The Changing Prognosis of Ulcerative Colitis and Crohn Disease by Decades.

We present a bird's eye view of the prognosis for both ulcerative colitis and Crohn disease as contained in the database of an Inflammatory Bowel Disease gastroenterologist covering the period from 1950 until the present utilizing the variables of medical therapy, surgical intervention, complications, and deaths by decades.

Increasing Pediatricians' Awareness of the Association between Anal Skin Tags and Earlier Diagnosis of Crohn's Disease.

OBJECTIVE: To seek the habits of pediatricians by which anorectal skin tags (AST) of Crohn's disease might be overlooked. METHODS: Questionnaires were sent to pediatricians affiliated with the Northwell Health System. RESULTS: Based on the responses, the majority of pediatricians did feel the abdomen of children presenting with abdominal pain or diarrhea but did not spread the buttocks to seek the presence of AST unless there was rectal pain, rectal bleeding, or, in some cases, loose stools. CONCLUSIONS: The diagnosis of Crohn's disease could be made earlier when asymptomatic AST are searched for in children with gastrointestinal symptoms.

Obesity/Bariatric Surgery and Crohn's Disease.

BACKGROUND: Crohn's disease (CD) following bariatric surgery has been previously described. It is not clear whether the clinical entity is due to rapid metabolism of fat, change in the bacterial milieu of the bowel, the loss of defense mechanisms of the stomach, or even a coincidence. OBJECTIVES: To present observations which might serve to sort out these various etiologies. DESIGN: We present 5 cases of colitis, ileocolitis or enteritis, some with fistula formation, with clinical onset following bariatric surgery and add these to the 7 cases previously identified as CD reported elsewhere. We provide the clinical features of these 12 cases to reconcile with causative mechanisms. LIMITATIONS: It remains possible that the onset of CD (or other inflammatory bowel disease) precedes the bariatric surgery which then accelerates the clinical manifestations described. Furthermore, without controls the association could remain a coincidence. CONCLUSIONS: We review the evidence for release of proinflammatory cells and cytokines contained in fat following the bariatric surgery, and also consider the roles that the surgical resection of stomach and shortening of the bowel may also bring about this syndrome. The earlier onset is more likely due to surgical loss of defenses of the stomach and the later onset to a metabolic alteration of the presurgical obesity, involving fat metabolism, and/or the microbiome. The role of characteristic creeping fat of CD is also addressed.

High Incidence of Recurrent Crohn's Disease Following Colectomy for Ulcerative Colitis Revealed with Long Follow-Up.

BACKGROUND AND AIMS: Ulcerative colitis (UC) patients with progression of their disease despite optimized medical therapy may warrant "curative" proctocolectomy with end ileostomy or ileo-anal pouch (IPAA) anastomosis. The aim of our study was to assess the incidence of later recurrent ileitis that lead to altering the initial diagnosis to Crohn's disease (CD). METHODS: A retrospective analysis was conducted on the inflammatory bowel disease database at Lenox Hill Hospital. The database consisted of patients that were diagnosed with UC or CD based on clinical assessment, endoscopic appearance, gross and histological examination, and imaging between 1960 and 2015. The post-colectomy follow-up period was at least 10 years. Recurrent disease was classified by evidence of transmural inflammation in the distal ileum, fistulizing disease, or stricturing disease. RESULTS: From our IBD database, we identified 128 patients who underwent elective or urgent colectomy with the preoperative diagnosis of UC. Thirty-two (25%) had either an IPAA or end ileostomy with documented recurrence of inflammation in the small bowel mucosa consistent with CD. There was no significant difference between the type of surgical approach and the chance of recurrent disease (p = .20). The average time to clinically significant recurrence was 5 years. CONCLUSION: The incidence of recurrent CD following colectomy for ulcerative colitis, when followed postoperatively for an average of 20 years, was 25%, considerably more than previously reported. Patients who come to colectomy for ulcerative colitis and are followed for at least 10 years show a high incidence of recurrent Crohn's disease in the ileostomy or ileo-anal pouch. Extended follow-up should be included in patients coming to colectomy for ulcerative colitis before they should be considered cured of their disease.

