Overall and cause-specific mortality in Korean patients with inflammatory bowel disease: A hospital-based cohort study

Perianal Fistulizing Crohn's Disease-Associated Anorectal and Fistula Cancers: Systematic Review and Expert Consensus

BACKGROUND & AIMS

Perianal fistulizing Crohn's disease (PFCD)-associated anorectal and fistula cancers are rare but often devastating diagnoses. However, given the low incidence and consequent lack of data and clinical trials in the field, there is little to no guidance on screening and management of these cancers. To inform clinical practice, we developed consensus guidelines on PFCD-associated anorectal and fistula cancers by multidisciplinary experts from the international TOpClass consortium.

METHODS

We conducted a systematic review by standard methodology, using the Newcastle-Ottawa Scale quality assessment tool. We subsequently developed consensus statements using a Delphi consensus approach.

RESULTS

Of 561 articles identified, 110 were eligible, and 76 articles were included. The overall quality of evidence was low. The TOpClass consortium reached consensus on 6 structured statements addressing screening, risk assessment, and management of PFCD-associated anorectal and fistula cancers. Patients with long-standing (>10 years) PFCD should be considered at small but increased risk of developing perianal cancer, including squamous cell carcinoma of the anus and anorectal carcinoma. Risk factors for squamous cell carcinoma of the anus, notably human papilloma virus, should be considered. New, refractory, or progressive perianal symptoms should prompt evaluation for fistula cancer. There was no consensus on timing or frequency of screening in patients with asymptomatic perianal fistula. Multiple modalities may be required for diagnosis, including an examination under anesthesia with biopsy. Multidisciplinary team efforts were deemed central to the management of fistula cancers.

CONCLUSIONS

Inflammatory bowel disease clinicians should be aware of the risk of PFCD-associated anorectal and fistula cancers in all patients with PFCD. The TOpClass consortium consensus statements outlined herein offer guidance in managing this challenging scenario.

Sex-related differences in profiles and clinical outcomes of Inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic and idiopathic condition that includes both Crohn's disease (CD) and ulcerative colitis (UC). The impact of sex on the disease course and the clinical outcomes not fully understood. Our systematic review and meta-analysis aims to explore the differences in the clinical outcomes in IBD.

METHOD

A systematic review and meta-analysis was done by searching in the PubMed /MEDLINE, Embase, and Scopus databases. We used the Random-Effects model to estimate risk ratios (RR) for binary outcomes and mean difference and hedges' g for continuous outcomes.

RESULT

A total of 44 unique studies were included. Our analysis revealed distinct sex differences in various outcomes of IBD. Anxiety was more prevalent in females (RR: 0.73; 95% CI [0.64, 0.82]) and females in the CD subgroup (RR: 0.76; 95% CI [0.62, 0.93]; p = 0.01. While depression was diagnosed more frequently in females (RR: 0.80; 95% CI [0.66, 0.97] in the total population of the study, subgroup analysis showed no sex difference. Additionally, quality of life scores were worse in females in the total population (Hedges' g: 0.24; 95% CI [0.05, 0.42]) with no significant difference in subgroup analyses. A significantly higher mortality risk was estimated in males (RR: 1.26; 95% CI [1.07, 1.48]) and in subgroup analysis for males with UC (RR: 1.48; 95% CI [1.19, 1.84]; p = 0.00) with no significant difference in CD. Regarding disease location, male patients were less likely to present with proctitis (RR: 0.67; 95% CI [0.50, 0.91]) when compared to females. Males had more frequent indications for surgery (RR: 1.10; 95% CI [1.01, 1.20]), however, no significant difference was found in subgroup analyses for CD or UC. Also, males were older at the time of admission (MD: 1.39 years; 95% CI [0.10, 2.68]). No significant sex differences were found in terms of hospitalization rates or disease behavior.

