- Email: [email protected]
Arthropathies in IBD Patients
AGA Abstracts
and Escape Behavior [n=144 (21.9%); score 2.39 (0.32)]. The less frequently used were Cognitive Escape [(n=15 (2.2%); score 1.67 (0.44)] and Consumption of Alcohol or Drugs [(n=1 (0.1%); score 1.04 (0.19)]. Patients with CD and UC adopted similar coping strategies. There was also no difference regarding clinical activity of the disease. However, women adopted more frequently than men Cognitive Escape (p=0.003) and Emotion-focused Coping (p<0.0005). Conclusions: Behavioral Coping Problem was the most frequently adopted coping strategy in patients with IBD. On the contrary, Consumption of Alcohol or Drugs was negligible. Coping strategies do not depend on the disease activity or type of disease. The impact of coping strategies on the compliance of patients and clinical course of the disease deserves further research.
Tu1291 Inflammatory Bowel Disease Patients With Ileitis or Small Bowel Resection Are Likely to Have Low Vitamin D Levels Ashish Zalawadia, Inge Hanschu, Ann L. Silverman Purpose: Recent studies have shown that Vitamin D is an important immune regulator and is critical in bone health. In animal models, Vitamin D can prevent or forestall autoimmune disease. While sunlight can provide adequate Vitamin D levels, northern climates and winter months are associated with lower serum Vitamin D levels. Many other variables affect Vitamin D levels including BMI, age, degree of skin pigmentation. Current recommended daily doses of Vitamin D do not provide adequate serum levels. The purpose of this study was to determine baseline Vitamin D levels in patients with inflammatory bowel disease to develop strategies for replacement. Methods: We retrospectively reviewed the charts of patients with inflammatory bowel disease to determine baseline serum levels of 25 OH Vitamin D. We collected data regarding patients' age, race, body mass index (BMI), steroid use, type of IBD, extent of bowel disease, disease activity, season of collection, previous small bowel resection and associated liver disease. None of these patients were receiving Vitamin D supplementation except multivitamin. Active disease was defined as an increase in bowel frequency, elevated markers of inflammation, abdominal pain with or without blood in the stool at the time of the Vitamin D level. The comparisons were made using the Chi-square test or the Fischer exact test as appropriate. Results: We reviewed 130 charts of IBD patients. 74 (56.9%) had Crohn's Disease (CD) and 56 (43.1%) had Ulcerative Colitis (UC). Forty (30.8%) patients were age ≥50 years, ninety (69.2%) patients were caucasian and thirty (23.1%) patients had BMI ≥30. We found 82 (63.1%) patients with Vitamin D level less than 30 mg/dL (Group 1) and 48 (36.9%) patients with Vitamin D level more than 30 mg/dL (Group 2). Table 1 shows comparison between group 1 and 2. We found statistically significant difference in Vitamin D level in CD patients with ileitis or ileocolitis (p value = 0.001) and patients who had previous small bowel resection (p value = 0.010). We did not found statistically significant difference in Vitamin D level for race, steroid use, type of IBD, disease activity, liver disease or season of collection. Conclusion: Our study showed that IBD patients with ileal involvement or surgical resection of the ileum had a higher risk of Vitamin D deficiency. Over half of the patients with IBD had a low Vitamin D level. These patients may require higher doses of Vitamin D replacement to achieve and maintain normal Vitamin D level. Prospective studies need to be done to determine oral replacement dose of Vitamin D in IBD patients. Table 1: Comparison between Group 1 and 2
Tu1289 Crohn's Disease Phenotype at Diagnosis is More Severe in the East (China) Than the West (Australia) and is Managed Differently. Lani Prideaux, Siew C. Ng, Michael A. Kamm, Peter P. De Cruz, Sally Bell, William Connell, Steven J. Brown, Mark Lust, Alana S. Bruce, Heyson Chan, Dorothy K. Chow, Joseph J. Sung, Francis K. L. Chan, Bing Xia, Paul Desmond Introduction and Aims: Crohn's disease (CD) is increasing in incidence in Asia. However it has traditionally been regarded as a milder disease, compared to the severe phenotype in the West. We aimed to characterise this further, by comparing CD characteristics at diagnosis and subsequent management in Melbourne Australia, a location of known high IBD incidence, and Hong Kong (HK) China, a location of previously low but increasing IBD incidence. Methods: Patient records of all CD patients attending the specialist IBD clinic at 2 