Ruud Beukers

The risk of inflammatory bowel disease-related colorectal carcinoma is limited: results from a nationwide nested case-control study.

OBJECTIVES:The risk for inflammatory bowel disease (IBD)-related colorectal cancer (CRC) remains a matter of debate. Initial reports mainly originate from tertiary referral centers, and conflict with more recent studies. Overall, epidemiology of IBD-related CRC is relevant to strengthen the basis of surveillance guidelines. We performed a nationwide nested case–control study to assess the risk for IBD-related CRC and associated prognostic factors in general hospitals.METHODS:IBD patients diagnosed with CRC between January 1990 and July 2006 in 78 Dutch general hospitals were identified as cases, using a nationwide automated pathology database. Control IBD patients without CRC were randomly selected. Clinical data were collected from detailed chart review. Poisson regression analysis was used for univariable and multivariable analyses.RESULTS:A total of 173 cases were identified through pathology and chart review and compared with 393 controls. The incidence rate of IBD-related CRC was 0.04%. Risk factors for IBD-related CRC were older age, concomitant primary sclerosing cholangitis (PSC, relative ratio (RR) per year duration 1.05; 95% confidence interval (CI) 1.01–1.10), pseudopolyps (RR 1.92; 95% CI 1.28–2.88), and duration of IBD (RR per year 1.04; 95% CI 1.02–1.05). Using immunosuppressive therapy (odds ratio (OR) 0.3; 95% CI 0.16–0.56, P<0.001) or anti-tumor necrosis factor (TNF) (OR 0.09; 95% CI 0.01–0.68, P<0.02) was protective.CONCLUSIONS:We found a limited risk for developing IBD-related CRC in The Netherlands. Age, duration of PSC and IBD, concomitant pseudopolyps, and use immunosuppressives or anti-TNF were strong prognostic factors in general hospitals.

Phenotype of inflammatory bowel disease at diagnosis in the Netherlands: a population-based inception cohort study (the Delta Cohort).

Background: To describe the clinical characteristics of inflammatory bowel disease (IBD) at diagnosis in The Netherlands at the population level in the era of biologics. Methods: All patients with newly diagnosed IBD (diagnosis made between January 1, 2006 and January 1, 2007) followed in 9 general hospitals in the southwest of the Netherlands were included in this population-based inception cohort study. Results: A total of 413 patients were enrolled, of which 201 Crohn’s disease (CD) (48.7%), 188 ulcerative colitis (UC) (45.5%), and 24 IBD unclassified (5.8%), with a median age of 38 years (range, 14–95). Seventy-eight patients with CD (38.8%) had ileocolonic disease and 73 patients (36.3%) had pure colonic disease. In 8 patients (4.0%), the upper gastrointestinal tract was involved. Nineteen patients with CD (9.5%) had perianal disease. Thirty-nine patients with CD (19.4%) had stricturing phenotype. Of the patients with UC and IBDU, 39 (18.4%) suffered from pancolitis and 61 (29%) from proctitis. Severe endoscopic lesions at diagnosis were seen in 119 patients (28.8%, 68 CD, 49 UC, and 2 IBDU), whereas 98 patients (23.7%) had severe histological disease activity. Thirteen patients (3.1%, 10 CD and 3 UC) had extraintestinal manifestations at diagnosis. Twenty-three patients (5.6%, 20 CD and 3 UC) had fistula at diagnosis. Conclusions: In this cohort, 31% of the patients with CD had complicated disease at diagnosis, 39% had ileocolonic disease, 9.5% had perianal disease, and in 4% the upper gastrointestinal tract was involved. Most patients with UC suffered from left-sided colitis (51%). Severe endoscopic lesions were reported in 34% of the patients with CD and 26% of the patients with UC. Three percent of the patients with IBD had extraintestinal manifestations.

The transferrin/log(ferritin) ratio: a new tool for the diagnosis of iron deficiency anemia

Abstract Background: Serum ferritin is the best single laboratory test to diagnose iron deficiency anemia (IDA). Ferritin levels <20 μg/L are highly specific for IDA, and ferritin levels >100 μg/L usually exclude IDA. However, ferritin concentrations between 20 and 100 μg/L are often inconclusive. The objective of this study was to improve the diagnosis of IDA when ferritin levels are inconclusive. Methods: We evaluated the predictive performance of classic (ferritin, mean corpuscular volume, transferrin and serum iron) and modern [reticulocyte hemoglobin content, serum transferrin receptor and soluble transferrin receptor (sTfR)/log(ferr)] iron status parameters to diagnose IDA in 2084 anemic, non-hospitalized patients. The results were validated in an independent cohort of 274 anemic patients. Results: In our study population, 29% (595 patients) of the patients had a ferritin level between 20 and 100 μg/L, hampering diagnosis of IDA. None of the classic or modern parameters was capable of completely separating the IDA population from the non-IDA population. However, using a new parameter, the transferrin/log(ferritin) ratio, the IDA and non-IDA populations can be completely separated. At a cut-off value of 1.70, the transferrin/log(ferritin) ratio indicates IDA in 29% of the patients with inconclusive ferritin levels. Conclusions: The transferrin/log(ferritin) ratio is a practical new tool that improves diagnosis of iron deficiency when ferritin levels are inconclusive.

