Jessica Philpott

Trends in Hospitalizations of Children With Inflammatory Bowel Disease Within the United States From 2000 to 2009

Background The incidence and prevalence of pediatric inflammatory bowel disease (IBD) seems to be increasing in North America and Europe. Our objective was to evaluate hospitalization rates in children with IBD in the United States during the decade 2000 to 2009. Methods We analyzed cases with a discharge diagnosis of Crohn disease (CD) and ulcerative colitis (UC) within the Healthcare Cost and Utilization Project Kids’ Inpatient Database, Agency for Healthcare Research and Quality. Results We identified 61,779 pediatric discharges with a diagnosis of IBD (CD, 39,451 cases; UC, 22,328 cases). The number of hospitalized children with IBD increased from 11,928 to 19,568 (incidence, 43.5–71.5 cases per 10,000 discharges per year; P < 0.001). For CD, the number increased from 7757 to 12,441 (incidence, 28.3–45.0; P < 0.001) and for UC, 4171 to 7127 (15.2–26.0; P < 0.001). Overall, there was a significant increasing trend for pediatric hospitalizations with IBD, CD, and UC (P < 0.001). In addition, there was an increase in IBD-related complications and comorbid disease burden (P < 0.01). Conclusion There was a significant increase in the number and incidence of hospitalized children with IBD in the United States from 2000 to 2009.

Efficacy of Vedolizumab in Patients with Antibiotic and Anti-tumor Necrosis Alpha Refractory Pouchitis

Refractory pouchitis is a risk factor for pouch failure and surgical excision. While TNFa inhibitors have been reported to be effective as treatment for pouchitis there is no data regarding the use of vedolizumab in refractory pouchitis. In this study we evaluated the clinical and endoscopic response to vedolizumab in refractory pouchitis. This is an open label case series. Three patients were identified as having refractory pouchitis with loss or lack of response to antibiotics, corticosteroids, and at least one TNFa inhibitor along with a variety of other modalities of therapy. Each patient underwent pouch endoscopy before initiation of vedolizumab and repeat endoscopy within 4 months of initiation of treatment. Vedolizumab was administered as per standard dosing regimen. The Pouch Disease Activity Index (PDAI) endoscopic subscore was evaluated by the 2 investigators independently and reported as an average. The clinical record was reviewed to determine patient reported response to therapy. Patient 1, a 54 year old male, had undergone colectomy and IPAA in 2000 for medically refractory ulcerative colitis (UC). He suffered from ankylosing spondylitis and chronic pouchitis. He had been treated serially with antibiotics, budesonide, infliximab, methotrexate, adalimumab, in combination with hyperbaric oxygen therapy with severe diarrhea. His pouchoscopy prior to initiation revealed confluent ulceration with PDAI endoscopic subscore of 4. Endoscopy 4 months after the initiation of vedolizumab therapy revealed visual improvement, with few small ulcers noted, with PDAI endoscopic subscore of 3. He experienced improvement in clinical symptoms and has avoided surgical resection of his pouch but did require maintenance therapy with budesonide. Patient 2, a 54 year old female underwent colectomy and IPAA in 1991 for medically refractory UC. She developed recurrent stricturing at the pouch inlet and afferent limb and pouchitis, treated with surgical stricturoplasty, antibiotics, thiopurines, mesalamine, intravenous immunoglobulin therapy, fecal microbiota transplant, and adalimumab. She continued to have symptoms of diarrhea and pain. Pouch endoscopy revealed chronic pouchitis with edema and loss of vascular pattern consistent with a PDAI score of 5, along with cuffitis, and ulcerated strictures in the neo-terminal ileum. She underwent pouchoscopy 4 months after the therapy with vedolizumab which revealed improvement in pouchitis, normal appearing mucosa and PDAI endoscopic subscore 1, but ongoing ulceration at cuff and inlet. Patient 3, a 54 year old female post restorative proctocolectomy for refractory UC in 2012 had required pouch redo surgery in 2014 for severe pouch dysfunction. She suffered from diarrhea requiring intravenous hydration despite use of antibiotics, infliximab with azathioprine, and mesalamine. Her pouchoscopy revealed pouchitis and ileitis with a PDAI score of 3. Pouch endoscopy 4 months after initiation of vedolizumab which revealed improved mucosa of the pouch with PDAI score of 1. She noted improvement in symptoms of diarrhea. All 3 patients had improved endoscopic scores and reported clinical improvement in terms of diarrhea and pain. Vedolizumab in open label use for chronic antibiotic- and anti- TNFα-refractory, chronic pouchitis demonstrated improvement in both symptoms and endoscopy scores.

