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Fan YH, Wang MW, Gao YN, Li WM, Jiao Y. Genetic and environmental factors influencing Crohn's disease. World J Gastrointest Surg 2025; 17:98526. [PMID: 40162410 PMCID: PMC11948133 DOI: 10.4240/wjgs.v17.i3.98526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 12/14/2024] [Accepted: 01/06/2025] [Indexed: 02/24/2025] Open
Abstract
This editorial discusses Pellegrino and Gravina's essay. Crohn's disease (CD) is a complex and multifactorial disease that is influenced by a combination of genetic and environmental factors. While genetic factors play a key role in the development of the disease, environmental factors also play a significant role in influencing the risk of developing CD. By looking at present understanding of CD pathogenesis, we emphasize the important factors involved in the development of this illness, such as nucleotide-binding oligomerization domain-2, smoking, and vitamin D. Understanding the interplay between genetic and environmental factors is crucial for developing effective strategies for preventing and treating this chronic inflammatory bowel disease.
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Affiliation(s)
- Ye-Hui Fan
- Department of The First Operation Room, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Ming-Wei Wang
- Ministry of Health Key Laboratory of Radiobiology, School of Public Health of Jilin University, Changchun 130000, Jilin Province, China
| | - Yu-Ning Gao
- Department of Gastrointestinal Surgery, Changchun Central Hospital, Changchun 130000, Jilin Province, China
| | - Wen-Mao Li
- Department of Rehabilitation, The Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Yan Jiao
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
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2
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Szemes K, Farkas N, Sipos Z, Bor R, Fabian A, Szepes Z, Farkas K, Molnar T, Schafer E, Szamosi T, Salamon A, Vincze A, Sarlos P. Co-Administration of Proton Pump Inhibitors May Negatively Affect the Outcome in Inflammatory Bowel Disease Treated with Vedolizumab. Biomedicines 2024; 12:158. [PMID: 38255263 PMCID: PMC10813460 DOI: 10.3390/biomedicines12010158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 12/31/2023] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Concomitant medications may alter the effect of biological therapy in inflammatory bowel disease. The aim was to investigate the effect of proton pump inhibitors on remission rates in patients with inflammatory bowel disease treated with the gut-selective vedolizumab. Patients from the Hungarian nationwide, multicenter vedolizumab cohort were selected for post hoc analysis. Primary outcomes were the assessment of clinical response and endoscopic and clinical remission at weeks 14 and 54. Secondary outcomes were the evaluation of the combined effect of concomitant steroid therapy and other factors, such as smoking, on remission. A total of 108 patients were identified with proton pump inhibitor data from 240 patients in the original cohort. Patients on steroids without proton pump inhibitors were more likely to have a clinical response at week 14 than patients on concomitant PPI (95% vs. 67%, p = 0.005). Non-smokers with IBD treated with VDZ were more likely to develop a clinical response at week 14 than smokers, particularly those not receiving PPI compared with patients on co-administered PPI therapy (81% vs. 53%, p = 0.041, and 92% vs. 74%, p = 0.029, respectively). We found that the use of PPIs in patients treated with VDZ may impair the achievement of response in certain subgroups. Unnecessary PPI prescriptions should be avoided.
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Affiliation(s)
- Kata Szemes
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, 13 Ifjúság Street, 7624 Pecs, Hungary
| | - Nelli Farkas
- Institute of Bioanalysis, Medical School, University of Pécs, 7624 Pecs, Hungary
| | - Zoltan Sipos
- Institute of Bioanalysis, Medical School, University of Pécs, 7624 Pecs, Hungary
| | - Renata Bor
- First Department of Medicine, University of Szeged, 6720 Szeged, Hungary
| | - Anna Fabian
- First Department of Medicine, University of Szeged, 6720 Szeged, Hungary
| | - Zoltan Szepes
- First Department of Medicine, University of Szeged, 6720 Szeged, Hungary
| | - Klaudia Farkas
- First Department of Medicine, University of Szeged, 6720 Szeged, Hungary
| | - Tamas Molnar
- First Department of Medicine, University of Szeged, 6720 Szeged, Hungary
| | - Eszter Schafer
- Department of Gastroenterology, Hungarian Defence Forces Military Hospital, 1134 Budapest, Hungary
| | - Tamas Szamosi
- Department of Gastroenterology, Hungarian Defence Forces Military Hospital, 1134 Budapest, Hungary
| | | | - Aron Vincze
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, 13 Ifjúság Street, 7624 Pecs, Hungary
| | - Patricia Sarlos
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, 13 Ifjúság Street, 7624 Pecs, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pecs, Hungary
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Boronat-Toscano A, Vañó I, Monfort-Ferré D, Menacho M, Valldosera G, Caro A, Espina B, Mañas MJ, Marti M, Espin E, Saera-Vila A, Serena C. Smoking Suppresses the Therapeutic Potential of Adipose Stem Cells in Crohn’s Disease Patients through Epigenetic Changes. Cells 2023; 12:cells12071021. [PMID: 37048094 PMCID: PMC10093550 DOI: 10.3390/cells12071021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/21/2023] [Accepted: 03/25/2023] [Indexed: 03/29/2023] Open
Abstract
Patients with Crohn’s disease (CD) who smoke are known to have a worse prognosis than never-smokers and a higher risk for post-surgical recurrence, whereas patients who quit smoking after surgery have significantly lower post-operative recurrence. The hypothesis was that smoking induces epigenetic changes that impair the capacity of adipose stem cells (ASCs) to suppress the immune system. It was also questioned whether this impairment remains in ex-smokers with CD. ASCs were isolated from non-smokers, smokers and ex-smokers with CD and their interactions with immune cells were studied. The ASCs from both smokers and ex-smokers promoted macrophage polarization to an M1 pro-inflammatory phenotype, were not able to inhibit T- and B-cell proliferation in vitro and enhanced the gene and protein expression of inflammatory markers including interleukin-1b. Genome-wide epigenetic analysis using two different bioinformatic approaches revealed significant changes in the methylation patterns of genes that are critical for wound healing, immune and metabolic response and p53-mediated DNA damage response in ASCs from smokers and ex-smokers with CD. In conclusion, cigarette smoking induces a pro-inflammatory epigenetic signature in ASCs that likely compromises their therapeutic potential.
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Abdallah B, Arif M, Al-Malki M, Hourani R, Al-Maadeed T, Khodr N, Al-Kuwari G, Al-Siddiqi M, Kane T, Chivese T. The Association Between Inflammatory Bowel Disease and Exposure to Tobacco Smoking: A Case-Control Study in Qatar. Int J Gen Med 2023; 16:233-242. [PMID: 36711427 PMCID: PMC9875733 DOI: 10.2147/ijgm.s393284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 01/06/2023] [Indexed: 01/21/2023] Open
Abstract
Objective This research investigated the association between childhood and adulthood tobacco smoking exposure with ulcerative colitis (UC) and Crohn's disease (CD) in Qatar. Study Design and Setting In this case-control study, CD and UC cases were matched to controls of the same age and sex. The associations between UC and CD and childhood passive smoking and adulthood active smoking were assessed using conditional multivariable logistic regression. Results A total of 89 CD cases, median age of 37 years (IQR 29-47), and 362 UC cases, median age of 35 years (IQR 28-44), and equal numbers of controls were included. After multivariable logistic regression, CD was associated with higher odds of being a current smoker (OR 2.51, 95% CI 0.85-7.37, p=0.095), with weak evidence against the null hypothesis. This association was more pronounced in women, where CD was associated with both adulthood current smoking (OR 42.71, 95% CI, 1.17-1559.57, p=0.041), and childhood smoking exposure (OR 8.23, 95% CI, 1.36-49.66, p=0.021). In males, no associations were observed between CD and the smoking exposures. No associations were observed between UC and both smoking variables. Conclusion In Qatar, adulthood tobacco smoking appears to increase the odds of CD. Further, our findings suggest that both childhood and adulthood cigarette smoke exposure may possibly have a detrimental effect on the odds of CD in females but not in males, although further research is needed.
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Affiliation(s)
- Bushra Abdallah
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Mariah Arif
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Maryam Al-Malki
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Razan Hourani
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Tamader Al-Maadeed
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Nidal Khodr
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Ghaith Al-Kuwari
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Mashael Al-Siddiqi
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Tanya Kane
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Tawanda Chivese
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar,Correspondence: Tawanda Chivese, Department of Population Medicine, College of Medicine, QU Health, Qatar University, P O BOX 2713, Doha, Qatar, Tel +974 4403 7831, Email
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Smoking-induced microbial dysbiosis in health and disease. Clin Sci (Lond) 2022; 136:1371-1387. [PMID: 36156126 PMCID: PMC9527826 DOI: 10.1042/cs20220175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/09/2022] [Accepted: 09/07/2022] [Indexed: 11/25/2022]
Abstract
Smoking is associated with an increased risk of cancer, pulmonary and cardiovascular diseases, but the precise mechanisms by which such risk is mediated remain poorly understood. Additionally, smoking can impact the oral, nasal, oropharyngeal, lung and gut microbiome composition, function, and secreted molecule repertoire. Microbiome changes induced by smoking can bear direct consequences on smoking-related illnesses. Moreover, smoking-associated dysbiosis may modulate weight gain development following smoking cessation. Here, we review the implications of cigarette smoking on microbiome community structure and function. In addition, we highlight the potential impacts of microbial dysbiosis on smoking-related diseases. We discuss challenges in studying host–microbiome interactions in the context of smoking, such as the correlations with smoking-related disease severity versus causation and mechanism. In all, understanding the microbiome’s role in the pathophysiology of smoking-related diseases may promote the development of rational therapies for smoking- and smoking cessation-related disorders, as well as assist in smoking abstinence.
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Hua X, Lopes EW, Burke KE, Ananthakrishnan AN, Richter JM, Lo CH, Lochhead P, Chan AT, Khalili H. Smoking Behaviour Changes After Diagnosis of Inflammatory Bowel Disease and Risk of All-cause Mortality. J Crohns Colitis 2022; 16:1030-1038. [PMID: 35102373 PMCID: PMC9351977 DOI: 10.1093/ecco-jcc/jjac015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/30/2021] [Accepted: 01/25/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS We examined smoking behaviour changes after diagnoses of Crohn's disease [CD] and ulcerative colitis [UC] and evaluated their impact on mortality. METHODS Study population included incident CD or UC cases from three cohorts of the Nurses' Health Study [NHS], NHSII, and Health Professionals Follow-up Study. Smoking and other risk factors were prospectively assessed. Smoking behaviour changes were categorised as never, former [i.e., quit smoking before diagnosis], quitters [i.e., quit smoking after diagnosis], and current [i.e., continue smoking after diagnosis]. Follow-up for date and cause of death was completed through linkage to the National Death Index. Cox proportional hazard regression was used to estimate hazard ratios [HRs] and 95% confidence intervals [CIs]. RESULTS Among 909 eligible CD and UC cases, 45% were never smokers, 38% were past smokers, and 16% were active smokers at the time of diagnosis. Among active smokers, 70% of patients with CD and 44% of patients with UC continued to smoke after diagnosis. In patients with CD, compared with current smokers, the multivariable-adjusted HRs [95% CI] of death were 0.19 [0.10 to 0.38] for never smokers, 0.31 [0.16 to 0.57] for former smokers, and 0.41 [0.18 to 0.93] for quitters. Similarly for UC, compared with current smokers, we observed a reduced risk of mortality for never smokers [HR = 0.23, 95% CI 0.10 to 0.51], former smokers [HR = 0.23, 95% CI 0.11 to 0.48], and quitters [HR = 0.28, 95% CI 0.11 to 0.72]. CONCLUSIONS In three cohorts of health professionals, a substantial proportion of patients with new diagnosis of CD and UC and history of smoking continued to smoke after diagnosis. Smoking cessation around the time of diagnosis was associated with a significant reduction in mortality.