hospitals in Melbourne and HK were reviewed for patient demographics, risk factors, disease phenotype (Montreal classification), medications and surgery. Comparisons: Chi-squared and MannWhitney U tests. Results: 438 CD patients were studied: Melbourne 273 and HK 165. Demographics: The proportion of female patients was higher in Melbourne than HK (55% v 32%, p<0.001). Median follow-up was 128 months for Melbourne and 108 months for HK (p=0.018). Median age at diagnosis was lower in Melbourne than HK (24 v 30 years, p<0.001), with more patients in Melbourne diagnosed <17 years (16% v 4%, p<0.001). Less patients in Melbourne than HK had never smoked at diagnosis (50% v 91%, p<0.001). Disease distribution and complications: Ileocolonic disease (26% v 52%, p<0.001), stricturing disease (7% v 21%, p<0.001), and perianal disease (16% v 29%, p=0.002) at diagnosis was less common in Melbourne than HK. There was no difference in the incidence of fistulising disease at diagnosis between the 2 centres. Treatment: (i) Surgery: The number of patients requiring surgery did not differ between sites (Melbourne v HK, 55% v 46%, p=0.054) but more patients in Melbourne required more than 1 operation (22% vs 11%, p=0.003). Median time to first surgery was longer in Melbourne than HK (38 v 7 months, p=0.011). (ii) Drug treatment: Steroids were used more at diagnosis in Melbourne v HK (61% v 37%, p<0.001), but there was no difference in the proportion on steroids at last review (21% v 16%, p=0.283). Thiopurine use (82% v 64%, p<0.001), methotrexate use (35% v 11%, p<0.001) and anti-TNF use (40% v 11%, p<0.001) were all more common in Melbourne than HK. At last review substantially more patients in Melbourne were on anti-TNF compared with HK (26% v 1%, p<0.001). Conclusions: Crohn's disease in Hong Kong is diagnosed at an older age and has a more severe phenotype at diagnosis than in Melbourne. These differences may relate to real differences in disease, delayed diagnosis due to late presentation in HK or less disease recognition in HK. Despite the severe phenotype drug treatment in Hong Kong was less intense. Countries in Asia in which IBD is emerging will need to focus on management and resource use for patients with Crohn's disease. Tu1290 Proctocolectomy and Ileal Pouch Anal Anastomosis (IPAA) Significantly Impairs Fertility and Pregnancy Outcomes in Ulcerative Colitis (UC) Patients Iris Dotan, Noya Horowitz, Joseph Klausner, Zamir Halpern, Micha Y. Rabau, Hagit Tulchinsky Background: IPAA is the surgical treatment of choice for patients requiring proctocolectomy for UC. Females undergoing IPAA are usually young and within the reproductive years. Data regarding female fertility, pregnancy and pregnancy outcomes after IPAA are scarce. Significant decrease in fertility has been reported. Aim: To evaluate the effects of IPAA on fertility and pregnancy in UC-IPAA patients. Methods: Female UC patients undergoing IPAA before age 44 who were either married, cohabiting or attempting to become pregnant filled out questionnaires regarding fertility and pregnancy. Demographic and pouch status data were collected from a prospective database. Results: Questionnaires were filled by 40/46 eligible patients (87% response rate, age 45 ±10 years, 50% Ashkenazi Jews, 7% smokers). Mean age at surgery was 31±9 years. Range of follow up after IPAA was 48-312 months. Before IPAA, 27 women had 71 pregnancies, 62 deliveries (2.4 offspring/patient) while after IPAA-24 women had 34 pregnancies, 25 deliveries (0.7±0.97 offspring/patient, p=0.007). Only 1 woman (4%) failed to conceive before IPAA in contrast to 8 (33%) after (p=0.001), and spontaneous pregnancies significantly decreased from 56 (90%) before vs. 15 (60%) after IPAA (p=0.001). Time to conception after IPAA was longer: 5.25±11.9 vs. 15.1±24.9 months (p=0.064) and more In Vitro fertilization was used: 3 (4%) vs. 6 (18%) after IPAA (p=0.008). The number of spontaneous abortions was comparable (9 in each group). Gestational age significantly decreased from 39.4 ±2.4 to 34.6±11.4 weeks after IPAA (p= 0.043). Delivery by Cesarean section significantly increased from 6 (10%) before to 11 (44%) after IPAA (p=0.0003). Offspring weight significantly decreased from 3.2±0.61 Kg before to 2.7±0.68 Kg after IPAA (p=0.008). Conclusions: IPAA in UC patients is associated with an 8-fold increased risk of infertility, longer time to conception, decreased gestational age and decreased offspring weight. Thus, females considering IPAA should be counseled accordingly. Alternative surgical and medical approaches for the treatment of UC should be investigated.
