Clinical factors associated with severity in patients with inflammatory bowel disease in Brazil based on 2-year national registry data from GEDIIB

The Brazilian Organization for Crohn's Disease and Colitis (GEDIIB) established a national registry of inflammatory bowel disease (IBD). The aim of the study was to identify clinical factors associated with disease severity in IBD patients in Brazil. A population-based risk model aimed at stratifying the severity of IBD based on previous hospitalization, use of biologics, and need for surgery for ulcerative colitis (UC) and Crohn's Disease (CD) and on previous complications for CD. A total of 1179 patients (34.4 ± 14.7y; females 59%) were included: 46.6% with UC, 44.2% with CD, and 0.9% with unclassified IBD (IBD-U). The time from the beginning of the symptoms to diagnosis was 3.85y. In CD, 41.2% of patients presented with ileocolic disease, 32% inflammatory behavior, and 15.5% perianal disease. In UC, 46.3% presented with extensive colitis. Regarding treatment, 68.1%, 67%, and 47.6% received biological therapy, salicylates and immunosuppressors, respectively. Severe disease was associated with the presence of extensive colitis, EIM, male, comorbidities, and familial history of colorectal cancer in patients with UC. The presence of Montreal B2 and B3 behaviors, colonic location, and EIM were associated with CD severity. In conclusion, disease severity was associated with younger age, greater disease extent, and the presence of rheumatic EIM.

microRNA-mRNA Networks Linked to Inflammation and Immune System Regulation in Inflammatory Bowel Disease

The molecular processes linked to the development and progression of Crohn's disease (CD) and ulcerative colitis (UC) are not completely understood. MicroRNAs (miRNAs) regulate gene expression and are indicated as diagnostic, prognostic, and predictive biomarkers in chronic degenerative diseases. Our objectives included the identification of global miRNA expression in CD and UC, as well as miRNA target genes, miRNA-mRNA interaction networks, and biological functions associated with these different forms of inflammatory bowel disease (IBD).

METHODS

By performing a comprehensive meta-analysis, we integrated miRNA expression data from nine studies in IBD. We obtained detailed information on significantly deregulated miRNAs (fold change, FC ≥ 2 and p < 0.05), sample type and number, and platform applied for analysis in the training and validation sets. Further bioinformatic analyses were performed to identify miRNA target genes, by using the microRNA Data Integration Portal tool. We also sought to identify statistically enriched pathways of genes regulated by miRNAs using ToppGene Suite. Additional analyses were performed to filter for genes expressed in intestinal tissue using the European Bioinformatics Institute (EBI) database.

RESULTS

Our findings showed the upregulation of 15 miRNAs in CD and 33 in UC. Conversely, six miRNAs were downregulated in CD, while seven were downregulated in UC. These results indicate a greater deregulation of miRNAs in UC compared to CD. Of note, miRNA target genes were enriched for immune system regulation pathways. Among significantly deregulated miRNAs with a higher number of miRNA-target gene interactions, we identified miR-199a-5p and miR-362-3p altered in CD, while among UC case patients, miRNA-target gene interactions were higher for miR-155-5p.

CONCLUSIONS

The identified miRNAs play roles in regulating genes associated with immune system regulation and inflammation in IBD. Such miRNAs and their target genes have the potential to serve as clinically relevant biomarkers. These findings hold promise for enhancing the accuracy of diagnoses and facilitating the development of personalized treatment strategies for individuals with various forms of IBD.

Risk factors for major complications after surgical treatment of primary ileocecal Crohn's disease. A multicentric Latin American experience

INTRODUCTION

Complications after ileocecal resection for Crohn's disease (CD) are frequent. The aim of this study was to analyze risk factors for postoperative complications after these procedures.

MATERIALS AND METHODS

We conducted a retrospective analysis of patients treated surgically for Crohn's disease limited to the ileocecal region during an 8-year period at 10 medical centers specialized in inflammatory bowel disease (IBD) in Latin America. Patients were allocated into 2 groups: those who presented major postoperative complications (Clavien-Dindo > II), the "postoperative complication" (POC) group; and those who did not, the "no postoperative complication" (NPOC) group. Preoperative characteristics and intraoperative variables were analyzed to identify possible factors for POC.

RESULTS

In total, 337 patients were included, with 51 (15.13%) in the POC cohort. Smoking was more prevalent among the POC patients (31.37 vs. 17.83; P = .026), who presented more preoperative anemia (33.33 vs. 17.48%; P = .009), required more urgent care (37.25 vs. 22.38; P = .023), and had lower albumin levels. Complicated disease was associated with higher postoperative morbidity. POC patients had a longer operative time (188.77 vs. 143.86 min; P = .005), more intraoperative complications (17.65 vs. 4.55%; P < .001), and lower rates of primary anastomosis. In the multivariate analysis, both smoking and intraoperative complications were independently associated with the occurrence of major postoperative complications.

CONCLUSION

This study shows that risk factors for complications after primary ileocecal resections for Crohn's disease in Latin America are similar to those reported elsewhere. Future efforts in the region should be aimed at improving these outcomes by controlling some of the identified factors.

Intestinal complications in patients with Crohn’s disease in the Brazilian public healthcare system between 2011 and 2020

BACKGROUND

This is a secondary database study using the Brazilian public healthcare system database.

AIM

To describe intestinal complications (ICs) of patients in the Brazilian public healthcare system with Crohn’s disease (CD) who initiated and either only received conventional therapy (CVT) or also initiated anti-tumor necrosis factor (anti-TNF) therapy between 2011 and 2020.

METHODS

This study included patients with CD [international classification of diseases – 10^th revision (ICD-10): K50.0, K50.1, or K50.8] (age: ≥ 18 years) with at least one claim of CVT (sulfasalazine, azathioprine, mesalazine, or methotrexate). IC was defined as a CD-related hospitalization, pre-defined procedure codes (from rectum or intestinal surgery groups), and/or associated disease (pre-defined ICD-10 codes), and overall (one or more type of ICs).

RESULTS

In the 16809 patients with CD that met the inclusion criteria, the mean follow-up duration was 4.44 (2.37) years. In total, 14697 claims of ICs were found from 4633 patients. Over the 1- and 5-year of follow-up, 8.3% and 8.2% of the patients with CD, respectively, presented at least one IC, of which fistula (31%) and fistulotomy (48%) were the most commonly reported. The overall incidence rate (95%CI) of ICs was 6.8 (6.5–7.04) per 100 patient years for patients using only-CVT, and 9.2 (8.8–9.6) for patients with evidence of anti-TNF therapy.

CONCLUSION

The outcomes highlighted an important and constant rate of ICs over time in all the CD populations assessed, especially in patients exposed to anti-TNF therapy. This outcome revealed insights into the real-world treatment and complications relevant to patients with CD and highlights that this disease remains a concern that may require additional treatment strategies in the Brazilian public healthcare system.

Intestinal complications in Brazilian patients with ulcerative colitis treated with conventional therapy between 2011 and 2020

BACKGROUND

This was an observational, descriptive, and retrospective study from 2011 to 2020 from the Department of Informatics of the Brazilian Healthcare System database.

AIM

To describe the intestinal complications (IC) of patients with ulcerative colitis (UC) who started conventional therapies in Brazil´s public Healthcare system.

