John D. Betteridge

Inflammatory Bowel Disease Prevalence by Age, Gender, Race, and Geographic Location in the U.S. Military Health Care Population

Background:There is limited data examining the prevalence of inflammatory bowel disease (IBD) in a diverse North American population. Methods:Using International Classification of Diseases, Ninth Revision codes, patients with Crohns disease (CD) and ulcerative colitis (UC) seen within the military health care system (Tricare) from October 1, 2008 to September 30, 2009 were identified. This database comprised all active duty military, retirees, and dependents. The overall prevalence of IBD, UC, and CD was calculated, and the prevalence by age, gender, race, and geographic location. Results:A total of 35,404 cases of IBD were identified in 10.2 million military health care beneficiaries establishing a prevalence of total IBD, UC, and CD of 348, 202, and 146 per 100,000, respectively. IBD was more prevalent in females compared with males (417 versus 284 per 100,000; relative risk, 1.53; 95% confidence interval, 1.50–1.57). There was an increased prevalence of IBD with each decade of life. IBD was more common in Caucasians (324 per 100,000) compared with blacks, Asians, Hispanics, and American Indians (239, 162, 147, and 224 per 100,000, respectively; relative risk, 1.60; 95% confidence interval, 1.53–1.67). There was no difference in prevalence when comparing Northern versus Southern states (339 versus 333 per 100,000, respectively, P = 0.114). Conclusions:This large population study establishes a prevalence of IBD, UC, and CD (348, 202, and 146 per 100,000, respectively) in the military health care population. The prevalence of IBD, UC, and CD was higher in females and with increasing age, whereas IBD was most common in whites compared with other ethnicities in our patient population.

Drug-Induced Liver Injury From Initial Dose of Infliximab

Acute hepatotoxicity secondary to infliximab can occur with or without autoimmunity. A growing body of infliximab drug-induced liver injury cases without autoantibody formation is emerging. Nearly all other reported cases occur after at least three doses. This suggests infliximab may have a direct cytotoxic effect on the liver. We report a case of drug-induced liver injury resulting after an initial dose of infliximab.

Su1345 Vitamin D Malabsorption Is Associated With Tobacco Use and Surgery in Patients With Crohn's Disease

on the 8 point score was r=.64. There was no correlation between shifts in religiosity and IBD symptom scores, or in IBD symptom shift (years 1-4 compared to years 8-10), or with pain scores (SF-36) at years 1-4. IBD symptoms did not drive people to or from religion. Spiritual values gave strength to face everyday difficulties: A lot for 26%, Some for 21%, A little for 20%, Not at all for 32%. Spiritual values helped in understanding the difficulties of life: A lot, 21%; Some, 25%; A little, 21%; Not at all, 32%, Missing, 1%. Doctors were seen as the most important factor in health, with a mean of 4.2 out of 6, followed by self, score of 3.5, fate score of 2.9 and finally God, score of 1.7. Doctor health locus of control correlated with cross-sectional IBDQ bowel symptoms r = -18 (p = .02), Self health locus of control showed a correlation of r = -.16 (p = .04). Conclusions Spirituality was used as a coping strategy but believing that oneself and ones doctors are in charge of health correlated with lower levels of symptoms. Belief that fate or God is in charge is neither good nor bad.

P-017 YI Spontaneous Closure of Enterovesicular Fistula with Adalimumab

BACKGROUND: Crohn’s disease is a chronic inflammatory disorder which affects approximately 700,000 patients in the United States. Of these patients, up to 40% will have fistulizing disease, which represent a more aggressive phenotype often failing medical therapy and requiring surgery for definitive treatment. We present 2 cases of fistulizing Crohn’s disease complicated by entero vesicular fistula successfully treated with Adalimumab monotherapy. METHODS: Case 1: 23 y/o male who presented to Walter Reed National Military Medical Center (WRNMMC) with a 4 month history of RLQ pain, relapsing fevers, pneumaturia and dysuria. Evaluation via CT Scan of the Abdomen was significant for long segment terminal ileitis with evidence of an entero-vesicular fistula. Colonoscopy showed nodular and erythematous terminal ileal mucosa with biopsies confirming Crohn’s ileitis. Cystoscopy revealed an area of erythematous and edematous mucosa along the posterior bladder wall. An initial prolonged course of Ciprofloxacin and Metronidazole partially improved symptoms. The patient was started on Adalimumab induction dosing followed by 40 mg subcutaneously bi-weekly with complete resolution of symptoms over the course of 2 months. Subsequent MRE showed no evidence of fistulous tract along with significant improvement in small bowel disease. The patient remains in clinical remission approximately 1 year after initiation of Adalimumab. RESULTS: Case 2: 27 y/o male who presented to WRNMMC with a 1 month history of dysuria, fecaluria, hematuria and scant hematochezia. Patient was initially evaluated at Landsthul Army Medical center, Germany where he underwent cystoscopy which showed evidence of ulcerative cystitis and a fistulous tract. Colonoscopy was significant for cobblestone appearing terminal ileum with ulcerated mucosa. Biopsies showed crypt abscess formation and distortion consistent with Crohn’s ileitis. Patient was initially placed on Ciprofloxacin and metronidazole with no improvement in symptoms. MR enterography (MRE) showed the presence of an entero-vesicular fistula with associated distal ileal inflammation. The patient was started on Adalimumab induction dosing followed by 40 mg subcutaneously every other week. Over the course of 4 months the patient reported complete resolution of all symptoms. Re-evaluation with cystoscopy was notable for no residual fistula and MRE approximately 8 months later demonstrated no evidence of an entero vesicular fistula. CONCLUSIONS: Enterovesicular fistulas occur in 2%–5% of patients with Crohn’s disease. When present, typical symptoms include recurrent urinary tract infections, pneumaturia and fecaluria. Surgical management is often necessary but can have serious complications such as perforation and abscess formation in as many as 12% of patients. In patients in whom medical management is attempted, there have been limited reported cases of successful closure of enterovesicular fistulas with anti TNF agents. These 2 cases represent the only reported sustained successful management of enterovesicular Crohn’s fistulas confirmed by both clinical response and radiographic evidence on anti-TNF therapy. The early use of anti-TNF in a patient presenting with a fistula (“top-down” approach) may be the reason fistulas healed so effectively. Use of anti-TNF therapy should be considered early in the treatment of fistulizing Crohn’s to include enterovesicular fistulas.