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The Modified Postoperative Endoscopic Recurrence Score for Crohn's Disease: Does it Really Make a Difference in Predicting Clinical Recurrence?
AGA Abstracts
frequent extra-intestinal disease manifestations (EIM). However, the stability of IBD phenotype characteristics between these racial groups and differences in disease course have not been evaluated. Methods: Subjects with confirmed IBD were recruited from the Johns Hopkins adult outpatient gastroenterology clinics from 2003 to 2010. Phenotype characteristics and complications were determined at time of recruitment and then at >3 years of follow up by chart review of all records available. Chi-square, t test and Fisher's Exact were used to compare demographic factors and progression of disease in location, behavior, surgeries, EIM, and medications by race. Results: Of 314 subjects, 103 (70 CD and 27 UC) had 3 or more years of follow-up; 61 were AA and 42 were white (Figure 1) with an average of 7.08 ± 0.34 yrs for AA and 6.49 ± 0.32 yrs for whites (P=0.116) between initial phenotyping at recruitment and time of most recent follow up. There were also no differences in age at diagnosis or attained age at time of initial follow up. 19 CD subjects had progression of their disease to a new location (EGD, Jejunal, Ileal, Colorectal, or Perianal), with significantly more AAs progressing than whites (P=0.041). Among the sites, only perianal disease varied significantly by race, with greater progression in AAs (P=0.019). UC location only extended in 6 subjects, 3 of each race. For CD, there was no difference in progression by race from B1 to complicated disease (B2 or B3). 31 IBD subjects developed a new EIM. Large joint EIM development differed significantly by race; all 7 were whites. Development of skin or eye EIMs did not differ by race. Among the 70 CD subjects, 14 AA and 1 white subjects required one or more abdominal surgeries during the follow-up period (P=0.006). Among 31 CD subjects (AA=22, white=9) with no prior bowel resection, only AAs (n=10) required resections (p=0.006, Fishers Exact). UC colectomy rates were similar by race. First medications for moderate to severe IBD (anti-TNF inhibitors or immunomodulators) did not differ by race. Conclusions: Perianal disease is a persistent feature of AA CD relative to whites, now with greater progression over time. AAs were more likely to have at least one new abdominal surgery or a first abdominal surgery during the follow-up period. These differences may be due to intrinsic need for surgery later in the disease course, or to disparities in disease management or accessing care, especially since progression to complicated disease was similar by race.
Figure 1: Kaplan-Meier curve showing the cumulative probability for clinical relapse after ileocolonic resection in Crohn's disease patients stratifed by the modified Rurtgeerts' score at index endoscopy after the surgery.
Sa1868 THE MODIFIED POSTOPERATIVE ENDOSCOPIC RECURRENCE SCORE FOR CROHN'S DISEASE: DOES IT REALLY MAKE A DIFFERENCE IN PREDICTING CLINICAL RECURRENCE? Pauline Rivière, Severine Vermeire, Gert A. Van Assche, Paul Rutgeerts, Anthony de Buck van Overstraeten, Andre D'Hoore, Marc Ferrante Background: The endoscopic Rutgeerts' score (RS) is widely used to guide post-operative management of patients with Crohn's disease (CD). It is unclear whether all lesions from the i2 category should be considered clinically relevant. The modified RS differentiates lesions at the anastomosis with or without < 5 isolated neo-terminal ileal erosions (i2a) from presence of ≥5 isolated neo-terminal ileal erosions with or without anastomotic lesions (i2b), but its predictive value has not been validated. We investigated if clinical relapse (CR) and need for endoscopic/surgical intervention (ESI) differ between i2a and i2b endoscopic recurrence (ER). Methods: This was a retrospective, single-center study including all consecutive patients with an i2 ER observed 6-12 months after right hemicolectomy with ileocolonic anastomosis. The modified RS was attributed based on the available endoscopic report and on the images captured during endoscopy. CR was defined as the occurrence of CD related symptoms along with biological, endoscopic (i3-i4) and/or radiologic signs of disease activity. ESI was defined as the need for balloon dilatation or stricturoplasty