METHODS

Patients ≥ 18 years of age who had at least one claim related to UC 10^th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) code and at least 2 claims for conventional therapies were included. IC was defined as at least one claim of: UC-related hospitalization, procedures code for rectum or intestinal surgeries, and/or associated disease defined by ICD-10 codes (malignant neoplasia of colon, stenosis, hemorrhage, ulcer and other rectum or anus disease, megacolon, functional diarrhea volvulus, intussusception and erythema nodosum). Descriptive statistics, annual incidence, and incidence rate (IR) [per 100 patient-years (PY)] over the available follow-up period were cal-culated.

RESULTS

In total, 41229 UC patients were included (median age, 48 years; 65% women) and the median (interquartile range) follow-up period was 3.3 (1.8-5.3) years. Conventional therapy used during follow-up period included: mesalazine (87%), sulfasalazine (15%), azathioprine (16%) or methotrexate (1%) with a median duration of 1.9 (0.8-4.0) years. Overall IR of IC was 3.2 cases per 100 PY. Among the IC claims, 54% were related to associated diseases, 20% to procedures and 26% to hospitalizations. The overall annual incidence of IC was 2.9%, 2.6% and 2.5% in the first, second and third year after the first claim for therapy (index date), respectively. Over the first 3 years, the annual IR of UC-related hospitalizations ranged from 0.8% to 1.1%; associated diseases from 0.9% to 1.2% - in which anus or rectum disease, and malignant neoplasia of colon were the most frequently reported; and procedure events from 0.6% to 0.7%, being intestinal resection and polyp removal the most frequent ones.

CONCLUSION

Study shows that UC patients under conventional therapy seem to present progression of disease developing some IC, which may have a negative impact on patients and the burden on the health system.

INTERACTION BETWEEN FOOD PYRAMID AND GUT MICROBIOTA. A NEW NUTRITIONAL APPROACH

The food pyramid is a pre-established nutritional education tool. The integration between the intestinal microbiome, food groups, and SCFA-producing bacteria, which benefit from the ingestion of these foods, has the potential to further improve and innovate healthy eating. The diet-microbiome interaction needs to be incorporated into nutrition science, and the food pyramid might assist in this interaction and nutritional learning. Against this context, this brief communication proposes through the food pyramid, the interactions between the intestinal microbiota, food groups, and SCFAs-producing bacteria.

Quality of care in patients with inflammatory bowel disease from a public health center in Brazil

BACKGROUND

Inflammatory bowel diseases (IBDs) are chronic diseases that demand continuous interaction between patients and healthcare providers. Quality of care (QoC) is a factor that contributes to a patient’s adherence to treatment and its success.

AIM

To evaluate QoC in patients from a single IBD reference center.

METHODS

This cross-sectional study included 133 patients from a single Brazilian IBD public health center. QoC was evaluated through the QoC Through the Eyes of Patients with IBD (QUOTE-IBD) questionnaire (based on patient perspectives), which measures eight dimensions of care. We compared QoC among patients with Crohn’s disease and ulcerative colitis and analyzed the clinical and psychological factors associated with QoC satisfaction. Clinical evaluations assessed disease characteristics, quality of life, anxiety, and depression levels.

RESULTS

Sixty-nine patients with Crohn’s disease and 64 with ulcerative colitis were interviewed. The mean age was 37.26 years ± 13.05 years, and 63.91% of the patients were women. The mean duration of the disease was 8.44 years ± 7.59 years, where most patients were in remission (70.31% of patients with ulcerative colitis and 62.32% with Crohn’s disease). The total QoC score of the sample was 8.61 years ± 1.31 points, indicating that the QoC provided by the center was unsatisfactory. According to univariate logistic regression, patients with Crohn’s disease had higher satisfaction rates than those with ulcerative colitis [odds ratio (OR): 2.746; 95% confidence interval (CI): 1.360-5.541; P = 0.0048] and patients on infliximab (OR: 2.175; 95%CI: 1.037-4.562; P = 0.0398).

CONCLUSION

Patients from the IBD public center reported good doctor-patient relationships, but had problems related to the healthcare structure. Evaluation of healthcare centers is of paramount to improve QoC for the patients involved.

Epidemiology of inflammatory bowel diseases in the state of Rio Grande do Sul, Brazil

BACKGROUND

This is the first study on the epidemiology of inflammatory bowel diseases (IBDs) in Rio Grande do Sul (RS), the southernmost state of Brazil with the country’s fifth largest population. Crohn’s disease (CD) and ulcerative colitis (UC) are collectively termed IBDs. They have high incidence and prevalence rates in high-income countries, although in recent years there has been a change in the classic geographical distribution of IBDs, with growing rates in traditionally low-incidence regions.

AIM

To estimate the incidence and prevalence of IBDs in the RS state, Brazil, between 2014 and 2019.

METHODS

This is a cross-sectional descriptive observational study. Patients with IBD who had initiated treatment and met the inclusion criteria of the RS state free drug distribution program were included. Data were obtained from registration or renewal records of the RS state specialty pharmacy. The male, female, and total populations were estimated according to mid-year data from the Brazilian Institute of Geography and Statistics, which served as a reference for calculating the incidence and prevalence rates of IBDs during the study period. Results were described using mean, standard deviation, and range.

RESULTS

We included 1082 patients with IBD, of whom 57.5% were female and 42.5% were male. Patients with CD accounted for 72.45% of the sample, and those with UC accounted for 27.54%. IBD prevalence during the study period was 9.51 per 100000 population, of which 6.89 corresponded to people with CD and 2.62, to people with UC. Incidence rates per 100000 population/year were 2.54 in 2014, 2.61 in 2015, 1.91 in 2016, 0.80 in 2017, 0.83 in 2018, and 0.96 in 2019. The mean IBD incidence rate per 100000 population was 1.61, of which 1.17 corresponded to CD and 0.44, to UC. The mean age was 41 years, and patients were mostly aged 30-40 years. Prevalence by region was higher in the state capital metropolitan area: 12.69 per 100000 population.

CONCLUSION

Our results demonstrated an IBD prevalence of 9.51% and incidence of 1.61 per 100000 population. The patients were predominantly female, and CD was more prevalent than UC.

Immune Thrombocytopenic Purpura as an Extraintestinal Manifestation in a Patient with Ulcerative Colitis

Immune thrombocytopenic purpura (ITP) is characterized by the presence of autoantibodies against platelet membrane antigens, leading to immune-mediated platelet destruction. ITP is considered as a rare extraintestinal manifestation (EIM) of ulcerative colitis (UC). This report aimed to describe a rare case of UC associated with ITP and a review of the literature. A 49-year-old man was admitted to our hospital with severe acute colitis which was responsive to treatment (hydrocortisone 300 mg/day). The patient was discharged from the hospital with prednisone 60 mg/day and azathioprine 50 mg/day. During the follow-up, the dose of azathioprine was increased to 100 mg/day (1.3 mg/kg), while prednisone tapering was started. After 3 months, the patient presented with thrombocytopenia (30,000 platelets/µL) without improvement despite receiving the suspension of azathioprine; thus, a bone marrow aspirate was performed. The bone marrow analysis showed hyperplasia of the erythroid series, megaloblastosis, hyperplasia of megakaryocytes with mild dyspoiesis, and absence of cytotoxicity, a morphological finding consistent with ITP. The patient was treated with prednisone 1 mg/kg/day which resulted in partial improvement of the condition and his still being followed up as outpatient using mesalazine 3.2 g for UC and a platelet count of approximately 50,000/µL using eltrombopag. As reported, ITP is a rare EIM in patients with UC. Due to the risk of complications, such as bleeding, hematological changes in these patients should be considered. The disease should be suspected in the presence of thrombocytopenia, always excluding the side effects of medications in advance, especially immunosuppressants. The correct diagnosis of this rare manifestation and proper treatment are essential to control the condition, prevent complications, and improve the patient's prognosis.

