Jason K. Hou

Dietary Intake and Risk of Developing Inflammatory Bowel Disease: A Systematic Review of the Literature

OBJECTIVES:The incidence of inflammatory bowel disease (IBD) is increasing. Dietary factors such as the spread of the “Western” diet, high in fat and protein but low in fruits and vegetables, may be associated with the increase. Although many studies have evaluated the association between diet and IBD risk, there has been no systematic review.METHODS:We performed a systematic review using guideline-recommended methodology to evaluate the association between pre-illness intake of nutrients (fats, carbohydrates, protein) and food groups (fruits, vegetables, meats) and the risk of subsequent IBD diagnosis. Eligible studies were identified via structured keyword searches in PubMed and Google Scholar and manual searches.RESULTS:Nineteen studies were included, encompassing 2,609 IBD patients (1,269 Crohn’s disease (CD) and 1,340 ulcerative colitis (UC) patients) and over 4,000 controls. Studies reported a positive association between high intake of saturated fats, monounsaturated fatty acids, total polyunsaturated fatty acids (PUFAs), total omega-3 fatty acids, omega-6 fatty acids, mono- and disaccharides, and meat and increased subsequent CD risk. Studies reported a negative association between dietary fiber and fruits and subsequent CD risk. High intakes of total fats, total PUFAs, omega-6 fatty acids, and meat were associated with an increased risk of UC. High vegetable intake was associated with a decreased risk of UC.CONCLUSIONS:High dietary intakes of total fats, PUFAs, omega-6 fatty acids, and meat were associated with an increased risk of CD and UC. High fiber and fruit intakes were associated with decreased CD risk, and high vegetable intake was associated with decreased UC risk.

Distribution and manifestations of inflammatory bowel disease in asians, hispanics, and african americans: A systematic review

OBJECTIVES:Although inflammatory bowel disease (IBD) has been reported worldwide, most studies have focused on Caucasian populations. Our aim was to summarize the existing epidemiological literature, identify temporal trends, and highlight areas for future research.METHODS:We carried out a systematic review following standard guidelines to evaluate the incidence, prevalence, temporal trends, disease characteristics, and extra-intestinal manifestations (EIMs) of IBD in African American, Hispanic, and Asian adult patients. Two investigators independently identified eligible studies through 2008 using structured keyword searches in PubMed, applied several inclusion and exclusion criteria, and abstracted the data.RESULTS:Twenty-eight publications were included, encompassing 1,272 Hispanic, 547 African American, and 35,844 Asian patients with IBD. Greater proportions of Hispanic (36.7–84.3%) and Asian (30.6–74.7%) patients were diagnosed with ulcerative colitis (UC) than with Crohns disease (CD) compared with African Americans (27.6–40.6%). The prevalence rates of IBD in Hispanics in Puerto Rico varied between 5 (rural) and 62 (urban) per 100,000. Crude prevalence rates in Asia varied between 6 (Singapore) and 136 (South Asians in UK) per 100,000 for UC, and between 3 (Singapore) and 33 (South Asians in UK) per 100,000 for CD. Three studies reported a rising annual incidence rate among Hispanics (from 2.6 to 7.5 per 100,000) and Asians (from 0.22 to 3.62 per 100,000). Fistulizing CD was reported in nearly one-third of Hispanic patients, up to one-quarter of African-American patients, and up to one-half of Asian patients. Ileocolonic disease was the most common site of CD among the three racial/ethnic groups, with skin and joint manifestations noted as the most common EIMs.CONCLUSIONS:Prevalence and incidence rates in Hispanics and Asians have recently increased. There are many similarities and differences in disease location and behavior among racial/ethnic groups. There is a paucity of literature on all aspects of the disease in Hispanics, in the incidence and prevalence of IBD in African Americans, and in Asians with IBD outside Asia.

