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Mo1723 Identification of Risk Factors for Intraabdominal Abscess Formation in Patients With Crohn's Disease
and can last from months to years. High BMI, short duration from diagnosis of IBD to stoma construction and concurrent asthma were risk factors for PPG. Demographic and clinicopathological variables.
children. Medical therapy seems to be poorly effective in avoiding intestinal resection and common clinical variables are not of value in discriminating between responder and non responders to medical therapy. Prospective studies are needed to define the optimal management strategy of stricturing CD and to identify predictive factors of medical treatment failure.
AGA Abstracts
Mo1725 There is a Need to Modify FRAX Score When Assessing Risk for Osteoporosis in IBD Orlaith B. Kelly, Syapiq Long, Gavin C. Harewood, Stephen Patchett, Frank Murray INTRODUCTION: Despite guidelines, early identification of inflammatory bowel disease (IBD) patients at risk of osteoporosis remains challenging. The FRAX score, developed by the WHO, is a free web-based clinical scale assessing 10-year fracture risk and need for advice, dual X-ray absorptiometry (DEXA) scanning or treatment and has been incorporated into U.S. guidelines for prevention and treatment of osteoporosis. The FRAX algorithm does not include IBD as a fracture risk and thus may underestimate risk in this population. Previous studies indicate FRAX alone may be useful in identifying IBD patients at high risk of osteoporosis. Here we examined an IBD cohort with and without osteoporosis and compared FRAX scores between groups. Association of clinical and serological disease activity parameters was also assessed. METHODS: Patients identified from a computerised IBD database in a tertiary referral centre who had undergone DEXA scanning were included. FRAX scores were retrospectively calculated. Patients were divided into osteoporosis and normal bone mineral density (BMD) groups. Disease site, duration, endoscopic severity, inflammatory markers, medications and surgery rates were recorded. Results were analysed using contingency table analyses. p values <0.05 were deemed significant. RESULTS: 1014 IBD patient records were examined. 498 patients with DEXA scans were identified. 18.6% had osteoporosis. 34.4% had normal BMD. Median age in the osteoporosis group was 56 years (IQR 27-67) and 41 (36-49) in the normal BMD group. Distribution of ulcerative colitis and Crohn's Disease was similar in both groups. 18.3% of the osteoporotic group had one or more fractures compared to <1% of the normal BMD group (p<0.001). FRAX score identified 46% of the osteoporosis group as high risk (requiring treatment/ BMD assessment) and 23.8% of the normal BMD group (p<0.01). Thus, FRAX score as an identifier of risk for osteoporosis had a sensitivity of 44.8%, specificity of 80.5% and positive predictive value of 87.5%. Disease site, surgery rates and medication use did not differ between groups. The osteoporosis group were 3-fold more likely to have endoscopically severe disease. Disease duration was 11.8 ±7 years compared to 8.58 ± 4.4 (p<0.001). 27.7% of the osteoporosis group had persistent C reactive protein (CRP) elevation, independent of disease severity (p<0.01) CONCLUSIONS: Two measures of fracture risk, bone mineral density and FRAX score are clinically useful in IBD. Our data suggest that although FRAX can be helpful in predicting risk, thereby reducing unnecessary scans and treatment, when used in isolation may underestimate osteoporosis in IBD. Clinical parameters warranting consideration are endoscopic severity, elevated CRP and disease duration. Therefore, this global diagnostic algorithm requires refinement when assessing patients with IBD.