Clinical and Psychological Factors Associated with Addiction and Compensatory Use of Facebook Among Patients with Inflammatory Bowel Disease: A Cross-Sectional Study

Background

Inflammatory bowel diseases are chronic conditions characterized by incapacitating symptoms, which can compromise patient’s quality of life and social interaction. As social media use is continuously increasing and Facebook is one of the most accessed social media worldwide, this study aimed to evaluate the use of Facebook and identify clinical and psychological factors associated with addiction and compensatory use among patients.

Methods

This case-control study enrolled 100 outpatients and 100 healthy individuals, who were classified into the patient and control groups, respectively. Facebook use was evaluated using the questionnaire Psycho-Social Aspects of Facebook Use (PSAFU). The IBD Questionnaire and the 36-Item Short-Form Health Survey (SF-36) were used to measure Health-related quality of life. Anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale; self-esteem, using the Rosenberg Self-Esteem scale.

Results

The patient group included 54 patients with Crohn’s disease and 46 with ulcerative colitis. Facebook use was similar between the patient and control groups in all evaluated aspects (p=0.21). In the patient and the control groups, the compensatory use of Facebook was directly related to the symptoms of depression (patients: R = 0.22; p = 0.03; controls: R = 0.34; p = 0.0006) and inversely related to self-esteem scale (patients: R = −0.27; p = 0.006; controls: R = −0.37; p = 0.0001). Facebook addiction showed an inverse correlation with self-esteem (patients: R = −0.32; p = 0.001; controls: R = −0.24; p = 0.02) and quality of life (patients: IBDQ score, R = −0.30; p = 0.003; controls: SF-36 score, R = −0.29; p = 0.004).

Conclusion

The use of Facebook was not different between study groups. Psychological aspects such as depression and low self-esteem were associated with the compensatory use of Facebook in both groups, which may be related to unsatisfactory personal aspects of social interaction.

Management of inflammatory bowel disease and serum level of infliximab in newborn exposed to anti-TNF therapy during pregnancy: Case report and literature review

RATIONALE

Heightened inflammatory bowel disease (IBD) activity during pregnancy is associated with higher rates of preterm birth, miscarriage, and low birth weight. Therefore, its adequate treatment is essential, considering the risk-benefit of medication use. Although previous literature has described the management of IBD during pregnancy, few studies have assessed the pharmacokinetics of IBD drugs in the newborn. In this case report, we describe the management of ulcerative colitis during pregnancy and discuss the benefits of checking serum levels of infliximab in newborns exposed to the medication during pregnancy.

PATIENT CONCERN

A 37-year-old patient with ulcerative colitis in clinical and endoscopic remission had been undergoing treated with infliximab since 2008. The patient became pregnant in 2018.

DIAGNOSIS AND INTERVENTION

Infliximab medication was discontinued at the 29th week of pregnancy.

OUTCOMES

The pregnancy was uneventful, and the levels of infliximab in the umbilical cord were >20 μg/dL. Live vaccinations were postponed until the baby was 6 months old, when a new serum drug level proved to be undetectable.

LESSONS

Our case suggests that the use of infliximab is safe in pregnancy, and drug discontinuation could be considered from the 24th week of pregnancy onward to reduce placental transfer to the newborn in patients at low risk of relapse. Vaccines with live attenuated organisms should be delayed for at least 6 months or until the serum level of the medication is undetectable.

Heart failure as an adverse effect of infliximab for Crohn's disease: A case report and review of the literature

BACKGROUND

Anti-tumor necrosis factor agents were the first biologic therapy approved for the management of Crohn's disease (CD). Heart failure (HF) is a rare but potential adverse effect of these medications. The objective of this report is to describe a patient with CD who developed HF after the use of infliximab.

CASE SUMMARY

A 50-year-old woman with a history of hypertension and diabetes presented with abdominal pain, diarrhea, and weight loss. Colonoscopy and enterotomography showed ulcerations, areas of stenosis and dilation in the terminal ileum, and thickening of the intestinal wall. The patient underwent ileocolectomy and the surgical specimen confirmed the diagnosis of stenosing CD. The patient started infliximab and azathioprine treatment to prevent post-surgical recurrence. At 6 mo after initiating infliximab therapy, the patient complained of dyspnea, orthopnea, and paroxysmal nocturnal dyspnea that gradually worsened. Echocardiography revealed biventricular dysfunction, moderate cardiac insufficiency, an ejection fraction of 36%, and moderate pericardial effusion, consistent with HF. The cardiac disease was considered an infliximab adverse effect and the drug was discontinued. The patient received treatment with diuretics for HF and showed improvement of symptoms and cardiac function. Currently, the patient is using anti-interleukin for CD and is asymptomatic.

CONCLUSION

This reported case supports the need to investigate risk factors for HF in inflammatory bowel disease patients and to consider the risk-benefit of introducing infliximab therapy in such patients presenting with HF risk factors.

Leukocytoclastic Vasculitis as an Extraintestinal Manifestation of Crohn's Disease

Cutaneous involvement is one of the most common extraintestinal manifestations of inflammatory bowel disease (IBD). More commonly, pyoderma gangrenosum and erythema nodosum are noted, but psoriasis, aphthous stomatitis, Sweet's syndrome, and vasculitis may also occur. Leukocytoclastic vasculitis (LCV) is a rare cutaneous manifestation, characterized by the appearance of palpable purpura, urticaria, and ulcer-necrotic lesions predominantly in the lower extremities that improve with immunosuppressive therapy. In this case, we report a patient with CD and LCV. We also searched the literature on the diagnosis and treatment of LCV in patients with CD. Female, 31, presented with diarrhea containing mucus and blood, abdominal pain, arthralgia, and enanthematous plaques and ulcers with a hematinic background in the lower extremities. The results of the colonoscopy were compatible with CD and skin biopsy showed signs of LCV. Systemic autoimmune disease and primary vasculitis were ruled out. The patient received treatment with a systemic corticosteroid and the skin lesions improved. Outpatient treatment with antitumor necrosis factor therapy was initiated to promote skin healing and IBD clinical remission. As LCV is a rare manifestation of IBD, it is necessary to distinguish this dermatopathy from other systemic vasculitis. The engagement of a multidisciplinary team is essential for the correct diagnosis and management.

COMPARATIVE ANALYSIS OF TWO ORAL CONTRAST AGENT VOLUMES FOR COMPUTED TOMOGRAPHY ENTEROGRAPHY IN CROHN'S DISEASE PATIENTS

BACKGROUND

Crohn's disease (CD) is an inflammatory bowel disease characterized by a chronic and recurrent inflammation of the gastrointestinal tract caused by an interaction of genetic and environmental factors.

OBJECTIVE

To compare the quality and acceptance of two different oral contrast volumes for computed tomography enterography in Crohn's disease patients.

METHODS

A cross-sectional study was conducted in 58 consecutive Crohn's disease patients who randomly received an oral contrast agent composed of 78.75 g polyethylene glycol diluted in either 1,000 mL or 2,000 mL of water. An examination was performed to evaluate the presence of inflammation or complications in the small bowel. The variables included the quality of intestinal segment filling and luminal distension, and oral contrast agent acceptance and tolerance in the patients. Statistical analysis included descriptive statistics and association tests.

