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P147 Role of endoscopic biopsy in distinguishing between Crohn's disease and intestinal tuberculosis
S122 P144 Sarcopenia and osteopenia in patients with Crohn’s disease I.A. Pintilie *, I. Cracana, O. Jigaranu, C. Mihai, C. Cijevschi. University of Medicine and Pharmacy “Gr. T. Popa” Iasi, Institute of Gastroenterology, Iasi, Romania Background: Patients with Crohn’s disease (CD) are prone to sarcopenia and osteopenia. Sarcopenia represents the loss of muscle mass and strength, and is considered as well as osteopenia secondary to malnutrition. The aim of the study was to determine the prevalence of sarcopenia and osteopenia in CD patients and its relationship. Methods: We included 48 cases with CD (23 female/25 male; median age of 40 years ±15; body mass index (BMI) 20.36±3.6) and 20 healthy volunteers (10 female/10 male; median age 40 years ±15; BMI 23.2±2.7). Sarcopenia was assessed by grip strength (estimate muscle strength) and dual-energy x-ray absorptiometry (DXA) (estimate lean body mass) and defined as a skeletal muscle index (SMI) below 5.45 kg/m2 for women and 7.26 kg/m2 for men. Osteopenia was defined as a T-score for bone mineral density (BMD) below 1.0 measured by DXA. Results: We found sarcopenia in 56.2% of CD patients and osteopenia in 47.9% vs 15% and 5% of controls, respectively (P < 0.01). HGS, SMI as well as BMD was significantly lower in patients with CD than in controls (35 kg ±5 vs. 50 kg ±10; 5.9 kg/m2 ±1.2 vs. 6.4 kg/m2 ±1.5; 1.7 g/cm2 ±0.6 vs. 0.9 g/cm2 ±0.3; P < 0.01). Sarcopenic patients had significantly (P < 0.01) lower BMI (19.64 versus 21.9) than non-sarcopenic patients; 74% of sarcopenic patients were also osteopenic. Conclusions: The prevalence of sarcopenia and osteopenia is high in CD patients. These two phenomens may share similar mechanisms. Screening for sarcopenia and osteopenia may play an important role in the evaluation of CD patients. P145 Small bowel capsule endoscopy for assessing the early postoperative recurrence of Crohn’s disease: Correlation with the endoscopic score at 6 and 12 months in a prospective study G. Condino1 *, E. Calabrese1 , S. Onali1 , E. Lolli1 , M. Ascolani1 , F. Zorzi1 , G. Sica2 , C. Petruzziello1 , F. Pallone1 , L. Biancone1 . 1 Universit` a di Roma Tor Vergata, Medicina dei sistemi, cattedra di Gastroenterologia, Roma, Italy, 2 Universit` a di Roma Tor Vergata, Chirurgia, Roma, Italy Background: The role of Small Bowel Capsule Endoscopy (SBCE) for assessing early Crohn’s Disease (CD) recurrence is undefined. In a prospective longitudinal study, we aimed to compare the usefulness of SBCE for assessing the early postoperative recurrence of CD, when using ileocolonoscopy (IC) as gold standard. Whether SBCE visualizes the proximal small bowel (SB) lesions not detected by standard imaging and the interobserver variation was also assessed. Methods: From Feb. 2011-October 2013, all consecutive patients (pts) undergoing ileo-colonic resection for CD were enrolled. Clinical assessment (CDAI) was performed at 3, 6, 12 months (mos). Recurrence was assessed by IC 6 mos (T6) and at 12 mos (T12) (Rutgeerts’ score: recurrence 1). Small Intestine Contrast Ultrasonography (SICUS) was performed at T6 followed, 4 wks, by SBCE in pts with no stenosis. CD lesions at SBCE were blindly graded by 2 gastroenterologists (score 0 3, recurrence 1; Buchman AJG2004). Statistical analysis: Data expressed as median (range). Student’s T test. Results: Enrolled pts were 26 (17M, age 36, range 19 74). SBCE was not performed in 15 pts, due to impact risk (n = 6), low compliance to perform SBCE (n = 7) or IC (n = 2). At T6, clinical recurrence (CDAI >150) occurred in 1/11 pts performing the 3 procedures and endoscopic recurrence in 9/11 pts (grades: 1:n = 2; 2:n = 4; 3:n = 3). At T6, findings compatible with recurrence were detected by SICUS in 7/11 pts (7TP; 2TN; 2FN) and by SBCE in 10/11 pts (both observers: grade
