Spondyloarthritis is an extraintestinal manifestation of inflammatory bowel disease with important clinical impact, although the frequency is uncertain. We sought to assess the cumulative incidence and clinical spectrum of spondyloarthritis in patients with Crohn’s disease (CD) in a population-based cohort.
The medical records of a population-based cohort of Olmsted County, Minnesota residents diagnosed with CD between 1970 and 2004 were reviewed. Patients were followed longitudinally until migration, death, or December 31, 2010. We used the European Spondyloarthropathy Study Group, Assessment of Spondyloarthritis international Society (ASAS) criteria and modified New York criteria to identify patients with spondyloarthritis. The Kaplan-Meier method was used to estimate the cumulative incidence of spondyloarthritis following CD diagnosis.
The cohort included 311 patients with CD (49.8% females; median age, 29.9 years [range, 8–89]). Thirty-two patients developed spondyloarthritis based on ASAS criteria. The cumulative incidence of spondyloarthritis after CD diagnosis was 6.7% (95% confidence interval, 2.5%–6.7%) at 10 years, 13.9% (8.7%–18.8%) at 20 years, and 18.6% (11.0%–25.5%) at 30 years. The 10-year cumulative incidence of ankylosing spondylitis was 0 while both the 20-year and 30-year cumulative incidences were 0.5% (95% CI, 0–1.6%).
We have for the first time defined the actual cumulative incidence of spondyloarthritis in CD using complete medical record information in a population-based cohort. The cumulative incidence of all forms of spondyloarthritis increased to approximately 19% by 30 years from CD diagnosis. Our results emphasize the importance of maintaining a high level of suspicion for spondyloarthritis when following patients with CD.
Spondyloarthritis; Crohn’s disease; epidemiology; ankylosing spondylitis
Background and aims
We followed a population based cohort of patients with inflammatory bowel disease (IBD) from Olmsted County, Minnesota, in order to analyse long term survival and cause specific mortality.
Material and methods
A total of 692 patients were followed for a median of 14 years. Standardised mortality ratios (SMRs, observed/expected deaths) were calculated for specific causes of death. Cox proportional hazards regression was used to determine if clinical variables were independently associated with mortality.
Fifty six of 314 Crohn's disease patients died compared with 46.0 expected (SMR 1.2 (95% confidence interval (CI) 0.9–1.6)), and 62 of 378 ulcerative colitis (UC) patients died compared with 79.2 expected (SMR 0.8 (95% CI 0.6–1.0)). Eighteen patients with Crohn's disease (32%) died from disease related complications, and 12 patients (19%) died from causes related to UC. In Crohn's disease, an increased risk of dying from non‐malignant gastrointestinal causes (SMR 6.4 (95% CI 3.2–11.5)), gastrointestinal malignancies (SMR 4.7 (95% CI 1.7–10.2)), and chronic obstructive pulmonary disease (COPD) (SMR 3.5 (95% CI 1.3–7.5)) was observed. In UC, cardiovascular death was reduced (SMR 0.6 (95% CI 0.4–0.9)). Increased age at diagnosis and male sex were associated with mortality in both subtypes. In UC but not Crohn's disease, a diagnosis after 1980 was associated with decreased mortality.
In this population based study of IBD patients from North America, overall survival was similar to that expected in the US White population. Crohn's disease patients were at increased risk of dying from gastrointestinal disease and COPD whereas UC patients had a decreased risk of cardiovascular death.
death causes; Crohn's disease; inflammatory bowel disease; ulcerative colitis; survival; mortality; prognosis
Patient awareness and concern regarding the potential health risks from ionizing radiation have peaked recently (Coakley et al., 2011) following widespread press and media coverage of the projected cancer risks from the increasing use of computed tomography (CT) (Berrington et al., 2007). The typical young and educated patient with inflammatory bowel disease (IBD) may in particular be conscious of his/her exposure to ionising radiation as a result of diagnostic imaging. Cumulative effective doses (CEDs) in patients with IBD have been reported as being high and are rising, primarily due to the more widespread and repeated use of CT (Desmond et al., 2008). Radiologists, technologists, and referring physicians have a responsibility to firstly counsel their patients accurately regarding the actual risks of ionizing radiation exposure; secondly to limit the use of those imaging modalities which involve ionising radiation to clinical situations where they are likely to change management; thirdly to ensure that a diagnostic quality imaging examination is acquired with lowest possible radiation exposure. In this paper, we synopsize available evidence related to radiation exposure and risk and we report advances in low-dose CT technology and examine the role for alternative imaging modalities such as ultrasonography or magnetic resonance imaging which avoid radiation exposure.