Sequential Crohn's Ileitis, Ileosigmoidal Fistula, Segmental Sigmoid Polyposis, and Sigmoid Stricture: The Natural History.

BACKGROUND: We have previously recognized segmental sigmoid polyps as an indicator of a fistula from Crohn's ileitis to the sigmoid or the proximal rectum. In the course of this study, we realized that many patients with this fistula had no sigmoid polyps, but the sigmoid was the site of marked inflammation and early or late stricture formation. Furthermore, in some patients with a stricture, the fistula was not recognized until the surgeon (or the pathologist) dissected an inflammatory peri-ileal and/or a perisigmoidal mass.In this study, we have sought to clarify the sequence of events by focusing on the segmental inflammation and the stricturing of the sigmoid so that its significance can be recognized as a local complication of the ileitis and the progression of its severity as opposed to arising sui generis. MATERIALS AND METHODS: From our database of >3000 patients with inflammatory bowel disease at Lenox Hill Hospital, we identified 45 patients with Crohn's ileitis and ileosigmoid fistula (ISF): 24 had segmental sigmoid polyps and 18 had segmental inflammatory sigmoid strictures. The fistula was first seen by imaging in 36 patients, but not until resection by the surgeon or dissection by the pathologist in 7 patients. RESULTS: The method of diagnosis for the initial recognition of the ISF and the sigmoid stricture is presented in Table 1. In 36 of the 45 cases, the ISF was recognized by radiologic imaging. In total, 31 of the 36 cases required surgical intervention, not because of the fistula, but because of small-bowel obstruction due to the ileitis. In 7 of the 31 (22%) cases, the fistula was recognized only by dissection of the inflammatory ileosigmoid mass by the surgeon or examination of the surgical specimen by the pathologist. The sequence of events from the originating ileitis to the ISF to the segmental sigmoid polyposis and stricture, with the resulting sigmoid obstruction, is shown in Figures 1A-E. CONCLUSIONS: We emphasize the natural history of the ISF so that its recognition will lead to earlier medical management of the originating ileitis. Furthermore, it adds evidence of the recognition that the causative agent of Crohn's disease is carried by the fecal stream.

Histological healing favors lower risk of colon carcinoma in extensive ulcerative colitis.

AIM: To search for the answer in extensive ulcerative colitis as to whether histological inflammation persisting despite endoscopic mucosal healing serves to increase the risk of colon cancer (CC) or high grade dysplasia (HGD). METHODS: This is a single center (Lenox Hill Hospital) retrospective cohort and descriptive study of extensive ulcerative colitis (UC) for 20 years or more with a minimum of 3 surveillance colonoscopies and biopsies performed after the first 10 years of UC diagnosis. Data analyzed included: duration of UC, date of diagnosis of (CC) or (HGD), number of surveillance colonoscopies, and biopsies showing histological inflammation and its severity in each of 6 segments when endoscopic appearance is normal. Two subgroups of patients were compared: group 1 patients who developed CC/HGD and group 2 patients who did not develop CC/HGD. RESULTS: Of 115 patients with longstanding UC reviewed, 68 patients met the inclusion criteria. Twenty patients were in group 1 and 48 in group 2. We identified the number of times for each patient when the endoscopic appearance was normal but biopsies nevertheless showed inflammation. Overall, histological disease activity in the absence of gross/endoscopic disease was found in 31.2% (95%CI: 28%-35%) of colonoscopies performed on the entire cohort of 68 patients. Histological disease activity when the colonoscopy showed an absence of gross disease activity was more common in group 1 than group 2 patients, 88% (95%CI: 72%-97%) vs 59% (95%CI: 53%-64%). Only 3/20 (15%) of patients in group 1 ever had a colonoscopy completely without demonstrated disease activity (i.e., no endoscopic or histological activity) as compared to 37/48 (77%) of patients in group 2, and only 3.3% (95%CI: 0.09%-8.3%) of colonoscopies in group 1 had no histological inflammation compared to 23% (95%CI: 20%-27%) in group 2. CONCLUSION: Progression to HGD or CC in extensive ulcerative colitis of long standing was more frequently encountered among those patients who demonstrate persistent histological inflammation in the absence of gross mucosal disease. Our findings support including the elimination of histological inflammation in the definition of mucosal healing, and support this endpoint as an appropriate goal of therapy because of its risk of increasing dysplasia and colon cancer.

