Bradley Anderson

Men with inflammatory bowel disease are rarely counseled regarding effects of immunosuppressive therapy on fertility and pregnancy

We read with interest the article by Vermeire et al.,1 “Management of inflammatory bowel disease in pregnancy”, J Crohns and Colitis 2012; 6:811–823, which reviews the use of immunosuppressive therapy in patients with inflammatory bowel disease (IBD) in regard to fertility, pregnancy, and lactation. Vermeire et al. concluded that fertility is normal in IBD patients except for females after ileal pouch–anal reanastomosis and males under sulfasalazine treatment. Multiple immunosuppressive medications have been shown to affect male fertility, spermatogenesis, and teratogenecity.2–4 Data on the …

P-105 Gastroenterologist Laboratory Testing in Patients with Inflammatory Bowel Disease Does Not Increase Linearly by Decade

BACKGROUND: Laboratory testing is important in the overall management of chronic diseases. Aging can result in increased utilization of laboratory services. Individuals with inflammatory bowel disease (IBD) frequently require laboratory tests because they can serve as objective measurements of disease activity. There is limited data which has evaluated the use of laboratory testing in the different age ranges of adult patients with inflammatory bowel disease. This study correlated decade of age with the frequency of gastroenterologist-ordered laboratory testing in individuals with IBD. METHODS: A retrospective medical record review of inflammatory bowel disease patients at a university medical center during an 18 month period was performed using a multispecialty electronic health record. There were no exclusion factors. Patient age, gender, disease type, and laboratory testing performed by the gastroenterologist were obtained. A database, maintaining patient confidentiality, was created. Assessment of the frequency of laboratory tests were performed at the following age decades: <20, 20–29, 30–39, 40–49, 50–59, 60–69, and 70+ years. Statistical analysis was performed using ANOVA and T-testing, with statistical significance set at P < 0.05. The study was approved by the university institutional review board. RESULTS: Medical record of 316 IBD patients were reviewed. There were 189 women and 127 men, with a mean age of 41.8 years. One hundred seventy-one patients had Crohn’s disease, 143 with Ulcerative Colitis, and 2 with indeterminate colitis. A mean of 5.8 outpatient laboratory encounters occurred in patients <20, 6.8 in patients 20–29, 10.2 in patients 30–39, 11.1 in patients 40–49, 6.8 in patients 50–59, 7.0 in age 60–69 and 6.0 in patients age 70 or order during the study period (P = 0.034). Both young and geriatric patients received less laboratory studies on average when compared to patients age 30–50. This finding was pronounced in women: a mean of 9 outpatient laboratory occurred in women <20, 7.2 in women 20–29, 10.8 in women 30–39, 14.5 in women age 40–49, 6.9 age 50–59, 8.2 in women 60–69, and 5.1 in women 70 or older (P = 0.014). In men, however, differences in mean labs per decade did not reach statistical significance (P = 0.772). Women overall received an average of 9.3 tests during the study period while men received 7.2 (P = 0.044). CONCLUSIONS: Few studies have analyzed utilization of laboratory tests in inflammatory bowel disease at different age ranges. This study revealed that laboratory testing does not increase linearly with advancing decades of age. The number of gastroenterologist-ordered laboratory tests for inflammatory bowel disease peaked at age 30–50 years. The reason for this pattern is uncertain, but may represent new diagnoses or increased exacerbations. As this effect was statistically significant in women, this raises the question about the potential for gender-specific concerns. Less frequent laboratory testing in older patients may reflect gastroenterologist’ desire not to duplicate existing laboratory studies performed by other specialty providers. While inflammatory bowel disease is a chronic illness that warrants close monitoring, there is no evidence that laboratory expenditures by gastroenterologists linearly increase with advancing age. Further examination of physician laboratory testing patterns in inflammatory bowel disease is warranted.

P-055 Evaluating Whether Platelet Counts Are a Low Cost Alternative to ESR and CRP in the Evaluation of IBD Patients

BACKGROUND: Inflammatory markers including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are commonly checked in IBD patients who present with symptoms of active disease. These markers have been shown to correlate with disease activity. Inflammatory markers can be costly and are affected by other factors including age, anemia, temperature and time to processing. Thrombocytosis has also been shown to positively correlate with disease activity. In an effort to reduce the financial burden associated with the delivery of healthcare, we evaluated whether measuring thrombocytes is an effective alternative to monitoring inflammatory markers in IBD patients with active disease. METHODS: Medical records of 321 patients with ulcerative colitis (UC) and Crohn’s disease at an urban academic inflammatory bowel disease center during an eighteen-month period were evaluated. All encounter-types in which either platelets, ESR, or CRP were available within one week of the visit were examined. Patient age, disease type, symptom activity, ESR and CRP were obtained. A database was created using Microsoft Excel. Statistical analysis was performed using Fisher’s Exact test with significant set at P <0.05. The study was approved by the institutional review board. RESULTS: In 165 encounters of patients with symptoms of active disease, platelets were obtained in 144 encounters, ESR in 57 encounters and CRP in 59 encounters. In 343 encounters of patients without symptoms consistent with active disease, platelets were obtained in 299 encounters, ESR in 79 encounters and CRP in 78 encounters. Thrombocytosis (P = 0.0047), elevated ESR (P = 0.0051) and elevated CRP (P = 0.0039) were all found to be significantly associated with active disease symptoms. In 52 encounters with symptomatic patients, ESR and platelet counts were obtained concurrently. Among encounters associated with elevated ESR, 36% had thrombocytosis while 64% had normal platelet counts. There was no significant difference in these groups (P = 0.12). In 50 encounters with symptomatic patients, CRP and platelet counts were obtained concurrently. Thirty-one percent of encounters associated with elevated CRP values had thrombocytosis, while 69% had normal platelets. There was no significant difference in these groups (P = 0.32). CONCLUSIONS: With the rising cost of healthcare and initiatives such as the Affordable Health Care Act, there is increasing pressure to deliver quality, cost-effective care to patients. Thus, it is important that testing not only enhance the quality of medical care, but be financially appropriate. Similar to previous reports, thrombocytosis, elevated ESR, and elevated CRP were all significantly associated with symptoms of active disease in IBD patients. In this study, thrombocytosis did not significantly correlate with elevated inflammatory markers. While not statistically significant, the inflammatory markers were more commonly elevated in symptomatic patients compared to the presence of thrombocytosis. These outcomes may be due to the low total number of patient encounters in which both tests were obtained. Despite additional costs, judicious use of ESR and CRP is appropriate in the evaluation of patients whose symptoms are suggestive of active disease. Further studies are needed to examine the cost-effectiveness of these tests.

