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Lee YM, Kim ES, Choi S, Jang HJ, Kim YB, Choi SY, Choe BH, Kang B. Fecal Calprotectin at Postinduction Is Capable of Predicting Persistent Remission and Endoscopic Healing after 1 Year of Treatment with Infliximab in Pediatric Patients with Crohn's Disease. Gut Liver 2024; 18:498-508. [PMID: 38013474 PMCID: PMC11096907 DOI: 10.5009/gnl230022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 07/02/2023] [Accepted: 08/25/2023] [Indexed: 11/29/2023] Open
Abstract
Background/Aims : The recent update on Selecting Therapeutic Targets in Inflammatory Bowel Disease initiative has added a decrease in fecal calprotectin (FC) to an acceptable range as an intermediate target for Crohn's disease (CD). We aimed to investigate whether postinduction FC could predict future persistent remission (PR) and endoscopic healing (EH) after 1 year of treatment with infliximab (IFX) in pediatric patients with CD. Methods : This multicenter retrospective observational study included pediatric patients with CD who were followed up for at least 1 year after starting IFX. The association of postinduction FC with PR and EH was investigated. Results : A total of 132 patients were included in this study. PR and EH were observed in 71.2% (94/132) and 73.9% (82/111) of the patients, respectively. In multivariate logistic regression analysis, only the postinduction FC level was associated with PR (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.08 to 0.66; p=0.009). The FC levels at initiation of IFX and postinduction were significantly associated with EH (OR, 0.73; 95% CI, 0.53 to 0.99; p=0.044 and OR, 0.20; 95% CI, 0.06 to 0.49; p=0.002, respectively). According to the receiver operating characteristic curve analysis, the optimal cutoff level for postinduction FC associated with PR was 122 mg/kg, and that associated with EH was 377 mg/kg. Conclusions : Postinduction FC was associated with PR and EH after 1 year of treatment with IFX in pediatric patients with CD. Our findings emphasize the importance of FC as an intermediate target in the treat-to-target era.
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Affiliation(s)
- Yoo Min Lee
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Eun Sil Kim
- Department of Pediatrics, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sujin Choi
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
- Crohn’s and Colitis Association in Daegu-Gyeongbuk (CCAiD), Daegu, Korea
| | - Hyo-Jeong Jang
- Crohn’s and Colitis Association in Daegu-Gyeongbuk (CCAiD), Daegu, Korea
- Department of Pediatrics, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Yu Bin Kim
- Department of Pediatrics, Ajou University Medical Center, Suwon, Korea
| | - So Yoon Choi
- Department of Pediatrics, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
| | - Byung-Ho Choe
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
- Crohn’s and Colitis Association in Daegu-Gyeongbuk (CCAiD), Daegu, Korea
| | - Ben Kang
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
- Crohn’s and Colitis Association in Daegu-Gyeongbuk (CCAiD), Daegu, Korea
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McCurdy JD, Weng R, Parlow S, Dawkins YM, Brar G, Oliveira L, Saloojee N, Murthy S, Kenshil S, Macdonald B, Sabri E, Moloo H, Sy R. Video Capsule Endoscopy can Identify Occult Luminal Crohn's Disease in Patients with Isolated Perianal Fistulas. J Crohns Colitis 2023; 17:1624-1630. [PMID: 37101357 DOI: 10.1093/ecco-jcc/jjad078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Indexed: 04/28/2023]
Abstract
BACKGROUND Accurate tools to distinguish Crohn's disease [CD] from cryptoglandular disease in patients with perianal fistulas without detectable luminal inflammation on ileocolonoscopy and abdominal enterography (isolated perianal fistulas [IPF]) are lacking. We assessed the ability of video capsule endoscopy [VCE] to detect luminal inflammation in patients with IPF. METHODS We studied consecutive adults [>17 years] with IPF who were evaluated by VCE after a negative ileocolonoscopy and abdominal enterography between 2013 and 2022. We defined luminal CD by VCE as diffuse erythema, three or more aphthous ulcers, or a Lewis score greater than 135. We compared rates of intestinal inflammation in this cohort with age- and sex-matched controls without perianal fistulas, who underwent VCE for other indications. We excluded persons with pre-existing inflammatory bowel disease [IBD] and exposure to non-steroidal anti-inflammatory drugs or immunosuppressive treatments. RESULTS A total of 45 patients with IPF underwent VCE without complications. Twelve patients [26%] met our definition of luminal CD. Luminal CD was more common in patients with IPF than in controls [26% vs 3%; p <0.01]. Among patients with IPF, male sex (OR [odds ratio], 9.2; 95% confidence interval [CI] [1.1-79.4]), smoking (OR, 4.5; 95% CI [0.9-21.2]), abscess (OR, 6.3; 95% CI [1.5-26.8]), rectal enhancement on magnetic resonance imaging [MRI] (OR, 9.0; 95% CI [0.8-99.3]), and positive antimicrobial serology (OR, 7.1; 95% CI, [0.7-70.0]) were more common in those with a positive VCE study. CONCLUSIONS VCE detected small intestinal inflammation suggestive of luminal CD in approximately one-quarter of patients with IPF. Larger studies are required to validate these findings.
