Crohn's disease in the elderly

Is the age at surgery in Crohn's disease clinically relevant? Differences and peculiarities: a wide single centre experience after long-term follow-up

PURPOSE

The Montreal classification for Crohn's disease includes "age at diagnosis" as a parameter but few is reported about the age at surgery. The aim of this study is to evaluate the short- and long-term differences in the postoperative surgical outcome and disease behaviour, according to the age at the first surgery.

METHODS

Patients consecutively operated for abdominal Crohn's disease during the period 1986-2012 at our centre were systematically analysed according to their age at first surgery. In our retrospective cohort, the age at first surgery ranged from 13 to 83 years, and patients were arbitrarily divided into four groups: ≤ 19 (G1), 20-39 (G2), 40-59 (G3) and ≥ 60 (G4) years old.

RESULTS

In total, 1051 patients were included with a median follow-up time of 232 months. The four groups exhibited statistically significant differences in age at diagnosis, smoke habit, time between diagnosis and surgery, disease location and behaviour, history of perianal fistula or abscess, severe malnutrition requiring total parental nutrition before surgery, type of surgery, total length of resected bowel, median duration of hospitalization, incidence of abdominal recurrences and number of surgical recurrences. G1 displays an inverse linear trend with time in the severity of clinical characteristics when compared to G4 groups. On the contrary, the incidence of short-term complications, types of abdominal recurrence and presence of concomitant perianal disease did not vary among groups. In addition, at multivariate analysis, the age at surgery and the disease location were the only independent risk factors for abdominal surgical recurrence.

CONCLUSION

Despite first surgery is extremely more frequent between 20 and 59 years, patients from G1 and G4 groups showed clinical differences and peculiarities when compared to the other age groups. The most indolent CD behaviour and occurrence of surgical recurrence was observed in patients having their first abdominal surgery in the elderly, while patients operated before the age of 19 experienced a more aggressive disease course.

A Comprehensive Review of the Diagnosis and Pharmacological Management of Crohn's Disease in the Elderly Population

Crohn's disease (CD) in the elderly is rising in prevalence, which is related to an increase in its incidence and improving life expectancies. There are differences in the presentation, natural history, and treatment of CD between adult-onset patients who progress to older age and patients who are initially diagnosed at an older age. Presentation at an older age may also delay or make diagnosis challenging due to accumulating co-morbidities that mimic inflammatory bowel disease. Differences exist between adult- and older-onset disease, yet many guidelines do not specifically distinguish the management of these two distinct populations. Identifying patients at high risk for progression or aggressive disease is particularly important as elderly patients may respond differently to medical and surgical treatment, and may be at higher risk for adverse effects. Despite newer agents being approved for CD, the data regarding efficacy and safety in the elderly are currently limited. Balancing symptom management with risks of medical and surgical therapy is an ongoing challenge and requires special consideration in these two distinct populations.

Small Bowel Lesions Mimicking Crohn's Disease

PURPOSE OF REVIEW

Not all injuries of the terminal ileum are Crohn's disease. It is the purpose of this review to consider the differential diagnosis of other acute and chronic ileal lesions.

RECENT FINDINGS

The recognition of a granulomatous disease of the terminal ileum, distinct from tuberculosis, dates back over 85 years and perhaps much farther, but over the past decades, many other clinical pathologic entities have been described that are neither tuberculosis nor Crohn's eponymous regional enteritis. In recent years, the catalog of lesions mimicking Crohn's disease of the small bowel and proposals for differential diagnosis and treatment have expanded to include newly reported appendiceal pathology, primary cancers and lymphomas of the intestine, unexpected metastases from distant organs, unusual infections, vasculitides and other ischemic conditions, Behçet's disease, endometriosis, and drug reactions. A diagnosis of Crohn's disease should not be a reflex action in the face of small bowel structural or inflammatory lesions without consideration of pathology in adjacent organs, primary and metastatic lesions of the small intestine, infections, vascular diseases, infiltrative diseases, drug injury, or other "idiopathic" conditions.

European Crohn's and Colitis Organisation Topical Review on IBD in the Elderly

This ECCO topical review of the European Crohn's and Colitis Organisation [ECCO] focuses on the epidemiology, pathophysiology, diagnosis, management and outcome of the two most common forms of inflammatory bowel disease, Crohn's disease and ulcerative colitis, in elderly patients. The objective was to reach expert consensus to provide evidence-based guidance for clinical practice.

Older Age- and Health-related Quality of Life in Inflammatory Bowel Diseases

BACKGROUND

The burden of inflammatory bowel disease (IBD) in the older population is increasing. Older-onset disease is associated with reduced use of immunosuppressive medications. In addition, older patients may be more vulnerable to the effect of disease-related symptoms and consequently may experience worse health-related quality of life (HRQoL) compared with younger patients.

METHODS

This prospective study included a cohort of patients with Crohn's disease and ulcerative colitis recruited from a single center. All patients completed the Short Inflammatory Bowel Disease Questionnaire (SIBDQ) and the short form-12 (SF-12) questionnaire yielding general physical health (PCS) and mental health component scale subscores (MCS). Patients older than 60 years were compared with those younger than 60 years using multivariable regression analysis.

RESULTS

Our study included 1607 patients, among whom 186 were older than 60 at the time of assessment. Older patients were more likely to have isolated colonic disease and less likely to use immunosuppressive therapy. On multivariable analysis, older patients with IBD had higher SIBDQ (2.34, 95% confidence interval, 0.82-3.87) and SF-12 mental subscores (3.78, 95% confidence interval, 2.26-5.30), but lower physical HRQoL (-1.80, 95% confidence interval, -3.21 to -0.38). There was no difference in the SIBDQ and PCS scores between older patients and newly diagnosed IBD or with established disease.

CONCLUSIONS

Older age was associated with modestly higher SIBDQ and mental HRQoL scores, but lower physical HRQoL. Comprehensive care of the older patient with IBD should include assessment of factors impairing physical quality of life to ensure appropriate interventions.

Recent advances in clinical practice: a systematic review of isolated colonic Crohn's disease: the third IBD?

