Tobacco consumption and disease duration are associated with fistulizing and stricturing behaviors in the first 8 years of Crohn's disease

Current Approach to Risk Factors and Biomarkers of Intestinal Fibrosis in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD), especially Crohn's disease (CD), characterized by a chronic inflammatory process and progressive intestinal tissue damage, leads to the unrestrained proliferation of mesenchymal cells and the development of bowel strictures. Complications induced by fibrosis are related to high rates of morbidity and mortality and lead to a substantial number of hospitalizations and surgical procedures, generating high healthcare costs. The development of easily obtained, reliable fibrogenesis biomarkers is essential to provide an important complementary tool to existing diagnostic and prognostic methods in IBD management, guiding decisions on the intensification of pharmacotherapy, proceeding to surgical methods of treatment and monitoring the efficacy of anti-fibrotic therapy in the future. The most promising potential markers of fibrosis include cartilage oligomeric matrix protein (COMP), hepatocyte growth factor activator (HGFA), and fibronectin isoform- extra domain A (ED-A), as well as antibodies against granulocyte macrophage colony-stimulating factor (GM-CSF Ab), cathelicidin (LL-37), or circulatory miRNAs: miR-19a-3p and miR-19b-3p. This review summarizes the role of genetic predisposition, and risk factors and serological markers potentially contributing to the pathophysiology of fibrotic strictures in the course of IBD.

[Health goals amongst patients with Crohn's disease.]

INTRODUCTION

Inflammatory bowel diseases, including Crohn's disease, have a significant impact on patients' lifestyle, requiring lifelong attention to health behavior.

OBJECTIVE

The aim of our study was to investigate health-related goals, emotions related to health goals, the use of infocommunication tools and their associations.

METHOD

79 patients with Crohn's disease (59.5% female, mean age 40.7 years, SD = 11.89) participated in the study. They answered demographic and health behaviour questions and completed the Personal Health Plans Questionnaire, which assessed their personal health goals, positive and negative emotions about health goal(s), support for personal health goals from their physician, negative and positive effects (barriers/support) of achieving health goals, and digital technology and internet use.

RESULTS

70% of patients had at least 1 health goal. The health goals were classified into four categories: physical activity (43.6%), stress management (25.4%), nutrition (18%) and smoking cessation (7%). 71% of participants experienced at least average levels of positive emotions related to the health goal, but about 50% also experienced negative emotions. 51% of those with a health goal regularly use the internet and apps on smartphones. Infocommunication device use showed a medium-strength correlation with perceived health goal-related barrier/support (ρ = 0.55, p<0.01), support from the person's doctor (ρ = 0.45, p<0.05) and physical activity (ρ = 0.40, p<0.01).

DISCUSSION

More than two-thirds of patients had a health goal; most of the goals were related to health behaviours that are also relevant to Crohn's disease, but few had healthy eating and smoking cessation as health goals. Half of those with a health goal regularly use the internet and apps on smartphones. Among health behaviours, physical activity was associated with infocommunication device use.

CONCLUSION

It is recommended to investigate patients' health goals and infocommunication device use in the care of patients with Crohn's disease. This would allow the development of specific interventions to improve their health behaviour, which could increase the quality of life and disease prognosis. Orv Hetil. 2023; 164(28): 1102-1110.

Immigrant IBD Patients in Spain Are Younger, Have More Extraintestinal Manifestations and Use More Biologics Than Native Patients

BACKGROUND

Previous studies comparing immigrant ethnic groups and native patients with IBD have yielded clinical and phenotypic differences. To date, no study has focused on the immigrant IBD population in Spain.

METHODS

Prospective, observational, multicenter study comparing cohorts of IBD patients from ENEIDA-registry who were born outside Spain with a cohort of native patients.

RESULTS

We included 13,524 patients (1,864 immigrant and 11,660 native). The immigrants were younger (45 ± 12 vs. 54 ± 16 years, p < 0.001), had been diagnosed younger (31 ± 12 vs. 36 ± 15 years, p < 0.001), and had a shorter disease duration (14 ± 7 vs. 18 ± 8 years, p < 0.001) than native patients. Family history of IBD (9 vs. 14%, p < 0.001) and smoking (30 vs. 40%, p < 0.001) were more frequent among native patients. The most prevalent ethnic groups among immigrants were Caucasian (41.5%), followed by Latin American (30.8%), Arab (18.3%), and Asian (6.7%). Extraintestinal manifestations, mainly musculoskeletal affections, were more frequent in immigrants (19 vs. 11%, p < 0.001). Use of biologics, mainly anti-TNF, was greater in immigrants (36 vs. 29%, p < 0.001). The risk of having extraintestinal manifestations [OR: 2.23 (1.92-2.58, p < 0.001)] and using biologics [OR: 1.13 (1.0-1.26, p = 0.042)] was independently associated with immigrant status in the multivariate analyses.

CONCLUSIONS

Compared with native-born patients, first-generation-immigrant IBD patients in Spain were younger at disease onset and showed an increased risk of having extraintestinal manifestations and using biologics. Our study suggests a featured phenotype of immigrant IBD patients in Spain, and constitutes a new landmark in the epidemiological characterization of immigrant IBD populations in Southern Europe.

Polysubstance use in inflammatory bowel disease

OBJECTIVES

We aimed to evaluate the incidence, predisposing factors and impacts of polysubstance use (PSU) (ie, the concurrent use or abuse of two or more drugs or substances) in inflammatory bowel disease (IBD).

METHODS

Data of patients enrolled between 1 January 2015 and 31 August 2019 from a single tertiary care referral center were retrospectively collected. Patients' baseline and clinical characteristics and their antidepressant and/or anxiolytic medications were abstracted. Associations between PSU and patients' characteristics were analyzed. Multivariate logistic regression models were fit, incorporating significant clinical factors.

RESULTS

Altogether 315 patients with IBD (166 women, 149 men; 214 with Crohn's disease and 101 ulcerative colitis) were enrolled. Of them, 66 (21.0%) exhibited PSU (CD 21.5%, UC 19.8%); 37.5% had moderate to severe disease activity, 34.3% with extraintestinal manifestations (EIM), 41.6% with an anxious or depressed state and 69.8% had used healthcare resources in the prior 12 months. Moreover, 71.2% used two substances, while 27.3% used three substances. In the total cohort, EIM (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.14-3.34, P = 0.019) and antidepressant or anxiolytic use (OR 2.51, 95% CI 1.45-4.39, P < 0.001) were positively associated with PSU on multivariate analysis. PSU was associated with increased rate of IBD-associated imaging (57.6% vs 47.0%, P < 0.05).

CONCLUSIONS

PSU is common in IBD. EIM, antidepressant and/or anxiolytic use and imaging studies were independently associated with PSU. This study reinforces the importance of screening patients with IBD for substance use, particularly those with EIM and using antidepressants and/or anxiolytics.

Machine learning for prediction of intra-abdominal abscesses in patients with Crohn's disease visiting the emergency department

BACKGROUND

Intra-abdominal abscess (IA) is an important clinical complication of Crohn's disease (CD). A high index of clinical suspicion is needed as imaging is not routinely used during hospital admission. This study aimed to identify clinical predictors of an IA among hospitalized patients with CD using machine learning.

METHODS

We created an electronic data repository of all patients with CD who visited the emergency department of our tertiary medical center between 2012 and 2018. We searched for the presence of an IA on abdominal imaging within 7 days from visit. Machine learning models were trained to predict the presence of an IA. A logistic regression model was compared with a random forest model.

RESULTS

Overall, 309 patients with CD were hospitalized and underwent abdominal imaging within 7 days. Forty patients (12.9%) were diagnosed with an IA. On multivariate analysis, high C-reactive protein (CRP) [above 65 mg/l, adjusted odds ratio (aOR): 16 (95% CI: 5.51-46.18)], leukocytosis [above 10.5 K/μl, aOR: 4.47 (95% CI: 1.91-10.45)], thrombocytosis [above 322.5 K/μl, aOR: 4.1 (95% CI: 2-8.73)], and tachycardia [over 97 beats per minute, aOR: 2.7 (95% CI: 1.37-5.3)] were independently associated with an IA. Random forest model showed an area under the curve of 0.817 ± 0.065 with six features (CRP, hemoglobin, WBC, age, current biologic therapy, and BUN).

CONCLUSION

In our large tertiary center cohort, the machine learning model identified the association of six clinical features (CRP, hemoglobin, WBC, age, BUN, and biologic therapy) with the presentation of an IA. These may assist as a decision support tool in triaging CD patients for imaging to exclude this potentially life-threatening complication.