Screening for gastrointestinal malignancy in patients with iron deficiency anemia by general practitioners: An observational study

Abstract Background. The prevalence of iron deficiency anemia (IDA) is 2–5% in men and postmenopausal women in the developed world. IDA is commonly caused by chronic gastrointestinal blood loss, and a thorough examination of the gastrointestinal tract must be standard practice. Objective. To retrospectively study endoscopic evaluations of patients from general practitioners diagnosed with IDA in a peripheral hospital laboratory in order to determine the cause of IDA and the number of gastrointestinal malignancies. Material and methods. We retrospectively evaluated all patients with IDA diagnosed in a peripheral hospital laboratory by the general practitioner in the region of our hospital from 1 January 2004 until 31 December 2005. We included women older than 50 and men 18 years and older without a history of IDA in the previous 2 years. Results. In 2 years, 287 patients were newly diagnosed with IDA in our hospital laboratory. Only 90 (31%) patients were endoscopically evaluated within 4 months. Gastrointestinal endoscopy revealed at least one lesion potentially responsible for blood loss in 41 of 90 (46%) patients. The most common lesions identified by gastroduodenal endoscopy were erosive esophagitis, gastritis and duodenitis (14%). Cancer was the most commonly detected lesion in the colon, accounting for 17 of 21 colonic lesions explaining IDA. In total, gastrointestinal malignancy was diagnosed in 2% of screened patients. Factors determining the decision for endoscopic screening were lower hemoglobin level, lower ferritin level and male gender. Conclusion. In our retrospective study of patients with IDA, only 31% received any form of endoscopic evaluation. In general practice, IDA is investigated suboptimally, and interventions other than the issuing of guidelines are needed to change practice.

Benefit of Earlier Anti-TNF Treatment on IBD Disease Complications?

BACKGROUND Anti-tumour necrosis factor [anti-TNF] treatment was demonstrated to have disease-modifying abilities in inflammatory bowel disease [IBD]. In this study, we aimed to determine the effect of anti-TNF treatment timing on IBD disease complications and mucosal healing [MH]. METHODS The following IBD-related complications were tested in relation to timing of anti-TNF therapy start in newly diagnosed IBD patients [n = 413]: fistula formation, abscess formation, extra-intestinal manifestations [EIM], surgery, referral to academic centre, and MH. RESULTS A total of 85 patients [21%] received anti-TNF (66 Crohns disease [CD], 16 ulcerative colitis [UC], 3 inflammatory bowel disease unclassified [IBDU]) of whom 57% [48 patients] were treated < 16 months after diagnosis. Patients receiving anti-TNF early [< 16 months] did not differ from patients receiving anti-TNF late [> 16 months] regarding gender, age, smoking status, and familial IBD. More importantly, patients receiving anti-TNF early did not suffer less IBD-related complications during follow-up as compared with patients started on anti-TNF late, nor was more MH observed. Similar results were obtained when anti-TNF treated patient were stratified more stringently, ie < 12 months [40 patients] vs >2 4 months [24 patients]. Cox regression analysis showed no beneficial correlations between anti-TNF timing and IBD-related complications. Anti-TNF treated patients achieving MH were 11 times less likely to develop EIMs compared with patients who did not achieved MH while on anti-TNF. CONCLUSIONS This study was unable to confirm a benefit of earlier anti-TNF treatment on IBD disease complications. This could be explained by more aggressive treatment earlier in disease, resulting in fewer IBD complications. However, it seems more likely that inappropriate selection of patients for therapy leads to suboptimal treatment and subsequently suboptimal outcome.

Clinical Course of Nodular Regenerative Hyperplasia in Thiopurine Treated Inflammatory Bowel Disease Patients

&NA; Nodular regenerative hyperplasia (NRH) is a poorly understood liver condition, which is increasingly recognized in thiopurine‐treated patients with inflammatory bowel disease (IBD).1 It is difficult to establish an optimal approach to NRH patients, because its manifestations are highly variable (from asymptomatic to symptoms of noncirrhotic portal hypertension [NCPH]) and the prognosis is unknown.2 The aim of this study was to identify NRH cases in IBD patients treated with azathioprine, mercaptopurine, and/or thioguanine, and to describe its clinical course.

P528 Complications of IBD in the anti-TNF era: reason for optimism?

