Arjan P. Visscher

Epidemiology and clinical characteristics of autoimmune hepatitis in the Netherlands

Abstract Background and aims. Epidemiological data on autoimmune hepatitis (AIH) are scarce. In this study, we determined the clinical and epidemiological characteristics of AIH patients in the Netherlands (16.7 million inhabitants). Methods. Clinical characteristics were collected from 1313 AIH patients (78% females) from 31 centers, including all eight academic centers in the Netherlands. Additional data on ethnicity, family history and symptoms were obtained by the use of a questionnaire. Results. The prevalence of AIH was 18.3 (95% confidential interval [CI]: 17.3–19.4) per 100,000 with an annual incidence of 1.1 (95% CI: 0.5–2) in adults. An incidence peak was found in middle-aged women. At diagnosis, 56% of patients had fibrosis and 12% cirrhosis in liver biopsy. Overall, 1% of patients developed HCC and 3% of patients underwent liver transplantation. Overlap with primary biliary cirrhosis and primary sclerosing cholangitis was found in 9% and 6%, respectively. The clinical course did not differ between Caucasian and non-Caucasian patients. Other autoimmune diseases were found in 26% of patients. Half of the patients reported persistent AIH-related symptoms despite treatment with a median treatment period of 8 years (range 1–44 years). Familial occurrence was reported in three cases. Conclusion. This is the largest epidemiological study of AIH in a geographically defined region and demonstrates that the prevalence of AIH in the Netherlands is uncommon. Although familial occurrence of AIH is extremely rare, our twin data may point towards a genetic predisposition. The high percentage of patients with cirrhosis or fibrosis at diagnosis urges the need of more awareness for AIH.

Long-term follow-up after surgery for simple and complex cryptoglandular fistulas: fecal incontinence and impact on quality of life.

BACKGROUND: Surgical management of cryptoglandular fistulas is a challenge because the consequences of anal surgery potentially include fecal incontinence and impaired quality of life. OBJECTIVE: To assess factors associated with fecal incontinence after surgery for simple and complex cryptoglandular fistulas and to determine the impact of incontinence on quality of life. DESIGN: The design is retrospective and cross-sectional. SETTINGS: This study was conducted at an academic tertiary center and at a private center specializing in proctologic surgery. PATIENTS: All patients who underwent preoperative endoanal ultrasound for cryptoglandular fistula between 2002 and 2012. MAIN OUTCOME MEASURES: A questionnaire was sent out in October 2013 to evaluate incontinence (Wexner-score) and its impact on quality of life (FIQL). Variables tested for association were patient demographics, fistula type, number of incised abscesses (0, 1, >1), number of fistulotomies (0, 1, >1) and number of sphincter-sparing procedures (0, 1, >1). RESULTS: Of the 141 patients participating, 116 (82%; 76 men, 40 women) returned all the questionnaires. Median follow-up from the first perianal fistula surgery was 7.8 years (range, 2.1–18.1 years). Thirty-nine patients (34%) experienced incontinence. Surgical fistulotomy, multiple abscess drainages and a high transsphincteric or suprasphincteric fistula tract were associated with incontinence. As compared to simple fistula (Wexner score, 1.2 [SD, 2.1]), incontinence was worse after surgery for complex fistula (Wexner score, 4.7 [SD, 6.2], p = 0.001), as were quality of life elements, including lifestyle (p = 0.030), depression (p = 0.077) and embarrassment (p < 0.001). LIMITATIONS: Mainly retrospective design without a standardized treatment protocol. CONCLUSION: Surgical fistulotomy is the strongest risk factor for fecal incontinence. The severity of incontinence increases with the complexity of the fistula, negatively influencing quality of life. Special attention should be paid to these patients so as to mitigate symptoms later in life. A shift to sphincter-sparing procedures appears warranted.

Endoanal ultrasound in perianal fistulae and abscesses.

Abstract Endoanal ultrasound is a technique that provides imaging of the anal sphincters and its surrounding structures as well as the pelvic floor. However, endoanal magnetic resonance imaging (MRI) is preferred by most physicians, although costs are higher and demand easily outgrows availability. Endoanal ultrasound is an accurate imaging modality delineating anatomy of both cryptoglandular as well as Crohn perianal fistula and abscess. Endoanal ultrasound is comparable with examination under anesthesia and equally sensitive as endoanal MRI in fistula detection. When fistula tracts or abscesses are located above the puborectal muscle, an additional endoanal MRI should be performed. Preoperative imaging is advocated in recurrent cryptoglandular fistula because a more complex pattern can be expected. Endoanal ultrasound can help avoid missing tracts during surgery, lowering the chance for the fistula to persist or recur. It can easily be performed in an outpatient setting and endosonographic skills are quickly incremented. Costs are low and endoanal ultrasound has the potential to improve outcome of patients with both cryptoglandular and fistulizing Crohn disease; therefore, it values more attention.