AGA Abstracts
(C) = Chi-square Test (F) = Fisher Exact Test * Statistically Significant, P < 0.05 Tu1292 Arthropathies in IBD Patients Lianne Brakenhoff, Rosaline van den Berg, Désirée van der Heijde, Daniel W. Hommes, Tom Huizinga, Herma Fidder Introduction: Arthropathies, the most common extraintestinal manifestation in patients with inflammatory bowel diseases (IBD), are a major medical problem in these patients. The aim of this study was to characterize arthropathies in IBD patients. Methods: A cohort of 510 IBD patients, 321 (63%) Crohn's Disease (CD), 186 (37%) ulcerative colitis (UC) and 3 (1%) indeterminate colitis, were questioned about joint pain. Of the patients reporting articular complaints a complete rheumatologic examination was performed in 94 patients. Peripheral arthralgia was defined as joint pain without swelling, arthritis as joint pain and swelling. Enthesopathy was scored using the Maastricht Ankylosing Spondylitis Enthesitis Score and dactylitis was defined as a ‘sausage digit’. Inflammatory back pain (IBP) was defined using the Assessment of SpondyloArthritis international Society (ASAS) criteria. The modified New York criteria were used to classify ankylosing spondylitis (AS). Human leukocyte antigen (HLA)-B27 was typed. Axial and peripheral spondyloarthritis (SpA) were defined using the recently published ASAS criteria. Results: A total of 310/510 (61%) IBD patients suffered from joint pain. Joint pain was more frequently reported by CD than UC patients: 67% vs. 31% (OR 1.62 95% CI 1.12-2.34) and more in female than in male patients (67%
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vs. 34%), (OR 2.19 95% CI 1.52-3.15). 142/ 510 (28%) IBD patients reported back pain for more than three months, 272 (53%) patients had peripheral joint pain and/or swelling and 105 (21%) had both back pain and peripheral joint pain and/or swelling. Ninety-four IBD patients were thus far examined (table 1). Axial involvement occurred in 8 (9%) patients, peripheral involvement in 45 (48%) patients and 41 (44%) patients had axial, as well as, peripheral involvement. No differences in manifestations were observed between CD and UC. AS was found in 2 (2%) IBD patients with IBP. HLA-B27 was positive in 5 (5%) of patients and was more frequently seen in IBD patients with IBP than in IBD patients without IBP (26 vs. 1%). Three (3%) patients could be classified as axial SpA and 4 (4%) as peripheral SpA. Conclusion: Joint complaints are reported by the majority of IBD patients, more frequent in CD patients and in female patients. Arthralgia is the most often seen joint manifestation in IBD patients and mainly affects the knees and small joints of the hands. Joint manifestations did not differ between CD and UC. A positive HLA-B27 was more frequently observed in IBD patients with IBP. Table 1: Characteristics of 94 IBD patients with joint manifestations
well tolerated with a good health related quality of life. Long-term therapy was not associated with significant drug related complications in our cohort.
Early Versus Late Surgery in Patients With Intestinal Behcet's Disease Yoon Suk Jung, Sung Pil Hong, Tae Il Kim, Won Ho Kim, Jae Hee Cheon Background/aims: To date, the appropriate timing of surgery in patients with intestinal Behcet's disease (BD) remains unclear. Here, we investigated the long-term clinical outcomes in intestinal BD patients diagnosed surgically (“early surgery”) compared to those diagnosed clinically or those requiring surgical resection during the course of the disease (“late surgery”). Methods: We reviewed the medical records of 272 consecutive intestinal BD patients between March 1986 and August 2010. The clinical outcomes after diagnosis and operation were assessed by univariate analysis using the Kaplan-Meier method, log-rank test, and multivariate analysis using Cox proportional hazard regression models. Results: Forty of 272 patients were diagnosed with intestinal BD at surgery (surgical diagnosis = early surgery); the remaining 232 were diagnosed clinically, with 62 undergoing surgery during follow-up after clinical diagnosis (late surgery). The surgical diagnosis group showed a lower risk of further intestinal resection compared to the clinical diagnosis group (p=0.0264). The cumulative probabilities of postoperative clinical recurrence and surgical recurrence (reoperation) were significantly lower in the early surgery group than in the late surgery group (p=0.0451 and p=0.0029, respectively). In multivariate analysis, early surgery was the only independent factor significantly associated with a reduced probability of reoperation (HR 0.26; 95% CI 0.10-0.71; P = 0.008). Conclusions: According to the current study, intestinal BD patients undergoing early surgery showed good prognoses. Early surgery may be an effective alternative approach to medical treatment in patients with uncontrolled disease. Tu1295 A Descriptive Analysis of Colorectal Carcinoma in Patients With Ulcerative Colitis Seen Over a Three Year Period Jeremy S. Ditelberg, Francis A. Farraye, Robert M. Genta Purpose: Patients with longstanding and extensive ulcerative colitis (UC) are at increased risk for developing colorectal carcinoma (CRC). Recent epidemiologic studies have suggested an overall decrease in the incidence of CRC in individuals with UC but that men appear to have a higher risk of developing CRC. We reviewed a large nationwide pathology database to examine demographic, histologic and other features associated with CRC in individuals with UC. Methods: Patients with a diagnosis of UC were selected from the database of Caris Life Sciences, a specialized gastrointestinal pathology group receiving specimens