CONCLUSION

In conclusion, our meta-analysis shows that males face higher risks of early mortality and require more IBD surgeries, whereas females experience greater levels of anxiety and depression. These findings emphasize the need to consider sex disparities in IBD management.

Effects of the N-Butanol Extract of Pulsatilla Decoction on Neutrophils in a Mouse Model of Ulcerative Colitis

Ulcerative colitis (UC) is a chronic inflammatory disease, the incidence of which is increasing worldwide. However, the etiology and pathogenesis of UC remains unclear. The n-butanol extract of Pulsatilla decoction (BEPD), a traditional Chinese medicine, has been shown to be effective in treating UC. This study aimed to explore the molecular mechanism underlying the effects of BEPD on UC, in particular its effects on neutrophil extracellular trap (NET) formation by neutrophils. High-performance liquid chromatography was used to determine the principal compounds of BEPD. UC was induced in mice using dextran sodium sulfate, and mice were treated with 20, 40, or 80 mg/kg BEPD daily for seven days. Colonic inflammation was determined by assessing the disease activity index, histopathology, colonic mucosal damage index, colonic mucosal permeability, and pro- and anti-inflammatory cytokine levels. The infiltration and activation status of neutrophils in the colon were determined by analyzing the levels of chemokine (C-X-C motif) ligand (CXCL) 1 and CXCL2, reactive oxygen species, Ly6G, and numerous NET proteins. The findings suggest that BEPD improved the disease activity index, histopathology, and colonic mucosal damage index scores of mice with UC, and restored colonic mucosal permeability compared with untreated mice. The expression levels of the pro-inflammatory cytokines interleukin-1β, interleukin-6, and tumor necrosis factor-α in colon tissues were significantly decreased, while the expression levels of anti-inflammatory cytokines in colon tissues were significantly increased, exceeding those of control mice. In addition, BEPD reduced the expression of the neutrophil chemokines CXCL1 and CXCL2 in the colon tissue of mice with UC, reduced neutrophil infiltration, reduced reactive oxygen species levels, and significantly reduced the expression of NET proteins. BEPD also significantly reduced NET formation. The results of this study suggest that BEPD exerts therapeutic effects in a murine model of UC by inhibiting neutrophil infiltration and activation in the colon, as well as by inhibiting the expression of key proteins involved in NET formation and reducing NET formation, thereby alleviating local tissue damage and disease manifestations.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

The evaluation of liver abnormalities in inflammatory bowel disease patients

PURPOSE OF REVIEW

Develop a clinical presentation-based approach for common liver abnormalities encountered by providers caring for patients with inflammatory bowel disease (IBD). Develop a treatment pathway for those with nonalcoholic fatty liver disease (NAFLD) arising in IBD. Discuss recent studies of prevalence, incidence, risk factors, and prognosis NAFLD in the IBD population.

RECENT FINDINGS

The work-up for liver abnormalities should be approached systematically in IBD patients, similar to the general population, while still appreciating the differing prevalence of underlying liver diagnoses. Although immune mediated liver diseases occur commonly in patients with IBD, NAFLD is still the most common liver disease in patients with IBD paralleling its expanding prevalence in the general population. IBD is also an independent risk factor for NAFLD, developing in many patients with lower degrees of adiposity. Furthermore, the more severe histologic subtype, nonalcoholic steatohepatitis, is both more common and difficult to treat considering the lower effectiveness of weight loss interventions.

SUMMARY

Having a standard approach to the most common liver disease presentations and care pathway for NAFLD will improve the quality of care provided and ease the medical decision making complexity for IBD patients. The early identification of these patients should prevent the development of irreversible complications like cirrhosis or hepatocellular carcinoma.

Epidemiology, Disease Course, and Clinical Outcomes of Perianal Fistulas and Fissures Crohn's Disease: A Nationwide Population-Based Study in Taiwan

Background

Population-based data on the course of perianal disease in East Asian populations with Crohn's disease (CD) are limited. This study examined the prevalence, clinical course, and compared the outcomes of CD patients with perianal CD (pCD) versus without pCD in Taiwan.