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Affiliation(s)
- Jeffrey D McCurdy
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Robin Weng
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Simon Parlow
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Yvonne M Dawkins
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Gurmun Brar
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Liliana Oliveira
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Nav Saloojee
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sanjay Murthy
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sana Kenshil
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Blair Macdonald
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Elham Sabri
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Husein Moloo
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Richmond Sy
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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Zhou Z, Ouboter LF, Peeters KCMJ, Hawinkels LJAC, Holman F, Pascutti MF, Barnhoorn MC, van der Meulen-de Jong AE. Crohn's Disease-Associated and Cryptoglandular Fistulas: Differences and Similarities. J Clin Med 2023; 12. [PMID: 36675403 DOI: 10.3390/jcm12020466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/01/2023] [Accepted: 01/04/2023] [Indexed: 01/09/2023] Open
Abstract
Perianal fistulas are defined as pathological connections between the anorectal canal and the perianal skin. Most perianal fistulas are cryptoglandular fistulas, which are thought to originate from infected anal glands. The remainder of the fistulas mainly arises as complications of Crohn's disease (CD), trauma, or as a result of malignancies. Fistulas in CD are considered as a consequence of a chronic and transmural inflammatory process in the distal bowel and can, in some cases, even precede the diagnosis of CD. Although both cryptoglandular and CD-associated fistulas might look similar macroscopically, they differ considerably in their complexity, treatment options, and healing rate. Therefore, it is of crucial importance to differentiate between these two types of fistulas. In this review, the differences between CD-associated and cryptoglandular perianal fistulas in epidemiology, pathogenesis, and clinical management are discussed. Finally, a flow chart is provided for physicians to guide them when dealing with patients displaying their first episode of perianal fistulas.
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Chin Koon Siw K, Engel J, Visva S, Mallick R, Hart A, de Buck van Overstraeten A, McCurdy JD. Strategies to Distinguish Perianal Fistulas Related to Crohn's Disease From Cryptoglandular Disease: Systematic Review With Meta-Analysis. Inflamm Bowel Dis 2022; 28:1363-1374. [PMID: 34792583 DOI: 10.1093/ibd/izab286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Management of perianal fistulas differs based on fistula type. We aimed to assess the ability of diagnostic strategies to differentiate between Crohn's disease (CD) and cryptoglandular disease (CGD) in patients with perianal fistulas. METHODS We performed a diagnostic accuracy systematic review and meta-analysis. A systematic search of electronic databases was performed from inception through February 2021 for studies assessing a diagnostic test's ability to distinguish fistula types. We calculated weighted summary estimates with 95% confidence intervals for sensitivity and specificity by bivariate analysis, using fixed effects models when data were available from 2 or more studies. The Quality Assessment of Diagnostic Accuracy Studies tool was used to assess study quality. RESULTS Twenty-one studies were identified and included clinical symptoms (2 studies; n=154), magnetic resonance imaging (MRI) characteristics (3 studies; n=296), ultrasound characteristics (7 studies; n=1003), video capsule endoscopy (2 studies; n=44), fecal calprotectin (1 study; n=56), and various biomarkers (8 studies; n=440). MRI and ultrasound characteristics had the most robust data. Rectal inflammation, multiple-branched fistula tracts, and abscesses on pelvic MRI and the Crohn's ultrasound fistula sign, fistula debris, and bifurcated fistulas on pelvic ultrasonography had high specificity (range, 80%-95% vs 89%-96%) but poor sensitivity (range, 17%-37% vs 31%-63%), respectively. Fourteen of 21 studies had risk of bias on at least 1 of the Quality Assessment of Diagnostic Accuracy Studies domains. CONCLUSIONS Limited high-quality evidence suggest that imaging characteristics may help discriminate CD from CGD in patients with perianal fistulas. Larger, prospective studies are needed to confirm these findings and to evaluate if combining multiple diagnostic tests can improve diagnostic sensitivity.
