2014 IBD Abstracts
Ultrasound Stiffness Imaging of Bowel Wall to Predict Medication Failure in Obstructive Crohn's Disease.
Stidham Ryan, Dillman Jonathan, Waljee Akbar, Rubin Jonathan, Higgins Peter University of Michigan, Ann Arbor, Michigan
BACKGROUND: Overtime, cycles of in ammation and aberrant healing lead to 60% of patients developing progressive irreversible brostenotic complications. Frequently, patients present with deep bowel injury composed of both medically-responsive in ammatory and non-responsive brotic changes. Management decisions here are challenging because despite the presence of an in ammatory target, medical therapy may be futile when a suf cient amount of underlying bowel brosis is present. The current practice of empirically using anti-in ammatory therapy in most patients with CD-related bowel wall thickening and obstructive symptoms in the hope of success leads to many unnecessary side effects, infections, worse surgical outcomes, and long delays of appropriate surgical intervention when signi cant brostenotic disease is already present. Ultrasound stiffness imaging, using acoustic radiation force impulse imaging (ARFI), provides real-time non-invasive bedside elastography of bowel wall reported as shear wave velocity (SWV). In our continuing work, we hypothesize that ARFI SWV of luminal stricturing disease may differentiate those more likely to have medically responsive (in ammatory) from those with non-responsive (predominantly brotic) ileal Crohn's disease; we present an interim analysis.
METHODS: Patients with known ileal Crohn's disease who are hospitalized for abdominal pain, with evidence of small bowel dilation of .3.5cm upstream of ileal disease without penetrating features, and were started on methylprednisone as clinically indicated, were enrolled. Subjects underwent bedside ultrasound scan of affected bowel using Siemens Acuson S3000 and quantitative acoustic radiation force impulse (Siemens, USA). Scans of affected bowel were preformed within 24 hours of methylprednisone initiation and again 3 days following the baseline scan. Shear wave velocity measurements (SWV) were collected at applied strain of 0% and 10%. Demographics, body mass index (BMI), medical history, and Harvey-Bradshaw index (HBI) were measured. The primary outcome was surgical resection of disease bowel within 90 days of hospital discharge.
RESULTS: In 18 subjects with complete follow up to date, 7/18 have undergone surgical bowel resection within 90 days. Patient demographic features, BMI, CRP, anti- TNF and immunomodulator use did not signi cantly differ between surgical and non- surgical groups. Baseline mean SWV without use of freehand force (0% strain) did not discriminate those requiring surgery within 90 days, with SWV speeds of 1.48m/s 6
0.094 versus 1.54m/s 6 0.055, P 0.166]. Application of 10% freehand strain to the affected segment, baseline SWV demonstrated trends suggesting discrimination of
future surgery within 90 days 2.01m/s 6 0.166 versus subjects avoiding surgery 1.86 m/s 6 0.055, although statistical signi cance was not reached at this interim point of the study, P 0.081. No signi cant difference in SWV change between baseline and
day 3 was observed between the surgical and non-surgical cohorts.
CONCLUSIONS: Ultrasound stiffness imaging using ARFI elastography demonstrates trends that higher SWV values identify medically non-responsive intestinal strictur- ing Crohn's disease, though the differences do not reach predetermined statistical signi cance of P < 0.05. Further optimization of stress-strain preloading of bowel prior to SWV assessment may improve the discrimination of medically responsive versus surgical disease in patients admitted with stricturing Crohn's disease.
Association Between 25-Hydroxy Vitamin D and Risk of Cancer in Patients with Primary Sclerosing Cholangitis and In ammatory Bowel Disease
Jegadeesan Ramprasad1, Njei Basile2, Lourdusamy Vennisvasanth1, Navaneethan Udayakumar1
1Cleveland Clinic Foundation, Cleveland, Ohio, 2Yale University, New Haven, Connecticut
BACKGROUND: Vitamin D de ciency has been associated with increased risk of cancer in patients with in ammatory bowel disease (IBD). Primary sclerosing cholangitis (PSC) is associated with increased risk of cancers in patients with IBD. The impact of Vitamin D de ciency in patients with PSC and IBD is not known. Our aim was to study the association of Vitamin D de ciency and the risk of cancers in patients with PSC-IBD.
METHODS: Patients with PSC and IBD followed up at a single institution from 1985 to 2014 were included. The primary outcome was development of any cancer. Patients with 1 measurement of plasma 25 (OH) D were included in the analysis. We examined the association between plasma 25 (OH) D levels and the risk of any cancer after adjusting for other covariates.
