The Burden of Vaccine-preventable Diseases in Patients With Inflammatory Bowel Disease.

BACKGROUND: Patients with inflammatory bowel disease (IBD) are at an increased risk of infections, including vaccine-preventable diseases (VPDs). The aim of this study was to explore the inpatient prevalence of VPD in patients with IBD, as well as inpatient outcomes. METHODS: Retrospective study using the 2013-2017 Nationwide Inpatient Sample databases. All patients 18 years of age or older with International Classification of Diseases, Ninth and 10th Revisions , Clinical Modification (ICD-9/10 CM) codes for IBD were included, as well as patients with VPDs as a principal diagnostic code. The primary outcome was the occurrence and odds of VPD in patients with IBD compared with patients with no IBD. Secondary outcomes were inpatient mortality, morbidity, and economic burden compared with patients with IBD and non-vaccine-preventable infections (VPIs). Multivariate regression yielded adjusted odds ratios. RESULTS: Of 1,622,245 (0.9%) patients with a diagnosis of IBD, 3560 (0.2%) had associated VPDs, while 131,150 patients had non-VPI (8.1%). The most common VPDs were influenza, herpes zoster (HZ), pneumococcal pneumonia, and varicella. Only HZ and varicella had increased odds of occurrence in patients with IBD of all ages. Patients with IBD 65 years of age or older had increased odds of VPD compared with patients under 65 years. Patients with IBD and associated VPD had higher odds of intensive care unit stay, systemic inflammatory response syndrome, and multiorgan failure compared with patients with IBD and non-VPI. CONCLUSIONS: VPDs represent a clinically relevant cause of infectious disease-related hospital admissions in patients with IBD. Patients with IBD are at increased risk for hospitalization due to HZ and varicella. Those hospitalized for VPD have higher morbidity compared with patients with IBD and non-VPI. These findings echo the importance of instituting optimal immunization schedules in patients with IBD, particularly in patients 65 years or older.

Decreased Risk of Colorectal Cancer after Colonoscopy in Patients 76-85 Years Old in the United States.

BACKGROUND/AIMS: The benefits of colonoscopy in reducing colorectal cancer (CRC) risk for patients over 75 years are controversial. We aimed to determine whether colonoscopy use is associated with a decreased risk of CRC in patients 76-85 years old in the United States (US). PATIENTS AND METHODS: All patients in the Medicare 5% random sample of the Surveillance, Epidemiology and End Results-Medicare linked database 76-85 years old at outpatient colonoscopy between January 1, 1998 and December 31, 2002 were identified. Using the Kaplan-Meier method, we estimated the cumulative incidence of CRC in the above-mentioned colonoscopy group and compared with the control group of patients without colonoscopy. All patients were followed until diagnosis of CRC or carcinoma in situ, death or December 31, 2005. The multivariate Cox proportional hazards model was used in statistical analysis. CRC was separated by location into distal vs. proximal CRC in subgroup analysis. RESULTS: Of 5,701 patients in the colonoscopy group, 37 (0.65%) patients were diagnosed with CRC, compared to 379 (1.55%) out of 24,437 patients in the control group (p < 0.001). The cumulative incidences of distal and proximal CRC were lower in the colonoscopy group compared to those in the control group (5-year distal CRC: 0.26 vs. 0.77%; 5-year proximal CRC: 0.43 vs. 0.79%, both p < 0.05). In multivariate Cox regression, colonoscopy was associated with decreased risk of all CRC (hazard ratio ((HR) 0.42, 95% CI 0.28-0.65), distal CRC (HR 0.36, 95% CI 0.18-0.70), and proximal CRC (HR 0.53, 95% CI 0.30-0.92)). CONCLUSION: Among patients 76-85 years old in the United States, colonoscopy use was associated with decreased risks of both distal and proximal CRC, with a smaller risk reduction in distal colon. Due to inherent limitations associated with our retrospective design, future prospective studies are needed to validate these findings.

Double-balloon enteroscopy and outcomes in patients older than 80.

