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Factors Associated With Repeat Hospitalizations in Inflammatory Bowel Disease
AGA Abstracts
Tu1264
Tu1266
Factors Associated With Repeat Hospitalizations in Inflammatory Bowel Disease Adeeti Chiplunker, Yelena Zadvornova, Mazen Issa, Daniel J. Stein, Lilani P. Perera, Nanda Venu, Amar S. Naik
Post-Operative Crohn's Disease Recurrence: Impact of Endoscopic Monitoring and Treatment Step-up on Outcome Peter P. De Cruz, Maria-Pia Bernardi, Patrick B. Allen, Lani Prideaux, Michael Johnston, Alexander Heriot, James Keck, Richard Brouwer, Rodney Woods, Steven J. Brown, Sally Bell, Ross Elliott, William Connell, Paul Desmond, Michael A. Kamm
INTRODUCTION:Health care utilization is high in Inflammatory Bowel Disease (IBD) patients. Hospitalizations have been shown to be an independent negative prognostic factor of longterm IBD outcomes. We examined our hospitalized IBD patients for risk factors associated with repeat hospitalizations at our tertiary referral center. METHODS:This was a retrospective study that examined IBD patients admitted to our IBDcenter within the past 2 years. Reasons for admissions were disease flares, partial small bowel obstruction (pSBO), infectious complications, and disease-related complications. We collected patient demographics and disease characteristics (anatomical involvement, behavior, duration). Health related quality of life was assessed using the Short Inflammatory Bowel Disease Questionnaire (SIBDQ). We evaluated disease activity with inflammatory markers (ESR, CRP, WBC, Hemoglobin/Hematocrit, platelets) and Harvey Bradshaw Index (HBI). Admission heart rate, need for packed red blood cells (pRBC) transfusion, and inpatient total parenteral nutrition (TPN) use, maintenance therapy, treatment history, surgical history, inpatient narcotic and steroid use were recorded. RESULTS:Of the total 1243 outpatients at our IBD center during the study, there were 222 IBD-related hospital admissions during this time interval. (145 CD, 77 UC: 98 male and 124 female). 44% of patients were on immunomodulators and 36% patients were on biologics at admission. Mean disease duration upon admission was 267 + 26 mos. Groups were split into Repeat Hospitalization (RH) and Single Hospitalization (SH). 37% of patients had at least 1 repeat hospitalization in the 2-year time period. The repeat hospitalization (RH) group had lower SIBDQ following discharge (39 vs 47; p<0.05) and higher Harvey Bradshaw Index (HBI) following discharge. (3 vs 5; p<0.05). Inpatient narcotic administration increased RH rate twofold (OR 1.92, p<0.05). Mean length of stay did not differ between both groups. Mean disease duration in the RH group was significantly shorter (180 vs 318 months; p=0.05). AZA intolerance (52%) (p=0.017) and anti-tumor necrosis factor failure ((p=0.007) were higher in the (RH) group. Admission and discharge CRP, ESR, platelets, WBC did also were not significantly different. Having an inpatient endoscopy did not impact repeat hospitalization rate. CONCLUSIONS:Factors related to repeat hospitalizations were the use of narcotics while inpatient, increased HBI after discharge and lower SIBDQ after discharge. Shorter disease duration, azathioprine intolerance, and anti-tumor necrosis factor failure were seen in these patients as well, suggesting a relation with an aggressive disease phenotype. Typical markers of disease activity, such as prior surgery, maintenance therapy, admission ESR/CRP were not significant predictive factors.