RESULTS

A total of 58 patients were assessed, in which 58.6% were female, 34.5% exhibited clinically-active disease, and 63.8% were receiving biologic therapy. As for comparative analysis between the two different volumes of oral contrast, no statistically significant difference was found regarding bowel loop filling (P=0.58) and adequate luminal distension (P=0.45). Patients who received a larger volume (2,000 mL) exhibited side-effects more frequently (51.7% vs 31.0%; P=0.06) and had greater difficulty ingesting the agent (65.5% vs 37.9%; P=0.07) compared with a volume of 1,000 mL.

CONCLUSION

The quality of computed tomography enterography was not influenced by the contrast volume. However, acceptance and tolerance were better in the 1,000 mL group.

Perception and clinical decisions from inflammatory bowel diseases' specialists towards positioning of new therapies in Crohn's disease and ulcerative colitis: A national web-based survey from the Brazilian IBD study group (GEDIIB)

BACKGROUND

In the last decade, new therapies with different mechanisms of action have been approved for the treatment of moderate to severe Crohn's disease (CD) and ulcerative colitis (UC). Due to the lack of comparative head-to-head trials, the ideal positioning of agents as the most appropriate first- or second-line therapies remains to be defined.

OBJECTIVE

This survey aimed to evaluate the perception and decisions of Brazilian Inflammatory Bowel Diseases (IBD) specialists in positioning of new therapies (vedolizumab [VEDO], ustekinumab [UST] and tofacitinib [TOFA]) in the management of IBD in different clinical scenarios.

METHODOLOGY

An anonymous national web-based questionnaire was used to determine the positioning of treatment options in different clinical scenarios (using Google Forms platform), which involved different age ranges, phenotypes, clinical situations and previous exposure to anti-TNF agents (14 scenarios for CD and 10 scenarios for UC). In CD, physicians could choose between UST or VEDO, whilst in UC, between UST, VEDO or TOFA. Six reasons for the specific choice were proposed, such as mechanism of action, safety, method of administration or onset of action. Statistical analysis was carried out with chi-square and t-tests.

RESULTS

A total of 150 out of 672 GEDIIB IBD specialists (22.32%) responded to the survey. In CD scenarios, UST was the most dominant choice (11/14 scenarios), with VEDO dominating only 3 clinical situations. In UC scenarios, VEDO was the dominant choice (8/10), with UST being chosen for scenarios that included extraintestinal manifestations. Among the reasons for specific choices, the most commonly chosen were the higher efficacy due to the intrinsic mechanism of action and safety profile.

CONCLUSIONS

UST was the dominant choice as compared to VEDO in CD in most scenarios, especially due to its mechanism of action and safety. VEDO was the dominant choice as compared to UST and TOFA in UC scenarios, mainly for reasons also related to its mechanism of action and safety profile. Comparative studies including patient outcomes are needed to better define the positioning of new IBD therapeutic options in our country.

Pulmonary Tuberculosis After Therapy with Anti-Tumor Necrosis Factor (TNF) for Crohn Disease: A Case Report

Patient: Male, 38-year-old

Final Diagnosis: Crohn’s disease • pulmonary tuberculosis

Symptoms: Abdominal pain • bloody bowel movements • diarrhea • dry cough • fever • hyporexia • malaise • weight loss

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology

Treatment of acute severe ulcerative colitis using accelerated infliximab regimen based on infliximab trough level: A case report

BACKGROUND

Acute severe ulcerative colitis (ASUC) is a complication of ulcerative colitis associated with high levels of circulating tumor necrosis factor alpha, due to the intense inflammation and faster stool clearance of anti-tumor necrosis factor drugs. Dose-intensified infliximab treatment can be beneficial and is associated with lower rates of colectomy. The aim of the study was to present a case of a patient with ASUC and megacolon, treated with hydrocortisone and accelerated scheme of infliximab that was monitored by drug trough level.

CASE SUMMARY

A 22-year-old female patient diagnosed with ulcerative colitis, presented with diarrhea, rectal bleeding, abdominal pain, vomiting, and distended abdomen. During investigation, a positive toxin for Clostridium difficile and colonic dilatation of 7 cm consistent with megacolon were observed. She was treated with oral vancomycin for pseudomembranous colitis and intravenous hydrocortisone for severe colitis, which led to the resolution of megacolon. Due to the persistent severe colitis symptoms, infliximab 5 mg/kg was prescribed, monitored by drug trough level (8.8 μg/mL) and fecal calprotectin of 921 μg/g (< 30 μg/g). Based on the low infliximab trough level after one week from the first infliximab dose, the patient received a second infusion at week 1, consistent with the accelerated regimen (infusions at weeks 0, 1, 2 and 6). We achieved a positive clinical and endoscopic response after 6 mo of therapy, without the need for a colectomy.

CONCLUSION

Infliximab accelerated infusions can be beneficial in ASUC unresponsive to the treatment with intravenous corticosteroids. Longitudinal studies are necessary to define the best therapeutic drug monitoring and treatment regimen for these patients.

BRAZILIAN IBD STUDY GROUP POSITION STATEMENT ON SARS-COV2 VACCINATION

Mass vaccination offers the best strategy to fight against COVID-19 pandemic, and SARS-CoV2 vaccines are being approved in several countries for emergency use. In Brazil, vaccine approval is expected in the next few days, however potential concerns exist regarding vaccine recommendations for specific populations, such as patients with inflammatory bowel disease (IBD). To address these questions, the Brazilian IBD Study Group (GEDIIB) provides this practical advice with key recommendations about the COVID-19 vaccines in IBD population.

Risk stratification and geographical mapping of Brazilian inflammatory bowel disease patients during the COVID-19 outbreak: Results from a nationwide survey

BACKGROUND

Coronavirus disease 2019 (COVID-19) pandemic is still evolving globally, and Brazil is currently one of the most affected countries. It is still debated whether patients with inflammatory bowel disease (IBD) are at a higher risk for developing COVID-19 or its complications.

AIM

To assess geographical distribution of IBD patients at the highest risk and correlate these data with COVID-19 mortality rates in Brazil.

METHODS

The Brazilian IBD Study Group (Grupo de Estudos da Doença Inflamatória Intestinal do Brasil) developed a web-based survey adapted from the British Society of Gastroenterology guidelines. The included categories were demographic data and inquiries related to risk factors for complications from COVID-19. Patients were categorized as highest, moderate or lowest individual risk. The Spearman correlation test was used to identify any association between highest risk and mortality rates for each state of the country.

RESULTS

A total of 3568 patients (65.3% females) were included. Most participants were from the southeastern and southern regions of Brazil, and 84.1% were using immunomodulators and/or biologics. Most patients (55.1%) were at moderate risk, 23.4% were at highest risk and 21.5% were at lowest risk of COVID-19 complications. No association between the proportion of IBD patients at highest risk for COVID-19 complications and higher mortality rates was identified in different Brazilian states (r = 0.146, P = 0.467).

CONCLUSION

This study indicates a distinct geographical distribution of IBD patients at highest risk for COVID-19 complications in different states of the country, which may reflect contrasting socioeconomic, educational and healthcare aspects. No association between high risk of IBD and COVID-related mortality rates was identified.

