Change in the diagnosis of inflammatory bowel disease: a hospital-based cohort study from Korea

Diagnosis change in pediatric inflammatory bowel disease

OBJECTIVES

This study aims to characterize pediatric inflammatory bowel disease (IBD) patients who change diagnosis and describe the characteristics of that change.

METHODS

A retrospective study was conducted on pediatric IBD patients from the ImproveCareNow (ICN) multicenter international cohort from 2007 to January 2019. Primary outcome was change in diagnosis after the first four visits. Other variables included demographics, diagnostics, disease characteristics, and timing.

RESULTS

6.1% of 18,055 patients aged 1-20 years changed diagnosis. Median time between the baseline visit and first diagnosis change was 0.9 years. Change in diagnosis occurred in 257/12,178 (2.1%) patients with Crohn's disease (CD), 347/4758 (7.3%) patients with ulcerative colitis (UC), and 495/1119 (44.2%) patients with IBD-Unclassified (IBD-U). In multivariable analysis, initial diagnosis of IBD-U and longer follow-up times were associated with greater odds of a diagnosis change.

CONCLUSION

IBD-U initial diagnosis and longer follow-up were associated with increased diagnosis change risk. The most common change was reclassification to CD. Disease activity, moderate malnutrition, and presence of EIMs were not associated with change in diagnosis.

PD-1-positive cells contribute to the diagnosis of inflammatory bowel disease and can aid in predicting response to vedolizumab

Differentiating inflammatory bowel disease (IBD) from other inflammatory diseases is often challenging. Programmed cell death protein-1 (PD-1) is expressed in T cells and is an indicator of their exhaustion. The role of PD-1 expression in diagnosing IBD and predicting the response of biologic agents remains inconclusive. In this study, endoscopic biopsy samples of 19 patients diagnosed with IBD, intestinal tuberculosis, and intestinal Behcet's disease were analyzed using multiplexed immunohistochemistry. Additionally, a separate "vedolizumab (VDZ) cohort" established in ulcerative colitis patients who underwent endoscopic biopsy before VDZ administration was analyzed to predict response to VDZ. In the immunohistochemistry analysis, the cell density of T cell subsets, including PD-1 + cells, was investigated and compared between IBD and other inflammatory diseases (OID). Cell densities of PD-1 + cells (p = 0.028), PD-1 + helper T cells (p = 0.008), and PD-1 + regulatory T cells (p = 0.024) were higher in IBD compared with OID. In the VDZ cohort, patients with a 14-week steroid-free clinical response had higher levels of PD-1 + cells (p = 0.026), PD-1 + helper T cells (p = 0.026), and PD-1 + regulatory T cells (p = 0.041) than the no response group. PD-1 + immune cells may contribute to the diagnosis of IBD and could be used to predict response to VDZ in ulcerative colitis patients.

IBD barriers across the continents - East Asia

Inflammatory bowel diseases (IBDs) are chronic illnesses with significant morbidities and impact on patients' quality of life. There has been a rapid increase in the incidence of IBD in East Asia in recent decades. However, there is a huge unmet need in the diagnosis and management of IBD in this region. With the increasing awareness of IBD in East Asia and a persistently high rate of tuberculosis in this region, this poses a significant challenge in the diagnosis and management of IBD. In this review, we will explore the barriers to the diagnosis and management of IBD in the East Asia, hoping to provide an insight on how to improve the healthcare system in the management of this complex disease.

Thirty-year Trend in Inflammatory Bowel Disease on Jeju Island, South Korea

Background/Aims

Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is increasing in South Korea. On the other hand, there are no reports of the incidence and prevalence of IBD specific to Jeju Island, prompting the necessity of this study.

Methods

In this retrospective design, the medical records of 453 patients diagnosed with IBD at Jeju National University Hospital from January 1990 to December 2019 were analyzed.