Objectives: Eighty percent of patients with Crohn's disease require surgery for their condition at some time in their life, of whom 70 percent will go on to have a further operation. Recurrence occurs predictably at the anastomosis, and to a variable extent elsewhere. Postoperative colonoscopy and treatment step-up may decrease clinical recurrence. This study aimed to assess the impact of post-operative colonoscopy on clinical and surgical recurrence. Methods: Retrospective review of up to 10 years outcome on all patients who had a bowel resection at two hospitals from 1998 till 2008, to assess whether those who had a postoperative colonoscopy within a year of surgery had a different outcome to those who did not. Patients were included only if no clinical recurrence occurred prior to their colonoscopy, if it was known whether they had had a post-operative colonoscopy within the first year of surgery, and if the anastomosis was endoscopically accessible. Results: 222 patients underwent surgery. Of these, 142 patients (69 male, mean age 34, mean disease duration 8 years), had an endoscopically accessible anastomosis following ileo-colonic resection (n= 126), isolated colonic resection (n=5) and simultaneous ileo-colonic resection and colonic resection (n=11). Median follow-up was 4.5 years. Of the 70 patients with, and 72 without, post-operative colonoscopy within 12 months of surgery, clinical recurrence occurred in 50% and 49% of both groups respectively (P=NS) and further surgery occurred in 9% and 6% respectively (P=NS). Eighty percent of all patients received post-operative medications. 86% of colonoscoped patients had a record of a decision based on colonoscopic findings (record unavailable in 14%): 21% had a step-up in medical therapy with >1 medications including: antibiotics (n=10), aminosalicylates (n=2), thiopurine (n=5), and methotrexate (n=1). No patient had step-up with anti-TNF therapy. 63% had no step-up in medical therapy. Of the colonoscoped patients clinical recurrence occurred in 9 of 15 (60%) with, and 23 of 44 (51%) without a step up in medications. Surgical recurrence occurred in 2 of 15 (13%) patients with, and 4 of 44 (9%) without step-up medication (P=NS). Conclusions: Clinical recurrence occurs in a majority of patients within a short time period after surgery for Crohn's disease. In this series there was no clear benefit from post-operative colonoscopy. This may relate to lack of standardised response to endoscopic findings. At most step-up medication consisted of modest immunosuppression therapy. Note that patients were treated prior to the recognition of the value of post-operative anti-TNF therapy. To achieve improved outcomes, colonoscopy may need to be performed at a standardised time post-operatively, with a consistent approach to the findings, including more intense treatment such as antiTNF therapy.
Tu1265 Post-Intestinal Resection Management of Pediatric Crohn's Disease Marc Schaefer, Christine R. Langton, James Markowitz, David R. Mack, Jonathan Evans, Marian D. Pfefferkorn, Anne M. Griffiths, Anthony R. Otley, Athos Bousvaros, Joel R. Rosh, David J. Keljo, Ryan Carvalho, Marsha H. Kay, Maria Oliva-Hemker, Michael Kappelman, Farhat N. Ashai-Khan, Michael C. Stephens, Charles M. Samson, Andrew B. Grossman, Reed A. Dimmitt, Boris Sudel, William A. Faubion, Neal S. Leleiko, Jeffrey S. Hyams
Tu1267
Background: There is no consensus for prophylactic management to prevent post-operative Crohn's disease (CD) recurrence in the adult or pediatric literature. Aim: To describe the contemporary management of pediatric CD patients after intestinal resection. Methods: Patients < 16 years of age with newly diagnosed CD were enrolled in a prospective, multicenter (25 site) observational study since 2002. Uniform data from 1127 consecutively enrolled pediatric CD patients from the Pediatric IBD Collaborative Research Group Registry were reviewed to identify the patients that underwent an intestinal resection. For the patients with an intestinal resection, additional data were requested from the Registry sites with a uniform query form. Results: One hundred (8.9%) of the 1127 Crohn's disease patients enrolled in the Registry underwent an intestinal resection. Additional data were available on 96 patients (mean age at diagnosis 12.5 years, mean age at surgery 13.8 years, 54% male). The most common indications for intestinal resection were obstruction (55%), failure of medical therapy (45%), and perforation (32%) (more than one possible). 34% had residual disease after intestinal resection. Of the 96 patients with an intestinal resection, 88 (92%) received post-operative prophylaxis: 23% were on a 5-ASA, 60% on an immunomodulator (6-MP, azathioprine, or methotrexate), 25% on a biologic (infliximab or adalimumab), 7% on an immunomodulator plus a biologic, 26% on an antibiotic (ciprofloxacin, metronidazole, or other), 19% on prednisone, and 1% on budesonide. The mean age of patients not on post-operative prophylaxis (n=8) (11 years old) was significantly lower than the mean age of patients on post-operative prophylaxis (n=88) (14 years old) (p= 0.0031). 17% of patients ≤ 12 years old at intestinal resection had residual disease compared with 40% of patients > 12 years old (p= 0.049). Being on an immunomodulator or biologic preoperatively was associated with being on an immunomodulator (OR = 21.3, 95% CI 7.1, 63.8, p<0.0001) or biologic post-operatively (OR = 15.1, 95% CI 5.0, 45.5, p<0.0001). Conclusions: Over 90% of children with CD undergoing intestinal resection receive post-operative prophylaxis for disease recurrence. It appears that younger children may be less likely to receive postoperative prophylaxis than older children, possibly because younger patients had a lower incidence of residual disease after surgery. Pre-operative treatments with an immunomodulator or a biologic were significantly related to the use of these medications post-operatively. Longitudinal follow-up of this large cohort of young children will better define the role of post-operative immunosuppression in delaying or preventing recurrent disease.
