A Review of Extraintestinal Manifestations and Complications of Inflammatory Bowel Disease

Colonic strictures in Crohn's disease: a non-surgical survival

BACKGROUND

Colonic stenosis in Crohn's disease (CD) is uncommon, and data on surgery-free survival are limited. This study aimed to determine surgery-free survival rates and identify associated factors.

PATIENTS AND METHODS

A retrospective study was conducted from 2003 to 2022, including patients with CD complicated by colonic stenosis. Patients with uncertain diagnoses or follow-up periods of less than six months were excluded.

RESULTS

Fifty-six patients were included (median age 44 years [range 14-65], male-to-female ratio = 0.93). Surgery-free survival rates were 58.9% at 6 months, 43.7% at 2 years, and 31.7% at 5 years, with an average surgery-free survival of 46.7 months. Univariate analysis showed that joint manifestations (p = 0.01), corticosteroids (p = 0.02), anti-TNF alpha (p = 0.02), salicylates (p = 0.02), and azathioprine (p = 0.01) increased surgery-free survival. Complications such as collections or internal fistulas (p = 0.03), parietal ulceration on imaging (p = 0.01), and acute intestinal obstruction (p = 0.01) were associated with reduced surgery-free survival. In multivariate analysis, biologic therapy was the only independent protective factor against surgery (p = 0.001, OR = 0.19).

CONCLUSION

The early introduction of biologic therapy is crucial for increasing surgery-free survival in patients with colonic stenosis in CD, given the limited effectiveness of conventional treatments.

Colitis can reduce the cingulate cortex neuronal density in rats

BACKGROUND AND AIM

Hyperalgesia and hypersensitivity in patients with Inflammatory Bowel Disease (IBD) can be related to central nervous system (CNS) changes, particularly in the pain pathways. The objective of this study was to examine the neuronal density of the cingulate cortex area (CC) and amygdala in an animal model of colitis.

MATERIALS AND METHODS

In this experiment, 13 male Wistar rats were subjected to study. Colitis was induced in the rats by transrectally administering 1 cc of acetic acid 3% under sedation with xylazine 10% (5 mg/kg). After 14 days of colitis, the rats were euthanized under high doses of anesthesia with ketamine (50 mg/kg), xylazine (10 mg/kg), and diazepam (2.5 mg/kg). Their brains were then removed surgically. Six-micrometer-thick brain slices were stained with cresyl violet, and the neuronal density of the amygdala, area 1 of the cingulate cortex area (CC1), and area 2 of the cingulate cortex area (CC2) was assessed via microscopic imaging.

RESULTS

The mean ± standard deviation (SD) of the neuronal density in CC1 was significantly decreased in rats with colitis compared to the control group in both the right CC1 (43.53 ± 9.63 vs. 62.7 ± 11.89; p-value ˂ 0.001), and left CC1 (41.19 ± 9.05 and 63.1 ± 7.44; p-value ˂ 0.001). Additionally, the neuronal density of CC2 in the colitis group was found to be significantly lower than that of the controls in both the right CC2 (57.8 ± 13.23 vs. 87.95 ± 8.76; p-value ˂ 0.001), and left CC2 (55.42 ± 11.3 vs. 98 ± 8.99; p-value ˂ 0.001). Furthermore, the amygdala had a lower neuronal density in both hemispheres in rats with colitis in comparison to the controls bilaterally: right hemisphere (24.51 ± 5.49 and 36.3 ± 7.44; p-value = 0.360), and left hemisphere (24.52 ± 5.53 VS. 35.25 ± 5.6; P-value = 0.869).

CONCLUSION

This study showed that colitis can reduce the neuronal density within cortical areas and amygdala of both hemispheres. Considering the cingulate cortex's role in suppressing pain perception, any harm inflicted upon this region of the brain can has the ability to impact the cognitive and sensory aspects of pain.

Bilateral Retinal Artery Occlusions and Uveitis as the First Manifestation of Crohn's Disease

PURPOSE

To present a case of newly diagnosed Crohn's disease, in which retinal artery occlusion (RAO) with uveitis was the first clinical manifestation.

CASE DESCRIPTION

A 55-year-old man presented with bilateral blurred vision, with decreased best corrected visual acuity (BCVA) to light perception (right eye, RE) and 20/40 (left eye, LE). Ophthalmological examination revealed bilateral iritis, vitritis, disc edema, and retinal vascular occlusions. Because of concurrent fever and leukocytosis, a systemic infection was highly suspected. However, whole-body imaging was unrevealing. Subsequently, the patient presented with massive bloody stool. Histopathological specimen from emergent hemicolectomy confirmed transmural granulomatous inflammation. Crohn's disease was finally diagnosed. Following treatment, the BCVA recovered to 20/40 (RE) and 20/22 (LE). The systemic condition remained stable after a 3-year follow-up.

CONCLUSION

RAO with uveitis is a possible manifestation of Crohn's disease. In complex uveitis cases, clinicians should be aware of inflammatory bowel diseases as an important differential diagnosis.

Probiotics for inflammatory bowel disease: Is there sufficient evidence?

Inflammatory bowel disease (IBD) refers to chronic inflammatory disorders of the gut. Ulcerative colitis (UC) and Crohn's disease (CD) are two subtypes of IBD. Evidence suggests that the intestinal microbiota plays a role in the pathogenesis of IBD, so probiotics have garnered a lot of interest as a potential treatment or prevention for IBD. However, clinical evidence of the efficacy of probiotics is still debatable. We performed a literature review. An advanced search considered clinical studies on probiotic for IBD from inception to 2023 in PubMed, Embase, Cochrane Library, and Web of Science. In the treatment of UC with probiotics, only Escherichia coli Nissle 1917 for maintenance treatment of UC in remission, and Bifidobacterium and VSL#3 for induction of remission in patients with mild to moderately active UC have shown strong evidence. Currently, there are no definitive conclusions regarding the effectiveness of probiotics in CD. The mechanism of probiotic treatment for IBD may be related to reducing oxidative stress, repairing the intestinal barrier, regulating intestinal flora balance, and modulating intestinal immune response. Differences in the benefits of probiotics between CD and UC may be attributable to the different lesion extent and immune-mediated pathophysiology. More robust randomized clinical trials are required to validate the efficacy and safety of diverse probiotic strains in IBD.