Development of Anti-fibrotic Therapy in Stricturing Crohn's Disease: Lessons from Randomized Trials in Other Fibrotic Diseases

Intestinal fibrosis is considered an inevitable complication of Crohn's disease (CD) that results in symptoms of obstruction and stricture formation. Endoscopic or surgical treatment is required to treat the majority of patients. Progress in the management of stricturing CD is hampered by the lack of effective anti-fibrotic therapy; however, this situation is likely to change because of recent advances in other fibrotic diseases of the lung, liver and skin. In this review, we summarized data from randomized controlled trials (RCT) of anti-fibrotic therapies in these conditions. Multiple compounds have been tested for the anti-fibrotic effects in other organs. According to their mechanisms, they were categorized into growth factor modulators, inflammation modulators, 5-hydroxy-3-methylgultaryl-coenzyme A (HMG-CoA) reductase inhibitors, intracellular enzymes and kinases, renin-angiotensin system (RAS) modulators and others. From our review of the results from the clinical trials and discussion of their implications in the gastrointestinal tract, we have identified several molecular candidates that could serve as potential therapies for intestinal fibrosis in CD.

Links Between Inflammatory Bowel Disease and Chronic Obstructive Pulmonary Disease

Inflammatory bowel disease (IBD) and chronic obstructive pulmonary disease (COPD) are chronic inflammatory diseases of the gastrointestinal and respiratory tracts, respectively. These mucosal tissues bear commonalities in embryology, structure and physiology. Inherent similarities in immune responses at the two sites, as well as overlapping environmental risk factors, help to explain the increase in prevalence of IBD amongst COPD patients. Over the past decade, a tremendous amount of research has been conducted to define the microbiological makeup of the intestine, known as the intestinal microbiota, and determine its contribution to health and disease. Intestinal microbial dysbiosis is now known to be associated with IBD where it impacts upon intestinal epithelial barrier integrity and leads to augmented immune responses and the perpetuation of chronic inflammation. While much less is known about the lung microbiota, like the intestine, it has its own distinct, diverse microflora, with dysbiosis being reported in respiratory disease settings such as COPD. Recent research has begun to delineate the interaction or crosstalk between the lung and the intestine and how this may influence, or be influenced by, the microbiota. It is now known that microbial products and metabolites can be transferred from the intestine to the lung via the bloodstream, providing a mechanism for communication. While recent studies indicate that intestinal microbiota can influence respiratory health, intestinal dysbiosis in COPD has not yet been described although it is anticipated since factors that lead to dysbiosis are similarly associated with COPD. This review will focus on the gut-lung axis in the context of IBD and COPD, highlighting the role of environmental and genetic factors and the impact of microbial dysbiosis on chronic inflammation in the intestinal tract and lung.

Divergent Effect of Cigarette Smoke on Innate Immunity in Inflammatory Bowel Disease: A Nicotine-Infection Interaction

Cigarette smoke (CS) has adverse effects in patients with Crohn’s disease (CD), an inflammatory bowel disease (IBD) that has been associated with microbial infection, immuno-dysregulation, and mucosal dysfunction. However, CS seems to provide relief and protection to patients with another IBD known as ulcerative colitis (UC). These two subsets are featured as M1- and M2-mediated responses, respectively. Nicotine is the most active, addictive, and studied ingredient in CS. The mechanism of how nicotine and/or other CS ingredients induce pro-inflammatory or anti-inflammatory phenotypes in IBD patients remains under investigation. Our most recent in vitro nicotine study provided significant insights toward understanding the contradictory effects of nicotine on IBD patients, and it elucidated the mechanistic role of α7nAChR in modulation of macrophages in tobacco smokers. Shifting the beneficial effect of nicotine to a harmful outcome in CD patients was linked to a nicotine-microbe interaction that supports a microbial etiology in CD pathogenesis. Among the most debated pathogens in CD etiology is Mycobacterium avium subspecies paratuberculosis (MAP). Other studies associated nicotine with upregulation of miR-124 expression in macrophages, which led to anti-inflammatory response. This review discusses published work on the role of nicotine in modulation of the innate immune response and subsequent signaling in macrophages in IBD subsets.

Effect of Lifestyle Factors on Outcomes in Patients With Inflammatory Bowel Diseases

Various lifestyle factors including physical activity and obesity, stress, sleep, and smoking may modify the risk of developing inflammatory bowel diseases (IBDs). In patients with established IBD, these lifestyle factors may significantly impact the natural history and clinical outcomes. Recreational exercise decreases the risk of flare and fatigue in patients with IBD. In contrast, obesity increases the risk of relapse and is associated with higher anxiety, depression, fatigue, and pain and higher health care utilization. Obesity also modifies pharmacokinetics of biologic agents unfavorably and is associated with a higher risk of treatment failure. Sleep disturbance is highly prevalent in patients with IBD, independent of disease activity, and increases the risk of relapse and chronic fatigue. Similarly, stress, particularly perceived stress rather than major life events, may trigger symptomatic flare in patients with IBD, although its impact on inflammation is unclear. Cigarette smoking is associated with unfavorable outcomes including the risk of corticosteroid dependence, surgery, and disease progression in patients with Crohn's disease; in contrast, smoking does not significantly impact outcomes in patients with ulcerative colitis, although some studies suggest that it may be associated with a lower risk of flare. The effect of alcohol and cannabis use in patients with IBD is inconsistent, with some studies suggesting that cannabis may decrease chronic pain in patients with IBD, without a significant effect of biological remission. Although these lifestyle factors are potentially modifiable, only a few interventional studies have been conducted. Trials of structured exercise and psychological therapy including mindfulness-based therapies such as meditation and yoga and gut-directed hypnotherapy have not consistently demonstrated benefit in clinical and/or endoscopic disease activity in IBD, although may improve overall quality of life.

Inpatient Management of Inflammatory Bowel Disease-Related Complications

Despite advances in therapeutic options, a sizeable proportion of patients with inflammatory bowel disease require hospitalization or surgery during their lifetime. While current treatment guidelines for the management of ulcerative colitis and Crohn's disease cover the spectrum of disease severity and behavior, management of acute complications of inflammatory bowel disease can present unique challenges that are not always addressed in these guidelines. In this review, the authors provide a comprehensive summary of the existing literature focused on management of patients hospitalized with complications of inflammatory bowel disease. Proposed management algorithms are provided to guide clinicians through common scenarios to determine the most appropriate interventions - escalation of medical therapies, non-surgical therapeutic interventions (drainage of intra-abdominal abscess or endoscopic balloon dilation) or surgery. Prevention of complications is proposed through a multi-disciplinary approach that involves surgeons, dieticians, radiologists, pathologists and infectious disease consultants.

The effect of a multidisciplinary approach for smoking cessation in patients with Crohn's disease: Results from an observational cohort study

INTRODUCTION

Cigarette smoking is the most important risk factor for Crohn’s disease (CD). The effectiveness of smoking cessation programs (SCPs) in patients with CD is still poorly understood.

METHODS

This was a retrospective, observational, single-centre, cohort study of 136 active smokers with mean age 55 years (SD=11), 58% males, including 27 (19.8%) patients with CD who entered the multidisciplinary SCP of the Luigi Sacco University Hospital of Milan from January 2017 through January 2019. A pulmonologist was responsible for the clinical and pharmacological management, while a psychiatrist and a psychologist conducted the counselling and assessed the motivation to quit, anxiety and depression using the Brief Psychiatric Rating Scale (BPRS) and the nicotine dependence with the Fagerström test. Patients were defined as quitters after 12 months.

RESULTS

Demographic and clinical characteristics, and Fagerström score, did not differ in patients with and without CD. At baseline, patients with CD had a higher BPRS (median: 27, IQR: 22–32; vs 25 and 22–28.5; p=0.03), and a lower motivation to quit score (median: 10, IQR: 9–13; vs 14 and 12–15; p<0.001). After 12 months, the quitting rate of smokers with CD was significantly lower (14.8% vs 36.7%; p<0.022) and the chance of quitting was negatively associated with the baseline BPRS (r=-0.256; p<0.003). Varenicline and nicotine replacement therapy tended to be less effective in patients with CD.

CONCLUSIONS

The lower efficacy of SCPs in patients with CD might be secondary to a higher prevalence of anxiety and depression. Psychological issue recognition and support should be enhanced to increase SCP effectiveness in CD.

Role of environmental factors in the pathogenesis of Crohn's disease: a critical review

PURPOSE

To review role of environmental factors in the pathogenesis of Crohn's disease.

METHODS

We systematically reviewed trials and systematic reviews using PubMed and Web of science databases. Here, we review the current information on the causative factors and mechanisms of CD, including smoking, exercise, diet, animal protein, breastfeeding, history of childhood infection and vaccination, oral contraceptives, and antibiotics of CD. We also highlight important knowledge gaps that need to be filled in order to advance the field of CD research.

RESULTS

Epidemiological studies have indicated the significance of environmental factors in the disease behavior and outcome of Crohn's disease (CD). There are a few recognized environmental factors, such as cigarette smoking, exercise, dietary habits, and breastfeeding, which are associated with the pathogenesis of CD. These factors are hypothesized to change the epithelial barrier function, which disturbs both the innate and adaptive immune systems and the intestinal flora. However, the effect of several risk factors, such as appendectomy and pharmaceutical use, differs across several studies, indicating the need for more rigorous research. Furthermore, few studies have examined effective interventions based on environmental factors that can improve disease outcomes. Recent studies have indicated that the pathogenesis of CD is related to environmental and genetic factors.