Background. The expression of mucins in Crohn's Disease (CD) ileum and its possible relationship with the development of postoperative recurrence has not been investigated. Aims. In a prospective longitudinal study, we aimed to assess the expression of ileal mucins (sialomucins) and colonic mucins (sulphomucins) in established vs early ileal lesions in CD. Possible relation with the development of recurrence was investigated. Materials and methods. 20 patients undergoing ileo-colonic resection for CD were prospectively enrolled from February 2007 to March 2010. At 6 and 12 months recurrence was assessed according to clinical (CDAI) and endoscopic assessment (Rutgeerts score 0-4). In all 20 patients ileal samples were taken at both surgery and during colonoscopy at 6 months, while in 12/20 patients ileal samples were also taken at 12 months. All samples were stained by both H&E and by histochemistry for mucins, including sialo for ileal epithelium and sulphomucins for colonic epithelium (iron diamine). Mucins expression was scored as percentage of mucins in each considered sample. Results. Clinical recurrence. Recurrence (CDAI>150) was shown by 2/20 patients at 6 months and by 2/12 patients at 12 months. Endoscopic recurrence. Recurrence (score ≥1) was shown by 16/20 patients at 6 months and by 10/12 patients at 12 months. The endoscopic score did not increase at 12 vs 6 months (median: 2, range 04 vs2.5, range 0-4;p=0.83). Histochemistry. Sialomucins. Sialomucins (ileal mucins) were expressed in all ileal samples at both surgery and at 6 and 12months. The median percentage of expression significantly increased at both 6 and 12 months vs surgery (median: 65% range 1-100 vs 100%, range 80-100 vs 100%, range 99-100, respectively; p<0.001). Sulphomucins. Sulphomucins (colonic mucins) were expressed in all 20 established ileal lesions at surgery, while sulphomucin expression in the ileum after surgery was observed in only 8/20 samples at 6months and in 3/12 samples at 12months. The median percentage of expression significantly reduced at both 6 and 12months vs surgery (median: 32%, range 0-99 vs 0%, range 0-20, vs 0%, range 0-1, respectively; p<0.001 for both). The median percentage of expression was higher for sialo vs sulphomucins at all times (p<0.001). The median percentage of expression of both mucins did not differ between patients with or without recurrence (p= n.s.). Conclusions. In CD, colonic mucins (sulphomucins) are expressed in the involved ileum at surgery, while ileal mucins (sialomucins) are expressed in the ileum uninvolved or showing early lesions related to CD recurrence. Possible relations with the development of CD recurrence is under investigation. Expression of mucins at surgery, at 6 and 12 months
In Crohn's Disease Colonic Mucins Are Expressed in the Established Ileal Lesions at Surgery While Ileal Mucins Are Mainly Expressed in the Early Ileal Recurrence: A Prospective Longitudinal Study Livia Biancone, Claudia Mescoli, Marta Ascolani, Emma Calabrese, Sara Onali, Giuseppe S. Sica, Francesca Zorzi, Giampiero Palmieri, Massimo Rugge, Francesco Pallone
a. p<0.001 at 6 and 12 months vs surgery; b. p<0.001 at 6 and 12 months vs surgery
AGA Abstracts
S-782
Tu1264
Tu1266