Results

Of the 453 IBD subjects (165 CD, 288 UC) included, the UC: CD ratio was 1.75:1. The incidence of IBD increased continuously from 0.19/105 in 1990 to 6.39/105 in 2017 and after that decreased to 4.92/105 in 2019. The male:female ratio was 2.24:1 for CD and 1.29:1 for UC. In the CD subjects, the disease activity included remission (33.3%), mild (25.5%), moderate (30.9%), and severe (6.1%). In UC subjects, the disease activity included remission (24.0%), mild (35.4%), moderate (28.8%), and severe (6.2%). According to the Montreal classification, the cases were as follows: CD: terminal ileum (22.4%), colon (9.7%), ileocolon (66.1%), and upper gastrointestinal involvement (27.3%), and perianal fistula/abscess was present in 43.6% of subjects before or at diagnosis: UC: proctitis (43.4%), left-sided colitis (29.1%), and pancolitis (23.3%) at diagnosis.

Conclusions

The incidence of IBD on Jeju Island has increased steadily for approximately 30 years but has exhibited a decline since 2017. Therefore, the incidence of IBD in Jeju is believed to have plateaued. Further study will be needed for clarification.

A Case Report and Literature Review of Rectosigmoid Crohn's Disease: A Diagnostic Pitfall Ultimately Leading to Spontaneous Colonic Perforation

Inflammatory bowel disease (IBD) is a chronic condition that affects the gastrointestinal tract, with ulcerative colitis (UC) and Crohn's disease (CD) as the two major entities. While these conditions share some similarities in clinical presentation, they have distinct histopathological features. UC is a mucosal disease affecting the left colon and rectum, while CD can affect any part of the gastrointestinal tract and all layers of the bowel wall. Accurate diagnosis of UC and CD is important for effective management and prevention of complications. However, distinguishing between the two conditions based on limited biopsy specimens or atypical clinical presentations can be challenging. We present a case of a patient diagnosed with UC based on a single endoscopic biopsy from the sigmoid colon, who later presented with colonic perforation and was found to have CD on the colectomy specimen. This case emphasizes the importance of clinical guidelines when dealing with any patient of suspected IBD, considering alternative diagnoses in patients with atypical presentations and the need for careful clinical, endoscopic, and histological evaluation to make an accurate diagnosis. Delayed or missed diagnosis of CD can lead to significant morbidity and mortality.

Efficacy of vedolizumab as maintenance therapy in a patient with ulcerative colitis receiving haemodialysis in end-stage kidney failure: A case report

This report describes vedolizumab's clinical efficacy and safety in a patient with severe ulcerative colitis on haemodialysis for an end-stage kidney failure. The patient was a 75-year-old man on long-standing chronic diffusive three times per week haemodialytic treatment due to vascular nephropathy. At the presentation, the patient had severe bloody diarrhoea treated with a steroid cycle with temporary benefits and then developed steroid dependence. Upon remission, the patient started vedolizumab (Entivyo^®) as maintenance therapy. After 6 weeks of induction, patient started the maintenance therapy with an infusion every 8 weeks. After the sixth infusion, the interval was prolonged to 9 weeks because of the good and fast response. Vedolizumab treatment proceeded without adverse events. However, no changes in renal function were noted during the same period, no complications were reported, and the patient regularly continued haemodialysis. At the second induction infusion (week 2) and the second maintenance infusion (week 22), we measured vedolizumab serum level before and after haemodialysis, observing no significant changes. Our case is the first report about using vedolizumab in a patient under haemodialysis, showing that vedolizumab can be safe, well tolerated, and effective in patients undergoing haemodialysis. However, more extensive trials are needed to prove its use in these patients.

Inflammatory bowel disease in Korea: epidemiology and pathophysiology

Inflammatory bowel disease (IBD) refers to a group of disorders, including Crohn's disease and ulcerative colitis, that exhibit similar but distinct manifestations. These diseases are characterized by refractory and chronic inflammation of the bowel. IBD is usually accompanied by severe symptoms. When a patient presents with suspected IBD, physicians encounter various challenges in terms of diagnosis and treatment. In addition, given such characteristics, the associated medical expenses gradually increase. Although IBD was formerly known as a disease of Western countries, the incidence and prevalence are increasing in Korea. Korean investigators have accumulated a great deal of knowledge about the regional characteristics and epidemiology of the disease, especially via well-organized, joint cohort studies. Against this background, this article describes the epidemiology of IBD in Korea compared to that in the West. In addition, an overview of the pathophysiology of the disease is provided, focusing on the latest results.