CONCLUSION

We review the current information on the causative factors and mechanisms of CD, including smoking, exercise, diet, animal protein, breastfeeding, history of childhood infection and vaccination, oral contraceptives, and antibiotics of CD. However, further studies are needed to understand knowledge gaps in the field of CD.

Current smoking habits in British IBD patients in the age of e-cigarettes

Background

Smoking has a detrimental effect on Crohn’s disease (CD) while data on ulcerative colitis (UC) are conflicting. Smoking habits have changed dramatically in the UK due to a public smoking ban and the advent of e-cigarettes. We describe current smoking rates in patients with inflammatory bowel disease (IBD) and any effects on disease course.

Methods

Self-reported smoking status was elicited in outpatients with IBD, and clinical data were extracted from patient records.

Results

Of 465 patients (58% CD, 42% UC), 247 (53.1%) were ever-smokers (37.4% ex-smokers, 15.7% current smokers). Electronic cigarettes (e-cigarettes) were ever used by 28 patients (15 current users). All e-cigarette users had previously smoked cigarettes and 13 had stopped smoking completely. Patients with CD were more likely to currently smoke (21.5% vs 7.7%, p<0.001) than those with UC. Ever use of biological therapy was higher in current smokers compared with never smokers (49% vs 35%, p=0.034). The need for surgery was higher in current smokers compared with never smokers (43% vs 25%, p=0.006). The risk of CD complications during 21-month prospective follow-up was numerically higher for current smoker versus e-cigarette users (53% vs 17%, p=0.19).

Compared with the general population, the proportion of current cigarette smokers (14.9% vs 15.1%) and e-cigarette users was similar in our cohort (4.26% vs 5.5%).

Conclusions

Patients with IBD show similar smoking behaviour to the general population. E-cigarettes were used as replacement for cigarettes or by some as an intermediate step for smoking cessation. Larger, prospective studies are required to fully determine the effects of e-cigarettes on IBD.

Practices, attitudes, and knowledge about Crohn's disease and smoking cessation among gastroenterologists

OBJECTIVE

Cigarette smoking is one of the most important, modifiable environmental factors in Crohn's disease (CD) and screening for tobacco use is an official recommendation and quality measure in the care of CD patients. The objective of this study was to learn more about gastroenterologists' practices, opinions, and knowledge in this area.

PATIENTS AND METHODS

A 15 question survey was sent through email to two national gastroenterology distribution lists. Questions were written in multiple choice formats and were designed to collect information about gastroenterologists' practices, attitudes, and knowledge regarding smoking cessation in CD patients. Responses were stratified by practice setting, experience, and inflammatory bowel disease-focus. Responses were anonymous and were collected in a secure, online database.

RESULTS

A total of 141 respondents completed the survey. Overall, 89% of participants screened their CD patients for smoking more than 75% of the time. In all, 62% provided smoking cessation counseling more than 75% of the time. Overall, 94% of respondents felt comfortable discussing the benefits of smoking cessation with their patients. In all, 56% felt comfortable discussing smoking cessation strategies with their patients. Overall, 88% of respondents agreed that gastroenterologists should provide smoking cessation counseling; however, 43 and 11% agreed that the gastroenterologist should be the primary counselor and primary prescriber of cessation-related pharmacotherapy, respectively.

CONCLUSION

Surveyed gastroenterologists agree that smoking cessation is an important part of the care of CD patients and this is reflected in their screening practices. Counseling occurs irregularly and many gastroenterologists do not feel comfortable discussing cessation strategies. Future guidelines should provide further guidance on the gastroenterologist's role in smoking cessation counseling for CD patients.

Preoperative optimization of patients with inflammatory bowel disease undergoing gastrointestinal surgery: a systematic review

PURPOSE

Surgical management of inflammatory bowel disease (IBD) is a challenging task. The aim of preoperative optimization (PO) is to decrease the risk of complications and reduce the length of postoperative stay. The aim of this study was to review and grade the available evidence, attain clear recommendations, and point out potential future research.

METHODS

Studies were identified from electronic databases (PubMed, Embase, and Cochrane Library) and scanning reference lists in relevant papers. English-written studies examining PO in adult patients with IBD were included. Eight PO factors were investigated.

RESULTS

Management of IBD is a multidisciplinary task. Steroid withdrawal is recommended while steroid stress dose is not recommended. Thiopurines appear to be safe, but it may be prudent to plan the procedure remotely from the last dose of an anti-TNF agent. Nutritional risk screening is recommended to unveil and correct any malnutrition. Thrombosis prophylaxis prior to surgery is well supported by evidence while extended 4-week prophylaxis needs further research. Percutaneous ultrasound or CT-guided drainage for intra-abdominal abscesses is recommended, but it is unclear for how long supplementary antibiotics (ABs) should be used. Oral AB 24 h prior to open surgery might improve outcome if given as complementary to IV perioperative AB. Mechanical bowel preparation is not supported by evidence. Comorbidities must be treated accordingly prior to surgical intervention. Smoking cessation can be beneficial for wound healing.

CONCLUSION

Multimodel PO intervention in IBD patients is recommended.

Modifiable Environmental Factors in Inflammatory Bowel Disease

PURPOSE OF REVIEW

Environmental factors may influence predisposition to develop inflammatory bowel diseases (Crohn's disease, ulcerative colitis) or alter its natural history by modification of both the host immune response and intestinal microbial composition. The purpose of this review is to translate such evidence into clinical practice by a focus on interventional studies that have modified such environmental influences to improve disease outcomes.

RECENT FINDINGS

Several environmental influences have been identified in the recent literature including tobacco use, diet, antibiotics, vitamin D deficiency, stress, appendectomy, and oral contraceptive use. Some risk factors have similar influences on both Crohn's disease and ulcerative colitis while others are disease-specific or have divergent effects. Emerging epidemiologic evidence has confirmed the association of many of these factors with incident disease using prospective data. In addition, laboratory data has supported their mechanistic plausibility and relevance to intestinal inflammation.

Platelets Toll-like receptor-4 in Crohns disease

BACKGROUND

Platelets are activated in Crohn's disease (CD) and interplay with leukocytes. Engagement of Toll-like receptor-4 (TLR-4), which is expressed in human platelets, may be involved in crosstalks between platelets and leukocytes leading to their mutual activation for host defense.

MATERIALS AND METHODS

Human neutrophil peptides (HNPs), lipoprotein binding peptides, and sCD14 were determined by enzyme-linked immunosorbent assays in 42 patients with active CD, in 43 patients with CD in remission, and in 30 healthy individuals. Neutrophil-platelet aggregates and binding of the TLR-4 monoclonal antibody to platelets were determined by flow cytometry.

RESULTS

Levels of HNPs were higher in patients with CD than in controls (P = 0.0003 vs. active CD and P = 0.01 vs. CD in remission). Likewise, neutrophils with adhering platelets were higher in patients with active CD than in controls (P = 0.004). Binding of the TLR-4 antibody in patients with active CD was similar to that in controls, while patients in remission had significantly higher binding capacities (P = 0.59 and P = 0.003). Incubation of plasma from patients with active disease or patients in remission with platelets from healthy controls confirmed lower binding of the TLR-4 antibody in the presence of plasma from active diseased patients compared to controls (P = 0.039), possibly due to high levels of lipopolysaccharides, as suggested by high levels of sCD14 and lipoprotein binding protein.

CONCLUSION

Our study indicates involvement of platelet TLR-4 in enhancing the secretion of antimicrobial peptides from neutrophils. While platelet aggregation can be due to a variety of mechanisms in inflammatory disease, the mutual activation of platelets and neutrophils may augment host defense.

Zinc Deficiency is Associated with Poor Clinical Outcomes in Patients with Inflammatory Bowel Disease

BACKGROUND

Zinc plays a pivotal role in wound repair, tissue regeneration, and the immune response. Although zinc deficiency is common in patients with inflammatory bowel disease (IBD), the impact of low serum zinc levels on disease course is not known.

METHODS

Patients enrolled in a prospectively collected IBD registry with at least 2 serum zinc measurements were included in the analysis. Using a logistic regression model, rates of IBD-related surgeries, IBD-related hospitalizations, and IBD-related complications were evaluated after a diagnosis of zinc deficiency (serum concentration <0.66 μg/mL) compared with those with normal zinc concentrations. In patients who were zinc deficient, outcomes were also analyzed between those who had normalization of zinc levels within 12 months and those who remained deficient.

RESULTS

A total of 773 patients with Crohn's disease (CD) and 223 with ulcerative colitis (UC) were included in the analysis. After adjusting for covariates, zinc deficiency was associated with an increased risk of subsequent hospitalizations, surgeries, and disease-related complications in patients with CD and UC (CD: hospitalizations, odds ratio 1.44, 95% confidence interval [1.02-2.04]; surgeries, 2.05 [1.38-3.05]; complications, 1.50 [1.04-2.15]; UC: hospitalizations, 2.14 [1.07-4.29]; surgeries, 1.64 [0.59-4.52]; complications, 1.97 [0.94-4.11]). Normalization of zinc was associated with improvement in these outcomes in patients with both CD and UC.