Background and Aims
The degree of diagnostic radiation exposure in children with inflammatory bowel diseases (IBD) is largely unknown. Here we describe this exposure in a population-based sample of children with IBD and determine characteristics associated with moderate radiation exposure.
We ascertained radiological study use, demographic characteristics, IBD medication use, and the requirement for hospitalization, emergency department (ED) encounter, or inpatient GI surgery among children with IBD within a large insurance claims database. Characteristics associated with moderate radiation exposure (at least one computed tomography (CT) or three fluoroscopies over two years) were determined using logistic regression models.
We identified 965 children with Crohn’s Disease (CD) and 628 with Ulcerative Colitis (UC). Over 24 months, 34% of CD subjects and 23% of UC subjects were exposed to moderate diagnostic radiation [odds ratio (OR) 1.71, 95% confidence interval (CI), 1.36–2.14]. CT accounted for 28% and 25% of all studies in CD and UC subjects, respectively. For CD subjects, moderate radiation exposure was associated with hospitalization (OR 4.89, 95% CI 3.37–7.09), surgery (OR 2.93, 95% CI 1.59–5.39), ED encounter (OR 2.65, 1.93–3.64 95% CI), oral steroids (OR 2.25, 95% CI 1.50–3.38), and budesonide (OR 1.80, 95% CI 1.10–3.06); an inverse association was seen with immunomodulator use (OR 0.67, 95% CI 0.47–0.97). Except for oral steroids and immunomodulators, similar relationships were seen in UC.
A substantial proportion of children with IBD are exposed to moderate amounts of radiation as a result of diagnostic testing. This high utilization may impart long-term risk given the chronic nature of the disease.
Background and aims: The potentially high costs of care associated with inflammatory bowel disease (IBD) are recognised but we have little knowledge of the scale, profile, or determinants of these costs in the UK. This study aimed to describe costs of illness for a group of IBD patients and determine factors associated with increased healthcare costs.
Setting: A university hospital serving a target population of approximately 330 000.
Patients and methods: A six month cohort of IBD patients receiving any form of secondary care was identified, comprising 307 cases of ulcerative (or indeterminate) colitis and 172 cases of Crohn’s disease. Demographic and clinical data were abstracted from clinical records and individual resource use was itemised for all attributable costs (including extraintestinal manifestations). Item costs were derived from national and local sources. Cost data were expressed as mean six month costs per patient (with 95% confidence interval (CI)) obtained using non-parametric bootstrapping. Determinants of cost were analysed using generalised linear regression modelling. A postal survey of patients was undertaken to examine indirect costs, out of pocket expenses, and primary care visits.
Results: Inpatient services (medical and/or surgical) were required by 67 patients (14%) but accounted for 49% of total secondary care costs. Drug costs accounted for less than a quarter of total costs. Individual patient costs ranged from £73 to £33 254 per six months. Mean (95% CI) six month costs per patient were £1256 (£988, £1721) for colitis and £1652 (£1221, £2239) for Crohn’s disease. Hospitalisation, disease severity grade, and disease extent correlated positively with cost of illness but costs were independent of age or sex. Compared with quiescent cases of IBD, disease relapse was associated with a 2–3-fold increase in costs for non-hospitalised cases and a 20-fold increase in costs for hospitalised cases. Survey data suggested average six month costs were <£30 per patient for primary care visits (both diseases) and median loss of earnings were £239 for colitis and £299 for Crohn’s disease.