The genetics of isolated colonic Crohn's disease place it approximately midway between Crohn's disease with small intestinal involvement and UC, making a case for considering it as a separate condition. We have therefore systematically reviewed its epidemiology, pathophysiology and treatment. Key findings include a higher incidence in females (65%) and older average age at presentation than Crohn's disease at other sites, a mucosa-associated microbiota between that found in ileal Crohn's disease and UC, no response to mesalazine, but possibly better response to antitumour necrosis factor than Crohn's disease at other sites. Diagnostic distinction from UC is often difficult and also needs to exclude other conditions including ischaemic colitis, segmental colitis associated with diverticular disease and tuberculosis. Future studies, particularly clinical trials, but also historical cohorts, should assess isolated colonic Crohn's disease separately.

Systematic Review and Meta-analysis: Phenotype and Clinical Outcomes of Older-onset Inflammatory Bowel Disease

BACKGROUND

Little is known of the clinical outcome of patients with older-onset inflammatory bowel disease [IBD]. We performed a systematic review to determine phenotype and outcomes of older-onset IBD compared with younger-onset subjects.

METHODS

A systematic search of Embase and Medline up to June 2015 identified studies investigating phenotype and outcomes of older-onset [diagnosed at age ≥ 50 years] Crohn's disease [CD] and ulcerative colitis [UC] subjects. Pooled analyses of disease phenotype, medication use, and disease-related surgery were calculated.

RESULTS

We analysed findings from 43 studies comprising 8274 older-onset and 34641 younger-onset IBD subjects. Compared with younger-onset patients, older-onset CD patients were more likely to have colonic disease (odds ratio [OR] 2.56, 95% confidence interval [CI] 1.88 - 3.48) and inflammatory behaviour [OR 1.19, 95% CI 1.07 - 1.33], and less likely to have penetrating disease or perianal involvement. More older-onset UC patients had left-sided colitis [OR 1.49, 95% CI 1.18 - 1.88]. Although fewer older-onset IBD patients received immunomodulators [CD: OR 0.44; UC: OR 0.60] or biologicals [CD: OR 0.34; UC: OR 0.41], older-onset CD was similar in the need for surgery [OR 0.70, 95% CI 0.40 - 1.22] whereas more older-onset UC patients underwent surgery [OR 1.36, 95% CI 1.18 - 1.57].

CONCLUSIONS

Elderly IBD patients present with less complicated disease, but have similar or higher rates of surgery than non-elderly patients. Whether this reflects a non-benign disease course, physicians' reluctance to employ immunomodulators, or both, merits further study which is essential for improving the care of IBD in the elderly.

Epidemiology and Long-term Outcome of Inflammatory Bowel Disease Diagnosed at Elderly Age-An Increasing Distinct Entity?

BACKGROUND

Elderly onset (EO) inflammatory bowel disease (IBD) may become a more common entity as a result of population aging and the rising IBD incidence. Its management is challenging, because of multimorbidity, polypharmacy, and frailty. Insight into the long-term outcome is essential for optimal patient counseling and treatment. We studied the incidence and disease outcome of elderly-onset IBD in direct comparison to adult-onset (AO) IBD.

METHODS

All 2823 cases with IBD from the Dutch population-based IBD South Limburg cohort, diagnosed between 1991 and 2011, were included. Long-term outcome (hospitalization, surgery, and disease phenotype) was compared between AO (<60 years at diagnosis) and EO (≥60 years at diagnosis) disease, for Crohn's disease (CD) and ulcerative colitis (UC) separately.

RESULTS

In total, 1162 patients with CD (136 EO/1026 AO) and 1661 patients with UC (373 EO/1288 AO) were included. The EO IBD incidence increased from 11.71 per 100,000 persons in 1991 to 23.66 per 100,000 persons in 2010, P < 0.01. Immunomodulators were less often used in EO CD (61.8% versus 77.1%, P = 0.03) and EO UC (22.8% versus 35.4%, P < 0.01), even as biologicals (25.1% versus 55.1%, P = 0.03 and 7.8% versus 18.0%, P < 0.01, respectively). No differences were observed in surgery risk (CD: hazard ratio [HR] 1.19; 95% confidence interval [CI], 0.85-1.67 and UC: HR, 0.88; 95% CI, 0.53-1.46), or in CD phenotype progression (HR, 0.81; 95% CI, 0.52-1.25), but more patients with EO UC required hospitalization (HR, 1.29; 95% CI, 1.01-1.63).

CONCLUSIONS

EO IBD is rising, warranting physicians' alertness for IBD in elderly patients. The long-term outcome was not different from AO disease, despite a less frequent use of immunomodulators and biologicals.

Age of Diagnosis is Associated with Disease Presentation and Therapeutic Complications in Patients with Crohn's Disease

BACKGROUND

Although Crohn's disease (CD) is usually diagnosed at a younger age, a growing population of patients with inflammatory bowel disease is diagnosed above age 60 (elderly). The aim of this study was to compare disease phenotype, behavior, and therapy in elderly patients with CD to young patients diagnosed between 18 to 25 years.

METHODS

This retrospective case-control study identified patients diagnosed with CD at age 60 or above (elderly) and matched them by gender and disease duration with 2 "young" controls diagnosed between 18 and 25 years. Demographic data, disease information, and medical and surgical history were collected from the University of Chicago Medicine inflammatory bowel disease database.

RESULTS

Thirty-two patients were identified in the "elderly" group and matched to 64 "young" patients. Crohn's colitis was more common in older patients (37.5% versus 15.6%, P = 0.02) who were also less likely to have ileocolonic, perianal, or penetrating disease with less extraintestinal manifestations. After 1998, there was no difference in the use of steroids, 5-aminosalicylates, immunomodulators, biologics, or immunomodulators + biologics. No difference was found in the rates of bowel surgery between the 2 groups. Elderly patients developed fewer therapy-related noninfectious complications and Crohn's-related abscesses. Three serious infections (staphylococcal septicemia, pneumonia, and cryptococcal meningitis) were identified in 3 elderly patients on combination immunomodulators + biologics.

