Gastroduodenal Involvement in Asymptomatic Crohn's Disease Patients in Two Areas of Emerging Disease: Asia and Eastern Europe

Crohn disease but not ulcerative colitis increases the risk of acute pancreatitis: A 2-sample Mendelian randomization study

Accumulating evidence has indicated an increased risk of acute pancreatitis in individuals with inflammatory bowel disease (IBD); however, the establishment of a clear and direct causal connection between IBD and acute pancreatitis remains uncertain. Utilizing genetic data from publicly accessible genome-wide association studies (GWAS), we conducted a 2-sample MR analysis to identify the associations between IBD, ulcerative colitis (UC), Crohn disease (CD), and acute pancreatitis risk. Rigorous quality control steps ensured the selection of eligible single nucleotide polymorphisms (SNPs) with strong associations to IBD. The primary estimation used the inverse-variance weighted method. We also assessed heterogeneity, potential pleiotropy, and conducted sensitivity analyses. The direction of causality was confirmed using the Steiger test. The MR analysis showed that IBD increased the risk of acute pancreatitis (IVW: OR = 1.032, 95% CI: 1.006-1.06, P = .015). Among the subgroup of IBD, CD (IVW: OR = 1.034, 95% CI: 1.008-1.06, P = .007) indicates a significant increase in the risk of acute pancreatitis compared to UC (IVW: OR = 1.02, 95% CI: 0.99-1.051, P = .189). The MR analysis assessing the association between CD and acute pancreatitis showed no evidence of heterogeneity or horizontal pleiotropy. Likewise, the leave-one-out (LOO) method indicated no significant influence of any individual SNP on the overall findings. In addition, the Steiger direction test revealed that CD was the cause for increased risk of acute pancreatitis, but not vice versa. In summary, this research pioneers in proposing a causal relationship between CD and acute pancreatitis among the European population.

Comparison of endoscopic balloon dilation and surgery for duodenal stricture in patients with Crohn's disease

BACKGROUND

Few studies have compared endoscopic balloon dilation (EBD) and surgery in the treatment of duodenal stricture in patients with Crohn's disease (CD).

METHODS

We performed a retrospective study to compare the efficacy and safety among patients with CD-associated duodenal stricture treated with EBD or surgery from October 2013 to December 2021. Univariate and multivariate analyses were performed to evaluate factors associated with recurrence-free or surgery-free survival.

RESULTS

A total of 48 eligible patients were included, including 30 patients treated with EBD only and 18 patients treated with surgery. Patients treated with surgery experienced more symptomatic improvement (100% vs. 63.33%, p = 0.003) and significantly longer recurrence-free survival (6.31 [IQR: 3.00-8.39] years vs. 2.96 [IQR: 1.06-5.42] years, p = 0.01) but suffered more postprocedural adverse events (16.67% vs. 0.74% per procedure, p = 0.001). In patients initially treated with EBD (n = 41), a total of 11 (26.83%) required subsequent surgical intervention. Younger age at CD diagnosis (HR = 0.90, 95% CI: 0.81-1.00, p = 0.04) was associated with a higher risk for subsequent surgery.

CONCLUSIONS

Surgery for CD-associated duodenal strictures was associated with a longer recurrence-free survival. EBD was safe and effective with minimal postprocedural adverse events but led to a high frequency of recurrence.

A systematic review and meta-analysis of prevalence and clinical features of upper gastrointestinal (UGI) tract Crohn's disease in adults compared to non-UGI types

Background and Aim

Crohn's disease is an inflammatory condition that affects the gastrointestinal (GI) system. This study aimed to determine the prevalence of upper gastrointestinal Crohn's disease (UGICD) and compare its features to non-UGICD types.

Methods

We conducted a systematic search in the databases PubMed, Web of Science, Scopus, and Google Scholar. The heterogeneity of prevalence estimates was examined, subgroup analyses were carried out, and meta-analyses were conducted using random-effects modeling. Prognostic data were qualitatively reviewed and combined.

