered to be the original site of inflammation in CrD. Novel ELISAs, employing recombinant GP2 as the solid phase antigen, have confirmed the presence of IgA and IgG anti-GP2 PABs in CrD patients and revealed an association of anti-GP2 IgA as well as IgG levels with a specific clinical phenotype in CrD. Also, GP2 plays an important role in modulating innate and acquired intestinal immunity. Its urinary homologue, Tamm-Horsfall protein or uromodulin, has a similar effect in the urinary tract, further indicating that GP2 is not just an epiphenomenon of intestinal destruction. This review discusses the role of anti-GP2 autoantibodies as novel CrD-specific markers, the quantification of which provides the basis for further stratification of IBD patients. Given the association with a disease phenotype and the immunomodulating properties of GP2 itself, an important role for GP2 in the immunopathogenesis of IBD cannot be excluded.
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Affiliation(s)
- Dirk Roggenbuck
- Faculty of Natural Sciences, Lausitz University of Applied Sciences, Senftenberg, Germany.
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Mukewar S, Wu X, Lopez R, Kiran RP, Remzi FH, Shen B. Ethnicity and the risk of development of Crohn's disease of the ileal pouch. J Crohns Colitis 2013; 7:e178-85. [PMID: 22939817 DOI: 10.1016/j.crohns.2012.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 07/02/2012] [Accepted: 08/01/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND A system-wide, multi-ethnicity study on Crohn's disease (CD) of the pouch, including Indian American (IA) patients has not been conducted. AIM To compare the frequency of subsequent development of CD of the pouch for African-American (AA), Hispanic-American (HA), IA and Caucasian patients with ulcerative (UC) undergoing ileal-pouch anal anastomosis (IPAA). METHODS In this historical cohort study from our Pouch Registry, patients with restorative proctocolectomy and IPAA for IBD with identifiable, self-declared racial background (i.e. AA, HA, IA or Caucasian) were included. Univariable and multivariable analyses were performed to identify risk factors for CD of the pouch. RESULTS The study included 235 patients: AA (N=26), HA (N=37), IA (N=22) and randomly selected Caucasian (N=150) controls. Greater number of HA and Caucasians had a history of smoking than IA (27.3% and 27.0% vs. 0; p=0.007). Caucasians and HA were also more likely to have a family history of IBD than IA or AA (25% vs. 27% vs. 5% vs. 4%; p=0.016.) IA less frequently had extensive colitis before colectomy than Caucasians (71.4% vs. 94.0%; p=0.004) and more frequently required anti-TNF biologics than HA (22.7% vs. 0; p=0.016). On multivariable logistic regression analysis, AA (odds ratio [OR]=10.1, 95% confidence interval [CI]: 1.03, 1365.8, p=0.004) and Caucasians (OR=11.1, 95% CI: 1.4, 1427.2, p=0.015) had a higher risk of developing CD of the pouch than IA. However, the event-free survival was not significantly different between the groups on Cox regression analysis, presumably due to the sample size. CONCLUSION Racial background may be associated with different risk for the development of CD of the pouch for patients with IBD undergoing IPAA.
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Affiliation(s)
- Saurabh Mukewar
- Department of Gastroenterology/Hepatology, Cleveland Clinic Foundation, OH 44195, United States
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Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) has been shown to increase the risk for chronic pouchitis. However, the association between PSC and Crohn's disease (CD) of the pouch has not been studied. METHODS Consecutive inflammatory bowel disease patients undergoing proctocolectomy with ileal pouch-anal anastomosis in our Pouchitis Registry from 2002 to 2012 were studied. Cases consisted of patients with CD of the pouch. Both univariable and multivariable analyses were performed. RESULTS A total of 1425 patients met the inclusion criteria, including 265 (18.6%) with CD of the pouch and 78 (5.5%) with PSC. In the whole cohort, 799 patients (56.1%) were male and the mean ages at the time of diagnosis of inflammatory bowel disease and at pouch surgery were 25.5 ± 12.3 years and 35.4 ± 13.9 years, respectively. Patients with PSC had a longer duration from inflammatory bowel disease diagnosis to pouch construction (P < 0.001). Fewer patients with PSC had toxic megacolon at the time of colectomy (P = 0.009), but more patients with PSC had neoplasia as the indication for colectomy (P < 0.001), concurrent autoimmune disorders (P < 0.001), and liver transplantation (P = 0.001). In the multivariate analysis, the presence of PSC was shown to be inversely associated with the risk for the development of CD of the pouch, with a hazard ratio of 0.39 (95% confidence interval: 0.16 to 0.95, P = 0.038). However, no significant difference in terms of the distribution of phenotypes of CD of the pouch between patients with and without PSC was identified (P = 0.59). CONCLUSIONS The presence of PSC is inversely associated with the development of CD of the pouch.