Kidney Diseases Associated With Inflammatory Bowel Disease: Impact of Chronic Histologic Damage, Treatments, and Outcomes

INTRODUCTION

Kidney disease is a well-known extraintestinal manifestation (EIM) associated with inflammatory bowel disease (IBD), with a variety of underlying etiologies. However, little is known about the overall outcomes and predictors.

METHODS

This is a retrospective, observational cohort study. Patients with IBD in whom a native kidney biopsy was performed at Mayo Clinic (Rochester, MN) between 1994 and 2022, were included. Demographic, clinical, and histologic characteristics of prognostic interest were collected. The main outcomes were kidney failure, disease remission, kidney function changes at last follow-up, and death.

RESULTS

From a total cohort of 318 patients, we selected a study group of 111 patients followed-up with at our institution (45 ulcerative colitis [UC] and 66 Crohn's disease [CD]), with a mean age of 48 ± 17 years (40% females). IgA nephropathy (IgAN), chronic interstitial nephritis (CIN), and acute interstitial nephritis (AIN) were the most common diagnoses (22%, 19%, 13%, respectively). Median estimated glomerular filtration rate (eGFR) at presentation was 30 ml/min per 1.73 m2 (interquartile range [IQR]: 17-54) and urinary protein-to-creatinine ratio [UPCR] 0.8 g/g (0.3-3.4), without differences between IBD types. During a median follow-up of 59 months (12-109), 29 patients (26%) reached kidney failure. By multivariable analysis, the main predictors of kidney failure were age (hazard ratio [HR]: 1.04; P = 0.002), baseline eGFR (HR: 0.94; P = 0.003) and histologic chronicity score (HR: 4.01; P < 0.001). Therapeutic management varied according to underlying etiology. Global survival (kidney failure + death) was significantly better in patients who achieved complete or partial remission, or stabilization or improvement of kidney function.

CONCLUSION

One-fourth of patients with IBD with kidney disease may reach kidney failure, and the main determinants of this outcome is age, baseline eGFR, and degree of chronicity in kidney biopsy.

Non-alcoholic fatty liver disease (NAFLD) and obesity in inflammatory bowel disease (IBD) patients in Gorgan

Background

According to the significance of extraintestinal symptoms in inflammatory bowel disease (IBD) patients and their connection with obesity, we aimed to investigate the prevalence of fatty liver in IBD patients of Sayyad Shirazi Hospital in Gorgan, Iran, in relation to obesity, anthropometric indicators and body image in these patients.

Methods

Forty patients with IBD were recruited from all registered patients at the Golestan Research Center of Gastroenterology and Hepatology, following the specified inclusion and exclusion criteria. After obtaining written informed consent and filling in the questionnaire, the demographic and anthropometric indicators, and variables related to the disease were measured. The liver sonography was performed on all patients and graded by an expert radiologist. Data were analyzed using SPSS Version 16.0 statistical software at the significance level of 0.05.

Results

We showed no significant difference between the distribution of demographic and anthropometric indicators in different groups of IBD patients. However, we demonstrated that the inappropriate values of HDL (0.004) and high values of LDL (0.015) were associated with fatty liver in IBD patients. Our findings also showed that NAFLD was significantly associated with overweight and obesity among IBD patients (P = 0.003).

Conclusion

Our findings showed the epidemiological burden of NAFLD in IBD patients. Since fatty liver was associated with obesity, it is recommended that IBD patients be screened for risk factors associated with NAFLD to prevent liver disease.

Arabinogalactan Alleviates Lipopolysaccharide-Induced Intestinal Epithelial Barrier Damage through Adenosine Monophosphate-Activated Protein Kinase/Silent Information Regulator 1/Nuclear Factor Kappa-B Signaling Pathways in Caco-2 Cells

Intestinal epithelial barrier (IEB) damage is an important aspect in inflammatory bowel disease (IBD). The objective of this study was to explore the protective effects and mechanisms of arabinogalactan (AG) on lipopolysaccharide (LPS)-stimulated IEB dysfunction. The results show that AG (1, 2, and 5 mg/mL) mitigated 100 μg/mL LPS-stimulated IEB dysfunction through increasing transepithelial electrical resistance (TEER), reducing fluorescein isothiocyanate (FITC)-dextran (4 kDa) flux, and up-regulating the protein and mRNA expression of tight junction (TJ) proteins (Claudin-1, Zonula occludens-1 (ZO-1) and Occludin). In addition, AG ameliorated LPS-stimulated IEB dysfunction by reducing interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and IL-1β levels, decreasing the reactive oxygen species (ROS) level, increasing superoxide dismutase (SOD) activity, increasing the glutathione (GSH) level, and decreasing the levels of malondialdehyde (MDA) and intracellular calcium ([Ca2+]i). Furthermore, 2 mg/mL AG up-regulated the expression of silent information regulator 1 (SIRT1), the phosphorylated adenosine monophosphate-activated protein kinase (AMPK), and peroxisome proliferator-activated receptor gamma coactivator (PGC)-1α and inhibited the phosphorylation of nuclear factor kappa-B (NF-κB) and the inhibitor of NF-κBα (IκBα). Therefore, AG could maintain IEB integrity by activating AMPK/SIRT1 and inhibiting the NF-κB signaling pathway. In conclusion, AG can regulate the AMPK/SIRT1/NF-κB signaling pathway to reduce inflammation and oxidative stress, thus alleviating LPS-stimulated IEB damage.

