Rhys O. Butcher

Patient knowledge in inflammatory bowel disease: CCKNOW, how much do they know?

investigation on a cohort of children diagnosed with IBD between 1989 and 2003 whom were registered in the IBD center at Texas Childrens Hospital. Children demographics, including age, sex, and age at diagnosis, were obtained. The diagnosis of IBD was based on clinical, radiological, endoscopic, and histological examinations. Disease distribution was identified on the basis of a review of all endoscopic, colonoscopic, pathological, and radiological records. All of the patients underwent a detailed whole-body examination by a gastroenterologist and rheumatologist. Diagnosis of arthritis was made by the assigned rheumatologist. We identified the date of onset of diagnosis for each IBD and arthritis. Results: There were 420 children diagnosed with IBD between1989-2003, 230 (55%) had CD, 112 (26.5%) had UC and 78 (18.5%) had IC. The prevalence of IBD-related arthritis (IBDA) among the total IBD population was 13%; 17% in CD, 11% ulcerative colitis; 4% IC; p = 0.02). There was no gender effect on IBDA, 52% of the overall patients were girls. The mean age at first diagnosis of IBDA was identical for boys and girls (12.5+3.2). No difference was observed among the three studied ethnic groups, IBDA was found in 11% of African-American children diagnosed with IBD, 12% in Caucasians, and 15% in Hispanics (P=0.2). Arthritis was peripheral in 35 cases (64%), axial in 10 cases (18%), combined peripheral and axial in 8 cases (14.5%) and spondyliothesis in 2 cases (3.5%). In 17 cases (31%), arthritis was diagnosed at a mean 20 (+28.2) months prior to the diagnosis of IBD. The remaining 69% of the arthritis cases were diagnosed after a mean duration of IBD of 28 (+26.5) months. Conclusions: IBDA is a frequent extra-intestinal complication of IBD and usually diagnosed after the IBD onset. Crohns disease patients have a higher risk to develop IBDA than UC or IC. IBD may share environmental triggers, genetic susceptibilities or alterations in immune homeostasis with arthritis

Radiation exposure in patients with inflammatory bowel disease—primum non nocere?

Abstract Background. Patients with Inflammatory Bowel disease (IBD) are frequently exposed to diagnostic medical radiation for the diagnosis and evaluation of their disease. Despite increasing awareness of the potentially serious downstream effects, few studies have quantified radiation exposure in IBD patients. Methods. We conducted a retrospective review of 280 consecutive patients attending IBD clinics at our hospital. All incidences of diagnostic medical radiation from initial diagnosis until 30 June 2010 inclusive were recorded. The radiation dose for each procedure was obtained from standardized tables and the effective dose for each procedure calculated by multiplying this value by the number of procedures during the study period. The sum of doses received was the cumulative effective dose. Results. The mean and median cumulative effective radiation doses were 10.17 mSv and 4.12 mSv respectively. Crohns disease patients had significantly higher cumulative effective radiation exposure than UC patients (p < 0.001) with exposure exceeding 10 mSv in 58.3%, 25 mSv in 18.1% and 50 mSv in 6.3%, respectively. Smoking status, disease duration, and previous surgery were significant predictors for increased radiation exposure even after adjusting for other predictors. 47 small bowel magnetic resonance (MR) studies were undertaken as an alternative to ionising radiation in the last 3 years. Conclusions. Patients with IBD, particularly those with Crohns disease are exposed to significant amounts of diagnostic medical radiation in their lifetime. Clinicians must remain vigilant to the risk of cumulative radiation when evaluating these patients and consider non-ionizing alternatives such as intestinal ultrasound and MR imaging where clinically appropriate.

Information resources and inflammatory bowel disease.