CONCLUSIONS

Elderly CD is more likely to present with Crohn's colitis and less likely to present with ileocolonic, perianal, or penetrating disease with less extraintestinal manifestations. Elderly are more likely to develop serious therapy-related infectious complications. Larger prospective trials are needed to evaluate the risks of CD immunosuppressive therapy in elderly patients.

Systematic review with meta-analysis: inflammatory bowel disease in the elderly

BACKGROUND

Elderly patients represent an increasing proportion of the inflammatory bowel disease (IBD) population.

AIM

To critically review available data regarding the care of elderly IBD patients.

METHODS

Bibliographic searches (MEDLINE) up to June 2013.

RESULTS

Approximately 10-15% of cases of IBD are diagnosed in patients aged >60 years, and 10-30% of the IBD population are aged >60 years. In the elderly, IBD is easily confused with other more common diseases, mainly diverticular disease and ischaemic colitis. The clinical features of IBD in older patients are generally similar to those in younger patients. Crohn's disease (CD) in elderly patients is characterised by its predominantly colonic localisation and uncomplicated course. Proctitis and left-sided ulcerative colitis are more common in patients aged >60 years. Infections are associated with age and account for significant mortality in IBD patients. The treatment of IBD in the elderly is generally similar. However, the therapeutic approach in the elderly should be 'start low-go slow'. The benefit of thiopurines in older CD patients remains debatable. Although the indications for anti-tumour necrosis factors in the elderly are generally similar to those for younger patients, lower response and higher adverse events have been reported in the elderly. Surgery in elderly patients does not generally differ. Ileal pouch-anal anastomosis can be successful, provided the patient retains good anal sphincter function.

CONCLUSIONS

Management of the older IBD patient differs from that of younger patients; therefore, conventional practice algorithms may have to be modified to account for advanced age.

Comparison of demographic and clinical characteristics of patients with early vs. adult vs. late onset ulcerative colitis

BACKGROUND & AIMS

There is limited data comparing influence of age on the presentation, clinical course, and therapeutic response of patients with ulcerative colitis. We aimed to compare the demographic and clinical characteristics of patients diagnosed with UC in older age vs. adulthood vs. early age.

METHODS

Five-hundred sixty one patients with UC seen at our center from 1995 to 2011 were categorized into early onset (EO), adult onset (AO) and late onset (LO) due to age at date of initial diagnosis. Patients diagnosed younger than age 17 were defined as EO, while those diagnosed between 17 and 60 were defined as AO and older than age 60 as LO. All patients were analyzed for demographic and clinical characteristics.

RESULTS

There was a male predominancy among LO patients (50% vs. 57.7% vs. 78.6%, p=0.004). Patients with EO UC were more likely to be non-smokers (p<0.001), and had higher family history of UC (p=0.02). Patients with EO UC had more steroid use (p=0.03), total colectomy (p=0.04), presence of chronic active disease (p=0.04) rates when compared with AO and LO groups. Patients in EO group had higher overall probability of surgery in 1, 5 and 10 years, when compared with patients in LO group (p=0.02), but it wasn't different between EO and AO groups (p=0.09).

CONCLUSIONS

Our study showed that clinical course of UC was more aggressive in younger ages. Also the difference between the demographic characteristics suggests that different age groups have different risk factors for the disease development.

Old-age inflammatory bowel disease onset: A different problem?

Inflammatory bowel disease (IBD) in patients aged > 60 accounts for 10%-15% of cases of the disease. Diganostic methods are the same as for other age groups. Care has to be taken to distinguish an IBD colitis from other forms of colitis that can mimick clinically, endoscopically and even histologically the IBD entity. The clinical pattern in ulcerative colitis (UC) is proctitis and left-sided UC, while granulomatous colitis with an inflammatory pattern is more common in Crohn’s disease (CD). The treatment options are those used in younger patients, but a series of considerations related to potential pharmacological interactions and side effects of the drugs must be taken into account. The safety profile of conventional immunomodulators and biological therapy is acceptable but more data are required on the safety of use of these drugs in the elderly population. Biological therapy has risen question on the possibility of increased side effects, however this needs to be confirmed. Adherence to performing all the test prior to biologic treatment administration is very important. The overall response to treatment is similar in the different patient age groups but elderly patients have fewer recurrences. The number of hospitalizations in patients > 65 years is greater than in younger group, accounting for 25% of all admissions for IBD. Mortality is similar in UC and slightly higher in CD, but significantly increased in hospitalized patients. Failure of medical treatment continues to be the most common indication for surgery in patients aged > 60 years. Age is not considered a contraindication for performing restorative proctocolectomy with an ileal pouch-anal anastomosis. However, incontinence evaluation should be taken into account an individualized options should be considered

Risk of ischemic stroke in patients with Crohn's disease: a population-based nested case-control study

BACKGROUND

Observational studies have linked Crohn's disease (CD) to an increased risk of venous thromboembolic complications. Case reports of ischemic stroke in CD patients have raised the question of a similar association, but data from observational studies are lacking.

METHODS

Using data from the UK General Practice Research Database we conducted a nested case-control analysis within a population-based cohort of 8054 patients with and 161,078 patients without CD. A total of 1748 cases of ischemic stroke were identified to whom 17,348 controls were matched on age, sex, and year of cohort entry. Adjusted odds ratios (ORs) of ischemic stroke associated with CD were calculated by conditional logistic regression. Stratified analyses were performed for age and sex.

RESULTS

While CD was not associated with an overall increased risk of ischemic stroke (OR 1.10, 95% confidence interval [CI] 0.85-1.43), stratified analyses revealed an increase in risk in younger patients (<50 years: OR 2.93; 95% CI 1.44-5.98) but not in elderly patients (> or =50 years: OR 0.99; 95% CI 0.75-1.30; P for interaction <0.01). The interaction with age remained statistically significant even after changing the cutoff value for the younger and older age group to 45, 55, or 60 years in a sensitivity analysis. There was no interaction with sex (P = 0.79).

CONCLUSIONS

The study indicates that younger patients with CD may be under an increased risk of ischemic stroke.