Poster presentations 3:n = 10; grade 0:n = 1; 9TP, 1TN, 1FP; 100% agreement). In 4/11 pts, SBCE showed multiple aphtoid ulcers in the proximal SB not detected by standard imaging. No SBCE retention was observed. At 12mos, 9/11 pts already performed IC, showing recurrence 7/7 pts with evaluable anastomosis (grade 2:n = 5; 3:n = 1; 0:n = 1). When the analysis was restricted to the 7 pts already completing the study, clinical recurrence was observed in 1pt at T6 and in 2pts at T12. The SBCE score at T6 was not correlated with the endoscopic score at T6 (p = 0.19; r = 0.55). Differently, the SBCE score at T6 was significantly correlated with the endoscopic score at T12 (p = 0.004; r = 0.91). Conclusions: Early after surgery for CD, SBCE may visualize superficial lesions of the proximal SB not detected by standard techniques. The severity of CD lesions assessed by SBCE early after surgery appears significantly correlated with the endoscopic score at 1 year. P146 Role of fecal neutrophil gelatinase-associated lipocalin assessment in patients with inflammatory bowel disease D. Mukhametova1 , D. Abdulganieva1 *, O. Zinkevich2 , N. Saphina2 , A. Odintsova3 , M. Koporulina2 . 1 Kazan State Medical University, Hospital Therapy, Kazan, Russian Federation, 2 Kazan State Medical Academy, Central Research Laboratory, Kazan, Russian Federation, 3 Republican Clinical Hospital, Department of Gastroenterology, Kazan, Russian Federation Background: Neutrophil gelatinase-associated lipocalin (NGAL) is known as a marker of intestinal inflammation. Aim: To evaluate the fecal concentration of NGAL in different courses of inflammatory bowel disease (IBD). Methods: We prospectively included 33 patients with IBD exacerbation [11 pts with Crohn’s disease (CD) and 22 pts with ulcerative colitis (UC)] and 11 healthy volunteers. The concentration of NGAL in faeces was determined by enzyme immunoassay. The average age of patients with CD was 40.9±4.2 years, UC 40.7±11.3 years, in the control group 31.1±3.6 years. Severity of UC was assessed by Mayo score: mild UC was seen in 4 (18.2%), moderate 12 (54.5%), severe 6 (27.3%), in CD by CDAI: mild 1 (9%), moderate 5 (45.5%), severe 5 (45.5%). Results: Fecal NGAL level was increased in both UC and CD exacerbation. In active CD [mean 5924.27±2067.6 ng/ml] (p < 0.01) and UC [mean 5826.09±891.8 ng/ml] (p < 0.001) NGAL levels were higher than in the control group [mean 658.8±237.7 ng/ml]. Concentration of fecal NGAL correlated with the severity of CD: in severe attacks NGAL level were increased (r = 0.74; p = 0.008), in UC we observed only tendency. Also in CD NGAL levels had a significant correlation with the C-reactive protein (r = 0.77; p = 0.04), as well as with some clinical features the severity of fever (r = 0.75; p < 0.05), in UC we didn’t found any correlations. Conclusions: The fecal concentration of neutrophil gelatinaseassociated lipocalin significantly increased during flare of IBD. The concentration of NGAL was more informative in CD correlated with the severity and activity of CD. P147 Role of endoscopic biopsy in distinguishing between Crohn’s disease and intestinal tuberculosis R. Thomas1 , P. Kakkadasam Ramaswami2 *, H. Joshi2 , N. Toke2 , C. Panackel2 , S. Mathai2 . 1 Medical Trust Hospital, Department of Pathology, Ernakulam, India, 2 Medical Trust Hospital, Department of Gastroenterology, Ernakulam, India Background: Distinguishing Crohn’s disease (CD) from Intestinal Tuberculosis (ITB) in endemic areas is challenging as both conditions have overlapping clinical, radiological, endoscopic