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Affiliation(s)
- Xinwei Hua
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translation Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Emily W Lopes
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translation Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Kristin E Burke
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translation Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translation Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Chun-Han Lo
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Paul Lochhead
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translation Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew T Chan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Clinical and Translation Epidemiology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA,Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Hamed Khalili
- Corresponding author: Hamed Khalili, MD, MPH, Digestive Healthcare Center, Crohn’s and Colitis Center, Massachusetts General Hospital, 165 Cambridge Street, 9th Floor, Boston, MA 02114, USA. Tel.: 617 726 7933; fax: 617 726 3080;
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Sotona O, Peterová E, Örhalmi J, Dušek T, Mrkvicová A, Knoblochová V, Lochman P, Malý O, Páral J, Bureš J. Gene Expression of Antioxidant Enzymes in the Resected Intestine in Crohn's Disease. ACTA MEDICA (HRADEC KRÁLOVÉ) 2021; 64:153-157. [PMID: 34779380 DOI: 10.14712/18059694.2021.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The inflammatory process in Crohn's disease (CD) is closely associated with the formation of reactive oxygen species. Antioxidant enzymes can play an important role in the outcome of CD and may influence postoperative recurrence in these patients. The aim of our study was to evaluate gene expression of intracellular antioxidant enzymes in surgically resected intestinal specimens of patients with CD, both in macroscopically normal and in inflamed tissue. METHODS A total of 28 patients referred for elective bowel resection were enrolled in the study. Full-thickness small intestinal specimens were investigated. Gene expression of antioxidant enzymes - superoxide dismutase (SOD), glutathione peroxidase (GPX), glutathione reductase (GSR) - was evaluated both in macroscopically normal and inflamed samples. RESULTS There were significantly lower levels of SOD1 mRNA (p = 0.007) and GSR mRNA (p = 0.027) in inflamed tissue compared to macroscopically normal areas. No significant differences were found between affected and non-affected intestinal segments in mRNA for SOD2, SOD3 and GPX. CONCLUSIONS Our pilot data clearly showed that the gene expression of major antioxidant enzymes is not a uniform mechanism in the pathogenesis of Crohn's disease. Topically decreased gene expression of SOD1 and GSR might facilitate the segmental tissue injury caused by reactive oxygen species.
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Affiliation(s)
- Otakar Sotona
- Department of Field Surgery, Faculty of Military Health Sciences, University of Defence, Hradec Králové, Czech Republic. .,Department of Surgery, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic.
| | - Eva Peterová
- Department of Medical Biochemistry, Charles University, Faculty of Medicine in Hradec Králové, Czech Republic
| | - Július Örhalmi
- Department of Surgery, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic
| | - Tomáš Dušek
- Department of Field Surgery, Faculty of Military Health Sciences, University of Defence, Hradec Králové, Czech Republic.,Department of Surgery, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic
| | - Alena Mrkvicová
- Department of Medical Biochemistry, Charles University, Faculty of Medicine in Hradec Králové, Czech Republic
| | - Veronika Knoblochová
- 2nd Department of Internal Medicine - Gastroenterology, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic
| | - Petr Lochman
- Department of Field Surgery, Faculty of Military Health Sciences, University of Defence, Hradec Králové, Czech Republic.,Department of Surgery, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic
| | - Ondřej Malý
- Department of Field Surgery, Faculty of Military Health Sciences, University of Defence, Hradec Králové, Czech Republic.,Department of Surgery, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic
| | - Jiří Páral
- Department of Field Surgery, Faculty of Military Health Sciences, University of Defence, Hradec Králové, Czech Republic.,Department of Surgery, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic
| | - Jan Bureš
- 2nd Department of Internal Medicine - Gastroenterology, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic
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Syal G, Serrano M, Jain A, Cohen BL, Rieder F, Stone C, Abraham B, Hudesman D, Malter L, McCabe R, Holubar S, Afzali A, Cheifetz AS, Gaidos JKJ, Moss AC. Health Maintenance Consensus for Adults With Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 27:1552-1563. [PMID: 34279600 PMCID: PMC8861367 DOI: 10.1093/ibd/izab155] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND With the management of inflammatory bowel disease (IBD) becoming increasingly complex, incorporating preventive care health maintenance measures can be challenging. The aim of developing these updated recommendations is to provide more specific details to facilitate their use into a busy clinical practice setting. METHOD Fifteen statements were formulated with recommendations regarding the target, timing, and frequency of the health maintenance interventions in patients with IBD. We used a modified Delphi method and a literature review to establish a consensus among the panel of experts. The appropriateness of each health maintenance statement was rated on a scale of 1 to 5 (1-2 as inappropriate, and 4-5 as appropriate) by each panelist. Interventions were considered appropriate, and statements were accepted if ≥80% of the panelists agreed with a score ≥4. RESULTS The panel approved 15 health maintenance recommendations for adults with IBD based on the current literature and expert opinion. These recommendations include explicit details regarding specific screening tools, timing of screening, and vaccinations for adults with IBD. CONCLUSIONS Patients with IBD are at an increased risk for infections, malignancies, and other comorbidities. Given the complexity of caring for patients with IBD, this focused list of recommendations can be easily incorporated in to clinical care to help eliminate the gap in preventative care for patients with IBD.
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Affiliation(s)
- Gaurav Syal
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Animesh Jain
- University of North Carolina, Chapel Hill, North Carolina, USA
| | | | | | - Christian Stone
- Comprehensive Digestive Institute of Nevada, Las Vegas, Nevada, USA
| | | | - David Hudesman
- New York University Langone Medical Center, New York, New York, USA
| | - Lisa Malter
- NYU Grossman School of Medicine, Bellevue Hospital Center, New York, New York, USA
| | | | | | - Anita Afzali
- Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Adam S Cheifetz
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Alan C Moss
- Boston University School of Medicine, Boston, Massachusetts, USA
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Optimal strategies to prevent recrudescent Crohn's disease after resection. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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10
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Di Candido F, Moggia E, Spinelli A. Pre-operative optimisation in Crohn's Disease. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Santus P, Radovanovic D, Raiteri D, Pini S, Spagnolo G, Maconi G, Rizzi M. The effect of a multidisciplinary approach for smoking cessation in patients with Crohn's disease: Results from an observational cohort study. Tob Induc Dis 2020; 18:29. [PMID: 32336967 PMCID: PMC7177387 DOI: 10.18332/tid/119161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/09/2020] [Accepted: 03/17/2020] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Cigarette smoking is the most important risk factor for Crohn’s disease (CD). The effectiveness of smoking cessation programs (SCPs) in patients with CD is still poorly understood. METHODS This was a retrospective, observational, single-centre, cohort study of 136 active smokers with mean age 55 years (SD=11), 58% males, including 27 (19.8%) patients with CD who entered the multidisciplinary SCP of the Luigi Sacco University Hospital of Milan from January 2017 through January 2019. A pulmonologist was responsible for the clinical and pharmacological management, while a psychiatrist and a psychologist conducted the counselling and assessed the motivation to quit, anxiety and depression using the Brief Psychiatric Rating Scale (BPRS) and the nicotine dependence with the Fagerström test. Patients were defined as quitters after 12 months. RESULTS Demographic and clinical characteristics, and Fagerström score, did not differ in patients with and without CD. At baseline, patients with CD had a higher BPRS (median: 27, IQR: 22–32; vs 25 and 22–28.5; p=0.03), and a lower motivation to quit score (median: 10, IQR: 9–13; vs 14 and 12–15; p<0.001). After 12 months, the quitting rate of smokers with CD was significantly lower (14.8% vs 36.7%; p<0.022) and the chance of quitting was negatively associated with the baseline BPRS (r=-0.256; p<0.003). Varenicline and nicotine replacement therapy tended to be less effective in patients with CD. CONCLUSIONS The lower efficacy of SCPs in patients with CD might be secondary to a higher prevalence of anxiety and depression. Psychological issue recognition and support should be enhanced to increase SCP effectiveness in CD.
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Affiliation(s)
- Pierachille Santus
- Division of Pulmonary Diseases, Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milan, Italy
| | - Dejan Radovanovic
- Division of Pulmonary Diseases, Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milan, Italy
| | - Davide Raiteri
- Division of Pulmonary Diseases, Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milan, Italy
| | - Stefano Pini
- Division of Pulmonary Diseases, Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milan, Italy
| | - Giuseppe Spagnolo
- Department of Medical and Surgical Physiopathology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Maconi
- Division of Gastroenterology, Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milan, Italy
| | - Maurizio Rizzi
- Division of Pulmonary Diseases, Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milan, Italy
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12
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Rate of Reoperation Decreased Significantly After Year 2002 in Patients With Crohn's Disease. Clin Gastroenterol Hepatol 2020; 18:898-907.e5. [PMID: 31336198 DOI: 10.1016/j.cgh.2019.07.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 06/14/2019] [Accepted: 07/02/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with Crohn's disease (CD) can require multiple intestinal surgeries. We examined time trends and risk factors for reoperation in patients with CD who underwent intestinal surgery, focusing on the effects of postoperative medical treatments. METHODS We performed a retrospective analysis of 1871 patients with CD who underwent initial intestinal resection at 10 tertiary care institutions in Japan, with an initial surgical date after May 1982. We collected data on the background characteristics of all patients, including Montreal Classification, smoking status, and medical therapy after surgery (tumor necrosis factor antagonists [anti-TNF] agents or immunomodulators). The primary outcome was requirement for first reoperation. Rate of reoperation was estimated using the Kaplan-Meier method, and risk factors for reoperation were identified using the Cox regression model. RESULTS The overall cumulative 5- and 10-year reoperation rates were 23.4% and 48.0%, respectively. Multivariable analysis showed that patients who underwent the initial surgery after May 2002 had a significantly lower rate of reoperation than patients who underwent surgery before April 2002 (hazard ratio [HR], 0.72; 95% CI, 0.61-0.86). Preoperative smoking (HR, 1.40; 95% CI, 1.18-1.68), perianal disease (HR, 1.50; 95% CI, 1.27-1.77), and ileocolic type of CD (HR, 1.42; 95% CI, 1.20-1.69) were significant risk factors for reoperation. Postoperative use of immunomodulators (HR, 0.60; 95% CI, 0.44-0.81) and anti-TNF therapy (HR, 0.71; 95% CI, 0.57-0.88) significantly reduced the risk. Anti-TNF was effective in the bionaive subgroup. CONCLUSIONS The rate of reoperation in patients with CD significantly decreased after May 2002. Postoperative use of anti-TNF agents might reduce the reoperation rate for bionaive patients with CD.