FACTORS ASSOCIATED WITH PATIENT´S PREFERENCE IN CHOOSING THEIR THERAPY FOR INFLAMMATORY BOWEL DISEASE IN BRAZIL

OBJECTIVE

This study aims to evaluate patient's preferences in the choice of their therapy and the factors that influence this choice.

METHODS

This cross-sectional study enrolled 101 outpatients with Crohn's disease or ulcerative colitis. The inclusion criteria were age ≥18 years and no previous exposure to biological therapy. Patients' preferences were assessed through questions that addressed the preferred mode of administration (oral, subcutaneous, or intravenous) and the factors that determined the choice of medication (efficacy, medical indication, fear of medication, convenience, mode of application, and personal doctors' indication).

RESULTS

The mean age was 43.6±13.5 years, 75.3% were female, and 81.2% were cases of ulcerative colitis. Regarding the mode of administration, the majority of patients preferred oral (87.1%), followed by intravenous (6.93%) and subcutaneous (5.94%) medications. The reasons were "I prefer to take it at home" (42.57%), "I have more freedom" (36.63%), "I don't like self-application" (29.70%), and "I believe it works better" (19.80%). Younger patients and patients in clinical disease activity preferred intravenous mode compared to the oral route (P<0.05). Doctor's opinion (98%) was an important factor associated with the medication choice.

CONCLUSION

Oral route was the preferred mode of administration and most patients took their physician's opinion into account in their choice of medication.

DISCONTINUATION RATES FOLLOWING A SWITCH FROM A REFERENCE TO A BIOSIMILAR BIOLOGIC IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS

BACKGROUND

Biologics have revolutionized the treatment of inflammatory bowel disease (IBD). However, these drugs had a significant influence on treatment-related costs, which resulted in the development of biosimilars.

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the drug discontinuation rate in the IBD population who switched from originator to biosimilars in real-world switching studies and address potential nocebo effects as reasons for drug discontinuation.

METHODS

Medline (via PubMed), EMBASE, Cochrane Library, and abstract databases of selected congresses were screened for reports of monoclonal antibody (mAb) switching with a minimum post-switch follow-up of >6 months or three infusions. All available information on discontinuation rates was assessed.

RESULTS

A total of 30 observational studies were included, involving 3,594 patients with IBD. Twenty-six studies reported a switch from infliximab to CT-P13, two studies involved a switch to SB2, and switching information was not available in two studies. The discontinuation rates were 8%, 14%, and 21% at 6, 12, and 24 months, respectively. The main reasons for drug discontinuation and their respective risks were: disease worsening (2%), remission (4%), loss of adherence (4%), adverse events (5%), and loss of response (7%). The quality of the evidence ranged from low to very low depending on the outcome analyzed. Subjective symptoms leading to drug discontinuation were infrequently reported, and the nocebo effect was clearly assessed in just one of the included papers.

CONCLUSION

Discontinuation rates following a switch to a biosimilar in patients with IBD increase over time. However, it was not possible to confirm the nocebo effect as a reason for discontinuation. Therefore, long-term studies evaluating the use of biosimilars to monitor adverse events and potential nocebo effects in post-marketing surveillance are still needed.

Real-world disease activity and sociodemographic, clinical and treatment characteristics of moderate-to-severe inflammatory bowel disease in Brazil

BACKGROUND

Understanding the treatment landscape of inflammatory bowel diseases (IBD) is essential for improving disease management and patient outcomes. Brazil is the largest Latin American country, and it presents socioeconomic and health care differences across its geographical regions. This country has the highest increase in IBD incidence and prevalence in Latin America, but information about the clinical and treatment characteristics of IBD is scarce.

AIM

To describe the sociodemographic, clinical, and treatment characteristics of IBD outpatients in Brazil overall and in the Southeast, South and Northeast/Midwest regions.

METHODS

Multicenter, cross-sectional study with a 3-year retrospective chart review component. Patients with moderate-to-severe Crohn's disease (CD) or ulcerative colitis (UC) were consecutively enrolled between October 2016 and February 2017. Active CD at enrollment was defined as a Harvey Bradshaw Index ≥ 8 or a CD Activity Index ≥ 220 or a calprotectin level > 200 μg/g or an active result based on colonoscopy suggestive of inadequate control during the previous year; active UC was defined as a partial Mayo score ≥ 5. Descriptive statistics were used to analyze all variables.

RESULTS

In a total of 407 included patients, CD was more frequent than UC, both overall (264 CD/143 UC patients) and by region (CD:UC ratios of 2.1 in the Southeast, 1.6 in the South and 1.2 in the Northeast/Midwest). The majority of patients were female (54.2% of CD; 56.6% of UC), and the mean ages were 45.9 ± 13.8 years (CD) and 42.9 ± 13.0 years (UC). The median disease duration was 10.0 (range: 0.5-45) years for both IBD types. At enrollment, 44.7% [95% confidence interval (CI): 38.7-50.7] of CD patients and 25.2% (95%CI: 18.1-32.3) of UC patients presented with active disease. More than 95% of IBD patients were receiving treatment at enrollment; CD patients were commonly treated with biologics (71.6%) and immunosuppressors (67.4%), and UC patients were commonly treated with mesalazine [5-Aminosalicylic acid (5-ASA)] derivates (69.9%) and immunosuppressors (44.1%). More than 50% of the CD patients had ileocolonic disease, and 41.7% presented with stricturing disease. One-quarter of CD patients had undergone CD-related surgery in the past 3 years, and this proportion was lower in the Northeast/Midwest region (2.9%).

CONCLUSION

In Brazil, there are regional variations in IBD management. CD outweighs UC in both frequency and disease activity. However, one-quarter of UC patients have active disease, and most are receiving 5-ASA treatment.

Modern surgical strategies for perianal Crohn's disease

One of the most challenging phenotypes of Crohn’s disease is perianal fistulizing disease (PFCD). It occurs in up to 50% of the patients who also have symptoms in other parts of the gastrointestinal tract, and in 5% of the cases it occurs as the first manifestation. It is associated with severe symptoms, such as pain, fecal incontinence, and a significant reduction in quality of life. The presence of perianal disease in conjunction with Crohn’s disease portends a significantly worse disease course. These patients require close monitoring to identify those at risk of worsening disease, suboptimal biological drug levels, and signs of developing neoplasm. The last 2 decades have seen significant advancements in the management of PFCD. More recently, newer biologics, cell-based therapies, and novel surgical techniques have been introduced in the hope of improved outcomes. However, in refractory cases, many patients face the decision of having a stoma made and/or a proctectomy performed. In this review, we describe modern surgical management and the most recent advances in the management of complex PFCD, which will likely impact clinical practice.

Hidradenitis Suppurativa as a Paradoxical Side Effect to the Use of Adalimumab in Patients with Crohn's Disease?

Background

Hidradenitis suppurativa is a chronic inflammatory skin disorder associated with inflammatory bowel disease. However, it can arise as a paradoxical side effect of anti-TNF treatment.

Methods

The article reports on three patients with Crohn's disease who developed hidradenitis suppurativa during the treatment with adalimumab.