P528 Complications of IBD in the anti-TNF era: reason for optimism? V. Nuij1 *, G. Fuhler1, A. Edel1, R. Ouwendijk2, M. Rijk3, R. Beukers4, R. Quispel5, A. van Tilburg6, T. Tang7, H. Smalbraak8, K. Bruin9, F. Lindenburg10, L. Peyrin-Biroulet11, C.J. van der Woude1. 1ErasmusMC University Medical Center, Gastroenterology and Hepatology, Rotterdam, Netherlands, 2Ikazia Hospital, Gastroenterology and Hepatology, Rotterdam, Netherlands, 3Amphia Hospital, Gastroenterology and Hepatology, Breda, Netherlands, 4Albert Schweitzer Hospital, Gastroenterology and Hepatology, Rotterdam, Netherlands, 5Reinier de Graaf Gasthuis, Gastroenterology and Hepatology, Rotterdam, Netherlands, 6Sint Franciscus Gasthuis, Gastroenterology and Hepatology, Rotterdam, Netherlands, 7 IJsselland Hospital, Gastroenterology and Hepatology, Capelle aan den IJssel, Netherlands, 8Lievensberg Hospital, Internal Medicine, Bergen op Zoom, Netherlands, 9Tweesteden Hospital, Gastroenterology and Hepatology, Tilburg, Netherlands, 10Franciscus Hospital, Gastroenterology and Hepatology, Roosendaal, Netherlands, 11Nancy University Hospital, Universite de Lorraine, Gastroenterology and Hepatology, Vandoeuvre-les-Nancy, France

Su1234 Microscopic Severity Is Related to Earlier Surgery in Newly Diagnosed CD Patients: Results From the DELTA Cohort

Background: Adherence to therapy is a key factor when analyzing the efficacy of a given treatment in clinical practice. Inflammatory bowel disease (IBD) is associated with high rates of non-compliance to therapy. The aim of our study was to assess the prevalence of non-adherence to treatment among patients with IBD and evaluate which factors could be related. Methods: One hundred consecutive IBD outpatients (60% with Crohn’s disease and 40% with Ulcerative Colitis) filled in an anonymous questionnaire, which included information about demography, duration of the disease, specific therapy for IBD, and data possibly related to extent of non-adherence to treatment. Statistics were performed with SPSS v.18.0. For continuous variables, mean and standard deviation were calculated and for categorical variables percentages were provided. Categorical variables were compared with Fisher’s exact test. A p value <0.05 was considered statistically significant. Results: Overall non-adherence was reported by 38% (n = 38) of patients. 78.9% (n = 30) of patients reported unintentional non-adherence and 55.3% (n = 21) forgot at least one dose per week. Non-adherence was statistically associated with: high educational level (p < 0.001); the perception that medical therapy isn’t effective enough (p < 0.001); therapy with corticosteroids (p = 0.019); recent diagnosis (p = 0.020); and young age (p = 0.007). On the other hand, different factors such as gender (p = 0.668), disease type (p = 0.211), smoker status (p = 0.626), occurrence of minor side effects (p = 0.217), use of alternative medicine (p = 1.000), previous IBD-related admissions (p = 0.676) or previous surgeries (p = 0.794) did not correlate with the degree of adherence. Conclusions: The overall non-adherence is relatively high among IBD patients and gastroenterologist’s attention should be focused on it. Risk factors of non-compliance must be evaluated at each follow-up visit to improve adherence to therapy. P431 Microscopic severity is related to earlier surgery in newly diagnosed CD patients: results from the DELTA cohort V. Nuij1 *, C. Looman2, M. Rijk3, R. Beukers4, R. Ouwendijk5, R. Quispel6, A. van Tilburg7, T. Tang8, H. Smalbraak9, K. Bruin10, F. Lindenburg11, L. Peyrin-Biroulet12, C.J. van der Woude13. 1Erasmus Medical Center, Gastroenterology and Hepatology, Rotterdam, Netherlands, 2Erasmus Medical Center, Public Health, Rotterdam, Netherlands, 3Amphia Hospital, Gastroenterology & Hepatology, Breda, Netherlands, 4Albert Schweitzer Hospital, Gastroenterology & Hepatology, Dordrecht, Netherlands, 5Ikazia Hospital, Gastroenterology & Hepatology, Rotterdam, Netherlands, 6Reinier de Graaf Hospital, Gastroenterology and Hepatology, Delft, Netherlands, 7Sint Franciscus Gasthuis, Gastroenterology & Hepatology, Rotterdam, Netherlands, 8IJsselland Hospital, Gastroenterology & Hepatology, Capelle aan den IJssel, Netherlands, 9Lievensberg Hospital, Internal Medicine, Bergen op Zoom, Netherlands, 10Tweesteden Hospital, Gastroenterology & Hepatology, Tilburg, Netherlands, 11Franciscus Hospital, Gastroenterology and Hepatology, Roosendaal, Netherlands, 12Nancy University Hospital, Universite de Lorraine, Gastroenterology and Hepatology, Vandoeuvre-les-Nancy, France, 13Erasmus Medical Center, Department of Gastroenterology & Hepatology, Rotterdam, Netherlands

The solitary air-filled abdominal mass: remember the colonic duplication cyst

Abstract Diverticulosis may have a diverse set of complications and comorbidity, one of which is a giant diverticulum. This single air-filled bubble, with a diameter of 4 cm or more, can evolve from a pseudodiverticulum by two pathways: by secondary infection or by means of a so-called ball-valve mechanism. Perforation of an infected pseudodiverticulum into a colonic duplication cyst can result in the same clinical and radiological findings. In our case report, we present a patient with a duplication cyst of the colon, which is rarely found at other locations than the small bowel.