Jimmy K. Limdi

Dietary Practices and Beliefs in Patients with Inflammatory Bowel Disease.

Background:An epidemiological association implicating diet in IBD risk or protection is widely accepted. Patients with IBD often make links to diet, but there is a dearth of literature exploring dietary perceptions and practices in this population. Our objective was to evaluate dietary beliefs and behaviors in IBD patients. Methods:We developed a questionnaire assessing demographics, dietary beliefs and habits in IBD patients. This was prospectively administered to 400 consecutive patients attending our IBD clinics. Results:Mean patient age was 48.4 years; 55% were female, 88% white, 39% had Crohns disease and 51% had ulcerative colitis. Around 48% felt that diet could be the initiating factor in IBD and 57% felt it could trigger a flare. Worsening symptoms with certain foods was reported by 60%. About 66% deprived themselves of their favorite foods in order to prevent relapse. Three-fourth of patients believed that IBD affects appetite, more so during a relapse. Nearly half had never received any formal dietary advice, and two-thirds requested for further dietary advice. After adjusting for other predictors, the IBD subtype and ethnicity of the patients remained as significant factors for influencing beliefs held by patients. Conclusions:Our study showed that patients hold beliefs pertaining to the role of diet in IBD, with a high level of consistency around key perceived triggers. Whether all the symptoms reported are due to active inflammation cannot be ascertained, but the potential exists for dietary components triggering active disease and perpetuating gut injury, impacting on quality of life and health care costs.

Structured gastroenterological intervention and improved outcome for patients with chronic gastrointestinal symptoms following pelvic radiotherapy

PurposeFifty percent of patients develop chronic gastrointestinal (GI) symptoms following pelvic radiotherapy that adversely affect quality of life. Fewer than 20xa0% are referred to a gastroenterologist. We aimed to determine if structured gastroenterological evaluation is of benefit to this patient group.MethodsSixty patients with GI symptoms at ≥6xa0months after radical pelvic radiotherapy were identified prospectively from oncology clinics in this service evaluation. Those requiring urgent investigation were excluded. Patients were assessed at baseline using patient-reported questionnaires: inflammatory bowel disease questionnaire (IBDQ), Vaizey incontinence questionnaire, and the Common Terminology Criteria for Adverse Events (CTCAE) pelvis questionnaire. Participants were referred for gastroenterological evaluation using an algorithmic approach. Further assessments were made at 3 and 6xa0months.ResultsTwenty men and 36 women with primary gynecological (31), urological (17), or lower GI (8) tumors were included (mean age, 58.5xa0years). Median time from radiotherapy to baseline assessment was 3.0xa0years. Multiple GI symptoms were reported (median, 8; range, 4–16) including frequency, urgency, loose stool, fecal incontinence, flatulence, bloating/distension, and rectal bleeding. Common diagnoses included radiation proctopathy, bile acid malabsorption, diverticulosis, and colonic polyps. Statistically significant improvements in all questionnaire scores between baseline and 6xa0months were found: IBDQ (pu2009=u20090.014), Vaizey (pu2009<u20090.0005), and CTCAE rectum-bowel subset (pu2009=u20090.001).ConclusionsGastroenterological evaluation identifies significant, potentially treatable diagnoses in patients who develop chronic GI symptoms following pelvic radiotherapy. Some findings are incidental and unrelated to previous cancer treatment. Radiation-induced GI symptoms have historically been considered “untreatable.” We report the first data to show that structured gastroenterological assessment has the potential to improve outcome by identifying diagnoses and facilitating focused treatment.

An Update on Surveillance in Ulcerative Colitis

Purpose of ReviewPatients with long-standing ulcerative colitis have an increased risk for the development of colorectal cancer (CRC). Colitis-related dysplasia appears to confer the greatest risk. Colonoscopic surveillance to detect dysplasia has been advocated by gastrointestinal societies. The aim of surveillance is the reduction of mortality and morbidity of CRC through detection and resection of dysplasia or detecting CRC at an earlier and potentially curable stage. Traditional surveillance has relied on mucosal assessment with targeted biopsy of visible lesions and random biopsy sampling on the premise that dysplasia was not visible at endoscopy. Advances in optical technology permitting increased detection of dysplasia and evidence that most dysplasia is visible has had practice-changing implications.Recent FindingsEmerging evidence favours chromoendoscopy (CE) for dysplasia detection and is gaining wider acceptance through recent international (International Consensus Statement on Surveillance and Management of Dysplasia in Inflammatory Bowel Disease (SCENIC)) recommendations and endorsed by many gastrointestinal societies. Adoption of CE as the gold standard of surveillance has been met with by scepticism, from conflicting data, operational barriers and the need to understand the true impact of increasingly higher dysplasia detection on overall CRC mortality.SummaryValid debate notwithstanding, implementation of a risk stratification protocol that includes CE is an effective approach allowing earlier detection of dysplasia and colorectal neoplasia, determination of surveillance intervals with appropriate allocation of resources and limiting morbidity from CRC and colonoscopy itself. Further prospective data should define the true and long-term impact of dysplasia detection with modern techniques.