We read with interest the excellent paper by Bernstein et al on the information needs and preferences of recently diagnosed patients with inflammatory bowel disease (IBD). An unprecedented explosion of information and technology has created an environment of increasing health consciousness and led to a paradigm shift in attitudes and perceptions of patients in the last two decades. Patients are increasingly turning to the Internet and other sources for their unmet and complex information needs. This important area remains under-researched. We report a recent British experience based on a prospective questionnaire-based study of 160 consecutive patients attending IBD clinics at our institution. Our study aimed at identifying the sources of information used by patients with IBD. Patient demographics, disease duration, characteristics, educational level, access and use of information technology, and other resources were recorded. Patients listed Internet sites they visited for IBD health-related information and graded the trust to information received on a visual analog scale (0, Not trustworthy; 10, Very trustworthy). Our Institutional Review Board reviewed the study, although formal ethical approval was not required. Eighty-five of the 160 patients who completed the study were female. The median age range was 45–64 years. Patient demographics and educational level are shown in Table 1. TABLE 1. Demographic Details and Educational Level (n 1⁄4 160).

Complementary and alternative medicine use in inflammatory bowel disease.

We read with interest the review by Hilsden et al on the use of complementary and alternative medicine (CAM) by patients with inflammatory bowel disease (IBD). An unprecedented explosion of information and technology has created an environment of increasing health consciousness and led to a paradigm shift in attitudes and perceptions of patients with IBD over the last two decades. Complementary medicine practices are often based on beliefs and practices that often have not been subjected to the rigorous processes of scientific research. The exclusion of CAM therapies from the realms of scientific medicine and consequent underrepresentation in teaching and research have led to a situation where commercial enthusiasm has outpaced scientific evidence, with bolder claims that now enter medical territory. Data on the use of CAM therapies in IBD are meanwhile limited. We conducted a prospective questionnaire-based study of 160 consecutive patients attending IBD clinics at our hospital. Our study aimed at identifying the use of nonprescription remedies or supplements and sources of such advice in patients with IBD. The study was approved by our Institutional Review Board. Clinical data including patient demographics, disease characteristics, educational level, access and use of information technology, and other resources were recorded. Previous or current use of vitamins (other than iron, B12, folic acid, and calcium supplementation advised by physicians for clinical reasons), herbal or alternative medicine, and food/nutritional supplements and the source of such advice were noted. Eighty-five of the 160 IBD patients were female. Ninety-one percent were Caucasian and the median age range was 45–64 years. Patient demographics and education level are shown in Table 1. Twenty-seven (16.9%) were members of Crohn’s and Colitis UK. Current or previous use of CAM was used in 62 (38.8%) and is shown in Table 2. We explored Internet use and sources of information relied upon by IBD patients using CAM medications, as shown in Tables 3 and 4. Recommendations for vitamin therapy came from the gastroenterologist (14), general practitioner (GP) (8), other health professionals (4), Internet (3), family and friends (5), other patients (1), and other unspecified sources (1). Recommendations for food/nutritional supplements came from the gastroenterologist (9), GP (4), other health professionals (5), family and friends (5), and the Internet (2). In contrast, herbal medicines were recommended by family and friends in eight patients, other patients (4), and the Internet in two patients, while alternative medicine was recommended by the gastroenterologist (2), GP (1), family and friends (1), and other unspecified sources in two patients. Our data demonstrate that the use of CAM therapy in IBD patients is probably increasing and supervising clinicians may not always be aware of this. The popular notion that all natural remedies are safe is not entirely

Mo1302 Incidental Diagnosis of Inflammatory Bowel Disease in a British Bowel Cancer Screening Cohort: A Multi-Centre Study