P-115 Geriatric Inflammatory Bowel Disease Patients Have Increased Occurrence of Ocular Extraintestinal Manifestations

BACKGROUND: Extraintestinal manifestations (EIMs) are common complicating sequelae of Crohn’s disease and ulcerative colitis. Ocular manifestations are seen in 4%–12% of inflammatory bowel disease (IBD) patients and include uveitis, episcleritis, conjunctivitis and blepharitis. Geriatric patients have increased ocular disorders. However, there is limited data which has specifically evaluated ophthalmologic disorders related to IBD in the older patient. This study evaluated the frequency of ocular manifestations of IBD in the geriatric patients. METHODS: A retrospective medical record review of all inflammatory bowel disease patients age ≥65 at a university medical center was performed using a multispecialty electronic health record. Patient age, gender, disease type, and ophthalmologic manifestations were obtained. Maintaining patient confidentiality, a database was created. Assessment of the frequency of EIMs in patients ≥65 years was performed. Statistical analysis was performed using an unpaired t-test and chi-square test, with statistical significance set at P < 0.05. The study was approved by the university institutional review board. RESULTS: Twenty-four medical records were reviewed. There were 15 women and 9 men, mean age of 70.1 years, and an average duration of disease of 19.8 years. Twelve patients had Crohn’s disease and 12 had ulcerative colitis. Ocular EIMs were documented in 5 patients (21%): 1 with uveitis and blepharitis, 1 with episcleritis, and 3 with blepharitis. Four patients had documented ocular manifestations by ophthalmology. One patient had documented ocular manifestation by gastroenterology with 4 patients noted to have “no extraintestinal manifestations.” There was no significant difference in the rate of EIMs in geriatric patients based upon gender (P = 1.00) or disease type (P = 0.37). CONCLUSIONS: The frequency of EIMs in geriatric patients with inflammatory bowel disease is uncertain. Aging results in increased frequency of ocular manifestations in the general population. However, it is unclear if aging results in an increase in ophthalmologic disorders related to inflammatory bowel disease. This study revealed that geriatric patients had more ocular manifestations than anticipated when compared to population based statistics (21% versus 4%–12%). Notably, gastroenterologists identified only 20% of the documented ocular disorders in the geriatric IBD patients. Recognition of EIMs by gastroenterologists is important for optimal management of IBD patients. Further study is necessary to increase the knowledge about ocular manifestations of inflammatory bowel disease in the elderly patient.

P-114 Extraintestinal Rheumatologic Manifestations Occur Infrequently in Geriatric Inflammatory Bowel Disease Patients

BACKGROUND: Extraintestinal manifestations (EIMs) are common complicating sequela of Crohn’s disease and ulcerative colitis. Rheumatologic manifestations are the most common EIM in IBD affecting up to 35% of inflammatory bowel disease (IBD) patients. Rheumatologic EIMs include arthritis, ankylosing spondylitis, sacroiliitis, osteoporosis, and polychondritis. It has been speculated that geriatric patients with IBD have increased rheumatologic manifestations. However, there is limited data which has specifically evaluated rheumatologic disorders related to IBD in the older patient. This study evaluated the frequency of potential rheumatologic manifestations of IBD in the geriatric patients with IBD. METHODS: A retrospective medical record review of all inflammatory bowel disease patients age ≥65 at a university medical center was performed using a multispecialty electronic health record. Patient age, gender, disease type, and rheumatologic manifestations were obtained. Maintaining patient confidentiality, a database was created. Assessment of the frequency of rheumatologic EIMs in patients ≥65 years was obtained. The study was approved by the university institutional review board. RESULTS: Twenty-four medical records were reviewed. There were 15 women and 9 men, mean age of 70.1 years, and an average duration of disease of 19.8 years. Twelve patients had Crohn’s disease and 12 had ulcerative colitis. EIMs were noted in 8 of 24 patients (33%). Six patients had ophthalmologic manifestations, 1 erythema nodosum and 1 with sacroiliitis. EIM documentation by specialty included: 2 patients by gastroenterology, 5 patients by ophthalmology, and 1 patient by rheumatology. Joint disease was identified in 1 patient: sacroilitis (4%). This finding was identified by rheumatology consultant with the gastroenterologist specifically documenting “no extraintestinal manifestations.” CONCLUSIONS: The frequency of total EIMs in geriatric patients with inflammatory bowel disease may be similar to EIMs in the general IBD population. However, this study noted that geriatric patients had less rheumatologic manifestations than anticipated based on population based statistics (4% versus 35%). It is uncertain if this finding is a result of less EIMs actually occurring in geriatric IBD patients or less complaints are offered due to concerns about non-IBD related rheumatologic conditions. While this study is limited due to size and retrospective design, it offers information about inflammatory bowel disease in the older patient. Further study is necessary to increase the knowledge about rheumatologic manifestations in the elderly inflammatory bowel disease patient.