Tarun Rai

Frequency and risk factors of low immunoglobulin levels in patients with inflammatory bowel disease

Background and aims: Inflammatory bowel diseases (IBD) are considered to be dysregulated, immune-mediated disorders; and immunosuppressive medications are the mainstay of their treatment. Clinically, we have often observed low serum immunoglobulin (Ig) levels in these patients. The aim of this study was to assess the frequency and risk factors of secondary humoral immunodeficiency in IBD patients. Methods: We conducted a cross-sectional study of eligible IBD patients with Crohn’s disease (CD), ulcerative colitis (UC), indeterminate colitis (IC) or restorative proctocolectomy with ileal pouch, who having serum Ig measured. Demographic and clinical variables were measured. Univariate and multivariate analyses were performed. Results: A total of 324 patients was included, with a mean age of 38.8 years and 158 (48.8%) being male. Low IgG, IgG1, IgA, and IgM were found in 22.7%, 23.4%, 7.9%, and 10.9% of patients, respectively. The shared risk factors for a low IgG or IgM level were increasing age [odds ratio (OR) = 1.13; 95% confidence interval (CI) 1.03–1.23 for low IgG level and OR = 1.33; 95% CI 1.15–1.56 for low IgM level] and hypoalbuminemia (OR = 1.83; 95% CI 1.01–3.33 for low IgG level and OR = 3.17; 95% CI 1.23–8.15 for low IgM level). In addition, thioprine use was associated with low IgA level (OR = 2.76; 95% CI 1.03–7.39). IBD disease duration was a risk factor for low IgG1 level (OR = 1.40; 95% CI 1.12–1.76). The presence of concurrent primary sclerosing cholangitis (OR = 0.064; 95% CI 0.007–0.60) and the use of biologics (OR = 0.16; 95% CI 0.033–0.79) were associated with normal IgG1 level. IgG level was lower in CD patients than that in UC/IC and ileal pouch patients (P = 0.042). IgG and IgA levels were elevated in patients with inflammatory conditions of the pouch (P = 0.01; P = 0.003, respectively). Conclusions: Low Ig level appears to be common in IBD patients. Increasing age, disease duration and hypoalbuminemia appeared to be risk factors. The findings may provide rationale for targeted therapy to boost humoral immunity in selected patients with IBD.

Adenoma detection rate in high-risk patients differs from that in average-risk patients

BACKGROUND Adenoma detection rates (ADRs) are established as quality targets in average-risk (AR) individuals undergoing colorectal cancer (CRC) screening colonoscopy. Little is known about the ADR in high-risk (HR) individuals undergoing index or surveillance colonoscopy. OBJECTIVE To determine and compare ADR in HR versus AR individuals undergoing colonoscopy. DESIGN AND SETTING Retrospective study, tertiary care center. PATIENTS AND INTERVENTION We reviewed records of 7357 patients who underwent colonoscopy by 66 multispecialty endoscopists at our institution during the period 2008 to 2009. Both screening and surveillance colonoscopies in AR and HR patients for CRC were studied. HR patients were further divided into 3 subgroups: those with a (1) personal history of polyps (PHP), (2) family history of polyps (FHP), and (3) family history of CRC (FHCRC). Multivariable logistic regression analysis was performed to evaluate differences in ADR between the groups after adjusting for possible confounders. MAIN OUTCOME MEASUREMENTS ADR in HR patients. RESULTS The study included 4141 patients, of whom 2170 were AR and 1971 were HR. Patients in the HR group were older (64.5 ± 9.1 years vs 59.1 ± 7.9 years, P < .001). HR patients were more likely to have adenomas (30.7% vs 25.6%, P < .001). Adenomas were detected more often in the proximal colon than in the distal colon (29.3% vs 21.0%, P < .001 and 22.8% vs 15.8%, P < .001, respectively). Patients with a PHP had the highest ADR (33.1%, P < .001). However, after adjusting for confounders, HR status was not found to be associated with ADR (odds ratio [OR] 1.2; 95% confidence interval [CI], 0.93-1.6; P = .15 for females and 0.93; 95% CI, 0.70-1.2; P = .61 for males). HR females were found to have a 40% greater likelihood of having proximal adenomas than AR females (1.4; 95% CI, 1.01-2; P = .04). LIMITATIONS Retrospective design, single tertiary center. CONCLUSIONS Patients with a PHP have a significantly higher ADR compared with AR patients. Defining a minimum target ADR for individuals with a PHP undergoing surveillance colonoscopy is important.

