Role of Pathogenic Bacteria in Disease Course of Pouchitis

AGA Abstracts

Table 1. Multivariate Analysis of Factors Associated with Post-Operative Complications

Sa1836 ROLE OF PATHOGENIC BACTERIA IN DISEASE COURSE OF POUCHITIS Amandeep Singh, Gursimran Kochhar, Rocio Lopez, Jean Ashburn, Bo Shen Background: Ileal pouch-anal anastomosis (IPAA) after restorative proctocolectomy is the surgical treatment of choice for patients with medically refractory ulcerative colitis (UC) or familial adenomatous polyposis. The clinical implication of pathogenic bacteria beside Clostridium difficile infection (CDI) in patients with IPAA has not been well studied. This study was designed to investigate the cumulative incidence, risk factors, and outcome of pathogenic bacteria beside CDI in patients with IPAA. Methods: Consecutive IPAA patients (n = 2283) from 2002-2016 at our at our pouch center were included in the study. Patient with more than 3 bowel movements from their baseline, for greater than 4 weeks were included in the study group. Diagnosis was based on the presence of symptoms and positive stool cultures. Patients with positive stool cultures were compared in 1:4 ratio with controls (symptomatic without positive stool culture) (Table 1). Response to antibiotics, resolution of symptoms at one month, recurrence rate and rate of hospitalization at one and three months were assessed. Results: Baseline demographic characteristics between two groups were similar (Table 1). Out of 2283 patients 72.7% were male. A total of 643(28%) had stool cultures done and only 0.017% (11/643) had positive stool cultures. Campylobacter spp. (45%) was the most common pathogen followed by Aeromonas spp. (36%). %). Positive stool cultures were more prevalent in females (7/11), in patients with h/o UC (10/11), with J-pouch who had 2 stage surgery (10/11) and with h/o immunosuppression (8/9). Also, non- smokers and patients without any antibiotic use in the last 3 months were found to have higher prevalence of positive stool cultures. Initial and follow- up pouchoscopy showed less granularity and ulceration in patients with pathogenic bacteria, they required shorter duration of antibiotic treatment and were less likely to have repeat treatment as compared to controls. Patients with positive stool cultures were more likely to have AKI and hospitalization within 3 months (Table 2). Conclusion: Based on our study, we suggest all patients with pouchitis type symptoms should be screened for pathogenic bacteria beside CDI in stool. Further studies with higher number of patients with positive stool cultures need to be done to confirm these findings. Table 1: Demographics and Clinical Data

Sa1835 ROLE OF ASSISTED REPRODUCTIVE TECHNOLOGIES IN INFLAMMATORY BOWEL DISEASE: RESULTS FROM THE PIANO REGISTRY Priya Kathpalia, Christopher Martin, Sumona Saha, Kim L. Isaacs, Bincy Abraham, Sonia Friedman, Uma Mahadevan Background: Few studies discuss the use of in vitro fertilization (IVF) and other assisted reproductive technologies (ART) among patients with inflammatory bowel disease (IBD). National Health Statistics (NHS) data report that 12% of all women or their partners required assistance, whether IVF or other ART, to conceive. The aims of this study are to assess use of reproductive technologies in the IBD population that successfully conceived and identify which patient characteristics predict need for these technologies. Methods: In a multi-center prospective cohort of pregnant women with IBD, we collected mothers' demographics, IBD and reproductive history, and socioeconomic factors. Data was collected using questionnaires that were administered in person or via telephone each trimester. Logistic multivariable regression analysis was used to assess factors independently associated with use of IVF or other ART in pregnant women with IBD. Results: Of 1284 female patients enrolled in the PIANO registry, 163 (13%) required use of IVF (n=61) or other ART (n=102) to conceive, similar to rates in the general population. The mean age in the IVF and other ART groups was 35.3 (±4.8) years and 32.0 (±4.0) years, respectively compared to 30.8 (±4.5) years in the natural conception group. The mean duration of disease in the IVF group was 11.6 (±7.4) years and 8.6 (±6.4) years in the other ART group compared to 8.2 (±6.0) years in the natural conception group. Of those patients requiring IVF or other ART, 58.3% (95) had Crohn's disease, 37.4% (61) had ulcerative colitis, and 4.3% (7) had indeterminate colitis. History of IBD-related surgery was 27.6% in those with IVF or other ART, compared to 21.1% in the natural conception group (p=0.063). Nulliparous participants were less likely to use reproductive technologies (10.1% versus 14.4%, p=.024). Women using IVF or other ART had higher household income at conception, with 61% having incomes of >$100K, compared to 44% in the natural conception group (p=.002). Patient characteristics with adjusted odds ratios (OR) and 95% CIs for needing reproductive assistance (IVF or other ART) were maternal age ((>35 versus <26 years), OR=1.8 [0.64-5.22]), household income ((>$100K versus <$50K), OR= 4.0 [1.51-10.44]), and history of IBD-related surgery (OR=1.6 [1.02-2.64]). Nulliparity was not associated with IVF or other ART after controlling for the other factors in the model. Conclusions: Women with IBD have similar rates of ART use compared to the general population. Advanced maternal age, higher household income, and a history of IBD-related surgeries are associated with increased ART use. Understanding the impact of these maternal factors on conception can guide preconception counseling for women with IBD.

