A L Hart

Forty-Year Analysis of Colonoscopic Surveillance Program for Neoplasia in Ulcerative Colitis: An Updated Overview.

Objectives:This study provides an overview of the largest and longest-running colonoscopic surveillance program for colorectal cancer (CRC) in patients with long-standing ulcerative colitis (UC).Methods:Data were obtained from medical records, endoscopy, and histology reports. Primary end points were defined as death, colectomy, withdrawal from surveillance, or censor date (1 January 2013).Results:A total of 1,375 UC patients were followed up for 15,234 patient-years (median, 11 years per patient). CRC was detected in 72 patients (incidence rate (IR), 4.7 per 1,000 patient-years). Time-trend analysis revealed that although there was significant decrease in incidence of colectomy performed for dysplasia (linear regression, R=−0.43; P=0.007), IR of advanced CRC and interval CRC have steadily decreased over past four decades (Pearson’s correlation, −0.99; P=0.01 for both trends). The IR of early CRC has increased 2.5-fold in the current decade compared with past decade (χ2, P=0.045); however, its 10-year survival rate was high (79.6%). The IR of dysplasia has similarly increased (χ2, P=0.01), potentially attributable to the recent use of chromoendoscopy that was twice more effective at detecting dysplasia compared with white-light endoscopy (χ2, P<0.001). CRCs were frequently accompanied by synchronous CRC or spatially distinct dysplasia (37.5%). Finally, the risk of CRC was not significantly different between “indefinite” or low-grade dysplasia (log-rank, P=0.78).Conclusions:Colonoscopic surveillance may have a significant role in reducing the risk of advanced and interval CRC while allowing more patients to retain their colon for longer. Given the ongoing risk of early CRC, patients with any grade of dysplasia who are managed endoscopically should be monitored closely with advanced techniques.

Systematic review: the combined surgical and medical treatment of fistulising perianal Crohn's disease

The management of perianal Crohns fistulas represents a significant challenge. A combination of medical and surgical therapy, guided by radiology, is often required.

Review of local injection of anti-TNF for perianal fistulising Crohn’s disease

BackgroundPerianal fistulising Crohn’s disease (PFCD) affects a third of Crohn’s disease patients and represents a disabling phenotype with poor outcome. The anti-tumour necrosis factor alpha (TNF) therapies have been shown to maintain clinical remission in a third of patients after 1xa0year of treatment. Maintenance therapy with systematic administration schedules confers greatest benefit, but exposes patients to risks/side effects of continued systemic use and led to consideration of local drug delivery (first described in 2000). In this review, we analyse all published articles on local anti-TNF therapy in the treatment of PFCD.MethodsThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to systematically search Medline and Embase using the medical subject headings ‘fistula’, ‘anus’, ‘Crohn disease’, ‘infliximab’ and ‘adalimumab’. This was combined with free text searches, e.g. ‘local injection’ and ‘Crohn’s perianal disease’. Studies/abstracts describing local injection treatment with anti-TNF were included in this review.ResultsSix pilot studies including a total of 92 patients were included in this review. Outcomes reported were mostly clinical and included ‘complete/partial response’ to therapy and short-term results varied between 40 and 100%. There were no significant adverse events and the local injections were well tolerated.ConclusionsThere is paucity of data assessing this treatment modality. Local anti-TNF therapy appears safe, but outcome reporting is heterogeneous, subjective and long-term data are unavailable. Our review suggests a potential role may be in those in whom systemic treatment is contraindicated and calls for standardised reporting of outcomes in this field to enable better data interpretation.

Natural history of anorectal sepsis

Progression from anorectal abscess to fistula is poorly described and it remains unclear which patients develop a fistula following an abscess. The aim was to assess the burden of anorectal abscess and to identify risk factors for subsequent fistula formation.

Role of SMAD proteins in colitis-associated cancer: from known to the unknown.