Genetic dissection of inflammatory bowel disease: unravelling etiology and improving diagnostics

Over the past 10 years, remarkable advances in the mapping and identification of genes involved in susceptibility to inflammatory bowel disease have been witnessed. Most notable among these advances has been the discovery of variants in the CARD15, DLG5, SLC22A4 and SLC22A5 genes, which are associated with increased risk of inflammatory bowel disease or specifically Crohn’s disease. These discoveries have provided critical new insights into the molecular pathophysiology of inflammatory bowel disease and the pathways wherein genetic and environmental factors such as enteric bacterial flora may interact to trigger immune dysregulation and intestinal inflammation. This review will outline the discovery of these inflammatory bowel disease-related genes, describe future prospects for further inflammatory bowel disease gene identification, and consider the impact of a genetic understanding of inflammatory bowel disease on future clinical practice.

Dysplasia Surveillance in Inflammatory Bowel Disease

Abstract Patients with long-standing inflammatory bowel disease (IBD) are at an increased risk for development of colorectal cancer (CRC). Of all the risk factors associated with the development of CRC in IBD, colitis-related dysplasia appears to confer the greatest risk. The goal of endoscopic surveillance is to reduce mortality and morbidity of CRC by either detecting and resecting dysplasia or detecting CRC at an earlier and potentially curable stage. Surveillance strategies have relied on examination of the mucosa with targeted biopsies of visible lesions and random biopsy sampling. Advances in optical technology allowing for greater endoscopic identification of dysplasia and consensus that most dysplasia in patients with IBD is visible have led to a paradigm shift in our approach to surveillance and management of dysplasia. New imaging techniques such as chromoendoscopy (CE), narrow band imaging (NBI), and confocal endomicroscopy have been developed and recent evidence suggests that CE or high-definition white light endoscopy (HD WLE) are superior for dysplasia detection as a surveillance technique where appropriate expertise is available. Adoption of CE as the gold standard of surveillance has been met with by skepticism from conflicting data, operational barriers, and the need to understand the true impact of increasingly higher dysplasia detection on overall CRC mortality. This chapter will review the evolution in our understanding of dysplasia, outline the most recent surveillance guidelines, and discuss the management of dysplasia and controversies therein.

Anti-integrin Agents in IBD: Efficacy and Risk of Complications

Active inflammatory bowel disease (IBD) is characterised by the recruitment of leucocytes into the gastrointestinal mucosa through a highly coordinated and multistep process. Infiltrating leucocytes perpetuate the inflammatory process through the secretion of pro-inflammatory cytokines, endothelial cell activation and up-regulation of adhesion molecules with enhancement of inflammatory cell recruitment.

ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detections of complications

Christian Maaser,a Andreas Sturm,b Stephan R. Vavricka,c Torsten Kucharzik,d Gionata Fiorino,e Vito Annese,f Emma Calabrese,g Daniel C. Baumgart,h Dominik Bettenworth,i Paula Borralho Nunes,j, Johan Burisch,k, Fabiana Castiglione,l Rami Eliakim,m Pierre Ellul,n Yago González-Lama,o Hannah Gordon,p Steve Halligan,q Konstantinos Katsanos,r Uri Kopylov,m Paulo G. Kotze,s Eduards Krustiņš,t Andrea Laghi,u Jimmy K. Limdi,v Florian Rieder,w Jordi Rimola,x Stuart A. Taylor,y Damian Tolan,z Patrick van Rheenen,aa Bram Verstockt,bb, Jaap Stokercc; on behalf of the European Crohn’s and Colitis Organisation [ECCO] and the European Society of Gastrointestinal and Abdominal Radiology [ESGAR]

Incidence of Cancer and Screening in Inflammatory Bowel Disease

Patients with long-standing ulcerative colitis (UC) or Crohn’s colitis are at an increased risk for development of colorectal cancer (CRC). Although several risk factors for the development of CRC have been recognized, colitis-related dysplasia confers the greatest risk and colonoscopic surveillance to detect dysplasia has been advocated by gastrointestinal societies [1–9]. The goal of endoscopic surveillance is to reduce mortality and morbidity of CRC by either detecting and resecting dysplasia or detecting CRC at earlier and potentially curable stages [10]. Although recent literature has been conflicting on whether there have been changes in the risk of CRC in IBD patients, the majority of emerging studies from diverse population-based cohorts suggest that there has been a reduction in the risk of CRC in IBD patients [11–13]. The implementation of surveillance colonoscopy, allowing detection and endoscopic resection of dysplastic lesions before the development of CRC and appropriate timing of colectomy and more effective treatments resulting in mucosal healing may explain this temporal reduction [14].