CONCLUSIONS

Patients with IBD with serum zinc deficiency are more likely to have adverse disease-specific outcomes. As these outcomes improve with normalization of zinc, the results from this study support the role for close monitoring and replacement of zinc in patients with IBD.

Evolution of disease phenotype in pediatric-onset Crohn's disease after more than 10 years follow up-Cohort study

BACKGROUND

Pediatric-onset Crohn's disease (CD) is a heterogeneous disorder which is subjected to progression and complications in a substantial proportion of patients.

AIMS

We aimed to assess the progression in pediatric-onset CD phenotype on long term follow up.

METHODS

Medical charts of pediatric onset CD patients with at least 10 years follow-up were analyzed retrospectively. Disease phenotype was determined at diagnosis and during follow up at different time points. Phenotype was determined according to the Paris classification. The impact of possible predictors on phenotype progression was assessed as well as the association between different therapeutic regimens during disease course and phenotype progression.

RESULTS

Progression of disease location, behavior, and perianal involvement was observed in 20%, 38% and 20% of patients, respectively, after a median follow-up of 16.4 (±4.4) years. Microscopic ileocolonic disease at diagnosis was significant predictors for progression of disease extent. Treatment with anti tumor necrosis factor-ɑ agents and number of flares per years of follow-up were associated with progression of disease extent, behavior and perianal involvement.

CONCLUSION

Disease extent, behavior and prevalence of perianal disease change significantly over time in pediatric-onset CD. In our cohort, most clinical, laboratory and endoscopic parameters do not serve as predictors for long-term disease progression.

A Promoter Variant Within the Aryl Hydrocarbon Receptor Gene Is Associated with an Epithelial Barrier Defect in Smokers with Crohn's Disease

BACKGROUND

Smoking worsens Crohn's disease (CD). The aryl hydrocarbon receptor (AhR) is a transcription factor that mediates the toxicity of dioxinlike chemicals. We hypothesized that AHR variants and smoking influence CD.

METHODS

Exon-intron boundaries and coding and promoter regions of AHR gene were sequenced (28 patients with inflammatory bowel disease; 4 healthy controls). Two identified variants (rs7796976 and rs2066853) were studied for an association with intestinal permeability (IP, oral sugar test) in patients with inflammatory bowel disease (stratified according to the smoking status). AHR expression was analyzed by quantitative real-time polymerase chain reaction in colonic biopsies from patients with CD (n = 53). Case-control analysis including a genotype-phenotype correlation was performed for both variants (n = 767 patients with inflammatory bowel disease; n = 466 healthy controls).

RESULTS

Sequencing identified a putative promoter variant (rs7796976) and a nonsynonymous variant (rs2066853; Arg554Lys) in AHR, both predicted to be functionally relevant. The major G-allele of rs7796976 increased the risk for disturbed IP (odds ratio 1.9, 95% confidence interval [CI], 1.1-3.2) in CD but not ulcerative colitis. We observed an additive effect of the rs7796976 genotype and smoking on IP (P = 0.005), which was also shown for rs2066853 (P = 0.004; variants not linked). Both variants showed a genotype-dependent AHR expression in colonic biopsies of patients with CD. No overall association with either CD or ulcerative colitis was observed; however, the rs7796976 genotype and smoking increased the risk for the L4 phenotype in CD.

CONCLUSION

Smoking and functionally relevant AHR variants increase IP in CD. Because AhR is known to mediate between smoking and inflammation, these variants might be involved in the deleterious effect of smoking on CD.

Patients With Inflammatory Bowel Disease Are Unaware of the Impact of Smoking on Their Disease

BACKGOUND

Tobacco is one of the most significant risk factors for inflammatory bowel disease (IBD).

GOALS

The main objective was to assess the knowledge of patients with IBD regarding the effects of tobacco on their disease. Secondary objectives were to determine the source of their knowledge, the influence of their knowledge on their intent to quit smoking, and the association between patients' characteristics and their knowledge.

STUDY

Patients with IBD completed a self-administered questionnaire on demographic data, severity of disease, and effects of tobacco on their disease.

RESULTS

In total 259 patients [182 with Crohn's disease, 77 with ulcerative colitis (UC)] participated. The prevalence of current smokers, exsmokers, and nonsmokers was 19.6%, 40.2%, and 40.2%, respectively. Patients with Crohn's disease were more aware of the effects of tobacco on their disease compared with those with UC (57.7% vs. 13.0%, P<0.0001). In informed patients, the main source of information was the gastroenterologist (56.9%). The intent to quit smoking was superior in informed patients compared with those uninformed (78.6% vs. 47.8%, P=0.046). Older patients (odds ratio=0.97, P=0.01) and patients with UC (odds ratio=0.11, P<0.0001) were less likely to be informed.

CONCLUSIONS

Only half of patients with IBD are aware of the risks of smoking associated with their disease, whereas their intent to quit smoking is directly related to their awareness. In the scope of IBD's treatment, management of smoking cessation should be undertaken in all smokers.

The Association of Smoking and Surgery in Inflammatory Bowel Disease is Modified by Age at Diagnosis

Objectives:

We assessed the association of smoking at diagnosis of inflammatory bowel disease (IBD) on the need for an intestinal resection.

Methods:

The Health Improvement Network was used to identify an inception cohort of Crohn's disease (n=1519) and ulcerative colitis (n=3600) patients from 1999–2009. Poisson regression explored temporal trends for the proportion of newly diagnosed IBD patients who never smoked before their diagnosis and the risk of surgery within 3 years of diagnosis. Cox proportional hazard models assessed the association between smoking and surgery, and effect modification was explored for age at diagnosis.

Results:

The rate of never smokers increased by 3% per year for newly diagnosed Crohn's disease patients (incidence rate ratio (IRR) 1.03; 95% confidence interval (CI): 1.02–1.05), but not for ulcerative colitis. The rate of surgery decreased among Crohn's disease patients aged 17–40 years (IRR 0.96; 95% CI: 0.93–0.98), but not for ulcerative colitis. Smoking at diagnosis increased the risk of surgery for Crohn's disease patients diagnosed after the age of 40 (hazard ratio (HR) 2.99; 95% CI: 1.52–5.92), but not for those diagnosed before age 40. Ulcerative colitis patients diagnosed between the ages of 17 and 40 years and who quit smoking before their diagnosis were more likely to undergo a colectomy (ex-smoker vs. never smoker: HR 1.66; 95% CI: 1.04–2.66). The age-specific findings were consistent across sensitivity analyses for Crohn's disease, but not ulcerative colitis.

Conclusions:

In this study, the association of smoking and surgical resection was dependent on the age at diagnosis of IBD.

[Smoking, smoking cessation and Crohn's disease]

CONTEXT

Smoking whose prevalence is higher in patients with Crohn's disease (CD) worsens its evolution. Ulcerative colitis mostly affect non- or ex-smokers; smoking may improve the course of the disease.

OBJECTIVES

Systematic literature review of data on the relationship between smoking, smoking cessation and Crohn'disease.

DOCUMENTARY SOURCES

Medline, on the period 1980-2015 with the keywords "Crohn's disease" or "inflammatory bowel disease" and "smoking" or "smoking cessation"; limits "Title/Abstract"; the selected languages were English or French.

STUDY SELECTION

Among 1315 articles, 168 abstracts have given rise to a dual reading to select 69 studies (case-control, retrospective, reviews or meta-analysis). Data were extracted using a reading gate.

RESULTS

Smoking increases the risk of complications, recurrences and resort of surgery, corticosteroids or immunosuppressants. These deleterious effects are more common in women. Stopping smoking improves the course of the disease and represents an essential component of its management.

LIMITS

Heterogeneity of the studies collected according to the type, population characteristics, definition of smoking status and the validation of smoking cessation.

CONCLUSION

Smokers suffering from CD must routinely be made aware of the disadvantages of smoking, benefits of abstinence and helped to quit smoking.

Impact of Smoking Cessation on the Clinical Course of Crohn's Disease Under Current Therapeutic Algorithms: A Multicenter Prospective Study

OBJECTIVES

Given the importance of tobacco smoking (TS) as the only environmental factor repeatedly linked to the development of the Crohn's disease (CD), it is surprising that very few prospective studies have assessed whether TS is associated with an increased frequency of clinical relapse. Our aim was to evaluate the current impact of TS on disease relapse and the clinical benefit of quitting smoking in the present era of widespread use of anti-TNF drugs and immunosuppressants.

METHODS

This was a multicenter prospective cohort study, which included 573 CD patients in clinical remission with various smoking habits. All smokers were advised to quit. Patients not exposed to tobacco before inclusion (non- and former smokers), continuing smokers, and quitters were compared regarding differences in disease outcomes during a follow-up of 4 years.

RESULTS

A total of 148 continuing smokers, 190 nonsmokers, 160 former smokers, and 75 quitters were included. In comparison with nonsmokers, continuing smokers relapsed more frequently with an incidence rate ratio of 1.53 (95% confidence interval (CI): 1.10-2.17). Former smokers and quitters had similar relapse incidences compared with nonsmokers. Smoking was an independent predictor for disease relapse in the multivariate analysis (hazard ratio: 1.58 (95% CI 1.20-2.09). In the time-dependent analysis, continuing smokers had earlier relapse, regardless of anti-TNF or immunosuppressant use.