Small mothers against decapentaplegic (SMAD) proteins are a family of signal transduction molecules in transforming growth factor β (TGFβ) ligand pathways that have been found to have a key role in the pathogenesis of inflammatory bowel disease (IBD). Long standing IBD predisposes individuals to colitis-associated colorectal cancer (CAC), an entity that possess unique characteristics compared to hereditary and sporadic cancer. The ligands of the TGFβ super family along with SMADs have also been implicated in several aspects of colorectal cancer formation. SMAD proteins are shown to be involved in a number of potentially carcinogenic mechanisms such as altering gene transcription, controlling stem cell differentiation to causing epigenetic changes. Modulation of these proteins has emerged as a novel therapeutic intervention for IBD although its effect on carcinogenesis remains elusive. This account reviews available evidence linking SMAD proteins to CAC and explores the potential areas for future research in this area.

P575 A new tool for the surveillance of Crohn's perianal fistulae

Background: Magnetic Resonance Imaging (MRI) is the tool used to assess response to medical therapy for the treatment of perianal Crohn’s fistulae. Quantifying fistula volumes would be more beneficial than relying on subjective MRI reports. We aim to use computer software and MRI segmentation to design 3D models of fistula tracks and measure baseline and post-biologics treatment fistula volumes. Methods: Ten baseline and post-biologics MRI images of Crohn’s perianal fistulae were randomly selected. Three-Dimensional fistula models were independently created by a surgeon and radiologist • Manual fistula volumes were calculated for each patient and the results compared • Data were obtained on Perianal Disease Activity Index (PDAI) scores, clinical and radiological healing for these patients. Data were analysed using Spearman’s correlation to determine whether a change in fistula volume over a one-year period correlated with a change in PDAI score over the same time period. Fistula volumes and PDAI score were also correlated with degrees of clinical healing. Results: Baseline volumes for the surgeon showed a median of 9766mm3 (IQR 4636, 30980). Post-biologics volumes had a median of 4200mm3 (IQR 2720, 20070). A change in baseline and post-treatment volumes was also observed by the radiologist; the median volume was 9207mm3 (IQR 5132, 21710) for the baseline MRIs and 2872mm3 (IQR 1827, 18830) for the post-treatment ones.

Volume assessment magnetic resonance imaging technique for monitoring perianal Crohn’s fistulas:

Background: Perianal Crohn’s fistula and their response to anti-tumour necrosis factor (TNF) therapies are best assessed with magnetic resonance imaging (MRI), but radiologist reporting is subjective and variable. This study investigates whether segmentation software could provide precise and reproducible objective measurements of fistula volume. Methods: Retrospective analysis of patients with perianal Crohn’s fistula at our institution between 2007 and 2013. Pre- and post-biologic MRI scans were used with varying time intervals. A total of two radiologists recorded fistula volumes, mean signal intensity and time taken to measure fistula volumes using validated Open Source segmentation software. A total of three radiologists assessed fistula response to treatment (improved, worse or unchanged) by comparing MRI scans. Results: A total of 18 cases were reviewed for this pilot study. Inter-observer variability was very good for volume and mean signal intensity; intra-class correlation (ICC) 0.95 [95% confidence interval (CI) 0.91–0.98] and 0.95 (95% CI 0.90–0.97) respectively. Intra-observer variability was very good for volume and mean signal intensity; ICC 0.99 (95% CI 0.97–0.99) and 0.98 (95% CI 0.95–0.99) respectively. Average time taken to measure fistula volume was 202 s and 250 s for readers 1 and 2. Agreement between three specialist radiologists was good [kappa 0.69 (95% CI 0.49–0.90)] for the subjective assessment of fistula response. Significant association was found between objective percentage volume change and subjective consensus agreement of response (pu2004=u20040.001). Median volume change for improved, stable or worsening fistula response was −67% [interquartile range (IQR): −78, −47], 0% (IQR: −16, +17), and +487% (IQR: +217, +559) respectively. Conclusion: Quantification of fistula volumes and signal intensities is feasible and reliable, providing an objective measure of perianal Crohn’s fistula and response to treatment.