Diet and Inflammatory Bowel Disease: Review of Patient-Targeted Recommendations

Patients have strong beliefs about the role of diet in the cause of inflammatory bowel disease (IBD) and in exacerbating or alleviating ongoing symptoms from IBD. The rapid increase in the incidence and prevalence of IBD in recent decades strongly suggests an environmental trigger for IBD, one of which may be dietary patterns. There are several pathways where diet may influence intestinal inflammation, such as direct dietary antigens, altering the gut microbiome, and affecting gastrointestinal permeability. However, data that altering diet can change the natural history of IBD are scarce, and evidence-based dietary guidelines for patients with IBD are lacking. Patients, therefore, seek nonmedical resources for dietary guidance, such as patient support groups and unverified sources on the Internet. The aim of this review is to identify patient-targeted dietary recommendations for IBD and to critically appraise the nutritional value of these recommendations. We review patient-targeted dietary information for IBD from structured Internet searches and popular defined diets. Patient-targeted dietary recommendations focus on food restrictions and are highly conflicting. High-quality dietary intervention studies are needed to facilitate creation of evidence-based dietary guidelines for patients with IBD.

Viral hepatitis and inflammatory bowel disease

&NA; Viral hepatitis is common worldwide and in the United States. Inflammatory bowel disease (IBD) patients with chronic hepatitis B virus (HBV) with active disease (elevated alanine aminotransferase level and viral replication) should receive HBV treatment. HBV reactivation is associated with significant morbidity and mortality in patients receiving immunosuppression. IBD patients may require long‐term immunosuppression, and therefore should be considered candidates for vaccination against new HBV infection as well as prophylaxis against HBV reactivation prior to immunosuppressive therapy. Tumor necrosis factor alpha antagonists and immunomodulators appear compatible with use in IBD patients with HCV, although prednisone may increase viral replication. HCV treatment with peg‐interferon and ribavirin may exacerbate gastrointestinal symptoms, and therefore the decision to treat HCV needs to be individualized. Management of IBD patients with viral hepatitis is addressed in this review. (Inflamm Bowel Dis 2010;)

MicroRNA signatures differentiate Crohn’s disease from ulcerative colitis

BackgroundExcessive and inappropriate immune responses are the hallmark of several autoimmune disorders, including the inflammatory bowel diseases (IBD): Crohn’s disease (CD) and ulcerative colitis (UC). A complex etiology involving both environmental and genetic factors influences IBD pathogenesis. The role of microRNAs (miRNAs), noncoding RNAs involved in regulating numerous biological processes, to IBD pathology, in terms of initiation and progression, remains ill-defined. In the present study, we evaluated the relationship between colon, peripheral blood, and saliva whole miRNome expression in IBD patients and non-inflammatory bowel disease (non-IBD) controls to identify miRNAs that could discriminate CD from UC. Quantitative real-time PCR (qRT-PCR) was used to validate and assess miRNA expression.ResultsMicroarray analysis demonstrated that upwards of twenty six miRNAs were changed in CD and UC colon biopsies relative to the non-IBD controls. CD was associated with the differential expression of 10 miRNAs while UC was associated with 6 miRNAs in matched colon tissues. CD was associated with altered expression of 6 miRNAs while UC was associated with 9 miRNAs in whole blood. Expression of miR-101 in CD patients and miR-21, miR-31, miR-142-3p, and miR-142-5p in UC patients were altered in saliva.ConclusionsOur results suggest that there is specific miRNA expression patterns associated with UC versus CD in three separate tissue/body fluids (colon, blood, and saliva). Further, the aberrant miRNA expression profiles indicate that miRNAs may be contributory to IBD pathogenesis, or at least reflect the underlying inflammation. Scrutinizing miRNA expression in saliva and blood samples may be beneficial in monitoring or diagnosing disease in IBD patients. A panel of miRNAs (miR-19a, miR-21, miR-31, miR-101, miR-146a, and miR-375) may be used as markers to identify and discriminate between CD and UC.