Inflammatory bowel disease in the elderly

This article reviews the epidemiology, clinical manifestations, diagnosis, prognosis, and treatment of inflammatory bowel disease (IBD), which will grow in prevalence as the population ages. Prognosis of late-onset ulcerative colitis (UC) is generally similar to that of early-onset UC, whereas in Crohn disease it is probably better because of a tendency for colonic involvement. Disease complications are related more to the duration of the inflammatory bowel disease than the subject's current age. The diagnosis in elderly patients can be challenging due to the large number of conditions that mimic IBD on radiologic, endoscopic, and histologic testing. Distinguishing these conditions from IBD will significantly alter prognosis and treatment. Complications related to IBD and its treatment are common and must be recognized early to limit their impact in a vulnerable elderly population.

[Epidemiology of inflammatory bowel disease in the elderly]

INTRODUCTION

Inflammatory bowel disease has classically been considered a disorder with onset in young people. However, between 5 and 15% of patients are diagnosed when aged more than 60 years old. Epidemiological studies comparing these two age groups are controversial and consequently new studies are required to define the characteristics in each group.

OBJECTIVES

To determine the epidemiological characteristics specific to Crohn's disease and ulcerative colitis in the elderly and to compare these characteristics with the form of presentation in young people in Spain.

METHOD

We performed a case-control, descriptive study. Patients with inflammatory bowel disease registered in the database of the Crohn-Colitis Unit were included. The patients were stratified in two groups according to age at symptom onset: the first group consisted of patients with onset at age 60 years or above and the second group was a control group consisting of patients aged less than 60 years old. The control group was composed of two patients for each case matched by sex and diagnosis.

RESULTS

Thirty-three cases aged more than 60 years old (4.1%) were included, eight with Crohn's disease and 25 with ulcerative colitis. The control group included 66 patients (16 with Crohn's disease and 50 with ulcerative colitis). Statistically significant differences were observed between the two groups both in the form of presentation (tenesmus and occlusive symptoms were more frequent and abdominal pain was less frequent in the group aged more than 60 years than in the control group) and in treatment response (corticosteroid dependency and refractoriness and requirement for immunosuppressive treatment were more frequent in the elderly).

CONCLUSION

The results of the present study suggest that there are epidemiological differences in inflammatory bowel disease among the elderly, notably a lower frequency of abdominal pain and a lower rate of refractoriness to steroid treatment.

Age at onset of inflammatory bowel disease and the risk of surgery for non-neoplastic bowel disease

BACKGROUND

There is conflicting data regarding the response to medical and surgical therapy for inflammatory bowel disease with respect to age at disease onset.

AIM

To determine if the age at onset of Crohn's disease and ulcerative colitis is a risk factor for surgery for non-neoplastic bowel disease.

METHODS

This was a case-control study of patients evaluated between 1998 and 2001. Cases had undergone an initial operation for bowel disease. Controls were matched 1:1 for gender, disease subtype, date of first visit (+/-2 years), time from diagnosis prior to first visit (+/-3 years) and duration of follow-up. Association with age, disease extent, smoking history, medication use and co-morbidities vs. case/control status was assessed using multiple variable conditional logistic regression to estimate the odds ratio (OR) and 95% confidence intervals (CI) for undergoing surgery.

RESULTS

Among 132 Crohn's patients, older patients had lower odds for surgery (OR per 5 years, 0.86; 95% CI: 0.75-0.98). The rate of surgery for non-neoplastic bowel disease was not significantly associated with disease distribution, co-morbidities or cigarette smoking. Among 234 ulcerative colitis patients, the rate of surgery was unrelated to age, disease extent, co-morbidities or cigarette smoking,

CONCLUSIONS

For Crohn's disease, but not ulcerative colitis, the risk of surgery for non-neoplastic bowel disease decreases with increasing age at diagnosis, irrespective of disease distribution and history of cigarette smoking.

Crohn's disease in the over-60 age group: a population based study

OBJECTIVES

Late-onset Crohn's disease (CD) may show a distinctive pattern of expression. The aim of our study was to describe the incidence or presentation of CD in the elderly and compare the outcomes in patients < 60 years or > or = 60 years at diagnosis.

METHODS

The study included a population based inception cohort of all incident CD cases diagnosed in Brittany (France) between 1994 and 1997. Sixty-three patients were > or = 60 years and 201 were < 60 years at diagnosis. The physicians managing the patients used standardized questionnaires to collect the study data. The questionnaires on outcomes and treatments were completed in 2002.

RESULTS

In patients > or = 60 years, the annual incidence was 2.5 per 10 persons and clinical features were similar to those in younger patients, except for a higher rate of colon involvement. Among older patients, those with diverticula (29/63, 46%) were more likely to have granulomas (58% vs 33% of patients without diverticula, P < 0.04), but the diagnosis of CD was confirmed by lesions remote from the diverticula in most cases (23/29). Early resection rates were not higher in older patients, who were less likely to require immunosuppressants or re-admission for CD flares, as compared to younger patients. Five year mortality in older patients was 16% but was unrelated to CD.

CONCLUSIONS

In Brittany, the age specific incidence, clinical features, and prognosis of CD among the elderly are comparable to those in younger individuals. Colon involvement is more common. Concomitant diverticular disease is common and should prompt a search for CD lesions at other sites to confirm the diagnosis. Older patients are less likely to require immunosuppressants or admission for flares.

Clinical characteristics of familial versus sporadic Crohn's disease using the Vienna Classification

BACKGROUND

The etiology of Crohn's disease, an illness protean in its manifestations, may be better resolved through studies involving more homogenous subgroups of patients. Because a strong genetic influence exists, family history of inflammatory bowel disease may be a useful variable for patient classification if patients with familial and sporadic Crohn's disease are clinically different. Our study attempted to define any possible differences.

METHODS

The medical records of 552 patients were reviewed, and patients were classified according to guidelines of the Vienna Classification. Patients were then divided based on family history of inflammatory bowel disease, and the familial and sporadic groups were compared.