CONCLUSIONS

Continuing smokers have more disease relapses, and patients who quit smoking have a similar relapse incidence compared with nonsmokers.

Influence of environmental factors in the development of inflammatory bowel diseases

Idiopathic inflammatory bowel diseases (IBD), Crohn's disease (CD) and ulcerative colitis (UC), are multifactorial diseases that are manifested after disruption of a genetic predisposed individual and its intestinal microflora through an environmental stimulus. Urbanization and industrialization are associated with IBD. Epidemiological data, clinical observations and family/immigrants studies indicate the significance of environmental influence in the development of IBD. Some environmental factors have a different effect on the subtypes of IBD. Smoking and appendectomy is negatively associated with UC, but they are aggravating factors for CD. A westernized high fat diet, full of refined carbohydrates is strongly associated with the development of IBD, contrary to a high in fruit, vegetables and polyunsaturated fatty acid-3 diet that is protective against these diseases. High intake of nonsteroidal antiinflammatory drug and oral contraceptive pills as well as the inadequacy of vitamin D leads to an increased risk for IBD and a more malignant course of disease. Moreover, other factors such as air pollution, psychological factors, sleep disturbances and exercise influence the development and the course of IBD. Epigenetic mechanism like DNA methylation, histone modification and altered expression of miRNAS could explain the connection between genes and environmental factors in triggering the development of IBD.

Smoking behaviour and knowledge of the health effects of smoking in patients with inflammatory bowel disease

BACKGROUND

The detrimental effect of smoking on development and progression of Crohn's disease (CD) is generally accepted.

AIM

To evaluate the awareness of smoking risks in a Belgian inflammatory bowel disease (IBD) population.

METHODS

In the out-patient clinic of a tertiary referral centre, 625 consecutive patients with CD, 238 patients with ulcerative colitis (UC) and 289 non-IBD controls, filled out a simple questionnaire. This questionnaire included data on smoking behaviour and awareness of smoking-related health effects, including effects on IBD.

RESULTS

At diagnosis, more CD patients were active smokers compared to UC (40% vs. 17%, P < 0.001). Remarkably, smoking cessation rates after diagnosis were similar for CD and UC (both 56%, P = 0.997). The great majority recognised a detrimental influence of smoking on general health (98-99%), lung cancer (95-97%), myocardial infarction (89-92%) and stroke (78-87%). Although CD patients more frequently acknowledged risks of smoking on their disease, only 37% were aware of a link with CD development, 30% of increased surgical rates and 27% of increased post-operative CD recurrence. Active smokers more frequently denied an increased risk of surgery and higher post-operative CD recurrence. Intriguingly, within the active smokers with CD, those not willing to quit smoking most often denied a potential bad influence of smoking. Taking into account disease duration, previous surgery, education level, working status and nicotine dependence, we were unable to define specific subgroups of patients requiring extra education.

CONCLUSION

Although patients with Crohn's disease were better informed on the detrimental effects of smoking, the awareness rate was still low.

High Rates of Smoking Especially in Female Crohn's Disease Patients and Low Use of Supportive Measures to Achieve Smoking Cessation--Data from the Swiss IBD Cohort Study

BACKGROUND AND AIMS

Smoking is a crucial environmental factor in inflammatory bowel disease [IBD]. However, knowledge on patient characteristics associated with smoking, time trends of smoking rates, gender differences and supportive measures to cease smoking provided by physicians is scarce. We aimed to address these questions in Swiss IBD patients.

METHODS

Prospectively obtained data from patients participating in the Swiss IBD Cohort Study was analysed and compared with the general Swiss population [GSP] matched by age, sex and year.

RESULTS

Among a total of 1770 IBD patients analysed [49.1% male], 29% are current smokers. More than twice as many patients with Crohn's disease [CD] are active smokers compared with ulcerative colitis [UC] [UC, 39.6% vs CD 15.3%, p < 0.001]. In striking contrast to the GSP, significantly more women than men with CD smoke [42.8% vs 35.8%, p = 0.025], with also an overall significantly increased smoking rate compared with the GSP in women but not men. The vast majority of smoking IBD patients [90.5%] claim to never have received any support to achieve smoking cessation, significantly more in UC compared with CD. We identify a significantly negative association of smoking and primary sclerosing cholangitis, indicative of a protective effect. Psychological distress in CD is significantly higher in smokers compared with non-smokers, but does not differ in UC.

CONCLUSIONS

Despite well-established detrimental effects, smoking rates in CD are alarmingly high with persistent and stagnating elevations compared with the GSP, especially in female patients. Importantly, there appears to be an unacceptable underuse of supportive measures to achieve smoking cessation.

Impact of smoking on the surgical outcome of Crohn's disease: a propensity-score matched National Surgical Quality Improvement Program analysis

AIM

Smoking is known to have a deleterious effect on Crohn's disease (CD). The present study addressed the specific impact of smoking on the outcome of surgery for CD.

METHOD

A review of the National Surgical Quality Improvement Program (NSQIP) database (2005-2012) identified 7631 patients with CD who underwent surgical resection. Patients were stratified based on smoking status and were compared with univariate statistical tests. Generalized linear regression and multiple logistic regressions were used to model the impact of smoking on the surgical outcome [length of stay (LOS), mortality, postoperative complications and readmission]. To confirm the validity of the regression models and to evaluate the influence of smoking in comparable patient cohorts, a propensity score match was also performed.

RESULTS

There were 2047 (26.8%) patients with CD identified as current smokers, and 5584 (74.2%) identified as non- or ex-smokers. Smokers were more likely to have a pulmonary comorbidity, preoperative weight loss and a higher American Society of Anesthesiologists classification. No differences in mortality were observed between smokers and non- or ex-smokers in univariate analysis. In multivariate analysis, smoking status was not significantly associated with LOS. Morbidity (OR 1.20, P = 0.003), particularly infectious (OR 1.30, P < 0.001) and pulmonary (OR 1.87, P < 0.001) complications, and readmission (OR 1.58, P = 0.004) were significantly associated with smoking status. These findings were validated on propensity-score matching analysis.

CONCLUSION

In patients with CD, the detrimental effects of smoking on surgical outcomes are driven by infectious and pulmonary complications, and by an increased likelihood of readmission.

The Influence of Second-Hand Cigarette Smoke Exposure during Childhood and Active Cigarette Smoking on Crohn's Disease Phenotype Defined by the Montreal Classification Scheme in a Western Cape Population, South Africa

Background

Smoking may worsen the disease outcomes in patients with Crohn’s disease (CD), however the effect of exposure to second-hand cigarette smoke during childhood is unclear. In South Africa, no such literature exists. The aim of this study was to investigate whether disease phenotype, at time of diagnosis of CD, was associated with exposure to second-hand cigarette during childhood and active cigarette smoking habits.

Methods

A cross sectional examination of all consecutive CD patients seen during the period September 2011-January 2013 at 2 large inflammatory bowel disease centers in the Western Cape, South Africa was performed. Data were collected via review of patient case notes, interviewer-administered questionnaire and clinical examination by the attending gastroenterologist. Disease phenotype (behavior and location) was evaluated at time of diagnosis, according to the Montreal Classification scheme. In addition, disease behavior was stratified as ‘complicated’ or ‘uncomplicated’, using predefined definitions. Passive cigarette smoke exposure was evaluated during 3 age intervals: 0–5, 6–10, and 11–18 years.

Results

One hundred and ninety four CD patients were identified. Cigarette smoking during the 6 months prior to, or at time of diagnosis was significantly associated with ileo-colonic (L3) disease (RRR = 3.63; 95%CI, 1.32–9.98, p = 0.012) and ileal (L1) disease (RRR = 3.54; 95%CI, 1.06–11.83, p = 0.040) compared with colonic disease. In smokers, childhood passive cigarette smoke exposure during the 0–5 years age interval was significantly associated with ileo-colonic CD location (RRR = 21.3; 95%CI, 1.16–391.55, p = 0.040). No significant association between smoking habits and disease behavior at diagnosis, whether defined by the Montreal scheme, or stratified as ‘complicated’ vs ‘uncomplicated’, was observed.

Conclusion

Smoking habits were associated with ileo-colonic (L3) and ileal (L1) disease at time of diagnosis in a South African cohort.

Delayed diagnosis is influenced by the clinical pattern of Crohn's disease and affects treatment outcomes and quality of life in the long term: a cross-sectional study of 361 patients in Southern Italy

OBJECTIVES

Three patterns of Crohn's disease (CD) have been described. Our aim was to investigate for differences in diagnostic delay between patterns of CD, and differences in treatment outcomes, need for surgery and quality of life (QoL).

PATIENTS AND METHODS

This is a cross-sectional study. First, the data of CD patients observed at our IBD Referral Centre between 2000 and 2009 were analysed. We gathered demographical characteristics and data on the onset of clinical symptoms, progression until diagnosis and treatment. The risk of delayed diagnosis was computed for each pattern. We then asked patients to fill the Inflammatory Bowel Disease Questionnaire (IBDQ). QoL scores of patients receiving a diagnosis within 18 months from the onset of symptoms were matched with those of the remaining patients.