Methods

A nationwide population-based study was implemented from 2000 to 2017 by using the Taiwan National Health Insurance Research Database.

Results

Of 2424 patients with CD, 358 (14.8%) patients with pCD were identified. Most patients with CD and pCD were men (79.3%). The mean age at CD diagnosis was lower in patients with pCD (33.7 years) than in those without pCD (44.9 years). Approximately half the patients with pCD received the pCD diagnosis at least 6 months before receiving a CD diagnosis. Approximately one-third (121/358) of patients with pCD had recurrent fistula; the median recurrence interval was 239 days. Compared with patients without pCD, patients with pCD had higher mean incidences of hospitalization (7.0 vs 3.8, P < .01), outpatient visits (13 vs 2.9, P < .01), and emergency room visits (10.3 vs 4.4, P < .01) over a 15-year period. Although patients with pCD had higher rates of healthcare utilization, their 15-year mortality rate was lower than that of those without pCD (6.1% vs 17.3%, P < .01).

Conclusions

The period prevalence of pCD in Taiwanese patients with CD was 14.8%. Although patients with pCD required more intensive care and had greater healthcare utilization, they did not have inferior survival outcomes compared with those without pCD.

Risk of all-cause and cause-specific mortality associated with immune-mediated inflammatory diseases in Korea

Objective

Immune-mediated inflammatory disease (IMID) is associated with an increased risk of mortality. It is unclear whether the higher mortality is attributable to the IMIDs themselves or to the higher prevalence of comorbidities in IMIDs. We aimed to investigate whether IMIDs per se confer a higher risk of mortality.

Methods

From the Korean National Health Insurance Service-National Sample Cohort database, this population-based cohort study included 25,736 patients newly diagnosed with IMIDs between January 2007 and December 2017, and 128,680 individuals without IMIDs who were matched for age, sex, income, hypertension, type 2 diabetes, dyslipidemia, and the Charlson comorbidity index. All individuals were retrospectively observed through December 31, 2019. The outcomes included all-cause and cause-specific mortalities. Adjustments for age, sex, and comorbidities were performed using multivariable Cox proportional hazard regression analyses, and adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for the outcomes were estimated.

Results

The adjusted risk of all-cause mortality was significantly lower in patients with IMIDs than that in those without (aHR, 0.890; 95% CI, 0.841-0.942). Regarding cause-specific mortality, cancer-specific (aHR, 0.788; 95% CI, 0.712-0.872) and cardiovascular disease-specific (aHR, 0.798; 95% CI, 0.701-0.908) mortalities were the two causes of death that showed significantly lower risks in patients with IMIDs. A similar trend was observed when organ based IMIDs were analyzed separately (i.e., gut, joint, and skin IMIDs).

Conclusion

After adjusting for comorbidities, IMIDs were associated with a lower risk of all-cause mortality compared to those without IMIDs. This was attributable to the lower risks of cancer-and cardiovascular disease-specific mortalities.

Association of inflammatory bowel disease with suicidal ideation, suicide attempts, and suicide: A systematic review and meta-analysis

OBJECTIVE

Inflammatory bowel disease (IBD) is associated with psychiatric comorbidities. However, the association between IBD and suicidal ideation or suicide attempts has not been well established. This study aimed to perform a systematic review and meta-analysis to elucidate the relationship between IBD and suicidal ideation, suicide attempts, and suicide.

METHODS

We systematically searched five electronic databases - PubMed, Embase, CENTRAL, Web of Science, and PsycINFO - from their inception to January 28, 2022. Quality assessment, data synthesis, subgroup analyses, sensitivity analyses, and publication bias assessment were performed on the included studies.