RESULTS

Overall, 422 (78.9%) patients were diagnosed before age 40 years (A1) and 114 (21.1%) at age 40 years or older (A2). There were 141 (26.3%) patients with disease involving the terminal ileum only (L1), 211 (39.4%) in the colon only (L2), 117 (21.9%) in the terminal ileum and colon (L3), and 66 (12.3%) in the upper gastrointestinal tract (L4). Disease behavior, as determined at the time of last visit or telephone contact, was nonstricturing, nonpenetrating (B1) in 149 (27.9%) patients, stricturing (B2) in 50 (9.3%) patients, and penetrating (B3) in 336 (62.8%) patients. Comparisons among the groups of 53 patients with first-degree relatives only, the 96 patients with either first-, second-, or third-degree relatives (familial CD group), and the 439 patients with sporadic disease demonstrated no differences in sex, age at diagnosis, or disease location. There was a difference in disease behavior between the familial and sporadic groups (p = 0.048) that failed to exist when nonstricturing, nonpenetrating cases were excluded. No such difference was observed between the first-degree relatives only group and the sporadic group (p > 0.10).

CONCLUSIONS

Using the Vienna Classification, familial and sporadic Crohn's disease differed only in disease behavior. However, this difference failed to exist after patients with nonstricturing, nonpenetrating disease were excluded. Therefore, familial and sporadic groups appear to be quite similar clinically, and family history does not appear to be a variable useful for disease subclassification.

Inflammatory bowel disease

Although inflammatory bowel disease (IBD) usually presents in adolescents and young adults, both ulcerative colitis and Crohn's disease can also present in older adults. The diagnosis of IBD in the elderly is often difficult and can easily be confused with diverticulitis or ischaemic colitis. The symptoms and complications of IBD in the elderly are similar to those found in younger patients. However, when IBD presents later in life the disease is often less extensive and milder. Older IBD patients are treated with the same medications as younger patients, although the risk for drug toxicity is greater, especially with corticosteroid therapy. Comorbid illness in older patients often has a significant impact on the outcome of medical and surgical therapy for IBD but, in the absence of significant co-morbid disease, most elderly IBD patients can expect a good response to therapy.

Malabsorption and malnutrition

In this article, disease of the small intestine will be discussed, with particular reference to those conditions leading to malabsorption and malnutrition. The work up of these entities will be emphasized, with focus on bacterial overgrowth, celiac sprue and nonsteroidal-induced enteropathy.

Inflammatory bowel disease in the elderly

Approximately 15% of all patients with IBD first develop symptoms after age 65. As the number of elderly in the population continues to grow, clinicians should expect to see a greater number of elderly IBD patients. In general, the presenting features of IBD are similar to those encountered in younger patients, but the broad differential diagnosis of colitis in the elderly can make definitive diagnosis more challenging. Although most therapies for IBD have not been studied specifically in the elderly, as a general rule, medical and surgical treatment options are the same regardless of age. Osteoporosis, a condition generally associated with aging, should be managed aggressively in patients with IBD because many older persons already have a substantial baseline risk for accelerated bone loss.

Gender-related differences in the clinical course of Crohn's disease

OBJECTIVE

The aim of this study was to analyze the clinical and epidemiological differences between women and men affected by Crohn's disease.

METHODS

The clinical course of 275 female Crohn's disease patients was compared with that of 266 male patients.

RESULTS

Mean age at onset of symptoms and at diagnosis was 25.7 yr versus 27.7 yr and 28.8 yr versus 30.7 yr in women and men, respectively. Mean lag-time between onset of symptoms and establishment of the diagnosis were similar in both groups, without differences in presenting symptoms and initial localization of lesions. In women, however, some extraintestinal manifestations of Crohn's disease were found to occur more often. The percentage of patients who underwent an abdominal operation was quite similar in both groups (81% vs 77%). Mean lag-time between onset of symptoms and first bowel resection was not different. However, the lag-time between bowel resection and recurrence of disease was significantly shorter in women than in men (respectively, 4.8 yr vs 6.5 yr, p = 0.04), particularly regarding primary ileocecal resections. Overall, ileocecal resections were significantly more frequently performed in female than male patients (44% and 32%, respectively, p = 0.004). Female patients were also found to have significantly more often relatives in the first or second degree affected by Crohn's disease than male patients (15% vs 8.3%, p = 0.02).

CONCLUSIONS

Extraintestinal manifestations occur more often in female Crohn's disease patients than in male patients. Furthermore, an ileocecal resection, which is accompanied by an earlier recurrence, is more often performed in female than in male patients. Female patients have more often relatives with the same disease.

Crohn's disease in the elderly: clinical features and long-term outcome of 19 Greek patients

AIM

To study the clinical course, prognosis, treatment and follow-up of 19 patients with Crohn's disease aged 60 years or over at the time of onset of symptoms.

PATIENTS AND METHODS

A series of 12 males and 7 females aged 65 +/- 4. 9 and 66. 6 +/- 6 years at the onset of symptoms and the time of diagnosis, respectively (elderly group), were studied. Another group of patients(83 males, 53 females aged 29.8 +/- 12.4 and 32.2 +/- 12.7 at the onset of symptoms and of diagnosis, respectively) served as a control group (young group). Both groups were followed-up for a mean period of 7.2 and 9.8 years, respectively.

RESULTS

The most common site of involvement in the elderly group was the distal ileum (47.4%), followed by large bowel (36.6%) and concurrent large and small bowel involvement (16%). Acute presentation was significantly more common in the older group. Fever and loss of weight were significantly less common in the older group (p<0.05). A higher rate of complications especially acute abdomen, was observed in the elderly group. There were no significant differences in the indication for surgery and type of surgical procedure applied between the two groups. However significantly fewer patients in the elderly group were operated on because of perianal abscess compared to the young group (p<0.05). Follow-up data revealed that elderly patients with Crohn's disease who had been operated upon showed no significant differences in the course of their disease compared to operated young patients.

CONCLUSION

Crohn's disease in elderly persons of Greek origin follows much the same pattern as in other developed countries of the world.