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Vrablicova Z, Soltys K, Krajcovicova A, Stuchlikova K, Sturdik I, Koller T, Huorka M, Payer J, Killinger Z, Jackuliak P, Tkacik M, Stuchlik S, Sekac J, Hlavaty T. Impact of smoking cigarette on the mRNA expression of cytokines in mucosa of inflammatory bowel disease. Physiol Res 2019; 68:S183-S192. [PMID: 31842582 DOI: 10.33549/physiolres.934301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
It is well known that smoking is the risk factor in the development and clinical course of Crohn s disease (CD), but on the other hand, smoking is a protective factor against ulcerative colitis (UC). The pathways that are influenced by smoking in CD and UC are poorly understood. The aim of our study was to analyse the influence of smoking on the mRNA expression of cytokines in mucosa in patients with CD and UC. We performed a cross-sectional study. The cohort consisted of 86 IBD patients (48 CD patients and 38 UC patients) and took place at the IBD Centre at the University Hospital Bratislava-Ružinov. We took the demographic and clinical data of each patient, including information about their smoking habits. We performed a colonoscopy on each patient and took biopsies from both inflamed and non-inflamed sigma (CD, UC) and terminal ileum (CD). mRNA was extracted from mucosal biopsy samples for each cytokine and was normalized to a housekeeping gene (GAPDH). Finally, we compared the mRNA expression of target cytokines in the mucosa of smokers and non-smokers in IBD patients. Smokers with Crohn s disease have a significantly higher mRNA expression of pro-inflammatory cytokine TNF ? (p=0.003) in inflamed mucosa in sigma compared with non-smokers. In smokers with ulcerative colitis, we observed significantly higher mRNA expression of anti-inflammatory cytokine IL 10 (p=0.022) in non-inflamed mucosa of sigma. Similarly, smokers with UC have a significantly decreased mRNA expression of cytokine TLR 2 (p=0.024) and CCR1 (p=0.049) in non-inflamed mucosa of sigma. Based on our results, smoking has a positive influence on cessation and the clinical course of UC due to the stimulation of anti-inflammatory cytokine IL 10 in mucosa. On the other hand, smokers with CD have a higher expression of pro-inflammatory cytokine TNF ?, which could be associated with a worsening of the disease and response to therapy.
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Affiliation(s)
- Z Vrablicova
- 5th Department of Internal Medicine, Sub-department of Gastroenterology and Hepatology, Faculty of Medicine, Comenius University Bratislava, University Hospital Bratislava, Slovak Republic
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Penetrating Crohn Disease Is Not Associated With a Higher Risk of Recurrence After Surgery. Ann Surg 2019; 270:827-834. [DOI: 10.1097/sla.0000000000003531] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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15
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Intra-abdominal Sepsis After Ileocolic Resection in Crohn's Disease: The Role of Combination Immunosuppression. Dis Colon Rectum 2018; 61:1393-1402. [PMID: 30303885 DOI: 10.1097/dcr.0000000000001153] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intra-abdominal sepsis complicates <10% of ileocolic resections for Crohn's disease, but the impact of combination immunosuppression and repeat resection on its development remains unknown. OBJECTIVE The purpose of this study was to determine risk factors for intra-abdominal sepsis after ileocolic resection, specifically examining the role of combination immunosuppression and repeat intestinal resection. DESIGN This was a retrospective review of patient records from 2007 to 2017. SETTINGS The study was conducted at a single-institution IBD tertiary referral center. PATIENTS Patients with a diagnosis of Crohn's disease who were undergoing ileocolic resection with primary anastomosis were included. Diverted patients were excluded. MAIN OUTCOME MEASURES Preoperative and intraoperative variables, including preoperative immunosuppressive regimens and previous intestinal resection, were evaluated as potential risk factors for intra-abdominal sepsis. RESULTS A total of 621 patients (55% women) underwent ileocolic resection for Crohn's disease; 393 (63%) were first-time resections. The rate of 30-day intra-abdominal sepsis was 8% (n = 50). On univariate analysis, triple immunosuppression (combination of a corticosteroid, immunomodulator, and biological) and previous intestinal resection were significantly associated with intra-abdominal sepsis. Both risk factors remained significant on multivariable analysis (OR for triple immunosuppression (vs none) = 3.53 (95% CI, 1.27-9.84); previous intestinal resection OR = 2.27 (95% CI, 1.25-4.13)). A significant trend was seen between an increasing number of these risk factors (triple immunosuppression and previous intestinal resection) and rate of intra-abdominal sepsis (5%, 12%, and 22% for 0, 1, and 2 risk factors; p < 0.01). A trend was observed between increasing number of previous intestinal resections and the rate of intra-abdominal sepsis (p < 0.01). LIMITATIONS This study is limited by its single-institution tertiary referral center scope. CONCLUSIONS Combination immunosuppression and previous intestinal resection were both associated with the development of intra-abdominal sepsis. In light of these results, surgeons should consider the effects of combination immunosuppression and a history of previous intestinal resection, in addition to other risk factors, when deciding which patients warrant temporary intestinal diversion. See Video Abstract at http://links.lww.com/DCR/A664.
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Auzolle C, Nancey S, Tran-Minh ML, Buisson A, Pariente B, Stefanescu C, Fumery M, Marteau P, Treton X, Hammoudi N, Jouven X, Seksik P, Allez M. Male gender, active smoking and previous intestinal resection are risk factors for post-operative endoscopic recurrence in Crohn's disease: results from a prospective cohort study. Aliment Pharmacol Ther 2018; 48:924-932. [PMID: 30126030 DOI: 10.1111/apt.14944] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 06/08/2018] [Accepted: 07/21/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND After ileocaecal resection for Crohn's disease (CD), inflammatory lesions frequently recur on the anastomosis and/or on the neo-terminal ileum. AIM To identify predictors of early post-operative endoscopic recurrence. METHODS From September 2010 to September 2017, the REMIND group conducted a prospective nationwide study in nine French academic centres. Data were collected at the time of surgery and endoscopy, performed 6-12 months after surgery. Endoscopic recurrence was defined as a Rutgeerts score ≥i2. Baseline factors associated with endoscopic recurrence were searched by univariate and multivariate regression analysis. RESULTS Two hundred and eighty-nine CD patients were included. Endoscopy within 1 year following surgery was performed in 225 (78%) patients (104M/121F). Mean age and disease duration were 35 (12.2) and 8.8 (8.9) years respectively. Seventy (32%) patients were active smokers at surgery. One hundred and forty-two (63%) patients received at least one anti-TNF therapy before surgery. After surgery, 40 (18%) patients received thiopurines and 66 (29%) received an anti-TNF agent. Endoscopic recurrence occurred in 107 (47%) patients. In multivariate analysis, male gender (OR = 2.48 [IC 95% 1.40-4.46]), active smoking at surgery (OR = 2.65 [IC 95% 1.44-4.97]) and previous resection (OR = 3.03 [IC 95% 1.36-7.12]) were associated with a higher risk of endoscopic recurrence. Inversely, post-operative anti-TNF treatment decreased the risk of endoscopic recurrence (OR = 0.50 [IC 95% 0.25-0.96]). CONCLUSIONS Male gender, active smoking at surgery and previous intestinal resection are associated with a higher risk of endoscopic post-operative recurrence, while post-operative anti-TNF treatment is associated with a lower risk.
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Affiliation(s)
- Claire Auzolle
- Department of Gastroenterology, Hôpital Saint-Louis, APHP, INSERM U1160, University Denis Diderot, Paris, France.,PARCC, Paris, France
| | - Stephane Nancey
- Department of Gastroenterology, Lyon Sud Hospital, Hospices Civils de Lyon, Lyon, France
| | - My-Linh Tran-Minh
- Department of Gastroenterology, Hôpital Saint-Louis, APHP, INSERM U1160, University Denis Diderot, Paris, France
| | - Anthony Buisson
- Université Clermont Auvergne, Inserm U1071, M2iSH, 3iHP, CHU Clermont-Ferrand, Service de Médecine de l'Appareil Digestif Clermont-Ferrand, Clermont-Ferrand, France
| | - Benjamin Pariente
- Department of Gastroenterology, Claude Huriez Hospital, University of Lille 2, Lille, France
| | - Carmen Stefanescu
- Hôpital Beaujon, Service de Gastroentérologie, MICI et Assistance Nutritive, Clichy, France
| | - Mathurin Fumery
- Department of Hepatogastroenterology, Amiens University Hospital, Amiens, France
| | - Philippe Marteau
- Gastroenterology, Sorbonne Universités, AP-HP, Hospital Saint-Antoine, Paris, France
| | - Xavier Treton
- Hôpital Beaujon, Service de Gastroentérologie, MICI et Assistance Nutritive, Clichy, France
| | - Nassim Hammoudi
- Department of Gastroenterology, Hôpital Saint-Louis, APHP, INSERM U1160, University Denis Diderot, Paris, France
| | | | | | - Philippe Seksik
- Gastroenterology, Sorbonne Universités, AP-HP, Hospital Saint-Antoine, Paris, France
| | - Matthieu Allez
- Department of Gastroenterology, Hôpital Saint-Louis, APHP, INSERM U1160, University Denis Diderot, Paris, France
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17
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Practices, attitudes, and knowledge about Crohn's disease and smoking cessation among gastroenterologists. Eur J Gastroenterol Hepatol 2018; 30:155-160. [PMID: 29240002 DOI: 10.1097/meg.0000000000001010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Cigarette smoking is one of the most important, modifiable environmental factors in Crohn's disease (CD) and screening for tobacco use is an official recommendation and quality measure in the care of CD patients. The objective of this study was to learn more about gastroenterologists' practices, opinions, and knowledge in this area. PATIENTS AND METHODS A 15 question survey was sent through email to two national gastroenterology distribution lists. Questions were written in multiple choice formats and were designed to collect information about gastroenterologists' practices, attitudes, and knowledge regarding smoking cessation in CD patients. Responses were stratified by practice setting, experience, and inflammatory bowel disease-focus. Responses were anonymous and were collected in a secure, online database. RESULTS A total of 141 respondents completed the survey. Overall, 89% of participants screened their CD patients for smoking more than 75% of the time. In all, 62% provided smoking cessation counseling more than 75% of the time. Overall, 94% of respondents felt comfortable discussing the benefits of smoking cessation with their patients. In all, 56% felt comfortable discussing smoking cessation strategies with their patients. Overall, 88% of respondents agreed that gastroenterologists should provide smoking cessation counseling; however, 43 and 11% agreed that the gastroenterologist should be the primary counselor and primary prescriber of cessation-related pharmacotherapy, respectively. CONCLUSION Surveyed gastroenterologists agree that smoking cessation is an important part of the care of CD patients and this is reflected in their screening practices. Counseling occurs irregularly and many gastroenterologists do not feel comfortable discussing cessation strategies. Future guidelines should provide further guidance on the gastroenterologist's role in smoking cessation counseling for CD patients.
