- Email: [email protected]
Tu1289 An Unusual Cluster of IBD in a Town Downstream From a Potential Environmental Risk Factor
AGA Abstracts
questionnaire for CD found breastfed infants were protected from the development of CD (OR 0.272, 95% CI 0.087-0.855) but not UC. Dietary factors in the US included yogurt 5ydx that was protective for CD (OR 0.284, 95% CI 0.11-0.73) and fish 5ydx that was protective for UC (OR 0.359, 95% CI 0.16-0.83). These factors were not significant in India. In the OSCCAR subset, more education, and well water vs. a government source each reduced the risk of UC (MV). No other significant associations were found by the environmental questionnaire including socioeconomic status, born in hospital, Caesarean section, lefthandedness, fast food and alcohol use among others. Conclusion: Risk factors for IBD are not uniform in different countries. IBD in emerging countries may result from a different set of environmental factors than those identified in western countries.
Percentage of patients treated with different medication for induction of remission for the last relapse
Percentage of patients continued treatment with different medication for maintenance of remission after the last relapse
Tu1289 An Unusual Cluster of IBD in a Town Downstream From a Potential Environmental Risk Factor Sharyle A. Fowler, Molly Nestor, Elisabeth B. Cole, Joshua R. Korzenik
Tu1291
Background: The geographic proximity of clusters of patients with the same disease may be useful in identifying a common environmental risk factor. A potential cluster of patients with inflammatory bowel disease (IBD) was identified in Northport, Washington (NWA), a town of 297 people (2010 census). NWA is located along the Columbia River, just south of Trail, British Columbia, the location of a large lead and zinc smelter. Aims: To identify and verify IBD cases among residents of NWA and assess potential environmental risk factors. Methods: Questionnaires were developed to ascertain medical history, environmental risks for IBD, and exposures relating to the smelter. These were delivered by post, email and in person to those who lived or currently live in NWA. Medical records were requested for those reporting IBD. Analysis utilized healthy controls matched first for time/era in NWA, and then by age and sex. As the population of NWA has remained stable around 350, we conservatively estimated an at risk population of 525 for incidence calculations (95%CI calculated assuming a Poisson distribution). Results: Of the 119 surveys returned there were 19 cases of self-reported IBD. Medical records were obtained confirming 16 cases and excluding 2. Records are pending in one case of probable IBD based on questionnaire data and this case is included in the analysis. The 17 cases of IBD, diagnosed between 19762010, represent mostly unrelated cases (11) and 6 cases from two families (1 sibling pair; 1 sibling pair and 2 nephews). Average age at diagnosis was 24 and 53% were female. 12 had ulcerative colitis (UC) and 5 had Crohn's disease (CD): 1 ileitis, 1 ileocolitis, 1 colitis and extent unknown in 2. All received therapy for IBD with 5-ASA in 17 (100%), steroids in 12 (71%), antibiotics in 7 (41%), topical therapy in 7 (41%), immunomodulator in 2 (12%) and anti-tumor necrosis factor in 1 (6%). Eight patients (47%) had surgery for IBD: 6 UC pts had total colectomies, 1 CD pt had an ileocecal resection and repair of enterovesicular fistula, a CD pt had unknown surgery. The incidence of IBD was 95/105 person-years (95%CI 55-152): UC 76/105 (95%CI 39-133) and CD 30/105 (95%CI 10-70). In 2011, the prevalence of IBD was 4857/105 (95%CI 2829-7777): UC 3429/105 (95%CI 1772-5990) and CD 1429/105 (95%CI 464-3335). Compared to controls, patients with IBD were more likely to be non-smokers (88 vs 43%, p=0.007). The environmental exposure questionnaire did not identify particular risk factors though 7 cases lived on one street along the river. Conclusion: We have identified and confirmed the largest IBD cluster described with incidence and prevalence 10-15 times the expected rates. The particular environmental exposures in this town warrant further investigation to identify potentially novel environmental risk factors for IBD.