Systematic evaluation of the diagnostic approach of inflammatory bowel disease guidelines

OBJECTIVE

To collect and evaluate the diagnostic approach of inflammatory bowel disease (IBD) guidelines and provide useful feedback for guideline developers and evidence-based clinical information to help physicians make decisions.

METHODS

Diagnostic guidelines for IBD were retrieved by performing systemic and manual searches. Qualified clinical practice guidelines (CPGs) were included and then evaluated by four well-trained evaluators using the AGREE II instrument. To reduce the bias generated in this process, we used the Measurement Scale of Rate of Agreement (MSRA) tool to interpret the results. Guidelines with good recommendation distributions among the diagnostic field were further reclassified and evaluated.

RESULTS

Fifteen diagnostic CPGs for IBD were identified and evaluated, and 70.3% (11/15) of the CPGs were above the recommended level. We observed heterogeneity among the diagnostic CPGs for IBD and discrepancies among different domains in one specific guideline. Potential improvements were identified in the fields of stakeholder involvement, rigour of development and applicability. By further analysing the heterogeneity of the recommendations and evidence in 5 UC-CPGs, we found the following issues: no discussion of diagnosing severe complications of UC, disputed significance of serologic and genetic diagnoses of UC, insufficient attention towards medical histories/physical examinations/differential diagnoses and discrepancy in classification criteria.

CONCLUSION

The included diagnostic CPGs for IBD were generally of good quality, but heterogeneity was identified. Addressing these issues will provide useful feedback for the guideline updating process, and it will also benefit current clinical practice and eventually patient outcome.

Clinical characteristics and prognosis of patients with ulcerative colitis that shows rectal sparing at initial diagnosis

BACKGROUND

Ulcerative colitis (UC) is characterised by mucosal inflammation from the rectum to its proximal area in a symmetric and continuous fashion. However, although uncommon, we encounter cases of UC with rectal sparing in the initial stage.

AIM

To evaluate the clinical characteristics and clinical course for rectal sparing UC compared with typical UC.

METHODS

We looked at records from 2004 to 2015, and selected patients who were newly diagnosed with UC, and who could be followed up for at least 5 years in our hospital. We then retrospectively analysed the medical records and endoscopic findings of those patients. To compare the clinical course and prognosis, we matched each patient with rectal sparing UC 1:3 with controls by age, sex, and disease extent.

RESULTS

Of 619 UC patients, 24 (3.9%) showed rectal sparing at diagnosis. During the follow-up period (median 8 years), in two (8.3%) of the 24 patients, rectal sparing remained through follow-up inspections; but for the other 22 (91.7%) patients, obvious rectal inflammation was found at follow-up endoscopy. Of the 24 patients, 8 (33.3%) were initially misdiagnosed with infectious colitis. No diagnosis was changed to Crohn’s disease. The uses of corticosteroid or biologic agents, hospitalisation rate, and colectomy rates were not different between the rectal sparing UC group and typical UC group.

CONCLUSION

Some patients with UC can reveal atypical patterns of disease distribution, such as rectal sparing in its initial stage; but despite this, the clinical course and prognosis may not differ from those of typical UC patients.

Current status of inflammatory bowel diseases in Korea

Background: Inflammatory bowel disease (IBD) is a disease of unknown origin that causes chronic inflammation of the intestines and is classified as either ulcerative colitis or Crohn’s disease. The incidence and prevalence of IBD in Korea have been rapidly increasing during the past three decades. This paper describes the current status of IBD in Korea.Current Concepts: Compared with western countries, genotypes and phenotypes of IBD in Korea demonstrate some distinct features, which may have an impact on the diagnosis, treatment, and prognosis of IBD. We continue to experience some difficulties in making early and accurate diagnoses of IBD in Korea due to a low awareness of the disease and the high prevalence of infectious enterocolitis, such as intestinal tuberculosis, which needs to be differentiated from IBD. The treatment of IBD can be influenced by differences in genetic, environmental, and social factors. NUDT15 variants limit the use of thiopurines. Infectious diseases, including tuberculosis, hepatitis B, and cytomegalovirus colitis, are usually more common in Asia than in western countries and can adversely influence the management of IBD. Biologic agents, which have changed the treatment paradigm of IBD, are equally efficacious in Asian patients as in Western patients. However, their use is limited due to a strict Korean government health insurance reimbursement policy. The prognosis of ulcerative colitis in Korea may be better than that in western countries, as indicated by a lower colectomy rate. However, this difference is less distinct in Crohn’s disease.Discussion and Conclusion: IBD in Korea differs from that in western countries in many respects. With rapid increase in the prevalence of IBD in Korea, medical costs for IBD are expected to become a significant financial burden. Koreans need to be prepared for this eventuality.