Results

Case 1: A 38-year-old female exhibited an infiltrative lesion in the inguinal region and vulva, consistent with hidradenitis suppurativa, after three months of adalimumab. These lesions were treated with partial vulvectomy. Case 2: After adalimumab treatment, a 27-year-old female, originally diagnosed with ileocolonic Crohn's disease, went into clinical and endoscopic remission. The patient eventually presented two hyperchromic nodules in the inguinal region, which were diagnosed as hidradenitis suppurativa. The patient showed improvement after treatment with oral doxycycline and local therapy. Case 3: A 34-year-old female with fistulizing and stenosing ileocolonic Crohn's disease, started adalimumab in 2010, with optimization in 2015. One year after, the patient developed bilateral, erythematous, hardened, inguinal nodulations with purulent drainage, consistent with hidradenitis suppurativa. Treatment with oral doxycycline, fusidic acid, and infiltration with triamcinolone resulted in partial improvement of the lesions. In 2018, the lesions deteriorate. The patient underwent surgical treatment.

Conclusion

Patients with inflammatory bowel disease are more likely to the development of other mediated inflammatory diseases, such as hidradenitis suppurativa. Hidradenitis suppurativa may appear as a paradoxical reaction to anti-TNF therapy. Clinical teams must be aware of this type of complication. Early diagnosis and treatment are essential for controlling the disease and preventing the onset of complications.

Risk factors for ulcerative colitis-associated colorectal cancer: A retrospective cohort study

Inflammatory bowel disease is associated with an increased risk of colorectal cancer. The study aims to identify the risk factors for ulcerative colitis-colorectal cancer and to perform a survival curve analysis of the outcome.This retrospective cohort study included 254 patients from March 2016 to October 2017. Age, age at diagnosis, follow-up time, smoking status, and family history of colorectal cancer were analyzed as risk factors for colorectal cancer.The mean patient age was 46.6 ± 16.9 years; 5.5% of the patients were smokers and 49.6% had pancolitis. Six patients (2.36%) had colorectal cancer, which was associated with age at diagnosis (odds/hazard ratio 1.059 [95% confidence interval: 1.001-1.121]; P = .04), family history of colorectal cancer (12.992 [1.611-104.7]; P = .02), and follow-up time (0.665 [0.513-0.864]; P = .002). Active smoking was the main identified risk factor, after both logistic (8.477 [1.350-53.232]; P = .02) and Cox proportional-hazards (32.484 [2.465-428.1]; P = .008) regression analysis. The risk of colorectal cancer was 3.17% at 10 years and 4.26% at 20 years of follow-up.Active smoking and family history were identified as risk factors for colorectal cancer. These findings should aid the early identification of patients who require vigorous surveillance, and prevent exposure to risk factors.

Immunosuppression and Malignant Neoplasms: Risk-Benefit Assessment in Patients with Inflammatory Bowel Disease

Patient: Male, 70-year-old

Final Diagnosis: Ulcerative colitis

Symptoms: Abdominal pain • bloody diarrhea

Medication: Azathioprine • infliximab

Clinical Procedure: Clinical treatment • surgical treatment

Specialty: Gastroenterology and Hepatology

Progression of Inflammatory Bowel Diseases Throughout Latin America and the Caribbean: A Systematic Review

BACKGROUND & AIMS

The incidence of inflammatory bowel diseases (IBD) is increasing in Latin America. We performed a systematic review to identify clinical and epidemiologic features of IBD in Latin America (including Mexico, Central America, and South America) and the Caribbean.

METHODS

We searched MEDLINE, EMBASE, and SciELO databases for clinical or epidemiologic studies of Crohn's disease (CD) or ulcerative colitis (UC) from Latin American and Caribbean countries and territories that reported incidence, prevalence, ratio of UC:CD, IBD phenotype, and treatment, through September 12, 2018. Data were extracted from 61 articles for analysis.

RESULTS

The incidence and prevalence of IBD have been steadily increasing in Latin America and the Caribbean. The incidence of CD in Brazil increased from 0.08 per 100,000 person-years in 1988 to 0.68 per 100,000 person-years in 1991-1995 to 5.5 per 100,000 person-years in 2015. The highest reported prevalence of IBD was in Argentina, in 2007, at 15 and 82 per 100,000 person-years for CD and UC, respectively. The ratio of UC:CD exceeded 1 in all regions throughout Latin America and the Caribbean with the exception of Brazil. Treatment with tumor necrosis factor antagonists increased steadily for patients with CD (43.4% of all patients in Brazil were treated in 2014) but less so for patients with UC (4.5% of all patients were treated in 2014). Surgery for IBD decreased with time. In Chile, surgeries were performed on 57.0% of patients with CD and 18.0% of patients with UC during the period of 1990-2002; these values decreased to 38.0% and 5.0%, respectively, during the period of 2012-2015. In Peru, 6.9% of patients with UC received colectomies in the period of 2001-2003 and 6.2% in 2004-2014.

CONCLUSIONS

In a systematic review, we found the incidence of IBD to be increasing throughout Latin America and the Caribbean. Population-based epidemiology studies are needed to evaluate the increase in IBD in these regions, which differ from other global regions in climate, culture, demographics, diet, healthcare delivery and infrastructure, and socioeconomic status.

Anti-TNF and Postoperative Complications in Abdominal Crohn's Disease Surgery

Background: :

Biological therapy with anti-Tumour Necrosis Factor (TNF)-α agents revolutionised the treatment of inflammatory bowel disease over the last decades. However, there may be an increased risk of postoperative complications in Crohn’s disease (CD) patients treated with anti-TNF-α agents prior to abdominal surgery.

Objective::

To evaluate the effects of preoperative anti-TNF-α therapy on the incidence of complications after surgery.

Methods: :

A critical assessment of the results of clinical trial outcomes and meta-analyses on the available data was conducted.

Results: :

Based on the outcomes of previous reports including meta-analyses, preoperative use of anti- TNF-α agents modestly increased the risk of overall complications and particularly infectious complications after abdominal surgery for CD. Nevertheless, previous studies have several limitations. The majority of them were retrospective research with heterogeneous outcome measures and single centre trials with relatively small sample size. In retrospective studies, the standard protocol for assessing various types of postoperative complications was not used. The most serious limitation of the previous studies was that multiple confounding factors such as malnutrition, use of corticosteroids, and preoperative sepsis were not taken into consideration.

Conclusion::

Among patients treated with preoperative anti-TNF-α therapy, the risk of overall complications and infectious complications may slightly increase after abdominal surgery for CD. Nevertheless, the previous reports reviewed in this study suffered from limitations. To rigorously evaluate the risk of anti-TNF-α therapy prior to surgery, large prospective studies with standardised criteria for assessing surgical complications and with proper adjustment for confounding variables are warranted.

Fecal microbiota transplantation in refractory ulcerative colitis - a case report

Studies comparing gut microbiota profiles of inflammatory bowel disease (IBD) patients have shown several changes in microbiota composition, with marked reduction of local biodiversity relative to that of healthy controls. Modulation of the bacterial community is a promising strategy to reduce the proportion of harmful microorganisms and increase the proportion of beneficial bacteria; this is expected to prevent or treat IBD. The exact mechanism of fecal microbiota transplantation (FMT) remains unknown; however, replacing the host microbiota can reestablish gut microbial composition and function in IBD patients. The present report describes an ulcerative colitis patient who underwent FMT. A 17-year-old male with moderate to severe clinical activity, which was refractory to mesalazine, azathioprine, and infliximab, underwent FMT as alternative therapy. The patient exhibited clinical improvement after the procedure; however, the symptoms returned. A second FMT was performed 8 months after the first procedure, but the patient did not improve. In conclusion, despite the FMT failure observed in this patient, the procedure is a promising therapeutic option for IBD patients, and more in-depth studies of this method are needed.