Treatment of chronic radiation proctitis with cryoablation

BACKGROUND Chronic radiation proctitis (CRP) is a common problem in patients receiving pelvic radiation. Current therapies have the potential for deep tissue injury with ulcerations, perforation, and fistula formation. Cryospray ablation therapy offers superficial ablation of mucosa and is a potential method to endoscopically treat CRP safely and effectively. OBJECTIVE To determine tolerability of and response to cryotherapy in patients with radiation proctitis. DESIGN Prospective case-series pilot study. SETTING Baylor College of Medicine, Michael E. DeBakey Medical Center, Houston, Texas. PATIENTS Ten patients were prospectively recruited with chronic hemorrhagic radiation proctitis. INTERVENTIONS Endoscopic cryoablation of CRP. MAIN OUTCOME MEASUREMENTS Symptom severity of CRP was obtained by using the Radiation Proctitis Severity Assessment Scale (RPSAS). Endoscopic assessment was obtained using the rectal telangiectasia density grade. The primary endpoint of the study was endoscopic improvement of CRP based on the change in rectal telangiectasia density at 3-month follow-up. Secondary endpoints included symptomatic improvement based on RPSAS and adverse events at 3 months. RESULTS Ten patients with hemorrhagic radiation proctitis were treated with endoscopic cryoablation. Endoscopic severity improved as measured by rectal telangiectasia density from 2.7 to 1.7 (P=.004). Overall subjective clinical scores improved as determined by the Radiation Proctitis Severity Assessment Scale from 27.7 to 13.6 (P=.003). Endoscopic improvement correlated with symptom improvement. LIMITATIONS Nonpowered case series pilot study. CONCLUSIONS Cryoablation improved clinical and endoscopic indices in CRP. Further controlled studies are needed to identify the safety and efficacy of cryoablation for CRP.

Multi-center colonoscopy quality measurement utilizing natural language processing

Background:An accurate system for tracking of colonoscopy quality and surveillance intervals could improve the effectiveness and cost-effectiveness of colorectal cancer (CRC) screening and surveillance. The purpose of this study was to create and test such a system across multiple institutions utilizing natural language processing (NLP).Methods:From 42,569 colonoscopies with pathology records from 13 centers, we randomly sampled 750 paired reports. We trained (n=250) and tested (n=500) an NLP-based program with 19 measurements that encompass colonoscopy quality measures and surveillance interval determination, using blinded, paired, annotated expert manual review as the reference standard. The remaining 41,819 nonannotated documents were processed through the NLP system without manual review to assess performance consistency. The primary outcome was system accuracy across the 19 measures.Results:A total of 176 (23.5%) documents with 252 (1.8%) discrepant content points resulted from paired annotation. Error rate within the 500 test documents was 31.2% for NLP and 25.4% for the paired annotators (P=0.001). At the content point level within the test set, the error rate was 3.5% for NLP and 1.9% for the paired annotators (P=0.04). When eight vaguely worded documents were removed, 125 of 492 (25.4%) were incorrect by NLP and 104 of 492 (21.1%) by the initial annotator (P=0.07). Rates of pathologic findings calculated from NLP were similar to those calculated by annotation for the majority of measurements. Test set accuracy was 99.6% for CRC, 95% for advanced adenoma, 94.6% for nonadvanced adenoma, 99.8% for advanced sessile serrated polyps, 99.2% for nonadvanced sessile serrated polyps, 96.8% for large hyperplastic polyps, and 96.0% for small hyperplastic polyps. Lesion location showed high accuracy (87.0–99.8%). Accuracy for number of adenomas was 92%.Conclusions:NLP can accurately report adenoma detection rate and the components for determining guideline-adherent colonoscopy surveillance intervals across multiple sites that utilize different methods for reporting colonoscopy findings.

The incidence and prevalence of inflammatory bowel disease among U.S. veterans: a national cohort study.