from community-based gastroenterologists in 42 states, Washington D.C. and Puerto Rico. The database includes demographic and clinical information, summary of the endoscopic report, biopsy location, and the histopathologic report for each biopsy. Cases of UC with a report date from 11/1/07 to 10/31/10 were extracted from the database and stored in a Microsoft Access file. Cases of CRC arising in association with UC were extracted from the Access file. Follow-up and prior information was obtained, when available, from the Caris database. Results: From 11/1/07 to 10/31/10, Caris Life Sciences interpreted biopsies from colonoscopies on 682,982 patients. Of these, 12,577 unique patients (6437 men and 6127 women) had histological and clinical features of UC and underwent 13,761 total colonoscopic procedures. During the same time period, 5671 colorectal carcinomas were diagnosed (52.7% male, 47.3% female). Of these cancers, 12 occurred in patients with UC (prevalence of 12/ 12577 = 0.095%). Ten patients were male and two were female. The mean age was 56.3 years (median 55.0 years, standard deviation 14.6 years, range 41 to 84 years). Eight of the carcinomas occurred in the rectum (see table). One patient had a concurrent separate focus of flat low grade dysplasia at the time of cancer diagnosis. Of these tumors, seven were moderately differentiated and five were poorly differentiated. Of the poorly differentiated tumors, two were mucinous type with signet ring cells. In contrast, National Cancer Institute SEER data from 2003 to 2007 demonstrate an overall rate of 7.4% for mucinous adenocarcinoma and 1.1% for signet ring cell carcinoma in sporadic CRC. Poorly differentiated adenocarcinoma accounts for <10% of sporadic CRC in most studies. Conclusions: In this cohort, the rate of poorly differentiated adenocarcinoma (42%), mucinous adenocarcinoma (17%) and signet ring carcinoma (17%) was much higher than seen in sporadic CRC. The majority of the tumors were identified in the rectum and sigmoid and in men. Our data supports clinical recommendations to take more extensive biopsies in the distal colon in patients with ulcerative colitis during surveillance colonoscopy and confirm an increased risk of CRC in male patients with UC. UC Patients with CRC
Tu1293 Long-Term Use of Purine Analogues in Inflammatory Bowel Disease: A Single Referral Center Experience Mazen Issa, Yelena Zadvornova, Daniel J. Stein, Nanda Venu, Lilani P. Perera, David G. Binion, Amar S. Naik Introduction: While purine analogues (PA) (azathioprine (AZA) and 6-mercaptopurine (6MP)) are well established therapies for moderate to severe inflammatory bowel disease (IBD) (both Crohn's disease (CD) and ulcerative colitis (UC)), data on long-term outcomes (>10 years) is limited. We evaluated the experience of IBD patients on PAs at our IBD center with emphasis on drug safety, disease course, quality of life, and rates of hospitalizations and surgeries. Methods: A retrospective analysis of all IBD patients treated with PA between 1998 and 2010 in our IBD cohort was performed. We identified patients with at least 10year exposure to PAs. Patient demographics and disease characteristics were recorded. We evaluated disease course using the inflammatory markers [sedimentation rate (ESR) and Creactive protein (CRP)] and health related quality of life using the Short Inflammatory Bowel Disease Questionnaire (SIBDQ). Disease complications including hospitalizations and surgeries while on PAs were recorded. Results: A total of 1163 IBD patients were exposed to PA in our cohort. Of these, 391 pts were on PA monotherapy. We identified 45 pts (23 male and 22 female) with exposure for more than 10 years (25 pts on monotherapy, 20 pts on combination of PA with biologics). Most were diagnosed with CD (91%) with mean disease duration of 242 ± 16 months at time of PA initiation. In the monotherapy group, (25 pts) the mean SIBDQ, ESR, and CRP were 59, 12±2, 0.7 ± 0.1mg/dL, respectively. Mean PA doses were (AZA: 133 ± 17mg and 6-MP: 65 ± 10mg). Overall rates of hospitalizations and surgeries during PA treatment were 0.52 ± 1.12 and 1.52 ± 1.9, respectively. Biologic therapy was added in 20 pts following mean monotherapy duration of 59.8 months (range 0-148.2 months). The mean dose of PA was (AZA: 80 ± 8mg, 6-MP: 60 ± 18mg). The mean SIBDQ, ESR, and CRP in this group were 52, 17 ± 2, 1.3 ± 0.3mg/dL respectively. During PA treatment, overall rates of hospitalizations and surgeries were 0.65 ± 0.87 and 2.15 ± 1.6 respectively. No pts in either group encountered therapy related complications (infectious, lymphoproliferative disorders). Conclusions: In our subset of moderate to severe IBD patients, long-term immunosuppressive therapy with PA, alone or in combination with biologics, is
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AGA Abstracts
AGA Abstracts
Tu1294
and Escape Behavior [n=144 (21.9%); score 2.39 (0.32)]. The less frequently used were Cognitive Escape [(n=15 (2.2%); score 1.67 (0.44)] and Consumption of Alcohol or Drugs [(n=1 (0.1%); score 1.04 (0.19)]. Patients with CD and UC adopted similar coping strategies. There was also no difference regarding clinical activity of the disease. However, women adopted more frequently than men Cognitive Escape (p=0.003) and Emotion-focused Coping (p<0.0005). Conclusions: Behavioral Coping Problem was the most frequently adopted coping strategy in patients with IBD. On the contrary, Consumption of Alcohol or Drugs was negligible. Coping strategies do not depend on the disease activity or type of disease. The impact of coping strategies on the compliance of patients and clinical course of the disease deserves further research.