EpidemIBD: rationale and design of a large-scale epidemiological study of inflammatory bowel disease in Spain

BACKGROUND

Inflammatory bowel disease (IBD) is associated with a considerable burden to the patient and society. However, current data on IBD incidence and burden are limited because of the paucity of nationwide epidemiological studies, heterogeneous designs, and a low number of participating centers and sample size. The EpidemIBD study is a large-scale investigation to provide an accurate assessment of the incidence of IBD in Spain, as well as treatment patterns and outcomes.

METHODS

This multicenter, population-based incidence cohort study included patients aged >18 years with IBD (Crohn's disease, ulcerative colitis, or unclassified IBD) diagnosed during 2017 in 108 hospitals in Spain, covering 50% of the Spanish population. Each participating patient will attend 10 clinic visits during 5 years of follow up. Demographic data, IBD characteristics and family history, complications, treatments, surgeries, and hospital admissions will be recorded.

RESULTS

The EpidemIBD study is the first large-scale nationwide study to investigate the incidence of IBD in Spain. Enrollment is now completed and 3627 patients are currently being followed up.

CONCLUSIONS

The study has been designed to overcome many of the limitations of previous European studies into IBD incidence by prospectively recruiting a large number of patients from all regions of Spain. In addition to epidemiological information about the burden of IBD, the 5-year follow-up period will also provide information on treatment patterns, and the natural history and financial burden of IBD.

Impact of Cumulative Corticosteroid Dosage on Preventable Hospitalization among Taiwanese Patients with Ankylosing Spondylitis and Inflammatory Bowel Disease

Background: Corticosteroids are commonly prescribed for autoimmune conditions, but their impact on preventable hospitalization rates is unclear. This study sought to investigate the effect of corticosteroid use on hospitalization for ambulatory care sensitive conditions among Taiwanese patients with ankylosing spondylitis (AS) or inflammatory bowel disease (IBD). Methods: This was a retrospective cohort study using adults in the Taiwan National Health Insurance Research database receiving a new diagnosis of AS (n = 40,747) or IBD (n = 4290) between January 2002 and June 2013. Our main outcome measure was odds of preventable hospitalization for eight ambulatory care-sensitive conditions defined by the Agency for Healthcare Research and Quality. Results: In the first quarter (three months) following diagnosis, corticosteroid usage was common among patients with AS and IBD (18.5% and 30%, respectively). For every 100 mg increase in corticosteroid dose per quarter, adjusted odds of preventable hospitalization in the following quarter increased by 5.5% for patients with AS (aOR = 1.055, 95% CI 1.037-1.074) and 6.4% for those with IBD (aOR = 1.064, 95% CI 1.046-1.082). Conclusions: Relatively low doses of corticosteroids significantly increase AS and IBD patients' short-term odds of hospitalization for ambulatory care-sensitive conditions. As recommended by current clinical guidelines, physicians should use corticosteroids sparingly in these populations, and prioritize initiation/escalation of disease-modifying anti-rheumatic drugs for long-term management. If corticosteroids cannot be avoided, patients may require monitoring and/or prophylaxis for corticosteroid-associated comorbidities (e.g., diabetes) which can result in preventable hospitalizations.