Conclusions: This study represents the first detailed characterisation of the scale and determinants of costs of illness for IBD in a British hospital. Hospitalisation affected a minority of sufferers but accounted for half of the total direct costs falling on the healthcare system.
inflammatory bowel disease; ulcerative colitis; Crohn’s disease; costs; economics
Crohn’s disease, a transmural inflammatory bowel disease, remains a difficult entity to diagnose clinically. Over the last decade, multidetector computed tomography (CT) has become the method of choice for non-invasive evaluation of the small bowel, and has proved to be of significant value in the diagnosis of Crohn’s disease. Advancements in CT enterography protocol design, three dimensional (3-D) post-processing software, and CT scanner technology have allowed increasing accuracy in diagnosis, and the acquisition of studies at a much lower radiation dose. The cases in this review will illustrate that the use of 3-D technique, proper enterography protocol design, and a detailed understanding of the different manifestations of Crohn’s disease are all critical in properly diagnosing the full range of possible complications in Crohn’s patients. In particular, CT enterography has proven to be effective in identifying involvement of the small and large bowel (including active inflammation, stigmata of chronic inflammation, and Crohn’s-related bowel neoplasia) by Crohn’s disease, as well as the extra-enteric manifestations of the disease, including fistulae, sinus tracts, abscesses, and urologic/hepatobiliary/osseous complications. Moreover, the proper use of 3-D technique (including volume rendering and maximum intensity projection) as a routine component of enterography interpretation can play a vital role in improving diagnostic accuracy.
Crohn’s disease; Computed tomography angiography; Multidetector computed tomography; Three dimensional technique; Volume rendering; Maximum intensity projection; Fistula; Dose reduction
Plasma levels of circulating carcinoembryonic antigen (CEA) were measured by zirconyl phosphate gel radioimmunoassay in 112 patients with chronic inflammatory bowel disease. The levels were then related to category, extent, duration, and severity of disease, as well as to the ages and surgical status of the patients. The distribution of CEA levels and their mean values were significantly raised over the levels in 33 normal control subjects, and were similar among patients with ulcerative colitis compared with those with granulomatous bowel disease. Positive values were defined as those in excess of 2·5 ng/ml. Positive assays occurred in 42% of ulcerative colitis patients, in 38% of Crohn's disease patients, and in 40% of the total group with inflammatory bowel disease. Among normal control subjects, only 3% were positive. Among inflammatory bowel disease patients, positive CEA assays occurred more frequently with more severe disease, more extensive anatomical involvement, younger ages, and shorter duration of disease. Those patients who had undergone total colectomy showed levels of circulating CEA and frequency of CEA positivity similar to those of an age-matched normal control group. Levels of CEA did not correspond with known cancer risk factors in patients with inflammatory bowel disease. Although rising or persisting plasma CEA values unrelated to severity and extent of disease may indicate an unfavourable prognosis in cancer, this study shows that a single CEA value in patients with chronic inflammatory bowel disease is not a reliable indicator of cancer risk.
The growing use of interventional and fluoroscopic imaging in children represents a tremendous benefit for the diagnosis and treatment of benign conditions. Along with the increasing use and complexity of these procedures comes concern about the cancer risk associated with ionizing radiation exposure to children. Children are considerably more sensitive to the carcinogenic effects of ionizing radiation than adults, and children have a longer life expectancy in which to express risk. Numerous epidemiologic cohort studies of childhood exposure to radiation for treatment of benign diseases have demonstrated radiation-related risks of cancer of the thyroid, breast, brain and skin, as well as leukemia. Many fewer studies have evaluated cancer risk following diagnostic radiation exposure in children. Although radiation dose for a single procedure might be low, pediatric patients often receive repeated examinations over time to evaluate their conditions, which could result in relatively high cumulative doses. Several cohort studies of girls and young women subjected to multiple diagnostic radiation exposures have been informative about increased mortality from breast cancer with increasing radiation dose, and case-control studies of childhood leukemia and postnatal diagnostic radiation exposure have suggested increased risks with an increasing number of examinations. Only two long-term follow-up studies of cancer following cardiac catheterization in childhood have been conducted, and neither reported an overall increased risk of cancer. Most cancers can be induced by radiation, and a linear dose-response has been noted for most solid cancers. Risks of radiation-related cancer are greatest for those exposed early in life, and these risks appear to persist throughout life.
Radiation risks; Carcinogenesis; Diagnostic radiation; Therapeutic radiation
One hundred and four children were initially assessed by clinical, radiological, and endoscopic criteria as chronic inflammatory bowel disease. All were assessed independently using precise histological diagnostic criteria. Fifty eight patients were diagnosed as Crohn's disease, 25 as ulcerative colitis, 15 remained provisionally categorised as indeterminate colitis and six proved to be normal. Diagnostic granulomas were found in 36% of endoscopic biopsies from the 58 children with Crohn's disease. This appears to be an underestimate as only four of 14 children with granulomatous Crohn's disease operated on had granulomas on endoscopic biopsy. This study shows that there is a spectrum of histological appearances in endoscopic biopsies in chronic inflammatory bowel disease in childhood ranging from definite Crohn's disease to definite ulcerative colitis with indeterminate features in between. Accurate histological diagnosis of chronic inflammatory bowel disease is dependent upon either multiple endoscopic biopsies or assessment of a surgically resected specimen.