BACKGROUND: double-balloon enteroscopy (DBE) is becoming more commonly used for investigation of small bowel pathology. Currently, there are limited data to describe its safety and efficacy in the population over age 65. AIM: to investigate the indications, findings and outcomes of DBE performed in patients older than 80, as well as the correlation between DBE and prior capsule endoscopy (CE) findings. METHODS: we retrospectively reviewed our large DBE database, including procedures from January 2006 to September 2012. Patients aged 80 or older at the time of DBE were included in the study. The indications, findings, outcomes and diagnostic yield of DBE were calculated by frequency analysis. RESULTS: two hundred and fifteen DBEs were performed in 130 patients aged 80 or older. The mean age was 83.6 ± 3.03 years (range: 80-94). Twelve patients (9.2%) were assigned an American Society of Anaesthesiologists score of II prior to procedure, 102 patients (78.4%) were assigned a score of III and 16 patients (12.3%) were given a score of IV. The most common indication for DBE was obscure gastrointestinal bleeding (N = 204, 94.9%). One hundred and fourteen patients (87.7%) underwent CE prior to DBE, and correlation between findings of CE and DBE occurred in 74.6% of these patients. The overall diagnostic yield of DBE was 77.2% (N = 166). There were no immediate post-procedural complications or failed procedures. CONCLUSION: DBE is a safe and effective technique for investigation of the small bowel in patients aged 80 and older. Age alone should not be a contraindication to performing DBE when clinically indicated.

Use of surveillance colonoscopy in medicare patients with inflammatory bowel disease prior to colorectal cancer diagnosis.

BACKGROUND: Patients with longstanding inflammatory bowel disease (IBD) involving large intestine proximal to rectum are considered to be at increased risk for colorectal cancer (CRC). One prior study showed low utilization of surveillance colonoscopy in patients with ≥ 8 years of ulcerative colitis (UC) in the USA. AIMS: To study use of surveillance colonoscopy among Medicare beneficiaries with IBD in the 2-year period prior to CRC diagnosis. DATA AND METHODS: Our study sample included Medicare beneficiaries in the SEER-Medicare-linked database who were diagnosed with CRC during 2001-2005 and had ≥ 3 physician visits with ICD-9 diagnosis code for IBD prior to CRC diagnosis. Medicare beneficiaries aged >85 years without Part B coverage or enrolled in HMOs were excluded. Colonoscopy performed within 6-30 months prior to CRC diagnosis was defined as surveillance colonoscopy. The χ² test and multivariate logistic regression were used in statistical analysis. RESULTS: Of 241 Medicare beneficiaries with IBD and diagnosed with CRC, 92 (38%) patients underwent ≥ 1 surveillance colonoscopy in the 2 years prior to cancer diagnosis. The use of surveillance colonoscopy was similar between Crohn's disease (28/86, 33%) and UC (64/155, 41%). In multivariate logistic regression, older age (odds ratio (OR) 0.97, 95% confidence interval (CI) 0.94-0.99) was negative associated with surveillance colonoscopy use and personal history of colon polyp (OR 2.73, 95% CI 1.09-6.87) was positively associated with surveillance colonoscopy use. CONCLUSIONS: Use of surveillance colonoscopy was low among Medicare beneficiaries with IBD in the 2 years prior to CRC diagnosis.

Intussusception of a small bowel large B-cell lymphoma.

Gastrointestinal tumors can rarely cause intestinal intussusception. Herein, we describe a 74 year-old male with a presumed diagnosis of Crohn's disease who presented with persistent symptoms refractory to medical management. Radiography demonstrated small bowel intussusception into the cecum. Lower endoscopy with biopsy diagnosed small bowel large Bcell lymphoma. Management included laparoscopic ileocecectomy and adjuvant R-CHOP chemotherapy. Long term outcomes of small bowel large B-cell lymphoma are related to disease stage at diagnosis, and average close to 75 %.

Racial/Ethnic and regional differences in the prevalence of inflammatory bowel disease in the United States.

BACKGROUND: The magnitude of racial/ethnic and regional differences in the prevalence of inflammatory bowel disease (IBD) in the United States remains largely unknown. AIMS: To estimate differences in the prevalence of IBD by race/ethnicity and region. METHODS: The Medical Expenditure Panel Survey, a nationally representative survey of US households and medical conditions, was used. A multivariate logistic model was used in statistical analysis. RESULTS: Among 202,468 individuals surveyed during 1996-2007, 316 were diagnosed with IBD (26 Blacks, 21 Hispanics, and 5 Asians). The prevalence of IBD was higher in Whites [Crohn's disease: 154; ulcerative colitis (UC): 89] than Blacks (Crohn's disease: 68; UC: 25), Hispanics (Crohn's disease: 15; UC: 35), and Asians (Crohn's: 45; UC: 40) (all p < 0.05, except for UC in Asians). The differences in Crohn's disease between Whites and minorities and the difference in UC between Whites and Blacks remained significant in multivariate analysis. In multivariate analysis, there was no regional difference in the prevalence of Crohn's disease, but the prevalence of UC was higher in the Northeast than the South (p < 0.05). CONCLUSIONS: There were significant racial/ethnic differences in the prevalence of IBD in the USA. The underlying etiology of these differences warrants additional research.