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and histological characteristics. The aim of this study was to revalidate existing pathological criteria that have been claimed to be useful in differentiating these two conditions and to identify simple, practically useful parameters. Methods: Fifty patients with a diagnosis of Ileocolonic Crohn’s Disease or Intestinal tuberculosis from July 2011 to April 2013 based on established clinical, endoscopic and histological features and with a follow up for a minimum period of 6 months were retrospectively evaluated. A total of 29 patients with a diagnosis of CD and 21 patients with ITB were included. All patients had undergone full length colonoscopic examination with mucosal biopsies. Upper GI Endoscopy and gastric antral biopsies were available in 24 patients (22 CD and 2 ITB). A total of 109 sites from patients with CD and 34 sites from patients with ITB were studied. Segmental colonic biopsies from 3 or more sites were available in 19 CD patients and 3 patients with ITB. Selected histological parameters which were reported in previous studies as salient distinguishing features between CD and ITB were evaluated. Results: A morphological diagnosis was possible in 26 cases of CD (90%) and 17 cases of ITB (81%). The features in the remaining 7 cases (3 CD and 4 ITB) were not distinctive enough to make a categorical diagnosis. Endoscopic changes in three or more colonic segments were present in 17/29 cases of CD (58.6%) but only in 5/21 (23.8%) cases of ITB. Terminal ileal involvement was present in all cases of ITB with 16 cases (76%) showing changes at that site only. In contrast, changes restricted to terminal ileum was seen in only 5 cases of CD (17%) and 7 cases showed normal ileal mucosa. Granulomas were present in all the 29 cases of CD (100%) and 19 cases of TB (91%). Table: Histological parameters in patients with intestinal tuberculosis (ITB) and Crohn’s disease (CD) ITB (n = 21) CD (n = 29) Caseous necrosis 29 Confluent granulomas 71 >5 granulomas/biopsy 43 Large granulomas 57 Pericryptal granuloma 5 Microgranuoma 19 Ulcers lined by epitheloid histiocytes 43 Lymphoid cuff 63
00 24 28 3 48 66 17 48
Values in are percentages. The table shows the features of granulomas in our study. Granulomatous inflammation in more than one segment was seen in 85% of CD patients. 16/22 (73%) patients with CD showed focally enhanced gastritis +/ granulomas. Gastroscopy was normal in 12 of these patients indicating the absence of correlation with gastroscopic findings. Conclusions: In our study, large granulomas and crypt related granuloma were features favouring TB and CD respectively. None of the previous studies have included Gastric antral biopsies which, we feel, significantly increases the diagnostic yield. P148 Role of interferon gamma release assay (IGRA) in differentiating gastrointestinal tuberculosis from Crohn’s disease P. Kakkadasam Ramaswami *, H. Joshi, N. Toke, C. Panackel, S. Mathai. Medical Trust Hospital, Department of Gastroenterology, Ernakulam, India Background: The clinical, endoscopic, and histological features of Crohn’s disease (CD) and Intestinal Tuberculosis (ITB) mimic each other so much that it becomes difficult to differentiate
between them. The aim of our study was to assess the sensitivity and specificity of IGRA in differentiating the two diseases. Methods: We prospectively included 53 patients with Ileocolonic ulcers and 30 normal subjects as controls. Demographic, clinical, laboratory, endoscopic and histological features were noted. All patients were evaluated with a IGRA [QuantiFERONGOLD TB (QGTB)]. Patients were diagnosed as either ITB or CD based on clinical, endoscopic and histologic criteria. Patients were followed up and a repeat colonoscopy was performed at the end of 3 months of treatment; diagnosis was revised if the patient did not demonstrate mucosal healing or an improvement when compared to the previous colonoscopy. Results: Twenty-eight (52.8%) patietnts were male, and the mean age was 36.7 years (Range 10 81 years). A final diagnosis of CD was made in 35 patients (66%), ITB in 18 patients (34%). QGTB test was positive in 22 patients, of which 17 patients had a final diagnosis of ITB and 5 patients had CD. One patient who had a final diagnosis of Tuberculosis had a negative QGTB test. Of the 18 patients with Intestinal Tuberculosis, two patients also had evidence of disseminated Tuberculosis. Table 1. Clinical characteristics of the two groups