RESULTS

Three-hundred and sixty-one patients were identified. The mean age of the patients at the onset of symptoms and at diagnosis was 30 ± 14 and 32 ± 14 years. The penetrating pattern showed an association only with perianal symptoms at onset (P = 0.0015). The risk of delayed diagnosis was 21, 27 and 59% for inflammatory, stricturing and penetrating patterns. We found a significant difference between penetrating and nonpenetrating patterns (P = 0.043). A delayed diagnosis was associated with poorer treatment outcomes, QoL and higher surgery rate.

CONCLUSION

Our study suggests a correlation between delayed diagnosis and the CD pattern. The delay in diagnosis between the CD subtypes can influence outcomes and QoL.

Clinical markers of Crohn's disease severity and their association with opiate use

BACKGROUND

The safety of opiate use for patients with Crohn's disease (CD) has long been a concern. The recent Crohn's therapy, resource, evaluation, and assessment tool (TREAT) registry update has added to these concerns by demonstrating an association of opiate use with an increased risk of infection and death in CD. While the association is clear, the relationship of opiates to these negative outcomes is not. It is unknown whether opiates are a contributing factor to these negative outcomes or if their use is merely a marker of more severe disease. We hypothesized that opiate use is not harmful in CD but is a marker of disease severity and would be associated with commonly accepted clinical markers of severe CD such as early age at CD onset, disease duration, small intestinal involvement, a history of fistula or stricture, and lower quality of life (QOL) scores.

METHODS

Data on CD history including pain medication usage were obtained from an interviewer directed survey of patients admitted to two tertiary care hospitals over a 2-year period. CD as the primary admitting diagnosis was not required. Active opiate use was defined by usage within the past month prior to admission.

RESULTS

A total of 133 patients were approached to participate, of whom 108 consented to the survey, and 51 were active opiate users. Opiate using CD patients were more commonly smokers (22% vs. 3.45%, P < 0.010), had fistulas (40% vs. 22.4%, P < 0.048) and had a poorer quality of life score by short form inflammatory bowel disease questionnaire (mean 3.80 vs. 4.34, P < 0.036) than non-opiate users. No difference was found between opiate users and non-users for age of diagnosis, disease duration, or a history of strictures.

CONCLUSIONS

The study findings demonstrate that opiate use in CD is associated with markers of disease severity including fistulas, smoking, and lower QOL scores. The findings suggest that opiates may not be directly harmful to patients with CD, but may merely be another marker of disease severity. However, given opiates unproven benefits for long term CD pain control and risk of dependence, caution should still be exercised in their use.

Is it possible to change phenotype progression in Crohn's disease in the era of immunomodulators? Predictive factors of phenotype progression

OBJECTIVES

Crohn's disease (CD) induces cumulative structural damage, initially characterized by a non-stenosing non-penetrating behavior (B1) with progression over time to a fibro-stenosing (B2) and/or penetrating phenotype (B3). Our aim was to assess the long-term evolution of disease behavior of CD and determine what factors predict phenotype progression.

METHODS

This was a study based on prospectively collected data from a CD database in an inflammatory bowel disease outpatient clinic. B1 corresponds to a non-stenosing non-penetrating disease, B2 to a stenosing behavior, and B3 to a penetrating one.

RESULTS

Seven hundred and thirty-six patients with CD (368 female) were followed up for 12.3 years (± 8.4), with 87.0% of them exhibiting B1 phenotype at diagnosis. Of these patients, 28.5% progressed to B2 phenotype and 23.5% to B3. Fifty percent of the patients started azathioprine treatment before phenotype change and 13.9% started anti-tumor necrosis factor-α (anti-TNFα) treatment before phenotype change. Monotherapy with azathioprine before phenotype change as well as combination therapy with azathioprine/anti-TNFα before phenotype change delayed disease progression (B1-B2 or B3) in comparison with patients who did not receive treatment (P<0.001). The hazard ratio (HR) for disease progression was lower for both monotherapy with azathioprine (HR: 0.15, P<0.001) or combination therapy with anti-TNFα (HR: 0.33, P<0.001). Upper gastrointestinal tract involvement, male gender, and steroid use were associated with an early progression of phenotype from B1 to B2 or B3 (P<0.001). The HR for disease progression was higher in patients who used steroids without criteria of dependence or resistance (HR: 2.67, P<0.001) and was even higher in patients with criteria of dependence or resistance (HR: 6.44, P<0.001). Longer delays between CD diagnosis and beginning of therapy with azathioprine and/or anti-TNFα were associated with disease progression. The longer the duration of treatment, the less likely the disease progression.

CONCLUSIONS

Monotherapy with azathioprine before behavior change as well as combination therapy with azathioprine and anti-TNFα before behavior change delays phenotype progression of CD, whereas upper gastrointestinal tract involvement, male gender, and steroid use with or without criteria of steroid dependence are associated with a higher risk for disease progression.

Increased responsiveness to thrombin through protease-activated receptors (PAR)-1 and -4 in active Crohn's disease

BACKGROUND AND AIMS

Platelets are essential in hemostasis and inflammation, thereby linking coagulation with inflammation. Abundant thrombin generation in association with inflammation is considered a major reason for the increased risk for thromboembolic events. We therefore investigated platelet responsiveness to thrombin.

METHODS

In this case-control study 85 patients with Crohn's disease (active CD 42, remission 43) and 30 sex- and age-matched controls were enrolled. Clinical disease activity (Harvey-Bradshaw-Index) was assessed and CD-related data were determined by chart review. Platelets' response to protease activated receptor-1 and -4 (PAR-1, -4) was assessed by whole blood platelet aggregometry (MEA), levels of platelets adhering to monocytes (PMA), and platelet surface P-selectin.

RESULTS

Platelets' aggregation after activation with the specific PAR-1 agonist (SFLLRN) and PAR-4 agonist (AYPGKF) was higher in patients with active CD compared to patients in remission and controls (p=0.0068 and p=0.0023 for SFLLRN, p=0.0019 and 0.0003 for AYPGKF). Likewise, levels of PMA after activation with PAR-1 and PAR-4 receptor agonists were higher in patients with active CD compared to patients in remission and controls (p=0.0001 and p<0.0001 for SFLLRN, p=0.0329 and p=0.0125 for AYPGKF). However, P-selectin expression on human platelets showed heterogeneous results. Only PAR-1 activation of platelets resulted in significant differences between CD patients and controls (p=0.0001 and p=0.0022 for active and inactive CD versus controls, respectively).

CONCLUSIONS

Our data suggest a new mechanism of platelet activation which has the potential to increase risk for thromboembolism in patients with active CD which might be due to platelets poised for thrombin-inducible activation.

Comparative Outcomes of Trocar Puncture With Sump Drain, Percutaneous Drainage, and Surgical Drainage in the Management of Intra-abdominal Abscesses in Crohn’s Disease

Background. Intra-abdominal abscess is a common complication in Crohn’s disease (CD). Traditional percutaneous catheter drainage (PCD) and surgical intervention could not obtain satisfactory results in some cases. We herein demonstrate a novel management option and compare it with traditional strategies. Methods. A total of 77 patients were retrospectively collected into 3 groups. Postoperative complication, postoperative recurrence of abscess, subsequent surgery, ultimate stoma creation rate, and survival rate were analyzed. Results. Patients were divided into the trocar group (n = 21), PCD group (n = 25), and surgery group (n = 31). The incidences of postoperative complication as well as the incidence of recurrent abscess were lowest in trocar group, and ultimate stoma creation rate was highest in the surgery group. Subsequent surgery after initial intervention and survival rate during the follow-up period were similar among the 3 groups. Conclusions. Trocar puncture with sump drain had lower incidence of postoperative complication, postoperative recurrence of abscess, and ultimate stoma creation compared with conventional PCD and surgical interventions. This novel technique might be an optimal option in the management of intra-abdominal abscesses in CD.

Role of genes, the environment and their interactions in the etiology of inflammatory bowel diseases

Few of the studied genes demonstrate association with inflammatory bowel disease (IBD). Three mutations in the nucleotide-binding oligomerization domain 2 gene have consistently shown to be independent risk factors for Crohn's disease, but none of the alleles exhibited high sensitivity or specificity for IBD. Linkage analysis implicated several loci on various chromosomes, and epistasis has been demonstrated. The etiopathogenesis of IBD remains unknown, and environmental contribution to their pathogenesis is evident from genetic studies that demonstrated incomplete monozygotic twins concordandance rate for both Crohn's and ulcerative colitis. Smoking has shown an opposite effect on disease phenotype, with an adverse effect on disease course for Crohn's disease, but a slight beneficial effect in ulcerative colitis. The contribution of infectious agents to susceptibility to IBD appears to be strong. However, the role of nutrition on the etiology and therapy of IBD is not clear. Inconsistencies in environmental risk factors could be due to gene-environment interactions, making it essential to study the role of genetics and environmental contribution to the etiopathology of IBD. Transgenic or knockout mice, such as interleukin-10(-/-), T-cell receptor alpha(-/-), Galphai(2) (-/-) and N-cadherin(-/-), develop colitis-like inflammation similar to humans. Therefore, animal models must be further studied to explore mechanistic interactions.