Background:Temporal trends in incidence and prevalence of Crohns disease (CD) and ulcerative colitis (UC) in the United States have been reported only in regional populations. The Veterans Affairs (VA) health care system encompasses a national network of clinical care facilities. The aim of this study was to identify temporal trends in the incidence and prevalence of CD and UC among VA users using national VA data sets. Methods:Veterans with CD and UC were identified during fiscal years 1998 to 2009 in the national VA outpatient and inpatient files. Incident and prevalent cases were identified by diagnosis code, and age-standardized and gender-standardized annual prevalence and incidence rates were estimated using the VA 1998 population as the standard population. Results:The total of unique incident cases were 16,842 and 26,272 for CD and UC, respectively; 94% were men. The average annual age-standardized and gender-standardized incidence rate of CD was 33 per 100,000 VA users (range, 27–40), whereas the average for UC was 50 per 100,000 VA users (range, 36–65). In 2009, the age-standardized and gender-standardized point prevalence rate of CD was 287 per 100,000 VA users, whereas the point prevalence of UC was 413 per 100,000 VA users. Conclusions:Prevalence of CD and UC increased 2-fold to 3-fold among VA users between 1998 and 2009. The incidence of UC decreased among VA users from 1998 to 2004 but has remained stable from 2005 to 2009. The incidence of CD has remained stable during the observed time period.

Epidemiology of inflammatory bowel disease among an indigent multi-ethnic population in the United States

Background: Environmental factors, including socioeconomic status, may affect inflammatory bowel disease (IBD). There is a paucity of data on the epidemiology of IBD among patients of low socioeconomic status. Aim: To examine the epidemiologic features of IBD among African-American, Hispanic, and Caucasian patients from a county hospital, where the majority of the patients are socioeconomically disadvantaged. Methods: A retrospective study was conducted on a cohort of patients diagnosed with IBD based on clinical, radiologic, endoscopic, and histological data. We reviewed charts of adults aged 20–70 years diagnosed with IBD between 2000 and 2006. Demographic data, disease subtype, and phenotypic features of IBD were recorded based on the Montreal Classification. The data were analyzed using the chi-square, Fisher exact, Wilcoxon rank-sum, and Student’s t-tests. Results: The study cohort included 273 patients, with 54% female, 30% Caucasian, 44% African-American, and 26% Hispanic. Over half (54%) of the patients had Crohn’s disease (CD), and 46% had ulcerative colitis (UC). The mean age at diagnosis was 40 ± 14 years with no significant difference between CD and UC (age 43 ± 13 versus 44.5 ± 14, respectively; P = 0.5). Females were diagnosed at a significantly later age than males (46 ± 13 years versus 40 ± 13, respectively; P = 0.001). This trend remained significant for females with CD and UC, and across each racial/ethnic group. Hispanic patients were diagnosed with UC more often than Caucasian patients (64% versus 34%; odds ratio [OR] 3.5; 95% confidence interval [CI]: 1.8–6.5, P = 0.0003) or African-Americans (64% versus 43%; OR 2.3; 95% CI: 1.3–4.3, P = 0.005). Among the 147 patients with CD, 54% had fistulizing and/or stricturing disease. The prevalence of fistulizing, stricturing, and inflammatory CD was similar across all age, gender, and racial/ethnic groups. Conclusions: Within an indigent population, UC was diagnosed more often in Hispanics than CD. Females were diagnosed at a significantly older age than males across all racial/ethnic groups. There was no difference in the CD phenotypes between the three ethnic groups. Understanding the epidemiology of IBD will require examination of the interactions between gender, race/ethnicity, and environmental factors.