Male/Female Mean age in years (range) Abdomial pain Bleeding PR Diarrhoea Weight loss Fever Stricturing disease Fistulizing disease
CD (n = 35)
TB (n = 18)
18/17 32.7 (10 65) 30 (85%) 8 (22.8%) 24 (68.5%) 21 (60%) 3 (8.5%) 8 (23%) 6 (17%)
10/8 44 (18 81) 17 (94%) 00 9 (50%) 13 (72%) 8 (44%) 00 1 (5.5%)
Table 1 shows the clinical characteristics of the patients. All 30 control subjects had a negative test. The sensitivity of the QGTB test was 94.4% and specificity was 85.7%. Positive Predictive Value was 77.2%, negative predictive value was 96.7%. Conclusions: The QGTB Test is both sensitive and specific for diagnosing Gastrointestinal Tuberculosis and can be useful in differentiating Tuberculosis from Crohn’s Disease. P149 Risk factors for post-colectomy complications in patients with ulcerative colitis Y. Hirayama *, T. Ando, K. Ishiguro, O. Maeda, O. Watanabe, K. Morise, K. Maeda, M. Matsushita, K. Furukawa, K. Funasaka, M. Nakamura, R. Miyahara, H. Goto. Nagoya University Graduate School of Medicine, Departmant of Gastroenterology and Hepatology, Nagoya, Japan Background: Despite a wide range of treatment options, a significant proportion of patients with ulcerative colitis (UC) remain refractory to medical therapy. About 20 30% of patients with UC may require colectomy for treatment of their disease, and sometimes experience postoperative complications. Methods: We conducted this study in an attempt to clarify the risk factors for post-colectomy complications. The records of 72 consecutive patients who underwent proctocolectomy with ileal pouch-anal anastomosis or subtotal colectomy with ileostomy for UC from April 2003 to December 2012 were reviewed. Statistical analysis included univariate and multivariate studies of clinical and biological parameters. Results: 72 patients (M/F: 43/29) who underwent colectomy for UC were enrolled. 11 cases of dysplasia and colitic cancer were also included. Age at onset was 29.3±14.4 years. Age at surgery
Poster presentations 3:n = 10; grade 0:n = 1; 9TP, 1TN, 1FP; 100% agreement). In 4/11 pts, SBCE showed multiple aphtoid ulcers in the proximal SB not detected by standard imaging. No SBCE retention was observed. At 12mos, 9/11 pts already performed IC, showing recurrence 7/7 pts with evaluable anastomosis (grade 2:n = 5; 3:n = 1; 0:n = 1). When the analysis was restricted to the 7 pts already completing the study, clinical recurrence was observed in 1pt at T6 and in 2pts at T12. The SBCE score at T6 was not correlated with the endoscopic score at T6 (p = 0.19; r = 0.55). Differently, the SBCE score at T6 was significantly correlated with the endoscopic score at T12 (p = 0.004; r = 0.91). Conclusions: Early after surgery for CD, SBCE may visualize superficial lesions of the proximal SB not detected by standard techniques. The severity of CD lesions assessed by SBCE early after surgery appears significantly correlated with the endoscopic score at 1 year. P146 Role of fecal neutrophil gelatinase-associated lipocalin assessment in patients with inflammatory bowel disease D. Mukhametova1 , D. Abdulganieva1 *, O. Zinkevich2 , N. Saphina2 , A. Odintsova3 , M. Koporulina2 . 1 Kazan State Medical University, Hospital Therapy, Kazan, Russian Federation, 2 Kazan State Medical Academy, Central Research Laboratory, Kazan, Russian Federation, 3 Republican Clinical Hospital, Department of Gastroenterology, Kazan, Russian Federation Background: Neutrophil gelatinase-associated lipocalin (NGAL) is known as a marker of intestinal inflammation. Aim: To evaluate the fecal concentration of NGAL in different courses of inflammatory bowel disease (IBD). Methods: We prospectively included 33 patients with IBD exacerbation [11 pts with Crohn’s disease (CD) and 22 pts with ulcerative colitis (UC)] and 11 healthy volunteers. The concentration of NGAL in faeces was determined by enzyme immunoassay. The average age of patients with CD was 40.9±4.2 years, UC 40.7±11.3 years, in the control group 31.1±3.6 years. Severity