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18
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Berkowitz L, Schultz BM, Salazar GA, Pardo-Roa C, Sebastián VP, Álvarez-Lobos MM, Bueno SM. Impact of Cigarette Smoking on the Gastrointestinal Tract Inflammation: Opposing Effects in Crohn's Disease and Ulcerative Colitis. Front Immunol 2018; 9:74. [PMID: 29441064 PMCID: PMC5797634 DOI: 10.3389/fimmu.2018.00074] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 01/11/2018] [Indexed: 01/06/2023] Open
Abstract
Cigarette smoking is a major risk factor for gastrointestinal disorders, such as peptic ulcer, Crohn’s disease (CD), and several cancers. The mechanisms proposed to explain the role of smoking in these disorders include mucosal damage, changes in gut irrigation, and impaired mucosal immune response. Paradoxically, cigarette smoking is a protective factor for the development and progression of ulcerative colitis (UC). UC and CD represent the two most important conditions of inflammatory bowel diseases, and share several clinical features. The opposite effects of smoking on these two conditions have been a topic of great interest in the last 30 years, and has not yet been clarified. In this review, we summarize the most important and well-understood effects of smoking in the gastrointestinal tract; and particularly, in intestinal inflammation, discussing available studies that have addressed the causes that would explain the opposite effects of smoking in CD and UC.
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Affiliation(s)
- Loni Berkowitz
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile.,Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Bárbara M Schultz
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Geraldyne A Salazar
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Catalina Pardo-Roa
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Valentina P Sebastián
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Manuel M Álvarez-Lobos
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Susan M Bueno
- Millennium Institute on Immunology and Immunotherapy, Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
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19
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Lin WC, Chou JW, Yen HH, Hsu WH, Lin HH, Lin JK, Chuang CH, Huang TY, Wang HY, Wei SC, Wong JM. Outcomes of limited period of adalimumab treatment in moderate to severe Crohn's disease patients: Taiwan Society of Inflammatory Bowel Disease Study. Intest Res 2017; 15:487-494. [PMID: 29142516 PMCID: PMC5683979 DOI: 10.5217/ir.2017.15.4.487] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 07/14/2017] [Accepted: 07/20/2017] [Indexed: 12/15/2022] Open
Abstract
Background/Aims In Taiwan, due to budget limitations, the National Health Insurance only allows for a limited period of biologics use in treating moderate to severe Crohn's disease (CD). We aimed to access the outcomes of CD patients following a limited period use of biologics, specifically focusing on the relapse rate and remission duration; also the response rate to second use when applicable. Methods This was a multicenter, retrospective, observational study and we enrolled CD patients who had been treated with adalimumab (ADA) according to the insurance guidelines from 2009 to 2015. Results A total of 54 CD patients, with follow-up of more than 6 months after the withdrawal of ADA, were enrolled. The average period of treatment with ADA was 16.7±9.7 months. After discontinuing ADA, 59.3% patients suffered a clinical relapse. In the univariate analysis, the reason for withdrawal was a risk factor for relapse (P=0.042). In the multivariate analysis, current smoker became an important risk factor for relapse (OR, 3.9; 95% CI, 1.2−14.8; P=0.044) and male sex was another risk factor (OR, 2.9; 95% CI, 1.1−8.6; P=0.049). For those 48 patients who received a second round of biologics, the clinical response was seen in 60.4%, and 1 anaphylaxis occurred. Conclusions Fifty-nine percent of patients experienced a relapse after discontinuing the limited period of ADA treatment, and most of them occurred within 1 year following cessation. Male sex and current smoker were risk factors for relapse. Though 60.4% of the relapse patients responded to ADA again.
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Affiliation(s)
- Wei-Chen Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Jen-Wei Chou
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Hsu-Heng Yen
- Department of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan
| | - Wen-Hung Hsu
- Department of Gastroenterology, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Hsin Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Jen-Kou Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chiao-Hsiung Chuang
- Department of Internal Medicine, National Cheng-Kung University Hospital, National Cheng-Kung University Medical College, Tainan, Taiwan
| | - Tien-Yu Huang
- Department of Gastroenterology, Tri-Service General Hospital, Taipei, Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shu-Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jau-Min Wong
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Abstract
The high frequency of intestinal strictures in patients with Crohn's disease and the different treatment approaches specific for each type of stenosis make the differentiation between fibrotic and inflammatory strictures crucial in management of the disease. However, there is no standardized approach to evaluate and discriminate intestinal strictures, and until now, there was no established cross-sectional imaging modality to detect fibrosis. New techniques, such as contrast-enhanced ultrasound and sonoelastography allow the assessment of vascularization and mechanical properties of stenotic bowel tissue, respectively. These techniques have shown great potential to characterize strictures in Crohn's disease. The aim of this review is to sum up the current knowledge on bowel ultrasound tools to discriminate inflammatory from fibrotic stenosis in Crohn's disease considering the most recent published studies in the field.
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21
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Boucher AL, Pereira B, Decousus S, Goutte M, Goutorbe F, Dubois A, Gagniere J, Borderon C, Joubert J, Pezet D, Dapoigny M, Déchelotte PJ, Bommelaer G, Buisson A. Endoscopy-based management decreases the risk of postoperative recurrences in Crohn’s disease. World J Gastroenterol 2016; 22:5068-5078. [PMID: 27275099 PMCID: PMC4886382 DOI: 10.3748/wjg.v22.i21.5068] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 04/14/2016] [Accepted: 04/20/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate whether an endoscopy-based management could prevent the long-term risk of postoperative recurrence.
METHODS: From the pathology department database, we retrospectively retrieved the data of all the patients operated on for Crohn’s disease (CD) in our center (1986-2015). Endoscopy-based management was defined as systematic postoperative colonoscopy (median time after surgery = 9.5 mo) in patients with no clinical postoperative recurrence at the time of endoscopy.
RESULTS: From 205 patients who underwent surgery, 161 patients (follow-up > 6 mo) were included. Endoscopic postoperative recurrence occurred in 67.6%, 79.7%, and 95.5% of the patients, respectively 5, 10 and 20 years after surgery. The rate of clinical postoperative recurrence was 61.4%, 75.9%, and 92.5% at 5, 10 and 20 years, respectively. The rate of surgical postoperative recurrence was 19.0%, 38.9% and 64.7%, respectively, 5, 10 and 20 years after surgery. In multivariate analysis, previous intestinal resection, prior exposure to anti-TNF therapy before surgery, and fistulizing phenotype (B3) were postoperative risk factors. Previous perianal abscess/fistula (other perianal lesions excluded), were predictive of only symptomatic recurrence. In multivariate analysis, an endoscopy-based management (n = 49/161) prevented clinical (HR = 0.4, 95%CI: 0.25-0.66, P < 0.001) and surgical postoperative recurrence (HR = 0.30, 95%CI: 0.13-0.70, P = 0.006).
CONCLUSION: Endoscopy-based management should be recommended in all CD patients within the first year after surgery as it highly decreases the long-term risk of clinical recurrence and reoperation.
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22
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Yamamoto T, Shimoyama T, Kuriyama M. Letter: deleterious effects of smoking on post-operative Crohn's disease. Aliment Pharmacol Ther 2016; 43:1247-8. [PMID: 27137736 DOI: 10.1111/apt.13610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- T Yamamoto
- Inflammatory Bowel Disease Centre, Yokkaichi Hazu Medical Centre, Yokkaichi, Mie, Japan
| | - T Shimoyama
- Inflammatory Bowel Disease Centre, Yokkaichi Hazu Medical Centre, Yokkaichi, Mie, Japan.
| | - M Kuriyama
- Inflammatory Bowel Disease Centre, Yokkaichi Hazu Medical Centre, Yokkaichi, Mie, Japan
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23
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De Bie C, Ballet V, Hendriks N, Coenen S, Weyts E, Van Assche G, Vermeire S, Ferrante M. Smoking behaviour and knowledge of the health effects of smoking in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2015; 42:1294-302. [PMID: 26435040 DOI: 10.1111/apt.13423] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 08/20/2015] [Accepted: 09/14/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND The detrimental effect of smoking on development and progression of Crohn's disease (CD) is generally accepted. AIM To evaluate the awareness of smoking risks in a Belgian inflammatory bowel disease (IBD) population. METHODS In the out-patient clinic of a tertiary referral centre, 625 consecutive patients with CD, 238 patients with ulcerative colitis (UC) and 289 non-IBD controls, filled out a simple questionnaire. This questionnaire included data on smoking behaviour and awareness of smoking-related health effects, including effects on IBD. RESULTS At diagnosis, more CD patients were active smokers compared to UC (40% vs. 17%, P < 0.001). Remarkably, smoking cessation rates after diagnosis were similar for CD and UC (both 56%, P = 0.997). The great majority recognised a detrimental influence of smoking on general health (98-99%), lung cancer (95-97%), myocardial infarction (89-92%) and stroke (78-87%). Although CD patients more frequently acknowledged risks of smoking on their disease, only 37% were aware of a link with CD development, 30% of increased surgical rates and 27% of increased post-operative CD recurrence. Active smokers more frequently denied an increased risk of surgery and higher post-operative CD recurrence. Intriguingly, within the active smokers with CD, those not willing to quit smoking most often denied a potential bad influence of smoking. Taking into account disease duration, previous surgery, education level, working status and nicotine dependence, we were unable to define specific subgroups of patients requiring extra education. CONCLUSION Although patients with Crohn's disease were better informed on the detrimental effects of smoking, the awareness rate was still low.
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Affiliation(s)
- C De Bie
- Department of Gastroenterology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - V Ballet
- Department of Gastroenterology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - N Hendriks
- Department of Clinical and Experimental Medicine, Translational Research Centre for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - S Coenen
- Department of Gastroenterology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Department of Clinical and Experimental Medicine, Translational Research Centre for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - E Weyts
- Department of Gastroenterology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - G Van Assche
- Department of Gastroenterology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Department of Clinical and Experimental Medicine, Translational Research Centre for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - S Vermeire
- Department of Gastroenterology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Department of Clinical and Experimental Medicine, Translational Research Centre for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - M Ferrante
- Department of Gastroenterology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.,Department of Clinical and Experimental Medicine, Translational Research Centre for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
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Fornaro R, Caratto E, Caratto M, Fornaro F, Caristo G, Frascio M, Sticchi C. Post-operative recurrence in Crohn's disease. Critical analysis of potential risk factors. An update. Surgeon 2015; 13:330-347. [PMID: 26049657 DOI: 10.1016/j.surge.2015.04.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 04/22/2015] [Accepted: 04/26/2015] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Crohn's disease is associated with high rates of postoperative recurrence. At 10 years after surgery a high percentage of patients suffer recurrence (as many as 75% and above) and many of these (up to 45%) require re-intervention. The aim of the study was to identify, amongst the various "potential predictive factors", those which today should be considered "real risk factors" for postoperative recurrence. METHODS A review of literature of the last 30 years was carried out. A medical literature search was conducted using Medline, Embase, Ovid Journals, Science Direct, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews. Potential risk factors related to the patient, disease, type of surgery and pharmacological treatment were analyzed. RESULTS According to most Authors predictive factors, in addition to smoke, are also represented by an extent of disease superior to 100 cm and by absence of postoperative pharmacological treatment. Moreover, according to "the second European evidence-based Consensus on the diagnosis and the management of Crohn's disease: Special situations", localization of disease in the colon, penetrative behavior of disease, extensive small bowel resection and prior intestinal surgery should also be considered predictive factors. CONCLUSIONS The high incidence of postoperative recurrence in Crohn's disease mandates a strict follow up (clinical, laboratory and instrumental monitoring). Identifying patients with increased risk would enable physicians to plan a surveillance program and to implement a rational therapeutic prophylaxis.