Results

Two-thousand nine-hundred and forty studies were retrieved and 32 studies were included in the final analysis. Pooled prevalence of UGICD was 15% (CI: 11-18%) among 14 509 patients. UGICD prevalence did not show any significant increase with time (P = 0.45). The most prevalent (38%, CI: 30-47%) behavior of UGICD was B1 (nonstricturing-nonpenetrating), while the most common concurrent location was L3 (ileocolon) with a prevalence of 47% (CI: 34-59%). UGICD patients had higher stricturing phenotype (B2) compared to non-UGICD (0.38 vs 0.30; P = 0.03). There was no significant difference in the prevalence of UGICD between patients classified according to the Montreal or Vienna classification. Stricturing phenotype was more common among Asian patients compared to Western patients (0.44 vs 0.24; P < 0.001). UGICD was a risk factor for surgery and drug therapy and was associated with an aggressive course of the disease and more resections. Pooled prevalence of UGICD was 15%.

Conclusion

Nonstricturing-nonpenetrating type was the most prevalent UGICD. UGICD patients had more complications and worse outcomes compared to non-UGICD patients.

Systematic review with meta-analysis: The prevalence, risk factors and outcomes of upper gastrointestinal tract Crohn's disease

AIMS

Upper gastrointestinal Crohn's disease (UGI-CD) is an important subclassification of Crohn's Disease (CD). We performed a systematic review and meta-analysis to evaluate the prevalence, risk factors, and clinical outcomes associated with UGI-CD.

METHODS

We searched Embase and Medline for articles reporting the clinical information of UGI-CD in CD patients, through 27 October 2020. Disease location and phenotype were coded according to the Montreal classification, and results were pooled with random effects by DerSimonian and Laird model.

RESULTS

26 articles were included. The prevalence of UGI-CD was 13%. UGI-CD was most commonly found in the stomach (56%) and was associated with concurrent ileocolonic involvement (54%). Non-stricturing, non-penetrating UGI-CD was the most common behavioral phenotype (61%). L4-jejunal disease was associated with the highest rates of surgery. Region of origin did not significantly influence the location and phenotype of UGI-CD. Young, male patients presenting with erythema nodosum, aphthous ulcers and stricturing-phenotype are more likely to have UGI-CD, which in turn is linked to increased risk of hospitalization and surgery.

CONCLUSION

UGI-CD is present in 13% of patients with CD, and patients with L4-jejunal disease are more likely to require surgery. Further studies examining the effect of ethnicity and region on UGI-CD are needed.

Long-Term Outcome of Endoscopic Balloon Dilation for Duodenal Crohn's Disease-Associated Strictures

BACKGROUND

Duodenal Crohn's disease (CD) is rare and may present with obstructive symptoms, and few reports have focused on endoscopic balloon dilation (EBD) for duodenal CD-associated strictures.

AIMS

To evaluate the efficacy and safety of EBD for duodenal CD-associated strictures.

METHODS

Patients with duodenal CD-associated strictures who underwent EBD were recruited. The clinical date, stricture characteristics, number of EBDs, dilation diameter, complications, surgical interventions, and follow-up periods were recorded. Patients were also divided into a serial dilation group and a nonserial dilation group to analyze the efficacy and safety of serial EBD for duodenal strictures.

RESULTS

A total of 54 patients with duodenal CD-associated strictures underwent a total of 153 dilations. Technical success was achieved in 98.69% (151/153) of cases. The short-term efficacy at 1 month and 2 months was 100%. At a median follow-up period of 223 days (range 30-866), 11 patients underwent surgery, and the total clinical efficacy was 79.63% (43/54). No difference in the safety or efficacy was noted between the serial dilation group and the nonserial dilation group. The median surgery-free survival of 507 days (range 170-857) and the median recurrence-free survival of 215 days (range 30-866) in the serial dilation group were significantly longer than those in the nonserial dilation group (185.5 days (range 73-275) and 124 days (range 30-699), respectively).

CONCLUSIONS

EBD is a safe and effective treatment for duodenal CD-associated strictures. Serial dilations could delay recurrence and surgical intervention but did not change the long-term outcome or prevent surgery.

Association Between Helicobacter pylori Colonization and Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Various observational studies have examined a potential relationship between Helicobacter pylori colonization and inflammatory bowel diseases (IBDs); however, results are inconclusive. This systematic review evaluates articles reporting an association between human H. pylori colonization and IBD.