Mo1723 Identification of Risk Factors for Intraabdominal Abscess Formation in Patients With Crohn's Disease Joseph Duratinsky, Karla Helvie, Mahmoud M. Al-Hawary, Jeremy Adler, Darashana Punglia, Ellen Zimmermann Chronic intestinal inflammation leads to stricture formation and complications such as fistula and abscess formation. Treatment of abscesses requires interruption of the immunosuppressive therapies used to treat Crohn's disease (CD). The aim of this study is to identify characteristics that can predict the future development of an intraabdominal abscess in CD patients. Methods: A billing database of 4,173 inflammatory bowel disease patients was randomly sampled to identify CD patients diagnosed with an intraabdominal abscess (excluding perioperative abscesses) and control subjects with no history of intraabdominal abscess seen near the same date. Electronic medical records were investigated for radiographic, endoscopic, laboratory and clinical data. Results: 48 CD patients with a history of intraabdominal abscess were identified. 47 control patients seen within 6 months of the abscess case were well matched for disease duration but were diagnosed with CD at a slightly older age (control 27.3±2.3 vs abscess group 21.3±1.4, p=0.03). Patients developed their first intraabdominal abscess at 30.2±2.1 years of age, with 8.8±1.4 years elapsing between diagnosis of CD and the development of their first abscess. Additionally, 50% of the patients developing an intraabdominal abscess were on an immunomodulator or biologic medications in the month prior to abscess formation, and 56.2% were on corticosteroids in the year prior to abscess development. All patients developing an intraabdominal abscess were treated with antibiotics; additionally, 23.0% were treated with surgical incision and drainage, 29.2% were treated with percutaneous drainage via interventional radiology, 4.2% were treated with both interventional radiology and surgery, and 43.8% were treated with antibiotics alone. CD patients developing an intraabdominal abscess were more likely to have a prior history of stricture (57.4 vs 34.0%, p=0.03), intraabdominal fistula (53.1 vs 17.0%, p= 0.0002), or either (76.5 vs 38.2%, p=0.0002). Nearly all strictures and intraabdominal fistulae that were identified were visualized radiographically on CT or MR prior to the diagnosis of intraabdominal abscess. Conclusions: A high percentage of patients have a diagnosed stricture or intraabdominal fistula prior to the development of an intraabdominal abscess. In most cases these risk factors were identified by routine radiographic imaging, such as CT or MRI scans. The presence of a stricture or fistula should alert clinicians to the potential for an abscess, and disease modifying therapy or surgery should be considered before the abscess develops to possibly avoid this difficult to manage complication.
Mo1726 IBD Patients Have a Higher Rate of Femoral Neck Fractures: A Record-Linkage Study of English Hospital Admissions From 1999-2008 Jesse S. Siffledeen, Clare Wotton, Simon Travis, Michael Goldacre Background: Inflammatory Bowel Disease (IBD) is characterized by altered bone metabolism and increased risk of metabolic bone disease, both from inflammatory activity and the use of corticosteroids. Although studies have shown an increased fracture risk in Crohn's disease (CD) and less so in ulcerative colitis (UC), the relative risk of hip fractures, which are most closely related to osteoporosis and mortality, remains unclear. Methods: The English National Hospital Episodes (HES) database is a linked records dataset on hospital admissions and daycase care between 1998 and 2008. As part of a study on the burden of IBD, retrospective cohort analyses were conducted, with Rate Ratios (RR) determined for femoral neck fractures (FNF) in patients with IBD, following an episode of hospitalization for IBD compared (30:1) with healthy age- and gender-matched controls. Factors associated with higher risk of FNF were determined. Result: 213 557 patients with IBD were admitted to hospitals in England during the decade 1999-2008 (86427 CD/127130 UC). In this period, 2336 femoral neck fractures were observed (1002 in CD, 1334 in UC), yielding an incidence rate of 1.95 and 1.78 per 1000 pt.yrs, respectively, in hospitalized IBD patients. RR for admission with FNF was significantly higher for both CD [1.55, (95% CI 1.45-1.65)] and UC [1.19, (1.12-1.25)] groups with prior IBD hospitalizations. Factors associated with a higher risk of admission for FNF were increasing age, female gender, the number and duration of hospital admissions for IBD, and a higher social deprivation score. In multivariate analysis, age>50 [CD incidence rate ratio 15.9 (13.0-19.4), UC 23.3 (18.3-29.7)], female gender [CD 2.1 (1.9-2.5), UC 2.6 (2.3-2.9)], were most associated with the risk of FNF in both UC and CD. A significant association with FNF was also identified for a surrogate marker of disease severity (hospital stay >5days [CD 1.7 (1.5-1.9), UC 2.3 (2.1-2.6)]), while abdominal surgery during the study period was inversely associated with FNF [CD 0.6 (0.4-0.8), UC 0.5 (0.4-0.8)]. Conclusion: Hip fractures, presumably related to osteoporosis, are more common in IBD, which contributes to the overall burden of disease. Increasing age and female gender are most closely related to fracture risk, but disease severity, marked by frequent (≥2/10 years) and longer (>5 days) hospital stays for IBD, also appear to contribute to risk, prompting the need for closer monitoring and management of bone health in these patients.