Ulcerative Colitis Patients Taking Immunosuppressive Medications Report Inadequate Understanding of Surgical Options Meenakshi Bewtra, Corey A. Siegel, James D. Lewis Background: Chronic immunosuppression therapy can delay the need for colectomy in ulcerative colitis (UC) but may not be ideal for all patients due to unclear durable efficacy and potential serious adverse events. Choosing between surgery and chronic immunosuppression requires an understanding of the potential benefits and harms of each treatment strategy. There is limited data on UC patients' self-reported understanding of the surgical options available for their disease. Methods: 389 adult UC outpatients at two academic institutions received a questionnaire about their perceived understanding of surgical options for their UC. Baseline demographic covariates were collected including history of surgery and medication use. Logistic regression was used to identify factors associated with perceived good understanding of surgical options. Results: 196 patients (50%) completed the survey with useable data. The majority (65%; 127/196) had no first- or second-hand experience with bowel surgery. 18% (36/196) of patients had a history of bowel resection surgery and were not included in further analysis. The majority of the remaining 160 patients (87/160, 54%) had never discussed surgical options for their UC with their physician or a surgeon. Of patients who had discussed surgery options, fewer patients had remaining questions if that discussion occurred with a surgeon (46%, 11/24) versus with another physician (64%, 41/ 64). 55% (88/160) of respondents currently or had previously had their medical management escalated to immunosuppressive medications. Of these patients, 34% (30/88) had never discussed surgery with a physician or surgeon, but one third of these patients felt they understood their surgical options very well and had no further questions regarding surgery. 64% (56/88) of patients currently or previously on immunosuppression still had questions regarding surgical options including 20% (18/88) who reported having no information at all regarding surgery for UC. In multivariate logistic regression, the only factor identified with complete understanding of surgical options for UC was having spoken with a surgeon (OR 4.26, 95% CI 1.31-13.86). Conclusion: The majority of patients with UC have never discussed surgical options for their disease with any physician; and even among those who have discussed surgery, the majority continue to have significant questions. In patients in whom medical management has been escalated, two thirds report inadequate information regarding surgery for their UC. These findings suggest that current dialogue with patients regarding surgical options for UC is insufficient, even in patients in whom the decision has been made to step up medical therapy. Improved methods of educating patients about surgical options are needed to allow patients to make informed treatment decisions.
Tu1290 Social, Demographic and Clinical Features of Inflammatory Bowel Disease in Russia Elena Belousova, Igor Khalif
Tu1292
Background There is a lack of data on IBD patient's profile, clinical course, disease severity and treatment patterns in Russia. Methods Consecutive patients with Crohn's disease (CD) or ulcerative colitis (UC) from 22 dedicated IBD centers from all over Russia were enrolled between Dec.2009 and Dec.2010. Demographic and clinical characteristics of these patients are described. Results Demographic data: 1254 UC and 543 CD patients from the ages of 16-87 years (median 33.8 and 32.3 respectively) were examined, f:m ratio=1.1 for both diseases. The peak age of initial diagnosis was between 20-40 years: 58% in UC and 50% in CD. There was no difference between number of smoking and nonsmoking patients. There was a family history of IBD in 3.6% and 3.1% of UC/CD patients. 30.9% of UC and 40.9% of CD patients were classified as disabled (disease severe enough to qualify for state funded treatment), mainly due to IBD. Clinical features: Mean duration of symptoms prior to diagnosis was 1.5 and 3.5 years for UC/CD. Clinically, mild, moderate or severe disease in was found in 26%, 49% and 9.8 % of patients with UC and 26%, 37% and 14% in CD. Pan colitis was diagnosed in 38 %, left-sided in 35.1% and proctitis in 26.9% of UC patients; 46.8% of CD patients had colitis, 29.9% terminal ileitis and 22.2% ileocolitis. Recurrent form UC and CD was in 63 and 56% of patients (1 and1.5 relapses per year), about 18% had continuous and 20 % -acute form for both UC and CD. Almost 15% had a fulminant onset of IBD. Intestinal complications were diagnosed in 19.9% in UC; with intestinal bleeding as most frequent (68%) and colorectal cancer in 5.3%. 74% of CD patients had intestinal complications by history or at the time of examination; with fistulas and strictures in almost 60% and 50% of patients. More than 30% of IBD patients had extraintestinal manifestations, with arthropathies being most frequent (65% of UC and 54% of CD patients). Treatment options: The treatment options for the last/ongoing attack are presented in the tables 1,2.There was a history of surgery in 9.3% of UC and 41.6 % of CD patients and half of all recurrent patients were not on any preventive therapy prior to the last relapse. Steroidrefractory or dependence was noted in 21% of UC and 27% of CD. Conclusion The key learnings of the study are in Russia: 1) the late diagnosis of IBD may contribute to the high frequency of systemic manifestation, complications, surgery and disability observed; 2) almost half of all patients have moderate or severe forms of IBD; 3) the lack of use of immunosupressors and biologics either for induction or maintenance therapy. These findings have demonstrated the need for a proactive approach in IBD diagnostics and treatment in Russia.