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Affiliation(s)
- Rosario Fornaro
- University of Genoa, Department of Surgery, IRCCS San Martino Hospital IST, Largo Rosanna Benzi n 10, 16132 Genova, Italy.
| | - Elisa Caratto
- University of Genoa, Department of Surgery, IRCCS San Martino Hospital IST, Largo Rosanna Benzi n 10, 16132 Genova, Italy
| | - Michela Caratto
- University of Genoa, Department of Surgery, IRCCS San Martino Hospital IST, Largo Rosanna Benzi n 10, 16132 Genova, Italy
| | - Francesco Fornaro
- University of Genoa, Department of Surgery, IRCCS San Martino Hospital IST, Largo Rosanna Benzi n 10, 16132 Genova, Italy
| | - Giuseppe Caristo
- University of Genoa, Department of Surgery, IRCCS San Martino Hospital IST, Largo Rosanna Benzi n 10, 16132 Genova, Italy
| | - Marco Frascio
- University of Genoa, Department of Surgery, IRCCS San Martino Hospital IST, Largo Rosanna Benzi n 10, 16132 Genova, Italy
| | - Camilla Sticchi
- ARS - Agenzia Regionale Sanitaria, Liguria - Area Epidemiologia e Prevenzione, Piazza della Vittoria n 15, 16121 Genova, Italy
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25
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Abstract
The disease spectrum and natural course of Crohn's disease and ulcerative colitis are highly variable. The majority of Crohn's disease patients will require surgery at a certain stage in their disease compared to only a fraction of the ulcerative colitis patients. Similarly, some patients are destined to experience an indolent disease course while others will require early intensive therapy. Ideally, these subtypes of patients should be identified as early as possible with the help of reliable prognostic factors in order to guide personalized therapeutic decisions. In this review, the authors focused on the most relevant reports on the use of different prognostic factors to predict disease course, postoperative recurrence and response to therapy in patients with inflammatory bowel disease. The last 15 years have seen a wealth of novel genetic and serological markers of disease severity. Nevertheless, none of these markers have proven to be superior to careful clinical phenotyping and endoscopic features early in the disease course. Future attempts should apply an integrated approach that unites clinical, serological and (epi)genetic information with environmental influences, with a clear focus on the microbiome to ultimately identify molecular-based and clinically relevant subgroups.
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Abstract
Crohn disease is a chronic disease that is treated with aminosalicylates, antibiotics, and immunosuppressant agents. Most patients ultimately require surgical intervention and many will require additional surgery for recurrent disease. Consequently, surgery is generally performed only when medical management fails; however, these patients are often malnourished and immunosuppressed. Preoperative optimization is necessary to minimize morbidity, including intra-abdominal septic complications and anastomotic leaks. In this article, the authors review some considerations to improve the surgical outcome in Crohn disease.
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Affiliation(s)
- Amit Sharma
- Division of Colon and Rectal Surgery, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Edison, New Jersey
| | - Bertram T Chinn
- Division of Colon and Rectal Surgery, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Edison, New Jersey
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Jones GR, Kennedy NA, Lees CW, Arnott ID, Satsangi J. Systematic review: The use of thiopurines or anti-TNF in post-operative Crohn's disease maintenance--progress and prospects. Aliment Pharmacol Ther 2014; 39:1253-65. [PMID: 24738574 DOI: 10.1111/apt.12743] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 12/23/2013] [Accepted: 03/20/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Post-operative recurrence of Crohn's disease is an important management challenge, with 2-year recurrence rates defined by clinical, endoscopic and radiological parameters of up to 77%, 64% and 49%. Clinical and severe endoscopic recurrence vary widely in controlled trials from 13% to 36% and 22% to 56% with thiopurine treatment or 0% and 9% with infliximab treatment respectively at 1 year. AIMS To provide a review of the evidence for thiopurine or anti-TNF use in post-operative Crohn's disease, and to assess the ability to identify those patients at highest risk of recurrent disease. METHODS A literature search was undertaken using Medline, Embase and Cochrane databases to identify studies using search terms 'thiopurine', 'azathioprine', 'mercaptopurine', 'Infliximab', 'adalimumab', 'Anti-TNF', 'Crohn's disease', 'post-operative' and 'recurrence'. RESULTS Trials to examine this important area have proved difficult to execute, with recruitment and retention of patients posing major challenges to randomised clinical trials. There have been four RCTs of 433 patients of thiopurine therapy (with three meta-analyses of these data), and one of anti-TNF therapy involving 24 patients. Overall the efficacy data for thiopurine use in this setting are inconclusive, and other than smoking, there are no consistent predictors of post-operative relapse. CONCLUSIONS At present, evidence for routine use of thiopurine treatment in post-operative Crohn's disease is heterogeneous and unconvincing. Stratification by risk of relapse emerges as a key challenge in post-operative management that needs to be addressed, using clinical parameters and emerging biomarkers. The evidence for prophylactic anti-TNF use is limited though promising, with its routine use guided by early assessment of relapse.
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Affiliation(s)
- G R Jones
- Department of Gastroenterology, Western General Hospital, Edinburgh, UK
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Hagel AF, Hahn A, Dauth W, Matzel K, Konturek PC, Neurath MF, Raithel M. Outcome and complications of endoscopic balloon dilatations in various types of ileocaecal and colonic stenosis in patients with Crohn's disease. Surg Endosc 2014; 28:2966-72. [PMID: 24853850 DOI: 10.1007/s00464-014-3559-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 04/17/2014] [Indexed: 12/12/2022]
Abstract
AIM We examined the outcome and the complications of endoscopic balloon dilatation (EBD) of ileocaecal and colonic strictures due to Crohn's disease. METHODS We examined 237 dilatation procedures in 77 patients with symptomatic ileocaecal and colonic stenosis regarding outcome, individual perforation risk, the need for further interventions, and other complications within a 10 years observation period. RESULTS In 50 of 77 patients (64.9%), endoscopic dilatation procedures were successful within a median follow-up period of 24 months (25th and 75th percentile 10-38.5 months). Thirty five patients (45.5%) were successfully dilated with only one endoscopic procedure, while the remaining patients required two or more EBDs. Albeit the EBD, 27 patients of the whole cohort (35.1%) underwent surgical repair of the stenosis in due course. Overall complication rate was 7.6%, with postdilatation bleeding in 1.7% and abdominal pain longer than 24 h in 4.2%. Perforation occurred in 4 of 77 patients (5.2%), resulting in a perforation rate of 1.7% per intervention, or, more importantly, for the individual patient in a long-term perforation rate of 5.2% per patient, respectively. DISCUSSION Endoscopic balloon dilatation (EBD) is a safe and effective approach to ileocaecal and colonic stenosis in approximately 65% of Crohn's disease patients. Even in case of recurrence, further endoscopic treatments can be undertaken. The perforation rate depending on the number of interventions is low, but for the individual patient a cumulative per patient perforation risk of 5.2% in the long-term should be considered during patient information and decisions for or against surgical interventions.
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Affiliation(s)
- Alexander F Hagel
- Department of Medicine I, University of Erlangen, Ulmenweg 18, 91054, Erlangen, Germany,
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Yamamoto T, Watanabe T. Strategies for the prevention of postoperative recurrence of Crohn's disease. Colorectal Dis 2013; 15:1471-80. [PMID: 23809911 DOI: 10.1111/codi.12326] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 03/22/2013] [Indexed: 12/13/2022]
Abstract
AIM To review the optimal strategy to prevent recurrence of Crohn's disease (CD) after surgery, with particular emphasis on the risk factors that predict postoperative recurrence, methods of monitoring for recurrence and medications used to prevent postoperative recurrence. METHOD MEDLINE and the Cochrane Library were searched for clinical trials and meta-analyses that studied postoperative recurrence and prophylactic medications in CD. RESULTS The most significant factor that predicted postoperative recurrence was patient smoking status. Smokers had an increased risk of recurrence (odds ratio = 2.15; 95% confidence interval (CI) = 1.42-3.27). Similarly, perforating CD appeared to be associated with a higher recurrence rate compared with nonperforating CD (hazard ratio = 1.50; 95% CI = 1.16-1.93). The optimal monitoring strategy for postoperative recurrence has yet to be established. Nonetheless, ileocolonoscopy is considered to be the gold standard. Noninvasive imaging techniques including contrast ultrasonography and capsule endoscopy appear to be useful for postoperative monitoring. A number of meta-analyses found that mesalazine, nitroimidazole antibiotics and purine analogues (azathioprine/6-mercaptopurine) significantly reduced the risk of postoperative recurrence when compared with placebo. Additionally, recent randomized controlled trials have suggested that an early intervention with infliximab is likely to prevent recurrence after ileocolonic resection. Likewise, in prospective studies, biological therapy (infliximab/adalimumab) reduced clinical and endoscopic CD activity in patients with early endoscopic recurrence after surgery. CONCLUSION Although additional evidence is necessary, endoscopic monitoring and treatment step-up should be used to prevent postoperative recurrence of CD.