Abdominal surgery in the older Crohn's population

BACKGROUND

The surgical literature perceives that the elderly cohort of Crohn's patients may have increased risk with surgery.

METHODS

A retrospective review and prospective database analysis of all patients with histologically proven Crohn' s disease who had a laparotomy at a single Sydney teaching hospital were performed. The last laparotomy of each patient was included in the analysis for morbidity and mortality to assess whether an older cohort was at an increased risk.

RESULTS

A total of 156 patients had 298 laparotomies for histopathologically proven Crohn's disease. The frequency distribution of age at last laparotomy was bimodal, and the statistically determined cut-off age between younger and older cohorts was 55 years. Thirty-three patients were older than 55 years. There was no difference in duration of symptoms before first diagnosis (older, 17 months vs younger, 25 months), previous number of Crohn's operations (42.4 vs 39.8%), or duration of known Crohn's disease. Isolated large bowel disease was more common in the elderly cohort (42.4 vs 18.7%, chi2 = 8.09, P < 0.01). Small bowel and ileocaecal resections were more common in the younger cohort (72.4 vs 51.6%, chi2 = 5.19, P < 0.025). There was one death in each cohort (overall mortality 1.3%) and anastomotic leak rates (defined as the number of leaks per number of patients with anastomoses), were 4.3% (older) vs 5.3% (younger) despite frank sepsis present in 21.2% of all subjects at the time of surgery. The older group had more cardiac (18.2 vs 0.8%, P < 0.001) and respiratory complications (18.2 vs 2.4%; P = 0.0003) and a longer mean but not median postoperative hospital admission.

CONCLUSIONS

In conclusion, clinical features and presentation are similar in the older and younger Crohn's patients having a laparotomy. However, in the older patient there is a greater likelihood of large bowel disease, ileocaecal resection is done less commonly, there is a higher risk of minor cardiopulmonary postoperative complications, but with similar mortality and anastomotic leak rates to the younger patient.

Crohn's disease in the elderly: a comparison with young adults

We compare the clinicopathological features of 98 Crohn's disease (CD) patients with initial symptoms at 40 years of age or older (elderly; male n = 56, female n = 42) with those of 347 CD patients with onset of symptoms between the age of 16 and 40 years (young adults; male n = 166, female n = 181). The frequency of presenting symptoms, such as diarrhea, rectal blood loss, and weight loss were comparable in both groups, except for abdominal pain/cramps, which occurred somewhat less frequently in the elderly (59% vs. 71%, p < 0.05). The mean lag time between onset of symptoms and first visit to a general practitioner (GP) was considerably shorter in the elderly than in the young adults (0.2 years vs. 0.6 years, p < 0.001), as was the lag time between GP and referral to a specialist (0.6 years vs. 1.0 years, p < 0.07). Overall, this resulted in a significantly (p < 0.01) shorter time to establish the diagnosis in the elderly (1.8 years vs. 2.7 years). Crohn's disease as correct initial diagnosis was in the elderly less frequently observed than in the young adults (49% vs. 61%, p < 0.05), in contrast to diverticulitis (7.1% vs. 0%) and malignancy (6.1% vs. 0.9%), which were more frequently encountered as incorrect preliminary diagnosis in the elderly (both p < 0.005). The percentage of patients who underwent an abdominal operation was similar in both groups (83% vs. 77%), but the diagnosis CD was in the elderly more frequently established at first operation than in young adults (25% and 12%, p < 0.005). The elderly were found to undergo a bowel operation or resection earlier after onset of symptoms. The development of recurrence after bowel resection, although occurring in a lower percentage of patients, was significantly shorter than in the young adults (3.7 years vs. 5.8 years, p < 0.02). Arthritic extraintestinal manifestations were equally frequent in both groups, but elderly patients had significantly less relatives in the first or second degree affected by CD (3.1% vs. 12%, p < 0.02). We conclude that the diagnosis Crohn's disease is more readily established in elderly patients. Moreover, these patients less frequently have abdominal pain/cramps as a presenting symptom, a shorter time interval between onset of symptoms and first resection, and subsequent recurrence of the disease. In addition, elderly CD patients have less relatives affected by the same disease. Thus, CD in the elderly appears to be characterized by a more rapid development.

Clinical course of colorectal Crohn's disease: a 35-year follow-up study of 507 patients

BACKGROUND & AIMS

Crohn's disease (CD) confined to the colon and rectum is an increasing clinical entity. The aim of this study was to assess the features and clinical course of colorectal CD.

METHODS

This was a retrospective cohort study of 507 patients in whom colonic or rectal CD had been diagnosed between 1955 and 1989.

RESULTS

Colonic distribution was segmental in 40%, total in 31%, and left-sided in 26%. Perianal/rectal fistulas occurred in 37%. In patients who attained clinical remission, the 5-year cumulative relapse rate after diagnosis was 67% (95% confidence interval [CI], 62-72). At the initial presentation of CD, the frequency of major surgery decreased from 24% to 14% (P < 0.005) over time. Still, the overall long-term probability of major surgery after 10 years was unaltered (49% vs. 47%). The presence of fistulas increased the probability of surgical resection (relative risk [RR], 1.7 [95% CI, 1.3-2.2]), whereas left-sided disease was associated with a decrease (RR, 0.6 [95% CI, 0.4-0.8]). Twenty-four percent of the patients developed inflammation in the small bowel. The cumulative risk for a permanent ileostomy was 25% (95% CI, 21-29) 10 years after diagnosis.

CONCLUSIONS

Colorectal CD is an increasing entity carrying substantial morbidity. Half of the patients will undergo surgical resection within the first 10 years, and half of those will ultimately undergo ileostomy. Changed management at diagnosis has not affected the long-term probability of resection.