Introduction The UK Bowel Cancer Screening Programme (BCSP) was launched in 2006 and rolled out in successive waves covering the entire population of England and Wales. It screens individuals aged 60–69 years with a Faecal Occult Blood test (FOBt) followed by a screening colonoscopy if FOBt positive. Our study aimed to quantify the incidental diagnosis of Inflammatory Bowel Disease (IBD) through BCSP and patient outcome in this cohort. Methods We conducted a retrospective review of BCSP outcomes at our centres from launch in February 2007 until September 2011. Screening data included the number of patients invited, number screened (FOBt outcome “normal” or “abnormal”) and number of colonoscopies performed. In those with newly diagnosed IBD at colonoscopy confirmed on histology, clinical data including demographics, disease characteristics, treatment and outcome were obtained from case note and electronic patient record review. Results Of 378 424 patients invited, 172 244 were screened, representing an uptake of 45.52% and FOBt positivity of 2.71%. Colonoscopy was performed in 4195 patients (female 1761). Polyps were detected in 1870 (40.14%), cancer in 279 (5.99%) and 1216 (26.10%) had a normal examination. 83 patients had endoscopic appearance suggestive of IBD, confirmed at histology in 44. Seven patients were excluded as the diagnosis of colitis preceded the screening examination on case note review. Eleven of 37 incidental cases were female. Median age at diagnosis was 64. Twelve patients had Crohn9s disease (CD), 22 ulcerative colitis (UC) and three had IBD-type unclassified (IBDU). 31 patients had follow-up data available with a mean follow-up period of 24.4 months. Fifteen patients (48.4%) were asymptomatic at diagnosis. Mean values for CRP were 11.8, Hb 13.8, Platelets 278.5, and Albumin 42.9. Treatment included steroids (8), 5-ASA (25), immunomodulators (azathioprine 5; methotrexate 1) and anti-TNF (infliximab 2; adalimumab 1). None required surgery. Those requiring immunomodulators and/or anti-TNF therapy (male 4; female 1) had asymptomatic extensive UC, symptomatic left sided UC, symptomatic left-sided IBDU, symptomatic Crohn9s colitis and symptomatic stricturing terminal ileal CD at diagnosis. Conclusion An incidental diagnosis of IBD is not uncommon and with the advent of bowel cancer screening this number is set to increase. These patients may present an important model for study of early disease with novel insights and evolving treatment paradigms. Competing interests None declared.

Vitamin D status in Inflammatory Bowel Disease: Are clinicians seeing the light?

Dear Sir, We write to you in connection with the timely and excellent papers recently published in the JCC, concerning Vitamin D deficiency in Crohns disease (CD).1,2 There has been resurgent interest in recent years in the pro-hormone vitamin D beyond its classical role in bone metabolism, recognizing its effects and additional benefits in immune regulation, prevention of colorectal cancer and treatment of depression among others.2 Improving understanding of UV-radiation induced immune suppression via IL-4 and IL-10 induction and 1,25(OH)2-vitamin D induced dendritic cell maturation and cathelcidin production underpin its pivotal role in innate immunity with exciting …

Sa1896 Incidental Diagnosis of Inflammatory Bowel Disease in a British Bowel Cancer Screening Cohort: 6-Year Clinical Outcome Follow-Up of the First Reported Cohort

Introduction The UK Bowel Cancer Screening programme (BCSP) was launched in 2006 in England and Wales, screening individuals aged 60–69 years with a Faecal Occult Blood test (FOBt) followed by a screening colonoscopy if FOBt positive. We reported the first ever experience of incidental diagnosis of Inflammatory bowel disease (IBD) through screening in 2012. We present a 6 year follow-up of this cohort. Methods We conducted a retrospective case record review of clinical outcomes until 31 st December 2015 for patients diagnosed with IBD from the BCSP from April 2008 until September 2011. We reviewed their symptoms at diagnosis, treatment course and compared stage of disease at initial presentation to that at last follow-up. Results Between April 2008 and September 2011, 136,811 patients were invited to the BCSP and 67,485 were screened with a 49.33% uptake and FOBt positivity of 2.02%. Colonoscopy was performed in 1401 patients and 13 patients (3 female) were diagnosed with IBD. Of these, 6 patients had Ulcerative colitis (UC), 5 had Crohn’s disease (CD), 2 had IBD-unclassified (IBDU). One IBDU patient was subsequently re-classified as UC during follow-up. At diagnosis 7 (53.8%) patients were asymptomatic. An asymptomatic patient died of an unrelated cause, with follow-up data available for 12 patients. Median follow-up time was 80 months (range 39–87 months). Using the Montreal classification the distribution for UC included E1 (2), E2 (2) and E3 (2) and in CD showed L2 (7). Four CD patients had B1 disease and 1 had B2. Disease progressed in 2 patients and all 6 (100%) asymptomatic patients developed symptoms during follow-up. Treatment included steroids (10), 5 ASA (12), Azathioprine (6); Methotrexate (1) and Anti-TNF (Infliximab (2); Adalimumab (1)). Median time to immunomodulator was 29.5 months and to anti-TNF, 28.0 months. Mean CRP at diagnosis for those who progressed to Immunomodulator was 10.4 compared to 5.5 in those that didn’t and 15.5 in those that required biologics. A patient with symptomatic IBDU underwent subtotal colectomy 54 months after diagnosis but died 7 days post-operatively. Another patient died at 39 months from an unrelated cause. Conclusion Incidental diagnosis of IBD presents an important model for the study of early disease. A proportion of initially asymptomatic patients demonstrate disease progression with a rapid requirement for treatment escalation. Disclosure of Interest None Declared