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(0-4) with 0 corresponding to "not at all" and 4 being "a great deal". Results: 70% were female, 65% had CD, 66% were married, mean age was 42.1 (14.0) and mean age of initial IBD diagnosis was 29. 82% identified a factor associated with worsening of symptoms. As shown in the Table, the factor identified as most frequently causing an exacerbation of symptoms was stress or worry. Eating certain foods was the next most frequently identified factor. Other psychosocial factors (likely overlapping with stress) were identified as frequently associated with exacerbations including overwork, emotional difficulty, conflict with an important person, and sleep difficulties. An evaluation of the association of the ratings with sex and age indicated that the results were not related to these respondent characteristics. Conclusion: Participants were clearly able to identify factors associated with periods of increased symptoms, with stress and dietary factors identified as having the greatest impact. Further research will focus on better delineation of the components of these factors which may drive symptom exacerbation, and on the populations most susceptible to these influences Even those factors with lower mean ratings (such as use of more alcohol or changing or stopping IBD medicine) may be particularly important to a meaningful proportion of patients with IBD (more than 10% rated each as important) and are worth investigating further. Factors considered to trigger increases in IBD symptoms

Sa1837 PREFERENCES FOR CARE FOR ACTIVE SYMPTOMS OF IBD IN A POPULATION BASED SAMPLE Matthew Bernstein, Tarun Chhibba, John Walker, Leigh Anne Shafer, Melony Ivekovic, Harminder Singh, Laura E. Targownik, Charles N. Bernstein Background Persons with IBD frequently attend Emergency Departments (ED) when they are acutely ill, though many could be better served in an alternative setting. We aimed to determine the care preferences of people with IBD when seeking care for active symptoms. Methods 1143 Persons aged 18-64 in the population-based University of Manitoba IBD Research Registry participated in the survey (46% response rate). Results 95% reported having a family doctor (FD), 10% a nurse practitioner, 61% a gastroenterologist (GE), and 18% a GI surgeon (GIS). Only 42% reported being able to call a GE for advice in managing active symptoms, and only 29% could call a GE for an appointment within 1 week. Respondents were asked how likely they were to take a wide range of actions if they were having severe symptoms. The likely or very likely actions were to make an appointment with their regular GE/GIS (68%), phone regular GE/GIS (65%), go to an ED (49%), or search the Internet for information (48%). When asked to choose one preferred service, the most frequent were calling a GE/GIS (38%), the ED (36%), and calling their FD (17%). If they were having mild/moderate symptoms, they indicated they were likely/very likely to: wait it out as long as possible (59%), make an appointment to see FD (46%), make an appointment to see regular GE/GIS (45%), or phone regular GE/GIS (42%); only 12% would go to ED. In choosing only one service, 30% preferred to call or make appointment with FD, 29% would call or make appointment with GE or GIS, and 17% would wait it out. When experiencing severe symptoms, persons with Crohn's disease indicated they would be more likely to go to ED (OR=2.77, 95%CI=2.10-3.66) and less likely to adjust medications on their own (OR=.41, 95%CI=.31-.55) than people with UC. Persons who had seen a GE within the year would be more likely to phone a GE/GIS (OR=4.00, 95%CI=2.94-5.44) or phone a nurse specialist (OR=1.74, 95%CI=1.28-2.35), and were less likely to call a FD (OR=.51, 95%CI=.39-.69) or go to a walk-in clinic (OR=.56, 95%CI=.37-.85) than those who had not seen a GE. However, having seen a GE within 1 year did not impact on the likelihood of stating they would attend an ED. When participants were asked, in the event they were having urgent problems with IBD, about their likelihood of seeking a range of services not currently available but which could be made available in the future, they reported they were very likely or likely to use the following services: phone contact with an IBD nurse (77%), phone contact with a GE (75%), and going to a walk-in GE clinic (71%). Conclusions Persons with IBD are interested in choices other than accessing the ED when they are experiencing IBD symptoms; however, attending the ED remains a prominent choice. Improved access to specialized care may improve timeliness of care and reduce ED attendance.