Illuminating an Invisible Epidemic: A Systemic Review of the Clinical and Economic Benefits of Early Diagnosis and Treatment in Inflammatory Disease and Related Syndromes

Healthcare expenditures in the United States are growing at an alarming level with the Centers for Medicare and Medicaid Services (CMS) projecting that they will reach $5.7 trillion per year by 2026. Inflammatory diseases and related syndromes are growing in prevalence among Western societies. This growing population that affects close to 60 million people in the U.S. places a significant burden on the healthcare system. Characterized by relatively slow development, these diseases and syndromes prove challenging to diagnose, leading to delayed treatment against the backdrop of inevitable disability progression. Patients require healthcare attention but are initially hidden from clinician's view by the seemingly generalized, non-specific symptoms. It is imperative to identify and manage these underlying conditions to slow disease progression and reduce the likelihood that costly comorbidities will develop. Enhanced diagnostic criteria coupled with additional technological innovation to identify inflammatory conditions earlier is necessary and in the best interest of all healthcare stakeholders. The current total cost to the U.S. healthcare system is at least $90B dollars annually. Through unique analysis of financial cost drivers, this review identifies opportunities to improve clinical outcomes and help control these disease-related costs by 20% or more.

Perforated diverticulitis in the setting of ulcerative colitis: An unusual case report

INTRODUCTION

The association of diverticulitis with ulcerative colitis (UC) is rare and not well described. The sequelae of inflammatory bowel disease (IBD) such as perforation and fistula formation can mimic diverticular complications. Therefore, in an IBD patient, it can be difficult to distinguish the etiology of such complications and render definitive care.

PRESENTATION OF CASE

A 43-year-old man with a long history of UC presented with spontaneous sigmoid perforation and subsequent complications of colovesicular and colocutaneous fistulae requiring multiple procedural interventions. Ultimately, the etiology was confirmed as perforated diverticulitis superimposed on severe ulcerative colitis.

DISCUSSION

As perforated diverticulitis superimposed on UC is a rare entity in the current literature and there are many diagnostic difficulties that complicate this scenario. It is important to rule out other entities such as misdiagnosis of IBD or segmental colitis associated with diverticula (SCAD) that may have overlapping features.

CONCLUSION

Although diverticulitis in the setting of UC is an uncommon presentation, it remains important for medical practitioners to consider this scenario when encountering patients who may present in a similar fashion. As such, we put forth a process to aid in a diagnosis and management such that definitive care may not be delayed.

Assessment of factors associated with smoking cessation at diagnosis or during follow-up of Crohn's disease

BACKGROUND AND AIM

Smoking cessation is known to improve the course of Crohn's disease (CD). However, the factors associated with smoking cessation after CD diagnosis have not been well established.

METHODS

Clinical characteristics and change in smoking status were evaluated in 445 current smokers at the time of CD diagnosis. Patients were classified into three subgroups based on their final smoking status and time of smoking cessation: non-quitters, quitters at diagnosis, and quitters during follow-up.

RESULTS

The overall smoking cessation rate was 55.7% (248 of 445 patients). The diagnosis of CD was the main reason for quitting (41.5%, 103 of 248 patients). Smoking cessation at the time of CD diagnosis was associated with intestinal resection within 3 months from CD diagnosis (odds ratio [OR] 2.355, 95% confidence interval [CI] 1.348-4.116, P = 0.003), light smoking (OR 2.041, 95% CI 1.157-3.602, P = 0.014), and initiation of smoking before 18 years of age (OR 0.570, 95% CI 0.327-0.994, P = 0.047). Light smoking (OR 1.762, 95% CI 1.019-3.144, P = 0.043) and initiation of smoking before 18 years (OR 0.588, 95% CI 0.381-0.908, P = 0.017) were also associated with overall smoking cessation.

CONCLUSION

Quitters after CD diagnosis, including quitters at diagnosis and quitters during follow-up, had features distinct from those of non-quitters. Given the motivation at CD diagnosis, a detailed history of smoking habits should be taken and all current smokers should be encouraged to quit smoking at the time of CD diagnosis.

Incidence and Clinical Outcomes of Inflammatory Bowel Disease in South Korea, 2011-2014: A Nationwide Population-Based Study

BACKGROUND

The incidence of inflammatory bowel disease (IBD) is increasing in East Asia; however, population-based data from this region are lacking.