RESULTS

We identified 28 studies with 1,047,755 patients with IBD. The pooled prevalence of suicidal ideation in patients with IBD was 17.3% (95% CI, 9.5%-25.2%). Patients with IBD were associated with an increased risk of suicide attempts (relative risk [RR], 1.39; 95% CI, 1.08-1.79) and suicide deaths (RR, 1.25; 95% CI, 1.09-1.43) than the controls without IBD. Patients with Crohn's disease subtypes, female IBD, pediatric-onset IBD, young adult IBD, and short-duration IBD had a particularly high risk for suicide.

CONCLUSION

Patients with IBD had a high prevalence of suicidal ideation and a significantly higher likelihood of suicide attempts and suicide. Caring for patients with IBD, including their mental health needs, may require concerted efforts among gastroenterologists and other healthcare providers.

Mesalazine and inflammatory bowel disease - From well-established therapies to progress beyond the state of the art

Inflammatory bowel disease incidence has been constantly rising for the past few decades. Current therapies attempt to mitigate its symptoms since no cure is established. The most commonly prescribed drug for these patients is 5-aminosalicylic acid (5-ASA). Due to the low rate and seriousness of side effects compared to other therapies, 5-ASA is still largely prescribed in many stages of inflammatory bowel disease, including scenarios where evidence suggests low effectiveness. Although commercialized formulations have come a long way in improving pharmacokinetics, it is still necessary to design and develop novel delivery systems capable of increasing effectiveness at different stages of the disease. In particular, micro- and nano-sized particles might be the key to its success in Crohn's disease and in more serious disease stages. This review provides an overview on the clinical significance of 5-ASA formulations, its limitations, challenges, and the most recent micro- and nanoparticle delivery systems being designed for its controlled release. Emergent alternatives for 5-ASA are also discussed, as well as the future prospects for its application in inflammatory bowel disease therapies.

Trends and risk factors of mortality analysis in patients with inflammatory bowel disease: a Taiwanese nationwide population-based study

Background

Inflammatory bowel disease (IBD) was emerging as a worldwide epidemic disease, and the advanced therapy changed the clinical course and possibly the outcomes. Our previous study reported a higher mortality rate from (IBD) in Taiwan than in Western countries. We proposed to analyze the trend and risk factors of mortality in order to improve the care quality of IBD patients.

Methods

This retrospective study was conducted to analyze data for January 2001 to December 2015 from a registered database, compiled by the Taiwan’s National Health Insurance.

Results

Between 2001 and 2015, a total of 3806 IBD patients [Crohn’s disease (CD): 919; ulcerative colitis (UC): 2887] were registered as having catastrophic illness, and 8.2% of these patients died during follow-up. The standardized mortality ratios (SMRs) of CD and UC were 3.72 (95% CI 3.02–4.55) and 1.44 (95% CI 1.26–1.65), respectively, from 2001 to 2015, respectively. A comparison of the periods of 2011–2015 and 2001–2005 revealed a decrease in the mortality rates from both UC and CD. Multivariate Cox proportional hazards analysis identified elderly individuals; sepsis and pneumonia were the risk factors for IBD mortality. The specific risk factors of mortality were liver cancer for UC and surgeries for CD.

Conclusion

For further decreasing IBD-related mortality in Taiwan, we need to pay special attention toward elderly individuals, infection control, cancer screening and improvement in perioperative care.

Crohn's disease-specific mortality: a 30-year cohort study at a tertiary referral center in Japan

BACKGROUND

In this study, survival and cause of death were investigated in patients with Crohn's disease (CD) at a tertiary referral center.

METHODS

A database was created based on the medical records of 1108 CD patients who had a history of visiting our hospital to investigate background characteristics, cumulative survival rates from diagnosis, causes of death, and the standardized mortality ratio (SMR) for each cause of death. A follow-up questionnaire survey of patients followed up inadequately was also conducted. The cumulative survival rate from diagnosis was determined using the life table method and compared with that of a sex- and age-matched population model from the year 2000.