Tu1291 Inflammatory Bowel Disease Patients With Ileitis or Small Bowel Resection Are Likely to Have Low Vitamin D Levels Ashish Zalawadia, Inge Hanschu, Ann L. Silverman Purpose: Recent studies have shown that Vitamin D is an important immune regulator and is critical in bone health. In animal models, Vitamin D can prevent or forestall autoimmune disease. While sunlight can provide adequate Vitamin D levels, northern climates and winter months are associated with lower serum Vitamin D levels. Many other variables affect Vitamin D levels including BMI, age, degree of skin pigmentation. Current recommended daily doses of Vitamin D do not provide adequate serum levels. The purpose of this study was to determine baseline Vitamin D levels in patients with inflammatory bowel disease to develop strategies for replacement. Methods: We retrospectively reviewed the charts of patients with inflammatory bowel disease to determine baseline serum levels of 25 OH Vitamin D. We collected data regarding patients' age, race, body mass index (BMI), steroid use, type of IBD, extent of bowel disease, disease activity, season of collection, previous small bowel resection and associated liver disease. None of these patients were receiving Vitamin D supplementation except multivitamin. Active disease was defined as an increase in bowel frequency, elevated markers of inflammation, abdominal pain with or without blood in the stool at the time of the Vitamin D level. The comparisons were made using the Chi-square test or the Fischer exact test as appropriate. Results: We reviewed 130 charts of IBD patients. 74 (56.9%) had Crohn's Disease (CD) and 56 (43.1%) had Ulcerative Colitis (UC). Forty (30.8%) patients were age ≥50 years, ninety (69.2%) patients were caucasian and thirty (23.1%) patients had BMI ≥30. We found 82 (63.1%) patients with Vitamin D level less than 30 mg/dL (Group 1) and 48 (36.9%) patients with Vitamin D level more than 30 mg/dL (Group 2). Table 1 shows comparison between group 1 and 2. We found statistically significant difference in Vitamin D level in CD patients with ileitis or ileocolitis (p value = 0.001) and patients who had previous small bowel resection (p value = 0.010). We did not found statistically significant difference in Vitamin D level for race, steroid use, type of IBD, disease activity, liver disease or season of collection. Conclusion: Our study showed that IBD patients with ileal involvement or surgical resection of the ileum had a higher risk of Vitamin D deficiency. Over half of the patients with IBD had a low Vitamin D level. These patients may require higher doses of Vitamin D replacement to achieve and maintain normal Vitamin D level. Prospective studies need to be done to determine oral replacement dose of Vitamin D in IBD patients. Table 1: Comparison between Group 1 and 2
Tu1289 Crohn's Disease Phenotype at Diagnosis is More Severe in the East (China) Than the West (Australia) and is Managed Differently. Lani Prideaux, Siew C. Ng, Michael A. Kamm, Peter P. De Cruz, Sally Bell, William Connell, Steven J. Brown, Mark Lust, Alana S. Bruce, Heyson Chan, Dorothy K. Chow, Joseph J. Sung, Francis K. L. Chan, Bing Xia, Paul Desmond Introduction and Aims: Crohn's disease (CD) is increasing in incidence in Asia. However it has traditionally been regarded as a milder disease, compared to the severe phenotype in the West. We aimed to characterise this further, by comparing CD characteristics at diagnosis and subsequent management in Melbourne Australia, a location of known high IBD incidence, and Hong Kong (HK) China, a location of previously low but increasing IBD incidence. Methods: Patient records of all CD patients attending the specialist IBD clinic at 2 hospitals in Melbourne and HK were reviewed for patient demographics, risk factors, disease phenotype (Montreal classification), medications and surgery. Comparisons: Chi-squared and MannWhitney U tests. Results: 438 CD patients were studied: Melbourne 273 and HK 165. Demographics: The proportion of female patients was higher in Melbourne than HK (55% v 32%, p<0.001). Median follow-up was 128 months for Melbourne and 108 months for HK (p=0.018). Median