at site of the anastomosis, or new right hemicolectomy. Kaplan-Meier curves were plotted for time from index endoscopy to CR and ESI. Results: The study population consisted of 94 patients [43 males, median age at index endoscopy 37 years], operated between December 2000 and December 2013. At index endoscopy, 53 patients (56%) had an i2a ER, and 41 (44%) an i2b ER. At endoscopy, the two groups were not different regarding disease characteristics and post-operative prophylactic therapy. Medical treatment was optimized or initiated according to index colonoscopy in 8 (15%) patients with i2a and 20 (49%) with i2b ER (Odds ratio (OR) 5.2 (95%CI 2.0-14.6), p<0.001). During a median (IQR) follow-up of 78 (37-109) months, CR and ESI were observed in 47 (50%) and 21 (22%) patients, respectively. As shown in Figures 1 and 2, the modified i2a and i2b scores were not predictive of CR and ESI (Log Rank p=0.37 and p=0.10, respectively). Also after exclusion of patients with immediate post-endoscopy treatment optimization, the modified i2a and i2b scores were not predictive of CR and ESI (Log Rank p=0.73 and p=0.34, respectively). A previous ileocolonic resection (OR 2.0 (95%CI 1.1-3.9), p=0.04) was associated with CR; immediate post-operative prophylactic therapy by anti-TNF was protective against CR (p=0.03). Postoperative prophylactic therapy by thiopurine was protective against ESI (p=0.02). Conclusion: In this cohort, no difference was observed in terms of clinical relapse and need for endoscopic or surgical intervention between i2a and i2b ER after a right hemicolectomy with ileocolonic anastomosis in CD patients. Further study is needed to confirm these results and evaluate the outcome of Rutgeerts' score i2 patients.
AGA Abstracts
Figure 2: Kaplan-Meier curve showing the cumulative probability for endoscopic or surgical intervention after ileocolonic resection in Crohn's disease patients stratifed by the modified Rurtgeerts' score at index endoscopy after the index surgery.
Sa1869 WHAT ARE THE MOST COMMON SYMPTOMS REPORTED IN A SELFREPORTED FLARE OF IBD? THE MANITOBA LIVING WITH IBD STUDY Kelcie Witges, Laura E. Targownik, Clove Haviva, Kathryn Sexton, John Walker, Lesley Graff, Lisa Lix, Norine Miller, Charles N. Bernstein Background: Patient and provider definitions of an IBD flare don't always agree. A better understanding of the self-reported symptoms related to the transition into a worse disease state will provide clinicians with a better understanding of how persons with IBD experience a flare. Aims: A case-control study to assess the relationship between a 7-point indicator measuring a change in symptoms over time, and 3 symptom sub-scores derived from the newly developed Short IBD Symptom Index (SIBDSI) score: a bowel symptom (BS) score, an abdominal discomfort (AD) score, and a fatigue (F) score. Methods: Persons 18-75 yrs., living in Manitoba with an IBD diagnosis (n=135) completed surveys every 2 weeks for 1 yr. An IBD flare was identified using a score ≥ 6 on the 7-point indicator. Participants who flared were systematically matched to controls (participants who had never flared) based on date of enrolment, and matched by sex and disease type. We compared the three symptom sub-scores (BS, AD, F) of flares and controls at 2 weeks before the flare (Time 1) and at the time of the flare (Time 2). By controlling for symptom sub-scores at Time 1, a logistic regression model was used to determine whether change in individual symptom sub-scores were important, and which were more so in predicting a transition into a flare. Results: 25% of participants flared during the study period. There was a greater change in all symptom sub-scores between Time 1 and Time 2 among flares than controls (Table 1). Symptom sub-scores at Time 1 and Time 2 were regressed into the model in blocks to control for any variation between flares and controls prior to the transition into a flare at Time 2; no symptom sub-scores at Time 1 significantly predicted a flare at Time 2. The block including symptom sub-scores at Time 1 predicted 12.8% of the variation in flares and controls. Symptom sub-scores at Time 2 were then added into the regression; it was determined that persons who transitioned into a flare at Time 2 were more likely to experience an increase in bowel symptoms (odds ratio, (OR)=1.67 95%CI=1.18-2.35), p<0.01 and an increase in fatigue symptoms (OR=1.67 95% CI=1.03-2.71), p<0.05 (ORs are reported per 1 point