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Affiliation(s)
- T Yamamoto
- Inflammatory Bowel Disease Centre and Department of Surgery, Yokkaichi Social Insurance Hospital, Yokkaichi, Mie, Japan
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Nunes T, Etchevers MJ, Domènech E, García-Sánchez V, Ber Y, Peñalva M, Merino O, Nos P, Garcia-Planella E, Casbas AG, Esteve M, Taxonera Samsó C, Montoro Huguet M, Gisbert JP, Martín Arranz MD, García-Sepulcre MF, Barreiro-de Acosta M, Beltrán B, Alcaide Suárez N, Saro Gismera C, Cabriada JL, Cañas-Ventura A, Gomollón F, Panés J. Smoking does influence disease behaviour and impacts the need for therapy in Crohn's disease in the biologic era. Aliment Pharmacol Ther 2013; 38:752-60. [PMID: 23980933 DOI: 10.1111/apt.12440] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 06/14/2013] [Accepted: 07/13/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recently, the notion that smoking may adversely affect Crohn's disease (CD) outcomes has been challenged by the suggestion that the widespread use of immunosuppressants and anti-TNF drugs might offset the adverse effects of tobacco. AIM To reassess the influence of tobacco smoking on disease phenotype and complications on a time-dependent analysis, taking into account the different therapeutic interventions. METHODS We designed a retrospective cohort study of 3224 patients with Crohn's disease. The data were collected from the Spanish national inflammatory bowel disease registry (ENEIDA), including information regarding demographics, clinical characteristics, disease complications, therapeutic interventions and smoking status. Patients were classified as nonsmokers, smokers and former smokers, according to their present and past smoking habits. RESULTS In the univariate analysis, smokers had more strictures (22.6% vs. 19.3%, P < 0.05) and less colonic involvement (7.2% vs. 10.9%, P < 0.05), and were more frequently under treatment with steroids (91.6% vs. 85.8%, P < 0.05), immunosuppressants (73.5% vs. 63.6% P < 0.05) or anti-TNF drugs (31.4% vs. 25.1%, P < 0.05) than nonsmokers. In the time-dependent multivariate analysis, smokers were found to have a significantly decreased survival free of stricturing disease (HR: 1.5, CI 95% 1.18-1.90) or perianal complications (HR: 1.50, CI 95% 1.01-1.46), and had a higher risk for requiring thiopurine therapy (HR: 1.20, CI 95% 1.05-1.30). CONCLUSION These results suggest that, despite the widespread use of immunosuppressants and anti-TNF drugs, smokers with Crohn's disease still have a more severe disease course, with increased therapeutic requirements when compared with nonsmokers.
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Affiliation(s)
- T Nunes
- Hospital Clınic, Barcelona, Spain
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Kennelly RP, Subramaniam T, Egan LJ, Joyce MR. Smoking and Crohn's disease: active modification of an independent risk factor (education alone is not enough). J Crohns Colitis 2013; 7:631-5. [PMID: 23036508 DOI: 10.1016/j.crohns.2012.08.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Revised: 08/12/2012] [Accepted: 08/29/2012] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Smoking can induce the onset of Crohn's disease in genetically susceptible patients and may accelerate progression and disease severity. There is a paucity of information as to patient knowledge of the impact of smoking on disease progression. The aim of this study was to assess patient awareness, initiate smoking cessation therapy and monitor the effectiveness of an active smoking cessation programme in patients with Crohn's disease. METHODS All patients with a diagnosis of Crohn's disease over a ten year period were identified from a prospectively managed database. Details of smoking history and patient knowledge of the link between Crohn's disease and smoking were collected through a telephone questionnaire. Current smokers who wished to quit were enrolled in a smoking cessation programme and followed prospectively for 12 months. RESULTS 340 patients were identified with 281 eligible for inclusion. 181 patients agreed to a telephone survey (64.4% patient uptake). Smokers had an increased incidence of surgical intervention (OR 2.2; CI 1.02, 4.78 P=0.043). Awareness of the link between smoking and Crohn's disease was highest in the current smoking cohort and lowest in the non-smoking cohort (CS:NS; 79.5%:43% p<0.001). 29% of patients with a smoking history had previously been offered smoking cessation therapy. 77% of current smokers opted for smoking cessation therapy. At 6 months 53% of these patients remained smoke free and 37% at 12 months. CONCLUSION In patients with Crohn's disease, information alone is ineffective at achieving smoking cessation. Good cessation rates are achievable if information is supported by active smoking cessation therapy.
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Affiliation(s)
- Rory P Kennelly
- Department of Colorectal Surgery, University College Hospital Galway, Newcastle, Co. Galway, Ireland.
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Sorrentino D. State-of-the-art medical prevention of postoperative recurrence of Crohn's disease. Nat Rev Gastroenterol Hepatol 2013; 10:413-22. [PMID: 23648935 DOI: 10.1038/nrgastro.2013.69] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Postoperative recurrence of Crohn's disease is a frequent and often severe sequela of the disease. Until a few years ago it was deemed inescapable, as all the conventional medications used to treat the disease have been proven of little benefit in preventing recurrence after surgical treatment. In the past few years, anti-TNF agents given immediately after surgery have shown a remarkable efficacy in the prevention of disease recurrence. Large, randomized, controlled trials are currently underway to confirm these findings. Anti-TNF treatment of endoscopic lesions that occur after surgery seems to be less effective than using TNF antagonists to prevent recurrence. However, although the data are limited, this treatment strategy seems to be still superior to all the other prevention strategies that are not based on anti-TNF agents. Limited data are available on long-term outcomes of patients treated with anti-TNF agents after surgery. They suggest that these medications are safe and effective after many years of treatment. In addition, these agents might prevent recurrence even at doses lower than those used in patients with Crohn's disease who have not had surgery.
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Affiliation(s)
- Dario Sorrentino
- Division of Gastroenterology, Virginia Tech-Carilion School of Medicine, 3 Riverside Circle, Roanoke, VA 24016, USA.
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Nunes T, Etchevers MJ, Merino O, Gallego S, García-Sánchez V, Marín-Jiménez I, Menchén L, Barreiro-de Acosta M, Bastida G, García S, Gento E, Ginard D, Martí E, Gomollón F, Arroyo M, Monfort D, García-Planella E, Gonzalez B, Loras C, Agustí C, Figueroa C, Sans M. High smoking cessation rate in Crohn's disease patients after physician advice--the TABACROHN Study. J Crohns Colitis 2013; 7:202-7. [PMID: 22626507 DOI: 10.1016/j.crohns.2012.04.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Revised: 04/24/2012] [Accepted: 04/24/2012] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Tobacco smoking has a significant impact on the development of Crohn's disease (CD) and its clinical course, making smoking cessation one of the main goals in CD therapeutic strategy. AIMS To evaluate the effectiveness of an advice-based smoking cessation strategy among CD patients. METHODS We have performed a prospective multicenter study which enrolled 408 CD smokers. At inclusion all patients were instructed about the risks of smoking and subsequently followed every 3 months. Each center used additional smoking cessation strategies based on available resources. Urinary cotinine and exhaled carbon monoxide levels were evaluated in a subgroup of patients. RESULTS Median study follow up was 18 months. 31% of the patients achieved complete smoking cessation and 23% were smoking-free at the end of their follow up with 8% of smoking relapse. Most patients not achieving smoking cessation did not change their smoking habit with only 5% presenting a decrease in tobacco load. 63% of patients willing to quit smoking received help from another specialist, most frequently the pulmonologist (47%). Surprisingly, most patients (88%) tried to quit smoking with no pharmacological therapy and bupropion, varenicline and nicotine replacement treatment were used in few patients. Urinary cotinine and exhaled CO levels tested in a subgroup of patients proved to have a good correlation with the self-reported smoking habit. No predictors of successful smoking cessation were identified. CONCLUSION Our results underline that an anti-tobacco strategy mostly based on CD patients's education and counseling is feasible and effective in helping patients reach complete abstinence.
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Shiraki M, Yamamoto T. Letter: the impact of smoking on clinical outcomes after endoscopic dilatation in Crohn's disease. Aliment Pharmacol Ther 2013; 37:500. [PMID: 23336688 DOI: 10.1111/apt.12191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 12/04/2012] [Indexed: 12/15/2022]
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Nunes T, Etchevers MJ, Merino O, Gallego S, García-Sánchez V, Marín-Jiménez I, Menchén L, Barreiro-de Acosta M, Bastida G, García S, Gento E, Ginard D, Gomollón F, Arroyo M, Monfort D, García-Planella E, Gonzalez B, Loras C, Agustí C, Figueroa C, Sans M. Does smoking influence Crohn's disease in the biologic era? The TABACROHN study. Inflamm Bowel Dis 2013; 19:23-9. [PMID: 22467185 DOI: 10.1002/ibd.22959] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND While most studies have found a negative effect of smoking on Crohn's disease (CD) phenotype, more recent data have failed to reproduce this association, which might be due to a current wider use of thiopurines and biologic therapy. The TABACROHN study aimed at defining the impact of smoking on CD in the largest published series. METHODS This multicenter cross-sectional study included 1170 CD patients. Patients were classified as nonsmokers, current smokers, or former smokers according to their present smoking status. Clinical data regarding disease characteristics, treatment, and complications were collected. RESULTS Smokers were more frequently under maintenance treatment when compared to nonsmokers. In addition, current smokers presented higher use of biologic drugs compared to nonsmokers. Tobacco exposure and a higher tobacco load were independent predictors of need for maintenance treatment and stenosing phenotype, respectively. CONCLUSIONS In the era of early and widespread use of immunosuppressants and biologics, tobacco exposure is an independent predictor of need for maintenance treatment, specifically biologic therapy. The wider use of biologics and immunosuppressants could account for the existence of no major differences in disease behavior and complications between nonsmokers and current smokers.
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Beaugerie L, Sokol H. Clinical, serological and genetic predictors of inflammatory bowel disease course. World J Gastroenterol 2012; 18:3806-13. [PMID: 22876031 PMCID: PMC3413051 DOI: 10.3748/wjg.v18.i29.3806] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 03/26/2012] [Accepted: 04/22/2012] [Indexed: 02/06/2023] Open
Abstract
Patients with extensive or complicated Crohn’s disease (CD) at diagnosis should be treated straightaway with immunosuppressive therapy according to the most recent guidelines. In patients with localized and uncomplicated CD at diagnosis, early use of immunosuppressive therapy is debated for preventing disease progression and limiting the disabling clinical impact. In this context, there is a need for predictors of benign or unfavourable subsequent clinical course, in order to avoid over-treating with risky drugs those patients who would have experienced spontaneous mid-term asymptomatic disease without progression towards irreversible intestinal lesions. At diagnosis, an age below 40 years, the presence of perianal lesions and the need for treating the first flare with steroids have been consistently associated with an unfavourable subsequent 5-year or 10-year clinical course. The positive predictive value of unfavourable course in patients with 2 or 3 predictors ranges between 0.75 and 0.95 in population-based and referral centre cohorts. Consequently, the use of these predictors can be integrated into the elements that influence individual decisions. In the CD postoperative context, keeping smoking and history of prior resection are the strongest predictors of disease symptomatic recurrence. However, these clinical predictors alone are not as reliable as severity of early postoperative endoscopic recurrence in clinical practice. In ulcerative colitis (UC), extensive colitis at diagnosis is associated with unfavourable clinical course in the first 5 to 10 years of the disease, and also with long-term colectomy and colorectal inflammation-associated colorectal cancer. In patients with extensive UC at diagnosis, a rapid step-up strategy aiming to achieve sustained deep remission should therefore be considered. At the moment, no reliable serological or genetic predictor of inflammatory bowel disease clinical course has been identified.