age at diagnosis was lower in Melbourne than HK (24 v 30 years, p<0.001), with more patients in Melbourne diagnosed <17 years (16% v 4%, p<0.001). Less patients in Melbourne than HK had never smoked at diagnosis (50% v 91%, p<0.001). Disease distribution and complications: Ileocolonic disease (26% v 52%, p<0.001), stricturing disease (7% v 21%, p<0.001), and perianal disease (16% v 29%, p=0.002) at diagnosis was less common in Melbourne than HK. There was no difference in the incidence of fistulising disease at diagnosis between the 2 centres. Treatment: (i) Surgery: The number of patients requiring surgery did not differ between sites (Melbourne v HK, 55% v 46%, p=0.054) but more patients in Melbourne required more than 1 operation (22% vs 11%, p=0.003). Median time to first surgery was longer in Melbourne than HK (38 v 7 months, p=0.011). (ii) Drug treatment: Steroids were used more at diagnosis in Melbourne v HK (61% v 37%, p<0.001), but there was no difference in the proportion on steroids at last review (21% v 16%, p=0.283). Thiopurine use (82% v 64%, p<0.001), methotrexate use (35% v 11%, p<0.001) and anti-TNF use (40% v 11%, p<0.001) were all more common in Melbourne than HK. At last review substantially more patients in Melbourne were on anti-TNF compared with HK (26% v 1%, p<0.001). Conclusions: Crohn's disease in Hong Kong is diagnosed at an older age and has a more severe phenotype at diagnosis than in Melbourne. These differences may relate to real differences in disease, delayed diagnosis due to late presentation in HK or less disease recognition in HK. Despite the severe phenotype drug treatment in Hong Kong was less intense. Countries in Asia in which IBD is emerging will need to focus on management and resource use for patients with Crohn's disease. Tu1290 Proctocolectomy and Ileal Pouch Anal Anastomosis (IPAA) Significantly Impairs Fertility and Pregnancy Outcomes in Ulcerative Colitis (UC) Patients Iris Dotan, Noya Horowitz, Joseph Klausner, Zamir Halpern, Micha Y. Rabau, Hagit Tulchinsky Background: IPAA is the surgical treatment of choice for patients requiring proctocolectomy for UC. Females undergoing IPAA are usually young and within the reproductive years. Data regarding female fertility, pregnancy and pregnancy outcomes after IPAA are scarce. Significant decrease in fertility has been reported. Aim: To evaluate the effects of IPAA on fertility and pregnancy in UC-IPAA patients. Methods: Female UC patients undergoing IPAA before age 44 who were either married, cohabiting or attempting to become pregnant filled out questionnaires regarding fertility and pregnancy. Demographic and pouch status data were collected from a prospective database. Results: Questionnaires were filled by 40/46 eligible patients (87% response rate, age 45 ±10 years, 50% Ashkenazi Jews, 7% smokers). Mean age at surgery was 31±9 years. Range of follow up after IPAA was 48-312 months. Before IPAA, 27 women had 71 pregnancies, 62 deliveries (2.4 offspring/patient) while after IPAA-24 women had 34 pregnancies, 25 deliveries (0.7±0.97 offspring/patient, p=0.007). Only 1 woman (4%) failed to conceive before IPAA in contrast to 8 (33%) after (p=0.001), and spontaneous pregnancies significantly decreased from 56 (90%) before vs. 15 (60%) after IPAA (p=0.001). Time to conception after IPAA was longer: 5.25±11.9 vs. 15.1±24.9 months (p=0.064) and more In Vitro fertilization was used: 3 (4%) vs. 6 (18%) after IPAA (p=0.008). The number of spontaneous abortions was comparable (9 in each group). Gestational age significantly decreased from 39.4 ±2.4 to 34.6±11.4 weeks after IPAA (p= 0.043). Delivery by Cesarean section significantly increased from 6 (10%) before to 11 (44%) after IPAA (p=0.0003). Offspring weight significantly decreased from 3.2±0.61 Kg before to 2.7±0.68 Kg after IPAA (p=0.008). Conclusions: IPAA in UC patients is associated with an 8-fold increased risk of infertility, longer time to conception, decreased gestational age and decreased offspring weight. Thus, females considering IPAA should be counseled accordingly. Alternative surgical and medical approaches for the treatment of UC should be investigated.