Prognosis and management of Crohn's disease in the over-55 age group

The course, prognosis and management of 62 patients with Crohn's disease aged 55 years or over at diagnosis has been reviewed. The distal ileus was the commonest site of disease in the older patient, where the characteristic presentation was acute after initially mild symptoms. Early local resection was often required, particularly where there was diagnostic doubt or suspicion of caecal malignancy. Recurrence rates were much lower in the older patient than after resection in younger patients. Medical treatment played a minor role in the management of patients with distal ileal disease, in part because stricture formation was present at diagnosis and the acute nature of symptoms at presentation led to early surgical treatment. Colonic Crohn's disease was usually confined to the distal or left side of the colon and initially could be difficult to distinguish from diverticular disease. Extensive colonic Crohn's disease was rare. The apparently limited disease was not necessarily associated with a good prognosis, since disease at this site sometimes progressed rapidly, necessitating urgent surgical resection. Medical treatment (corticosteriod therapy, with or without azathioprine) was usually effective initially for treatment of symptomatic colonic Crohn's disease, but sustained remission was rare. Those patients with persistent symptoms were restored to good health with surgical treatment but at a price, in that nearly half eventually required a permanent stoma.

Inflammatory bowel disease in the elderly. Practical treatment guidelines

Although Crohn's disease and ulcerative colitis were initially described in young adults, it has become increasingly apparent that inflammatory bowel disease (IBD) affects the elderly, with the new onset of disease occurring well into the seventh and eighth decades of life. The diagnosis of IBD in the elderly may be difficult because it can be easily confused with infectious, ischaemic and drug-related processes, as well as with diverticulitis and carcinoma. Although medical treatment for IBD is similar in the young and the elderly, consideration must be given to comorbid illnesses in the older patient. Topical agents should be used as first-line therapy for patients with distal colonic disease. In patients with more proximal involvement, oral mesalazine or sulfasalazine should be used for maintenance therapy, with corticosteroids being reserved for patients with active disease. Metronidazole is particularly efficacious in patients with colonic Crohn's disease. Finally, immunomodulators can be helpful in patients who are steroid-dependent or refractory to the therapies noted above. This article reviews and outlines practical treatment guidelines for the older patient with IBD.

Relationship between site of disease and familial occurrence in Crohn's disease

Concordance in the extent of disease among the family members of patients with Crohn's disease has not been widely investigated. Furthermore, the relationship between the site of the disease and familial occurrence has never been studied. Our aim was to evaluate the familial occurrence of Crohn's disease in the various sites. Nine hundred thirty-four patients with Crohn's disease, observed consecutively in two gastrointestinal departments, were investigated to determine first-degree familial incidence (in both Crohn's disease and ulcerative colitis). Whenever two or more members were attending the same clinic, only one was regarded as a propositus. The analysis, therefore, was carried out on 882 patients. The exact site of the disease was determined in all patients either at diagnosis or during the follow-up by colonoscopy and by small bowel enema. The rate of concordance in the extent of disease and familial occurrence in the various sites was evaluated and the difference was calculated by chi-square test. Sixty-one propositi were identified among all the patients. Forty-nine had familial occurrence for the same disease (concordant patients), whereas 12 had at least one relative with ulcerative colitis (discordant patients). In 44 propositi with only one relative affected, the rates of concordance in the extent of the disease were 84, 68, 18, and 0% respectively, for the ileum, the ileum-right colon, the ileum-total colon, and the colon. The number of propositi in the various sites was as follows: 4 of 162 (2.4%) patients with the disease located in the colon, 1 of 9 (11%) with the jejunum site, 24 of 380 (6.3%) with the ileum site, 16 of 165 (9.7%) with the ileum and right colon site, and 16 of 164 (9.7%) with the ileum and total colon site. The chi-square values of propositi distribution among other sites and the colon was, respectively, as follows: jejunum, 2.2 (N.S.); ileum, 3.4 (P = 0.06); ileum and right colon, 7.4 (P = 0.006); and ileum and total colon, 7.4 (P = 0.006). This study shows a pronounced concordance in the site of the disease for family members with Crohn's disease and suggests that familial occurrence in Crohn's disease is less frequent when the disease is located in the colon rather than elsewhere.

Crohn's disease in a 92-year-old male

A case of Crohn's disease in an extremely elderly man (92-years-old) is reported. He was admitted for abdominal pain and was operated on under a diagnosis of ischemic colitis. At the mucosal surface, many linear and irregularly shaped shallow ulcers were found on the mesenteric side. Microscopically, transmural inflammatory cell infiltration, bead-like lymphoid aggregates around the propriate muscle, small epithelioid cell granulomas, fissure, and volcano-like streamers of inflammatory cells were found. Nerve fibers in Meissner's and Auerbach's plexi seemed to be increased in number, and some were hyperplastic. There was no feature of ischemic colitis or Yersinia enteritis. Serially sectioned tissue specimens did not show dysplastic mucosal change. Many cases of Crohn's disease in the elderly have been reported but an extremely elderly patient such as the present one is very rare, especially in Japan. Characteristics of elderly patients with Crohn's disease are discussed.

Inflammatory bowel disease in older patients

The onset of UC and CD may occur later in life. Although making the diagnosis of IBD in the elderly can be challenging, the clinical course, natural history, and response to treatment are similar for older and younger patients. In fact, both UC and CD tend to be less extensive in older patients, a feature that may contribute to the overall favorable prognosis for elderly patients with IBD. Overall mortality rates for both UC and CD appear to be similar to that of the general population except for those few patients that present with severe initial disease. Typical features of IBD in the elderly are summarized in Table 3. The differential diagnosis of IBD in the elderly includes infectious causes of enterocolitis, ischemic colitis, and diverticular disease as well as several other mimics of IBD. Awareness of the possibility of late-onset disease and the unique manifestations of disease in the elderly contributes to accurate diagnosis and timely treatment.