Mo1724 Disease Course and Outcome of Medical Therapy in Pediatric Stricturing Crohn’s Disease Marina Aloi, Giulia D'Arcangelo, Fortunata Civitelli, Giovanni Di Nardo, Federica Nuti, Anna Dilillo, Claudia Alessandri, Franca Viola, Salvatore Cucchiara BACKGROUND. Stricturing pattern is the most common complicated phenotype in children with Crohn′s disease (CD), but only few studies have described its course and there are no data on the efficacy of medical treatment. AIM. To retrospectively describe the course of stricturing CD in children and assess clinical and radiological response to medical therapy. PATIENTS AND METHODS. 36 patients (pts) with stricturing CD (64% males, age range: 7.3-20.2 years, median 14.7), were identified by our department database. Records were reviewed for disease duration before detecting stenosis, location of strictures, type of medical treatment received, number of disease recurrences and hospitalizations. Pediatric Crohn's disease Activity Index (PCDAI), need to change medical treatment or surgery, magnetic resonance imaging or small intestine contrast ultrasonography were used as outcomes and evaluated at 6,12,18 and 24 months after diagnosis of stenosis. RESULTS. Strictures were ileal in 61% of pts, ileocolonic in 28% and colonic in 11%; 6 pts (17%) also had proximal jejunal stenosis. Thirteen pts (36%) had a stricturing disease at the time of CD diagnosis, while 64% developed it at the follow-up (2.48±4.12 years after CD diagnosis). Cumulative risk for developing stenosis was 22%, 27% and 28% at 12, 18 and 24 months, respectively. At baseline, 89% of pts underwent medical treatment, while 11% had surgical resection: in a multivariate analysis, only ileal stenosis and severe abdominal pain significantly differed between the two groups (p:0.05 and p:0.006, respectively). At 6, 12, 18, and 24 months, 53%, 50%, 42%, and 35% had a complete response to medical treatment, respectively; whereas 34%, 43%, 40%, and 34% had a partial response, defined as a radiological evidence of stenosis requiring a change of their medical therapy. Overall, 44% were unresponsive to medical therapy and required surgery during 24 months follow-up; responders and nonresponders did not statistically differ for clinical variables such as duration of disease, location of stenosis, mean PCDAI at the beginning of the therapy and type of medical treatment. CONCLUSIONS. A stricturing phenotype is not uncommon at the diagnosis of CD in
AGA Abstracts
S-670
children. Medical therapy seems to be poorly effective in avoiding intestinal resection and common clinical variables are not of value in discriminating between responder and non responders to medical therapy. Prospective studies are needed to define the optimal management strategy of stricturing CD and to identify predictive factors of medical treatment failure.
AGA Abstracts
Mo1725 There is a Need to Modify FRAX Score When Assessing Risk for Osteoporosis in IBD Orlaith B. Kelly, Syapiq Long, Gavin C. Harewood, Stephen Patchett, Frank Murray INTRODUCTION: Despite guidelines, early identification of inflammatory bowel disease (IBD) patients at risk of osteoporosis remains challenging. The FRAX score, developed by the WHO, is a free web-based clinical scale assessing 10-year fracture risk and need for advice, dual X-ray absorptiometry (DEXA) scanning or treatment and has been incorporated into U.S. guidelines for prevention and treatment of osteoporosis. The FRAX algorithm does not include IBD as a fracture risk and thus may underestimate risk in this population. Previous studies indicate FRAX alone may be useful in identifying IBD patients at high risk of osteoporosis. Here we examined an IBD cohort with and without osteoporosis and compared FRAX scores between groups. Association of clinical and serological disease activity parameters was also assessed. METHODS: Patients identified from a computerised IBD database in a tertiary referral centre who had undergone DEXA scanning were included. FRAX scores were retrospectively calculated. Patients were divided into osteoporosis and normal bone mineral density (BMD) groups. Disease site, duration, endoscopic severity, inflammatory markers, medications and surgery rates were recorded. Results were analysed using contingency table analyses. p values <0.05 were deemed significant. RESULTS: 1014 IBD patient records were examined. 498 patients with DEXA scans were identified. 18.6% had osteoporosis. 34.4% had normal BMD. Median age in the osteoporosis group was 56 years (IQR 27-67) and 41 (36-49) in the normal BMD group. Distribution of ulcerative colitis and Crohn's Disease was similar in both groups. 18.3% of the osteoporotic group had one or more fractures compared to <1% of the normal BMD group (p<0.001). FRAX score identified 46% of the osteoporosis group as high risk (requiring treatment/ BMD assessment) and 23.8% of the normal BMD group (p<0.01). Thus, FRAX score as an identifier of risk for osteoporosis had a sensitivity of 44.8%, specificity of 80.5% and positive predictive value of 87.5%. Disease site, surgery rates and medication use did not differ between groups. The osteoporosis group were 3-fold more likely to have endoscopically severe disease. Disease duration was 11.8 ±7 years compared to 8.58 ± 4.4 (p<0.001). 27.7% of the osteoporosis group had persistent C reactive protein (CRP) elevation, independent of disease severity (p<0.01) CONCLUSIONS: Two measures of fracture risk, bone mineral density and FRAX score are clinically useful in IBD. Our data suggest that although FRAX can be helpful in predicting risk, thereby reducing unnecessary scans and treatment, when used in isolation may underestimate osteoporosis in IBD. Clinical parameters warranting consideration are endoscopic severity, elevated CRP and disease duration. Therefore, this global diagnostic algorithm requires refinement when assessing patients with IBD.
