Sheldon Lidofsky

Risk of early surgery for Crohn's disease: implications for early treatment strategies.

OBJECTIVES:In this study we aimed to define the rate of early surgery for Crohns disease and to identify risk factors associated with early surgery as a basis for subsequent studies of early intervention in Crohns disease.METHODS:We assembled a retrospective cohort of patients with Crohns disease diagnosed between 1991 and 1997 and followed for at least 3 yr, who were identified in 16 community and referral-based practices in New England. Chart review was performed for each patient. Details of baseline demographic and disease features were recorded. Surgical history including date of surgery, indication, and procedure were also noted. Risk factors for early surgery (defined as major surgery for Crohns disease within 3 yr of diagnosis, exclusive of major surgery at time of diagnosis) were identified by univariate analysis. Multiple logistic regression was used to identify independent risk factors.RESULTS:Of 345 eligible patients, 69 (20.1%) required surgery within 3 yr of diagnosis, excluding the 14 patients (4.1%) who had major surgery at the time of diagnosis. Overall, the interval between diagnosis and surgery was short; one half of all patients who required surgery underwent operation within 6 months of diagnosis. Risk factors identified by univariate analysis as significantly associated with early surgery included the following: smoking; disease of small bowel without colonic involvement; nausea and vomiting or abdominal pain on presentation; neutrophil count; and steroid use in the first 6 months. Disease localized to the colon only, blood in the stool, use of 5-aminosalicylate, and lymphocyte count were inversely associated with risk of early surgery. Logistic regression confirmed independent associations with smoking as a positive risk factor and involvement of colon without small bowel as a negative risk factor for early surgery.CONCLUSIONS:The rate of surgery is high in the first 3 yr after diagnosis of Crohns disease, particularly in the first 6 months. These results suggest that improved risk stratification and potent therapies with rapid onset of action are needed to modify the natural history of Crohns disease.

Fatigue is highly associated with poor health‐related quality of life, disability and depression in newly‐diagnosed patients with inflammatory bowel disease, independent of disease activity

Fatigue is common in Crohns disease (CD) and ulcerative colitis (UC). Data on fatigue in newly diagnosed patients are unavailable.

Menstrual cycle changes in women with inflammatory bowel disease: a study from the ocean state Crohn's and colitis area registry.

Background:The effect of the inflammatory bowel diseases (IBD) on menstrual function is largely unknown. The aims of this study were to determine whether changes in menstrual function occur in the year before IBD diagnosis or in the initial years after diagnosis. Methods:Women aged 18 years and older in the Ocean State Crohns and Colitis Area Registry with at least 2 years of follow-up were eligible for this study. All patients were enrolled within 6 months of IBD diagnosis and followed prospectively. Menstrual cycle characteristics were retrospectively assessed. To assess for changes over time, general linear models for correlated data were used for continuous outcomes, and generalized estimating equations were used for discrete outcomes. Results:One hundred twenty-one patients were studied. Twenty-five percent of patients experienced a change in cycle interval in the year before IBD diagnosis and 21% experienced a change in the duration of flow. Among women with dysmenorrhea, 40% experienced a change in the intensity of their menstrual pain and 31% experienced a change in its duration. Overall cycle regularity increased over time. Quality of life was significantly lower in women without regular cycles across all time points. Conclusions:Changes in menstrual function occur frequently in the year before IBD diagnosis; therefore, screening for menstrual irregularities should be considered in women with newly diagnosed IBD. Patients can be reassured that cycles typically become more regular over time.

Body image dissatisfaction in patients with inflammatory bowel disease.

Background:Despite the fact that the inflammatory bowel diseases (IBD) and their treatments may affect physical appearance, the effect of IBD on body image is poorly understood. The aims of this study were to determine whether body image dissatisfaction (BID) changes over time in patients with IBD and to examine the demographic and disease-related variables associated with decreased body image. Methods:Adults aged 18 and above in the Ocean State Crohns and Colitis Area Registry with at least 2 years of follow-up were eligible for this study. All patients were enrolled within 6 months of IBD diagnosis and followed prospectively. BID was assessed using a modified version of the Adapted Satisfaction With Appearance questionnaire. Total Adapted Satisfaction With Appearance scores and 2 subscores were calculated. To assess for changes over time, general linear models for correlated data were used for continuous outcomes, and generalized estimating equations were used for discrete outcomes. Results:Two hundred seventy-four patients were studied. BID was found to be stable over time among men and women with IBD despite overall improvements in disease activity. No differences were found in BID according to IBD subtype. Female gender, greater disease activity, higher symptom burden, longer duration of steroid use, dermatologic and musculoskeletal manifestations of IBD, and ileocolonic disease location among patients with Crohns disease were associated with greater BID. Greater BID was associated with lower health-related quality of life. Conclusions:BID remains stable in an incident cohort of IBD despite improved disease activity and is associated with lower health-related quality of life.