of UC was assessed by Mayo score: mild UC was seen in 4 (18.2%), moderate 12 (54.5%), severe 6 (27.3%), in CD by CDAI: mild 1 (9%), moderate 5 (45.5%), severe 5 (45.5%). Results: Fecal NGAL level was increased in both UC and CD exacerbation. In active CD [mean 5924.27±2067.6 ng/ml] (p < 0.01) and UC [mean 5826.09±891.8 ng/ml] (p < 0.001) NGAL levels were higher than in the control group [mean 658.8±237.7 ng/ml]. Concentration of fecal NGAL correlated with the severity of CD: in severe attacks NGAL level were increased (r = 0.74; p = 0.008), in UC we observed only tendency. Also in CD NGAL levels had a significant correlation with the C-reactive protein (r = 0.77; p = 0.04), as well as with some clinical features the severity of fever (r = 0.75; p < 0.05), in UC we didn’t found any correlations. Conclusions: The fecal concentration of neutrophil gelatinaseassociated lipocalin significantly increased during flare of IBD. The concentration of NGAL was more informative in CD correlated with the severity and activity of CD. P147 Role of endoscopic biopsy in distinguishing between Crohn’s disease and intestinal tuberculosis R. Thomas1 , P. Kakkadasam Ramaswami2 *, H. Joshi2 , N. Toke2 , C. Panackel2 , S. Mathai2 . 1 Medical Trust Hospital, Department of Pathology, Ernakulam, India, 2 Medical Trust Hospital, Department of Gastroenterology, Ernakulam, India Background: Distinguishing Crohn’s disease (CD) from Intestinal Tuberculosis (ITB) in endemic areas is challenging as both conditions have overlapping clinical, radiological, endoscopic
Clinical: Diagnosis & outcome
S123
and histological characteristics. The aim of this study was to revalidate existing pathological criteria that have been claimed to be useful in differentiating these two conditions and to identify simple, practically useful parameters. Methods: Fifty patients with a diagnosis of Ileocolonic Crohn’s Disease or Intestinal tuberculosis from July 2011 to April 2013 based on established clinical, endoscopic and histological features and with a follow up for a minimum period of 6 months were retrospectively evaluated. A total of 29 patients with a diagnosis of CD and 21 patients with ITB were included. All patients had undergone full length colonoscopic examination with mucosal biopsies. Upper GI Endoscopy and gastric antral biopsies were available in 24 patients (22 CD and 2 ITB). A total of 109 sites from patients with CD and 34 sites from patients with ITB were studied. Segmental colonic biopsies from 3 or more sites were available in 19 CD patients and 3 patients with ITB. Selected histological parameters which were reported in previous studies as salient distinguishing features between CD and ITB were evaluated. Results: A morphological diagnosis was possible in 26 cases of CD (90%) and 17 cases of ITB (81%). The features in the remaining 7 cases (3 CD and 4 ITB) were not distinctive enough to make a categorical diagnosis. Endoscopic changes in three or more colonic segments were present in 17/29 cases of CD (58.6%) but only in 5/21 (23.8%) cases of ITB. Terminal ileal involvement was present in all cases of ITB with 16 cases (76%) showing changes at that site only. In contrast, changes restricted to terminal ileum was seen in only 5 cases of CD (17%) and 7 cases showed normal ileal mucosa. Granulomas were present in all the 29 cases of CD (100%) and 19 cases of TB (91%). Table: Histological parameters in patients with intestinal tuberculosis (ITB) and Crohn’s disease (CD) ITB (n = 21) CD (n = 29) Caseous necrosis 29 Confluent granulomas 71 >5 granulomas/biopsy 43 Large granulomas 57 Pericryptal granuloma 5 Microgranuoma 19 Ulcers lined by epitheloid histiocytes 43 Lymphoid cuff 63
00 24 28 3 48 66 17 48