Factors Associated With Repeat Hospitalizations in Inflammatory Bowel Disease Adeeti Chiplunker, Yelena Zadvornova, Mazen Issa, Daniel J. Stein, Lilani P. Perera, Nanda Venu, Amar S. Naik
Post-Operative Crohn's Disease Recurrence: Impact of Endoscopic Monitoring and Treatment Step-up on Outcome Peter P. De Cruz, Maria-Pia Bernardi, Patrick B. Allen, Lani Prideaux, Michael Johnston, Alexander Heriot, James Keck, Richard Brouwer, Rodney Woods, Steven J. Brown, Sally Bell, Ross Elliott, William Connell, Paul Desmond, Michael A. Kamm
INTRODUCTION:Health care utilization is high in Inflammatory Bowel Disease (IBD) patients. Hospitalizations have been shown to be an independent negative prognostic factor of longterm IBD outcomes. We examined our hospitalized IBD patients for risk factors associated with repeat hospitalizations at our tertiary referral center. METHODS:This was a retrospective study that examined IBD patients admitted to our IBDcenter within the past 2 years. Reasons for admissions were disease flares, partial small bowel obstruction (pSBO), infectious complications, and disease-related complications. We collected patient demographics and disease characteristics (anatomical involvement, behavior, duration). Health related quality of life was assessed using the Short Inflammatory Bowel Disease Questionnaire (SIBDQ). We evaluated disease activity with inflammatory markers (ESR, CRP, WBC, Hemoglobin/Hematocrit, platelets) and Harvey Bradshaw Index (HBI). Admission heart rate, need for packed red blood cells (pRBC) transfusion, and inpatient total parenteral nutrition (TPN) use, maintenance therapy, treatment history, surgical history, inpatient narcotic and steroid use were recorded. RESULTS:Of the total 1243 outpatients at our IBD center during the study, there were 222 IBD-related hospital admissions during this time interval. (145 CD, 77 UC: 98 male and 124 female). 44% of patients were on immunomodulators and 36% patients were on biologics at admission. Mean disease duration upon admission was 267 + 26 mos. Groups were split into Repeat Hospitalization (RH) and Single Hospitalization (SH). 37% of patients had at least 1 repeat hospitalization in the 2-year time period. The repeat hospitalization (RH) group had lower SIBDQ following discharge (39 vs 47; p<0.05) and higher Harvey Bradshaw Index (HBI) following discharge. (3 vs 5; p<0.05). Inpatient narcotic administration increased RH rate twofold (OR 1.92, p<0.05). Mean length of stay did not differ between both groups. Mean disease duration in the RH group was significantly shorter (180 vs 318 months; p=0.05). AZA intolerance (52%) (p=0.017) and anti-tumor necrosis factor failure ((p=0.007) were higher in the (RH) group. Admission and discharge CRP, ESR, platelets, WBC did also were not significantly different. Having an inpatient endoscopy did not impact repeat hospitalization rate. CONCLUSIONS:Factors related to repeat hospitalizations were the use of narcotics while inpatient, increased HBI after discharge and lower SIBDQ after discharge. Shorter disease duration, azathioprine intolerance, and anti-tumor necrosis factor failure were seen in these patients as well, suggesting a relation with an aggressive disease phenotype. Typical markers of disease activity, such as prior surgery, maintenance therapy, admission ESR/CRP were not significant predictive factors.