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Affiliation(s)
- Kevin Chin Koon Siw
- Division of Gastroenterology and Hepatology, University of Ottawa, Ottawa, ON, Canada
| | - Jake Engel
- Faculty of Medicine, University of Ottawa, ON, Canada
| | | | | | - Ailsa Hart
- Division of Gastroenterology, St Mark's Hospital, London, United Kingdomand the
| | | | - Jeffrey D McCurdy
- Division of Gastroenterology and Hepatology, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
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5
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Lansdorp CA, Buskens CJ, Gecse KB, Löwenberg M, Stoker J, Bemelman WA, D'Haens GRAM, van Hulst RA. Hyperbaric oxygen therapy for the treatment of perianal fistulas in 20 patients with Crohn's disease: Results of the HOT-TOPIC trial after 1-year follow-up. United European Gastroenterol J 2022; 10:160-168. [PMID: 35146959 PMCID: PMC8911540 DOI: 10.1002/ueg2.12189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/01/2021] [Indexed: 12/18/2022] Open
Abstract
Background Previously published short‐term results (week 16) of this trial showed a significant improvement in clinical, radiologic and biochemical outcomes in Crohn's disease patients with therapy‐refractory perianal fistulas after treatment with hyperbaric oxygen therapy. Objective To assess the long‐term (week 60) efficacy, safety and feasibility of hyperbaric oxygen therapy in perianal fistula in Crohn's disease. Methods Crohn's disease patients with high perianal fistula(s) failing conventional treatment >6 months were included. Exclusion criteria were presence of a stoma, rectovaginal fistula(s) and recent changes in treatment regimens. Patients received 40 hyperbaric oxygen sessions and outcomes were assessed at week 16 and week 60. Results Twenty patients were included (median age 34 years). At week 16, median scores of the perianal disease activity index and modified Van Assche index (co‐primary outcomes) decreased from 7.5 (95% CI 6–9) to 4 (95% CI 3–6, p < 0.001) and 9.2 (95% CI 7.3–11.2) to 7.3 (95% CI 6.9–9.7, p = 0.004), respectively. At week 60, the respective scores remained significantly lower than baseline: 4 (95% CI 3–7, p < 0.001) and 7.7 (95% CI 5.2–10.2, p = 0.003). Perianal disease activity index score of 4 or less (representing inactive perianal disease) was observed in 13 patients at week 16 and 12 patients at week 60. Using fistula drainage assessment, 12 and 13 patients showed a clinical response at week 16 and 60, respectively, and clinical remission was achieved in four patients for both time points. At week 16, a statistically significant biochemical improvement (C‐reactive protein and faecal calprotectin levels) was found, but this effect was no longer significant at week 60. Conclusions The clinical and radiologic improvement of perianal fistula in Crohn's disease, that was found at week 16 after treatment with hyperbaric oxygen therapy, is maintained at 1‐year follow‐up.
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Affiliation(s)
- Corine A Lansdorp
- Department of Anaesthesiology/Hyperbaric Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Christianne J Buskens
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Krisztina B Gecse
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Mark Löwenberg
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Geert R A M D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Rob A van Hulst
- Department of Anaesthesiology/Hyperbaric Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
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D'Amico F, Rubin DT, Kotze PG, Magro F, Siegmund B, Kobayashi T, Olivera PA, Bossuyt P, Pouillon L, Louis E, Domènech E, Ghosh S, Danese S, Peyrin‐Biroulet L. International consensus on methodological issues in standardization of fecal calprotectin measurement in inflammatory bowel diseases. United European Gastroenterol J 2021; 9:451-460. [PMID: 33961734 PMCID: PMC8259254 DOI: 10.1002/ueg2.12069] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/26/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Fecal calprotectin (FC) is a non-invasive marker of gut inflammation which is frequently used to guide therapeutic decisions in patients with inflammatory bowel diseases (IBD). Each step of FC measurement can influence the results, leading to misinterpretations and potentially impacting the management of IBD patients. To date, there is high heterogeneity between FC measurements and no current method is universally accepted as a standard. AIMS Our aim was to provide clear position statementsabout the pre-analytical and the analytical phases of FC measurement to homogenize FC levels and to minimize variability and risk of misinterpretation through aninternational consensus. MATERIALS & METHODS Fourteen physicians with expertise in the field of IBD and FC from 11 countries attended a virtual international consensus meeting on July 17th, 2020. A systematic literature was conducted and the literature evidence was shared and discussedamong the participants. Statements were formulated, discussed, and voted. Statements were considered approved if all participants agreed. RESULTS Nine statements were formulated and approved. Based on the available evidence, quantitative tests should be preferred for measuring FC. Furthermore, FC measurement, if possible, should always be performed with the same method and factors influencing FC levels should be taken into account when interpreting the results. DISCUSSION FC has an increasingly important role in the management of patients with IBD. However, large multicenter studies should be conducted to define the reproducibility and to confirm the diagnostic accuracy of the available FC tests. CONCLUSION FC concentrations guide clinicians' treatment decisions. Our statements have a relevant impact in daily practice and could be applied in clinical trials to standardize FC measurement.
