E. Garcia-Planella

Infliximab safety profile and long-term applicability in inflammatory bowel disease: 9-year experience in clinical practice

Aliment Pharmacol Theru200231, 553–560

Infecciones oportunistas en pacientes con enfermedad inflamatoria intestinal bajo tratamiento inmunosupresor

Resumen Los farmacos inmunosupresores (azatioprina, metotrexato) se emplean cada vez con mas frecuencia en el tratamiento de la enfermedad inflamatoria intestinal. El uso de inmunosupresores se asocia a un mayor riesgo de infecciones oportunistas, siendo las mas frecuentes las causadas por citomegalovirus y virus de la varicela-zoster. Presentamos 4 casos de infeccion oportunista por virus de la familia Herpesvirus en pacientes afectados de enfermedad de Crohn que recibian tratamiento inmunosupresor con azatioprina para el control de su enfermedad. Asimismo, se revisa la bibliografia existente al respecto. Dos pacientes presentaron varicela cutanea complicada con neumonia y esofagitis, respectivamente, un paciente herpes zoster cutaneo y el restante una neumonia fatal posiblemente causada por Herpesvirus . En los tres primeros el curso evolutivo de la infeccion fue favorable tras suspenderse el tratamiento inmunosupresor e iniciarse tratamiento con aziclovir. El tratamiento con azatioprina en pacientes con enfermedad de Crohn condiciona un mayor riesgo de infeccion oportunista por Herpesvirus . Sin embargo, y en ausencia de otros factores que incrementen el estado de inmunosupresion, esta suele presentar una evolucion benigna con tratamiento antiviral especifico.

Clinical outcome of newly diagnosed Crohn’s disease: a comparative, retrospective study before and after infliximab availability

Backgroundu2002 Infliximab (IFX) could change the course of Crohn’s disease (CD) by reducing steroid use, surgery or prompting earlier introduction of immunomodulators (IMM).

Perianal disease in patients with ulcerative colitis: A case-control study

BACKGROUNDnPatients with ulcerative colitis (UC) and concomitant perianal disease (PAD) are occasionally seen, but the impact of PAD on UC outcome has been scarcely assessed.nnnAIMSnTo evaluate the prevalence, clinical features and outcomes of PAD among UC patients.nnnMETHODSnPatients with an initial diagnosis of UC who ever developed PAD were identified from three IBD hospital databases. Each case was matched by age, disease extent at diagnosis, and year of diagnosis, with two UC patients who never developed PAD.nnnRESULTSnThirty-seven UC patients (5% of the whole series) developed PAD (complex in about a half of them), being more frequent among men (62%), with distal (50%) or extense (34%) disease. Proximal spread of UC occurred in 19% of cases. No differences in demographic features, rate of proximal spread or colectomy during follow-up were found as compared to controls, but greater requirements of steroids (P=0.019) were detected in UC-PAD patients. A change in disease diagnosis occurred in 6 patients mainly because of transmural involvement in colectomy specimen, small intestinal involvement, and/or endoscopic appearance.nnnCONCLUSIONSnPAD may occur in up to 5% of UC patients. When complex it leads to a change in disease diagnosis in one third of cases. UC-related therapeutic requirements are not increased in these patients, except for steroids.

Does active smoking really influence the course of Crohn's disease? A retrospective observational study

BACKGROUNDnActive smoking has been associated with a higher risk of developing Crohns disease (CD). However, its impact on clinical outcomes has been controversial among studies.nnnAIMSnTo evaluate the influence of active smoking on initial manifestations of CD, the development of disease-related complications, and therapeutic requirements.nnnMETHODSnPatients diagnosed with CD within a ten-year period (1994-2003) were identified. Clinical and therapeutic features until October 2008 or loss of follow-up were recorded. Smoking status was assessed at each major disease-related event (e.g. penetrating and stricturing complications, perianal disease, intestinal resection, introduction of immunomodulators or biological agents).nnnRESULTSnA total of 259 patients were included in the study with a median follow-up period of 91 months. At diagnosis, 50.5% were active smokers and only 12% of them quit smoking during follow-up, mostly after a major disease-related event occurred. Smoking at diagnosis was not associated with a particular CD presentation. Active smoking did not influence the development of strictures, intraabdominal and perianal penetrating complications, or increased resectional surgery, biological therapy or immunomodulators requirements.nnnCONCLUSIONSnPatients who develop CD while smoking seem to have a similar disease course to those who never smoked.

Anemia hemolítica autoinmune asociada a colitis ulcerosa

Resumen En pacientes con enfermedad inflamatoria intestinal se ha descrito una incidencia de enfermedades de base inmunologica mayor que la de la poblacion general. La asociacion de colitis ulcerosa (CU) y anemia hemolitica autoimmune (AHAI) se describio por primera vez a principios de la decada de los cincuenta; sin embargo, no se han publicado mas de 50 casos en la bibliografia mundial. Se desconoce cuales son los mecanismos patogenicos detallados que se hallan implicados en esta asociacion. La evolucion clinica de la AHAI y la respuesta al tratamiento en estos pacientes parece cursar de forma independiente a la propia CU, requiriendo en ocasiones tratamiento inmunomodulador e incluso tratamiento quirurgico. Se presentan 2 casos de AHAI asociada a CU, con distinta respuesta al tratamiento convencional, y se revisa la bibliografia al respecto.