RESULTS: We analyzed data from 188 patients with PSC-IBD and a mean plasma level of 25 (OH) D of 21.0 ng/mL. More than one-half of patients (96/188, 51.1%) had de cient levels of vitamin D ( < 20 ng/mL). During a median follow-up period of 10.4 years, 26 patients (13.8%) developed cancer (excluding non-melanoma skin cancer). The various cancers were colon cancer 15.4%, cholangiocarcinoma 15.4%, hepatocellular carcinoma 11.5%, gall bladder cancer 3.8%, breast cancer 3.8%, prostate cancer 11.5%, lung cancer
3.8%, bladder cancer 3.8%, lymphoproliferative cancer 7.7%, bone cancer 3.8%, and thyroid CA 15.4%. On multivariate analysis after controlling for age, sex, body mass index, and duration of Vitamin D supplementation, patients with vitamin D de ciency did not have an increased risk of cancer (adjusted odds ratio, 1.00; 95% con dence interval, 0.97- 1.03) compared with those with suf cient levels. (Table 1).
CONCLUSIONS: In our study of PSC-IBD patients, Vitamin D de ciency was not associated with increased risk of cancers.
Long-Term Prognosis of Patients Presenting with Gastrointestinal Symptoms and Abnormal Calprotectin Diagnosed with Non-Organic Disease
Pavlidis Polychronis1, Pal Shrestha2, Chung-Faye Guy3, Hayee Bu'3
1King's College Hospital, London, United Kingdom, 2King's College University, London, United Kingdom, 3King's College Hospital, London, United Kingdom
BACKGROUND: Fecal calprotectin (fcal) is a non-invasive marker of intestinal in ammation that can assist physicians in investigating chronic gastrointestinal (GI) symptoms. Different cut-off values have been proposed, depending on the pre- test probability for organic disease, in order to improve diagnostic accuracy and to make the test more cost-effective. To support the use of a higher cut-off in clinical practice, we present data from a cohort of patients having been fully investigated for fcal levels above the lab reference cut-off.
METHODS: We retrospectively identi ed the patients who were referred to the Gastroenterology department at King's College Hospital, London, UK between January 2002 and 2004 with chronic gastrointestinal symptoms and had a fcal test. RESULTS: During this period 367 patients were tested. Two hundred (200/367, 55%) were given a diagnosis of non-organic disease and were discharged to their primary care physician. Sixty one (61/200, 31%) with a median age of 48 years (range 21, 85) and 2:1 female: male ratio tested positive for fcal (.60 mg/g, ELISA kit, B hlmann).
Thirty ve (35/61, 57%) had presented initially with altered bowel habit, 15 (25%) with abdominal pain, 7 (12%) with bloating and 4 (6%) with diarrhea. The median fcal was 113 mg/g (range 60, 850, .150 mg/g in 18 [30%] patients). All had a normal colonoscopy. The median follow up time from initial presentation to the initiation of this study was 10 years (range 9, 11). In this period 3 patients (3/61, 5%) were diagnosed with an organic condition. Two were diagnosed with Crohn's disease (1 with terminal ileal [TI] and 1 with isolated perianal disease) after 7 years of their initial presentation and 1 with collagenous colitis after 5 years. The repeat fcal for the patient with TI disease increased from 80mg/g to 1130mg/g prior to diagnosis. The other 2 had normal fcal when retested. Four patients were found, in retrospect, to take NSAIDs regularly, 3 had a diagnosis of cystic brosis, 2 with liver cirrhosis and 1 had a diagnosis of HIV at the time of referral. None of the patients with a negative calprotectin developed organic disease during their follow-up.
CONCLUSIONS: In patients presenting with chronic GI symptoms, fcal in the range 60-150 mg/g is associated with a very low incidence of organic or signi cant pathology. Sub- sequent routine investigation of these patients after normal colonoscopy (other than perhaps repeating fcal to demonstrate a trend over time) is not recommended.
Local Experience for Treatment of IBD-Related Recurrent Anal Fistulae Based on Autologous Stem-Cells and Platelet Rich Plasma
Kronberg Udo1, Wainstein Claudio1, Quera Rodrigo2, Lopez Francisco1, Jofre Claudio1, Zarate Alejandro1
1Clinica Las Condes, Las Condes, Chile, 2Clinica Las Condes, Las Condes, Chile