Autoimmune Haemolytic Anaemia as a Rare and Potentially Serious Complication of Crohn's Disease in a 11-Year-Old Child-Case Report and Minireview

Inflammatory bowel disease (IBD) is the term given to a heterogeneous group of chronic inflammatory diseases of the gastrointestinal tract (GI). These include ulcerative colitis (UC), where the inflammatory process involves only the intestinal mucosa, and Crohn's disease (CD), where it can involve the entire wall of the GI in all of its sections. In addition to typical gastrointestinal complaints, IBD manifests with a range of extraintestinal symptoms involving inter alia the eyes, joints, skin, liver and biliary tract. These can cause a number of extraintestinal complications; of these, one of the most common is anaemia, usually resulting from nutritional deficiencies, especially iron, or chronic inflammation. When treating patients with IBD, it is important to consider the possibility of rare but serious complications, including autoimmune haemolytic anaemia (AIHA). This condition occurs in only 0.2 to 1.7% of UC cases and is even rarer in CD. AIHA is usually mild but can occur suddenly and cause very rapid anaemia. In the article presented here, we describe the case of a patient who developed AIHA two years after a diagnosis of CD, causing a life-threatening diagnostic and therapeutic challenge for the medical team.

Pancreatic Involvement in the Course of Inflammatory Bowel Disease in Children-A Multi-Center Study

The coexistence of inflammatory bowel disease (IBD) with pancreatic pathology is rare in children. A retrospective analysis of data from 1538 children diagnosed with IBD in 2014-2021 was conducted to determine the frequency and causes of pancreatitis and asymptomatic hyperlipasemia (HL) or hyperamylasemia (HA) in this group of patients. Among the 176 children (11.4%) with pancreatic involvement (PI), acute pancreatitis (AP) was diagnosed in 77 children (43.8%), and HA or HL was observed in 88 children (50.0%). Only a few patients were diagnosed with autoimmune or chronic pancreatitis (6.2%). PI was observed at the time of the IBD diagnosis in 26.1% of the cases. A total of 54.5% of the patients had moderate to severe IBD, and 96% had colonic involvement at the time of diagnosis of PI. Idiopathic PI was the most common (57%), followed by drug-induced PI (37%) and azathioprine (AZA). In patients with AZA-induced AP, the successful introduction of 6-mercaptopurine (6-MP) to therapy was noted in 62.5% of the children. Our results suggest that routine monitoring of pancreatic enzymes in patients with IBD should be performed, especially after the initiation of the AZA treatment. The presence of transient HA/HL in IBD does not necessarily indicate pancreatic pathology.

Cerebral Sinus Vein Thrombosis and Gender: A Not Entirely Casual Relationship

Cerebral sinus venous thrombosis (CSVT) is a relatively rare acute disorder of cerebral circulation, but it can potentially be associated with serious sequelae and a poor prognosis. The neurological manifestations associated with it are often not adequately taken into consideration given the extreme variability and nuances of its clinical presentation and given the need for radiological methods suitable for this type of diagnosis. CSVT is usually more common in women, but so far there are little data available in the literature on sex-specific characteristics regarding this pathology. CSVT is the result of multiple conditions and is therefore to be considered a multifactorial disease where at least one risk factor is present in over 80% of cases. From the literature, we learn that congenital or acquired prothrombotic states are to be considered extremely associated with the occurrence of an acute episode of CSVT and its recurrences. It is, therefore, necessary to fully know the origins and natural history of CSVT, in order to implement the diagnostic and therapeutic pathways of these neurological manifestations. In this report, we summarize the main causes of CSVT considering the possible influence of gender, bearing in mind that most of the causes listed above are pathological conditions closely linked to the female sex.

A Review of Ophthalmic Complications in Inflammatory Bowel Diseases

Inflammatory bowel diseases (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), are chronic immune-mediated conditions caused by various polygenic and environmental factors. Clinical manifestations of IBD primarily occur in the gastrointestinal tract, but many patients are affected by extraintestinal complications, including eye diseases. Ocular disorders are the third most common extraintestinal manifestation (EIM), following musculoskeletal and mucocutaneous involvement. Episcleritis, frequently occurring in IBD patients, may be associated with exacerbation of the intestinal disease. Uveitis does not correlate with IBD activity but may be related to the presence of other EIMs, particularly erythema nodosum and peripheral arthritis. Early detection and specific therapy of ocular manifestations of IBD are fundamental to avoiding sight-threatening complications. Therefore, ophthalmic evaluation should be performed in all IBD patients. Systemic corticosteroids or immunosuppressants may be inevitable in severe cases to control ocular inflammation. Persistent and relapsing conditions usually respond well to TNF-α-inhibitors. Interdisciplinary cooperation between gastroenterologists and ophthalmologists is fundamental in initiating the appropriate treatment for patients.

Chronic steroid use: An overlooked impact on patients with inflammatory bowel disease

Background and Aim

Steroids have long been used in inducing remission of inflammatory bowel disease (IBD). Chronic use, defined as therapy greater than 3 months, has been implicated in complications including increased hospital length of stay (LOS), infections, and even death. In our retrospective study, we aim to identify the complications of chronic steroid use in patients with IBD.

Methods

The fourth quarter of 2015-2019 National Inpatient Sample (NIS) was used in this study. International Classification of Diseases (ICD-10) codes were used to identify patients with a diagnosis of IBD and chronic steroid use. Adverse outcomes of chronic steroid use in IBD patients were analyzed, such as osteoporosis, opportunistic infections, mortality rate, and LOS. Cohorts were weighted using an algorithm provided by the NIS allowing for accurate national estimates.

Results

A total of 283 970 patients had a diagnosis of IBD. Of those, 18 030 patients had concurrent chronic steroid use. Racial disparities existed, with 77.4% White, 12.7% Black, and 6.0% Hispanic. Patients with a history of IBD and chronic steroid use were found to have higher odds of developing osteoporosis, opportunistic infections, and acute thromboembolic events but did not have higher odds of mortality.

Conclusion

There is much controversy about whether IBD patients should be on chronic steroids for maintenance therapy and this study highlights the importance of this decision as patients on chronic steroid use had higher odds of developing adverse effects. These results stress the importance of monitoring patients on steroids and avoiding chronic use.