Mesenchymal tumours, immunosuppression and inflammatory bowel disease: rare, real or fortuitous?

Dear Sir, A 41-year old Caucasian man with a 25-year history of ileocolonic Crohns and 15 pack-year smoking history was noted to have a rapidly growing non-tender swelling on the left thigh. He was treated with Azathioprine for 5–6 years previously and Methotrexate for 2 years, both stopped due to perceived lack of efficacy and deemed steroid dependant on Prednisolone 15 mg daily for 15 years. He was on a 5-ASA (2.4 g), calcium and vitamin D and B12 supplements. A single infusion of Infliximab in 2002 resulted in a partial clinical response. Surgical options were considered and declined by the patient but he required emergency right hemi-colectomy in 2005 for acute bleeding with a post-operative course complicated by intestinal perforation. …

Diagnostic medical radiation in inflammatory bowel disease: primum non-nocere?

Introduction Patients with inflammatory bowel disease (IBD) are frequently exposed to diagnostic medical radiation for the diagnosis and evaluation of their disease. Despite increasing awareness of the potentially serious downstream effects, few studies have quantified radiation exposure in IBD patients. Methods We conducted a retrospective review of 220 consecutive patients attending IBD clinics at our hospital. Clinical data including demographics, disease characteristics and therapy were obtained from case note and electronic patient record review. All incidences of diagnostic medical radiation from initial diagnosis until 30 June 2010 inclusive were recorded from case note and computerised radiology database system review. The radiation dose for each procedure was obtained from published tables from the Royal College of Radiologists, UK. Effective dose for each procedure was calculated by multiplying this value by the number of procedures during the study period. The sum of doses received was the cumulative effective dose. Results One hundred and one of the 220 IBD patients reviewed were female, 119 were male. The median age was 48 (range 17–88) and mean disease duration 10 years. One hundred and one patients had Crohn9s disease, 111 patients had ulcerative colitis and 8 patients had an indeterminate colitis. The mean and median cumulative effective radiation doses were 11.61 mSv and 7.21 mSv respectively. A cumulative radiation dose greater than 10 mSv was seen in 41.8% (92) patients and greater than 25 mSv in 13.2% (29) patients. In 9 patients the cumulative effective dose was greater than 50 mSv. Crohn9s disease was associated with a higher cumulative effective dose with exposure exceeding 10 mSv in 62.4%, 25 mSv in 22.8% and 50 mSv in 8.9% patients respectively. CT imaging accounted for 43% and barium studies for 32% of the total cumulative effective dose exposure. Thirty-nine of these patients had small bowel magnetic resonance (MR) studies in the last 2 years as an alternative to ionising radiation procedures. Conclusion Patients with IBD, particularly those with Crohn9s disease are exposed to significant amounts of diagnostic medical radiation in their lifetime. The increased risk of cancer from cumulative radiation coupled with the inherent risk of colorectal malignancy in long standing IBD and the potential for immunomodulator drugs such as azathioprine to increase the risk of cancers (eg lymphoma) is of great clinical and public health concern. Clinicians must remain vigilant to these risks when evaluating these patients and radiation exposure should be minimised and where possible alternatives such as intestinal ultrasound and MR imaging preferred.