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Li Y, Zhu W, Zuo L, Zhang W, Gong J, Gu L, Cao L, Li N, Li J. Frequency and risk factors of postoperative recurrence of Crohn's disease after intestinal resection in the Chinese population. J Gastrointest Surg 2012; 16:1539-47. [PMID: 22555673 DOI: 10.1007/s11605-012-1902-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 04/24/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Data on risk factors of postoperative recurrence in patients with Crohn's disease (CD) have shown conflicting results. The aim of this retrospective study is to identify predictors of early symptomatic recurrence of CD after surgical intestinal resection in the Chinese population. MATERIALS AND METHODS Patients diagnosed as CD who underwent intestinal resection in Jinling Hospital between May 2004 and December 2010 were included in our study. Clinical data of these patients were reviewed. Multivariable survival analysis was performed to elucidate risk factors of early postoperative symptomatic recurrence. RESULTS There were a total of 141 CD patients who had at least one previous curative resection for CD under regular follow-up in our unit. Our data indicated disease behavior (95 % CI 1.01-1.70, P = 0.044), smoking habits (95 % CI 1.32-2.84, P = 0.001), indication of perforation (95 % CI 1.09-4.02, P = 0.026), and location of anastomosis (95 % CI 1.09-3.39, P = 0.023) which are, as a result, strong independent predictors of symptomatic recurrence, while the anastomosis type as side-to-side anastomosis (SSA) was significantly associated with a decreased risk of symptomatic recurrence when compared with other anastomosis type (95 % CI 0.26-0.94, P = 0.038). Medical prophylaxes also played a role in the prevention of postoperative symptomatic recurrence. CONCLUSIONS A smoking habits and perforation indication for surgery at the time of resection are associated with an increased risk of symptomatic recurrence. Anastomosis type with SSA is associated with a reduced risk of symptomatic recurrence. This population-based study supports the concept that environmental factors, disease character, and surgical technique influence the risk of postoperative symptomatic recurrence of CD.
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Affiliation(s)
- Yi Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing 210002, China
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Prevention of postoperative recurrence of Crohn's disease. J Crohns Colitis 2012; 6:637-46. [PMID: 22398096 DOI: 10.1016/j.crohns.2011.12.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Revised: 12/04/2011] [Accepted: 12/05/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Up to 75% of patients with Crohn's disease (CD) will have intestinal resection during their life. Most patients will, however, develop postoperative recurrence (endoscopic, clinical or surgical). Several medical and surgical strategies have been attempted to prevent postoperative recurrence. This review evaluates the efficacy of different drug regimens and surgical techniques in the prevention of clinical, endoscopic and surgical postoperative recurrence of CD. METHODS A literature search for randomized controlled trials on medical or surgical interventions was performed. The endpoints for efficacy were clinical, endoscopic and surgical recurrence. Meta-analyses were performed in case two or more RCTs evaluated the same drug or surgical technique. RESULTS Mesalamine is more effective in preventing clinical recurrence than placebo (P=0,012), as well as nitroimidazolic antibiotics at one year follow-up (P<0.001) and thiopurines (P=0.018). Nitroimidazolic antibiotics are also more effective than placebo in preventing endoscopic recurrence (P=0.037), as well as thiopurines (P=0.015) and infliximab (P=0.006). Budenoside, probiotics, Interleukin-10 nor any of the different surgical procedures showed any significant difference compared to placebo in postoperative recurrence rates of CD. CONCLUSION Among the different drug regimens and surgical techniques, only thiopurines and nitroimidazolic antibiotics are able to reduce postoperative clinical as well as endoscopic recurrence of CD. Mesalamine and infliximab also seem to be superior to placebo in preventing clinical recurrence and endoscopic recurrence, respectively. There is a paucity of trials evaluating long-term follow-up and prevention of surgical recurrence of CD.
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De Cruz P, Kamm MA, Prideaux L, Allen PB, Desmond PV. Postoperative recurrent luminal Crohn's disease: a systematic review. Inflamm Bowel Dis 2012; 18:758-77. [PMID: 21830279 DOI: 10.1002/ibd.21825] [Citation(s) in RCA: 145] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 06/15/2011] [Indexed: 12/20/2022]
Abstract
Despite improved immunosuppressive therapy, surgical resection is still often required for uncontrolled inflammatory disease and the stenosing and perforating complications of Crohn's disease. However, surgery is not curative. A majority of patients develop disease recurrence at or above the anastomosis. Subclinical endoscopically identifiable recurrence precedes the development of clinical symptoms; identification and treatment of early mucosal recurrence may therefore prevent clinical recurrence. Therapy to achieve mucosal healing should now be the focus of postoperative therapy. A number of clinical risk factors for the development of earlier postoperative recurrence have been identified, and reasonable evidence is now available regarding the efficacy of drug therapies in preventing recurrence. This evidence now needs to be incorporated into prospective treatment strategies.
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Affiliation(s)
- Peter De Cruz
- Department of Gastroenterology and Medicine, St Vincent's Hospital, Melbourne, Australia
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The outcome of initial percutaneous drainage versus surgical drainage for intra-abdominal abscesses in Crohn's disease. Int J Colorectal Dis 2012; 27:199-206. [PMID: 22052039 DOI: 10.1007/s00384-011-1338-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2011] [Indexed: 02/04/2023]
Abstract
PURPOSE Percutaneous drainage (PD) of Crohn's related abscesses is becoming popular with the development of techniques. We retrospectively analyzed the outcome of initial PD versus initial surgical drainage for intra-abdominal abscesses in Crohn's disease. METHODS Twenty-three patients of Crohn's disease complicated with intra-abdominal or pelvic abscesses treated in our institution between July 2001 and April 2010 were retrospectively identified from 188 patients with proven Crohn's disease. Outcome measures included abscess recurrence after different treatments, post-drainage complications, ultimate stoma creation, and subsequent surgery for Crohn's disease. RESULTS Patients were divided into initial PD group (n = 10) and initial surgery group (n = 13): post-drainage complications were more common in initial surgery group (2/10 vs 9/13, P = 0.036), abscess recurred in three patients (2/10 vs 1/13, NS), and subsequent surgery was needed in 10 patients (6/10 vs 4/13, NS). Ultimate stoma creation were significantly more in initial surgery group (1/10 vs 9/13, P = 0.01). CONCLUSIONS Initial PD group had lower rate of post-drainage complications and ultimate stoma creation compared to the initial surgery group. Although subsequent surgery may not be avoided after PD, it can provide safe anastomosis for resections. Long-term follow-up should be done to assess the outcome of PD.
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Predicting, treating and preventing postoperative recurrence of Crohn's disease: the state of the field. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2011; 25:140-6. [PMID: 21499578 DOI: 10.1155/2011/591347] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The majority of patients diagnosed with Crohn's disease eventually require surgical intervention. Unfortunately, postsurgical remission tends to be short lived; a significant number of patients experience clinical relapse and many require additional operations. The pathogenesis of this postoperative recurrence is poorly understood and, currently, there are no reliable tools to predict when and in whom the disease will recur. Furthermore, the postoperative prophylaxis profiles of available Crohn's disease therapeutic agents such as 5-aminosalicylates, immunomodulators, steroids and probiotics have been disappointing. Recently, the combination of antibiotics and azathioprine in selected high-risk patients has demonstrated some potential for benefit. The goal of the present article is to provide a coherent summary of previous and new research to guide clinicians in managing the challenging and complex problem of postoperative Crohn's disease recurrence.
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Cunningham MF, Docherty NG, Coffey JC, Burke JP, O'Connell PR. Postsurgical recurrence of ileal Crohn's disease: an update on risk factors and intervention points to a central role for impaired host-microflora homeostasis. World J Surg 2011; 34:1615-26. [PMID: 20195604 DOI: 10.1007/s00268-010-0504-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND A pressing need exists to identify factors that predispose to recurrence after terminal ileal resection for Crohn's disease (CD) and to determine effective prophylactic strategies. This review presents an up-to-date summary of the literature in the field and points to a role for bacterial overproliferation in recurrence. METHODS The literature (Medline, Embase, and the Cochrane Library, 1971-2009) on ileal CD and postoperative recurrence was searched, and 528 relevant articles were identified and reviewed. RESULTS Smoking is a key independent risk factor for recurrence. NOD2/CARD15 polymorphisms and penetrating phenotype are associated with aggressive disease and higher reoperation rates. Age at diagnosis, disease duration, gender, and family history are inconsistent predictors of recurrence. Prophylactic 5-aminosalicylic acid therapy and nitromidazole antibiotics are beneficial. Combination therapies with immunosuppressants are also effective. Anti-TNFalpha-based regimens show benefit but the evidence base is small. Corticosteroid, interleukin-10, and probiotic therapies are not effective. Wider, stapled anastomotic configurations are associated with reduced recurrence rates. Strictureplasty and laparoscopic approaches have similar long-term recurrence rates to open resection techniques. Length of resection and presence of microscopic disease at resection margins do not influence recurrence. A lack of consensus exists regarding whether the presence of granulomas or plexitis affects outcome. CONCLUSIONS Current evidence points to defects in mucosal immunity and intestinal dysbiosis of either innate (NOD2/CARD15) or induced (smoking) origin in postoperative CD recurrence. Prophylactic strategies should aim to limit dysbiosis (antibiotics, side-to-side anastomoses) or prevent downstream chronic inflammatory sequelae (anti-inflammatory, immunosuppressive, and immunomodulatory therapy).
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Affiliation(s)
- Michael F Cunningham
- Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Pelletier AL, Stefanescu C, Vincent C, Etienney I, Mentré F, Soulé JC. Is the length of postoperative recurrence on the neo ileum terminal ileum predictable in Crohn's disease? J Crohns Colitis 2011; 5:24-7. [PMID: 21272800 DOI: 10.1016/j.crohns.2010.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Revised: 08/27/2010] [Accepted: 08/27/2010] [Indexed: 01/20/2023]
Abstract
UNLABELLED Crohn's disease (CD) often has a stricturing phenotype on the terminal ileum requiring surgery due to obstruction. Recurrence is frequent, creating a risk of multiple surgeries. We studied patients with ileal or ileo-colic CD who had undergone at least two surgical bowel resections between 1968 and 2008 for obstructive symptoms. AIMS The aim of this retrospective study was to determine if the length of the removed diseased bowel varied from one surgical resection to the next. The measurements obtained from radiology (small bowel follow-up), surgery and histology were compared. RESULTS Twenty four patients were included. Seventeen had 2 resections, 5 patients had 3 resections and two had 4 resections. The resected length of the diseased ileum was significantly shorter for the second intervention than for the first as assessed by radiology (median 16 cm vs 37 cm; p=0.0005), surgery (20 cm vs 40 cm; p=0.005) and histology (15 cm vs 25 cm; p=0.02) while there was no difference between the second and third resections (16 cm, 13 cm, 19.5 cm respectively) for the three types of measurements (p=NS). The surgeon's assessment of the diseased segment was longer than the histologist's (p=0.003). No factor was found to be significantly associated with the length of the diseased bowel on recurrence. CONCLUSION This study shows that the length of the excised neo-terminal ileum during the first episode of recurrence was shorter than during the first episode of disease and remained stable for the third episode. This is an important prognostic finding that could influence the therapeutic choices for this disease and reduce hesitation to indicate surgery.