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Singh S, Sharma PK, Loftus EV, Pardi DS. Meta-analysis: serological markers and the risk of acute and chronic pouchitis. Aliment Pharmacol Ther 2013; 37:867-75. [PMID: 23480145 DOI: 10.1111/apt.12274] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 02/09/2013] [Accepted: 02/16/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Serological markers such as anti-neutrophil cytoplasmic antibody (ANCA) and anti-Saccharomyces cerevisiae antibody (ASCA) may be associated with pouchitis after ileal pouch-anal anastomosis (IPAA). AIM To perform a systematic review with meta-analysis of studies evaluating the association of ANCA and ASCA status with risk of acute and chronic pouchitis after IPAA. METHODS We searched multiple databases (upto September 2012) for studies reporting ANCA and/or ASCA status along with risk of acute or chronic pouchitis after IPAA in adults with ulcerative colitis (UC). We abstracted odds ratio (OR) or raw data from the individual studies to calculate summary OR estimates with 95% CIs using random-effects model. RESULTS Eight studies reporting 184 cases of acute pouchitis and six studies reporting 151 cases of chronic pouchitis were included. The odds of chronic pouchitis were 76% higher in ANCA-positive patients than ANCA-negative (six studies; OR: 1.76; 95% CI: 1.19-2.61; P < 0.01). ASCA-positivity was not associated with the risk of chronic pouchitis (three studies; OR: 0.89; 95% CI: 0.49-1.59; P = 0.68). Neither ANCA (eight studies; OR: 1.54; 95% CI: 0.79-3.02; P = 0.21) nor ASCA-positivity (two studies; OR: 1.28; 95% CI: 0.25-6.54; P = 0.77) were associated with the risk of acute pouchitis. CONCLUSIONS The risk of chronic pouchitis after IPAA is higher in ANCA-positive patients, but the risk of acute pouchitis is unaffected by ANCA status. ASCA status was not associated with the risk of acute or chronic pouchitis. This information may be used to counsel UC patients regarding their risk of pouchitis after IPAA.
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Affiliation(s)
- S Singh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Li Y, Wu B, Shen B. Diagnosis and differential diagnosis of Crohn's disease of the ileal pouch. Curr Gastroenterol Rep 2013; 14:406-13. [PMID: 22855236 DOI: 10.1007/s11894-012-0282-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Approximately 20%-30% of patients with ulcerative colitis will eventually require colectomy despite recent advances in medical therapy. Ileal pouch-anal anastomosis has become the surgical treatment of choice. A subset of patients with ileal pouches can develop Crohn's disease or a Crohn's-disease-like condition of the ileal pouch after surgery. Diagnosis, differential diagnosis, and management of Crohn's disease of the ileal pouch have been challenging. A combined assessment of clinical history, endoscopy, histology, abdominal/pelvic imaging, and examination under anesthesia is often necessary for accurate diagnosis, disease classification, management, and prognosis. A multidisciplinary approach with gastroenterologists, colorectal surgeons, gastrointestinal pathologists, and radiologists is advocated.
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Affiliation(s)
- Yue Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
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Weizman AV, Silverberg MS. Have genomic discoveries in inflammatory bowel disease translated into clinical progress? Curr Gastroenterol Rep 2012; 14:139-45. [PMID: 22302508 DOI: 10.1007/s11894-012-0248-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Inflammatory bowel disease (IBD) is a heterogeneous disease that can be challenging to diagnose and manage. As a result, significant efforts have been made in attempting to identify clinical, genomic, and serologic markers of disease that can aid in patient assessment and treatment. Recent genomic discoveries have the potential to change clinical practice by identifying those susceptible to IBD, predict natural history and guide choice of therapy. Panels of genetic and genomic markers are more likely to emerge as clinical tools, as opposed to individual allelic variants. Serology and biomarkers are already being used and guiding management but await integration with genomic panels before achieving their maximal potential. This article reviews the current state of IBD genetics and evolving molecular approaches that may have potential clinical impact.
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Affiliation(s)
- Adam V Weizman
- Mount Sinai Hospital Inflammatory Bowel Disease Group, Zane Cohen Centre for Digestive Diseases, University of Toronto, Ontario, Canada
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Abstract
IPAA is a technically demanding procedure that requires appropriate skills and expertise. Adverse sequelae of IPAA are common. Accurate diagnosis and classification of pouch disorders and associated complications are important for proper management and prognosis. Based on presenting symptoms, appropriate and combined diagnostic modalities should apply. A multidisciplinary approach involving gastroenterologists, colorectal surgeons, gastrointestinal pathologists, and gastrointestinal radiologists is advocated for diagnosis and treatment of pouch disorders.
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Affiliation(s)
- Yue Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
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Papadakis KA. Predicting outcomes after restorative proctocolectomy for ulcerative colitis. Clin Gastroenterol Hepatol 2012; 10:447-9. [PMID: 22289871 DOI: 10.1016/j.cgh.2012.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 01/11/2012] [Accepted: 01/15/2012] [Indexed: 02/07/2023]
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