Sa1839 POOR CONSUMPTION OF FIBER, NOT FAT, IS ASSOCIATED WITH ACTIVE DISEASE IN INFLAMMATORY BOWEL DISEASE Alyce J. Anderson, Sinthana Umakanthan, Dmitriy Babichenko, Claudia Ramos Rivers, Benjamin H. Click, Ioannis Koutroubakis, William Rivers, Jana G. Hashash, Michael A. Dunn, Marc Schwartz, Arthur Barrie, Jason Swoger, Miguel D. Regueiro, David G. Binion Diet plays an important role in the susceptibility and clinical course of inflammatory bowel disease (IBD) and other functional gastrointestinal disorders. However, few studies have examined the differences between fiber and fat as it relates to IBD severity. Methods: We prospectively collected food frequency questionnaires at outpatient visits from patients enrolled in a prospective natural history IBD registry. Grams of fiber and percentage of energy intake from fat was calculated using the validated PhenX Toolkit's age and gender stratified regression coefficients. Daily fiber intake was categorized as low (<10g), moderate (10-20g), high (>20g), and percent energy from fat as low (<33%) and high (>33%). All healthcare utilization and disease severity data from the same year was derived from the IBD registry and temporally organized. We used parametric and non-parametric statistical analyses as well as univariate linear regression to analyze the association between fiber, fat, disease activity, and healthcare utilization. Results: A total of 557 patients completed dietary questionnaires in 2015 and were included (67% Crohn's disease, 30% ulcerative colitis, 3% IBD-unclassified, mean age 43.0 ± 13.9 years, 58.3% female). 27% had low fiber intake, 62%, moderate, and 11% high. Patients ranged from 22.8 - 55.7%, but the majority (60%) had <33% percent energy from fat. The total daily grams of fiber were not statistically associated with the percentage of energy consumed from fat. Lower dietary fiber was associated with active disease (p=0.001) as measured by disease specific questionnaires, poor quality of life (p=0.007) as measured by the short inflammatory bowel disease questionnaire, lower mean hemoglobin (p=0.001) and albumin (p=0.001), more radiologic tests (p=0.04), and increased annual financial charges (p=0.01). Fat intake was not significantly associated with any of these measures. Neither fat nor fiber was associated with abnormal C-reactive protein. Hospitalization rates, surgeries and endoscopies were not statistically different between fat and fiber groups. Neither fiber nor fat were associated with exposure to biologics, immunomodulators, steroids, or antibiotics. Conclusions: Dietary fiber consumption appears to be related to disease activity and quality of life in IBD patients, while the percentage of energy derived from fat is not associated with disease activity, quality of life or healthcare utilization outcomes. This suggests fiber may play an important role in the diets of IBD patients, while dietary fat does not appear to relate to IBD course.

Sa1838 A SURVEY OF PATIENT VIEWS OF FACTORS PRODUCING SYMPTOM EXACERBATIONS IN THE LIVING WITH IBD STUDY John Walker, Laura E. Targownik, Kelcie Witges, Clove Haviva, Kathryn Sexton, Lesley Graff, Lisa Lix, Kathy Vagianos, Gayle Restall, Charles N. Bernstein Background: There has been considerable research into risk factors that may exacerbate symptoms in IBD. There has been limited research on the factors which patients have observed to exacerbate symptoms and often this research has considered one or two factors at a time and not the broad range of possible triggers of symptom exacerbation. Identifying common triggers of symptom exacerbations would aid caregivers in better managing and mitigating the effects of these factors on IBD symptoms Methods. Persons aged 18-75, living in Manitoba with an IBD diagnosis (n=135) were recruited for a longitudinal study of factors associated with IBD symptoms that involved biweekly assessments over a one year period. Subjects were asked at baseline about 12 potential triggers of symptom exacerbation, with question stated as "How much have the following been related to your IBD symptoms going from inactive to active in the past". These triggers were identified through earlier qualitative research and consultation with the patient advisory committee and IBD specialists, and included stomach or bowel infections, any other infection, being overworked, sleep problems, conflict with an important person, stress or worry, drinking more alcohol than usual, overeating, stopping or changing IBD medication, emotional difficulties, eating certain foods, not eating certain foods. Subjects rated the impact of these triggers using a 5-point scale

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AGA Abstracts

Table 2: Outcomes