The description of the prognosis of inflammatory bowel disease (IBD) is based on systematic follow-up of population-based cohorts. A steady increase in incidence of IBD has occurred. The distribution of ulcerative colitis (UC) is fairly uniform with a preponderance of left-sided disease. One-third of Crohn’s disease (CD) patients present with colonic disease, one-third with ileocolonic disease and one-third with small bowel disease. IBD is associated with extra-intestinal manifestations (EIMs) in up to 36% of patients. Uveitis and episcleritis are the most common. The cumulative probability of a relapsing course in UC is 90% after 25 years. In CD disease behaviour varies substantially with time. At diagnosis behaviour is inflammatory in 70% of patients. At follow-up there is a change to either stricturing or penetrating disease. Most patients with CD will eventually require surgery. Risk factors for CD recurrence after surgery include penetrating/fistulizing disease behaviour, young age, short duration of disease before first surgery and ileocolonic disease. The incidence of colorectal cancer (CRC) in UC seems to be decreasing. The risk of CRC in CD seems to be equivalent to the risk in UC. Patients with small bowel CD are also at increased risk of small bowel adenocarcinoma. CD is associated with a mortality rate 20–70% higher than expected, whereas mortality in UC is equivalent to that of the general population. The improved prognosis of IBD, especially UC, could be due to a chemopreventive effect of the medications used. Further studies are needed to develop the best strategy for the reduction of mortality and cancer risk in IBD.
inflammatory bowel disease; epidemiology; prognosis; disease course; mortality; colorectal cancer
Seventy young adults (50 with Crohn's disease (CD) and 20 with ulcerative colitis (UC) (from a geographically derived cohort of patients with juvenile onset inflammatory bowel disease were interviewed and examined at a mean of 14 (range 5.2-29.5) years after diagnosis. Details of education and employment were collected as part of a structured clinical interview. Although 57% had had periods of absence from school of two months or more, their school examination pass rates were similar to those of the healthy population. The achievements of CD patients were consistently better than those of the UC group. In 15 patients, relapses of inflammatory bowel disease had adversely affected examination performance or prevented them from sitting school examinations. Extra tuition in hospital had been provided for only four patients, and three others had had privately arranged tuition at home. Fifty per cent proceeded to full time higher education. At the time of review, seven patients were full time students, one was a university research fellow, 47 were in full time and three in part time employment, one was self employed, four were housewives, and only six were involuntarily unemployed. All four unemployed CD patients attributed this to inflammatory bowel disease, but other factors were relevant in the unemployed UC patients. Few had direct evidence of rejection by employers on health grounds, though some did not declare their illness to prospective employers.
OBJECTIVE--To establish the frequency of permanent growth failure in juvenile onset inflammatory bowel disease. DESIGN--Measurement of height and weight in a geographically based cohort at a mean of 14 (range 5.2-29.5) years after diagnosis. Comparison with data from surveys of British adults in 1980 and 1987. SETTING--NHS hospitals throughout Scotland. SUBJECTS--105 Children admitted to hospital during 1968-83 who fulfilled diagnostic criteria for Crohn's disease or ulcerative colitis and lived in specified regions. 87 were aged over 18 and living in Britain at follow up. MAIN OUTCOME MEASURES--Height, weight, body mass index, and sexual maturity. RESULTS--All patients were sexually mature. 67 of the 70 patients examined were of normal height, and three women with Crohn's disease were abnormally short. Weight and body mass index were normal in all patients with ulcerative colitis. Patients with Crohn's disease had significantly lower weight than those with ulcerative colitis (men 66.8 (9.5) kg v 78.4 (13.8) kg, P = 0.04; women 51.5 (8.2) kg v 63.0 (12.1) kg, P < 0.02) irrespective of disease activity. Body mass index was also significantly lower than the normal distribution (P < 0.01). Growth retardation was not mentioned as a problem for any of the 17 patients interviewed only by telephone. CONCLUSIONS--Despite growth retardation in the teenage years most young people with inflammatory bowel disease will eventually achieve normal height. Reasons for lower weight in patients with Crohn's disease remain to be established.