Inflammatory bowel disease epidemiology in São Paulo State, Brazil

Purpose

This study aimed to estimate the incidence and prevalence of inflammatory bowel disease (IBD) in São Paulo, Brazil, for 2012–2015.

Patients and methods:

This observational, descriptive, and cross-sectional study included 22,638 IBD patients out of 43,046,555 inhabitants, who had initiated their treatment through the Governmental Program of the Brazilian Unified National Health System between the years of 2012 and 2015. The onset of the disease (used to determine incidence) was established as the date of the patient’s initial registration in the Governmental Program with a diagnosis for Crohn’s disease (CD) or ulcerative colitis (UC). Every patient registered in the system as of December 2015 was included in determining the prevalence. The demographic and clinical data, such as age and sex, were collected for each patient. Statistical analysis included mean and SD, absolute and percentage frequencies, and Pearson’s chi-squared test (c²). The incidence and prevalence rates were calculated based on the estimated annual population of the State of São Paulo.

Results

The study population consisted of 10,451 (46.16%) CD patients and 12,187 (53.84%) UC patients. The mean age was 42.66 (SD±16.2) years for the CD group and 47.87 (SD±16.6) years for the UC group. There was a predominance of females corresponding to 59.70% of the study population (female:male =1.48:1.00; P<0.0001). The incidence of IBD was 13.30 new cases/100,000 inhabitants per year, while the overall prevalence was 52.6 cases/100,000 inhabitants.

Conclusion

This population-based study demonstrated a stability in IBD incidence rates and an increase in IBD prevalence rates in São Paulo state between 2012 and 2015. The IBD incidence and prevalence rates were comparable to European countries, with a higher occurrence in the female participants.

SERUM INFLIXIMAB MEASUREMENT IN INFLAMMATORY BOWEL DISEASE PATIENTS IN REMISSION: A COMPARATIVE ANALYSIS OF TWO DIFFERENT METHODS IN A MULTICENTRIC BRAZILIAN COHORT

BACKGROUND

Infliximab (IFX) therapeutic drug monitoring is an important tool to guide therapeutic decision in inflammatory bowel disease patients. Currently, there are two methods to measure trough levels of IFX, ELISA assays or rapid tests. Despite that the ELISA assay is the most used method in therapeutic drug monitoring, the results take long to be available for clinical use, and it needs to be performed by trained personnel. In contrary, the results of a rapid test take 20 to 30 minutes to be available and can be performed by non-trained lab personnel.

OBJECTIVE

The aim of the study was to compare a rapid test (QB-IFX) for quantitative determination of IFX level to one ELISA assay in a cohort of inflammatory bowel disease patients.

METHODS

Cross-sectional multicentric study with 49 inflammatory bowel disease patients on maintenance therapy with IFX. Blood samples for IFX serum levels were collected immediately before infusion. IFX serum levels were classified as undetectable, low (<3.0 μg/mL), adequate (3.1-7.0 μg/mL) or high (>7.1 μg/mL). A sensitivity and specificity of each test and a comparison between tests was based on ROC curves.

RESULTS

Thirty-four Crohn's disease patients and 15 ulcerative colitis patients in clinical remission were evaluated. The majority of patients had low or adequate serum levels of IFX. In relation to the serum levels proportions with the two methods, there was no significant difference (P=0.84). The ROC analysis identified a concentration threshold >2.9 μg/mL with the QB-IFX test (area under the ROC, 0.82; P<0.0001, sensitivity, 100%; specificity, 61.9%), and >3.83 μg/mL using the ELISA assay (area under the ROC, 0.96; P<0.0001, sensitivity, 100%; specificity, 92.9%).

CONCLUSION

QB-IFX and ELISA assays to measure IFX levels were comparable. Both methods had accurate sensitivity and specificity to detect undetectable, low and adequate levels, but had showed low specificity for supra therapeutic levels of IFX.

ADALIMUMAB FOR ULCERATIVE COLITIS: RESULTS OF A BRAZILIAN MULTICENTER OBSERVATIONAL STUDY

BACKGROUND

Adalimumab is a monoclonal antibody, tumor necrosis factor-alpha (TNFα) inhibitor that has efficacy for inducing and maintaining remission in moderate-to-severe ulcerative colitis. Real world studies with adalimumab in Latin American ulcerative colitis patients are scarce.

OBJECTIVE

To assess the clinical remission rates in induction and maintenance with adalimumab therapy in ulcerative colitis.

METHODS

Observational, multicenter and retrospective study on a case series of patients with moderate-to-severe ulcerative colitis under adalimumab therapy. The variables analyzed were: demographic data, previous infliximab status, concomitant drugs, the Montreal Classification, disease activity (Mayo score) at weeks 0, 8, 26 and 52, or until the last follow-up. Clinical remission was defined as a partial Mayo score ≤2 and Last observation carried forward (LOCF) and Non responder imputation (NRI) analysis were used.

RESULTS

Thirty-six patients were included in the study. With LOCF analysis, remission rates at weeks 8, 26 e 52 were of 41.7%, 47.2% and 47.2%, respectively. With NRI analysis, remission rates at weeks 8, 26 and 52 were of 41.7%, 41.7% and 27.8%, respectively.

CONCLUSION

Adalimumab was effective in the treatment of moderate-to-severe ulcerative colitis. Clinical remission was observed in approximately 40% of the patients at weeks 8 and 26, and in almost a quarter of the patients after 1 year of follow up.

Factors affecting the incidence of early endoscopic recurrence after ileocolonic resection for Crohn's disease: a multicentre observational study

AIM

Early endoscopic recurrence is frequently observed in patients following resection for Crohn's disease (CD). However, factors affecting the incidence of an early postoperative endoscopic recurrence (EPER) have not been fully determined. The aim of this study was to evaluate risk factors for EPER after ileocolonic resection for CD.

METHOD

This was a retrospective, international multicentre study, in which 127 patients with a first ileocolonoscopy conducted between 6 and 12 months after ileocolonic resection for CD were included. Endoscopic recurrence was defined as a Rutgeerts score of ≥ i2. The following variables were investigated as potential risk factors for EPER: gender, age at surgery, location and behaviour of CD, smoking, concomitant perianal lesions, preoperative use of steroids, immunomodulators and biologics, previous resection, blood transfusion, surgical procedure (open vs laparoscopic approach), length of resected bowel, type of anastomosis (side-to-side vs end-to-end), postoperative complications, granuloma and postoperative biological therapy. Variables related to the patient, disease and surgical procedure were investigated as potential risk factors for EPER, with univariate and multivariate (logistic regression) analyses.

RESULTS

43/127 (34%) patients had EPER at the time of the first postoperative ileocolonoscopy. In univariate analysis, only preoperative steroid use was significantly associated with a higher rate of EPER [21/45 patients (47%) on steroids and 22/82 patients (27%) without steroids (P = 0.04)]. In multivariate analysis, only preoperative steroid use was a significant independent risk factor for EPER (odds ratio 3.28, 95% confidence interval: 1.30-8.28; P = 0.01).

CONCLUSIONS

This study found that only preoperative steroid use was a significant risk factor for EPER after ileocolonic resection for CD. Prospective studies are necessary to evaluate precisely the impact of perioperative medications on EPER rates.