Clinical presentation of venous thromboembolism in inflammatory bowel disease

BACKGROUND AND AIMS

Patients with inflammatory bowel disease (IBD) are at increased risk of venous thromboembolism (VTE), but data on frequency, site of thrombosis and risk factors are limited. We sought to determine prevalence, incidence as well as location and clinical features of first VTE among IBD patients.

METHODS

We evaluated a cohort of 2811 IBD patients for a history of symptomatic, objectively confirmed first VTE, recruited from 14 referral centers. Patients with VTE before IBD diagnosis or cancer were excluded. Incidence rates were calculated based on person-years from IBD diagnosis to first VTE or end of follow-up, respectively.

RESULTS

2784 patients (total observation time 24,778 person-years) were analyzed. Overall, of 157 IBD patients with a history of VTE, 142 (90.4%) had deep vein thrombosis (DVT) and/or pulmonary embolism (PE), whereas 15 (9.6%) had cerebral, portal, mesenteric, splenic or internal jugular vein thrombosis. The prevalence and incidence rate of all VTE was 5.6% and 6.3 per 1000 person years, respectively. Patients with VTE were older at IBD diagnosis than those without VTE (34.4±14.8years vs 32.1±14.4years, p=0.045), but did not differ regarding sex, underlying IBD and disease duration. 121 (77.1%) VTE were unprovoked, 122 (77.7%) occurred in outpatients and 78 (60.9%) in patients with active disease. Medication at first VTE included corticosteroids (42.3%), thiopurines (21.2%), and infliximab (0.7%).

CONCLUSION

VTE is frequent in IBD patients. Most of them are unprovoked and occur in outpatients. DVT and PE are most common and unusual sites of thrombosis are rare.

Smoking does influence disease behaviour and impacts the need for therapy in Crohn's disease in the biologic era

BACKGROUND

Recently, the notion that smoking may adversely affect Crohn's disease (CD) outcomes has been challenged by the suggestion that the widespread use of immunosuppressants and anti-TNF drugs might offset the adverse effects of tobacco.

AIM

To reassess the influence of tobacco smoking on disease phenotype and complications on a time-dependent analysis, taking into account the different therapeutic interventions.

METHODS

We designed a retrospective cohort study of 3224 patients with Crohn's disease. The data were collected from the Spanish national inflammatory bowel disease registry (ENEIDA), including information regarding demographics, clinical characteristics, disease complications, therapeutic interventions and smoking status. Patients were classified as nonsmokers, smokers and former smokers, according to their present and past smoking habits.

RESULTS

In the univariate analysis, smokers had more strictures (22.6% vs. 19.3%, P < 0.05) and less colonic involvement (7.2% vs. 10.9%, P < 0.05), and were more frequently under treatment with steroids (91.6% vs. 85.8%, P < 0.05), immunosuppressants (73.5% vs. 63.6% P < 0.05) or anti-TNF drugs (31.4% vs. 25.1%, P < 0.05) than nonsmokers. In the time-dependent multivariate analysis, smokers were found to have a significantly decreased survival free of stricturing disease (HR: 1.5, CI 95% 1.18-1.90) or perianal complications (HR: 1.50, CI 95% 1.01-1.46), and had a higher risk for requiring thiopurine therapy (HR: 1.20, CI 95% 1.05-1.30).

CONCLUSION

These results suggest that, despite the widespread use of immunosuppressants and anti-TNF drugs, smokers with Crohn's disease still have a more severe disease course, with increased therapeutic requirements when compared with nonsmokers.

High smoking cessation rate in Crohn's disease patients after physician advice--the TABACROHN Study

INTRODUCTION

Tobacco smoking has a significant impact on the development of Crohn's disease (CD) and its clinical course, making smoking cessation one of the main goals in CD therapeutic strategy.

AIMS

To evaluate the effectiveness of an advice-based smoking cessation strategy among CD patients.

METHODS

We have performed a prospective multicenter study which enrolled 408 CD smokers. At inclusion all patients were instructed about the risks of smoking and subsequently followed every 3 months. Each center used additional smoking cessation strategies based on available resources. Urinary cotinine and exhaled carbon monoxide levels were evaluated in a subgroup of patients.

RESULTS

Median study follow up was 18 months. 31% of the patients achieved complete smoking cessation and 23% were smoking-free at the end of their follow up with 8% of smoking relapse. Most patients not achieving smoking cessation did not change their smoking habit with only 5% presenting a decrease in tobacco load. 63% of patients willing to quit smoking received help from another specialist, most frequently the pulmonologist (47%). Surprisingly, most patients (88%) tried to quit smoking with no pharmacological therapy and bupropion, varenicline and nicotine replacement treatment were used in few patients. Urinary cotinine and exhaled CO levels tested in a subgroup of patients proved to have a good correlation with the self-reported smoking habit. No predictors of successful smoking cessation were identified.

CONCLUSION

Our results underline that an anti-tobacco strategy mostly based on CD patients's education and counseling is feasible and effective in helping patients reach complete abstinence.

Recommendations for identifying Crohn's disease patients with poor prognosis

Clinical presentation at diagnosis and the disease course of Crohn's disease is heterogeneous and variable over time. The majority of patients with Crohn's disease will develop at least one stricturing or perforating complication requiring surgery during follow-up. New data support a change in the natural history of the disease associated with the advent of biologicals and tailored treatment strategy. Therefore, it is important to identify patients at risk for disease progression as soon as possible. In recent years, much emphasis has been placed on determining important predictive factors. Complex evaluation of factors such as clinical and endoscopic presentation, fecal, serological and routine laboratory tests, and genetic factors is needed. This review summarizes the available evidence and will hopefully assist clinicians when choosing a treatment strategy in everyday practice.

Does smoking influence Crohn's disease in the biologic era? The TABACROHN study

BACKGROUND

While most studies have found a negative effect of smoking on Crohn's disease (CD) phenotype, more recent data have failed to reproduce this association, which might be due to a current wider use of thiopurines and biologic therapy. The TABACROHN study aimed at defining the impact of smoking on CD in the largest published series.

METHODS

This multicenter cross-sectional study included 1170 CD patients. Patients were classified as nonsmokers, current smokers, or former smokers according to their present smoking status. Clinical data regarding disease characteristics, treatment, and complications were collected.

RESULTS

Smokers were more frequently under maintenance treatment when compared to nonsmokers. In addition, current smokers presented higher use of biologic drugs compared to nonsmokers. Tobacco exposure and a higher tobacco load were independent predictors of need for maintenance treatment and stenosing phenotype, respectively.

CONCLUSIONS

In the era of early and widespread use of immunosuppressants and biologics, tobacco exposure is an independent predictor of need for maintenance treatment, specifically biologic therapy. The wider use of biologics and immunosuppressants could account for the existence of no major differences in disease behavior and complications between nonsmokers and current smokers.

Impact of environmental and dietary factors on the course of inflammatory bowel disease

Besides their possible effects on the development of inflammatory bowel disease (IBD), some environmental factors can modulate the clinical course of both ulcerative colitis (UC) and Crohn’s disease (CD). This review is mainly devoted to describing the current knowledge of the impact of some of these factors on the outcome of IBD, with special emphasis on smoking and diet. Although the impact of smoking on the susceptibility to develop CD and UC is firmly established, its influence on the clinical course of both diseases is still debatable. In CD, active smoking is a risk factor for postoperative recurrence. Beyond this clinical setting, smoking cessation seems to be advantageous in those CD patients who were smokers at disease diagnosis, while smoking resumption may be of benefit in ex-smokers with resistant UC. The role of dietary habits on the development of IBD is far from being well established. Also, food intolerances are very frequent, but usually inconsistent among IBD patients, and therefore no general dietary recommendations can be made in these patients. In general, IBD patients should eat a diet as varied as possible. Regarding the possible therapeutic role of some dietary components in IBD, lessons should be drawn from the investigation of the primary therapeutic effect of enteral nutrition in CD. Low-fat diets seem to be particularly useful. Also, some lipid sources, such as olive oil, medium-chain triglycerides, and perhaps omega-3 fatty acids, might have a therapeutic effect. Fermentable fiber may have a role in preventing relapses in inactive UC.

Are inherited thrombotic risk factors associated with fibrostenosis in Crohn's disease?

BACKGROUND

Fibrostenotic lesions are common complications in Crohn's disease (CD) often requiring surgery. Inherited thrombotic risk factors are associated with fibrosis in other chronic inflammatory diseases. The aim of the study was to assess whether inherited thrombotic risk factors are associated with fibrostenosis in CD.

METHODS

Clinical data on 529 CD patients were collected retrospectively. Subjects were tested for and grouped according to the presence of factor V Leiden (FVL), the prothrombin G20210A, and the methylenetetrahydrofolate reductase C677T mutation (MTHFR). Patients who underwent CD-related intestinal surgery were assessed for the presence of fibrostenosis, which was the primary endpoint. The diagnosis of fibrostenosis was based on surgical, pathological, and histopathological reports. A Cox proportional hazards model was used for statistical analysis.