Background and aims: Two divergent patterns of mortality for smoking related diseases in ulcerative colitis and Crohn’s disease patients were suggested in a previous population based study in Florence, Italy. Long term follow up (median 15 years) was completed to re-evaluate mortality in this Mediterranean cohort.
Patients and methods: Overall, 920 patients with inflammatory bowel disease were followed until December 2001 or death, with seven patients (0.8%) lost to follow up. A total of 14 040 person years were available for analysis; 118 deaths were observed (81/689 in ulcerative colitis and 37/231 in Crohn’s disease). Expected deaths were estimated using age, sex, and calendar specific national and local mortality rates; standardised mortality ratios (SMR) and 95% confidence interval (CI) were calculated.
Results: Among Crohn’s disease patients, mortality was strongly increased for gastrointestinal diseases (SMR 4.49 (95% CI 1.80–9.25)), all cancers (SMR 2.10 (95% CI 1.22–3.36)), and lung cancer (SMR 4.00 (95% CI 1.60–8.24)), leading to a significant 50% excess total mortality. Ulcerative colitis patients showed a significantly reduced total mortality because of lower cardiovascular (SMR 0.67 (95% CI 0.45–0.95)) and lung cancer (SMR 0.32 (95% CI 0.07–0.95)) mortality. No significant excess for colorectal cancer mortality was evident in this extended follow up.
Conclusions: These clearly divergent patterns of mortality correlate with documented differences in smoking habits between Crohn’s disease and ulcerative colitis patients. Family doctors and gastroenterologists should consider stopping cigarette smoking a specific priority for Crohn’s disease patients; the latter should be offered free participation in structured programmes for smoking cessation, with the aim of reducing smoking related excess mortality. Overall, no evidence of an increased mortality for large bowel cancer emerged in this series.
Crohn’s disease; ulcerative colitis; inflammatory bowel disease; mortality; epidemiology
The overall age and sex adjusted incidence of Crohn's disease among Olmsted County, Minnesota, residents was 4.0 per 100,000 person-year in the period 1943-1982. Ileitis, ileocolitis, and colitis each accounted for about one third of the 103 incidence cases. Incidence rates were greater in woman than men, were higher in the urban portions of the county, and rose over time. Overall, the natural history of Crohn's disease in the community may be milder than that reported for patients at referral centres, as over half of all patients had no complications and only a third required surgery for Crohn's disease. Only one developed adenocarcinoma of the colon (relative risk = 2.0, NS). Survival was relatively unimpaired for the cohort, but Crohn's disease may have played a role in half of the deaths. The prevalence of Crohn's disease was 90.5/100,000 population on 1 January 1980.
Using standard diagnostic algorithms it is not always possible to establish the correct phenotype of inflammatory bowel disease which is essential for therapeutical decisions. Endoscopic ultrasound elastography is a new endoscopic procedure which can differentiate the stiffness of normal and pathological tissue by ultrasound. Therefore, we aimed to investigate the role of transrectal ultrasound elastography in distiction between Crohn's disease and ulcerative colitis.
A total 30 Crohn's disease, 25 ulcerative colitis, and 28 non-inflammatory bowel disease controls were included. Transrectal ultrasound elastography was performed in all patients and controls. In all ulcerative coltis patients and 80% of Crohn's disease patients endoscopy was performed to assess disease activity in the rectum.
Significant difference in rectal wall thickness and strain ratio was detected between patients with Crohn's disease and controls (p = 0.0001). CD patients with active disease had higher strain ratio than patients in remission (p = 0.02). In ulcerative colitis group a significant difference in rectal wall thickness was found between controls and patients with active disease (p = 0.03). A significant difference in rectal wall thickness (p = 0.02) and strain ratio (p = 0.0001) was detected between Crohn's disease and ulcerative colitis patient group. Crohn's disease patients with active disease had a significantly higher strain ratio compared to ulcerative colitis patients with active disease (p = 0.0001).
Transrectal ultrasound elastography seems to be a promising new diagnostic tool in the field of inflammatory bowel disease. Further study on a larger cohort of patients is needed to definitely assess the role of transrectal ultrasound elastography in inflammatory bowel disease.