Hepatic cytochrome P450 8B1 and cholic acid potentiate intestinal epithelial injury in colitis by suppressing intestinal stem cell renewal

Although disrupted bile acid (BA) homeostasis is implicated in inflammatory bowel disease (IBD), the role of hepatic BA metabolism in the pathogenesis of colitis is poorly understood. Here, we found that cholic acid (CA) levels were increased in patients and mice. Cytochrome P450 8B1 (CYP8B1), which synthesizes CA, was induced in livers of colitic mice. CA-treated or liver Cyp8b1-overexpressing mice developed more severe colitis with compromised repair of the mucosal barrier, whereas Cyp8b1-knockout mice were resistant to colitis. Mechanistically, CA inhibited peroxisome proliferator-activated receptor alpha (PPARα), resulting in impeded fatty acid oxidation (FAO) and impaired Lgr5+ intestinal stem cell (ISC) renewal. A PPARα agonist restored FAO and improved Lgr5+ ISC function. Activation of the farnesoid X receptor (FXR) suppressed liver CYP8B1 expression and ameliorated colitis in mice. This study reveals a connection between the hepatic CYP8B1-CA axis and colitis via regulating intestinal epithelial regeneration, suggesting that BA-based strategies might be beneficial in IBD treatment.

Ocular Manifestations in Patients with Inflammatory Bowel Disease in the Biologics Era

Background: Extra-intestinal manifestations are frequent in inflammatory bowel disease (IBD). Ocular disorders are generally under diagnosed as they are challenging diagnosis. Aims: We assessed the prevalence of ophthalmological manifestations in patients with IBD, and investigated characteristics associated with ocular manifestations. Methods: We performed a retrospective study including patients followed for IBD and had an ophthalmologic visit from January 2013 to July 2020, among 1432 patients followed during this period. Two groups were considered: the first group included patients whose an ocular diagnosis was considered as “related to IBD”, and the second group including patients whose an ocular diagnosis was considered “not related to IBD”. Results: Among 1432 patients with IBD, eighty-seven (6.1%) patients had an ophthalmologic visit. Fifty-three patients (3.7%) were considered to have an ocular extra-intestinal manifestation or an iatrogenic effect of IBD treatment, and 34 diagnoses (2.4%) were considered not related to IBD. Inflammatory surface pathologies were the most frequent (33.2%), including 15 patients with dry eye (17.2%), 9 with blepharitis (10.3%), and 5 with chalazions (meibomian cyst) (5.7%). Uveitis was diagnosed in 13 patients (14.9%), episcleritis in 5 patients (5.7%), and scleritis in 2 patients (2.3%). Characteristics of patients with an ophthalmological diagnosis “related to IBD” versus “not related to IBD” were not statistically different. Conclusion: In our cohort, less than 5% of patients had ophthalmological extra-intestinal manifestation. The most frequent ocular diagnosis were dry eye and uveitis. No disease characteristics of IBD were found to be associated with ocular manifestations.

Effects of CB2 and TRPV1 Stimulation on Osteoclast Overactivity Induced by Iron in Pediatric Inflammatory Bowel Disease

BACKGROUND

The reduction of bone mineral density and osteoporosis have high impacts on the health of patients with inflammatory bowel diseases (IBD). We have previously shown that a dysregulated iron metabolism occurs in IBD and leads to a decrease in circulating iron concentration and excessive intracellular sequestration of iron. Studies suggest that iron overload significantly affects the bone, accelerating osteoclast (OC) differentiation and activation, promoting bone resorption. Moreover, we demonstrated that iron overload causes OC overactivity. The cannabinoid receptor type 2 (CB2) and the transient receptor potential vanilloid type-1 (TRPV1) are potential therapeutic targets for bone diseases. The aim of this study was to evaluate the roles of CB2 and TRPV1 receptors and of iron in the development of osteoporosis in pediatric IBD.

METHODS

We differentiated OCs from peripheral blood mononuclear cells of patients with IBD and healthy donors and evaluated CB2 and TRPV1 receptor expression; OC activity, and iron metabolism by Western blot, TRAP assays, bone resorption assays, and iron assays. Moreover, we analyzed the effects of the pharmacological modulation of CB2 and TRPV1 receptors on OC activity and on the iron metabolism.

RESULTS

We confirmed the well-known roles of CB2 and TRPV1 receptors in bone metabolism and suggested that their stimulation can reduce the OC overactivity induced by iron, providing new insights into the pathogenesis of pediatric IBD-related bone resorption.

CONCLUSIONS

Stimulation of CB2 and TRPV1 could reduce IBD-related osteoporosis due to their direct effects on OC activity and to modulating the iron metabolism.

Review of the Effects and Mechanism of Curcumin in the Treatment of Inflammatory Bowel Disease

Curcumin is extracted from the rhizomes of Curcuma longa L. It is now widely used in food processing, cosmetics, dyes, etc. Current researching indicates that curcumin has high medical value, including anti-inflammatory, antioxidant, anti-tumor, anti-apoptotic, anti-fibrosis, immune regulation and other effects, and can be used to treat a variety of diseases. Inflammatory bowel disease (IBD) is a nonspecific inflammatory disease of the intestine including Crohn’s disease (CD) and ulcerative colitis (UC). The drug treatment effect is often limited and accompanied by side effects. A large number of basic and clinical studies have shown that curcumin has the effect of treating IBD and also can maintain the remission of IBD. In this review, the research of curcumin on IBD in recent years is summarized in order to provide reference for further research and application of curcumin.

Osteosarcopenia in autoimmune cholestatic liver diseases: Causes, management, and challenges

Primary biliary cholangitis and primary sclerosing cholangitis (PSC) are the most common cholestatic liver diseases (CLD) in adults and are both characterized by an immune pathogenesis. While primary biliary cholangitis is a model autoimmune disease, with over 90% of patients presenting very specific autoantibodies against mitochondrial antigens, PSC is considered an immune mediated disease. Osteoporosis is the most common bone disease in CLD, resulting in frequent fractures and leading to significant morbidity. Further, sarcopenia is emerging as a frequent complication of chronic liver diseases with a significant prognostic impact and severe implications on the quality of life of patients. The mechanisms underlying osteoporosis and sarcopenia in CLD are still largely unknown and the association between these clinical conditions remains to be dissected. Although timely diagnosis, prevention, and management of osteosarcopenia are crucial to limit the consequences, there are no specific guidelines for management of osteoporosis and sarcopenia in patients with CLD. International guidelines recommend screening for bone disease at the time of diagnosis of CLD. However, the optimal monitoring strategies and treatments have not been defined yet and vary among centers. We herein aim to comprehensively outline the pathogenic mechanisms and clinical implications of osteosarcopenia in CLD, and to summarize expert recommendations for appropriate diagnostic and therapeutic approaches.