Efficacy, Safety, and Long-term Outcome of Serial Endoscopic Balloon Dilation for Upper Gastrointestinal Crohn’s Disease-associated Strictures—A Cohort Study

Background Gastric and duodenal Crohns disease [CD]-associated strictures are rare. Evidence on endoscopic balloon dilation [EBD] of upper gastrointestinal [GI] CD strictures is limited, in particular in respect to serial dilations. Methods Prospective short- and long-term outcome data as well as complication rates on a cohort of upper GI CD-associated stricture dilations [stomach and duodenum] were collected from 1999 to 2015. Factors linked with clinical and technical success, long-term efficacy and complication rates were investigated. Results A total of 35 CD patients with symptomatic CD-associated upper GI strictures [20% gastric, 67% duodenal, 11% both; mean age at diagnosis 25 years; mean CD duration to stricture 79.9 months; median post-dilation follow-up 22.1 months] underwent a total of 96 pneumatic dilations [33 gastric and 63 duodenal]. The median maximal dilation diameter was 15 mm. Technical success was achieved in 93% and clinical success in 87%, with a complication rate of 4% per procedure. The mean time to re-dilation was 2.2 months and mean time to stricture-related surgery after first dilation was 2.8 months. There was no difference in short-term efficacy, safety, or long-term outcome between the first and any later dilation procedure in the same patient. Conclusions Pneumatic dilation of upper GI CD-associated strictures has a high rate of short-term technical and clinical success, with moderate long-term efficacy and acceptable complication rates. Serial dilations do not change the efficacy and could be a feasible option to delay or prevent surgical intervention.

Challenges in Transitional Care in Inflammatory Bowel Disease: A Review of the Current Literature in Transition Readiness and Outcomes

Transitional care for patients with IBD focuses on efforts to successfully transfer care from pediatric to adult providers while encouraging the assumption of health care responsibility. As 25% of patients will be diagnosed with IBD before the age of 18 years, many will undergo this process. Efforts to enhance this process have included transition clinics and other means to improve patient comfort with transition and develop the skill of health care self-management. Currently, most pediatric practitioners provide transition care with informal education and emphasize independence without formal programs. A variety of tools to assess transition readiness have been developed. Given the varied disease process, often varied and subjective outcomes, and lack of studies such as randomized controlled trials, further data are necessary to determine the best avenue to transition and assess outcomes. Critically relevant to providing adequate care to transitioning patients includes understanding the development of self-management skills and the developmental processes relevant to young adults with IBD. Transition represents an area for quality improvement, and although progress has been made in recognition and promotion of transition practices, future directions in research will allow improved understanding of the evidence-based practices and needs of these individuals to further enhance their care.

Vedolizumab in the treatment of Crohn’s disease of the pouch

Abstract Background Our recent study showed the efficacy and safety of vedolizumab in the treatment of chronic antibiotic-refractory pouchitis. However, there are no published studies on its efficacy and safety in Crohn’s disease (CD) of the pouch. The aim of this study was to assess the efficacy and safety of vedolizumab in those patients. Methods This case series included all eligible patients with CD of the pouch from our prospectively maintained, IRB-approved Pouchitis Registry from 2015 to 2017. Disease activity in pouch patients can be monitored using the modified Pouchitis Disease Activity Index (mPDAI). mPDAI is the 18-point pouchitis disease activity index consisting of three principal component scores: symptom (range, 0–6 points), endoscopy, (range 0–6 points), and histology (range, 2–6 points). Pre- and post- treatment (minimum 6 months) pouchoscopy and clinical visits were used to calculate mPDAI. Results A total of 12 patients were included in this study, who had restorative proctocolectomy with ileal pouch anal anastomosis for medically refractory ulcerative colitis (UC). The mean age at the time of pre-colectomy diagnosis of UC was 25.0 ± 11.5 years. The mean current age was 41.0 ± 12.1 years, nine (75.0%) were female, three (25.0%) had smoked and eight (66.7%) had used anti-tumor necrosis factor agents prior to vedolizumab use. The mean duration of vedolizumab use was 1.0 ± 6.4 years. There was a significant reduction in mPDAI symptom subscores after vedolizumab therapy (3.50 ± 1.93 vs 5.08 ± 0.79, P = 0.015). The pre- and post-treatment mean endoscopy subscores were 1.25 ± 1.36 and 0.91 ± 1.50 in the afferent limb (P = 0.583); 2.58 ± 1.68 and 2.27 ± 2.05 (P = 0.701) in the pouch body; and 2.67 ± 1.93 and 2.09 ± 2.12 (P = 0.511) in the cuff, respectively. None of the patients experienced side effects throughout the vedolizumab therapy. Conclusion The findings of our study suggests that vedolizumab appears to be effective and safe in reducing the symptoms in patients with CD of the pouch.