Crohn's disease; ulcerative colitis; elastography; ultrasound
OBJECTIVE--To investigate the mode of inheritance of ulcerative colitis and Crohn's disease by complex segregation analysis. DESIGN--Cross sectional population based survey of familial occurrence of chronic inflammatory bowel disease. SETTING--Population of the Copenhagen county in 1987. SUBJECTS--662 patients in whom inflammatory bowel disease had been diagnosed before 1979, of whom 637 (96%) provided adequate information. Of 504 patients with ulcerative colitis, 54 had 77 relatives with ulcerative colitis and of 133 patients with Crohn's disease, five had seven relatives with Crohn's disease. MAIN OUTCOME MEASURES--Patterns of segregation of either disease as assessed by complex segregation analysis performed with the computer program POINTER. RESULTS--The analysis suggested that a major dominant gene with a penetrance of 0.20-0.26 is present in 9-13% of adult patients with ulcerative colitis. The analysis did not allow for other components in the familial aggregation. For Crohn's disease the best fitting model included a major recessive gene with complete penetrance, for which 7% of the patients are homozygous. However, this model was not significantly different from a multifactorial model. CONCLUSIONS--The segregation pattern indicates that a major dominant gene has a role in ulcerative colitis, and suggests that a major recessive gene has a role in Crohn's disease.
Background: An increased incidence of paediatric Crohn’s disease was reported recently by our group.
Aims: To assess the incidence and characteristics of inflammatory bowel disease (IBD) in northern Stockholm between 1990 and 2001.
Methods: All records of individuals 0–15 years of age with suspected IBD in the population based catchment area of 180 000 individuals were scrutinised using defined diagnostic criteria. Patient files were searched for relatives with IBD, and for concomitant autoimmune diseases.
Results: A total of 152 children were diagnosed with IBD, corresponding to an overall incidence (per 100 000) of IBD of 7.4. The incidence of Crohn’s disease (CD) was 4.9, ulcerative colitis (UC) 2.2, and indeterminate colitis 0.2. Between 1990 and 2001, there was a marked increase in the incidence of CD while the incidence of UC was almost unchanged, leading to a net increase in the overall occurrence of IBD. There was a male dominance of CD. Fourteen per cent and 11% of patients with CD and UC, respectively, had a first or second degree relative with IBD. Eighteen per cent and 10% of patients with CD and UC, respectively, had a concomitant autoimmune disease. Ten patients with CD (10%) underwent surgery.
Conclusions: The incidence of CD has increased in northern Stockholm. The current incidence is higher than that reported from other areas. Our results suggest a shift in presentation and diagnosis from UC towards CD, but also a net increase in IBD. Concomitant autoimmune disorders and family history are common in paediatric IBD.
Crohn’s disease; epidemiology; inflammatory bowel disease; ulcerative colitis
There were no data concerning the incidence of inflammatory bowel disease (IBD) in France. The aim of this study was to investigate the incidence of Crohn's disease and ulcerative colitis in northern France. This prospective population based study was realised through the gastroenterologists of the region Nord-Pas de Calais and the Somme Department. Each gastroenterologist referred patients consulting for the first time with clinical symptoms compatible with IBD. Data were collected by an interviewer practitioner present at the gastroenterologist's consulting room. Two independent expert gastroenterologists assessed each case in a blind manner and made a final diagnosis of Crohn's disease, ulcerative colitis, ulcerative proctitis, or unclassifiable chronic colitis. From 1988 to 1990, 1291 cases of IBD were recorded: 674 (52%) Crohn's disease, 466 (36%) ulcerative colitis including 162 proctitis (35%), and 151 (12%) unclassifiable chronic colitis. The mean annual incidence was 4.9 per 100,000 for Crohn's disease and 3.2 for ulcerative colitis. The sex ratio F/M was 1.3 for Crohn's disease and 0.8 for ulcerative colitis. The highest age specific incidence rate for Crohn's disease was between 20 and 29 years: 13.1 for women and 9.8 for men. The highest age specific incidence rate for ulcerative colitis was between 20 and 39 years: 5.5 for women and 6.5 for men. This first French prospective study has shown an incidence rate for Crohn's disease comparable with that seen in north European studies but lower than that seen for ulcerative colitis. These results could be related to the different environmental factors or the genetic background of the population studied, or both.