Cerebral Venous Sinus Thrombosis is a Reversible Complication of Ulcerative Colitis

Patients with inflammatory bowel disease (IBD) are at higher risk of venous thrombosis than the general population, with thromboembolism being a recognized extraintestinal manifestation. Although thrombotic events typically present as deep vein thrombosis and pulmonary embolism, other presentations are possible. Cerebral venous sinus thrombosis (CVST) is a relatively rare example associated with high morbidity and a mortality rate of 50% when misdiagnosed or the diagnosis is delayed. Despite this, CVST is a reversible complication with favorable outcomes when diagnosed early and treated appropriately. In this report, we present a case of cerebral sinus thrombosis in a 35-year-old female during a relapse of ulcerative colitis. During the relapse of ulcerative colitis, CVST manifested with a seizure, focal neurological deficit, and altered mental status. After blood workup, magnetic resonance imaging (MRI), and venography, the diagnosis of CVST was confirmed. We immediately started the patient on low-molecular-weight heparin, and during a six-month follow-up period, she made a full recovery with recanalization of the thrombosis on imaging. Despite CVST being a fatal complication of IBD, our report and data in the literature indicate that full remission is possible when it is correctly diagnosed and treated.

Immunosuppressive regimens and outcomes of inflammatory bowel disease patients requiring kidney transplantation

Patients with inflammatory bowel disease (IBD) can develop extra-renal complications and as a result, suffer from end stage renal failure requiring kidney transplantation (KT). A brief review of available literature revealed that IBD patients undergoing KT have shorter overall survival rates compared to their controls. Literature reporting steroid regimens and survival outcomes specific to IBD and post kidney transplant are scarce and these studies have small sample sizes thus making it difficult to draw accurate conclusions. Further research is required in the form of a randomized controlled study to clarify the effect and mechanism of steroid immunosuppression on the prognosis of renal transplant recipients and explore new treatment schemes.

Pyoderma gangrenosum with pulmonary involvement: a pulmonary special report and literature review

INTRODUCTION

Pyoderma gangrenosum (PG) is the prototypical neutrophilic dermatosis, commonly associated with inflammatory bowel disease, with pulmonary involvement being the commonest extracutaneous manifestation. PG with tracheobronchial involvement may present as upper airway obstruction and can be life-threatening.

AREAS COVERED

To evaluate the clinical characteristics and predictors of PG with pulmonary involvement, we reported a case of PG with tracheobronchial involvement in China, and performed a literature retrieval on PG with pulmonary involvement. Demographic data, clinical presentations, underlying diseases, radiological and histopathological findings, treatments, and clinical outcomes were collected and subjected to statistical analysis. Forty-seven cases (including ours) were identified. Diseases associated with PG with pulmonary involvement were similar. Clinical presentation of PG with pulmonary involvement was non-specific, with cough and dyspnea being the most common clinical symptoms, and pulmonary infiltrates and cavitation being the most common radiological signs. Further univariate analysis suggested stridor and young age (p < 0.01) may be predictors of tracheobronchial involvement in PG.

EXPERT OPINION

PG with tracheobronchial involvement can be life-threatening, with young age and stridor being possible predictors. Therefore, prompt airway assessment and management are required in younger patients with PG with pulmonary involvement presenting with stridor.

Garcinia mangostana and α-Mangostin Revive Ulcerative Colitis-Modified Hepatic Cytochrome P450 Profiles in Mice

&lt;b&gt;Background and Objective:&lt;/b&gt; Ulcerative colitis (UC) is inflammation of the large intestine with ulceration but can also cause extraintestinal manifestations (EIM) by damaging surrounding organs such as the liver. &lt;i&gt;Garcinia mangostana&lt;/i&gt; (GM) pericarp and α-mangostin (MGS) have been reported to have anti-inflammatory activity. This study evaluated the effects of GM pericarp extract and MGS on the expression of hepatic cytochrome P450 (CYP) enzymes as an EIM of UC. &lt;b&gt;Materials and Methods:&lt;/b&gt; Male ICR mice were orally administered GM pericarp extract (40, 200 and 1000 mg/kg/day), MGS (30 mg/kg/day) or sulfasalazine (SUL) (100 mg/kg/day) daily for 7 days. On days 4-7, UC was induced by dextran sulfate sodium (DSS 40 kDa, 6 g/kg/day). Profiles of CYP mRNA expression were determined by RT/qPCR. Alkoxyresorufin &lt;i&gt;O&lt;/i&gt;-dealkylation (including ethoxy-, methoxy-, pentoxy- and benzyloxy-resorufin), aniline hydroxylation and erythromycin &lt;i&gt;N&lt;/i&gt;-demethylation CYP responsive activities were also examined. &lt;b&gt;Results:&lt;/b&gt; The DSS-induced UC mice showed suppressed expression&lt;i&gt; &lt;/i&gt;of &lt;i&gt;Cyp1a1&lt;/i&gt;, &lt;i&gt;Cyp1a2&lt;/i&gt;, &lt;i&gt;Cyp2b9/10&lt;/i&gt;, &lt;i&gt;Cyp2e1&lt;/i&gt;, &lt;i&gt;Cyp2c29&lt;/i&gt;, &lt;i&gt;Cyp2d9&lt;/i&gt;, &lt;i&gt;Cyp3a11&lt;/i&gt; and &lt;i&gt;Cyp3a13&lt;/i&gt; mRNAs. The GM pericarp extract and MGS restored expression of all investigated CYPs and their responsive enzyme activities in DSS-induced UC mice to levels comparable to the control and parallel to the effects of the anti-inflammatory control SUL. &lt;b&gt;Conclusion:&lt;/b&gt; The GM is a promising therapy to restore UC-modified hepatic CYP profiles.