Objectives: Eighty percent of patients with Crohn's disease require surgery for their condition at some time in their life, of whom 70 percent will go on to have a further operation. Recurrence occurs predictably at the anastomosis, and to a variable extent elsewhere. Postoperative colonoscopy and treatment step-up may decrease clinical recurrence. This study aimed to assess the impact of post-operative colonoscopy on clinical and surgical recurrence. Methods: Retrospective review of up to 10 years outcome on all patients who had a bowel resection at two hospitals from 1998 till 2008, to assess whether those who had a postoperative colonoscopy within a year of surgery had a different outcome to those who did not. Patients were included only if no clinical recurrence occurred prior to their colonoscopy, if it was known whether they had had a post-operative colonoscopy within the first year of surgery, and if the anastomosis was endoscopically accessible. Results: 222 patients underwent surgery. Of these, 142 patients (69 male, mean age 34, mean disease duration 8 years), had an endoscopically accessible anastomosis following ileo-colonic resection (n= 126), isolated colonic resection (n=5) and simultaneous ileo-colonic resection and colonic resection (n=11). Median follow-up was 4.5 years. Of the 70 patients with, and 72 without, post-operative colonoscopy within 12 months of surgery, clinical recurrence occurred in 50% and 49% of both groups respectively (P=NS) and further surgery occurred in 9% and 6% respectively (P=NS). Eighty percent of all patients received post-operative medications. 86% of colonoscoped patients had a record of a decision based on colonoscopic findings (record unavailable in 14%): 21% had a step-up in medical therapy with >1 medications including: antibiotics (n=10), aminosalicylates (n=2), thiopurine (n=5), and methotrexate (n=1). No patient had step-up with anti-TNF therapy. 63% had no step-up in medical therapy. Of the colonoscoped patients clinical recurrence occurred in 9 of 15 (60%) with, and 23 of 44 (51%) without a step up in medications. Surgical recurrence occurred in 2 of 15 (13%) patients with, and 4 of 44 (9%) without step-up medication (P=NS). Conclusions: Clinical recurrence occurs in a majority of patients within a short time period after surgery for Crohn's disease. In this series there was no clear benefit from post-operative colonoscopy. This may relate to lack of standardised response to endoscopic findings. At most step-up medication consisted of modest immunosuppression therapy. Note that patients were treated prior to the recognition of the value of post-operative anti-TNF therapy. To achieve improved outcomes, colonoscopy may need to be performed at a standardised time post-operatively, with a consistent approach to the findings, including more intense treatment such as antiTNF therapy.
Tu1265 Post-Intestinal Resection Management of Pediatric Crohn's Disease Marc Schaefer, Christine R. Langton, James Markowitz, David R. Mack, Jonathan Evans, Marian D. Pfefferkorn, Anne M. Griffiths, Anthony R. Otley, Athos Bousvaros, Joel R. Rosh, David J. Keljo, Ryan Carvalho, Marsha H. Kay, Maria Oliva-Hemker, Michael Kappelman, Farhat N. Ashai-Khan, Michael C. Stephens, Charles M. Samson, Andrew B. Grossman, Reed A. Dimmitt, Boris Sudel, William A. Faubion, Neal S. Leleiko, Jeffrey S. Hyams
Tu1267
Background: There is no consensus for prophylactic management to prevent post-operative Crohn's disease (CD) recurrence in the adult or pediatric literature. Aim: To describe the contemporary management of pediatric CD patients after intestinal resection. Methods: Patients < 16 years of age with newly diagnosed CD were enrolled in a prospective, multicenter (25 site) observational study since 2002. Uniform data from 1127 consecutively enrolled pediatric CD patients from the Pediatric IBD Collaborative Research Group Registry were reviewed to identify the patients that underwent an intestinal resection. For the patients with an intestinal resection, additional data were requested from the Registry sites with a uniform query form. Results: One hundred (8.9%) of the 1127 Crohn's disease patients enrolled in the Registry underwent an intestinal resection. Additional data were available on 96 patients (mean age at diagnosis 12.5 years, mean age at surgery 13.8 years, 54% male). The most common indications for intestinal resection were obstruction (55%), failure of medical therapy (45%), and perforation (32%) (more than one possible). 34% had residual disease after intestinal resection. Of the 96 patients with an intestinal resection, 88 (92%) received post-operative prophylaxis: 23% were on a 5-ASA, 60% on an immunomodulator (6-MP, azathioprine, or methotrexate), 25% on a biologic (infliximab or adalimumab), 7% on an immunomodulator plus a biologic, 26% on an antibiotic (ciprofloxacin, metronidazole, or other), 19% on prednisone, and 1% on budesonide. The mean age of patients not on post-operative prophylaxis (n=8) (11 years old) was significantly lower than the mean age of patients on post-operative prophylaxis (n=88) (14 years old) (p= 0.0031). 17% of patients ≤ 12 years old at intestinal resection had residual disease compared with 40% of patients > 12 years old (p= 0.049). Being on an immunomodulator or biologic preoperatively was associated with being on an immunomodulator (OR = 21.3, 95% CI 7.1, 63.8, p<0.0001) or biologic post-operatively (OR = 15.1, 95% CI 5.0, 45.5, p<0.0001). Conclusions: Over 90% of children with CD undergoing intestinal resection receive post-operative prophylaxis for disease recurrence. It appears that younger children may be less likely to receive postoperative prophylaxis than older children, possibly because younger patients had a lower incidence of residual disease after surgery. Pre-operative treatments with an immunomodulator or a biologic were significantly related to the use of these medications post-operatively. Longitudinal follow-up of this large cohort of young children will better define the role of post-operative immunosuppression in delaying or preventing recurrent disease.