Is treatment with 6-mercaptopurine for colitis associated with the development of colorectal cancer?

BACKGROUND: Patients with ulcerative colitis and Crohn's colitis have an increased risk of colon cancer influenced by the duration, extent, and severity of disease. Surveillance colonoscopy serves to detect cancer and precancerous dysplasia at the earliest possible time. Reduction of inflammation should theoretically reduce the development of cancer. Immunosuppressives should do so, but there is a fear that indeed the risk of cancer might be increased with their use. Our study was conducted to determine whether a relationship exists between receiving treatment with 6-MP for ulcerative and Crohn's colitis and increasing or decreasing the incidence of colorectal cancer (CRC). METHODS: We conducted a single-center, retrospective cohort study of patients with long standing colitis (ulcerative and Crohn's) using the database of the senior investigator (B.I.K.). Two groups were matched based on their propensity to receive treatment with 6-MP; one group received 6-MP treatment, the other did not. Both groups were compared on the incidence of colon cancer. RESULTS: No significant differences existed between the two cohorts with regard to type of disease, duration, extent, age, and sex. Six out of 27 patients not on 6-MP and seven out of 27 patients on 6-MP developed CRC (P= 1). CONCLUSIONS: We conclude that there is neither sufficient evidence currently to state that 6-MP is associated with an increased development of CRC, nor that it has a chemopreventive effect.

Rectal strictures in Crohn's disease and coexisting perirectal complications.

BACKGROUND: The significance of the presence of rectal strictures in Crohn's disease has not been well studied. The aim of this study was to examine patients diagnosed with Crohn's disease associated with rectal strictures and to describe co-existing manifestations of perianal disease (abscesses, fistulae, or skin tags) and strictures located elsewhere in the colon or small intestine. METHODS: A cohort of 70 Crohn's disease patients with rectal strictures were compared with controls without rectal strictures matched for age, gender, and duration of disease. Analysis was done to better elucidate the association of rectal strictures with location of disease and other perirectal complications. RESULTS: The average age of both groups of our Crohn's disease patients was 54 years and the average duration of disease since diagnosis was 315 months for the patients and 314 months for the controls. 54% of patients were women and 46% were men. 61.4% of the study population had Crohn's colitis, whereas the remaining 38.6% of patients had ileo-colonic involvement. In contrast, the majority of the control population had ileo-colonic involvement (74.3%). Perirectal fistulae were present in 61% of patients with rectal strictures versus 34.3% of controls (p value = 0.001). Perirectal abscesses were present in 50% of rectal stricture patients vs. 17.1% of controls (p value < 0.001). Anal skin tags were observed in 23% of study patients vs. 15.7% of controls (p value = 0.275). 37% of patients with rectal strictures also had strictures more proximal in the colon as compared to 54% of controls (p value = 0.07). Only 10% of the study population had small bowel strictures vs. 55.7% of the controls (p value < 0.001). CONCLUSIONS: This observational study of Crohn's disease patients suggests that the majority of patients with rectal strictures have colonic involvement and increased perianal fistulae and abscesses. Only a minority of patients was observed to have ileal or ileo-colonic disease, perianal skin tags, or strictures elsewhere. A future study will examine whether the severity of stricturing disease can tell us anything about the disease distribution, prognosis, or response to treatment. Patients with rectal strictures and associated perirectal disease may represent a specific phenotypic presentation of Crohn's disease that warrants further study and correlation with serological markers so as to better aid this subgroup of patients.