Incidence of Crohn's Disease and Ulcerative Colitis in Rhode Island: Report from the Ocean State Crohn's and Colitis Area Registry.

Background:Studies describing the incidence of Crohns disease (CD) and ulcerative colitis (UC) are uncommon in the United States. We sought to determine the incidence of CD and UC in the state of Rhode Island. Methods:The Ocean State Crohns and Colitis Area Registry is a state-based inception cohort of patients newly diagnosed with inflammatory bowel disease (IBD) in Rhode Island. To confirm a diagnosis of CD, UC, or IBD unclassified (IBDU), the National Institute of Diabetes and Digestive and Kidney Diseases IBD Genetics Consortium criteria were applied in a review of medical records from gastroenterology practices located in the state of Rhode Island and adjacent to the Rhode Island border in Massachusetts and Connecticut. Using population-based data, we determined the statewide incidence of IBD in Rhode Island from 2008 to 2010. Results:A total of 971 Rhode Island residents were diagnosed with IBD, including 444 with CD, 486 with UC, and 41 with IBD unclassified from 2008 to 2010. The overall age- and sex-adjusted IBD incidence was 30.2 (95% confidence interval, 28.3–32.1) per 100,000 persons in this time frame with 13.9, 15.1, and 1.3 per 100,000 diagnosed with CD, UC, and IBD unclassified, respectively. Of the total incident cases in Rhode Island, 30% (n = 291) were enrolled in Ocean State Crohns and Colitis Area Registry for follow-up. Conclusions:The incidence of IBD in Rhode Island is higher than that previously reported by other population-based cohorts in the United States. Prospective follow-up of individuals enrolled in the community-based Ocean State Crohns and Colitis Area Registry cohort is ongoing.

Colorectal Kaposi Sarcoma in an Immunosuppressed Ulcerative Colitis Patient

A 49-year-old man with a long history of left-sided ulcerative colitis (UC), treated primarily with mesalamine and intermittent steroid enemas, developed recurrent flares associated with worsening bloody diarrhea. This resulted in the need for repeated courses of steroids (between 15 and 30 mg of prednisone daily) and the initiation of azathioprine. Although biologic therapy was recommended, the patient had declined this option due to concerns of possible side-effects and also refused surgical intervention. On routine surveillance colonoscopy, after almost 2 years of steroid-dependency, he was noted to have two inflammatory mass-like lesions, one in the proximal sigmoid colon and one in the distal rectum, both of which were biopsied (see Fig. 1). The biopsy results revealed spindle cell tumors with prominent capillary and slit-like vascular spaces, which tested positive on immunohistochemistry for human herpesvirus-8 (HHV-8). On physical examination, the patient had no cutaneous manifestations of Kaposi sarcoma (KS). His abdominal exam was notable for a palpable mass on digital rectal exam, 4 cm from the anal verge. The patient reported no risks factors for AIDS, tested negative for HIV, and had a normal complete blood count with differential. At that point, the patient agreed to surgery but was keen to have a restorative option and avoid a permanent stoma. Accordingly, he underwent an initial laparoscopic subtotal colectomy with end ileostomy. Pathological examination revealed focally active left-sided colitis with aphthous mucosal ulceration, mild chronic changes consistent with ulcerative colitis, and a focus of KS in the sigmoid colon submucosa (see Fig. 2). Over the next 2 months, the patient was successfully weaned from steroids and immunosuppressive agents. Proctoscopic surveillance over the next 6 months showed full resolution of his distal rectal KS lesion. Subsequently, a completion proctectomywith an ileal pouch to anal anastomosis in a double-stapled fashion was performed with creation of a temporary loop ileostomy. There was no evidence of KS on the rectum specimen on pathology. The ileostomy was ultimately reversed 3 months later to restore intestinal continuity. At 2year follow-up, the patient reported good pouch function with a normal pouch endoscopy.