Values in are percentages. The table shows the features of granulomas in our study. Granulomatous inflammation in more than one segment was seen in 85% of CD patients. 16/22 (73%) patients with CD showed focally enhanced gastritis +/ granulomas. Gastroscopy was normal in 12 of these patients indicating the absence of correlation with gastroscopic findings. Conclusions: In our study, large granulomas and crypt related granuloma were features favouring TB and CD respectively. None of the previous studies have included Gastric antral biopsies which, we feel, significantly increases the diagnostic yield. P148 Role of interferon gamma release assay (IGRA) in differentiating gastrointestinal tuberculosis from Crohn’s disease P. Kakkadasam Ramaswami *, H. Joshi, N. Toke, C. Panackel, S. Mathai. Medical Trust Hospital, Department of Gastroenterology, Ernakulam, India Background: The clinical, endoscopic, and histological features of Crohn’s disease (CD) and Intestinal Tuberculosis (ITB) mimic each other so much that it becomes difficult to differentiate
between them. The aim of our study was to assess the sensitivity and specificity of IGRA in differentiating the two diseases. Methods: We prospectively included 53 patients with Ileocolonic ulcers and 30 normal subjects as controls. Demographic, clinical, laboratory, endoscopic and histological features were noted. All patients were evaluated with a IGRA [QuantiFERONGOLD TB (QGTB)]. Patients were diagnosed as either ITB or CD based on clinical, endoscopic and histologic criteria. Patients were followed up and a repeat colonoscopy was performed at the end of 3 months of treatment; diagnosis was revised if the patient did not demonstrate mucosal healing or an improvement when compared to the previous colonoscopy. Results: Twenty-eight (52.8%) patietnts were male, and the mean age was 36.7 years (Range 10 81 years). A final diagnosis of CD was made in 35 patients (66%), ITB in 18 patients (34%). QGTB test was positive in 22 patients, of which 17 patients had a final diagnosis of ITB and 5 patients had CD. One patient who had a final diagnosis of Tuberculosis had a negative QGTB test. Of the 18 patients with Intestinal Tuberculosis, two patients also had evidence of disseminated Tuberculosis. Table 1. Clinical characteristics of the two groups
Male/Female Mean age in years (range) Abdomial pain Bleeding PR Diarrhoea Weight loss Fever Stricturing disease Fistulizing disease
CD (n = 35)
TB (n = 18)
18/17 32.7 (10 65) 30 (85%) 8 (22.8%) 24 (68.5%) 21 (60%) 3 (8.5%) 8 (23%) 6 (17%)
10/8 44 (18 81) 17 (94%) 00 9 (50%) 13 (72%) 8 (44%) 00 1 (5.5%)
Table 1 shows the clinical characteristics of the patients. All 30 control subjects had a negative test. The sensitivity of the QGTB test was 94.4% and specificity was 85.7%. Positive Predictive Value was 77.2%, negative predictive value was 96.7%. Conclusions: The QGTB Test is both sensitive and specific for diagnosing Gastrointestinal Tuberculosis and can be useful in differentiating Tuberculosis from Crohn’s Disease. P149 Risk factors for post-colectomy complications in patients with ulcerative colitis Y. Hirayama *, T. Ando, K. Ishiguro, O. Maeda, O. Watanabe, K. Morise, K. Maeda, M. Matsushita, K. Furukawa, K. Funasaka, M. Nakamura, R. Miyahara, H. Goto. Nagoya University Graduate School of Medicine, Departmant of Gastroenterology and Hepatology, Nagoya, Japan Background: Despite a wide range of treatment options, a significant proportion of patients with ulcerative colitis (UC) remain refractory to medical therapy. About 20 30% of patients with UC may require colectomy for treatment of their disease, and sometimes experience postoperative complications. Methods: We conducted this study in an attempt to clarify the risk factors for post-colectomy complications. The records of 72 consecutive patients who underwent proctocolectomy with ileal pouch-anal anastomosis or subtotal colectomy with ileostomy for UC from April 2003 to December 2012 were reviewed. Statistical analysis included univariate and multivariate studies of clinical and biological parameters. Results: 72 patients (M/F: 43/29) who underwent colectomy for UC were enrolled. 11 cases of dysplasia and colitic cancer were also included. Age at onset was 29.3±14.4 years. Age at surgery