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Affiliation(s)
- Ferdinando D'Amico
- Department of Biomedical SciencesHumanitas UniversityMilanItaly
- Department of Gastroenterology and Inserm U1256Nutrition – Genetics and Exposure to Environmental RisksUniversity Hospital of NancyUniversity of LorraineVandoeuvre‐lès‐NancyFrance
| | - David T. Rubin
- Section of Gastroenterology, Hepatology and NutritionUniversity of Chicago Department of MedicineChicagoIllinoisUSA
| | | | - Fernando Magro
- Department of GastroenterologyCentro Hospitalar São JoãoPortoPortugal
| | - Britta Siegmund
- Medizinische Klinik m. S. Gastroenterologie, Infektiologie und RheumatologieCharité ‐ Universitätsmedizin BerlinCorporate Member of Freie Universität BerlinHumboldt‐Universität zu Berlinand Berlin Institute of HealthBerlinGermany
| | - Taku Kobayashi
- Center for Advanced IBD Research and TreatmentKitasato University Kitasato Institute HospitalTokyoJapan
| | - Pablo A. Olivera
- Gastroenterology SectionDepartment of Internal MedicineCentro de Educación Médica e Investigaciones Clínicas (CEMIC)Buenos AiresArgentina
| | - Peter Bossuyt
- Imelda GI Clinical Research CenterImelda General HospitalBonheidenBelgium
| | - Lieven Pouillon
- Imelda GI Clinical Research CenterImelda General HospitalBonheidenBelgium
| | - Edouard Louis
- Department of GastroenterologyCHU Liège University HospitalLiègeBelgium
| | - Eugeni Domènech
- Gastroenterology DepartmentHospital Universitari Germans Trias i PujolBadalonaCataloniaSpain
- Departament de MedicinaUniversitat Autònoma de BarcelonaBarcelonaSpain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)MadridSpain
| | - Subrata Ghosh
- NIHR Biomedical Research CentreUniversity of Birmingham and University Hospitals NHS Foundation TrustBirminghamUK
| | - Silvio Danese
- Department of Biomedical SciencesHumanitas UniversityMilanItaly
- IBD CenterHumanitas Research HospitalIRCCSMilanItaly
| | - Laurent Peyrin‐Biroulet
- Department of Gastroenterology and Inserm U1256Nutrition – Genetics and Exposure to Environmental RisksUniversity Hospital of NancyUniversity of LorraineVandoeuvre‐lès‐NancyFrance
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Yzet C, Sabbagh C, Loreau J, Turpin J, Brazier F, Dupas JL, Nguyen-Khac É, Fumery M. Inflammatory bowel disease symptoms at the time of anal fistula lead to the diagnosis of Crohn's disease. Clin Res Hepatol Gastroenterol 2020; 44:968-972. [PMID: 32336615 DOI: 10.1016/j.clinre.2020.03.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Most anal fistulas are crypto-glandular. Nevertheless, anal fistulas can reveal Crohn's disease (CD). The aim of our study was to evaluate the risk of developing CD in patients undergoing surgery for anal fistula. PATIENTS AND METHODS All patients undergoing surgery for anal fistula in our center between January 1, 2008 and January 31, 2017 were identified through a prospective administrative database. Demographic, clinical, and laboratory data were retrospectively collected. RESULTS Ninety-three patients underwent anal exploration under general anesthesia. The median age at diagnosis of fistula was 43 years (IQR, 34-56) and 27% (n=29) were women. Twenty-seven percent (n=16) had had at least one previous fistula episode. After a median follow-up of 16.8 months (IQR, 7.2-42.0), seven (7.4%) patients were diagnosed with CD. The median time between the diagnosis of fistula and that of CD was 7.6 months (IQR, 2.7, 26.1). Chronic diarrhea (P=0.0003), weight loss (P=0.001), and chronic abdominal pain (P=0.002) were associated with the diagnosis of CD. Characteristics of the fistulas (number, simple/complex, abscess), smoking, extra-digestive manifestations of CD, or a family history of IBD were not associated with the diagnosis of CD. CONCLUSION A medical history of anal fistula surgery resulted in the diagnosis of CD in 7% of cases. Weight loss and the presence of digestive symptoms were associated with the diagnosis of CD. These elements could be used to select patients requiring endoscopic exploration after anal fistula.