Mo1723 Identification of Risk Factors for Intraabdominal Abscess Formation in Patients With Crohn's Disease Joseph Duratinsky, Karla Helvie, Mahmoud M. Al-Hawary, Jeremy Adler, Darashana Punglia, Ellen Zimmermann Chronic intestinal inflammation leads to stricture formation and complications such as fistula and abscess formation. Treatment of abscesses requires interruption of the immunosuppressive therapies used to treat Crohn's disease (CD). The aim of this study is to identify characteristics that can predict the future development of an intraabdominal abscess in CD patients. Methods: A billing database of 4,173 inflammatory bowel disease patients was randomly sampled to identify CD patients diagnosed with an intraabdominal abscess (excluding perioperative abscesses) and control subjects with no history of intraabdominal abscess seen near the same date. Electronic medical records were investigated for radiographic, endoscopic, laboratory and clinical data. Results: 48 CD patients with a history of intraabdominal abscess were identified. 47 control patients seen within 6 months of the abscess case were well matched for disease duration but were diagnosed with CD at a slightly older age (control 27.3±2.3 vs abscess group 21.3±1.4, p=0.03). Patients developed their first intraabdominal abscess at 30.2±2.1 years of age, with 8.8±1.4 years elapsing between diagnosis of CD and the development of their first abscess. Additionally, 50% of the patients developing an intraabdominal abscess were on an immunomodulator or biologic medications in the month prior to abscess formation, and 56.2% were on corticosteroids in the year prior to abscess development. All patients developing an intraabdominal abscess were treated with antibiotics; additionally, 23.0% were treated with surgical incision and drainage, 29.2% were treated with percutaneous drainage via interventional radiology, 4.2% were treated with both interventional radiology and surgery, and 43.8% were treated with antibiotics alone. CD patients developing an intraabdominal abscess were more likely to have a prior history of stricture (57.4 vs 34.0%, p=0.03), intraabdominal fistula (53.1 vs 17.0%, p= 0.0002), or either (76.5 vs 38.2%, p=0.0002). Nearly all strictures and intraabdominal fistulae that were identified were visualized radiographically on CT or MR prior to the diagnosis of intraabdominal abscess. Conclusions: A high percentage of patients have a diagnosed stricture or intraabdominal fistula prior to the development of an intraabdominal abscess. In most cases these risk factors were identified by routine radiographic imaging, such as CT or MRI scans. The presence of a stricture or fistula should alert clinicians to the potential for an abscess, and disease modifying therapy or surgery should be considered before the abscess develops to possibly avoid this difficult to manage complication.