AGA Abstracts
(C) = Chi-square Test (F) = Fisher Exact Test * Statistically Significant, P < 0.05 Tu1292 Arthropathies in IBD Patients Lianne Brakenhoff, Rosaline van den Berg, Désirée van der Heijde, Daniel W. Hommes, Tom Huizinga, Herma Fidder Introduction: Arthropathies, the most common extraintestinal manifestation in patients with inflammatory bowel diseases (IBD), are a major medical problem in these patients. The aim of this study was to characterize arthropathies in IBD patients. Methods: A cohort of 510 IBD patients, 321 (63%) Crohn's Disease (CD), 186 (37%) ulcerative colitis (UC) and 3 (1%) indeterminate colitis, were questioned about joint pain. Of the patients reporting articular complaints a complete rheumatologic examination was performed in 94 patients. Peripheral arthralgia was defined as joint pain without swelling, arthritis as joint pain and swelling. Enthesopathy was scored using the Maastricht Ankylosing Spondylitis Enthesitis Score and dactylitis was defined as a ‘sausage digit’. Inflammatory back pain (IBP) was defined using the Assessment of SpondyloArthritis international Society (ASAS) criteria. The modified New York criteria were used to classify ankylosing spondylitis (AS). Human leukocyte antigen (HLA)-B27 was typed. Axial and peripheral spondyloarthritis (SpA) were defined using the recently published ASAS criteria. Results: A total of 310/510 (61%) IBD patients suffered from joint pain. Joint pain was more frequently reported by CD than UC patients: 67% vs. 31% (OR 1.62 95% CI 1.12-2.34) and more in female than in male patients (67%
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vs. 34%), (OR 2.19 95% CI 1.52-3.15). 142/ 510 (28%) IBD patients reported back pain for more than three months, 272 (53%) patients had peripheral joint pain and/or swelling and 105 (21%) had both back pain and peripheral joint pain and/or swelling. Ninety-four IBD patients were thus far examined (table 1). Axial involvement occurred in 8 (9%) patients, peripheral involvement in 45 (48%) patients and 41 (44%) patients had axial, as well as, peripheral involvement. No differences in manifestations were observed between CD and UC. AS was found in 2 (2%) IBD patients with IBP. HLA-B27 was positive in 5 (5%) of patients and was more frequently seen in IBD patients with IBP than in IBD patients without IBP (26 vs. 1%). Three (3%) patients could be classified as axial SpA and 4 (4%) as peripheral SpA. Conclusion: Joint complaints are reported by the majority of IBD patients, more frequent in CD patients and in female patients. Arthralgia is the most often seen joint manifestation in IBD patients and mainly affects the knees and small joints of the hands. Joint manifestations did not differ between CD and UC. A positive HLA-B27 was more frequently observed in IBD patients with IBP. Table 1: Characteristics of 94 IBD patients with joint manifestations
well tolerated with a good health related quality of life. Long-term therapy was not associated with significant drug related complications in our cohort.
Early Versus Late Surgery in Patients With Intestinal Behcet's Disease Yoon Suk Jung, Sung Pil Hong, Tae Il Kim, Won Ho Kim, Jae Hee Cheon Background/aims: To date, the appropriate timing of surgery in patients with intestinal Behcet's disease (BD) remains unclear. Here, we investigated the long-term clinical outcomes in intestinal BD patients diagnosed surgically (“early surgery”) compared to those diagnosed clinically or those requiring surgical resection during the course of the disease (“late surgery”). Methods: We reviewed the medical records of 272 consecutive intestinal BD patients between March 1986 and August 2010. The clinical outcomes after diagnosis and operation were assessed by univariate analysis using the Kaplan-Meier method, log-rank test, and multivariate analysis using Cox proportional hazard regression models. Results: Forty of 272 patients were diagnosed with intestinal BD at surgery (surgical diagnosis = early surgery); the remaining 232 were diagnosed clinically, with 62 undergoing surgery during follow-up after clinical diagnosis (late surgery). The surgical diagnosis group showed a lower risk of further intestinal resection compared to the clinical diagnosis group (p=0.0264). The cumulative probabilities of postoperative clinical recurrence and surgical recurrence (reoperation) were significantly lower in the early surgery group than in the late surgery group (p=0.0451 and p=0.0029, respectively). In multivariate analysis, early surgery was the only independent factor significantly associated with a reduced probability of reoperation (HR 0.26; 95% CI 0.10-0.71; P = 0.008). Conclusions: According to the current study, intestinal BD patients undergoing early surgery showed good prognoses. Early surgery may be an effective alternative approach to medical treatment in patients with uncontrolled disease. Tu1295 A Descriptive Analysis of Colorectal Carcinoma in Patients With Ulcerative Colitis Seen Over a Three Year Period Jeremy S. Ditelberg, Francis A. Farraye, Robert M. Genta Purpose: Patients with longstanding and extensive ulcerative colitis (UC) are at increased risk for developing colorectal carcinoma (CRC). Recent epidemiologic studies have suggested an overall decrease in