AIM

We conducted a nationwide, population-based study to examine the incidence and disease course of IBD in South Korea.

METHODS

Using the National Health Insurance claims data, we collected data on patients diagnosed with IBD [10,049 with ulcerative colitis (UC) and 5595 with Crohn's disease (CD)] from 2011 to 2014.

RESULTS

During the study period, the average annual incidence of UC was 5.0 per 10⁵, while that of CD was 2.8 per 10⁵. Among patients with UC, the cumulative rates of surgery 1 and 4 years after diagnosis were 1.0 and 2.0%; those among patients with CD were 9.0 and 13.9%, respectively. The 1- and 4-year cumulative rates of moderate- to high-dose corticosteroid use were, respectively, 26.6 and 45.2% among patients with UC, and 29.9 and 50.8% among those with CD. Similarly, the 1- and 4-year cumulative rates of immunomodulator use were 14.1 and 26.4% among patients with UC, and 58.3 and 76.1% among those with CD, respectively. With regard to biologic use, the 1- and 4-year cumulative rates were 3.0 and 9.0% among patients with UC, and 11.1 and 31.7% among those with CD, respectively.

CONCLUSIONS

The recent incidence of IBD in South Korea has been the highest in East Asia. Patients who had been diagnosed recently with IBD showed lower rates of surgery and higher rates of immunomodulator and biologic use compared to those reported ever in South Korea.

Clinical course of ulcerative colitis patients who develop acute pancreatitis

AIM

To investigate the clinical course of ulcerative colitis (UC) patients who develop acute pancreatitis.

METHODS

We analyzed 3307 UC patients from the inflammatory bowel disease registry at Asan Medical Center from June 1989 to May 2015. The clinical course of UC patients who developed acute pancreatitis was compared with that of non-pancreatitis UC patients.

RESULTS

Among 51 patients who developed acute pancreatitis, 13 (0.40%) had autoimmune, 10 (0.30%) had aminosalicylate-induced, and 13 (1.73%) had thiopurine-induced pancreatitis. All 13 patients with autoimmune pancreatitis (AIP) had type 2 AIP. Two (15.4%) patients had pre-existing AIP, and three (23.1%) patients developed AIP and UC simultaneously. Compared to non-pancreatitis patients, AIP patients had UC diagnosed at a significantly younger age (median, 22.9 years vs 36.4 years; P = 0.001). AIP and aminosalicylate-induced pancreatitis patients had more extensive UC compared to non-pancreatitis patients. All patients with pancreatitis recovered uneventfully, and there were no recurrences. Biologics were used more frequently in aminosalicylate- and thiopurine-induced pancreatitis patients compared to non-pancreatitis patients [adjusted OR (95%CI), 5.16 (1.42-18.67) and 6.90 (1.83-25.98), respectively]. Biologic utilization rate was similar among AIP and non-pancreatitis patients [OR (95%CI), 0.84 (0.11-6.66)]. Colectomy rates for autoimmune, aminosalicylate-induced, and thiopurine-induced pancreatitis, and for non-pancreatitis patients were 15.4% (2/13), 20% (2/10), 15.4% (2/13), and 7.3% (239/3256), respectively; the rates were not significantly different after adjusting for baseline disease extent.

CONCLUSION

Pancreatitis patients show a non-significant increase in colectomy, after adjusting for baseline disease extent.

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

BACKGROUND AND AIM

Limited data are available regarding mortality from inflammatory bowel disease in non-Caucasian populations. Herein, we evaluated overall and cause-specific mortality in a hospital-based cohort of Korean inflammatory bowel disease patients.

METHODS

We determined mortality in 2414 Crohn's disease patients and 2798 ulcerative colitis patients diagnosed between 1977 and 2013. Standardized mortality ratios were calculated in several demographic and phenotypic subgroups.