RESULTS

Thirty-two (6.1%, heterozygous 30, homozygous 2) patients were carriers of FVL, 19 (3.6%, all heterozygous) carried the prothrombin variant, and 318 (60.1%) the MTHFR variant (243 heterozygous, 75 homozygous). In all, 303 (57.3%) patients underwent intestinal surgery. Fibrostenosis was identified in 219 (72.3%) surgical specimens. The rate of first intestinal surgeries with fibrostenosis tended to be more frequent in patients with the homozygous 677TT MTHFR mutation (hazard ratio, HR 1.39; 95% confidence interval [CI]: 0.98-1.97; P = 0.067). After adjustment for potential confounders homozygous 677TT MTHFR mutation did not remain a risk factor for intestinal surgery with fibrostenosis (HR 1.23; 95% CI: 0.77-1.98; P = 0.387). FVL and the prothrombin variant had no influence on the primary endpoint.

CONCLUSIONS

The MTHFR 677TT mutation, factor V Leiden, and the prothrombin G20210A mutation are not associated with fibrostenosis in CD.

Impact of smoking on disease phenotype and postoperative outcomes for Crohn's disease patients undergoing surgery

AIM

Whether smoking affects disease distribution, phenotype, and perioperative outcomes for Crohn's disease (CD) patients undergoing surgery is not well characterized. The aim of this study is to evaluate the impact of smoking on disease phenotype and postoperative outcomes for CD patients undergoing surgery

METHODS

Prospectively collected data of CD patients undergoing colorectal resection were evaluated. CD patients who were current smokers (CS) were compared to nonsmokers (NS) and ex-smokers (ES) for disease phenotype, anatomic site involved, procedures performed, postoperative outcomes, and quality of life using the Cleveland Global Quality of Life instrument (CGQL).

RESULTS

Of 691 patients with a diagnosis of CD requiring surgery 314 were classified as CS, 330 as NS, and 47 as ES. CS and ES in comparison to NS were significantly older at diagnosis of Crohn's disease (mean, 29.3 vs. 29.2 vs. 26.3 years) (P = 0.001) and older at the time of primary surgery (mean, 42.9 vs. 48.4 vs. 39 years) (P = 0.001) with a greater frequency of diabetes. In all groups requiring surgery, there was a significant change in disease phenotype from the time of diagnosis to surgical intervention. The predominant phenotype at diagnosis was inflammatory which changed to stricturing and penetrating as the dominant phenotypes at time of surgery. All groups had a significant improvement in CGQL scores post-surgery with the greatest benefit observed in NS. Postoperative complications and 30-day readmission rates were similar between all groups.

CONCLUSIONS

The findings of this study show that in patients with CD, disease phenotype changes over time. This occurs independent of smoking. Smoking does not appear to predispose to complications for CD patients undergoing surgery. CS and ES have a persistently reduced quality of life in comparison to NS post-surgery.

Factors associated with esophageal stricture formation after endoscopic mucosal resection for neoplastic Barrett's esophagus

BACKGROUND

EMR for early neoplastic Barrett's esophagus is gaining favor over esophagectomy. Esophageal stricture development has been reported as a common complication of EMR, photodynamic therapy, and combination endoscopic therapy.

OBJECTIVE

To determine clinical and procedural predictors of symptomatic stricture formation after EMR.

DESIGN

Retrospective analysis.

SETTING

Tertiary-care referral university hospital.

PATIENTS

Data were retrospectively reviewed on 73 patients at our institution who underwent EMR monotherapy for Barrett's esophagus with high-grade dysplasia or intramucosal cancer since January 2006.

INTERVENTION

EMR.

MAIN OUTCOME MEASUREMENTS

Symptomatic esophageal stricture formation.

RESULTS

Symptomatic esophageal stricture formation was noted in 24.7% of patients undergoing EMR. Stricture formation on univariate analysis was associated with percentage of circumference of esophageal lumen resected, total pieces resected, number of EMR sessions, and tobacco use. A threshold effect was found at 50% of esophageal circumference resected (66.7% vs 27.2% developed strictures above and below the threshold, respectively; P = .004). A 25-pack-year or greater history of tobacco use had a threshold effect on esophageal stricture formation (77.8% vs 7.2% developed strictures above and below the threshold, respectively; P = .02). In multivariate analysis, resection of >50% of the circumference was strongly associated with stricture formation (odds ratio [OR] 4.17; 95% confidence interval [CI], 1.27-13.7). A 25-pack-year or greater history of tobacco use also trended toward stricture formation (OR 3.33; 95% CI, 0.929-12.1).

LIMITATIONS

Retrospective design, sample size.

CONCLUSION

Resection of at least 50% of the esophageal mucosal circumference is strongly associated with stricture formation. Patients with strong histories of tobacco use also may be more likely to develop esophageal strictures following EMR.

Current strategies in the management of intra-abdominal abscesses in Crohn's disease

Crohn's disease is characterized by inflammation that involves the full thickness of the bowel wall, which can lead to serious complications including intra-abdominal and pelvic abscesses. The combination of an intra-abdominal abscess with active Crohn's disease poses a particular dilemma for the treating physician, who must weigh the benefits of using immunosuppressive therapies for the inflammatory bowel disease against the risks of immunosuppression in the presence of serious abdominal infection. Traditionally, Crohn's-related abscesses were managed with early surgery, which often involved external drainage procedures, bowel resection, and the creation of diverting ostomies in acutely ill patients. Today such abscesses often can be managed initially with antibiotics and percutaneous drainage, with evaluation for the need for delayed surgery in selected patients. With delayed surgery performed electively, the surgeon frequently can resect the diseased bowel and create a primary anastomosis, thus avoiding emergency operations and multistage procedures. In highly selected cases, surgery might be avoided entirely. This report reviews the literature on the pathophysiology and management of intra-abdominal abscesses in Crohn's disease (including the roles of percutaneous drainage, immunosuppressive therapy, and surgery), and provides a suggested approach to the management of patients with this difficult problem.

Management of Crohn's disease in smokers: is an alternative approach necessary?

Inflammatory bowel disease is a chronic condition with a pathogenic background that involves both genetic and environmental factors. Although important progress has been made regarding the former in the last decade, scarce knowledge is available for the latter. In this sense, smoking remains the most important environmental factor in IBD. Active smoking increases the risk of developing Crohn's disease (CD). Moreover, CD patients who start or continue smoking after disease diagnosis are at risk for poorer outcomes such as higher therapeutic requirements and disease-related complications, as compared to those patients who quit smoking or who never smoked. However, the harmful effect of active smoking is not uniform in all patients or in all clinical scenarios. Interventions designed to facilitate smoking cessation may impact the course of the disease. In this article, the available evidence of the deleterious effects of smoking on CD is reviewed in detail, and alternative therapeutic approaches to CD in smokers are proposed.

Differences in inflammatory bowel disease phenotype between South Asians and Northern Europeans living in North West London, UK

OBJECTIVES

The incidence and prevalence of inflammatory bowel disease (IBD) is increasing throughout Asia. Since the 1950s, there has been substantial migration from South Asia (India, Pakistan, and Bangladesh) to the United Kingdom. The aim of this study was to define the clinical phenotype of IBD in UK South Asians living in North West London, and to compare the results with a white Northern European IBD cohort.

METHODS

The phenotypic details of 367 South Asian IBD patients (273 ulcerative colitis (UC) and 94 Crohn's disease (CD)), undergoing active follow-up in five North West London hospitals, were compared with those of 403 consecutively collected white Northern European IBD patients (188 UC and 215 CD).

RESULTS

The phenotype of IBD differed significantly between the two populations. 63.0% of South Asian UC patients had extensive colitis compared with 42.5% of the Northern European cohort (P < 0.0001). Proctitis was uncommon in South Asian UC patients (9.9 vs. 26.1% in Northern European patients, P<0.0001). In the South Asian CD cohort, disease location was predominantly colonic (46.8%). CD behavior differed significantly between the groups, with less penetrating disease compared with Northern Europeans (P=0.01) and a reduced need for surgery (P=0.003).

CONCLUSIONS

The phenotype of IBD in South Asians living in North West London is significantly different from that of a white Northern European IBD cohort. Knowledge of ethnic variations in disease phenotype may help to identify key genetic, environmental, and behavioral factors contributing to the development of IBD.

The impact of smoking in Crohn's disease: no smoke without fire

Smoking habit is the most widely accepted environmental factor affecting the incidence and disease progression in the inflammatory bowel diseases. The contrasting effects in Crohn's disease (CD) and ulcerative colitis are unexplained. The purpose of this review is to summarise the existing data on the effects of smoking in CD on disease history, recurrence after surgery, effects on drug responses and to review available evidence that carriage of some of the known susceptibility genes may be disproportionate in smokers with CD. The review also highlights potential mechanisms involved and factors that might affect patients' smoking habits. The clinical and scientific implications of the data are discussed.