Increased odds of interval left-sided colorectal cancer after flexible sigmoidoscopy compared with colonoscopy in older patients in the United States: a population-based analysis of the SEER-Medicare linked database, 2001-2005.

OBJECTIVES: To compare the proportion of interval left-sided colorectal cancers (CRCs) after flexible sigmoidoscopy vs colonoscopy in older patients and to identify factors associated with interval CRC. PATIENTS AND METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare-linked database, we studied patients 67 years or older with left-sided CRC who had at least one lower endoscopy performed within the previous 36 months between July 1, 2001, and December 31, 2005. The CRCs diagnosed within 6 months of lower endoscopy were defined as detected CRCs; CRCs diagnosed 6 to 36 months after lower endoscopy were defined as interval CRCs. The proportion of interval CRCs was calculated as number of interval CRCs divided by number of detected and interval CRCs. The χ(2) test and a multivariate logistic regression model were used in the statistical analysis. RESULTS: Of 15,484 older patients with left-sided CRC, the proportion of interval CRCs after flexible sigmoidoscopy was 8.8% compared with 2.5% after colonoscopy (P<.001). This difference was similar across left colon locations and largest in the descending colon (17.1% vs 3.5%; P<.001). In multivariate logistic regression, the odds of interval CRC after flexible sigmoidoscopy was 3 times as high as that after colonoscopy (odds ratio, 3.52; 95% CI, 2.66-4.65). CONCLUSION: In older patients with left-sided CRC, the odds of interval CRC after flexible sigmoidoscopy was 3 times as high as that after colonoscopy. Whether this finding reflects differences in bowel preparation quality, sedation use, or depth of insertion warrants future research.

Risk of colorectal cancer after colonoscopy compared with flexible sigmoidoscopy or no lower endoscopy among older patients in the United States, 1998-2005.

OBJECTIVE: To determine whether the risk of colorectal cancer (CRC) decreases after colonoscopy compared with sigmoidoscopy or no lower endoscopy. PATIENTS AND METHODS: Patients 67 to 80 years old in the 5% random Medicare sample of the Surveillance, Epidemiology and End Results and Medicare-linked database were grouped into those who underwent colonoscopy or flexible sigmoidoscopy from January 1, 1998, through December 31, 2002, and those who did not undergo lower endoscopy. We excluded patients with inflammatory bowel disease, history of colon polyps, or family history of CRC. All patients were followed up until the diagnosis of CRC or carcinoma in situ, death, or December 31, 2005. The risk of CRC after colonoscopy was compared with the risk after sigmoidoscopy or no lower endoscopy. The multivariate Cox proportional hazards model was used in statistical analysis. RESULTS: In the colonoscopy group (n=12,266), 58 CRCs (0.5%) were diagnosed during follow-up compared with 66 CRCs (1.0%) in the sigmoidoscopy group (n=6402) and 634 (1.5%) in the control group (n=41,410) (all P<.001). In the sigmoidoscopy group, 771 patients (12.0%) underwent colonoscopy within the next 12 months. In multivariate Cox regressions, colonoscopy was associated with a decreased risk of distal CRC (hazard ratio [HR], 0.266; 95% CI, 0.161-0.437) and proximal CRC (HR, 0.451; 95% CI, 0.305-0.666); sigmoidoscopy was associated with a decreased risk of distal CRC (HR, 0.409; 95% CI, 0.207-0.809) but not proximal CRC. CONCLUSION: Among older patients, the risk of distal CRC decreased after both colonoscopy and sigmoidoscopy; the risk of proximal CRC decreased after colonoscopy but not sigmoidoscopy.

Small bowel tumors discovered during double-balloon enteroscopy: analysis of a large prospectively collected single-center database.

BACKGROUND: The emergence of capsule endoscopy and double-balloon enteroscopy (DBE) has greatly enhanced the management of small bowel tumors (SBTs). DBE is particularly useful as a diagnostic modality because it allows for direct investigation of the gastrointestinal lumen, yet little data exist regarding its clinical efficacy. AIM: : To determine the diagnostic yield of DBE in detection of SBTs. METHODS: We restrospectively reviewed our large prospectively collected DBE database from September 2005 to May 2012. Patients who were diagnosed with SBTs by DBE were included in the study. The diagnostic yield of DBE in detection of SBTs was calculated by frequency analysis. RESULTS: A total of 1106 patients underwent 1652 DBE procedures. Of these patients, 134 (12.1%) were found to have an SBT. The majority (56.7%) of patients diagnosed with SBT were male, and the average age at the time of diagnosis was 64 years (SD±14 y). Indications for performing DBE included suspected mass lesion in 54.5% (73/134) of SBT patients, obscure gastrointestinal bleeding in 26.9% (36/134), and overt gastrointestinal bleeding in 14.9% (20/134). The most common SBTs identified were: carcinoid (26/134, 19.4%), hamartoma (14/134, 10.4%), inflammatory polyp (11/134, 8.2%), gastrointestinal stromal tumor (10/134, 7.5%), and lymphoma (10/134, 7.5%). CONCLUSIONS: DBE is a valuable tool in the evaluation of SBTs. The incidence of SBTs in our patient population was significantly higher than the generally accepted incidence for the overall population, but was comparable with other similar studies. Carcinoid tumor was the most common SBT identified, and was most often seen in the ileum.