AGA Abstracts
Interaction of Childhood Environmental Factors With NOD2 in Crohn's Disease Francisco Garcia, Roberto Vendrell, Jonathan Rodriguez, Julio A. Peguero, Jerome I. Rotter, Dermot P. McGovern, Esther A. Torres, Kent D. Taylor Background: Nucleotide-binding oligomerization domain-containing protein 2 (NOD2) gene polymorphisms and exposure to certain childhood environmental factors have each been associated with susceptibility to Crohn's disease (CD). A synergistic association between these risk factors has not yet been demonstrated. Aim: To test the association between CD, NOD2 gene polymorphisms, and childhood environmental factors in Puerto Ricans. Methods: 281 Puerto Ricans with an established diagnosis of Crohn's disease and 315 controls participated in the study. Demographic and clinical data were obtained from questionnaires and medical records. Blood samples were obtained from each subject. Genotyping was performed using the ImmunoChip (Illumina, San Diego, California). The Fisher's exact test was used to test the association between CD and several childhood environmental risk factors and the Mantel-Haenszel test was used to test for synergism across the presence or absence of the rs17313265 T allele. This allele “tags” 3 known susceptibility SNPs for CD in the Puerto Rico population: snp 8, snp12, and snp13. Results: The associations resulting from the combination of genetic and environmental factors in CD subjects are tabulated bellow. Conclusion: Our study revealed synergism between the NOD2 rs17313265 T allele and a marker of a “cleaner” environment in childhood, the presence of drinking water in the home. This observation suggests that there is increased risk for CD when both NOD2 susceptibility alleles and a “cleaner” childhood environment are present and that the study of childhood environmental factors and CD is possible in the Puerto Rican population. Study support: Grants U01 DK 062413, 5S21MD000242 and 5S21MD000138. Association of CD & presence of risk factor in home in early childhood
S-794
questionnaire for CD found breastfed infants were protected from the development of CD (OR 0.272, 95% CI 0.087-0.855) but not UC. Dietary factors in the US included yogurt 5ydx that was protective for CD (OR 0.284, 95% CI 0.11-0.73) and fish 5ydx that was protective for UC (OR 0.359, 95% CI 0.16-0.83). These factors were not significant in India. In the OSCCAR subset, more education, and well water vs. a government source each reduced the risk of UC (MV). No other significant associations were found by the environmental questionnaire including socioeconomic status, born in hospital, Caesarean section, lefthandedness, fast food and alcohol use among others. Conclusion: Risk factors for IBD are not uniform in different countries. IBD in emerging countries may result from a different set of environmental factors than those identified in western countries.
Percentage of patients treated with different medication for induction of remission for the last relapse
Percentage of patients continued treatment with different medication for maintenance of remission after the last relapse
Tu1289 An Unusual Cluster of IBD in a Town Downstream From a Potential Environmental Risk Factor Sharyle A. Fowler, Molly Nestor, Elisabeth B. Cole, Joshua R. Korzenik
Tu1291
Background: The geographic proximity of clusters of patients with the same disease may be useful in identifying a common environmental risk factor. A potential cluster of patients with inflammatory bowel disease (IBD) was identified in Northport, Washington (NWA), a town of 297 people (2010 census). NWA is located along the Columbia River, just south of Trail, British Columbia, the location of a large lead and zinc smelter. Aims: To identify and verify IBD cases among residents of NWA and assess potential environmental risk factors. Methods: Questionnaires were developed to ascertain medical history, environmental risks for IBD, and exposures relating to the smelter. These were delivered by post, email and in person to those who lived or currently live in NWA. Medical records were requested for those reporting IBD. Analysis utilized healthy controls matched first for time/era in NWA, and then by age and sex. As the population of NWA has remained stable around 350, we conservatively estimated an at risk population of 525 for incidence calculations (95%CI calculated assuming a Poisson distribution). Results: Of the 119 surveys returned there were 19 cases of self-reported IBD. Medical records were obtained confirming 16 cases and excluding 2. Records are pending in one case of probable IBD based on questionnaire data and this case is included in the analysis. The 17 cases of IBD, diagnosed between 19762010, represent mostly unrelated cases (11) and 6 cases from two families (1 sibling pair; 1 sibling pair and 2 nephews). Average age at diagnosis was 24 and 53% were female. 