Inflammatory bowel disease. Part II: Clinical and therapeutic aspects

Once regarded as medical curiosities, ulcerative colitis and Crohn's disease have achieved a remarkable change in status recently and today are among the more compelling of all human illnesses. The cause(s) of inflammatory bowel disease (IBD) are not known. Genetic, environmental, microbial, and immunologic factors are involved, but the precise mechanisms are obscure. The incidence of ulcerative colitis is relatively stable, while Crohn's disease continues to increase in frequency. In 10% to 15% of patients, it is hard to differentiate between ulcerative colitis and Crohn's colitis, however, problems with diagnosis usually resolve with time and repeated examinations. In part I of his two-part monograph on IBD, Dr. Kirsner addressed the nature and pathogenesis of the disease. Increased study of ulcerative colitis and Crohn's disease in recent years has generated new knowledge regarding their etiology. Part I focused on microbial, immunologic, and genetic mechanisms of, and the inflammatory process involved in the disease. In this part, Dr. Kirsner deals with the clinical features, course, and management of IBD, based on the author's 55 years of experience with these problems and supplemented by critical examination of the recent (1988-1990) literature. Particular attention is directed to the symptoms and physical findings of ulcerative colitis and Crohn's disease. The laboratory, radiologic, endoscopic, and pathologic features, and the many systemic complications. IBDs are mimicked by several enterocolonic infections and other conditions making differential diagnosis necessary. Inflammatory bowel disease in children and the elderly conforms to conventional clinical patterns modified by the health circumstances of the respective age groups. Because the cause of IBD has not been established, current medical therapy is facilitative and supportive rather than curative. The principles of medical treatment are approximately the same for ulcerative colitis and Crohn's disease. Treatment emphasizes a program rather than a drug and also considers the individuality of the therapeutic response. A clearer understanding of dietary and nutritional needs, including hyperalimentation and electrolyte and fluid balance, aids treatment. Antidiarrheal and antispasmodal preparation and sedatives are prescribed for symptom relief. The bowel inflammation is controlled with sulfasalazine or the newer 5-amino-salicylic acid (5-ASA) compounds, antibacterial drugs for complications of Crohn's disease and IBD, adrenocortical steroids, and the immunosuppressive compounds 6-mercaptopurine (6MP), azathioprine, and cyclosporine, as determined in each patient. The surgical procedures available for treatment of ulcerative colitis include total proctocolectomy and ileostomy or ileoanal anastomosis.(ABSTRACT TRUNCATED AT 400 WORDS)

Crohn's disease in the city of Derby, 1951-85

An epidemiological survey of Crohn's disease in the city of Derby showed that the incidence of the condition increased from 0.7/10(5) per year between 1951 and 1955 to 6.67/10(5) per year between 1981 and 1985 but seemed to reach a plateau between 1976 and 1985. Large bowel Crohn's disease was more common in patients presenting aged 60-79 years than in those aged 20-39 years. The increase in incidence was not solely due to the detection of milder disease. There was no evidence that the Asian (Indian subcontinent) population of Derby was resistant to the development of Crohn's disease.

Clinical course of Crohn's disease in older patients. A retrospective study

The authors retrospectively reviewed the records of 50 patients whose initial diagnosis of Crohn's disease was made after the age of 50 years on the basis of strict histopathologic criteria. Progress of the 32 women and 18 men with a median age of 60 years (range, 50 to 78 years) was followed for a median of 95.5 months (range, 81.1 to 236.6 months). The most common presenting signs and symptoms were abdominal pain (82 percent), diarrhea (70 percent), weight loss (56 percent), bleeding from the gastrointestinal tract (26 percent), abdominal mass (16 percent), and fistula (14 percent). Initial operations performed were ileocolic resection (38 percent), proctocolectomy (16 percent), small bowel resection (10 percent), colostomy (2 percent), and a variety of segmental resections of the colon (34 percent). The overall recurrence rate of disease in patients in whom all obvious disease was resected, based on distribution of disease, was 80 percent (ileocolitis), 38 percent (ileitis), and 35 percent (colitis). Crohn's disease more often affects the distal gastrointestinal tract in older age groups. After resection, however, the clinical course is similar to that of the younger population. The high recurrence rate of Crohn's colitis is probably a result of the large number of initial segmental resections.

Prognosis after surgery for colonic Crohn's disease

The long-term prognosis including operation rates, the incidences of recurrent disease, morbidity and mortality and current status has been analysed in a group of 360 patients with Crohn's colitis grouped according to the primary site of macroscopic disease at diagnosis. The group has been followed from diagnosis for a mean period of 14.9 years. The overall operation rate was 76 per cent. Prolonged spontaneous or drug induced remission occurred at all sites: right-sided disease (11 per cent), extensive colonic disease (21 per cent) and left-sided disease (38 per cent). The cumulative reoperation rates at 5 and 10 years after right hemicolectomy were 26 and 46 per cent, after colectomy and ileorectal anastomosis 46 and 60 per cent, and after panproctocolectomy 10 and 21 per cent, respectively. There was a twofold excess mortality rate from related Crohn's disease deaths during the period of review, but the mortality rate has fallen with time. There have only been 11 related deaths in the last decade, of which eight were probably unavoidable. The current status of most patients is good, although treatment has included a permanent stoma in less than half (41 per cent) the patients still under review. Currently all but 14 patients are well and symptom-free and only 16 are receiving specific medical treatment. Until the aetiology of Crohn's colitis is understood, if medical treatment has failed to resolve symptoms, appropriate surgical treatment in experienced hands is an effective way of restoring patients with chronic persistent symptoms to good health.

Coexistent Crohn's disease and sigmoid diverticulosis

This study reports six patients with a diagnosis of diverticular disease with associated localized Crohn's colitis who were all treated by segmental resection. Two patients died in the post-operative period from disease unrelated to their colonic pathology. The remaining four patients remain well, show no signs of recurrent disease and have required no further surgery. The behaviour and significance of the two conditions occurring in the same patient is discussed.

Crohn's disease of late onset in Blackpool

Fifty five (26%) of two hundred and fifteen patients presenting with Crohn's disease in the Blackpool area over a 15 year period (1969-1983) were over 60 years of age. There were twice as many women as men (38:17). In 60% disease was limited to the large bowel compared to only 29% in the younger age group. Many of these were women with mild distal colitis. Twenty one patients required operative management. In general, the prognosis was good in colonic disease, but in small bowel and ileocolonic disease the necessity for early operative intervention was potentially fatal. Delayed diagnosis, poor nutritional state and associated disease were relevant adverse factors. The majority of patients at the time of review were well and, where necessary, were coping satisfactorily with a stoma.