Rate of early/missed colorectal cancers after colonoscopy in older patients with or without inflammatory bowel disease in the United States.

OBJECTIVES: Patients with inflammatory bowel disease (IBD) have an increased risk for colorectal cancer (CRC). Previous studies on early/missed CRCs after colonoscopy excluded IBD patients. The aim of this study was to compare the rate of early/missed CRCs after colonoscopy among IBD and non-IBD patients, and identify factors associated with early/missed CRCs. METHODS: All patients in the Surveillance, Epidemiology and End-Results Medicare-linked database who were 67 years or older at colonoscopy during 1998-2005 and those who were subsequently diagnosed with CRC within 36 months were identified. CRCs diagnosed within 6 months of colonoscopy were categorized as detected CRCs; CRCs diagnosed 6-36 months after colonoscopy were categorized as early/missed CRCs. The rate of early/missed CRCs was calculated as number of early/missed CRCs divided by number of detected and early/missed CRCs. The χ(2) test and multivariate logistic regression were used in statistical analysis. RESULTS: Of 55,008 CRC patients (304 Crohn's disease; 544 ulcerative colitis (UC)), the rate of early/missed CRCs was 5.8% for non-IBD patients, 15.1% for Crohn's, and 15.8% for UC (P<0.001). Compared with older non-IBD patients, early/missed CRCs among older IBD patients were less likely right-sided (both P<0.05). In multivariate logistic regression, the risk of early/missed CRCs was three times as high for IBD patients (Crohn's odds ratio (OR), 3.07; 95% confidence interval (CI) 2.23-4.21; UC OR, 3.05; 95% CI, 2.44-3.81). Sensitivity analyses confirmed the robustness of this finding. CONCLUSIONS: Older IBD patients had a higher rate of early/missed CRCs after colonoscopy. Our finding supports intensive surveillance colonoscopy for older IBD patients as recommended by guidelines.

Food poisoning and diarrhea: small intestine effects.

Transmission of foodborne pathogens remains a growing concern despite increasing public awareness and heightened federal measures to control infection. Over 76 million cases of acute diarrhea secondary to ingestion of contaminated food occur annually in the United States. Fortunately, most are self-limited and resolve without therapy, but up to 6000 deaths occur on an annual basis. Mechanisms of infection include consumption of a preformed toxin, formation of toxin following ingestion, and direct invasion of intestinal epithelial cells by the infecting organism. Diagnosis is most often confirmed through an accurate history, as cultures are often of low yield.

Inflammatory bowel disease in the elderly.

This article reviews the epidemiology, clinical manifestations, diagnosis, prognosis, and treatment of inflammatory bowel disease (IBD), which will grow in prevalence as the population ages. Prognosis of late-onset ulcerative colitis (UC) is generally similar to that of early-onset UC, whereas in Crohn disease it is probably better because of a tendency for colonic involvement. Disease complications are related more to the duration of the inflammatory bowel disease than the subject's current age. The diagnosis in elderly patients can be challenging due to the large number of conditions that mimic IBD on radiologic, endoscopic, and histologic testing. Distinguishing these conditions from IBD will significantly alter prognosis and treatment. Complications related to IBD and its treatment are common and must be recognized early to limit their impact in a vulnerable elderly population.

Intestinal ischemia in the elderly.

Mesenteric ischemia in the elderly is an uncommon but often fatal disorder for which the prognosis depends entirely on the speed and accuracy of the diagnosis. A high index of suspicion is required as the early signs and symptoms, at a time when ischemic changes are reversible, are typically nonspecific or absent. This article reviews the clinical spectrum of mesenteric ischemia in the elderly with particular emphasis on the varied presentations, evaluation, and management of ischemic disorders of the intestines.

Immunomodulators are associated with a lower risk of first surgery among patients with non-penetrating non-stricturing Crohn's disease.