Temporal Relationship of Extraintestinal Manifestations in Inflammatory Bowel Disease

OBJECTIVES

Thus far, few attempted to characterize the temporal onset of extraintestinal manifestations (EIM) in inflammatory bowel diseases (IBD). We sought to determine the time of onset of these findings in a patient cohort with IBD.

METHODS

We reviewed the electronic health records of 508 IBD patients (303 CD, 205 UC) and summarized general patient characteristics and the temporal relationship and order of presentation of extraintestinal manifestations.

RESULTS

CD patients were younger at diagnosis. CD patients with ileocolonic involvement (L3) were younger, and UC patients with pancolitis (E3) were slightly younger at diagnosis. A total of 127 out of 303 (41.91%) CD and 81 out of 205 (39.51%) UC patients had EIMs (p = 0.5898). Some patients presented with EIMs before the diagnosis of IBD (9.45% of Crohn's disease and 17.28% of ulcerative colitis patients with EIMs, respectively). Of these, seven cases (four in CD and three in UC) were visible by inspection of the patients (either dermatologic or ocular findings). The diagnosis of IBD and extraintestinal symptoms often occurred within a year (22.83% of CD and 16.04% of UC patients). Typically, the diagnosis of the first extraintestinal symptoms happened after the onset of bowel disease (+4.3 (±6.3) years, range: 10 years before to 30 years after in Crohn's disease and +3.8 (±10) years, range: 24 years before to 30 years after) in ulcerative colitis. UC patients with pancolitis (E3) usually had EIMs earlier in the disease course and displayed EIMs more frequently before IBD diagnosis. Furthermore, patients with pancolitis developed EIMs more frequently than other sub-groups.

CONCLUSION

Extraintestinal manifestations in inflammatory bowel diseases can present at any time, relative to the bowel symptoms. In cases, the presence of a characteristic EIM might be a harbinger of the development of IBD.

A review of ophthalmic manifestations of inflammatory bowel disease and associated treatments

PURPOSE OF REVIEW

To review the ocular manifestations of inflammatory bowel disease (IBD) and the treatments for each of these, including novel therapies and their effects on uveitis. With the advent of newer treatments for ulcerative colitis and Crohn's disease, it is important to investigate whether these therapies have beneficial effects for extraintestinal manifestations (EIM) of IBD, in particular, ocular manifestations.

RECENT FINDINGS

The newer treatments for IBD, including biologics, such as golimumab (Simponi), certolizumab (Cimzia), vedolizumab (Entyvio), and interleukin (IL) receptor inhibitors, such as ustekinimab (Stelara), could potentially have treatment benefits for patients with uveitis and IBD.

SUMMARY

Ocular manifestations of IBD are important to detect early and treat appropriately. With novel treatments for IBD, it is important to further study whether these therapies have benefits for ocular manifestations of IBD, such as uveitis. Future clinical trials need to be conducted to investigate this.

Association Between Ischemic Optic Neuropathy and Inflammatory Bowel Disease: A Population-Based Cohort Study in Taiwan

Background: Ischemic optic neuropathy (ION) is a possible extraintestinal manifestation (EIM) of inflammatory bowel disease (IBD). We investigate the relation between IBD and ION and possible risk factors associated with their incidence.

Methods: Medical records were extracted from the National Health Insurance Research Database (NHIRD) from January 1, 2000, to December 31, 2013. The main outcome was ION development. Univariate and multivariate Cox regression analyses were performed.

Results: We enrolled 22,540 individuals (4,508 with IBD, 18,032 without). The cumulative risk of developing ION was significantly greater for patients with IBD vs. patients without (Kaplan–Meier survival curve, p = 0.009; log-rank test). Seven (5%) and five (0.03%) patients developed ION in the IBD and control groups, respectively. Patients with IBD were significantly more likely to develop ION than those without IBD [adjusted hazard ratio (HR) = 4.135; 95% confidence interval: 1.312–11.246, p = 0.01]. Possible risk factors of ION development were age 30–39 years, diabetes mellitus (DM), hypertension, ischemic heart disease (IHD), atherosclerosis, and higher Charlson comorbidity index revised (CCI_R) value.

Conclusion: Patients with IBD are at increased risk of subsequent ION development. Moreover, for patients with comorbidities, the risk of ION development is significantly higher in those with IBD than in those without.

Pancreatic Associated Manifestations in Pediatric Inflammatory Bowel Diseases

Inflammatory bowel diseases (IBDs) are chronic relapsing inflammatory conditions of the gastrointestinal tract, encompassing Crohn's disease (CD), ulcerative colitis (UC) and inflammatory bowel disease unclassified (IBD-U). They are currently considered as systemic disorders determined by a set of genetic predispositions, individual susceptibility and environmental triggers, potentially able to involve other organs and systems than the gastrointestinal tract. A large number of patients experiences one or more extraintestinal manifestations (EIMs), whose sites affected are mostly represented by the joints, skin, bones, liver, eyes, and pancreas. Pancreatic abnormalities are not uncommon and are often underestimated, encompassing acute and chronic pancreatitis, autoimmune pancreatitis, exocrine pancreatic insufficiency and asymptomatic elevation of pancreatic enzymes. In most cases they are the result of environmental triggers. However, several genetic polymorphisms may play a role as precipitating factors or contributing to a more severe course. The aim of this paper is to provide an updated overview on the available evidence concerning the etiology, pathogenesis and clinical presentation of pancreatic diseases in IBD pediatric patients.

The impact of colectomy on the course of extraintestinal manifestations in Swiss inflammatory bowel disease cohort study patients

Background and Aims

Extraintestinal manifestations are reported to occur in up to 45% of inflammatory bowel disease (IBD) patients during the course of disease. It is unknown whether colectomy reduces the rate of de novo extraintestinal manifestations (EIMs) or impacts on severity of EIMs following a parallel versus independent disease course from underlying IBD.