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frequent extra-intestinal disease manifestations (EIM). However, the stability of IBD phenotype characteristics between these racial groups and differences in disease course have not been evaluated. Methods: Subjects with confirmed IBD were recruited from the Johns Hopkins adult outpatient gastroenterology clinics from 2003 to 2010. Phenotype characteristics and complications were determined at time of recruitment and then at >3 years of follow up by chart review of all records available. Chi-square, t test and Fisher's Exact were used to compare demographic factors and progression of disease in location, behavior, surgeries, EIM, and medications by race. Results: Of 314 subjects, 103 (70 CD and 27 UC) had 3 or more years of follow-up; 61 were AA and 42 were white (Figure 1) with an average of 7.08 ± 0.34 yrs for AA and 6.49 ± 0.32 yrs for whites (P=0.116) between initial phenotyping at recruitment and time of most recent follow up. There were also no differences in age at diagnosis or attained age at time of initial follow up. 19 CD subjects had progression of their disease to a new location (EGD, Jejunal, Ileal, Colorectal, or Perianal), with significantly more AAs progressing than whites (P=0.041). Among the sites, only perianal disease varied significantly by race, with greater progression in AAs (P=0.019). UC location only extended in 6 subjects, 3 of each race. For CD, there was no difference in progression by race from B1 to complicated disease (B2 or B3). 31 IBD subjects developed a new EIM. Large joint EIM development differed significantly by race; all 7 were whites. Development of skin or eye EIMs did not differ by race. Among the 70 CD subjects, 14 AA and 1 white subjects required one or more abdominal surgeries during the follow-up period (P=0.006). Among 31 CD subjects (AA=22, white=9) with no prior bowel resection, only AAs (n=10) required resections (p=0.006, Fishers Exact). UC colectomy rates were similar by race. First medications for moderate to severe IBD (anti-TNF inhibitors or immunomodulators) did not differ by race. Conclusions: Perianal disease is a persistent feature of AA CD relative to whites, now with greater progression over time. AAs were more likely to have at least one new abdominal surgery or a first abdominal surgery during the follow-up period. These differences may be due to intrinsic need for surgery later in the disease course, or to disparities in disease management or accessing care, especially since progression to complicated disease was similar by race.
Figure 1: Kaplan-Meier curve showing the cumulative probability for clinical relapse after ileocolonic resection in Crohn's disease patients stratifed by the modified Rurtgeerts' score at index endoscopy after the surgery.
Sa1868 THE MODIFIED POSTOPERATIVE ENDOSCOPIC RECURRENCE SCORE FOR CROHN'S DISEASE: DOES IT REALLY MAKE A DIFFERENCE IN PREDICTING CLINICAL RECURRENCE? Pauline Rivière, Severine Vermeire, Gert A. Van Assche, Paul Rutgeerts, Anthony de Buck van Overstraeten, Andre D'Hoore, Marc Ferrante Background: The endoscopic Rutgeerts' score (RS) is widely used to guide post-operative management of patients with Crohn's disease (CD). It is unclear whether all lesions from the i2 category should be considered clinically relevant. The modified RS differentiates lesions at the anastomosis with or without < 5 isolated neo-terminal ileal erosions (i2a) from presence of ≥5 isolated neo-terminal ileal erosions with or without anastomotic lesions (i2b), but its predictive value has not been validated. We investigated if clinical relapse (CR) and need for endoscopic/surgical intervention (ESI) differ between i2a and i2b endoscopic recurrence (ER). Methods: This was a retrospective, single-center study including all consecutive patients with an i2 ER observed 6-12 months after right hemicolectomy with ileocolonic anastomosis. The modified RS was attributed based on the available endoscopic report and on the images captured during endoscopy. CR was defined as the occurrence of CD related symptoms along with biological, endoscopic (i3-i4) and/or radiologic signs of disease activity. ESI was defined as the need for balloon dilatation or stricturoplasty at site of the anastomosis, or new right hemicolectomy. Kaplan-Meier curves were plotted for time from index