Choosing Wisely and the Perceived Drivers of Endoscopy Use

Choosing Wisely is a campaign led by the American Board of Internal Medicine (ABIM) Foundation in collaboration with specialty medical societies including the American Gastroenterological Association (AGA)1. Choosing Wisely seeks to reduce several categories of overutilization of health care services (e.g., overtreatment, and failures in care coordination and execution of care processes)2. Choosing Wisely is based on principles of Parsimonious Medicine: an appeal to professionalism and physicians’ “good, sound judgment” to identify and apply clinical evidence 3. Parsimonious medicine suggests that appropriate utilization occurs when physician judgment and best evidence are applied within the context of individual patient’s needs3. Choosing Wisely addresses both physicians and patients through the publication of lists of “Five Things Physicians and Patients Should Question” for each specialty. The Choosing Wisely items identified by the AGA highlight potential overutilization of 1) pharmacologic treatments for gastroesophageal reflux disease, 2) screening colonoscopy in average risk individuals, 3) surveillance colonoscopy in individuals with low-risk polyps, 4) surveillance esophagogastroduodenoscopy (EGD) in individuals with Barrett’s Esophagus (BE), and 5) computed tomography (CT) in individuals with functional abdominal pain.1 The success of Choosing Wisely will depend on how patients and physicians weight the importance of best evidence against other factors that shape decisions at the clinical encounter. As part of a patient-centered, comparative effectiveness study of screening and surveillance esophagogastroduodenoscopy (EGD), we conducted qualitative interviews to explore patient and physician perceptions of one of the AGA Choosing Wisely items.4 Analysis of these interviews identified factors perceived to influence under and over utilization of surveillance EGD for Barrett’s Esophagus in the context of AGA clinical practice guidelines. We conducted in-depth qualitative interviews with 20 patients with BE who use the Veterans Administration (VA) system and 14 gastroenterologists from three practice settings: tax-supported public, private academic, and VA settings. We concluded sampling for each subgroup at the point of thematic saturation5. Interview content was informed by models of decision-making6. Interviews with patients elicited information about their experiences, perceptions, and attitudes regarding BE and surveillance EGD. Interviews with physicians elicited perceptions of practice guidelines and decision making regarding surveillance EGD in patients with BE. All interviews were recorded, transcribed, and analyzed for content.5 Of our sample of 20 patients with BE, the mean age of participants was 62.9±7.3 years; all male; and 10 had BE without dysplasia and 9 had BE with low-grade dysplasia. All of the 14 gastroenterologists interviewed were experienced endoscopists, 36% were female, 50% practiced in private settings full or part time; and had a median of 14 (range 1–36) years post-fellowship experience. Table 1 describes quotes from patients and gastroenterologists that frame the drivers of utilization of EGD for patients with BE as part of guideline-based cancer surveillance. Figure 1 depicts these 9 themes as drivers of utilization for surveillance EGD. Figure 1 Table 1 Drivers of Utilization Among Patients and Gastroenterologists Our interviews identified drivers of over and under utilization of EGD within the context of BE surveillance. Patients and physicians endorsed many factors (Figure 1) that drive utilization of EGD, other than the quality of evidence, that may not be influenced by appeals for professionalism or quality of evidence. These factors include, access and payments for healthcare (for patients), financial incentives and medical-legal considerations (for physicians). The results of our study specifically explore one of the Choosing Wisely items co-sponsored by AGA: follow-up surveillance examination should not be performed in less than three years as per published guidelines for BE patients without dysplasia1. However, current practice is not indicative of adherence to this item; for example, a recent three-site study (including one VA facility) found EGD overutilization was common among BE patients and insurance-related incentives were the primary driver of utilization6. The emphasis that Choosing Wisely places on Parsimonious Medicine is unlikely to mitigate the many drivers of overtreatment given some of the current evidence and structural issues related to heathcare delivery in a largely fee-for-service system. High quality evidence is critical because it anchors definitions of appropriate utilization (as illustrated in Figure 1). However, three of the five Choosing Wisely items from the AGA directly address overutilization of endoscopy (colonoscopy and EGD) where evidence guiding the optimal time interval between repeat studies is modest at best, yet there are multiple perceived factors driving overutilization. Moreover, systematic changes affecting incentive structures and medico-legal concerns are needed to encourage and enable the types of shared decisions that are consistent with best evidence. Without incentives to counteract the factors favoring overutilization, Choosing Wisely will struggle to meaningfully impact clinical decision making.