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Affiliation(s)
- Anne-Laure Pelletier
- Service d'Hépato-gastroentérologie, Hôpital Bichat, 46 rue Huchard, 75877 Paris cedex 18, France.
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Thia KT, Sandborn WJ, Harmsen WS, Zinsmeister AR, Loftus EV. Risk factors associated with progression to intestinal complications of Crohn's disease in a population-based cohort. Gastroenterology 2010; 139:1147-55. [PMID: 20637205 PMCID: PMC2950117 DOI: 10.1053/j.gastro.2010.06.070] [Citation(s) in RCA: 562] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 06/17/2010] [Accepted: 06/30/2010] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS We sought to assess the evolution of Crohn's disease behavior in an American population-based cohort. METHODS Medical records of all Olmsted County, Minnesota residents who were diagnosed with Crohn's disease from 1970 to 2004 were evaluated for their initial clinical phenotype, based on the Montreal Classification. The cumulative probabilities of developing structuring and/or penetrating complications were estimated using the Kaplan-Meier method. Proportional hazards regression was used to assess associations between baseline risk factors and changes in behavior. RESULTS Among 306 patients, 56.2% were diagnosed between the ages of 17 and 40 years. Disease extent was ileal in 45.1%, colonic in 32.0%, and ileocolonic in 18.6%. At baseline, 81.4% had nonstricturing nonpenetrating disease, 4.6% had stricturing disease, and 14.0% had penetrating disease. The cumulative risk of developing either complication was 18.6% at 90 days, 22.0% at 1 year, 33.7% at 5 years, and 50.8% at 20 years after diagnosis. Among 249 patients with nonstricturing, nonpenetrating disease at baseline, 66 changed their behavior after the first 90 days from diagnosis. Relative to colonic extent, ileal, ileocolonic, and upper GI extent were significantly associated with changes in behavior, whereas the association with perianal disease was barely significant. CONCLUSIONS In a population-based cohort study, 18.6% of patients with Crohn's disease experienced penetrating or stricturing complications within 90 days after diagnosis; 50% experienced intestinal complications 20 years after diagnosis. Factors associated with development of complications were the presence of ileal involvement and perianal disease.
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Affiliation(s)
- Kelvin T. Thia
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA, Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - William J. Sandborn
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Edward V. Loftus
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Smoking and inflammatory bowel diseases: what in smoking alters the course? Int J Colorectal Dis 2010; 25:671-80. [PMID: 20333390 DOI: 10.1007/s00384-010-0925-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2010] [Indexed: 02/08/2023]
Abstract
Epidemiological studies provide strong evidence to confirm the correlation between cigarette smoking and inflammatory bowel diseases. This relationship is proved to be positive in Crohn's disease and negative in ulcerative colitis. What in smoking alters the course of inflammatory bowel diseases is still a mystery. Different smoking parts have different and may be opponent actions. Smoking has dual effects. Some of its activities are, sometimes, constructive as they are working in an antagonistic manner to the mechanism of the disease, such as reducing rectal blood flow and accordingly less recruitments of inflammatory mediators to the area of inflammation, enhancement of mucosal production, and consequently, strengthening the membranes, and inhibition of pro-inflammatory mediators' liberation and activity in subjects with ulcerative colitis. Yet the outcome of smoking actions may be affected by the existence of other cofactors. Odd factors, such as shortage of zinc in subjects with Crohn's disease, may facilitate liberation of pro-inflammatory mediators and their activities and accordingly exacerbates symptoms.
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Seksik P, Nion-Larmurier I, Sokol H, Beaugerie L, Cosnes J. Effects of light smoking consumption on the clinical course of Crohn's disease. Inflamm Bowel Dis 2009; 15:734-41. [PMID: 19067428 DOI: 10.1002/ibd.20828] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cigarette smoking is associated with a more severe Crohn's disease (CD) course. However, the effect of light consumption is not known. Our aim was to characterize the effect of a light tobacco consumption on the course of CD. METHODS We analyzed the course of CD during the period 1995-2007 from data collected in 2795 consecutive patients in whom smoking habits were recorded. Patients were classified as nonsmokers (n = 1420), light smokers (1-10 cigarettes/day; n = 385), heavy smokers (>10 cigarettes/day; n = 638), and intermittent smokers (change in smoking habits; n = 352). Patient-years while smoking were compared to patient-years without smoking. The analyses considered patient-years regarding annual disease activity and therapeutic requirements. RESULTS The percentage of years with active disease was 37% in nonsmokers versus 46% in light smokers (P < 0.001; adjusted hazard ratio 1.30 [1.19-1.43]) and 48% in heavy smokers (P < 0.001; adjusted hazard ratio 1.68 [1.57-1.81]), despite an increased use of immunosuppressants in smokers. Hospitalization rates were also increased in both groups of smokers, with 12% in nonsmokers versus 15% in both groups of smokers (P < 0.001 for both comparisons). The annual rate of intestinal resection was 4.5% in nonsmokers, 5.1% in light smokers, and 5.5% in heavy smokers, with a significant difference observed between nonsmokers and heavy smokers only (P < 0.01). CONCLUSIONS Light smokers are doing worse than nonsmokers regarding disease activity and the need for immunosuppressants. Complete smoking cessation should be advised in all smokers with CD.
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Affiliation(s)
- Philippe Seksik
- Gastroenterology & Nutrition Department, Hôpital Saint-Antoine & Université Pierre et Marie Curie, Paris VI, AP-HP, Paris, France.
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Clinical and surgical recurrence of Crohn's disease after ileocolonic resection in a specialist unit. Eur J Gastroenterol Hepatol 2009; 21:551-7. [PMID: 19182680 DOI: 10.1097/meg.0b013e328326a01e] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postoperative clinical and endoscopic recurrence is common in Crohn's disease. AIM We aimed to assess postoperative recurrence and management in a cross-sectional patient cohort in one specialist unit, before the introduction of a uniform postoperative preventive strategy. METHODS Review of patients who had an ileocolonic resection for Crohn's disease between 2002 and 2005 in a secondary and tertiary care specialist centre. RESULTS Ninety-nine patients (42 male; 57 female; mean age, 37 years) with a median disease duration of 10 years, were reviewed. Indications for surgery were obstruction (n=61), failed medical therapy (n=31) and internal fistula(e) (n=7). Thirty patients (30%) were active smokers at the time of resection. Fifty patients (51%) had at least one previous Crohn's resection. Clinical and surgical recurrence rates were 28 and 5%, respectively, at 1 year. All five patients had the same indication for their further surgery as for their index operation (four fistulizing or stricturing). Median time to clinical recurrence was 10 months in those with recurrence. Nineteen percent of patients had an ileocolonoscopy at a median of 6 months after surgery, and 60% had been reviewed by a gastroenterologist, after surgery. Clinical recurrence occurred in nine of 28 (32%) without and 19 of 71 with (26%) postoperative medical therapy (P=NS). CONCLUSION Postoperative recurrence of Crohn's disease was high in the short term. The indication for repeat surgery stayed true within patients. Prospective treatment strategies, based on recent trial evidence, are needed to diminish postoperative recurrence.
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Hoffmann JC, Heller F, Faiss S, von Lampe B, Kroesen AJ, Wahnschaffe U, Schulzke JD, Zeitz M, Bojarski C. Through the endoscope balloon dilation of ileocolonic strictures: prognostic factors, complications, and effectiveness. Int J Colorectal Dis 2008; 23:689-96. [PMID: 18338175 DOI: 10.1007/s00384-008-0461-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2008] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS About half of all Crohn's disease (CD) patients undergo surgery at some point, many because of strictures. An alternative possibility is to dilate strictures endoscopically. However, little is known about prognostic factors. PATIENTS AND METHODS Thirty-two patients with primary CD (n=2), radiogenic strictures (n=1), or postoperative strictures (27 because of CD; 2 after resection because of cancer), were planned to undergo colonoscopic dilatation of which 25 patients were dilated (10 men; 15 women; median age 48). Length of stenosis, diameter of stricture, balloon size, smoking status, ulcer in the stricture, passage postdilatation, hemoglobin level, complications, redilatation, and subsequent surgery were recorded. Only patients with at least 6 months follow up were included. RESULTS Five out of 32 patients had no stenosis, marked inflammation, or fistulas adjacent to the stricture. One patient each had a long stricture (8 cm) or a filiform stenosis ruling out dilatation [technical success, 25/27 (92.6%)]. Among these 25 patients, 39 colonoscopies with 51 dilatations were performed. After a single dilatation, 52% were asymptomatic while 48% needed another intervention, half of them surgery. Bleeding without need for transfusion occurred in 3 out of 39 colonoscopies and one perforation required surgery. Significant prognostic factors were smoking and ulcers in the stricture (P<0.05 each). Some ulcers led to intussusception requiring surgery in spite of good dilatation results. CONCLUSION Through the endoscope balloon stricture dilatation is a relatively safe and often effective treatment modality in ileocolonic strictures. The presence of ulcers in the stricture have a worse outcome as do smokers.
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Affiliation(s)
- Jörg C Hoffmann
- Medizinische Klinik I mit Schwerpunkt Gastroenterologie, Infektiologie, Rheumatologie, Charité, Campus Benjamin Franklin, 12200 Berlin, Germany.
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Mahid SS, Mulhall AM, Gholson RD, Eichenberger MR, Galandiuk S. Inflammatory bowel disease and African Americans: a systematic review. Inflamm Bowel Dis 2008; 14:960-7. [PMID: 18266229 DOI: 10.1002/ibd.20389] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is comprised of Crohn's disease (CD) and ulcerative colitis (UC). There are conflicting reports on whether African Americans have a more severe disease course, presentation, and more frequent extraintestinal manifestations (EIM). We examined the precise nature of this relationship by conducting a systematic review. METHODS Using predefined inclusion criteria we searched multiple healthcare databases and Grey literature. Eight reports met the inclusion criteria. Using the parameters as defined in the Montreal classification and the presence or absence of EIM, we compared IBD in African Americans and Caucasians. RESULTS Over 2000 IBD cases were pooled from 8 reports with African Americans comprising 17%. African Americans and Caucasians had similar distribution of types of IBD, with CD being more common than UC in both groups (CD 76% versus 68% and UC 24% versus 32%, respectively). With respect to CD, both groups presented with nonstricturing and nonpenetrating disease behavior (55% versus 41%) more frequently and had similar rates of ileocolonic disease location (42% versus 38%), and presence of perianal disease (26% versus 29%). In UC patients, proctitis was the most frequent initial presentation in both races. Joint complications were the most frequent EIM in both African Americans (52%) and Caucasians (60%). CONCLUSIONS This study dispels the commonly held views that African Americans with IBD generally have more colonic disease, more severe disease behavior, and more perianal disease than Caucasians. African Americans also have similar variety and frequency of EIMs as compared to Caucasians.
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Affiliation(s)
- Suhal S Mahid
- Price Institute of Surgical Research and the Section of Colorectal Surgery, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky 40292, USA
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