12 had ulcerative colitis (UC) and 5 had Crohn's disease (CD): 1 ileitis, 1 ileocolitis, 1 colitis and extent unknown in 2. All received therapy for IBD with 5-ASA in 17 (100%), steroids in 12 (71%), antibiotics in 7 (41%), topical therapy in 7 (41%), immunomodulator in 2 (12%) and anti-tumor necrosis factor in 1 (6%). Eight patients (47%) had surgery for IBD: 6 UC pts had total colectomies, 1 CD pt had an ileocecal resection and repair of enterovesicular fistula, a CD pt had unknown surgery. The incidence of IBD was 95/105 person-years (95%CI 55-152): UC 76/105 (95%CI 39-133) and CD 30/105 (95%CI 10-70). In 2011, the prevalence of IBD was 4857/105 (95%CI 2829-7777): UC 3429/105 (95%CI 1772-5990) and CD 1429/105 (95%CI 464-3335). Compared to controls, patients with IBD were more likely to be non-smokers (88 vs 43%, p=0.007). The environmental exposure questionnaire did not identify particular risk factors though 7 cases lived on one street along the river. Conclusion: We have identified and confirmed the largest IBD cluster described with incidence and prevalence 10-15 times the expected rates. The particular environmental exposures in this town warrant further investigation to identify potentially novel environmental risk factors for IBD.
Ulcerative Colitis Patients Taking Immunosuppressive Medications Report Inadequate Understanding of Surgical Options Meenakshi Bewtra, Corey A. Siegel, James D. Lewis Background: Chronic immunosuppression therapy can delay the need for colectomy in ulcerative colitis (UC) but may not be ideal for all patients due to unclear durable efficacy and potential serious adverse events. Choosing between surgery and chronic immunosuppression requires an understanding of the potential benefits and harms of each treatment strategy. There is limited data on UC patients' self-reported understanding of the surgical options available for their disease. Methods: 389 adult UC outpatients at two academic institutions received a questionnaire about their perceived understanding of surgical options for their UC. Baseline demographic covariates were collected including history of surgery and medication use. Logistic regression was used to identify factors associated with perceived good understanding of surgical options. Results: 196 patients (50%) completed the survey with useable data. The majority (65%; 127/196) had no first- or second-hand experience with bowel surgery. 18% (36/196) of patients had a history of bowel resection surgery and were not included in further analysis. The majority of the remaining 160 patients (87/160, 54%) had never discussed surgical options for their UC with their physician or a surgeon. Of patients who had discussed surgery options, fewer patients had remaining questions if that discussion occurred with a surgeon (46%, 11/24) versus with another physician (64%, 41/ 64). 55% (88/160) of respondents currently or had previously had their medical management escalated to immunosuppressive medications. Of these patients, 34% (30/88) had never discussed surgery with a physician or surgeon, but one third of these patients felt they understood their surgical options very well and had no further questions regarding surgery. 64% (56/88) of patients currently or previously on immunosuppression still had questions regarding surgical options including 20% (18/88) who reported having no information at all regarding surgery for UC. In multivariate logistic regression, the only factor identified with complete understanding of surgical options for UC was having spoken with a surgeon (OR 4.26, 95% CI 1.31-13.86). Conclusion: The majority of patients with UC have never discussed surgical options for their disease with any physician; and even among those who have discussed surgery, the majority continue to have significant questions. In patients in whom medical management has been escalated, two thirds report inadequate information regarding surgery for their UC. These findings suggest that current dialogue with patients regarding surgical options for UC is insufficient, even in patients in whom the decision has been made to step up medical therapy. Improved methods of educating patients about surgical options are needed to allow patients to make informed treatment decisions.