RESULTS

During the mean 9-year follow up, 114 patients died: 35 with Crohn's disease and 79 with ulcerative colitis. The overall standardized mortality ratios were 1.40 (95% confidence interval: 0.97-1.94) in Crohn's disease and 0.73 (0.58-0.91) in ulcerative colitis. In Crohn's disease, female sex, age < 30 years at diagnosis, disease duration > 10 years, ileocolonic disease at diagnosis, perianal fistula, intestinal resection, and ever-use of corticosteroids were associated with higher mortality. In ulcerative colitis, male sex, age ≥ 30 years at diagnosis, disease duration ≤ 5 years, proctitis at diagnosis, and no history of colectomy were associated with lower mortality, while primary sclerosing cholangitis was associated with higher mortality. In both Crohn's disease and ulcerative colitis, high mortality rates due to nonmalignant gastrointestinal causes (standardized mortality ratios: 4.59 and 2.32, respectively) and gastrointestinal malignancies (standardized mortality ratios: 16.59 and 3.45, respectively) were observed. Cardiovascular mortality was lower in ulcerative colitis (standardized mortality ratio: 0.47).

CONCLUSIONS

The overall mortality tended to be higher in Crohn's disease patients than in the general population; it was slightly lower in ulcerative colitis patients than in the general population.

Human alpha defensin 5 is a candidate biomarker to delineate inflammatory bowel disease

Inability to distinguish Crohn's colitis from ulcerative colitis leads to the diagnosis of indeterminate colitis. This greatly effects medical and surgical care of the patient because treatments for the two diseases vary. Approximately 30 percent of inflammatory bowel disease patients cannot be accurately diagnosed, increasing their risk of inappropriate treatment. We sought to determine whether transcriptomic patterns could be used to develop diagnostic biomarker(s) to delineate inflammatory bowel disease more accurately. Four patients groups were assessed via whole-transcriptome microarray, qPCR, Western blot, and immunohistochemistry for differential expression of Human α-Defensin-5. In addition, immunohistochemistry for Paneth cells and Lysozyme, a Paneth cell marker, was also performed. Aberrant expression of Human α-Defensin-5 levels using transcript, Western blot, and immunohistochemistry staining levels was significantly upregulated in Crohn's colitis, p< 0.0001. Among patients with indeterminate colitis, Human α-Defensin-5 is a reliable differentiator with a positive predictive value of 96 percent. We also observed abundant ectopic crypt Paneth cells in all colectomy tissue samples of Crohn's colitis patients. In a retrospective study, we show that Human α-Defensin-5 could be used in indeterminate colitis patients to determine if they have either ulcerative colitis (low levels of Human α-Defensin-5) or Crohn's colitis (high levels of Human α-Defensin-5). Twenty of 67 patients (30 percent) who underwent restorative proctocolectomy for definitive ulcerative colitis were clinically changed to de novo Crohn's disease. These patients were profiled by Human α-Defensin-5 immunohistochemistry. All patients tested strongly positive. In addition, we observed by both hematoxylin and eosin and Lysozyme staining, a large number of ectopic Paneth cells in the colonic crypt of Crohn's colitis patient samples. Our experiments are the first to show that Human α-Defensin-5 is a potential candidate biomarker to molecularly differentiate Crohn's colitis from ulcerative colitis, to our knowledge. These data give us both a potential diagnostic marker in Human α-Defensin-5 and insight to develop future mechanistic studies to better understand crypt biology in Crohn's colitis.

Endoscopic Diagnosis and Differentiation of Inflammatory Bowel Disease

Patients with inflammatory bowel disease have significantly increased in recent decades in Korea. Intestinal tuberculosis (ITB) and intestinal Behcet’s disease (BD), which should be differentiated from Crohn’s disease (CD), are more frequent in Korea than in the West. Thus, the accurate diagnosis of these inflammatory diseases is problematic in Korea and clinicians should fully understand their clinical and endoscopic characteristics. Ulcerative colitis mostly presents with rectal inflammation and continuous lesions, while CD presents with discontinuous inflammatory lesions and frequently involves the ileocecal area. Involvement of fewer than four segments, a patulous ileocecal valve, transverse ulcers, and scars or pseudopolyps are more frequently seen in ITB than in CD. A few ulcers with discrete margins are a typical endoscopic finding of intestinal BD. However, the differential diagnosis is difficult in many clinical situations because typical endoscopic findings are not always observed. Therefore, clinicians should also consider symptoms and laboratory, pathological, and radiological findings, in addition to endoscopic findings.