OBJECTIVES: Early immunomodulator therapy may alter the natural history of Crohn's disease in certain patients. We determined whether immunomodulator use was associated with a lower risk of first surgery among patients with non-stricturing non-penetrating Crohn's disease. METHODS: A total of 159 consecutive patients with non-penetrating non-stricturing Crohn's disease from 1994 to 2005 were retrospectively identified and followed from diagnosis to either first surgery (surgery group) or last clinic follow-up (medication group) in a historical cohort analysis. Immunomodulator use, duration, disease location, age at diagnosis, smoking, family history, and decade of diagnosis were compared. Cox proportional hazards models were adjusted for propensity score to determine whether immunomodulator use lasting >6 months decreased the risk of first surgery and whether duration of therapy affected risk. RESULTS: The median duration of follow-up was similar (6.0 vs. 5.5 years), age at diagnosis 10 years earlier, and isolated colonic disease three times less common (18 vs. 49%) in the surgery group as compared with the medication group. Immunomodulator use increased with time but overall was less common in the surgical group (24 vs. 48%). In the multivariate Cox proportional hazards model immunomodulator use was associated with a lower risk of surgery (hazard ratio, 0.41; 95% confidence interval 0.21-0.81) after adjustment for propensity score. Similarly, risk of surgery declined with duration of use. CONCLUSIONS: Immunomodulator use is associated with a decreased risk of first surgery among patients with non-stricturing non-penetrating CD. Early immunomodulator therapy may be beneficial in preventing first surgery in this population that has yet to develop penetrating or fistulizing complications.

Celiac disease.

As many as one in every 100 to 200 persons in the United States has celiac disease, a condition resulting from an inappropriate immune response to the dietary protein gluten. The manifestations of celiac disease range from no symptoms to overt malabsorption with involvement of multiple organ systems and an increased risk of some malignancies. When celiac disease is suspected, initial testing for serum immunoglobulin A (IgA) tissue transglutaminase (tTG) antibodies is useful because it offers adequate sensitivity and specificity at a reasonable cost. A positive IgA tTG result should prompt small bowel biopsy with at least four tissue samples to confirm the diagnosis. However, 3 percent of patients with celiac disease have IgA deficiency. Therefore, if the serum IgA tTG result is negative but clinical suspicion for the disease is high, a serum total IgA level may be considered. Screening of asymptomatic patients is not recommended. The basis of treatment for celiac disease is adherence to a gluten-free diet, which may eliminate symptoms within a few months. Patients should also be evaluated for osteoporosis, thyroid dysfunction, and deficiencies in folic acid, vitamin B12, fat-soluble vitamins, and iron, and treated appropriately. Serum IgA tTG levels typically decrease as patients maintain a gluten-free diet.

Oral mesalamine and clinical remission are associated with a decrease in the extent of long-standing ulcerative colitis.

OBJECTIVE: To compare colonoscopy alone with surveillance biopsy for the determination of anatomic extent in long-standing ulcerative colitis (UC). To assess the influences of mesalamine use and clinical disease activity on the change of histologic extent with time. MATERIALS AND METHODS: Disease extent (proctosigmoiditis, left-sided colitis, or pancolitis) measured by colonoscopy and surveillance biopsy was compared among 212 consecutive patients with long-standing UC. Among the 102 patients who had 2 consecutive colonoscopies with surveillance biopsies, the following influences on change in histologic extent were determined: disease activity, mesalamine use, age at disease onset, folic acid, corticosteroid and azathioprine/6-mercaptopurine use, and time between colonoscopies. RESULTS: Agreement between gross and microscopic findings was poor (kappa = 0.39). Colonoscopy underestimated and overestimated extent in 25.9% and 8.5%, respectively. Microscopic distribution between consecutive colonoscopies remained the same in 60.8%. Where distribution changed, an increase was twice as common as a decrease in extent. There was no difference in age at onset, time between colonoscopies, or disease duration among those with an increase, decrease, or no change in extent. Clinical remission and oral mesalamine were independently associated with 10.7 and 5.8 times the odds of a decrease in disease extent, respectively. Folic acid, topical mesalamine, corticosteroids, and immunomodulators did not influence change in extent. CONCLUSIONS: UC extent is best determined by surveillance biopsy. Among patients with long-standing UC, histologic extent fluctuates with time. Disease remission and oral mesalamine were independently associated with decreases in disease extent.

Diagnosis and treatment of postprandial nausea, allergy, and eosinophilia.

We report a case of a 16-year-old male patient who presented with postprandial fullness and nausea. He had a history of seasonal allergies, asthma, and peripheral eosinophilia. Endoscopy of the stomach with mucosal biopsies revealed predominate eosinophils. A diagnosis of eosinophilic gastroenteritis was made. The patient's disease course and management is described in this article.