Methods

Using data from the Swiss Inflammatory Bowel Disease Cohort Study we aimed to analyse the course of EIMs in ulcerative colitis (UC) and Crohn’s disease (CD) patients undergoing colectomy during the cohort’s prospective follow‐up.

Results

One hundred and twenty‐one IBD patients (33 CD, 81 UC and seven unclassified) underwent colectomy during prospective follow‐up in the Swiss Inflammatory Bowel Disease Cohort Study. Within the 114 patients with UC or CD any EIM was reported in 40 (nine CD and 31 UC) patients. Activity of EIMs ceased entirely after colectomy in 21 patients (52.5%). Complete cessation of EIM after colectomy was higher in patients with UC versus CD with 58.1% versus 33.3%. After colectomy, 29 out of the 114 patients (25.4%) experienced any EIM. Two thirds of these (19 patients) represented persisting EIMs, while in one third (10 patients) EIM represented a de‐novo event after colectomy. Overall, 13.5% of IBD patients developed a de‐novo EIM after colectomy.

Conclusions

In IBD patients undergoing colectomy, EIMs present prior to surgery will persist in about half of patients. Complete cessation of EIM after colectomy may be less common in CD than in UC. In patients who never experienced EIMs prior to colectomy de‐novo manifestations thereafter should be expected in up to one in seven patients.

Pathogenesis of the inflammatory bowel disease in context of SARS-COV-2 infection

To date, the latest research results suggest that the novel severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) can enter host cells directly via the gastrointestinal tract by binding to the enterocyte-expressed ACE2 receptor, or indirectly as a result of infection of type II alveolar epithelial cells. At the same time, entry of SARS-CoV-2 through the gastrointestinal tract initiates the activation of innate and adaptive immune responses, the formation of an excessive inflammatory reaction and critical increase in the expression of proinflammatory cytokines, which, subsequently, can presumably increase inflammation and induce intestinal damage in patients suffering from inflammatory bowel disease (IBD). The aims of the present review were to reveal and analyze possible molecular pathways and consequences of the induction of an innate and adaptive immune response during infection with SARS-CoV-2 in patients with IBD. A thorough literature search was carried out by using the keywords: IBD, SARS-CoV-2, COVID-19. Based on the screening, a number of intracellular and extracellular pathways were considered and discussed, which can impact the immune response during SARS-CoV-2 infection in IBD patients. Additionally, the possible consequences of the infection for such patients were estimated. We further hypothesize that any virus, including the new SARS-CoV-2, infecting intestinal tissues and/or entering the host's body through receptors located on intestinal enterocytes may be a trigger for the onset of IBD in individuals with a genetic predisposition and/or the risk of developing IBD associated with other factors.

Leukocytapheresis in patients with inflammatory bowel diseases

Leukocytapheresis, a blood purification therapy, exerts anti-inflammatory effects by removing activated leukocytes from the peripheral blood through extracorporeal circulation. It is a potential option of treatment for patients with inflammatory bowel diseases (IBD), especially those with ulcerative colitis (UC), who do not respond to conventional therapy. Given that it has a favourable safety profile and seems to have steroid sparing effects, its position in the treatment of UC is likely to expand. However, there is inadequate evidence to draw any conclusions about the efficacy of leukocytapheresis in patients with Crohn's disease, and it should only be used in accordance with special arrangements for consent. Considering the current level of knowledge, it is essential to conduct large, well-designed, randomized clinical trials to evaluate the effects of leukocytapheresis in the management of IBD patients.

Extraintestinal manifestations at baseline, and the effect of tofacitinib, in patients with moderate to severe ulcerative colitis

INTRODUCTION

Extraintestinal manifestations (EIMs) in patients with ulcerative colitis (UC) are common. Tofacitinib is an oral, small molecule Janus kinase inhibitor for the treatment of UC. We evaluated the efficacy of tofacitinib in patients with EIMs, and the impact of tofacitinib on EIMs in patients with UC in the OCTAVE clinical program.

METHODS

Data from two 8-week induction studies (OCTAVE Induction 1 and 2) and a 52-week maintenance study (OCTAVE Sustain) were analyzed. The effect of tofacitinib on efficacy outcomes stratified by EIM status, proportion of predefined prior and active EIMs at baseline, and change from baseline in EIMs were determined at the end of the treatment period (weeks 8 or 52), or at early termination.

RESULTS

At baseline of OCTAVE Induction 1 and 2, and OCTAVE Sustain, 27.0% and 9.0% of patients had a history of EIMs (prior or active), respectively. Patients treated with tofacitinib 10 mg twice daily (BID) achieved remission and had endoscopic improvement in all studies, irrespective of any history of EIMs. A greater proportion of patients had active peripheral arthritis at baseline of OCTAVE Induction 1 and 2 versus OCTAVE Sustain. In OCTAVE Induction 1 and 2, similar proportions of tofacitinib and placebo-treated patients with active peripheral arthritis experienced either no change (81.3% and 85.7%, respectively) or an improvement (15.6% and 14.3%, respectively). By week 52 of OCTAVE Sustain, improvements in active peripheral arthritis were only observed in tofacitinib-treated patients (16.7% and 33.3% with tofacitinib 5 and 10 mg BID, respectively).

CONCLUSION

Any history of EIMs did not influence the efficacy of tofacitinib 10 mg BID for induction or maintenance of UC. The most common active EIM was peripheral arthritis, for which many patients in OCTAVE Induction 1 and 2, and OCTAVE Sustain, reported improvement or no change from baseline with tofacitinib treatment.Clinicaltrials.gov:NCT01465763; NCT01458951; NCT01458574.