Background. Iron-deficiency anemia is described to be a common problem in patients with inflammatory bowel disease (IBD), which is frequently associated with a reduced quality of life. Therefore, the aim of this study is to assess the prevalence of iron deficiency anemia in a population-based cohort at time of first diagnosis and during the early course of the disease. Methods. As far as available, lab values of patients registered in the population-based “Oberpfalz cohort” were screened. In anemic patients, we further investigated all laboratory results to differentiate between iron deficiency and other reasons for anemia. All patients with any kind of anemia were interviewed separately according to symptoms of iron-deficiency anemia and administration of iron. Results. In total, we evaluated hemoglobin values of 279 patients (183 Crohn's disease, 90 ulcerative colitis, and 6 indeterminate colitis). Lab data which allowed further differentiation of the type of anemia were available in 70% of anemic patients, in 34.4% values of iron, ferritin and transferrin saturation had been measured. At time of first diagnosis, an iron-deficiency anemia was diagnosed in 26 of 68 patients with anemia (38.2%, 20 CD, 4 UC, and 2 IC patients), but only 9 patients (34.6%) received subsequent iron therapy. After one year, 27 patients were identified to have an iron-deficiency anemia (19 CD, 8 UC), 20 of them were treated with iron (71.4%). Of 9 patients with proven iron-deficiency anemia at time of first diagnosis and subsequent administration of iron, 5 (55.5%) had iron-deficiency anemia despite permanent treatment after one year. In total, 38 patients (54.3%) did not receive any iron substitution at all despite of proven iron-deficiency anemia, and only 13 patients of 74 patients were treated with intravenous iron (17.6%). Conclusion. We found a high prevalence of iron-deficiency anemia at different points during the early course of disease in this population-based cohort of IBD patients. Surprisingly, only in one-third of patients with proven anemia, further diagnostic approach was undertaken. Even patients with diagnosed iron-deficiency anemia were infrequently and inconsequently treated with iron preparations, despite the high impact on quality of life.
To determine population-based rates of use of diagnostic imaging procedures with ionizing radiation in children, stratified by age and gender.
Retrospective cohort analysis.
All settings utilizing imaging procedures with ionizing radiation.
Individuals less than 18 years old, alive and continuously enrolled in Unitedhealthcare between January 1, 2005 and December 31, 2007 in 5 large U.S. healthcare markets.
Main Outcome Measure
Number and type of diagnostic imaging procedures utilizing ionizing radiation in children.
355,088 children were identified. A total of 436,711 imaging procedures using ionizing radiation were performed in 150,930 (42.5%) patients. The highest rates of use were in children greater than 10 years old, with frequent use in infants under 2 years old as well. Plain radiography accounted for nearly 85% of imaging procedures performed. Computed tomography (CT) scans – associated with substantially higher doses of radiation – were commonly used, accounting for 12% of all procedures during the study period. Overall, 7.9% of children received at least one CT and 3.5% received 2 or more, with CT of the head most frequent.
Exposure to ionizing radiation from medical diagnostic imaging procedures may occur frequently among children. Efforts to optimize and ensure appropriate use of these procedures in the pediatric population should be encouraged.
BACKGROUND: Patients with inflammatory bowel disease are at risk of developing metabolic bone disease. AIMS: To compare bone mineral density in patients with Crohn's disease with patients with ulcerative colitis and healthy subjects, and to evaluate possible risk factors for bone loss in inflammatory bowel disease. PATIENTS: 60 patients with Crohn's disease, 60 with ulcerative colitis, and 60 healthy subjects were investigated. Each group consisted of 24 men and 36 women. METHODS: Lumbar spine, femoral neck, and total body bone mineral density were measured by dual x ray absorptiometry (DXA), and Z scores were obtained by comparison with age and sex matched normal values. RESULTS: Mean Z scores were significantly lower in patients with Crohn's disease compared with patients with ulcerative colitis and healthy subjects. Patients with ulcerative colitis had bone mineral densities similar to healthy subjects. Use of corticosteroids, body mass index (BMI), and sex were significant predictor variables for bone mineral density in Crohn's disease. In ulcerative colitis only body mass index and sex were of significant importance. Disease localisation and small bowel resections had no influence on bone mineral density in patients with Crohn's disease. CONCLUSIONS: Patients with Crohn's disease have reduced bone mineral density. Several factors are probably involved, but the reduction is associated with corticosteroid therapy. When studying skeletal effects of inflammatory bowel disease, patients with Crohn's disease and those with ulcerative colitis should be evaluated separately.