METHODS

A systematic search of studies was conducted to evaluate a possible relationship between H. pylori colonization and IBD. Seven databases and different types of gray literature were searched. After screening for relevant articles, selection and data extraction were done. After that, the data were analyzed, and pooled odds ratios (ORs) were calculated, using meta-analysis. Heterogeneity, sensitivity, and subgroups analyses were conducted. Funnel plots followed by Begg and Egger tests were done to assess the publication bias.

RESULTS

Among 58 studies, including 13,549 patients with IBD and 506,554 controls, the prevalence of H. pylori colonization was 22.74% and 36.30%, respectively. A significant negative association was observed between H. pylori colonization and IBD (pooled OR: 0.45, 95% confidence interval 0.39-0.53, P≤0.001). The random-effect model showed significant statistical heterogeneity in the included studies (I2=79%). No publication bias was observed. Among subgroups, ORs were notably different when the data were stratified by the age difference between patient and control group, and by study regions and/or continent. Finally, the meta-regression analysis showed significant results, in terms of the age difference and region variables.

CONCLUSIONS

In this meta-analysis, all statistical data support the theory that H. pylori has a protective role in IBD. However, more primary studies using proper methodology are needed to confirm this association.

Single Donor FMT Reverses Microbial/Immune Dysbiosis and Induces Clinical Remission in a Rat Model of Acute Colitis

Deviation in the gut microbial composition is involved in various pathologies, including inflammatory bowel disease (IBD). Faecal microbiota transplant (FMT) can act as a promising approach to treat IBD by which changes in microbiome can be reversed and homeostasis restored. Therefore, the aim of this study was to investigate the effect of FMT on the remission of acute inflammatory response using dextran sulfate sodium (DSS)-induced rat colitis model. Faecal microbial communities were analysed using the 16S rRNA approach, and clinical manifestations together with histological/haematological/biochemical/immunological analyses were assessed. Our study demonstrated significant shifts in the dominant species of microbiota under inflammatory conditions induced by DSS and evident restoration effect of FMT treatment on microbial composition. These faecal microbial alterations in FMT-treated rats led to a relative restoration of colon length, and a significant decrease in both epithelium damage and disease severity, which was reflected in lower serum pro-inflammatory cytokine levels. Haematological/biochemical parameters in DSS-treated animals showed signs of anaemia with a significant reduction in red blood cell count together with increasing levels of total bilirubin, creatinine and phosphorus suggesting potential protective effect of FMT. These results support FMT as a valuable therapeutic strategy to control inflammation during acute colitis.

The relationship between inflammatory bowel disease and Helicobacter pylori across East Asian, European and Mediterranean countries: a meta-analysis

Background

The current literature suggests a protective benefit of Helicobacter pylori (H. pylori) infection against inflammatory bowel disease (IBD). Here we assessed whether this effect varied by IBD subtype—Crohn’s disease (CD) or ulcerative colitis (UC)—and geographic region: East Asia, Europe (non-Mediterranean) or Mediterranean region.

Methods

A database search was performed up to July 2019 inclusive for all studies that compared H. pylori infection in IBD patients vs. non-IBD controls. The relative risk (RR) was used to quantify the association between IBD and H. pylori, and the effects were combined across studies using a mixed-effects meta-regression model, which included IBD subtype and geographic region as categorical moderator variables.

Results

Our meta-regression model exhibited moderate heterogeneity (I²=48.74%). Pooled RR depended on both region (P=0.02) and subtype (P<0.001). Pooled RRs were <1 for all subtype and region combinations, indicative of a protective effect of H. pylori against IBD. The pooled RR was 28% (9%, 50%; P=0.001) greater for UC vs. CD and 43% (4%, 96%; P=0.02) greater for Mediterranean countries vs. East Asia. The pooled RR was 18% (-13%, 60%; P=0.48) greater for Europe vs. East Asia and 21% (-13%, 68%; P=0.42) greater for Mediterranean vs. Europe, though these differences were not statistically significant.

Conclusions

The protective effect of H. pylori on IBD varied by both subtype (more protection against CD vs. UC) and region (East Asia more protected than Mediterranean regions). Variation due to these effects could provide insight into IBD etiology.