Predictors of favourable outcome in inflammatory Crohn's disease. A retrospective observational study

BACKGROUNDnNo studies have specifically searched for predictors of a favourable outcome that would allow a conservative therapeutic approach in adult Crohns disease (CD).nnnAIMSnTo identify predictors of a favourable disease course over time at CD diagnosis.nnnMETHODSnWe identified and included all patients diagnosed with CD between January 1994 and December 2003, who had CD with an inflammatory pattern and no perianal disease at diagnosis, and who were followed up for at least 5 years. Clinical and therapeutic features until December 2008 and losses to follow-up were identified. We defined a favourable outcome as the absence of stricturing and penetrating complications of the disease (including perianal disease), together with the absence of need for anti-TNF therapy or resectional surgery during follow up.nnnRESULTSnOne hundred and forty-five patients were included and followed up for a median of 96 months (IQR, 79-140). At diagnosis, location was ileal in 39%, colonic in 28%, and ileocolonic in 32%; 50% of the patients were active smokers, and 41% used immunomodulators. Eighty-two patients (57%) met the criteria for a favourable outcome at the end of follow-up. The only factor associated with a favourable outcome was isolated colonic involvement (P=0.022), with 73% of these patients meeting the criteria for a favourable outcome.nnnCONCLUSIONSnA favourable outcome of initially uncomplicated CD is not easily predicted at disease diagnosis by means of clinical or epidemiologic factors. Nevertheless, patients with isolated colonic disease are less likely to have an aggressive course.

Diarrea crónica: definición, clasificación y diagnóstico

Chronic diarrhoea is a common presenting symptom in both primary care medicine and in specialized gastroenterology clinics. It is estimated that >5% of the population has chronic diarrhoea and nearly 40% of these patients are older than 60 years. Clinicians often need to select the best diagnostic approach to these patients and choose between the multiple diagnostic tests available. In 2014 the Catalan Society of Gastroenterology formed a working group with the main objective of creating diagnostic algorithms based on clinical practice and to evaluate diagnostic tests and the scientific evidence available for their use. The GRADE system was used to classify scientific evidence and strength of recommendations. The consensus document contains 28 recommendations and 6 diagnostic algorithms. The document also describes criteria for referral from primary to specialized care.

P064 - Influence of smoking on the clinical outcome of new-onset Crohn's disease

Markov assumption, is an increasingly favoured approach in time-dependent outcomes-analysis in complex diseases. Methods: The European Collaborative Study of Inflammatory Bowel Disease (EC-IBD) Group prospectively incepted European and Israeli patients at diagnosis of Crohn’s disease from 1991 to 1993. Patients with >5 years unbroken tracking from diagnosis were grouped into clinical transition states by: (1) medical and surgical therapies recorded in continuous quarter-year cycles, (2) presence of flare-years in a minority ( 50%) of follow-up years with a 10-year time horizon. Clinical transition states based on medical and surgical therapy (a surrogate for disease severity) were calculated by a Markov model (SPSS 16, STATA 10.1). These transition states were as follows: “remission” (symptomatic treatment), “mild-moderate” (local corticosteroids, budesonide, mesalazine, antibiotics), “severe” (systemic steroids, immunosuppression, biologics), surgery, and death (from Crohn’s disease). Healthcare costs per patient per cycle were calculated and matched to the transition states. Results: 348 patients had 12861 cycles; sample transition state probabilities appear in Table. In 308 minority flare-years patients the probability of worsening (entering a subsequent more severe transition state requiring more medication or surgery, or dying) from the initial “remission state” was 0.0985, from “mild-moderate state” 0.0875, from “severe state” 0.1853. In 40 majority flare-years patients, the corresponding probabilities were: 0.2602, 0.2260, 0.1500. Minority flare-year patients in an initial “surgery state” had probabilities of 0.3176 for subsequent severe disease and 0.0765 for further surgery; in majority flare-year patients these respective probabilities were 0.3651 and 0.1111. The subsequent “surgery state” in minority flare-years patients derived cases mostly from initial “surgery” (probability 0.0765) but in majority flare-years patients from initial “remission” (probability 0.0528), “mildmoderate” (probability 0.0400), and “severe” (probability 0.0355). Mean healthcare costs (euros/patient-cycle, year 2004 values) were: remission 147, mild-moderate 287, severe 967, surgery 7023, death 1225. Surgery accounted for 63% of total healthcare costs in year 1, rising to 90% by follow-up year 6. Conclusions: Markov analysis shows that cases with severe disease (more intensive therapy, frequent flares) have a poor prognosis and engender high healthcare costs. Surgery constitutes the greatest expense. Medical therapy must try to maintain patients in a state of remission and avoid the need for surgery. Transition probabilities, minority flare-years

P059 - Incidence of pre-malignant lesions in patients with long standing ulcerative colitis

(L1/L4), 1 with colonic localization (L2). PCDAI was 21.9±11.2. Terminal/neoterminal lesions were detected at SICUS in 23 patients, confirmed at ileo-colonoscopy in 22 and at surgery in 1. Terminal/neoterminal lesions were excluded at SICUS in 1 patient with CD of the colon and in 2 operated patients with no recurrence and confirmed at ileo-colonoscopy. SICUS detected additional jejunal/proximal ileum lesions in 7 pts confirmed at radiology and/or WCE or surgery. At SICUS the extension of the proximal and distal SB lesions was 26±22.8 cm and 17±10 cm respectively. Furthermore SICUS detected extraluminal CD findings, namely nodes enlargement and mesenteric involvement, in 21/26 patients. Conclusions: These findings indicate that the non invasive procedure SICUS: 1) has a high accuracy for diagnosing Crohn’s lesions of the SB, 2) is comparable to endoscopic, radiological and WCE examination, in detecting presence and site of SB lesions, and 3) furthermore enables to assess the extension of the SB lesions. These findings support the use of non-invasive SICUS as a first choice examination in the diagnostic work up and follow up of CD pediatric patients.