Inflammatory bowel disease (IBD) has been associated with renal stone formation. The objective of this study was to determine prospectively the prevalence of nephrolithiasis in a community-based population of patients with IBD and to analyze factors associated with renal calculus formation.
Screening renal ultrasound was performed in a well characterized cohort of patients seen between 2009 and 2012 at an IBD clinic. We enrolled 168 patients, including 93 with Crohn’s disease and 75 with ulcerative colitis. Clinical and phenotypic variables associated with asymptomatic nephrolithiasis were determined.
Nephrolithiasis was detected in 36 patients with Crohn’s disease and in 28 patients with ulcerative colitis (38% for both). Although none of the patients had been previously hospitalized for symptomatic nephrolithiasis, nine with Crohn’s disease and five with ulcerative colitis had recurrent urinary tract infections or hydronephrosis. In patients with Crohn’s disease, ileocolonic (L3) disease was associated with a greater risk of nephrolithiasis than was ileal (L1) or colonic (L2) disease (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.8–7). Active ulcerative colitis (regardless of severity) represented a significant risk factor for formation of renal calculi (OR 4.2, 95% CI 1.1–15, P = 0.02).
In surgery-naïve patients with IBD in the community, asymptomatic nephrolithiasis is common and should be considered when renal dysfunction or infection is detected.
clinical activity indices; Crohn’s disease; inflammatory bowel disease; nephrolithiasis; ulcerative colitis
The development of strictures in Crohn's disease is a main cause of hospitalization and often represent an indication for surgery. The differentiation between inflammatory and fibrotic strictures is useful to determine the optimal treatment. Today, the availability of noninvasive methods to assess the presence and extension of strictures offers new tools for the diagnosis and follow-up of the disease.
Bowel ultrasound, power doppler ultrasound, contrast-enhanced ultrasound, magnetic resonance imaging offer the additional advantage that they do not expose patients to ionizing radiation. In this paper we provide an update on the accuracy of these noninvasive methods for the diagnosis of Crohn's disease.
The inflammatory bowel diseases, consisting of Crohn’s disease, ulcerative colitis and indeterminate colitis, are distinguished by idiopathic and chronic inflammation of the digestive tract. The distinction between inflammatory bowel diseases and functional bowel disorders, such as irritable bowel syndrome, can be complex because they often present with similar symptoms. Rapid and inexpensive noninvasive tests that are sensitive, specific and simple are needed to prevent patient discomfort, delay in diagnosis, and unnecessary costs. None of the current commercially available serological biomarker tests can be used as a stand-alone diagnostic in clinics. Instead, these are used as an adjunct to endoscopy in diagnosis and prognosis of the disease. Along these lines,, fecal lactoferrin and calprotectin tests seem to be one step further from other tests with larger number of studies, higher sensitivity and specificity and wider availability.
Inflammatory bowel disease; Diagnosis; Serology; Fecal markers
Both ulcerative colitis and Crohn’s disease carry an increased risk of developing colorectal cancer. Established risk factors for cancer among patients with inflammatory bowel disease (IBD) include the younger age at diagnosis, greater extent and duration of disease, increased severity of inflammation, family history of colorectal cancer and coexisting primary sclerosing cholangitis. Recent evidence suggests that current medical therapies and surgical techniques for inflammatory bowel disease may be reducing the incidence of this complication. Nonetheless heightened vigilance and a careful, comprehensive approach to prevent or minimize the complications of invasive cancer are warranted in this unique cohort of patients. Current guidelines for the prevention and early detection of cancer in this high risk population are grounded in the concept of an inflammation-dysplasia-carcinoma sequence. A thorough understanding of the definition and natural history of dysplasia in IBD, as well as the challenges associated with detection and interpretation of dysplasia are fundamental to developing an effective strategy for surveillance and prevention, and understanding the limitations of the current approach to prevention. This article reviews the current consensus guidelines for screening and surveillance of cancer in IBD, as well as presenting the evidence and rationale for chemoprevention of cancer and a discussion of emerging technologies for the detection of dysplasia.
Cancer; Dysplasia; Inflammatory bowel disease; Ulcerative colitis; Crohn’s disease; Chemoprevention