Deepak, Parakkal

Abstract In this review, through a series of questions and answers, we explore the current approach to classifying patients with Crohn disease into low-risk (mild-moderate) and high-risk (moderate-severe) categories with the recommended treatment approaches per guidelines from the International Organization for the Study of Inflammatory Bowel Diseases, American Gastroenterological Association, the American College of Gastroenterology, and the European Crohn's and Colitis Organization detailed here. The development pipeline of potential therapies is also summarized. We also review key information from magnetic resonance enterography and pelvis imaging studies that the abdominal radiologist can communicate to a multidisciplinary treatment team that includes gastroenterologists and colorectal surgeons, with a goal of achieving optimal patient outcomes. Lastly, endoscopic and radiological treatment targets in a treat-to-target approach in Crohn disease are explored.

AbstractBackgroundGaps exist in our understanding of the clinical course of pouch-related disorders.MethodsWe evaluated baseline disease activity and longitudinal treatment patterns among patients with inflammatory conditions of the pouch.ResultsAmong 468 patients with an ileal pouch-anal anastomosis (IPAA), 94 (20%) had acute pouchitis, 96 (21%) had chronic pouchitis, and 192 (41%) had Crohn disease of the pouch. Following an IPAA, 38% of patients were treated with a biologic and 11% underwent inflammatory bowel disease- or bowel-related surgery.ConclusionsTreatment patterns after IPAA indicate that pouch-related disorders have a significant impact on individual patients and the healthcare system.

Abstract Background and Aims Our goal was to determine the importance of ileal inflammation at computed tomography or magnetic resonance enterography in Crohn’s disease patients with normal ileoscopy. Methods Patients with negative ileoscopy and biopsy within 30 days of CT or MR enterography showing ileal inflammation were included. The severity [0–3 scale] and length of inflammation within the distal 20 cm of the terminal ileum were assessed on enterography. Subsequent medical records were reviewed for ensuing surgery, ulceration at ileoscopy, histological inflammation, or new or worsening ileal inflammation or stricture on enterography. Imaging findings were classified as: Confirmed Progression [subsequent surgery or radiological worsening, new ulcers at ileoscopy or positive histology]; Radiologic Response [decreased inflammation with medical therapy]; or Unlikely/Unconfirmed Inflammation. Results Of 1471 patients undergoing enterography and ileoscopy, 112 [8%] had imaging findings of inflammation with negative ileoscopy, and 88 [6%] had negative ileoscopy and ileal biopsy. Half [50%; 44/88] with negative biopsy had moderate/severe inflammation at enterography, with 45%, 32% and 11% having proximal small bowel inflammation, stricture or fistulas, respectively. Two-thirds with negative biopsy [67%; 59/88] had Confirmed Progression, with 68%, 70% and 61% having subsequent surgical resection, radiological worsening or ulcers at subsequent ileoscopy, respectively. Mean length and severity of ileal inflammation in these patients was 10 cm and 1.6. Thirteen [15%] patients had Radiologic Response, and 16 [18%] had Unlikely/Unconfirmed Inflammation. Conclusion Crohn’s disease patients with unequivocal imaging findings of ileal inflammation at enterography despite negative ileoscopy and biopsy are likely to have active inflammatory Crohn’s disease. Disease detected by imaging may worsen over time or respond to medical therapy.