A four-decade analysis of the incidence trends, sociodemographic and clinical characteristics of inflammatory bowel disease patients at single tertiary centre, Kuala Lumpur, Malaysia

BACKGROUND

Inflammatory bowel disease (IBD) was once considered as a Western disease. However, recent epidemiological data showed an emerging trend of IBD cases in the Eastern Asia countries. Clinico-epidemiological data of IBD in Malaysia is scarce. This study aimed to address this issue.

METHODS

Retrospective analysis of ulcerative colitis (UC) and Crohn's disease (CD), diagnosed from January 1980 till June 2018 was conducted at our centre.

RESULTS

A total of 413 IBD patients (281 UC, 132 CD) were identified. Mean crude incidence of IBD has increased steadily over the first three decades: 0.36 (1980-1989), 0.48 (1990-1999) and 0.63 per 100,000 person-years (2000-2009). In the 2010 to 2018 period, the mean crude incidence has doubled to 1.46 per 100,000 person-years. There was a significant rise in the incidence of CD, as depicted by reducing UC:CD ratio: 5:1 (1980-1989), 5:1 (1990-1999), 1.9:1 (2000-2009) and 1.7:1 (2010-2018). The prevalence rate of IBD, UC and CD, respectively were 23.0, 15.67 and 7.36 per 100,000 persons. Of all IBD patients, 61.5% (n = 254) were males. When stratified according to ethnic group, the highest prevalence of IBD was among the Indians: 73.4 per 100,000 persons, followed by Malays: 24.8 per 100,000 persons and Chinese: 14.6 per 100,000 persons. The mean age of diagnosis was 41.2 years for UC and 27.4 years for CD. Majority were non-smokers (UC: 76.9%, CD: 70.5%). The diseases were classified as follows: UC; proctitis (9.2%), left-sided colitis (50.2%) and extensive colitis (40.6%), CD; isolated ileal (22.7%), colonic (28.8%), ileocolonic (47.7%) and upper gastrointestinal (0.8%). 12.9% of CD patients had concurrent perianal disease. Extra intestinal manifestations were observed more in CD (53.8%) as compared to UC (12%). Dysplasia and malignancy, on the other hand, occurred more in UC (4.3%, n = 12) than in CD (0.8%, n = 1). Over one quarter (27.3%) of CD patients and 3.6% of UC patients received biologic therapy.

CONCLUSION

The incidence of IBD is rising in Malaysia, especially in the last one decade. This might be associated with the urbanization and changing diets. Public and clinicians' awareness of this emerging disease in Malaysia is important for the timely detection and management.

Duodenal Crohn's Disease

Symptomatic duodenal Crohn's disease (CD) is an uncommon disease presentation, especially in isolation. The most common duodenal disease phenotype is stricturing disease rather than inflammatory or perforating. Most patients are asymptomatic and are therefore diagnosed incidentally by cross-sectional imaging or endoscopy. Medical management includes proton pump inhibitor therapy and immunosuppressive therapy including corticosteroids, immunomodulatory therapy, and biologic therapy. Symptomatic strictures can often be treated medically or endoscopically, and do not always require surgery. Surgical options include resection with primary anastomosis, bypass with a gastrojejunostomy, and strictureplasty. Treatment recommendations are largely based on limited evidence from small series and expert opinion. Therefore, the optimal treatment algorithm remains largely subjective and undefined.

Oral and upper gastrointestinal Crohn's disease

Crohn's disease is a heterogeneous, inflammatory condition that can affect any location of the gastrointestinal tract. Proximal gastrointestinal involvement occurs in 0.5-16% of patients, and it is usually diagnosed after recognition of intestinal disease. Symptoms are often mild and nonspecific; however, upper gastrointestinal disease predicts a more severe Crohn's phenotype with a greater frequency of complications such as obstruction and perforation. Gastroscopy and biopsy is the most sensitive diagnostic investigation. There is a paucity of data examining the treatment of this condition. Management principles are similar to those for intestinal disease, commencing with topical therapy where appropriate, progressing to systemic therapy such as glucocorticoids, 5-aminosalicylic acid, immunomodulators, and biologics. Acid suppression therapy has symptomatic but no anti-inflammatory benefit for gastroduodenal and esophageal involvement. Surgical intervention with bypass, strictureplasty, or less frequently, endoscopic balloon dilation may be required for complications or failed medical therapy.