the incidence of CRC in individuals with UC but that men appear to have a higher risk of developing CRC. We reviewed a large nationwide pathology database to examine demographic, histologic and other features associated with CRC in individuals with UC. Methods: Patients with a diagnosis of UC were selected from the database of Caris Life Sciences, a specialized gastrointestinal pathology group receiving specimens from community-based gastroenterologists in 42 states, Washington D.C. and Puerto Rico. The database includes demographic and clinical information, summary of the endoscopic report, biopsy location, and the histopathologic report for each biopsy. Cases of UC with a report date from 11/1/07 to 10/31/10 were extracted from the database and stored in a Microsoft Access file. Cases of CRC arising in association with UC were extracted from the Access file. Follow-up and prior information was obtained, when available, from the Caris database. Results: From 11/1/07 to 10/31/10, Caris Life Sciences interpreted biopsies from colonoscopies on 682,982 patients. Of these, 12,577 unique patients (6437 men and 6127 women) had histological and clinical features of UC and underwent 13,761 total colonoscopic procedures. During the same time period, 5671 colorectal carcinomas were diagnosed (52.7% male, 47.3% female). Of these cancers, 12 occurred in patients with UC (prevalence of 12/ 12577 = 0.095%). Ten patients were male and two were female. The mean age was 56.3 years (median 55.0 years, standard deviation 14.6 years, range 41 to 84 years). Eight of the carcinomas occurred in the rectum (see table). One patient had a concurrent separate focus of flat low grade dysplasia at the time of cancer diagnosis. Of these tumors, seven were moderately differentiated and five were poorly differentiated. Of the poorly differentiated tumors, two were mucinous type with signet ring cells. In contrast, National Cancer Institute SEER data from 2003 to 2007 demonstrate an overall rate of 7.4% for mucinous adenocarcinoma and 1.1% for signet ring cell carcinoma in sporadic CRC. Poorly differentiated adenocarcinoma accounts for <10% of sporadic CRC in most studies. Conclusions: In this cohort, the rate of poorly differentiated adenocarcinoma (42%), mucinous adenocarcinoma (17%) and signet ring carcinoma (17%) was much higher than seen in sporadic CRC. The majority of the tumors were identified in the rectum and sigmoid and in men. Our data supports clinical recommendations to take more extensive biopsies in the distal colon in patients with ulcerative colitis during surveillance colonoscopy and confirm an increased risk of CRC in male patients with UC. UC Patients with CRC
Tu1293 Long-Term Use of Purine Analogues in Inflammatory Bowel Disease: A Single Referral Center Experience Mazen Issa, Yelena Zadvornova, Daniel J. Stein, Nanda Venu, Lilani P. Perera, David G. Binion, Amar S. Naik Introduction: While purine analogues (PA) (azathioprine (AZA) and 6-mercaptopurine (6MP)) are well established therapies for moderate to severe inflammatory bowel disease (IBD) (both Crohn's disease (CD) and ulcerative colitis (UC)), data on long-term outcomes (>10 years) is limited. We evaluated the experience of IBD patients on PAs at our IBD center with emphasis on drug safety, disease course, quality of life, and rates of hospitalizations and surgeries. Methods: A retrospective analysis of all IBD patients treated with PA between 1998 and 2010 in our IBD cohort was performed. We identified patients with at least 10year exposure to PAs. Patient demographics and disease characteristics were recorded. We evaluated disease course using the inflammatory markers [sedimentation rate (ESR) and Creactive protein (CRP)] and health related quality of life using the Short Inflammatory Bowel Disease Questionnaire (SIBDQ). Disease complications including hospitalizations and surgeries while on PAs were recorded. Results: A total of 1163 IBD patients were exposed to PA in our cohort. Of these, 391 pts were on PA monotherapy. We identified 45 pts (23 male and 22 female) with exposure for more than 10 years (25 pts on monotherapy, 20 pts on combination of PA with biologics). Most were diagnosed with CD (91%) with mean disease duration of 242 ± 16 months at time of PA initiation. In the monotherapy group, (25 pts) the mean SIBDQ, ESR, and CRP were 59, 12±2, 0.7 ± 0.1mg/dL, respectively. Mean PA doses were (AZA: 133 ± 17mg and 6-MP: 65 ± 10mg). Overall rates of hospitalizations and surgeries during PA treatment were 0.52 ± 1.12 and 1.52 ± 1.9, respectively. Biologic therapy was added in 20 pts following mean monotherapy duration of 59.8 months (range 0-148.2 months). The mean dose of PA was (AZA: 80 ± 8mg, 6-MP: 60 ± 18mg). The mean SIBDQ, ESR, and CRP in this group were 52, 17 ± 2, 1.3 ± 0.3mg/dL respectively. During PA treatment, overall rates of hospitalizations and surgeries were 0.65 ± 0.87 and 2.15 ± 1.6 respectively. No pts in either group encountered therapy related complications (infectious, lymphoproliferative disorders). Conclusions: In our subset of moderate to severe IBD patients, long-term immunosuppressive therapy with PA, alone or in combination with biologics, is
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AGA Abstracts
AGA Abstracts
Tu1294