RESULTS

The study included 1108 patients whose mean age at diagnosis was 25.6 ± 10.8 years. The mean duration of follow-up was 14.6 ± 9.4 years, and there were 52 deaths. The cumulative survival rate was significantly lower 25 years after the diagnosis of CD (91.7%) than in the standard population model (95.7%). SMRs for both all causes [3.5; 95% confidence interval (CI): 2.7-4.6] and CD-specific causes (36.7; 95% CI 26.1-51.6) were high. Among the CD-specific causes, SMRs were especially high for small intestine and colorectal cancers, gastrointestinal diseases including intestinal failure (IF), perioperative complications, and amyloidosis.

CONCLUSION

The SMRs for both all causes and CD-specific causes were high in CD patients. CD-specific causes including intestinal cancer, IF, perioperative complications, and amyloidosis showed especially high SMRs.

Increased end-stage renal disease risk in patients with inflammatory bowel disease: A nationwide population-based study

AIM

To estimate the risk of end-stage renal disease (ESRD) in patients with inflammatory bowel disease (IBD).

METHODS

From January 2010 to December 2013, patients with Crohn’s disease (CD) and ulcerative colitis (UC) were identified, based on both the International Classification of Diseases, 10^th revision (ICD-10) and the rare, intractable disease registration program codes from the National Health Insurance (NHI) database in South Korea. We compared 38812 patients with IBD to age- and sex-matched non-IBD controls with a ratio of 1:3. Patients newly diagnosed with ESRD were identified with the ICD-10 code.

RESULTS

During a mean follow-up of 4.9 years, ESRD was detected in 79 (0.2%) patients with IBD and 166 (0.1%) controls. The incidence of ESRD in patients with IBD was 0.42 per 1000 person-years. Patients with IBD had a significantly higher risk of ESRD than controls [adjusted hazard ratio (HR) = 3.03; 95% confidence interval (CI): 1.77-5.20; P < 0.001]. The incidences (per 1000 person-years) of ESRD were 0.51 in patients with CD and 0.13 in controls, respectively (adjusted HR = 6.33; 95%CI: 2.75-14.56; P < 0.001). In contrast, the incidence of ESRD was similar between the UC and control groups (0.37 vs 0.37 per 1000 person-years; adjusted HR = 2.01; 95%CI: 0.90-4.51; P = 0.089).

CONCLUSION

The risk of ESRD was elevated in patients with CD, but not UC. Patients with CD should be monitored carefully for signs of renal insufficiency.

Inflammatory bowel disease and cardiovascular disease incidence and mortality: A meta-analysis

Background

The risk of cardiovascular disease occurrence and death in inflammatory bowel disease patients is still unclear.

Design

Meta-analysis.

Methods

Pertinent studies were identified by searching articles in PubMed and Web of Knowledge to December 2017 and reviewing the reference lists of the retrieved articles. We used the fixed-effect model to pool the study-specific estimates when there was no indication of heterogeneity; otherwise, the random-effect model was used.

Results

A total of 27 articles was included, of which 11 studies reported the risk of cardiovascular disease incidence and 16 studies reported the risk of cardiovascular disease death. The pooled relative risks were 1.25 (95% confidence interval (CI): 1.08, 1.44), 1.17 (95% CI: 1.07, 1.27) and 1.12 (95% CI: 1.05, 1.21) for cerebrovascular disease, coronary heart disease and myocardial infarction, respectively. In particular, the pooled relative risk was much higher in females. The pooled standardized mortality ratios were 1.01 (95% CI: 0.90, 1.14) for Crohn's disease patients and 0.93 (95% CI: 0.86, 1.01) for ulcerative colitis patients with low heterogeneity across studies. No publication bias was detected.

Conclusions

There was a positive association between inflammatory bowel disease and higher risk of cardiovascular disease incidence, particularly in females. Such an association was not observed for cardiovascular disease mortality.