Risk factors for complications after ileocolonic resection for Crohn's disease with a major focus on the impact of preoperative immunosuppressive and biologic therapy: A retrospective international multicentre study

BACKGROUND

Author note: TY, AS, YS, FVT and PGK designed the study. All authors did data collection and gave scientific contribution to the study design and discussion. TY, AS and PGK drafted the article. All authors read and approved the final version of the manuscript.In the era of biologic agents, risk factors for complications following resection for Crohn's disease have not been fully identified. In particular, the association of preoperative use of immunosuppressive and biologic agents with the incidence of complications after resection remains to be elucidated.

AIM

This retrospective multicentre study aimed to identify risk factors for complications after ileocolonic resection for Crohn's disease, with a major focus on the impact of preoperative immunosuppressive and biologic therapy.

METHODS

A total of 231 consecutive patients who underwent ileocolonic resections for active Crohn's disease in seven inflammatory bowel disease referral centres from three countries (Japan, Brazil and Italy) were included. The following variables were investigated as potential risk factors: age at surgery, gender, behaviour of Crohn's disease (perforating vs. non-perforating disease), smoking, preoperative use (within eight weeks before surgery) of steroids, immunosuppressants and biologic agents, previous resection, blood transfusion, surgical procedure (open vs. laparoscopic approach), and type of anastomosis (side-to-side vs. end-to-end). Postoperative complications occurring within 30 days after surgery were recorded.

RESULTS

The rates of overall complications, intra-abdominal sepsis, and anastomotic leak were 24%, 12% and 8%, respectively. Neither immunosuppressive nor biologic therapy prior to surgery was significantly associated with the incidence of overall complications, intra-abdominal sepsis or anastomotic leak. In multivariate analysis, blood transfusion, perforating disease and previous resection were significant risk factors for overall complications (odds ratio [OR] 3.02, 95% confidence interval [CI] 1.21-7.52; P = 0.02), intra-abdominal sepsis (OR 2.67, 95% CI 1.04-6.86; P = 0.04) and anastomotic leak (OR 2.87, 95% CI 1.01-8.18; P = 0.048), respectively.

CONCLUSIONS

Blood transfusion, perforating disease and previous resection were significant risk factors for overall complications, intra-abdominal sepsis and anastomotic leak after ileocolonic resection for Crohn's disease, respectively. Preoperative immunosuppressive or biologic therapy did not increase the risk of postoperative complications.

Direct retrospective comparison of adalimumab and infliximab in preventing early postoperative endoscopic recurrence after ileocaecal resection for crohn's disease: results from the MULTIPER database

BACKGROUND AND AIMS

Both adalimumab [ADA] and infliximab [IFX] seem to be effective in the prevention of early postoperative endoscopic recurrence [EPER] after ileocaecal resection in Crohn's disease [CD] patients. There is lack of data with direct comparison between the two agents in the postoperative scenario. The aim of this study was to compare the rates of EPER in patients treated with ADA and IFX after ileocaecal resection for CD.

METHODS

This was a multicentre retrospective analysis of EPER rates in CD patients after ileocaecal resections, from seven referral centres in three countries. Endoscopic recurrence was defined as Rutgeerts' score ≥ i2. The patients were allocated according to treatment to two groups: ADA or IFX. The EPER rates were compared between the two treatment groups.

RESULTS

Among the 168 patients included in the database, 96 received anti-tumour necrosis factor [TNF] agents after resection [37 in the ADA and 59 in the IFX groups] and were included in this comparative study. The groups were comparable in all baseline characteristics, mainly age, gender, previous resections, perianal CD, and mono or combination therapy. EPER was identified in 9/37 [24.32%] in the ADA group vs 16/59 [27.12%] in the IFX group [p = 0.815].

CONCLUSIONS

In this retrospective direct comparison between ADA and IFX therapy after ileocaecal resection, there was no significant difference between the two anti-TNF agents in terms of EPER rates. However, prospective randomised studies are needed to confirm these data and better define the role of each agent in the prevention of EPER.

Impact on overall survival and disease-free survival of adjuvant chemotherapy after neoadjuvant chemoradiotherapy for rectal cancer

e14173

Background: Colorectal cancer is the second most common cancer with 2,4 million people diagnosed. The rectal cancer (RC) is 27% of these cases. Neoadjuvant chemoradiotherapy (NCRT) has become standard but brought controversy in the adjuvant treatment. The objective was to assess the impact of adjuvant chemotherapy after NCRT. Methods: Between mar/96 and Oct/2010, 84 patients received NCRT, and 58 patients underwent resection of the rectum. The NCRT consisted of 5-FU 350mg/m2, D1-D5 (50% of cases) or 5-FU 425mg/m2, D1-D3 (43%) with LV 20mg/m2 bolus in the 1st and 5th week of the 25 sessions of radiotherapy in linear accelerator (total 45 - 50 Gy). When performed, Adjuvant chemotherapy (ADJC) consisted of 5-FU 425mg/m2, LV 20mg/m2, both on D1-D5 for 4 cycles. Evaluation of Overall Survival (O.S) and Disease-Free Survival (DFS) performed using Kaplan-Meier curve in SPSS version 13.0 Results: Of the 58 patients who underwent surgery, 90% were stage II, 51% occurred in the lower rectum and 66% were ECOG 1. Pathologic Complete Response (PCR) was obtained in 25.8% (15) of patients (group 1). Of these, 20% (3) received ADJC. Patients without PCR (group 2) received ADJC in 51% of the cases (22). The mean follow-up was 41 months. Both the DFS (HR: 2.594, 95% CI: 1134-5938, p = 0.024) and OS (HR: 2.615, 95% CI: 1005-6807, p = 0.0488) were higher in patients with PCR independent of the use of ADJC. On the other hand, patient treated with ADJC vs without ADJC, independent of presence of PCR, did not alter DFS (p = 0.74) or OS (p = 0.32). In PCR patients, ADJC do not interfere in the outcome (DFS, p = 0.76; SG, p = 0.73). In group 2 (patients without PCR), the subgroup with ADJC, there was a trend towards better SLD (p = 0.06) and OS (p = 0.06). Those who did not receive ADJC in group 2 had worse SLD (p = 0.011) and OS (p = 0.028) compared with group-1. Conclusions: Adjuvant treatment after NCRT did not increase OS or DFS. Patients without PRC had worse results without ADJC, compared to those with PCR. The first, probably, the subgroup of patients who benefited most from the use of ADJC. PCR improves OS and DFS regardless of ADJC, being perhaps the group that does not deserve ADJC.

Effects of intraperitoneal injection of phenol, glycerin and acetic acid on neoplastic ascitis in guinea pigs

PURPOSE

To investigate the histolytic action of a solution composed by phenol, glycerin and acetic acid on neoplastic ascitis in guinea pigs.

METHODS

Thirty-two guinea pigs were used. The animals were randomly distributed in experimental and control groups, and the effects of the peritoneal injection of the testing solution were studied. Saline solution was used for the control groups. Biochemical and anatomopathological (heart, lungs, kidneys, spleen and peritoneal serous membrane) were evaluated at 24 hours and 4 weeks of development.

RESULTS

It was observed that solution E, when infused into the peritoneal cavity, caused no clinical, histological or laboratory alterations in these animals when compared to those in the control group.

CONCLUSION

Given our results, it would be interesting to study the effects of the proposed solution on cases with experimental neoplastic ascites with a later view to treating it in humans.