Tu1290 Social, Demographic and Clinical Features of Inflammatory Bowel Disease in Russia Elena Belousova, Igor Khalif
Tu1292
Background There is a lack of data on IBD patient's profile, clinical course, disease severity and treatment patterns in Russia. Methods Consecutive patients with Crohn's disease (CD) or ulcerative colitis (UC) from 22 dedicated IBD centers from all over Russia were enrolled between Dec.2009 and Dec.2010. Demographic and clinical characteristics of these patients are described. Results Demographic data: 1254 UC and 543 CD patients from the ages of 16-87 years (median 33.8 and 32.3 respectively) were examined, f:m ratio=1.1 for both diseases. The peak age of initial diagnosis was between 20-40 years: 58% in UC and 50% in CD. There was no difference between number of smoking and nonsmoking patients. There was a family history of IBD in 3.6% and 3.1% of UC/CD patients. 30.9% of UC and 40.9% of CD patients were classified as disabled (disease severe enough to qualify for state funded treatment), mainly due to IBD. Clinical features: Mean duration of symptoms prior to diagnosis was 1.5 and 3.5 years for UC/CD. Clinically, mild, moderate or severe disease in was found in 26%, 49% and 9.8 % of patients with UC and 26%, 37% and 14% in CD. Pan colitis was diagnosed in 38 %, left-sided in 35.1% and proctitis in 26.9% of UC patients; 46.8% of CD patients had colitis, 29.9% terminal ileitis and 22.2% ileocolitis. Recurrent form UC and CD was in 63 and 56% of patients (1 and1.5 relapses per year), about 18% had continuous and 20 % -acute form for both UC and CD. Almost 15% had a fulminant onset of IBD. Intestinal complications were diagnosed in 19.9% in UC; with intestinal bleeding as most frequent (68%) and colorectal cancer in 5.3%. 74% of CD patients had intestinal complications by history or at the time of examination; with fistulas and strictures in almost 60% and 50% of patients. More than 30% of IBD patients had extraintestinal manifestations, with arthropathies being most frequent (65% of UC and 54% of CD patients). Treatment options: The treatment options for the last/ongoing attack are presented in the tables 1,2.There was a history of surgery in 9.3% of UC and 41.6 % of CD patients and half of all recurrent patients were not on any preventive therapy prior to the last relapse. Steroidrefractory or dependence was noted in 21% of UC and 27% of CD. Conclusion The key learnings of the study are in Russia: 1) the late diagnosis of IBD may contribute to the high frequency of systemic manifestation, complications, surgery and disability observed; 2) almost half of all patients have moderate or severe forms of IBD; 3) the lack of use of immunosupressors and biologics either for induction or maintenance therapy. These findings have demonstrated the need for a proactive approach in IBD diagnostics and treatment in Russia.
AGA Abstracts
Interaction of Childhood Environmental Factors With NOD2 in Crohn's Disease Francisco Garcia, Roberto Vendrell, Jonathan Rodriguez, Julio A. Peguero, Jerome I. Rotter, Dermot P. McGovern, Esther A. Torres, Kent D. Taylor Background: Nucleotide-binding oligomerization domain-containing protein 2 (NOD2) gene polymorphisms and exposure to certain childhood environmental factors have each been associated with susceptibility to Crohn's disease (CD). A synergistic association between these risk factors has not yet been demonstrated. Aim: To test the association between CD, NOD2 gene polymorphisms, and childhood environmental factors in Puerto Ricans. Methods: 281 Puerto Ricans with an established diagnosis of Crohn's disease and 315 controls participated in the study. Demographic and clinical data were obtained from questionnaires and medical records. Blood samples were obtained from each subject. Genotyping was performed using the ImmunoChip (Illumina, San Diego, California). The Fisher's exact test was used to test the association between CD and several childhood environmental risk factors and the Mantel-Haenszel test was used to test for synergism across the presence or absence of the rs17313265 T allele. This allele “tags” 3 known susceptibility SNPs for CD in the Puerto Rico population: snp 8, snp12, and snp13. Results: The associations resulting from the combination of genetic and environmental factors in CD subjects are tabulated bellow. Conclusion: Our study revealed synergism between the NOD2 rs17313265 T allele and a marker of a “cleaner” environment in childhood, the presence of drinking water in the home. This observation suggests that there is increased risk for CD when both NOD2 susceptibility alleles and a “cleaner” childhood environment are present and that the study of childhood environmental factors and CD is possible in the Puerto Rican population. Study support: Grants U01 DK 062413, 5S21MD000242 and 5S21MD000138. Association of CD & presence of risk factor in home in early childhood
S-794