endoscopy to CR and ESI. Results: The study population consisted of 94 patients [43 males, median age at index endoscopy 37 years], operated between December 2000 and December 2013. At index endoscopy, 53 patients (56%) had an i2a ER, and 41 (44%) an i2b ER. At endoscopy, the two groups were not different regarding disease characteristics and post-operative prophylactic therapy. Medical treatment was optimized or initiated according to index colonoscopy in 8 (15%) patients with i2a and 20 (49%) with i2b ER (Odds ratio (OR) 5.2 (95%CI 2.0-14.6), p<0.001). During a median (IQR) follow-up of 78 (37-109) months, CR and ESI were observed in 47 (50%) and 21 (22%) patients, respectively. As shown in Figures 1 and 2, the modified i2a and i2b scores were not predictive of CR and ESI (Log Rank p=0.37 and p=0.10, respectively). Also after exclusion of patients with immediate post-endoscopy treatment optimization, the modified i2a and i2b scores were not predictive of CR and ESI (Log Rank p=0.73 and p=0.34, respectively). A previous ileocolonic resection (OR 2.0 (95%CI 1.1-3.9), p=0.04) was associated with CR; immediate post-operative prophylactic therapy by anti-TNF was protective against CR (p=0.03). Postoperative prophylactic therapy by thiopurine was protective against ESI (p=0.02). Conclusion: In this cohort, no difference was observed in terms of clinical relapse and need for endoscopic or surgical intervention between i2a and i2b ER after a right hemicolectomy with ileocolonic anastomosis in CD patients. Further study is needed to confirm these results and evaluate the outcome of Rutgeerts' score i2 patients.
AGA Abstracts
Figure 2: Kaplan-Meier curve showing the cumulative probability for endoscopic or surgical intervention after ileocolonic resection in Crohn's disease patients stratifed by the modified Rurtgeerts' score at index endoscopy after the index surgery.
Sa1869 WHAT ARE THE MOST COMMON SYMPTOMS REPORTED IN A SELFREPORTED FLARE OF IBD? THE MANITOBA LIVING WITH IBD STUDY Kelcie Witges, Laura E. Targownik, Clove Haviva, Kathryn Sexton, John Walker, Lesley Graff, Lisa Lix, Norine Miller, Charles N. Bernstein Background: Patient and provider definitions of an IBD flare don't always agree. A better understanding of the self-reported symptoms related to the transition into a worse disease state will provide clinicians with a better understanding of how persons with IBD experience a flare. Aims: A case-control study to assess the relationship between a 7-point indicator measuring a change in symptoms over time, and 3 symptom sub-scores derived from the newly developed Short IBD Symptom Index (SIBDSI) score: a bowel symptom (BS) score, an abdominal discomfort (AD) score, and a fatigue (F) score. Methods: Persons 18-75 yrs., living in Manitoba with an IBD diagnosis (n=135) completed surveys every 2 weeks for 1 yr. An IBD flare was identified using a score ≥ 6 on the 7-point indicator. Participants who flared were systematically matched to controls (participants who had never flared) based on date of enrolment, and matched by sex and disease type. We compared the three symptom sub-scores (BS, AD, F) of flares and controls at 2 weeks before the flare (Time 1) and at the time of the flare (Time 2). By controlling for symptom sub-scores at Time 1, a logistic regression model was used to determine whether change in individual symptom sub-scores were important, and which were more so in predicting a transition into a flare. Results: 25% of participants flared during the study period. There was a greater change in all symptom sub-scores between Time 1 and Time 2 among flares than controls (Table 1). Symptom sub-scores at Time 1 and Time 2 were regressed into the model in blocks to control for any variation between flares and controls prior to the transition into a flare at Time 2; no symptom sub-scores at Time 1 significantly predicted a flare at Time 2. The block including symptom sub-scores at Time 1 predicted 12.8% of the variation in flares and controls. Symptom sub-scores at Time 2 were then added into the regression; it was determined that persons who transitioned into a flare at Time 2 were more likely to experience an increase in bowel symptoms (odds ratio, (OR)=1.67 95%CI=1.18-2.35), p<0.01 and an increase in fatigue symptoms (OR=1.67 95% CI=1.03-2.71), p<0.05 (ORs are reported per 1 point
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