Mo1726 IBD Patients Have a Higher Rate of Femoral Neck Fractures: A Record-Linkage Study of English Hospital Admissions From 1999-2008 Jesse S. Siffledeen, Clare Wotton, Simon Travis, Michael Goldacre Background: Inflammatory Bowel Disease (IBD) is characterized by altered bone metabolism and increased risk of metabolic bone disease, both from inflammatory activity and the use of corticosteroids. Although studies have shown an increased fracture risk in Crohn's disease (CD) and less so in ulcerative colitis (UC), the relative risk of hip fractures, which are most closely related to osteoporosis and mortality, remains unclear. Methods: The English National Hospital Episodes (HES) database is a linked records dataset on hospital admissions and daycase care between 1998 and 2008. As part of a study on the burden of IBD, retrospective cohort analyses were conducted, with Rate Ratios (RR) determined for femoral neck fractures (FNF) in patients with IBD, following an episode of hospitalization for IBD compared (30:1) with healthy age- and gender-matched controls. Factors associated with higher risk of FNF were determined. Result: 213 557 patients with IBD were admitted to hospitals in England during the decade 1999-2008 (86427 CD/127130 UC). In this period, 2336 femoral neck fractures were observed (1002 in CD, 1334 in UC), yielding an incidence rate of 1.95 and 1.78 per 1000 pt.yrs, respectively, in hospitalized IBD patients. RR for admission with FNF was significantly higher for both CD [1.55, (95% CI 1.45-1.65)] and UC [1.19, (1.12-1.25)] groups with prior IBD hospitalizations. Factors associated with a higher risk of admission for FNF were increasing age, female gender, the number and duration of hospital admissions for IBD, and a higher social deprivation score. In multivariate analysis, age>50 [CD incidence rate ratio 15.9 (13.0-19.4), UC 23.3 (18.3-29.7)], female gender [CD 2.1 (1.9-2.5), UC 2.6 (2.3-2.9)], were most associated with the risk of FNF in both UC and CD. A significant association with FNF was also identified for a surrogate marker of disease severity (hospital stay >5days [CD 1.7 (1.5-1.9), UC 2.3 (2.1-2.6)]), while abdominal surgery during the study period was inversely associated with FNF [CD 0.6 (0.4-0.8), UC 0.5 (0.4-0.8)]. Conclusion: Hip fractures, presumably related to osteoporosis, are more common in IBD, which contributes to the overall burden of disease. Increasing age and female gender are most closely related to fracture risk, but disease severity, marked by frequent (≥2/10 years) and longer (>5 days) hospital stays for IBD, also appear to contribute to risk, prompting the need for closer monitoring and management of bone health in these patients.
Mo1724 Disease Course and Outcome of Medical Therapy in Pediatric Stricturing Crohn’s Disease Marina Aloi, Giulia D'Arcangelo, Fortunata Civitelli, Giovanni Di Nardo, Federica Nuti, Anna Dilillo, Claudia Alessandri, Franca Viola, Salvatore Cucchiara BACKGROUND. Stricturing pattern is the most common complicated phenotype in children with Crohn′s disease (CD), but only few studies have described its course and there are no data on the efficacy of medical treatment. AIM. To retrospectively describe the course of stricturing CD in children and assess clinical and radiological response to medical therapy. PATIENTS AND METHODS. 36 patients (pts) with stricturing CD (64% males, age range: 7.3-20.2 years, median 14.7), were identified by our department database. Records were reviewed for disease duration before detecting stenosis, location of strictures, type of medical treatment received, number of disease recurrences and hospitalizations. Pediatric Crohn's disease Activity Index (PCDAI), need to change medical treatment or surgery, magnetic resonance imaging or small intestine contrast ultrasonography were used as outcomes and evaluated at 6,12,18 and 24 months after diagnosis of stenosis. RESULTS. Strictures were ileal in 61% of pts, ileocolonic in 28% and colonic in 11%; 6 pts (17%) also had proximal jejunal stenosis. Thirteen pts (36%) had a stricturing disease at the time of CD diagnosis, while 64% developed it at the follow-up (2.48±4.12 years after CD diagnosis). Cumulative risk for developing stenosis was 22%, 27% and 28% at 12, 18 and 24 months, respectively. At baseline, 89% of pts underwent medical treatment, while 11% had surgical resection: in a multivariate analysis, only ileal stenosis and severe abdominal pain significantly differed between the two groups (p:0.05 and p:0.006, respectively). At 6, 12, 18, and 24 months, 53%, 50%, 42%, and 35% had a complete response to medical treatment, respectively; whereas 34%, 43%, 40%, and 34% had a partial response, defined as a radiological evidence of stenosis requiring a change of their medical therapy. Overall, 44% were unresponsive to medical therapy and required surgery during 24 months follow-up; responders and nonresponders did not statistically differ for clinical variables such as duration of disease, location of stenosis, mean PCDAI at the beginning of the therapy and type of medical treatment. CONCLUSIONS. A stricturing phenotype is not uncommon at the diagnosis of CD in
AGA Abstracts
S-670