Effect of quality of bowel preparation on quality indicators of adenoma detection rates and colonoscopy completion rates

Background and aim: Adequate bowel preparation is important for safe and effective colonoscopy. Quality indicators (QI) for colonoscopy include achieving at least 95% completion rate and an adenoma detection rate (ADR) of at least 25% in average-risk men and 15% in average-risk women aged over 50. Our aim was to investigate the impact of bowel preparation on ADR and colonoscopy completion rates. Methods: This retrospective cohort study included patients who underwent colonoscopy between January 2008 and December 2009. The main outcome measurements were ADR and colonoscopy completion rates to the cecum. Results: A total of 2519 patients was included; 1030 (41.0%) had excellent preparation, 1145 (45.5%) good-, 240 (9.5%) fair-, and 104 (4.1%) poor preparation. Colonoscopy completion rates were significantly lower in patients with poor or fair preparation (72.1% and 75.4%, respectively) than in those with good and excellent preparation (99.7% and 99.9%, respectively; P < 0.001), and significantly lower than the QI of 95% (P < 0.001). ADR in men and women combined was similar in all four grades of preparation (excellent, good, fair and poor) at 24.2% vs. 26.8% vs. 32.1% vs. 22.1%, respectively; P = 0.06. All the groups had ADR above the QI (25% for men and 15% for women) with evidence of significantly higher ADR in the women with excellent or good preparation and in men with excellent, good or fair preparation. On multivariate analysis, male gender was significantly associated with increased ADR (P < 0.001), while the quality of bowel preparation did not influence ADR. Conclusions: Patients with fair and poor standards of preparation have significantly lower colonoscopy completion rates than those with excellent and good preparation. However, there was no difference in ADR between the different grades of preparation.

Primary sclerosing cholangitis and the risk of colon neoplasia in patients with Crohn’s colitis

Background and aim: Crohn’s colitis (CC) is associated with primary sclerosing cholangitis (PSC). However the risk of colon cancer or dysplasia in CC and PSC is unclear. Our aim was to study the risk of colon neoplasia in CC in patients with and without PSC. Methods: This is a nested, case-control cohort study of all patients diagnosed with concurrent CC and PSC, seen at the Cleveland Clinic between 1985 and 2012. Forty-three patients with both CC and PSC were compared with a random sample of 159 CC controls without PSC during the same period. Results: Seven (16.3%) of 43 CC patients with PSC developed colon cancer or dysplasia, compared with 22 (13.8%) of 159 controls (P = 0.98). Of seven colon neoplasia cases in the PSC group, 100% occurred proximal to the splenic flexure, compared with 50% (11/22) cases of colon neoplasia in controls occurring in the proximal colon (P = 0.001). Based on Cox regression analysis, male gender independently increased the risk of neoplasia [hazard ratio (HR) = 2.68; 95% confidence interval (CI) 1.30–5.54; P = 0.008], as did age at CC diagnosis (HR = 1.29; 95% CI 1.14–1.47; P < 0.001), while the use of azathioprine/6-mercaptopurine was protective (HR = 0.30; 95% CI 0.13–0.70; P = 0.005). The presence of PSC did not increase the risk for colon neoplasia (HR = 0.45; 95% CI 0.18–1.13; P = 0.09). Conclusions: CC patients with PSC appear not to be at increased risk of developing colon neoplasia. Among patients in our cohort with colon neoplasia and concurrent PSC, the neoplasia occurred in the proximal colon in all cases.