Background. The expression of mucins in Crohn's Disease (CD) ileum and its possible relationship with the development of postoperative recurrence has not been investigated. Aims. In a prospective longitudinal study, we aimed to assess the expression of ileal mucins (sialomucins) and colonic mucins (sulphomucins) in established vs early ileal lesions in CD. Possible relation with the development of recurrence was investigated. Materials and methods. 20 patients undergoing ileo-colonic resection for CD were prospectively enrolled from February 2007 to March 2010. At 6 and 12 months recurrence was assessed according to clinical (CDAI) and endoscopic assessment (Rutgeerts score 0-4). In all 20 patients ileal samples were taken at both surgery and during colonoscopy at 6 months, while in 12/20 patients ileal samples were also taken at 12 months. All samples were stained by both H&E and by histochemistry for mucins, including sialo for ileal epithelium and sulphomucins for colonic epithelium (iron diamine). Mucins expression was scored as percentage of mucins in each considered sample. Results. Clinical recurrence. Recurrence (CDAI>150) was shown by 2/20 patients at 6 months and by 2/12 patients at 12 months. Endoscopic recurrence. Recurrence (score ≥1) was shown by 16/20 patients at 6 months and by 10/12 patients at 12 months. The endoscopic score did not increase at 12 vs 6 months (median: 2, range 04 vs2.5, range 0-4;p=0.83). Histochemistry. Sialomucins. Sialomucins (ileal mucins) were expressed in all ileal samples at both surgery and at 6 and 12months. The median percentage of expression significantly increased at both 6 and 12 months vs surgery (median: 65% range 1-100 vs 100%, range 80-100 vs 100%, range 99-100, respectively; p<0.001). Sulphomucins. Sulphomucins (colonic mucins) were expressed in all 20 established ileal lesions at surgery, while sulphomucin expression in the ileum after surgery was observed in only 8/20 samples at 6months and in 3/12 samples at 12months. The median percentage of expression significantly reduced at both 6 and 12months vs surgery (median: 32%, range 0-99 vs 0%, range 0-20, vs 0%, range 0-1, respectively; p<0.001 for both). The median percentage of expression was higher for sialo vs sulphomucins at all times (p<0.001). The median percentage of expression of both mucins did not differ between patients with or without recurrence (p= n.s.). Conclusions. In CD, colonic mucins (sulphomucins) are expressed in the involved ileum at surgery, while ileal mucins (sialomucins) are expressed in the ileum uninvolved or showing early lesions related to CD recurrence. Possible relations with the development of CD recurrence is under investigation. Expression of mucins at surgery, at 6 and 12 months
In Crohn's Disease Colonic Mucins Are Expressed in the Established Ileal Lesions at Surgery While Ileal Mucins Are Mainly Expressed in the Early Ileal Recurrence: A Prospective Longitudinal Study Livia Biancone, Claudia Mescoli, Marta Ascolani, Emma Calabrese, Sara Onali, Giuseppe S. Sica, Francesca Zorzi, Giampiero Palmieri, Massimo Rugge, Francesco Pallone
a. p<0.001 at 6 and 12 months vs surgery; b. p<0.001 at 6 and 12 months vs surgery
AGA Abstracts
S-782