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Affiliation(s)
- Clara Yzet
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France.
| | - Charles Sabbagh
- Department of Digestive Surgery, Amiens University Hospital, Picardie University, Amiens, France
| | - Julien Loreau
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France
| | - Justine Turpin
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France
| | - Franck Brazier
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France
| | - Jean-Louis Dupas
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France
| | - Éric Nguyen-Khac
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France
| | - Mathurin Fumery
- Department of Gastroenterology, Amiens University Hospital, Picardie University, Amiens, France
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McCurdy JD, Parlow S, Dawkins Y, Samji K, Rhee GG, Oliveira L, Macdonald B, Sabri E, Murthy S. Tumor Necrosis Factor Inhibitors May Have Limited Efficacy for Complex Perianal Fistulas Without Luminal Crohn's Disease. Dig Dis Sci 2020; 65:1784-1789. [PMID: 31642006 DOI: 10.1007/s10620-019-05905-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/12/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND Complex perianal fistulas occurring in the absence of luminal inflammation (isolated perianal disease, IPD) may represent a specific phenotype of Crohn's disease (CD). AIM We assessed the effectiveness of tumor necrosis factor (TNF)-antagonists in patients with IPD compared to those with perianal CD (PCD) with luminal inflammation. METHODS Patients were identified through our institutional radiology database and were classified as PCD or IPD based on the presence or absence of luminal inflammation by ileocolonoscopy and abdominal enterography. Consecutive adults (> 17 years) with recurrent IPD who were treated with TNF antagonists were matched by age and gender to patients with complex PCD (1:2 ratio). Fistula remission was defined as an absence of fistula drainage. Surgery-free survival was assessed by Cox proportional hazard models. RESULTS Twenty-two patients with IPD treated with a TNF antagonist were compared with 44 matched patients with PCD. A similar proportion of patients with IPD and PCD were treated with concomitant immunomodulators (55% vs. 66%) and underwent examinations under anesthesia prior to therapy (36% vs. 46%). Fistula remission at 3, 6, and 12 months was lower for the IPD cohort: 9.5% versus 34%; 19% versus 39%; and 19% versus 43%. Surgical intervention after initiating anti-TNF therapy was more common for patients with IPD (HR 3.99: 95% CI, 1.62-9.83; p = 0.0026). CONCLUSIONS Fewer patients with IPD achieved fistula remission, and more required surgical intervention after anti-TNF therapy, suggesting that TNF antagonists may not be as effective in these patients.
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Affiliation(s)
- Jeffrey D McCurdy
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, 737 Parkdale Ave, Suite 468, Ottawa, ON, K1Y 1J8, Canada. .,The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada.
| | - Simon Parlow
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, 737 Parkdale Ave, Suite 468, Ottawa, ON, K1Y 1J8, Canada
| | - Yvonne Dawkins
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, 737 Parkdale Ave, Suite 468, Ottawa, ON, K1Y 1J8, Canada
| | - K Samji
- Department of Medical Imaging, The Ottawa Hospital, Ottawa, ON, Canada
| | - Glara Gaeun Rhee
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, 737 Parkdale Ave, Suite 468, Ottawa, ON, K1Y 1J8, Canada
| | - Lilianna Oliveira
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, 737 Parkdale Ave, Suite 468, Ottawa, ON, K1Y 1J8, Canada
| | - Blair Macdonald
- Department of Medical Imaging, The Ottawa Hospital, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Elham Sabri
- The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Sanjay Murthy
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, 737 Parkdale Ave, Suite 468, Ottawa, ON, K1Y 1J8, Canada.,The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
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