Validation of Risk Factors for Fecal Incontinence in Patients With Crohn’s Disease

BACKGROUND: Fecal incontinence has a great impact on daily life, and many patients are reluctant to report it. OBJECTIVE: The purpose of this study was to estimate the prevalence of fecal incontinence in patients with Crohn’s disease, validate risk factors, and relate outcome with quality of life. DESIGN: The design was cross-sectional. SETTINGS: The study was conducted at an academic tertiary center. PATIENTS: Consecutive patients with Crohn’s disease treated between 2003 and 2013 were included in this study. MAIN OUTCOME MEASURES: A questionnaire was sent out in October 2013 to evaluate perianal disease, current symptoms of fecal incontinence, and its impact on quality of life (Fecal Incontinence Quality of Life questionnaire). Risk factors were validated with univariate and multivariate analyses. RESULTS: The questionnaire was responded by 325 (62%) of 528 patients. Median age was 42 years (range, 18–91 y), 215 (66%) were women, and a diagnosis of Crohn’s disease was established for a median period of 12 years (interquartile range, 6–21 y). Fecal incontinence was reported by 65 patients (20%). Fecal incontinence was associated with liquid stools (p = 0.0001), previous IBD-related bowel resections (p = 0.001), stricturing behavior of disease (p = 0.02), and perianal disease (p = 0.03). Quality of life (lifestyle, coping, depression, and embarrassment) was poor in patients with fecal incontinence, particularly in patients with more frequent episodes of incontinence. LIMITATIONS: There was no correction for disease activity in the multivariate regression analysis. CONCLUSIONS: The prevalence of fecal incontinence in a tertiary population with Crohn’s disease is substantially higher than in the community-dwelling population. Considering the reduced quality of life in incontinent patients, active questioning to identify fecal incontinence is recommended in those with liquid stools, perianal disease, or previous (intestinal or perianal) surgery. See Video Abstract at http://journals.lww.com/dcrjournal/Pages/videogallery.aspx.

Temperature-Controlled Delivery of Radiofrequency Energy in Fecal Incontinence: A Randomized Sham-Controlled Clinical Trial

BACKGROUND: Controlled delivery of radiofrequency energy has been suggested as treatment for fecal incontinence. OBJECTIVE: The aim of this study was to determine whether the clinical response to the radiofrequency energy procedure is superior to sham in patients with fecal incontinence. DESIGN: This was a randomized sham-controlled clinical trial from 2008 to 2015. SETTING: This study was conducted in an outpatient clinic. PATIENTS AND METHODS: Forty patients with fecal incontinence in whom maximal conservative management had failed were randomly assigned to receiving either radiofrequency energy or sham procedure. MAIN OUTCOME MEASURES: Fecal incontinence was measured using the Vaizey incontinence score (range, 0–24). The impact of fecal incontinence on quality of life was measured by using the fecal incontinence quality-of-life score (range, 1–4). Measurements were performed at baseline and at 6 months. Anorectal function was evaluated using anal manometry and anorectal endosonography at baseline and at 3 months. RESULTS: At baseline, Vaizey incontinence score was 16.8 (SD 2.9). At t = 6 months, the radiofrequency energy group improved by 2.5 points on the Vaizey incontinence score compared with the sham group (13.2 (SD 3.1), 15.6 (SD 3.3), p = 0.02). The fecal incontinence quality-of-life score at t = 6 months was not statistically different. Anorectal function did not show any alteration. LIMITATIONS: Patients with severe fecal incontinence were included in the study, thus making it difficult to generalize the results. CONCLUSIONS: Both radiofrequency energy and sham procedure improved the fecal incontinence score, the radiofrequency energy procedure more than sham. Although statistically significant, the clinical impact for most of the patients was negligible. Therefore, the radiofrequency energy procedure should not be recommended for patients with fecal incontinence until patient-related factors associated with treatment success are known. See Video Abstract at http://links.lww.com/DCR/A373.

Mo2009 Factors Associated With Fecal Incontinence and Quality of Life After Perianal Surgery for Cryptoglandular Fistulas

Introduction: Surgical management of perianal fistulas remains a challenge as consequences of repetitive anal surgery can cause profound morbidity and impair experienced quality of life (QOL). In recent years new sphincter sparing procedures such as ligation of the intersphincteric fistula tract (LIFT) have been implemented potentially lowering the chance of developing fecal incontinence (FI). Aim: This study evaluated factors associated with FI and impact on QOL after surgical treatment for perianal sepsis. Methods: All patients with cryptoglandular perianal fistulas who underwent pre-operative endoanal ultrasound (EAUS) between 2002 and 2012 at our tertiary centre and in a local clinic specialised in proctologic surgery were sent questionnaires regarding FI (Wexner (WX)and Vaizey (VS) score) and impact of FI on QOL (FIQL) in October 2013. Data was abstracted regarding patients demographics and all surgical procedures ever received for perianal sepsis. Predictor variables analysed were sex, age of first complains, age at follow up, fistula type, fistula ramifications, no. of perianal abscesses surgically incised and drained (I&D) (0, 1, or > 1), no. of fistulotomys received (0, 1 or > 1) and no. of sphincter sparing procedures (mucosal advancement flap or fistulectomy) received (0, 1 or 2, or > 2). The likelihood of each of these outcomes was estimated by using a multivariate regression model. The correlation coefficient was calculated