P-065 Impact of Diabetes on Short-Term Postoperative Morbidities in Patients Undergoing Ileal Pouch Surgery

BACKGROUND: Although medical management of diabetes has improved, there are data suggesting increased risk of adverse outcomes for abdominal surgeries in diabetics. Previously identified risk factors for short-term postoperative morbidities in ileal pouch surgery include preoperative hypoalbuminemia and steroid use. The aim of this study is to determine whether diabetes is an independent risk factor for adverse perioperative outcomes of ileal pouch surgery. METHODS: The America College of Surgeons National Surgical Quality Improvement (NSQIP) program database (2005 to 2011) was queried to identify patients undergoing ileal pouch-anal anastomosis (IPAA). Patient characteristics, comorbidities, steroid use, and 30-day morbidities were compared between diabetics and nondiabetics. Serious complications were defined as organ failure, stroke, mortality, return for further surgery, and transfusion. Univariate and multivariable analyses were performed to evaluate the impact of diabetes on 30-day postoperative outcomes. RESULTS: During the period of study, 2,957 patients were identified in the NSQIP database as having undergone IPAA. Of these patients, 175 (5.9%) were diabetic. Steroid use and anemia were not significantly different between the groups, but preoperative albumin was lower (3.89 versus 3.6, P = 0.0013), BMI was higher in diabetics and comorbidities including CHF, renal impairment, COPD were increased among diabetics. The unadjusted incidence of mortality was higher in diabetics with 6/175 (3.4%) in diabetics versus 12/2,789 deaths (0.4%) in nondiabetics (P = 0.0004). Septic shock, wound infection, cardiac arrest, and organ failure were significantly increased in diabetics with univariate analysis. Length of stay was longer for diabetics (8.25 versus 10.11 days, P = 0.0013). Multivariate analysis did not reveal diabetes as an independent risk factor for serious complications (OR 1.35, CI 0.9–2.03). Preoperative sepsis was identified as a risk factor for complications (OR 2.89, 1.69–4.96). CONCLUSIONS: Conclusion: Analysis of data from a national database reveals that diabetics undergoing IPAA have an unadjusted increased risk of 30 day mortality. However diabetes is was not an independent risk factor for serious short term complications of surgery in these analyses. Identification of risk factors in diabetics may improve outcomes and risk stratification.

Trends in Hospitalization Rates and Disease Behavior in Pediatric Inflammatory Bowel Disease in the United States From 2000 to 2009: P-145 YI

BACKGROUND: Recent studies suggest an increasing incidence of inflammatory bowel disease (IBD) in children. However, the impact of this increase on the secular trends of inpatient care and disease burden in hospitalized children with IBD is unknown. Therefore, the aims of this study were to evaluate the rate of hospitalization and disease behavior in hospitalized children with IBD in the United States from 2000 to 2009. METHODS: We used the U.S. Healthcare Cost and Utilization Project Kids’ Inpatient Database. Data were weighted to generate national-level estimates. RESULTS: We identified 61,779 cases of pediatric IBD during four triennial periods from 2000 to 2009. During the period of study, the rate of hospitalization of children with any diagnosis of IBD increased from 43.6 to 72.0 (cases per 10,000 total hospitalizations entered into the database per year; 2000 vs. 2009; P <0.001). Specifically, for Crohn’s disease (CD) the rate increased from 28.3 to 45.7 (P <0.001) and for ulcerative colitis (UC) 15.2 to 26.1 (P <0.001). There was an increasing trend in the rate of hospitalization in pediatric cases of IBD overall, and CD and UC individually (evaluation of entire time period, Cochran-Armitage test for trend, P <0.001 for each disease). The age distribution of hospitalized children with IBD did not change over the decade of study. Mortality (1 per 1,000 cases of IBD) and length of hospital stay (LOS; median, 4 days) remained constant. Hospitalization charges (adjusted for inflation) increased (median,

Risk factors for Crohn’s disease of the neo-small intestine in ulcerative colitis patients with total proctocolectomy and primary or secondary ileostomies.

11,614 to

Women's health issues after ileal pouch surgery

20,724, P <0.001). Significant increasing trends were found for comorbid disease burden and systemic complications (including electrolyte disturbances and anemia), and the need for blood transfusion and parenteral nutrition (P <0.001 for each). There, also, was an increase in the number of cases with fistulae, obstruction, and perianal disease (P <0.001 for each). In comparison of IBD and non-IBD cases, those with IBD had lower mortality, longer LOS, and higher charges (P <0.001 for each). Case-control matching demonstrated a lower risk of death (adjusted odds ratio, aOR 0.25, 95% CI, 0.20-0.31), longer LOS (aOR 2.48, 95% CI, 2.40-2.50), and higher charges (aOR 1.92, 95% CI, 1.88-1.96) in those with IBD. CONCLUSION(S): These results demonstrate an increasing trend in the number of pediatric cases with IBD admitted to the hospital from 2000 to 2009. Moreover, we found an increasing trend in disease-specific and systemic complications in these children along with an increasing cost of the hospital stay. These findings are consistent with earlier studies demonstrating that the epidemiology of pediatric IBD is changing as demonstrated by an increase in hospitalized cases. Also, these data suggest there has been an increase in the severity and frequency of complicated disease.