The Temporal Relationships and Associations between Cutaneous Manifestations and Inflammatory Bowel Disease: A Nationwide Population-Based Cohort Study

The temporal relationships between inflammatory bowel disease (IBD)-associated cutaneous manifestations and IBD remain uncertain, with existing evidence mostly from separate cross-sectional studies. We sought to determine the risks of IBD-related dermatologic diseases before and after the diagnosis of IBD. We identified 2847 cases of IBD and 14,235 matched controls from the Taiwan National Health Insurance Research Database between 2003 and 2014. The risks of cutaneous manifestations before and after the diagnosis of IBD were estimated with multivariable-adjusted analyses. At diagnosis, IBD was associated with atopic dermatitis (odds ratio (OR) = 1.61; 95% confidence interval (CI), 1.14-2.28), erythema nodosum (OR = 7.44; 95%CI, 3.75-14.77), aphthous stomatitis (OR = 2.01; 95%CI, 1.72-2.35), polyarteritis nodosa (OR = 5.67; 95%CI, 2.69-11.98), rosacea (OR = 1.67, 95%CI = 1.19-2.35), and cutaneous T cell lymphoma (OR = 21.27; 95%CI, 2.37-191.00). IBD was associated with the subsequent development of pyoderma gangrenosum (hazard ratio (HR) = 17.79; 95%CI, 6.35-49.86), erythema nodosum (HR = 6.54; 95%CI, 2.83-15.13), polyarteritis nodosa (HR = 2.69; 95%CI, 1.05-6.90), hidradenitis suppurativa (HR = 2.48; 95%CI, 1.03-5.97), psoriasis (HR = 2.19; 95%CI, 1.27-3.79), rosacea (HR = 1.92; 95%CI, 1.39-2.65), and aphthous stomatitis (HR = 1.45; 95%CI, 1.22-1.72). This study clarified the associations and temporal relationships between cutaneous manifestations and IBD, highlighting the need for interdisciplinary care in the patient with specific dermatologic diseases presenting with abdominal symptoms, or the IBD patients with cutaneous lesions.

Quality of life in inflammatory bowel diseases: it is not all about the bowel

BACKGROUND/AIMS

The inflammatory bowel diseases (IBD), ulcerative colitis (UC), and Crohn's disease (CD) are chronic diseases mostly affecting young patients. As they are diseases accompanying patients for their entire life, and the quality of life (QUOL) interacts with disease activity, improving QUOL should be one of the main goals of therapy. This study aims to identify factors contributing to good or impaired QUOL.

METHODS

Questionnaires addressing health-related QUOL and other psychological and social features were positioned on our institutions' webpage and on the webpage of the largest self-help group for IBD in Germany. Patients were subdivided according to their QUOL score with a cutoff of <60. We used the Short Inflammatory Bowel Disease Questionnaire, the Assessment of the Demand for Additional Psychological Treatment, and the Fear of Progression Questionnaire Short Form.

RESULTS

High numbers of patients in both subgroups showed an impaired QUOL (87.34% in UC, 91.08% in CD). Active extraintestinal manifestations, smoking, high fear of progression and high demand for psychotherapy were associated with reduced QUOL. In addition, polypharmacological interventions did not result in a good QUOL, but ostomies are linked to improved QUOL especially in CD patients.

CONCLUSIONS

Scores used in clinical day-to-day-practice mainly focusing on somatic factors do not sufficiently address important aspects concerning QUOL. Most importantly, extraintestinal manifestations show a hitherto underestimated impact on QUOL.

Metabolic Profiling by UPLC-Orbitrap-MS/MS of Liver from C57BL/6 Mice with DSS-Induced Inflammatory Bowel Disease

Liver disorder often occurs in patients with inflammatory bowel disease (IBD); however, the changes in IBD-induced liver disorder at the intrinsic molecular level (chiefly metabolites) and therapeutic targets are still poorly characterized. First, a refined and translationally relevant model of DSS chronic colitis in C57BL/6 mice was established, and cecropin A and antibiotics were used as interventions. We found that the levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6 in the liver tissues of mice were highly increased in the context of DSS treatment but were lowered by cecropin A and antibiotics. Subsequently, an untargeted metabolomics analysis was performed by UPLC–Orbitrap–MS/MS to reveal the metabolic profile and attempt to find the potential therapeutic targets of the liver disorders that occur in IBD. Notably, 133 metabolites were identified by an integrated database. Metabolism network and pathway analyses demonstrated that the metabolic disturbance of the liver in IBD mice was mainly enriched in bile acid metabolism, arachidonic acid metabolism, amino acid metabolism, and steroid hormone biosynthesis, while those disturbances were regulated or reversed through cecropin A and antibiotic treatment. Furthermore, the top 20 metabolites, such as glutathione, maltose, arachidonic acid, and thiamine, were screened as biomarkers via one-way analysis of variance (one-way ANOVA, p < 0.05) coupled with variable importance for project values (VIP >1) of orthogonal partial least-squares discriminant analysis (OPLS-DA), which could be upregulated or downregulated with the cecropin A and antibiotics treatment. Spearman correlation analysis showed that the majority of the biomarkers have a significant correlation with cytokines (TNF-α, IL-1β, IL-6, and IL-10), indicating that those biomarkers may act as potential targets to interact directly or indirectly with cecropin A and antibiotics to affect liver inflammation. Collectively, our results extend the understanding of the molecular alteration of liver disorders occurring in IBD and offer an opportunity for discovering potential therapeutic targets in the IBD process.

Acute pancreatitis as an initial presentation of Crohn's disease: A case report

Acute pancreatitis (AP) is not commonly known to be an extra-intestinal manifestations of Crohn's disease (CD). Several cases have been reported discussing the relation of AP with CD. However, no specific etiological factors for pancreatitis were found, which appears to support the possibility of a relationship between AP and CD. We report a 30-year-old male present with generalized abdominal pain associated with watery diarrhea. Diagnosis of AP was made. A CT abdomen showed pancreatic inflammation with a terminal ileum thickening. Colonoscopy with multiple biopsy was done for the patient, which confirmed the diagnosis of CD. The patient started on adalimumab for 6 months, showed good response, and became symptomatically free. No recurrent attacks after 2 years of follow-up. The association between AP and CD is not yet clear. Therefore, patients presenting with idiopathic pancreatitis should be investigated to rule out the coexistence of IBD for better outcome.