AbstractBackgroundAn association between inflammatory bowel disease (IBD) and obesity has been observed. Little is known about the effect of weight loss on IBD course. Our aim was to determine the impact of bariatric surgery on long-term clinical course of obese patients with IBD, either Crohn's disease (CD) or ulcerative colitis (UC).MethodsPatients with IBD who underwent bariatric surgery subsequent to IBD diagnosis were identified from 2 tertiary IBD centers. Complications after bariatric surgery were recorded. Patients were matched 1:1 for age, sex, IBD subtype, phenotype, and location to patients with IBD who did not undergo bariatric surgery. Controls started follow-up at a time point in their disease similar to the disease duration in the matched case at the time of bariatric surgery. Inflammatory bowel disease medication usage and disease-related complications (need for corticosteroids, hospitalizations, and surgeries) among cases and controls were compared.ResultsForty-seven patients met inclusion criteria. Appropriate matches were found for 25 cases. Median follow-up among cases (after bariatric surgery) and controls was 7.69 and 7.89 years, respectively. Median decrease in body mass index after bariatric surgery was 12.2. Rescue corticosteroid usage and IBD-related surgeries were numerically less common in cases than controls (24% vs 52%; odds ratio [OR], 0.36; 95% confidence interval [CI], 0.08–1.23; 12% vs 28%; OR, 0.2; 95% CI, 0.004–1.79). Two cases and 1 control were able to discontinue biologics during follow-up.ConclusionsInflammatory bowel disease patients with weight loss after bariatric surgery had fewer IBD-related complications compared with matched controls. This observation requires validation in a prospective study design.

Abstract Background Proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the surgical procedure of choice for medically refractory ulcerative colitis and familial adenomatous polyposis. While rare, a pouch volvulus can occur. We aimed to determine the frequency, presentation, and management approach of pouch volvulus in patients with IPAA. Methods A systematic search of published literature was performed by a medical reference librarian on 10 August 2018 and two independent reviewers identified relevant publications, extracted data, and assessed the methodological quality based on a validated tool. A retrospective review of the Mayo Clinic electronic medical records identified one case of pouch volvulus between January 2008 and August 2018. Results The frequency of pouch volvulus from one large published study reporting long-term outcomes of IPAA was 0.18% (3/1,700). A total of 22 patients (18 ulcerative colitis) were included (median age 32 years, 73% females). Median time to volvulus after IPAA was 36 months while median interval to volvulus diagnosis from symptom onset was 24 hours. Abdominal pain was the most commonly reported symptom (76%). The diagnosis was made primarily by abdominal computed tomography (13/17 patients, 76%). Endoscopic treatment was successful in 1 of 11 patients (9%). Surgery was performed in 20 patients and pouch-pexy and pouch excision were the most frequent surgical operations. A redo IPAA was performed in five patients (25%). Conclusion Pouch volvulus is a rare but serious complication of IPAA and should be suspected even in the absence of obstruction symptoms. Endoscopic treatment often fails and surgery is effective when performed early.

Abstract Background and Aims Inflammation of the pouch after ileal pouch-anal anastomosis (IPAA) can significantly impact quality of life and be difficult to treat. We assessed the effectiveness and safety of vedolizumab in Crohn’s disease (CD) of the pouch and chronic antibiotic-dependent or antibiotic-refractory pouchitis. Methods This was a retrospective, multicenter cohort study at 5 academic referral centers in the United States. Adult patients with endoscopic inflammation of the pouch who received vedolizumab were included. The primary outcome was clinical response at any time point. Secondary outcomes included clinical remission, endoscopic response, and remission. Univariate analysis and multivariate analysis were performed for the effect of the following variables on clinical response: fistula, onset of pouchitis less than 1 year after IPAA, younger than 35 years old, gender, previous tumor necrosis factor inhibitor-alpha use, and BMI >30. Results Eighty-three patients were treated with vedolizumab for inflammation of the pouch between January 2014 and October 2017. Median follow-up was 1.3 years (interquartile range 0.7–2.1). The proportion of patients that achieved at least a clinical response was 71.1%, with 19.3% achieving clinical remission. Of the 74 patients with a follow-up pouchoscopy, the proportion of patients with endoscopic response and mucosal healing was 54.1% and 17.6%, respectively. Patients who developed pouchitis symptoms less than 1 year after undergoing IPAA were less likely to respond to vedolizumab, even after controlling for other risk factors. Conclusions Vedolizumab is safe and effective in the management of CD of the pouch and chronic pouchitis. Further studies are needed to compare vedolizumab with other biologic therapies for pouchitis and CD of the pouch.