P446 Patient and public involvement in a clinical trial for perianal Crohn’s fistula

the two groups. Patients with active fistulas had significantly more work impairment (median 0.20 vs. 0.10, p = 0.010). Furthermore, patients with active fistulas held more negative views concerning the effects of their illness on daily functioning (adjusted β = 0.78; CI(95%) = 0.28 to 1.27 (95% CI), p = 0.003). No differences were found in coping strategies between the two groups. Conclusions: Patients with active perianal fistulas have a lower physical health, experience more work impairment and perceived more illness consequences compared with CD patients without perianal fistulas, which is important for the gastroenterologist to consider when treating these patients. Reference 1. van Erp SJ et al. Classifying back pain and peripheral joint complaints in inflammatory bowel disease patients: a prospective longitudinal follow-up study. J Crohns Colitis, 2016;10:166–175.

Management of Perianal Crohn’s Disease in the Biologic Era

Perianal Crohn’s disease represents a distinct, aggressive phenotype of Crohn’s disease associated with increased morbidity. It encompasses a variety of manifestations including perianal fistula which has a very significant on patient’s quality of life. Anti-TNF therapy has heralded a change in the management of these patients and a combination of medical and surgical treatment is required for most perianal manifestations. A multidisciplinary approach involving gastroenterologists, surgeons, radiologists, IBD nurse specialists and dieticians, and an understanding of all forms of perianal Crohn’s disease and options for treatment are crucial to minimise the often disabling morbidity that can potentially effect this group of patients.

OC-064 Risk Factors for Colorectal Neoplasia in Ulcerative Colitis: Results from the Largest and Longest-Running Colonoscopic Surveillance Program

Introduction Whilst patients with ulcerative colitis (UC) have an increased risk of developing colorectal cancer (CRC), its absolute risk remains very low. As most CRCs develop from pre-existing dysplasia, identifying those patients at high risk of developing dysplasia is important. The aim of this study was to identify risk factors associated with development of colorectal neoplasia (CRN) in patients with UC. Methods Patients with extensive UC who were under surveillance from 2003 to 2012 were identified and followed up to July 2013. Each surveillance episode was scored for endoscopic and histological severity of inflammation based on the segment worst affected by colitis: (0, normal/quiescent; 1, mild; 2, moderate; 3, severe active). Potential predictors (n = 18) were correlated against colorectal neoplasia (CRN) outcome, which was defined as non-polypoid low-grade dysplasia, high-grade dysplasia or CRC. To take into account the variables that may change over time, we employed Cox-regression analysis with time-dependent covariates. Results A total of 987 UC patients underwent 6,985 colonoscopies (median, 6; interquartile range (IQR), 4–9 per patient) over 12,305 patient-years (median follow-up, 11; IQR, 7–17) since starting their surveillance. Of these, 97 (9.8%) developed CRN (41 cancers). After multivariate analysis, following variables remained as significant contributory factor for the CRN outcome: increased average histological inflammation score (average-HIS; average score of all surveillance colonoscopies for each patient), endoscopic signs of disease chronicity (i.e. tubular, featureless or shortened colon), colonic stricture and primary sclerosing cholangitis (Table 1). Furthermore, while average-HIS was the most influential predictor, HIS of the immediately preceding colonoscopy showed comparable predictive value (Table 1). Post-inflammatory polyps and scarring were not significant at multivariate level.Abstract OC-064 Table 1 Conclusion This is the largest detailed cohort study to date looking at individual risk factors for CRC in UC. Patients with PSC, pertinent macroscopic features (tubular, featureless, shortened colon or stricture) or persistent microscopic inflammation require intensive colonoscopic surveillance. In addition, the histological assessment of inflammation severity at the time of colonoscopy may be used to predict future CRN risk. Disclosure of Interest None Declared